682 UNIT V Middle Range Nursing Theories The theory was influenced by various theoretical and
philosophical stances, adding breadth and texture.
been found valid and reliable in studies (Beck, 2002b; Maternity nurses are able to read the theory and under-
Hanna, Jarman, Savage, et al., 2004; Oppo, Mauri, stand how to apply it in their practice. Beck and others
Ramacciotti, et al., 2009). An important feature of continue to expand the theory by exploring its applica-
Beck’s theory is its immediate accessibility and dy- bility to different cultures and exploring ways of reach-
namic potential to impact women’s lives. ing women who have potential for its benefit.
Importance
The value of Beck’s work is of growing importance Increasingly, nurses and the wider society are rec-
within nursing and other disciplines. Perinatal mood ognizing that issues of postpartum depression have
disorders are obviously more than transient inconve- not been adequately understood or acknowledged.
niences for women and their families. The sequence Nursing, like other health care professions, has been
of events in the life of women (Meier, 2002) points to shocked by unanticipated events when postpartum
the extraordinary need for greater awareness and use depression leads to untoward outcomes that appear in
of Beck’s Postpartum Depression Theory for preven- the evening news. Even among nurses and other
tion, identification, early intervention, and treatment. health professionals, their knowledge does not miti-
gate the effects of this illness. These events point out
There is a growing awareness that the responsibility the importance of this theory. Dr. Cheryl Tatano
for identification and early intervention of postpar- Beck’s work has demonstrated that nursing research
tum depression belongs to more than those who are provides evidence to understand and prevent postpar-
primarily responsible for caring for women during tum depression. Her research and instruments facili-
pregnancy and immediately after birth (Beck, 2003; tate detection, early intervention, and treatment.
Kennedy, Beck, & Driscoll, 2002). Because of consis-
tent interactions with mothers, pediatric and neonatal CASE STUDY
nurses can make valuable contributions to successful At the tender age of 11 years, Kim was “sold” by her
interventions for mothers suffering from postpartum mother to three adult men for an evening of sex
depression. Psychiatric nurses might also be able to and drugs. Kim related that as her mother went out
identify problems in women (or their children) that do the door, she advised her to “do what they tell you
not immediately indicate postpartum depression. and I’ll be back in the morning.” Kim was never
okay again. Although she did relatively well during
However, knowledge about postpartum depres- the sporadic times she went to school, her life was
sion is developing in a way that sheds light on less a series of drug and sex binges. At 17, Kim was in
obvious consequences. Recently, postpartum depres- jail and pregnant. She had been arrested several
sion has been linked to adverse effects on children’s times and released, but the judge insisted that this
cognitive and emotional development and behavior time she stay incarcerated until after the baby was
problems of older children in school. Postpartum born to guarantee the baby would be crack-free at
depression could have a negative effect upon situa- birth. Kim’s prenatal records, however, did not in-
tions such as substance use, traffic accidents, criminal dicate drug or alcohol use, and neither did her
behaviors, domestic violence, progress in school, em- jail records. She adamantly insisted that she never
ployment and income, and many others. A growing used drugs or alcohol once she found out she was
awareness within nursing, other health care profes- pregnant (late in the first trimester). Through a
sionals, and the public will allow greater identification series of misunderstandings, she was released
of postpartum depression in the many contexts within 2 weeks before the baby’s birth. However, Kim did
which people live their lives. well, continued to stay drug-free, refused medica-
tion during labor, and delivered a beautiful healthy
Summary baby—a baby whose blood test results were nega-
tive for drugs.
The development of Beck’s Postpartum Depression
Theory is the quintessential example of how creative
nursing knowledge is developed from nursing observa-
tions, utilizing multiple methods and rigorous testing.
Kim recalls that she began motherhood believ- CHAPTER 34 Cheryl Tatano Beck 683
ing this would be the event that would turn her life Kim once remarked that she loved being preg-
around. It did for several weeks, but slowly Kim nant, loved giving birth, and loved the idea of
became involved in her old life. She received being a mother. She said, “It would be great in
money to buy clothes and food for her baby. In the beginning, but after a couple of months I’d
spite of that help, however, Kim had no place to start feeling bad. It seems like with both my babies
live and no money to support herself. She never that around 6 or 7 months, I just couldn’t handle
held a legal job in her life. She qualified for post- anything.”
partum medical care for 6 weeks, but after that she Although Kim took the baby to a pediatrician
was on her own. for follow-up care, none of those care providers
knew her or knew her history—they were pri-
When the baby was 7 months old, Kim called a marily concerned with her son’s health. Kim’s
nurse who had once cared for her during her preg- affect is usually very upbeat; she smiles easily.
nancy and asked for help to give her daughter up It is not likely that anyone ever asked her any
for adoption. She believed she would simply never important questions about her life or her experi-
be able to give her baby the life she knew all babies ence of being a mother. Kim was, for all intents
deserved. Kim was using drugs again, and the baby and purposes, “lost to follow-up.”
was being kept by whoever was in the mood to do Kim’s story illustrates the kinds of complexi-
so. Kim absolutely loved this baby, and the choice ties that can make postpartum depression espe-
for adoption came from this love. Kim chose a local cially challenging for women who live amid
Christian adoption agency. Staff there gave her the drugs and chaos. In the midst of this life, women
opportunity to read the profiles of potential fami- still want to be good mothers and have the same
lies, see pictures of them, and actually choose the hopes and same dreams we all have. Drugs, alco-
family who would raise her baby. Though she did hol, crimes, and all the other ways Kim’s life
not know the family’s name or address, the family was chaotic were the only avenues by which she
and the agency committed to regular photographs received services—after-the-fact services.
and updates about her daughter. Interventions by others could have made a
difference at many points in Kim’s life. One of
Without resources or support, and without her these points was during her prenatal period. She
baby, Kim returned to the only life she had ever clearly evidenced most of the risk factors for
known among the only people she really knew. postpartum depression, despite her cheerful atti-
Eighteen months later, Kim gave birth to another tude toward the pregnancy. If you had been a
baby. This time, she swore things would be differ- nurse caring for Kim during her prenatal care
ent. When this new baby was also about 7 months and identified her to be at risk for postpartum
old, Kim found herself deeply involved in crack depression, what kind of care plan would you
use, with her baby being passed around from rela- have developed before or after her baby’s birth?
tive to relative and from friend to friend. Unfortu- Would you have been willing to intervene on
nately, Kim was present during the commission of behalf of Kim or her baby, even though their
a violent crime with a predictably tragic outcome. needs occurred within the community and not in
Although Kim did not actually commit this crime, the confines of a hospital or office?
she was present and was ultimately sent to prison.
CRITICAL THINKING ACTIVITIES 3 . Were any of her experiences suggestive of risk for
postpartum depression?
1 . Interview a friend or family member about her
prenatal and postnatal experiences. 4. Explore the resources available in your community
for women with postpartum depression.
2 . Did she have feelings that you expected? Did she
have any that surprised you?
684 UNIT V Middle Range Nursing Theories Beck Instruments
POINTS FOR FURTHER STUDY n Beck, C. T. (1998). Postpartum Depression Pre-
dictors Inventory (PDPI). Available from Journal
n Beck, C. T. (2008). State of the science on post- of Obstetric, Gynecologic, & Neonatal Nursing,
partum depression: What nurse researchers have published on behalf of the Association of
contributed. Part 1. American Journal of Maternal Women’s Health, Obstetrics and Neonatal Nurses,
Child Nursing, 33, 151–156. by Sage Science Press, an imprint of Sage Publica-
tions; Print ISSN: 0884–2175.
n Beck, C. T. (2008). State of the science on post-
partum depression: What nurse researchers have n Beck, C. T., & Gable, R. K. (2002). Postpartum
contributed. Part 2. American Journal of Maternal Depression Screening Scale (PDSS). Available
Child Nursing, 33, 121–126. through Western Psychological Services, 12031
Wilshire Blvd., Los Angeles, CA 90025–1251.
n Polit, D., & Beck, C. T. (2007). Nursing research:
Generating and assessing evidence for nursing
practice (8th ed.). Philadelphia: Lippincott.
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35C H A P T E R
Kristen M. Swanson
1953 to present
Theory of Caring
Danuta M. Wojnar
“Caring is a nurturing way of relating to a valued other toward
whom one feels a personal sense of commitment and responsibility”
(Swanson, 1991, p. 162).
Credentials and Background master’s degree in nursing in 1978, she worked
of the Theorist briefly as clinical instructor of medical-surgical
nursing at the University of Pennsylvania School of
Kristen M. Swanson, RN, PhD, FAAN, was born in Nursing and subsequently enrolled in the Ph.D. in
Providence, Rhode Island. She earned her baccalaure- nursing program at the University of Colorado in
ate degree (magna cum laude) from the University of Denver. There she studied psychosocial nursing
Rhode Island, College of Nursing in 1975. She began with an emphasis on the concepts of loss, stress,
her career as a registered nurse at the University of coping, interpersonal relationships, person and per-
Massachusetts Medical Center in Worcester, because sonhood, environments, and caring.
the founding nursing administration clearly articu-
lated a vision for professional nursing practice and While a doctoral student, as part of a hands-on
actively worked with nurses to apply these ideals experience with a self-selected health promotion
while working with clients (Swanson, 2001). activity, Swanson participated in a cesarean birth sup-
port group focused on miscarriage. The guest speaker,
As a novice nurse, more than anything Swanson a physician, focused on pathophysiology and health
wanted to become a knowledgeable and technically problems prevalent after miscarriage, but women
skillful practitioner with a goal of teaching others. attending the meeting were more interested in talking
Hence, she pursued graduate studies in Adult about their personal experiences with pregnancy loss.
Health and Illness Nursing at the University of That day Swanson decided to learn more about the
Pennsylvania in Philadelphia. After receiving a human experience and responses to miscarrying.
688
Caring and miscarriage became the focus of her doc- CHAPTER 35 Kristen M. Swanson 689
toral dissertation and subsequently her program of
research. Theoretical Sources
Swanson received an individually awarded National Swanson has drawn on various theoretical sources
Research Service postdoctoral fellowship from the while developing her Theory of Caring. She recalls
National Center for Nursing Research, which she that from the beginning of her nursing career, her
completed under the direction of Dr. Kathryn E. education and clinical experience made her acutely
Barnard at the University of Washington in Seattle. aware of the profound difference caring made in the
She joined the faculty at the University of Washington lives of people she served:
School of Nursing and continued her scholarly work
as professor and chairperson of the Department of Watching patients move into a space of total depen-
Family Child Nursing until summer 2009. In addi- dency and come out the other side restored was like
tion to teaching and administrative responsibilities witnessing miracles unfold. Sitting with spouses in
at the University of Washington, She conducted re- the waiting room while they entrusted the heart
search funded by the National Institutes of Nursing (and lives) of their partner to the surgical team was
Research; published, mentored faculty and students, awe inspiring. It was encouraging to observe the
and served as a consultant at national and interna- inner reserves family members could call upon in
tional levels. She has been an invited speaker or order to hand over that which they could not con-
visiting professor on multiple occasions, including trol. It warmed my heart to be so privileged as to be
Karolinska Institute in Sweden, IWK (Isaac Walton invited into the spaces that patients and families
Killam) Health Centre, a tertiary care hospital for created in order to endure their transitions through
women, children, and families in Halifax, Nova Scotia, illness, recovery, and, in some instances, death
Canada, and, most recently, the National Cheng
Kung University in Taiwan, Taiwan. While at the (Swanson, 2001, p. 412).
University of Washington in 2009, Swanson also
held the University of Washington Medical Center Swanson credits several nursing scholars for insights
Term Professorship in Nursing Leadership. that shaped her beliefs about the nursing discipline and
influenced her program of research. She acknowledges
In 2009, Swanson was appointed Dean and Dr. Jacqueline Fawcett’s course on the conceptual basis
Alumni Distinguished Professor at the University of of nursing practice, which led her to understand the
North Carolina (UNC) School of Nursing at Chapel differences between the goals of nursing and other
Hill and Associate Chief Nursing Officer for Aca- health disciplines, and to realize that caring for others as
demic Affairs at UNC Hospitals. Dr. Swanson con- they go through life transitions of health, illness, heal-
tinues her scholarship, which in recent years shifted ing, and dying was congruent with her personal values
to translational research and consulting with vari- (Swanson, 2001). Swanson chose Dr. Jean Watson as
ous organizations to enact the Theory of Caring in mentor during her doctoral studies. She attributes the
clinical practice, education, and research. Her ser- emphasis on exploring the concept of caring in her doc-
vice contributions include service on the editorial toral dissertation to Dr. Watson’s influence. However,
board or reviewer for Journal of Nursing Scholarship, despite the close working relationship and emphasis on
Nursing Outlook, Research in Nursing and Health,and caring in Swanson’s dissertation, Swanson’s program of
the International Journal of Human Caring. In recog- research on caring and miscarriage is not an application
nition of many outstanding contributions to the of Watson’s Theory of Human Caring (Watson, 1979,
nursing discipline, among other honors, Swanson 1988, 1999). Instead, both Swanson and Watson assert
was inducted as a fellow in the American Academy of that compatibility of findings on caring in their indi-
Nursing in 1991, received a Distinguished Alumnus vidual programs of research adds credibility to their
Award from the University of Rhode Island in 2002, theoretical assertions (Swanson, 2001). Swanson ac-
and was selected as a fellow for the Robert Wood knowledges Dr. Kathryn E. Barnard for encouraging
Johnson Foundation Nurse Executive Fellows pro- her transition from the interpretive to a contemporary
gram in 2004. empiricist paradigm and for transferring caring
knowledge from her phenomenological investigations
to intervention research and clinical practice with
women who have miscarried.
690 UNIT V Middle Range Nursing Theories
MAJOR CONCEPTS & DEFINITIONS comforting, performing skillfully and competently,
Caring and protecting the one cared for while preserving his
Caring is a nurturing way of relating to a valued or her dignity (Swanson, 1991).
other toward whom one feels a personal sense of
commitment and responsibility (Swanson, 1991). Enabling
Enablingis facilitating the other’s passage through
Knowing life transitions and unfamiliar events by focusing
Knowing is striving to understand the meaning of an on the event, informing, explaining, supporting,
event in the life of the other, avoiding assumptions, validating feelings, generating alternatives, think-
focusing on the person cared for, seeking cues, as- ing things through, and giving feedback (Swanson,
sessing meticulously, and engaging both the one 1991).
caring and the one cared for in the process of know-
ing (Swanson, 1991). Maintaining Belief
Maintaining belief is sustaining faith in the other’s
Being With capacity to get through an event or transition and
Being with means being emotionally present to the face a future with meaning, believing in other’s ca-
other. It includes being there in person, conveying pacity and holding him or her in high esteem,
availability, and sharing feelings without burdening maintaining a hope-filled attitude, offering realistic
the one cared for (Swanson, 1991). optimism, helping to find meaning, and standing
by the one cared for no matter what the situation
Doing For (Swanson, 1991).
