Nursing Theories & Nursing Practice

280 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm

The first was that simply having a disease After receiving her PhD in 1971, Newman
does not make a person unhealthy. Although joined the NYU faculty. While there, Newman
Newman’s mother’s life was confined by the published a seminal article in Nursing Outlook
disease, her life was not defined by it. In other on nursing’s theoretical evolution (Newman,
words, she could experience health and whole- 1972) and with colleague Florence Downs
ness in the midst of having a chronic and coauthored two editions of a book on re-
progressive disease. The second important re- search in nursing (Downs & Newman, 1977).
alization was that time, movement, and space Newman’s early career in academia was cen-
are in some way interrelated with health, tered on articulating the knowledge of the dis-
which can be manifested by increased connect- cipline and how it was developed.
edness and quality of relationships.
In 1977, Newman joined the faculty at Penn
These early seeds of the HEC theory found State University as the professor-in-charge of
fertile ground in 1959 when Newman entered graduate studies. At that time, she was invited
nursing school at the University of Tennessee to speak at a theory conference to be held in
(UT) in Memphis. Her mother died 2 weeks New York in 1978. It was in that address that
before the beginning of the fall semester. she first clearly articulated her theory of health.
Newman knew she could not go back to her The transcript of her talk was published as a
previous life; the experience with her mother chapter in a book she wrote about theory de-
had deeply changed her. velopment in nursing (Newman, 1979), which
was one of the first books published on the sub-
After graduating from UT’s baccalaureate ject. Newman also organized a Nursing Theory
nursing program, Newman stayed on at UT as Think Tank. She was also a member of a group
a clinical instructor. The next year she went to of nurse theorists facilitated by Sister Callista
the University of California, San Francisco Roy to discern how to organize nursing diag-
(UCSF), to obtain her master’s degree in med- noses so that they would be rooted in the
ical–surgical nursing. When she graduated knowledge of the discipline of nursing. This
from UCSF in 1964, Newman was recruited group presented papers in 1978 and 1980 to the
back to Memphis to become the director of the North American Nursing Diagnosis Associa-
Clinical Research Center. After directing tion. In 1982, they presented an organizing
the Clinical Research Center for 21/2 years, framework they had developed for nursing
Newman decided to pursue doctoral studies diagnoses called patterns of unitary man
in nursing at New York University (NYU), (humans).
where she would be able to study with Martha
Rogers. In her doctoral work at NYU, In 1984, Newman took a position as nurse
Newman began studying movement, time, and theorist at the University of Minnesota. As
space as parameters of health; however, she did part of her theory development work, she con-
so out of a logical positivist scientific paradigm. ducted a pilot study of pattern identification.
She designed an experimental study that ma- She invited Richard Cowling from Case
nipulated participants’ movements and then Western and Jim Vail from the Army Nurse
measured their perception of time (Newman, Corps to collaborate with her. Newman was at
1971, 1982). Her results showed a changing that time also a consultant to the Army Nurse
perception of time across the life span, with Corps.
people’s subjective sense of time increasing
with age in such a way that time expanded for While at the University of Minnesota,
them (Newman, 1987). Although her work Newman published two editions of her book,
seemed to support what she later would term Health as Expanding Consciousness (Newman,
health as expanding consciousness, at the time 1986, 1994a), which attracted international at-
Newman felt the method precluded direct ap- tention. She conducted a series of lectures and
plication to shape nursing practice, which was dialogues in New Zealand in 1985 and in
what most interested her (Newman, 1997a). Finland in 1987 on health as expanding con-
sciousness and nursing knowledge development.

CHAPTER 16 • Margaret Newman’s Theory of Health as Expanding Consciousness 281

Shortly after retiring from her position at during short time spans. Newman’s interest in
the University of Minnesota, Margaret New- attending to what is meaningful to the patient
man returned to Memphis, Tennessee, where was influenced by Ida Jean Orlando’s deliber-
she continues to work on nursing knowledge ative nursing approach. Inspired by Orlando’s
development through her writing and by dia- theoretical work, Newman began making
loguing with students and scholars from deliberative observations about patients and
around the world. reflecting what she observed back to the pa-
tient. The specific attention stimulated patients
Honors awarded to Dr. Newman include to respond by talking about what was mean-
being named a Fellow of the American Acad- ingful in their unique circumstances.
emy of Nursing and a New York University
Distinguished Scholar in Nursing. She has In a publication of the results of her explo-
received Sigma Theta Tau International’s ration of this approach to nursing during short
Founders Award for Excellence in Nursing time spans, Newman (1966) recounted walk-
Research and the E. Louise Grant Award for ing into the room of a patient who had been
Nursing Excellence from the University of in the hospital for some time. The patient was
Minnesota. She has been honored as an out- reading the newspaper, and Newman noticed
standing alumna by both the University of that the woman was reading the want ads.
Tennessee and New York University. In 2008, Newman simply stated, “Reading the want
Dr. Newman was named a Living Legend by ads, huh?” and waited for a response. The
the American Academy of Nursing.1 woman, who had been diagnosed with a
chronic lung problem, worked in a factory that
Overview of the Theory exuded toxic fumes, and she would no longer
be able to work there. She was deeply con-
As previously described, the seeds for the theory cerned about her future. What ensued through
of HEC were planted in Margaret Newman’s their dialogue was a breakthrough for the
childhood and experience of caring for her patient, whose health-care predicament was
mother as a young adult. Newman’s undergrad- couched in the larger context of her potential
uate studies at the UT, master’s studies at the loss of income. Newman asked the woman if
UCSF, and doctoral studies at NYU also greatly she had discussed this with her physician, and
influenced her quest for exploring and articulat- the woman responded that she had not dis-
ing the knowledge of the discipline of nursing. cussed it with anyone. When Newman asked
Reading and reflecting on the philosophical why not, the woman replied that no one had
work of scholars from various disciplines— asked her about it. Once the meaning of her
mainly Bentov (1978), Bohm (1980), Johnson illness was understood within the context of
(1961), Prigogene (1976), Rogers (1970), and her entire life, not just her physical state, a path
Young (1976)—stretched Newman’s view of toward health became apparent for the patient.
the possibilities of nursing, and thus enriched This process of focusing on meaning in pa-
the theory of HEC. Work and dialogue with tients’ lives to understand where the current
colleagues and students further explicated the health predicament fits in the whole of peo-
theory. ple’s lives has endured as central to HEC.

Academic and Philosophical Newman’s theoretical insights evolved as
Influences on the Theory she delved into the works of Martha Rogers
and Itzhak Bentov, while at the same time re-
During her time at the University of California, flecting back on her own experience (Newman,
San Francisco, Newman explored how nurses 1997b). Several of Martha Rogers’s assump-
could respond to patients in a meaningful way tions became central in enriching Margaret
Newman’s theoretical perspective (Newman,
1For additional information please go to bonus chapter 1997b). First and foremost, Rogers saw health
content available at FA Davis http://davisplus.fadavis.com and illness not as two separate realities, but

282 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm

rather as a unitary process. This was congruent • Disease/pathology can be considered a
with Margaret Newman’s earlier experience manifestation of the underlying pattern of
with her mother and with her patients. On a the person.
very deep level, Newman knew that people
can experience health even when they are • The pattern of the person manifesting itself
physically or mentally ill. Health is not the op- as disease was present before the structural
posite of illness, but rather health and illness and functional changes of disease.
are both manifestations of a greater whole.
One can be very healthy in the midst of a ter- • Removal of the disease/pathology will not
minal illness. change the pattern of the individual.

Second, Rogers argued that all of reality is • If becoming “ill” is the only way a person’s
a unitary whole and that each human being pattern can be manifested, then that is
exhibits a unique pattern. Rogers (1970) saw health for the person.
energy fields to be the fundamental unit of all
that is living and nonliving, and she posited • Health is the expansion of consciousness
that there is interpenetration between the (Newman, 1979).
fields of person, family, and environment. Per-
son, family, and environment are not separate Newman’s presentation drew thunderous
entities but rather are an interconnected, uni- applause as she ended with, “[t]he responsibil-
tary whole (Rogers, 1990). Finally, Rogers saw ity of the nurse is not to make people well, or
the life process as showing increasing complex- to prevent their getting sick, but to assist peo-
ity. These assumptions from Rogers’s theory, ple to recognize the power that is within them
along with the work of Itzhak Bentov (1978), to move to higher levels of consciousness”
helped to enrich Margaret Newman’s (1997b) (Newman, 1978).
conceptualization of health and eventually the
articulation of her theory. Bentov viewed life Although Margaret Newman never set out
as a process of expanding consciousness, which to become a nursing theorist, in that 1978
he defined as the informational capacity of the presentation in New York City, she articulated
system and the quality of interactions with the a theory that resonated with what was mean-
environment. ingful in the practice of nurses in many coun-
tries throughout the world. Nurses wanted to
Basic Assumptions of the Theory of go beyond combating diseases; they wanted to
Health as Expanding Consciousness accompany their patients in the process of dis-
covering meaning and wholeness in their lives.
Reflecting on these theoretical works helped Margaret Newman’s proposed theory served as
Newman prepare for her Toward a Theory of a guide for them to do so; it offered a new way
Health presentation at the 1978 nursing theory of looking at the essence of nursing practice.
conference in New York City. It was at that
conference that the theory of health as expand- Developing the Theory of HEC
ing consciousness was first formally explicated.
In her address (Newman, 1978) and in a writ- After identifying the basic assumptions of the
ten overview of the address (Newman, 1979), theory of HEC, the next step was to focus on
Newman outlined the basic assumptions that how to test the theory with nursing research and
were integral to her theory at that time. Draw- how the theory could inform nursing practice.
ing on the work of Martha Rogers and Itzhak Newman began to concentrate on the following:
Bentov and on her own experience and insight,
she proposed that: • The mutuality of the nurse–client interac-
tion in the process of pattern recognition
• Health encompasses conditions known as
disease or pathology, as well as states where • The uniqueness and wholeness of the pattern
disease is not present. in each client situation

• The sequential configurations of pattern
evolving over time

• Insights occurring as choice points of action
potential

• The movement of the life process toward
expanded consciousness (Newman, 1997a)

CHAPTER 16 • Margaret Newman’s Theory of Health as Expanding Consciousness 283

To test the theory of HEC, which em- to be able to see pattern as insight into the
braces reality as an undivided whole, Newman whole. Newman (2008b) states that practicing
found that Western scientific research method- within a unitary paradigm requires a com-
ologies, which isolate particulate variables and pletely new way of seeing reality—it is like
analyze the relationships between them, were moving from seeing the Sun as revolving
insufficient. around Earth to realizing that it is actually
Earth that revolves around the Sun.
Newman saw a need to articulate that her
work fell within a new paradigm of nursing. Newman (1997a) asserted that knowledge
Like Martha Rogers (1970, 1990), Newman emanating from the unitary–transformative
sees human beings as unitary and inseparable paradigm is the knowledge of the discipline
from the larger unitary field that combines and that the focus, philosophy, and theory of
person, family, and community all at once. the discipline must be consistent with each
Seeing change as unpredictable and transfor- other and therefore cannot flow out of differ-
mative, she named the paradigm within ent paradigms. Newman (1997a) stated:
which her work and the work of Martha
Rogers are situated the unitary-transformative The paradigm of the discipline is becoming clear.
paradigm (Newman, Sime, & Corcoran-Perry, We are moving from attention on the other as object
1991). A nurse practicing within the unitary– to attention to the we in relationship, from fixing
transformative paradigm does not think of things to attending to the meaning of the whole, from
mind, body, spirit, and emotion as separate hierarchical one-way intervention to mutual process
entities but rather sees them as manifestations partnering. It is time to break with a paradigm of
of an undivided whole. health that focuses on power, manipulation, and
control and move to one of reflective, compassionate
Newman’s theory (1979, 1990, 1994a, consciousness. The paradigm of nursing embraces
1997a, 1997b, 2008b) proposes that we cannot wholeness and pattern. It reveals a world that is mov-
isolate, manipulate, and control variables to ing, evolving, transforming—a process. (p. 37)
understand the whole of a phenomenon. The
nurse and client form a mutual partnership Newman points the way for nurses to
to attend to the pattern of meaningful rela- practice and conduct research within a uni-
tionships and life experiences. In this way, a tary–transformative paradigm. In the unitary–
patient who has had a heart attack can under- transformative paradigm, the process of the
stand the experience of the heart attack in the nurse–patient partnership as integral to the
context of all that is meaningful in his or her evolving definition of health for the patient
life and, through the insight gained with pat- (Litchfield, 1993, 1999; Newman, 1997a) and
tern recognition, experience expanding con- is synchronous with participatory philosophi-
sciousness. Newman’s (1994a, 1997a, 1997b) cal thought (Skolimowski, 1994) and research
methodology does not divide people’s lives into methodology (Heron & Reason, 1997).
fragmented variables but rather attends to the
nature and meaning of the whole, which be- When nurses view the world from a unitary
comes apparent in the nurse–patient dialogue. perspective, they begin to see the nature of re-
lationships and their meaning in an entirely
A nurse practicing within the HEC theo- new light. The work of Frank Lamendola and
retical perspective possesses multifaceted levels Margaret Newman (1994) with people with
of awareness and is able to sense how physical HIV/AIDS illustrates this. In a study they
signs, emotional conveyances, spiritual insights, conducted, they found that the experience of
physical appearances, and mental insights are HIV/AIDS opened participants to suffering
all meaningful manifestations of a person’s and physical deterioration and at the same
underlying pattern. These manifestations also time introduced greater sensitivity and open-
provide insight into the nature of the person’s ness to themselves and others. Drawing on the
interactions with his or her environment. It work of cultural historian William Irwin
takes disciplined study and reflection on prac- Thompson, systems theorist Will McWhinney,
tical experience applying the theory for nurses

284 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm

and musician David Dunn, Lamendola and Concepts important to nursing practice
Newman, stated: grounded in the theory of HEC include expand-
ing consciousness, time, presence, resonance
They [Thompson, McWhinney, and Dunn] see the with the whole, pattern, meaning, insights as
loss of membranal integrity as a signal of the loss of choice points, and the mutuality of the nurse–
autopoetic unity analogous to the breaking down of patient relationship.
boundaries at a global level between countries, ide-
ologies, and disparate groups. Thompson views Expanding Consciousness
HIV/AIDS not simply as a chance infection but part
of a larger cultural phenomenon and sees the Ultimate consciousness has been equated with
pathogen not as an object but as heralding the need love, which embraces all experience equally and
for living together characterized by a symbiotic rela- unconditionally: pain as well as pleasure, failure
tionship. (Lamendola & Newman, 1994, p. 14) as well as success, ugliness as well as beauty,
disease as well as nondisease.
These authors pointed out that the AIDS —M. A. NEWMAN (2003, P. 241)
epidemic has necessitated greater intercon-
nectedness on the interpersonal, community, Consciousness within the theory of HEC
and global level. It has also called for a recon- is not limited to cognitive thought. Newman
ceptualization of the nature of the self and (1994a) defined consciousness as the infor-
of treatment—inviting a new sense of har- mation of the system: the capacity of the sys-
monic integration within the immune system. tem to interact with the environment. In the
Lamendola and Newman quoted Thompson human system, the informational capacity
(1989), who stated that we need to “learn to includes not only all the things we normally
tolerate aliens by seeing the self as a cloud in associate with consciousness, such as think-
a clouded sky and not as a lord in a walled-in ing and feeling, but also all the information
fortress.” This change in perspective helps embedded in the nervous system, the im-
nurses and patients move away from military mune system, the genetic code, and so on.
metaphors in relationship to patients’ bodies The information of these and other systems
(i.e., combating disease, waging battles against reveals the complexity of the human system
invading cells, etc.) to focus instead on har- and how the information of the system inter-
mony and balance. Nursing care within a uni- acts with the information of the environmen-
tary perspective unveils meaning and opens tal system (p. 33).
the possibility for a new way of living for
people with chronic conditions. To illustrate consciousness as the interac-
tional capacity of the person–environment,
Applications of the Theory Newman (1994a) drew on the work of Bentov
(1978), who presented consciousness on a
Essential Aspects of Nursing Practice continuum ranging from rocks on one end of
Within the HEC Perspective the spectrum (which have little known inter-
action with their environment), to plants
Newman (2008b) synthesizes the basic as- (which provide nutrients, give off oxygen, and
sumptions of HEC in the following way: draw carbon dioxide from the atmosphere) to
animals (which can move about and interact
• Health is an evolving unitary pattern of the freely), to humans (who can reflect and make
whole, including patterns of disease. in-depth plans regarding how they want to in-
teract with their environment), and ultimately
• Consciousness is the informational capacity to spiritual beings on the spectrum’s other
of the whole and is revealed in the evolving end. Newman sees death as a transformation
pattern. point, with a person’s consciousness continu-
ing to develop beyond the physical life, be-
• Pattern identifies the human–environmental coming a part of a universal consciousness
process and is characterized by meaning. (p. 6) (Newman, 1994a).

