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Nursing Theory Application Brochure

Open Posted By: highheaven1 Date: 24/09/2020 Graduate Coursework Writing

      

     

     

Please use nursing theory from Madeleine M. Leininger: Care Theory of Diversity and Universality 

(I have attached my textbook, chapter 22) to create a brochure. APA format. 

Nursing Theory Application Brochure 

Please   select a nursing theory that has resonated with you. Design a brochure that nursing   administration could use to introduce this theory to their nursing staff,   faculty or patients within their nursing clinical unit, education or research   environment.

In a simple   and concise manner, describe the selected theory and how it could be useful   and relevant to your chosen nursing environment. Please pay close attention to ensure that   you attend to the following criteria:

1. Briefly describe the nursing environment that   you wish to support (1 pt)

2. Describe the nursing theory/model that you   plan to introduce (2 pts)

3. What are the strengths of that nursing   theory? Why is it useful and relevant to that particular nursing unit, educational or research   environment

4. Use the six QSEN Competencies to explain how your   chosen theory can be applied 

a. Patient-centered care

b. Teamwork and collaboration

c. Evidenced-based practice (EBP)

d. Quality Improvements (QI)

e. Safety

f. Informatics

5. Select any two concerns below 

Design a professional brochure that expresses   clearly how your chosen theory could be applied to improve quality of any two   of the following areas:

a. Patient care 

b. Nursing education

c. Nursing research 

d. Health disparities 

6. Creativity: clarity and conciseness of the   brochure 

Please provide a complete and concise   description of each of the areas being asked for. Vague write ups   will not be assigned points.


Category: Business & Management Subjects: Business Law Deadline: 12 Hours Budget: $120 - $180 Pages: 2-3 Pages (Short Assignment)

Attachment 1

AND THEIR WORK Nursing Theorists

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AND THEIR WORK Nursing Theorists

Martha Raile Alligood, PhD, RN, ANEF Professor Emeritus College of Nursing

East Carolina University Greenville, North Carolina

3251 Riverport Lane St. Louis, Missouri 63043

NURSING THEORISTS AND THEIR WORK, EIGHTH EDITION ISBN: 978-0-323-09194-7

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Copyright © 2010, 2006, 2002, 1998, 1994, 1989, 1986 by Mosby, Inc., an affiliate of Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher.

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such informa- tion or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Nursing theorists and their work / [edited by] Martha Raile Alligood. — Eighth edition. p. ; cm. Includes biographical references and index. ISBN 978-0-323-09194-7 9pbk. ; alk. Paper) I. Alligood, Martha Raile, editor of compilation. [DNLM: 1. Nursing Theory. 2. Models, Nursing. 3. Nurses—Biography. Philosophy, Nursing. WY 86] RT84.5 610.7301—dc23

2013023220

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Senior Content Strategist: Yvonne Alexopoulos Content Development Specialist: Danielle M. Frazier Publishing Services Manager: Deborah L. Vogel Project Manager: Pat Costigan Design Direction: Karen Pauls

Dedicated to the memory of my mother: Winifred Havener Raile, RN

1914-2012 Class of 1936,

Good Samaritan School of Nursing, Zanesville, Ohio

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vii

Contributors

Herdis Alvsvåg, RN, Cand Polit Associate Professor Department of Education and Health Promotion University of Bergen Bergen, Norway; Associate Professor II Bergen Deaconess University College Bergen, Norway

Donald E. Bailey, Jr., PhD, RN Associate Professor School of Nursing Duke University Durham, North Carolina

Barbara Banfield, RN, PhD Farmington Hills, Michigan

Violeta A. Berbiglia, EdD, MSN, RN Associate Professor, Retired The University of Texas Health Science Center

at San Antonio School of Nursing San Antonio, Texas

Debra A. Bournes, RN, PhD Director of Nursing New Knowledge and Innovation University Health Network Toronto, Canada

Nancy Brookes, PhD, RN, BC, MSc (A), CPMHN (C) Nurse Scholar and Adjunct Professor Royal Ottawa Health Care Group Royal Ottawa Mental Health Centre University of Ottawa Faculty of Health Sciences Ottawa, Ontario, Canada

Janet Witucki Brown, PhD, RN, CNE Associate Professor College of Nursing University of Tennessee Knoxville, Tennessee

Karen A. Brykczynski, PhD, RN, FNP-BC, FAANP, FAAN Professor School of Nursing at Galveston The University of Texas Medical Branch Galveston, Texas

Sherrilyn Coffman, PhD, RN Professor and Assistant Dean School of Nursing Nevada State College Henderson, Nevada

Doris Dickerson Coward, RN, PhD Associate Professor, Retired School of Nursing The University of Texas at Austin Austin, Texas

Thérèse Dowd, PhD, RN, HTCP Associate Professor Emeritus College of Nursing The University of Akron Akron, Ohio

Nellie S. Droes, DNSc, RN Associate Professor, Emerita College of Nursing East Carolina University Greenville, North Carolina

Contributorsviii

Margaret E. Erickson, PhD, RN, CNS, AHN-BC Executive Director American Holistic Nurses’ Certification Corporation Cedar Park, Texas

Mary E. Gunther, RN, MSN, PhD Associate Professor College of Nursing University of Tennessee Knoxville, Tennessee

Dana M. Hansen, RN, MSN, PhD Assistant Professor College of Nursing Kent State University Kent, Ohio

Sonya R. Hardin, PhD, RN, CCRN, NP-C Professor College of Nursing East Carolina University Greenville, North Carolina

Robin Harris, PhD, ANP-BC, ACNS-BC Nurse Practitioner Wellmont CVA Heart Institute Kingsport, Tennessee

Patricia A. Higgins, PhD, RN Assistant Professor Frances Payne Bolton School of Nursing Case Western Reserve University Cleveland, Ohio

Bonnie Holaday, DNS, RN, FAAN Professor and Director, Graduate Studies School of Nursing and Institute on Family and

Neighborhood Life Clemson University Clemson, South Carolina

Eun-Ok Im, PhD, MPH, RN, CNS, FAAN Professor and Marjorie O. Rendell Endowed

Professor School of Nursing The University of Pennsylvania Philadelphia, Pennsylvania

D. Elizabeth Jesse, PhD, RN, CNM Associate Professor College of Nursing East Carolina University Greenville, North Carolina

Lisa Kitko, PhD, RN, CCRN Assistant Professor School of Nursing The Pennsylvania State University University Park, Pennsylvania

Theresa Gunter Lawson, PhD, APRN, FNP-BC Assistant Professor Department of Nursing Lander University Greenwood, South Carolina

Unni Å. Lindström, PhD, RN Professor Department of Caring Science Faculty of Social and Caring Sciences Åbo Academy University Vasa, Finland

M. Katherine Maeve, PhD, RN Nurse Researcher Charlie Norwood VAMC Augusta, Georgia

Marilyn R. McFarland, PhD, RN, FNP, BC, CTN Associate Professor of Nursing and Family Nurse

Practitioner Urban Health and Wellness Center University of Michigan Flint, Michigan

Gwen McGhan, PhD(c), RN Jonas/Hartford Doctoral Scholar School of Nursing The Pennsylvania State University University Park, Pennsylvania

Molly Meighan, RNC, PhD Professor Emerita Division of Nursing Carson-Newman College Jefferson City, Tennessee

Contributors ix

Patricia R. Messmer, PhD, RN-BC, FAAN Director Patient Care Services Research Children’s Mercy Hospital and Clinics Kansas City, Missouri

Gail J. Mitchell, PhD, RN, MScN, BScN Professor School of Nursing Chair/Director York-UHN Nursing Academy York University Toronto, Ontario, Canada

Lisbet Lindholm Nyström, PhD, RN Associate Professor Department of Caring Science Faculty of Social and Caring Sciences Åbo Academy University Vasa, Finland

Janice Penrod, PhD, RN, FGSA, FAAN Director, Center for Nursing Research Associate Professor School of Nursing The Pennsylvania State University University Park, Pennsylvania

Susan A. Pfettscher, DNSc, RN Retired Bakersfield, California

Kenneth D. Phillips, PhD, RN Professor and Associate Dean for Research and

Evaluation College of Nursing The University of Tennessee Knoxville, Tennessee

Marie E. Pokorny, PhD, RN Director of the PhD Program College of Nursing East Carolina University Greenville, North Carolina

Marguerite J. Purnell, PhD, RN, AHN-BC Assistant Professor Christine E. Lynn College of Nursing Florida Atlantic University Boca Raton, Florida

Teresa J. Sakraida, PhD, RN Assistant Professor College of Nursing University of Colorado, Denver Aurora, Colorado

Karen Moore Schaefer, PhD, RN Associate Chair and Associate Professor, Retired Department of Nursing College of Health Professions Temple University Philadelphia, Pennsylvania

Ann M. Schreier, PhD, RN Associate Professor College of Nursing East Carolina University Greenville, North Carolina

Carrie J. Scotto, PhD, RN Associate Professor College of Nursing University of Akron Akron, Ohio

Christina L. Sieloff, PhD, RN, NE, BC Associate Professor College of Nursing Montana State University Billings, Montana

Janet L. Stewart, PhD, RN Assistant Professor Department of Health Promotion and Development School of Nursing University of Pittsburgh Pittsburgh, Pennsylvania

Contributorsx

Danuta M. Wojnar, PhD, RN, MEd, IBCLC Assistant Professor College of Nursing Seattle University Seattle, Washington

Joan E. Zetterlund, PhD, RN Professor Emerita of Nursing School of Nursing North Park University Chicago, Illinois

xi

Jean Logan, RN, PhD Professor Grand View University Des Moines, Iowa

Karen Pennington, PhD, RN Associate Professor Regis University Denver, Colorado

Reviewers

Nancy Stahl, RN, MSN, CNE Associate Professor BSN Coordinator University of North Georgia Dahlonega, Georgia

xii

About the Editor

Martha Raile Alligood is professor emeritus at East Carolina University College of Nursing in Greenville, North Carolina, where she was Director of the Nursing PhD program. A graduate of Good Samaritan School of Nursing, she also holds a bachelor of sacred literature (BSL) from Johnson University, a BSN from University of Virginia, an MS from The Ohio State University, and a PhD from New York University.

Her career in nursing education began in Zimbabwe (formerly Rhodesia) in Africa and has included graduate appointments at the University of Florida, University of South Carolina, and University of Tennessee. Among her professional memberships are Epsilon and Beta Nu Chapters of Sigma Theta Tau International (STTI), Southern Nursing Research Society (SNRS), North Carolina Nurses Association/American Nurses Association (NCNA/ANA), and Society of Rogerian Scholars (SRS).

A recipient of numerous awards and honors, she is a Fellow of the National League for Nursing (NLN) Acad- emy of Nursing Education, received the SNRS Leadership in Research Award, and was honored with the East Carolina University Chancellors’s Women of Distinction Award. A member of the Board of Trustees at Johnson University, Dr. Alligood chairs the Academic Affairs Committee.

She served as contributing editor for the Theoretical Concerns column in Nursing Science Quarterly, Vol. 24, 2011, and is author/editor of Nursing Theory: Utilization & Application, fifth edition, as well as this eighth edition of Nursing Theorists and Their Work.

xiii

This book is a tribute to nursing theorists and a classic in theoretical nursing literature. It presents many major thinkers in nursing, reviews their important knowledge-building ideas, lists their publications, and points the reader to those using the works and writing about them in their own theoretical publications. Unit I introduces the text with a brief history of nursing knowledge development and its significance to the

discipline and practice of the profession in Chapter 1. Other chapters in Unit I discuss the history, philosophy of science and the framework for analysis used throughout the text, logical reasoning and theory development processes, and the structure of knowledge and types of knowledge within that structure. Ten works from earlier editions of Nursing Theorists and Their Work are introduced and discussed briefly as nursing theorists of historical significance in Chapter 5. They are Peplau; Henderson; Abdellah; Wiedenbach; Hall; Travelbee; Barnard; Adam; Roper, Logan, Tierney, and Orlando.

In Unit II, the philosophies of Nightingale, Watson, Ray, Benner, Martinsen, and Eriksson are presented. Unit III includes nursing models by Levine, Rogers, Orem, King, Neuman, Roy, and Johnson. The work of Boykin and Schoenhofer begins Unit IV on nursing theory, followed by the works of Meleis; Pender; Leininger; Newman; Parse; Erickson, Tomlin, and Swain; and the Husteds. Unit V presents middle range theoretical works of Mercer; Mishel; Reed; Wiener and Dodd; Eakes, Burke, and Hainsworth; Barker; Kolcaba; Beck; Swanson; Ruland and Moore. Unit VI addresses the state of the art and science of nursing theory from three perspectives: the philosophy of nursing science, the expansion of theory development, and the global nature and expanding use of nursing theoretical works.

The works of nurse theorists from around the world are featured in this text, including works by international theorists that have been translated into English. Nursing Theorists and Their Work has also been translated into numerous languages for nursing faculty and students in other parts of the world as well as nurses in practice.

Nurses and students at all stages of their education are interested in learning about nursing theory and the use of nurse theorist works from around the world. Those who are just beginning their nursing education, such as associate degree and baccalaureate students, will be interested in the concepts, definitions, and theoreti- cal assertions. Graduate students, at the masters and doctoral levels, will be more interested in the logical form, acceptance by the nursing community, the theoretical sources for theory development, and the use of empirical data. The references and extensive bibliographies are particularly useful to graduate students for locating primary and secondary sources that augment the websites specific to the theorist. The following comprehensive websites are excellent resources with information about theory resources and links to the individual theorists featured in this book:

• Nursing Theory link page, Clayton College and State University, Department of Nursing: http: //www. healthsci.clayton.edu/eichelberger/nursing.htm

• Nursing Theory page, Hahn School of Nursing and Health Science, University of San Diego: http: //www. sandiego.edu/academics/nursing/theory/

• A comprehensive collection of nursing theory media, The Nurse Theorists: Portraits of Excellence, Vol. I and Vol. II and Nurse Theorists: Excellence in Action: http: //www.fitne.net/

The works of the theorists presented in this text have stimulated phenomenal growth in nursing literature and enriched the professional lives of nurses around the world by guiding nursing research, education, administra- tion, and practice. The professional growth continues to multiply as we analyze and synthesize these works,

Preface

Prefacexiv

generate new ideas, and develop new theory and applications for education in the discipline and quality care in practice by nurses.

The work of each theorist is presented with a framework using the following headings to facilitate uniformity and comparison among the theorists and their works:

• Credentials and background • Theoretical sources for theory development • Use of empirical data • Major concepts and definitions • Major assumptions • Theoretical assertions • Logical form • Acceptance by the nursing community • Further development • Critique of the work • Summary • Case study based on the work • Critical thinking activities • Points for further study • References and bibliographies

Acknowledgments I am very thankful to the theorists who critiqued the original and many subsequent chapters about themselves to keep the content current and accurate. The work of Paterson and Zderad was omitted at their request.

I am very grateful to those who have contributed or worked behind the scenes with previous editions to develop this text over the years. In the third edition, Martha Raile Alligood joined Ann Marriner Tomey, to reorder the chapters, serve as a contributing author, and edit for consistency with the new organization of the text. Subsequently Dr. Tomey recommended Dr. Alligood to Mosby-Elsevier to design and coedit a practice focused text, Nursing Theory: Utilization and Application and based on Alligood’s expertise in nursing theory, invited her to become coeditor and contributing author to future editions of this text, Nursing Theorists and Their Work. I want to recognize and thank Ann Marriner Tomey for her vision to develop the first six editions of this book. Her mentorship, wisdom, and collegial friendship have been special to me in my professional career. Most of all, she is to be commended for her dedication to this text that continues to make an important and valuable contribution to the discipline and the profession of nursing. I wish Ann well in her retirement.

Finally, I would like to thank the publishers at Mosby-Elsevier for their guidance and assistance through the years to bring this text to this eighth edition. The external reviews requested by Mosby-Elsevier editors have contributed to the successful development of each new edition. The chapter authors who over the years have contributed their expert knowledge of the theorists and their work continue to make a most valuable contribution.

Martha Raile Alligood

xv

UNIT I Evolution of Nursing Theories 1 Introduction to Nursing Theory: Its History, Significance, and Analysis, 2 Martha Raile Alligood

2 History and Philosophy of Science, 14 Sonya R. Hardin

3 Theory Development Process, 23 Sonya R. Hardin

4 The Structure of Specialized Nursing Knowledge, 38 Martha Raile Alligood

5 Nursing Theorists of Historical Significance, 42 Marie E. Pokorny

Hildegard E. Peplau Virginia Henderson Faye Glenn Abdellah Ernestine Wiedenbach Lydia Hall Joyce Travelbee Kathryn E. Barnard Evelyn Adam Nancy Roper, Winifred W. Logan, and Alison J. Tierney Ida Jean (Orlando) Pelletier

UNIT II Nursing Philosophies 6 Florence Nightingale: Modern Nursing, 60 Susan A. Pfettscher

7 Jean Watson: Watson’s Philosophy and Theory of Transpersonal Caring, 79 D. Elizabeth Jesse and Martha R. Alligood

8 Marilyn Anne Ray: Theory of Bureaucratic Caring, 98 Sherrilyn Coffman

9 Patricia Benner: Caring, Clinical Wisdom, and Ethics in Nursing Practice, 120 Karen A. Brykczynski

10 Kari Martinsen: Philosophy of Caring, 147 Herdis Alvsvåg

11 Katie Eriksson: Theory of Caritative Caring, 171 Unni Å. Lindström, Lisbet Lindholm Nyström, and Joan E. Zetterlund

Contents

Contentsxvi

UNIT III Nursing Conceptual Models 12 Myra Estrin Levine: The Conservation Model, 204 Karen Moore Schaefer

13 Martha E. Rogers: Unitary Human Beings, 220 Mary E. Gunther

14 Dorothea E. Orem: Self-Care Deficit Theory of Nursing, 240 Violeta A. Berbiglia and Barbara Banfield

15 Imogene M. King: Conceptual System and Middle-Range Theory of Goal Attainment, 258 Christina L. Sieloff and Patricia R. Messmer

16 Betty Neuman: Systems Model, 281 Theresa G. Lawson

17 Sister Callista Roy: Adaptation Model, 303 Kenneth D. Phillips and Robin Harris

18 Dorothy E. Johnson: Behavioral System Model, 332 Bonnie Holaday

UNIT IV Nursing Theories 19 Anne Boykin and Savina O. Schoenhofer: The Theory of Nursing as Caring: A Model for

Transforming Practice, 358 Marguerite J. Purnell

20 Afaf Ibrahim Meleis: Transitions Theory, 378 Eun-Ok Im

21 Nola J. Pender: Health Promotion Model, 396 Teresa J. Sakraida

22 Madeleine M. Leininger: Culture Care Theory of Diversity and Universality, 417 Marilyn R. McFarland

23 Margaret A. Newman: Health as Expanding Consciousness, 442 Janet Witucki Brown and Martha Raile Alligood

24 Rosemarie Rizzo Parse: Humanbecoming, 464 Debra A. Bournes and Gail J. Mitchell

25 Helen C. Erickson, Evelyn M. Tomlin, Mary Ann P. Swain: Modeling and Role-Modeling, 496

Margaret E. Erickson

26 Gladys L. Husted and James H. Husted: Symphonological Bioethical Theory, 520 Carrie Scotto

UNIT V Middle Range Nursing Theories 27 Ramona T. Mercer: Maternal Role Attainment—Becoming a Mother, 538 Molly Meighan

28 Merle H. Mishel: Uncertainty in Illness Theory, 555 Donald E. Bailey, Jr. and Janet L. Stewart

Contents xvii

29 Pamela G. Reed: Self-Transcendence Theory, 574 Doris D. Coward

30 Carolyn L. Wiener and Marylin J. Dodd: Theory of Illness Trajectory, 593 Janice Penrod, Lisa Kitko, and Gwen McGhan

31 Georgene Gaskill Eakes, Mary Lermann Burke, and Margaret A. Hainsworth: Theory of Chronic Sorrow, 609

Ann M. Schreier and Nellie S. Droes

32 Phil Barker: The Tidal Model of Mental Health Recovery, 626 Nancy Brookes

33 Katharine Kolcaba: Theory of Comfort, 657 Thérèse Dowd

34 Cheryl Tatano Beck: Postpartum Depression Theory, 672 M. Katherine Maeve

35 Kristen M. Swanson: Theory of Caring, 688 Danuta M. Wojnar

36 Cornelia M. Ruland and Shirley M. Moore: Peaceful End-of-Life Theory, 701 Patricia A. Higgins and Dana M. Hansen

UNIT VI The Future of Nursing Theory 37 State of the Art and Science of Nursing Theory, 712 Martha Raile Alligood

Index, 721

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n Searching for specialized nursing knowledge led nurse scholars to theories that guide research, education, administration, and professional practice.

n Nursing followed a path from concepts to conceptual frameworks to models to theories, and finally to middle range theory, in this theory utilization era.

n Nursing history demonstrates the significance of theory for nursing as a division of education (the discipline) and a specialized field of practice (the profession).

n Knowledge of the theory development process is basic to a personal understanding of the theoretical works of the discipline.

n Analysis facilitates learning through systematic review and critical reflection of the theoretical works of the discipline.

n Theory analysis begins the process of identifying a decision making framework for nursing research or nursing practice.

Evolution of Nursing Theories

UNIT I

2

“The systematic accumulation of knowledge is essential to progress in any profession . . . however theory and practice must be constantly interactive.

Theory without practice is empty and practice without theory is blind.” (Cross, 1981, p. 110).

Introduction to Nursing Theory: Its History, Significance, and Analysis

Martha Raile Alligood

CH A P T ER 1

Bixler, 1959; Chinn & Kramer, 2011; George, 2011; Im & Chang, 2012; Judd, Sitzman & Davis, 2010; Meleis, 2007; Shaw, 1993).

This text is designed to introduce the reader to nursing theorists and their work. Nursing theory became a major theme in the last century, and it con- tinues today to stimulate phenomenal professional growth and expansion of nursing literature and edu- cation. Selected nursing theorists are presented in this text to expose students at all levels of nursing to a broad range of nurse theorists and various types of theoretical works. Nurses of early eras delivered excellent care to patients; however, much of what was known about nursing was passed on through forms of education that were focused on skills and functional tasks. Whereas many nursing practices seemed effective, they were not tested nor used uni- formly in practice or education. Therefore, a major goal put forth by nursing leaders in the twentieth century was the development of nursing knowledge on which to base nursing practice, improve quality of care, and gain recognition of nursing as a profession. The history of nursing clearly documents sustained efforts toward the goal of developing a specialized body of nursing knowledge to guide nursing practice (Alligood, 2010a; Alligood & Tomey, 1997; Bixler &

Previous authors: Martha Raile Alligood, Elizabeth Chong Choi, Juanita Fogel Keck, and Ann Marriner Tomey.

This chapter introduces nursing theory from three different perspectives: history, significance, and anal- ysis. Each perspective contributes understanding of the contributions of the nursing theorists and their work. A brief history of nursing development from vocational to professional describes the search for nursing substance that led to this exciting time in nursing history as linkages were strengthened be- tween nursing as an academic discipline and as pro- fessional practice. The history of this development provides context and a perspective to understand the continuing significance of nursing theory for the dis- cipline and profession of nursing. The history and significance of nursing theory leads logically into analysis, the third section of the chapter and final perspective. Analysis of nursing theoretical works and its role in knowledge development is presented as an essential process of critical reflection. Criteria for analysis of the works of theorists are presented, along with a brief discussion of how each criterion

CHAPTER 1 Introduction to Nursing Theory: Its History, Significance, and Analysis 3

and individual hospital procedure manuals (Alligood, 2010a; Kalisch & Kalisch, 2003). Although some nurs- ing leaders aspired for nursing to be recognized as a profession and become an academic discipline, nursing practice continued to reflect its vocational heritage more than a professional vision. The transition from vocation to profession included successive eras of his- tory as nurses began to develop a body of specialized knowledge on which to base nursing practice. Nurs- ing had begun with a strong emphasis on practice, and nurses worked throughout the century toward the development of nursing as a profession. Progress toward the goal of developing a specialized basis for nursing practice has been viewed from the perspec- tive of historical eras recognizing the thrust toward professional development within each era (Alligood, 2010a; Alligood & Tomey, 1997).

The curriculum era addressed the question of what content nurses should study to learn how to be a nurse. During this era, the emphasis was on what courses nursing students should take, with the goal of arriving at a standardized curriculum (Alligood, 2010a). By the mid-1930s, a standardized curriculum had been published and adopted by many diploma programs. However, the idea of moving nursing edu- cation from hospital-based diploma programs into colleges and universities also emerged during this era (Judd, Sitzman & Davis, 2010). In spite of this early idea for nursing education, it was the middle of the century before many states acted upon this goal, and during the second half of the twentieth century, diploma programs began closing and significant numbers of nursing education programs opened in colleges and universities (Judd, Sitzman, & Davis, 2010; Kalisch & Kalisch, 2003). The curriculum era emphasized course selection and content for nursing programs and gave way to the research era, which focused on the research process and the long-range goal of acquiring substantive knowledge to guide nursing practice.

As nurses increasingly sought degrees in higher education, the research emphasis era began to emerge. This era began during the mid-century as more nurse leaders embraced higher education and arrived at a common understanding of the scientific age—that research was the path to new nursing knowledge. Nurses began to participate in research, and research courses were included in the nursing curricula of early

contributes to a deeper understanding of the work (Chinn & Kramer, 2011).

History of Nursing Theory The history of professional nursing began with Flor- ence Nightingale. Nightingale envisioned nurses as a body of educated women at a time when women were neither educated nor employed in public service. Following her wartime service of organizing and car- ing for the wounded in Scutari during the Crimean War, Nightingale’s vision and establishment of a School of Nursing at St. Thomas’ Hospital in London marked the birth of modern nursing. Nightingale’s pioneering activities in nursing practice and education and her subsequent writings became a guide for establishing nursing schools and hospitals in the United States at the beginning of the twentieth century (Kalisch & Kalisch, 2003; Nightingale, 1859/1969).