Doing for means to do for others what one would do
for self if at all possible, including anticipating needs,
Use of Empirical Evidence mothers, fathers, physicians, and nurses who were
responsible for care of infants in the NICU. Hence,
Swanson formulated her Theory of Caring induc- she retained the wording that described the acts of
tively, as a result of several investigations. For her caring and proposed that all-inclusive care in a com-
doctoral dissertation, using descriptive phenomenol- plex environment embraces balance among caring
ogy, she analyzed data from in-depth interviews with (for the self and the one cared for), attaching (to oth-
20 women who had recently miscarried. As a result of ers and roles), managing responsibilities (assigned by
this phenomenological investigation, Swanson pro- self, others, and society), and avoiding bad outcomes
posed two models: (1) The Caring Model, and (2) The (Swanson, 1990).
Human Experience of Miscarriage Model. The Caring
Model proposed five basic processes (knowing, being In a subsequent phenomenological investigation
with, doing for, enabling, and maintaining belief) that conducted with socially at-risk mothers, Swanson
give meaning to acts labeled as caring (Swanson- (1991) explored what it had been like for these
Kauffman, 1985, 1986, 1988a, 1988b). This was foun- mothers to receive an intense, long-term nursing
dational for Swanson’s (1991) middle-range Theory of intervention. Swanson recalls that after this study
Caring. she was finally able to define caring and refine the
understanding of caring processes. Collectively,
While a postdoctoral fellow, Swanson conducted phenomenological inquiries with women who mis-
a phenomenological study, exploring what it was like carried, caregivers in the NICU, and socially at-risk
to be a provider of care to vulnerable infants in the mothers formed a basis for expansion of the Caring
neonatal intensive care unit (NICU). Swanson (1990) Model into the middle-range Theory of Caring
discovered that the caring processes she identified (Swanson, 1991, 1993).
with women who miscarried were also applicable to
Swanson tested her Theory of Caring with women CHAPTER 35 Kristen M. Swanson 691
who miscarried in investigations funded by the National • The fourth domain refers to actions of caring.
Institutes of Nursing Research and other funding • The fifth domain refers to the consequences or the
sources. Swanson’s (1999a, 1999b) intervention research
(N 5 242) examined the effects of caring-based coun- intentional and unintentional outcomes of caring
seling sessions on women coming to terms with loss for both the client and the provider (Swanson,
and emotional well-being during the first year after 1999c).
miscarrying. Additional aims were examination of the Conducting the literary metaanalysis clarified the
effects of passage of time on healing during that first meaning of the concept of caring as it is used in the
year and development of strategies to monitor caring nursing discipline and validated the transferability of
interventions. This study established that passing of Swanson’s middle-range Theory of Caring beyond
time had positive effects on women’s healing after mis- perinatal context.
carriage, however, caring interventions had a positive Subsequently, Swanson authored or coauthored
impact on decreasing the overall disturbed mood, an- numerous scholarly articles and book chapters on
ger, and level of depression. The second aim was to application of caring-healing relationships in clinical
monitor the caring variable and determine if caring was practice and education or tested the theory of caring.
delivered as intended. To do so, caring was monitored Swanson coauthored an article on nursing’s historical
in the following three ways: legacy as a caring—healing profession, and the mean-
1. Approximately 10% of counseling sessions were ing, significance, and consequences of optimal healing
environments for modern nursing practice, education,
transcribed and data were analyzed using inductive and research (Swanson & Wojnar, 2004).
and deductive content analysis. The article presented the core foci of nursing as a
2. Before each caring session, the counselor com- discipline: what it means to be a person and experi-
pleted McNair, Lorr, and Droppleman’s (1981) ence personhood; the meaning of health at the indi-
Profile of Mood States to monitor whether the vidual, family, and societal levels; how environments
counselor’s mood was associated with women’s create or diminish the potential for the promotion,
ratings of caring after each session, using an inves- maintenance, or restoration of well-being; and the
tigator-developed Caring Professional Scale. caring-healing therapeutics of nursing. A book
3. After each session, the counselor completed an chapter followed toenhance nurses’ capacity for com-
investigator-developed Counselor Rating Scale and passionate caring (Swanson, 2007). In it, Swanson
took narrative notes about her own counseling. explored how caring matters to well-being of every
The most noteworthy finding of monitoring caring person and described conditions that impact quality
was that clients were highly satisfied with caring re- of nurse caring ranging from the interpersonal rela-
ceived during counseling sessions, suggesting caring tionships through physical environments, to execu-
was delivered and received as intended. tive/managerial leadership. Swanson’s coauthored
Swanson’s (1999c) subsequent investigation was a works focused on social and economic factors that
literary metaanalysis on caring. An in-depth review of affect nursing shortage and quality of care (Grant &
130 investigations on caring led Swanson to propose Swanson, 2006) and consumer satisfaction with
that knowledge about caring may be categorized into health care (Mowinski-Jennings, Heiner, Loan, et al.,
five hierarchical domains (levels), and research con- 2005). Swanson and colleagues also explored comple-
ducted in any one domain assumes the presence of all mentary and alternative medicine (CAM) attitudes
previous domains (Swanson, 1999c). and competencies of nursing students and faculty and
• The first domain refers to the persons’ capacities to the results of integrating CAM into the nursing cur-
deliver caring. riculum as a holistic approach to nursing (Booth-
• The second domain refers to individuals’ concerns Laforce, Scott, Heitkemper, et al., 2010).
and commitments that lead to caring actions. In her own program of research, Swanson tested
• The third domain refers to the conditions (nurse, the usability of the Theory of Caring. In 2003, Swanson
client, organizational) that enhance or diminish and colleagues published results from an investiga-
the likelihood of delivering caring. tion on the miscarriage effects on interpersonal and
sexual relationships during the first year after loss
692 UNIT V Middle Range Nursing Theories Researchers concluded that applying the Theory of
from women’s perspective and investigated the context Caring in clinical practice is an effective strategy to
and evolution of women’s responses to miscarriage promote healing after unexpected pregnancy loss for
during the first year after loss (Swanson, Connor, women and men as individuals and as couples.
Jolley, et al., 2007). In 2009, Swanson and her
research team published results of a funded inter- Swanson continues to contribute to research of
vention study called Couples Miscarriage Healing other scholars. In 2006, Wojnar and Swanson ex-
Project. The purpose was to better understand the plored why lesbian mothers should deserve special
effects of miscarriage on men and women as indi- consideration when it comes to healing after miscar-
viduals and as couples, to explore the effects of mis- riage. As a result, Wojnar, Swanson, and Adolfsson
carriage on couple relationships, and to identify best (2011) offered a revised conceptual model of miscar-
ways of helping men and women heal as individuals riage inclusive of lesbian population for clinical
and as couples after unexpected pregnancy loss. practice and research. Swanson coauthored findings
Study participants (341 heterosexual couples) were from an investigation that explored soldiers’ experi-
randomly assigned to control or one of the follow- ences with military health care (Jennings, Loan,
ing three treatment groups: (1) nurse caring, which Heiner, et al., 2005). Findings suggest that quality of
entailed attending three counseling sessions with a care for soldiers is improved by narrowing the gap
nurse, (2) self-caring, which involved completing between what is offered for them as consumers and
three videos and workbooks, or (3) combined caring, what they experience when they seek care. Most
which involved attending one nurse caring session recently, Swanson coauthored results from a study
and completion of three videos and workbooks, that explored the experiences of parents following
to determine the most effective way of supporting moderate to severe traumatic brain injury of their
couples after miscarriage. Interventions, based on child (Roscigno & Swanson, 2011) as well as the
Swanson’s Theory of Caring and Meaning of Miscar- quality of life for children following traumatic brain
riage Model, were offered at 1, 5, and 11 weeks after injury (Roscigno, Swanson, Solchany, et al., 2011),
enrollment. Outcomes included depression (CES-D) where participants described health and cultural
and grief, pure grief (PG), and grief-related emo- barriers leading to misunderstandings that could be
tions (GRE). Differences in rates of recovery were easily avoided.
estimated via multilevel modeling conducted in a
Bayesian framework. Bayesian odds (BO) ranging Swanson’s Theory of Caring has been validated for
from 3.0 to 7.9 showed that nurse caring was most a wide range of usage in research, education, and
effective for accelerating women’s resolution of de- clinical practice.
pression. BO of 3.2 to 6.6 favored nurse caring inter-
vention and no treatment over self, and combined Major Assumptions
caring for resolving men’s depression. BO of 3.1 to
7.0 favored all three interventions over no treatment In 1993, Swanson further developed her theory of
for accelerating women’s grief resolution, and BO of informed caring by making her major assumptions
18.7 to 22.6 favored nurse caring and combined car- explicit about the four main phenomena of concern
ing over self-caring or no treatment for resolving to the nursing discipline: nursing, person/client, health,
men’s grief. BO ranging from 2.4 to 6.1 favored and environment.
nurse-caring and self caring over combined caring Nursing
or no treatment for promoting women’s resolution of Swanson (1991, 1993) defines nursing as informed
grief-related emotions. BO from 3.5 to 17.9 favored caring for the well-being of others. She asserts that the
nurse caring, combined caring, and control over nursing discipline is informed by empirical knowledge
self-caring for resolving men’s grief emotions. Nurse- from nursing and other related disciplines, as well as
caring had the overall most positive impact on cou- “ethical, personal and aesthetic knowledge derived
ples’ resolution of grief and depression. In addition, from the humanities, clinical experience, and personal
grief resolution was accelerated by self-caring for and societal values and expectations” (Swanson, 1993,
women and combined caring intervention for men. p. 352).
Person CHAPTER 35 Kristen M. Swanson 693
Swanson (1993) defines persons as “unique beings
who are in the midst of becoming and whose whole- creativity, relatedness, femininity, masculinity,
ness is made manifest in thoughts, feelings, and be- and sexuality, to name just a few” (p. 353).
haviors” (p. 352). She posits that the life experiences of
each individual are influenced by a complex interplay Thus, Swanson sees reestablishing well-being as a
of “a genetic heritage, spiritual endowment and the complex process of curing and healing that includes
capacity to exercise free will” (Swanson, 1993, p. 352). “releasing inner pain, establishing new meanings, re-
Hence, persons both shape and are shaped by the storing integration, and emerging into a sense of re-
environment in which they live. newed wholeness” (Swanson, 1993, p. 353).
Environment
Swanson (1993) views persons as dynamic, grow- Swanson (1993) defines environment by situation. She
ing, self-reflecting, yearning to be connected with maintains that for nursing it is “any context that influ-
others, and spiritual beings. She suggests the follow- ences or is influenced by the designated client” (p. 353).
ing: “ . . . spiritual endowment connects each being to Swanson states that there are many kinds of influences
an eternal and universal source of goodness, mystery, on environment, such as the cultural, social, biophysi-
life, creativity, and serenity. The spiritual endowment cal, political, and economic realms, to name only a few.
may be a soul, higher power/Holy Spirit, positive According to Swanson (1993), the terms environment
energy, or, simply grace. Free will equates with choice and person-client in nursing may be viewed inter-
and the capacity to decide how to act when confronted changeably. For example, Swanson posits, “for heuristic
with a range of possibilities” (p. 352). Swanson (1993) purposes the lens on environment/designated client
noted, however, that limitations set by race, class, may be specified to the intra-individual level, wherein
gender, or access to care might prevent individuals the ‘client’ may be at the cellular level and the environ-
from exercising free will. Hence, acknowledging ment may be the organs, tissues or body of which the
free will mandates nursing discipline to honor indi- cell is a component” (p. 353). Therefore, what is consid-
viduality and consider a whole range of possibilities ered an environment in one situation may be consid-
that are acceptable or desirable to those whom the ered a client in another.
nurses attend.
Theoretical Assertions
Moreover, Swanson posits that the other, whose
personhood nursing discipline serves, refers to fam- Swanson’s Theory of Caring (Swanson, 1991, 1993,
ilies, groups, and societies. Thus, with this under- 1999b) was empirically derived through phenomeno-
standing of personhood, nurses are mandated to logical inquiry. It offers a clear explanation of what it
take on leadership roles in fighting for human rights, means for nurses to practice in a caring manner and
equal access to health care, and other humanitarian emphasizes that the goal of nursing is promotion of
causes. Lastly, when nurses think about the other to well-being. Swanson (1991) defines caring as “a nur-
whom they direct their caring, they also need to turing way of relating to a valued other toward whom
think of self and other nurses and their care as that one feels a personal sense of commitment and respon-
cared-for other. sibility” (p. 162).
Health According to Swanson, a fundamental and univer-
According to Swanson (1993), to experience health sal component of good nursing is caring for the
and well-being is: client’s biopsychosocial and spiritual well-being.
Swanson (1993) asserts that caring is grounded
“ . . . to live the subjective, meaning-filled experi- in maintenance of a basic belief in human beings,
ence of wholeness. Wholeness involves a sense of supported by knowing the client’s reality, conveyed
integration and becoming wherein all facets of by being emotionally and physically present, and
being are free to be expressed. The facets of being enacted by doing for and enabling the client. The car-
include the many selves that make us a human: ing processes overlap and may not exist in separation.
our spirituality, thoughts, feelings, intelligence, Each is an integral component of the overarching
694 UNIT V Middle Range Nursing Theories
The Structure of Caring
Maintaining Knowing Being Doing Enabling ( )Client
belief with for well-
being
Philosophical attitudes Informed understanding Message Therapeutic Intended
towards persons (in of the clinical condition (in conveyed actions outcome
general) and the desig- general) and the situation to client
nated client (in specific) and client (in specific)
FIGURE 35-1 The structure of caring as linked to the nurse’s philosophical attitude, informed under-
standings, message conveyed, therapeutic actions, and intended outcome. (From Swanson, K. M. [1993].
Nursing as informed caring for the well-being of others. Image: The Journal of Nursing Scholarship, 25[4],
352–357.)
structure of caring (Figure 35–1). Swanson (1993) who received long-term care from master’s-prepared
has noted that the repertoire of caring therapeutics nurses. Swanson claims that her in-depth meta-
of novice nurses might be limited and restricted by analysis of research on caring has supported the
inexperience. Conversely, the techniques and knowl- generality of her theory beyond a perinatal context
edge imbedded in caring of experienced nurses are (Swanson, 1999c).
elaborate and subtle, so caring might go unnoticed
by an uninformed observer. Yet, Swanson (1993) Acceptance by the Nursing Community
asserts that, regardless of the years of nursing experi- Practice
ence, caring is delivered as a set of sequential pro-
cesses (subconcepts) created by the nurse’s own The usefulness of Swanson’s Theory of Caring has
philosophical attitude (maintaining belief), under- been demonstrated in research, education, and clini-
standing (knowing), verbal and nonverbal messages cal practice. The proposition that caring is central to
conveyed to the client (being with), therapeutic ac- nursing practice had its beginning in the theorist’s
tions (doing for and enabling), and the consequences own insights into the importance of caring in profes-
of caring (intended client outcome). sional nursing practice and in findings from Swanson’s
phenomenological investigations. Her subsequent in-
Logical Form vestigations demonstrated applicability of the Theory
of Caring in clinical nursing practice, education, and
Swanson’s middle-range Theory of Caring was devel- research. Swanson’s theory has been embraced as a
oped empirically using an inductive approach. Chinn framework for professional nursing practice in the
and Kramer (2011) note, “With induction people United States, Canada, and Sweden. An example is the
induce hypotheses and relationships by observing or Dalhousie University School of Nursing in Halifax,
experiencing an empiric reality and reaching some Nova Scotia, Canada, which selected Swanson’s
conclusion” (p. 182). Swanson’s theory was generated Theory of Caring to guide the development of future
from phenomenological investigations with women generations of nurses as caring professionals. Likewise,
who experienced unexpected pregnancy loss, caregiv- nurses at IWK (Isaac Walton Killam) Health Centre,
ers of premature and ill babies in the newborn inten- a tertiary care hospital for women, children, and
sive care unit (NICU), and socially at-risk mothers families in Halifax, Nova Scotia, have recognized the
traditional legacy of nursing as a caring-healing CHAPTER 35 Kristen M. Swanson 695
discipline and the concepts in Swanson’s theory
as applicable in practice. Since 1998, the Nursing who have experienced unexpected pregnancy loss.
