Nursing Theories & Nursing Practice

330 SECTION V • Grand Theories about Care or Caring

describe the goals, missions, and purposes of • Mentor self and others in using and extend-
the International Caritas Consortium (ICC) ing the theory of human caring to trans-
and the WCSI as two interrelated entities. form education and clinical practices.
The general goals and objectives of the WCSI
are to steward and serve the ICC in its activi- • Develop and disseminate caring science
ties and more specifically to: models of clinical scholarship and profes-
• Transform the dominant model of medical sional excellence in the various settings in
the world.
science to a model of caring science by
reintroducing the ethic of caring and love, Activities for Caritas Consortium
necessary for healing. Gatherings
• Deepen the authentic caring–healing rela-
tionships between practitioner and patient • Provide a safe forum to explore, create, and
to restore love and heart-centered human renew self and system through reflective
compassion as the ethical foundation of time out.
health care.
• Translate the model of caring–healing/ • Share ideas, inspire each other, and learn
caritas into more systematic programs and together.
services to help transform health care one
nurse, one practitioner, one educator, and • Participate in use of appreciative inquiry in
one system at a time. which each member is facilitative of each
• Ensure caring and healing for the public, other’s work, each participant learning from
reduce nurse turnover, and decrease costs others.
to the system.
• Create opportunities for original scholar-
International Caritas Consortium ship and new models of caring science–
Charter based clinical and educational practices.

The main purposes of the unfolding and emerg- • Generate and share multisite projects in
ing ICC (Watson, 2008a, pp. 278–280) are as caring theory/caring science scholarship.
follows:
• Network for educational and professional
1. To explore diverse ways to bring the caring models of advancing caring–healing
theory to life in academic and clinical prac- practices and transformative models of
tice settings by supporting and learning nursing.
from each other
• Share unique experiences for authentic self-
2. To share knowledge and experiences so growth within the caring science context.
that we might help guide self and others in
the journey to live the caring philosophy • Educate, implement, and disseminate
and theory in our personal and professional exemplary experiences and findings to
lives. broader professional audiences through
scholarly publications, research, and
The consortium gatherings, sponsored by formal presentations.
systems implementing caring theory in practice:
• Envision new possibilities for transforming
• Provide an intimate forum to renew, re- nursing and health care.
store, and deepen each person’s and each
system’s commitment and authentic prac- Because of the many national and interna-
tices of human caring in their personal/ tional developments and sincere desire for
professional life and work. authentic change, new projects using caring
science, caritas theory, and the philosophy
• Learn from each other through shared work of human caring are now underway in many
of original scholarship, diverse forms of car- systems. The WCSI and the ICC are examples
ing inquiry, and modeling of caring–healing of individuals and representatives of systems
practices. convening (in these cases, once a year) to
deepen and sustain what is referred to as caritas
nursing—that is, bringing caring and love and
heart-centered human-to-human practices
back into our personal life and work world
(Watson, 2008a).

CHAPTER 18 • Jean Watson’s Theory of Human Caring 331

Caring Indicators and Programs • Place magnets on patient’s door with
positive affirmations and reminders of
Although these earlier-named systems are caring practices.
identified as sponsors of the growing ICC, ex-
amples of how these systems are implementing • Explore documentation of caring language
the theory are captured through identified acts and integration in computerized documen-
and processes depicting such transformative tation systems.
changes.
• Participate in multisite research assessing
Caring theory-in-action reflects transfor- caring among staff and patients.
mative processes that are representative of ac-
tions taking place in many of the systems in • Create healing environments, attending to
the ICC and other systems guided by caring the subtle environment or caritas field.
science and caring theory. The following are
examples of such caring-in-action indicators: • Display healing objects, stones, or a blessing
basket.
• Make human caring integral to the organi-
zational vision and culture through new • Create Caritas Circles to share caring
language and documentation of caring, moments.
such as posters.
• Perform Caring Rounds at bedside with
• Introduce and name new professional car- patients.
ing practice models, leading to new patterns
of delivery of caring/care (e.g., Attending • Interview and select staff on the basis of a
Caring Nursing Project, Patient Care “caring” orientation. Asking candidates to
Facilitator Role, the 12-Bed Hospital). describe a “caring moment.”

• Create conscious intentional meaningful • Develop of “caring competencies” using
rituals—for example, hand washing is for caritas literacy as guide to assess and pro-
infection control but may also be a mean- mote staff development and ensure caring.
ingful ritual of self-caring—energetically
cleansing, blessing, and releasing the last These and other practices are occurring in a
situation or encounter, and being open to variety of hospitals across the United States,
the next situation. often in Magnet hospitals or those seeking
Magnet recognition, where caring theory and
• Selectively use of caring–healing modalities models of human caring are used to transform
for self and patients (e.g., massage, thera- nursing and health care for staff and patients
peutic touch, reflexology, aromatherapy, alike.
calmative essential oils, sound, music, arts,
a variety of energetic modalities). The names of other health-care clinical and
educational systems incorporating caring
• Dim the unit lights and have designated theory into professional nursing practice mod-
“quiet time” for patients, families, and staff els (many are Magnet hospitals or preparing
alike to soften, slow down, and calm the to become Magnet hospitals) can be found
environment. at www.watsoncaringscience.org.

• Create healing spaces for nurses—sanctuaries These identified system examples are ex-
for their own time out; this may include emplars of the changing momentum today
meditation or relaxation rooms for quiet and are guided by a shift toward an evolved
time. consciousness. They rely on moral, ethical,
philosophical, and theoretical foundations to
• Cultivate one’s own spiritual heart-centered restore human caring and healing and health
practices of loving kindness and equanimity in a system that has gone astray—educationally,
to self and others. economically, clinically, and socially. This
shift is in a hopeful direction and is based
• Intentionally pause and breathe, preparing on a grassroots transformation of nursing,
the self to be present before entering one that emerging from the inside out. The
patient’s room. dedicated leaders who are ushering in these
changes serve as an inspiration for sustaining
• Use centering exercises and mindfulness nursing and human caring for practitioners
practices, individually and collectively. and patients alike.

332 SECTION V • Grand Theories about Care or Caring

Conclusion increasingly evident as nursing makes its major
contribution to health care and matures as
Consistent with the wisdom and vision of Flo- a distinct caring–healing profession—one that
rence Nightingale, nursing is a lifetime journey balances and complements conventional,
of caring and healing, seeking to understand medical–institutional practices and processes.
and preserve the wholeness of human existence Nevertheless, much work remains to be done.
across time and space and national/geographic New transformative, human-spirit–inspired
boundaries, to offer heart-centered compas- approaches are required to reverse institutional
sionate, informed knowledgeable human car- and system lethargy and darkness. To create
ing to society and humankind. This timeless the necessary cultural change, the human spirit
view of nursing transcends conventional minds has to be invited back into our health-care sys-
and mindsets of illness, pathology, and disease tems. Professional and personal models are re-
that are located in the physical body with cur- quired that open the hearts of nurses and other
ing as end goal, often at all costs. In nursing’s practitioners. New horizons of possibilities
timeless model, caring, kindness, love, and have to be explored to create space whereby
heart-centered compassionate service to hu- compassionate, intentional, heart-centered
mankind are restored. The unifying focus and human caring can be practiced. Such authentic
process is on connectedness with self, other, personal/professional practice models of caring
nature, and God/the Life Force/the Absolute. science are capable of leading us, locally and
This vision and wisdom is being reignited globally, toward a moral community of caring.
today through a blend of old and new values, This community will restore healing and health
ethics, and theories and practices of human at a level that honors and sustains the dignity
caring and healing. These caritas consciousness and humanity of practitioners and patients alike.
practices preserve humanity, human dignity,
and wholeness and are the very foundation of The Watson Caring Science Institute is
transformed thinking and actions. dedicated to create, conduct, and sponsor
Caring Science/Caritas education, training,
Such a values-guided relational ontology and support to serve the current and future
and expanded epistemology and ethic is em- generations of health-care professionals glob-
bodied in caring science as the disciplinary ally (www.watsoncaringscience.org; WCSI,
ground for nursing, now and in the future. The 4405 Arapahoe Avenue, Suite 100, Boulder,
advancement of nursing theory, which in- CO 80303).
cludes both ideals and practical guidance, is

Practice Exemplar

Practice Exemplar by Terry and modeled by Dr. Jean Watson, through ex-
Woodward, RN, MSN. periential interactions with caring–healing
modalities. The end of the retreat opened op-
October 2002 presented the opportunity for portunities for participants to merge caring
17 interdisciplinary health-care professionals theory and pain theory into an emerging
at the Children’s Hospital in Denver, Col- caring-healing praxis.
orado, to participate in a pilot study designed
to (1) explore the effect of integrating caring Returning from the retreat to the preexist-
theory into comprehensive pediatric pain ing schedules, customs, and habits of hospital
management and (2) examine the Attending routine was both daunting and exciting. We
Nurse Caring Model® (ANCM) as a care de- had lived caring theory, and not as a remote
livery model for hospitalized children in pain. and abstract philosophical ideal; rather, we
A 3-day retreat launched the pilot study. Par- had experienced caring as the very core of our
ticipants were invited to explore transpersonal true selves, and it was that call that had led us
human caring theory (caring theory) as taught into the health-care professions. Invigorated

CHAPTER 18 • Jean Watson’s Theory of Human Caring 333

Practice Exemplar cont. cocreation, we can build on existing founda-
tions to nurture evolution from what is to what
by the retreat, we returned to our 37-bed acute can be.
care inpatient pediatric unit, eager to apply
caring theory to improve pediatric pain man- Our mission—to translate caring theory
agement. Our experiences throughout the re- into praxis—had strong foundational support.
treat had accentuated caring as our core value. Building on this supportive base, we commit-
Caring theory could not be restricted to a ted our intentions and energies toward creat-
single area of practice. ing a caring culture. The following is not
intended as an algorithm to guide one through
Wheeler and Chinn (1991) define praxis as varied steps until caring is achieved but is
“values made visible through deliberate action” rather a description of our ongoing processes
(p. 2). This definition unites the ontology, and growth toward an ever-evolving caring
or the essence, of nursing to nursing actions, praxis. These processes are cocreations that
to what nurses do. Nursing within acute care emerged from collaboration with other ANCM
inpatient hospital settings is practiced depend- participants, fellow health professionals, pa-
ently, collaboratively, and independently tients and families, our environment, and our
(Bernardo, 1998). Bernardo described depend- caring intentions.
ent practice as energy directed by and requiring
physician orders, collaborative practice as in- First Steps
terdependent energy directed toward activities
with other health-care professionals, and inde- One of our first challenges was to make the
pendent practice as “where the meaningful role ANCM visible. Six tangible exhibits were dis-
and impact of nursing may evolve” (p. 43). Our played on the unit as evidence of our commit-
vision of nursing practice was based in the car- ment to caring values. First, a large, colorful
ing paradigm of deep respect for humanity and poster titled “CARING” was positioned at the
all life, of wonder and awe of life’s mystery, and entrance to our unit. Depicting pictures of di-
the interconnectedness from mind–body–spirit verse families at the center, the poster states our
unity into cosmic oneness (Watson, 1996). three initial goals for theory-guided practice:
Gadow (1995) described nursing as a lived (1) create caring–healing environments, (2) op-
world of interdependency and shared knowl- timize pain management through pharmaco-
edge, rather than as a service provided. Caring logical and caring–healing measures, and
praxis within this lived world is a praxis that (3) prepare children and families for procedures
offers “a combination of action and reflection and interventions. Watson’s clinical caritas
. . . praxis is about a relationship with self, and processes were listed, as well as an abbreviated
a relationship with the wider community” version of her guidelines for cultivating caring–
(Penny & Warelow, 1999, p. 260). Caring healing throughout the day (Watson, 2002).
praxis, therefore, is collaborative praxis. This poster, written in caring theory language,
expressed our intention to all and reminded us
Collaboration and cocreation are key ele- that caring is the core of our praxis.
ments in our endeavors to translate caring the-
ory into practice. They reveal the nonlinear Second, a shallow bowl of smooth, rounded
process and relational aspect of caring praxis. river stones was located in a prominent posi-
Both require openness to unknown possibili- tion at each nursing desk. A sign posted by the
ties, both honor the unique contributions of stones identified them as “Caring–Healing
self and other(s), and both acknowledge Touch Stones,” inviting one to select a stone
growth and transformation as inherent to life as “every human being has the ability to share
experience. These key elements support the their incredible gift of loving–healing. These
evolution of praxis away from predetermined stones serve as a reminder of our capacity to
goals and set outcomes toward authentic caring– love and heal. Pick up a stone, feel its smooth
healing expressions. Through collaboration and
Continued

334 SECTION V • Grand Theories about Care or Caring

Practice Exemplar cont. Attending Caring Team (ACT)

cool surface, let its weight remind you of your To honor the collaborative partnership of our
own gifts of love and healing. Share in the love ANCM participants, to include patients and
and healing of all who have touched this stone families as equal partners in the health-care
before you and pass on your love and healing team, and to open participation to all, we
to all who will hold this stone after you.” adopted the name Attending Caring Team
(ACT). The acronym ACT reinforces that our
Third, latched wicker blessing baskets were actions are opportunities to make caring visi-
placed adjacent to the caring–healing touch ble. Care as the core of praxis differs from the
stones. Written instructions invited families, centrality of cure in the medical model. To de-
visitors, and staff to offer names for a blessing scribe our intentions to others, we compiled
by writing the person’s initials on a slip of the following “elevator” description of ACT,
paper and placing the paper in the basket. a terse, 30-second summary that rendered the
Every Monday through Friday, the unit chap- meaning of ACT in the time frame of a shared
lain, holistic clinical nurse specialist (CNS), elevator ride:
and interested staff devoted 30 minutes of
meditative silence within a healing space to ask The core of the Attending Caring Team (ACT)
for peace and hope for all names contained is caring-healing for patients, families, and
within the baskets. ourselves. ACT cocreates relationships and col-
laborative practices between patients, families
Fourth, signs picturing a snoozing cartoon- and health care providers. ACT practice enables
styled tiger were posted on each patient’s door health care providers to redefine themselves as
announcing “Quiet Time.” Quiet time was a caregivers rather than taskmasters. We provide
midday, half-hour pause from hospital hustle- Health Care not Health Tasks.
bustle. Lights in the hall were dimmed, voices
hushed, and steps softened to allow a pause for Large signs were professionally produced
reflection. Staff members tried not to enter and hung at various locations on our unit.
patient rooms unless summoned. These signs served a dual purpose. The largest,
posted conspicuously at our threshold, identi-
Fifth, a booklet was written and published fied our unit as the home of the Attending
to welcome families and patients to our unit, Caring Team. Smaller signs, posted at each
to introduce health team members, unit rou- nurse’s station, spelled out the above ACT
tines, available activities, and define frequently definition, inviting everyone entering our unit
used medical terms. This book emphasized to participate in the collaborative cocreation of
that patients, parents, and families are mem- caring–healing.
bers of the health team. A description of our
caring attending team was also included. Giving ourselves a name and making our
caring intentions visible contributed to estab-
Sixth and most recently, the unit chaplain, lishing an identity, yet may be perceived as pe-
child-life specialist, and social worker organ- ripheral activities. For these expressions to be
ized a weekly support session called “Goodies deliberate actions of praxis, the centrality of
and Gathering,” offered every Thursday morn- caring as our core value was clearly articulated.
ing. It was held in our healing room—a con- Caring theory is the flexible framework guid-
ference room painted to resemble a cozy room ing our unit goals and unit education and has
with a beautiful outdoor view and redecorated been integrated into our implementation of an
with comfortable armchairs, soft lighting, and institutional customer-service initiative.
plants. Goodies and Gathering extended a safe
retreat within the hospital setting. Offering Unit goals are written yearly. Reflective of
1 hour to parents and another to staff, these the broader institutional mission statement,
professionals provided snacks to feed the body, each unit is encouraged to develop a mission
a sacred space to nourish emotions, and their
caring presence to nurture the spirit.

CHAPTER 18 • Jean Watson’s Theory of Human Caring 335

Practice Exemplar cont. shifts, clock hours provide a way for staff
members to fulfill continuing educational
statement and outline goals designed to requirements during workdays.
achieve that mission. In 2003, our mission
statement was rewritten to focus on provision Customer Service to Covenantal
of quality family-centered care, defined as “an
environment of caring-healing recognizing In the practice of human caring as a formal
families as equal partners in collaboration with theory and practice model, there is a philo-
all health care providers.” One of the goals to sophical shift from a customer-service mindset
achieve this mission literally spelled out caring. to viewing nursing and human caring as
We promote a caring-healing environment for a covenant with humanity to sustain human
patients, families, and staff through: caring in the world.