Nightingale’s (1859/1969) vision of nursing has been practiced for more than a century, and theory development in nursing has evolved rapidly over the past 6 decades, leading to the recognition of nursing as an academic discipline with a specialized body of knowledge (Alligood, 2010a, 2010b; Alligood & Tomey, 2010; Bixler & Bixler, 1959; Chinn & Kramer, 2011; Fawcett, 2005; Im & Chang, 2012; Walker & Avant, 2011). It was during the mid-1800s that Night- ingale recognized the unique focus of nursing and declared nursing knowledge as distinct from medical knowledge. She described a nurse’s proper function as putting the patient in the best condition for nature (God) to act upon him or her. She set forth the follow- ing: that care of the sick is based on knowledge of persons and their surroundings—a different knowl- edge base than that used by physicians in their prac- tice (Nightingale, 1859/1969). Despite this early edict from Nightingale in the 1850s, it was 100 years later, during the 1950s, before the nursing profession began to engage in serious discussion of the need to develop nursing knowledge apart from medical knowledge to guide nursing practice. This beginning led to aware- ness of the need to develop nursing theory (Alligood, 2010a; Alligood, 2004; Chinn & Kramer, 2011; Meleis, 2007; Walker & Avant, 2011). Until the emergence of nursing as a science in the 1950s, nursing practice was based on principles and traditions that were handed down through an apprenticeship model of education

UNIT I Evolution of Nursing Theories4

developing graduate nursing programs (Alligood, 2010a). In the mid-1970s, an evaluation of the first 25 years of the journal Nursing Research revealed that nursing studies lacked conceptual connections and theoretical frameworks, accentuating the need for conceptual and theoretical frameworks for develop- ment of specialized nursing knowledge (Batey, 1977). Awareness of the need for concept and theory devel- opment coincided with two other significant mile- stones in the evolution of nursing theory. The first milestone is the standardization of curricula for nurs- ing master’s education by the National League for Nursing accreditation criteria for baccalaureate and higher-degree programs, and the second is the deci- sion that doctoral education for nurses should be in nursing (Alligood, 2010a).

The research era and the graduate education era developed in tandem. Master’s degree programs in nursing emerged across the country to meet the pub- lic need for nurses for specialized clinical nursing practice. Many of these graduate programs included a course that introduced the student to the research process. Also during this era, nursing master’s pro- grams began to include courses in concept develop- ment and nursing models, introducing students to early nursing theorists and knowledge development processes (Alligood, 2010a). Development of nursing knowledge was a major force during this period. The baccalaureate degree began to gain wider acceptance as the first educational level for professional nursing, and nursing attained nationwide recognition and acceptance as an academic discipline in higher edu- cation. Nurse researchers worked to develop and clarify a specialized body of nursing knowledge, with the goals of improving the quality of patient care, providing a professional style of practice, and achiev- ing recognition as a profession. There were debates and discussions in the 1960s regarding the proper direction and appropriate discipline for nursing knowledge development. In the 1970s, nursing con- tinued to make the transition from vocation to pro- fession as nurse leaders debated whether nursing should be other-discipline based or nursing based. History records the outcome, that nursing practice is to be based on nursing science (Alligood, 2010a; Fawcett, 1978; Nicoll, 1986). It is as Meleis (2007) noted, “theory is not a luxury in the discipline of nursing . . . but an integral part of the nursing lexicon

in education, administration, and practice” (p. 4). An important precursor to the theory era was the gen- eral acceptance of nursing as a profession and an academic discipline in its own right.

The theory era was a natural outgrowth of the re- search and graduate education eras (Alligood, 2010a; Im & Chang, 2012). The explosive proliferation of nursing doctoral programs from the 1970s and nursing theory literature substantiated that nursing doctorates should be in nursing (Nicoll, 1986, 1992, 1997; Reed, Shearer, & Nicoll, 2003; Reed & Shearer, 2009; 2012). As understanding of research and knowledge development increased, it became obvi- ous that research without conceptual and theoretical frameworks produced isolated information. Rather, there was an understanding that research and theory together were required to produce nursing science (Batey, 1977; Fawcett, 1978; Hardy, 1978). Doctoral education in nursing began to flourish with the introduction of new programs and a strong emphasis on theory development and testing. The theory era accelerated as works began to be recognized as theory, having been developed as frameworks for curricula and advanced practice guides. In fact, it was at the Nurse Educator Conference in New York City in 1978 that theorists were recognized as nurs- ing theorists and their works as nursing conceptual models and theories (Fawcett, 1984; Fitzpatrick & Whall, 1983).

The 1980s was a period of major developments in nursing theory that has been characterized as a tran- sition from the pre-paradigm to the paradigm period (Fawcett, 1984; Hardy, 1978; Kuhn, 1970). The pre- vailing nursing paradigms (models) provided per- spectives for nursing practice, administration, educa- tion, research, and further theory development. In the 1980s, Fawcett’s seminal proposal of four global nursing concepts as a nursing metaparadigm served as an organizing structure for existing nursing frame- works and introduced a way of organizing individual theoretical works in a meaningful structure (Fawcett, 1978, 1984, 1993; Fitzpatrick & Whall, 1983). Clas- sifying the nursing models as paradigms within a metaparadigm of the person, environment, health, and nursing concepts systematically united the nurs- ing theoretical works for the discipline. This system clarified and improved comprehension of knowledge development by positioning the theorists’ works in a

CHAPTER 1 Introduction to Nursing Theory: Its History, Significance, and Analysis 5

larger context, thus facilitating the growth of nursing science (Fawcett, 2005). The body of nursing science and research, education, administration, and prac- tice continues to expand through nursing scholar- ship. In the last decades of the century, emphasis shifted from learning about the theorists to utiliza- tion of the theoretical works to generate research questions, guide practice, and organize curricula. Evidence of this growth of theoretical works has pro- liferated in podium presentations at national and international conferences, newsletters, journals, and books written by nurse scientists who are members of societies as communities of scholars for nursing models and theories. Members contribute to the gen- eral nursing literature and communicate their re- search and practice with a certain paradigm model or framework at conferences of the societies where they present their scholarship and move the science of the selected paradigm forward (Alligood, 2004; Alligood 2014, in press; Fawcett & Garity, 2009; Im & Chang, 2012; Parker, 2006).

These observations of nursing theory develop- ment bring Kuhn’s (1970) description of normal science to life. His philosophy of science clarifies our understanding of the evolution of nursing theory through paradigm science. It is important histori- cally to understand that what we view collectively today as nursing models and theories is the work of individuals in various areas of the country who pub- lished their ideas and conceptualizations of nursing. These works later were viewed collectively within a systematic structure of knowledge according to analysis and evaluation (Fawcett, 1984, 1993, 2005). Theory development emerged as a process and prod- uct of professional scholarship and growth among nurse leaders, administrators, educators, and practi- tioners who sought higher education. These leaders recognized limitations of theory from other disci- plines to describe, explain, or predict nursing out- comes, and they labored to establish a scientific basis for nursing management, curricula, practice, and research. The development and use of theory con- veyed meaning for nursing processes, resulting in what is recognized today as the nursing theory era (Alligood, 2010a; Alligood 2010b; Nicoll, 1986, 1992, 1997; Reed, Shearer, & Nicoll, 2003; Reed & Shearer, 2012; Wood, 2010). It was as Fitzpatrick and Whall (1983) had said, “. . . nursing is on the brink of an

exciting new era” (p. 2). This awareness ushered in the theory utilization era.

The accomplishments of normal science accompa- nied the theory utilization era as emphasis shifted to theory application in nursing practice, education, administration, and research (Alligood, 2010c; Wood, 2010). In this era, middle-range theory and valuing of a nursing framework for thought and action of nursing practice was realized. This shift to the appli- cation of nursing theory was extremely important for theory-based nursing, evidence-based practice, and future theory development (Alligood, 2011a; Alligood, 2014, in press; Alligood & Tomey, 2010; Alligood & Tomey, 1997, 2002, 2006; Chinn & Kramer, 2011; Fawcett, 2005; Fawcett & Garity, 2009).

The theory utilization era has restored a balance between research and practice for knowledge devel- opment in the discipline of nursing. The reader is referred to the fifth edition of Nursing Theory: Utili- zation & Application (Alligood, 2014, in press) for case applications and evidence of outcomes from utilization of nursing theoretical works in practice. Table 1-1 presents a summary of the eras of nursing’s search for specialized nursing knowledge. Each era addressed nursing knowledge in a unique way that contributed to the history. Within each era, the per- vading question “What is the nature of the knowl- edge that is needed for the practice of nursing?” was addressed at a level of understanding that prevailed at the time (Alligood, 2010a).

This brief history provides some background and context for your study of nursing theorists and their work. The theory utilization era continues today, emphasizing the development and use of nursing theory and producing evidence for professional practice. New theory and new methodologies from qualitative research approaches continue to expand ways of knowing among nurse scientists. The utili- zation of nursing models, theories, and middle- range theories for the thought and action of nursing practice contributes important evidence for quality care in all areas of practice in the twenty-first century (Alligood, 2010b; Fawcett, 2005; Fawcett & Garity, 2009; Peterson, 2008; Smith & Leihr, 2008; Wood, 2010). Preparation for practice in the pro- fession of nursing today requires knowledge of and use of the theoretical works of the discipline (Alligood, 2010c).

UNIT I Evolution of Nursing Theories6

Significance of Nursing Theory At the beginning of the twentieth century, nursing was not recognized as an academic discipline or a profession. The accomplishments of the past century led to the recognition of nursing in both areas. The terms discipline and profession are interrelated, and some may even use them interchangeably; however they are not the same. It is important to note their differences and specific meaning, as noted in Box 1-1:

The achievements of the profession over the past century were highly relevant to nursing science devel- opment, but they did not come easily. History shows that many nurses pioneered the various causes and challenged the status quo with creative ideas for both the health of people and the development of nursing. Their achievements ushered in this exciting time when nursing became recognized as both an aca- demic discipline and a profession (Fitzpatrick, 1983; Kalisch & Kalisch, 2003; Meleis, 2007; Shaw, 1993). This section addresses the significance of theoretical works for the discipline and the profession of nursing. Nursing theoretical works represent the most com- prehensive presentation of systematic nursing knowl- edge; therefore, nursing theoretical works are vital to the future of both the discipline and the profession of nursing.

Significance for the Discipline Nurses entered baccalaureate and higher-degree programs in universities during the last half of the twentieth century, and the goal of developing knowl- edge as a basis for nursing practice began to be real- ized. University baccalaureate programs proliferated, master’s programs in nursing were developed, and

TABLE 1-1 Historical Eras of Nursing’s Search for Specialized Knowledge

Historical Eras Major Question Emphasis Outcomes Emerging Goal

Curriculum Era:

1900 to 1940s

What curriculum content should student nurses study to be nurses?

Courses included in nursing programs

Standardized curricula for diploma programs

Develop specialized knowledge and higher education

Research Era: 1950 to 1970s

What is the focus for nursing research?

Role of nurses and what to research

Problem studies and studies of nurses

Isolated studies do not yield unified knowledge

Graduate Edu- cation Era:

1950 to 1970s

What knowledge is needed for the practice of nursing?

Carving out an advanced role and basis for nursing practice

Nurses have an impor- tant role in health care

Focus graduate educa- tion on knowledge development

Theory Era: 1980 to 1990s

How do these frame- works guide research and practice?

There are many ways to think about nursing

Nursing theoretical works shift the focus to the patient

Theories guide nursing research and practice

Theory Utilization Era: Twenty-first

Century

What new theories are needed to produce evidence of quality care?

Nursing theory guides research, practice, education, and administration

Middle-range theory may be from quanti- tative or qualitative approaches

Nursing frameworks produce knowledge (evidence) for quality care

Alligood, M. R. (2014, in press). Nursing theory: Utilization & application. Maryland Heights, (MO): Mosby-Elsevier.

n A discipline is specific to academia and refers to a branch of education, a department of learning, or a domain of knowledge.

n A profession refers to a specialized field of prac- tice, founded upon the theoretical structure of the science or knowledge of that discipline and accompanying practice abilities.

BOX 1-1 The Meaning of a Discipline and a Profession

Data from Donaldson, S. K., & Crowley, D. M. (1978). The discipline of nursing. Nursing Outlook, 26(2), 1113–1120.; Orem, D. (2001). Nursing: Concepts of practice (6th ed.). St. Louis: Mosby.; Styles, M. M. (1982). On nursing: Toward a new endowment. St. Louis: Mosby.

CHAPTER 1 Introduction to Nursing Theory: Its History, Significance, and Analysis 7

a standardized curriculum was realized through accreditation. Nursing had passed through eras of gradual development, and nursing leaders offered their perspectives on the development of nursing sci- ence. They addressed significant disciplinary ques- tions about whether nursing was an applied science or a basic science (Donaldson & Crowley, 1978; Johnson, 1959; Rogers, 1970). History provides evidence of the consensus that was reached, and nursing doctoral programs began to open to generate nursing knowledge.

The 1970s was a significant period of development. In 1977, after Nursing Research had been published for 25 years, studies were reviewed comprehensively, and strengths and weaknesses were reported in the journal that year. Batey (1977) called attention to the impor- tance of nursing conceptualization in the research process and the role of a conceptual framework in the design of research for the production of science. This emphasis led the theory development era and moved nursing forward to new nursing knowledge for nursing practice. Soon the nursing theoretical works began to be recognized to address Batey’s call (Johnson, 1968, 1974; King, 1971; Levine, 1969; Neuman, 1974; Orem, 1971; Rogers, 1970; Roy, 1970).

In 1978, Fawcett presented her double helix meta- phor, now a classic publication, on the interdependent relationship of theory and research. Also at this time, nursing scholars such as Henderson, Nightingale, Orlando, Peplau, and Wiedenbach were recognized for the theoretical nature of their earlier writings. These early works were developed by educators as frameworks to structure curriculum content in nurs- ing programs. Similarly, Orlando’s (1961, 1972) theory was derived from the report of an early nationally funded research project designed to study nursing practice.

I attended the Nurse Educator Nursing Theory Conference in New York City in 1978, where the ma- jor theorists were brought together on the same stage for the first time. Most of them began their presenta- tions by stating that they were not theorists. Although complete understanding of the significance of these works for nursing was limited at the time, many in the audience seemed to be aware of the significance of the event. After the first few introductions, the audi- ence laughed at the theorists’ denial of being theorists and listened carefully as each theorist described the

theoretical work they had developed for curricula, research, or practice.

Also noteworthy, Donaldson and Crowley (1978) presented the keynote address at the Western Com- mission of Higher Education in Nursing Conference in 1977, just as their nursing doctoral program was about to open. They reopened the discussion of the nature of nursing science and the nature of knowl- edge needed for the discipline and the profession. The published version of their keynote address has be- come classic for students to learn about nursing and recognize the difference between the discipline and the profession. These speakers called for both basic and applied research, asserting that knowledge was vital to nursing as both a discipline and a profession. They argued that the discipline and the profession are inextricably linked, but failure to separate them from each other anchors nursing in a vocational rather than a professional view.

Soon nursing conceptual frameworks began to be used to organize curricula in nursing programs and were recognized as models that address the values and concepts of nursing. The creative conceptualiza- tion of a nursing metaparadigm (person, environ- ment, health, and nursing) and a structure of knowl- edge clarified the related nature of the collective works of major nursing theorists as conceptual frame- works and paradigms of nursing (Fawcett, 1984). This approach organized nursing works into a system of theoretical knowledge, developed by theorists at different times and in different parts of the country. Each nursing conceptual model was classified on the basis of a set of analysis and evaluation criteria (Fawcett, 1984; 1993). Recognition of the separate nursing works collectively with a metaparadigm um- brella enhanced the recognition and understanding of nursing theoretical works as a body of nursing knowledge. In short, the significance of theory for the discipline of nursing is that the discipline is dependent upon theory for its continued existence, that is, we can be a vocation, or we can be a discipline with a professional style of theory-based practice. The theoretical works have taken nursing to higher levels of education and practice as nurses have moved from the functional focus, or what nurses do, to a knowledge focus, or what nurses know and how they use what they know for thinking and decision mak- ing while concentrating on the patient.

UNIT I Evolution of Nursing Theories8

Frameworks and theories are structures about human beings and their health; these structures pro- vide nurses with a perspective of the patient for profes- sional practice. Professionals provide public service in a practice focused on those whom they serve. The nursing process is useful in practice, but the primary focus is the patient, or human being. Knowledge of persons, health, and environment forms the basis for recognition of nursing as a discipline, and this knowl- edge is taught to those who enter the profession. Every discipline or field of knowledge includes theoretical knowledge. Therefore, nursing as an academic disci- pline depends on the existence of nursing knowledge (Butts & Rich, 2011). For those entering the profes- sion, this knowledge is basic for their practice in the profession. Kuhn (1970), noted philosopher of science, stated, “The study of paradigms . . . is what mainly prepares the student for membership in the particular scientific community with which he [or she] will later practice” (p. 11). This is significant for all nurses, but it is particularly important to those who are entering the profession because “in the absence of a paradigm . . . all of the facts that could possibly pertain to the devel- opment of a given science are likely to seem equally relevant” (Kuhn, 1970, p. 15). Finally, with regard to the priority of paradigms, Kuhn states, “By studying them and by practicing with them, the members of their cor- responding community learn their trade” (Kuhn, 1970, p. 43). Master’s students apply and test theoreti- cal knowledge in their nursing practice. Doctoral students studying to become nurse scientists develop nursing theory, test theory, and contribute nursing sci- ence in theory-based and theory-generating research studies.

Significance for the Profession Not only is theory essential for the existence of nursing as an academic discipline, it is vital to the practice of professional nursing. Recognition as a profession was a less urgent issue as the twentieth century ended because nurses had made consistent progress toward professional status through the century. Higher-degree nursing is recognized as a profession today having used the criteria for a profession to guide development. Nursing development was the subject of numerous studies by sociologists. Bixler and Bixler (1959) pub- lished a set of criteria for a profession tailored to nurs- ing in the American Journal of Nursing (Box 1-2).

These criteria have historical value for enhancing our understanding of the developmental path that nurses followed. For example, a knowledge base that is well defined, organized, and specific to the discipline was formalized during the last half of the twentieth century, but this knowledge is not static. Rather, it continues to grow in relation to the profession’s goals for the human and social welfare of the society that nurses serve. So although the body of knowledge is important, the theories and research are vital to the discipline and the profession, so that new knowledge continues to be generated. The application of nursing knowledge in practice is a criterion that is currently at the forefront, with emphasis on accountability for nursing practice, theory-based evidence for nursing practice, and the growing recognition of middle-range theory for professional nursing practice (Alligood, 2014, in press).

1. Utilizes in its practice a well-defined and well- organized body of specialized knowledge [that] is on the intellectual level of the higher learning

2. Constantly enlarges the body of knowledge it uses and improves its techniques of education and service through use of the scientific method

3. Entrusts the education of its practitioners to institutions of higher education

4. Applies its body of knowledge in practical services vital to human and social welfare

5. Functions autonomously in the formulation of professional policy and thereby in the control of professional activity

6. Attracts individuals with intellectual and personal qualities of exalting service above personal gain who recognize their chosen occupation as a life work

7. Strives to compensate its practitioners by providing freedom of action, opportunity for continuous professional growth, and economic security

BOX 1-2 Criteria for Development of the Professional Status of Nursing

Data from Bixler, G. K., & Bixler, R. W. (1959). The professional status of nursing. American Journal of Nursing, 59(8), 1142–1146.

CHAPTER 1 Introduction to Nursing Theory: Its History, Significance, and Analysis 9

In the last decades of the twentieth century, in anticipation of the new millennium, ideas targeted toward moving nursing forward were published. Styles (1982) described a distinction between the col- lective nursing profession and the individual profes- sional nurse and called for internal developments based on ideals and beliefs of nursing for continued professional development. Similarly, Fitzpatrick (1983) presented a historical chronicle of twentieth century achievements that led to the professional status of nursing. Both Styles (1982) and Fitzpatrick (1983) referenced a detailed history specific to the develop- ment of nursing as a profession. Now that nursing is recognized as a profession, emphasis in this text is placed on the relationship between nursing theoreti- cal works and the status of nursing as a profession. Similarities and differences have been noted in sets of criteria used to evaluate the status of professions; however, they all call for a body of knowledge that is foundational to the practice of the given profession (Styles, 1982).

As individual nurses grow in their professional status, the use of substantive knowledge for theory- based evidence for nursing is a quality that is charac- teristic of their practice (Butts & Rich, 2011). This commitment to theory-based evidence for practice is beneficial to patients in that it guides systematic, knowledgeable care. It serves the profession as nurses are recognized for the contributions they make to the health care of society. As noted previously in relation to the discipline of nursing, the development of knowl- edge is an important activity for nurse scholars to pursue. It is important that nurses have continued recognition and respect for their scholarly discipline and for their contribution to the health of society. Finally and most important, the continued recognition of nursing theory as a tool for the reasoning, critical thinking, and decision making required for quality nursing practice is important because of the following:

Nursing practice settings are complex, and the amount of data (information) confronting nurses is virtually endless. Nurses must analyze a vast amount of information about each patient and decide what to do. A theoretical approach helps practicing nurses not to be overwhelmed by the mass of information and to progress through the nursing process in an orderly manner. Theory

enables them to organize and understand what happens in practice, to analyze patient situations critically for clinical decision making; to plan care and propose appropriate nursing interven- tions; and to predict patient outcomes from the care and evaluate its effectiveness.

(Alligood, 2004, p. 247)

Professional practice requires a systematic approach that is focused on the patient, and the theoretical works provide just such perspectives of the patient. The theo- retical works presented in this text illustrate those various perspectives. Philosophies of nursing, concep- tual models of nursing, nursing theories, and middle- range theories provide the nurse with a view of the patient and a guide for data processing, evaluation of evidence, and decisions regarding action to take in practice (Alligood 2014, in press; Butts & Rich, 2011; Chinn & Kramer, 2011; Fawcett & Garity, 2009). With this background of the history and significance of nursing theory for the discipline and the profession, we turn to analysis of theory, a systematic process of critical reflection for understanding nursing theoreti- cal works (Chinn & Kramer, 2011).

Analysis of Theory Analysis, critique, and evaluation are methods used to study nursing theoretical works critically. Analysis of theory is carried out to acquire knowledge of theo- retical adequacy. It is an important process and the first step in applying nursing theoretical works to education, research, administration, or practice. The analysis criteria used for each theoretical work in this text are included in Box 1-3 with the questions that guide the critical reflection of analysis.

n Clarity: How clear is this theory? n Simplicity: How simple is this theory? n Generality: How general is this theory? n Accessibility: How accessible is this theory? n Importance: How important is this theory?

BOX 1-3 Analysis Questions to Determine Theoretical Adequacy

Data from Chinn, P. L., & Kramer, M. K. (2011). Integrated knowledge development in nursing (8th ed.). St. Louis: Elsevier-Mosby.

UNIT I Evolution of Nursing Theories10

The analysis process is useful for learning about the works and is essential for nurse scientists who intend to test, expand, or extend the works. When nurse scientists consider their research interests in the context of one of the theoretical works, areas for further development are discovered through the pro- cesses of critique, analysis, and critical reflection. Therefore, analysis is an important process for learn- ing, for developing research projects, and for expand- ing the science associated with the theoretical works of nursing in the future. Understanding a theoretical framework is vital to applying it in your practice.

Clarity Clarity and structure are reviewed in terms of seman- tic clarity and consistency and structural clarity and consistency. Clarity speaks to the meaning of terms used, and definitional consistency and structure speaks to the consistent structural form of terms in the the- ory. Analysis begins as the major concepts and sub- concepts and their definitions are identified. Words have multiple meanings within and across disciplines; therefore, a word should be defined carefully and specifically according to the framework (philosophy, conceptual model, or theory) within which it is de- veloped. Clarity and consistency are facilitated with diagrams and examples. The logical development and type of structure used should be clear, and assumptions should be stated clearly and be consistent with the goal of the theory (Chinn & Kramer, 2011; Reynolds, 1971; Walker & Avant, 2011). Reynolds (1971) speaks to intersubjectivity and says, “There must be shared agreement of the definitions of concepts and relation- ships between concepts within a theory” (p. 13). Hardy (1973) refers to meaning and logical adequacy and says, “Concepts and relationships between concepts must be clearly identified and valid” (p. 106). Ellis (1968) used “the criterion of terminology” to evaluate theory and warns about “the danger of lost meaning when terms are borrowed from other disciplines and used in a different context” (p. 221). Walker and Avant (2011) assess “logical adequacy” according to “the logical structure of the concepts and statements” pro- posed in the theory (p. 195).

Simplicity Simplicity is highly valued in nursing theory devel- opment. Chinn and Kramer (2011) called for simple

forms of theory, such as middle range, to guide prac- tice. A theory should be sufficiently comprehensive, presented at a level of abstraction to provide guid- ance, and have as few concepts as possible with simplistic relations to aid clarity. Reynolds (1971) contends, “The most useful theory provides the greatest sense of understanding” (p. 135). Walker and Avant (2011) describe theory parsimony as “brief but com- plete” (p. 195).

Generality The generality of a theory speaks to the scope of application and the purpose within the theory (Chinn & Kramer, 2011). Ellis (1968) stated, “The broader the scope . . . the greater the significance of the the- ory” (p. 219). The generality of a theoretical work varies by how abstract or concrete it is (Fawcett, 2005). Understanding the levels of abstraction by doctoral students and nurse scientists facilitated the use of abstract frameworks for the development of middle-range theories. Rogers’ (1986) Theory of Accelerating Change is an example of an abstract theory from which numerous middle-range theories have been generated.

Accessibility Accessibility is linked to the empirical indicators for testability and ultimate use of a theory to describe aspects of practice (Chinn & Kramer, 2011). Acces- sible” addresses the extent to which empiric indica- tors for the concepts can be identified and to what extent the purposes of the theory can be attained” (Chinn & Kramer, 2011, p. 203). Reynolds (1971) evaluates empirical relevance by examining “the cor- respondence between a particular theory and the objective empirical data” (p. 18). He suggests that scientists should be able to evaluate and verify results by themselves. Walker and Avant (2011) evaluate testability based on the theory’s capacity to “generate hypotheses and be subjected to empirical research” (p. 195).