CHAPTER 16 • Margaret Newman’s Theory of Health as Expanding Consciousness 285

The process of expanding consciousness is what is of utmost importance to them, to dis-
characterized by the evolving pattern of the cern the patient’s unique path toward health
person–environment interaction (Newman, (Newman, 1966). Newman’s latest work as-
1994a). The process of expanding conscious- serts that it is only when nurses move away
ness is defined by Newman (2008b) as “a from a sense of linear time to a more universal
process of becoming more of oneself, of finding synchronization with the here and now that
greater meaning in life, and of reaching new they can be truly present to patients in a mean-
heights of connectedness with other people and ingful and whole manner (Newman, 2008a).
the world” (p. 6). Nurses and their clients know Newman stated:
that there has been an expansion of conscious-
ness when there is a richer, more meaningful There is a need to get back to the natural cycles of
quality to their relationships. Relationships that the universe. The time of civilization (clock time and
are more open, loving, caring, connected, and the Gregorian calendar) is not the same as the time
peaceful are a manifestation of expanding con- of the rest of the biosphere, our living planet earth.
sciousness. These deeper, more meaningful re- Natural time is radial in nature, projecting from the
lationships may be interpersonal, or they may center, and continuously moving in the direction of
be relationships with the wider community or greater consciousness. (2008a, p. 227)
biosphere. Expanding consciousness is evident
when people transcend their own egos, dedi- Newman asserted that the artificial time
cate their energy to something greater than frame of clinic schedules and hospital shift
the individual self, and learn to build order work places nurses at odds with the natural
against the trend of disorder. The process of ex- rhythm of nurse–patient relationships, serves
panding consciousness may look differently the needs of health systems administrations
with changes in cognitive function; nurses must more than those of patients, and disrupts a
carefully discern patterns of meaning when this meaningful nursing practice. She pointed out
is the case. For example, when being present to that the discipline of nursing has followed a
people with dementia or to very young chil- trajectory from adherence to artificial linear
dren, nurses realize that there is no past or time to the synchronization of time in inter-
future—there is only the present, and they personal relationships, and now must move to
must be fully present in the present on a deeper the “instantaneous flow of information in each
level than cognitive and verbal processes can center of consciousness” and that “it is time to
take them (Newman, 2008b). People are best opt for practice that reflects this dimension”
able to experience expanding consciousness (Newman, 2008a, p. 227). When nurses must
when they are not chained to linear time. move out of a Western sense of time, they can
be more fully present to patients.
Time and Presence
Newman (2008b) asserted that it is only in
The time experienced relationship that people can fully come to
In a moment know themselves. She drew on the work of T.
Expands or diminishes D. Smith (2001), who suggested that “when
With consciousness. the nurse considers the patient a mystery to be
If I am fully present engaged in rather than a problem to be solved, the
There is relationship is characterized by presence”
No time. (Newman, 2008b, p. 53). Newman further
Only consciousness. stated that “presence is enhanced by the nurse’s
—M. A. NEWMAN (2008A, P. 225) openness and sensitivity to the other” and in-
volves the nurse letting go of judgments of
Newman’s earliest published work pointed to “good” or “bad” in relationship to patients’
the ability of nurses to quickly and effectively health behaviors.
attend to what is most important to patients
and, by engaging patients in a dialogue about When nurses are truly present to patients
they concentrate more on intuitive knowing

286 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm

than on the gathering of facts and health- Learning to resonate with patients involves
related data. They enter into a relaxed alertness relational engagement and reflection.
and realize that transforming presence involves
a keen awareness of their oneness with the Most conventional education programs
patient (Newman, 2008b; Newman, Smith, teach analytic processes attending to what is
Pharris, & Jones, 2008). Understanding the “logical.” This leads students away from under-
concept of resonance enables a transforming standing the whole. Methods that involve em-
presence. pirical investigation assume that the whole
comes after the parts; these methods tend to
Resonating With the Whole blind investigators to their relationship with the
whole. Newman (2008b) drew on the work of
Newman (2008b) described resonance as the Bohm (1980) to stress that “wholeness is what
mechanism for acquiring essential information is real, with fragmentation as our response to
to guide nursing actions and to understand fragmentary thought. The whole is irreducible
meaning in patients’ lives. She stated, “This is and omnipresent” (p. 40). Newman (2008b)
an important distinction in the explication of differentiated between the general and the uni-
nursing knowledge. Knowledge at the unitary, versal. “Seeing comprehensively is concrete and
transformative level includes and transcends holistic, whereas generalization is abstract and
energy transfer at the sensorial level. It is analytical; these ways of seeing go in opposite
nonenergetic, nonlocal, and present everywhere” directions” (p. 47). Resonance is a way to sense
(p. 35). She differentiated this information into the whole through attention to one aspect
transfer from the transfer of sensory informa- or part of it, always with an eye on compre-
tion (like heat and touch, which involve phys- hending the whole. Resonance enables nurses
ical energy transfer) and suggests nurses to tap into the pattern of the whole.
continually rely on this information transfer
when intuitive insights arise during the care of Attention to Pattern and Meaning
patients. Newman cautioned that “intellectu-
alization breaks the field of resonance. If we Essential to Margaret Newman’s theory is
analyze or evaluate an experience before we the belief that each person exhibits a distinct
have resonated with it, the field is broken—the pattern, which is constantly unfolding and
resonance is damped” (p. 37). “For instance, evolving as the person interacts with the envi-
sometimes when we see familiar symptoms of ronment. Pattern is information that depicts
a disease, we jump into a diagnostic conclusion the whole of a person’s relationship with the
and preclude receptivity to other data that environment and gives an understanding of the
would present a more complete picture. It as- meaning of the relationships all at once (Endo,
sumes we are all the same” (p. 45). Resonance 1998; Newman, 1994a). Pattern is character-
enables nurses to sense the unique situation ized by meaning (Newman, 2008b) and is a
and concerns of patients. manifestation of consciousness.

To resonate with patients and form open To describe the nature of pattern, Newman
relationships, nurses must let go of personal draws on the work of David Bohm (1980), who
judgments about patients and transcend cul- said that anything explicate (that which we can
tural beliefs and values. In other words, the hear, see, taste, smell, touch) is a manifestation
nurse needs to free himself or herself of of the implicate (the unseen underlying pattern;
all “should” and “ought to” attitudes and all Newman, 1997b). In other words, there is in-
personal preoccupations that might prevent formation about the underlying pattern of each
total presence. Newman states there is no pre- person in all that we sense about them, such as
scriptive way to sense the whole through res- their movements, tone of voice, interactions
onance. She recommended that nurses pay with others, activity level, genetic pattern, and
attention to the client at the simplest level, vital signs. People can be identified from a dis-
begin with whatever presents itself, and as- tance by someone who knows them, just from
sume that it is purposeful (Newman, 2008b). the way in which they move. There is also in-
formation about their underlying pattern in all

CHAPTER 16 • Margaret Newman’s Theory of Health as Expanding Consciousness 287

that they tell us about their experiences and different way. By the next meeting, his move-
perceptions, including stories about their life, ments had become smooth and sure, his com-
recounted dreams, and portrayed meanings. plexion had cleared up, he was now able to
reflect on his insights, and he no longer was
The HEC perspective sees disease, disorder, involved in the chaos and fighting in his cell-
disconnection, and violence as an explication block. He was able to let go of his need to con-
of the underlying implicate pattern of the per- trol everything and was able to connect with
son, family, and community. Reflecting on the the emotions of his childhood experiences; he
meaning of these conditions can be part of the was also able to cry for the first time in years.
process of expanding consciousness (Newman,
1994a, 1997a, 1997b). In their subsequent work together, this
young man and the nurse were able to distin-
Pharris (1999) offered the example of a guish between his implicate pattern, which had
16-year-old young man placed in an adult cor- now become clear through their dialogue, and
rectional facility after a murder conviction. the impact that keeping the abusive experience
This young man was constantly getting into a secret had had on him and on other members
fights and generally feeling lost. As he and the of his family. He was able to free himself of
nurse researcher met over several weeks to gain the shame he was carrying, which did not be-
insight into patterns of meaningful people and long to him. Since that time, the young man
events in his life, the process seemed to be has been able to transcend previous limitations
blocked, with no pattern emerging and little and has become involved in several efforts to
insight gained. He spoke of how he felt he had help others, both in and out of the prison en-
lost himself several years back when he went vironment. He has entered into several warm
from being a straight-A student from a stable and loving relationships with family members
family to stealing cars, drinking, getting into and friends and has achieved academic success.
fights, and eventually murdering someone. This was evidence of expanding consciousness
One week he walked into the room where the for the young man. He reflected that he
nurse was waiting, and his movements seemed wished he had had a nurse to talk with before
more controlled and labored; he sat with his “catching his case” (being arrested for murder).
arms tightly cradling his bloated abdomen, and He had been seen by a nurse in the juvenile
his chest was expanded as though he were detention center, who performed a physical
about to explode. His palms were glistening examination and gave him aspirin for a
with sweat. His face was erupting with acne. headache. A few days before the murder, he
He talked as usual in a very detached manner, saw a nurse practitioner in a clinic who wrote
but his words came out in bursts. The nurse a prescription for antibiotics and talked with
chose to give him feedback about what she was him about safe sex. These interactions are ex-
seeing and sensing from his body. She re- plications of the pattern of the U.S. health-
flected that he seemed to be exerting a great care system and the increasingly task-oriented
deal of energy holding back something that role that nursing is being pressured to take as
was erupting within him. With this insight, he juxtaposed with the transforming presence of
was quiet for a few minutes, and tears began a nurse whose practice is rooted in partnership
rolling down his cheeks. Suddenly he began that focuses on what is of utmost importance
talking about a very painful family history of to the person (Jonsdottir, Litchfield, & Pharris,
sexual abuse that had been kept secret for 2003, 2004).
many years. It became obvious that the expe-
rience of covering up the abuse had been so all- The focus of nursing is on pattern and
encompassing that his pattern had been meaning. That which is underlying makes itself
suppressed. known in the physical realm. Nurses grounded
in the theory of HEC are able to be in rela-
This young man had reached a point at tionships with patients, families, and commu-
which he realized his old ways of interacting nities in such a way that insights arising in
with others were no longer serving him, and their pattern recognition dialogue shed light
he chose to interact with his environment in a

288 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm

on an expanded horizon of potential actions 2002, 2005, 2011; Pharris & Endo, 2007;
(Litchfield, 1999; Newman, 1997a). Picard, 2000, 2005; Pierre-Louis, Akoh,
White & Pharris, 2011; Rosa, 2006; Ruka,
Insights Occurring as Choice Points 2005; Tommet, 2003; Yang, Xiong, Vang, &
of Action Potential Pharris, 2009).

The disruption of disease and other traumatic Newman (1999) pointed out that nurse–
life events may be critical points in the expan- client relationships often begin during periods
sion of consciousness. To explain this phe- of disruption, uncertainty, and unpredictability
nomenon, Newman (1994a, 1997b) drew on in patients’ lives. When patients are in a state
the work of Ilya Prigogine (1976), whose the- of chaos because of disease, trauma, loss, or
ory of dissipative structures asserts that a sys- other causes, they often cannot see their past
tem fluctuates in an orderly manner until some or future clearly. In the context of the nurse–
disruption occurs, and the system moves in a patient partnership, which centers on the
seemingly random, chaotic, disorderly way meaning the patient gives to the health
until at some point it chooses to move into a predicament, insight for action arises, and it
higher level of organization (Newman, 1997b). becomes clear to the patient how to get on
Nurses see this all the time—the patient who with life (Jonsdottir et al., 2003, 2004; Litch-
is lost to his work and has no time for his fam- field, 1999; Newman, 1999). Litchfield (1993,
ily or himself, and then suddenly has a heart 1999) explained this as experiencing an ex-
attack, which leaves him open to reflecting on panding present that connects to the past and
how he has been using his energy. Insights creates an extended horizon of action potential
gained through this reflection give rise to for the future.
transformation and decisions about where en-
ergy will be spent; and his life becomes more Endo (1998), in her work in Japan with
creative, relational, and meaningful. Nurses women with cancer; Noveletsky-Rosenthal
also see this in people diagnosed with a termi- (1996), in her work in the United States with
nal illness that causes them to reevaluate what people with chronic obstructive pulmonary
is really important, attend to it, and then to disease; and Pharris (2002), in her work with
state that for the first time they feel as though U.S. adolescents convicted of murder, found
they are really living. The expansion of con- that it is when patients’ lives are in the greatest
sciousness is an innate tendency of humans; states of chaos, disorganization, and uncer-
however, some experiences and processes pre- tainty that the HEC nursing partnership and
cipitate more rapid transformations. Nurse re- pattern recognition process is perceived as
searchers working within the theory of HEC most beneficial to patients (Fig. 16-1).
have clearly demonstrated how nurses can cre-
ate a mutual partnership with their patients to Many nurses who encounter patients in times
reflect on their evolving pattern and the points of chaos strive for stability; they feel they have
of transformation. Through this process, ex- to fix the situation, not realizing that this disor-
panding consciousness is realized (Barron, ganized time in the patient’s life presents an op-
2005; Endo, Minegishi, & Kubo, 2005; Endo portunity for growth. Newman (1999) states:
et al., 2000; Endo, Takaki, Nitta, Abbe, &
Terashima, 2009; Flanagan, 2005, 2009; The “brokenness” of the situation is only a point in
Hayes & Jones, 2007; Jonsdottir, 1998; the process leading to a higher order. We need to
Jonsdottir et al., 2003, 2004; Kiser-Larson, join in partnership with clients and dance their
2002; Lamendola, 1998; Lamendola & dance, even though it appears arrhythmic, until order
Newman, 1994; Litchfield, 1993, 1999, 2005; begins to emerge out of chaos. We know, and we
Moch, 1990; Musker, 2008; Neill, 2002a, can help clients know, that there is a basic, underly-
2002b; Newman, 1995; Newman & Moch, ing pattern evolving even though it might not be
1991; Noveletsky-Rosenthal, 1996; Pharris, apparent at the time. The pattern will be revealed at
a higher level of organization. (p. 228)

CHAPTER 16 • Margaret Newman’s Theory of Health as Expanding Consciousness 289

Normal, Emergence of new
predictable order at higher level of
fluctuation organization

Period of disorganization,
unpredictability,
uncertainty (response to
disease, trauma, loss, etc.)

Giant
fluctuation

Time when partnership with
an HEC nurse can be of
greatest benefit

Fig 16 • 1 Prigogine’s theory of dissipative structures applied to health as expanding consciousness
(HEC) nursing.

The disruption brought about by the pres- and unrestricted choice. These stages can be con-
ence of disease, illness, and traumatic or ceptualized as seven equidistant points on a
stressful events creates an opportunity for V shape (Fig. 16-2). Beginning at the upper-
transformation to an expanded level of con- most point on the left is the first stage, potential
sciousness (Newman, 1997b, 1999) and repre- freedom. The next stage is binding. In this stage,
sents a time when patients most need nurses the individual is sacrificed for the sake of the col-
who are attentive to that which is most mean- lective, with no need for initiative because every-
ingful. Newman (1999, p. 228) stated, “Nurses thing is being regulated for the individual. The
have a responsibility to stay in partnership with third stage, centering, involves the development
clients as their patterns are disturbed by illness of an individual identity, self-consciousness, and
or other disruptive events.” This disrupted state self-determination. “Individualism emerges in
presents a choice point for the person to either the self’s break with authority” (Newman,
continue going on as before, even though the 1994b). The fourth stage, choice, is situated at the
old rules are not working, or to shift into a new base of the V. In this stage, the individual learns
way of being. To explain the concept of a choice that the old ways of being are no longer working.
point more clearly, Newman drew on Arthur It is a stage of self-awareness, inner growth, and
Young’s (1976) theory of the evolution of transformation. A new way of being becomes
consciousness. necessary. Newman (1994b) described the fifth
stage, decentering, as being characterized by a
Young suggested that there are seven stages shift from the development of self (individua-
of binding and unbinding, which begin with tion) to dedication to something greater than
total freedom and unrestricted choice, followed the individual self. The person experiences out-
by a series of losses of freedom. After these standing competence; his or her works have a
losses come a choice point and a reversal of the life of their own beyond the creator. The task is
losses of freedom, ending with total freedom

