Nursing Theories & Nursing Practice

180 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Practice Exemplar cont. Developmental: Gloria has significant rela-
tionships with her co-workers.
perceptions and found none. She identified
the intrapersonal, interpersonal, and extraper- Spiritual: Gloria is supported by her pastor
sonal factors that made up Gloria’s environ- and friends at church.
ment. To ensure the assessment was holistic
and comprehensive, she identified the physi- Extrapersonal factors
ological, psychological, sociocultural, develop- Physiological: From a co-worker, Gloria re-
mental, and spiritual variables for each of these
factors. Gloria identified caring for her mother ceived the gift of a comfortable bed mat-
with Alzheimer’s disease as her major stressor. tress that promotes her sleep.
Psychological: Gloria shared that reading her
Assessment Bible helps her think positive thoughts.
Sociocultural: Gloria earns $35,000 per year.
The nurse’s assessment of Gloria’s environ- Developmental: Gloria can feel “in charge of
mental factors is identified below. Examples the situation” with a comfortable house
of assessment data for each variable are for her mom.
included. Spiritual: Gloria attends church services in
Intrapersonal factors her neighborhood 2 or 3 times a week.
Physiological: Gloria experiences occasional The nurse applied the NSM nursing process
format (Neuman & Fawcett, 2011, p. 338) fo-
signs and symptoms of increased anxiety cusing on the following: (1) nursing diagnosis
such as rapid heart rate and increased (based on valid database), (2) nursing goals
blood pressure. negotiated with the client including appropri-
Psychological: Gloria occasionally worries ate levels of prevention as interventions, and
about the future, but she tries to focus on (3) nursing outcomes.
the present and prides herself on her sense The nurse prepared a comprehensive list of
of humor. nursing diagnoses based on her holistic and
Sociocultural: Gloria values her belief that comprehensive assessment and then priori-
African American families take care of tized the list. She validated her findings with
their elderly. Gloria to ensure that their perceptions were in
Developmental: Gloria is in Erickson’s agreement.
(1959) developmental stage of middle The nurse and Gloria identified Gloria’s
adulthood with its crisis of generativity full-time role as a caregiver for her mother
versus stagnation. She strives to look out- with Alzheimer’s disease as a significant
side of herself to care for others. stressor. The nurse considered the research
Spiritual: Gloria reports that religion, faith, study by Jones-Cannon and Davis (2005),
and prayer help her cope with caregiving which reported that caregivers of a family
demands. member with dementia believed attendance
Interpersonal factors at a support group influenced their caregiving
Physiological: Gloria occasionally has inter- in a positive way. One of the nursing diag-
rupted sleep when her mother awakens noses they determined was “risk for caregiver
and wanders during the night. role strain.” Although this was identified as
Psychological: Gloria reminds herself when a risk, they both agreed there was not a sup-
physically caring for her mother that this porting sign or symptom to validate the exis-
is an expected part of her mother’s aging. tence of caregiver role strain at this time.
Sociocultural: Gloria is the full-time care- However, it was important to prevent this
giver of her mother, who has Alzheimer’s strain in the future.
disease. She works full-time with sup- The nurse recognized that their observa-
portive people but does not attend an tions provided a glimpse of Gloria’s normal
Alzheimer’s support group because she line of defense; then they identified an
didn’t know anything about them.

CHAPTER 11 • Betty Neuman’s Systems Model 181

Practice Exemplar cont. strength or ability to cope). An example of
each follows.
immediate goal to strengthen her flexible Secondary prevention as intervention: Assist
line of defense.
Gloria to schedule respite care for a deter-
The goal is that Gloria will report that she mined period of time.
has participated in a monthly Alzheimer sup- Tertiary prevention as intervention: Provide
port group session by (date). They could have ongoing education at each visit about
identified intermediate and future goals at that practical resources that will provide care-
time. Together they planned nursing actions giver support.
for primary prevention as intervention. The nurse would have continued to use
the nursing process by implementing and
The nurse also used the tool and nursing evaluating their plan; reassessing, as part of
process to provide holistic comprehensive care evaluation, for a reduction or elimination of
for Gloria’s mother, and the family client caregiver role strain; and maintenance of
system was strengthened. By strengthening system stability. Neuman refers to this as
Gloria’s lines of defense, the nurse helped reconstitution.
strengthen Gloria’s mother’s lines of defense. Reconstitution represents the return and
The model is dynamic as the individual and maintenance of system stability after treatment
family client systems are assessed continu- of a stressor reaction, which may result in a
ously, leading to new diagnoses, goals, and in- higher or lower level of wellness than previously.
terventions that promote optimal holistic It represents successful mobilization of energy
comprehensive nursing care. The desired out- resources (Neuman, 2002c, p. 324).
come goal for Gloria in the case example was The desired outcome goals are for optimal
optimal health retention. health retention, restoration, and mainte-
nance. In Neuman’s model, high importance
If this had been an actual problem of care- is placed on validating nurse and client per-
giver role strain, they would have identified ceptions and validating data.
secondary prevention as interventions and
tertiary prevention as interventions that would
activate resource factors (lines of resistance)
to protect Gloria’s basic structure (organ

■ Summary

“The Neuman Systems Model is well positioned as a conceptual model to observe and interpret
as a contemporary and future guide for health the phenomena of nursing and health care
care practice, research, education and adminis- globally. The model is well accepted by
tration far into the 21st century. The concepts the nursing profession and is guided by the
and processes of the model are so universal and Neuman Systems Model Trustees, Inc. The
timeless that they are easily understood by all Trustees are dedicated to the improvement of
members of the health care teams worldwide” health for people worldwide through develop-
(Neuman and Fawcett, 2011, p. 317). ment and use of the NSM to guide practice,
education, research, and administration (www
The NSM has been used for more than .neumansystemsmodel.org/trustees).
three decades, first as a teaching tool and later

182 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
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Helen Erickson, Evelyn Tomlin, 12Chapter
and Mary Ann Swain’s Theory
of Modeling and Role Modeling

HELEN L. ERICKSON Introducing the Theorist

Introducing the Theorist My life journey, filled with challenges and
Overview of Modeling and Role-Modeling opportunities, helped me discover the essence
of my Self, understand my Reason for Being,
Theory and uncover my Life Purpose (H. Erickson,
Practice Applications 2006a). My Self is reflected in my values and
beliefs; my Reason for Being is to learn that
Practice Exemplar unconditional love is the key to human rela-
Summary tionships; and my Life Purpose is to facilitate
growth in others. The following snippets of my
References journey offer an occasional glimpse into my
Self and the underlying philosophy of model-
Helen L. Erickson Mary Ann Swain ing and role-modeling (MRM).

Born and raised in north-central Michigan
with one older brother and two younger sisters,
I learned that our early experiences affect who
we become. My father worked for the highway
department; our mother cared for the family
and worked part-time as a retail clerk. I learned
that family connections, caring about others,
positive attitudes, respect for the environment,
and hard work are essential.

I was 5 years old when World War II was
declared. Although too young to understand
the implications of the war, I learned that it
was important to stand up for our beliefs and
life principles.

I learned that anything is possible if we are
persistent, our goals have integrity, and we are
honest with others and ourselves. I started
working when I was about 10 years old. My
jobs included babysitting, keeping house for a
family in need, waitressing, and clerking. Each
was an opportunity to learn about myself, and
each was a step toward nursing school.

I enrolled in a diploma program for nurses,
and in my junior year, I met my future husband
and his family. His father, Milton Erickson,

185

186 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

well known for his work with mind–body heal- as associate dean of academic affairs and then
ing, taught me that people know more about moved to the University of Texas, where I as-
themselves than health-care providers do, that sumed the role of professor and chair of adult
their inner-knowing is essential to healing, and health nursing. When I retired in 1997, the
that we can help them by attending to their Helen L. Erickson Endowed Lectureship on
worldview. I committed to married life, moved Holistic Nursing was established at the
to Texas, and accepted the position of head University of Texas in Austin.
nurse in the emergency room of the Midland
Memorial Hospital. I have authored or coauthored chapters
on MRM and/or holistic nursing (Clayton,
Between 1959 and 1967, I worked in a va- Erickson, & Rogers, 2006; H. Erickson, 1996,
riety of settings in Texas, Michigan, and Puerto 2002, 2006b, 2006c, 2006d, 2006e, 2007,
Rico and welcomed four children into our fam- 2008; M. Erickson, Erickson, & Jensen, 2006;
ily. I learned valuable lessons about blind prej- Walker & Erickson, 2006), some of which are
udice, discrimination, and staying true to self; included in the second book on MRM, and
about how personal stories provide insight into more recently, a book on the relationship be-
client needs; and about the uniqueness of peo- tween the philosophy and discipline of holistic
ple and how limiting labels did not capture nursing. I know now that advancing holistic
their wholeness. I had opportunities to develop health care is my mission, my life work; MRM
a professional practice model. is a vehicle for that purpose.1

In 1974, I completed my RN-BSN pro- Overview of Modeling and
gram at the University of Michigan and was Role-Modeling Theory
recruited as a faculty member and consultant
at the University Hospital. MRM is based in several nursing principles
that guide the assessment, intervention, and
I enrolled in the master’s program in evaluation aspects of practice. These principles,
medical–surgical and psychiatric nursing and reflected in the data collection categories
graduated in 1976. During this time, Evelyn (H. Erickson et al., 2009, pp. 148–168), are linked
Tomlin and I talked freely about the nursing to intervention aims and goals (H. Erickson
model I had derived from practice. I labeled et al., 2009, pp. 168–201). Although both in-
and developed the adaptive potential assess- tervention aims and goals involve nursing
ment model and worked with Mary Ann actions, they differ in their purpose. Nursing
Swain to test some of my hypotheses (H. Er- interventions should have intent; nurses should
ickson & Swain, 1982). I continued in my fac- aim to make something happen that facilitates
ulty position and advanced to chairman of the health and healing when they interact with
undergraduate program and assistant dean. clients. There should also be markers that help
us evaluate the efficacy of our activities—
Over the next 10 years, my model of nursing intervention goals. Table 12-1 shows the rela-
acquired a life of its own. By the early 1980s, I tions among MRM principles of nursing, data
had speaking invitations but little had been needed to practice this model, the aims of
written (H. Erickson, 1976; H. Erickson & nursing actions, and specific goals.
Swain, 1982). Together Evelyn, Mary Ann, and
I further elaborated some of the concepts. The Modeling
term modeling and role-modeling (MRM), first
coined by Milton Erickson, was selected as the The modeling process involves assessment of a
best descriptor of this work. The original edition client’s situation. It starts when we initiate an in-
was printed in November 1982 (H. Erickson, teraction with an individual and concludes with
Tomlin, & Swain, 2009), has had eight reprints,
and is now considered a classic by the Society 1For additional information, please see the bonus chapter
for the Advancement of Modeling and Role- content available at http://davisplus.fadavis.com.
Modeling (SAMRM). I completed my PhD in
1984, left Michigan in 1986, spent 2 years at the
University of South Carolina School of Nursing

CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 187

Table 12 • 1 Relations Among Principles, Data Categories, Intervention Goals,
and Aims

Principles Categories of Data Goals Aims

The nursing process Description of the Develop a trusting Build trust.
requires that a trusting situation and functional rela-
and functional relation- tionship between self Promote client’s
ship exist between Expectation and your client. positive orientation.
nurse and client.
Affiliated-individuation (External) Resource Facilitate a self- Promote client’s
is contingent on the potential projection that is control.
individual’s perceiving futuristic and positive.
that he or she is an ac- (Internal) Resource Affirm and promote
ceptable, respectable, potential Promote affiliated- client’s strengths.
and worthwhile human individuation with
being. (Internal) Resource the minimum degree Set mutual goals that
Human development is potential of ambivalence are health directed.
dependent on the indi- possible.
vidual’s perceiving that Goal and life tasks
he or she has some Promote a dynamic,
control over life while adaptive, and holistic
concurrently sensing a state of health.
state of affiliation.
There is an innate drive Promote (and nurture)
toward holistic health coping mechanisms
that is facilitated by that satisfy basic needs
consistent and system- and permit growth-
atic nurturance. need satisfaction.
Human growth is de- Facilitate congruent
pendent on satisfaction actual and chrono-
of basic needs and is fa- logical development
cilitated by growth-need stages.
satisfaction.

Adapted with permission from Erickson, H., Tomlin, E., & Swain, M. A. (Eds.). (2009). Modeling and role-modeling: A the-
ory and paradigm for nursing (p. 171). Cedar Park, TX: EST.

an understanding of that person’s perspective of Table 12-3 shows the priority given to the
their circumstances. We aim to learn how that in- information we collect. Primary data are ac-
dividual describes the situation, what he or she quired from the client; secondary data include
expects will happen, and his or her perceived re- the nurse’s observations and information from
sources and life goals. As we listen and observe, the family. Tertiary data include information
we interpret the information using the constructs from medical records and other sources. Pri-
embedded in the theory. Stated simplistically, mary and secondary data are essential for pro-
modeling is the process we use to build a mirror image fessional practice, whereas tertiary data are
of an individual’s worldview. This worldview helps added as needed.
us understand what that person perceives to be im-
portant, what has caused his or her problems, what Role-Modeling
will help, and how he or she wants to relate to others.
The role-modeling process requires both objec-
Table 12-2 shows the categories of data and tive and artistic actions. First, we analyze the
the type of information needed in the model- data using theoretical propositions in the MRM
ing process. model (Table 12-4; H. Erickson et al., 2009,

188 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Table 12 • 2 Categories of Data and Purpose for Obtaining Data

Categories of Data Collection Purpose of Data Is to Obtain

Description of the 1. An overview of client’s perception of the problem
Situation 2. The etiology of the problem including stressors and distressors
Expectations 3. Client’s perceived therapeutic needs
Resource Potential 1. Immediate expectations
2. Long-term expectations
Goal and Life Tasks 1. External: Social network, support system, and health-care

system
2. Internal: Self-strengths, adaptive potential, feeling states,

physiological states
1. Current goals
2. Plans for future

Adapted with permission from Erickson, H., Tomlin, E., & Swain, M. A. (Eds.). (2009). Modeling and role-modeling: A the-
ory and paradigm for nursing (p. 119). Cedar Park, TX: EST.

Table 12 • 3 Sources of Information

Primary Source Client’s self-care knowledge

Secondary Source Information from family and nurses’ observations
Tertiary Source Medical records and other information related to client’s case

Table 12 • 4 Selected Theoretical Propositions in MRM Theory

1. Developmental task resolution is related to basic need status.
2. Growth depends on basic need status and is facilitated by growth need satisfaction.
3. Basic need satisfaction leads to object attachment.
4. Object loss leads to basic need deficits.
5. Affiliated-individuation is dependent on one’s perception of acceptance and worth.
6. Feelings of worth result in a sense of futurity.
7. Development of self-care resources is related to basic need satisfaction.
8. Ability to mobilize coping resources is related to need satisfaction.
9. Responses to stressors are mediated by internal and external resources.
10. Ability to mobilize appropriate and adequate resources determines resultant health status.

pp. 148–167). We interpret the meaning of sections elaborate each of these objectives. The
what has been provided and search for linkages first section addresses the philosophical assump-
among the data that will help us understand tions that underlie this model; theoretical under-
the client’s worldview. As we analyze the data, pinnings follow with implications for practice.
implications for nursing actions emerge (H. Finally, the global applications of MRM are
Erickson et al., 2009, pp. 168–220). Nursing ac- presented.
tions are then artistically designed with intent
(i.e., the aims of interventions) and specific out- Philosophical Assumptions
comes (i.e., intervention goals). Our overall ob-
jectives are to help people grow and heal and to Nursing has a metaparadigm that includes four
find meaning in their experiences. The following extant constructs: person, environment, health,
and nursing; sometimes social justice is added

CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 189

as a fifth construct (Schim, Benkert, Bell, Biophysical
Walker, & Danford, 2007). The operational
definitions of these constructs provide the con- Cognitive Genetic base Psychological
text necessary to clarify how an individual’s and spiritual D.G.P.I.
actions are unique to nursing as opposed to the
actions of another profession. Although all Social
nursing theories are developed and articulated A The Holistic model
within this context, our personal philosophy
affects how we define and operationalize the Biophysical Social
constructs of nursing and therefore how we ar-
ticulate our models (H. Erickson, 2010). For Psychological Cognitive
this reason, it is important to be clear about
our own philosophical beliefs and how they B
affect our conceptual definitions and our the- The Wholistic model
oretical models. Nurses can use clear philo-
sophical statements to determine whether Fig 12 • 1 Holism versus wholism.
the underpinnings of a theoretical model are
consistent with their own belief systems journey. Table 12-5 provides examples of each
(H. Erickson, 2010). When they are not, dis- of these. Although some might argue that all
crepancies among nursing’s philosophical be- animals have an innate instinct to cope and
liefs, the nurse’s personal belief system, and the some have an innate ability to receive and in-
theoretical propositions often create disso- terpret stimuli, most would agree that not all
nance that impedes the nurses’ ability to use animals have an innate drive to receive stimuli
the model (H. Erickson et al., 2009). The in a cognitive form, to acquire skills necessary
philosophical assumptions underlying the to perceive and understand stimuli, to give and
MRM theory and paradigm are described in receive feedback, the freedom to speak, or the
the text that follows. The first section presents
MRM’s orientation toward two of nursing’s
metaparadigm constructs: person and environ-
ment. Health, nursing, and social justice are
described in the following sections.