Importance A parallel can be drawn between outcome and impor- tance. Because research, theory, and practice are closely related, nursing theory lends itself to research testing, and research testing leads to knowledge for practice. Nursing theory guides research and practice,

CHAPTER 1 Introduction to Nursing Theory: Its History, Significance, and Analysis 11

generates new ideas, and differentiates the focus of nursing from that of other professions (Chinn & Kramer, 2011). Ellis (1968) indicates that to be con- sidered useful, “it is essential for theory to develop and guide practice . . . theories should reveal what knowledge nurses must, and should, spend time pur- suing” (p. 220).

The five criteria for the analysis of theory—clarity, simplicity, generality, accessibility, and importance— guide the critical reflection of each theoretical work in Chapters 6 to 36. These broad criteria facilitate the analysis of theoretical works, whether they are applied to works at the level of philosophies, concep- tual models, theories, or middle-range theories.

Summary This chapter presents an introduction to nursing theory with a discussion of its history, significance, and analysis. A nurse increases professional power when using theoretical research as systematic evi- dence for critical thinking and decision making. When nurses use theory and theory-based evidence to structure their practice, it improves the quality of care. They sort patient data quickly, decide on appro- priate nursing action, deliver care, and evaluate out- comes. They also are able to discuss the nature of their practice with other health professionals. Con- sidering nursing practice in a theory context helps students to develop analytical skills and critical thinking ability and to clarify their values and as- sumptions. Theory guides practice, education, and research (Alligood 2014, in press; Chinn & Kramer, 2011; Fawcett, 2005; Meleis, 2007).

Globally, nurses are recognizing the rich heritage of the works of nursing theorists, that is, the philoso- phies, conceptual models, theories, and middle- range theories of nursing. The publication of this text in multiple (at least 10) languages reflects the global use of theory. The contributions of global theorists present nursing as a discipline and provide knowledge structure for further development. The use of theory-based research supports evidence- based practice. There is worldwide recognition of the rich diversity of nursing values the models rep- resent. Today we see added clarification of the theo- retical works in the nursing literature as more and more nurses learn and use theory-based practice. Most important, the philosophies, models, theories, and middle-range theories are used broadly in all areas—nursing education, administration, research, and practice.

There is recognition of normal science in the theoretical works (Wood, 2010). The scholarship of the past 3 decades has expanded the volume of nursing literature around the philosophies, mod- els, theories, and middle-range theories. Similarly, the philosophy of science has expanded and fos- tered nursing knowledge development with new qualitative approaches. As more nurses have ac- quired higher education, understanding of the im- portance of nursing theory has expanded. The use of theory by nurses has increased knowledge devel- opment and improved the quality of nursing prac- tice (Alligood, 2010a; Alligood, 2011b; Chinn & Kramer, 2011; Fawcett & Garity, 2009; George, 2011; Im & Chang, 2012; Reed & Shearer, 2012; Wood, 2010).

POINTS FOR FURTHER STUDY n Judd, D., Sitzman, K., & Davis, G. M. (2010). A his-

tory of American nursing. Boston: Jones & Bartlett. n The Nursing Theory Page at Hahn School of

Nursing, University of San Diego: Retrieved from: http://www.sandiego.edu/ACADEMICS/nursing/ theory.

n Donaldson, S. K., & Crowley, D. M. (1978). The disci- pline of nursing. Nursing Outlook, 26(2), 1113–1120.

n Fawcett, J. (1984). The metaparadigm of nursing: current status and future refinements. Image: The Journal of Nursing Scholarship, 16, 84–87.

n Kalisch, P. A., & Kalisch, B. J. (2003). American nursing: A history (4th ed.). Philadelphia: Lippincott Williams & Wilkins.

UNIT I Evolution of Nursing Theories12

Alligood, M. R. (2011a). The power of theoretical knowl- edge. Nursing Science Quarterly, 24(4), 304–305.

Alligood, M. R. (2011b). Theory-based practice in a major medical centre. The Journal of Nursing Management, 19, 981–988.

Alligood, M. R. (2014, in press). Nursing theory: Utilization & application, (5th ed.). Maryland Heights, (MO): Mosby-Elsevier.

Alligood, M. R. (2010a). The nature of knowledge needed for nursing practice. In M. R. Alligood (Ed.), Nursing theory: Utilization & application (4th ed., pp. 3-15). St. Louis: Mosby.

Alligood, M. R. (2010b). Models and theories: critical thinking structures. In M. R. Alligood (Ed.), Nursing theory: Utilization & application (4th ed., pp. 43–65). St. Louis: Mosby.

Alligood, M. R. (2010c). Areas for further development of theory-based nursing practice. In M. R. Alligood (Ed.), Nursing theory: Utilization & application (4th ed., pp. 487–497). St. Louis: Mosby.

Alligood, M. R. (2004). Nursing theory: the basis for professional nursing practice. In K. K. Chitty (Ed.), Professional nursing: Concepts and challenges (4th ed., pp. 271–298). Philadelphia: Saunders.

Alligood, M. R., & Tomey, A. M. (Eds.). (1997). Nursing theory: Utilization & application. St. Louis: Mosby.

Alligood, M. R., & Tomey, A. M. (Eds.). (2002). Nursing theory: Utilization & application (2nd ed.). St. Louis: Mosby.

Alligood, M. R., & Tomey, A. M. (Eds.). (2006). Nursing theory: Utilization & application (3rd ed.). St. Louis: Mosby.

Alligood, M. R. & Tomey, A. M. (Eds.). (2010). Nursing theorists and their work (7th ed.). Maryland Heights, (MO): Mosby-Elsevier.

Batey, M. V. (1977). Conceptualization: knowledge and logic guiding empirical research. Nursing Research, 26(5), 324–329.

Bixler, G. K., & Bixler, R. W. (1959). The professional status of nursing. American Journal of Nursing, 59(8), 1142–1146.

Butts, J. B., & Rich, K. L. (2011). Philosophies and theories for advanced nursing practice. Sudbury, (MA): Jones & Bartlett.

Chinn, P. L., & Kramer, M. K. (2011). Integrated knowledge development in nursing (8th ed.). St. Louis: Elsevier- Mosby.

Cross, K. P. (1981). Adults as learners. Washington DC: Jossey-Bass.

Donaldson, S. K., & Crowley, D. M. (1978). The discipline of nursing. Nursing Outlook, 26(2), 1113–1120.

Ellis, R. (1968). Characteristics of significant theories. Nursing Research, 27(5), 217–222.

Fawcett, J. (1978). The relationship between theory and research: a double helix. Advances in Nursing Science, 1(1), 49–62.

Fawcett, J. (1984). The metaparadigm of nursing: current status and future refinements. Image: The Journal of Nursing Scholarship, 16, 84–87.

Fawcett, J. (1993). Analysis and evaluation of nursing theories. Philadelphia: F. A. Davis.

Fawcett, J. (2005). Contemporary nursing knowledge: Conceptual models of nursing and nursing theories (2nd ed.). Philadelphia: F. A. Davis.

Fawcett, J., & Garity, J. (2009). Evaluating research for evidence-based nursing practice. Philadelphia: F.A.Davis.

Fitzpatrick, M. L. (1983). Prologue to professionalism. Bowie, (MD): Robert J. Brady.

Fitzpatrick, J., & Whall, A. (1983). Conceptual models of nursing. Bowie, (MD): Robert J. Brady.

George, J. (2011). Nursing theories (6th ed.). Upper Saddle River, (NJ): Pearson.

Hardy, M. E. (1973). Theories: components, development, evaluation. Nursing Research, 23(2), 100–107.

Im, E. O., & Chang, S. J. (2012). Current trends in nursing theories. Journal of Nursing Scholarship, 44(2), 156–164.

Johnson, D. (1959). The nature of a science of nursing. Nursing Outlook, 7, 291–294.

Johnson, D. (1968). One conceptual model for nursing. Unpublished paper presented at Vanderbilt University, Nashville,(TN).

Johnson, D. (1974). Development of the theory: a requisite for nursing as a primary health profession. Nursing Research, 23, 372–377.

Judd, D., Sitzman, K., & Davis, G. M. (2010). A history of American nursing. Boston: Jones & Bartlett.

Kalisch, P. A., & Kalisch, B. J. (2003). American nursing: A history (4th ed.). Philadelphia: Lippincott.

King, I. (1971). Toward a theory of nursing. New York: Wiley. Kuhn, T. S. (1970). The structure of scientific revolutions.

Chicago: University of Chicago Press. Levine, M. (1969). Introduction to clinical nursing. Phila-

delphia: F. A. Davis. Meleis, A. (2007). Theoretical nursing: Development and

progress (4th ed.). Philadelphia: Lippincott. Neuman, B. (1974). The Betty Neuman health systems model:

a total person approach to patient problems. In J. P. Riehl & C. Roy (Eds.), Conceptual models for nursing practice (pp. 94–114). New York: Appleton-Century-Crofts.

Nicoll, L. (1986). Perspectives on nursing theory. Boston: Little, Brown.

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CHAPTER 1 Introduction to Nursing Theory: Its History, Significance, and Analysis 13

Nicoll, L. (1992). Perspectives on nursing theory (2nd ed.). Philadelphia: Lippincott, Williams & Wilkins.

Nicoll, L. (1997). Perspectives on nursing theory(3rd ed.). Philadelphia: Lippincott, Williams & Wilkins.

Nightingale, F. (1969). Notes on nursing: What it is and what it is not. New York: Dover. (Originally published 1859.)

Orem, D. (1971). Nursing: Concepts of practice. St. Louis: Mosby.

Orem, D. (2001). Nursing: Concepts of practice (6th ed.). St. Louis: Mosby.

Orlando, I. (1961). The dynamic nurse-patient relationship. New York: Putnam.

Orlando, I. (1972). The discipline and teaching of nursing process. New York: Putnam.

Parker, M. (2006). Nursing theory and nursing practice (2nd ed.). Philadelphia: F. A. Davis.

Peterson, S. (2008). Middle-range theories: Applications to nursing research (2nd ed.). Philadelphia: Lippincott, Williams & Wilkins.

Reed, P., & Shearer, N. (2009). Perspectives on nursing theory (5th ed.). New York: Lippincott Williams & Wilkins.

Reed, P., & Shearer, N. (2012). Perspectives on nursing theory (6th ed.). New York: Lippincott Williams & Wilkins.

Reed, P., Shearer, N., & Nicoll, L. (2003). Perspectives on nursing theory (4th ed.). Philadelphia: Lippincott, Williams & Wilkins.

Reynolds, P. D. (1971). A primer for theory construction. Indianapolis: Bobbs-Merrill.

Rogers, M. E. (1970). An introduction to the theoretical basis of nursing. Philadelphia: F. A. Davis.

Rogers, M. E. (1986). Science of unitary human beings. In V. Malinski (Ed.), Explorations on Martha Rogers’ science of unitary human beings. Norwalk, (CT): Appleton-Century-Crofts.

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Smith, M., & Leihr, P. (2008). Middle range theory for nursing (2nd ed.). New York: Springer.

Styles, M. M. (1982). On nursing: Toward a new endowment. St. Louis: Mosby.

Walker, L. O., & Avant, K. C. (2011). Strategies for theory construction in nursing (5th ed.). Boston: Prentice Hall.

Wood, A. F. (2010). Nursing models: normal science for nursing practice. In M. R. Alligood (Ed.) Nursing theory: Utilization & application, 4th ed. (pp. 17–46). Maryland Heights, (MO): Mosby-Elsevier.

14

“Why should nurses be interested in the history and philosophy of science? The history and philosophy of science is important as a foundation for exploring whether scientific results are actually

truth. As nurses our practice should be based upon truth and we need the ability to interpret the results of science. Nursing science provides us with knowledge to describe, explain and predict outcomes. The legitimacy of any profession is built on its ability to generate and apply theory.”

(McCrae, 2011, p. 222)

History and Philosophy of Science Sonya R. Hardin

CH A P T ER 2

Modern science was established over 400 years ago as an intellectual activity to formalize given phenomena of interest in an attempt to describe, explain, predict, or control states of affairs in nature. Scientific activity has persisted because it has improved quality of life and has satisfied human needs for creative work, a sense of order, and the desire to under- stand the unknown (Bronowski, 1979; Gale, 1979; Piaget, 1970). The development of nursing science has evolved since the 1960s as a pursuit to be understood as a scientific discipline. Being a scientific discipline means identifying nursing’s unique contribution to the care of patients, families, and communities. It means that nurses can conduct clinical and basic nursing research to establish the scientific base for the care of individuals across the life span. For example, research revealed gaps between the pain management needs of patients and the information communicated by patients and clinicians during office visits. Although many older adults have painful but not readily visible conditions (e.g., symptomatic osteoarthritis), little re- search has examined how the style or format of a health care practitioner’s questions influence the quality and amount of diagnostic information obtained from older

adults. A recent study tested the theory that a certain type of question would elicit the most response. The theory was confirmed when findings supported that the open-ended questions prompted patients to provide a larger amount of diagnostically useful pain informa- tion than did the closed-ended questions (McDonald, Shea, Rose, & Fedo, 2009). While this study is one example of nursing science, advance practice nurses should be familiar with the long history of the science of nursing.

Previous author: Sue Marquis Bishop.

Historical Views of the Nature of Science

To formalize the science of nursing, basic questions must be considered, such as: What is science, knowl- edge, and truth? What methods produce scientific knowledge? These are philosophical questions. The term epistemology is concerned with the theory of knowledge in philosophical inquiry. The particular philosophical perspective selected to answer these questions will influence how scientists perform sci- entific activities, how they interpret outcomes, and even what they regard as science and knowledge

CHAPTER 2 History and Philosophy of Science 15

additional research is conducted or modifications are made in the theory and further tests are devised; otherwise, the theory is discarded in favor of an alternative explanation (Gale, 1979; Zetterberg, 1966). Popper (1962) argued that science would evolve more rapidly through the process of conjectures and refuta- tions by devising research in an attempt to refute new ideas. For example, his point is simple; you can never prove that all individuals without social support have frequent rehospitalizations since there might be one individual that presents with no rehospitalization. A single person with no social support that does not have a readmission disproves the theory that all individuals with a lack of social support have hospital readmis- sions. From Popper’s perspective, “research consists of generating general hypotheses and then attempting to refute them” (Lipton, 2005, p. 1263). So the hypoth- esis that a lack of social support results in hospital readmission is the phenomena of interest to be refuted.

The rationalist view is most clearly evident in the work of Einstein, the theoretical physicist, who made extensive use of mathematical equations in developing his theories. The theories Einstein constructed offered an imaginative framework, which has directed research in numerous areas (Calder, 1979). As Reynolds (1971) noted, if someone believes that science is a process of inventing descriptions of phenomena, the appropriate strategy for theory construction is the theory-then- research strategy. In Reynolds’ view, “as the continuous interplay between theory construction (invention) and testing with empirical research progresses, the theory becomes more precise and complete as a description of nature and, therefore, more useful for the goals of science” (Reynolds, 1971, p. 145).

Empiricism The empiricist view is based on the central idea that scientific knowledge can be derived only from sensory experience (i.e., seeing, feeling, hearing facts). Francis Bacon (Gale, 1979) received credit for popularizing the basis for the empiricist approach to inquiry. Bacon believed that scientific truth was discovered through generalizing observed facts in the natural world. This approach, called the inductive method, is based on the idea that the collection of facts precedes attempts to formulate generalizations, or as Reynolds (1971) called it, the research-then-theory strategy. One of the best examples to demonstrate this form of logic in nursing

(Brown, 1977). Although philosophy has been docu- mented as an activity for 3000 years, formal science is a relatively new human pursuit (Brown, 1977; Foucault, 1973). Scientific activity has only recently become the object of investigation.

Two competing philosophical foundations of sci- ence, rationalism and empiricism, have evolved in the era of modern science with several variations. Gale (1979) labeled these alternative epistemologies as centrally concerned with the power of reason and the power of sensory experience. Gale noted similarity in the divergent views of science in the time of the classical Greeks. For example, Aristotle believed that advances in biological science would develop through systematic observation of objects and events in the natural world, whereas Pythagoras believed that knowl- edge of the natural world would develop from mathe- matical reasoning (Brown, 1977; Gale, 1979).

Nursing science has been characterized by two branching philosophies of knowledge as the discipline developed. Various terms are utilized to describe these two stances: empiricist and interpretive, mechanistic and holistic, quantitative and qualitative, and deductive and inductive forms of science. Understanding the nature of these philosophical stances facilitates appre- ciation for what each form contributes to nursing knowledge.

Rationalism Rationalist epistemology (scope of knowledge) empha- sizes the importance of a priori reasoning as the appropriate method for advancing knowledge. A priori reasoning utilizes deductive logic by reasoning from the cause to an effect or from a generalization to a particular instance. An example in nursing is to reason that a lack of social support (cause) will result in hos- pital readmission (effect). This causal reasoning is a theory until disproven. The traditional approach pro- ceeds by explaining hospitalization with a systematic explanation (theory) of a given phenomenon (Gale, 1979). This conceptual system is analyzed by address- ing the logical structure of the theory and the logical reasoning involved in its development. Theoretical assertions derived by deductive reasoning are then subjected to experimental testing to corroborate the theory. Reynolds (1971) labeled this approach the theory-then-research strategy. If the research findings fail to correspond with the theoretical assertions,

UNIT I Evolution of Nursing Theories16

has to do with formulating differential diagnoses. For- mulating a differential diagnosis requires collecting the facts and then devising a list of possible theories to explain the facts.

The strict empiricist view is reflected in the work of the behaviorist Skinner. In a 1950 paper, Skinner asserted that advances in the science of psychology could be expected if scientists would focus on the collection of empirical data. He cautioned against drawing premature inferences and proposed a mora- torium on theory building until further facts were collected. Skinner’s (1950) approach to theory con- struction was clearly inductive. His view of science and the popularity of behaviorism have been credited with influencing psychology’s shift in emphasis from the building of theories to the gathering of facts between the 1950s and 1970s (Snelbecker, 1974). The difficulty with the inductive mode of inquiry is that the world presents an infinite number of possible observations, and, therefore, the scientist must bring ideas to his or her experiences to decide what to observe and what to exclude (Steiner, 1977).

In summary, deductive inquiry uses the theory- then-research approach, and inductive inquiry uses the research-then-theory approach. Both approaches are utilized in the field of nursing.

Early Twentieth Century Views of Science and Theory

During the first half of this century, philosophers focused on the analysis of theory structure, whereas scientists focused on empirical research (Brown, 1977). There was minimal interest in the history of science, the nature of scientific discovery, or the simi- larities between the philosophical view of science and the scientific methods (Brown, 1977). Positivism, a term first used by Comte, emerged as the dominant view of modern science (Gale, 1979). Modern logical positivists believed that empirical research and logical analysis (deductive and inductive) were two ap- proaches that would produce scientific knowledge (Brown, 1977).

The logical empiricists offered a more lenient view of logical positivism and argued that theoretical propo- sitions (proposition affirms or denies something) must be tested through observation and experimentation (Brown, 1977). This perspective is rooted in the idea

that empirical facts exist independently of theories and offer the only basis for objectivity in science (Brown, 1977). In this view, objective truth exists independently of the researcher, and the task of science is to discover it, which is an inductive method (Gale, 1979). This view of science is often presented in research method courses as: “The scientist first sets up an experiment; observes what occurs . . . reaches a preliminary hy- pothesis to describe the occurrence; runs further ex- periments to test the hypothesis [and] finally corrects or modifies the hypothesis in light of the results” (Gale, 1979, p. 13).

The increasing use of computers, which permit the analysis of large data sets, may have contributed to the acceptance of the positivist approach to modern sci- ence (Snelbecker, 1974). However, in the 1950s, the literature began to reflect an increasing challenge to the positivist view, thereby ushering in a new view of science in the late twentieth century (Brown, 1977).

Emergent Views of Science and Theory in the Late Twentieth Century

In the latter years of the twentieth century, several authors presented analyses challenging the positivist position, thus offering the basis for a new perspective of science (Brown, 1977; Foucault, 1973; Hanson, 1958; Kuhn, 1962; Toulmin, 1961). Foucault (1973) published his analysis of the epistemology (knowledge) of human sciences from the seventeenth to the nine- teenth century. His major thesis stated that empirical knowledge was arranged in different patterns at a given time and in a given culture and that humans where emerging as objects of study. In The Phenome- nology of the Social World, Schutz (1967) argued that scientists seeking to understand the social world could not cognitively know an external world that is indepen- dent of their own life experiences. Phenomenology, set forth by Edmund Husserl (1859 to 1938) proposed that the objectivism of science could not provide an ade- quate apprehension of the world (Husserl 1931, 1970). A phenomenological approach reduces observations or text to the meanings of phenomena independent of their particular context. This approach focuses on the lived meaning of experiences.

In 1977, Brown argued an intellectual revolution in philosophy that emphasized the history of science was replacing formal logic as the major analytical tool

CHAPTER 2 History and Philosophy of Science 17

in the philosophy of science. One of the major per- spectives in the new philosophy emphasized science as a process of continuing research rather than a product focused on findings. In this emergent episte- mology, emphasis shifted to understanding scientific discovery and process as theories change over time.

Empiricists view phenomena objectively, collect data, and analyze it to inductively proposed theory (Brown, 1977). This position is based upon objective truth existing in the world, waiting to be discovered. Brown (1977) set forth a new epistemology challenging the empiricist view proposing that theories play a significant role in determining what the scientist observes and how it is interpreted. The following story illustrates Brown’s premise that observations are con- cept laden; that is, an observation is influenced by values and ideas in the mind of the observer:

“An elderly patient has been in a trauma and appears to be crying. The nurse on admission observes that the patient has marks on her body and believes that she has been abused; the ortho- pedist has viewed an x-ray and believes that the crying patient is in pain due to a fractured femur that will not require surgery only a closed reduc- tion; the chaplain observes the patient crying and believes the patient needs spiritual support. Each observation is concept laden.”

Brown (1977) presented the example of a chemist and a child walking together past a steel mill. The chemist perceived the odor of sulfur dioxide and the child smelled rotten eggs. Both observers in the exam- ples responded to the same observation but with dis- tinctly different interpretations. Concepts and theories set up boundaries and specify pertinent phenomena for reasoning about specific observed patterns. These examples represent different ideas that emerge for each person.

If scientists perceive patterns in the empirical world based on their presupposed theories, how can new patterns ever be perceived or new discoveries become formulated? Gale (1979) answered by pro- posing that the scientist is able to perceive forceful intrusions from the environment that challenge his or her a priori mental set, thereby raising questions regarding the current theoretical perspective. Brown (1977) maintained that a presupposed theoretical framework influences perception, however theories

are not the single determining factor of the scientist’s perception. He identified the following three differ- ent views of the relationship between theories and observation: 1. Scientists are merely passive observers of occur-

rences in the empirical world. Observable data are objective truth waiting to be discovered.

2. Theories structure what the scientist perceives in the empirical world.

3. Presupposed theories and observable data interact in the process of scientific investigation (Brown, 1977, p. 298). Brown’s argument for an interactionist’s perspective

coincides with the scientific consensus in the study of pattern recognition in how humans process informa- tion. The following distinct mini-theories have directed research efforts in this area: (1) the data-driven, or bottom-up, theory and (2) the conceptually driven, or top-down, theory (Norman, 1976). In the former, cognitive expectations (what is known or ways of orga- nizing meaning) are used to select input and process incoming information from the environment. The second theory asserts that incoming data are perceived as unlabeled input and analyzed as raw data with in- creasing levels of complexity until all the data are clas- sified. Current research evidence suggests that human pattern recognition progresses through an interaction of both data-driven and conceptually driven processes, and it uses sources of information in both currently organized, cognitive categories and in stimuli from the sensory environment. The interactionist’s perspective also is clearly reflected in Piaget’s theory of human cognitive functioning:

“Piagetian man actively selects and interprets environmental information in the construction of his own knowledge, rather than passively copying the information just as it is presented to his senses. While paying attention to and taking account of the structure of the environment during knowledge seeking, Piagetian man reconstrues and reinter- prets that environment [according to] his own mental framework . . . The mind neither copies the world . . . nor does it ignore the world [by] creating a private mental conception of it out of whole cloth. The mind meets the environment in an extremely active, self-directed way.”

(Flavell, 1977, p. 6)

UNIT I Evolution of Nursing Theories18

If the thesis is accepted that objective truth does not exist and science is an interactive process between invented theories and empirical observations, how are scientists to determine truth and scientific knowledge? In the new epistemology, science is viewed as an ongoing process. Much importance is given to the idea of consensus among scientists. As Brown (1977) con- cluded, it is a myth that science can establish final truths. Tentative consensus based on reasoned judg- ments about the available evidence is what can be expected. In this view, scientific knowledge is what the consensus of scientists in any given historical era regard as scientific knowledge. At any point in time, the current consensus among scientists determines the truth of a given theoretical statement by concluding whether or not it presents a plausible description of reality (Brown, 1977). This consensus is possible through the collaboration of many scientists as they make their work available for public review and debate and as they build upon previous scientific discoveries (Randall, 1964).

In any given era and in any given discipline, science is structured by an accepted set of presuppositions that define the phenomena for study and define the appro- priate methods for data collection and interpretation (Brown, 1977; Foucault, 1973; Kuhn, 1962). These pre- suppositions set the boundaries for the scientific enter- prise in a particular field. In Brown’s view of the trans- actions between theory and empirical observation:

“Theory determines what observations are worth making and how they are to be understood, and observation provides challenges to accepted theoretical structures. The continuing attempt to produce a coherently organized body of theory and observation is the driving force of research, and the prolonged failure of specific research projects leads to scientific revolutions.”

(Brown 1977, p. 167)

The presentation and acceptance of a revolution- ary theory may alter the existing presuppositions and theories, thereby creating a different set of boundaries and procedures. The result is a new set of problems or a new way to interpret observations; that is, a new picture of the world (Kuhn, 1962). In this view of science, the emphasis must be placed on ongoing research rather than established findings. According to Kuhn, science progresses from a pre-science, then

to a normal science, then to a crisis, then to a revolu- tion, and then to a new normal science. Once normal science develops, the process begins again when a crisis erupts and leads to revolution, and a new normal science emerges once again (Kuhn, 1970; Nyatanga, 2005). This is what Kuhn refers to as paradigm shift in the scientific development within a discipline. For example, recent research supports that early mobiliza- tion of critically ill patients shows better patient out- comes (Schweickert & Kress, 2011). Theory-based nursing practice has demonstrated the capacity to restructure professional care, improving outcomes and satisfaction (Alligood, 2011).