290 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm

Potential freedom Real freedom Nursing within the HEC perspective involves
being fully present to the patient without judg-
Binding Unbinding ments, goals, or intervention strategies. It in-
volves being with rather than doing for. It is
Centering De-centering caring in its deepest, most respectful sense with
a focus on what is important to the patient.
Choice The nurse–patient interaction becomes like a
pure reflection pool through which both the
Fig 16 • 2 Young’s spectrum of the evolution of nurse and the patient achieve a clear picture of
consciousness. their pattern and come away transformed by
the insights gained.
transcendence of the ego. Form is transcended,
and the energy becomes the dominant feature— To illustrate the mutually transforming
in terms of animation, vitality, a quality that is effect of the nurse–patient interaction, New-
somehow infinite. In this stage, the person ex- man (1994a) offers the image of a smooth lake
periences the power of unlimited growth and has into which two stones are thrown. As the
learned how to build order against the trend of stones hit the water, concentric waves circle
disorder (pp. 45–46). out until the two patterns reach one another
and interpenetrate. The new pattern of their
Newman (1994b) stated that few experi- interaction ripples back and transforms the two
ence the sixth stage, unbinding, or the sev- original circling patterns. Nurses are changed
enth stage, real freedom, unless they have had by their interactions with their patients, just as
these experiences of transcendence character- patients are changed by their interactions with
ized by the fifth stage. It is in the moving nurses. This mutual transformation extends to
through the choice point and the stages of the surrounding environment and relation-
decentering and unbinding that a person ships of the nurse and patient.
moves on to higher levels of consciousness
(Newman, 1999). Newman proposed a corol- In the process of doing this work, it is im-
lary between her theory of health as expand- portant that the nurse sense his or her own
ing consciousness and Young’s theory of the pattern. Newman states:
evolution of consciousness in that we “come
into being from a state of potential con- We have come to see nursing as a process of rela-
sciousness, are bound in time, find our iden- tionship that coevolves as a function of the interpen-
tity in space, and through movement we etration of the evolving fields of the nurse, client, and
learn ‘the law’ of the way things work and the environment in a self-organizing, unpredictable
make choices that ultimately take us beyond way. We recognize the need for process wisdom,
space and time to a state of absolute con- the ability to come from the center of our truth and
sciousness” (Newman, 1994b, p. 46). act in the immediate moment. (Newman, 1994b,
p. 155)
The Mutuality of the Nurse–Client
Interaction in the Process of Pattern Sensing one’s own pattern is an essential
Recognition starting point for the nurse. In her book Health
as Expanding Consciousness, Newman (1994a,
We come to the meaning of the whole not by pp. 107–109) outlines a process of focusing to
viewing the pattern from the outside, but by assist nurses as they begin working in the
entering into the evolving pattern as it unfolds. HEC perspective. It is important that the
—M. A. NEWMAN nurse be able to practice from the center of his
or her own truth and be fully present to the
patient. The nurse’s consciousness, or pattern,
becomes like the vibrations of a tuning fork
that resonate at a centering frequency, and the
client has the opportunity to resonate and tune

CHAPTER 16 • Margaret Newman’s Theory of Health as Expanding Consciousness 291

to that clear frequency during their interactions revealed the need to look at health as expanding
(Newman, 1994a; Quinn, 1992). The nurse– consciousness using a research methodology that
patient relationship ideally continues until the acknowledges, understands, and honors the
patient finds his or her own rhythmic vibra- undivided wholeness of the human health expe-
tions without the need of the stabilizing force rience. Newman, Cowling, and Vail’s study par-
of the nurse–patient dialogue. Newman (1999) ticipants were nurses at Walter Reed Hospital.
points out that the partnership demands that Newman described one of the interviews she
nurses develop tolerance for uncertainty, dis- conducted as Vail and Cowling watched from
organization, and dissonance, even though it another room. Newman asked the nurse to de-
may be uncomfortable. It is in the state of dis- scribe meaningful events in her life and Newman
equilibrium that the potential for growth ex- diagrammed the unfolding trajectory of the
ists. She states, “The rhythmic relating of nurse nurse’s life. When they met the next day to re-
with client at this critical boundary is a window flect the sequential patterns Newman had iden-
of opportunity for transformation in the health tified, the nurse was able to see that experiences
experience” (Newman, 1999, p. 229). she had previously viewed as being extremely
negative (e.g., a divorce), actually were stepping
Relevance of HEC Across Cultures stones to expanded possibilities; she was sud-
denly able to view her life in a new way. The
Margaret Newman’s theory of health as ex- nurse researchers and participants were excited
panding consciousness is being used through- about the insights they gained. The pattern
out the world, but it has been more quickly recognition research method was a powerful
embraced and understood by nurses from in- nursing practice process that shed light on
digenous and Eastern cultures, who are less theory—research, theory, and practice each illu-
bound by linear, three-dimensional thought minated and developed the other two. Newman
and physical concepts of health and who are went on to develop her pattern recognition nurs-
more immersed in the metaphysical, mystical ing research method in which theory, practice,
aspect of human existence. Increasingly, how- and research are one undivided process, each
ever, HEC is being enthusiastically embraced aspect shedding greater light on the other two.
by nurses in industrialized nations who are
finding it difficult to nurse in the modern tech- Newman realized a need to step inside to
nologically driven and intervention-oriented view the whole from within—which is simply
health-care system, which is dependent on a metaphorical process since the researcher has
diagnosing and treating diseases (Jonsdottir been integrally within the whole all along.
et al., 2003, 2004). Practicing from an HEC Newman’s pattern recognition method cleared
perspective involves a holistic approach, which away the murky waters surrounding research,
places what is meaningful to patients back theory, and practice and what previously ap-
into the center of the nurse's focus and what peared to be three separate islands, became
is meaningful to students back into the center clearly visible as mountaintops on one undi-
of the focus of nurse educators. This person- vided piece of land, newly emerged but always
centered approach has wide appeal across there as an undivided whole. HEC research as
cultures. praxis unfolded uniquely in various countries
and settings as nurse researcher-practitioner-
HEC Research as Praxis theorists engaged in partnerships with individ-
uals, families, and communities to understand
Margaret Newman’s early research (1966, 1971, patterns of meaning.
1972, 1976, 1982, 1986, 1987) added to an
understanding of the interrelatedness of time, Focusing on the Process of Health
movement, space, and consciousness as mani- Patterning and the Nurse–Patient
festations of health. Newman’s further reflection Partnership
on these studies in light of work she did at
Walter Reed Hospital with Richard Cowling Merian Litchfield (1993) from New Zealand
and John Vail related to pattern recognition, was the first researcher to apply the theory of

292 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm

health as expanding consciousness to a nursing within the nurse–client relationship, what
partnership with families. Litchfield (1993, changes may occur in the evolving pattern?”
1999, 2005) has led the way in focusing on the Attending to the flow of meaningful thoughts
process of the nursing partnership with pa- for each participant and building on the pre-
tients and families. In her first study, Litchfield vious work of Litchfield (1993), Endo found
(1993) described health patterning as “a four common phases of the process of expand-
process of nursing practice whereby, through ing consciousness for all participants: client–
dialogue, families with researcher as practi- nurse mutual concern, pattern recognition,
tioner, recognize pattern in the life process vision and action potential, and transformation.
providing opportunity for insight as the poten- Participants differed in the pace of evolving
tial for action; a process by which there may movement toward a turning point and in the
be increased self-determination as a feature characteristics of personal growth at the turn-
of health” (p. 10). Litchfield (1993) described ing point. The characteristics of growth ranged
her research as a “shared process of inquiry from assertion of self, to emancipation of self,
through which participants are empowered to transcendence of self. Reflecting on her
to act to change their circumstances” (p. 20). experience, Endo (1998) put forth that pattern
Through her research over several years with recognition is “not intended to fix clients’
families with complex health predicaments re- problems from a medical diagnostic stand-
quiring repeated hospitalizations, Litchfield point, but to provide individuals with an op-
(1993, 1999, 2005) found that she could not portunity to know themselves, to find meaning
stand outside of the process of recognizing in their current situation and life, and to gain
pattern to observe a fixed health pattern of the insight for the future” (p. 60).
family. She saw the pattern as continuously
evolving dialectically in the dialogue within the Endo et al. (2000) conducted a similar
nursing partnership. The findings are literally study with Japanese families in which the wife-
created in the participatory process of the part- mother was hospitalized because of a cancer
nership (Litchfield, 1999). For this reason, diagnosis. Families found meaning in their
Litchfield did not use diagrams to reflect pat- patterns and reported increased understanding
tern because she thought they would imply of their present situation. In the pattern recog-
that the pattern is static rather than continually nition process, most families reconfigured
evolving. As the family reflects on the pattern from being a collection of separated individuals
of their interactions with each other and the to trustful, caring relationships as a family
environment, insight into action may involve unit, showing more openness and connected-
a transformative process, with the same events ness. The researchers concluded that pattern
being seen in a new light. Family health is seen recognition as a nursing intervention was a
as a function of the nurse–family relationship. “meaning-making transforming process in the
Many of the families in partnership with family–nurse partnership” (p. 604).
Litchfield (1999, 2005) gained insight into
their own predicaments in such a way that they HEC-Inspired Practice
required less interaction and service from tra-
ditional health-care services, and thus a cost Patricia Tommet (2003) used the HEC
saving in such services was realized. hermeneutic dialectic methodology to explore
the pattern of nurse–parent interaction in fam-
Exploring Pattern Recognition as a ilies faced with choosing an elementary school
Nursing Intervention for their medically fragile children. She found
a pattern of living in uncertainty in the families
Emiko Endo (1998) explored HEC pattern during the intense period of disruption and
recognition as a nursing intervention in Japan disorganization after the birth of their med-
with women living with ovarian cancer. She ically fragile child through the first few years.
asked, “When a person with cancer has an op- After 2 to 3 years, the families exhibited a pat-
portunity to share meaning in the life process tern of order in chaos where they learned how
to live in the present, letting go of the way they

CHAPTER 16 • Margaret Newman’s Theory of Health as Expanding Consciousness 293

lived in the past. Tommet found that “families partner with families without having predeter-
changed from being passive recipients to active mined goals and outcomes that the families
participants in the care of their children” and nurses must achieve. These nurses are free
(p. 90) and that the “experience of their chil- to focus on family health as defined and expe-
dren’s birth and life transformed these families rienced by the families themselves.
and through them, transformed systems of
care” (p. 86). Tommet demonstrated insights Endo and colleagues (Endo, Minegishi, &
gained in family pattern recognition and con- Kubo, 2005; Endo, Miyahara, Suzuki, &
cluded that a nurse–parent partnership could Ohmasa, 2005) in Japan have expanded their
have a more profound impact on these fami- work to incorporate the pattern recognition
lies, and hence the services they use, during the process at the hospital nursing unit level. After
first 3 years of their children’s lives. engaging the professional nursing staff in read-
ing and dialogue about the theory of HEC,
Working with colleagues in New Zealand, nurses were encouraged to incorporate the ex-
Litchfield undertook a pilot project that in- ploration of meaningful events and people into
cluded 19 families in a predicament of strife their practice with their patients. Nurses kept
(Litchfield & Laws, 1999). The goal of the journals and came together to reflect on the ex-
pilot project, which built on Litchfield’s pre- perience of expanding consciousness in their
vious work (1993, 1999), was to explore a patients and in themselves. Endo, Miyahara,
model of nurse case management incorporat- Suzuki, and Ohmasa (2005) concluded:
ing the use of a family nurse who understands
the theory of health as expanding conscious- Retrospectively it was found through dialogue in the
ness. In the context of a family–family nurse research/project meetings that in the usual nurse–
partnership, the unfolding pattern of family client relationships, nurses were bound by their re-
living was attended to. Family nurses shared sponsibilities within the medical model to help clients
their stories of the families with the research get well, but in letting go of the old rules, they en-
group, who reflected together on the families’ countered an amazing experience with clients’ trans-
changing predicaments and the whole picture formations. The nurses’ transformation occurred
of family living in terms of how each family concomitantly, and they were free to follow the
moved in time and place. Subsequent visits clients’ paths and incorporate all realms of nursing
with the families focused on recognition interventions in everyday practice into the unitary per-
of pattern and potential for action. The family spective. (p. 145)
nurse mobilized relief services if necessary
and orchestrated services as needs emerged Jane Flanagan (2005, 2009) transformed
in the process of pattern recognition. The re- the practice of presurgical nursing by develop-
search group found that families became more ing the preadmission nursing practice model,
open and spontaneous through the process of which is based on HEC. The nursing practice
pattern recognition, and their interactions ev- model shifted from a disease focus to a process
idenced more focus, purposefulness, and coop- focus, with attention being given to the nurses
eration. In analyzing costs of medical care for knowing their patients and what is meaningful
one participating family, it was estimated that to them so that the surgery experience could
a 3% to 13% savings could be seen by employ- be put in proper context and appropriate care
ing the model of family nursing, with greater provided. Nursing presurgical visits were em-
savings being possible when family nurses are phasized. Flanagan reported that the nursing
available immediately after a family disruption staff members were exuberant to be free to be
takes place (Litchfield & Laws, 1999). Based nurses once again, and patients frequently
on Litchfield’s work with families with com- stopped by to comment on their preoperative
plex health predicaments, the government experience and evolving life changes.
funded a large demonstration project to sup-
port family nurses who would be able to nurse Similarly, Susan Ruka (2005) made HEC
from unitary-transformative perspective and pattern recognition the foundation of care at a
long-term-care nursing facility, transforming the

294 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm

nursing practice and the sense of connectedness In a related study comparing the evolving
among staff, families, and residents: Each be- patterns of Hmong women living in the
came more peaceful, relaxed, and loving. United States with diabetes, Yang et al. (2009)
found that the women’s blood sugars rose and
Application of HEC at the fell with their experiences of trauma, loss, sep-
Community Level aration, and isolation. Women in the study de-
scribed their lives in Laos where they walked
Pharris (2002, 2005) attempted to understand up and down hills carrying large bags of rice
a community pattern of rising youth homicide on their backs, picked fresh fruits and vegeta-
rates by conducting a study with incarcerated bles that grew near their homes, and engaged
teens convicted of murder. The youth in the in myriad interactions with family and friends
study reported the pattern recognition process in the community. Then they described their
to be transformative, and expanding con- life in the United States where they sit alone
sciousness was visible in changed behaviors, at home all day watching television in a lan-
increased connectedness, and more loving guage they do not understand and where they
attention to meaningful relationships. The ex- are fearful to walk outside and are driven by
perience of the young men demonstrated that their sons and daughters to the grocery store,
alterations in movement, time, and space in- where they buy food wrapped in plastic. Dia-
herent in the prison system can intensify the logue on these findings, which were presented
process of expanding consciousness. When the by two Hmong students as a play at a commu-
experiences of meaningful events and relation- nity dinner for Hmong women living with
ships were compared across participants, the diabetes, shed light on needed individual,
pattern of disconnection with the community family, and community actions so that Hmong
became evident. People from various aspects women living with diabetes could lead happy
of the community (youth workers, juvenile and healthy lives.
detention staff, emergency hospital staff, pedi-
atric nurses and physicians, social workers, Similarly, Pierre-Louis et al. (2011) con-
educators, etc.) were engaged in dialogues re- ducted an HEC study with African American
flecting on the youths’ stories and the commu- women with diabetes. Pattern recognition re-
nity pattern. Insights transformed community vealed that blood sugars rose and fell with
responses to young people at risk for violent stress, depression, and trauma and that spiri-
perpetration. System change ensued. tual strength, mentors, and sister friends help
to balance energy demands. Findings were
Pharris (2005) and colleagues extended the woven into a spoken-word performance by the
community pattern recognition process through Black Story Tellers Alliance to engage African
partnerships within a multiethnic community American women who have diabetes in action
interested in understanding and transforming planning so that health can flourish in their
patterns of racism and health disparities. They lives.
engaged women and girls from all walks of life
in the community in dialogue about their ex- Pavlish and Pharris (2012) published a
periences of health, well-being, and racism. book on community-based collaborative action
Findings were woven into a spoken word nar- research, which is rooted in Newman’s theory
rative that was presented in various forms (per- and provides a framework for nurses to engage
formances at meetings and gatherings, through communities—whether hospital units, refugee
community television and radio, and showing camps, small towns, or groups of people—in
of DVD recordings) to members of the com- a process of pattern recognition and action
munity so that meaningful dialogue could research to promote human flourishing.
ensue. The process of reflecting on the com-
munity pattern generated insight into the na- Sharon Falkenstern (2003, 2009) found the
ture of the community and what actions could community pattern to emerge as significant
be taken to dismantle racism and enhance when she studied the process of HEC nursing
health and well-being. with families with a child with special health-
care needs. She emphasized the importance of

CHAPTER 16 • Margaret Newman’s Theory of Health as Expanding Consciousness 295

nursing partnership with families as they The pattern of the community is visible
struggle to make sense of their experiences and in the stories of individuals and families.
try to discern how to get on with their lives. Nurses can play an important role in engag-
The evolving pattern of the families in Falken- ing communities in dialogue as these stories
stern’s study illuminated the social and politi- are shared and their meaning reflected on.
cal forces on families from the educational, Methods that engage communities in dia-
disabilities support, and health-care systems, logue about the meaning of patterns of health
as well as community patterns of caring, prej- hold great potential. For example, if an HEC
udice, and racism. Falkenstern summarized nurse were to take on the task of engaging
her experience of using HEC with families nurses at the national level in a dialogue about
with children with special health-care needs in what is meaningful in their practice, expand-
the following way: ing consciousness would be manifest as the
profession reorganizes at a higher level of
My experience with this study has rekindled my pas- functioning, with resultant health-care sys-
sion for nursing. I felt affirmed that in the world of tems change. In the process, the population
managed health care and educational cutbacks, a would no doubt experience a fuller, more
movement is growing to recapture the essence and equitable, and deeper sense of health, inter-
value of nursing. While there is still much to be done connectedness, and meaning.
for nursing within the political realm of health care,
each nurse can control where and how they choose Readers who are interested in learning more
to practice. Especially, I realized that a nurse can about Margaret Newman’s theory of health as
experience joy and renewed energy by choosing to expanding consciousness are referred to an inte-
practice nursing within health as expanding con- grative review by Dr. Marlaine Smith (2011)
sciousness. (2003, p. 232) and to Dr. Newman’s website: healthasexpand-
ingconsciousness.org

Practice Exemplar

Sandra is an adult nurse practitioner working and loved by the faculty. She had ample expe-
in a community clinic in an urban area of the rience performing problem-solving approaches
United States; she is about to enter the room through the medical paradigm that leads to di-
of Gloria, a new patient with diabetes and hy- agnoses, yet she realized that her nursing ac-
pertension. Gloria was referred by Anna, a tions were best guided by a dialogue focused on
physician colleague who felt that Gloria was understanding Gloria’s physical health within
“noncompliant,” as evidenced by her uncon- the context of her life situation. She knew that
trolled hypertension and hemoglobin A1c lev- the focus of her care for Gloria would arise out
els that consistently hovered around 10. Anna of their dialogue; she could not prescribe or
felt that Gloria needed more care than she predetermine the best care for Gloria.
could provide for her.
Before entering the room where Gloria is
Sandra’s graduate program in nursing was waiting, Sandra consciously attends to freeing
based on the theory of health as expanding con- herself of any personal preoccupations or expec-
sciousness; the faculty paid attention to know- tations of what might happen. She wants to fully
ing her and what was meaningful to her in her attend to Gloria and sense what is of greatest
educational and vocational journey. She expe- importance to her right now, knowing that this
rienced a relationship-based education process will guide Sandra’s nursing actions so that they
where the teacher is seen as “a catalyst to help can be of most benefit to Gloria. Sandra is con-
students become who they will become rather fident that she will get a sense of this not only
than be ‘trained’” and the learning process is by asking questions and listening deeply but also
a “dance between content and resonance” through intuitive hunches that will arise through
(Newman, 2008b, p. 75). Sandra felt known her resonant presence with Gloria.