Practice Council at IWK used Swanson’s Theory of Recent review of computerized databases (MEDLINE,
Caring as their framework for professional nursing CINHAL, and Digital Dissertations) indicated that
practice. Swanson’s work on caring and miscarriage has been
cited or otherwise utilized in over 160 data-based pub-
Nurse caring is manifested in different ways and lications. Examples of applications of Swanson’s The-
practice contexts. For example, in a postpartum con- ory of Caring in clinical research include exploring
text, demonstration of a baby bath to new parents clinical scholarship in practice (Kish & Holder, 1996);
incorporates all five caring processes. The act involves guidelines for nurses working with patients diagnosed
being with by demonstrating bathing the newborn to with multiple sclerosis (Yorkston, Klasner, & Swanson,
the parents. The unrushed timing of the bath so the 2001); assessing the impact of caring in work with
infant is awake and parents are present conveys will- vulnerable populations (Kavanaugh, Moro, Savage,
ingness (doing for or enabling); and the observing, et al., 2006); the importance of creating a caring envi-
querying, and involving parents in the task engages ronment for older adults (Sikma, 2006); Wojnar’s (2007)
them in their own infant’s care (intended outcome) study of lesbian couples who miscarried; and Roscigno’s
while acknowledging that they are perfectly capable research of children who sustained traumatic brain
of caring for their new child and that their preferences injury (Roscigno & Swanson, 2011; Roscigno, Swanson,
matter (knowing and maintaining belief). In carrying Solchany, et al., 2011).
out this seemingly simple act, the nurse creates an
optimal environment for learning that enables new Further Development
parents to make decisions about infant care, while
leveraging the task as an opportunity to engage in a Swanson is interested in further development by test-
meaningful social encounter and developing a trust- ing and applying her theory in clinical practice. There
ing relationship. is much potential for further development by testing
Swanson’s Theory of Caring in various contexts of
Education health and illness. Also, her processes of caring suggest
Humane and altruistic caring occurs when the theory that the theory is applicable in other helping disciplines
is used in various practice areas such as feeding or such as teaching, social work, and medicine as well as
grooming an incapacitated older adult, monitoring other life situations for nursing.
and managing the recovery of a patient who suffered
a stroke, or enhancing infant care skills of new par- Critique
ents. Nurse caring, as demonstrated by Swanson in Clarity
research with women who miscarried, caregivers in
the NICU, and socially at-risk mothers, recognizes The concept of caring and caring processes (knowing,
the importance for nurses to attend to the wholeness being with, doing for, enabling, and maintaining belief)
of humans in their everyday lives. Thus Swanson’s that are central to the theory are clearly defined and
theory offers nurse educators a simple way of initiat- arranged in a logical sequence that describes the pro-
ing students into the profession by immersing them cesses of caring delivery. Swanson’s theory offers clear
in the language of what it means to be caring and definitions and contextual linkages with the concepts
cared for in order to promote, restore, or maintain the of the nursing discipline (person, nurse, environment,
optimal wellness of individuals. and health) in nurse-client interactions, thus further
explicating the definitions.
Research Simplicity
Swanson has persisted in the development of her the- A simple theory has a minimal number of concepts.
ory, describing and defining the concept of caring and Swanson’s Theory of Caring is simple yet elegant. It
basic caring processes, instrument development, and brings the importance of caring to the forefront and
testing in intervention research with women and men exemplifies the discipline’s values. The main purpose
696 UNIT V Middle Range Nursing Theories beyond nurse-client encounters. Recent applications
in clinical nursing practice show tangible positive re-
of the theory is to foster delivery of nursing care fo- sults. For example, since coming to the UNC School
cused on the needs of the individuals while fostering of Nursing at Chapel Hill as Dean, Swanson has
their dignity, respect, and empowerment. Simplicity focused on intensifying the linkages among nursing
and consistent language used to define the concepts education, research, and practice. In partnership with
and processes allows students and nurses to under- Clinical Professor Dr. Mary Tonges, Chief Nursing
stand and apply Swanson’s theory in their practice. Officer and Senior Vice President for Patient Care
Services at UNC Hospital, Swanson has worked on
Generality strengthening the scholarship that supports nursing
Swanson’s Theory of Caring may be applied in re- practice and enhances the relevance of nursing educa-
search and clinical work with diverse populations. tion and research to clinical practice through quality
The conditions essential for delivering caring that improvement projects. This research partnership has
promotes individuals’ wholeness across the life span already resulted in positive outcomes on nursing
have been described clearly (Swanson, 1999c). Hence, workplace satisfaction and patient safety. Likewise,
the theory is generalizable to nurse-client relation- Swanson’s Theory of Caring has been applied in clini-
ships in many clinical settings. cal practice and evaluated on selected variables at
Virginia Mason Medical Center in Seattle, Washing-
Accessibility ton, resulting in positive outcomes for patients and
Swanson’s Theory of Caring concepts and assump- nurses.
tions are grounded in clinical nursing practice and
research using an empirical approach. The com- CASE STUDY
pleteness and simplicity of operational definitions 1 . The birth of a child is one of the most memo-
strengthen empirical precision of this theory. Swan-
son and others have successfully applied her theory rable experiences in a woman’s life. You are a
in numerous studies. Swanson and her research birth unit nurse, and at the change of a shift
team tested the Theory of Caring in a clinical trial you are assigned to care for a teen mother
with women and men who experienced miscar- who came to hospital alone and is now in
riage and demonstrated that caring intervention active labor. When you arrive in her room,
resulted in decreased depressive mood and facili- you notice that she is teary and appears
tated healthy grieving for both genders. Swanson frightened. Describe how you would apply
has published research guidelines with colleagues Swanson’s theory to connect emotionally and
for assessing the impact of caring healing relation- deliver caring in your practice with this
ships in clinical nursing (Quinn, Smith, Ritenbaugh, young mother.
et al., 2003) and developed self-report instruments 2. A 56 year old obese man presents in the out-
to measure caring as delivered by health care pro- patient clinic. He is experiencing polydipsia
fessionals and by couples to each other (Swanson, and polyuria for over a week. He also reports
2002). The template for delivering caring-based in- a weight loss of 5 kg in the past few weeks.
terventions and the research-based instruments He delayed his clinic visit for as long as
open possibilities for use and further testing with possible because he feared he may have
other populations. diabetes like his father and was afraid to face
the reality. You check his sugar level and it is
Importance 430. The man bursts into tears. Describe how
Swanson’s Theory of Caring describes nurse-client you would apply Swanson’s theory to help the
relationships that promote wholeness and healing. The client face the diagnosis of chronic disease,
theory offers a framework for enhancing contempo- cope with the disease process, and promote
rary nursing practice, education, and research while well-being?
bringing the discipline to its traditional values and
caring-healing roots. Swanson’s Theory of Caring has
been applied to interdisciplinary caring relationships
CRITICAL THINKING ACTIVITIES CHAPTER 35 Kristen M. Swanson 697
1 . Consider Swanson’s Theory of Caring as a frame- 3 . Think about an interaction with a client-family
work for your own nursing practice and research. in your clinical practice that you wish you could
How is it applicable? change or improve. Use the processes of the
Theory of Caring to critically assess about where
2. Think about a time when you felt that someone you might have made more appropriate actions. If
cared about you deeply. Remember what it felt like it were possible to improve this interaction, what
to experience caring. Now reflect on that experi- would you change and why?
ence and review your experience in the context of
the processes of caring in Swanson’s theory. nursing research (pp. 31–60). Thousand Oaks, (CA):
Sage.
POINTS FOR FURTHER STUDY n Swanson, K. M., & Wojnar, D. (2004). Optimal
healing environments in nursing. Journal of
n Swanson, K. M. (1998). Caring made visible. Alternative and Complementary Medicine,
Creative Nursing, 4(4), 8–11, 16. 10(1), 43–48.
n Swanson, K. M., Chen, H. T., Graham, J. C.,
n Swanson, K. M. (1999a). Research-based practice Wojnar, D. M., & Petras, A. (2009). Resolution
with women who have had miscarriages. Image: of depression and grief during the first year after
The Journal of Nursing Scholarship, 31(4), miscarriage: A randomized controlled clinical
339–345. trial of couples-focused interventions. Journal
of Women’s Health and Gender-based Medicine,
n Swanson, K. M. (1999b). The effects of caring, 18(8), 1245–1257.
measurement, and time on miscarriage impact
and women’s well-being in the first year subse- Kish, C. P., & Holder, L. M. (1996). Helping to say good-
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36C H A P T E R
Cornelia M. Ruland Shirley M. Moore
1954 to present 1948 to present
Peaceful End-of-Life Theory
Patricia A. Higgins and Dana M. Hansen
“Standards of care offer a promising approach for the development of middle-range
prescriptive theories because of their empirical base in clinical practice
and their focus on linkages between interventions and outcomes”
(Ruland & Moore, 1998, p. 169).
Credentials and Background evaluation of information systems to support it. She
of the Theorists focuses on aspects of and tools for shared decision
making in clinically challenging situations: (1) for pa-
Cornelia M. Ruland tients confronted with difficult treatment or screening
Cornelia M. Ruland received her Ph.D. in nursing in decisions for which they need help to understand the
1998 from Case Western Reserve University in potential benefits and harms of alternative options and
Cleveland, Ohio. She is Director of the Center for to elicit their values and preferences, and (2) prefer-
Shared Decision Making and Nursing Research at ence-adjusted management of chronic or serious long-
Rikshospitalet University Hospital in Oslo, Norway, term illness over time. As primary investigator on a
and holds an adjunct faculty appointment in the number of research projects, she has received awards
Department of Biomedical Informatics at Columbia for her work.
University in New York. Ruland has established a
research program on improving shared decision Shirley M. Moore
making and patient-provider partnerships in health Shirley M. Moore is Associate Dean for Research and
care, and the development, implementation, and Professor, School of Nursing, Case Western Reserve
The authors wish to express their appreciation to Cornelia Ruland and Shirley Moore for their contributions to the chapter.
701
702 UNIT V Middle Range Nursing Theories philosophers to explain and define quality of life
University. She received her diploma in nursing from (Sandoe, 1999), a concept that is significant in end-
the Youngstown Hospital Association School of Nurs- of-life research and practice. In preference theory,
ing (1969) and her bachelor’s degree in nursing from the good life is defined as getting what one wants, an
Kent State University (1974). She earned a master’s approach that seems particularly appropriate in end-
degree in psychiatric and mental health nursing of-life care. It can be applied to both sentient per-
(1990) as well as a Ph.D. in nursing science (1993) at sons and incapacitated persons who have previously
Case Western Reserve University. She has taught provided documentation related to end-of-life deci-
nursing theory and nursing science to all levels of sion making. Quality of life, therefore, is defined and
nursing students and conducts a program of research evaluated as a manifestation of satisfaction through
and theory development that addresses recovery after empirical assessment of such outcomes as symptom
cardiac events. Early in her doctoral study, Moore was relief and satisfaction with interpersonal relation-
encouraged by nurse theorists Joyce J. Fitzpatrick, ships. Incorporating patient preferences into health
Jean Johnson, and Elizabeth Lenz to not only use care decisions is considered appropriate (Ruland &
theory but to develop it as well. The Rosemary Ellis Bakken, 2001; Ruland, Kresevic, & Lorensen, 1997)
Theory Conference, held annually for several years at and necessary for successful processes and outcomes
Case Western Reserve University, offered Moore an (Ruland & Moore, 2001).
opportunity to explore theory as a practical tool for
practitioners, researchers, and teachers. Influenced This theory was derived in a doctoral theory course
by these experiences, Moore has assisted in the devel- in which Ruland was a student and Moore was fac-
opment and publication of several theories (Good ulty. Middle-range theories were just emerging, and
& Moore, 1996; Huth & Moore, 1998; Ruland & there were few good definitions or examples. The class
Moore, 1998). Moore considers theory construction was challenged to think about the future use and de-
an essential skill for doctoral students. velopment of middle range theory for nursing science
and practice. The students discussed knowledge
Theoretical Sources sources from which they could derive middle range
theory, such as empirical knowledge, clinical practice
The Peaceful End-of-Life Theory is informed by a knowledge, and synthesized knowledge. Each student
number of theoretical frameworks (Ruland & Moore, was asked to derive a middle range theory from a
1998). It is based primarily on Donabedian’s model of knowledge source of choice. Ruland had just com-
structure, process, and outcomes, which in part was pleted a major project to develop a clinical practice
developed from general system theory. General sys- standard for peaceful end of life with a group of can-
tem theory is pervasive in other types of nursing cer nurses in Norway. The standard was synthesized
theory, from conceptual models to middle-range and into the theory of peaceful end of life by Ruland
micro-range theories—an indicator of its usefulness and later was refined with Moore’s assistance. This
in explaining the complexity of health care interac- is an example of middle range theory developed by
tions and organizations. In the Peaceful End-of-Life doctoral nursing students as they study knowledge
Theory, the structure-setting is the family system development methods. This theory is also an example
(terminally ill patient and all significant others) that of middle range theory development using a standard
is receiving care from professionals on an acute care of practice as a source.
hospital unit, and process is defined as those actions
(nursing interventions) designed to promote the Use of Empirical Evidence
positive outcomes of the following: (1) being free
from pain, (2) experiencing comfort, (3) experienc- The Peaceful End-of-Life Theory is based on empiri-
ing dignity and respect, (4) being at peace, and cal evidence from direct experience of expert nurses
(5) experiencing a closeness to significant others and review of the literature addressing components of
and those who care. the theory. The group of expert practitioners who
developed the standard of care for peaceful end of life
A second theoretical underpinning is preference had at least 5 years of clinical experience caring for
theory (Brandt, 1979), which has been used by
CHAPTER 36 Cornelia M. Ruland and Shirley M. Moore 703
MAJOR CONCEPTS & DEFINITIONS can be derived from these relational statements to be
Not Being in Pain tested their usefulness. The authors of the standard
Being free of the suffering or symptom distress is the of care and authors of the theory attempted to incor-
central part of many patients’ end-of-life experience. porate clearly described, observable concepts and
Pain is considered an unpleasant sensory or emo- relationships that expressed the notion of caring.
tional experience associated with actual or potential
tissue damage (Lenz, Suppe, Gift, et al., 1995; Pain Major Assumptions
terms, 1979). Nursing, Person, Health and Environment
Experience of Comfort As in other middle-range theories the focus of the
Comfort is defined inclusively, using Kolcaba and theory of peaceful end of life does not address each
Kolcaba’s (1991) work as “relief from discomfort, metaparadigm concept. The theory was derived from
the state of ease and peaceful contentment, and standards of care written by a team of expert nurses
whatever makes life easy or pleasurable” (Ruland who were addressing a practice problem, therefore,
& Moore, 1998, p. 172). the metaparadigm concepts explicitly addressed were
nursing and person. The theory addresses the nursing
Experience of Dignity and Respect phenomena of complex, holistic care to support per-
Each terminally ill patient is “respected and valued sons’ peaceful end of life.
as a human being” (Ruland & Moore, 1998, p. 172).