• Compassion, competence, commitment Within this exemplar, caring theory has
• Advocacy provided depth to an institutional initiative to
• Respect, research use FISH philosophy to enhance customer
• Individuality service (Lundin, Paul, & Christensen, 2000).
• Nurturing Imported from the Pike Place Fish Market in
• Generosity Seattle, FISH advocates four premises to im-
prove employee and customer satisfaction:
Education presence, make their day, play, and choose
your attitude. Briefly summarized, FISH ad-
Unit educational offerings were also revised to vocates that when employees bring their full
reflect caring theory. Phase classes, a 2-year awareness through presence, focus on cus-
curriculum of serial seminars designed to sup- tomers to make their day, invoke fun into the
port new hires in their clinical, educational, day through appropriate play, and through
and professional growth, now include a unit conscious awareness choose their attitude,
on self-care to promote personal healing and work environments improve for all. When the
support self-growth. The unit on pain man- four FISH premises are viewed from the per-
agement was expanded to include use of spective of transpersonal caring, they become
caring–healing modalities. A new interactive opportunities for authentic human-to-human
session on the caritas processes was added that connectedness through I–Thou relationships.
asks participants to reflect on how these The merger of caring theory with FISH
processes are already evident in their praxis philosophy has inspired the following activi-
and to explore ways they can deepen caring ties. A parade composed of patients, their
praxis both individually and collectively as a families, nurses, and volunteers—complete
unit. The tracking tool used to assess a new with marching music, hats, streamers, flags,
employee’s progress through orientation now and noisemakers—is celebrated two to three
includes an area for reflection on growing in times a week just before the playroom closes
caring competencies. In addition to changes in for lunch. This flamboyant display lasts less
phase classes, informal “clock hours” were of- than 5 minutes but invigorates participants
fered monthly. Clock hours are designed to re- and bystanders alike. In addition to being vital
spond to the immediate needs of the unit and for children and especially appropriate in a
encompass a diverse range of topics, from con- pediatric setting, play unites us all in the life
flict resolution, debriefing after specific events, and joy of each moment. When our parade
and professional development, to health treat- marches, visitors, rounding doctors, and all
ment plans, physiology of medical diagnosis, others on the unit pause to watch, wave, and
and in-services on new technologies and phar- cheer us on. A weekly bedtime story is read in
macological interventions. Offered on the unit our healing room. Patients are invited to bring
at varying hours to accommodate all work

Continued

336 SECTION V • Grand Theories about Care or Caring

Practice Exemplar cont. the families’ goals. Transitional conferences
provide an opportunity to coordinate conti-
their pillows and favorite stuffed animal or doll nuity of care, share insight into the unique
and come dressed in pajamas. Night- and day- personality and preferences of the child, coor-
shift staff members have honored one another dinate team effort, meet families, provide them
with surprise beginning-of-the-shift meals, with tours of our unit, and collaborate with
staying late to care for patients and families, families. Other caring–healing arts offered on
and refusing to give off-going report until our unit are therapeutic touch, guided imagery,
their on-coming coworkers had eaten. Color- relaxation, visualization, aromatherapy, and
ful caring stickers are awarded when one staff massage. As ACT participants, our challenge
member catches another in the ACT of car- is to express our caring values through every ac-
ing, being present, making another’s day, play- tivity and interaction. Caring theory guides us
ing, and choosing a positive attitude. These and manifests in innumerable ways. Our inter-
acts are authentic and not performed as hos- view process, meeting format, and clinical
pitality acts and within the customer mindset; nurse specialist (CNS) role have been transfig-
rather, they are a professional covenant nurs- ured through caring theory. Our interview
ing has with humanity around the world. process has transformed from an interrogative
three-step procedure into more of a sharing
ACT Guidelines dialogue. We are adopting another meeting
style that expresses caring values.
Placing caring theory at the core of our praxis
supports practicing caring–healing arts to pro- Our unit director had the foresight to
mote wholeness, comfort, harmony, and inner budget a position for a CNS to support the
healing. The intentional conscious presence of cocreation of caring praxis. The traditional
our authentic being to provide a caring–healing CNS roles—researcher, clinical expert, collab-
environment is the most essential of these arts. orator, educator, and change agent—have
Presence as the foundation for cocreating car- allowed the integration of caring theory devel-
ing relationships has led to writing ACT opment into all aspects of our unit program.
guidelines. Written in the doctor order section The CNS role advocates self-care and facili-
of the chart, ACT guidelines provide a formal tates staff members to incorporate caring-healing
way to honor unique families’ values and be- arts into their practice through modeling and
liefs. Preferred ways of having dressing changes hands-on support. In addition to providing
performed, most helpful comfort measures, assistance, searching for resources, acting as
home schedules, and special needs or requests liaison with other health-care teams, and
are examples of what these guidelines might promoting staff in their efforts, the very pres-
address. ACT members purposefully use the ence of the CNS on the unit reinforces our
word guideline as opposed to order as more con- commitment to caring praxis.
gruent with cocreative collaborate praxis and to
encourage critical thinking and flexibility. Conclusion
Building practice on caring relationships has
led to an increase in both the type and volume We continue to work toward incorporating
of care conferences held on our unit. Previ- caring ideals in every action. Currently, we are
ously, care conferences were called as a way to modifying our competency-based guidelines
disseminate information to families when to emphasize caring competency within tasks
complicated issues arose or when communica- and skills. Building relationships for support-
tion between multiple teams faltered and fam- ive collaborative practice is the most exciting
ilies were receiving conflicting reports, plans, and most challenging endeavor we are now
and instructions. Now these conferences are facing as old roles are reevaluated in light
offered proactively as a way to coordinate team of cocreating caring-healing relationships.
efforts and to ensure we are working toward

CHAPTER 18 • Jean Watson’s Theory of Human Caring 337

Practice Exemplar cont. focused intentionality toward caring and healing
Watson and Foster (2003) described the relationships and modalities, a shift toward a
potential of such collaboration: spiritualization of health vs. a limited medical-
ized view. (p. 361)
The new caring-healing practice environment is
increasingly dependent on partnerships, negoti- Our ACT commitment is to authentic re-
ation, coordination, new forms of communica- lationships and the creation of caring–healing
tion pattern and authentic relationships. The environments.
new emphasis is on a change of consciousness, a

■ Summary spiritual dimensions of care much more com-
pletely.
Nursing’s future and nursing in the future
will depend on nursing maturing as the dis- Thus, nursing is at its own crossroad of
tinct health, healing, and caring profession possibilities, between worldviews and para-
that it has always represented across time but digms. Nursing has entered a new era; it is in-
has yet to fully actualize. Nursing thus iron- vited and required to build on its heritage and
ically is now challenged to stand and mature latest evolution in science and technology but
within its own caring science paradigm, must transcend itself for a new future, yet to
while simultaneously having to transcend it be known. However, nursing’s future holds
and share with others. The future already re- promises of caring and healing mysteries and
veals that all health-care practitioners will models yet to unfold, as opportunities for of-
need to work within a shared framework fering compassionate caritas services at indi-
of caring–healing relationships and human– vidual, system, societal, national, and global
environmental energetic field modalities. levels for self, for profession, and for the
Practitioners of the future pay attention to broader world community. Nursing has a
consciousness, intentionality, energetic human critical role to play in sustaining caring in hu-
presence, transformed mind–body–spirit med- manity and making new connections between
icine, and will need to embrace healing arts caring, love, healing, and peace in the world.
and caring practices and processes and the

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Boulder, CO: University Press of Colorado.



Theory of Nursing as Caring 19Chapter

ANNE BOYKIN AND SAVINA O. Introducing the Theorists
SCHOENHOFER
Anne Boykin
Introducing the Theorists
Nursing as Caring: An Overview Anne Boykin is Professor Emerita and past
Dean of the Christine E. Lynn College of
Applications of the Theory Nursing at Florida Atlantic University. She is
Practice Exemplar Director of the College’s Anne Boykin Insti-
Summary tute for the Advancement of Caring in Nurs-
References ing. This institute provides global leadership
for nursing education, practice, and research
Anne Boykin Savina O. Schoenhofer grounded in caring; promotes the valuing of
caring across disciplines; and supports the car-
ing mission of the college. She has demon-
strated a long-standing commitment to the
advancement of knowledge in the discipline,
especially regarding the phenomenon of caring.

Positions she has held within the Interna-
tional Association for Human Caring include:
president-elect (1990–1993), president (1993–
1996), and member of the nominating commit-
tee (1997–1999). As immediate past president,
she served as co-editor of the journal Interna-
tional Association for Human Caring from 1996
to 1999.

Her scholarly work is centered in caring as
the grounding for nursing. This is evidenced in
her coauthored book, Nursing as Caring: A
Model for Transforming Practice (Boykin &
Schoenhofer, 1993, rev. ed. 2001a), and the
book Living a Caring-based Program (Boykin,
1994). The latter book illustrates how caring
grounds all aspects of a nursing education pro-
gram. Dr. Boykin has also authored numerous
book chapters and articles. She is currently re-
tired and serves as a consultant locally, region-
ally, nationally, and internationally on the topic
of caring-based health-care transformations.

341

342 SECTION V • Grand Theories about Care or Caring

Dr. Boykin is a graduate of Alverno College broad, encompassing understanding of any and
in Milwaukee, Wisconsin; she received her all situations of nursing practice (Boykin &
master’s degree from Emory University in Schoenhofer, 1993, 2001a). This theory serves
Atlanta, Georgia, and her doctorate from as an organizing framework for nursing scholars
Vanderbilt University in Nashville, Tennessee. in the various roles of practitioner, researcher,
administrator, teacher, and developer.
Savina O. Schoenhofer
Initially, we present the theory in its most
Savina O’Bryan Schoenhofer began her initial abstract form, addressing assumptions and key
nursing study at Wichita State University, themes. We then illustrate the meaning of the
where she earned undergraduate degrees in theory of nursing as caring through exemplars
nursing and psychology and graduate degrees in the role dimensions of nursing care, nursing
in nursing and counseling. She completed a education, nursing administration and nursing
PhD in educational foundations/administra- research.
tion at Kansas State University in 1983. In
1990, Schoenhofer cofounded Nightingale Nursing as Caring: Historical
Songs, an early venue for communicating the Perspective
beauty of nursing in poetry and prose. In ad-
dition to her work on caring, she has written The theory of nursing as caring is an outgrowth
on nursing values, primary care, nursing edu- of the curriculum development work in the
cation, support, touch, personnel management Christine E. Lynn College of Nursing at Florida
in nursing homes, and mentoring. Her career Atlantic University, where both authors were
in nursing has been significantly influenced among the faculty group revising the caring-
by three colleagues: Lt. Col. Ann Ashjian based curriculum for initial program accredi-
(Ret.), whose community nursing practice in tation. When the revised curriculum was in
Brazil presented an inspiring model of nursing; place, each of us recognized the potential and
Marilyn E. Parker, PhD, a faculty colleague even the necessity of continuing to develop and
who mentored her in the idea of nursing as a structure ideas and themes toward a compre-
discipline, the academic role in higher educa- hensive expression of the meaning and purpose
tion, and the world of nursing theories and of nursing as a discipline and a profession. The
theorists; and Anne Boykin, PhD, who intro- point of departure was the acceptance that car-
duced her to caring as a substantive field of ing is the end, rather than the means, of nursing,
nursing study. and that caring is the intention of nursing, rather
than merely its instrument. This work led to the
Schoenhofer coauthored the book, Nurs- statement of focus of nursing as “nurturing
ing as Caring: A Model for Transforming Prac- persons living caring and growing in caring.”
tice (1993, 2001a) with Boykin. Boykin and
Schoenhofer, together with Kathleen Valentine, Further work to identify foundational as-
coauthored the book, Health Care System Trans- sumptions about nursing clarified the idea of
formation for Nursing and Health Care Leaders: the nursing situation, a shared lived experience
Implementing a Culture of Caring (2013). in which the caring between nurse and nursed
enhances personhood, with personhood un-
Nursing As Caring: derstood as living grounded in caring. The
Overview clarified focus and the idea of the nursing sit-
uation are the key themes that draw forth the
This chapter is intended as an overview of the meaning of the assumptions underlying the
theory of nursing as caring, a general theory, theory and permit the practical understanding
framework, or disciplinary view of nursing. A of nursing as both a discipline and a profes-
general theory or framework of nursing presents sion. As critique of the theory and study of
an abstract, integrated, comprehensive picture nursing situations progressed, the notion of
of nursing as a practiced discipline. The theory nursing being primarily concerned with health
of nursing as caring offers a view that permits a was seen as limiting, and we now understand
nursing to be concerned with human living.

Three bodies of work significantly influ- CHAPTER 19 • Theory of Nursing as Caring 343
enced the initial development of nursing as
caring. Roach’s (1987/2002) basic thesis that • Persons are whole and complete in the
caring is the human mode of being was incor- moment.
porated into the most basic assumption of the
theory. We view Paterson and Zderad’s (1988) • Persons are caring, moment to moment.
existential phenomenological theory of hu- • Personhood is a way of living grounded in
manistic nursing as the historical antecedent
of nursing as caring. Seminal ideas from hu- caring.
manistic nursing such as “the between,” “call • Personhood is enhanced through participa-
for nursing,” “nursing response,” and “person-
hood” serve as substantive and structural bases tion in nurturing relationships with caring
for our conceptualization of nursing as caring. others.
Mayeroff’s (1971) work, On Caring, provided • Nursing is both a discipline and a profession.
a language that facilitated the recognition and
description of the practical meaning of caring Key Themes
in nursing situations. Roach’s (1987/2002) five
Cs (described in detail later) of caring expand Caring
on that basic language. In addition to the work Caring is an altruistic, active expression of love
of these thinkers, both authors are long-standing and is the intentional and embodied recogni-
members of the community of nursing schol- tion of value and connectedness. Caring is not
ars whose study focuses on caring and are sup- the unique province of nursing. However, as a
ported and undoubtedly influenced in many discipline and a profession, nursing uniquely
subtle ways by the members of this community focuses on caring as its central value, its pri-
and their work. mary interest, its focus for scholarship, and the
direct intention of its practice. “As an expres-
Fledgling forms of the theory of nursing as sion of nursing, caring is the intentional and au-
caring were first published in 1990 and 1991, thentic presence of the nurse with another who is
with the first complete exposition of the theory recognized as person living caring and growing in
presented at a conference in 1992 (Boykin & caring” (Boykin & Schoenhofer, 2001a, p. 13).
Schoenhofer, 1990, 1991; Schoenhofer & The full meaning of caring cannot be restricted
Boykin, 1993), followed by the publication of to a definition but is illuminated in the expe-
Nursing as Caring: A Model for Transforming rience of caring and in dynamic reflection on
Practice in 1993 (Boykin & Schoenhofer, 1993), that experience.
which was revised with the addition of an epi- Focus and Intention of Nursing
logue in 2001 (Boykin & Schoenhofer, 2001a). Disciplines as identifiable entities or “branches
of knowledge” grow from the holistic “tree of
Assumptions and Key Themes knowledge” as need and purpose develop. A
of Nursing as Caring discipline is a community of scholars with a
particular perspective on the world and on
Assumptions what it means to be in the world. The discipli-
nary community represents a value system that
Certain fundamental beliefs about what it is expressed in its unique focus on knowledge
means to be human underlie the theory of and practice. The focus of nursing, from the per-
nursing as caring. The following assumptions spective of the theory of nursing as caring, is
reflect a particular set of values that provide a person living caring and growing in caring. The
basis for understanding and explicating the general intention of nursing as a practiced dis-
meaning of nursing and are key to understand- cipline is nurturing persons living caring and
ing the practical meaning of the theory of growing in caring.
nursing as caring. Nursing Situation
The practice of nursing, and thus the practical
• Persons are caring by virtue of their knowledge of nursing, lives in the context of
humanness. person-with-person caring. The nursing situa-
tion involves particular values, intentions, and
actions of two or more persons choosing to live
a nursing relationship. Nursing situation is