Continued

296 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm

Practice Exemplar cont. Sandra reflects back to Gloria that she sees
all of Gloria’s energy going out to others and
On entering the room, Sandra warmly none coming back to her. She has gone from
greets Gloria and concentrates on what she is being very active to only moving around
sensing from Gloria’s presence. She sits down within her apartment. Tears run down Gloria’s
next to Gloria in a relaxing and open manner. cheeks as she listens to Sandra’s reflection.
What most strongly calls Sandra’s attention is “That is so true!” They talk about sources of
that Gloria is wringing her hands, which are support, nurturance, and energy. Gloria iden-
sweaty; and her muscles seem very tense. tifies a woman in her building whose company
she enjoys. They talk about the possibility of
After pausing for a moment, Sandra the two women walking to the supermarket
chooses to reflect back to Gloria what she sees. together and simply getting together to talk.
“Your muscles seem tense, like you might be They identify a neighborhood women’s walk-
anxious about something. How has life been ing group, which might be a source of support.
going for you?” Gloria looks at Sandra, curious They also talk about a women’s group at the
that Sandra is interested in her life. She re- local library, but Gloria seems hesitant.
sponds, “Well, things have been hard.” Sandra
responds, “Hmm, tell me about that.” Gloria During the course of their conversation,
explains that it has been difficult to take care Sandra has tried to clear herself of her own
of the two children she provides day care for. concerns, yet, as they talk, she keeps thinking
She says she doesn’t have the energy but needs about an experience of racism she witnessed at
the money to pay her rent, which leaves her that library. She decides that it is important
very little money to buy food, and she cannot information and shares the story with Gloria.
afford her medications. This provokes an outpouring of emotion from
Gloria as she recounts her experiences of
Sandra assures Gloria that the clinic has a racism. They discuss how distorting these ex-
plan that will provide her with her medications periences are and how to move through them.
and that she will see that this is taken care of They talk about how blood sugar and pressure
today—that she will go home with adequate respond to these situations and ways in which
medications. She tells Gloria that she would Gloria can best cope.
like to learn a little more about what has been
meaningful in her life and asks her to describe Sandra does all of the things for Gloria that
meaningful events. Sandra uses the examina- her medical colleagues would do. She also dis-
tion table paper to draw a diagram of what cusses the services of the social worker, dieti-
Gloria tells her. In very little time, Sandra has tian, and psychologist at the clinic so that
sketched a diagram of the flow of important Gloria can choose what might be most helpful
events in Gloria’s life. She learns that when to her at this time. Gloria hugs Sandra as she
immigrating to the United States from Africa, leaves, saying that she feels so much better,
Gloria suffered intense abuse and was sepa- and adding, “You are a very good nurse!” Gloria
rated from her family and friends. She has leaves with a greater understanding of herself,
children in the United States who constantly of what is meaningful to her, and what actions
call her to babysit their children and to help she might take. Sandra is left with the same
them out. Gloria has also experienced intimate enhanced understanding of herself and her
partner violence, and her current economic practice.
stress and depression have flowed from this
experience. Gloria lives in a small apartment Sandra tucks the diagram they have drawn
in a neighborhood where she would need to into a folder so that it can be elaborated on at
walk 2 miles to get to a store that sells fresh subsequent visits. Sandra knows that Gloria’s
fruits and vegetables. She tells Sandra she is experience of health and well-being will evolve
hesitant to leave her apartment.

CHAPTER 16 • Margaret Newman’s Theory of Health as Expanding Consciousness 297

Practice Exemplar cont. patients in a holistic manner, sponsoring com-
munity forums on racism and how to deal with
and that she can serve as a catalyst, witnessing it, embedding a mental health practitioner
and engaging in dialogue about the meaning in the medical clinic, partnering with a com-
of the pattern of Gloria’s evolving health. Sandra munity recreational facility so that patients
will continue to focus on what she senses as have a safe place to exercise, encouraging com-
meaningful to Gloria and engage in a relation- munity microeconomic enterprises for women,
ship centered on Gloria’s unfolding pattern of working with a community coop to provide
health. Hemoglobin A1c levels and blood an affordable source of nutritious food in the
pressure readings are only one aspect of that immediate neighborhood, and lobbying for
pattern. health-care financing reform.

As Sandra engages with more and more The circle of dialogue continues for Sandra.
patients with similar predicaments, she gets a Her attention is on pattern and meaning in the
sense of the community pattern of health. She evolving health of her patients and the com-
brings her insight to the clinic staff meetings munity. She trusts that health is inherently
where a rich dialogue about community health present in her patients and the community and
ensues. Sandra joins the CEO for a dialogue that reflection on what is meaningful is a cat-
with the clinic’s community board of directors alyst for its evolving pattern. With this real-
to offer their insights. Through the subsequent ization, Sandra is able to return home where
dialogue, the board of directors and CEO she can be fully present to her family.
commit themselves to ensuring that health-
care providers have sufficient time to attend to

■ Summary

Margaret Newman’s theory of health as ex- the context of the patient’s expression of
panding consciousness calls nurses to focus on meaningful relationships and events. The
that which is meaningful in their practice and focus is not on predetermined outcomes
in the lives of their patients. It attends to the mandated by the health system or on fixing
evolving pattern of interactions with the envi- the patient but rather on partnering with the
ronment for individuals, families, and commu- patient in his or her experience of health.
nities. It is a theory that is relevant across Rather than simply using technological tools
practice settings and cultures. It informs and and following prescribed clinical pathways,
guides nursing practice, health-care adminis- nurses offer their own transforming presence,
tration, and education. The theory of HEC knowing that the direction of their interac-
presents a philosophy of being with rather than tion with patients will arise out of the rela-
simply doing for. It involves a different way of tionship’s focus on the patient’s evolving
knowing—of resonating with patients, stu- experience of health. Nurses realize that the
dents, and health-care colleagues. process of expanding consciousness involves
transcendence and new possibilities as people
Nurses grounded in the theory of health age or encounter a challenging life event. As
as expanding consciousness bring to the pa- nurses come to understand the meaning of
tient encounter all that they have learned in patterns in the lives of individuals, families,
school and in practice, yet they begin with a and communities, they gain insights that in-
sense of nonknowing to take in what is most form population level dialogue for health
meaningful to the patient. Nurses attend to policy transformation.
the patient’s definition of health and see it in

298 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm

Newman (2008b) stated: funding to review the Margaret A. Newman
archives housed at the University of Ten-
This theory asserts that every person in every situation, nessee and to interview Dr. Newman. That
no matter how disordered and hopeless it may seem, work has informed this chapter and her
is part of a process of expanding consciousness—a life. She also thanks Dr. Newman for editing
process of becoming more of oneself, of finding greater this chapter and adding the section, “Losing
meaning in life, and of reaching new heights of con- Our Senses, Finding Our Selves,” which
nectedness with other people and the world. (p. 6) includes her current thinking related to gero-
trancendence and health as expanding con-
Acknowledgments sciousness and can be accessed in the
electronic supplement to this chapter. This
The author thanks St. Catherine University section can be found in the online supple-
for sabbatical support and scholarly research mentary materials for the chapter at: http://
davisplus.fadavis.com

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VSection

Grand Theories about Care
or Caring

301

Section Grand Theories about Care or Caring

V Three of the grand theories in this book focus on the phenomenon of care or caring
in nursing. These theorists describe care or caring as the central domain of the
discipline of nursing. Rather than place these in either the interactive–integrative
or unitary–transformative paradigm, we situated them in a category of their own.

Madeleine Leininger’s theory of cultural care diversity and universality is cov-
ered in Chapter 17. The theory is described, and practice applications of the
theory are provided. Leininger was the first to define care as the essence of nurs-
ing; she asserted that care or nurturance can be understood only within cultural
contexts.

Jean Watson’s work can be conceptualized as a philosophy, grand theory,
or middle-range theory, depending on the lens of the nurse working with the
theory. Watson’s theory is composed of the ten caritas processes, the transper-
sonal caring relationship, the caring occasion, and caring–healing modalities.
Watson’s theory draws from a spiritual dimension affirming that transpersonal
caring is connecting and embracing the spirit or soul of another. She shares
examples of how her theory is being advanced and applied as a model for
practice through the Watson Caring Science Institute and the International
Caritas Consortium.

The premise of Anne Boykin and Savina Schoenhofer’s theory of nursing as
caring is that the focus of nursing is the person living and growing in caring. The
theory encompasses coming to know the other as caring, hearing and answering
calls for caring, and nurturing the growth of the other as caring person. This theory
has transformed, and is currently transforming, care in a variety of settings.

302

Madeleine Leininger’s Theory 17Chapter
of Culture Care Diversity and

Universality

HIBA WEHBE-ALAMAH Introducing the Theorist
Introducing the Theorist
Overview of the Theory Madeleine M. Leininger (1925–2012) founded
Applications of the Theory the worldwide field of transcultural nursing, the
International Transcultural Nursing Society,
Summary and the Journal of Transcultural Nursing.
Practice Exemplar Dr. Leininger obtained her initial nursing ed-
ucation at St. Anthony School of Nursing in
References Denver, Colorado. She earned her undergrad-
uate degree from Mt. St. Scholastic College in
Madeleine M. Leininger Atchison, Kansas; her master’s degree in psy-
chiatric and mental health nursing from the
Catholic University of America; and her PhD
in social and cultural anthropology at the Uni-
versity of Washington (Boyle & Glittenberg
Hinrichs, 2013). Dr. Leininger served as dean
at the Universities of Washington and Utah,
where she helped initiate and direct the first
doctoral programs in nursing and facilitated
the development of master’s degree programs
in nursing at American and overseas institu-
tions. Recognized as a Living Legend by the
American Academy of Nursing and a distin-
guished fellow by the Australian Royal College
of Nursing, she served as a professor emerita in
the College of Nursing at Wayne State Uni-
versity and adjunct professor at the University
of Nebraska College of Nursing. Dr. Leininger
passed away at her home in Omaha, Nebraska,
at the age of 87 on August 10, 2012.

In the span of her prolific career, Madeleine
Leininger published 35 books, wrote approxi-
mately 3,000 articles (some of which were
never published), and gave more than 5,000
presentations or public lectures throughout the
United States and abroad, in addition to con-
tributing to numerous books and videos (Boyle
& Glittenberg Hinrichs, 2013). Some of her
well-known books include Basic Psychiatric

303

304 SECTION V • Grand Theories about Care or Caring

Concepts in Nursing (Leininger & Hofling, scientific and humanistic dimensions of caring
1960); Caring: An Essential Human Need for people of diverse and similar cultures.
(1981); Care: The Essence of Nursing and Health
(1984); Care: Discovery and Uses in Clinical and The theory of culture care diversity and uni-
Community Nursing (1988); Ethical and Moral versality was developed to establish a substantive
Dimensions of Care (1990d); and Culture Care knowledge base to guide nurses in discovery and
Diversity and Universality: A Theory of Nursing use of transcultural nursing practices. During
(1991a, 2006a). Nursing and Anthropology: Two the post–World War II period, Dr. Leininger
Worlds to Blend (1970) was the first book to realized nurses would need transcultural knowl-
bring together nursing and anthropology. The edge and practices to function with people of
first book on transcultural nursing was Trans- diverse cultures worldwide (Leininger, 1970,
cultural Nursing: Concepts, Theories, and Practices 1978). Many new immigrants and refugees
(1978, 1995, 2002). Her book Qualitative Re- were coming to the United States, and the
search Methods in Nursing (1985, 1998) was the world was becoming more multicultural.
first published qualitative research methods
book in nursing. In 1989, Dr. Leininger Leininger held that caring for people of
founded the Journal of Transcultural Nursing, many cultures was a critical and essential need,
the first transcultural nursing journal in the yet nurses and other health professionals were
world. not prepared to meet this global challenge.
Instead, nursing and medicine were focused on
Dr. Leininger conducted the first field using new medical technologies and treatment
study of the Gadsup Akuna of the Eastern regimens. They concentrated on biomedical
Highlands of New Guinea in the early 1960s study of diseases and symptoms. Shifting to
and went on to study more than cultures. She a transcultural perspective was a major but
developed the first nursing research method critically needed change.
called ethnonursing, used by scholars in nursing
and other disciplines. She initiated the idea of This part of the chapter presents an
worldwide certification of nurses prepared overview of the theory of culture care diversity
in transcultural nursing. Today, Basic (under- and universality, along with its purpose, goals,
graduate) and Advanced (graduate) certifica- assumptions, theoretical tenets, predicted
tions are available through the Transcultural hunches, related general features, and newest
Nursing Society. features. The next part of the chapter discusses
applications of the knowledge in clinical and
Overview of the Theory community settings. For a more in-depth dis-
cussion of the theorist’s perspectives, consult
One of Dr. Leininger’s most significant and the primary literature on the theory (Leininger,
unique contributions was the development 1970, 1981, 1989a, 1989b, 1990a, 1990b,
of her culture care diversity and universality the- 1991a, 1995, 1997a, 1998, 2002, 2006a;
ory, also known as the culture care theory McFarland, 2010).
(CCT), which she introduced in the early
1960s to provide culturally congruent and Factors Leading to the Theory
competent care (Leininger, 1991b, 1995,
2006a; McFarland, 2010). She believed that Dr. Leininger’s major motivation for the de-
transcultural nursing care could provide mean- velopment of the CCT was the desire to dis-
ingful, therapeutic health and healing out- cover unknown or little-known knowledge
comes. As she developed the theory, she about cultures and their core values, beliefs,
identified transcultural nursing concepts, prin- and needs. The idea for the CCT came to
ciples, theories, and research-based knowledge her while she was a clinical child nurse spe-
to guide, challenge, and explain nursing prac- cialist in a child guidance home in a large
tices. This was a significant innovation in nurs- Midwestern city (Leininger, 1970, 1991a,
ing and has helped open the door to new 1995, 2006a). From her focused observations
and daily nursing experiences with the chil-
dren in the home, she became aware that
they were from many cultures, differing in

CHAPTER 17 • Madeleine Leininger’s Theory of Culture Care Diversity and Universality 305

their behaviors, needs, responses, and care ex- and survival (Leininger, 1977, 1981, 2006a).
pectations. In the home were youngsters who She argued that what humans need is human
were Anglo American, African American, caring to survive from birth to old age, when
Jewish American, Appalachian, and many ill or well. Nevertheless, care needed to be
other cultures. Their parents responded to specific and appropriate to cultures.
them differently, and their expectations of
care and treatment modes were different. The Her next step in the theory was to con-
reality was a shock to Leininger because she ceptualize selected cultural perspectives and
was not prepared to care for children of di- transcultural nursing concepts derived from
verse cultures. Likewise, nurses, physicians, anthropology. She developed assumptions of
social workers, and health professionals in the culture care to establish a knowledge base for
guidance home were also not prepared to the new field of transcultural nursing. Synthe-
respond to such cultural differences. sizing or interfacing culture care into nursing
was a real challenge. (Leininger, 1976, 1978,
It soon became evident that she needed 1990a, 1990b, 1991a, 2006a). Findings from
cultural knowledge to be helpful to the chil- the theory could provide the knowledge to care
dren. Her psychiatric and general nursing for people of different cultures. The idea of
care knowledge and experiences were inade- providing care was largely taken for granted or
quate. She decided to pursue doctoral study assumed to be understood by nurses, clients,
in anthropology. While in the anthropology and the public (Leininger, 1981, 1984). Yet
doctoral program, she discovered a wealth the meaning of “care” from the perspective of
of potentially valuable knowledge that would different cultures was unknown to nurses and
be helpful from a nursing perspective. did not appear in the literature before the es-
To care for children of diverse cultures and tablishment of Leininger’s theory in the early
link such knowledge into nursing knowledge 1960s. Care knowledge had to be discovered
and practice was a major challenge. It was with cultures.
essential to incorporate new cultural knowl-
edge that went beyond the traditional Leininger (1981, 1988, 1990a, 1991a,
physical and emotional needs of clients. 1995) maintained that before her work, there
Leininger was concerned about whether such were no theories explicitly focused on care and
learning would be possible, given nursing’s culture in nursing environments, let alone
traditional norms and orientation toward research studies to explicate care meanings
medical knowledge. and phenomena in nursing. Theoretical
and practical meanings of care in relation to
At that time, she questioned what made specific cultures had not been studied, espe-
nursing a distinct and legitimate profession. cially from a comparative cultural perspective.
She declared in the mid-1950s that care is (or Leininger saw the urgent need to develop a
should be) the essence and central domain of whole new body of culturally based care
nursing. However, according to Leininger, knowledge to support transcultural nursing
many nurses resisted this idea because they care. Shifting nurses’ thinking and attitudes
thought care was unimportant, too feminine, from medical symptoms, diseases, and treat-
too soft, and too vague and that it would ments to that of knowing cultures and caring
never explain nursing and be accepted by values and patterns was a major task. But
medicine (Leininger, 1970, 1977, 1981, 1984). nursing needed an appropriate theory to
Nonetheless, Leininger firmly held to the discover care, and Leininger held that her the-
claim and began to teach, study, and write ory was “the only theory focused on develop-
about care as the essence of nursing, its unique ing new knowledge for the discipline of
and dominant attribute (Leininger, 1970, transcultural nursing” (Leininger, 2006a, p. 7).
1981, 1988, 1991a, 2006a). From both anthro- Essential features of the CCT and the eth-
pological and nursing perspectives, she held nonursing research method were developed
that care and caring were basic and essential and/or revisited throughout Leininger’s life
human needs for human growth, development, (Leininger, 2006a, 2011).