This concept incorporates the idea of personal Two assumptions of Ruland and Moore’s (1998)
worth, as expressed by the ethical principle of theory are identified as follows:
autonomy or respect for persons, which states that 1 . The occurrences and feelings at the end-of-life
individuals should be treated as autonomous
agents, and persons with diminished autonomy are experience are personal and individualized.
entitled to protection (United States, 1978). 2 . Nursing care is crucial for creating a peaceful end-
Being at Peace of-life experience. Nurses assess and interpret cues
Peace is a “feeling of calmness, harmony, and con- that reflect the person’s end-of-life experience and
tentment, (free of) anxiety, restlessness, worries, intervene appropriately to attain or maintain a
and fear” (Ruland & Moore, 1998, p. 172). A peaceful experience, even when the dying person
peaceful state includes physical, psychological, and cannot communicate verbally.
spiritual dimensions. Two additional assumptions are implicit:
1. Family, a term that includes all significant others,
Closeness to Significant Others is an important part of end-of-life care.
Closeness is “the feeling of connectedness to other 2. The goal of end-of-life care is not to optimize care,
human beings who care” (Ruland & Moore, 1998, in the sense that it must be the best, most techno-
p. 172). It involves a physical or emotional near- logically advanced treatment, a type of care that
ness that is expressed through warm, intimate frequently results in overtreatment. Rather, the
relationships. goal in end-of-life care is to maximize treatment,
that is, the best possible care will be provided
through the judicious use of technology and com-
fort measures, in order to enhance quality of life
and achieve a peaceful death.
terminally ill patients. The standard of care consisted Theoretical Assertions
of best practices based on research-derived evidence
in the areas of pain management, comfort, nutrition, Six explicit relational statements were identified
and relaxation. This prescriptive theory comprises (Ruland and Moore, 1998) as theoretical assertions
several proposed relational statements for which for the theory, as follows:
more empirical evidence is needed. Explicit hypotheses 1. Monitoring and administering pain relief and
applying pharmacologic and nonpharmacologic
704 UNIT V Middle Range Nursing Theories care was an interim step that effectively linked clinical
interventions contribute to the patient’s experience practice and theory.
of not being in pain.
Ruland and Moore (2001) detailed the steps they
2 . Preventing, monitoring, and relieving physical dis- followed in the development of the standard for
comfort, facilitating rest, relaxation, and content- peaceful end of life, which included review of relevant
ment, and preventing complications contribute to literature, clarification of important concepts, and
the patient’s experience of comfort. incorporation of clinical practice knowledge. Each
step is analogous to those used in theory develop-
3 . Including the patient and significant others in de- ment. Thus, the logic for the development of this
cision making regarding patient care, treating the theory is straightforward, and the process used is
patient with dignity, empathy and respect, and clearly stated.
being attentive to the patient’s expressed needs,
wishes, and preferences contribute to the patient’s Acceptance by the Nursing Community
experience of dignity and respect. Practice
4 . Providing emotional support, monitoring and A small but growing number of articles cite the Peace-
meeting the patient’s expressed needs for anti- ful End-of-Life Theory. It is included on the Clayton
anxiety medications, inspiring trust, providing the State University School of Nursing Theory Link page
patient and significant others with guidance in with a link to American Journal of Critical Care,
practical issues, and providing physical presence of End-of-Life Care (Kirchhoff, Spuhler, Walker, et al.,
another caring person if desired contribute to the 2000). Liehr and Smith (1999) refer to the theory’s
patient’s experience of being at peace. development of a practice standard as a foundation
for developing theory, Kehl (2006) cites it in her con-
5. Facilitating participation of significant others in cept analysis of a “good death,” and Baggs and Schmitt
patient care; attending to significant others’ grief, (2000) discuss the potential usefulness of the theory
worries, and questions; and facilitating opportuni- as a means to improve end-of-life decision making
ties for family closeness contribute to the patient’s for critically ill adults. Kirchoff (2002) continued
experience of closeness to significant others or the discussion on creating an environment of care
persons who care. in the intensive care unit that promotes a peaceful
death by synthesizing information from three sources
6. The patient’s experiences of not being in pain, (the Peaceful End-of-Life Theory [Ruland & Moore,
comfort, dignity, and respect, being at peace, and 1998], the Institute of Medicine’s definition of peace-
closeness to significant others or persons who care ful death [Field & Cassell, 1997], and precepts from
contribute to the peaceful end of life (p. 174). the American Association Colleges of Nursing’s
“Peaceful Death: Recommended Competencies and
Logical Form Curricular Guidelines for End of Life Nursing Care,”
1997). The Peaceful End-of-Life Theory was one of
The Peaceful End-of-Life Theory was developed using the theories used to develop a model for holistic
inductive and deductive logic. A unique feature of the palliative care for sickle cell patients (Wilkie, Johnson,
theory is its development from a standard of care. The Mack, et al., 2010). In Taiwan, Lee and colleagues
peaceful end-of-life standard was created by expert (2009) cite Peaceful End-of-Life Theory as important
nurses in response to a lack of direction for managing to establish a framework to identify the major barriers
the complex care of terminally ill patients. The stan- of good end-of-life care in an ICU.
dard was developed for the surgical gastroenterologi-
cal care unit in a university hospital in Norway. Thus, Education
the standard served as a logical intermediary step Peaceful end of life has been integrated into nursing
linking practice and theory. Standards of care serve courses for generations with a focus on care of the
as credible, authoritative statements that describe patient and family. End-of-life content has become
a practitioner’s roles and responsibilities and an
expected performance level of nursing care by which
the quality of practice can be evaluated (American
Association of Critical Care Nurses, 1998). In this
instance of knowledge development, the standard of
CHAPTER 36 Cornelia M. Ruland and Shirley M. Moore 705
more standardized in the form of theory, competen- and relieving physical discomfort) and the peace pro-
cies, and curricular guidelines. Ruland and Moore cess criterion (monitoring and meeting patient’s
(1998) are an example of an early end-of-life theory as needs for antianxiety medication). Nonpharmaco-
attention to hospice and palliative care has developed. logical interventions (e.g., music, humor, relaxation)
Ruland and Moore (1998) were cited by Kirchoff and that serve to distract a dying patient are useful for
colleagues (2000) when End of Life was a featured the relief of pain, anxiety, and general physical
topic of a CE (continuing education) offering for discomfort. Future studies are suggested to explore
critical care nurses in their online journal. linkages of the Peaceful End-of-Life Theory to other
Research middle-range theories such as one for acute pain
The Peaceful End-of-Life Theory has gained interna- based on practice guidelines (Good and Moore,
tional recognition as containing key components of a 1996), pain management (Good, 1998), and unpleas-
peaceful death. Kongsuwan and colleagues created a ant symptoms (Lenz, Pugh, Milligan, et al., 1997;
conceptual model (Kongsuwan & Touhy, 2009) and Lenz, Suppe, Gift, et al., 1995).
conducted qualitative (Kongsuwan & Locsin, 2009)
and quantitative research (Kongsuwan, Keller, Touhy Critique
et al., 2010) on peaceful death in adult patients in Clarity
Thailand. Ruland and Moore’s (1998) Peaceful End-
of-Life Theory served as a comparison model for All elements of the theory are stated clearly, including
Kongsuwan and colleagues’ work and was cited as the setting, assumptions, concepts, and relational
possessing qualities essential for a peaceful death that statements. These concepts vary considerably in their
have been identified in many cultures. level of abstraction, from more concrete (pain and
comfort) to more abstract (dignity).
In Quebec, an ethnographic study was conducted
to identify key components of a good death for rural Simplicity
residents, and the authors identified The Peaceful Despite uncomplicated terms and clear expression of
End-of-Life Theory as important to developing an ideas, the theory has been described as one of a
understanding of the concept of a good death (Wilkie, higher-level middle-range theories (Higgins & Moore,
Johnson, Mack, et al., 2010). 2000), primarily because of the level of abstraction
of the outcome criteria and the multidimensional
Further Development complexity expressed in its relational statements.
Ruland and Moore acknowledge the need for contin- Generality
ued refinement and development of the theory. There The Peaceful End-of-Life Theory has specific bound-
are a number of potential ideas to advance its devel- aries related to time, setting, and patient population.
opment, and testing the theory is in the planning It was developed for use with terminally ill adults and
stage; for example, testing the relationships among their families who are receiving care in an acute care
the five major concepts is a possibility. Another idea setting. The concept of peaceful end of life came from
is merging some of the process criteria from the three a Norwegian context and may not be appropriate for
concepts of pain, comfort, and peace to explore out- all cultures; however it has been noted for practice by
comes related to physical-psychological symptom nurses in other cultures. Its concepts and relation-
management. Concept analysis or mapping could be ships resonate with many nurses, and it comprehen-
used to determine if the process criteria associated sively addresses the multidimensional aspects of
with the three concepts are different or sufficiently end-of-life care. For example, the outcome indicators
alike to allow merging. For the concept of pain, two associated with the five concepts address the techni-
process criteria (monitoring and administering pain cal aspect of care (providing both pharmacological
relief and applying pharmacological and nonpharma- and nonpharmacological interventions for the relief
cological interventions) are closely related to the of symptoms), communication (decision making),
comfort process criterion (preventing, monitoring, the psychological aspect (emotional support), and
706 UNIT V Middle Range Nursing Theories identified need for a comprehensive middle-range
theory to guide care of patients in the end-of-life
dignity and respect (treating the patient with dignity, experience, Ruland and Moore’s (2001) work clearly
empathy, and respect) (Figure 36–1). illustrates the richness of practice and standards as a
Accessibility source for the development of theory.
The deductive and inductive logic used to develop this
theory provides a solid basis for developing testable All of the outcome indicators are measurable, us-
hypotheses among the five concepts of the theory. ing qualitative, quantitative or both methodology
Theoretical congruency is demonstrated through the (see Figure 36–1). Unlike some middle-range theories
outcome indicators, all of which are conceptualized that have a specific instrument to measure a particu-
from the perspective of the patients and their families. lar concept, no instrument has been developed for
Importance Peaceful End-of-Life Theory. For future studies
As a successful synthesis of clinical practice and among the five concepts, instruments need to be
scholarly theory development, the Peaceful End-of- identified to measure hypothesized relationships.
Life Theory illustrates a way to bridge the theory- Mixed methods (Tashakkori & Teddlie, 2003) was
practice-research continuum. Besides addressing an described as an appropriate approach for investigat-
ing the concepts. For example, a phenomenological
Peaceful End of Life
Not being Experience of Experience of Being at peace Closeness to
in pain comfort dignity/respect significant others/
persons who care
Monitoring and Preventing, Including patient Providing Facilitating participation
administering monitoring, and and significant emotional support of significant others
relieving physical in patient care
pain relief others in Monitoring and
Applying discomfort decision making meeting patient’s Attending to significant
pharmacological Facilitating rest, Treating patient others’ grief, worries
and nonpharma- relaxation, and needs for and, questions
cological with dignity, antianxiety Facilitating
interventions contentment empathy, and medications opportunities for
Preventing Inspiring trust family closeness
complications respect Providing patient/
Being attentive significant others
with guidance
to patient’s in practical issues
expressed needs,
wishes, and
preferences
Providing physical
assistance of
another caring
person, if desired
FIGURE 36-1 Relationships among the concepts of the Peaceful End-of-Life Theory. (From Ruland, C. M.,
& Moore, S. M. [1998]. Theory construction based on standards of care: A proposed theory of the peaceful
end of life. Nursing Outlook, 46[4], 174.)
CHAPTER 36 Cornelia M. Ruland and Shirley M. Moore 707
approach could be used to investigate patient and breathing, even though her mother has a Do Not
family perceptions of their opportunities for and sat- Resuscitate (DNR) order.
isfaction with family closeness, decision making, or
both. Also with attention to linkages, a number of The physician has ordered home hospice care.
existing instruments could be considered to measure The daughter greets the social worker and nurse at
outcome indicators associated with the five concepts the door and insists the word hospice is not men-
(see Figure 36–1) such as perception of symptoms tioned to her mother, as it would “kill” her. During
with the Memorial Symptom Assessment Scale the hospice admission, it became clear that Becky
(Portenoy, Thaler, Kornblith, et al., 1994) or the Gen- understands she is dying and sees how much her
eral Comfort Questionnaire (Kolcaba, 2003). children are grieving over the thought of losing
another parent. After several weeks on the hospice
CASE STUDY program, Becky continues to report discomfort,
Becky is a 66-year-old woman who was diag- high pain levels, shortness of breath, and difficulty
nosed with stage IV congestive heart failure in communicating with her children about her
(CHF). She is recently widowed (approximately wishes. She is not ready to say good-bye to her
6 months ago) and the mother of four devoted children or grandchildren and is afraid to die.
young adult children and the grandmother of
two. Her youngest daughter (Sue) lives with her Despite prescribed medication and team-focused
mother and is a student at a local University. Sue care (social worker, nurse, nursing assistant, and
has taken leave from the University to care for clergy), Becky continues to rate her pain level at
her mother. Becky has completed her advance severe (8 to 10) and talks about her suffering, fear of
directives, and is adamant that she not receive death, and concern over what will happen to her
extraordinary measures to sustain her life. This family when she is gone. During a team meeting, it
has been a difficult issue for her children, as they was decided to ask Becky to describe three different
cannot fathom the loss of another parent. Sue is kinds of pain (physical, emotional, and spiritual).
the durable power of attorney (DPOA) and states Becky had a physical pain rating of 3 to 4, and both
she will call 911 in the event her mother stops emotional and spiritual pains were rated as severe
(8 to 10). The adult children continue to ask about
treatments that are more aggressive; however, they
also state that they do not like to see her suffer.
CRITICAL THINKING ACTIVITIES to suffering (e.g., emotional, spiritual, and psy-
chological) in a case from your clinical practice?
The end of life is filled with complex physiological, In the case of Becky?
psychological, spiritual, and family relationship 2. Use the concepts of “closeness to significant others”
problems that affect the patient’s comfort and ability and “experience of dignity and respect” from the
to achieve peaceful end of life. In addition, unre- Peaceful End-of-Life Theory to assist you in devel-
solved issues in family relationships can lead to oping a nursing practice strategy to address the
complicated grieving for family members before relationship issues for Becky and her family.
and after the death. Suffering outside of physical 3. With the professional ethical standards for nursing
discomfort is not readily understood, but the relief practice (such as ANA), evaluate the correspon-
of suffering is a fundamental goal of end-of-life care dence with the “experience of dignity and respect”
and is necessary to achieve comfort and a peaceful in this theory. Discuss the similarity, difference,
end of life. relevance, significance, scope, usefulness, and
1 . Explore the Peaceful End-of-Life Theory in adequacy.
relation to your practice. How does it assist
you in identifying and addressing issues related
708 UNIT V Middle Range Nursing Theories nursing interventions? What limitations of the
4 . Describe how the concepts of the Peaceful End- theory did you find in these considerations?