Person and Environment

Humans are inherently holistic. This means
that all aspects of the human are intercon-
nected and dynamically interactive; what af-
fects one part affects another. This is different
from the wholistic person, wherein the parts
are associated but not necessarily intercon-
nected or interactive (Fig. 12-1). When we ap-
proach people from a wholistic perspective, we
can break them down into systems, organs,
and other parts. When we view them as holis-
tic, we understand that all the dimensions of
the human being are interconnected; what af-
fects one part has the potential to affect other
parts. Our holistic nature is manifested
through our innate instincts and drives: in-
stincts and drives necessary for humans to
maneuver through the pathways of their life

190 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Table 12 • 5 Selected List of Human Instincts and Drives

Instincts Inherent in To receive and interpret stimuli
Human Nature To cope and adapt to stressors
To experience mind–body–spirit intraconnectedness, or holistic
Drives That Motivate well-being
Our Behavior To cognitively interpret stimuli
To acquire skills necessary to perceive and interpret stimuli
To give and receive feedback
To communicate freely
To choose and act freely
To experience balanced affiliated-individuation
To be self-actualized

freedom to choose. These latter characteristics diminishes our ability to fully understand the
are unique to the human species, are innate, person’s situation.
and often motivate our behavior (Maslow,
1968, 1982). I have added one instinct—an Humans are inherently intuitive. We know
inherent instinct for holistic well-being—and (at some level) what we need. We know what
two human drives: the drive for healthy has made us sick and what will help us get well,
affiliated-individuation and the drive for self- grow, develop, and heal. We have instinctual
actualization. These instincts and drives affect information about our own personhood and
how we function as holistic beings. The holistic our mind–body–spirit linkages. This informa-
person is one in whom the whole is greater tion is called self-care knowledge. Our percep-
than the sum of the parts, whereas a wholistic tions of what we have available to help us are
person is one in whom the whole is equal to called self-care resources. Self-care resources are
the sum of the parts (H. Erickson et al., 2009, both internal and external. We have resources
pp. 45–46). within ourselves as well as resources within our
external environment. Our actions, thoughts,
As holistic beings, our mind, body, and spirit biophysical responses, and behavior that help
are inextricably interrelated with continuous us get our needs met are our self-care actions.
feedback loops. Cells in each dimension can We are inherently social beings with an innate
produce stimuli affecting responses in cells of drive to grow and develop, to become the most
other dimensions. Cellular responses have the that we can be, find meaning in our lives, fulfill
potential to become new stimuli, moving the our potential, and self-actualize. However,
chain reaction around and among the dimen- we are vulnerable. Our ability to grow and de-
sions of the human being. These interactions velop is dependent on repeated satisfaction of
are dynamic and ongoing. Because we have an our needs. We want and need to be connected
internal environment (i.e., within the confines or affiliated to others in some way. Simulta-
of our physical being) and an external environ- neously, we also need to perceive ourselves as
ment (i.e., outside the confines of the biopsy- unique and individuated from these same
chosocial being), external stimuli have the people. We call this affiliated-individuation
potential to create multiple internal responses, (Acton, 1992; H. Erickson et al., 2009, p. 47;
and vice versa. To agree that we are holistic is M. Erickson et al., 2006, pp. 182–207). Our
to believe that we are human beings, living in drive to be both affiliated and individuated at
a context that includes all that is within us and the same time mandates a balance between
within our external environment—holistic be- being connected while perceiving a sense of
ings, constantly in process both internally and one’s self as a unique human being, separate
externally. These dynamically interactive di- from others. We achieve our drive for a bal-
mensions cannot be separated without a loss anced affiliated-individuation through our in-
of information about the person, a loss that teractions with others. How well we achieve

CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 191

this balance at any point in our life will deter- people grow, develop, and, when necessary, to
mine how we relate to others in the following heal. We use all of our skills acquired through
years. formal education as well as our own innate abil-
ity to connect with others to help them recover
Although we are social beings with a drive from illnesses and to live meaningful lives. We
for affiliated-individuation with others, we are do this from the beginning of physical life to
also spiritual beings with an inherent drive to the end, even as people are taking their last
be connected with our soul (H. Erickson et al., breath. Within this context, our intent, or what
2009, 2006). More specifically, our drive for we aim to facilitate when we interact with an-
individuation is to fulfill our psychosocial other human being, is important.
needs while doing soul-work unique to our life
journey. Social Justice

Health As professional nurses, we are committed to
live by the ethics of our profession, serve as ad-
Health is a matter of perception. It is a state vocates for our clients, and serve the public as
of well-being in the whole person, not just a defined by our professional standards. For
part of the person. It is not the presence, ab- nurses who use the MRM theory, this means
sence, or control of disease; one’s ability to that we are committed to recognize the indi-
adapt; or one’s ability to perform social roles. vidual’s worldview as valid information, to act
Instead, it is a eudemonistic health that incor- on that information with the intent of nurtur-
porates all of these and more. It is a sense of ing and facilitating growth and well-being in
well-being in the holistic, social being. It in- our clients, and to practice within the context
cludes one’s perceptions of her life quality, of the Standards of Holistic Nursing as defined
her ability to find meaning in her existence, by the American Holistic Nurses Association
and a capacity to enjoy a positive orientation (AHNA, 2013) and recognized by the American
toward the future. As a result, personal per- Nurses Association (ANA, 2008).
ceptions of health may differ from those of
others. It is possible for persons with no ob- Theoretical Constructs
vious physical problem to perceive a low level
of health, while at the same time others, tak- People have an innate instinct to cope and
ing their last mortal breath, may perceive adapt to stressors and related stress responses
themselves as very healthy. The perception of that confront us constantly. We adapt as
health status is always related to perceived much as we are able to, given our life situa-
balance of affiliated-individuation. tion. We need oxygen, glucose, and protein to
maintain our physical systems; we also need
Nursing to feel safe and to be loved. When these needs
are perceived to be unmet, they create stres-
Nursing is the unconditional acceptance of the sors; stressors produce the stress response.
inherent worth of another human being. Stress responses can become new stressors
When we have unconditional acceptance for mandating still more responses, and so on
another person, we recognize that all humans (Benson, 2006, pp. 240–266; H. Erickson,
have an innate need to be loved, to belong, to 1976; H. Erickson et al., 2009). Many of our
be respected, and to feel worthy. Uncondi- stress responses are instinctual, a part of our
tional acceptance of a person as a worthwhile human makeup; however, some have to be
being is not the same as accepting all behaviors learned and developed. As our needs are met,
without conditions. It does mean, however, the stressors decrease; and we are able to work
that we recognize that behaviors are motivated through the stress response.
by unmet needs. Our work, then, is to help
people find ways to get their needs met with- Adaptive Potential
out harming themselves or others.
Our ability to mobilize resources at any mo-
We do this through nurturance and facili- ment in time can be identified as our Adaptive
tation of the holistic person. Our goal is to help

192 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Potential. The adaptive potential assessment Human Needs
model (APAM; Fig. 12-2), first labeled in
1976 (H. Erickson, 1976; H. Erickson & Human needs, classified as basic, social, and
Swain, 1982; H. Erickson et al., 2009), was growth needs, drive our behavior. They provide
derived by synthesizing Selye’s (1974, 1976, motivation for our self-care actions and emerge
1980, 1985) work with that of George Engel in a quasi-hierarchical order. Physiological
(1964). Our adaptive potential has three states: needs must be met to some degree before social
equilibrium, arousal, and impoverishment. needs emerge. Growth or higher-level needs
Equilibrium, a state of nonstress or eustress, emerge after the basic and social needs have
represents maximum ability to mobilize re- been met to some degree (for a more detailed
sources. The individual in equilibrium is in a taxonomy of human needs, see H. Erickson,
healthy balance between need demands and 2006a, pp. 484–485). Basic needs are related to
need resources. survival of the species. When they are unmet,
tension rises, motivating behavioral response(s)
Arousal and impoverishment are both stress necessary to decrease the tension. When self-
states; needs are unmet, creating stressors and care actions decrease the tension, the need dis-
the related stress responses. However, people sipates. When the need is completely satisfied,
in arousal are temporarily able to mobilize their the tension disappears. When needs are met
resources, whereas those in impoverishment are repeatedly, need assets are built. Conversely,
not. Persons in the first group (arousal) need when the need is not met, the tension rises, and
help solving their problem, finding alternatives. need deficits emerge. When the tension contin-
They tend to be tense and anxious but do not ues, need deprivation exists. Need status can
demonstrate depleted resources through the ex- be classified on a 0 to 5 scale ranging from
pression of fatigue and sadness. On the other deprivation to asset status (Fig. 12-3). Growth
hand, impoverished people show the wear and needs are different. Because people have an in-
tear of prolonged stress. They have diminished nate drive for self-actualization, growth needs
physical resources and are fatigued and sad. emerge when basic needs are met (to some de-
People in arousal are at risk for becoming gree). Unmet growth needs do not create ten-
impoverished, and impoverished people are at sion unless they are related to a basic need.
risk for depleting their resources, getting sick, Instead, satisfaction of growth needs creates ten-
developing complications, and even dying sion. The need increases in intensity. Until one
(Barnfather, 1987; Barnfather & Ronis, 2000; feels satiated, the need to continue to behave in
Benson, 2006, pp. 242–254; H. Erickson, ways that will meet growth needs continues.
1976; H. Erickson et al., 2009, pp. 75–83;
H. Erickson & Swain, 1982). As indicated, a Need Satisfaction and the Object
person’s ability to cope is related to how well Attachment Process
his or her needs are met at any given point in
time. Objects that repeatedly meet humans needs
become attachment objects. These objects take
Equilibrium on significance unique to the individual, are
both human and nonhuman, have a physical
Stressor Coping form (so they stimulate one of the five senses)
Coping Stressor or are abstract (such as an idea), and are nec-
essary throughout life. When a person per-
ceives that the object is or will be lost, a
grieving response occurs. Loss is a subjective

Arousal Stressor Impoverishment Deprivation Deficit Unmet Met Satisfied Assets
Stress

Fig 12 • 2 The adaptive potential assessment 0 1 23 4 5
model.
Fig 12 • 3 The needs status scale, 0 to 5.

CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 193

experience known by the individual; it can be before the experienced loss. Resources are
real, threatened, or perceived. Any loss pro- based on one’s ability to work through the nor-
duces a grieving process. One’s difficulty in re- mal developmental tasks encountered during
solving the loss depends on the significance of the human journey. This issue is discussed fur-
the lost object. The grieving response is nor- ther in the text that follows.
mal, occurs in a predetermined sequence, and
is self-limited. Normal grieving processes take Attachment to new objects is necessary for
about 1 year (Fig. 12-4). Grief resolution oc- continued growth and grief resolution. The new
curs as the individual finds new ways to view object can be the same object, perceived in a
the lost object or finds alternative objects new way, or a completely new object. Some-
that meet their needs. Commonly accepted times transitional objects are used to facilitate
processes of grief include sequential phases of this process. Transitional objects are those
shock/disbelief, anger, bargaining, sadness, that symbolize the lost object and are never
and acceptance (Kübler-Ross, 1969). Other human, but are almost always concrete. For
models (Engel, 1964; Bowlby, 1973) indicate example, mothers attached to their children as
slightly different phases (M. Erickson, 2006, preschoolers often experience a loss when their
p. 229). Table 12-6 compares three of these children start school and become increasingly
models. I believe that their differences are independent. It is common to see these moth-
based in the nature of the lost object, its mean- ers attach to their child’s baby shoes, pictures,
ing to the individual, and the resources accrued or some other symbol of who they were in their
previous life stage.

Satisfied Secure Health- High-level
needs attachment promoting wellness
behaviors
to object Resolution
meeting Positive of loss with
needs developmental reattachment
and satisfied
residual
needs

Basic Situational or Holistic
needs developmental well-being
loss and grief

Unmet Insecure Negative Nonresolution
needs attachment developmental of loss with
with continued continued
unmet needs residual unmet needs
and morbid

grief

Health- Physical and
impeding psychological
behaviors
problems

Fig 12 • 4 The needs–attachment–development–loss–reattachment model.

194 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Table 12 • 6 Stages of Grief According to Contributing Authors

Engel Kübler-Ross Bowlby

Shock/disbelief Denial/shock Protest
Awareness Anger/hostility
Resolution Bargaining Despair
Loss resolution Depression Detachment
Idealization Acceptance

Italicized stages indicate unresolved loss with movement toward morbid grief.
Reprinted with permission from Erickson, H. (Ed.). (2006). Modeling and role-modeling: A view from the client’s world

(p. 229). Cedar Park, TX: Unicorns Unlimited.

Morbid grief emerges when the individual able to grow and develop, to integrate mind–
is unable to find alternative objects that will body–spirit, to perceive themselves as worthy
repeatedly meet their needs. Because we are human beings, and to experience a healthy
holistic beings, morbid grief has the potential balance of affiliated-individuation. When this
to result in physical symptoms, illness, and happens, they are interested in others as indi-
over the long period, disease. What happens viduals who are unique and worthwhile. They
in one part of the holistic person has the enjoy both a sense of connectedness and a
potential of creating disease in another part, sense of individuation. Their life orientation is
disease that becomes distressful, mandates called a being orientation because they are in-
mobilization of resources often not available, terested in becoming all they can be and in
and therefore producing alternative biophysi- participating in the same way with others.
cal responses, depleting psychoneuroimmuno-
logical resources (Walker & Erickson, 2006 However, when needs are repeatedly unmet,
growth is limited, and people have difficulty
Behaviors that indicate emergence of mor- with their developmental processes. Their rela-
bid grief include an inability to move on and tionships with others exist within a context of
let go of the lost object, combined with vacil- what can be obtained from the other. They are
lation between anger and sadness (M. Erickson, not interested in the well-being of the other,
2006, pp. 209–239; Lindeman, 1944, pp. 141– might be threatened by growth in significant
148). Initially individuals are able to focus their others, and are intolerant of the uniqueness of
anger and sadness, but with time, anger grows others. More interested in what they can get
into hostility and sadness into depression. from someone than what they can give, these
When this happens, people are less able to ar- people often view others as a source of getting
ticulate the focus of their feelings or recognize their basic needs met. As a result, often unable
the loss that produced the grieving response in to meet the needs of significant others, they are
the beginning. They often use language that perceived as “needy people.” Their life orienta-
describes giving up rather than letting go, and tion is called a deficit orientation. Being and
sometimes express nostalgia for the lost object. deficit orientations exist on a scale; most people
In contrast, those who have let go of the lost have some of both. The balance between the
object, worked through the normal grief re- two is what determines one’s overriding traits
sponse, and reattached to a new object can or personal attributes, one’s values and virtues,
usually describe the importance of moving on. and one’s ways of interacting with others.

Need Satisfaction and Life Orientation Developmental Processes

The degree to which a person’s needs are met People have an inherent drive for self-
repeatedly determines how he or she relates to actualization. This requires that they pass
others; it affects his or her life orientation. through predetermined chronological develop-
When needs are met repeatedly, people are mental stages—stages with tasks that mandate

CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 195

attention as they emerge. Our ability to work on stages, and their related tasks emerge during a
these developmental tasks depends on our ability specific time frame in our lives. During that
to mobilize resources. Resources are derived by time, the task becomes predominate in our life
getting our needs met at any given time as well journey, drawing resources, focusing attention,
as our past experiences. Because our experiences and motivating behaviors.
are always contextual, how we resolve our devel-
opmental tasks will determine the resources Epigenesis
we have to work on current tasks. As we work
through a stage-related task, a developmental Development is also epigenetic. Although we
residual is produced. This residual includes have specific tasks that focus our attention at spe-
positive and negative attributes, strengths, and cific times in life, we also rework earlier life tasks
virtues. In our original work, we followed Erik and set the framework for later tasks at the same
Erikson’s (1994) work to define eight stages, time. This later work is done within the context
their tasks, and the associated residual. Our more of the appointed life task. Simply stated, we re-
recent work has expanded the stages to include peatedly work on all of the developmental tasks
one prebirth and another at the time of death at every stage of life, although we have a key task
because the work of the soul affects the devel- that dominates at any given time. Our ability to
opmental processes during one’s physical life manage multiple tasks is dependent on the resid-
(M. Erickson, 2006, pp. 121–181; Table 12-7). ual we have produced throughout the process and
our current ability to have our needs met.
Sequential Development
Linkages
Development occurs as a series of predeter-
mined stages with specific tasks in each stage. Three key theoretical linkages exist in the
It is also chronological: unique, sequential MRM model. Relations exist between or
among (1) adaptive potential and need status;

Table 12 • 7 Developmental Stages, Residual, Virtues, and Strengths

Stages/Age Residual Virtue Strength(s)
Groundedness Awareness
Integration of Spirit Unity vs. duality Hope
(pre–post birth) Willpower Drive toward future
Building Trust Trust vs. mistrust
(birth–15 months) Purpose Self-control
Acquiring Autonomy vs. Competence
Autonomy introspection Fidelity Drive
(12–36 months) Love
Taking Initiative Initiative vs. Caring Methodological
(2–7 years) responsibility Wisdom problem-solving
Developing Industry Competency vs. Oneness Devotion
(5–13 years) inferiority
Developing Identity Self-identity vs. Affiliation with
(11–30 years) role confusion individuation
Building Intimacy Intimacy vs. Production
(20–50 years) isolation
Developing Genera- Generativity vs. Renunciation
tivity (midlife to 60s) stagnation
Ego Integrity (60s to Ego integrity vs. Peace, cosmic under-
transformation) despair standing, compassion
Transformation (end Reconnecting vs.
of physical life) disconnecting

Adapted with permission from Erickson, H. (Ed.). (2006). Modeling and role-modeling: A view from the client’s world
(Table 5.1, pp. 128–129). Cedar Park TX: Unicorns Unlimited.