306 SECTION V • Grand Theories about Care or Caring

Rationale for Transcultural Nursing: caring for clients of diverse cultures. They
Signs and Need complained that they did not understand
the peoples’ needs, values, and lifeways.
The rationale for change in nursing in America
and elsewhere (Leininger, 1970, 1978, 1984, Although anthropologists were clearly ex-
1989a, 1990a, 1995) was based on the following perts about cultures, many did not know what
observations: to do with patients, nor were they interested
in nurses’ work, in nursing as a profession, or
1. There were global migrations and interac- in the study of human care phenomena in the
tions of people from virtually every place in early 1950s. Most anthropologists in those
the world due to modern electronics, trans- early days were far more interested in medical
portation, and communication. These peo- diseases, archaeological findings, and in phys-
ple needed sensitive and appropriate care. ical and psychological problems of culture. For
these reasons and many others, it was clearly
2. There were signs of cultural stresses and evident in the 1960s that people of different
cultural conflicts as nurses tried to care cultures were not receiving care congruent with
for clients from diverse Western and their cultural beliefs and values (Leininger,
non-Western cultures. 1978, 1995). Nurses and other health profes-
sionals urgently needed transcultural knowl-
3. There were cultural indications of con- edge and skills to work efficiently with people
sumer fears and resistance to health of diverse cultures.
personnel as they used new technologies
and treatment modes that did not fit their Leininger therefore took a leadership role
clients’ values and lifeways. in the new field she called transcultural nursing.
She defined transcultural nursing as an area of
4. There were signs that some clients from study and practice focused on cultural care
different cultures were angry, frustrated, (caring) values, beliefs, and practices of partic-
and misunderstood by health personnel ular cultures. The goal was to provide culture-
owing to ignorance of the clients’ cultural specific and congruent care to people of diverse
beliefs, values, and expectations. cultures (Leininger, 1978, 1984, 1995, 2006a).
The central purpose of transcultural nursing
5. There were signs of misdiagnosis and mis- was to use research-based knowledge to help
treatment of clients from diverse cultures nurses discover care values and practices and
because health personnel did not under- use this knowledge in safe, responsible, and
stand the culture of the client. meaningful ways to care for people of different
cultures. Today the CCT has led to a wealth
6. There were signs that nurses, physicians, of research-based knowledge to guide nurses
and other professional health personnel and other health professionals in the care of
were becoming quite frustrated in caring clients, families, and communities of different
for clients from unfamiliar cultures. Cul- cultures or subcultures.
ture care factors were largely misunder-
stood or neglected. Major Theoretical Tenets

7. There were signs that consumers of dif- In developing the theory of culture care diver-
ferent cultures, whether in the home, sity and universality, Leininger identified sev-
hospital, or clinic, were being treated in eral predictive tenets or premises as essential
ways that did not satisfy them and this for nurses and others to use.
influenced their recovery.
Diversities and Commonalities
8. There were many signs of intercultural
conflicts and cultural pain among staff A principal tenet was that diversities and sim-
that led to tensions. ilarities (or commonalities) in culture care ex-
pressions, meanings, patterns, and practices
9. There were very few health personnel of
diverse cultures caring for clients.

10. Nurses were beginning to work in foreign
countries in the military or as missionar-
ies, and they were having great difficulty
understanding and providing appropriate

CHAPTER 17 • Madeleine Leininger’s Theory of Culture Care Diversity and Universality 307

would be found within cultures. This tenet the theory and to bring forth new insights and
challenges nurses to discover this knowledge new knowledge. These data disclose ways that
so that nurses could use cultural data to pro- clients can stay well and prevent illnesses. In-
vide therapeutic outcomes. It was predicted deed, to meet the theory’s goal of making de-
there would be a gold mine of knowledge if cisions that provide culturally congruent care,
nurses were patient and persistent to discover holistic cultural knowledge must be discovered
care values and patterns within cultures, a di- (Leininger, 1991a, 2006a).
mension that had been missing from tradi-
tional nursing. Leininger maintained that Discovering cultural care knowledge re-
human beings are born, live, and die with their quires entering the cultural world to observe,
specific cultural values and beliefs, as well as listen, and validate ideas. Transcultural nursing
with their historical and environmental con- is an immersion experience, not a “dip in and
text, and that care is important for their sur- dip out” experience. No longer can nurses rely
vival and well-being. Leininger predicted that only on fragments of medical and psychologi-
discovering which elements of care were cul- cal knowledge. Nurses must become aware of
turally universal and which were different the social structure, cultural history, language
would drastically revolutionize nursing and use, and the environment in which people live
ultimately transform health-care systems and to understand cultural care expressions. Thus,
practices (Leininger, 1978, 1990a, 1990b, nurses need to understand the philosophy of
1991a, 2006a). transcultural nursing, the culture care theory,
and ways to discover culture knowledge. Tran-
Worldview and Social Structure Factors scultural nursing courses and programs are
essential to provide the necessary instruction
Another major tenet of the theory was that and mentoring.
worldview and social structure factors—such
as technology, religion (including spirituality Professional and Generic Care
and philosophy), kinship (family ties), cultural
values, beliefs, and lifeways, political and legal Another major and predicted tenet of the the-
factors, economic and educational factors, ory is that differences and similarities exist
as well as ethnohistory, language expressions, between the practices of two kinds of care:
environmental context, and generic and pro- professional (etic) and generic (emic, tradi-
fessional care—influence ways individuals, tional, indigenous, or “folk”; Leininger, 1991a,
families, groups, and/or communities consider 2006a; McFarland, 2010). These differences
and deal with health, well-being, illness, heal- influence the health, illness, and well-being of
ing, disabilities, and death (Leininger, 1995, clients. Elucidating these differences identify
2006a). This broad and multifaceted view pro- gaps in care, inappropriate care, and also ben-
vides a holistic perspective for understanding eficial care. Such findings influence the recov-
people and grasping their world and environ- ery (healing), health, and well-being of clients
ment within a historical context. Data from of different cultures. Marked differences be-
this holistic research-based knowledge guides tween generic and professional care ideas and
nurses in caring for the health and well-being actions lead to serious client–nurse conflicts,
of the individual or to help disabled or dying potential illnesses, and even death (Leininger,
clients from different cultures. Social structural 1978, 1995). Such differences must be identi-
factors influencing care of people from differ- fied and resolved.
ent cultures provide new insights for culturally
congruent care. Systematic study by nurse re- Three Modalities
searchers rather than superficial knowledge of
culture is required to provide culturally con- Leininger identified three ways to attain and
gruent care. These factors, together with the maintain culturally congruent care (Leininger,
history of cultures and knowledge of their en- 1991a, 2006a; McFarland, 2010). The three
vironmental factors, were discovered to create modalities postulated are (1) culture care
preservation and/or maintenance, (2) culture
care accommodation and/or negotiation, and

308 SECTION V • Grand Theories about Care or Caring

(3) culture care restructuring and/or repattern- cultural and care factors influencing humans
ing (Leininger, 1991a, 1995, 2006a). These in health, sickness, and dying and to thereby
three modes were very different from traditional advance and improve nursing practices.
nursing practices, routines, or interventions.
They are focused on ways to use theoretical data The theory’s goal is to discover generic
creatively to facilitate congruent care to fit (folk) and professional care beliefs, expressions,
clients’ particular cultural needs. To arrive at and practices that could be incorporated into
culturally appropriate care, the nurse has to collaborative plans of care designed to provide
draw on fresh culture care research and discov- culturally appropriate, safe, beneficial, and
ered knowledge from the people along with satisfying care to people of diverse or similar
theoretical data findings. The care is tailored cultures, to promote their health and well-
to client needs. Leininger believed that rou- being, and to assist them in facing death or
tine interventions would not always be appro- disabilities. Thus, the ultimate and primary
priate and could lead to cultural imposition, goal of the theory is to provide culturally con-
tensions, and conflicts. Nurses need to shift gruent care that is tailor-made for the lifeways
from relying on routine interventions and and values of people (Leininger, 1991a, 1995,
from focusing on symptoms to employing care 2006a; McFarland, Mixer, Wehbe-Alamah, &
practices derived from the clients’ culture and Burke, 2012).
from the theory. They need to use holistic care
knowledge from the theory as opposed to Theory Assumptions
relying solely on medical data. Most impor-
tant of all, they need to use both generic and Leininger postulated several theoretical
professional care findings. This was a new assumptions, or basic beliefs, designed to as-
challenge but a rewarding one for the nurse sist researchers exploring Western and non-
and the client if thoughtfully done, as it fosters Western cultures (Leininger, 1970, 1977,
nurse–client collaboration. Examples of the 1981, 1984, 1991a, 1997b, 2006a):
use of the three modalities can be found in
several published sources (Leininger, 1995, 1. Care is the essence and the central
1999, 2002; McFarland et al., 2011; Wehbe- dominant, distinct, and unifying focus
Alamah, 2008a, 2011) and are presented in of nursing.
the next part of this chapter.
2. Humanistic and scientific care are essen-
Use of Leininger’s theory has led to the dis- tial for human growth, well-being, health,
covery of new kinds of transcultural nursing survival, and to face death and disabilities.
knowledge. Culturally based care can prevent
illness and maintain wellness. Methods for 3. Care (caring) is essential to curing or
helping people throughout the life cycle, from healing, for there can be no curing with-
birth to death, have been discovered. Cultural out caring. (This assumption was held to
patterns of caring and health maintenance have profound relevance worldwide.)
along with environmental and historical factors
are important. Most important, the use of 4. Culture care is the synthesis of two major
Leininger’s theory has helped uncover signifi- constructs that guide the researcher to
cant cultural differences and similarities. discover, explain, and account for health,
well-being, care expressions, and other
Theoretical Assumptions: Purpose, human conditions.
Goal, and Definitions of the Theory
5. Culture care expressions, meanings,
This section discusses some of the major as- patterns, processes, and structural forms
sumptions, definitions, and purposes of the are diverse; but some commonalities
theory. The theory’s overriding purpose is to (universalities) exist among and between
discover, document, analyze, and identify the cultures.

6. Culture care values, beliefs, and practices
are influenced by and embedded in the
worldview, social structure factors (e.g., re-
ligion, philosophy of life, kinship, politics,

CHAPTER 17 • Madeleine Leininger’s Theory of Culture Care Diversity and Universality 309

economics, education, technology, and others with evident or anticipated needs to
cultural values) and the ethnohistorical and ameliorate or improve a human condition
environmental contexts. or lifeway. Caring refers to actions, atti-
7. Every culture has generic (lay, folk, natu- tudes, and practices to assist or help others
ralistic, mainly emic) and usually some toward healing and well-being (Leininger,
professional (etic) care to be discovered 2006a, p. 12). Care is both an abstract and
and used for culturally congruent care a concrete phenomenon.
practices. 3. Culture care: Subjectively and objectively
8. Culturally congruent and therapeutic care learned and transmitted values, beliefs, and
occurs when culture care values, beliefs, patterned lifeways that assist, support,
expressions, and patterns are explicitly facilitate, or enable another individual or
known and used appropriately, sensitively, group to maintain well-being and health,
and meaningfully with people of diverse to improve their human condition and
or similar cultures. lifeway, or to deal with illness, handicaps,
9. The three modes of care offer therapeutic or death (Leininger, 1991a, p. 47).
ways to help people of diverse cultures. 4. Culture Care Diversity: The differences or
10. Qualitative research paradigmatic methods variabilities among human beings with
offer important means to discover largely respect to culture care meanings, patterns,
embedded, covert, epistemic, and ontolog- values, lifeways, symbols, or other features
ical culture care knowledge and practices. related to providing beneficial care to
11. Transcultural nursing is a discipline with clients of a designated culture (Leininger,
a body of knowledge and practices to at- 2006a, p. 16).
tain and maintain the goal of culturally 5. Culture Care Universality: The commonly
congruent care for health and well-being shared or similar culture care phenomena
(Leininger, 2006a, pp. 18–19). features of human beings with recurrent
meanings, patterns, values, lifeways, or
Orientational Theory Definitions symbols that serve as a guide for caregivers
to provide assistive, supportive, facilitative,
To encourage discovery of qualitative knowl- or enabling people care for healthy out-
edge, Leininger used orientational (not oper- comes (Leininger, 2006a, p. 16).
ational) definitions for her theory, to allow the 6. Professional (etic) care: Formal and explicit
researcher to discern previously unknown phe- cognitively learned professional care knowl-
nomena or ideas. Orientational terms allow edge and practices obtained generally
discovery and are usually congruent with the through educational institutions. They are
client lifeways. They are important in using the taught to nurses and others to provide assis-
qualitative ethnonursing discovery method, tive, supportive, enabling, or facilitative
which is focused on how people understand acts for or to another individual or group
and experience their world using cultural in order to improve their health, prevent
knowledge and lifeways (Leininger, 1985, illnesses, or to help with dying or other
1991a, 1997b, 1997c, 2002, 2006a). The fol- human conditions (Leininger, 2006a, p. 14).
lowing are select examples: 7. Generic (emic) care: The learned and trans-
mitted lay, indigenous, traditional, or local
1. Culture: The learned, shared, and transmit- folk knowledge and practices to provide
ted values, beliefs, norms, and lifeways of a assistive, supportive, enabling, and facilita-
particular group that guides their thinking, tive acts for or toward others with evident
decisions, and actions in patterned ways or anticipated health needs in order to
and often intergenerationally (Leininger, improve well-being or to help with dying
2006a, p. 13). or other human conditions (Leininger,
2006a, p. 14).
2. Care: Those assistive, supportive, and
enabling experiences or ideas toward