5. Identify signs of anticipatory grieving that exist
of-Life Theory apply to patients with diagnoses for Becky and her family, and then describe use
other than congestive heart failure, such as of the Peaceful End-of-Life Theory to address
Alzheimer’s disease, amyotrophic lateral sclerosis these issues and how to achieve a peaceful end
(ALS), or chronic obstructive pulmonary disease of life.
(COPD). Does the theory help you identify issues
and develop, implement, and evaluate appropriate
POINTS FOR FURTHER STUDY care unit nurses’ perspective of a peaceful
death: An empirical study. International
n Higgins, P. A., & Moore, S. M. (2000). Levels of Journal of Palliative Nursing, 16(5), 241–247.
theoretical thinking in nursing. Nursing Outlook, n Ruland, C. M., & Moore, S. M. (1998). Theory
48(4), 179–183. construction based on standards of care: A pro-
posed theory of the peaceful end of life. Nursing
n Kirchoff, K. T. (2002). Promoting a peaceful death Outlook, 46(4), 169–175.
in the ICU. Critical Care Nursing Clinics of North
America, 14(2), 201–206.
n Kongsuwan, W., Keller, K., Touhy, T., &
Schoenhofer, S. (2010). Thai Buddhist intensive
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Baggs, J. G., & Schmitt, M. H. (2000). End-of-life decisions Kirchhoff, K. T., Spuhler, V., Walker, L., Hutton, A., Cole,
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directions for the future. Nursing Outlook, 48(4), 158–164. care nurses’ experiences with end-of-life care. American
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Beckstrand, R. L., Callister, L. C., & Kirchoff, K. T. (2006).
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Brandt, R. B. (1979). A theory of the good and the right. Kolcaba, K. Y., & Kolcaba, R. J. (1991). An analysis of the
Oxford: Clarendon Press. concept of comfort. Journal of Advanced Nursing,
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peaceful death: An empirical study. International Journal of
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and the strategy. International Journal of Gerontology, Ruland, C. M., & Moore, S. M. (1998). Theory construc-
3(1), 26–30. tion based on standards of care: A proposed theory
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VIUNIT
The Future of Nursing Theory
n Nursing theoretical systems actively give direction and create understanding
in practice, research, administration, and education.
n Theoretical works of a discipline address pertinent questions, offer frame-
works to answer the questions, and develop knowledgeable evidence for
practice.
n Nursing models and theories exhibit normal science, that is, global communi-
ties of scholars whose research and practice contribute scientific achievements.
n Expansion of the philosophy of nursing science, qualitative approaches, and
quantitative methods has greatly increased the development and use of middle
range theories in nursing research and practice.
n Internet communication continues to greatly expand global sharing among
professional communities of nurse scholars.
37C H A P T E R
State of the Art and Science
of Nursing Theory
Martha Raile Alligood
“Nursing theoretical knowledge has demonstrated powerful contributions to education,
research, administration and professional practice for guiding nursing thought and action.
That knowledge has shifted the primary focus of the nurse from nursing functions to the
person. Theoretical views of the person raise new questions, create new approaches and
instruments for nursing research, and expand nursing scholarship throughout the world.”
Alligood, M. R. (2011). Nursing Science Quarterly, 24(4), p. 304.
It becomes obvious from studying texts such as this integrity of each work and keeping the size of the text
one that understanding and use of nursing theoreti- workable. Unit I content was updated and restructured,
cal works is active and growing globally, pointing the and a new Chapter 4 was added on knowledge struc-
way to new knowledge through research, education, ture and the role of analysis in theory development.
administration, and practice applications. Reviews of
the seventh edition of this text by consumers identified Units II to VI were updated, and the uniform outline
by the publisher as well as published reviews in schol- of each chapter was maintained. The philosophies, nurs-
arly nursing journals recognize its contribution to ing models, and theories in Units II to IV address each
professional nursing. Suggestions that are given receive metaparadigm concept (person, environment, health,
careful consideration for each new edition (Dickson & and nursing). Since middle-range nursing theories
Wright, 2012; Smith, 2012; Paley, 2006). Smith (2012) (Unit V) are limited in scope and specific to practice, care
points out, “The text is significant in that it provides was given to clarifying this and specifying the metapara-
nursing students with an accurate and scholarly refer- digm concepts addressed. Rodgers (2005) notes that
ence to identify significant philosophies, models and “middle-range theories currently have the most emphasis
theories that are pertinent to their own nursing prac- in nursing” (p. 191). Similarly, Im & Chang (2012) con-
tice” (p. 201). Similarly, Dickson and Wright (2012) clude that “ . . . middle range [theory] will play an essen-
conclude, the text “simply and elegantly describes the tial role in nursing research . . . ” (p. 162).
great progress that nursing as a discipline and profes-
sion has accomplished guided by the vision of leading As in previous editions, the chapters in this eighth
nursing theorists. The scope and depth … may address edition are written by those who use the various theo-
the concerns and critics who argue nursing theory retical works in their professional practice and research.
is outdated or irrelevant to current practice and re- Nurses around the world are increasingly recognizing
search” (p. 204). In this eighth edition, effort was given the vital nature of theoretical works and applying them
to updating the chapters while maintaining clarity and to their practice, research, education, and administra-
712 tion (Alligood & Marriner Tomey, 1997, 2002, 2006;
Alligood & Tomey, 2010; Butts & Rich, 2011; George,
CHAPTER 37 State of the Art and Science of Nursing Theory 713
2011; Marriner, 1986; Marriner Tomey, 1989; Marriner theory continue to grow globally as formally organized
Tomey, 1994; Marriner Tomey & Alligood, 1998; 2002; societies that share knowledge and address questions
2006). from their research and practice on websites and in
newsletters and journals. Nursing models and theories
As indicated in Chapter 1, this eighth edition con- address the central concepts of the discipline: person,
tinues to clarify the relevance of nursing theoretical environment, health, and nursing, (Fawcett, 1984b).
works, facilitate their recognition as systematic dem-
onstrations of nursing substance, and inspire their use Nurses generate theory-based scholarship for re-
as frameworks for nursing scholarship in practice, search and practice. Work by the communities of schol-
research, education, and administration. Simply put, ars in the nursing models has led to the development of
the framing of an issue guides to the desired outcome. research instruments or clinical measurement tools
There are many different ways to survey the art and unique to that paradigm (Fawcett, 2005, 2009).
science of nursing theory. This chapter explores the
growth of nursing theory from three perspectives. Kuhn (1970) stated, “Paradigms gain their status by
being more successful than their competitors in solving
First, as noted in Chapter 2, the philosophy of sci- a few problems that the group of practitioners have
ence continues to open new ways of developing and come to recognize as acute” (p. 23). Kuhn (1970) defines
using theoretical works (Butts & Rich, 2011; Carper, normal science as “research firmly based upon one or
1978; Chinn & Kramer, 2011; Fawcett & Garity, 2009; more past scientific achievements, achievements that
Kuhn, 1962, 1970). The significance of normal science some particular scientific community acknowledges for
(Chapter 3) to the discipline is considered (Kuhn, a time as supplying the foundation for its further prac-
1962, 1970). Second, nursing theory is viewed in the tice” (p. 10). The characteristics of paradigms that evi-
context of new growth that encourages framing dence their nature and lead to normal science include
knowledge in present day understanding. The phe- the following:
nomenal expansion of middle-range theory develop- • A community of scholars who base their research
ment and use in all areas of nursing is discussed
(Butts & Rich, 2011). Third and finally, the global and practice on the paradigm
development and use of nursing theoretical works by • The formation of specialized journals
nurse scholars around the world highlights growth • The foundation of specialists’ societies
and reminds the reader of the vital nature of theory • The claim for a special place in curricula (Kuhn,
for the profession, discipline, and science (Johnson &
Webber, 2004). 1970)
Rodgers (2005) describes normal science as . . . “the
Nature of Normal Science highly cumulative process of puzzle solving in which the
paradigm guides scientific activity and the paradigm is,
Many nursing models and theories included in this text in turn, articulated and expanded” (p. 100). Rodgers
exhibit characteristics of Kuhn’s (1970) criteria for nor- (2005) cites Kuhn’s premise that research in normal sci-
mal science (Wood, 2010). Increasingly over the past ence “is directed to the articulation of those phenomena
30 years, the conceptual models of nursing and nursing and theories that the paradigm supplies” (p.100).
theories as presented by Alligood (2010a, 2014), The conceptual models of nursing in this text exhibit
Alligood and Marriner Tomey (1997, 2002, 2006), these characteristics. Each model is unique with ranges
Alligood & Marriner Tomey (2010), Fawcett (1984a, of development in these characteristics. Rogers’ Science
1989, 1993, 1995, 2005), Fitzpatrick and Whall (1984, of Unitary Human Beings (Chapter 13) is an excellent
1989, 1996), George (1985, 1986, 1989, 1995, 2002, example having generated hundreds of research studies,
2011), Marriner Tomey (1986, 1989, 1994), Marriner 13 research instruments, and 12 nursing process clinical
Tomey and Alligood (1998, 2002, 2006), McEwen and tools for practice (Fawcett, 2005; Fawcett & Alligood,
Wills (2002, 2006), Meleis (1985, 1991, 1997, 2005, 2001). The Society of Rogerian Scholars, founded in
2007, 2012), and Parker (2001, 2006) have led to theory- 1988, publishes a refereed journal, Visions: The Journal
based education, administration, research, and practice. of Rogerian Nursing Science, with issues available on the
Communities of scholars associated with a model or Society of Rogerian Scholars website to foster develop-
ment of the science among the community of scholars.
Rogerian science is the basis of award winning texts
714 UNIT VI The Future of Nursing Theory from inquiry and guides practice” (Parse, 2008, p. 101).
and curricula for undergraduate and graduate nursing The growth of middle-range theory accentuates the
programs (Fawcett, 2005). In 2008, the Society of practice-theory connection opening new insights and
Rogerian Scholars celebrated 25 years of Rogerian vistas for theory development. The literature demon-
conferences, the 20th anniversary of the society and strates numerous ways for scholars to classify nursing
15 years of Visions: The Journal of Rogerian Nursing theoretical works. Classifications vary based on the
Science. Similarly, the International Orem Society for framework used for the classification. Of importance is
Orem’s Self-Care Deficit Theory (Chapter 14). King that nurses: know the individual works, recognize
International Nursing Group for King’s Conceptual them as evidence on which to base practice, teach them
System (Chapter 15), the Neuman Trustee Group for to students, and select one for a professional style of
Neuman’s Systems Model (Chapter 16), and the Boston- practice and improved quality of care.
based Adaptation Research in Nursing Society for Roy’s
Adaptation Model (Chapter 17) are well developed and Nurses eagerly embraced qualitative research ap-
productive communities of scholars. proaches to explore questions that quantitative research
methods could not answer, and this expanded theory
Nursing theories that have developed normal sci- development led to new qualitative middle-range theo-
ence include: Boykin & Schoenhofer’s Theory of Nurs- ries (Alligood & May, 2000; Peterson & Bredow, 2009;
ing as Caring (Chapter 19). Meleis’s Transitions Theory Sieloff & Frey, 2007; Smith & Liehr, 2008; Thorne,
(Chapter 20), Pender’s Health Promotion Model Kirkham, & O’Flynn-Magee, 2004). New theories
(Chapter 21), Leininger’s Theory of Culture Care expand the volume of middle-range or practice theory
(Chapter 22), Margaret Newman’s Theory of Health as applications. Examples include new theories in Orem
Expanding Consciousness (Chapter 23), Parse’s Theory (Biggs, 2008; Reigel, Jaarsma, & Stromberg, 2012), in
of Human Becoming (Chapter 24), and Erickson, Neuman (Bigbee & Issel, 2012; Casalenuovo, 2002;
Tomlin, and Swain’s Theory of Modeling and Role- Gigliotti, 2003; Shamsudin, 2002), in Roy (DeSanto-
Modeling (Chapter 25). Many of these have founded Madeya, 2007; Dobratz, 2011; Dunn, 2005; Hamilton &
consortia or societies for development of research, pre- Bowers, 2007; Roy, 2011), in Rogers (Kim, Kim, Park,
sentations, publications, and practice applications. et al., 2008; Malinski, 2012; Willis & Grace, 2011), in
Newman (Brown, 2011; MacNeil, 2012; Pharris &
Expansion of Theory Development Endo, 2007), in King (Alligood, 2010e; Sieloff & Frey,
2007), and in Parse (Smith, 2012; Wang, 2008). This
Theoretical works provide ways to think about nurs- exciting development closes the gap between research
ing. Johnson and Webber (2001, 2004) addressed the and practice (Alligood, 2010c) coming from quantita-
future of nursing in questions about the importance tive and qualitative methods.
of theory development for recognition of nursing as a
profession, as a discipline, and as a science. They Considering nursing knowledge in a generic
identify three significant areas affected by nursing structure as presented in Figure 37–1 is a view of
knowledge and dependent on its continued develop- knowledge based on the nature of the content within
ment. Theory affects recognition of nursing as 1) a nursing science rather than focusing on the research
profession, 2) a discipline, and 3) a science. Substan- method. Middle-range theories vary in range and
tive knowledge is the heart of nursing for recognition level of abstraction as the name of the classification
but most importantly for quality care of patients indicates. Actually, this is true for theoretical works
whom we serve. Moving nurses beyond functional in other classifications (philosophies, models, and
practice to a style of practice with a professional deliv- theories) as they also have similarities and differ-
ery model requires transposing from emphasis on ences in their levels of abstraction (Fawcett, 2005).
what the nurse does to emphasis on the patient. This Middle-range theories are recognizable as they include
requires practice based on a systematic presentation details that are specific to practice, such as the situation
and focus on persons. As knowledge is transferred to or health condition involved, client population or age
those coming into the profession, a style of practice is group, location or area of nursing practice, and action
also related. As nurses shift to a professional style of of the nurse or the nursing intervention (Alligood,
nursing, most agree that, “nursing knowledge arises 2010a, p. 482).