196 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

(2) need status, object attachment, loss, and new Establishing a Mindset
attachment status; and (3) developmental task Establishing a mindset involves three strate-
resolution and need satisfaction. Selected theo- gies: centering, focusing, and opening. Center-
retical propositions, derived from these linkages, ing helps to organize our resources so that we
are shown in Table 12-4. Others exist, limited can connect energetically with our client. It re-
only by an understanding of MRM. quires that we temporarily put aside other
thoughts, worries, or concerns and believe that
MRM Practice Strategies at some level we can discover what we need to
know to help our clients; it requires us to focus
Initiating the Relationship on the other with the intent of nurturing their
growth and facilitating their healing. When
Three sequential strategies are important for we focus on our client’s needs, we initiate an
those using the MRM model: (1) establishing energetic connection, necessary for a caring–
a mindset, (2) creating a nurturing space, and healing environment.
(3) facilitating the story (H. Erickson, 2006b, Creating a Nurturing Space
pp. 309–317; Table 12-8). Each can be done Creating a nurturing space follows naturally
in seconds once the essence of the strategy is when we have established a mind-set. Our
understood. However, before you can start, it goal is to create a caring–healing environment.
is necessary to reflect on your own beliefs Although one cannot force growth in others,
about human nature and nursing and to con- we can create environments that nurture
sider how these affect your practice. This growth. We do this by decreasing adverse
helps you clarify how to get your needs met—a stimuli while increasing positive ones. It is im-
prerequisite to meeting the needs of others. portant to remember that you are entering the
Unless we know how to initiate our own self- client’s space and to respect it. Even though
care, we have difficulty mobilizing the energy you may think it is important to close the door,
necessary to focus on the needs of our clients. turn on the radio, or fluff pillows, you will
Finally, we have to open ourselves to the want to assess whether your actions serve to
worth of each individual, to unconditionally comfort the client. Each of these processes
accept that each human has an inherent need helps you connect with your client in such a
to be valued, to be treated with respect, and
to live with dignity.

Table 12 • 8 Three Strategies That Facilitate a Trusting–Functional Relationship

Establish a Mindset Self-care preliminaries Enhance sense-of-self.
Moving forward Center self.
Create a Nurturing Focus intent.
Space Reduce distracting Open self to the essence of other.
stimuli. Attend to sounds, lights, smells, and other
Facilitate the Client’s Respect client’s space. stimuli that are distracting and discomforting.
Story Recognize and respect client’s physical/
Connect spirit to spirit. energetic space.
Use eye contact, soft tones, and gentle touch
Tap self-care to connect with client.
knowledge. Address stimuli, encourage focus on
nurse–client linkage.
Relate to beliefs about client’s self-care
knowledge as primary.
Encourage client’s perceptions of the
situation.

Adapted with permission from Erickson, H. (Ed.). (2006). Modeling and role-modeling: A view from the client’s world
(pp. 307–317). Cedar Park, TX: Unicorns Unlimited.

CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 197

way that you will initiate a trusting relationship this has happened?” or “What do you think
and create a caring–healing environment. Any has caused it?” and “How do you feel about
stimuli that affects the five senses has the pos- that?” and so forth (H. Erickson et al., 2009,
sibility of being comforting, uncomfortable, or pp. 153–167). The data are then organized into
discomforting. We can influence these by our four distinct but interrelated categories: de-
actions in the milieu and by our interactions scription of the situation, expectations, resource
with our client. For example, a noisy hallway potential, and goals (see Table 12-2). Informa-
or bright lights shining in our eyes are stimuli tion provided by our clients has to be inter-
that seem to drain energy from us, and no preted, aggregated, and analyzed before we can
doubt our clients experience the same thing. use it to plan interventions (H. Erickson et al.,
Or consider a beautiful picture, the glimpse of 2009, pp. 153–168).
a fully leafed tree swaying in a gentle breeze,
soft music of our choice, clean sheets against Phases of Understanding the Data
our skin, or the gentle touch of a loving person.
In thinking about how you respond to these There are three phases in understanding the in-
stimuli, you will understand that these have formation gained in MRM practice model. In
the possibility of comforting another human data interpretation, we use the philosophical
being. You will also understand that how you and theoretical underpinnings discussed earlier
touch, look, or speak to someone conveys a as we attend to words, affects, and nonverbal
message about your intent to comfort or not to cues, searching for evidence of coping potential
comfort. Of course, it is extremely important (i.e., adaptive potential), needs status, and de-
that we consider the individual’s cultural per- velopmental residual. Sometimes it is necessary
spectives and values as we consider how to cre- to clarify what we observe to avoid superimpos-
ate a nurturing space; what works for one ing our own interpretations on these data. For
person does not for another. The only way we example, clients might have a spouse or signifi-
can know is to ask our clients or, when they cant other but not perceive this individual
are unable to speak for themselves, to ask their as supportive. When this happens, they often
significant others. describe them as “draining” rather than invig-
Facilitating the Story orating. We cannot always make these dis-
Facilitating the story is the third strategy that tinctions without asking the client how they
MRM nurses use. Disclosure of our clients’ perceive their relationship with their significant
self-care knowledge provides basic information other (H. Erickson et al., 2009, pp. 160–163).
needed before we can decide what nursing ac- A person’s story usually includes information
tions are required—information that provides about interactions among the dimensions of
insight into their worldview. We learn about the holistic person, but nurses often have trou-
their perceptions and beliefs, what they believe ble understanding the significance of what they
about their current situation, what they expect have heard. For example, when people say they
will happen, what resources they believe they are sick because they are too stressed, our first
have, and what they would like to do to alter response might be to think about the cause and
the situation. It also allows them to “contextu- effect of disease—for example, bacteria (not
alize life experiences and present them in a way stress) cause infections. However, the MRM
that softens associated feelings” (H. Erickson, model supports a holistic perspective; we know
2006b, p. 315). that mind and body are inextricably interactive.
Therefore, we recognize that psychosocial stress
Our clients’ self-care knowledge is best ob- stimulates the hypothalamic–pituitary–adrenal
tained by allowing them to tell their story in axis interactions, compromising the immune
their own way. We use active listening to fa- system. When this happens, we have more
cilitate our clients to tell their stories. This can difficulty fighting bacterial invasions. As a re-
be done very quickly by initiating the discus- sult, we know that psychosocial stress has the
sion with statements such as, “Tell me about potential of causing signs and symptoms of
your situation” followed by “Why do you think physical illness and/or disease.

198 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

The second phase, data aggregation, some- that someone cares about us will help us grow
times occurs as we interpret data derived from and heal. We project these messages through
the primary source (i.e., the client), but not al- our actions when we unconditionally accept
ways. To aggregate data accurately, we need to the worth of another human being and set
consider data derived from the secondary and intent to facilitate health and healing.
tertiary sources as well as the data derived from Watzlawick (1967) stated that “we cannot
the client. Although data can be aggregated not communicate.” Our attitudes, nonverbal
with only the client’s story and the nurse’s clin- behaviors, and touch are often more important
ical knowledge, it is also helpful to hear the than what we say when we convey our intent
family’s perspective. Sometimes it is important to help others heal and grow; words are not al-
to include the information collected from ter- ways necessary. Our demeanor, the way we
tiary sources as well. look at the person, what we focus on first, and
how we touch our clients relays our intent.
When aggregating data, we consider all the When we enter a relationship with the intent
information and look for consistencies as well to comfort and nurture the other person, our
as inconsistencies across the sources of infor- energy field connects with his; we convey pres-
mation. Additional information may be nec- ence and initiate a caring–healing environment
essary to clarify perspectives. Usually, this (H. Erickson, 2006b, pp. 300–324).
phase helps determine what needs to be done
when moving into the intervention phase of Practice Applications
the nursing process.
MRM, recognized by AHNA as one of the
Data analysis is the next phase. Again, you extant holistic nursing theories, is used in a va-
may be doing all three—interpreting, aggre- riety of settings including educational institu-
gating, and analyzing—simultaneously. Dur- tions as a framework for entire programs or
ing the analysis phase, you look for theoretical specific courses, hospitals to guide practice,
linkages among the data and make diagnoses. and for independent practice (Table 12-9).

Proactive Nursing Care The Society for the Advancement of Mod-
eling and Role-Modeling (SAMRM; www
Often the process of assessing our clients’ .mrmnursingtheory.org), established in 1985,
worldview serves as a therapeutic intervention. meets biennially with retreats in alternate
People in arousal commonly state that they feel years. Selected publications (Table 12-10)
much better after talking. Some will ask for demonstrate how MRM has been applied
minimal help, but some require more sophis- across populations and settings from pediatrics
ticated help. In any case, based on our diag- to the elderly, chronically ill to the well, and
noses, nursing care is planned within the intensive care to home care. Others (such as
context of the MRM principles of care, aimed publications by Baas, Barnfather, Duke, Frisch,
at facilitating well-being in our clients, and de- Hertz, Kelly, and Perese; see Table 12-10)
signed specifically to meet intervention goals. describe MRM with those who have heart fail-
We do this as we manage technical care such ure, undereducated adult learners, and/or
as wound management, intravenous insertion, employed mothers with preschool children.
and so forth. We use nonjudgmental language, For example, Baas (2004) has tested relations
caring tones, and direct statements that relay between self-care resources and activities and
information needed to feel safe and cared quality of life and developed protocol for nurs-
about. We also use Ericksonian hypnothera- ing practice. Baas, Past President of the Amer-
peutic techniques to promote growth and ican Association of Heart Failure (AAFH)
facilitate healing (H. Erickson et al., 2009, Nurses and Director of Nursing Research at
pp. 84–85, 145–147; H. Erickson, 2006b, the University of Cincinnati Medical Center
pp. 315–317; 372–374; Zeig, 1982). (2009–2012), continues to be actively involved
in setting practice protocol for nurses working
We can also do this without ever touching
the person because we use ourselves as con-
duits of healing energy. Sometimes knowing

CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 199

Table 12 • 9 Agencies Using or Teaching Modeling and Role-Modeling

Harding University, School of Nursing, Theoretical foundation for pediatric clinical course

Searcy, Arkansas

Metro State University, School of Nursing, Theoretical foundation, and student advising

St. Paul, Minnesota

The College of St. Catherine’s, School of Theoretical foundation, ADN Program

Nursing, St. Paul, Minnesota

The University of Texas at Austin, School of Theoretical foundation, the Alternate Entry Program

Nursing

Contemporary Health Care, Austin, Texas Independent Nurse Practice Agency

with people experiencing congestive heart fail- theory derived from MRM that measures per-
ure. Duke, Professor of Nursing and Associate ceived enactment of autonomy in the elderly.
Dean for Research, University of Texas at Hertz, Professor and Director of Graduate
Tyler, previously interested in the experiences Studies, Northern Illinois University, is cur-
of single mothers (published in Weber, 1999), rently involved with mentoring graduate
is currently studying attitudes about and pref- students interested in advancing holistic care
erences for end-of-life care in persons of for the elderly. Case studies are reported by
Jewish, Hindu, Muslim, Buddhist, and Bhai’I practitioners in each of the SAMRM
faiths and living in Texas. Both Frisch & newsletters; these and additional publications
Frisch (2010) and Perese (2012) have pub- (Hertz, 2013; Hertz, Irving, & Bowman, 2010;
lished textbooks for mental health practition- Hertz, Koren, Rossetti, & Robertson, 2008;
ers; Frisch & Frisch’s book is used as a Jablonski & Duke, 2012; Mitty, Resnick,
foundational book, whereas Perese’s was writ- Allen, Bakerjian, Hertz, Gardner et al., 2010)
ten specifically for advanced practice nurses. can be found on the SAMRM website (www
Hertz has developed and tested a midrange .mrmnursingtheory.org).

Table 12 • 10 Practice/Intervention Studies Related to Modeling and Role-
Modeling (MRM) Theory and Paradigm

Author Tested Source
Identification of states of
Erickson, H. (1976) coping Unpublished master’s thesis, Univer-
MRM and well-being sity of Michigan, Ann Arbor
Erickson, H., & Swain, Research in Nursing & Health, 5,
M. (1982) Exploration of self-care 93–101
Erickson, H. (1984) knowledge Dissertation Abstracts International,
45, 171. University Microfilms
Darling-Fisher, C., & Measuring Eriksonian devel- No. AAD84–12136
Kline-Leidy, N. (1988) opmental residual in the adult Psychological Reports, 62,
Walsh, K., Vanden MRM applied to two clinical 747–754
Bosch, T., & Boehm, S. cases Journal of Advanced Nursing,
(1989) 14(9), 755–761
Barnfather, J., Swain, Construct validity the APAM
M. A. P., & Erickson, Issues in Mental Health Nursing,
H. (1989). MRM and hypertension 10, 23–40
Erickson, H., & Swain, reduction
M. (1990) Issues in Mental Health Nursing,
11(3), 217–235

Continued

200 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Table 12 • 10 Practice/Intervention Studies Related to Modeling and Role-
Modeling (MRM) Theory and Paradigm—cont’d

Author Tested Source

Finch, D. (1990) MRM nursing assessment Modeling and Role-Modeling:
model Theory, Practice and Research,
Kline-Leidy, N. (1990) 1(1), 203–213
Relations among stress, Nursing Research, 39, 230–236
Erickson, H. (1990) resources, and symptoms of
chronic illness In J.K. Zeig & Gilligan, S. (Eds.)
Acton, G., Irvin, B., & MRM with mind–body Brief Therapy: Myths, Methods, and
Hopkins, B. (1991) problems Metaphors. New York: Brunner/
Barnfather, J. (1993) Mazel, 473–491.
Theory testing research: Advances in Nursing Science,
Holl, R. (1993) Building the science 14(1), 52–61.
Testing a theoretical Issues in Mental Health Nursing,
Baas, L., Deges-Curl, proposition of MRM 14, 1–18.
E., Hertz, J., & MRM vs. restricted visiting Critical Care Nursing Quarterly,
Robinson, K. (1994) 16(2), 70–82
Webster, D., Vaughn, Innovative approaches to Advances in Nursing Science
K., Webb, M., & theory based measurement: Series: Advances in Methods of
Player, A. (1995) MRM research Inquiry, 5, 147–159.
Kline-Leidy, N., & MRM and brief solution- Issues in Mental Health
Travis, G. (1995) focused therapy Nursing, 16(6), 505–518

Hertz, J. (1996) Relations between Research in Nursing & Health, 18,
psychophysiological factors 535–546
Baldwin, C. (1996) and physical functioning
Perceived enactment of Issues in Mental Health Nursing,
Erickson, M. (1996) autonomy (PEA) 17, 261–273
Perceptions of hope The Journal of Multicultural Nursing
Sappington, J., & & Health, 2(3), 41–45
Kelly, J. (1996) EMBAT and maternal Issues in Mental Health Nursing,
Baas, L., Fontana, J., well-being 17, 185–200
& Bhat, G. (1997) A case study Journal of Holistic Nursing, 14(2),
Raudonis, B., & Acton, 130–141
G. (1997) Self-care resources and the Progress in Cardiovascular Nursing,
Acton, G., Mayhew, quality of life 12(1), 25–38
P., Hopkins, B., & Theory-based nursing Journal of Advanced Nursing,
Yauk, S. (1999) practice 26(1), 138–145
Acton, G. (1997) Communicating with persons Journal of Gerontological Nursing,
with dementia 25(2), 6–13
Irvin, B., & Acton,
G. (1997) The mediating effect of Journal of Holistic Nursing, 15(4),
Jensen, B. (1997) affiliated-individuation 336–357
Baas, L., Berry, T., Stress, hope and well-being Holistic Nursing Practice, 11(2),
Fontana, J., & Wag- 69–79
oner, L. (1999) Caring for the caregiver Home Care Provider, 2(6), 34–36
Jensen, B. (1999) Developmental growth in Journal of Holistic Nursing, 17(2),
adults with heart failure 117–138
Scheela, R. (1999)
Caregiver responses to MRM Dissertation Abstracts International,
Weber, G. (1999) B 56/06, 3127
Remodeling sex offenders Journal of Psychosocial Nursing and
Mental Health Services, 37(9), 25–31
The meaning of well-being Western Journal of Nursing
(self-care knowledge) Research, 21(6), 785–795

CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 201

Table 12 • 10 Practice/Intervention Studies Related to Modeling and Role-
Modeling (MRM) Theory and Paradigm—cont’d

Author Tested Source

Barnfather, J., & Ronis, Psychosocial resources, Research in nursing & health, 23,
D. (2000) stress, and health 55–66.
Timmerman, G., & Relations between needs and Issues in Mental Health Nursing,
Acton, G. (2001) emotional eating 22(7), 691–701
Mayhew, P., Acton, Communication, dementia, Gerontological Nursing, 22,
G., Yauk, S., & and well-being 106–110
Hopkins, B. (2001)
Berry, T., Baas, L., Spirituality in persons with Journal of Holistic Nursing, 20(1),
Fowler, C., & Allen, G. heart failure pp. 5–30
(2002)
Perese, E. (2002) Integrating psychiatric nurs- Journal of American Association of
ing into educational models Psychiatric Nurses, 8(5), 152–158
Hertz, J., Anschutz, C. Relationships among PEA, Journal of Holistic Nursing, 20,
(2002) self-care, and holistic health 166–186
Baas, L. (2004) Self-care resources, activities Dimensions of Critical Care Nurs-
as predictors of quality of life ing, 23(3), 131–138
Baas, L., Berry, T., Awareness in persons with Journal of Cardiovascular Nursing,
Allen, G., Wizer, M., heart failure or transplant 19(1), 32–40
&Wagoner, L. (2004)
Lombardo, S. L., & Application MRM to person Home Healthcare Nurse, 23(7),
Roof, M. (2005) with morbid obesity 425–428.
Berry, T., Baas, L., & Self-reported adjustment to Journal of Cardiovascular Nursing,
Henthorn, C. (2007) implanted cardiac devices 22(6), 516–524

We cannot cure people, but we can help acquired, these are secondary to using ourselves
them heal and grow, even as they are taking their as healing agents. As nurses, we nurture and
first or last breath. When people heal, they be- facilitate people to become the most that they
come more fully connected with the multiple di- can be. We help them actualize their life roles
mensions of their mind, body, and spirit, and as and find meaning in their existence. When this
a result, they become more fully actualized. A happens, it affects not only our clients but also
caring–healing environment, created by the those who are significant in their lives.
nurses’ intent, fosters growth and well-being in
their clients. Because people have inherent in- As nurses, every interaction with our clients
stincts and drives to grow, develop, and heal, all and their loved ones provides us with oppor-
nursing actions focus on facilitation and nurtu- tunities to affect the future; I call this the “long-
rance of these innate abilities. We use ourselves arm affect” (H. Erickson, 2006b, p. 390).
to connect with our clients in such a way that How we perceive our roles as nurses will de-
we can create trusting functional relationships termine our intent. This in turn affects what
with them, relationships that have a purpose or we do, how we interact, the focus of our work,
are aimed at some outcome. In the MRM and the outcomes of our relationships. We
model, these relationships aim to affirm clients’ cannot always change what will happen in our
worth; to help them mobilize and build resources lives or those of others, but we can set the in-
needed to cope with their stressors/stress; foster tent to help people grow, heal, and move on.
hope for the future; and promote a sense of J. M.’s letter (see Practice Exemplar 1) sug-
affiliated-individuation. When people have gests that I not only helped his family deal
these experiences, a sense of well-being follows. with a life tragedy but also helped them dis-
Although we use every professional skill we have cover ways to find meaning in the experience.
I helped them grow, heal, and move on.

202 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Practice Exemplar 1

A man who was the strong, dominant mem- Eight years later, I received a letter from his
ber of his family was lying in bed, inconti- son (only 16 at the time of his father’s death),
nent, riddled with cancer, and feeling notifying me that his mother had died. He
hopeless. When I learned that he no longer knew I would want to know that because of
allowed his family to visit, I gently took his what they had learned from me, she was able
hand and told him I was happy to be his to pass at home with her family at her side,
nurse that evening. He “looked at me with singing her favorite songs and strumming on
very sad eyes . . . [and said] that he didn’t want the guitar. He went on to state:
his family to see him in this condition. . . .
[H]e had always taken care of his family, and In the year my Dad was with you people in
now . . . he couldn’t take care of himself” Ann Arbor, you were of incalculable aid and com-
(H. Erickson, 2006a, p. 325). I rephrased his fort to both my parents—you gave them confidence
words and then told him that although he in you and your staff, and the dignity and respect
had been the breadwinner in the past and his which makes life worth living; no one else could,
family members had enjoyed and appreciated or did, more genuinely have their gratitude and
that, all they wanted now was to be with respect. When I would come down and all seemed to
him, to share his life, to show him that he be lost, the one bright spot was that Mrs. Erickson
was important because he loved them and would be coming on, and we could breathe a little
they loved him. He agreed, and for the next more easily as Dad’s anxiety visibly receded. Your
few days his family members took turns just kindness and humanity made the world a better
being with him. On the third day when he place at that time and without you the experience
quietly passed, he and his family were able would have been more difficult than you probably
to grieve with dignity and peace. believe. Thank you, J. M.

Practice Exemplar 2

Most data are easy to understand although Mr. S. looked surprised and said he didn’t
there are some that are symbolic of earlier know what had made him think of that event
losses. A middle-aged man I worked with a and hadn’t thought about it for years. When I
number of years ago had just been admitted asked him what he expected to happen to him,
to the hospital for a “workup.” Mr. S. had he said he guessed that he was going to die.
complained of chronic fatigue for the past 6 He went on to say that he thought he had de-
months. An hour or so before I saw him, he veloped leukemia because he hadn’t been re-
had learned that he had acute leukemia. sponsible, and when he wasn’t responsible;
When I asked him to tell me about his situ- people died. As we explored his resources, he
ation, he told me about his leukemia and explained that he had been promoted about
then launched into a story about his child- 9 months earlier and that his new job required
hood. He described a time when he was skills he didn’t think he had. His conclusions
about 16 years old, had been told to watch his were that he was sick because he had “worried
younger sister and had let her ride a horse himself to death.” He also stated that he didn’t
without supervision. She fell off and was want his wife to come see him, that he needed
killed. He remembered his father telling him to decide what he wanted to do first, and how
that he had not been responsible and that he he could take care of her now that he was sick?
needed to grow-up and be a man. When I asked if she or someone else could

CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 203

Practice Exemplar 2 cont. serve as an energetic conduit were strategies
used throughout our time together, pur-
help him consider options, he said no, that it posefully initiated with each visit.
was his responsibility to take care of himself. • When I asked him to tell me about his
To understand these data, I needed to recog- situation, I also stated that he could talk
nize the following: about anything that popped into his mind,
• People who link new stressful experiences even if it didn’t seem to be related to his
current situation. This strategy is used
to past experiences are usually dealing with because people have state-dependent
a loss related to the past experience. In his memory, their current experiences are often
case, it was not only the loss of his sister related to losses incurred in the past. Al-
but also the meaning of the loss. As a though they are unaware of these relations,
16-year-old boy, he was learning about his it may be important to help them “uncover”
ability to make sound decisions, to be inde- these experiences in their own time and
pendent, to determine who he was as a their own way so that they can begin to
unique human being in society. He had heal—a prerequisite for mobilizing re-
learned that “when he wasn’t responsible, sources needed to contend with the current
people died.” situation.
• Although he identified his wife as his sig- • I used active listening skills as he told his
nificant other, he was overindividuated. He story, using nonverbal communications to
needed to decide how to “tell” his wife encourage him to open up, staying energet-
about his problem—his problem of not ically connected, and remaining quiet when
being responsible, not being a “man.” He he paused, allowing him an opportunity to
did not perceive that it was appropriate to express his self-care knowledge.
seek comfort from her or others. • My question: What do you expect will hap-
• Mr. S. is in arousal with unmet safety and pen? was used to assess self-care resources
belonging needs, unresolved loss with mor- and to allow him to identify associated
bid grief, and both positive and negative factors and express his worse fears. His re-
residual from adolescence on. Strong posi- sponse indicated that he was depleted of
tive residual from early childhood provides resources (i.e., impoverished), his definition
some resources that could be mobilized of being responsible no longer worked for
with assistance. him, and he needed help reframing his be-
• Although Mr. S. is chronologically in the haviors and identifying new resources. I
stage of Intimacy versus Isolation, his stres- further explored his resources with the
sors are related to residuals from the stage follow-up questions.
of Competency versus Limitations. • Considering that the loss had occurred dur-
• Mr. S’s healthy affiliated–individuation has ing the age of adolescence and the task of
been threatened due to overindividuation. developing Identity and that healthy reso-
• Mr. S. wished to be “responsible” to “take lution of Identify is important for the devel-
care of his wife.” opment of healthy intimacy in the next
stage of life, follow-up interventions in-
Specific interventions used in this case are cluded exploring alternative ways to think
as follows: about “being responsible”—the role he had
• I centered myself and set intent to be ener- chosen for himself. Using open-ended
questions, I helped him consider his rela-
getically connected, using myself as a con- tionship with his family by thinking about
duit of healing energy from the universe. how he was like the 16-year-old boy and
Setting an intent to connect and serve as a how he was different; how he wanted to be
healing instrument is a prerequisite to facili-
tating a client’s storytelling. It is also an im- Continued
portant strategy for helping people mobilize
resources needed to help themselves heal.
Centering, setting intent to connect, and to

204 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Practice Exemplar 2 cont. of chemotherapy outcomes, I suggested
that chemotherapy was designed to fight
like that boy and how he wanted to be dif- with the bad cells, but he didn’t need to
ferent; and how he wanted to relate to his have the chemotherapy fight with his good
wife in the future and how he might start. cells, that he could protect them if he
Rhetorical questions, stated as curiosities wanted. When he expressed curiosity about
rather than a demand for a response, were protecting his good cells, I helped him
used to stimulate growth. Examples include learn how to use guided imagery so that the
statements such as I wonder how you are like chemotherapy would seek out bad cells and
that 16-year-old boy now, and how you are attach them, but leave the others alone. We
different? It might even be interesting to think then talked about ensuring that the
about how you want to be like that boy—or chemotherapy had a good chance of doing
different. its work by proactively getting sufficient
• Biophysical care was also offered and pro- sleep, drinking fluids, seeking nurturing re-
vided with consideration for his develop- lations, participating in activities that help
mental resources. Adolescents with healthy him laugh, and other activities that made
developmental resources often vacillate in him feel loved, happy, and at peace.
their need to be independent in their activi- • Upon discharge, I offered him a business
ties of daily life and their needs to have care card as a transitional object. I explained
consistent with earlier stages provided. The that it contained my name and contact in-
only way to know is to offer care and follow formation in the event that he wanted to
the client’s responses. Thus, when asked to talk with me at any time. I also stated that
help with foot care, it was provided; when many people find they are able remember
told that he could manage making his own our time together—what they felt, heard,
outpatient appointments, he was given the smelled, and saw—by holding the card
information needed to make his appoint- and/or even just by thinking about it.
ments and asked if he needed any other in-
formation after the appointments were I followed this gentleman for several weeks,
confirmed. visiting him occasionally in the outpatient
• As he prepared for discharge to the outpa- clinic. He always had my business card with
tient clinic for chemotherapy, I explored his him and often commented that it was magic
perceptions of the effects of chemotherapy. and that it helped him get through the bad
He stated that chemotherapy was a poison days. Two years later I received a letter thank-
and would make him sick, that he didn’t ing me for helping him and stating that he was
look forward to that. I agreed that in remission. He and his wife were planning a
chemotherapy was a poison, but that there trip to celebrate their anniversary.
were several things he could do to help
himself. Aiming to reframe the perception

■ Summary

Nurses who use modeling and role-modeling therapeutic interventions. During the model-
believe the human is holistic with ongoing, dy- ing process, nurses gain an understanding of
namic mind–body–spirit interactions; clients their clients perceptions of what has caused
are the primary source of information; and their health problem, what impedes their heal-
nurses are instruments of healing. Modeling is ing, and what will facilitate healing and
the process used to gain an understanding of growth. Modeling the client’s worldview also
their clients’ perceptions and understandings helps nurses to understand their clients’ rela-
of their conditions, health needs, and possible tionships and related roles, identify those that

CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 205

impede health and wellness and those that are in healthy self-care actions. Strategies are de-
meaningful and facilitate healing and growth. signed within the context of developmental
residual and with consideration for losses and
Role-modeling is helping clients find alter- related attachment objects. Verbal and nonver-
native ways to fulfill their desired roles in life. bal communication and basic biophysical nurs-
This requires interventions including biophys- ing skills are considered essential prerequisites
ical care as well as psychosocial strategies de- in the use of MRM.
signed to help people articulate their self-care
knowledge, mobilize resources, and participate

References

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Barbara Dossey’s Theory of 13Chapter
Integral Nursing

BARBARA MONTGOMERY DOSSEY Introducing the Theorist
Introducing the Theorist
Overview of the Theory Barbara Montgomery Dossey, PhD, RN,
Applications to Practice AHN-BC, FAAN, HWNC-BC, is interna-
Practice Exemplar tionally recognized as a pioneer in the holistic
Summary nursing movement and the integrative nurse
References coach movement as well as a Florence
Nightingale scholar. She is Co-Director, In-
Barbara Montgomery ternational Nurse Coach Association (INCA),
Dossey and Core Faculty, Integrative Nurse Coach
Certificate Program (INCCP); International
Co-Director, Nightingale Initiative for Global
Health (NIGH); and Director, Holistic Nurs-
ing Consultants. She is the author or coauthor
of 25 books. Her most recent books include

Nurse Coaching: Integrative Approaches for
Health and Wellbeing (2015), Holistic Nursing:
A Handbook for Practice (6th ed., 2013), The Art
and Science of Nurse Coaching: The Provider’s
Guide to Coaching Scope and Competencies (2013),
Florence Nightingale: Mystic, Visionary, Healer
(Commemorative Edition, 2010), and Florence
Nightingale Today: Healing, Leadership, Global
Action (2005).

B. M. Dossey’s theory of integral nursing
(2008, 2013) is considered a grand theory that
presents the science and art of nursing. Her
collaborative global nursing project, the
Nightingale Initiative for Global Health
(NIGH) and its initiative the Nightingale
Declaration Campaign (NDC), recognizes
the contributions of nurses worldwide as they
engage in the promotion of global health,
including the United Nations Millennium
Development Goals and the Post-2015 Sus-
tainable Development Goals. Dossey has re-
ceived many awards and recognitions. She is a
Fellow of the American Academy of Nursing,
Board Certified by the American Holistic
Nurses credentialing corporation as an advanced

207

208 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

holistic nurse (AHN-BC), and a health and nursing (nurse, person[s], health, and envi-
wellness nurse coach (HWNC-BC). She is a ronment [society]), six patterns of knowing
ten-time recipient of the prestigious American (personal, empirics, aesthetics, ethics, not
Journal of Nursing Book of the Year Award. knowing, sociopolitical), integral theory, and
Dossey received the 2014 Lifetime Achieve- theories outside of the discipline of nursing.
ment Award and was named the 1985 Holistic It builds on the existing integral, integrative,
Nurse of the Year by the American Holistic and holistic ultidimensional theoretical nurs-
Nurse’s Association. With her husband, Larry, ing foundations and has been informed by the
she received the 2003 Archon Award from work of other nurse theorists; it is not a free-
Sigma Theta Tau International, the Interna- standing theory. It incorporates concepts from
tional Honor Society of Nursing, honoring the various philosophies and fields that include
contribution that they have made to promote holistic, multidimensionality, integral, chaos,
global health. In 2004, Barbara and Larry also spiral dynamics, complexity, systems, and
received the Pioneer of Integrative Medicine many other paradigms. [Note: Concepts specific
Award from the Aspen Center for Integrative to the theory of integral nursing are in italics
Medicine, Aspen, Colorado. throughout this chapter. Please consider these
words as a frame of reference and a way to ex-
Overview of the Theory plain and explore what you have observed or ex-
perienced with yourself and others.]
As you begin to explore the theory of integral
nursing, I invite you to reflect on the following Integral nursing is a comprehensive integral
questions: Why am I here? Are my personal worldview and process that includes integrative
and professional actions sourced from my and holistic theories and other paradigms; ho-
soul’s purpose and wisdom? What is my call- listic nursing is included (embraced) and tran-
ing, mission, and vision for my work in the scended (goes beyond); this integral process
world? How can I strengthen my passion in and integral worldview enlarges our holistic
nursing and in my life? What am I currently nursing knowledge and understanding of
doing to become more aware of my personal body–mind–spirit connections and our know-
health and the health of my home and work- ing, doing, and being to more comprehensive
place? What am I doing locally that can affect and deeper levels. To delete the word “inte-
the health and well-being of humanity and our gral” or to substitute the word “holistic” dimin-
Earth? How am I connected to my nursing ishes the impact of the expansiveness of the
colleagues and concerned citizens in my com- integral process and integral worldview and its
munity, in other cities, and nations? What is implications.
my calling?
The theory of integral nursing includes an
The theory of integral nursing is a grand integral process, integral worldview, and inte-
theory that guides the science and art of inte- gral dialogues that compose praxis—theory in
gral nursing practice, education, research, and action (B. M. Dossey, 2008; 2013). An inte-
health-care policy. It incorporates physical, gral process is defined as a comprehensive way
mental, emotional, social, spiritual, cultural, to organize multiple phenomena of human
and environmental dimensions and an expan- experience and reality from four perspectives:
sive worldview. It invites nurses to think (1) the individual interior (personal/inten-
widely and deeply about personal health and tional), (2) individual exterior (physiology/
client, patient, and family health, as well as behavioral), (3) collective interior (shared/
that of the local community and the global vil- cultural), and (4) collective exterior (systems/
lage. This theory recognizes the philosophical structures). An integral worldview examines
foundation and legacy of Florence Nightin- values, beliefs, assumptions, meaning, purpose,
gale (1820–1910; Dossey, 2010; Dossey, and judgments related to how individuals per-
Selanders, Beck, & Attewell, 2005) healing ceive reality and relationships from the four
and healing research, the metaparadigm of perspectives. Integral dialogues are transforma-
tive and visionary explorations of ideas and

CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 209

possibilities across disciplines, where these four 2013; WHO, 2009). You are invited to sign
perspectives are considered as equally impor- the Nightingale Declaration at www.nightin-
tant to all exchanges, endeavors, and out- galedeclaration.net. Our Nightingale nursing
comes. With an increased integral awareness legacy, as discussed in the next section, is foun-
and an integral worldview, we are more likely dational to the theory of integral nursing
to raise our collective nursing voice and power and to understanding our important roles as
to engage in social action in our role and work 21st-century nurses.
of service for society—local to global.
Philosophical Foundation: Florence
As you read this chapter, 35 million nurses Nightingale’s Legacy
and midwives are engaged in nursing and
health care around the world (World Health Florence Nightingale, the philosophical
Organization [WHO], 2009). Together, we founder of modern secular nursing and the first
are collectively addressing human health—of recognized nurse theorist, was an integralist.
individuals, of communities, of environments Her worldview focused on the individual and
(interior and exterior) and the world as our first the collective, the inner and outer, and human
priority. We are educated and prepared— and nonhuman concerns. She identified envi-
physically, emotionally, socially, mentally, and ronmental determinants (clean air, water, food,
spiritually—to accomplish the required activi- houses, etc.) and social determinants (poverty,
ties effectively—on the ground—to create a education, family relationships, employ-
healthy world. Nurses are key in mobilizing ment)—local to global. She also experienced
new approaches in health education and and recorded her personal understanding of
health-care delivery in all areas of the profes- the connection with the Divine—that is,
sion and society as a whole. Theories, solu- awareness that something greater than she, the
tions, and evidence-based practice protocols Divine, was present in all aspects of her life.
can be shared and implemented around the
world through dialogues, the Internet, and Nightingale’s work was social action that
publications. clearly articulated the science and art of an in-
tegral worldview for nursing, health care, and
We are challenged to “act locally and think humankind. Her social action was also sacred
globally” and to address ways to create healthy activism (Harvey, 2007), the fusion of the
environments (B. M. Dossey, 2013; B. M. deepest spiritual knowledge with radical action
Dossey et al., 2005). For example, we can ad- in the world. Nightingale was ahead of her
dress global warming in our personal habits at time; her dedicated and focused 50 years of
home as well as in our workplace (using green work and service still inform and affect the nurs-
products, turning off lights when not in the ing profession and our global mission of health
room, using water efficiently) and simultane- and healing. In the 1880s, Nightingale began
ously address our personal health and the to write in letters that it would take 100 to
health of the communities where we live (Na- 150 years before sufficiently educated and ex-
tional Prevention Council, 2011). In 2000, the perienced nurses would arrive to change the
United Nations Millennium Goals were rec- health-care system. We are that generation of
ommended to articulate clearly how to achieve 21st-century Nightingales who can transform
health and decrease health disparities (United health care and carry forth her vision to create
Nations, 2000). As we expand our awareness a healthy world (B. M. Dossey, 2013; B. M.
of individual and collective states of healing Dossey, Luck, & Schaub, 2015; Beck, Dossey,
consciousness and integral dialogues, we are & Rushton, 2011; McDonald, 2001–2012;
able to explore integral ways of knowing, Mittelman et al., 2010).
doing, and being. We can unite 35 million
nurses and midwives and concerned citizens Personal Journey Developing the
through the Internet to create a healthy world Theory of Integral Nursing
through many endeavors such as the Nightingale
Declaration (B. M. Dossey et al., 2013; NIGH, As a young nurse attending my first nursing
theory conference in the late 1960s, I was

210 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

captivated by nursing theory and the eloquent therapies (biofeedback, relaxation, imagery,
visionary words of these theorists as they music, meditation, and other reflective prac-
spoke about the science and art of nursing. tices and touch therapies) and began to in-
This opened my heart and mind to explo- corporate them into our daily lives. As we
ration and to the necessity to understand and strengthened our capacities with self-care and
use nursing theory. Thus, I began my profes- self-regulation modalities, our personal and
sional commitment to address theory in all professional philosophies and clinical practices
endeavors as well as to increase my knowl- changed. As we integrated these modalities
edge of other disciplines that could inform a into our own lives, we began to introduce
deeper understanding about the human expe- them into the traditional health-care setting
rience. I realized that nursing was not either that today is called integrative and integral
“science” or “art,” but both. From the begin- health care.
ning of my critical care and cardiovascular
nursing focus, I learned how to combine sci- As a founding member in 1980 of the
ence and technology with the art of nursing. American Holistic Nurses Association (AHNA)
For example, for patients with severe pain and with my AHNA colleagues, our collective
after an acute myocardial infarction, I gave holistic nursing endeavors were recognized as
pain medication while simultaneously guid- the specialty of holistic nursing by the American
ing them in a relaxation or imagery practice Nurses Association (ANA) in November 2006
to enhance relaxation and release anxiety. I (AHNA & ANA, 2007, 2013). Holistic nurs-
also experienced a difference in myself when ing can now be expanded by using an integral
I used this approach to combine the science lens. An integral perspective can also further our
and art of nursing. endeavors in national health-care reform and
the implementation of Healthy People 2020 as
In the late 1960s, I began to study and a national strategy. The emerging movement for
attend workshops on holistic and mind– professional nurse coaching (Dossey, Luck, &
body-related ideas and to read in other disci- Schaub, 2015; Hess et al., 2013) and strategies
plines, such as systems theory, quantum physics, to increase patient engagement (Weil, 2013)
integral theory, Eastern and Western philoso- can be strengthened when considered from an
phy, and mysticism. I was reading theorists integral perspective.
from nursing and other disciplines that in-
formed my knowing, doing, and being in car- Beginning in 1992 in London, my Florence
ing, healing, and holism. My husband, a Nightingale primary, historical research of
physician of internal medicine who was caring studying and synthesizing her original letters,
for critically ill patients and their families, was army and public health documents, manu-
with me at the beginning of this journey of dis- scripts, and books, deepened my understanding
covery. As we cared for patients and families— of her relevance for nursing. My professional
some of our greatest teachers—we reflected on mission now is to articulate and use the inte-
how to blend the art of caring–healing modal- gral process and integral worldview in my
ities with the science of technology and tradi- nursing, integrative nurse coaching, and inter-
tional modalities. I discussed these ideas with professional endeavors, and to explore rituals
a critical care and cardiovascular nursing soul- of healing with many. My sustained nursing
mate, Cathie Guzzetta. We began writing career focus with nursing colleagues on whole-
teaching protocols and presenting in critical ness, unity, and healing and my Florence
care courses as well as writing textbooks and Nightingale scholarship have resulted in
articles with other contributors. numerous protocols and standards for practice,
education, research, and health-care policy.
My husband and I both had health chal- My integral focus since 2000 and my many
lenges—mine was postcorneal transplant re- conversations with Ken Wilber and the inte-
jection, and my husband’s challenge was gral team and other interdisciplinary integral
blinding migraine headaches. We both began colleagues has led to my development of the
to take courses related to body–mind–spirit theory of integral nursing.

CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 211

Theory of Integral Nursing disciplines (J. Baye, personal communication,
Developmental Process and Intentions 2007; Clark, 2006; Fiandt et al., 2003; Frisch,
2013; Jarrin, 2007; Quinn, Smith, Ritten-
The theory of integral nursing advances the baugh, Swanson, & Watson, 2003; Watson,
evolutionary growth processes, stages, and lev- 2005; Zahourek, 2013).
els of human development and consciousness
toward a comprehensive integral philosophy Content, Context, and Process
and understanding. It can assist nurses to map
human capacities that begin with healing and To present the theory of integral nursing, Bar-
evolve to the transpersonal self in connection bara Barnum’s (2005) framework to critique a
with the Divine, however defined or identified, nursing theory—content, context, and process—
in their endeavors to create a healthy world. provides an organizing structure that is most
useful. The philosophical assumptions of the
The theory of integral nursing has three theory of integral nursing are as follows:
intentions: (1) to embrace the unitary whole
person and the complexity of the nursing 1. An integral understanding recognizes
profession and health care; (2) to explore the the individual as an energy field con-
direct application of an integral process and in- nected to the energy fields of others and
tegral worldview that includes four perspec- the wholeness of humanity; the world is
tives of realities—the individual interior and open, dynamic, interdependent, fluid,
exterior and the collective interior and exterior; and continuously interacting with chang-
and (3) to expand nurses’ capacities as 21st- ing variables that can lead to greater
century Nightingales, health diplomats, and complexity and order.
integral nurse coaches for integral health—
local to global. 2. An integral worldview is a comprehensive
way to organize multiple phenomena of
Integral Foundation and the human experience from four perspectives
Integral Model of reality: (a) individual interior (subjective,
personal); (b) individual exterior (objective,
The theory of integral nursing adapts the work behavioral); (c) collective interior (interob-
of Ken Wilber, one of the most significant jective, cultural); and (d) collective exterior
American new-paradigm philosophers, to (interobjective, systems/structures).
strengthen the central concept of healing. His
elegant, four-quadrant model was developed 3. Healing is a process inherent in all living
over 35 years. In the eight-volume The Collected things; it may occur with curing of
Works of Ken Wilber (Wilber, 1999, 2000a), symptoms, but it is not synonymous
Wilber synthesizes the best known and most with curing.
influential thinkers to show that no individual
or discipline can determine reality or lay claim 4. Integral health is experienced by a per-
to all the answers. Many concepts within the son as wholeness with development
integral nursing theory have been researched toward personal growth and expanding
or are in formative stages of development states of consciousness to deeper levels
within integral medicine, integral health-care of personal and collective understanding
administration, integral business, integral of one’s physical, mental, emotional,
health-care education, and integral psy- social, spiritual, cultural, environmental
chotherapy (Wilber, 2000a, 2000b, 2005a, dimensions.
2005b, 2006). Within the nursing profession,
other nurses are exploring integral and related 5. Integral nursing is founded on an integral
theories and ideas. When nurses use an inte- worldview using integral language and
gral lens, they are more likely to expand nurses’ knowledge that integrates integral life
roles in transdisciplinary dialogues and to ex- practices and skills each day.
plore commonalities and differences across
6. Integral nursing is broadly defined to
include knowledge development and all
ways of knowing that also recognizes the
emergent patterns of not knowing.

212 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

7. An integral nurse is an instrument in the Healing
healing process and facilitates healing
through her or his knowing, doing, and Fig 13 • 1 A, Healing. Source: Copyright © Barbara
being. Dossey, 2007.

8. Integral nursing is applicable in practice, have a perception of healing having occurred
education, research, and health-care policy. (B. M. Dossey, 2013; Gaydos, 2004, 2005).

Content Components Healing embraces the individual as an en-
ergy field that is connected with the energy
Content of a nursing theory includes the subject fields of all humanity and the world. Healing is
matter and building blocks that give a theory transformed when we consider four perspectives
its form. It comprises the stable elements that of reality in any moment: (1) the individual
are acted on or that do the acting. In the theory interior (personal/intentional), (2) individual
of integral nursing, the subject matter and exterior (physiology/behavioral), (3) collective
building blocks are (1) healing, (2) the meta- interior (shared/cultural), and (4) collective ex-
paradigm of nursing, (3) patterns of knowing, terior (systems/structures). Using our reflective
(4) the four quadrants that are adapted from integral lens of these four perspectives of reality
Wilber’s (2000a) integral theory (individual in- assists us to more likely experience a unitary
terior [subjective, personal/intentional], indi- grasp within the complexity that emerges in
vidual exterior [objective, behavioral], collective healing.
interior [intersubjective, cultural], and collec-
tive exterior [interobjective, systems/struc- Healing is not predictable; it may occur with
tures]), and (5) Wilber’s “all quadrants, all curing of symptoms, but it is not synonymous
levels, all lines” (Wilber, 2000a, 2006). with curing. Curing may not always occur, but
the potential for healing is always present even
Content Component 1: Healing. The first until one’s last breath. Intention and intention-
content component in a theory of integral ality are key factors in healing (Barnum, 2004;
nursing is healing, illustrated as a diamond Engebretson, 1998; Zahourek, 2004; 2013).
shape in Figure 13-1A. The theory of integral Intention is the conscious determination to do
nursing enfolds from the central core concept a specific thing or to act in a specific manner; it
of healing. Healing includes knowing, doing, is the mental state of being committed to, plan-
and being, and is a lifelong journey and process ning to, or trying to perform an action. Inten-
of bringing together aspects of oneself at tionality is the quality of an intentionally
deeper levels of harmony and inner knowing performed action.
leading toward integration. This healing
process places us in a space to face our fears, to Content Component 2: Metaparadigm of
seek and express self in its fullness where we Nursing. The second content component in the
can learn to trust life, creativity, passion, and theory of integral nursing is the recognition
love. Each aspect of healing has equal impor- of the metaparadigm in a nurse theory: nurse,
tance and value that leads to more complex person/s, health, and environment (society;
levels of understanding and meaning. Fig. 13-1B) (Fawcett, Watson, Neuman,
Walker, & Fitzpatrick, 2001). Starting with
Healing capacities are inherent in all living healing at the center, a Venn diagram sur-
things. No one can take healing away from life; rounds healing and implies the interrelation,
however, we often get “stuck” in our healing interdependence, and effect of these domains
or forget that we possess it due to life’s contin- as each informs and influences the others; a
uing challenges and perceived barriers to change in one will create a degree(s) of change
wholeness. Healing can take place at all levels in the other(s), thus affecting healing at many
of human experience, but it may not occur si-
multaneously in every realm. In truth, healing
will most likely not occur simultaneously or
even in all realms, and yet the person may still

CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 213

Nurse Health includes an individual nurse who interacts with
a nursing colleague, other interprofessional
Healing health-care team members, or a group of com-
munity members or other groups.
Person(s) Environment
(society) Integral health is the process through which
we reshape basic assumptions and worldviews
Fig 13 • 1 B, Healing and Meta-Paradigm of about well-being and see death as a natural
Nursing. Source: Copyright © Barbara Dossey, 2007. process of the cycle of life. Integral health may
be symbolically seen as a jewel with many
levels. These concepts are important to the the- facets that is reflected as a “bright gem” or a
ory of integral nursing because they are en- “rough stone” depending on one’s situation
compassed within the quadrants of human and personal growth that influence states of
experience as seen in Content Component 4. health, health beliefs, and values (Gaydos,
2004). The jewel may also be seen as a spiral
An integral nurse is defined as a 21st- or as a symbol of transformation to higher
century Nightingale. Using terms coined by states of consciousness to more fully under-
Patricia Hinton Walker, PhD, RN, FAAN stand the essential nature of our beingness as
(personal communication, May 15, 2007), energy fields and expressions of wholeness
nurses’ endeavors of social action and sacred (Newman, 2003). This includes evolving one’s
activism engage “nurses as health diplomats” state of consciousness to higher levels of per-
and “integral nurse coaches” that are “coaching sonal and collective understanding of one’s
for integral health.” As nurses strive to be in- physical, mental, emotional, social, and spiri-
tegrally informed, they are more likely to move tual dimensions. It acknowledges the individ-
to a deeper experience of a connection with the ual’s interior and exterior experiences and the
Divine or Infinite, however defined or identi- shared collective interior and exterior experi-
fied. Integral nursing provides a comprehensive ences with others, where authentic power is
way to organize multiple phenomena of recognized within each person. Disease and
human experience in the four perspectives of illness at the physical level may manifest for
reality as previously described. The nurse is an many reasons and variables. It is important not
instrument in the healing process, bringing her to equate physical health, mental health, and
or his whole self into relationship to the whole spiritual health, as they are not the same
self of another or a group of significant others thing. They are facets of the whole jewel of
and thus reinforcing the meaning and experi- integral health.
ence of oneness and unity.
An integral environment(s) has both interior
A person(s) is defined as an individual and exterior aspects (Samueli Institute, 2013).
(patient/client, family members, significant The interior environment includes the individ-
others) who is engaged with a nurse who is re- ual’s mental, emotional, and spiritual dimen-
spectful of this person’s subjective experiences sions, including feelings and meanings as well
about health, health beliefs, values, sexual as the brain and its components that constitute
orientation, and personal preferences. It also the internal aspect of the exterior self. It in-
cludes patterns that may not be understood or
may manifest related to various situations or
relationships. These patterns may be related to
living and nonliving people and things—for
example, a deceased relative, a pet, lost pre-
cious object(s) that surface through flashes of
memories stimulated by a current situation
(e.g., a touch may bring forth past memories
of abuse, suffering). Insights gained through