344 SECTION V • Grand Theories about Care or Caring

understood to mean the shared lived experience uniquely, expressing personally meaningful
in which caring between nurse and nursed en- dreams and aspirations for growing in caring.
hances personhood. Nursing is created in the Calls for nursing are individually relevant ways
“caring between.” All knowledge of nursing is of saying, “Know me as caring person in the
created and understood within the nursing sit- moment and be with me as I try to live fully
uation. Any single nursing situation has the po- who I truly am.” Intentionality and authentic
tential to illuminate the depth and complexity presence open the nurse to hearing calls for
of nursing knowledge. Nursing situations are nursing. Because calls for nursing are unique
best communicated aesthetically to preserve the situated personal expressions of that which
lived meaning of the situation and the openness matters to the person nursed, they cannot be
of the situation as text. Storytelling, poetry, predicted, as in a “diagnosis.” Nurses develop
graphic arts, dance, and other expressive modes sensitivity and expertise in hearing calls through
effectively represent the lived experience of intention, experience, study, and reflection in
nursing and allowing for reflection and creativ- a broad range of human situations.
ity in advancing understanding. Nursing Response
Personhood As an expression of nursing, “caring is the in-
Personhood is understood to mean living tentional and authentic presence of the nurse
grounded in caring. From the perspective of with another who is recognized as living caring
the theory of nursing as caring, personhood is and growing in caring” (Boykin & Schoenhofer,
the universal human call. A profound under- 2001a, p. 13). The nurse enters the nursing
standing of personhood communicates the situation with the intentional commitment
paradox of person-as-person and person-in- of knowing the other as caring person, and in
communion all at once. that knowing, acknowledging, affirming, and
Direct Invitation celebrating the person as caring. The nursing
The concept of direct invitation was briefly response is a specific expression of caring nurtu-
introduced in the epilogue of the 2001 revised rance to sustain and enhance the one nursed in
edition of nursing as caring (Boykin & ways that matter as he or she lives caring and
Schoenhofer, 2001a). It evolved from a con- grows in caring in the situation of concern.
vergence of ontology and aesthetics as a way Nursing responses to calls for caring evolve as
to more effectively communicate nursing as nurses clarify their understandings of calls
caring in practice. through presence and dialogue. Nursing re-
sponses are uniquely created for the moment and
The context for understanding direct invi- cannot be predicted or automatically applied as
tation is the nursing situation. Direct invitation preplanned protocols. Sensitivity and skill in
communicates clearly that the core service of creating unique and effective ways of commu-
nursing is to offer caring and to invite the one nicating caring are developed through intention,
nursed to share that which matters most to experience, study, and reflection in a broad
them in that moment. It is through this invi- range of human situations.
tation that the call for nursing is heard and The “Caring Between”
nursing responses are created. Direct invitation The caring between is the source and ground of
establishes an openness between the nurse nursing. It is the loving relation into which
and one nursed and strengthens the caring nurse and nursed enter and which they cocre-
between. ate by living the intention to care. Without the
Call for Nursing loving relation of the caring between, unidirec-
“A call for nursing is a call for acknowledg- tional activity or reciprocal exchange can occur,
ment and affirmation of the person living car- but nursing in its fullest sense does not occur.
ing in specific ways in the immediate situation” It is in the context of the caring between that
(Boykin & Schoenhofer, 2001a, p. 13). Calls personhood is enhanced, each expressing self
for nursing are calls for nurturance through as caring and recognizing the other as caring
personal expressions of caring. Calls for nurs- person.
ing originate within persons as they live caring

Dance of Caring Persons CHAPTER 19 • Theory of Nursing as Caring 345
The relational model for organizational design
involving nursing is analogous to the dancing I care for him.
circle, the dance of caring persons. What this cir- The room is tense,
cle represents is the commitment of each It’s anger-filled,
dancer to understand and support the study of The air seems thick,
the discipline of nursing. Core dimensions of I’m with him now,
caring illustrated in the dance of caring persons I care for him.
model include the following: Time goes slowly by,
As our fears subside,
• Acknowledgment that all persons have the I can sense his calm,
capacity to care by virtue of their humanness He softens now,
I care for him.
• Commitment to respect for person in all in- His eyes meet mine,
stitutional structures and processes Unable to speak,
I feel his trust,
• Recognition that each participant in the I open my heart,
enterprise has a unique valuable contribu- I care for him.
tion to make to the whole and is present in It’s time to leave.
the whole Our bond is made,
Unspoken thoughts,
• Appreciation for the dynamic though But understood,
rhythmic nature of the dance of caring I care for him!
persons, enabling opportunities for human —J. M. COLLINS (1993)
creativity
Each encounter—each nursing experience—
Persons making up the dance of caring per- brings with it the unknown. In reflection, Jim
sons in any given situation involving nursing Collins shares a story of practice that illuminates
are the one nursed and family, nurses and the opportunity to live and grow in caring. In
other health-care workers, administrative and the nursing situation that inspired this poem,
support staff, and relevant corporate, govern- the nurse and nursed live caring uniquely. Ini-
mental, and social communities. Regardless of tially, the nurse experiences the familiar human
the role, the “responsibility of all is to recog- dilemma, aware of separateness while choosing
nize, value, and celebrate the unique ways car- connectedness as he responds to a yet unknown
ing is lived by colleagues, as well as to support call for nursing: [“My] hands are moist,/my
each other in the growth of caring” (Pross, heart is quick/my nerves are taut . . . I care for
Hilton, Boykin, & Thomas, 2011, p. 28). him.” As he enters the situation and encounters
the patient as person, he is able to “let go” of his
Lived Meaning of Nursing as Caring presumptive knowing of the patient as “angry.”
The nurse enters with the guiding perspective
Abstract presentations of assumptions and that all persons are caring. This allows Nurse
themes lay the groundwork and provide an ori- Jim to see past the “anger-filled” room and to
enting point. However, the lived meaning of be “with him” (Stanza 2). As they connect
nursing as caring can best be understood by the through their humanness, the beauty and
study of a nursing situation. The following wholeness of one nursed is uncovered and nur-
poem is one nurse’s expression of the meaning tured. By living caring moment to moment,
of nursing, situated in one particular experi- hope emerges and fear subsides. The nurse is-
ence of nursing and linked to a general con- sues a direct invitation as “I open my heart”
ception of nursing. (Stanza 4) to hear that which matters most in
the moment. Through this experience, both
I CARE FOR HIM nurse and nursed live and grow in their under-
My hands are moist, standing and expressions of caring.
My heart is quick,
My nerves are taut,
He’s in the next room,

346 SECTION V • Grand Theories about Care or Caring

In the first stanza, the nurse prepares Assumptions Underlying Nursing as
to enter the nursing relationship with the Caring in the Context of the Nursing
formed intention of offering caring in au- Situation
thentic presence. Perhaps he has heard a re-
port that the person he is about to encounter In Collins’s (1993) poem, the power of the
is a “difficult patient” and this is a part of his basic assumption that all persons are caring by
awareness; however, his nursing intention to virtue of their humanness enabled the nurse to
care reminds him that he and his patient are, find the courage to live his intentions. The idea
above all, caring persons. In the second that persons are whole and complete in the
stanza, the nurse enters the room, experiences moment permits the nurse to accept conflict-
the challenge that his intention to nurse has ing feelings and to be open to the nursed as a
presented, and responds to the call for au- person, not merely as an entity with a diagnosis
thentic presence and caring: “I’m with him and superficially understood behavior. The
now,/I care for him.” Patterns of knowing are nurse demonstrated an understanding of the
called into play as the nurse brings together assumption that persons live caring from
intuitive, personal knowing, empirical know- moment to moment, striving to know self and
ing, and the ethical knowing that it is right other as caring in the moment with a growing
to offer care, creating the integrated under- repertoire of ways of expressing caring. Per-
standing of aesthetic knowing that enables sonhood, a way of living grounded in caring
him to act on his nursing intention (Boykin, that can be enhanced in relationship with car-
Parker, & Schoenhofer, 1994; Carper, 1978). ing other, comes through in that the nurse is
Mayeroff’s (1971) caring ingredients of successfully living his commitment to caring in
courage, trust, and alternating rhythm are the face of difficulty and in the mutuality and
clearly evident. connectedness that emerged in the situation.
The assumption that nursing is both a disci-
Clarity of the call for nursing emerges as the pline and a profession is affirmed as the nurse
nurse begins to understand that this particular draws on a set of values and a developed
man in this particular moment is calling to be knowledge of nursing as caring to actively offer
known as a uniquely caring person, a person of his presence in service to the nursed.
value, worthy of respect and regard. The nurse
listens intently and recognizes the unadorned Nursing practice guided by the theory of
honesty that sounds angry and demanding and nursing as caring entails living the commit-
is a personal expression of a heartfelt desire to ment to know self and other as living caring in
be truly known and worthy of care. The nurse the moment and growing in caring. Living this
responds with steadfast presence and caring, commitment requires intention, formal study,
communicated in his way of being and of and reflection on experience. Mayeroff’s
doing. The caring ingredient of hope is drawn (1971) caring ingredients offer a useful starting
forth as the man softens and the nurse takes point for the nurse committed to knowing
notice. self and other as caring persons. These ingre-
dients include knowing, alternating rhythm,
In the fourth stanza, the “caring between” honesty, courage, trust, patience, humility, and
develops and personhood is enhanced as hope. Roach’s (1992) five Cs—commitment,
dreams and aspirations for growing in caring confidence, conscience, competence, and
are realized: “His eyes meet mine . . . I open compassion—provide another conceptual
my heart.” In the last stanza, the nursing situ- framework that is helpful in providing a lan-
ation is completed in linear time. But each one, guage of caring. Coming to know self as caring
nurse and nursed, goes forward newly affirmed is facilitated by:
and celebrated as caring person, and the nurs-
ing situation continues to be a source of living • Trusting in self; freeing self up to become
caring and growing in caring. what one can truly become, and valuing self.

• Learning to let go, to transcend—to let go CHAPTER 19 • Theory of Nursing as Caring 347
of problems, difficulties, in order to remem-
ber the interconnectedness that enables us ensure the completion of certain treatment and
to know self and other as living caring, even surveillance techniques. Still, in our eyes, that
in suffering and in seeking relief from suf- is an insufficient response—it certainly is not
fering. the nursing we advocate. The theory of nursing
as caring calls on the nurse to reach deep within
• Being open and humble enough to experi- a well-developed knowledge base that has been
ence and know self to be at home with one’s structured using all available patterns of know-
feelings. ing, grounded in the obligations inherent in the
commitment to know persons as caring. These
• Continuously calling to consciousness that patterns of knowing may develop knowledge as
each person is living caring in the moment intuition; scientifically quantifiable data emerg-
and we are each developing uniquely in our ing from research; and related knowledge from
becoming. a variety of disciplines, ethical beliefs, and many
other types of knowing. All knowledge held by
• Taking time to fully experience our human- the nurse that may be relevant to understanding
ness, for one can only truly understand in the situation at hand is drawn forward and in-
another what one can understand in self. tegrated into practice in particular nursing sit-
uations (aesthetic knowing). Although the
• Finding hope in the moment. (Schoenhofer degree of challenge presented from situation to
& Boykin, 1993, pp. 85–86) situation varies, the commitment to know self
and other as caring persons is steadfast.
Applications of
the Theory All persons are caring, even when not all
chosen actions of the person live up to the ideal
Nursing Practice to which we are all called by virtue of our hu-
manness. In discussions of hypothetical situa-
The nursing as caring theory, grounded in the tions involving child molesters, serial killers,
assumption that all persons are caring, has as and even political figures who have attempted
its focus a general call to nurture persons as mass destruction and racial annihilation, certain
they live caring uniquely and grow as caring ethical systems permit and even call for making
persons. The challenge for nursing, then, is not judgments. However, when such a person pres-
to discover what is missing, weakened, or ents to the nurse for care, the nursing ethic of
needed in another but to come to know the caring supersedes all other values. The theory
other as caring person and to nurture that per- of nursing as caring asserts that it is only
son in situation-specific, creative ways. We no through recognizing and responding to the
longer understand nursing as a “process” in the other as a caring person that nursing is created
sense of a complex sequence of predictable acts and personhood enhanced in that nursing sit-
resulting in some predetermined desirable end uation. Caring effectively in “difficult-to-care”
product. Nursing, we believe, is inherently a situations is the most challenging prospect a
process, in the sense that it is always unfolding nurse can face. It is only with sustained inten-
and guided by intention. tion, commitment, study, and reflection that
the nurse is able to offer nursing in these situ-
An everyday understanding of the meaning ations. Falling short in one’s commitment does
of caring is obviously challenged when the not necessitate self-deprecation nor warrant
nurse is presented with someone for whom it condemnation by others; rather, it presents an
is difficult to care. “Difficult to care” situations opportunity to care for self and other and to
are those that demonstrate the extent of knowl- grow in personhood. Making real the potential
edge and commitment needed to nurse effec- of such an opportunity calls for seeing with
tively. In these extreme (although not unusual) clarity, reaffirming commitment, and engaging
situations, a task-oriented, non–discipline-
based concept of nursing may be adequate to

348 SECTION V • Grand Theories about Care or Caring

in study and reflection, individually and in con- of dialogue is prescribed. Simple examples of
cert with caring others. living this intention to care follow.

To know the other as caring, the nurse must When the nurse goes first to the person,
find some basis for respectful human connec- rather than going directly to the IV or the
tion with the person. Does this mean that the monitor, it becomes clear that the use of tech-
nurse must like everything about the person, nology is one way the nurse expresses caring
including personal life choices? Perhaps not; for the person (Schoenhofer, 2001). In propos-
however, the nurse as nurse is not called on to ing his model of machine technologies and
judge the “other,” only to care for the other. A caring in nursing, Locsin (1995, 2001) distin-
concern with judging or censuring another’s ac- guishes between mere technological compe-
tions is a distraction from the real purpose for tence and technological competence as an
nursing—that is, coming to know the other as intentional expression of caring in nursing.
caring person, as one with dreams and aspira- Simply avowing an intention to care is not
tions of growing in caring, and responding to sufficient; the committed intention to care is
calls for caring in ways that nurture person- supported by serious study of caring and on-
hood, that matter to the one nursed. going reflection if nurses are to communicate
caring effectively from moment to moment. As
Nurses are frequently heard to say they have Locsin (1995, p. 203) so aptly stated:
no time for caring, given the demands of the
role (Boykin & Schoenhofer, 2000). All nurs- as people seriously involved in giving care know, there
ing roles are lived out in the context of a con- are various ways of expressing caring. Professional
temporary environment, and the environment nurses will continue to find meaning in their technolog-
for practice, administration, education, and re- ical caring competencies, expressed intentionally and
search is fraught with many challenges. Some authentically, to know another as a whole person.
of these challenges are the following: Through the harmonious coexistence of machine tech-
nology and caring technology the practice of nursing
• technological advancement and prolifera- is transformed into an experience of caring.
tion that can promote routinization and
depersonalization on the part of the care- Another example of living the commitment
giver as well as the one seeking care; to care is witnessed in caring for the uncon-
scious person. How is this commitment lived?
• demands for immediate and measurable It requires that all ways of knowing be brought
outcomes that favor a focus on the simplistic into action. The nurse must make self as caring
and the superficial; person available to the one nursed. The fullness
of the nurse as caring person is called forth.
• organizational and occupational configura- This requires use of Mayeroff’s caring ingredi-
tions that tend to promote fragmentation ents: the alternating rhythm of knowing about
and alienation; and the other and knowing the other directly
through authentic presence and attunement;
• economic focus and profit motive (“time is the hope and courage to risk opening self to
money”) as the apparent prime institutional one who cannot communicate verbally, pa-
value. tiently trusting in self to understand the other’s
mode of living caring in the moment; honest
Nurses express frustration when evaluating humility as one brings all that one knows and
their own caring efforts against an idealized, remains open to learning from the other. The
rule-driven conception of caring. Practice nurse attuned to the other as person might for
guided by the theory of nursing as caring re- example experience the vulnerability of the per-
flects the assumption that caring is created son who lies unconscious from surgical anes-
from moment to moment and does not de- thetic or traumatic injury. In that vulnerability,
mand idealized patterns of caring. Caring in the nurse recognizes that the one nursed is
the moment (and from moment to moment)
occurs when the nurse is living a committed
intention to know and nurture the other as car-
ing person (Boykin & Schoenhofer, 2000). No
predetermined ideal amount of time or form