CHAPTER 37 State of the Art and Science of Nursing Theory 715
Person Environment Health Nursing conferences alternate between the United States
and other countries. The 2010, the conference was held
Conceptual models of nursing in Thailand. Parse’s Institute of Humanbecoming
Grand theories, theories and Watson’s Consortium on Caring Science draw
international applicants each year. The 12th Interna-
Middle range theories tional Biennial Neuman Systems Model Symposium
was titled Enhancing Global Health with Nursing
Themes Theories—NSM. This may be attributed to global
Qualitative interpretation communication, increased world travel, and transla-
tion of nursing theory textbooks into other lan-
Text guages. Nurses around the world are embracing
FIGURE 37-1 M iddle-range theory in a generic structure of nursing theory as they experience its utility in their
nursing knowledge from quantitative research methods and practice. Numerous nursing journals publish articles
qualitative research approaches. (Includes data from Fawcett, J. by international scholars such as: Journal of Nursing
[2005]. Contemporary nursing knowledge: Nursing models and Scholarship, Nursing Science Quarterly, Journal of Ad-
theories. Philadelphia: F. A. Davis.) vanced Nursing, Visions: The Journal of Rogerian
Nursing Science,and International Journal for Human
Application of middle-range theories in nursing Caring, to name a few.
practice is improving nursing practice quality, whether
developed quantitatively or qualitatively. Both approaches Various editions of Nursing Theorists and Their
are at the level of practice and develop useful nursing Work (Marriner Tomey, 1989, 1994; Marriner Tomey
knowledge. Consideration of middle-range theory in a & Alligood, 1998; 2002; 2006; Alligood & Marriner
generic structure of knowledge reveals that theory from Tomey, 2010) and Nursing Theory: Utilization and Ap-
the hypothetical-deductive method and theory from plication (Alligood & Marriner Tomey, 1997, 2002,
qualitative approaches arrives at a similar level of abstrac- 2006; Alligood, 2010a) have been published in classi-
tion. In spite of different philosophical bases, methods, cal Chinese, which is Taiwanese, Finnish, German,
and approaches, the knowledge is at a similar level of Italian, Japanese, Korean, Spanish, and Portuguese as
abstraction (Figure 37–1). well as international circulation to English-speaking
countries. Publications demonstrate global interest in
Global Communities of Nursing nursing conceptual models and nursing theories. In
Scholars addition, the theoretical works of international theo-
rists are included in this text: Evelyn Adam, Canada
In addition to the growth stimulated by a broader phi- (Chapter 5). Roper, Logan, and Tierney, Scotland
losophy of nursing science and emergence of middle- (Chapter 5), Katie Eriksson, Finland (Chapter 11),
range theories, a major contribution to the state of the Phil Barker, Ireland (Chapter 32), Kari Martinsen,
art and science of nursing theory is globalization of Norway (Chapter 10), and Nightingale, England
communities of nurse scholars with vast communica- (Chapter 6). A PubMed search of nursing theory pub-
tion via the Internet. Most nursing conceptual model lications in each language possible in PubMed was
and theory societies or consortia have international conducted on October 23, 2008, and again on August
members. The International Orem Society biennial 24, 2012, which is evidence of growth. (Table 37–1)
Current trends indicate that global consciousness has
arrived evidenced by nursing theory articles from
around the world in nursing journals in the United
States and other countries (Hisama, 1999; Im & Chang,
2012; Tanaka, Katsuno, and Towako, et al., 2012). Sigma
Theta Tau International with worldwide membership
and international conferences has contributed along
with the Internet. The Journal of Nursing Scholarship
features articles from global members (Palese, Tomietto,
716 UNIT VI The Future of Nursing Theory
TABLE 37-1 Global Nursing Theory Several nursing theory websites provide informa-
Publications* tion such as the Nursing Theory Link Page maintained
by Clayton College and State University Department
Languages with Nursing Theory Nursing Theory of Nursing and the Nursing Theory Page maintained
Nursing Theory Publications Publications by the University of San Diego School of Nursing.
Publications These websites link to home pages or websites for most
October 23, 2008 August 24, 2012 theorists and their work.
English 10,144 12,629 In conclusion, the state of the art and science of
Japanese 409 413 nursing theory is exciting as we continue to see phe-
Portuguese 298 376 nomenal growth. First, nursing theoretical works are
German 295 340 used globally by nurse scholars who collaborate to
French 214 248 develop nursing science (Kuhn, 1970). Second, theory
Korean 79 102 development with qualitative research addresses un-
Chinese 59 91 answered nursing questions. New understanding
Dutch 56 56 from middle-range theories improves nursing prac-
Danish 54 55 tice (see Figure 37–1). Third, and finally, global nurse
Spanish 41 59 scholars are applying nursing theoretical works and
Norwegian 41 41 contributing new nursing knowledge. Nurses of the
Italian 33 37 world share ideas and knowledge with the Internet.
Sweden 28 28
Finnish 24 24 This is a crucial time in the history of nursing. I am
Polish 13 14 not speaking about the shortage of nurses, although this
Afrikaans 7 7 is extremely important. Rather, there are important
Russian 3 3 changes in process for nursing. We are moving forward
Greek 2 2 with continued challenges for Quality and Safety Edu-
Thai 1 1 cation for Nurses (QSEN), as noted in Robert Wood
Turkish 1 1 Johnson Foundation (2012) reports. Similarly, Benner
Hebrew 1 1 and colleagues (2010) have called for radical transfor-
Hungarian 1 2 mation of nursing education, and nurses are responding
Czeck 1 2 to the Institute of Medicine (IOM) report, The Future of
All other possible 0 0 Nursing: Leading Change (Ellerbe & Regen, 2012). In all
of these efforts, it is vital that nursing knowledge be
languages valued and nursing theory be taught, learned, used, and
examined applied in practice for development of the profession
and that nursing research continue to develop new
*Number of nursing theory publications retrieved when limited by each nursing knowledge for the discipline. One thing
language possible in a PubMed search (August 23, 2012). remains true for the nursing profession: “Theory with-
out practice is empty and practice without theory is
Suhonen, et al., 2011), and Nursing Science Quar- blind” (Cross, 1981, p. 110).
terly has a global column in each issue by nurses in
countries such as Canada, Malawi, Australia, New Nursing theory: Utilization & application (4th ed.,
Zealand, England, Japan, Sweden, Korea, Germany, pp. 481–493). Maryland Heights, (MO): Mosby Elsevier.
Turkey, Taiwan, Hong Kong, Ireland, and Israel. Alligood, M. R. (2010c). Philosophies, models, and theo-
ries: Critical thinking structures. In M. Alligood (Ed.),
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Index
Page numbers followed by “f ” indicate figures, “t” indicate tables, and “b” indicate boxes.
A Acquired immunodeficiency syndrome (AIDS), 453, 581
Abdellah, Faye Glenn, 46–47 Actions, 348, 614
accomplishments of, 46 deliberate, 242–243
nursing theory development, contributions to, 47 nursing, 348–349
professional nursing associations, role in, 46 perceived barriers of, 399
Abduction, 180 perceived benefits of, 399
Abductive conclusion, 528 self-care, 502
Abductive reasoning, 23, 528 Activities of living (ALs), 52–54
Abstract concepts, 24 Activity-related affect, 399
Acceptance, 500 Adam, Evelyn, 52, 715
Accessibility Adaptation, 223, 265, 550, 560
in Adaptation Model, 320 in Adaptation Model, 309
in Behavioral System Model, 346 in Conservation Model, 206
in Bureaucratic Caring Theory, 112 equilibrium, 346
in Caring, Theory of, 696 levels of, 305
in Caritative Caring Theory, 184 middle-range theory of, 317–318
in Chronic Sorrow Theory, 618 in Modeling and Role-Modeling Theory, 501
in Comfort Theory, 666 person, difference in characteristics of, 501
in Conservation Model, 211 problems with, 305
in Culture Care Theory of Diversity and Universality, 431 research instruments for, 317
in Goal Attainment Theory, 268 in Uncertainty in Illness Theory, 557
in Health as Expanding Consciousness Theory, 454 Adaptation Model, 303–331
in Health Promotion Model, 405 adaptive modes in, overview of, 321–322t
in Humanbecoming Theory, 479 case study based on, 322b
in Illness Trajectory Theory, 602 critiquing of, 319–320
in Maternal Role Attainment Theory, 551 empirical evidence for, 308
in Modeling and Role-Modeling Theory, 508 further developments of, 318–319
in Nursing as Caring Theory, 370 logical form of, 311–312
in nursing theory, analysis of, 10 major assumptions of, 308–309
in Peaceful End-of-Life Theory, 706 major concepts and definitions in, 305–307b
in Philosophy of Caring Theory, 160 nursing communities acceptance of, 312–318
in Postpartum Depression Theory, 681–682 summary of, 320–323
in Self-Care Deficit Theory of Nursing, 251 theoretical assertions of, 310–311
in Self-Transcendence Theory, 583 theoretical sources for, 304–307
in Symphonological Bioethical Theory, 531 Adaptation to Spinal Cord Injury Interview Schedule (ASCIIS), 317
in Systems Model, 291 Adaptive modes, 321–322t
in Theory of Nursing Practice Expertise, 135 Adaptive Potential Assessment Model (APAM), 500, 501,
in Tidal Model of Mental Health Recovery, 646
in Transitions Theory, 387 502–503, 504–505
in Uncertainty in Illness Theory, 564 Hopkins Clinical Assessment of, 504–505
in Unitary Human Beings Theory, 231 Adaptive responses, 306
Acculturation health assessment enabler, 427 ADHD. See Attention-deficit/hyperactivity disorder (ADHD)
Achievement, 347 Adjustment, 265
Achievement subsystems, 335, 346–347 Administration
Achieving Methods of Intraprofessional Consensus, Assessment in Bureaucratic Caring Theory, 107–108
health care, 529
and Evaluation (AMICAE), 126–127, 132 in Symphonological Bioethical Theory, 529–530
Acquired coping mechanisms, 306 in Transpersonal Caring, 87
721
722 Index ASCIIS. See Adaptation to Spinal Cord Injury Interview Schedule
(ASCIIS)
Adolescent empowerment, 317–318
Adolescent Lifestyle Profile, 404 Aspects of situation, 125
Advanced beginner, 124, 134 Assessment, 340–341, 347–348
Advance directives, 529 Attachment, 541
Advance nursing science, 31–33 Attachment-affiliative subsystems, 334, 346–347
Aesthetic patterns, 371 Attainment, 541, 550
Affect, in Health Promotion Model, 399 Attending-distancing, 469
Affiliated individuation (AI), 499–500, 501 Attending Nurse Caring Model (ANCM), 86–87
Affirming, 470 Attention-deficit/hyperactivity disorder (ADHD), 317
Agency, 522, 524 Attributes of situation, 125
Authority, 557
dependent-care, 246, 250–251 Autonomy, 504, 532
nursing, 246, 250–251 Awareness, 207, 382, 524–525
self-care, 246, 250–251 Axiomatic theory, 30
in Symphonological Bioethical Theory, 522 Axioms, 29–30
Agency for Healthcare Research and Quality, 405 B
Agent, 242 Bacon, Francis, 15–16
Aggressive-protective subsystems, 335, 346–347 Balance, 346
Agreement, 522–523, 524–525 Bandura, Albert, 398
AI. See Affiliated individuation (AI) Barker, Phil, 626–656. See also Tidal Model of Mental Health Recovery
AIDS. See Acquired immunodeficiency syndrome (AIDS)
Akayama, Tsuyoshi, 640 background of, 626–627
Alanen, Y., 635 credentials of, 626–627
All-at-onceness of human experience, 467 Barnard, Kathryn E., 51–52, 689
Allegiance Health, 288–289 Basic conditioning factors, 247
Altruistic values, 83 Basic needs, 501
Altschul, Annie, 629, 635 Basic Needs Satisfaction Inventory, 504–505
Alzheimer’s disease, 479 Basic Principles of Nursing Care, 45
American Academy of Nursing, 46, 51, 121, 205 Baumhart, Dr., 205
American Association Colleges of Nursing, 704 Beck, Cheryl Tatano, 672–687. See also Postpartum Depression
American Holistic Nurses’ Certification Corporation (AHNCC), 497
American Journal of Critical Care, 131–132, 704 Theory
American Journal of Health Promotion, 398 background of, 672–674
American Journal of Nursing, 8, 131–132 credentials of, 672–674
American Mental Health Aid to Israel, 205 Becoming, 179, 543, 546–547
American Nurses Association (ANA), 43–44 Becoming visible–invisible becoming of the emerging, 467
AMICAE. See Achieving Methods of Intraprofessional Consensus, Behavior
in Behavioral System Model, 334
Assessment and Evaluation (AMICAE) ethical, 525–526
ANA. See American Nurses Association (ANA) health-promoting, 400
ANCM. See Attending Nurse Caring Model (ANCM) health-seeking, 660
Anthropology, 420, 425 prior related, 399
Anticipatory stage of Maternal Role Attainment Theory, 545 Behavioral assessment, 347–348
Anxiety Behavioral science, 19–20
Behavioral system equilibrium, 341
Maternal Role Attainment Theory, 541 Behavioral System Model, 332–356, 339f
Postpartum Depression Theory, 677 case study based on, 347–349b
prenatal, 676 critiquing of, 346
APAM. See Adaptive Potential Assessment Model (APAM) empirical evidence for, 336–337
Appraisal, 563 further developments by, 344–345
Appraisal support, 542 logical form of, 340
A priori reasoning, 15, 17 major assumptions of, 337–338
Aristotle, 15, 173, 174, 180, 182, 522 major concepts & definitions of, 334–336b
Art nursing communities acceptance of, 340–344
clinical nursing, element of, 48 summary of, 346–349
normal science, nature of, 713–714 theoretical assertions of, 338–340
nursing scholars, global communities of, 715–716 theoretical sources for, 333–334
of nursing theory, 711–719
theory development, expansion of, 714–715
Articulation research, 121–122, 133
Behavior disorders, 346 Index 723
Being, dimension of health, 179
Being ill, 130 C
Being-nonbeing, 470 Calls for nursing, 363, 365, 445
Being situated, 130 Canadian Nurse, The, 48
Being with, 690, 695 Cancer, 600
Belief, 445, 690, 695 Carative factors of Transpersonal Caring, 82t
Belong to the person, 634 Care
Beneficence, 532
Benner, Patricia, 120–146. See also Theory of Nursing culture, 421
dependent, 244
Practice Expertise human, 421
background of, 120–121 moral practice, founded on, 155
credentials of, 120–121 nursing, 178, 422
Berdâev, Nikolaj, 174 people-based, 423
Bereavement, 616 in Philosophy of Caring Theory, 155
Best policies, 660, 664 suffering related to, 175–176