310 SECTION V • Grand Theories about Care or Caring

8. Culture care preservation and/or mainte- life; and cultural beliefs and values with
nance: Those assistive, supportive, facilita- gender and class difference. The theorist
tive, or enabling professional acts or has predicted that these diverse factors
decisions that help cultures to retain, must be understood as they directly or
preserve, or maintain beneficial care be- indirectly influence health and well-being
liefs and values or to face handicaps and (Leininger, 2006a, p. 14).
death (Leininger, 2006a, p. 8). 15. Culturally congruent care: Culturally based
care knowledge, acts, and decisions used
9. Culture care accommodation and/or negotia- in sensitive and knowledgeable ways to
tion: Those assistive, accommodating, fa- appropriately and meaningfully fit the
cilitative, or enabling creative provider care cultural values, beliefs, and lifeways of
actions or decisions that facilitate adapta- clients for their health and well-being,
tion to or negotiation with others for cul- or to prevent illness, disabilities, or death
turally congruent, safe, and effective care (Leininger, 2006a, p. 15).
for their health, well-being, or to deal with
illness or dying (Leininger, 2006a, p. 8). The Sunrise Enabler: A Conceptual
Guide to Knowledge Discovery
10. Culture care repatterning and/or restructur-
ing: Those assistive, supportive, facilita- Leininger developed the sunrise enabler
tive, or enabling professional actions and (Fig. 17-1) to provide a holistic and compre-
mutual decisions that help people to re- hensive conceptual picture of the major factors
order, change, modify, or restructure influencing culture care diversity and univer-
their lifeways and institutions for better sality (Leininger, 1995, 1997b; Leininger &
(or beneficial) health-care patterns, prac- McFarland, 2002, 2006). The model can be a
tices, or outcomes (Leininger, 2006a, valuable visual guide to elucidating multiple
p. 8). These patterns are mutually estab- factors that influence human care and lifeways
lished between caregivers and receivers. of different cultures. The enabler serves as a
cognitive guide for the researcher to reflect on
11. Ethnohistory: The past facts, events, in- different predicted influences on culturally
stances, and experiences of human beings, based care.
groups, cultures, and institutions that
occur over time in particular contexts The sunrise enabler can also be used as a
that help explain past and current lifeways valuable aid in cultural and health-care assess-
about culture care influencers of health ment of clients. As the researcher uses the
and well-being or the death of people model, the different factors alert him or her to
(Leininger, 2006a, p. 15). find culture care phenomena. Gender, sexual
orientation, race, class, and biomedical condi-
12. Environmental context: The totality of tions are studied as part of the theory. These
an event, situation, or particular experi- determinants tend to be embedded in the
ence that gives meaning to people’s worldview and social structure and take time
expressions, interpretations, and social to recognize. Care values and beliefs are usually
interactions within particular geophysical, lodged into environment, religion, kinship,
ecological, spiritual, sociopolitical, and and daily life patterns.
technological factors in specific cultural
settings (Leininger, 2006a, p. 15). The nurse can begin the discovery at any
place in the enabler and follow the informant’s
13. Worldview: The way people tend to look ideas and experiences about care. If one starts
out on their world or their universe to in the upper part of the enabler, one needs to
form a picture or value stance about life reflect on all aspects depicted to obtain holistic
or the world around them (Leininger, or total care data. Some nurses start with
2006a, p. 15). generic and professional care then look at how
religion, economics, and other influences affect
14. Cultural and social structure factors: religion these care modes. One always moves with the
(spirituality); kinship (social ties); politics;
legal issues; education; economics; tech-
nology; political factors; philosophy of

CHAPTER 17 • Madeleine Leininger’s Theory of Culture Care Diversity and Universality 311

CULTURE CARE

Worldview

Cultural & Social Structure Dimensions

Cultural Values,
Kinship & Beliefs & Political &
Social Legal
Lifeways Factors
Factors

Environmental Context,
Language & Ethnohistory

Religious & Influences Economic
Philosophical Factors

Factors

Technological Care Expressions Educational
Factors Patterns & Practices Factors

Holistic Health / Illness / Death

Focus: Individuals, Families, Groups, Communities or Institutions
in Diverse Health Contexts of

Generic (Folk) Nursing Care Professional
Care Practices Care–Cure
Practices

Cultural Care Decisions & Actions

Cultural Care Preservation/Maintenance

Culture Care Accommodation/Negotiation

Code: (Influencers) Culture Care Repatterning/Restructuring © M. Leininger 2004
--kl

Culturally Congruent Care for Health, Well-being or Dying

Fig 17 • 1 Leininger’s sunrise enabler to discover culture care. (©M. Leininger 2004.)

informants’, rather than the researcher’s, inter- process, the nurse holds his or her own etic
est and story. Flexibility in using the enabler biases in check so that the informant’s ideas
promotes a total or holistic view of care. will come forth, rather than the researcher’s.
Transcultural nurses are mentored in ways to
The three transcultural care decisions and withhold their biases or wishes and to enter the
actions (in the lower part of the figure) are very client’s worldview.
important to keep in mind. Nursing decisions
and actions are studied until one realizes the The nurse begins the study by making
care needed. The nurse discovers with the in- explicit a specific domain of inquiry. For exam-
formant the appropriate decisions, actions, or ple, the researcher may focus on a domain of
plans for care. Throughout this discovery inquiry such as “culture care of Mexican

312 SECTION V • Grand Theories about Care or Caring

American mothers caring for their children in culturally based care are important. The nurse/
their home.” Every word in the domain state- researcher listens attentively to informants’
ment is important and studied with the sunrise accounts about care and then documents the
enabler and the theory tenets. The nurse or re- ideas. What informants know and practice
searcher may have hunches about the domain about care or caring in their culture is signifi-
and care, but until all data have been studied cant. Documenting ideas from the informants’
with the theory tenets, she or he cannot prove emic viewpoint is essential to arrive at accurate
them. Informants’ viewpoints, experiences, culturally based care. Unknown care meanings,
and actions are fully documented. Generally, such as the concepts of protection, respect,
informants select what they like to talk about love, and many other care concepts, need to be
first, and the nurse/researcher accommodates teased out and explored in depth, as they are
their interest or stories about care. During in- the key words and ideas in understanding care.
depth study of the domain of inquiry, all areas Such care meanings and expressions are not al-
of the sunrise enabler are identified and con- ways readily known; informants ponder care
firmed with the informants. The informants meanings and are often surprised that nurses
become active participants throughout the dis- are focused on care instead of medical symp-
covery process in such a way as to feel comfort- toms. Sometimes informants may be reluctant
able and willing to share their ideas. to share ideas about social structure, religion,
and economics or politics, as they fear these
The real challenge is to focus care mean- ideas may not be accepted or understood by
ings, beliefs, values, and practices related to health personnel. Generic folk or indigenous
informants’ cultures so that subtle and obvi- knowledge often has rich care data and needs
ous differences and similarities about care are to be explored. Generic care ideas need to be
identified among key and general informants. appropriately integrated into the three tran-
The differences and similarities are important scultural modes of decisions and actions for
to document with the theory. If informants culturally congruent care outcomes. Generic
ask about the researcher’s views, the latter and professional care are integrated so that the
must be carefully and sparsely shared. The re- clients benefit from both types of care.
searcher keeps in mind that some informants
may want to please the researcher by talking The sunrise enabler was developed with
about professional medicines and treatments. the idea to “let the sun enter the researcher’s
Professional ideas, however, often cloud or mind” and discover largely unknown care
mask the client’s real interests and views. If factors of cultures. Letting the sun “rise and
this occurs, the researcher must be alert to shine” is important and offers fresh insights
such tendencies and keep the focus on the in- about care practices. A recent metasynthesis
formant’s ideas and on the domain of inquiry of 24 doctoral dissertations using Leininger’s
studied. The informant’s knowledge is always CCT and the ethnonursing research method
kept central to the discovery process about led to the discovery of interpretive and ex-
culture care, health, and well-being. If the re- planatory culture care findings, new theoretical
searcher finds some factors unfamiliar, such formulations, and evidence-based recommen-
as kinship, economics, and political and other dations to guide nursing practice (McFarland
considerations depicted in the model, the et al., 2011).
researcher should listen attentively to the
informant’s ideas. Obtaining insight into Newest Addition to the Theory
the informant’s emic (insider’s) views, beliefs,
and practices is central to studying the theory In the summer of 2011, Dr. Leininger intro-
(Leininger, 1985, 1991a, 1995, 1997b; duced collaborative care as a new care construct,
Leininger & McFarland, 2002, 2006). which she offered as the next phase in the evo-
lutionary development of CCT. She main-
Throughout the study and use of the theory, tained that diverse cultural values, beliefs,
the meanings, expressions, and patterns of expressions, actions, and practices within a

CHAPTER 17 • Madeleine Leininger’s Theory of Culture Care Diversity and Universality 313

family, a group, an institution, or other unit Applications of
may present with situations in which conflicts the Theory
may arise. She proposed collaborative care as a
means or a strategy to resolve differences and The purpose of this part of the chapter is to
provide culturally congruent care. present the implications for nursing practice of
the CCT and related ethnonursing research
Leininger defined the collaborative care findings. Many nursing theories are rather ab-
approach as those values, meanings, expres- stract and do not focus on how practicing
sions, and actions by informants that reveal a nurses might use the research findings related
desire and a plan to work with others in order to a theory. However, with the CCT, along
to identify, attain, and maintain health and with the ethnonursing method, there is a built-
well-being and to resolve conflicts. This care in means for discovering and confirming data
construct has been published by McFarland with informants in order to make practical
and Wehbe-Alamah (McFarland & Wehbe- nursing actions and decisions meaningful and
Alamah, 2015). culturally congruent (Leininger, 2002).1

Current Status of the Theory Leininger purposefully avoided using the
phrase nursing intervention because this term
Currently, the theory of culture care diversity often implies to clients from different cultures
and universality continues to be studied and used that the nurse is imposing his or her (etic)
in many schools of nursing within the United views, which may not be helpful. Instead, the
States and in other countries, such as Lebanon, term nursing actions and decisions was used, but
Jordan, Saudi Arabia, Taiwan, China, Japan, always with the clients helping to arrive at
and Finland (Leininger & McFarland, 2002, whatever actions or decisions were planned
2006; Wehbe-Alamah & McFarland; 2012). and implemented. The care modes fit with the
Interdisciplinary health personnel are becoming clients’ or peoples’ lifeways and are both ther-
increasingly aware of transcultural nursing con- apeutic and satisfying for them. The nurse can
cepts that help them in their work. Several dis- draw on scientific and evidence-based nursing,
ciplines including dentistry, medicine, social medical, and other knowledge with each care
work, and pharmacy have reported using the mode.
culturally congruent care theory or teaching it in
their programs (McFarland, 2011). Data collected from the upper and lower
parts of the sunrise enabler provide culture care
The theory of culture care will remain of knowledge for the nurse and other researchers
global interest and significance as nurses and to discover and establish useful ways to provide
other health-care professionals continue to quality care practices. Active participatory in-
explore cultures and their care needs and prac- volvement with clients is essential to arrive at
tices worldwide. Transcultural nursing con- culturally congruent care with one or all of the
cepts, principles, theory, and findings must three action modes to meet clients’ care needs
become fully incorporated into professional in their particular environmental contexts. The
areas of teaching, practice, consultation, and use of these modes in nursing care is one of the
research. When this occurs, one can anticipate most creative and rewarding features of tran-
true transcultural health practices and con- scultural and general nursing practice with
comitant benefits. Unquestionably, the theory clients of diverse cultures. Using Leininger’s
will continue to grow in relevance and use as care modes in clinical practice shows respect to
our world becomes more intensely multicul- clients’ beliefs, values, and expressions and es-
tural. Nurses and other health professionals are tablishes a partnership between health-care
expected to provide culturally congruent care
to people of diverse cultures. The theory, along 1For additional information about the Ethnonursing
with many transcultural nursing concepts, Research Method please go to bonus chapter content
principles, and research findings, will continue available at FA Davis http://davisplus.fadavis.com
to prove indispensable.

314 SECTION V • Grand Theories about Care or Caring

providers and clients to ensure safe, beneficent, understanding (beliefs, values, lifeways, and
and culturally congruent care (McFarland & environmental); connectedness; protection
Eipperle, 2008). (gender related); touching; and comfort meas-
ures (Leininger, 2006b; McFarland, 2002).
It is most important (and a shift in nursing) These care constructs are the most critical and
to carefully focus on the holistic dimensions, important universal or common findings to
as depicted in the sunrise enabler, to arrive at consider in nursing practice, but care diversi-
therapeutic culture care practices. All the fac- ties will also be found and must be considered.
tors in the sunrise enabler must be considered The ways in which culture care is applied and
to arrive at culturally congruent care. These used in specific cultures will reflect both simi-
include worldview; technological, religious, larities and differences among and within
kinship, political–legal, economic, and educa- different cultures.
tional factors; cultural values and lifeways;
environmental context, language, and ethno- Next, two ethnonursing studies are reviewed
history; and generic (folk) and professional with focus on the findings, which have impli-
care practices (Leininger, 2002, 2006a). Care cations for nursing practice.
generated from the CCT will become safe,
congruent, meaningful, and beneficial to Culture Care of Traditional Syrian
clients only when the nurse in clinical practice Muslims in the Midwestern United
becomes fully aware of and explicitly uses States
knowledge generated from the theory and eth-
nonursing method, whether in a community, In 2005, the theory of culture care diversity and
home, or institutional context. The CCT, used universality and the ethnonursing research
with the ethnonursing method, is a powerful method were used to guide a study of the cul-
means for exploring new directions and prac- ture care of traditional Syrian Muslims in the
tices in nursing. Incorporating culture-specific Midwestern United States (Wehbe-Alamah,
care into client care is essential to the practice 2008b, 2011). The domain of inquiry for this
of professional care and to licensure as regis- ethnonursing study was the generic and the
tered nurses. Culture-specific care is the safe professional care meanings, beliefs, and prac-
means to ensure culturally based holistic care tices related to health and illness of traditional
that fits the client’s culture—a major challenge Syrian Muslims living in several urban commu-
for nurses and other health-care professionals nities in the Midwestern United States. The
who practice and provide services in all health- purpose of this study was to discover, describe,
care settings. and analyze the effect of worldview, cultural
context, technological, religious, political, ed-
The Use of Culture Care Research ucational, and economic factors on the tradi-
Findings tional Syrian Muslims’ generic and professional
care meanings, beliefs, and practices. The goal
Over the past 5 decades, Dr. Leininger and was to provide practicing nurses and other
other research colleagues have used the CCT health-care providers with knowledge that can
and the ethnonursing method to focus on the be turned into care actions and decisions that
care meanings and experiences of 100 cultures facilitate the provision of culturally congruent
(Leininger, 2002). They discovered 187 care care to traditional Syrian Muslims living in
constructs in Western and non-Western cul- similar contexts (Wehbe-Alamah, 2011).
tures between 1989 and 1998 (Leininger,
1998a, 1998b). Leininger listed the 11 most Findings from this study revealed that the
dominant constructs of care in priority rank- worldview of traditional Syrian Muslims is
ing, with the most universal or frequently dis- deeply embedded in the Islamic religion and
covered first: respect for/about, concern the Syrian culture. Life is viewed as a test from
for/about; attention to (details)/in anticipation God and a journey in which one must attempt
of; helping–assisting or facilitative acts; active to do as many good deeds as possible and to
helping; presence (being physically there); behave in a righteous way whether conducting
business, taking care of housework, or engaging

CHAPTER 17 • Madeleine Leininger’s Theory of Culture Care Diversity and Universality 315

in any other regular daily activity. Kinship and be exemplified by withholding a diagnosis
familial relationships are treasured. Socializing and/or prognosis from a patient especially if
with family members and friends are consid- an impending death was expected and by bury-
ered important aspects of Syrian lifeway. Vis- ing the dead with 24 hours of their passing.
itations and telephone conversations as well as Caring attributes of nurses were identified as
Friday prayer congregations are major social smiling, responding quickly to the needs of
activities for Syrians. In Syrian Muslim society, sick patients, loving the nursing profession and
the man typically assumes the role of the role, and respecting the patient’s culture
breadwinner, whereas the woman takes on (Wehbe-Alamah, 2008b).
other responsibilities, such as managing the
household and raising the children (Wehbe- A plethora of generic or folk practices were
Alamah, 2008b). discovered and included some that are benefi-
cial to health and others with potentially
Some of the discovered traditional cultural harmful ramifications. One such example is
beliefs and practices included modesty, gener- the consumption of raw liver, which is rich in
ous hospitality, segregation of men and women iron and is used to treat anemia or iron defi-
during social events such as wedding parties ciency. Another example is treating head lice
and dinner invitations, wearing of a coat or jil- by pouring gasoline over the scalp and massag-
bab over clothes for women when in public, ing it into the hair. Folk practices that are ben-
caring for older family members within the eficial to health included eating in moderation,
home setting, as well as visiting, praying for, exercising, and taking vitamin C when treating
and cooking for the sick. Normal everyday ac- a cold (Wehbe-Alamah, 2008b).
tions were considered by many informants as
acts of worship. Engaging in religious practices Such information can be turned into cul-
such as prayer and Qur’an recitation or mem- turally congruent decisions and actions that
orization was reported as a source of physical, can impact clinical practice through the ap-
spiritual, emotional, and mental support by plication of Leininger’s culture care modes.
numerous informants. Religious beliefs were Accordingly, nurses and other health-care
determined to play an important role in a per- providers can preserve and/or maintain the cul-
son’s decision-making involving abortion, ster- tural beliefs, expressions, and practices of tra-
ilization, autopsy, organ donation, birth ditional Syrian Muslims by respecting the need
control, and other significant health issues for modesty and segregation and assigning
(Wehbe-Alamah, 2008a). same-sex health-care providers whenever pos-
sible. The cultural belief and practice of visiting
Caring was described as being considerate the sick can be accommodated by encouraging
of other people’s feelings and respecting their a large number of visitors within the hospital
beliefs. Empathy, sympathy, sensitivity, un- setting with the negotiation of having only a
selfishness, and understanding were other few visitors in the patient’s room at a time. The
qualities used to describe caring. Caring can be harmful folk practices of using gasoline to treat
expressed by checking on others, being avail- head lice and consuming raw liver to treat ane-
able to them, offering them help, cooking mia can be repatterned and/or restructured
healthy food, and keeping a clean body and a through education of ramifications and discus-
hygienic environment. Caring can additionally sion of healthier alternatives.

Practice Exemplar

A Middle Eastern patient in labor identified faith and wears a head cover. Her husband
as Mrs. Sarah Islam has just been admitted requests that only female health-care
to the obstetrics floor. She is accompanied providers (HCPs) be assigned to his wife.
by her husband and is dressed in loose cloth- The nurse provides culturally congruent care
ing that covers all of her body except for her to this family using Leininger’s culture care
face and hands. She belongs to the Muslim theory.