living caring in humility, hope, and trust. In- CHAPTER 19 • Theory of Nursing as Caring 349
stead of responding to the vulnerability, merely
“taking care of” the other, the nurse practicing “Yes, you must complete the paperwork.” And
nursing as caring might respond by honoring “Go talk to the family now,”
the other’s humility, by participating in the Then we turn back to you
other’s hopefulness, by steadfast trustworthi- And begin our reverent and loving care:
ness. Creating caring in the moment in this sit- Covering your wound, removing the lines,
uation might come from the nurse resonating
with past and present experiences of vulnera- cleansing your body,
bility. Connected to this form of personal One of us says, “We are being good nurses,”
knowing might be an ethical knowing that And another quips back, “It’s because we are
power as a reciprocal of vulnerability can de-
velop undesirable status differential in the old nurses,”
nurse–patient role relationship. As the nurse And we laugh
sifts through myriad empirical data, the most (But we know we will teach the young ones
significant information emerges—this is a
person with whom I am called to care. Ethical how to do this too),
knowing again merges with other pathways as We place you on a stretcher (not the gruesome
the nurse forms the decision to go beyond
vulnerability and engage the other as caring per- morgue gurney)
son, rather than as helpless object of another’s And take you to the viewing room,
concern. Aesthetic knowing comes in the praxis One of us goes and brings your family to you,
of caring, in living chosen ways of honoring Murmuring comfort, “We are so sorry for
humility, joining in hope, and demonstrating
trustworthiness in the moment (Schoenhofer your loss.”
& Boykin, 1993, pp. 86–87). After a few minutes, we leave
And return to the OR
A third example of living the intention to To take care of another patient.
care is evidenced in postmortem care. “Nurses —FLORENCE N. COOPER, RN
speak of caring for their deceased patients as
nursing those who have gone and who are still The nurse practicing within the caring con-
in some way present” (Boykin & Schoenhofer, text described here will most often be interfac-
2001a, p. 19). Nurses who practice in end- ing with the health-care system in two ways:
of-life situations offer genuine presence, con- first, communicating nursing so that it can be
tinue to feel the human connection to the per- understood; second, articulating nursing serv-
son who has recently died and to the family ice as a unique contribution within the system
circle that is part of that person’s life, and rec- in such a way that the system itself grows to
ognize postmortem care as truly nursing. One support nursing. Recognizing these system re-
nurse was moved by the beauty of post-mortem lationships as aspects of the dance of caring
nursing care offered by her colleagues in the persons involving the nursed and family and
operating room and shared this poetic expres- encompassing all who are part of the system is
sion of connectedness. crucial for creating the kind of environment in
which caring is expressed effectively and per-
Journey’s End ceived as growth-promoting.
The chaos has stopped,
The journey from birth to death has ceased, Nursing Administration
Your body lies on the OR table, alone,
We cluster at the end of the room, From the viewpoint of nursing as caring, the
Making the necessary phone calls, nurse administrator makes decisions through a
Starting the paperwork, lens in which the focus of nursing is on nurtur-
Telling the young resident: ing persons living caring and grow in caring.
All activities in the practice of nursing admin-
istration are grounded in a concern for creating,
maintaining, and supporting an environment
in which calls for nursing are heard and nur-
turing responses are given. From this point of
view, the expectation arises that nursing ad-
ministrators participate in shaping a culture

350 SECTION V • Grand Theories about Care or Caring

that evolves from the values articulated within and growing in caring; thus, all activities of the
nursing as caring and recognized as the dance program of study are directed toward develop-
of caring persons. ing, organizing, and communicating nursing
knowledge, that is, knowledge of nurturing
Although often perceived to be “removed” persons living caring and growing in caring.
from the direct care of the nursed, the nursing
administrator is intimately involved in multiple The dance of caring persons relational
nursing situations simultaneously, hearing calls model is relevant for organizational design
for nursing and participating in responses to of nursing education, as well as for nursing
these calls. As calls for nursing are known, one practice. Participants in the dance of caring
of the unique responses of the nursing admin- persons include administrators, faculty, col-
istrator is to enter the world of the nursed ei- leagues, students, staff, community, and the
ther directly or indirectly, to understand special nursed and their families. What the dance of
calls when they occur, and to assist in securing caring persons represents in nursing education
the resources needed by each nurse to nurture settings is the commitment of each dancer
persons living and growing in caring (Boykin to understand and support the study of the
& Schoenhofer, 1993). All administrative ac- discipline of nursing. The role of educational
tivities should be approached with this goal in administrator in the circle is more clearly un-
mind. Here, the nurse administrator reflects derstood through reflection on the origin of
on the obligations inherent in the role in rela- the word. The term administrator derives from
tion to the nursed. The presiding moral basis the Latin ad ministrare, to serve (according to
for determining right action is the belief that Webster’s New World Dictionary of the American
all persons are caring. Frequently, the nurse Language; Guralnik, 1976). This definition con-
administrator may enter the world of the notes the idea of rendering service. Administra-
nursed through the stories of colleagues who tors within the circle are by the nature of their
are assuming another role, such as that of nurse role obligated to ministering, to securing, and
manager. Policy formulation and implementa- to providing resources needed by faculty, stu-
tion allow for the consideration of unique situ- dents, and staff to meet program objectives.
ations. The nursing administrator assists others Faculty, students, and administrators dance to-
within the organization to understand the gether in the study of nursing. Faculty support
focus of nursing and to secure the resources an environment that values the uniqueness
necessary to achieve the goals of nursing. of each person and sustains each person’s
unique way of living and growing in caring.
Nursing Education This process requires trust, hope, courage, and
patience. Because the purpose of nursing edu-
From the perspective of nursing as caring, all cation is to study the discipline and practice of
nursing structures and activities should reflect nursing, the nursed must be in the circle. The
the fundamental assumption that persons are community created is that of persons living car-
caring by virtue of their humanness. This view ing in the moment and growing in personhood,
applies in nursing education as in practice and each person valued as special and unique.
administrative role engagement. Other as- (Boykin & Schoenhofer, 1993, pp. 73–74)
sumptions and values reflected in the education
program include knowing the person as whole In teaching nursing as caring, faculty assist
and complete in the moment and living caring students to come to know, appreciate, and
uniquely; understanding that personhood is a celebrate self and “other” as caring persons.
way of living grounded in caring and is en- Students, as well as faculty, are in a continual
hanced through participation in nurturing re- search to discover greater meaning of caring as
lationships with caring others; and, finally, uniquely expressed in nursing. Examples of a
affirming nursing as a discipline and profession. nursing education program based on values
similar to those of nursing as caring are illus-
The curriculum, the foundation of the edu- trated in the book Living a Caring-based
cation program, asserts the focus and domain Program (Boykin, 1994).
of nursing as nurturing persons living caring

Nursing Research and Development CHAPTER 19 • Theory of Nursing as Caring 351

The roles of researcher and developer in nurs- demonstrated that when nursing practice is
ing take on a particular focus when guided by intentionally focused on coming to know a
the theory of nursing as caring. The assump- person as caring and on nurturing and support-
tions and focus of nursing explicated in the ing those nursed as they live their caring, trans-
theory provide an organizing value system that formation of care occurs. Within these practice
suggests certain key questions and methods. models based on nursing as caring, those
Research questions lead to exploration and nursed could articulate the “experience of being
illumination of patterns of living caring per- cared for”; patient and nurse satisfaction in-
sonally (Schoenhofer, Bingham, & Hutchins, creased dramatically; nurse retention increased;
1998) and in nursing practice (Schoenhofer and the environment for care became grounded
& Boykin, 1998b). Dialogue, description, and in the values of and respect for person.
innovations in interpretative approaches char-
acterize research methods. Development of Touhy, Strews, and Brown (2005) described
systems and structures (e.g., policy formula- a project to transform an entire for-profit
tion, information management, nursing deliv- health-care organization by intentionally
ery, and reimbursement) to support nursing grounding it in nursing as caring. Caring from
necessitates sustained efforts in reframing the heart—the model for interdisciplinary prac-
and refocusing familiar systems as well as tice in a long-term care facility and based on
creating novel configurations (Schoenhofer, the theory of nursing as caring—was designed
1995; Schoenhofer & Boykin, 1998a; Boykin, through collaboration between project person-
Schoenhofer, & Valentine, 2013). nel and all stakeholders. Foundational values of
respect and coming to know ground the model,
The practicality of the theory of nursing as which revolves around the major themes of
caring has been tested in various nursing responding to that which matters, caring as a
practice settings. Nursing practice models way of expressing spiritual commitment, devo-
have been developed in acute and long-term tion inspired by love for others, commitment to
care settings. Research studies focused on creating a home environment, and coming to
designing, implementing and evaluating a know and respect person as person (2005). The
theory-based practice model using nursing as major building blocks of the nursing model for
caring on a telemetry unit of a for-profit hos- an acute care hospital and for a long-term care
pital (Boykin, Schoenhofer, Smith, St. Jean, facility each reflect central themes of nursing
& Aleman, 2003); the emergency department as caring, but those themes are drawn out in
of a community hospital (Boykin, Bulfin, ways unique to the setting and to the persons
Baldwin, & Southern, 2004; Boykin, Schoen- involved in each setting. The differences and
hofer, Bulfin, Baldwin, & McCarthy, 2005); similarities in these two practice models demon-
and the intensive care unit of a for-profit hos- strate the power of nursing as caring to trans-
pital (Dyess, Boykin, & Bulfin, 2013) have form practice in a way that reflects unity without
conformity, uniqueness within oneness.

PRACTICE EXEMPLAR

Nursing administration, nursing practice, nurs- and nursing research.1 The exemplars were
ing education, and nursing research require a drawn from the practice experience of the
full understanding of nursing as nurturing per- nurses who wrote them, and most illustrate
sons living caring and growing in caring. This stories of actual nursing situations. A nursing
online supplemental resource for this chapter administration exemplar addresses health-care
contains four practice exemplars, illustrating
the use of the nursing as caring theory to guide 1For additional practice exemplars please go to bonus
practice in nursing administration, clinical chapter content available at FA Davis http://davisplus
simulation laboratory in nursing education, .fadavis.com

Continued

352 SECTION V • Grand Theories about Care or Caring

Practice Exemplar cont. lived experiences of some of the early partici-
pants were very “fragile” and dealt with personal
system leadership and caring. The nursing ed- issues such as domestic violence and depres-
ucation exemplar illustrates the use of the sim- sion. As these women’s personhood and their
ulation laboratory in teaching nursing from the struggle with obesity and diabetes emerged, we
perspective of nursing as caring. Two research felt a need to protect them in this, their first
exemplars are also provided online, one focus- venture of sharing. These women’s lives had
ing on the development of a research approach been grounded in caring, but circumstances
compatible with nursing as caring, and a seemingly beyond their control had affected
second addressing the use of nursing as caring their personhood. A safe, nurturing relation-
as the nursing theoretical perspective under- ship with other caring individuals was needed
pinning a doctoral dissertation study. The to allow them to trust and grow again.
following advanced practice nursing exemplar
illuminates advanced nursing practice grounded Nursing Situation
in nursing as caring. One of the champions of this program, named
BP, a 42-year-old woman, was diagnosed with
Advanced Nursing Practice Exemplar: insulin-dependent diabetes 10 years ago. Be-
Primary Care Clinic Grounded in cause of the rapid progression of her disease
Nursing as Caring process, she had bilateral arterial bypass sur-
gery that resulted in limited mobility. BP took
Two nurse practitioners, Kathi Voege Harvey, a 2-year sabbatical from our clinic and has re-
FNP, and Elizabeth Tsarnas, FNP, whose cently returned. She had been without med-
practice setting is a primary care clinic, shared ications and supplies for months, which
their way of creating nursing as caring in a increased the neuropathic pain to her lower
community-based program of nursing for per- extremities. She also shared with us that she
sons living with diabetes. was under increased stress while preparing for
her upcoming wedding. Our conversations
Our primary care clinic serves the popula- would always include the importance of look-
tion of patients who are considered the under- ing into the future at 10, 20, and 30 years to
served and fall within the lower socioeconomic visualize the many disabilities she could de-
level, including those individuals labeled by velop within that time which would reduce her
society as the working poor, uninsured, unem- quality of life and how she could alter that
ployed, illiterate, disabled, homeless, and re- future. Over the past several months, she has
cent migrants from many parts of the world. taken control of her disease by checking her
This vulnerable population creates greater sugars more often and regularly taking her in-
challenges, yet we are empowered by our dis- sulin. She married a month ago and noticed
ciplinary view of the theory of nursing as car- that her husband, KP, had symptoms of dia-
ing to deliver quality and evidence-based betes. After checking his blood sugar, which
health care to all who come. consistently was very elevated, she brought
him to the clinic to receive health care. Her
Call for Nursing enthusiasm for improving her heath was con-
As a result of our observation that individuals tagious, and she was excited that she could
with diabetes struggled to incorporate a dia- share her journey with her new husband.
betic-friendly diet and exercise into their
lifestyles, we developed a collaborative program Several weeks later, BP introduced us
that brought experts in nursing and fitness to- to her mother-in-law, SP, who has prediabetes
gether in a world outside of the clinic setting. and with whom BP, her new husband, and her
This innovative program supports participants young nephew were living. SP was feeling like
in their endeavor to develop a new health-care she could not take control of her life, so she
plan through an exercise, education, and
support-group curriculum. The first group to
be formed was limited to women because the

CHAPTER 19 • Theory of Nursing as Caring 353

Practice Exemplar cont. with others in their situations of concern. We
feel comfortable to respond to calls for nursing
was referred to us for evaluation, and we without preplanned protocols or preconceived
invited her to join our group of women. One solutions because we are responding uniquely
evening after a support group, which BP and to each situation with the “other” with the in-
her mother-in-law attended, we walked them tention to communicate caring and commit-
to the front of the building where they met ment to work with them to achieve their goals.
BP’s husband, who had been exercising in the
gym, and his nephew, who was only 12 years Our nursing situation with the P family
old and had been abandoned by his natural began with one member, who sought help to
parents. As we introduced ourselves to this improve her health, which had been ravaged
shy, very thin, 12-year-old young man, we en- by diabetes. Over time, the loving relationship
gaged him in conversation so that we could of “caring between” developed among BP, her
come to know him. We learned that he had nurse practitioners, her trainer, and her class-
been made to come but was angry because he mates. Boundaries of roles disappeared in this
was too young to be in the gym. His grand- relationship, and BP began to experience
mother had previously confided in us that he wholeness and completeness in the moment
did not have any friends or participate in any- that was so healing that she invited her family
thing and that he was beginning to have anger members into her dance of caring persons so
outbursts. We identified yet another call for that they, too, could experience well-being.
nursing and decided to explore possible sports We have all grown through this lived experi-
or activities in which this young man would ence, and as nurse practitioners, our way of liv-
like to participate. After some investigation, ing grounded in caring has been reaffirmed.
we were able to include him in an adolescent
“boot camp” that met at the same time as his Lived Meaning of Nursing As Caring
family’s exercise classes and also a soccer team
right on the premises. As he experiences car- A patient first enters the doors of our free clinic
ing through nurturing with his family and us, appearing as an unopened rosebud with many
it is our hope that his fears will subside and thorns. The closed bud represents security and
allow him to realize the beauty of his unique- protection from the unknown. Many who have
ness and his boundless potential. limited exposure to a health-care system enter
our world with fear of what will be discovered
In this situation BP’s nurturing lived expe- and doubts about the competency of those giv-
rience enabled her to enhance her personhood ing something without cost. The thorns repre-
and touch the lives of those she loved in a way sent the patients’ defense system if they should
that she had been touched. BP was living in encounter threats to their safety. The rose
caring and growing in caring, and the com- petals gradually begin to open as the patient ex-
pleteness she experienced empowered her to periences each caring moment through the au-
care for others, like her family, so that they too thentic presence of the nurse whose intention
could be whole and complete in the moment. is to promote health and healing through phys-
ical, emotional, and spiritual discovery and
Nursing Response restoration. After the rose completely opens
All persons are caring by virtue of their human- and the thorns soften, the patient begins an ac-
ness. As nurses, we readily recognize calls for ceptance process, and true healing begins. Each
nursing that others might easily miss. Our per- room within the clinic resembles a beautiful
sonhood as nurses grounded in caring and vase that is full of roses of all shapes, sizes, and
equipped with the wisdom of knowledge about colors, representing the uniqueness of each in-
nurturing relationships and human well-being dividual the nurse encounters. Others within
that we have pursued passionately through our the room help to achieve the same goals as the
advanced education arm us with the confidence nurses and caregivers and represent oxygen,
to be intentionally and authentically present