214 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

dreams and other reflective practices that re- 2012; Newman, 2003). These patterns of
veal symbols, images, and other connections knowing assist nurses in bringing themselves
also influence one’s internal environment. The into a full presence in the moment, integrating
exterior environment includes objects that can aesthetics with science, and developing the flow
be seen and measured that are related to the of ethical experience with thinking and acting.
physical and social in some form in any of the
gross, subtle, and causal levels that are ex- Personal knowing is the nurse’s dynamic
panded later in Content Component 4. process of being whole that focuses on the syn-
thesis of perceptions and being with self. It
Content Component 3: Patterns of Knowing. may be developed through art, meditation,
The third content component in a theory of in- dance, music, stories, and other expressions of
tegral nursing is the recognition of the patterns the authentic and genuine self in daily life and
of knowing in nursing (Fig. 13-1C). These six nursing practice.
patterns of knowing are personal, empirics, aes-
thetics, ethics, not knowing, and sociopolitical. Empirical knowing is the science of nursing
As a way to organize nursing knowledge, that focuses on formal expression, replication,
Carper (1978) in her now-classic 1978 article and validation of scientific competence in
identified the four fundamental patterns of nursing education and practice. It is expressed
knowing (personal, empirics, ethics, aesthetics) in models and theories and can be integrated
followed by the introduction of the pattern of into evidence-based practice. Empirical indi-
not knowing by Munhall (1993) and the pat- cators are accessed through the known senses
tern of sociopolitical knowing by White that are subject to direct observation, measure-
(1995). All of these patterns continue to be ment, and verification.
refined and reframed with new applications
and interpretations (Averill & Clements, Aesthetic knowing is the art of nursing that
2007; Barnum, 2003; Burkhardt & Najai- focuses on how to explore experiences and
Jacobson, 2013; Chinn & Kramer, 2010; meaning in life with self or another that in-
Cowling, 2004; Fawcett et al., 2001; Halifax, cludes authentic presence, the nurse as a facil-
Dossey, & Rushton, 2007; Koerner, 2011; itator of healing, and the artfulness of a healing
McElligott, 2013; McKivergin, 2008; Meleis, environment. It calls forth resources and inner
strengths from the nurse to be a facilitator in
the healing process. It is the integration and

Personal Empirics

Not knowing Healing Sociopolitical

Aesthetics Ethics Fig 13 • 1 C, Healing and
patterns of knowing in nurs-
ing. Source: Adapted from B.

Carper (1978). Copyright ©

Barbara Dossey, 2007.

CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 215

expression of all the other patterns of knowing I It
in nursing praxis. By combining knowledge,
experience, instinct, and intuition, the nurse subjective objective
connects with a patient/client to explore the
meaning of a situation about the human expe- personal biological
riences of life, health, illness, and death.
intentional behavioral
Ethical knowing is the moral knowledge in Measureable
nursing that focuses on behaviors, expressions, Qualitative
and dimensions of both morality and ethics. Interpretive Healing
It includes valuing and clarifying situations to Quantitative
create formal moral and ethical behaviors in- We Its
tersecting with legally prescribed duties. It
emphasizes respect for the person, the family, intersubjective interobjective
and the community that encourages connect-
edness and relationships that enhance atten- cultural systems
tiveness, responsiveness, communication, and
moral action. shared values structures

Not knowing is the capacity to use healing Fig 13 • 1 D, Healing and the four quadrants
presence, to be open spontaneously to the mo- (I, We, It, Its). Source: Adapted with permission from
ment with no preconceived answers or goals to
be obtained. It engages authenticity, mindful- Ken Wilber. http://www.kenwilber.com. Copyright ©
ness, openness, receptivity, surprise, mystery,
and discovery with self and others in the sub- Barbara Dossey, 2007.
jective space and the intersubjective space that
allows for new solutions, possibilities, and center to represent our integral nursing philos-
insights to emerge. ophy, human capacities, and global mission,
dotted horizontal and vertical lines illustrate
Sociopolitical knowing addresses the impor- that each quadrant can be understood as per-
tant contextual variables of social, economic, meable and porous, with each quadrant’s expe-
geographic, cultural, political, historical, and rience(s) integrally informing and empowering
other key factors in theoretical, evidence-based all other quadrant experiences. Within each
practice and research. This pattern includes in- quadrant, we see “I,” “We,” “It,” and “Its” to
formed critique and social justice for the voices represent four perspectives of realities that are
of the underserved in all areas of society along already part of our everyday language and
with protocols to reduce health disparities. awareness.
[Note: Because all patterns of knowing in the
theory of integral nursing are superimposed on Virtually all human languages use first-
Wilber’s four quadrants, these patterns will be person, second-person, and third-person pro-
primarily positioned as seen; however, they may nouns to indicate three basic dimensions of
also appear in one, several, or all quadrants and reality (Wilber, 2000b). First-person is “the
inform all other quadrants.] person who is speaking,” which includes pro-
nouns like I, me, mine in the singular, and we,
Content Component 4: Quadrants. The us, ours in the plural (Wilber, 2000b, 2005a).
fourth content component in the theory of in- Second-person means “the person who is spo-
tegral nursing examines four perspectives for ken to,” which includes pronouns like you and
all known aspects of reality; expressed another yours. Third-person is “the person or thing
way, it is how we look at and/or describe any- being spoken about,” such as she, her, he, him,
thing (Fig. 13-1D). Healing, the core concept or they, it, and its. For example, if I am speak-
in the theory of integral nursing, is trans- ing about my new car, “I” am first-person, and
formed by adapting Ken Wilber’s (2000b) in- “you” are second-person, and the new car is
tegral model. Starting with healing at the third-person. If you and I are communicating,
the word “we” is used to indicate that we un-
derstand each other. “We” is technically first

216 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

person plural, but if you and I are communi- other, carries its own truths and language
cating, then you are second person and my first (Wilber, 2000b). The specifics of the quadrants
person is part of this extraordinary “we.” So we are provided in Table 13-1.
represent first-, second- and third-person as:
“I,” “We,” “It” and “Its.” • Upper-left (UL). In this “I” space (subjec-
tive), the world of the individual’s interior
These four quadrants show the four primary experiences can be found. These are the
dimensions or perspectives of how we experience thoughts, emotions, memories, perceptions,
the world; these are represented graphically as immediate sensations, and states of mind
the upper-left (UL), upper-right (UR), lower- (imagination, fears, feelings, beliefs, values,
left (LL), and lower-right (LR) quadrants. It is esteem, cognitive capacity, emotional matu-
simply the inside and the outside of an individual rity, moral development, and spiritual ma-
and the inside and outside of the collective. It turity). Integral nursing starts with “I.”
includes expanded states of consciousness where (Note: When working with various cultures, it
one feels a connection with the Divine and the is important to remember that within many
vastness of the universe, the infinite that is be- cultures, the “I” comes last or is never verbal-
yond words. Integral nursing considers all of ized or recognized as the focus is on the “We”
these areas in our personal development and any and relationships. However, this development
area of practice, education, research, and health- of the “I” and an awareness of one’s personal
care policy—local to global. Each quadrant, value, beliefs, and ethics is critical.)
which is intricately linked and bound to each

Table 13 • 1 Integral Model and Quadrants Upper right

Upper left Individual exterior
(behavioral/biological)
Individual interior
(intentional/personal) “It” space that includes brain and organisms
(physiology, pathophysiology [cells, mole-
“I” space includes self and consciousness
(self-care, fears, feelings, beliefs, values, cules, limbic system, neurotransmitters, phys-
ical sensations], biochemistry, chemistry,
esteem, cognitive capacity, emotional physics, behaviors [skill development in
maturity, moral development, spiritual matu- health, nutrition, exercise, etc.])

rity, personal communication skills, etc.)

• Subjective I It • Objective
• Interpretive We
• Qualitative Its • Observable
• Quantitative

Collective interior Collective exterior
(cultural/shared) (systems/structures)

“We” space includes the relationship to “Its” space includes the relation to social sys-
each other and the culture and worldview tems and environment, organizational struc-
tures and systems [in healthcare—financial
(shared understanding, shared vision, and billing systems], educational systems, in-
shared meaning, shared leadership fomation technology, mechanical structures
and other values, integral dialogues and and transportation, regulatory structures [en-
vironmental and governmental policies, etc.]
communication/morale, etc.)

Lower left Lower right

Source: Ken Wilber, Integral Psychology: Consciousness, Spirit, Psychology, Therapy (Boston: Shambhala, 2000). Table
adapted with permission from Ken Wilber. http://www.kenwilber.com. Copyright © by Barbara M. Dossey, 2007.

CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 217

• Upper-right (UR). In this “It” (objective) become fragmented and narrow, inhibiting our
space, the world of the individual’s exterior ability to reach meaningful outcomes and
can be found. This includes the material goals. The four quadrants are a result of the
body (physiology [cells, molecules, neuro- differences and similarities in Wilber’s inves-
transmitters, limbic system], biochemistry, tigation of the many aspects of identified real-
chemistry, physics), integral patient care ity. The model describes the territory of our
plans, skill development (health, fitness, ex- own awareness that is already present within
ercise, nutrition, etc.), behaviors, leadership us and an awareness of things outside of us.
skills, and integral life practices and any- These quadrants help us connect the dots of
thing that we can touch or observe scientifi- the actual process to more deeply understand
cally in time and space. Integral nursing who we are, and how we are related to others
with our nursing colleagues and health-care and all things.
team members includes the “It” of new be-
haviors, integral assessment and care plans, Content Component 5: AQAL (All Quad-
leadership, and skills development. rants, All Levels). The fifth content component
in the theory of integral nursing is the explo-
• Lower-left (LL). In this “We” (intersubjec- ration of Wilber’s “all quadrants, all levels, all
tive) space resides the interior collective of lines, all states, all types” or A-Q-A-L (pro-
how we can come together to share our cul- nounced ah-qwul), as seen in Figure 13-1E.
tural background, stories, values, meanings, These levels, lines, states, and types are impor-
vision, language, relationships, and to form tant elements of any comprehensive map of
partnerships to achieve a healing mission. reality. The integral model simply assists us in
This can decrease our fragmentation and further articulating and connecting all areas,
enhance collaborative practice and deep awareness, and depth in these four quadrants.
dialogue around things that really matter.
Integral nursing is built on “We.” Spirit Casual
Mind Subtle
• Lower-right (LR). In this “Its” space (in- Body Gross
terobjective) the world of the collective,
exterior things can be found. This includes Healing
social systems/structures, networks, organi-
zational structures, and systems (including Me Group
financial and billing systems in health care),
information technology, regulatory struc- Us Nation
tures (environmental and governmental
policies, etc.), any aspect of the technologi- All of us Global
cal environment, and the natural world.
Integral nursing identifies the “Its” in the Fig 13 • 1 E, Theory of integral nursing (healing,
structure that can be enhanced to create metaparadigm, patterns of knowing in nursing,
more integral awareness and integral four quadrants, and AQAL). Source: Adapted with
partnerships to achieve health and
healing—local to global. permission from Ken Wilber. http://www.kenwilber.com.

We see that the left-hand quadrants (UL, Copyright © Barbara Dossey, 2007.
LL) describe aspects of reality as interpretive
and qualitative (see Fig. 13-1D). In contrast,
the right-hand quadrants (UR, LR) describe
aspects of reality as measurable and quantita-
tive. When we fail to consider these subjective,
intersubjective, objective, and interobjective
aspects of reality, our endeavors and initiatives

218 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Briefly stated, these levels, lines, states, and center surrounded by three increasing concen-
types are as follows: tric circles with dotted lines of the four quad-
rants. This part of the integral theory moves to
• Levels: Levels of development that become higher orders of complexity through personal
permanent with growth and maturity (e.g., growth, development, expanded stages of con-
cognitive, relational, psychosocial, physical, sciousness (permanent and actual milestones of
mental, emotional, spiritual) that represent a growth and development), and evolution. These
level of increased organization or level of levels or stages of development can also be ex-
complexity. These levels are also referred to as pressed as being self-absorbed (such as a child
waves and stages of development. Each indi- or infant) to ethnocentric (centers on group,
vidual possesses both the masculine and the community, tribe, nation) to world-centric (care
feminine voice or energy. One is not superior and concern for all peoples regardless of race or
to the other; they are two equivalent types at national origin, color, sex, gender, sexual orien-
each level of consciousness and development. tation, creed, and to the global level).

• Lines: Developmental areas that are known In the UL, the “I” space, the emphasis is on
as multiple intelligences (e.g., cognitive line the unfolding “awareness” from body to mind
[awareness of what is]; interpersonal line to spirit. Each increasing circle includes the
[how I relate socially to others]; emo- lower as it moves to the higher level.
tional/affective line [the full spectrum of
emotions]; moral line [awareness of what In the UR, the “It” space, is the external of
should be]; needs line [Maslow’s hierarchy the individual. Every state of consciousness has
of needs]; aesthetics line [self-expression of a felt energetic component that is expressed
art, beauty, and full meaning]; self-identity from the wisdom traditions as three recognized
line [who am I?]; spiritual line [where bodies: gross, subtle, and causal (Wilber,
“spirit” is viewed as its own line of unfold- 2000b, 2005). We can think of these three
ing, and not just as ground and highest bodies as the increasing capacities of a person
state], and values line [what a person toward higher levels of consciousness. Each
considers most important; studied by Clare level is a specific vehicle that provides the actual
Graves and brought forward by Don Beck, support for any state of awareness. The gross
2007, in his spiral dynamics integral, which body is the individual physical, material, sen-
is beyond the scope of this chapter]). sorimotor body that we experience in our daily
activities. The subtle body occurs when we are
• States: Temporary changing forms of aware- not aware of the gross body of dense matter,
ness (e.g., waking, dreaming, deep sleep, but of a shifting to a light, energy, emotional
altered meditative states [such as occurs in feelings, and fluid and flowing images. Exam-
meditation, yoga, contemplative prayer, etc.]; ples might be in our shift during a dream, dur-
altered states [due to mood swings, physiol- ing different types of bodywork, walks in
ogy and pathophysiology shifts with nature, or other experiences that move us to a
disease/illness, seizures, cardiac arrest, low or profound state of bliss. The causal body is the
high oxygen saturation, drug-induced]; peak body of the infinite that is beyond space and
experiences [triggered by intense listening to time. Causal also includes nonlocality in which
music, walks in nature, lovemaking, mystical minds of individuals are not separate in space
experiences such as hearing the voice of God and time (L. Dossey, 1989; 2013). When this
or of a deceased person, etc.]. is applied to consciousness, separate minds be-
have as if they are linked, regardless of how far
• Types: Differences in personality and apart in space and time they may be. Nonlocal
masculine and feminine expressions and consciousness may underlie phenomena such
development (e.g., cultural creative types, as remote healing, intercessory prayer, telepa-
personality types, enneagram). thy, premonitions, as well as so-called miracles.
Nonlocality also implies that the soul does not
This part of the theory of integral nursing
(see Fig. 13-1E) starts with healing at the

CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 219

die with the death of the physical body—hence, to be aware of them and choose to integrate
immortality forms some dimension of con- integral awareness and integral practices. Be-
sciousness. Nonlocality can also be both upper cause these areas are already part of our being-
and lower quadrant phenomena. in-the-world and cannot be imposed from the
outside (they are part of our makeup from the
The LL, the “We” space, is the interior col- inside), our challenge is to identify specific
lective dimension of individuals that come to- areas for development and find new ways to
gether. The concentric circles from the center deepen our daily integral life practices.
outward represent increasing levels of com-
plexity of our relational aspect of shared cul- Structure
tural values, as this is where teamwork and the
interdisciplinary and transpersonal disciplinary The structure of the theory of integral nursing
development occur. The inner circle represents is shown in Figure 13-1F. All content compo-
the individual labeled as me; the second circle nents are represented together as an overlay
represents a larger group labeled us; the third that creates a mandala to symbolize wholeness.
circle is labeled as all of us to represent the Healing is placed at the center, then the meta-
largest group consciousness that expands to all paradigm of nursing, the patterns of knowing,
people. These last two circles may include peo- the four quadrants, and all quadrants and all
ple but also animals, nature, and nonliving levels of growth, development, and evolution.
things that are important to individuals. [Note: Although the patterns of knowing are su-
perimposed as they are in the various quadrants,
The LR, the “Its” space, the exterior social they can also fit into other quadrants.]
system and structures of the collective, is rep-
resented with concentric circles. An example Using the language of Ken Wilber (2000b)
within the inner circle might be a group of and Don Beck (2007) and his spiral dynamics
health-care professionals in a hospital clinic or integral, individuals move through primitive,
department or the complex hospital system infantile consciousness to an integrated lan-
and structure. The middle circle expands in in- guage that is considered first-tier thinking. As
creased complexity to include a nation; the they move up the spiral of growth, develop-
third concentric circle represents even greater ment, and evolution and expand their integral
increased complexity to the global level where worldview and integral consciousness, they
the health of all humanity and the world are move into what is second-tier thinking and par-
considered. It is also helpful to emphasize that ticipation. This is a radical leap into holistic,
these groupings are the physical dynamics such systemic, and integral modes of consciousness.
as the working structure of a group of health Wilber also expands to a third-tier of stages of
care professionals versus the relational aspect consciousness that addresses an even deeper
that is a LL aspect, and the physical and tech- level of transpersonal understanding that is be-
nical structural of a hospital or a clinic. yond the scope of this chapter (Wilber, 2006).