Interdependence of Theory and Research

Traditionally, theory building and research have been presented to students in separate courses. Often, this separation has caused problems for students in under- standing the nature of theories and in comprehending the relevance of research efforts (Winston, 1974). The acceptance of the positivist view of science may have influenced the sharp distinction between theory and research methods (Gale, 1979). Although theory and research can be viewed as distinct operations, they are regarded more appropriately as interdependent components of the scientific process (Dubin, 1978). In constructing a theory, the theorist must be knowledge- able about available empirical findings and be able to take these into account because theory is, in part, concerned with organizing and formalizing available knowledge of a given phenomenon. The theory is sub- ject to revision if hypotheses fail to correspond with empirical findings, or the theory may be abandoned in favor of an alternative explanation that accounts for the new information (Brown, 1977; Dubin, 1978; Kuhn, 1962).

In contemporary theories of science, the scientific enterprise has been described as a series of phases with an emphasis on the discovery and verification (or acceptance) phases (Gale, 1979; Giere, 1979). These phases are concerned primarily with the presentation and testing of new ideas. New ways of thinking about phenomena or new data are introduced to the scien- tific community during the discovery phase. During this time, the focus is on presenting a persuasive argu- ment to show that the new conceptions represent an

CHAPTER 2 History and Philosophy of Science 19

improvement over previous conceptions (Gale, 1979). Verification is characterized by the scientific commu- nity’s efforts to critically analyze and test the new conceptions in an attempt to refute them. The new views are then subjected to testing and analyses (Gale, 1979). However, Brown (1977) argued that discovery and verification could not be viewed as distinct phases, because the scientific community does not usually accept a new conception until it has been subjected to significant testing. Only then can it be accepted as a new discovery.

In any scientific discipline, it is not appropriate to judge a theory on the basis of authority, faith, or intu- ition; it should be judged on the basis of scientific consensus (Randall, 1964). For example, if a specific nursing theory is deemed acceptable, this judgment should not be made because a respected nursing leader advocates the theory. Personal feelings, such as “I like this theory” or “I don’t like this theory,” do not provide a valid basis for judgment. The theory should be judged acceptable on the basis of logical and conceptual or empirical grounds. The scientific community makes these judgments (Gale, 1979).

The advancement of science is thus a collaborative endeavor in which many researchers evaluate and build on the work of others. Theories, procedures, and findings from empirical studies must be made available for critical review by scientists for evidence to be cumulative. The same procedures can be used to support or refute a given analysis or finding. A theory is accepted when scientists agree that it provides a description of reality that captures the phenomenon based on current research findings (Brown, 1977). The acceptance of a scientific hypothesis depends on the appraisal of the coherence of theory, which in- volves questions of logic, and the correspondence of the theory, which involves efforts to relate the theory to observable phenomena through research (Steiner, 1978). Gale (1979) labeled these criteria as epistemo- logical and metaphysical concerns.

The consensus regarding the correspondence of the theory is, therefore, not based on a single study. Repeated testing is crucial. The study must be repli- cated under the same conditions, and the theoretical assertions must be explored under different condi- tions or with different measures. Consensus is, there- fore, based on accumulated evidence (Giere, 1979). When the theory does not appear to be supported by

research, the scientific community does not necessarily reject it. Rather than agreeing that a problem exists with the theory itself, the community may make judgments about the validity or the reliability of the measures used in testing the theory or about the appropriateness of the research design. These possibilities are considered in critically evaluating all attempts to test a given theory.

Scientific consensus is necessary in three key areas for any given theory as follows: (1) agreement on the boundaries of the theory; that is, the phenomenon it addresses and the phenomena it excludes (criterion of coherence), (2) agreement on the logic used in con- structing the theory to further understanding from a similar perspective (criterion of coherence), and (3) agreement that the theory fits the data collected and analyzed through research (criterion of corre- spondence) (Brown, 1977; Dubin, 1978; Steiner, 1977, 1978). Essentially, consensus in these three areas constitutes an agreement among scientists to “look at the same ‘things,’ to do so in the same way, and to have a level of confidence certified by an empirical test” (Dubin, 1978, p. 13). Therefore, the theory must be capable of being operationalized to test it against reality.

Scientific inquiry in normal science involves test- ing a given theory, developing new applications of a theory, or extending a given theory. Occasionally, a new theory with different assumptions is developed that could replace previous theories. Kuhn (1962) described this as revolutionary science and described the theory with different presuppositions as a revo- lutionary theory. A change in the accepted presup- positions creates a set of boundaries and procedures that suggest a new set of problems or a new way to interpret observations (Kuhn, 1962). One previously accepted theory is abandoned for another theory if it fails to correspond with empirical findings or if it does not present clear directions for further research. The scientific community judges the selected alterna- tive theory to account for available data and to sug- gest further lines of inquiry (Brown, 1977). Hence, a new worldview is formed.

In the social and behavioral sciences, there is some challenge to the assumptions underlying the accepted methods of experimental design, measurement, and statistical analysis that emphasizes the search for uni- versal laws and the use of procedures for the random assignment of subjects across contexts. Mishler (1979)

UNIT I Evolution of Nursing Theories20

argued that, in studying behavior, scientists should develop methods and procedures that are dependent on context for meaning rather than eliminate context by searching for laws that hold across contexts. This critique of the methods and assumptions of research is emerging from phenomenological and ethnomethod- ological theorists who view the scientific process from a very different paradigm (Bowers, 1992; Hudson, 1972; Mishler, 1979; Pallikkathayil & Morgan, 1991). Phenomenology is a science that describes how we experience the objects of the external world and pro- vides an explanation of how we construct objects of experience. In phenomenology, the investigator posits that all objects exist because people perceive and construct them as such. Ethnomethodology focuses on the world of “social facts” as accomplished or co-created through people’s interpretive work. When examining phenomena from this perspective, social reality and social facts are constructed, produced, and organized through the mundane actions and circum- stances of everyday life.

There is neither a single science nor a single scien- tific method. There are several sciences, each with unique phenomena and structure and methods for inquiry (Springagesh & Springagesh, 1986). How- ever, the commonality among sciences concerns the scientists’ efforts to separate truth from speculation to advance knowledge (Snelbecker, 1974). In ques- tions regarding the structure of knowledge in a given science, the consensus of scientists in the discipline decides what is to be regarded as scientific knowl- edge and the methods of inquiry (Brown, 1977; Gale, 1979).

Consensus has emerged in the field of nursing that the knowledge base for nursing practice is in- complete, and the development of a scientific base for nursing practice is a high priority for the disci- pline. The postpositivist and interpretive paradigms have achieved a degree of acceptance in nursing as paradigms to guide knowledge development (Ford- Gilboe, Campbell, & Berman, 1995). Postpositivism focuses on discovering patterns that may describe, explain, and predict phenomena. It rejects the older, traditional positivist views of an ultimate objective knowledge that is observable only through the senses (Ford-Gilboe, et al., 1995; Weiss, 1995). The interpre- tive paradigm tends to promote understanding by addressing the meanings of the participants’ social

interaction that emphasize situation, context, and the multiple cognitive constructions individuals cre- ate from everyday events (Ford-Gilboe, et al., 1995). A critical paradigm for knowledge development in nursing also has been described as an emergent, postmodern paradigm that provides the framework for inquiring about the interaction between social, political, economic, gender, and cultural factors and the experiences of health and illness (Ford- Gilboe, et al., 1995). A broad conception of post- modernism includes the particular philosophies that challenge the “objectification of knowledge,” such as phenomenology, hermeneutics, feminism, critical theory, and poststructuralism (Omery, Kasper, & Page, 1995).

The philosophy of nursing has been developing over a 150-year period. The philosophy of caring, naturalism, and holism are themes that can be found in the literature. Numerous authors have written about caring. Caring is the wholeness of the patient’s situation, which implies that nursing care requires interpretation, understanding, and hermeneutic ex- perience. The philosophy of caring involves knowl- edge, skills, patient trust, and the ability to manage all elements simultaneously in the context of care (Austgard, 2008).

Wholism is another philosophy in understanding the patient (Hennessey, 2011). Wholistic nursing views the biophysical, psychological, and sociological subsystems as related but separate, thus the whole is equal to the sum of the parts. Holistic nursing recog- nizes that multiple subsystems are in continuous interaction and that mind-body relationships do exist (Kinney & Erickson, 1990).

Naturalism has a metaphysical component that implicates that the natural world exists; there is no non-natural or supranatural realm. The natural world is open, because it depends upon what method the enquiry requires. Naturalism insists that knowledge and beliefs are gained by one’s senses guided by reason, and by the various methods of science (Hussey, 2011). While these philosophies are pro- posed in the literature, nursing science is in the early stages of scientific development.

As the discipline of nursing moves forward, there is abundant evidence that a greater number of nurse scholars are actively engaged in the advancement of knowledge for the discipline of nursing through

CHAPTER 2 History and Philosophy of Science 21

research and scholarly dialogue. This can be seen with the emergence of middle-range theories that utilize inductive, deductive, and synthesis theories from nursing and other disciplines (Peterson & Bredow, 2008; Sieloff & Frey, 2007; Smith & Liehr, 2008). This new century of nursing scholarship by nurse scientists and scholars explores nursing phenomena of interest and provides evidence for quality advanced practice.

Science as a Social Enterprise The process of scientific inquiry may be viewed as a social enterprise (Mishler, 1979). In Gale’s words, “Human beings do science” (Gale, 1979, p. 290). Therefore, it might be anticipated that social, eco- nomic, or political factors may influence the scientific

enterprise (Brown, 1977). For example, the popularity of certain ideologies may influence how phenomena are viewed and what problems are selected for study (Hudson, 1972). In addition, the availability of funds for research in a specified area may in- crease research activity in that area. However, sci- ence does not depend on the personal characteris- tics or persuasions of any given scientist or group of scientists, but it is powerfully self-correcting within the community of scientists (Randall, 1964). Science progresses by the diversity of dialogue within the discipline of nursing. The use of a single paradigm, multiple paradigms, or the creation of a merged paradigm from many paradigms is debated in rela- tionship to the advancement in the epistemology of nursing.

POINTS FOR FURTHER STUDY n Phenomenology: http://plato.stanford.edu/

entries/phenomenology/ n Naturalism: http://plato.stanford.edu/entries/

naturalism/

n 100 Basic Philosophical Terms:http://www.str.org/ site/News2?page5NewsArticle&id55493

n Edmund Husserl: http://plato.stanford.edu/ entries/husserl/

n Kant’s Philosophy of Science: http://plato.stanford. edu/entries/kant-science/

Alligood, M.R. (2011). Theory-based practice in a major medical center. Journal of Nursing Management, 19, 981–988.

Austgard, K. I. (2008). What characterises nursing care? A hermenutical philosophical inquiry. Scand J Caring, 22, 314–319.

Bowers, L. (1992). Ethnomethodology I: an approach to nursing research. International Journal of Nursing Studies, 29(1), 59–67.

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23

Theory Components Development of theory requires understanding of selected scholarly terms, definitions, and assumptions

CH A P T ER 3

Theory Development Process Sonya R. Hardin

Deductive reasoning is narrow and goes from general to specific. In the clinical area, nurses often have ex- perience with a general rule and apply it to a patient. Inductive reasoning is much broader and explor- atory in nature as one goes from specific to general. Abductive reasoning begins with an incomplete set of observations and proceeds to the likeliest possible explanation for the set. A medical diagnosis is an application of abductive reasoning: given this set of symptoms, what is the diagnosis that would best explain most of them? One aspect they have in com- mon is to approach theory development in a precise, systematic manner, making the stages of development explicit. The nurse who systematically devises a the- ory of nursing and publishes it for the nursing com- munity to review and debate engages in a process that is essential to advancing theory development. As scholarly work is published in the literature, nurse theoreticians and researchers review and critique the adequacy of the logical processes used in the develop- ment of the theory with fresh eyes in relation to prac- tice and available research findings.

Theory development in nursing is an essential component in nursing scholarship to advance the knowledge of the discipline. The legitimacy of any profession is built on its ability to generate and apply theory (McCrae, 2011, p. 222). Nursing theories that clearly set forth understanding of nursing phenomena (i.e., self care, therapeutic communication, chronic sorrow) guide scholarly development of the science of nursing through research. Once a nursing theory is proposed addressing a phenomenon of interest, sev- eral considerations follow, such as its completeness and logic, internal consistency, correspondence with empirical findings, and whether it has been operation- ally defined for testing. Analyses of these lead logically to the further development of the theory. Scientific evi- dence accumulates through repeated rigorous research that supports or refutes theoretical assertions and guides modifications or extensions of the theory. Nurs- ing theory development is not a mysterious activity, but a scholarly endeavor pursued systematically. Rigorous development of nursing theories, then, is a high priority for the future of the discipline and the practice of the profession of nursing.

It is important to understand the concept of sys- tematic development since approaches to construction of theory differ. A theory may emerge through deduc- tive, inductive, or retroductive (abductive) reasoning.

“Nursing’s potential for meaningful human service rests on the union of theory and practice for its fulfillment.”

(Rogers, 1970, p. viii)

Previous author: Sue Marquis Bishop.

UNIT I Evolution of Nursing Theories24

directly experienced and relate to a particular time or place (Chinn & Kramer, 2011; Hage, 1972; Reynolds, 1971) (Table 3-2).

The stretcher, stroke, wheelchair, and hospital bed are examples of concrete concepts of the abstract concept, transport and the other examples illustrate the concrete to abstract difference. In a given theo- retical system, the definition, characteristics, and functioning of a nurse competency clarify more spe- cific instances, such as medication administration nurse competency.

Concepts may be classified as discrete or continu- ous concepts. This system of labels differentiates types of concept that specify categories of phenomena. A discrete concept identifies categories or classes of phenomena, such as patient, nurse, health, or envi- ronment. A student can become a nurse or choose another profession, but he or she cannot become a partial nurse. Phenomena identified as belonging to, or not belonging to, a given class or category may be called nonvariable concepts. Sorting phenomena into nonvariable discrete categories carries the assump- tion that the associated reality is captured by the classification (Hage, 1972). The amount or degree of the variable is not an issue.

so that scholarly review and analysis may occur. At- tention is given to terms and defined meanings to understand the theory development process that was used. Therefore, the clarity of terms, their scientific utility, and their value to the discipline are important considerations in the process.

Hage (1972) identified six theory components and specified the contributions they make to theory (Table 3-1). Three categories of theory components are presented as a basis for understanding the function of each element in the theory-building process.

Concepts and Definitions Concepts, the building blocks of theories, classify the phenomena of interest (Kaplan, 1964). It is crucial that concepts are considered within the theoretical system in which they are embedded and from which they derive their meaning, since concepts may have differ- ent meanings in various theoretical systems. Scientific progress is based on critical review and testing of a researcher’s work by the scientific community.

Concepts may be abstract or concrete. Abstract concepts are mentally constructed independent of a specific time or place, whereas concrete concepts are

TABLE 3-1 Theory Components and Their Contributions to the Theory

Theory Components Contributions to the Theory

Concepts and Definitions Concepts Describe and classify phenomena

Theoretical definitions of concept Establish meaning

Operational definitions of concept Provide measurement

Relational Statements Theoretical statements Relate concepts to one another; permit analysis

Operational statements Relate concepts to measurements

Linkages and Ordering Linkages of theoretical statements Provide rationale of why theoretical statements are linked;

add plausibility

Linkages of operational statements Provide rationale for how measurement variables are linked; permit testability

Organization of concepts and definitions into primitive and derived terms

Eliminates overlap (tautology)

Organization of statements and linkages into premises and derived hypotheses and equations

Eliminates inconsistency

Modified from Hage, J. (1972). Techniques and problems of theory construction in sociology. New York: John Wiley & Sons.

CHAPTER 3 Theory Development Process 25

Theories may be used as a series of nonvariable discrete concepts (and subconcepts) to build typolo- gies. Typologies are systematic arrangements of con- cepts within a given category. For example, a typology on marital status could be partitioned into marital statuses in which a population is classified as married, divorced, widowed, or single. These discrete catego- ries could be partitioned further to permit the classi- fication of an additional variable in this typology. A typology of marital status and gender is shown in Table 3-3. The participants are either one gender or the other since there are no degrees of how much they are in this discrete category. Taking the illustration further, the typology could be partitioned adding the discrete concept of children. Participants would be classified for gender, marital status, and as having or not having children.

A continuous concept, on the other hand, permits classification of dimensions or gradations of a phe- nomenon, indicating degree of marital conflict. Mari- tal couples may be classified with a range representing

degrees of marital conflict in their relationships from low to high.

Degree of Marital Conflict

0 120

Low High

Other continuous concepts that may be used to classify couples might include amount of communi- cation, number of shared activities, or number of children. Examples of continuous concepts used to classify patients are degree of temperature, level of anxiety, or age. Another example is how nurses con- ceptualize pain as a continuous concept when they ask patients to rate their pain on a scale from 0 to 10 to better understand their pain threshold or pain experience.

Degree of Pain

0 10

Low High

Continuous concepts are not expressed in either/ or terms but in degrees on a continuum. The use of variable concepts on a continuum tends to focus on one dimension but does so without assuming that a single dimension captures all of the reality of the phenomenon. Additional dimensions may be de- vised to measure further aspects of the phenome- non. Instruments may measure a concept and have subscales that measure discrete concepts related to the overall concept. Variable concepts such as ratio of professional to nonprofessional staff, communica- tion flow, or ratio of registered nurses to patients, is used to characterize health care organizations. Although nonvariable concepts are useful in classi- fying phenomena in theory development, Hage (1972) notes several major breakthroughs in disci- plines as the focus shifts from nonvariable to vari- able concepts, because variable concepts permit the scoring of the phenomenon’s full range of variation.

The development of concepts, then, permits descrip- tion and classification of phenomena (Hage, 1972). The labeled concept specifies boundaries for selecting phe- nomena to observe and for reasoning about the phenom- ena of interest. New concepts may focus attention on new

Data from Chinn & Kramer, 2011; Hage, 1972; Reynolds, 1971

TABLE 3-2 Concepts: Abstract versus Concrete

Abstract Concepts Concrete Concepts

Transport Stretcher, wheelchair, hospital bed

Cardiovascular disease Stroke, myocardial infarction

Telemetry Electrocardiogram, Holter monitor

Loss of relationship Divorce, widowhood

Nurse competency Cultural, nasogastric tube placement, medication administration

TABLE 3-3 Typology of Marital Status and Gender

Marital Status

Participants Single Married Divorced Widowed

Male 15 75 23 6

Female 25 72 41 13

Total 40 147 64 19

UNIT I Evolution of Nursing Theories26

phenomena or facilitate thinking about phenomena in a different way (Hage, 1972). Scholarly analysis of the con- cepts in nursing theories is a critical beginning step in the process of theoretical inquiry. The concept process con- tinues to flourish with many examples in the nursing lit- erature. See Table 3-4 for references to analyses carried out using different approaches.

Concept analysis is an important beginning step in the process of theory development to develop a con- ceptual definition. It is crucial that concepts are clearly defined to reduce ambiguity in the given concept or set of concepts. To eliminate perceived differences in meaning, explicit definitions are necessary. As the theory develops, theoretical and operational defini- tions provide the theorist’s meaning of the concept and the basis for the empirical indicators. For exam- ple, McMahon and Fleury (2012) published a concept analysis on wellness in older adults. Wellness in older adults was theoretically defined as wellness is a pur- poseful process of individual growth, integration of experience, and meaningful connection with others, reflecting personally valued goals and strengths, and resulting in being well and living values. The concept of wellness in older adults was operationalized as an ever changing process of becoming, integrating, and relating.

Theories are tested in reality; therefore, the con- cepts must be linked to operational definitions that

relate the concepts to observable phenomena specify- ing empirical indicators. Table 3-5 provides examples of concepts with their theoretical and operational definitions. These linkages are vital to the logic of the theory, its observation, and its measurement.

The concept-building process emerges from prac- tice, incorporating the literature and research findings from multiple disciplines. Concepts are built into a conceptual framework and are further refined. A 10-phase process for concept building is described in the literature (Smith & Liehr, 2008; Smith & Liehr, 2012). The process of concept building is guided by patient stories. The 10 phases are as follows: (1) write a meaningful practice story; (2) name the central phe- nomenon in the practice story; (3) identify a theoretical lens for viewing the phenomenon; (4) link the phenom- enon to existing literature; (5) gather a story from some- one who has lived the phenomenon; (6) reconstruct the shared story (from Phase 5) and create a mini-saga that captures its message; (7) identify the core qualities of the phenomenon; (8) use the core qualities to create a definition; (9) create a model of the phenomenon; and (10) write a mini-synthesis that integrates the phe- nomenon with a population to suggest a research direc- tion. The process, which provides the scaffolding for beginning scholars to move from the familiarity of practice to the unfamiliarity of phenomena for research, will be shared with brief examples that demonstrate

TABLE 3-4 Examples of Published Concept Analyses with Different Approaches

Concept Approach Author

Spirituality Chinn & Kramer Buck (2006)

Readiness to change Chinn & Kramer Dalton & Gottlieb (2003)

Acculturation Morse Baker (2011)

Ethical sensitivity Morse Weaver, Morse, & Mitcham (2008)

Disability and aging Rodgers Greco & Vincent (2011)

Moral distress in neuroscience nursing Rodgers Russell (2012)

Symptom perception Schwartz-Barcott & Kim Posey (2006)

Being sensitive Schwartz-Barcott & Kim Sayers, K., & de Vries, K. (2008)

Work engagement in nursing Walker & Avant Bargagliotti (2012)

Migration Walker & Avant Freeman, Baumann, Blythe, Fisher, & Akhtar-Danesh (2012)

Infant distress Wilson method Hatfield & Polomano (2012)

Social justice Wilson method Buettner-Schmidt & Lobo (2012)

CHAPTER 3 Theory Development Process 27

potential and lessons learned in nearly a decade of use (Smith & Liehr, 2012, p. 65).

Relational Statements Statements in a theory may state definitions or rela- tions among concepts. Whereas definitions provide descriptions of the concept, relational statements pro- pose relationships between and among two or more concepts. Concepts are the building blocks of theory, and theoretical statements are the chains that link the blocks to build theory. Concepts must be connected with one another in a series of theoretical statements to devise a nursing theory.

In the connections between variables, one vari- able may be proposed to influence a second. In this case, the first variable may be viewed as the anteced- ent or determinate (independent) variable and the second as the consequent or resultant (dependent) variable (Giere, 1997). Zetterberg (1966) concluded that the development of two-variate theoretical statements could be an important intermediate step

in the development of a theory. These statements can be reformulated later as the theory evolves or as new information becomes available. An example of an antecedent and a consequent variable is explained looking at the concept of well in older adults, where the antecedents were identified as connecting with others, imagining opportunities, recognizing strengths, and seeking meaning. The consequences identified were living values and being well. These antecedents and consequences were developed from the literature (McMahon & Fleury, 2012).

Theoretical assertions are either a necessary or suf- ficient condition, or both. These labels characterize conditions that help explain the nature of the relation- ship between two variables in theoretical statements. For example, a relational statement expressed as a sufficient condition could be: If nurses react with approval of patients’ self-care behaviors (NA), patients increase their efforts in self-care activities (PSC). This is a type of compound statement linking antecedent and consequent variables. The statement does not assert

TABLE 3-5 Examples of Theoretical and Operational Definitions

Concept Theoretical Definition Operational Definition

Body temperature Homeothermic range of one’s internal environment maintained by the thermoregulatory system of the human body

Degree of temperature measured by oral thermometer taken for 1 minute under the tongue

Quality of Life Perceptions of the effects of heart failure and its treatment on daily life*

The physical, emotional, social, and mental dimensions of daily life when diagnosed with heart failure as measured with the Minnesota Living with Heart Failure Questionnaire†

Spirituality A pandimensional awareness of the mutual human/environmental field process (integrality) as a manifestation of higher-frequency patterning (resonancy) associated with innovative, increasingly creative and diverse (helicy) experiences‡

Score on the Spiritual Inventory Belief Scale (SIBS), an instrument that measures a person’s spirituality as the search for meaning and purpose§

The SIBS has four subscales: 1) Internal/fluid 2) Humility/personal application 3) External/meditative 4) External/ritual¶

*Hussey & Hardin, 2003. †Rector & Cohen, 1992. ‡Malinski, 1994. §Hatch, Burg, Naberhaus, & Hellmich, 1998. ¶Hardin, Hussey, & Steele, 2003.

UNIT I Evolution of Nursing Theories28

the truth of the antecedent. Rather, the assertion is made that if the antecedent is true, then the conse- quent is true (Giere, 1979). In addition, no assertion appears in the statement explaining why the anteced- ent is related to the consequent. In symbolic notation form, the statements may be expressed as:

NA PSC

(Antecedent/determinant Consequent/ resultant)

A sufficient condition asserts that one variable results in the occurrence of another variable. It does not claim it is the only variable that can result in the occurrence of the other variable. This statement asserts that nurse approval of a patient’s self-care behaviors is sufficient for the occurrence of the patient’s self-care activities. However, patient assumption of self-care activities resulting from other factors, such as the patient’s health status and personality variables, is not ruled out. There may be other antecedent con- ditions sufficient for the patient’s assumption of self- care activities.

A statement in the form of a necessary condition asserts that one variable is required for the occur- rence of another variable. For example: If patients are motivated to get well (WM 5 wellness motivation) then they adhere to their prescribed treatment regi- men (AR).

WM AR

This means that adherence to a treatment regimen (AR) never occurs unless wellness motivation (WM) occurs. It is not asserted that the patients’ adherence to the treatment regimen stems from their wellness motivation. However, it is asserted that if the wellness motivation is absent, patients will not assume strict adherence to their treatment regimens. The wellness motivation is a necessary, but not a sufficient, condi- tion for the occurrence of this consequent.