Continued

354 SECTION V • Grand Theories about Care or Caring

Practice Exemplar cont. The nurse administrator is subject to chal-
lenges similar to those of the practitioner and
sunlight, and water needed to foster growth often walks a precarious tightrope between
and strength. Reflecting on the beauty and direct caregivers and corporate executives
uniqueness of each rose prepares the nurse for (Boykin & Schoenhofer, 2001b). The nurse
a new unopened rosebud. administrator, whether at the executive or
managerial level of the organization chart, is
Ways of Knowing held accountable for “customer satisfaction”
Although we must be skilled in both science as well as for the “bottom line.” Nurses who
and clinical experience, the nurse is always move up the executive ladder may be sus-
nurturing and growing in caring to provide a pected of disassociating from their nursing
new dimension of healing that allows us to colleagues on the one hand and of not being
enter the patient’s world to experience and sufficiently cognizant of the harsh realities of
understand their needs in a way that is more fiscal constraint on the other hand. Admin-
than just a prescription or treatment modal- istrative practice guided by the assumptions
ity. This story reinforces the requisite not and themes of nursing as caring can enhance
only to have the knowledge to properly treat eloquence in articulating the connection be-
the disease process but also to offer encour- tween caregiver and institutional mission: the
agement through dialogue and physical avail- person seeking care. Nursing practice leaders
ability to help patients engage in exercise, who recognize their care role, indirect as it
classroom instruction, and healthy behaviors may be, are in an excellent position to act on
that produce positive results in patient out- their committed intention to promote caring
come measures. environments. Participating in rigorous ne-
gotiations for fiscal, material, and human re-
Personally, as we listened to the stories of all sources and for improvements in nursing
of the participants in this program, we realized practice calls for special skill on the part of
how lucky we were to experience this intensely the nurse administrator, skill in recognizing,
caring bond between what once were patients acknowledging, and celebrating the other
and nurse practitioners and now were persons, (e.g., CEO, CFO, nurse manager, or staff
whole and complete in the moment. We came nurse) as a caring person. The nurse admin-
to realize that our ability to care for others living istrator who understands the caring ingredi-
with chronic illnesses was being viewed through ents (Mayeroff, 1971) recognizes that caring
a much more realistic lens. We had always is neither soft nor fixed in its expression. A
known that changes in lifestyle to improve developed understanding of the caring ingre-
health outcomes were difficult to implement, dients helps the nurse administrator mobilize
no matter how much clinical sense they made. the courage to be honest with self and
But dwelling in the moment with these women “other,” to trust patience, and to value alter-
who were struggling to maintain well-being nating rhythm with true humility while living
while life just kept happening and who were a hope-filled commitment to knowing self
still able to lose weight, decrease their medica- and “other” as caring persons.
tions, and make difficult decisions about their
lives as our “caring between” relationship Health Care System Transformation for
evolved, made us realize that wherever we are, Nursing and Health Care Leaders: Implement-
whatever we do, we never stop caring, and we ing a Culture of Caring (Boykin, Schoenhofer,
never stop being nurses. As others who oversaw & Valentine, 2013) proposes practical strate-
this pilot program began to express amazement gies for total, integrated system transforma-
at what we saw as nursing, we knew our secret tion based on the tenets of the dance of caring
was out: Others in the community were begin- persons and grounded in the assumptions of
ning to identify nursing as caring, and one by
one they asked to join in the dance of caring
persons.

CHAPTER 19 • Theory of Nursing as Caring 355

Practice Exemplar cont. groups. Solutions implied in the Hospital
Consumer Assessment of Healthcare Providers
nursing as caring. Many of the challenges of and Systems are congruent with the values of
nurse managers and nurse administrators as nursing as caring and are amplified and given
well as those experienced by other health- substance by specific assumptions and con-
care system leaders are currently being ad- cepts of nursing as caring.
dressed by the Institute of Medicine, the
Joint Commission, and other health policy

■ Summary situation. In nursing situations, shared lived
experiences of caring, the nurse hears calls for
The theory of nursing as caring is grounded in caring and creates effective caring responses.
assumptions that persons are caring by virtue In the caring between nurse and nursed, per-
of their humanness, that caring unfolds mo- sonhood is enhanced.
ment to moment, that personhood is living
grounded in caring, and that personhood is en- The theory of nursing as caring is used by
hanced in relationships with caring persons. practitioners and administrators of nursing
From that basic philosophical perspective, the services in a range of institutional and commu-
focus of nursing as a discipline and a profes- nity-based nursing practice settings. The the-
sional practice is nurturing persons living car- ory is also used to guide nursing education,
ing and growing in caring. The nurse enters nursing education administration and nursing
into the world of the other with the intention research. More detailed information about the
of knowing the other as person living caring theory, an extensive bibliography, and exam-
and growing in caring. In authentic presence, ples of use of the theory are available at http://
the nurse offers a direct invitation to the one nursingascaring.com.
nursed to express what matters most in the

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VISection

Middle-Range Theories

357

Section Middle-Range Theories

VI Twelve middle-range theories in nursing are presented in the final section. Each
chapter is written by the scholars who developed the theory. Although we deter-
358 mine all to be at the middle range because of their more circumscribed focus on
a phenomenon and more immediate relationship to practice and research, they
still vary in level of abstraction.

Transitions are part of the human experience, and how we negotiate these
transitions affects health and well-being. Afaf Meleis’ transitions theory appears
in Chapter 20. The theory includes the elaboration of transition triggers, properties
of transitions, the conditions of change, and patterns of responses to transitions.
Nursing interventions to promote a smooth passage during transitions are
described.

Comfort is an important concept to nursing practice. Kolcaba’s middle-range
theory of comfort is presented in Chapter 21. She defines comfort as “to
strengthen greatly” and identifies relief, ease, and transcendence as types of com-
fort, and physical, psychospiritual, environmental, and sociocultural as contexts
in which comfort occurs.

Duffy’s quality-caring model, described in Chapter 22, is being used in many
health-care settings to address the issues of patient satisfaction, including patients’
perceptions of not feeling cared for in the acute care environment. In this model
the goal of nursing is to engage in a caring relationship with self and others to
engender feeling “cared for.”

Reed’s theory of self-transcendence is presented in Chapter 23. The focus of
the theory is on facilitating self-transcendence for the purpose of enhancing well-
being. Reed defines self-transcendence as the capacity to expand the self-bound-
ary intrapersonally (toward greater awareness of one’s beliefs, values, and
dreams), interpersonally (to connect with others, nature, and surrounding environ-
ment), transpersonally (to relate in some way to dimensions beyond the ordinary
and observable world), and temporally (to integrate one’s past and future in a
way that expands and gives meaning to the present).

Smith and Liehr present story theory in Chapter 24. They posit that story is a
narrative happening wherein a person connects with self-in-relation through nurse–
person intentional dialogue to create ease. This theory has already been applied
in a number of practice and research initiatives.

Parker and Barry’s community nursing practice model has guided nursing prac-
tice in community settings in several countries. The model is represented by con-
centric circles with the nursing situation as core and connected with the outer
spheres of influence in the community and environment.

Chapter 26 contains Locsin’s theory of technological competency-caring. This
theory dissolves the artificial and often assumed dichotomy between technology
and caring, and asserts that technology is a way of coming to know the person
as whole.

Ray and Turkel authored Chapter 27 on Ray’s theory of bureaucratic caring.
The theory uses a multidimensional, holographic model to facilitate the under-
standing of caring within complex healthcare environments.

In Chapter 28 Troutman-Jordan describes her theory of successful aging. The
theory was informed by Roy’s adaptation model and Tornstam’s theory of gero-
transcendence. Successful aging is characterized by living with meaning and

purpose. Intrapsychic factors, functional performance and spirituality contribute
to gerotranscendence and successful aging.

Elizabeth Barrett details her theory of power as knowing participation in
change in Chapter 29. This middle range theory is derived from Rogers’ science
of unitary human beings. Barrett identifies the dimensions of power as: awareness,
choices, freedom to act intentionally, and involvement in creating change.

In Chapter 30 Smith presents her theory of unitary caring. The theory evolved
from viewing caring through the lens of Rogers’ science of unitary human beings.
The concepts of the theory are: manifesting intentions, appreciating pattern, at-
tuning to dynamic flow, experiencing the Infinite and inviting creative emergence.

In Chapter 31 Swanson describes her trajectory and the process of developing
of her middle-range theory of caring from research. The chapter provides insight
to the evolution of theory. Swanson’s theory of caring includes the concepts of
knowing, being with, doing for, enabling, and maintaining belief.

359



Transitions Theory 20Chapter

AFAF I. MELEIS Introducing the Theorist
Introducing the Theorist
Overview of the Theory Dr. Afif I. Meleis is a Professor of Nursing and
Application of the Theory Sociology and the former Margaret Bond
Practice Exemplar by Diane Gullett Simon Dean of Nursing at the University of
Pennsylvania School of Nursing and the former
Summary Director of the School’s WHO Collaborating
References Center for Nursing and Midwifery Leadership.
Before coming to Penn, she was a Professor on
Afaf I. Meleis the faculty of nursing at the University of
California Los Angeles and the University of
California San Francisco for 34 years. She is a
Fellow of the Royal College of Nursing in the
United Kingdom, the American Academy
of Nursing, and the College of Physicians of
Philadelphia; a member of the Institute of
Medicine, the George W. Bush Presidential
Center Women’s Initiative Policy Advisory
Council, and the National Institutes of Health
Advisory Committee on Research on Women’s
Health; a Board Member of the Consortium of
Universities for Global Health; and cochair of
the IOM Global Forum on Innovation for
Health Professional Education and the Harvard
School of Public Health-Penn Nursing-Lancet
Commission on Women and Health. Dr.
Meleis is also President Emerita and Counsel
General Emerita of the International Council
on Women’s Health Issues and the former
Global Ambassador for the Girl Child Initiative
of the International Council of Nurses.

Dr. Meleis’s research scholarship is focused
on the theoretical development of the nursing
discipline, structure and organization of nurs-
ing knowledge, transitions and health, and
global immigrant and women’s health. She is
the originator of the transitions theory, a central
concept of nursing phenomenon. This theory
continues to be translated into policy, research,

361

362 SECTION VI • Middle-Range Theories Origins of the Theory

and evidence-based practice and better quality Three paradigms guided the development of
care in the 21st century. transitions theory in more than 40 years of clin-
ical research and theoretical work. The first is role
She has mentored hundreds of students, theory, a dynamic and interactionist paradigm
clinicians, and researchers from around the developed by Dr. Ralph Turner, whom I con-
world who, under her guidance, have achieved sider the father of interactive role theory. Role
prominent leadership positions. She is the au- theory framed the type and nature of questions
thor of more than 175 articles in social sci- about how to help patients, clients, and families
ences, nursing, and medical journals; more in their transition from one role to another, how
than 40 chapters; 7 books; and numerous to take on a new role, or change behaviors in a
monographs and proceedings. Her award- role. I wondered about the mechanisms and the
winning book, Theoretical Nursing: Develop- processes that new mothers and fathers learned
ment and Progress, now in its 5th edition (1985, and negotiated as they become adept at per-
1991, 1997, 2007, 2012), is used widely forming the behaviors of parenting, at picking
throughout the world. up the cues that differentiate the meaning of the
different crying episodes or different patterns of
Overview of Transition Theory sleep. From that theoretical heritage, I devel-
oped a framework for intervention that I called
A patient is admitted to the hospital; another role supplementation (Meleis, 1975). This frame-
is being discharged to a home, to a rehabilita- work requires the nurse to accurately analyze the
tion center, or to an assisted living facility; a goals, sentiments, and behaviors necessary for
third has just been diagnosed with a life- the role he or she wishes to help the client de-
threatening disease; a fourth is preparing for velop. Such roles might include parenting roles,
an intrusive surgery; a fifth just got the news patient roles, or wellness roles. The desired out-
that her spouse has a long-term illness, and come of applying role theory is the client’s mas-
finally, a sixth is a new graduate from a nursing tery of the role. Nurses help people acquire or
school beginning his first position as a nurse. change roles by modeling behaviors, allowing
What do they all have in common? Each their clients to rehearse roles, and providing
of these scenarios is about the experience and them with support while they are developing
responses of patients, families to health and these roles.
illness situations; the experience of coping with
changes from one phase, site, identity, posi- A second paradigm that influenced the de-
tion, role, or situation to another. The change velopment of transitions theory is the lived ex-
event itself—whether it is birthing a baby, start- perience, which contrasts the perceived views
ing a new position, receiving a life-changing with the received views. As we, in nursing, began
diagnosis, facing impending death, hospital- questioning what we know and how we know it,
ization, or surgery—is a turning point, but the it became apparent that other ways of knowing
experience is more fluid and longitudinal. The (Carper, 1978) that complement and, perhaps,
transition experience starts before the event transcend empirical knowing. This personal, ex-
and has an ending point that is fluid, that periential knowing is by its nature subjective. It
varies based on many variables. Understand- is more holistic and encompassing, embedded in
ing the nature of and responses to change, fa- practice, and framed by history. On the basis of
cilitating and supporting the experience and the writing of many illuminating nonnurse au-
responding to it at different phases, and re- thors (Polanyi, 1962) and nurse authors (among
maining or becoming healthy before, during or them Benner, Tanner, & Chesla, 1996;
at the end of the event, wherever that elusive Munhall, 1993; Sarvimaki, 1994), I described
ending point is, is what transitions theory is the perceived view (Meleis, 2012) and used it as
about. This theory provides a framework to a driving paradigm for the development of the
generate research questions and to serve as a concept of transitions (Chick & Meleis, 1986).
guide to effective nursing care before, during, This paradigm helped us focus on questions
and after the transition.

related to the nature and lived experience of the CHAPTER 20 • Transitions Theory 363
response to change and the experience of being
in transition. • Individuals have the capacity to learn
and enact new roles influenced by their
The third paradigm that informs transitions environment..
theory is that of feminist postcolonialism. The
tenets of this paradigm encompass an epis- • By producing critical and well-supported
temic system that questions power relation- evidence, inequities in health care can be
ships in societies and institutions and that links changed to more equitable systems of
societal and political oppressions that shape delivery.
the responses to change events. This paradigm
gave us a framework for understanding the ex- • Gender, race, culture, heritage, and sexual
perience of transition through the multiple orientation are contexts that shape people’s
lenses of race, ethnicity, nationality, and gen- experiences and outcomes of health–illness
der. Each of these qualities creates power dif- events as well as the health care provided.
ferentials that must be considered if we truly
want to understand how people experience and • Nursing perspective is defined by humanism,
cope with transition and to provide preventive holism, context, health, well-being, goals,
and therapeutic interventions to help them and caring.
achieve health and wellness outcomes. Using
a feminist postcolonialist framework helps us • Environment is defined as physical, social,
consider the conditions shaped by power in- cultural, organizational, and societal and
equities in a society or in institutions of healing influences experience, interventions, and
(e.g., hospitals, nursing homes, community outcomes.
agencies) and how these power inequities can
shape the allocation of resources as well as the • Individuals, families, and communities are
provision of nursing care through transitions. partners in the care processes.
The delineation of conditions surrounding the
transition experience was illuminated by em- Concepts and Propositions of
ploying a feminist postcolonialist framework. Transitions Theory

These three paradigms—roles theory, per- The transitions theory provides a framework to
ceived views on lived experiences, and femi- describe the experience of individuals who are
nist postcolonialism—shaped the evolution of confronting, living with, and coping with an
transitions theory through some 40 years of event, a situation, or a stage in growth and de-
its development. velopment that requires new skills, sentiments,
goals, behaviors, or functions. Transition is
Assumptions of the Theory defined as “a passage from one life phase, con-
dition, or status to another” (Chick & Meleis,
• A human being’s responses are shaped by 1986). It is a complex and multifaceted con-
interactions with significant others and cept embracing several components, including
reference groups. process, time span, and perception.1

• Change through health and illness events 1This section of the chapter borrows heavily from the
and situations trigger a process that begins at many publications about this theory, which evolved and
or before and extends beyond the event time. was transformed by many mentees and collaborators
over the years (Chick & Meleis, 1986; Schumacher &
• Whether aware or not aware, individuals Meleis, 1994; Meleis, Sawyer, Im, et al., 2000; and Meleis,
and/or families experience a process trig- 2010). Without the partnerships, the co-authorship, and
gered by changes with varied responses and collaboration of many mentees, I would not have been
outcomes. able to develop transitions theory. It is an integration
of all the previous writings about transition theory.
• Outcomes of the experience of the transition Their influence is manifested in the many co-authored
are shaped by the nature of the experience. publications. Among my mentee collaborators are
Drs. DeAnne Messias, Eun-Ok Im, Kathy Dracup,
• Preventative and therapeutic actions can Linda Sawyer, Karen, Schumacher, Pat Jones, Norma
influence outcomes. Chick, Leslie Swendsen, and Patrician Tragenstein.
While I acknowledge and respect the co-opted contribu-
tions of all my collaborators, the liberty I have taken in
integrating the theory from all previous work is entirely
my responsibility.