Integral nurses strive to integrate concepts Context
and practices related to body, mind, and spirit
(the all-levels) in self, culture, and nature (“all Context in a nursing theory is the environment
quadrants” part). The individual interior and in which nursing acts occur and the nature of
exterior—“I” and “It”—as well as the collective the world of nursing. In an integral nursing
interior and exterior—“We” and “Its”—must environment, the nurse strives to be an inte-
be developed, valued, and integrated into all gralist, which means that she or he strives to
aspects of culture and society. The AQAL in- be integrally informed and is challenged to fur-
tegral approach suggests that we consciously ther develop an integral worldview, integral life
touch all of these areas and do so in relation to practices, and integral capacities, behaviors,
self, to others, and the natural world. Yet to be and skills. The term nurse healer is used to de-
integrally informed does not mean that we scribe that a nurse is an instrument in the heal-
have to master all of these areas; we just need ing process and a major part of the external

220 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Spirit Casual

Mind Subtle

Body Gross

I Personal Empirics It
Nurse Health
subjective objective

personal biological

intentional behavioral
Measureable
Qualitative
Not knowingInterpretive Healing Sociopolitical
Quantitative
We Person(s) Environment Its
(society)
intersubjective interobjective
Ethics
cultural systems

shared values structures

Aesthetics

Me Group

Us Nation

All of us Global

Fig 13 • 1 F, Healing and AQAL (all quadrants, all levels). Source: Adapted with permission from Ken
Wilber. http://www.kenwilber.com. Copyright © Barbara Dossey, 2007.

healing environment of a patient or family. An doing to or doing for another person, and enters
integral nurse values, articulates, and models into a shared experience (or field of conscious-
the integral process and integral worldview and ness) that promotes healing potentials and an
integral life practices and self-care. Nurses as- experience of well-being.
sist and facilitate the individual person/s
(client/patient, family, and coworkers) to ac- Relationship-centered care is valued and inte-
cess their own healing process and potentials; grated as a model of caregiving that is based in a
they do not do the actual healing. An integral vision of community where three types of rela-
nurse recognizes herself or himself as a healing tionships are identified: (1) patient–practitioner
environment interacting with a person, family, relationship, (2) community–practitioner rela-
or colleague in a being with rather than always tionship, and (3) practitioner–practitioner rela-
tionship (Tresoli, 1994). Relationship-based care

CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 221

is also valued as it provides the map and high- this moment, shift your feelings and your inte-
lights the most direct routes to achieve the high- rior awareness (and believe it!) to “I am doing
est levels of care and serve to patients and the best I can in this moment” and “I have all
families (Koloroutis, 2004). the time needed to take a deep breath and relax
my tight chest and shoulder muscles.” This
Process helps you connect these four perspectives as fol-
lows: (1) the interior self (caring for yourself in
Process in a nursing theory is the method by this moment), (2) the exterior self (using a re-
which the theory works. An integral healing search-based relaxation and imagery integral
process contains both nurse processes and pa- practice to change your physiology), (3) the self
tient/family and health-care worker processes in relationship to others (shifting your aware-
(individual interior and individual exterior), ness creates another way of being with your
and collective healing processes of individuals patient and the radiology team member), and
and of systems/structures (interior and exte- (4) the relationship to the exterior collective of
rior). This is the understanding of the unitary systems/structures (considering how to work
whole person interacting in mutual process with the radiology team and department to im-
with the environment. prove a transportation procedure in the hospital).

Applications to Practice Professional burnout is high, with many
nurses disheartened. Self-care is a low priority;
The theory of integral nursing can guide nurs- time is not given or valued within practice set-
ing practice and strengthen our 21st-century tings to address basic self-care such as short
nursing endeavors. It considers equally impor- breaks for personal needs and meals. This is
tant data, meanings, and experiences from the worsened by short staffing and overtime. Also,
personal interior, the collective interior, the we do not consistently listen to the pain and
individual exterior, and the collective exterior. suffering that nurses experience within the pro-
Nursing and health care are fragmented. Col- fession, nor do we consistently listen to the pain
laborative practice has not been realized and suffering of the patient and family members
because only portions of reality are seen as or our colleagues (Dossey, Luck, & Schaub,
being valid within health care and society. 2015; McEligott, 2013). Often there is a lack
of respect for each other, with verbal abuse oc-
The nursing profession asks nurses to wrap curring on many levels in the workplace.
around “all of life” on so many levels with self
and others that we can often feel overwhelmed. Nurse retention and a global nursing short-
So how do we get a handle on “all of life?” The age are at a crisis level throughout the world
following questions always arise: How can (International Council of Nurses, 2004). As
overworked nurses and student nurses use an nurses deepen their understanding related to
integral approach or apply the theory of integral an integral process and integral worldview and
nursing? How do we connect the complexity of use daily integral life practices, we will more
so much information that arises in clinical prac- consistently be healthy and model health and
tice? The answer is to start right now. Remem- understand the complexities within healing
ber that healing, the core concept in this theory, and society. This enhances nurses’ capacities
is the innate natural phenomenon that comes for empowerment, leadership, and acting as
from within a person and reflects the indivisible change agents for a healthy world.
wholeness, the interconnectedness of all peo-
ple, all things. The practice situation that fol- An integral worldview and approach can
lows addresses these questions. help each nurse and student nurse increase her
or his self-awareness, as well as the awareness
Imagine that you are caring for a very ill pa- of how self affects others—that is the patient,
tient who needs to be transported to the radi- family, colleagues, and the workplace and
ology department for a procedure. The current community. As the nurse discovers her or his
transportation protocol between the unit and own innate healing from within, she or he is
the radiology department lacks continuity. In able to model self-care and how to release

222 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

stress, anxiety, and fear that manifest each day awareness of our own roles in creating a
in this human journey. All nursing curricula healthy world. We recognize the importance
can be mapped in the integral quadrants so of addressing one’s own shadow as described
that students learn to think integrally about by Jung (1981). This is a composite of personal
how these four perspectives create the whole characteristics and potentials that have been
(Clark 2006; Hess, 2013). denied expression in life and of which a person
is unaware; the ego denies the characteristics
Meaning of the Theory of Integral because they are in conflict and incompatible
Nursing for Practice with a person’s chosen conscious attitude.

A key concept in the theory of integral nursing Mindfulness is the practice of giving atten-
is meaning, which addresses that which is in- tion to what is happening in the present mo-
dicated, referred to, or signified (L. Dossey, ment such as our thoughts, feelings, emotions,
2003). Philosophical meaning is related to one’s and sensations. To cultivate the capacity of
view of reality and the symbolic connections mindfulness practice, one may include mind-
that can be grasped by reason. Psychological fulness meditation practice, centering prayer,
meaning is related to one’s consciousness, in- and other reflective practices such as journal-
tuition, and insight. Spiritual meaning is re- ing, dream interpretation, art, music, or poetry
lated to how one deepens personal experience that leads to an experience of nonseparateness
of a connection with the Divine, to feel a sense and love; it involves developing the qualities of
of oneness, belonging and feeling of connec- stillness and being present for one’s own suf-
tion in life. In the next section, four integral fering that will also allow for full presence
nursing principles are discussed that provide when with another.
further insight into how the theory of integral
nursing guides nursing practice and meaning In our personal process, we recognize con-
in practice. See Figure 13-1F for specifics for scious dying where time and thought is given to
each principle. contemplate one’s own death. Through a re-
flective practice, one rehearses and imagines
Integral Nursing Principle 1: Nursing one’s final breath to practice preparing for
Starts With “I” one’s own death. The experience prepares us to
not be so attached to material things nor to
Integral Nursing Principle 1 recognizes the in- spend so much time thinking about the future
terior individual “I” (subjective) space. Each of but to live in the moment as often as we can
us must value the importance of exploring and to live fully until death comes. We are
one’s health and well-being starting with our more likely to participate with deeper compas-
own personal work on many levels. In this “I” sion in the death process and to become more
space, integral self-care is valued, which means fully engaged in the death process. Death is
that integral reflective practices become part of seen as the mirror in which the entire meaning
and can be transformative in our developmen- and mystery of life is reflected—the moment
tal process. This includes how each of us con- of liberation. Within an integral perspective,
tinually addresses our own stress, burnout, the state of transparency, the understanding
suffering, and soul pain. It can assist us to that there is no separation between our prac-
understand the necessity of personal healing tice and our everyday life is recognized. This is
and self-care related to nursing as art where we a mature practice that is wise and empty of a
develop qualities of nursing presence and inner separate self.
reflection.
Integral Nursing Principle 2: Nursing
Nurse presence is also used and is a way of Is Built on “We”
approaching a person in a way that respects
and honors the person’s essence; it is relating Integral Nursing Principle 2 recognizes the im-
in a way that reflects a quality of “being with” portance of the “We” (intersubjective) space. In
and “in collaboration with.” Our own inner this “We” space, nurses come together and are
work also helps us to hold deeply a conscious conscious of sharing their worldviews, beliefs,

CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 223

priorities, and values related to working to- self, others, nature, and God/Life Force/
gether in ways to enhance integral self-care and Absolute/Transcendent.
integral health care. Deep listening, being pres-
ent and focused with intention to understand Within nursing, health care, and society,
what another person is expressing or not ex- there is much suffering (physical, mental, emo-
pressing, is used. Bearing witness to others, the tional, social, spiritual), moral suffering, moral
state achieved through reflective and mindful- distress, and soul pain. We are often called on
ness practices, is also valued (Beck et al., 2011; to “be with” these difficult human experiences
B. M. Dossey, 2013; B. M. Dossey, Beck, & and to use our nursing presence. Our sense of
Rushton, 2013; Halifax et al., 2007). Through “We” supports us to recognize the phases of
mindfulness one is able to achieve states of suffering—“mute” suffering, “expressive” suf-
equanimity—that is, the stability of mind that fering, and “new identity” in suffering (Halifax
allows us to be present with a good and impar- et al., 2007). When we feel alone, as nurses,
tial heart no matter how beneficial or difficult we experience mute suffering; this is an inabil-
the conditions; it is being present for the suf- ity to articulate and communicate with others
ferer and suffering just as it is while maintain- one’s own suffering. Our challenge in nursing
ing a spacious mindfulness in the midst of life’s is to more skillfully enter into the phase of
changing conditions. Compassion is where bear- “expressive” suffering, where sufferers seek lan-
ing witness and lovingkindness manifest in the guage to express their frustrations and experi-
face of suffering, and it is part of our integral ences such as in sharing stories in a group
practice. The realization of the self and another process (Levin & Reich, 2013). Outcomes of
as not being separate is experienced; it is the this experience often move toward new iden-
ability to open one’s heart and be present for all tity in suffering through new meaning-making
levels of suffering so that suffering may be in which one makes new sense of the past,
transformed for others, as well as for the self. interprets new meaning in suffering, and can
A useful phrase to consider is “I’m doing the envision a new future. A shift in one’s con-
best I can.” Compassionate care assists us in liv- sciousness allows for a shift in one’s capacity
ing as well as when being with the dying per- to be able to transform her or his suffering
son, the family, and others. We can touch the from causing distress to finding some new
roots of pain and become aware of new mean- truth and meaning of it. As we create times for
ing in the midst of pain, chaos, loss, grief, and sharing and giving voice to our concerns, new
also in the dying process. levels of healing may happen.

An integral nurse considers transpersonal From an integral perspective, spiritual care
dimensions. This means that interactions with is an interfaith perspective that takes into ac-
others move from conversations to a deeper di- count dying as a developmental and natural
alogue that goes beyond the individual ego; it human process that emphasizes meaningful-
includes the acknowledgment and appreciation ness and human and spiritual values. Religion
for something greater that may be referred is recognized as the codified and ritualized be-
to as spirit, nonlocality, unity, or oneness. liefs, behaviors, and rituals that take place in a
Transpersonal dialogues contain an integral community of like-minded individuals in-
worldview and recognize the role of spirituality volved in spirituality. Our challenge is to enter
that is the search for the sacred or holy that in- into deep dialogue to more fully understand
volves feelings, thoughts, experiences, rituals, religions different than our own so that we
meaning, value, direction, and purpose as valid may be tolerant where there are differences.
aspects of the universe. It is a unifying force of
a person with all that is—the essence of being- Integral action is the actual practice and
ness and relatedness that permeates all of process that creates the condition of trust
life and is manifested in one’s knowing, doing, wherein a plan of care is cocreated with the pa-
and being; it is usually, although not univer- tient and care can be given and received. Full
sally, considered the interconnectedness with attention and intention to the whole person,
not merely the current presenting symptoms,
illness, crisis, or tasks to be accomplished,

224 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

reinforce the person’s meaning and experience includes modeling integral life skills. For the
of community and unity. Engagement be- integral nurse and patient, it is also the space
tween an integral nurse and a patient and the where the “doing to” and “doing for” occurs.
family or with colleagues is done in a respectful However, if the patient has moved into the
manner; each patient’s subjective experience active dying process, the integral nurse com-
about health, health beliefs, and values are ex- bines her or his nursing presence with nursing
plored. We deeply care for others and recog- acts to assist the patient to access personal
nize our own mortality and that of others. strengths, to release fear and anxiety, and to
provide comfort and safety. Most often the
The integral nurse uses intention, the con- patient has an awareness of conscious dying
scious awareness of being in the present mo- and a time of sacredness and reverence in this
ment with self or another person, to help dying transition.
facilitate the healing process; it is a volitional
act of love. An awareness of the role of intu- Integral nurses, with nursing colleagues and
ition is also recognized, which is the per- health-care team members, compile the data
ceived knowing of events, insights, and around physiological and pathophysiological
things without a conscious use of logical, an- assessment, nursing diagnosis, outcomes, plans
alytical processes; it may be informed by the of care (including medications, technical pro-
senses to receive information. Integral nurses cedures, monitoring, treatments, traditional
recognize love as the unconditional unity of and integrative practice protocols), implemen-
self with others. This love then generates tation, and evaluation. This is also the space
lovingkindness and the open, gentle, and car- that includes patient education and evaluation.
ing state of mindfulness that assist one’s with Integral nurses cocreate plans of care with pa-
nursing presence. tients, when possible combining caring–healing
interventions/modalities and integral life prac-
Integral communication is a free flow of ver- tices that can interface and enhance the success
bal and nonverbal interchange between and of traditional medical and surgical technology
among people and pets and significant beings and treatment. Some common interventions
such as God/Life Force/Absolute/Transcen- are relaxation, music, imagery, massage, touch
dent. This type of sharing leads to explo- therapies, stories, poetry, healing environment,
rations of meaning and ideas of mutual fresh air, sunlight, flowers, soothing and calm-
understanding and growth and loving kind- ing pictures, pet therapy, and more.
ness. Intuition is a sudden insight into a feel-
ing, a solution, or problem in which time and Integral Nursing Principle 4: “Its”
actions and perceptions fit together in a uni- Is Systems and Structures
fied experience such as understanding about
pain and suffering, or a moment in time with Integral Nursing Principle 4 recognizes the
another. This is an aspect that may lead to importance of the exterior collective “Its” (in-
recognizing and being with the pattern of not terobjective) space. In this “Its” space, integral
knowing. nurses and the health-care team come together
to examine their work, their priorities, use of
Integral Nursing Principle 3: “It” Is About technologies and any aspect of the technolog-
Behavior and Skill Development ical environment, and create exterior healing
environments that incorporate nature and the
Integral Nursing Principle 3 recognizes the natural world when possible such as with out-
importance of the individual exterior “It” (ob- door healing gardens, green materials inside
jective) space. In this “It” space of the indi- with soothing colors, and sounds of music and
vidual exterior, each person develops and nature. Integral nurses identify how they might
integrates her or his integral self-care plan. work together as an interdisciplinary team to
This includes skills, behaviors, and action deliver more effective patient care and to coor-
steps to achieve a fit body and to consider dinate care while creating external healing
body strength training and stretching and environments.
conscious eating of healthy foods. It also

CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 225

Application of the Theory of Integral AHN-BC, introduced the theory of integral
Nursing in Practice, Education, nursing to their nurse educator colleagues, who
Research, Health-Care Policy, Global use the theory in their holistic undergraduate
Nursing and graduate curricula as they prepare holistic
nurses for the future (Barrere, 2013). Darlene
The world is currently anchored in one of the Hess, PhD, NP, AHN-BC, HWNC-BC,
most dramatic social shifts in health-care his- (Hess, 2013) used the theory of integral nurs-
tory, and the theory of integral nursing can in- ing in her Brown Mountain Visions consulting
form and shape nursing practice, education, practice to design an RN-to-BSN program at
research, and policy—local to global—to Northern New Mexico State (NNMC), in
achieve a healthy world. The theory of integral Espanola, New Mexico. This RN-to-BSN
nursing engages us to think deeply and pur- program prepares registered nurses to assume
posefully about our role as nurses as we face a leadership roles as integral nurses at the bed-
changing picture of health due to globalization side, within organizations, in the community,
that knows no natural or political boundaries. and other areas of professional practice. Hess
also uses the integral process in her private
Practice nurse coaching practice. In the Integrative
Nurse Coach Certificate Program (2013), the
The theory of integral nursing was published integral perspectives and change are major
in this author’s coauthored text in 2008 and components (Dossey, Luck, & Schaub, 2015).
2013 (Dossey, Beck, & Rushton, 2008; 2013) Juliann S. Perdue, DNP, RN, FNP, has
and is currently being used in many clinical adapted the theory of integral nursing into her
settings. The textbook clearly develops the in- integrative rehabilitation model (Perdue,
tegral, integrative, and holistic processes and 2011). Diane Pisanos, RNC, MS, NNP (per-
clinical application in traditional settings. It in- sonal communication, June 15, 2012) inte-
cludes guidance about the use of complemen- grates integral theory and process to organize
tary and integrative interventions. her life and health coaching practice.