The term if is generally used to introduce a suffi- cient condition, whereas only if and if . . . then are used to introduce necessary conditions (Giere, 1979). Usually conditional statements are not both necessary and sufficient. However, it is possible for a statement to express both conditions. In such instances, the term if and only if is used to imply that conditions are both necessary and sufficient for one another. In this

case, (1) the consequent never occurs in the absence of the antecedent and (2) the consequent always occurs when the antecedent occurs (Giere, 1979). It should be noted that not all conditional statements are causal. For example, “If this month is November, then the next month is December,” does not assert that November causes December to occur; rather, the sequence of months suggests that December follows November (Dubin, 1978; Giere, 1979).

Giere (1997) further differentiates deterministic models from probabilistic models in his discussion of causal statements. Theoretical statements from a de- terministic model assert that the presence or absence of one variable determines the presence or absence of a second variable. The probabilistic model is another approach that views humans as complex social and environmental phenomena best conceptualized from a probability framework. Probabilistic statements generally are based on statistical data and assert relationships between variables that do not occur in every instance, but are likely to occur based on some estimate of probability. As an example, it has been asserted that a lack of exercise may lead to obesity, a growing national health problem. It is clear that a lack of exercise (LE) does not always lead to obesity, be- cause not all couch potatoes become medically obese (MO). However, the probability of developing medi- cal obesity (P MO) may be increased for persons who routinely avoid exercise at least to some degree of probability. In symbolic notation:

IF LE P MO

Relational statements that assert connections between variables provide for analysis and establish a basis for explanation and prediction (Hage, 1972).

Linkages and Ordering Specification of linkages is a vital part of the develop- ment of theory (Hage, 1972). Although the theoretical statements assert connections between concepts, the rationale for the stated connections must be developed and clearly presented. Development of theoretical link- ages provides an explanation of why the variables are connected in a certain manner; that is, the theo- retical reason for particular relationships (Hage, 1972). Operational linkages contribute testability to the theory by specifying how measurement variables are connected (Hage, 1972). Operational definitions

CHAPTER 3 Theory Development Process 29

specify the measurability of the concepts, and opera- tional linkages provide the testability of the assertions. It is the operational linkages that contribute a perspec- tive for understanding the nature of the relationship between concepts, to know whether the relationship between the concepts is negative or positive, linear, or curvilinear (Hage, 1972). A theory may be considered fairly complete if it presents the concepts, definitions, relational statements, and linkages. Complete develop- ment of a theory, however, requires organizing the concepts, definitions, relational statements, and link- ages into premises and hypotheses (Hage, 1972). A premise is a proposition upon which an argument is based or from which a conclusion is drawn. A hypoth- esis is a proposed explanation made on the basis of limited evidence as a starting point for further investi- gation. As the theory evolves, concepts and theoretical statements are developed establishing a logical organi- zation of the theory components. The conceptual ar- rangement of statements and linkages into premises reveals any areas of inconsistency (Hage, 1972). Prem- ises (or axioms) are the more general assertions from which the hypotheses are derived. It is generally agreed that conceptual ordering of theoretical statements and their linkages is indicated when the theory contains a logical list of theoretical statements.

Reynolds (1971) describes three forms for organiz- ing theory: laws, theory, and causal process (prediction). Each is a different conceptual approach to organization with different limitations. Establishing a set of laws or- ganizes findings from available research in an area of particular interest from the literature for evaluation. Findings are evaluated and sorted into the categories of laws and hypotheses based on the degree of research evidence supporting each assertion (Reynolds, 1971). Limitations to the set-of-laws approach to theory building have been noted.

First, the nature of research requires focusing on the relationships between a limited set of variables, therefore attempts to develop a set-of-laws theory from statements of findings may result in a lengthy number of statements asserting relationships between but limited to two or more variables. The lengthy set of generalizations may be difficult to organize and interrelate. Second, for research to be conducted, con- cepts must be operationally defined so they can be measurable. Therefore, the reported empirical findings may eliminate the abstract or theoretical

concepts that are necessary to understand the phe- nomenon of interest (Foster, 1997).

Reynolds (1971) concluded that the set-of-laws approach provides for classification of phenomena or prediction of relationships between selected variables, however it does not further understanding or advance science since it is based on what is already known. Finally, Reynolds (1971) notes that each statement or law is considered to be independent, since the various statements have not been interrelated into a system of description and explanation or evolved from an organized conceptual model or framework. Table 3-6 describes the principles of theory develop- ment: laws, hypotheses, and theory. Therefore, each statement must be tested since the statements are not interrelated, and one statement does not provide support for another statement. This set of laws may be useful to begin theory development; however, research efforts must be more extensive.

The organizationof a theory is an interrelated, logi- cal system. Specifically, a theory consists of explicit definitions, a set of concepts, a set of existence state- ments, and a set of relationship statements arranged in hierarchical order (Reynolds, 1971). The concepts may include abstract, intermediate concepts, and concrete concepts. The set-of-existence statements describe situations in which the theory is applicable. Statements that delineate the boundaries describe the scope of the theory (Dubin, 1978; Hage, 1972;

TABLE 3-6 Theory Development Principles

Principle Definition Proof

Scientific laws

A statement of fact meant to describe an action or a set of actions.

Simple, true, universal, and absolute

Hypothesis An educated guess based upon observation

Has not been proved

Theory One or more hypotheses that explains a set of related observations or events and has been verified multiple times

Accepted at true and proved

UNIT I Evolution of Nursing Theories30

Reynolds, 1971). Relational statements consist of axioms and propositions. Abstract, theoretical state- ments, or axioms, are at the top of the hierarchy of relational statements. The other propositions are developed through logical deduction from the axioms or from research findings in the literature (Table 3-7). This results in a highly interrelated, explanatory system.

Theorists avoid the problem of contradictory axi- oms by using a conceptual system with a few broad axioms from which a set of propositions are derived. The seven nursing conceptual models (Unit III, Chapters 12 to 18) in this text are examples of frameworks with broad axioms from which theory may be developed. As science progresses and new empirical data are known, the general axioms may be modified or extended. Examples of this type of extension are some of the nursing theories and middle-range theories that were developed using a nursing conceptual model as their broad axioms. However, these additions must be consistent with the logical system of the model and not include con- tradictions in the theory, or the theory will be re- jected (Schlotfeldt, 1992). New theories may also subsume portions of previous theories as special cases (Brown, 1977). Einstein’s theory of relativity

incorporating Newton’s law of gravitation is a classic example. Axiomatic theories (theories with equations) are less common in the social and behavioral sci- ences, but they are quite evident in the fields of phys- ics and mathematics.

Developing theories in axiomatic form has several advantages (Reynolds, 1971; Salmon, 1973). First, because theory is a set of interrelated statements in which some statements derive from others, only con- cepts to be measured need to be operationally de- fined (Reynolds, 1971). This allows the theorist to incorporate highly abstract less measurable concepts to provide explanation. The theoretical system also may be more efficient for explanation than a lengthy number of theoretical statements in the form of laws. In addition, empirical support for one theoretical statement may be based on findings of support from earlier research, thereby permitting less extensive research than the requirement to test each statement in the laws form. In certain instances, the theory may be organized in a causal process form to increase understanding and substantiate findings.

The distinguishing feature of the causal process form of theory development is the theoretical state- ments that specify causal mechanisms between inde- pendent and dependent variables. Hence, the states

TABLE 3-7 Theory Development in the Scientific Method

Steps Example

Observation: Start with an observation that evokes a question.

Autotransfusion is time-consuming for nurses caring for total knee replacement patients.

Logical hypothesis: Using abductive, inductive, or deductive logic, state a possible answer (hypothesis).

Autotransfusion patients have a higher hemoglobin level at discharge than allogenic blood recipients.

Testing: Perform an experiment or test. Autotransfusion use results in an increased hemoglobin level at discharge.

Dissemination: Publish your findings for the discipline. Poulin-Tabor, D., & Hyrkas, K. (2008). Evaluation of postoperative blood salvage and re-transfusion in a total knee arthoplasty patient population: A retrospective study. MEDSURG Nursing, 17(5), 317-321.

Replication: Other scientists will read your published work and try to duplicate it (verification).

Faber, F. C., & Hardin, S. R. (2010). Outcomes of knee replacement patients using autotransfusion. Orthopedic Nursing, 29(5), 333-337.

Findings: No significant difference in hemoglobin

Theory: If experiments from other researchers support your hypothesis, it will become a theory.

No theory

CHAPTER 3 Theory Development Process 31

are to some degree attempting to predict. This form of theory organization consists of a set of concepts, a set of definitions, a set of existence statements, and a set of theoretical statements specifying a causal pro- cess (Reynolds, 1971). Concepts include abstract and concrete ideas. Existence statements function as they do in axiomatic theories to describe the scope condi- tions of the theory; that is, the assumed situations where the theory applies (Dubin, 1978; Hage, 1972; Reynolds, 1971). Causal statements specify the hy- pothesized effects of one variable upon one or more other variables for testing. In complex causal pro- cesses, feedback loops and paths of influence through several variables are hypothesized in a set of interre- lated causal statements (Mullins, 1971; Nowak, 1975). Reynolds (1971) concludes that the causal process form of theory provides for testing an explanation of the process of how events happen. He identified several advantages of the causal process form of orga- nization. First, like axiomatic theory, it provides for highly abstract, theoretical concepts. Second, like axiomatic theory, this form permits more efficient research testing with its interrelated theoretical state- ments. Finally, the causal process statements provide a sense of understanding in the phenomenon of inter- est that is not possible with other forms. This is a

highly developed form of theory development that builds successively on previous research findings in the researchers’ area of research with extensive theory building and testing over time. Figure 3-1 displays a causal model for testing a theory of active coping. The broken lines show direction of expected linkage. The dotted lines indicate potential new relationships. The arrows indicate the direction of cause that is pre- dicted in the hypotheses of the study. The numbers along the lines identify previous studies that lend sup- port for the relationships being proposed.

Contemporary Issues in Nursing Theory Development

Theoretical Boundaries and Levels to Advance Nursing Science Since Fawcett’s (1984) seminal proposal of the four metaparadigm concepts: person, environment, health, and nursing, general agreement has emerged among nursing scholars such that the proposed framework is now used without reference to the author for the development of nursing science. In general, a metapar- adigm should specify the broad boundaries of the phenomenon of concern in a discipline, for example, to set nursing apart from other disciplines, such as

Passive/ avoidance

coping

Psychological distress

Perceived stress

Active coping

Conflicts

Available/ enacted

social support

1,2,3,4 (+)

1,2,3,4 (+)

1,2,3 (+)

1,2,3 (+)

1,2,3 (+) 1,3 (+)

1,2,3 (+)

1,2,4 (+)

FIGURE 3-1 Causal model of active coping. (From Ducharme, F., Ricard, N., Duquette, A., & Lachance, I. (1998). Empirical testing of a longitudinal model derived from the Roy Adaptation Model. Nursing Science Quarterly, 11(4), 149–159.)

UNIT I Evolution of Nursing Theories32

medicine, clinical exercise physiology, or sociology. Fawcett (2005) proposed that a metaparadigm defines the totality of phenomena inherent in the discipline in a parsimonious way, as well as being perspective- neutral and international in scope. Her definition of perspective-neutral is that the metaparadigm con- cepts reflect nursing but not any particular nursing conceptual model or paradigm. This criterion is clearly illustrated as the nursing models and para- digms include the metaparadigm concepts but define each in distinctly different ways. This supports their generic nature as broad metaparadigm concepts but with specificity within each conceptual theory or paradigm. It is important to grasp the significance of Fawcett’s point. Since the metaparadigm is the highly philosophical level in the structure of knowledge, models and theories define the terms specifically within each of their works, and differences among them is anticipated. Thorne and colleagues (1998) pro- posed that it was not productive to continue metapara- digm debates about which conceptual system should define these concepts, and that each conceptual model is labeled as a nursing conceptual model because it clearly addresses each metaparadigm concept, though from different philosophical perspectives. Scholarly debates are expected to continue among doctoral stu- dents and communities of scholars engaged in scholar- ship and inquiry. Discussions in the nursing discipline and approaches to nursing knowledge are anticipated as nurses address dynamic social obligations, tentative- ness of theory, and new developments as the discipline advances (Monti & Tingen, 1999).

Viewing the metaparadigm from different cultural perspectives enhances our understanding and expands our ideas as the discipline develops globally. For example, the work conducted by Kao, Reeder, Hsu, & Cheng (2006) proposes a Chinese view of the western nursing paradigm through the lens of Confucianism and Taoism. The concept of person is more than a bio- psycho-social spiritual being, but also encompasses being responsibility bound. Health includes the flow of qi, yin-yang, and the five phases: wood, water, fire, metal, and earth. The challenge in knowledge develop- ment is to learn how to consider nursing phenomena through many lenses and to enhance the development of knowledge and improve nursing of people around the globe.

In the discipline of nursing, the earlier focus on theory development has evolved to an emphasis on theory utilization with development and use of middle-range theories focused at the practice level (Acton, Irvin, Jensen, Hopkins, & Miller, 1997; Good, 1998; Im & Meleis, 1999; Lawson, 2003; Liehr & Smith, 1999; Smith & Liehr, 2008; Smith & Liehr, 2002). Situation-specific theories (the term preferred by Meleis, 2007) are applicable to a nursing problem or specific group of patients. An integrative approach to situation-specific theories is summarized as involving four broad interrelated steps: checking assumptions for theory development, exploring the phenomenon through multiple sources, theorizing, and reporting/ validating (Im, 2005, 2006).

Middle-range theory was described very early in the nursing literature by a sociologist (Merton, 1967). He proposed that it focused on specific phenomena (rather than attempting to address a broader range of phenomena) and was comprised of hypotheses with two or more concepts that are linked together in a conceptual system. Today in the nursing literature, many middle-range theories are developed qualita- tively from practice observations and interviews and quantitatively from nursing conceptual models or theories. Middle-range theory is pragmatic at the practice level and contains specific aspects about the practice situation as follows: • The situation or health condition involved • Client population or age-group • Location or area of practice (such as community) • Action of the nurse or the intervention

It is these specifics that make middle-range theory so applicable to nursing practice (Alligood, 2010, p. 482). Therefore, the development of middle-range theory facilitates conceptions of relationships be- tween theory, nursing practice, and patient outcomes in focused areas. In 1996, Lenz (in Liehr & Smith, 1999) identified the following six approaches for devising middle-range theories: 1. Inductive approach through research 2. Deductive approach from grand nursing theories 3. Integration of nursing and non-nursing theories 4. Derivative (retroductive) approach from non-nursing

theories 5. Theories devised from guidelines for clinical practice 6. Synthesis approach from research findings

CHAPTER 3 Theory Development Process 33

Liehr and Smith (1999) reviewed 10 years of nurs- ing literature on middle-range theories from 1985 and 1995 and located 22 middle-range theories that could be categorized in five approaches to theory building. They did not identify any theories devised by simply synthesizing research findings.

The nursing literature abounds with a range of different approaches to middle-range theory build- ing and development. The recent nursing literature emphasizes the importance of relating middle-range theories to broader nursing theories and paradigms and continuing to pursue empirical testing and the replication of studies to advance nursing knowledge. Fahs, Morgan, and Kalman (2003) have called for the replication of research studies to ensure that nursing scholars can provide “a (reliable) research- to-practice link” . . . that (provides) “safe, effective, quality care to consumers” (p. 70). Middle-range theories have essentially grown over the last 10 years with textbooks into their second editions (Peterson, 2008; Sieloff & Frey, 2007; Smith & Liehr, 2008) and being taught in graduate education for theory-based practice.

Numerous authors have proposed criteria to evalu- ate theories (Chinn & Kramer, 2011; Fawcett, 2005; Meleis, 2007; Parker, 2006). They reflect the importance of nursing knowledge to the future of the discipline and some diversity in approaches. Is the theory relevant, significant, or functional to the discipline of nursing? Chapter 1 presents the criteria used for analysis of the- ory in this text (Chinn & Kramer, 2011).

Nursing Theory, Practice, and Research Theory-testing research may lead one nursing theory to fall aside as new theory is developed that explains nursing phenomena more adequately. Therefore, it is critical that theory-testing research continues to ad- vance the discipline. Nursing scholars have presented criteria for evaluating theory-testing research in nursing (Silva, 1986; Acton, Irvin, & Hopkins, 1991). These criteria emphasize the importance of using a nursing framework to design the purpose and focus of the study, to derive hypotheses, and to relate the significance of the findings back to nursing. In addi- tion to the call for more rigorous theory-testing re- search in nursing, nursing scholars and practitioners call for increased attention to the relationships among

theory, research, and practice. Their recommenda- tions include the following: • Continued development of nursing theories that

are relevant to nurses’ specialty practice • Increased collaboration between scientists and

practitioners (Lorentzon, 1998) • Encouraging nurse researchers to communicate

research findings to practitioners • Increased efforts to relate middle-range theories to

nursing paradigms • Increased emphasis on clinical research • Increased use of nursing theories for theory-based

practice and clinical decision making (See Chinn and Kramer, 2011; Cody, 1999; Hoffman

and Bertus, 1991; Liehr and Smith, 1999; Lutz, Jones, & Kendall, 1997; Reed, 2000; and Sparacino, 1991.)

Within education, some use one theory guiding nurs- ing curricula, however others utilize a framework of the metaparadigm. Malinski (2000) and others have urged increased attention to nursing theory–based research and strengthening of nursing theory–based curricula, especially in master’s and doctoral programs.

Regarding the use of nursing knowledge in clinical practice, Cody asserted, “It is a professional nurse’s ethical responsibility to utilize the knowledge base of her or his discipline” (1997, p. 4). In 1992, in the first issue of the journal Clinical Nursing Research, Schlotfeldt stated the following:

“It will be nursing’s clinical scholars . . . that will identify the human phenomena that are central to nurses’ practice . . . and that provoke consider- ation of the practice problems about which knowledge is needed but is not yet available. It is nursing’s clinical scholarship that must be de- pended on to generate promising theories for testing that will advance nursing knowledge and ensure nursing’s continued essential services to humankind.”

(Schlotfeldt, 1992, p. 9)

In summary, contemporary nursing scholars are emphasizing the following in theory-building processes: • Continued development of theoretical inquiry in

nursing • Continued scholarship with middle-range theories

and situation-specific theories, including efforts to relate to nursing theories and paradigms

UNIT I Evolution of Nursing Theories34

• Greater attention to synthesizing nursing knowledge • Development of stronger nursing theory-research-

practice linkages The discipline of nursing has evolved to an un-

derstanding of the relationships among theory, prac- tice, and research that no longer separates them into distinct categories. Rather, their complementary in- terrelationships foster the development of new un- derstanding about practice as theory is used to guide practice and practice innovations drive new-middle range theory. Similarly, nurse scientists have reached

a new understanding of the relationship of theory to research as quantitative study reports include explicit descriptions of their frameworks and quali- tative researchers interpret their findings in the con- text of nursing frameworks. The complementary nature of these relationships is fostering nursing sci- ence growth in this theory utilization era. So the chapter concludes as it began. Emphasis on theory is important because theory development in nursing is an essential component in nursing scholarship to advance the knowledge of the discipline.

POINTS FOR FURTHER STUDY

n Kaplan, A. (1964). The conduct of inquiry: Methodology for behavioral science. New York: Chandler.

n Mullins, N. (1971). The art of theory: Construction and use. New York: Harper & Row.

n Wilson, J.(1969). Thinking with concepts. Cambridge: Cambridge University Press.

n Webber, P. B. (2008). Yes, Virginia, nursing does have laws. Nurse Science Quarterly, 21(1), 68–73.

n Classic References n Dubin, R. (1978). Theory building. New York: Free

Press. n Hage, J. (1972). Techniques and problems of theory

construction in sociology. New York, Wiley.

CRITICAL THINKING ACTIVITY

a piece of paper and draw a building. At the foundation of the building, write paradigm. Label the walls conceptual models. Conceptual models are the structure supported by the foundational paradigm. Then color the interior walls inside the building and label this theory. Theories are similar to interior wall configuration. Some configurations have a clear purpose, and others do not. All interior walls are bound by outside walls (conceptual models) and supported by the foundation (paradigm). Draw the inside of a room with all of its décor. The unique concepts of theories are similar to the unique aspects of the décor. The décor are observable as are the concepts of a conceptual model.$

1. Show a photograph from the John A. Hartford Foundation website, available at http://www. bandwidthonline.org/images.asp. Look at the photograph for a minute, and ask yourself, What do I see? Make a list. Come back to the photo a second time, and ask yourself if this list is accurate. Then ask yourself what question comes to mind when looking at the photo. What is missing from the photo? What is missing from the situation? How did the situation in the photo occur and why? Each type of question will lead to different types of thinking.#

2. Move thinking from dualist to contextual with this exercise. Use the analogy of a building. Take

#Hanna, D.R. (2011). Teaching theoretical thinking for a sense of salience. Journal of Nursing Education, 50(8) 479–482. $Duff, E. (2011). Relating the nursing paradigm to practice: a teaching strategy. International Journal of Nursing Education Scholarship, 1(11), 1–8.

CHAPTER 3 Theory Development Process 35

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REFERENCES

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38

The Structure of Specialized Nursing Knowledge

Martha Raile Alligood

CH A P T ER 4

logical presentation. Early works that predate the nursing theory era, such as Nightingale (1969/1859), contributed to knowledge development by providing direction or a basis for subsequent developments. Later works reflect contemporary human science and its methods (Alligood, 2010a; Chinn & Kramer, 2011; Meleis, 2007). Selected works classified as nursing philosophies are presented in Unit II, Chapters 6 to 11.

A second type, nursing conceptual models, comprises nursing works by theorists referred to by some as pio- neers in nursing (Chinn & Kramer, 2011; Fawcett, 2005; Meleis, 2007). Fawcett (2005) explains, “A conceptual model provides a distinct frame of reference for its

This chapter presents the structure for specialized nursing knowledge used for the organization of the units of this text. As presented in Chapter 1, the requirement for a body of specialized knowledge for recognition of nursing as a profession was a driving force in the twentieth century. Because of the impor- tance of nurses to the nation’s health, early in the twentieth century, studies of nursing were legislated and conducted by sociologists who recommended that nursing be developed as a profession. The criteria for a profession provided guidance in this process (Bixler & Bixler, 1959; Kalish & Kalish, 2003). The criterion that called for specialized nursing knowledge and knowl- edge structure was a particularly important driving force in recognition of nursing as a profession (Bixler & Bixler, 1959). The criterion reads:

Utilizes in its practice a well-defined and well- organized body of specialized knowledge [that] is on the intellectual level of the higher learning (p. 1143).

The types of knowledge, levels, and examples of each are included in Table 4-1. The theoretical works presented in Chapters 6 to 36 are nursing frameworks organized into four types. Box 4-1 lists the theorists included in each type. The placement of works within the four types reflects a level of abstraction or the preference of the theorist.

The first type is nursing philosophy. Philosophy is the most abstract type and sets forth the meaning of nursing phenomena through analysis, reasoning, and

TABLE 4-1 Knowledge Structure Levels with Examples

Structure Level Example

Metaparadigm Person, environment, health, and nursing

Philosophy Nightingale

Conceptual models

Neuman’s systems model

Theory Neuman’s theory of optimal client stability

Middle-range theory

Maintaining optimal client stability with structured activity (body recall) in a community setting for healthy aging

Modified from Alligood, M. R. (2010). Nursing theory: Utilization & applica- tion (4th ed.). St. Louis: Mosby; and Fawcett, J. (2005). Contemporary nursing knowledge: Conceptual models of nursing and nursing theories (2nd ed.). Philadelphia: F. A. Davis.

CHAPTER 4 The Structure of Specialized Nursing Knowledge 39

where she derives a theory of the person as an adaptive system from her Adaptation model. The abstract level of Roy’s theory in this example facilitates derivation of many middle-range theories specific to nursing prac- tice from it (Alligood 2010b; 2010c). Theories may be specific to a particular aspect or setting of nursing practice. Another example is Meleis’s transition theory (Chapter 20) that is specific to changes in a person’s life process in health and illness. Nursing theories are presented in Unit IV, Chapters 19 to 26.

The fourth type, middle-range theory, has the most specific focus and is concrete in its level of abstraction (Alligood 2010b, 2010c; Chinn & Kramer, 2011; Fawcett, 2005). Middle-range theories are precise and answer specific nursing practice questions. They address the specifics of nursing situations within the perspective of the model or theory from which they are derived (Alligood, 2010a, 2006b; Fawcett, 2005; Wood, 2010). The specifics are such things as the age group of the patient, the family situation, the patient’s health condi- tion, the location of the patient, and, most importantly,

adherents . . . that tells them how to observe and inter- pret the phenomena of interest to the discipline” (p. 16). The nursing models are comprehensive, and each addresses the metaparadigm concepts of person, envi- ronment, health, and nursing (Fawcett, 1984; 2000; 2005). The nursing conceptual models have explicit theories derived from them by the theorist or other nurse scholars and implicit theories within them yet to be developed (Alligood, 2010b; Wood, 2010). Works classified as nurs- ing models are in Unit III, Chapters 12 to 18.

The third type, nursing theory, comprises works derived from nursing philosophies, conceptual models, abstract nursing theories, or works in other disciplines (Alligood, 2010a; Wood, 2010). A work classified as a nursing theory is developed from some conceptual framework and is generally not as specific as a middle-range theory. Although some use the terms model and theory interchangeably, theories dif- fer from models in that they propose a testable action (Alligood 2010a; 2010b; Wood, 2010). An example of theory derived from a nursing model is in Roy’s work,

Nursing Philosophies Nightingale Watson Ray Benner Martinsen Eriksson

Nursing Conceptual Models Levine Rogers Orem King Neuman Roy Johnson

Nursing Theories Boykin and Schoenhofer Meleis Pender Leininger Newman Parse Erickson, Tomlin, and Swain Husted and Husted

Middle-Range Nursing Theories Mercer Mishel Reed Wiener and Dodd Eakes, Burke, and Hainsworth Barker Kolcaba Beck Swanson Ruland and Moore

BOX 4-1 Types of Nursing Theoretical Works

UNIT I Evolution of Nursing Theories40

the action of the nurse (Alligood, 2010a; Wood, 2010). There are many examples of middle-range theories in the nursing literature that have been developed induc- tively as well as deductively. Selected middle-range theo- ries are presented in Unit V, Chapters 27 to 36.