364 SECTION VI • Middle-Range Theories people and may or may not require interfacing
with health-care professionals and the health-
Transition Triggers care system. Developmental phases and roles in-
fluence health and illness behaviors as well as
Four types of situations trigger a transition expe- inform the responses of individuals to such events
rience (Fig. 20-1). All are characterized by some as birthing, breastfeeding, among many others.
type of change. Change is related to an external These examples of developmental transitions are
event while transition is an internal process of interest to nursing because of the evidence in
(Chick & Meleis, 1986). The first trigger is a the literature that demonstrates how nurses deal
change in health or an illness situation that could with, what they write about and research, as well
initiate a diagnosis or an intervention process, as how they care for individual health-care needs
particularly the kinds that require prolonged di- during the many phases in their development.
agnostic procedures or treatment protocols, for
example, cancer, schizophrenia, autism, diabetes, Similarly, the third change trigger for a
or Alzheimer’s disease, among others. Each of transition is what we call situational transi-
these diagnoses is preceded by many unknowns, tions, all of which have health-care implica-
uncertainties about the processes that follow, and tions. These are exemplified by experiences
fears about consequences. They all also require and responses to situational changes such as
new behaviors, resources, and coping strategies, the admission to or discharge from a hospital
and they involve sets of relationships, newly es- or rehabilitation institution, as well as the
tablished, changed, or severed. changes that a new graduate nurse experi-
ences becoming a manager or an expert or
A second trigger is developmental transi- that a student nurse learning the ropes of his
tions, which are exemplified by life phases as or her first clinical rotation experiences at a
manifested by age (e.g., adolescence, aging, new hospital.
menopause) or by roles (e.g., mothering, father-
ing, marrying, divorcing). Developmental tran-
sitions influence the health and well-being of

Change Triggers Properties Conditions Patterns of Response
Developmental Time span Personal
Situational Process Process Outcome
Health-illness Disconnectedness Community
Organizational Awareness Society Engaging Mastery
Critical points Global
Locating and Fluid and
being situated integrative identity

Seeking and Resourcefulness
receiving support
Healthy interaction

Acquiring Perceived
confidence well-being

Preventitive Intervention Therapeutic

• Clarify roles,
competencies,
and meanings

• Identify milestones

• Mobilize support

• Debrief

Modified from Transitions: A Middle-Range Theory,
Meleis, Sawyer, Im, Messias, Schumacher, 2000)

Fig 20 • 1 Transitions: A middle-range theory. Modified from Meleis, A.I., Sawyer, L., Im, E., Schumacher, K., and
Messias D. (2000). Experiencing transitions: An emerging middle range theory. Advances in Nursing Science, 23(1), 12.

The fourth type of change trigger that starts CHAPTER 20 • Transitions Theory 365
a process of transition is linked to organizational
rules and functioning (Schumacher & Meleis, is health related, developmental, situational, or
1994). There are many examples of organiza- organizational, one of the properties of the tran-
tional transitions: the arrival of a new chief ex- sition experience is a sense of impending or actual
ecutive officer, chief nursing officer, or any other disconnectedness. A clear example is the imple-
new leader; the implementation of electronic mentation of electronic health records in a school
health records; a different system of care; use of or hospital. Those who will be experiencing the
new technology throughout an organization; or change will manifest responses that could reflect
moving nursing practice to the community. The a level of disconnect from their current mode of
experience of transition here is for a whole or- recording patients’ health data and maintaining
ganization as opposed to individuals or families. continuity in patients’ files. The transition expe-
rience reflects a disruption in a person’s feeling
Properties of Transition of security associated with what is known and fa-
miliar. There is a sense of loss—of familiar sign-
Besides a triggering change event, transitions posts, reference points, or state of health—and a
are characterized by properties that we de- feeling of incongruity between past, present, and
scribed in 1986 (Chick & Meleis 1986; see future expectations. Those who are responding
Table 20-1). The first is a time span, which to the change experience a discontinuity of reg-
could begin from the moment an event or a sit- ular patterns disrupted by the unfamiliar.
uation comes to the awareness of an individual.
It could be a symptom, a diagnosis, an emer- Another important property of transitions is
gency room visit, a flood, an earthquake, an ac- awareness—awareness of the change event, of
cident, or a decision to undergo surgery. Unlike the situation, of triggers, and of the internal ex-
its beginning, the end of a transition is fluid. The perience of transition. The difference between
end may be determined when a final goal is change and transition is the difference between
achieved, be it mastery of new roles, developing external and internal experience. Perception,
certain competencies, feeling a sense of well- awareness, and the defining and redefining of
being, or acquiring a desired quality of life. the meaning of the change for the self and others
are properties of a transition experience. They
Another property that defines transition is make transition dynamic, incorporating meaning
that it is a process. The change event itself is and changing interpretation over a span of time.
static, but the experience that ensues is a dynamic
and fluid process. The distance between the be- The presence of milestones that may be turn-
ginning of this process and when it exactly ends ing points is yet another property of transitions.
may correspond with other similar processes or Identifying milestones is essential to under-
may be unique. Bridges (1980, 1991) character- standing the phases in the transition experience
ized the process following change events as re- as well as to identifying the appropriate assess-
quiring at first an ending period followed by an ment points and intervention points. The goals
experience of confusion or a neutral period fol- of transition theory are to describe triggers, to
lowed by a period he calls the new beginning. anticipate experience, to predict outcomes, and
That is when the process is completed. to provide guidelines for interventions.

Disconnectedness is an additional character- Conditions of Change
istic of transition. Whether the triggering change
Change triggers initiate a process with patterns
Table 20 • 1 Concepts of responses that are both observable and
nonobservable behaviors and either functional or
• Time dysfunctional. These responses start from the
• Process moment a change trigger is anticipated and are
• Experiences influenced by personal, community, societal, or
• Milestones global conditions. Among the personal condi-
• Conditions tions are the meaning and the values attributed
to the change and the context of it. A person’s
experience and responses are also influenced by
the expectations of how self or others will react,

366 SECTION VI • Middle-Range Theories as well as in the actions and intervention
plans (Schumacher, Jones, & Meleis, 1999).
the level of knowledge and skills related to the Levels of engagement could be assessed
change, and the belief about what is expected of through patterns of questions, types of re-
those undergoing the change. Other personal sponses, and the congruency between actions,
conditions that influence the experience and re- sentiments, and goals of those who are experi-
sponses are the level of planning and the level of encing the transition and those who are guid-
existing health and well-being of the person, the ing and advising about these actions. Following
family, the organization, the community, or the directions, accuracy of perceived information,
country at large (Schumacher & Meleis, 1994). the consistency of meanings of the event, and
In addition, the responses are mediated by the the degree of involvement in all aspects of tran-
level of vulnerability and sense of marginaliza- sition experience and actions related to the
tion those experiencing the transition find them- change event are indicators of engagement
selves in or are subjected to (Hall, Stevens, & levels.
Meleis, 1994; Stevens, Hall, & Meleis, 1994).
Community conditions, such as support from A second process pattern of response is
partners and the availability of role models and called location and being situated (Meleis,
resources, promote or inhibit effective healthy Sawyer, Im, Schumacher, & Messias, 2000).
transitions. Community norms about and re- Recognizing one’s position in a complex system
sources for dealing with sexism, homophobia, of relationships and being connected and able
poverty, ageism, and nationalism also could pro- to interact with a web of different interactions
mote or inhibit healthy experiences and out- is a pattern of response that should be examined
comes of transitions. Global conditions that to uncover the nature of responses to a transi-
could influence the experience of transitions, in- tion trigger. How a person sees, initiates, and
cluding policies and mandates developed by in- relates to teams of health professionals follow-
ternational organizations, define how certain ing a diagnosis of cancer or to a new immi-
triggers are viewed and appear at the global con- grant’s environment determines a pattern
sciousness. For example, the transition of the of response. How and when a person, a family,
HIV/AIDS patient through the diagnosis and or a community confronted by a change trigger
treatment process could be mediated by the seek support from health-care providers, are
global attention and resources that have been indicators of the extent that they understand the
given to researchers, clinicians, and patients who needs and timeliness in seeking the support. It
have or are associated with the disease. There are is also an indication of realizing their position
vast differences between how infected individu- within the health-care system.
als experienced the diagnosis and treatment of
HIV/AIDS before the global attention to it and Another process pattern is the level of
post–President’s Emergency Plan for AIDS Re- confidence in handling the new, multiple, and
lief aid offered by the Western world. sometimes conflicting demands on a person,
family, or organization in the midst of attempt-
Patterns of Responses ing to deal with a triggering event. Similarly, the
level of confidence may be determined by the
How do individuals, families, and organizations individual’s ability to identify priorities of needs
respond to a change event? What questions and to outline different levels of actions or inter-
should be asked to define and understand their ventions. The actions could be as simple as
responses? This is an area of knowledge that is describing from whom they should seek help to
ripe for systematic investigation. Many theories more complex self-care interventions.
can describe responses. Among them are grief Outcome Patterns
theories (Kübler-Ross, 1969) and crisis theories Although patterns in process responses are
(Lindemann, 1979). We have proposed two sets assessed at different points in dealing with a
of responses from a nursing perspective: process change trigger, outcome responses are assessed
patterns and outcome patterns. at a point determined to be at the end of the
Process Patterns transition process. Five patterns of responses are
Process patterns are measured by the degree defined as outcomes—mastery, fluid integrative
of engagement in the particular change event

identities, resourcefulness, healthy interactions, CHAPTER 20 • Transitions Theory 367
and perceived well-being (Meleis et al., 2000).
Mastery includes role mastery, which is mani- providers while maintaining meaningful sup-
fested by integrating the sentiment, goals, and portive relationships in their lives. For example,
behaviors in one’s identity, and behaving with telehealth can play a significant role in facilitat-
confidence, knowledge, and expertise. Exam- ing caregivers’ abilities to meet the needs of
ples are becoming a mother (Hattar-Pollara, heart failure patients by maintaining continuous
2010; Mercer, 2004; Shin & Whitetraut 2007), communication with family and caregivers. Te-
accepting hospice or end-of-life care (Larkin, lenurses can then deliver the evidence-based
Dierckx de Casterlé, & Schotsmans, 2007), professional consulting and supportive care
or becoming adept at being at risk while based on technology that improves patients’
continuing to function in other roles. self-care behaviors. These interventions can also
alleviate caregivers’ burdens and improve their
Mastery goes beyond roles, however, and health outcomes, allowing them time to meet
includes mastery of one’s environment as mani- their own needs (e.g., health or social needs;
fested in seeking and utilizing appropriate re- Chiang, Chen, Dai, & Ho, 2012).
sources and co-opting supportive environmental
conditions. Learning to cope with technology These types of questions are important to an-
at home, living with it, and reformulating swer because some research has demonstrated
one’s identity to incorporate it in one’s daily that the health of partners or caregivers is inter-
repetitions is an example of this mastery (Fex, twined with that of seriously ill patients, that is,
Gullvi, Ik, & Soderhamn, 2010). the more an illness affects the patient’s physical
and mental ability, the greater the impact
Fluid and integrative identity is another out- this will have on the health of their partner or
come response pattern (Meleis et al., 2000). caregiver due to insurmountable stress, disrup-
This pattern is characterized by the ability to tion in their relationships, and neglect of their
swing back and forth between the multiple own health. These unintended health conse-
identities a person in transition experiences. quences may be further exacerbated by the lack
Let’s consider a person who must undergo kid- of social, emotional, or practical support the
ney dialysis and who emerges from her dialysis partner or caregiver experiences (Christakis &
session to assume other identities, without any Allison, 2006). For this reason, having strong
one of the identities dominating her time and social networks in place during these periods
energy. A person with an integrative identity of transition could play a significant role in
is able to live, function, and be well, despite promoting positive health outcomes for the
the uncertainties and ambiguities of living with caregiver, which would in turn positively affect
a chronic illness, a nagging pain, or a set of the health of the patient. For major areas of
essential treatments. This pattern of outcome investigation, see Table 20-2.
response is characterized by the ability to carry
the sentiments, the goals, the actions, and the Intervention Framework
baggage of different ways of being (Messias,
1997). It is the ability to “navigate unknown The goal of intervention within transitions the-
waters” (Duggleby et al., 2010). One indicator ory is to facilitate and inspire healthy process
for an outcome pattern of response is current and outcome responses. Nursing interventions
compared with previous quality of life. that support healthy process behaviors as well
as healthy outcome behaviors include the fol-
Another outcome pattern of response is lowing: clarifying meanings, providing expert-
healthy interactions and connections as mani- ise, setting goals, modeling the role of others;
fested in maintaining relationships and or providing resources, opportunities for rehearsal,
developing new connections or relationships access to reference groups and role models, and
that affirm the completion of a transition. debriefing.
Questions to be investigated are the extent to
which caregivers burdened by extensive health- Clarifying Roles, Meanings, Competen-
care needs of patients with heart failure are able cies, Expertise, Goals, and Role Taking
to develop relationships with health-care
Through interaction, dialogue, and interviews,
the nurse probes for the values of the person

368 SECTION VI • Middle-Range Theories

Table 20 • 2 Major Areas of Investigation

• Describe and interpret the different transition experiences and responses.
• Identify transition properties.
• Develop and test preventative and therapeutic interventions.
• Identify milestones and turning points associated with different change triggers.
• Describe and test determinants of process and outcome responses.
• Develop instruments and investigative tools for properties, conditions, processes, and outcome

responses.
• Explore strategies to modify policies essential to mitigate, facilitate or inhibit healthy processes

and outcome responses.