Best practices, 660, 664 transformation of, 368
Biennial Neuman Systems Model Symposium, 288, 290 universality of, 425
Biochemical loading, 674 Care continuum, 634–635
Bioethical concepts, 525 Caring, 365. See also Bureaucratic Caring Theory; Caring, Theory
Bioethical standards, 526b
Bioethics, 521 of; Caritative Caring Theory; Culture Care Theory of
Biographical work, 596 Diversity and Universality; Nursing as Caring Theory;
Biological factors, 399 Theory of Nursing Practice Expertise; Transpersonal Caring
Biopsychosocial systems, people as, 560 Theory
Birth experience, perception of, 541 act of, 175
Boca Raton Community Hospital, 367, 368 bureaucratic, 106
Body, 152, 596 in Bureaucratic Caring Theory, 102
Bourdieu, Pierre, 151 call for nursing as, 365
Boykin, Anne, 357–377. See also Nursing as in Caring, Theory of, 690
culturally based, 424
Caring Theory existential being as, 152
background of, 358–359 human care and, 421
credentials of, 358–359 literary metaanalysis on, 691
Brainstorming, 599 meaning of, 106
Bridge-builder, 154–156 moral, 156–157
Brigham and Women’s Hospital, 506 natural, 178
British Royal Sanitary Commission, 65 in nursing practice (See Theory of Nursing Practice Expertise)
Bureaucracy, 101–102 original, 178
Bureaucratic caring, 106 persons as, perspective of, 360
Bureaucratic Caring Theory, 98–119 philosophy of, 20, 147–170
case study based on, 113–114b practical, 156–157
critiquing of, 111–113 relational, 156–157
empirical evidence for, 102–105 spiritual-ethical, 102, 104, 106, 111–112
further developments by, 109–111 Caring, Theory of, 688–700
Holographic Theory of, 105f case study based on, 696b
logical form of, 106 critiquing of, 695–696
major assumptions of, 105–106 empirical evidence for, 690–692
major concepts & definitions of, 102–103b further developments by, 695
nursing communities acceptance of, 107–109 logical form of, 694
research publications related to, 110–111t major assumptions of, 692–693
summary of, 113–114 major concepts & definitions of, 690b
theoretical assertions of, 106 nursing communities acceptance of, 695
theoretical sources for, 100–103 theoretical assertions of, 693–694
Burke, Mary Lermann, 609–625. See also Chronic theoretical sources for, 689–690
Caring between phenomenon, 363, 365
Sorrow Theory Caring communion, 174–175, 180
background of, 609–612 Caring culture, 176
credentials of, 609–612 Caring from the heart model, 368–369
Burke/Eakes Chronic Sorrow Assessment, 617 Caring Inquiry Dynamics, 108–109
724 Index Clarity (Continued)
in Behavioral System Model, 346
Caring relationships, 67, 178 in Bureaucratic Caring Theory, 111–112
Caritas, 82, 178 in Caring, Theory of, 695
in Caritative Caring Theory, 183
in Caritative Caring Theory, 174 in Chronic Sorrow Theory, 617
process, 82t in Comfort Theory, 666
Caritas-based theory, 184 in Conservation Model, 211
Caritative caring ethics, 174, 175 in Goal Attainment Theory, 267
Caritative Caring Theory, 171–202 in Health as Expanding Consciousness Theory, 454
case study based on, 184–185b in Health Promotion Model, 404
critiquing of, 183–184 in Humanbecoming Theory, 478
empirical evidence for, 176–177 in Illness Trajectory Theory, 601
further developments by, 183 in Maternal Role Attainment Theory, 550–551
logical form of, 180–181 in Modeling and Role-Modeling Theory, 508
major assumptions of, 177–179 of Nightingale’s works, 69–70
major concepts & definitions of, 174–176b in Nursing as Caring Theory, 370
nursing communities acceptance of, 181–183 in nursing theory, analysis of, 10
summary of, 184–185 in Peaceful End-of-Life Theory, 705
theoretical assertions of, 179–180 in Philosophy of Caring Theory, 160
theoretical sources for, 173–176 in Postpartum Depression Theory, 681
Cassandra, 68 in Self-Care Deficit Theory of Nursing, 250
Casual process, 29, 30–31 in Self-Transcendence Theory, 582–583
Center for Epidemiological Studies Depression (CES-D) scale, in Symphonological Bioethical Theory, 530–531
in Systems Model, 291
576–577 in Theory of Nursing Practice Expertise, 134
Center for Human Caring, 80 in Tidal Model of Mental Health Recovery, 642–643
Center on Infant Mental Health and Development, 51 in Transitions Theory, 387
Certainty, 470, 526 in Transpersonal Caring, 88
CES-D. See Center for Epidemiological Studies Depression in Uncertainty in Illness Theory, 563–564
in Unitary Human Beings Theory, 230
(CES-D) scale
Changes, 382–383 Classification gaze, 154
Chaos theory, 100–101, 104–105, 560, 629 Clayton College, 716
Chaotic sense of reality, 637–638 Cleanliness, 63–64
Chardin, Pierre Teilhard De, 284 Client system
Charity, 178
Child abuse, 616 basic structure of, 284
Child care stress, 676 line of defense, 284
Child Health Assessment Interaction Theory, 52 lines of resistance, 284
Child-rearing attitudes, 541 in Systems Model, 284
Children’s Hospital of the University of Wisconsin, 506 Clinical forethought, 128
Choice, 348 Clinical grasp, 128
Chronic sorrow, 613 Clinical judgment, 135
Clinical knowledge, 134–135
concept of, 612 Clinical nurse specialists (CNSs), 132
definition of, 613 Clinical Nursing: A Helping Art, 47–48
triggers of, 613–614 Clinical nursing, elements specified by, 48
Chronic Sorrow Theory, 609–625 Clinical Nursing Research journal, 33
case study based on, 619b Clinical practice development models (CPDMs), 121
critiquing of, 617–619 Clinical wisdom in nursing practice. See Theory of Nursing
empirical evidence for, 613–614
further developments by, 617 Practice Expertise
logical form of, 615 Closeness, 703
major assumptions of, 614–615 CNSs. See Clinical nurse specialists (CNSs)
major concepts & definitions of, 613b Coaching for stress reduction, 661
nursing communities acceptance of, 615–616 Coconstitution, 466
summary of, 619 Coexistence, 466
theoretical assertions of, 615 Cognator subsystem, 306
theoretical sources for, 612–613 Cognitive Adaptation Processing Scale, 315
Claritas, 178
Clarity
in Adaptation Model, 319
Index 725
Cognitive capacities, 557 Connecting-separating, 469, 476–477
Cognitive coping mechanisms, 614 Conover, Martin, 241
Cognitive development, 499 Conscience, 359–360
Cognitive schema, 557 Consciousness, 444–445, 448–450
Cognitive stages of lifetime development, 501
Collectivist humanity, 160 concept of, 448
Comfort reflection of, 448
shared, 452
in Comfort Theory, 660 Consensus, 19, 20
defined, 660 Conservation
holistic, 661 in Conservation Model, 207
interventions for, 660 of energy, 207
mental, 658 of personal integrity, 208
in Peaceful End-of-Life Theory, 703 principles of, 207–208
Comfort Daisies, 665–666 of social integrity, 208
Comfort Theory, 657–671 of structural integrity, 207
case study based on, 667b Conservation Model, 203–219
conceptual framework for, 661f case study based on, 211–213b
critiquing of, 666–667 critiquing of, 211
empirical evidence for, 660–662 empirical evidence for, 208
further developments by, 665–666 further developments by, 211
logical form of, 663–664 logical form of, 209
major assumptions of, 662 major assumptions of, 208–209
major concepts & definitions of, 659–660b major concepts & definitions of, 206–208b
nursing communities acceptance of, 664–665 nursing communities acceptance of, 210–211
summary of, 667 summary of, 211–213
theoretical assertions of, 662–663 theoretical assertions of, 209
theoretical sources for, 658–660 theoretical sources for, 205–208
Commitment, 359–360 Consortium on Caring Science, 715
Common Journey Breast Cancer Support Group, 292 Contemporary theories of science, 18–19
Community-based health action model, 475–476 Context, 527
Community conditions, 383 of awareness, 524–525
Comparative care, inclusion of, 428–429 environmental, 422, 659
Compassion, 359–360 of knowledge, 524–525
Competency, 124–126, 134, 359–360 physical, 659
Competency-based testing, 132 psychospiritual, 659
Complete person, 363 sociocultural, 659
Complex Caring Dynamics, 108–109 in Symphonological Bioethical Theory, 522
Complexity, 101–102 Contextual stimulus, 293, 306
Complexity theory, 104 Continuous concepts, 24, 25
Comportment, 359–360 Continuum of care, 634–635
Concept analysis, 26 Contradictory axioms, 30
Concept-building process, 26–27 Control
Concepts, 24–27 in Behavioral System Model, 335
abstract, 24 loss of, 675
analysis of, 26 regaining, 675
classifying, 24 Cooperative inquiry, 453–454
concrete, 24 Coping, 123, 563
continuous, 24, 25 acquired mechanisms for, 306
defined, 24 cognitive strategies, 614
development of, 25–26 emotional strategies, 614
discrete, 24, 25 innate mechanisms of, 306
nonvariable, 24, 25 internal strategies, 612–613, 614
Conceptual system development, 261–262 interpersonal strategies, 614
Concrete concepts, 24 processes of, 306
Conditions, 28, 383 Core, Care, and Cure model, 48–50
Confidence, 359–360 Core ideas, 472
Conforming-not conforming, 470 Corrective mental provision for Transpersonal Caring, 82
726 Index Deduction, 180, 528, 663–664
Deductive inquiry, 16
Cotranscending with possibles Deductive logic, 287, 450, 706
in Humanbecoming Theory, 470 Deductive reasoning, 23
originating, 470 Deductive reformulation, 575
powering, 470 Deductive science, 15
transforming, 470 Deductive thinking, 340
Degree of reaction, 285
Counselor, 43–44 Degree on a continuum, 25
CPDMs. See Clinical practice development models (CPDMs) Deliberate action, 242–243
Created environment, 284, 287 Demand
Credible authority, 557
Criterion-Reference Measure of Goal Attainment Tool, 262–263 dependent-care, 246
Critical events, 383 immediate competing, 400
Critical hermeneutics, 154 therapeutic self-care, 245
Critical incidents, 131 Den Mångdimensionella Hälsan (Multidimensional Health), 182
Critical points, 383 Deontology, 521–522
Cross-cultural nursing, 420 Dependency subsystems, 334–335, 346–347
Cues of infant, 542 Dependent-care, 244, 250–251
Culturally based caring, 424 deficit, 246, 251
Culturally competent nursing care, 422 demand, 246
Culturally sensitive care, 529 Dependent-care agency, 246, 250–251
Cultural structure dimensions, 422 Dependent-care system, 251
Culture Dependent-care theory, 248–249
Depression, 541
caring, 176 history of, 676
in Culture Care Theory of Diversity and Universality, 421 postpartum, 675
inclusion of, 428–429 prenatal, 676
Culture care, 421 Derivable consequences, 70–71, 88
accommodation in, 422 De Shazer, Steve, 629
diversity in, 421 Deterministic model, 28
maintenance in, 422 Developmental Resources of Later Adulthood (DRLA), 576–577
negotiation in, 422 Developmental self-care requisites, 245
preservation in, 422 Diet, 63–64
repatterning in, 422 Differences, in transition experiences, 382–383
restructuring in, 422 Differential Caring, 103, 106
universality in, 422 Dignity, 175, 703
Culture Care Theory of Diversity and Universality, 417–441 Direct invitation, 361, 365
case study based on, 432b Disciplinary knowledge, 471
critiquing of, 431–432 Disciplines
empirical evidence for, 423–424 for graduate research education, 616
further developments by, 430–431 meaning of, 6b
logical form of, 425–427 of nursing, 20–21, 363–364, 420
major assumptions of, 424–425 nursing theory, significance of, 6–8
major concepts & definitions of, 421–422b scientific, 14
nursing communities acceptance of, 427–430 Discovery, 633
summary of, 432 Discrete concepts, 24, 25
theoretical assertions of, 425 Disequilibrium, 346
theoretical sources for, 420–422 Disorders, 340–341. See also Postpartum mood disorders
Curing, 85 attention-deficit/hyperactivity, 317
Curriculum era, 3 behavior, 346
postpartum obsessive-compulsive, 675
D postpartum-onset panic, 675
Dalhousie University, 641 Disturbances, 346
Dance of Caring Persons, 364, 368, 369 Diversity, culture care, 421
Da Silva, Antonio Barbosa, 174 Dodd, Marylin J., 593–608. See also Illness Trajectory Theory
Decision-making background of, 593–595
credentials of, 593–595
end-of-life, 582, 704 Doing, dimension of health, 179
ethical, 527, 531
model of, 526–528
scientific problem-solving method for, 82
Doing for, 690, 695 Index 727
Domains
Education (Continued)
of inquiry enabler, 427 undergraduate, 615–616
others, 633, 643 in Unitary Human Beings Theory, 226–227
self, 632–633, 643
of Theory of Nursing Practice Expertise, 126 Educational structures, 112
of Tidal Model of Mental Health Recovery, 632–633 Effective management, 613
world, 633, 643 Efficient drainage, 63–64
Dreyfus, Hubert, 122 Einstein, Albert, 15, 222–223
Dreyfus Model of Skill Acquisition, 122, 123, 131, 134. See also
theory of relativity, 30, 222–223
Theory of Nursing Practice Expertise Eliminative subsystems, 335, 346–347, 348
Drive, 348 Embodied knowing, 123
DRLA. See Developmental Resources of Later Adulthood (DRLA) Emic, 421, 422
Dunne, Joseph, 122 Emotional coping mechanisms, 614
Dying of self, 675 Emotional liability, 677
Emotional support, 542
E Emotivism, 521–522
Eakes, Georgene Gaskill, 609–625. See also Chronic Sorrow Empathy, 371
Empirical evidence
Theory
background of, 609–612 in Adaptation Model, 308
credentials of, 609–612 in Behavioral System Model, 336–337
Earthquake model, 674 in Bureaucratic Caring Theory, 102–105
Ease, 658 in Caring, Theory of, 690–692
Eating disturbances, 677 in Caritative Caring Theory, 176–177
Economic factors, 103 in Chronic Sorrow Theory, 613–614
Economic structures, 112 in Comfort Theory, 660–662
Education, 615–616 in Conservation Model, 208
in Adaptation Model, 314 in Culture Care Theory of Diversity and Universality, 423–424
in Behavioral System Model, 343 in Goal Attainment Theory, 260–263
in Bureaucratic Caring Theory, 102, 108 in Health as Expanding Consciousness Theory, 445
in Caritative Caring Theory, 181 in Health Promotion Model, 401
in Chronic Sorrow Theory, 615–616 in Humanbecoming Theory, 471–472
in Comfort Theory, 664 in Illness Trajectory Theory, 597–599
in Conservation Model, 210 in Maternal Role Attainment Theory, 540–543
continuing, 616 in Modeling and Role-Modeling Theory, 502–505
in Culture Care Theory of Diversity and Universality, 428–429 in Modern Nursing, 64–65
in Goal Attainment Theory, 266 Nightingale’s use of, 64–65
graduate research, 616 in Nursing as Caring Theory, 362
in Health as Expanding Consciousness Theory, 452–453 in Peaceful End-of-Life Theory, 702–703
in Health Promotion Model, 404 in Philosophy of Caring Theory, 154–156
in Humanbecoming Theory, 476 in Postpartum Depression Theory, 678
in Illness Trajectory Theory, 600 in Self-Care Deficit Theory of Nursing, 247
in Maternal Role Attainment Theory, 549 in Self-Transcendence Theory, 576–577