Over the years since the first edition of Nursing Theorists and Their Work (1986), the volume of theo- retical works has expanded considerably. There are nurses who made significant contributions during the pre-paradigm period of nursing knowledge develop- ment (Hardy, 1978). References to early works in the literature became increasingly limited in spite of their

important contributions to the development of special- ized nursing knowledge. Therefore, in the 6th edition of this text (2006), exemplars from that early develop- ment began to be recognized for their significant contributions to nursing knowledge development. This unit on the Evolution of Nursing Theoretical Works concludes with ten exemplars of early theoretical work of historical significance presented in Chapter 5 (Box 4-2). Those who are interested in learning more about these early nursing pioneers or any theorist’s work included in this text are referred to the their original publications.

Hildegard E. Peplau 1909 to 1999 Virginia Henderson 1897 to 1996 Faye Glenn Abdellah 1919 to present Earnestine Wiedenbach 1900 to 1996 Lydia Hall 1906 to 1969 Joyce Travelbee 1926 to 1973 Kathryn E. Barnard 1938 to present Evelyn Adam 1929 to present Nancy Roper* 1918 to 2004 Winifred Logan* Alison J. Tierney* Ida Jean Orlando Pelletier 1926 to 2007

BOX 4-2 Early Theorists of Historical Significance

*Roper, Logan, and Tierney collaborated on The Roper-Logan-Tierney Model of Nursing: Based on Activities of Living (2000).

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Fawcett, J. (1984). The metaparadigm of nursing: current status and future refinements. Image: The Journal of Nursing Scholarship, 16, 84–87.

Fawcett, J. (2000). Contemporary nursing knowledge: Conceptual models of nursing and nursing theories. Philadelphia: F. A. Davis.

Fawcett, J. (2005). Contemporary nursing knowledge: Conceptual models of nursing and nursing theories (2nd ed.). Philadelphia: F. A. Davis.

CHAPTER 4 The Structure of Specialized Nursing Knowledge 41

Hardy, M. E. (1978). Perspectives on nursing theory. Advances in Nursing Science, 1(1), 27–48.

Kalisch, P. A., & Kalisch, B. J. (2003). American nursing: A history (4th ed.). Philadelphia: Lippincott.

Marriner, A. (1986). Nursing theorists and their work. St. Louis: Mosby.

Meleis, A. (2007). Theoretical nursing: Development and progress (4th ed.). Philadelphia: Lippincott.

Nightingale, F. (1969). Notes on nursing: What it is and what it is not. New Yark: Dover. (Originally published in 1859.)

Tomey, A. M., & Alligood, M. R. (2006). Nursing theorists and their work (6th ed.). St. Louis: Mosby-Elsevier.

Wood, A. F. (2010). Nursing models: normal science for nursing practice. In M. R. Alligood (Ed.), Nursing theory: Utilization & application (4th ed., pp. 17–46). Maryland Heights, (MO): Mosby-Elsevier.

4242

Kathryn E. Barnard 1938–present

Evelyn Adam 1929–present

Ernestine Wiedenbach 1900–1996

Lydia Hall 1906–1969

Faye Glenn Abdellah 1919–present

Joyce Travelbee 1926–1973

Nancy Roper 1918–2004

Virginia Henderson 1897–1996

Hildegard E. Peplau 1909–1999

43

“The idea of nursing, historically rooted in the care of the sick and in the provision of nurturance for those vulnerable to ill health, is foundational to the profession.”

(Wolf, 2006, p. 301)

Ida Jean (Orlando) Pelletier 1926–2007

Alison J. TierneyWinifred W. Logan

CH A P T ER 5

Nursing Theorists of Historical Significance Marie E. Pokorny

This chapter presents selected theorists who are noted for their development of nursing theory during the pre-paradigm period. They each represent an important contribution to the development of specialized nursing knowledge.

Hildegard E. Peplau

Theory of Interpersonal Relations Hildegard E. Peplau has been described as the mother of psychiatric nursing because her theoretical and clinical work led to the development of the distinct specialty field of psychiatric nursing. Her scope of influence in nursing includes her contributions as a psychiatric nursing expert, educator, author, and nursing leader and theorist.

Peplau provided major leadership in the profes- sionalization of nursing. She served as executive direc- tor and president of the American Nurses Association (ANA). She was instrumental in the ANA (1980) definition of nursing that was nursing’s declaration of a social contract with society in Nursing: A Social Policy Statement (Butts and Rich, 2011). She promoted professional standards and regulation through cre- dentialing. Peplau taught the first classes for gradu- ate psychiatric nursing students at Teachers College, Columbia University, and she stressed the importance of nurses’ ability to understand their own behavior to help others identify perceived difficulties. Her sem- inal book, Interpersonal Relations in Nursing (1952), describes the importance of the nurse-patient rela- tionship as a “significant, therapeutic interpersonal

Photo Credit (Joyce Travelbee): Louisiana State University Health Sciences Center, School of Nursing, New Orleans, LA. Previous author: Ann Marriner Tomey.

UNIT I Evolution of Nursing Theories44

resource person, teacher, leader, surrogate, and coun- selor (Figure 5-3).

Peplau had professional relationships with others in psychiatry, medicine, education, and sociology that influenced her view of what a profession is and does and what it should be (Sills, 1998). Her work was influenced by Freud, Maslow, and Sullivan’s interpersonal relationship theories, and by the con- temporaneous psychoanalytical model. She bor- rowed the psychological model to synthesize her Theory of Interpersonal Relations (Haber, 2000). Her work on nurse-patient relationships is known well internationally and continues to influence nurs- ing practice and research. Recent publications using her model include research in staff-student relation- ships (Aghamohammadi-Kalkhoran, Karimollahi & Abdi, 2011), psychiatric workforce development (Hanrahan, Delaney, & Stuart 2012), care of patients with attention-deficit/hyperactivity disorder (Keoghan, 2011), subject recruitment, retention and participation in research (Penckofer, Byrn, Mumby, & Ferrans, 2011), the practice environment of nurses working in inpatient mental health (Roche, Duffield & White, 2011), and therapeutic relationships between women with anorexia and health care professionals (Wright & Hacking, 2012). Peplau’s work is specific to the nurse- patient relationship and is a theory for the practice of nursing.

process” (p. 16) and is recognized as the first nursing theory textbook since Nightingale’s work in the 1850s. She discussed four psychobiological experiences that compel destructive or constructive patient responses, as follows: needs, frustrations, conflicts, and anxieties. Peplau identified four phases of the nurse-patient relationship: orientation, identification, exploitation, and resolution (Figure 5-1). diagrammed changing aspects of nurse-patient relationships (Figure 5-2), and proposed and described six nursing roles: stranger,

Patient: personal goals

Entirely separate goals and interests Both are strangers to each other

Individual preconceptions on the meaning of the medical problem, the roles of each in the problematic situation

Partially mutual and partially individual understanding of the nature of the medical problem

Mutual understanding of the nature of the problem, roles of nurse and patient, and requirements of nurse and patient in the solution of the problem Common, shared health goals

Collaborative efforts directed toward solving the problem together, productively

Patient

Nurse: professional goals

Nurse

FIGURE 5-2 ​Continuum​Showing​Changing​Aspects​of​Nurse-Patient​Relationships.​(From Peplau, H. E. [1952]. Interpersonal​relations​in​nursing. New York: Putnam.)

O rie

nt at

io n

Id en

tif ic

at io

n

E xp

lo ita

tio n

R es

ol ut

io n

On admission

During intensive treatment period

Convalescence and rehabilitation

Discharge

FIGURE 5-1 ​Overlapping​Phases​in​Nurse-Patient​Relationships.​ ​(From Peplau, H. E. [1952]. Interpersonal​ relations​ in​ nursing.​ New York: Putnam.)

CHAPTER 5 Nursing​Theorists​of​Historical​Significance 45

Virginia Henderson

Definition of Nursing Virginia Henderson viewed the patient as an individual who requires help toward achieving independence and completeness or wholeness of mind and body. She clarified the practice of nursing as independent from the practice of physicians and acknowledged her interpretation of the nurse’s role as a synthesis of many influences. Her work is based on (1) Thorndike, an American psychologist, (2) her experiences with the Henry House Visiting Nurse Agency, (3) experience in rehabilitation nursing, and (4) Orlando’s conceptual- ization of deliberate nursing action (Henderson, 1964; Orlando, 1961).

Henderson emphasized the art of nursing and pro- posed 14 basic human needs on which nursing care is based. Her contributions include defining nursing, delineating autonomous nursing functions, stressing goals of interdependence for the patient, and creating self-help concepts. Her self-help concepts influenced the works of Abdellah and Adam (Abdellah, Beland, Martin, & Matheney, 1960; Adam, 1980, 1991).

Henderson made extraordinary contributions to nursing during her 60 years of service as a nurse, teacher, author, and researcher, and she published extensively throughout those years. Henderson wrote three books that have become nursing classics: Textbook of the Principles and Practice of Nursing (1955), Basic Principles of Nursing Care (1960), and The Nature of Nursing (1966). Her major contribution to nursing research was an

11-year Yale-sponsored Nursing Studies Index Project published as a four-volume-annotated index of nursing’s biographical, analytical, and historical literature from 1900 to 1959.

In 1958, the nursing service committee of the Inter- national Council of Nurses (ICN) asked Henderson to describe her concept of nursing. This now historical definition, published by ICN in 1961, represented her final crystallization on the subject:

“The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recov- ery (or to peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge; and to do this in such a way as to help him gain independence as rapidly as possible”

(Henderson, 1964, p. 63).

Henderson’s definition of nursing was adopted subsequently by the ICN and disseminated widely; it continues to be used worldwide. In The Nature of Nursing: A Definition and Its Implications for Practice, Research, and Education, Henderson (1966) proposed 14 basic needs upon which nursing care is based (Box 5-1).

Henderson identified three levels of nurse-patient relationships in which the nurse acts as: (1) a substi- tute for the patient, (2) a helper to the patient, and (3) a partner with the patient. Through the interper- sonal process, the nurse must get “inside the skin” of each of her patients in order to know what help

Nurse:

Patient:

Phases in nursing relationship:

Stranger Unconditional Surrogate mother

Counselor Resource person Leadership Surrogate: Mother Sibling

Adult person

Stranger Infant Child Adult personAdolescent

Orientation Identification

Exploitation

Resolution

FIGURE 5-3 ​Phases​ and​Changing​Roles​ in​Nurse-Patient​Relationships.​ (From Peplau, H. E. [1952]. Interpersonal​relations​in​nursing. New York: Putnam.)

UNIT I Evolution of Nursing Theories46

is needed (Harmer and Henderson, 1955, p. 5). Although she believed that the functions of nurses and physicians overlap, Henderson asserted that the nurse works in interdependence with other health care professionals and with the patient. She illustrated the relative contributions of the health care team in a pie graph.

In The Nature of Nursing: Reflections after 25 Years, Henderson (1991) added addenda to each chapter of the 1966 edition with changes in her views and opin- ions. Henderson said of her theory that “the complex- ity and quality of the service is limited only by the imagination and the competence of the nurse who interprets it” (Henderson, 2006). Her theory has been applied to research in the specialized area of organ donation (Nicely & DeLario, 2011) and framed a discussion of remembering the art of nursing in a technological age (Henderson, 1980; Timmins 2011).

Henderson’s work is viewed as a nursing philosophy of purpose and function.

Faye Glenn Abdellah

Twenty-One Nursing Problems Faye Glenn Abdellah is recognized as a leader in the development of nursing research and nursing as a profession within the Public Health Service (PHS) and as an international expert on health problems. She was named a “living legend” by the American Academy of Nursing in 1994 and was inducted into the National Women’s Hall of Fame in 2000 for a lifetime spent establishing and leading essential health care pro- grams for the United States. In 2012, Abdellah was inducted into the American Nurses Association Hall of Fame for a lifetime of contributions to nursing (ANA News Release, 2012).

Abdellah has been active in professional nursing associations and is a prolific author, with more than 150 publications. During her 40-year career as a Commissioned Officer in the U.S. Public Health Ser- vice (1949 to 1989), she served as Chief Nurse Officer (1970 to 1987) and was the first nurse to achieve the rank of a two-star Flag Officer (Abdellah, 2004) and the first woman and nurse Deputy Surgeon General (1982 to 1989). After retirement, Abdellah founded and served as the first dean in the Graduate School of Nursing, GSN, Uniformed Services University of the Health Sciences (USUHS).

Abdellah considers her greatest accomplishment being able to “play a role in establishing a foundation for nursing research as a science” (p. iii). Her book, Patient-Centered Approaches to Nursing, emphasizes the science of nursing and has elicited changes throughout nursing curricula. Her work, which is based on the problem-solving method, serves as a vehicle for delineating nursing (patient) problems as the patient moves toward a healthy outcome.

Abdellah views nursing as an art and a science that mold the attitude, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help individuals cope with their health needs, whether they are ill or well. She formulated 21 nursing problems based on a review of nursing research studies (Box 5-2). She used Henderson’s 14 basic human needs (see Box 5-1) and nursing

​ 1.​ Breathe normally. ​ 2.​ Eat and drink adequately. ​ 3.​ Eliminate body wastes. ​ 4.​ Move and maintain desirable postures. ​ 5.​ Sleep and rest. ​ 6.​ Select suitable clothes; dress and undress. ​ 7.​ Maintain body temperature within a normal

range by adjusting clothing and modifying the environment.

​ 8.​ Keep the body clean and well groomed and protect the integument.

​ 9.​ Avoid dangers in the environment and avoid injuring others.

​10.​ Communicate with others in expressing emotions, needs, fears, or opinions.

​11.​ Worship according to one’s faith. ​12.​ Work in such a way that there is a sense of

accomplishment. ​13.​ Play or participate in various forms of

recreation. ​14.​ Learn, discover, or satisfy the curiosity that

leads to normal development and health, and use the available health facilities.

BOX 5-1 Henderson’s 14 Needs

From Henderson, V. A. (1991). The nature of nursing: Reflections after 25 years (pp. 22–23). New York: National League for Nursing Press.

CHAPTER 5 Nursing​Theorists​of​Historical​Significance 47

research to establish the classification of nursing problems.

Abdellah’s work is a set of problems formulated in terms of nursing-centered services, which are used to determine the patient’s needs. Her contribution to nursing theory development is the systematic analysis of research reports and creation of 21 nursing prob- lems that guide comprehensive nursing care. The typology of her 21 nursing problems first appeared in Patient-Centered Approaches to Nursing (Abdellah, Beland, Martin, & Matheney, 1960). It evolved into Preparing for Nursing Research in the 21st Century: Evolution, Methodologies, and Challenges (Abdellah & Levine, 1994). The 21 nursing problems progressed to a second-generation development referred to as patient problems and patient outcomes. Abdellah edu- cated the public on AIDS, drug addiction, violence,

smoking, and alcoholism. Her work is a problem- centered approach or philosophy of nursing. Abdellah’s papers are available at: http://www.nlm.nih.gov/hmd/ manuscripts/msc.html.

Ernestine Wiedenbach

The Helping Art of Clinical Nursing Ernestine Wiedenbach is known for her work in theory development and maternal infant nursing developed while teaching maternity nursing at the School of Nursing, Yale University. Wiedenbach taught with Ida Orlando at Yale University and wrote with philosophers Dickoff and James a classic work on theory in a practice discipline that is used by those studying the evolution of nursing theory (Dickoff, James, & Wiedenbach, 1968). She directed

​ 1.​ To maintain good hygiene and physical comfort ​ 2.​ To promote optimal activity: exercise, rest, sleep ​ 3.​ To promote safety through prevention of accident, injury, or other trauma and through prevention of

the spread of infection ​ 4.​ To maintain good body mechanics and prevent and correct deformity ​ 5.​ To facilitate the maintenance of a supply of oxygen to all body cells ​ 6.​ To facilitate the maintenance of nutrition for all body cells ​ 7.​ To facilitate the maintenance of elimination ​ 8.​ To facilitate the maintenance of fluid and electrolyte balance ​ 9.​ To recognize the physiologic responses of the body to disease conditions—pathologic, physiologic,

and compensatory ​10.​ To facilitate the maintenance of regulatory mechanisms and functions ​11.​ To facilitate the maintenance of sensory function ​12.​ To identify and accept positive and negative expressions, feelings, and reactions ​13.​ To identify and accept interrelatedness of emotions and organic illness ​14.​ To facilitate the maintenance of effective verbal and nonverbal communication ​15.​ To promote the development of productive interpersonal relationships ​16.​ To facilitate progress toward achievement and personal spiritual goals ​17.​ To create or maintain a therapeutic environment ​18.​ To facilitate awareness of self as an individual with varying physical, emotional, and developmental

needs ​19.​ To accept the optimum possible goals in the light of limitations, physical and emotional ​20.​ To use community resources as an aid in resolving problems that arise from illness ​21.​ To understand the role of social problems as influencing factors in the cause of illness

BOX 5-2 Abdellah’s Typology of 21 Nursing Problems

From Abdellah, F. G., Beland, I. L., Martin, A., & Matheney, R. V. (1960). Patient-centered approaches to nursing. New York: Macmillan. Reprinted with the permission of Scribner, a division of Simon & Schuster.

UNIT I Evolution of Nursing Theories48

the major curriculum in maternal and newborn health nursing when the Yale School of Nursing established a master’s degree program (Kaplan & King, 2000) and authored books used widely in nurs- ing education. Her definition of nursing reflects her nurse-midwife background as follows: “People may differ in their concept of nursing, but few would dis- agree that nursing is nurturing or caring for someone in a motherly fashion” (Wiedenbach, 1964, p. 1).

Wiedenbach’s orientation is a philosophy of nurs- ing that guides the nurse’s action in the art of nursing. She specified four elements of clinical nursing: philoso- phy, purpose, practice, and art. She postulated that clinical nursing is directed toward meeting the patient’s perceived need for help in a vision of nursing that reflects considerable emphasis on the art of nursing. She followed Orlando’s theory of deliberate rather than automatic nursing and incorporated the steps of the nursing process. In her book (1964), Clinical Nursing: A Helping Art, Wiedenbach outlines nursing steps in sequence.

Wiedenbach proposes that nurses identify patients’ need for help in the following ways: 1. Observing behaviors consistent or inconsistent

with their comfort 2. Exploring the meaning of their behavior 3. Determining the cause of their discomfort or

incapability 4. Determining whether they can resolve their problems

or have a need for help Following this, the nurse administers the help

needed (Figure 5-4) and validates that the need for help was met (Figure 5-5) (Wiedenbach, 1964). Wiedenbach proposed that prescriptive theory would guide and improve nursing practice. Her work is considered a philosophy of the art of nursing.

Lydia Hall

Core, Care, and Cure Model Lydia Hall was a rehabilitation nurse who used her philosophy of nursing to establish the Loeb Center for Nursing and Rehabilitation at Montefiore Hospital in New York. She served as administrative director of the Loeb Center from the time of its opening in 1963 until her death in 1969. In the 1960s, she published more than 20 articles about the Loeb Center and her theories of long-term care and chronic disease

control. In 1964, Hall’s work was presented in “Nursing: What Is It?” in The Canadian Nurse. In 1969, the Loeb Center for Nursing and Rehabilitation was discussed in the International Journal of Nursing Studies.

Hall argued for the provision of hospital beds grouped into units that focus on the delivery of therapeutic nursing. The Loeb plan has been seen as similar to what later emerged as “primary nursing” (Wiggins, 1980). An evaluation study of the Loeb Center for Nursing published in 1975 revealed that those admitted to the nursing unit when compared with those in a traditional unit were readmitted less often, were more independent, had higher postdis- charge quality of life, and were more satisfied with their hospital experience (Hall, Alfano, Rifkin, & Levine, 1975).

Hall used three interlocking circles to represent aspects of the patient and nursing functions. The care circle represents the patient’s body, the cure circle represents the disease that affects the patient’s physi- cal system, and the core circle represents the inner feelings and management of the person (Figure 5-6). The three circles change in size and overlap in relation to the patient’s phase in the disease process. A nurse functions in all three circles but to different degrees. For example, in the care phase, the nurse gives hands- on bodily care to the patient in relation to activities of daily living such as toileting and bathing. In the cure phase, the nurse applies medical knowledge to treatment of the person, and in the core phase, the nurse addresses the social and emotional needs of the patient for effective communication and a comfort- able environment (Touhy & Birnbach, 2001). Nurses also share the circles with other providers. Lydia Hall’s theory was used to show improvement in patient- nurse communication, self-growth, and self-awareness in patients whose heart failure was managed in the home setting (McCoy, Davidhizar, & Gillum, 2007) and for the nursing process and critical thinking linked to disaster preparedness (Bulson, & Bulson, 2011).

Hall believed that professional nursing care has- tened recovery, and as less medical care was needed, more professional nursing care and teaching were necessary. She stressed the autonomous function of nursing. Her contribution to nursing theory was the development and use of her philosophy of nursing

CHAPTER 5 Nursing​Theorists​of​Historical​Significance 49

Patient indicates ability to resolve problem

Patient has no need-for-help

Patient indicates inability to resolve problem

Patient has need-for-help

Patient reveals cause of nonacceptance: interfering problem

Patient’s immediate need: to resolve problem

Nurse explores patient’s ability to resolve problem

Nurse formulates plan for meeting this need- for-help based on newly recognized resources; presents this plan to patient; and explores meaning to patient of his behavior in response to the new plan according to the out- line on this chart

Patient does not reveal cause of nonacceptance

Nurse may seek help in effort to establish cause of patient’s nonacceptance

Nurse explores for cause of patient’s nonacceptance

Nurse implements plan:

Ministration of help needed

Patient accepts suggestion

Patient does not accept suggestion

Nurse suggests to patient way of implementing plan

Nurse explores, for purpose of clarification, meaning to patient of perceived behavior following presentation of plan

Patient does not concur with plan

Nurse may seek help in effort to elicit definitive response

Patient concurs with plan

Nurse perceives patient’s behavior as consistent or inconsistent with her concept of acceptance of the plan

Nurse formulates plan for meeting patient’s need-for-help based on available resources: what patient thinks, knows, can do, has done � what nurse thinks, knows, can do, has done

Nurse presents plan to patient Patient responds to presentation of plan

FIGURE 5-4 ​Ministration​of​Help.​(From Wiedenbach, E. [1964]. Clinical​nursing:​A​helping​art [p. 61]. New York: Springer.)

UNIT I Evolution of Nursing Theories50

care at the Loeb Center for Nursing and Rehabilitation in New York. She recognized professional nurses and encouraged them to contribute to patient outcomes. Hall’s work is viewed as a philosophy of nursing.

Joyce Travelbee

Human-to-Human Relationship Model Joyce Travelbee presented her Human-to-Human Relationship Theory in her book, Interpersonal Aspects of Nursing (1966, 1971). She published predominantly in the mid-1960s and died at a young age in 1973. Travelbee proposed that the goal of nursing was to assist an individual, family, or community to prevent or cope with the experiences of illness and suffering and, if necessary, to find meaning in these experiences, with the ultimate goal being the presence of hope (Travelbee, 1966, 1971). She discussed her theory with Victor Frankel (1963), whom she credits along with Rollo May (1953) for influencing her thinking (Meleis, 2007). Travelbee’s work was conceptual, and she wrote about illness, suffering, pain, hope, communication, interaction, empathy, sympathy, rapport, and therapeu- tic use of self. She proposed that nursing was accom- plished through human-to-human relationships that began with (1) the original encounter and progressed through stages of (2) emerging identities, (3) develop- ing feelings of empathy and, later, (4) sympathy, until (5) the nurse and the patient attained rapport in the final stage (Figure 5-7). Travelbee believed that it was as important to sympathize as it was to empathize if the nurse and the patient were to develop a human- to-human relationship (Travelbee, 1964). She was ex- plicit about the patient’s and the nurse’s spirituality, observing the following:

“It is believed the spiritual values a person holds will determine, to a great extent, his perception of illness. The spiritual values of the nurse or her philosophical beliefs about illness and suffering will determine the degree to which he or she will be able to help ill persons find meaning, or no meaning, in these situations”

(Travelbee, 1971, p. 16).

Travelbee’s theory extended the interpersonal rela- tionship theories of Peplau and Orlando, and her unique synthesis of their ideas differentiated her work in terms of the therapeutic human relationship

The Person Social sciences

Therapeutic use of self— aspects of nursing

“The Core”

The Body Natural and biological

sciences Intimate bodily care—

aspects of nursing “The Care”

The Disease Pathological and therapeutic

sciences Seeing the patient and family through the medical care—

aspects of nursing “The Cure”

FIGURE 5-6 ​Core,​ Care,​ and​ Cure​ Model.​ (From Hall, L. [1964]. Nursing: what is it? The​Canadian​Nurse,​60[2], 151.)

Nurse explores, for purpose of clarification, meaning to patient of perceived behavior

Patient provides convincing evidence of comfort or capability

Need-for-help met

Patient does not provide convincing evidence of comfort or capability

Need-for-help may not have been met

Nurse may need to reconstruct experience to ascertain:

1. Whether the need-for-help has been identified

2. Whether nurse met need in an acceptable way

3. Whether nurse needs help to know where to start again and then take appropriate action

Nurse perceives patient’s behavior as consistent or inconsistent with her concept of comfor t or capability

FIGURE 5-5 ​Validation​ that​ the​ Need​ for​ Help​ was​ Met.​ ​(From Wiedenbach, E. [1964]. Clinical​ nursing:​ A​ helping​ art [p. 62]. New York: Springer.)

CHAPTER 5 Nursing​Theorists​of​Historical​Significance 51

between nurse and patient. Travelbee’s emphasis on caring stressed empathy, sympathy, rapport, and the emotional aspects of nursing (Travelbee, 1963, 1964). Rich (2003) revisited Travelbee’s argument on the value of sympathy in nursing and updated it with a reminder that compassion is central to holistic nursing care. Bunkers (2012) recently examined her human relationship model to explore the meaning of presence. Travelbee’s work is categorized as a nursing theory.