experiencing the transition process, as well as point when healing progresses or there is a
those of their significant others, and determines relapse, a point when infection, inflammation,
the meanings they attribute to the event and distress, anxiety, noncompliance, or other con-
the different stages in the transition. Compe- ditions may begin appearing and when an
tencies and the extent to which the person is appropriate intervention may advance the treat-
able to master each of the competencies are ment and healing course. Care is maximized at
identified, as well as the ease in performing the such a point. A 6-week check-up for a postpar-
competency and the level of engagement in tum mother has always been designated a critical
learning or modifying the competency—be it point or a milestone, but this milestone is driven
testing blood sugar levels, bathing a baby, by the biomedical model as it relates to when the
changing a nursing unit, or reaching out for uterus reverts to its normal size. However, it is
new connections in a nursing home. imperative to identify milestones from a nursing
perspective when our goals are self-care, quality
Similarly, observing, questioning or inter- of life, role mastery, and managed care. Identi-
viewing significant others—whether they are fying milestones or turning points is essential
partners or friends—to determine levels of in the trajectory of managing and facilitating
engagement and the extent of competency transitions. This area of the theory invites
mastery is another significant component of a research to provide evidence to identify and
program for intervention during transition support those points where there is a need for
process, especially at critical milestones. Signif- intervention to enhance both a healthy transition
icant others or reference groups to be included process and outcomes. Biomedical driven goals
in the assessment or the intervention are those are not inclusive of goals driven by a nursing
whose viewpoints are used as a frame of refer- perspective and holistic approach.
ence. Roles, whether they are new ones, at-risk
ones, or those that may be lost, are formed and Providing Supportive Resources,
imputed through a process of definition and Rehearsals, Reference Groups, and
redefinition. Similarly, new competencies are Role Models
acquired through a process of teaching, learn-
ing, rehearsing, modeling, and reinforcement Mobilizing partnerships, resources, and support-
by those who are in the support or network ive groups is another component in intervention
systems (Petch, 2009; Swendsen, Meleis, & strategies. Clarifying roles, competencies, values,
Jones, 1978; van Staa, 2010). and abilities to understand what others are ex-
periencing are important processes for facilitat-
Identifying Milestones and Using ing a healthy transition and in achieving healthy
Critical Points outcomes at the termination of a transition.
These may be accomplished by identifying a
A critical point is the time when questions tend nurse as a go-to person for questions, observing
to arise about a care trajectory or when signs and patients who may have gone through a similar
symptoms tend to manifest themselves. It is a

event, and being afforded opportunities to imag- CHAPTER 20 • Transitions Theory 369
ine, mentally enact, or actually practice what the
person may encounter, do, or feel during the mothers. Postnatal debriefing is a psychological
different phases of transition. Having a support intervention that enables women to come to
group, rehearsing competencies, becoming in terms with their experience and promotes
touch with feelings about events or competen- psychological well-being. Through postnatal
cies, visualizing different scenarios, and de- debriefing, health-care professionals can iden-
scribing the different if–then situations may tify the emotional and psychological needs of
enhance healthy transitions and outcomes. We the patient and refer them to appropriate
have called these processes role modeling and role resources or other mental health specialists.
rehearsal, as well as defining and identifying refer- This service gives new mothers the opportunity
ence groups (Meleis, 1975; Meleis & Swendsen, to ask questions, debrief about their experi-
1978). An example of this type of intervention ences, describe their feelings, and receive infor-
is an interdisciplinary mentoring program that mation and reasons for care they have been
the Hospital of the University of Pennsylvania provided or need (Steele & Beadle, 2003).
implemented, which pairs nurses with medical
students starting their first clinical rotations In addition to patients, nurses themselves, as
to facilitate the transitional adjustment of well as other health-care providers, also benefit
the medical students to their new environment. from debriefing. Hospitals have implemented
This program also highlights the important debriefing, or critical incident stress manage-
role nurses play in patient care, which fosters a ment, programs to help their staff cope with
sense of teamwork and collegiality between stress and sorrow at work and to mitigate the
medical students and nurses from the beginning impact of traumatic events. For example, Chil-
(Sapega, 2012). dren’s Memorial Hospital in Chicago launched
a mentor program that matched new nursing
Debriefing graduates with seasoned nurses to help them
cope with the stress and heartache of caring
Debriefing is a well-researched, core nursing for sick children and interacting with distressed
intervention used at critical points during parents and family members. This program
transition experiences. “Debriefing is defined significantly reduced the high turnover rate
as a process of communicating to others the among new nursing graduates that the hospital
experiences that a person or group encountered had been experiencing (Huff, 2006).
around a critical event” (Meleis, 2010, p. 457).
It is a tool used in nursing to help a person Applications of Transitions
come to terms with the transition experience Theory
and attain psychological well-being (Steele &
Beadle, 2003). Nurses ask their patients ques- Research
tions after birthing, traumatic events, disasters,
surgical procedures, during a new admissions Transitions theory has been used extensively
process, and at discharge. The patient may as a theoretical framework in research all
recount his or her story emotionally, relate to around the world to examine a broad spectrum
it cognitively, describe it, interpret its meaning, of transition experiences resulting from
reflect on it, or share feelings. The story usually health–illness, developmental, situational, and
includes the context, the before, the during, organizational transitions and the effect of
and the subsequent responses related to the ex- these transitions on the health of individuals,
perience. Nurses engage in dialogues with their families, and communities. It has been used to
patients about the events, ask questions, and develop strategies and interventions to facili-
provide patients and families with the oppor- tate healthy transitions and has served as a
tunity to process the events and the aftermath. conceptual basis and guide to
For example, a number of maternity units
provide postnatal debriefing services for new • understand and examine teenager’s concerns
as they transition through high school in the
United States (Rew, Tyler, & Hannah,
2012).

370 SECTION VI • Middle-Range Theories intervention using advanced practice nurses,
the transitional care model reflects the com-
• demonstrate in Taiwan that nurse-led transi- ponents of transition theory (Naylor, 2002).
tional care combining telehealth care and
discharge planning significantly alleviates Practice
family caregiver burden and stress and im-
proves family function (Chiang et al., 2012). Transitions theory has been applied in practice
by nurses to aid clients, families, and communities
• study the impact on self-care of people with in preparing for, navigating through, and adapt-
heart failure and develop strategies to imple- ing to transition experiences to enhance health
ment a therapeutic regimen in Portugal outcomes. The operationalization of transitions
(Mendes, Bastos, & Paiva, 2010). theory enhances nurses’ understanding of patient
and caregiver transitions and leads to the devel-
• explore in greater depth chronic obstructive opment of nursing therapeutics, interventions,
pulmonary disease (COPD) patients’ experi- and resources that are tailored to the unique
ences during and after pulmonary rehabilita- experiences of clients and their families in order
tion in Norway (Halding & Heggdal, 2011). to promote successful, healthy responses to tran-
sition. As mentioned earlier in this chapter, the
• analyze Finnish women’s hysterectomy expe- illness of patients can take a heavy toll on the
riences as a process of transition in their lives health of their caregivers due to the stress, role
and describe representations of hysterectomy transitions, disruption in relationships, and
in Finnish women’s and health magazines bereavement they may experience. Transitions
(Nykanen, Suominen, & Nikkonen, 2011). theory has been used as a conceptual framework
in practice to help health-care providers gain a
• assess the cultural factors that may contribute holistic understanding of the caregiver’s beliefs,
to the low diagnosis rate of postpartum views, unique experiences, and desired outcomes,
depression in Asian American (e.g., Asian which in turn enables nurses and health-care
Indian, Chinese, Filipina) mothers (Goyal, providers to allocate resources and implement
Wang, Shen, Wong, & Palaniappan, 2012). interventions targeted to the caregivers’ specific
needs to optimize the health of both the patient
These research studies demonstrate how and the caregiver (Blum & Sherman, 2010).
transitions theory has supported and aided It helps identify the barriers to, as well as facili-
nurse researchers and scholars to describe the tators of, the transition, unique to each individual
transition experiences and responses, confirm patient and caregiver, which in turn enhances
the components of the transition experience, the nurses’ or health-care providers’ ability to
and identify the essential properties of transi- effectively guide them through the transition
tion, including the critical points and events, experiences.
to ultimately reach the goal of promoting
healthy outcomes and easing transitions for The conceptual underpinnings of transi-
their clients, families, and communities. tions theory have also been used to analyze the
transitions that intensive care unit (ICU) pa-
• As indicated by Kralik, Visentin, and van tients and their families encounter after they are
Loon (2006) in their comprehensive litera- discharged from ICU and the provision of nurs-
ture review of transitions theory, future ing services needed for continuity of care. By
research to advance knowledge about digging deeper to fully comprehend the stress
transitions should include longitudinal patients and families experience when being
comparative and longitudinal cross discharged from ICU, including their potential
sectional designs. feelings of abandonment, unimportance, or am-
bivalence, nurses can better assist patients and
• In 2007, at the University of Pennsylvania, families in the ICU transfer process and ensure
we established the New Courtland Center on the provision of optimum health-care services
Transitions and Health. Transitions theory to continue care (Chaboyer, 2006).
provided the foundation for its theoretical
basis. Driven by Dr. Mary Naylor’s scholar-
ship, a current focus of the center is on the
transitional care model for the elderly popu-
lation. Although independently developed
on the East Coast of the United States as an

Transitions theory has also been used to CHAPTER 20 • Transitions Theory 371
understand and characterize the personal expe-
riences of perimenopausal and menopausal human diversity in health and illness among individ-
women. Findings from this research have been uals, families, and communities experiencing life tran-
translated into practice in the clinical setting. sitions. (Clayton State University, 2012)
Understanding women’s personal experiences
using transitions theory equips nurses to proac- At the University of California San Fran-
tively educate women on what to expect before cisco (UCSF), I taught a graduate course on
perimenopausal or menopausal symptoms begin, transitions and health to respond to an increas-
thus decreasing anxiety and confusion and in- ing educational demand of graduate students.
stead “normalizing the experience” (Marnocha, Additionally, many doctoral students in
Bergstrom & Dempsey, 2011). nursing and other disciplines around the
world, including Sweden and the United
Education States, have used transitions theory as a basis
for their doctoral dissertations.
Transitions theory is used in graduate and
undergraduate curricula in countries around Developing Situation-Specific Theories
the world. Universities that have integrated
transitions theory in their nursing education Transitions theory continues to be further
programs include the University of Connecticut developed, tested, and refined to understand
in Storrs and Clayton State University in Mor- and describe the relationships among the
row, Georgia. Clayton State University has used major beliefs, patterns, and concepts of diverse
transitions theory in its curriculum, and has groups of populations undergoing various
made it central to their nursing program’s phi- types of transition experiences. A number of
losophy. On its website, transitions theory is de- situation-specific theories have evolved from
fined, and it is emphasized that “[n]egotiating transitions theory. A situation-specific theory
successful transitions depends on the develop- is a coherent representation and depiction of a
ment of an effective relationship between the set of concepts and their interrelationships to
nurse and client. This relationship is a highly re- a set of outcomes related to health and illness
ciprocal process that affects both the client and experiences and responses, as well as to nursing
nurse” (Clayton State University, 2012). With actions to prevent the effects of illness or ame-
regard to the graduate curriculum in nursing liorate the effects of interventions (Meleis,
at the university, 2010). For example, a situation-specific the-
ory explaining the menopausal symptom
The culmination of graduate nursing education is the experiences of Asian immigrant women
synthesis of advanced skills in order to provide excel- within the sociocultural contexts in the United
lent nursing care and to foster ongoing professional States was grounded in transitions theory
development in order to promote nursing research, (Im, 2010). Others include Transitions and
ethical decision-making reflecting an appreciation of Health: A Framework for Gerontological Nursing
(Schumacher, Jones, & Meleis, 1999) and
Situation-Specific Theory of Pain Experience for
Asian American Cancer Patients (Im, 2008).

Practice Exemplar by Diane Lee Gullett, MSN, MPH

The following Practice Exemplar is framed with his eyes. Wayne presented with a chief com-
Afaf Meleis’ Transition Theory. plaint of insomnia, depression, nighttime
sweating, and a lack of energy for the past
I met Wayne when I was volunteering as 10 months. He informed me that the other
a nurse in a free clinic in New Orleans (N.O.) practitioners he visited had given him med-
in 2012. He was a 26-year-old young man ications for sleep and depression. He stated
who appeared gaunt with dark circles under

Continued

372 SECTION VI • Middle-Range Theories

Practice Exemplar by Diane Lee Gullett, MSN, MPH cont. you take what you think you need which you
later realize isn’t enough and isn’t what you
these had been unsuccessful in relieving his should have taken, but no one prepares you for
symptoms. I asked Wayne if any blood work that (Condition: Personal). I enrolled in classes
had been done. He suddenly became very at Louisiana State University in Baton Rouge
anxious, stood up and began pacing the 3 weeks after Katrina, since my old college
room, wringing his hands, looking at the wasn’t offering classes at that time. I lasted
floor, and refusing to make eye contact. He 5 minutes. I went through the whole process
started for the door and told me he didn’t and I just dropped out (Property: Milestone)
need to have any blood drawn and that this immediately after doing it because I just
was a mistake. I assured him that I would couldn’t wrap my mind around it.
not draw any blood without his consent and Nurse: Could you explain a bit more about
gently asked him if he would be willing to what you mean when you say you “couldn’t
stay and speak with me a bit further. wrap your mind around it.” (Clarifying
meaning)
Nurse: Can you remember when you first Wayne: I, it, was everything from my social
started noticing your symptoms? life, to what I was studying, to my financial
situation. I was on this path of what I was
Wayne: I guess it was in August or maybe going to do and when I came back, I just
September. couldn’t do it. I just, honestly, I just didn’t
care. It seemed like there were so many other
Nurse: Thinking back can you remember any more important things than worrying about
significant changes in your life at that time? my grades or what I was studying. I dropped
out of school with a 1.5 GPA and decided to
Wayne: You know, I have wracked my brain return to N.O. It was only about 3 months
thinking about that. The only thing I can after Katrina and too soon. My thought
think of is that this was about the time process, though, was just I need to get my life
Hurricane Katrina hit. back to normal, I need to get things to be the
way that they were. Even 7 years later, they
Nurse: Were you living in New Orleans (N.O.) are not. It is, you acknowledge on some level,
when Hurricane Katrina hit the city? that it is never going to be the way that it
was, but it’s like your driving force, this need
Wayne: Yeah, I was starting my freshman year to get your life back to normal (Property:
of college. Process). And then you get the new normal,
so it’s not what you had before, it’s not even
Nurse: Would you mind sharing some of your close. It’s not even, it's, I can’t even describe
experiences about that time in your life how different it is.
with me?
Change Triggers
(Intervention: Debriefing).
Hurricane Katrina serves as the situational
Wayne: I was a 19-year-old honors student change trigger for Wayne’s transitioning
(Condition: Personal). I had just moved to experience. The hurricane generated situa-
N.O. to major in international business tional changes including relocating to a new
10 days before the storm (Change trigger: city, enrolling at a new college, and living in a
Situational). The apartment community new community. The nature of Wayne’s tran-
where I lived was evacuated, so I was forced sitional experience; however, must also be con-
to leave the city and go to my stepfather’s house sidered within the context of other possible
in Arkansas (Property: Time span). I didn’t change triggers. Wayne is simultaneously
understand the severity of the situation at the
time, I mean I had never been through a hurri-
cane before (Condition: Personal). I thought it
would be an opportunity to get ahead with my
schoolwork and visit with my family. I didn’t
take much, two pairs of pants and some books. I
mean it never occurred to me that I would need
more than that. You know you have to leave, so

CHAPTER 20 • Transitions Theory 373

Practice Exemplar by Diane Lee Gullett, MSN, MPH cont. were before (Property: Disconnectedness).
Nurse: This must have been a very difficult
experiencing a developmental life phase
change moving from late adolescence to early time for you. How did you cope with all
adulthood manifested in his role transition these changes in your life? (Intervention:
from high school student to independent col- Questioning)
lege student. Limited worldly experience and Wayne: Things during the first year or two after
youth are personal conditions that inhibit I returned to the city are still a little hazy. I
Wayne’s ability to cope with the reality of the do remember totaling three cars within 2
changes triggered by Hurricane Katrina. His weeks after returning to N.O., you know I
inexperience is evident in his initial response don’t know where my head was (Property:
to Hurricane Katrina as a mini-vacation for Critical point). I haven’t been in an accident
which he took only a few articles of clothing, since. I haven’t even had a speeding ticket,
never thinking he wouldn’t be able to return but literally within this period I totaled three
to resume his college life or collect those cars. I can say speaking in honesty that you
things he held personally valuable. Wayne’s know for a long time after the storm that my
inability to effectively reconcile his previous way of dealing with my day to day life really
life with his new one inhibits a healthy out- was sex and drugs (Property: Critical point).
come response leading to his failure to main- What started with just every now and then
tain his GPA and eventually dropping out of became like weeks-long binges, and when you
school. The nurse recognizes Hurricane Kat- get involved with those things, it brings a
rina as the situational change trigger that con- completely new element into your life that
textually situates Wayne’s unique transition you probably wouldn’t have considered
experience and serves as the foundation for before. I mean, I will be the first to say I have
mutual meaning making between the nurse done things since the storm that I never
and Wayne. would have considered before. Such as
certain substances, sexually, bath houses. . . .
Nurse: Could you tell me a little bit more about (Property: Critical point). I think it was an
your feelings during that time and your ‘need escape; it was because when you are high,
to get your life back to normal’ (Clarifying when you are messed up, and you’re not
meaning). thinking about the things around you . . . you
are not thinking at all really, you are just you
Wayne: I came back with no plan other than know, you are getting away from all these
to try and resume my life, and without real- pressures that are on your mind (Property:
izing that all of the things that were in my Awareness).
life before might not be there after (Prop- Nurse: What did you feel like you needed to
erty: Disconnectedness). That is, even down escape from (Intervention: Clarifying
to grocery stores, you know for a long time meaning)?
you had to drive to the suburbs just to make Wayne: At the time, I had new financial strug-
groceries. Like, for example when my old gles that I hadn’t had before. Things like
apartment community reopened, I was work, some family problems, and the way
adamant that I wanted to move back. I had things were in the city. Everything was so
to move back into that same apartment, and different than it had been before Katrina
I did ultimately, but it wasn’t the same. It (Conditions: Personal and Community).
wasn’t physically the same because it had
been gutted and then it wasn’t the same Properties of Transition
because it wasn’t the same circumstances, it
wasn’t the same people. So I did not realize, Properties of transition (i.e., time span, process,
I just wanted to move back and continue my disconnectedness, awareness, and critical points)
life, I didn’t realize that the things that were
part of my life may not be there like they