in Modeling and Role-Modeling Theory, 506 in Symphonological Bioethical Theory, 523–524
Nightingale’s principles of, 68–69 in Systems Model, 282–285
in Nursing as Caring Theory, 366–367 in Theory of Nursing Practice Expertise, 126–128
in Peaceful End-of-Life Theory, 704–705 in Tidal Model of Mental Health Recovery, 635–636
in Philosophy of Caring Theory, 159 in Transitions Theory, 384–385
in Postpartum Depression Theory, 680 in Transpersonal Caring, 84
in Self-Transcendence Theory, 580 in Uncertainty in Illness Theory, 558–559
in Symphonological Bioethical Theory, 529 in Unitary Human Beings Theory, 222–223
in Systems Model, 289 Empirical patterns, 371
in Theory of Nursing Practice Expertise, 132–133 Empirical precision, 70, 88
in Tidal Model of Mental Health Recovery, 641 Empiricism, 15–16
in Transitions Theory, 386 Empiricist science, 15
in Transpersonal Caring, 87 Empowering Interactions Model, 636
in Uncertainty in Illness Theory, 561–562 Empowerment, 317–318, 629, 636
Enabler
acculturation health assessment, 427
inquiry, 427
728 Index Erickson, Helen C., 496–519. See also Modeling and Role-
Modeling Theory
Enabler (Continued)
observation participation reflection, 427 background of, 496–498
stranger to trusted friend, 427 credentials of, 496–498
Erickson Maternal Bonding-Attachment Tool, 504–505
Enabling, 690 Erikkson, Katie, 150, 171–202
Enabling-limiting, 469 credentials of, 171–173
Enabling process, 690, 695 Erikkson Psychosocial Stage Inventory, 504–505
Encountering terror, 675 Essential values, 630–632b
End-of-Life Care, 704 Eternity, 175
End-of-life decision making, 582, 704 Ethical behavior, 525–526
End-of-own-life issues, 578 Ethical comportment, 126
Endowment, inherent, 501 Ethical decisions, 527, 531
Energy, conservation of, 207 Ethical interaction, 529
Energy field, 222 Ethical patterns, 371
Enfolded order, 101 Ethical standards, 525–526
Engagement, 382, 628–629, 634 Ethics, 521
Engineered me, 642–643 caritas-based caring, 174
Environment caritative caring, 175
human existence, as primary condition of, 152–153
in Adaptation Model, 310 in nursing practice (See Theory of Nursing Practice Expertise)
assessment of, 348 Ethnohistory, 422
in Behavioral System Model, 338 Ethnomethodology, 19–20
in Bureaucratic Caring Theory, 105–106 Ethnonursing, 423, 424, 429
in Caring, Theory of, 693 Ethnonursing Research Method, 425, 430
in Caritative Caring Theory, 179 Ethos, 179
in Chronic Sorrow Theory, 614–615 Etic, 421, 422
in Comfort Theory, 662 European Standards for Nursing, 52–53
conceptual models of, 4–5 Evaluation, 340–341
in Conservation Model, 206, 209 Events
context of, 422, 659 congruence, 557
created, 284, 287 critical, 383
in Culture Care Theory of Diversity and Universality, 424–425 familiarity with, 557
external, 287 trigger, 613
facilitative, 663 Everyday-life work, 596
in Goal Attainment Theory, 263 Examining gaze, 154
in Health as Expanding Consciousness Theory, 447 Excess disabilities, 663
internal, 287 Exemplar, 126
in Maternal Role Attainment Theory, 544 Exercise Benefits-Barriers Scale (EBBS), 401
metaparadigm of, 4–5 Existence statements, 30–31
in Modeling and Role-Modeling Theory, 505 Existential being as caring, 152
modern nursing, 63–64 Existential-phenomenological forces, allowance for, 82
Nightingale’s concept of, 65–66 Experiences, 126, 471–472, 642
in Nursing as Caring Theory, 363 Experiential process of nurse-client, 450
in Peaceful End-of-Life Theory, 703 Expert, 125, 134
in Philosophy of Caring Theory, 157–158 Explicate conscious level, 101
in Postpartum Depression Theory, 678 Explicit-tacit imaging, 468
in Self-Transcendence Theory, 578 Exploitation of nurse-patient relationship, 43–44
spiritual, 82 External environment, 287
in Symphonological Bioethical Theory, 522–523, 524–525 External management, 614
in Systems Model, 283–284, 287 Extraction-synthesis process, 472
theoretical assertions in, 86 Eye of the heart concept, 156
in Tidal Model of Mental Health Recovery, 638
in Transitions Theory, 385 F
in Unitary Human Beings Theory, 224 Facilitative environment, 663
Episteme Award, 51 Facilitators, 406
Epistemology, 14–15, 16 Faith-hope, instillation of, 82
analysis of, 16
rationalist, 15
Equilibrium, 223, 335
Equilibrium adaptation, 346
Family, 542 Index 729
Far-from-equilibrium system, 560
Father, Maternal Role Attainment Theory, 544 Generality (Continued)
Fawcett, Jacqueline, 252, 689 in Transitions Theory, 387
Fear, 445 in Transpersonal Caring, 88
Feedback, 283 in Uncertainty in Illness Theory, 564
Feelings, promotion and acceptance, 82 in Unitary Human Beings Theory, 230–231
Fidelity, 532
Fight or flight syndrome, 206–207 Generalization, 135
Flanagan’s Critical Incident Technique, 636 Gestalt theory, 282
Flexibility, 541 Getting in the swim, engagement process and, 634
Flexible line of defense, 284 Glasgow mental health services, 640
Florida Nurses’ Association (FNA), 259 Global communities of nursing scholars, 715–716
Focal stimulus, 293, 306 Goal, 348
Formal stage of Maternal Role Attainment Theory, 545 Goal Attainment Theory, 258–280. See also Middle-Range Theory
Foss, Else, 159
Foucault, Michel, 151, 153–154 case study based on, 268–269b
Fourth National Conference on Modeling and Role-Modeling credentials of, 258–260
empirical evidence for, 260–263
Theory and Paradigm, 506, 507–508 further developments by, 267
Frankel, Victor, 50 logical form of, 265
Frank-Stromborg, Marilyn, 397 major assumptions of, 263
Freedom, 466–467, 473, 532 major concepts & definitions of, 260b
Free from pain, 703 Nightingale tribute to, 258–260
Functional requirements, 335, 348 nursing communities acceptance of, 265–267
propositions within, 264b
G summary of, 268–269
Gable, Robert, 674 theoretical assertions of, 263
Gadamer, Hans-Georg, 173 theoretical sources for, 260
General Comfort Questionnaire, 659, 661, 665–666 Goal-oriented nursing record (GONR), 265
Generality Gomez, Olga J., 108
Good death analysis, 704
in Adaptation Model, 319–320 Graduate education era, 4
in Behavioral System Model, 346 Graduate research education, 616
in Bureaucratic Caring Theory, 112 Gratification-satisfaction, 541
in Caring, Theory of, 696 Grief, morbid, 499–500
in Chronic Sorrow Theory, 618 Grounded theory approach, 102, 598–599, 600, 602
in Comfort Theory, 666 Group identity, 284
in Conservation Model, 211 Growing conscience-like feeling, 445
in Culture Care Theory of Diversity and Universality, 431 Guided imagery, 660–661
in Goal Attainment Theory, 268 Guilt, 677
in Health as Expanding Consciousness Theory, 454
in Health Promotion Model, 404–405 H
in Humanbecoming Theory, 478–479 Hainsworth, Margaret A., 609–625. See also Chronic Sorrow
in Illness Trajectory Theory, 602
in Maternal Role Attainment Theory, 551 Theory
in Modeling and Role-Modeling Theory, 508 background of, 609–612
of Nightingale’s works, 70 credentials of, 609–612
in Nursing as Caring Theory, 370 Hall, Lydia, 48–50
in nursing theory, analysis of, 10 Hall, Sir John, 61–62
in Peaceful End-of-Life Theory, 705–706 Hand massage, 661
in Philosophy of Caring Theory, 160 Healing touch, 661
in Postpartum Depression Theory, 681 Healing web, 452–453
in Self-Care Deficit Theory of Nursing, 251 Health
in Self-Transcendence Theory, 583 in Adaptation Model, 309–310
in Symphonological Bioethical Theory, 531 in Behavioral System Model, 338
in Systems Model, 291 in Bureaucratic Caring Theory, 105
in Theory of Nursing Practice Expertise, 134–135 in Caring, Theory of, 693
in Tidal Model of Mental Health Recovery, 643–645 in Caritative Caring Theory, 179
in Chronic Sorrow Theory, 614
in Comfort Theory, 662
conceptual models of, 4–5, 32
730 Index Health Promotion Model (HPM), 396–416, 400f
background of, 396–398
Health (Continued) case study based on, 405–406b
in Conservation Model, 209 credentials of, 396–398
in Culture Care Theory of Diversity and Universality, 422, 424 critiquing of, 404–405
definition of, 474 empirical evidence for, 401
deviation, 245 further developments by, 404
dimensions of, 179 logical form of, 403
in Goal Attainment Theory, 263 major assumptions of, 401–403
in Health as Expanding Consciousness Theory, 444, 447–448 major concepts & definitions of, 399–400b
in Humanbecoming Theory, 474 nursing communities acceptance of, 403–404
humanuniverse, viewed as, 474 revised, 402f
illness, 284 summary of, 405–406
justice, 640 theoretical assertions of, 403
as mastery, 380 theoretical sources for, 398–400
in Maternal Role Attainment Theory, 544
meaning of, 445 Health-seeking behaviors, 660
mental, 577 Healthy People 2020, 405
metaparadigm of, 4–5 Healthy Start CORPS: Inter-Conceptual Care Case Management
in Modeling and Role-Modeling Theory, 505
Nightingale’s definition of, 65 Project, 680
in Nursing as Caring Theory, 363 Heidegger, Martin, 149–150, 152
passive, 223 Helicy, 224–225, 466
in Peaceful End-of-Life Theory, 703 Helping methods, 246
personhood is living life grounded in caring, 363 Helping-trust relationship, development of, 82
phases of, 32 Henderson, Virginia, 45–46, 52
in Philosophy of Caring Theory, 157
in Postpartum Depression Theory, 678 nurse-patient relationships, levels identified by, 45–46
rituals of, 445 nursing defined by, 45–46
in Self-Transcendence Theory, 578 scope of influence of, 45
status, 541, 542 Herbert, Sidney, 61
in Symphonological Bioethical Theory, 523, 524 Hermeneutic dialectic, 453–454
in Systems Model, 284, 287 Hermeneutic phenomenology, 154
theoretical assertions of, 86 Hermeneutics, 126, 154
in Theory of Nursing Practice Expertise, 130 HIV. See Human immunodeficiency virus (HIV)
in Tidal Model of Mental Health Recovery, 637–638 Holism, 20, 206, 333, 501
in Transitions Theory, 385 Holistic comfort, 661
in Unitary Human Beings Theory, 223–224 Holistic intervention, 660–661
wellness and, 284 Holistic science, 15
Hologram, 101
Health as Expanding Consciousness Theory, 442–463 Holographic theory, 108
case study based on, 455b Holographic Theory of Bureaucratic Caring Theory, 105f
critiquing of, 454 Holography, 102
empirical evidence for, 445 Homeodynamics, 224–225, 224t
further developments by, 454 Homeostasis, 223
logical form of, 450 Hopkins Clinical Assessment of APAM, 504–505
major assumptions of, 445–448 HPLP-II. See Health Promotion Lifestyle Profile II (HPLP-II)
major concepts & definitions of, 444–445b HPM. See Health Promotion Model (HPM)
nursing communities acceptance of, 450–454 Humanbecoming Theory, 464–495
summary of, 454–455 case study based on, 481b
theoretical assertions of, 448–450 conceptualization of, 466
theoretical sources for, 443–445 critiquing of, 478–481
empirical evidence for, 471–472
Health care administration, 529 logical form of, 475
Health care needs, 659–660 major assumptions of, 472–474
Health care teams, 529 major concepts & definitions of, 468–470b
Health is the expansion of consciousness thesis, 446 mentoring model, 480
Health-promoting behavior, 400 nursing communities acceptance of, 475–478
Health Promotion Lifestyle Profile, 401, 404, 405 summary of, 481
Health Promotion Lifestyle Profile II (HPLP-II), 401
Humanbecoming Theory (Continued) Index 731
theoretical assertions of, 474
theoretical sources for, 465–470 Immediate preferences, 400
Implicate conscious level, 101
Human being, 265. See also Personhood Importance
Human care, 421
Human cognitive functioning, 17 in Adaptation Model, 320
Human existence, ethics as primary condition of, 152–153 in Behavioral System Model, 346
Human experience, all-at-onceness of, 467 in Bureaucratic Caring Theory, 112–113
Human immunodeficiency virus (HIV), 453, 581, 616 in Caring, Theory of, 696
Humanistic values, 83 in Caritative Caring Theory, 184
Humanity, 70, 160 in Chronic Sorrow Theory, 618–619
Human needs, 82, 499 in Comfort Theory, 666–667
Humanness, 363 in Conservation Model, 211
Human science, 479–480. See also Nursing in Culture Care Theory of Diversity and Universality, 432
Human social systems, 290 in Goal Attainment Theory, 268
Human subjectivity, 466 in Health as Expanding Consciousness Theory, 454
Human-to-Human Relationship model, 50–51 in Health Promotion Model, 405
Humanuniverse, 466, 467, 474 in Humanbecoming Theory, 479–481
Husserl, Edmund, 16, 149–150, 151–152 in Illness Trajectory Theory, 602
Husted, Gladys L. and James H., 520–536. See also in Maternal Role Attainment Theory, 551
in Modeling and Role-Modeling Theory, 508
Symphonological Bioethical Theory in Nursing as Caring Theory, 370
background of, 520–521 in nursing theory, analysis of, 10–11
credentials of, 520–521 in Peaceful End-of-Life Theory, 706–707
Husted Symphonological model, 528 in Philosophy of Caring Theory, 161
in Postpartum Depression Theory, 682
I in Self-Care Deficit Theory of Nursing, 251–252
ICN. See International Council of Nurses (ICN) in Self-Transcendence Theory, 583
Identification, phase of nurse-patient relationship, 43–44 in Symphonological Bioethical Theory, 531
Identity in Systems Model, 291–292
in Theory of Nursing Practice Expertise, 135–136
in Illness Trajectory Theory, 596 in Tidal Model of Mental Health Recovery, 646
maternal, 541, 550 in Transitions Theory, 387
personal role, 546 in Uncertainty in Illness Theory, 564
role, 550 in Unitary Human Beings Theory, 231
Illimitability, 467, 473 Individual, 265
Illinois Nurses Association, 205 Individuation, affiliated, 499–500, 501
Illness, 284 Induction, 180, 528, 663
health, 284 Inductive logic, 287, 450, 706
mental, 638, 639 Inductive method, 15–16
related to work, 596 Inductive reasoning, 23, 67, 600
suffering related to, 175–176 in Modern Nursing, 67
Illness Trajectory Theory, 593–608 Nightingale, use of, 67
case study based on, 602–603b Inductive science, 15
critiquing of, 601–602 Inductive thinking, 340
empirical evidence for, 597–599 Ineffective management, 613
further developments by, 601 Ineffective responses, 306
logical form of, 600 Ineffective transitions, 379
major assumptions of, 599 Infant
major concepts & definitions of, 596–597b characteristics of, 542
nursing communities acceptance of, 600–601 cues of, 542
summary of, 602–603 health status of, 542
theoretical assertions of, 599–600 temperament of, 542, 676
theoretical sources for, 595–597 Infectious diseases, 68
Illusion, 557 Inference, 180, 557
Imaging, 468 Infinity, 175
Immediate competing demands, 400 Inflammatory response, 207
Informal stage of Maternal Role Attainment Theory, 545
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Nursing Theory alligood 8th edition
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