Continued

316 SECTION V • Grand Theories about Care or Caring

Practice Exemplar cont. Culture care preservation and/or
maintenance:
According to this theory, the worldview
of every human being is affected by cultural • The nurse includes a note in the electronic
and social structural dimensions, including but health record about identified cultural and
not limited to cultural values, beliefs, and life- religious values, practices, needs, and pro-
ways, and kinship, social, and religious factors. hibitions. This will assist with continuity of
Therefore, professional nursing care must in- culturally congruent care.
corporate an understanding of these beliefs
and practices. As a result, the nurse proceeds • The nurse is female; therefore she is able to
by conducting a cultural assessment to identify care for Mrs. Islam.
important needs and prohibitions that need to
be addressed in the plan of care. The nurse be- • The nurse places a sign at Mrs. Islam door
gins by explaining that she would like to ask that reads: “No males allowed without
questions to learn about how to best care for permission.”
the client and her family. The cultural assess-
ment reveals the following: • The obstetrician and all nursing staff at-
tending the birth are informed about the
• Modesty and privacy are important values important practice of handing the newborn
to Mrs. and Mr. Islam and should be pre- to the father within minutes of birth. The
served whenever possible, according to cul- father recites the prayer in the baby’s ears.
tural and religious teachings. The couple The nurse attends the birth and ensures
explains that this can be achieved by assign- that this happens.
ing same-sex HCPs and by preventing
male individuals from entering the patient’s Culture care accommodation and/or
room without first obtaining permission to negotiation:
do so.
• The nurse arranges for kitchen staff to pro-
• Pork-derived products including gelatin are vide vegetarian Jello versus animal-derived
prohibited in Islam and therefore should Jello.
be excluded from diet and medications.
The couple explains that Jello and gelatin- • The nurse arranges for medications to be
encapsulated medications contain gelatin ordered or dispensed in tablet versus gelcap
and should be avoided. format.

• A special prayer needs to be whispered by • The nurse negotiates with the family to
the father in the newborn’s ears after birth. have visitors come at different times, wait in
The couple requests that the newborn be waiting room, and visit in numbers of 2 or
handed to the father as soon as possible 3 at a time.
after birth to facilitate this practice.
Culture care restructuring and/or
• Visitation by family members and friends is repatterning:
to be expected following birth. The couple in-
forms you that they expect at least 30 visitors. • The nurse educates the client and her
husband about dangers associated with
• Smoking the water pipe is a common smoking and secondhand smoking inhala-
cultural practice and is often carried in the tion implications to the newborn. She ad-
presence of children. Mr. Islam smokes vises the discontinuation of this practice.
the water pipe twice a day. (Alternatively, the nurse negotiates with
Mr Islam to only smoke outdoors and cut
Having identified important cultural and down to once a day.)
religious values, practices, needs, and prohibi-
tions, the nurse proceeds to develop a cultur- Upon discharge, Mr. and Mrs. Islam thank
ally congruent plan of care using Leininger’s you, the nurse, for providing them with the
Culture care modes: best care they have ever received in a Western
health-care setting.

CHAPTER 17 • Madeleine Leininger’s Theory of Culture Care Diversity and Universality 317

■ Summary

The purpose of the CCT and the ethnonurs- books and articles written by Dr. Madeleine
ing method is to discover culture care knowl- Leininger and researchers using her theory
edge and to combine generic and professional and method. Nurses in clinical practice can
care. The goal is to provide culturally congru- refer to research studies and doctoral disserta-
ent nursing care using the three modes of tions conceptualized within the CCT for ad-
nursing actions and decisions that are mean- ditional detailed nursing implications for
ingful, safe, and beneficial to people of similar clients from diverse cultures (Leininger &
and diverse cultures worldwide (Leininger, McFarland, 2002; McFarland et al., 2011).
1991b, 1995, 2006a). The clinical use of the
three major care modes (culture care preser- The theory of culture care diversity and uni-
vation and/or maintenance; culture care ac- versality is one of the most comprehensive yet
commodation and/or negotiation; and culture practical theories to advance transcultural and
care repatterning and/or restructuring) by general nursing knowledge with concomitant
nurses to guide nursing judgments, decisions, ways for practicing nurses to establish or im-
and actions is essential in order to provide cul- prove care to people. Nursing students and
turally congruent care that is beneficial, satis- practicing nurses have remained the strongest
fying, and meaningful to the people nurses advocates of the CCT (Leininger, 2002). The
serve. The studies presented here substantiate theory focuses on a long-neglected area in
that the three modes are care-centered and nursing practice—culture care—that is most
are based on the use of generic care (emic) relevant to our multicultural world.
knowledge along with professional care (etic)
knowledge obtained from research using the The theory of culture care diversity and uni-
CCT along with the ethnonursing method. versality is depicted in the sunrise enabler as a
This chapter has reviewed only a small selec- rising sun. This visual metaphor is particularly
tion of the culture care findings from eth- apt. The future of the CCT shines brightly in-
nonursing research studies conducted over the deed because it is holistic and comprehensive;
past 5 decades. There is a wealth of additional and it facilitates discovering care related to
findings of interest to practicing nurses who diverse and similar cultures, contexts, and ages
care for clients of all ages from diverse and of people in familiar and naturalistic ways. The
similar cultural groups in many different in- theory is useful to nurses and nursing as well
stitutional and community contexts around as to professionals in other disciplines such as
the world. More in-depth culture care find- physical, occupational, and speech therapy,
ings, along with the use of the three modes, medicine, social work, and pharmacy. Health-
can be found in the Journal of Transcultural care practitioners in other disciplines are
Nursing (1989–2013), in the Online Journal of beginning to use this theory because they also
Cultural Competence in Nursing and Healthcare need to become knowledgeable about and
(www.OJCCNH.org) and in the numerous sensitive and responsible to people of diverse
cultures who need care (Leininger, 2002;
McFarland, 2011).

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Jean Watson’s Theory of 18Chapter
Human Caring

JEAN WATSON

Introducing the Theorist Introducing the Theorist
Overview of the Theory
Applications of the Theory Dr. Jean Watson is distinguished professor
Practice Exemplar by Terri Woodward emerita and dean of nursing emerita at the Uni-
versity of Colorado Denver, where she served
Summary for more than 20 years and held an endowed
References Chair in Caring Science for more than 16 years.
She is founder of the original Center for
Jean Watson Human Caring at the University of Colorado
Health Sciences, is a Living Legend in the
American Academy of Nursing, and served as
president of the National League for Nursing.
Dr. Watson founded and directs the nonprofit
Watson Caring Science Institute, dedicated to
furthering the work of caring, science, and
heart-centered Caritas Nursing, restoring caring
and love for nurses’ and health-care clinicians’
healing practices for self and others.

Watson earned undergraduate and grad-
uate degrees in nursing and psychiatric–mental
health nursing and holds a doctorate in edu-
cational psychology and counseling from the
University of Colorado at Boulder. She is a
widely published author and is the recipient
of several awards and honors, including
an international Kellogg Fellowship in
Australia; a Fulbright Research Award in
Sweden; and 10 honorary doctoral degrees,
including seven from international universi-
ties in Sweden, the United Kingdom, Spain,
Japan, and British Colombia and Montreal,
Quebec, Canada.

Dr. Watson’s original book on caring was
published in 1979. Her second book, Nursing:
Human Science and Human Care, was written
while on sabbatical in Australia and reflects the
metaphysical and spiritual evolution of her
thinking. A third book, Postmodern Nursing
and Beyond, moves beyond theory to reflect the

321

322 SECTION V • Grand Theories about Care or Caring

ontological foundation of nursing as an overar- Overview of the Theory
ching framework for transforming caring and
healing practices in education and clinical care The theory of human caring was developed be-
(Watson, 1999). Additional empirical and clin- tween 1975 and 1979 while I was teaching at
ical caring research foci developments include the University of Colorado. It emerged from
the first and second editions of the book on car- my own views of nursing, combined and in-
ing instruments, Assessing and Measuring Caring formed by my doctoral studies in educational,
in Nursing and Health Sciences (2002, 2008b), clinical, and social psychology. It was my initial
which offers a critique and collation of more attempt to bring meaning and focus to nursing
than 20 instruments for assessing and measuring as an emerging discipline and distinct health
caring. Her Caring Science as Sacred Science makes profession that had its own unique values,
a case for a deep moral–ethical, spirit-filled knowledge, and practices, and its own ethic
foundation for caring science and healing based and mission to society. The work was also in-
on infinite love and an expanding cosmology. fluenced by my involvement with an integrated
Watson’s 2008(a) theoretical work, Nursing: The academic nursing curriculum and efforts to
Philosophy and Science of Caring, Revised New find common meaning and order to nursing
Edition, revisits and reworks her first book, that transcended settings, populations, spe-
Nursing: The Philosophy and Science of Caring cialty, and subspecialty areas.
(1979, reprinted 1985), bringing the original
publication up to date to include all the changes From my emerging perspective, I make ex-
made during the past 30 years. This latest update plicit that nursing’s values, ethic, philosophy,
introduces Caritas nursing as the culmination of knowledge, and practices of human caring re-
a caring science foundation for professional quire language order, structure, and clarity of
nursing. A coauthored educational book, Creat- concepts and worldview underlying nursing as
ing a Caring Science Curriculum: Emancipatory a distinct discipline and profession. The theory
Pedagogies by Marcia Hills and Watson, was goes beyond the dominant physical worldview
published in 2011 followed by two additional and opens to subjective, intersubjective, and
coauthored research and measurement books, inner meaning, underlying healing processes
and the life world of the experiencing person.
Measuring Caritas. International Research on This original (Watson, 1979) language framed
Caritas as Healing (Nelson & Watson, 2011) and this orientation that required unique caring–
Caring Science, Mindful Practice: Implementing healing arts. The human caring processes were
Watson’s Human Caring Theory (Sitzman & named the “10 carative factors,” which com-
Watson, 2014). plemented conventional medicine but stood in
stark contrast to “curative factors.” At the same
The Watson Caring Science Institute is time, this emerging philosophy and theory of
developing educational, clinical, and admin- human caring sought to balance the cure ori-
istrative–leadership and research models that entation of medicine, giving nursing its unique
seek to sustain and deepen authentic caring– disciplinary, scientific, and professional stand-
healing practices for self and other, trans- ing with itself and its public.
forming practitioners and patients alike. The
caring science model, integrating Caritas The early work has continued to evolve dy-
with the science of the heart in collaboration namically from the original writings of 1979,
with the Institute of HeartMath (www 1981, 1985, and the 1990s to a more updated
.heartMath.com), deepens intelligent heart- view of 10 caritas processes, to caring science
centered caring. All of Watson’s latest publica- as sacred science, and to a unitary global con-
tions and innovative educational partnerships, sciousness for leadership. My work now makes
activities, new programs, speaking calendar, connections between human caring, healing,
and directions and developments, including and even peace in our world, with nurses as
information about a nontraditional doctorate caritas peacemakers when they are practicing
in caring science as sacred science can be found human caring for self and others. This shift
on the website: www.watsoncaringscience.org. moves to more explicit metaphysical/spiritual

CHAPTER 18 • Jean Watson’s Theory of Human Caring 323

focus on transpersonal caring moment, post- This view takes nursing and healing work
modern critiques, to metaphysical—from the- beyond conventional thinking. The latest ori-
ory to ontological paradigm for caring science. entation is located within the ageless wisdom
A broad, evolving unitary caring science traditions and perennial ingredients of the dis-
worldview underlies the fluid evolution of the cipline of nursing, while transcending nursing.
theory and the philosophical-ethical founda- Caring science as a model for nursing allows
tion for this work. nursing’s caring–healing core to become both
discipline-specific and transdisciplinary. Thus,
Major Conceptual Elements nursing’s timeless, ancient, enduring, and most
noble contributions come of age through a
The major conceptual elements of the original caring-science orientation—scientifically, aes-
(and emergent) theory are as follows: thetically, ethically, and practically.

• Ten carative factors (transposed to ten Ten Carative Factors
caritas processes)
The original work (Watson, 1979) was organ-
• Transpersonal caring moment ized around 10 carative factors as a framework
• Caring consciousness/intentionality and for providing a format and focus for nursing
phenomena. Although carative factors is still
energetic presence the current terminology for the “core” of nurs-
• Caring–healing modalities ing, providing a structure for the initial work,
the term factor is too stagnant for my sensibil-
Other dynamic aspects of the theory that ities today. I have extended carative to caritas
have emerged or are emerging as more explicit and caritas processes as consistent with a more
components include: fluid and contemporary movement of these
ideas and with my expanding directions.
• Expanded views of self and person (unitary
oneness; embodied spirit) Caritas comes from the Latin word mean-
ing “to cherish and appreciate, giving special
• Caring–healing consciousness and energetic attention to, or loving.” It connotes something
heart-centered presence that is very fine; indeed, it is precious. The
word caritas is also closely related to the origi-
• Human–environmental field of a caring nal word carative from my 1979 book. At this
moment time, I now make new connections between
carative and caritas and without hesitation use
• Unitary oneness worldview: unbroken them to invoke love, which caritas conveys.
wholeness and connectedness of all This usage allows love and caring to come to-
gether for a new form of deep, transpersonal
• Advanced caring–healing modalities/ caring. This relationship between love and car-
nursing arts as a future model for advanced ing connotes inner healing for self and others,
practice of nursing qua nursing (consciously extending to nature and the larger universe,
guided by one’s nursing ethical–theoretical– unfolding and evolving within a cosmology
philosophical orientation) that is both metaphysical and transcendent
with the coevolving human in the universe.
Caring Science as Sacred Science This emerging model of transpersonal caring
moves from carative to caritas. This integrative
The emergence of the work is a more explicit de- expanded perspective is postmodern in that
velopment of caring science as a deep moral– it transcends conventional industrial, static
ethical context of infinite and cosmic love. As models of nursing while simultaneously evok-
soon as one is more explicit about placing the ing both the past and the future. For example,
human and caring within their science model, it the future of nursing is tied to Nightingale’s
automatically forces a relational unitary world- sense of “calling,” guided by a deep sense of
view and makes explicit caring as a moral ideal
to sustain humanity across time and space; one
of the gifts and the raison d’être of nursing in the
world, but yet to be recognized within and with-
out. Nevertheless, a caring-science orientation is
necessary for the survival of nursing as well as
humanity at this crossroads in human evolution.

324 SECTION V • Grand Theories about Care or Caring

commitment and a covenantal ethic of human its larger professional ethic and mission to
service, cherishing our phenomena, our subject society—its raison d’être for the public. That
matter, and those we serve. is where nursing theory comes into play, and
transpersonal caring theory offers another way
It is when we include caring and love in our that both differs from and complements that
work and in our life that we discover and which has come to be known as “modern”
affirm that nursing, like teaching, is more than nursing and conventional medical–nursing
just a job; it is also a life-giving and life- frameworks.
receiving career for a lifetime of growth and
learning. Such maturity and integration of past The 10 carative factors included in the orig-
with present and future now require trans- inal work are the following:
forming self and those we serve, including our
institutions and our profession. As we more 1. Formation of a humanistic–altruistic
publicly and professionally assert these posi- system of values.
tions for our theories, our ethics, and our
practices—even for our science—we also locate 2. Instillation of faith–hope.
ourselves and our profession and discipline 3. Cultivation of sensitivity to one’s self and
within a new, emerging cosmology. Such
thinking calls for a sense of reverence and to others.
sacredness with regard to life and all living 4. Development of a helping–trusting,
things. It incorporates both art and science, as
they are also being redefined, acknowledging human caring relationship.
a convergence among art, science, and spiritu- 5. Promotion and acceptance of the expres-
ality. As we enter into the transpersonal caring
theory and philosophy, we simultaneously sion of positive and negative feelings.
are challenged to relocate ourselves in these 6. Systematic use of a creative problem-
emerging ideas and to question for ourselves
how the theory speaks to us. This invites us solving caring process.
into a new relationship with ourselves and our 7. Promotion of transpersonal teaching–
ideas about life, nursing, and theory.
learning.
Original Carative Factors 8. Provision for a supportive, protective,

The original carative factors served as a guide and/or corrective mental, physical,
to what was referred to as the “core of nursing” societal, and spiritual environment.
in contrast to nursing’s “trim.” Core pointed to 9. Assistance with gratification of human
those aspects of nursing that potentiate ther- needs.
apeutic healing processes and relationships— 10. Allowance for existential–phenomenological–
they affect the one caring and the one being spiritual forces. (Watson, 1979, 1985)
cared for. Further, the basic core was
grounded in what I referred to as the philos- Although some of the basic tenets of the
ophy, science, and art of caring. Carative is original carative factors still hold and indeed
that deeper and larger dimension of nursing are used as the basis for some theory-guided
that goes beyond the “trim” of changing times, practice models and research, what I am pro-
setting, procedures, functional tasks, special- posing here, as part of my evolution and the
ized focus around disease, and treatment and evolution of these ideas and the theory itself,
technology. Although the “trim” is important is to transpose the carative factors into “clinical
and not expendable, the point is that nursing caritas processes.”
cannot be defined around its trim and what it
does in a given setting and at a given point in From Carative Caritas Processes
time. Nor can nursing’s trim define and clarify
As carative factors evolved within an expand-
ing perspective and as my ideas and values have
evolved, I now offer the following translation
of the original carative factors into caritas
processes, suggesting more open ways in which
they can be considered.