Education Research

The theory of integral nursing can assist edu- A theory of integral nursing can assist nurses
cators to be aware of all quadrants while or- to consider the importance of qualitative and
ganizing and designing curriculum, continuing quantitative research (B. M. Dossey, 2008,
education courses, health education presenta- 2013; Esbjorn-Hargens, 2006; Frisch, 2013;
tions, teaching guides, and protocols. In most Quinn, 2003; Zahourek, 2013). Our chal-
nursing curricula, there is minimal focus on the lenges in integral nursing are to consider the
individual subjective “I” and the collective findings from both qualitative and quantita-
intersubjective “We”; the emphasis is on teach- tive data and always consider triangulation of
ing concepts such as physiology and patho- data when appropriate. We must always value
physiology and passing an examination or introspective, cultural, and interpretive expe-
learning a new skill or procedure. Thus, the riences and expand our personal and collective
learner retains only small portions of what is capacities of consciousness as evolutionary
taught. Before teaching any technical skills, the progression toward achieving our goals. In
instructor might guide a student or patient in other words, knowledge emerges from all four
an integral practice such as relaxation and im- quadrants.
agery rehearsal of the event to encourage the
student to be in the present moment. Health-Care Policy

The following are examples of how the the- A theory of integral nursing can guide us to
ory of integral nursing is being used. At Quin- consider many areas related to health-care pol-
nipiac University, Hamden, Connecticut, icy. Compelling evidence in all of the health-
Cynthia Barrere, PhD, RN, CNS, AHN-BC, care professions shows that the origins of
and Mary Helming, PhD, APRN, FNP-BC,

226 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

health and illness cannot be understood by fo- that emerge when health becomes an essential
cusing only on the physical body. Only by ex- component and expression of global citizenship
panding the equations of health, exemplified (Beck et al., 2011; B. M. Dossey, Beck, &
by an integral approach or an AQAL approach Rushton, 2013; Gostin, 2007; Karpf , Swift,
to include our entire physical, mental, emo- Ferguson, & Lazarus, 2008; Karph, Ferguson,
tional, social, and spiritual dimensions and in- & Swift, 2010); J. Kreisberg, personal commu-
terrelationships can we account for a host of nication, August 25, 2011; WHO, 2007). It is
health events. Some of these include, for ex- an increased awareness that health is a basic
ample, the correlations among poverty, poor human right and a global good that needs to be
health, and shortened life span; job dissatisfac- promoted and protected by the global commu-
tion and acute myocardial infarction; social nity. Severe health needs exist in almost every
shame and severe illness; immune suppression community and nation throughout the world as
and increased death rates during bereavement; previously described in the UN Millennium
and improved health and longevity as spiritu- Goals. Thus, all nurses must raise their voices
ality and spiritual awareness is increased. and speak about global nursing as their health
and healing endeavors assist individuals to be-
Global Health Nursing come healthier. As Nightingale (1892) said,
“We must create a public opinion, which must
The theory of integral nursing can assist us as drive the government instead of the government
we engage in global health partnerships and having to drive us . . . an enlightened public
projects. Global health is the exploration of the opinion, wise in principle, wise in detail.”
value base and new relationships and agendas

Practice Exemplar

A nurse can use the theory of integral nursing reframing) before engaging the patient in
in any clinical situation; it assists us in inte- these practices.
grating the art and science of nursing simulta- Background
neously with all actions/interactions. As J. D. is a lean, extroverted, competitive, 6’4,”
discussed previously, healing, the core concept, 200-pound, 64-year-old global energy corpo-
can occur on many levels (physical, mental, rate executive who travels internationally.
emotional, social, spiritual). Having an inte- J. D., an avid jogger, had a recent executive
gral awareness and creating a space for the physical with normal stress test and blood
possibility that healing can occur allows for a work and was declared “a picture of good
unique field of experience. As nurses engage health.” His father and paternal grandfather
in their own healing, reflective integral prac- both died of heart attacks in their 60s. He eats
tices, personal development and self-care, they a Mediterranean diet when possible and
literally embody a special way of being with drinks several glasses of wine with meals. He
others. That is, they “walk their talk” of car- uses a treadmill or runs daily. J. D. has been a
ing–healing. There is a mutual respect for self widower for 2 years after a tragic head-on au-
and others in each encounter as the nurse is al- tomobile accident in which his wife was killed
ways part of the patient’s external environ- by an intoxicated driver. He has four grown
ment. Even while giving medications and children who live in the same city and who
performing various acute care technical skills, quarrel over loopholes in their inheritance left
a nurse’s healing presence in each encounter by their mother and maternal grandmother.
can reflect a “being with” and “in collaboration Two children are executives and have prob-
with.” Nurses must engage in their own devel- lems with alcohol abuse; two others are hap-
opment and also personally experience the var- pily married, and each has two preschool
ious reflective practices (relaxation, imagery, children.

CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 227

Practice Exemplar cont. J. D.: There is this sac around my heart; every
time I take a deep breath, my breath is cut off
One Sunday, J. D. placed second in a city by the pain [pericarditis]. My heart is like a
marathon and was disappointed he didn’t win. broken vase. I don’t think it is healing. The
On finishing a morning shower on Monday pain medication is helping.
morning after a restful night’s sleep before a
scheduled international trip, J. D. had severe Nurse: I can understand some of your frustra-
back pain. He tried stretching exercises, and tion and concern. However, some important
the pain went away, so he related it to a back things that are present right now show me
strain from the marathon. He then drove to that you are better than when you first came
his office and collapsed onto the steering to the CCU. Your persistent chest pain is
wheel after he parked his car. A friend saw this gone, and your heartbeats are now regular,
and immediately called 911. He was taken to which shows that the stent is very effective. If
a nearby emergency room, where he was you focus on what is going right, you can help
immediately assessed and sent for cardiac your heart and lift your spirits. Let me share
catheterization where he received a stent to some ideas so that you might be able to shift
open the complete occlusion of his right coro- to some positive thoughts.
nary artery. Later that night his cardiologist
confirmed from his electrocardiogram that he J. D.: I don’t know if I can.
had had a severe inferior myocardial infarction Nurse: I would like to show you how to breathe
with cardiac irritability; a few days later, he de-
veloped pericarditis secondary to the infarction more comfortably. Place your right hand on
and was placed on pain medication. your upper chest and your left hand on your
belly and begin to breathe with your belly.
His cardiac situation was even more com- With your next breath in, through your nose,
plicated. His cardiologist informed him that let the breath fill your belly with air. And as
he also had an 80% blockage at the bifurcation you exhale through your mouth, let your
in his left anterior descending coronary artery stomach fall back to your spine. As you focus
and circumflex that was in a difficult place for on this way of breathing, notice how still
a stent. Because he had excellent collateral cir- your upper chest feels.
culation, he was placed on cardiac medications J. D.: (After three complete breaths) This is the
and told that he would be monitored over the easiest breathing I’ve done today.
next few months to determine whether he Nurse: As you focused on breathing with your
needed further invasive procedures or possibly belly, you let go of fearing the discomfort with
open heart surgery. He was started on gradual your breathing. Can you tell me more about the
CCU cardiac rehabilitation. image you have of your heart as a broken vase?
J. D.: I saw this crack down the front of my
J. D. was very quiet when the nurse entered heart right after the doctor told me about my
the room after the cardiologist left. The nurse big arteries that have the 80% blockage. This
had a hunch that J. D. might want to talk is very scary.
about what he was experiencing. After a brief Nurse: (Taking a small plastic bag full of
exchange, the nurse followed with further ex- crayons out of her pocket and picking up a
ploration of the meaning and negative images piece of paper) Is it possible for you to choose a
that he conveyed. She asked him if he wanted few crayons and draw your heart as you just
to pursue some new ideas that might help him described it?
relax and to engage in a guided imagery to ac- J. D.: I can’t draw.
cess his inner healing resources and strengths. Nurse: This has nothing to do with drawing, but
He said that he would. This encounter took something usually happens when you place a
10 minutes. After the guided imagery, the few marks to create an image of your words.
following dialogue unfolded. J. D.: If you mean the image of a broken vase,
I can draw that.
Nurse: In your recovery now with your heart
healing, how do you experience your healing? Continued

228 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Practice Exemplar cont. of your heart as a healed vase and notice any
difference in your feelings?
He began to place an image on the paper. J. D.: Thanks for this talk.
When halfway through with the drawing, he
said, “I know this sounds crazy, but my father With a smile, he picked up several crayons
had a heart attack when he was 63. I was visit- and began to draw a healing image to encour-
ing my parents. Dad hadn’t been feeling well, age hope and healing.
even complained of his stomach hurting that
morning. He was in the living room, and as he When J. D. entered the outpatient cardiac
fell, he knocked over a large Chinese porcelain rehabilitation program, he was motivated to
vase that broke in two pieces. I can remember learn stress management skills and express his
so clearly running to his side. I can see that vase emotions. Two weeks into the program, J. D.
now, cracked in a jagged edge down the front. did not appear to be his usual extroverted self.
He made it to the hospital, but died 2 days The cardiac rehabilitation nurse engaged him in
later. You know, I think that might be where conversation, and before long, he had tears in
that image of a broken heart came from.” his eyes. He stated that he was very discouraged
about having heart disease. He said, “It just has
Nurse: Your story contains a lot of meaning. a grip on me.” The nurse took him into her of-
Remembering this image and event can be fice, and they continued the dialogue. After lis-
very helpful to you in your healing. What are tening to his story, she asked J. D. if he would
some of the things that you are most worried like to explore his feelings further. He nodded
about just now? yes. This next session took 15 minutes.

J. D.: Dying young. To facilitate the healing process, she
thought it might be helpful to have J. D. get
(Tears fill his eyes) I have this funny feeling in touch with his images and their locations in
in my stomach just now. I don’t want to die. his body. She began by saying, “If it seems
I’m too young. I have so much to contribute right to you, close your eyes and begin to focus
to life. I’ve been driving myself to excess at on your breathing just now.” She guided him
work. I need to learn to relax and manage my in a general exercise of head-to-toe relaxation,
stress and change my life. accompanied by an audiocassette music selec-
tion of sounds in nature. As his breathing pat-
Nurse: J., each day you are getting stronger. terns became more relaxed and deeper,
This time over the next few weeks can be a indicating relaxation, she began to guide him
time to reflect on what are the most impor- in exploring “the grip” in his imagination.
tant things in your life. Whenever you feel
discouraged, let images come to you of a beau- Nurse: Focus on where you experience the grip.
tiful vase that has a healed crack in it. This is Give it a size, ... a shape, ... a sound, ... a
exactly what your heart is doing right now. texture, ... a width, ... and a depth.
Even as we are talking, the area that has
been damaged is healing. As it heals, there J. D.: It’s in my chest, but not like chest pain.
will be a solid scar that will be very strong, It’s dull, deep, and blocks my knowing what I
just in the same way that a vase can be need to think or feel about living. I can’t be-
mended and become strong again. New blood lieve that I’m using these words. Well, it’s
supplies also come into the surrounding area bigger than I thought. It’s very rough, like
of your heart to help it heal. Positive images heavy jute rope tied in a knot across my chest.
can help you heal because you send a different It has a sound like a rope that keeps a sailboat
message from your mind to your body when tied to a boat dock. I’m now rocking back and
you are relaxed and thinking about becoming forth. I don’t know why this is happening.
strong and well. You help your body, mind,
and spirit function at their highest level. Is it Nurse: Stay with the feeling, and let it fill you
possible for you to once again draw an image as much as it can. If you need to change the

CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 229

Practice Exemplar cont. In a few moments, I will invite you back into
a wakeful state. On five, be ready to come
experience, all you have to do is take several back into the room and feel wide-awake and
deep breaths. relaxed. One ... two ... three ... four ... eyelids
J. D.: It’s filling me up. Where are these sounds, lighter, taking a deep breath ... and five, back
feelings, and sensations coming from? into the room, awake and alert, ready to go
Nurse: They are coming from your wise, inner about your day.
self, your inner healing resources. Just let J. D.: Where did all that come from? I’ve never
yourself stay with the experience. Continue to done that before.
use as many of your senses as you can to de- Nurse: All of these experiences are your inner
scribe and feel these experiences. healing resources that are always with you to
J. D.: Nothing is happening. I’ve gone blank. help you recognize quality and purpose in
Nurse: Focus again on your breath in ... and living each day. All you have to do is take the
feel the breath as you let it go. ... Can you time to remember to use them and direct your
allow an image of your heart to come to you self-talk and images toward a desired out-
under that tight grip? come. If you want, I can teach and share
J. D.: It is so small I can hardly see it. It’s all more of these skills.
wrapped up. J. D.: Ever since my wife died, I have had a
Nurse: In your imagination, can you introduce sense of “What is the meaning of my life? what
yourself to your heart as if you were introduc- is my purpose?” Some days I feel like I have
ing yourself to a person for the first time? Ask lost my soul. I go through my days doing and
your heart if it has a name. doing, and yes I do accomplish a lot. But deep
J. D.: It said hello, but it was with a gesture of down I am not happy. I have been asking
hello, no words. myself the question, “What am I doing . . . or
Nurse: That’s fine. Just say, “Nice to meet you,” NOT doing . . . that is feeding the problems I
and see what the response might be. don’t want and believing that I can find hap-
J. D.: My heart seems like an old soul, very piness out there?” Today with you in this ex-
wise. This feels very comfortable. perience, a light switch got turned on in me.
Nurse: Ask your heart a question for which you My happiness is buried inside me. I have to
would like an answer. Stay with this and gain access to it again somehow. I try to fix my
listen for what comes. kids by giving them more money. I actually
don’t really sit down with them. Sometimes I
After long pause: feel like I don’t really know anything about
them. I have grandkids that I rarely see. I get
J. D.: The answer is practice patience, that I am frustrated with my corporation as I feel we are
on the right track, that my heart disease has a contributing to environmental pollution. We
message, don’t know what it is. [the corporation] can do more about changing
this. You helped me identify my needs and how
Nurse: Just stay with your calmness and inner I can contribute differently. I feel a new kind
quiet. Notice how the grip has changed for of ownership about my life.
you. There are many more answers to come
for you. This is your wise self that has much to Evaluation and Outcomes
offer you. Whenever you want, you can get Together the patient and the nurse evaluate
back to this special kind of knowing. All you the encounter and determine whether the re-
have to do is take the time. When you set laxation and imagery experiences were useful
aside time to be quiet with your rich images, and discuss future outcomes. Such sessions
you will get more information. You might frequently open up profound information and
also find special music to assist you in this possibilities. To evaluate the session further,
process. ... Your skills with this way of know-
ing will increase each time you use this
process ... now that whatever is right for you
in this moment is unfolding, just as it should.

Continued