Kathryn E. Barnard

Child Health Assessment Kathryn E. Barnard is an active researcher, educator, and consultant. She has published extensively since the mid-1960s about improving the health of infants and their families. She is Professor Emeritus of Nursing and the founder and director of the Center

on Infant Mental Health and Development at the University of Washington. Her pioneering work to improve the physical and mental health outcomes of infants and young children earned her numerous honors, including the Gustav O. Leinhard Award from the Institute of Medicine, and the Episteme Award and the Living Legend Award in 2006 from the American Academy of Nursing. Barnard began by studying mentally and physically handicapped chil- dren and adults, moved into the activities of the well child, and expanded to methods of evaluating the growth and development of children and mother- infant relationships, and finally how environment influences development for children and families (Barnard, 2004). She is the founder of the Nursing Child Assessment Satellite Training Project (NCAST), providing health care workers around the globe with guidelines for assessing infant development and parent-child interactions.

Patient &

Nurse

Nurse Sympathy Patient

Nurse Empathy Patient

Nurse Emerging identities Patient

Nurse Original encounter Patient

Human Human

Rapport

FIGURE 5-7 ​Human-to-Human​Relationship.​(Conceptualized by William Hobble and Theresa Lansinger, based on Joyce Travelbee’s writings.)

UNIT I Evolution of Nursing Theories52

Although Barnard never intended to develop the- ory, her longitudinal nursing child assessment study provided the basis for a Child Health Assessment Interaction Theory (Figure 5-8). Barnard (1978) pro- posed that individual characteristics of members influ- ence the parent-infant system, and adaptive behavior modifies those characteristics to meet the needs of the system. Her theory borrows from psychology and human development and focuses on mother-infant interaction with the environment. Barnard’s theory is based on scales designed to measure the effects of feed- ing, teaching, and environment (Kelly & Barnard, 2000). Her theory remains population specific; it was originally designed to be applicable to interactions between the caregiver and the child in the first year and has been expanded to three years of life (Masters, 2012). With continual research, Barnard has refined the theory and has provided a close link to practice that has transformed the way health care providers evaluate children in light of the parent-child relationship. She models the role of researcher in clinical practice and engages in theory development in practice for the advancement of nursing science. Her sleep-activity record of the infant’s sleep-wake cycle was used in research on infant and mother circadian rhythm (Tsai, Barnard, Lentz, & Thomas 2011; Tsai, Thomas,

Lentz, & Barnard, 2012). Barnard’s work is a theory of nursing.

Evelyn Adam

Conceptual Model for Nursing Evelyn Adam is a Canadian nurse who started publish- ing in the mid-1970s. Her work focuses on the devel- opment of models and theories on the concept of nurs- ing (1983, 1987, 1999). She uses a model that she learned from Dorothy Johnson. In her book, To Be a Nurse (1980), she applies Virginia Henderson’s defini- tion of nursing to Johnson’s model and identifies the assumptions, beliefs, and values, as well as major units. In the latter category, Adam includes the goal of the profession, the beneficiary of the professional service, the role of the professional, the source of the benefi- ciary’s difficulty, the intervention of the professional, and the consequences. She expanded her work in a 1991 second edition. Her classic paper entitled simply “Modèles conceptuels” argues their importance in shaping a way of thinking and providing a framework for practice (Adam, 1999). Adam’s work is a good ex- ample of using a unique basis of nursing for further expansion. Adam’s argument for an ideological frame- work in nursing was described in a health telematics education conference (Tallberg, 1997). She contributed to theory development with clear explanation and use of earlier works. Adam’s work is a theory of nursing.

Nancy Roper, Winifred W. Logan, and Alison J. Tierney

A Model for Nursing Based on a Model of Living Nancy Roper is described as a practical theorist who produced a simple nursing theory, “which actually helped bedside nurses” (Dopson, 2004; Scott, 2004). After 15 years as a principal tutor in a school of nurs- ing in England, Roper began her career as a full-time book writer during the 1960s and published several popular textbooks, including Principles of Nursing (1967). She investigated the concept of an identifiable “core” of nursing for her MPhil research study, pub- lished in a monograph titled Clinical Experience in Nurse Education (1976). This work served as the basis for her work with theorists Winifred Logan and Alison Tierney. Roper worked with the European and

Environment Resources Inanimate Animate

Inter- action

Caregiver Physical health Mental health Coping Educational level

Child Temperament Regulation

FIGURE 5-8 ​Child​Health​Assessment​Model.​(From Sumner, G., & Spietz, A. [Eds.]. [1994].​ NCAST​ caregiver/parent-child​ interaction​teaching​manual​[p. 3]. Seattle: NCAST Publications, University of Washington School of Nursing.)

CHAPTER 5 Nursing​Theorists​of​Historical​Significance 53

Nursing and Midwifery Unit, where she was influen- tial in developing European Standards for Nursing (Hallett & Wagner, 2011; Roper, 1977). She authored The Elements of Nursing in 1980, 1985, and 1990. The trio collaborated in the fourth and most recent edi- tion of The Elements of Nursing: A Model for Nursing Based on a Model of Living (1996). During the 1970s, they conducted research to discover the core of nurs- ing, based on a Model of Living (Figure 5-9). Three decades of study of the elements of nursing by Roper evolved into a model for nursing with five main factors that influenced activities of living (ALs) (Figure 5-10 and Table 5-1).

Rather than revising the fourth edition of their text- book, these theorists prepared a monograph (Roper, Logan, & Tierney, 2000) about the model titled The Roper-Logan-Tierney Model of Nursing: Based on Activi- ties of Living, without application of the model. Holland,

Jenkins, Solomon, and Whittam (2003) explored the use of the Roper-Logan-Tierney Model of Nursing. They used case studies and exercises about adult patients with a variety of health problems in acute care and community-based settings to help students develop problem-solving skills.

In the Model of Nursing, the ALs include maintain- ing a safe environment, communicating, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobiliz- ing, working and playing, expressing sexuality, sleep- ing, and dying. Life span ranges from birth to death, and the dependence-independence continuum ranges from total dependence to total independence. The five groups of factors that influence the ALs are biological, psychological, sociocultural, environmental, and politi- coeconomic. Individuality of living is the way in which the individual attends to the ALs in regard to the

FACTORS INFLUENCING ACTIVITIES OF LIVING

Biological

Psychological

Sociocultural

Environmental

Politicoeconomic

ACTIVITIES OF LIVING

Maintaining a safe environment Communicating Breathing Eating and drinking Eliminating Personal cleansing and dressing Controlling body temperature Mobilizing Working and playing Expressing sexuality Sleeping Dying

DEPENDENCE-INDEPENDENCE CONTINUUM

INDIVIDUALITY IN LIVING

LIFE SPAN

FIGURE 5-9 ​Diagram​of​the​Model​of​Living.​(From Roper, N., Logan W. W., & Tierney, A. J. [1996]. The​ elements​of​nursing:​A​model​ for​nursing​based​on​a​model​of​ living​ [4th ed., p. 20]. Edinburgh: Churchill Livingstone.)

UNIT I Evolution of Nursing Theories54

individual’s place in the life span, on the dependence- independence continuum, and as influenced by bio- logical, psychological, sociocultural, environmental, and politico-economic factors. The five components can be used to describe the individual in relation to maintaining health, preventing disease, coping during periods of sickness and rehabilitation, coping posi- tively during periods of chronic ill health, and coping when dying. Individualizing nursing is accomplished by using the process of nursing, which involves four phases: (1) assessing, (2) planning, (3) implementing, and (4) evaluating. Nursing process is a method of logical thinking that should be used with an explicit nursing model, and the patient’s individuality in living must be borne in mind during all four phases of the process. This model has been used as a guide for nurs- ing practice, research, and education.

FACTORS INFLUENCING ACTIVITIES OF LIVING

Biological

Psychological

Sociocultural

Environmental

Politicoeconomic

ACTIVITIES OF LIVING

Maintaining a safe environment Communicating Breathing Eating and drinking Eliminating Personal cleansing and dressing Controlling body temperature Mobilizing Working and playing Expressing sexuality Sleeping Dying

DEPENDENCE-INDEPENDENCE CONTINUUM

INDIVIDUALIZING NURSING

Assessing Planning

Implementing Evaluating

LIFESPAN

FIGURE 5-10 ​Diagram​of​the​Model​for​Nursing.​(From Roper, N., Logan, W. W., & Tierney, A. J. [1996]. The​elements​of​nursing:​A​model​for​nursing​based​on​a​model​of​living​[4th ed., p. 34]. Edinburgh: Churchill Livingstone.)

Model of Living Model for Nursing

12​ALs 12​ALs

Life​span Life​span

Dependence-independence​ continuum

Dependence-independence​ continuum

Factors​influencing​the​ALs Factors​influencing​the​ALs

Individuality​in​living Individualizing​nursing

TABLE 5-1 Comparison of the Main Concepts in the Model of Living and the Model for Nursing

From Roper, N., Logan, W. W., & Tierney, A. J. (1996). The elements of nursing: A model for nursing based on a model of living (4th ed., p. 33). Edinburgh: Churchill Livingstone.

CHAPTER 5 Nursing​Theorists​of​Historical​Significance 55

Ida Jean (Orlando) Pelletier

Nursing Process Theory Ida Jean Orlando developed her theory from a study conducted at the Yale University School of Nursing, integrating mental health concepts into a basic nurs- ing curriculum. The study was carried out by observ- ing and participating in experiences with patients, students, nurses, and instructors and was derived inductively from field notes for this study. Orlando analyzed the content of 2000 nurse-patient contacts and created her theory based on analysis of these data (Schmieding, 1993). Meleis (2007) has noted, “ . . . Orlando was one of the early thinkers in nursing who proposed that patients have their own meanings and interpretations of situations and therefore nurses must validate their inferences and analyses with pa- tients before drawing conclusions . . . ” (p. 347). The theory was published in The Dynamic Nurse-Patient Relationship (1961), which was an outcome of the project. Her book purposed a contribution to concern about the nurse-patient relationship, the nurse’s profes- sional role and identity, and the knowledge develop- ment distinct to nursing (Schmieding, 1993). In 1990, the National League for Nursing (NLN) reprinted Orlando’s 1961 publication. In the preface to the NLN edition, Orlando states: “If I had been more courageous in 1961, when this book was first written, I would have proposed it as ‘nursing process theory’ instead of as a ‘theory of effective nursing practice’” (Orlando, 1990, p. vii). Orlando continued to develop and refine her work, and in her second book, The Discipline and Teaching of Nursing Process: An Evaluative Study (1972), she redefined and renamed deliberative nursing pro- cess as nursing process discipline.

Orlando’s nursing theory stresses the reciprocal relationship between patient and nurse. What the nurse and the patient say and do affects them both. Orlando

(1961) views the professional function of nursing as finding out and meeting the patient’s immediate need for help. She was one of the first nursing leaders to identify and emphasize the elements of nursing process and the critical importance of the patient’s par- ticipation in the nursing process. Orlando’s theory focuses on how to produce improvement in the patient’s behavior. Evidence of relieving the patient’s distress is seen as positive changes in the patient’s observable behavior. Orlando may have facilitated the develop- ment of nurses as logical thinkers (Nursing Theories Conference Group & George, 1980).

According to Orlando (1961), persons become patients who require nursing care when they have needs for help that cannot be met independently because they have physical limitations, have negative reactions to an environment, or have an experience that prevents them from communicating their needs. Patients experience distress or feelings of helplessness as the result of unmet needs for help (Orlando, 1961). Orlando proposed a positive correlation between the length of time the patient experiences unmet needs and the degree of distress. Therefore, immediacy is emphasized throughout her theory. In Orlando’s view, when individuals are able to meet their own needs, they do not feel distress and do not require care from a professional nurse. Practice guided by Orlando’s theory employs a reflexive principle for inference testing (May, 2010; Schmieding, 2006). Orlando emphasizes that it is crucial for nurses to share their perceptions, thoughts, and feelings so they can determine whether their inferences are con- gruent with the patient’s need (Schmieding, 2006). Abraham (2011) used Orlando’s theory to help nurses achieve more successful patient outcomes such as fall reduction. Orlando’s theory remains a most effective practice theory that is especially helpful to new nurses as they begin their practice.

POINTS FOR FURTHER STUDY

n Orlando, I. J. (1990). The dynamic nurse-patient relationship: function, process, and principles (Pub. No. 15-2341). New York: National League for Nursing.

n Orlando interview: Nursing process discipline. In Nurse theorists: Portraits of excellence, Volume 1 (video). Athens, (OH): Fitne.

n Kaplan, D., & King, C. (2000). Guide to the Ernes- tine Wiedenbach papers. Retrieved from: http://hdl. handle.net/10079/fa/mssa.ms.1647.

n May, B. A. (2010). Orlando’s nursing process theory and nursing practice. In M. R. Alligood (Ed.), Nursing theory: Utilization & application (4th ed., pp. 337–357). Maryland Heights, (MO): Mosby-Elsevier.

UNIT I Evolution of Nursing Theories56

n Peplau, H. (1952). Interpersonal relations in nursing. New York: Putnam.

n Peplau Interview: Interpersonal relations in nursing. In Nurse theorists: Portraits of excellence, Volume 1 (video). Athens, (OH): Fitne.

n Roper, N., Logan, W. W., & Tierney, A. J. (1996). The elements of nursing: A model for nursing based on a model of living (4th ed.). Edinburgh: Churchill Livingstone.

n Schmieding, N. J. (2006). Ida Jean Orlando (Pelletier): Nursing process theory. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (6th ed., pp. 431–451). St. Louis: Mosby.

n Travelbee, J. (1971). Interpersonal aspects of nursing (2nd ed.). Philadelphia: F. A. Davis.

Abdellah, F. G. (2004). Interview with Rear Admiral Faye Glenn Abdellah. Interview by Captain Melvin Lessing. Military Medicine, 169(11), iii–xi.

Abdellah, F. G., Beland, I. L., Martin, A., & Matheney, R. V. (1960). Patient-centered approaches to nursing. New York: Macmillan.

Abdellah, F. G., & Levine, E. (1994). Preparing for nursing research in the 21st century: Evolution, methodologies, challenges. New York: Springer.

Abraham, S. (2011). Fall prevention conceptual framework. The Health Care Manager, 30, 179–184.

Adam, E. (1980). To be a nurse. Philadelphia: Saunders. Adam, E. (1983). Frontiers of nursing in the 21st century:

development of models and theories on the concept of nursing. Journal of Advanced Nursing, 8,41–45.

Adam, E. (1987). Nursing theory: what it is and what it is not. Nursing papers. Perspectives in Nursing, 19, 5–14.

Adam, E. (1991). To be a nurse (2nd ed.). Montreal: Saunders.

Adam, E. (1999). Conceptual models. Canadian Journal of Nursing Research, 30, 103–114.

Aghamohammadi-Kalkhoran, M., Karimollahi, M., & Abdi, R. (2011). Iranian staff nurses’ attitudes toward nursing students. Nurse Education Today, 31, 477–481.

American Nurses Association, (June 14, 2012). Six regis- tered nurses to be inducted into ANA hall of fame for lifetime of contributions to nursing. Retrieved from: http://nursingworld.org/FunctionalMenuCategories/ MediaResources/PressReleases/ANAHallofFamePR- June2012.pdf.

Barnard, K. E. (1978). Nursing child assessment and train- ing: Learning resource manual. Seattle: University of Washington.

Barnard, K. E. (2004). Welcome and Opening Plenary. Pro- ceedings from AMCHP ’04: Mental health—Promoting a new paradigm for MCH public health practice. Retrieved from: http://128.248.232.90/archives/mchb/amchp2004/ p1/transcripts/session09f.htm.

Bulson, J. A., & Bulson, T. (2011). Nursing process and critical thinking linked to disaster preparedness. Journal of Emergency Nursing, 37, 477–483.

Bunkers, S. S. (2012). Presence: the eye of the needle. Nursing Science Quarterly, 25, 10–14.

Butts, J., & Rich, K. (2011). Philosophies and theories for advanced practice nursing. Sudbury, (MA): Jones & Bartlett.

Dickoff, J., James, P., & Wiedenbach, E. (1968). Theory in a practice discipline, part II: practice oriented research. Nursing Research, 17, 545–554.

Dopson, L. (October 15, 2004). Obituary: Nancy Roper. The Independent. Retrieved from: http://www.independent. co.uk.

Frankel, V. (1963). Man’s search for meaning: an introduc- tion to logotherapy. New Yark: Washington Square Press.

Haber, J. (2000). Hildegard E. Peplau: the psychiatric nursing legacy of a legend. Journal of the American Psychiatric Nurses Association, 6, 56–62.

Hall, L. E. (1964). Nursing: what is it? The Canadian Nurse, 60, 150–154.

Hall, L. E. (1969). The Loeb Center for Nursing and Rehabilitation. International Journal of Nursing Studies, 6, 81–95.

Hall, L. E., Alfano, G. J., Rifkin E., & Levine, H. S. (1975). Longitudinal effects of an experimental nursing process (final report). New Yark: Loeb Center for Nursing and Rehabilitation.

Hallett, D. C., & Wagner, L. (2011). Promoting the health of Europeans in a rapidly changing world: a historical study of the implementation of World Health Organi- zation policies by the nursing and midwifery unit, European regional office, 1970–2003. Nursing Inquiry, 18, 359–368.

Hanrahan, N. P., Delaney, D., & Stuart, G. W. (2012). Blueprint for development of the advanced practice psychiatric nurse workforce. Nursing Outlook, 60, 91–106.

REFERENCES

CHAPTER 5 Nursing​Theorists​of​Historical​Significance 57

Henderson, V. (1955). Textbook of the principles and prac- tice of nursing (5th ed.). New Yark: Macmillan. (Note: earlier editions were Harmer & Henderson).

Henderson, V. (1960). Basic principles of nursing care. London: International Council of Nurses.

Henderson, V. (1964). The nature of nursing. American Journal of Nursing, 64, 62–68.

Henderson, V. (1966). The nature of nursing: A definition and its implications for practice, research, and education. New York: Macmillan.

Henderson V. (1980). Preserving the essence of nursing in a technological age. Journal of Advanced Nursing, 5, 245–260.

Henderson, V. A. (1991). The nature of nursing: Reflections after 25 years. New Yark: National League for Nursing Press.

Henderson, V. (2006). The concept of nursing. Journal of Advanced Nursing, 53, 21–31.

Holland, K., Jenkins, J., Solomon, J., & Whittam, S. (2003). Applying the Roper-Logan-Tierney Model in practice. Edinburgh: Churchill Livingstone.

Kaplan, D., & King, C. (2000). Guide to the Ernestine Wiedenbach papers. Retrieved from: http://hdl.handle. net/10079/fa/mssa.ms.1647.

Kelly, J. F., & Barnard, K. E. (2000). Assessment of parent- child interaction: implications for early intervention. In S. Shonkoff & S. J. Meisels (Eds.), Handbook of early childhood intervention (pp. 258–289). Cambridge: Cambridge University Press.

Keoghan, S. (2011). Attention deficit hyperactivity disorder: a model of nursing care. Mental Health Practice, 215, 20–22.

Masters, K. (2012). Nursing theories: A framework for pro- fessional practice. Sudbury, (MA): Jones & Bartlett.

May, B A. (2010). Orlando’s nursing process theory and nursing practice. In M. R. Alligood (Ed.), Nursing theory: Utilization & application (4th ed., pp. 337–357). Maryland Heights, (MO): Mosby-Elsevier.

May, R. (1953). Man’s search for himself. New Yark: W. W. Norton.

McCoy, M. L., Davidhizar, R., & Gillum, D. R. (2007). A correlational pilot study of home health nurse manage- ment of heart failure patients and hospital readmis- sions. Home Health Care Management and Practice, 19, 392–396.

Meleis, A. (2007). Theoretical nursing: Development and progress (4th ed.). Philadelphia: Lippincott.

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Nicely, B., & DeLario, G. T. (2011). Virginia Henderson’s principles and practice of nursing applied to organ donation after brain death. Progress in Transplantation, 21, 72–77.

Nursing Theories Conference Group, & George, J. B. (Chairperson). (1980). Nursing theories: The base for professional practice. Englewood Cliffs, (NJ): Prentice-Hall.

Orlando, I. J. (1961). The dynamic nurse-patient relation- ship: Function, process and principles of professional nursing practice. New York: Putnam.

Orlando, I. J. (1972). The discipline and teaching of nursing process: An evaluative study. New York: Putnam.

Orlando, I. J. (1990). The dynamic nurse-patient relationship: Function, process, and principles (Pub. No. 15-2341). New Yark: National League for Nursing.

Penckofer, S., Byrn, M., Mumby, P., & Ferrans, C. E. (2011). Improving subject recruitment, retention, and participa- tion in research through Peplau’s theory of interpersonal relations. Nursing Science Quarterly, 24, 146–151.

Peplau, H. E. (1952). Interpersonal relations in nursing. New York: Putnam.

Rich, K. (2003). Revisiting Joyce Travelbee’s question: what’s wrong with sympathy? Journal of the American Psychiatric Association, 9(6), 202–205.

Roche, M., Duffield, C., & White, E., (2011). Factors in the practice environment of nurses working in inpatient mental health: a partial least squares path modeling approach. International Journal of Nursing Studies, 48, 1475–1486.

Roper, N. (1967). Principles of nursing. Edinburgh: Churchill Livingstone.

Roper, N. (1976). Clinical experience in nurse education (Research monograph). Edinburgh: Churchill Livingstone.

Roper, N. (1977). Paper (and working documents) on the assessment of patient/client needs for nursing care. NMU Archive Box 2, Kolding.

Roper, N. (1980). The elements of nursing: A model for nursing. Edinburgh: Churchill Livingstone.

Roper, N. (1985). The elements of nursing: A model for nursing (2nd ed.). Edinburgh: Churchill Livingstone.

Roper, N. (1990). The elements of nursing: A model for nursing based on a model of living (3rd ed.). Edinburgh: Churchill Livingstone.

Roper, N., Logan, W. W., & Tierney, A. J. (1996). The ele- ments of nursing: A model for nursing based on a model of living (4th ed.). Edinburgh: Churchill Livingstone.

Roper, N., Logan, W. W, & Tierney, A. J. (2000). The Roper-Logan-Tierney model of nursing: Based on activi- ties of living. Edinburgh: Churchill Livingstone.

UNIT I Evolution of Nursing Theories58

Schmieding, N. J. (1993). Ida Jean Orlando: A nursing pro- cess theory. Newbury Park, (CA): Sage Publications.

Schmieding, N. J. (2006). Ida Jean Orlando (Pelletier): nursing process theory. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (6th ed., pp. 431–451). St. Louis: Mosby.

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Sills, G. M. (1998). Peplau and professionalism: the emer- gence of the paradigm of professionalization. Journal of Psychiatric and Mental Health Nursing, 5, 167–171.

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Travelbee, J. (1963). What do we mean by rapport? American Journal of Nursing, 63, 70–72.

Travelbee, J. (1964). What’s wrong with sympathy? American Journal of Nursing, 64, 68–71.

Travelbee, J. (1966). Interpersonal aspects of nursing. Philadelphia: F. A. Davis.

Travelbee, J. (1971). Interpersonal aspects of nursing (2nd ed.). Philadelphia: F. A. Davis.

Tsai, S. Y., Barnard, K. E., Lentz, M. J., & Thomas, K. A. (2011). Mother-infant activity synchrony as a correlate of the emergence of circadian rhythm. Biological Research for Nursing, 1, 80–88.

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Wiedenbach, E. (1964). Clinical nursing: A helping art. New York: Springer.

Wiedenbach, E. (1970). Nurses’ wisdom in nursing theory. American Journal of Nursing, 70, 1057–1062.

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Wright, K. M., & Hacking, S. (2012). An angel on my shoulder: a study of relationships between women with anorexia and health care professionals. Journal of Psychiatric and Mental Health Nursing, 19, 107–112.

UNIT II

n Nursing philosophy sets forth the meaning of nursing phenomena through analysis, reasoning, and logical argument.

n Philosophies contributed to nursing knowledge by providing direction for the discipline, forming a basis for professional scholarship and leading to new theoretical understandings.

n Nursing philosophies represent early works predating the theory era, as well as contemporary works of a philosophical nature.

n Philosophies are works that provide broad understanding that advances the discipline and its professional application.

Nursing Philosophies

60

“Recognition of nursing as a professional endeavor distinct from medicine began with Nightingale” (Chinn & Kramer, 2011, p. 26).

Florence Nightingale 1820–1910

CH A P T ER 6

Modern Nursing Susan A. Pfettscher

others tutored her in mathematics, languages, religion, and philosophy (influences on her lifework). Although she participated in the usual Victorian aristocratic activities and social events during her adolescence, Nightingale developed the sense that her life should become more useful. In 1837, Nightingale wrote about her “calling” in her diary: “God spoke to me and called me to his service” (Holliday & Parker, 1997, p. 491). The nature of her calling was unclear to her for some time. After she understood that she was called to become a nurse, she was able to complete her nursing training in 1851 at Kaiserwerth, Germany, a Protestant religious community with a hospital facility. She was there for approximately 3 months, and at the end, her teachers declared her trained as a nurse.

After her return to England, Nightingale was em- ployed to examine hospital facilities, reformatories,

Credentials and Background of the Theorist

Florence Nightingale, the founder of modern nursing, was born on May 12, 1820, in Florence, Italy, while her parents were on an extended European tour; she was named after her birthplace. The Nightingales were a well-educated, affluent, aristocratic Victorian family with residences in Derbyshire (Lea Hurst their primary home) and Hampshire (Embley Park). This latter residence was near London, allowing the family to participate in London’s social seasons.

Previous authors: Susan A. Pfettscher, Karen R. de Graff, Ann Marriner Tomey, Cynthia L. Mossman, and Maribeth Slebodnik.

Although the extended Nightingale family was large, the immediate family included only Florence Nightingale and her older sister, Parthenope. During her childhood, Nightingale’s father educated her more broadly than other girls of the time. Her father and

CHAPTER 6 Florence Nightingale 61

She continued to concentrate on army sanitation reform, the functions of army hospitals, sanitation in India, and sanitation and health care for the poor in England. Her writings, Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army Founded Chiefly on the Experience of the Late War (Nightingale, 1858a), Notes on Hospi- tals (Nightingale, 1858b), and Report on Measures Adopted for Sanitary Improvements in India, from June 1869 to June 1870 (Nightingale, 1871), reflect her continuing concern about these issues.