1. Formation of a humanistic–altruistic sys-
tem of values becomes the practice of loving

CHAPTER 18 • Jean Watson’s Theory of Human Caring 325

kindness and equanimity within the 10. Allowance for existential–phenomenolog-
context of caring consciousness. ical–spiritual forces becomes opening and
2. Instillation of faith–hope becomes being attending to spiritual-mysterious and
authentically present and enabling and sus- existential dimensions of one’s own
taining the deep belief system and subjective life-death; soul care for self and the one
life world of self and one being cared for. being cared for. “Allowing for miracles.”
3. Cultivation of sensitivity to one’s self and
to others becomes cultivation of one’s own What differs in the caritas process frame-
spiritual practices and transpersonal self, work is that a decidedly spiritual dimension and
going beyond ego self, opening to others an overt evocation of love and caring are
with sensitivity and compassion. merged for a new unitary cosmology for this
4. Development of a helping–trusting, millennium. Such a perspective ironically places
human caring relationship becomes devel- nursing within its most mature framework and
oping and sustaining a helping–trusting, is consistent with the Nightingale model of
authentic caring relationship. nursing—yet to be actualized but awaiting its
5. Promotion and acceptance of the expres- evolution. This direction, while embedded
sion of positive and negative feelings in theory, goes beyond theory and becomes a
becomes being present to, and supportive converging paradigm for nursing’s future.
of, the expression of positive and negative
feelings as a connection with deeper Thus, I consider my work more a philo-
spirit of self and the one being cared for sophical, ethical, intellectual blueprint for
(authentically listening to another’s story). nursing’s evolving disciplinary/professional
6. Systematic use of a creative problem- matrix, rather than a specific theory per se.
solving caring process becomes creative use Nevertheless, others interact with the original
of self and all ways of knowing as part of work at levels of concreteness or abstractness.
the caring process; to engage in the artistry If the theory is “read” at the carative factor
of caring-healing practices (creative solu- level, it can be interpreted as a middle-range
tion seeking becomes caritas coach role). theory. If the theory is “read” at the transper-
7. Promotion of transpersonal teaching- sonal unitary caring science/transpersonal
learning becomes engaging in genuine caring consciousness level, the theory can be
teaching-learning experience that attends interpreted as a grand theory located within
to unity of being and meaning, attempting the unitary–transformative context.
to stay within others’ frames of reference.
8. Provision for a supportive, protective, The caring theory has been and increasingly
and/or corrective mental, physical, societal, is being used nationally and internationally as
and spiritual environment becomes creating a guide for educational curricula, clinical prac-
a healing environment at all levels (a phys- tice models, methods for research and inquiry,
ical and nonphysical, subtle environment and administrative directions for nursing and
of energy and consciousness, whereby health-care delivery.
wholeness, beauty, comfort, dignity, and
peace are potentiated). Reading the Theory
9. Assistance with gratification of human
needs becomes assisting with basic needs, The “theory” can be “read” as a philosophy,
with an intentional caring consciousness, an ethic, a paradigm, an expanded science
administering “human care essentials,” model, or a theory. If read as a theory, it can
which potentiate wholeness and unity of be “read” as a grand theory within the unitary–
being in all aspects of care; sacred acts of transformative paradigm when understood at
basic care; touching embodied spirit and the transpersonal, energetic-field level of caritas-
evolving spiritual emergence. universal love and evolving consciousness.

It can be “read” as middle-range theory
when read at the carative factors/caritas
process level, which provides the structure and

326 SECTION V • Grand Theories about Care or Caring

language of the theory, as both middle range to transform self and system. For more compre-
and specific. When used in clinical settings, hensive understanding of this work, see Nursing:
the theory helps nurses to frame their experi- The Philosophy and Science of Caring (revised 2nd
ences around the caritas processes to sustain ed.; Watson, 2008a). Indeed, the latest research
the caring-science focus, as well as developing based on the science of the heart has demon-
language systems, including computerized strated that the loving heart-centered person is
documentation systems, to document and radiating love that can be measured several feet
study caring within a designated language sys- beyond themselves, affecting the subtle environ-
tem (Rosenberg, 2006, p. 55). The middle- ment of all. Moreover, this research affirms that
range focus is also congruent with clinical the heart is actually sending more messages to
caring research projects, utilizing the caring the brain, rather than the other way around. For
language of carative/caritas. Indeed, many of more information, please visit www.heartMath
the more formalized caring assessment tools .com; www.heartMath.org
are based on the language of this structure.
Several multisite research projects are now un- This work posits a unitary oneness world-
derway using consistent caring assessment view of connectedness of all; it embraces a
tools, such as Duffy’s Caring Assessment Tool value’s explicit moral foundation and takes a
and the Nelson, Watson, and Inova Health specific position with respect to the centrality
Instrument Caring Factor Survey (Persky, of human caring, “caritas,” and universal love
Nelson, Watson, & Bent, 2008). The latest as an ethic and ontology. It is also a critical
Watson Caritas Patient Score is being used in starting point for nursing’s existence, broad
multisite clinical studies as an international re- societal mission, and the basis for further
search project. (For more information, go to advancement for caring–healing practices.
www.watsoncaringscience.org.) In addition, Nevertheless, its use and evolution are depend-
most of the current caring-science assessment ent on “critical, reflective practices that must
tools may be seen in Assessing and Measuring be continuously questioned and critiqued in
Caring in Nursing and Health Sciences, 2nd ed. order to remain dynamic, flexible, and end-
(Watson, 2008b). lessly self-revising and emergent” (Watson,
1996, p. 143).
Heart-Centered Transpersonal
Caring Moment: Caritas Field Transpersonal Caring Relationship

Whether the “theory” is read at different levels, The terms transpersonal and transpersonal caring
used as a language system for documentation, relationship are foundational to the work.
used as a guide for professional nursing prac- Transpersonal conveys a concern for the inner
tice models, or used as the focus of multisite life world and subjective meaning of another
or individual clinical caring research studies, who is fully embodied. But the transpersonal
the essence of the lived theory is in the transper- also energetically goes beyond the ego self and
sonal caring moment. The caring moment can beyond the given moment, reaching to the
be located within any caring occasion, as a deeper connections to spirit and with the
concept within middle-range or even prescrip- broader universe. Thus, a transpersonal caring
tive or practice-level theory. relationship moves beyond ego self and radi-
ates to spiritual, even cosmic, concerns and
However, the caring moment is most evi- connections that tap into healing possibilities
dent within the transpersonal caritas energetic and potentials. Transpersonal caring is both
field model, in that one’s consciousness, inten- immanent, fully physical and embodied phys-
tionality, energetic heart-centered presence is ically, while also paradoxically transcendent,
radiating a field beyond the two people or the beyond physical self.
situation, affecting the larger field. Thus, nurses
can become more aware, more awake, more Transpersonal caring seeks to connect with
conscious of manifesting/radiating a caritas field and embrace the spirit or soul of the other
of love and healing for self and others, helping through the processes of caring and healing
and being in authentic relation in the moment.

CHAPTER 18 • Jean Watson’s Theory of Human Caring 327

Such a transpersonal relationship is influenced comfort measures, pain control, a sense of
by the caring consciousness and intentionality well-being, wholeness, or even a spiritual tran-
and energetic presence of the nurse as she or scendence of suffering. The person is viewed as
he enters into the life space or phenomenal whole and complete, regardless of illness or
field of another person and is able to detect the disease (Watson, 1996, p. 153).
other person’s condition of being (at the soul
or spirit level). It implies a focus on the Assumptions of the Transpersonal
uniqueness of self and other and the unique- Caring Relationship
ness of the moment, wherein the coming to-
gether is mutual and reciprocal, each fully The nurse’s moral commitment, intentionality,
embodied in the moment, while paradoxically and caritas consciousness exist to protect, en-
capable of transcending the moment, open to hance, promote, and potentiate human dignity,
new possibilities. wholeness, and healing, wherein a person creates
or cocreates his or her own meaning for exis-
The transpersonal caritas consciousness tence, healing, wholeness, and living and dying.
nurse seeks to “see” the spirit-filled person be-
hind the patient, behind the colleague, behind The nurse’s will and consciousness affirm
the disease or the diagnosis or the behavior or the subjective-spiritual significance of the per-
personality one may not like and connect with son while seeking to sustain caring in the midst
that spirit-filled individual who exists behind of threat and despair—biological, institutional,
the illusion. This is heart-centered caritas prac- or otherwise. This honors the I–Thou rela-
tice guided by the very first caritas process: cul- tionship versus an I–It relationship (Buber,
tivation of loving kindness and equanimity 1923/1996).
with self and other, allowing for development
of more caring, love, compassion, and authen- The nurse seeks to recognize, accurately de-
tic caring moments. tect, and connect with the inner condition
of spirit of another through authentic caritas
Transpersonal caring calls for an authentic- (loving) presencing and being centered in the
ity of being and becoming, an ability to be caring moment. Actions, words, behaviors,
present to self and others in a reflective frame. cognition, body language, feelings, intuition,
The transpersonal nurse has the ability to cen- thought, senses, the energy field, and so on—all
ter consciousness and intentionality on caring, contribute to the transpersonal caring connec-
healing, and wholeness, rather than on disease, tion. The nurse’s ability to connect with an-
illness, and pathology. other at this transpersonal spirit-to-spirit level
is translated via movements, gestures, facial
Transpersonal caring competencies are re- expressions, procedures, information, touch,
lated to ontological development of the nurse’s sound, verbal expressions, and other scientific,
human caring literacy and ways of being and technical, esthetic, and human means of com-
becoming. Thus, “ontological caring compe- munication into nursing human art/acts or
tencies” become as critical in this model as intentional caring-healing modalities.
“technological curing competencies” to the
conventional modern, Western techno-cure The caring–healing modalities within the
nursing-medicine model, which is now com- context of transpersonal caring/caritas con-
ing to an end. sciousness potentiate harmony, wholeness, and
unity of being by releasing some of the dishar-
Within the model of transpersonal caring, mony, the blocked energy that interferes with
clinical caritas consciousness is engaged at a the natural healing processes. As a result, the
foundational ethical level for entry into this nurse helps another through this process to
framework. The nurse attempts to enter into access the healer within, in the fullest sense of
and stay within the other’s frame of reference Nightingale’s view of nursing.
for connecting with the inner life world of
meaning and spirit of the other. Together, Ongoing personal–professional develop-
they join in a mutual search for meaning and ment and spiritual growth and personal spiri-
wholeness of being and becoming, to potentiate tual practice assist the nurse in entering
into this deeper level of professional healing

328 SECTION V • Grand Theories about Care or Caring

practice, allowing the nurse to awaken to the the other at the spirit level; thus, the moment
transpersonal condition of the world and to ac- transcends time and space, opening up new
tualize more fully “ontological competencies” possibilities for healing and human connection
necessary for this level of advanced practice of at a deeper level than that of physical interac-
nursing. Valuable teachers for this work include tion. For example:
the nurse’s own life history and previous expe-
riences, which provide opportunities for fo- [W]e learn from one another how to be human by
cused studies, as the nurse has lived through or identifying ourselves with others, finding their dilem-
experienced various human conditions and has mas in ourselves. What we all learn from it is self-
imagined others’ feelings in various circum- knowledge. The self we learn about . . . is every
stances. To some degree, the necessary knowl- self. IT is universal—the human self. We learn to
edge and consciousness can be gained through recognize ourselves in others . . . [it] keeps alive
work with other cultures and the study of the our common humanity and avoids reducing self or
humanities (art, drama, literature, personal other to the moral status of object. (Watson, 1985,
story, narratives of illness journeys) along with pp. 59–60)
an exploration of one’s own values, deep beliefs,
relationship with self and others, and one’s Caring (Healing) Consciousness
world. Other facilitators include personal-
growth experiences such as psychotherapy, The dynamic of transpersonal caring (healing)
transpersonal psychology, meditation, bioener- within a caring moment is manifest in a field
getics work, and other models for spiritual of consciousness. The transpersonal dimen-
awakening. Continuous growth is ongoing for sions of a caring moment are affected by the
developing and maturing within a transper- nurse’s consciousness in the caring moment,
sonal caring model. The notion of health pro- which in turn affects the field of the whole.
fessionals as wounded healers is acknowledged The role of consciousness with respect to a
as part of the necessary growth and compassion holographic view of science has been discussed
called forth within this theory/philosophy. in earlier writings (Watson, 1992, p. 148) and
includes the following points:
Caring Moment/Caring Occasion
• The whole caring–healing–loving con-
A caring occasion occurs whenever the nurse sciousness is contained within a single
and another come together with their unique caring moment.
life histories and phenomenal fields in a
human-to-human transaction. The coming to- • The one caring and the one being cared
gether in a given moment becomes a focal for are interconnected; the caring-healing
point in space and time. It becomes transcen- process is connected with the other
dent, whereby experience and perception take human(s) and with the higher energy of the
place, but the actual caring occasion has a universe.
greater field of its own, in a given moment.
The process goes beyond itself yet arises from • The caring–healing–loving consciousness of
aspects of itself that become part of the life his- the nurse is communicated to the one being
tory of each person, as well as part of a larger, cared for.
more complex pattern of life (Watson, 1985,
p. 59; 1996, p. 157). • Caring–healing–loving consciousness exists
through and transcends time and space and
A caring moment involves an action and a can be dominant over physical dimensions.
choice by both the nurse and the other. The
moment of coming together presents the two Within this context, it is acknowledged that
with the opportunity to decide how to be in the process is relational and connected. It
the moment in the relationship—what to do transcends time, space, and physicality. The
with and in the moment. If the caring moment process is intersubjective with transcendent
is transpersonal, each feels a connection with possibilities that go beyond the given caring
moment.

CHAPTER 18 • Jean Watson’s Theory of Human Caring 329

Implications of the Caring Model beings having a human experience?” Such
thinking in regard to this philosophical
The caring model or theory can be considered a question can guide one’s worldview and
philosophical and moral/ethical foundation for help to clarify where one may locate self
professional nursing and is part of the central within the caring framework.
focus for nursing at the disciplinary level. A • Are those interacting and engaging in the
model of caring includes a call for both art and model interested in their own personal
science. It offers a framework that embraces and evolution? Are they committed to seeking
intersects with art, science, humanities, spiritu- authentic connections and caring–healing
ality, and new dimensions of mind–body–spirit relationships with self and others?
medicine and nursing evolving openly as central • Are those involved “conscious” of their
to human phenomena of nursing practice. caring caritas or noncaring consciousness
and intentionally in a given moment at an
I emphasize that it is possible to read, study, individual and a systemic level? Are they
learn about, and even teach and research the interested and committed to expanding
caring theory. However, to truly “get it,” one their caring consciousness and actions to
has to experience it personally. The model is self, other, environment, nature, and wider
both an invitation and an opportunity to inter- universe?
act with the ideas, to experiment with and • Are those working within the model inter-
grow within the philosophy, and to live it out ested in shifting their focus from a modern
in one’s personal and professional lives. medical science–technocure orientation
to a true heart-centered authentic caring–
Applications of the Theory healing–loving model?

The ideas as originally developed, as well as in This work, in both its original and evolv-
the current evolving phase (Watson, 1979, ing forms, seeks to develop caring as an
1985, 1999, 2003, 2005, 2008, 2011), provide ontological–epistemological foundation for a
us with a chance to assess, critique, and see theoretical–philosophical–ethical framework
where or how, or even if, we may locate our- for the profession and discipline of nursing
selves within a framework of caring science/ and to clarify its mature relationship and dis-
caritas as a basis for the emerging ideas in re- tinct intersection with other health sciences.
lation to our own theories and philosophies of Nursing caring theory–based activities as
professional nursing and/or caring practice. If guides to practice, education, and research
one chooses to use the caring-science perspec- have developed throughout the United States
tive as theory, model, philosophy, ethic, or and other parts of the world. The caring/
ethos for transforming self and practice, or self caritas model is consistently one of the nurs-
and system, the following questions may help ing caring theories used as a guide in Magnet
(Watson, 1996, p. 161): Hospitals in the United States and found to
be culturally consistent with nursing in many
• Is there congruence between the values and other cultures, nations, and countries. Nurses’
major concepts and beliefs in the model and reflective-critical practice models are increas-
the given nurse, group, system, organization, ingly adhering to a caring ethic and ethos as
curriculum, population needs, clinical ad- the moral and scientific foundation for a pro-
ministrative setting, or other entity that is fession that is coming of age for a new global
considering interacting with the caring era in human history.
model to transform and/or improve practice?
Latest Developments
• What is one’s view of “human”? And what
does it mean to be human, caring, healing, The Watson Caring Science Institute (WCSI)
becoming, growing, transforming, and so was established in 2007 as a nonprofit founda-
on? For example, in the words of Teilhard tion. The following statements define and
de Chardin (1959): “Are we humans having
a spiritual experience, or are we spiritual