Continued

374 SECTION VI • Middle-Range Theories

Practice Exemplar by Diane Lee Gullett, MSN, MPH cont. but they couldn’t at all understand what I
was going through (Property: Disconnected-
assist the nurse in describing change triggers, ness). There weren’t many people who stayed
specific milestones and ascertaining the differ- in the city and those who became my friends
ent phases of a person’s transition experience. ended up being the wrong crowd. I mean the
This knowledge assists the nurse in identifying city was a disaster there was a curfew, mili-
interventions and support mechanisms impor- tary presence, no garbage pickup for months,
tant in facilitating healthy transition experiences no grocery stores, and certainly no counseling
or recognizing those factors inhibiting healthy or places to go to for help (Condition: Com-
transitions. Wayne encounters the property of munity). It was as if those of us who stayed
time span when he first becomes aware of Hur- in the city were on our own. I think a lot of
ricane Katrina. The nurse recognizes Hurricane people were in bad shape. I remember hear-
Katrina as an external trigger of change which ing about a lot of people committing suicide.
in and of itself is static. Wayne’s process of tran- Nurse: Do you think you made the wrong deci-
sition, on the other hand, signifies a dynamic sion returning to N.O. so soon after Hurri-
internal change evident in his struggle to regain cane Katrina?
his old life, his inability to do so and his reluc- Wayne: Absolutely. You know, even now, if it
tance to accept the new normal. Disconnected- were going to happen again, I couldn’t, I
ness manifests in Wayne’s recognition of the would leave, I would leave my stuff, and I
disruption Hurricane Katrina brought to his fa- would not come back. It wasn’t the experience
miliar way of being in the world; from where itself, it was the after effect. And the way it
he shopped, where he lived, who his friends affected my life. . . . I can’t go back to trying
were, and who he understood himself to be. He to fit the pieces of my life back together or try-
sincerely yearns to return to the familiar only to ing to resume a sense of normalcy that will
find his environment (personal, community, never return because even though I know
and societal conditions) irrevocably changed. better now, while you intellectually know
The dynamic nature of awareness is reflected in better, emotionally you are still going to be
Wayne’s continual reinterpretation and willing- going through the processes (Process patterns:
ness to find meaning in his experiences follow- Engagement). There is nothing you can do
ing Katrina. His story is filled with a sense of about that, you can’t control that. . . . I just
movement from trying to return to normal to can’t do it. I am a pretty strong person, I al-
acknowledging the “new normal” and from par- ways have been, but that was one time in my
ticipating in risk-taking behaviors as coping life that I can sincerely say I had a mental
strategies to recognizing these as ineffective. and emotional breakdown. It was what it
The nurse recognizes many turning points or was, and I can’t do anything about that
milestones within Wayne’s transition experi- (Properties: Awareness).
ence starting with his dropping out of school,
crashing multiple cars, using drugs and alcohol, Conditions of Change
and engaging in unprotected sex. Without
appropriate interventions, all of these played a There are multiple personal, community, and
role in inhibiting a healthy transition experience societal conditions influencing Wayne’s pat-
for Wayne. terns of response to Hurricane Katrina and are
important for the nurse to recognize as part of
Nurse: Did you have anyone who was able to his transition process. Personal conditions are
support you or who you felt like you could go those, which center on an individual’s experi-
to for help during this time (Intervention: ence with the change trigger and other personal
Assessing support systems)? conditions that influence the well-being of the
individual within the broader framework of
Wayne: I wasn’t getting the support from my family and community. Wayne’s youth and lack
family because they couldn’t relate, they . . . I
suppose on some level they were like this sucks

CHAPTER 20 • Transitions Theory 375

Practice Exemplar by Diane Lee Gullett, MSN, MPH cont. of, and I know I am not alone in this, your
everyday mental process. Your life is sepa-
of experience with natural disasters are personal rated into before Katrina and after Katrina.
conditions that influenced Wayne’s responses And you refer to things like that, on a daily
to the situational change. Wayne naively re- basis your life before the storm and after the
turned to N.O. with the intent of getting his storm and you think about it every day. I
life back to normal only to be confronted with can’t imagine, I can’t imagine living some-
the reality of an irrevocably changed reality and where that you don’t think about that, I can’t
his place in it. Wayne also expresses feelings of imagine living somewhere where that is
isolation when discussing his belief that others not a part of your daily process, it’s not a
including his family could not relate to what he part of your shared experience (Patterns of
was going through. Wayne’s lack of knowledge response: Locating).
and skills, poor planning, and increased sense Nurse: After listening to your story, it seems
of marginalization reflect personal and commu- that the changes brought about by Hurricane
nity conditions that inhibited rather than facil- Katrina greatly affected your life. I think
itated a healthy transition experience. The some of the symptoms you described to me
limited level of existing community and social could be related to what you experienced
resources available within the city following during this very difficult time in your life.
Hurricane Katrina also inhibited Wayne’s tran- Speaking with others who have experienced
sition experience. Katrina created catastrophic similar circumstances may provide a way to
conditions within the city that left a nonexistent express what you have been through. I know
social, political, and economic infrastructure. of a local support group not far from here that
Employment, housing, medical care and men- has some members who were also in college at
tal health services were virtually nonexistent the time that Hurricane Katrina hit. Would
within the city. Wayne was not aware of the you be interested in attending one of these
fact that he needed help during this time and groups (Intervention: Mobilizing support)?
states the reality of limited access to even basic Wayne: I would like that. (Patterns of response:
services within the city. Community conditions Receiving support) I feel better just talking
including cultural and social norms were also with someone about all of this. Can I tell you
dramatically altered by the catastrophic condi- something and you won’t judge me (Patterns
tions that existed in the city. These conditions of response: Seeking support)?
for a young person such as Wayne may have Nurse: Of course. I want you to feel this is a
presented a loss of positive role-modeling es- safe environment and that I am not here to
sential to developing effective coping strategies judge you.
following such a traumatic experience. Wayne Wayne: You know when I told you about the
admits to engaging in homosexual behavior, bathhouses; well it happened a lot and with
unprotected sex, doing drugs, and hanging men. I didn’t use protection most of the time.
out with the wrong crowd. Societal conditions I am so ashamed and so scared.
stigmatizing homosexuality may have prohib- Nurse: Wayne, you do not need to be ashamed.
ited him from seeking support from his family A lot of young men and women experiment
or friends, further perpetuating his feelings of sexually throughout their lives, but it is
marginalization. important to practice safe sex. Can you tell
me more about what you are scared of specifi-
Nurse: Are you able to think about your future cally (Intervention: Clarifying meaning)?
at all, envision what you want to do moving Wayne: I am scared that I may have AIDS.
forward (Intervention: Visualizing different I took a home HIV test a couple of months
scenarios). ago, the kind that uses your saliva. It was

Wayne: One thing I can say moving forward, I
have, I really want to get out of N.O. It’s
that still even today, it is such a major part

Continued

376 SECTION VI • Middle-Range Theories

Practice Exemplar by Diane Lee Gullett, MSN, MPH cont. support group but not with anyone else.
Thank you so much for listening to me and
positive, but I have been too afraid to do for taking the time to help me.
anything about it or tell anyone. I know, I Nurse: You are welcome. Thank you for sharing
am stupid, right (Properties: Critical point)? your experience with me, for being brave
Nurse: No, I don’t think you are stupid. I think enough to talk about what you are going
you are rather brave for telling me and for through, for trusting me and allowing me
making the decision to talk about this to support you as you journey through this
(Intervention: providing expertise). process.
Wayne: I feel relieved but really scared, that is
the reason I was going to leave when you Patterns of Response
mentioned the blood test. I don’t know what
to do. It was my fault. I don’t even remember The nature of Wayne’s transition experience can
most of it. I wasn’t like this before Katrina, I be gleaned through his dialogue with the nurse.
don’t know what has happened to me since Process patterns are assessed at different points
then, I am a mess (Patterns of response: during the transition experience while outcome
Being situated). patterns are assessed at a point determined to
Nurse: I realize you are scared, but the first step be at the end of the transition process. Wayne’s
is setting up a time for you to get an HIV responses indicate he is still engaged in the
blood test, if you feel you are okay with that transition process despite the 7 years that had
(Intervention: Setting goals). I have the passed since Hurricane Katrina. He informs the
phone number of a local clinic, we can call nurse that he no longer hangs out with the
together and schedule an appointment for wrong crowd or participates in risky behaviors
you. There are counselors who will be there such as unprotected sex. Wayne’s willingness to
to support you through the process (Interven- stop engaging in risk-taking behaviors indicates
tion: Providing resources). You will not be a conscious choice to modify his behavior.
alone. Are you still engaging in unprotected Additionally, he opens up to the nurse about
sex with other partners or using drugs taking a home HIV test and decides to take a
that place you or someone else at risk HIV blood test, indicating an active search for
(Intervention: Providing expertise)? information by which to address his concerns.
Wayne: No, I haven’t done any of those things Both modifying his behavior and seeking out
in over a year. I stopped hanging out with information suggests Wayne is actively involved
that crowd and I don’t have any desire to go or engaged in the process of transition. The
back to doing any of those things (Patterns of nurse is aware that he is consistently comparing
response: Awareness). his actions using a before Katrina and after
Nurse: I believe it is important for you to explore Katrina perspective as a way to create new
your feelings and experiences before and after meaning from his experience or ‘locate’ himself.
Hurricane Katrina in a safe environment. I He is attempting to understand his new way of
think it would be helpful for you to meet with being in the world by comparing it to his old
a counselor in addition to attending a couple way of being in the world. These comparisons
of support groups. We can talk about your also provide Wayne with a way of “situating”
options and decide together how you would himself or a way to assist him with explaining
like to move forward, does that sound like a why he engaged in the high-risk behaviors. The
plan (Intervention: Mobilizing support and nurse inquires about Wayne’s family and
setting goals)? Are you close to anyone you feel friends to determine his support system. Wayne
would be supportive right now (Intervention: indicates that he does not have a close relation-
Assessing support systems)? ship with either his family or friends at this
Wayne: I don’t want anyone else to know about time. He seeks support from the nurse by
this for right now, if that is okay? I would expressing his concerns and fears about the
prefer to see a counselor and maybe go to a

CHAPTER 20 • Transitions Theory 377

Practice Exemplar by Diane Lee Gullett, MSN, MPH cont. including his new one as a potentially HIV-
positive patient; his at-risk ones, including
HIV testing. Additionally, he demonstrates a partaking in drugs, alcohol, and unprotected
willingness to receive support by agreeing to at- sex; and his old ones as college student offer
tend groups and see a counselor. Acquiring insight about his coping strategies and pat-
confidence is usually a progressive movement in terns of response. Milestones or critical points
the transition process marked by increasing are periods of heightened vulnerability in
confidence in dealing with the triggering event. which a person experiences difficulty with
This is accomplished by developing strategies self-care. Although Wayne’s story is rife with
for prioritizing needs and developing a sense of critical points, the one the nurse is most im-
wisdom generated through the lived experience. mediately concerned with is Wayne’s symp-
This can be seen in Wayne’s decision to make toms of depression and his anxiety over taking
an appointment to take an HIV blood test and an HIV blood test. Recognizing that Wayne
seek support. has a limited support system, the nurse’s in-
terventions to address his feelings of depres-
The nurse will assess for completion of the sion are aimed at identifying a counselor and
transition process when Wayne is able to encouraging participation in reference or sup-
demonstrate outcome responses including port groups. To address Wayne’s anxiety and
mastery, fluid and integrative identity, re- uncertainty over taking an HIV blood test the
sourcefulness, health interactions, and per- nurse provides supportive dialogue, expertise
ceived well-being. He may demonstrate about where to get tested, offers to schedule
mastery by integrating the skills he previously an appointment at a local clinic, discusses the
had in order to be an honors student in inter- process of taking the test, and identifies a
national business with the new skills he devel- counselor. Debriefing serves to provide con-
ops to positively cope with the changes text and meaning about Wayne’s experiences
brought about by Hurricane Katrina. A fluid with Hurricane Katrina as a traumatic change
and integrative identity may be assessed by trigger. The nurse uses clarifying questions
asking Wayne to describe his previous quality and authentic presence to encourage Wayne
of life compared with his current quality of to share his personal experiences, and in doing
life following intervention strategies. Wayne so, Wayne is able to find meaning in his
would demonstrate healthy interaction and experience.
thereby affirm the completion of his transition
process by developing and maintaining mean-
ingful and supportive relationships.

Intervention Framework Summary

The goal of interventions is to facilitate and Using authentic presence and awareness in this
inspire healthy process and outcome re- nursing situation created a space where Wayne
sponses. These interventions include clarifying and I could connect and develop a relationship
roles, meanings, and expertise; identifying grounded in trust and caring. This caring rela-
milestones; mobilizing support; and debrief- tionship provided an opportunity for Wayne to
ing. The nurse dialogues and interacts with share his experiences, fears, and anxieties with
Wayne to clarifying his statements as a way me. A caring-based philosophy of nursing
of determining the meaning he attributes to guided by Meleis’s transitions theory served as
Hurricane Katrina. This interaction also as- the lens through which I was able to recognize
sists the nurse in determining where in the Wayne’s symptoms as critical points or mile-
transition process Wayne is; for instance, the stones rather than medical diagnoses. I was also
nurse is able to determine that Wayne re- able to understand Hurricane Katrina as a
mains in the process of transitioning his major change trigger in Wayne’s life, which
experience. Identifying the process Wayne guided my nursing interventions. Without this,
uses to define and redefine his various roles Wayne could easily have left the clinic not

Continued

378 SECTION VI • Middle-Range Theories

Practice Exemplar by Diane Lee Gullett, MSN, MPH cont. drugs and alcohol, and dropping out of
school. These responses generated unhealthy
receiving the care he needed, resulting in de- outcomes manifested in Wayne’s current
layed testing for HIV, prolonged illness, and complaints of depression, insomnia, lethargy,
perhaps suicide. Through clarifying questions, and possibly HIV. Recognizing Wayne’s cur-
I was able to gain insight into the meaning rent symptoms as a critical point, I was able
of Wayne’s lived experience with Hurricane to develop appropriate nursing interventions.
Katrina and identify his current and past cop- These included debriefing, providing re-
ing strategies for adjusting to these changes. sources, and setting goals. Contemporary ap-
Not recognizing Katrina as a change trigger proaches to disaster remain, dominated by
may have led me to assume Wayne’s symptoms biomedical models of care grounded in objec-
were a result of other factors in his life. Wayne tive rather than subjective perspectives. This
has experienced multiple transitions in the approach may work in the short term when
7 years since Hurricane Katrina, resulting in the physical needs are paramount; however,
many unhealthy outcomes. His transition from when the needs of individuals transitioning a
living and attending school in N.O. to having disaster extend beyond the physical, biomed-
to do the same in Baton Rouge resulted in him ical approaches will fail to address their more
going from an honors student to a college holistic needs. Preventing unhealthy out-
dropout. His transition from living in N.O. comes such as those Wayne experienced will
before Katrina to living in N.O. after Katrina require a more holistic approach to nursing in
caused Wayne to have an emotional and men- disaster. Framing individual and collective re-
tal breakdown. Without appropriate interven- sponses to natural disaster using a nursing
tions or support, Wayne was unprepared theoretical lens such as Meleis’s transition
for the reality of the multiple changes in his theory serves as a foundation for generating
life following Hurricane Katrina. Wayne re- disciplinary specific knowledge and research
sponded with ineffective coping strategies on nursing in disaster.
identified as milestones or critical points and
included unprotected homosexual sex, using

■ Summary and evidence-based practice and better quality
care in the 21st century. It is for its potential,
Transitions theory continues to be used to ad- its utility, and for the research programs that
vance nursing knowledge about the experience have and could emanate from it that we have
and the responses of the many transitions that defined nursing as “facilitating transitions to
individuals, families, communities, and organ- enhance a sense of well-being” (Meleis &
izations encounter as well as the experiences, Trangenstein, 1994).
the responses, and the therapeutics that nurses
use, translating the theory to policy, research,

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