Shortly after her return to England, Nightingale confined herself to her residence in London, citing her continued ill health. Until 80 years of age, she wrote between 15,000 and 20,000 letters to friends, acquain- tances, allies, and opponents. Her strong, clear written word conveyed her beliefs, observations, and desire for change in health care and in society. Through these writings, she was able to influence issues in the world that concerned her. When necessary and when her health allowed, Nightingale received powerful persons as visitors in her home to maintain dialogue, plot strategies to support causes, and carry out her work.

During her lifetime, Nightingale’s work was recog- nized through the many awards she received from her own country and from many others. She was able to work into her 80s until she lost her vision; she died in her sleep on August 13, 1910, at 90 years of age.

Modern biographers and essayists have attempted to analyze Nightingale’s lifework through her family relationships, notably with her parents and sister. Film dramatizations have focused frequently and in- accurately on her personal relationships with family and friends. Although her personal and public life holds great intrigue for many, these retrospective analyses often are very negative and harshly critical or overly positive in their descriptions of this Victorian leader and founder of modern nursing. Many biogra- phies have been written to describe Nightingale’s life and work. Cook (1913) wrote the first original and comprehensive biography of Nightingale, which was based on her written papers, but it may have been biased by her family’s involvement in and oversight of the project. It remains the most positive biography written. Shortly thereafter, Strachey (1918) described her negatively as arrogant and manipulative in his book, Eminent Victorians. O’Malley (1931) wrote a more positive biography that focused on her life

and charitable institutions. Only 2 years after com- pleting her training (in 1853), she became the super- intendent of the Hospital for Invalid Gentlewomen in London.

During the Crimean War, Nightingale received a request from Sidney Herbert (a family friend and the Secretary of War) to travel to Scutari, Turkey, with a group of nurses to care for wounded British soldiers. She arrived there in November 1854, accompanied by 34 newly recruited nurses who met her criteria for professional nursing—young, middle-class women with a basic general education. To achieve her mis- sion of providing nursing care, she needed to address the environmental problems that existed, including the lack of sanitation and the presence of filth (few chamber pots, contaminated water, contaminated bed linens, and overflowing cesspools). In addition, the soldiers were faced with exposure, frostbite, louse infestations, wound infections, and opportunistic dis- eases as they recovered from their battle wounds.

Nightingale’s work in improving these deplorable conditions made her a popular and revered person to the soldiers, but the support of physicians and military officers was less enthusiastic. She was called The Lady of the Lamp, as immortalized in the poem “Santa Filomena” (Longfellow, 1857), because she made ward rounds during the night, providing emo- tional comfort to the soldiers. In Scutari, Nightingale became critically ill with Crimean fever, which might have been typhus or brucellosis and which may have affected her physical condition for years afterward.

After the war, Nightingale returned to England to great accolades, particularly from the royal family (Queen Victoria), the soldiers who had survived the Crimean War, their families, and the families of those who died at Scutari. She was awarded funds in recognition of this work, which she used to establish schools for nursing training at St. Thomas’s Hospital and King’s College Hospital in London. Within a few years, the Nightingale School began to receive requests to establish new schools at hospitals world- wide, and Florence Nightingale’s reputation as the founder of modern nursing was established.

Nightingale devoted her energies not only to the development of nursing as a vocation (profession), but even more to local, national, and international societal issues, in an attempt to improve the living environment of the poor and to create social change.

UNIT II Nursing Philosophies62

from 1820 to 1856; however, the second volume, which would have described the rest of her life and activities, was never published. Woodham-Smith’s book (1951) chronicled her entire life and was drawn primarily from original documents made available by her family. This is the biography with which most Americans are familiar; it has endured as the defini- tive biography of Nightingale’s life, and although it is more balanced, it maintains a positive tone. F. B. Smith (1982) wrote Florence Nightingale: Reputa- tion and Power, which is critical of Nightingale’s character and her work. Small (1998) published yet another Nightingale biography titled Florence Night- ingale: Avenging Angel. Although he is critical of specific aspects of her character and work, Small is more balanced in his presentation. He notes that Nightingale’s life “is better documented than perhaps any previous life in history” because of the vast quantity of family and personal papers that remain available today (Small, 2000). His concerns and disagreements with other biographers have been noted in reviews (Small, 2008). Small continues to study Nightingale and updates his website with additional information about the Crimean War and Nightingale. The controversy and intrigue about Nightingale’s role, her status, and her confined life- style continue; a London newspaper recently reported on newly found letters related to the conflicts Night- ingale had with Sir John Hall (chief British army medical officer in the Crimea) (Kennedy, 2007). An Internet search reveals thousands of sites that provide various articles, resources, and commentaries about Nightingale. Clearly, the world still is fascinated by this unique woman.

The nursing community in the United States remains similarly fascinated by the life and work of Nightingale. During their professional careers, Kalisch and Kalisch (1983a, 1983b, 1987) published several critiques of media portrayals that provide a better understanding of the many histories of Florence Nightingale; their techniques may provide methods of analyzing more recent publications and events for persons interested in studying Nightingale’s life and work. Dossey’s (2000) comprehensive book, Florence Nightingale: Mystic, Visionary, Healer, provides another in-depth history and interpretation of Nightingale’s personal life and work. Using quotes from Nightin- gale’s own writings (diaries and letters) and from

people with whom she interacted and corresponded during her lifetime, Dossey focused on interpreting the spiritual nature of her being and her lifework, creating yet another way of looking at Nightingale. In an intro- duction/prelude to her descriptions of spirituality for nurses’ lives based on Nightingale’s writings, Macrae (2001) explores Nightingale’s personal spirituality as she interprets it after review of writings and docu- ments. Lorentzon (2003) more recently has provided a review and analysis of letters written between Night- ingale and one of her former students that clearly dem- onstrate her role as mentor.

Finally, all of Nightingale’s surviving writings are in the process of being published as The Collected Works of Florence Nightingale. To date, fourteen of the sixteen volumes have been published under the leadership of sociologist and Nightingale scholar Lynn McDonald (McDonald, 2001-present). This large project and other newly discovered/released documents continue to spawn articles and books that explore, interpret, and speculate on Nightingale’s life and work. In addi- tion, she has published a new biography of Nightingale (McDonald, 2010a).

Theoretical Sources for Theory Development

Many factors influenced the development of Nightin- gale’s philosophy of nursing. Her personal, societal, and professional values and concerns all were integral to the development of her beliefs. She combined her individual resources with societal and professional resources available to her to produce immediate and long-term change throughout the world.

As noted, Nightingale’s education was an unusual one for a Victorian girl. Her tutelage by her well- educated, intellectual father in subjects such as mathe- matics and philosophy provided her with knowledge and conceptual thinking abilities that were unique for women of her time. Although her parents initially opposed her desire to study mathematics, they re- lented and allowed her to receive additional tutoring from well-respected mathematicians. Her aunt Mai, a devoted relative and companion, described her as having a great mind; this is not a description that was used at the time for Victorian women, but it is one that was accepted for Nightingale. It remains unknown whether or not Nightingale was a genius who would

CHAPTER 6 Florence Nightingale 63

have been a great leader and thinker under any circum- stance, or whether her unique, formal education and social status were necessary for this to occur at the time. Would Nightingale become such a leader if born today? What would nursing be today if she had not been born at that time and in that place?

The Nightingale family’s aristocratic social status provided her with easy access to people of power and influence. Many were family friends, such as Stanley Herbert, who remained an ally and staunch supporter until his death. Nightingale learned to understand the political processes of Victorian England through the experiences of her father during his short-lived political career and through his continuing role as an aristocrat involved in the political and social activities of his community. She most likely relied on this foundation and on her own experiences as she waged political battles for her causes.

Nightingale also recognized the societal changes of her time and their impact on the health status of individuals. The industrial age had descended upon England, creating new social classes, new diseases, and new social problems. Dickens’ social commen- taries and novels provided English society with scathing commentaries on health care and the need for health and social reform in England. In the serialized novel (1843 to 1844), Martin Chuzzlewit (Dickens, 1987), Dickens’ portrayal of Sairey Gamp as a drunken, untrained nurse provided society with an image of the horrors of Victorian nursing practice. Nightingale’s alliance with Dickens undoubtedly in- fluenced her definitions of nursing and health care and her theory for nursing; that relationship also provided her with a forum for expressing her views about social and health care issues (Dossey, 2000; Kalisch & Kalisch, 1983a; Woodham-Smith, 1951).

Similar dialogues with political leaders, intellectuals, and social reformers of the day (John Stuart Mill, Benjamin Jowett, Edwin Chadwick, and Harriet Marineau) advanced Nightingale’s philosophical and logical thinking, which is evident in her philosophy and theory of nursing (Dossey, 2000; Kalisch & Kalisch, 1983a; Woodham-Smith, 1951). These dialogues likely inspired her to strive to change the things she viewed as unacceptable in the society in which she lived.

Finally, Nightingale’s religious affiliation and beliefs were especially strong sources for her nursing theory. Reared as a Unitarian, her belief that action for the benefit of others is a primary way of serving God served as the foundation for defining her nursing work as a religious calling. In addition, the Unitarian com- munity strongly supported education as a means of developing divine potential and helping people move toward perfection in their lives and in their service to God. Nightingale’s faith provided her with personal strength throughout her life and with the belief that education was a critical factor in establishing the profession of nursing. Also, religious conflicts of the time, particularly between the Anglican and Catholic Churches in the British Empire, may have led to her strongly held belief that nursing could and should be a secular profession (Dossey, 2000; Helmstadter, 1997; Nelson, 1997; Woodham-Smith, 1951). Despite her strong religious beliefs and her acknowledgment of her calling, this was not a requirement for her nurses. Indeed, her opposition to the work of the nuns in Crimea (she reported that they were proselytizing) escalated the conflict to the level of involvement of the Vatican (Dossey, 2000; Woodham-Smith, 1951). Nelson’s review of pastoral care in the nineteenth century provides an interesting historical view of the role of religious service in nursing (Nelson, 1997).

Nightingale’s theory focused on environment, how- ever Nightingale used the term surroundings in her writing. She defined and described the concepts of ventilation, warmth, light, diet, cleanliness, and noise—components of surroundings usually re- ferred to as environment in discussions of her work. When reading Notes on Nursing (Nightingale, 1969) one can easily identify an emphasis on the physical

MAJOR CONCEPTS & DEFINITIONS

environment. In the context of issues Nightingale identified and struggled to improve (war-torn envi- ronments and workhouses) , this emphasis appears to be most appropriate (Gropper, 1990). Her con- cern about healthy surroundings involved hospital settings in Crimea and England, and also extended to the public in their private homes and to the physical living conditions of the poor. She believed

Continued

UNIT II Nursing Philosophies64

Her expertise as a statistician is evident in the reports that she generated throughout her lifetime on the varied subjects of health care, nursing, and social reform.

Use of Empirical Evidence Nightingale’s reports describing health and sanitary conditions in the Crimea and in England identify her as an outstanding scientist and empirical researcher.

that healthy surroundings were necessary for proper nursing care and restoration/maintenance of health. Her theoretical work on five essential components of environmental health (pure air, pure water, effi- cient drainage, cleanliness, and light) is as relevant today as it was 150 years ago.

Proper ventilation for the patient seemed to be of greatest concern to Nightingale; her charge to nurses was to “keep the air he breathes as pure as the exter- nal air, without chilling him” (Nightingale, 1969, p. 12). Nightingale’s emphasis on proper ventilation indicates that she recognized the surroundings as a source of disease and recovery. In addition to dis- cussing ventilation in the room or home, Nightingale provided a description for measuring the patient’s body temperature through palpation of extremities to check for heat loss (Nightingale, 1969). The nurse was instructed to manipulate the surroundings to maintain ventilation and patient warmth by using a good fire, opening windows, and properly posi- tioning the patient in the room.

The concept of light was also of importance in Nightingale’s theory. In particular, she identified direct sunlight as a particular need of patients. She noted that “light has quite as real and tangible effects upon the human body . . . Who has not observed the purifying effect of light, and especially of direct sun- light, upon the air of a room?” (Nightingale, 1969, pp. 84-85). To achieve the beneficial effects of sun- light, nurses were instructed to move and position patients to expose them to sunlight.

Cleanliness is another critical component of Nightingale’s environmental theory (Nightingale, 1969). In this regard, she specifically addressed the patient, the nurse, and the physical environment. She noted that a dirty environment (floors, carpets, walls, and bed linens) was a source of infection through the organic matter it contained. Even if the environment was well ventilated, the presence of organic material created a dirty area; therefore, appropriate handling

MAJOR CONCEPTS & DEFINITIONS—cont’d

and disposal of bodily excretions and sewage were required to prevent contamination of the environ- ment. Finally, Nightingale advocated bathing patients on a frequent, even daily, basis at a time when this practice was not the norm. She required that nurses also bathe daily, that their clothing be clean, and that they wash their hands frequently (Nightingale, 1969). This concept held special significance for individual patient care, and it was critically important in im- proving the health status of the poor who were living in crowded, environmentally inferior conditions with inadequate sewage and limited access to pure water (Nightingale, 1969).

Nightingale included the concepts of quiet and diet in her theory. The nurse was required to assess the need for quiet and to intervene as needed to maintain it (Nightingale, 1969). Noise created by physical activities in the areas around a patient’s room was to be avoided because it could harm the patient. Nightingale was also concerned about the patient’s diet (Nightingale, 1969). She instructed nurses to assess not only dietary intake, but also the meal schedule and its effect on the patient. She believed that patients with chronic illness could be starved to death unintentionally, and that intelligent nurses successfully met patients’ nutritional needs.

Another component of Nightingale’s writing was a description of petty management (nursing admin- istration) (Nightingale, 1969). She pointed out that the nurse was in control of the environment both physically and administratively. The nurse was to protect the patient from receiving of upsetting news, seeing visitors who could negatively affect recovery, and experiencing sudden disruptions of sleep. In addition, Nightingale recognized that pet visits (small animals) might be of comfort to the patient. Nightingale believed that the nurse remained in charge of the environment, even when she was not physically present, because she should oversee others who worked in her absence.

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Nightingale’s carefully collected information that illustrated the efficacy of her hospital nursing system and organization during the Crimean War is perhaps her best-known work. Her report of her experiences and collected data was submitted to the British Royal Sanitary Commission in Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army Founded Chiefly on the Experience of the Late War (Nightingale, 1858a). This Commis- sion had been organized in response to Nightingale’s charges of poor sanitary conditions. The data in this report provided a strong argument in favor of her proposed reforms in the Crimean hospital barracks. According to Cohen (1984), she created the polar area diagram to represent dramatically the extent of needless death in British military hospitals in the Crimea. In this article, Cohen summarized the work of Nightingale as both a researcher and a statistician by noting that “she helped to pioneer the revolution- ary notion that social phenomena could be objectively measured and subjected to mathematical analysis” (1984, p. 128). Palmer (1977) described Nightingale’s research skills as including recording, communicat- ing, ordering, coding, conceptualizing, inferring, ana- lyzing, and synthesizing. The observation of social phenomena at both individual and systems level was especially important to Nightingale and served as the basis of her writings. Nightingale emphasized the concurrent use of observation and performance of tasks in the education of nurses and expected them to continue to use both of these activities in their work.

Major Assumptions

Nursing Nightingale believed that every woman, at one time in her life, would be a nurse in the sense that nursing is being responsible for someone else’s health. Nightin- gale’s book Notes on Nursing was published originally in 1859, to provide women with guidelines for caring for their loved ones at home and to give advice on how to “think like a nurse” (Nightingale, 1969, p. 4). Trained nurses, however, were to learn additional scientific principles to be applied in their work and were to be more skilled in observing and reporting patients’ health status while providing care as the patient recovered.

Person In most of her writings, Nightingale referred to the person as a patient. Nurses performed tasks to and for the patient and controlled the patient’s environment to enhance recovery. For the most part, Nightingale described a passive patient in this relationship. How- ever, specific references are made to the patient per- forming self-care when possible and, in particular, being involved in the timing and substance of meals. The nurse was to ask the patient about his or her preferences, which reveals the belief that Nightingale saw each patient as an individual. However, Nightin- gale (1969) emphasized that the nurse was in control of and responsible for the patient’s environmental surroundings. Nightingale had respect for persons of various backgrounds and was not judgmental about social worth.

Health Nightingale defined health as being well and using every power (resource) to the fullest extent in living life. Additionally, she saw disease and illness as a reparative process that nature instituted when a person did not attend to health concerns. Nightingale envisioned the maintenance of health through prevention of disease via environmental control and social responsibility. What she described led to public health nursing and the more modern concept of health promotion. She distinguished the concept of health nursing as different from nursing a sick patient to enhance recovery, and from living better until peaceful death. Her concept of health nursing exists today in the role of district nurses and health workers in England and in other countries where lay health care workers are used to maintain health and teach people how to prevent disease and illness. Her concept of health nursing is a model employed by many public health agencies and depart- ments in the United States.

Environment Nightingale’s concept of environment emphasized that nursing was “to assist nature in healing the patient. Little, if anything, in the patient’s world is excluded from her definition of environment. Her admonition to nurses, both those providing care in the home and trained nurses in hospitals, was to create and maintain a therapeutic environment that would enhance the comfort and recovery of the

UNIT II Nursing Philosophies66

patient. Her treatise on rural hygiene includes an incredibly specific description of environmental problems and their results, as well as practical solutions to these problems for households and com- munities (Halsall, 1997).

Nightingale’s assumptions and understanding about the environmental conditions of the day were most relevant to her philosophy. She believed that sick poor people would benefit from environmental improvements that would affect both their bodies and their minds. She believed that nurses could be instru- mental in changing the social status of the poor by improving their physical living conditions.

Many aristocrats of the time were unaware of the living conditions of the poor. Nightingale’s mother, however, had visited and provided care to poor fami- lies in the communities surrounding their estates; Nightingale accompanied her on these visits as a child and continued them when she was older. Thus Nightingale’s understandings of physical surround- ings and their effect on health was acquired through first-hand observation and experience beyond her own comfortable living situation.

Theoretical Assertions Nightingale believed that disease was a reparative process; disease was nature’s effort to remedy a process of poisoning or decay, or it was a reaction against the conditions in which a person was placed. Although these concepts seem ridiculous today, they were more scientific than the prevailing ones of the time (e.g., disease as punishment). She often capitalized the word nature in her writings, thereby suggesting that it was synonymous with God. Her Unitarian religious beliefs would support this view of God as nature. However, when she used the word nature without capitalization, it is unclear whether or not the intended meaning is different and perhaps synonymous with an organic pathological process. Nightingale believed that the role of nursing was to prevent an interruption of the reparative process and to provide optimal conditions for its enhancement, thus ensuring the patient’s recovery.

Nightingale was totally committed to nursing edu- cation (training). She wrote Notes on Nursing (1969) for women caregivers, making a distinction between

the role of household servants and those trained specifically as nurses to provide care for the sick per- son. Nightingale (1969) believed that nurses needed to be excellent observers of patients and the environ- ment; observation was an ongoing activity for trained nurses. In addition, she believed that nurses should use common sense in practice, coupled with observa- tion, perseverance, and ingenuity. Finally, Nightingale believed that people desired good health, that they would cooperate with the nurse and nature to allow the reparative process to occur, and that they would alter their environment to prevent disease.

Although Nightingale has been ridiculed for say- ing she didn’t embrace the germ theory, she very clearly understood the concept of contagion and contamination through organic materials from the patient and the environment. Many of her observa- tions are consistent with the concepts of infection and the germ theory; for example, she embraced the concept of vaccination against various diseases. Small (2008) argues that Nightingale did indeed believe in a germ theory but not in the one that sug- gests that disease germs cause inevitable infection. Such a theory was antithetical to her belief that sanitation and good hygiene could prevent infec- tion. Her belief that appropriate manipulation of the environment could prevent disease underlies modern sanitation activities.

Nightingale did not explicitly discuss the caring behaviors of nurses. She wrote very little about inter- personal relationships, except as they influence the patient’s reparative processes. She did describe the phenomenon of being called to nursing and the need for commitment to nursing work. Her own example of nursing practice in the Crimea provides evidence of caring behaviors. These include her commitment to observing patients at night, a new concept and practice; sitting with them during the dying process; standing beside them during surgical procedures; writing letters for them; and providing a reading room and materials during their recuperation. Finally, she wrote letters to their families following soldiers’ deaths. Watson defines Nightingale’s descrip- tions/behaviors as a “blueprint for transpersonal meanings and models of caring” (Watson, 2010, p. 107). Neils (2010) describes a nursing role of caring as a liaison nurse based on Nightingale’s description of rounding. She interprets this activity as a way of

CHAPTER 6 Florence Nightingale 67

expressing caring and spiritual support while also achieving other nursing observations. Straughair (2012) reports that a loss of compassion in nursing (as a component of caring) was identified by patients in the National Health Service in England and pleads for nursing attention to this aspect of Nightingale’s Christian ideal of professional nursing.

Similarly, both Burkhart and Hogan (2008) and Wu and Lin (2011) have conducted research to identify the spiritual care in nursing practice as first described by Nightingale. The settings of these stud- ies (U.S. and Taiwan) reflect the universality of Nightingale’s work. Straughair (2012) makes the case that there needs to be a rediscovery of compas- sion that appears to be diminishing in modern nursing. Finally, Wagner and White (2010) explore and analyze “caring relationships” in Nightingale’s own writings. This historical study contributes to our understanding of how Nightingale described the modern concept of caring.

Nightingale believed that nurses should be moral agents. She addressed their professional relationship with their patients; she instructed them on the prin- ciple of confidentiality and advocated for care of the poor to improve their health and social situations. In addition, she commented on patient decision making, a component of a relevant modern ethical concept. Nightingale (1969) called for concise and clear deci- sion making by the nurse and physician regarding the patient, noting that indecision (irresolution) or changing the mind is more harmful to the patient than the patient having to make a decision. Hoyt (2010) analyzed how Nightingale defined nursing as an ethical profession and the ethical practices embedded in nursing.

Logical Form Nightingale used inductive reasoning to extract laws of health, disease, and nursing from her observations and experiences. Her childhood education, particularly in philosophy and mathematics, may have contributed to her logical thinking and inductive reasoning abili- ties. For example, her observations of the conditions in the Scutari hospital led her to conclude that the contaminated, dirty, dark environment led to disease. Not only did she prevent disease from flourishing in such an environment, but also validated the outcome

by careful record keeping. From her own training, her brief experience as a superintendent in London, and her experiences in the Crimea, she made observations and established principles for nurse training and patient care (Nightingale, 1969).

Acceptance by the Nursing Community

Practice Nightingale’s nursing principles remain the foundation of nursing practice today. The environmental aspects of her theory (i.e., ventilation, warmth, quiet, diet, and cleanliness) remain integral components of nursing care. As nurses practice in the twenty-first century, the relevance of her concepts continues; in fact, they have increased relevance as a global society faces new issues of disease control. Although modern sanita- tion and water treatment have controlled traditional sources of disease fairly successfully in the United States, contaminated water due to environmental changes or to the introduction of uncommon contami- nants remains a health issue in many communities. Global travel has altered dramatically the actual and potential spread of disease. Modern sanitation, ade- quate water treatment, and recognition and control of other methods of disease transmission remain challenges for nurses worldwide.

New environmental concerns have been created by modern architecture (e.g., sick-building syndrome); nurses need to ask whether modern, environmentally controlled buildings meet Nightingale’s principle of good ventilation. On the other hand, controlled environments increasingly protect the public from second-hand cigarette smoke, toxic gases, auto emis- sions, and other environmental hazards. Disposal of these wastes, including toxic waste, and the use of chemicals in this modern society challenge profes- sional nurses and other health care professionals to reassess the concept of a healthy environment (Butterfield, 1999; Gropper, 1990; Michigan Nurses Association (MNA), 1999; Sessler, 1999). Shaner- McRae, McRae, and Jas (2007) described environ- mental conditions of our hospitals that affect not only the individual patient environment but also the larger environment incorporating multiple environmental concepts identified by Nightingale. While they focus on Western hospitals, it is evident that this is a global challenge for nurses.

UNIT II Nursing Philosophies68

In health care facilities, the ability to control room temperature for an individual patient often is increas- ingly difficult. This same environment may create great noise through activities and the technology (equipment) used to assist the patient’s reparative process. Nurses have looked in a scholarly way at these problems as they continue to affect patients and the health care system (McCarthy, Ouimet, & Daun, 1991; McLaughlin, McLaughlin, Elliott, & Campalani, 1996; MNA, 1999; Pope, 1995).

Monteiro (1985) provided the American public health community with a comprehensive review of Nightingale’s work as a sanitarian and a social re- former, reminding them of the extent of her impact on health care in various settings and her concern about poverty and sanitation issues. Although other disciplines in the United States have increasingly ad- dressed such issues, it is clear that nurses and nurs- ing have an active role in providing direct patient care and in becoming involved in the social and political arenas to ensure healthy environments for all citizens.

McPhaul and Lipscomb (2005) have applied Night- ingale’s environmental principles to practice in occu- pational health nursing. These nurse specialists have increasingly recognized current environmental health problems at local, regional, and global levels. Modern changes in travel, migration, and the physical environ- ment are causing health problems for many.

Infectious diseases (e.g., HIV, TB, West Nile virus) are examples of these changes. In addition, nurses are confronted by an epidemic of toxic substances and nosocomial infections and the development of resistant organisms (e.g., MRSA) in their patient care environments; first-line prevention measures of handwashing and environmental cleanliness harken back to Nightingale’s original environmental theory and principles. Other problems created by environ- mental changes and pollution might astound Night- ingale, but she would probably approach them in a typically aggressive fashion for control. As health care systems and providers struggle to promote patient safety through prevention of infection in health care facilities, this work can be framed in these words of Florence Nightingale: “It seems a strange principle to enunciate, as the very first requirement, in a hospital that it should Do the Sick No Harm” (Vincent, 2005).

Although some of Nightingale’s rationales have been modified or disproved by medical advances and scientific discovery, many of her concepts have endured the tests of time and technological advances. It is clear that much of her theory remains relevant for nursing today. Concepts from Nightingale’s writings, from political commentary to scholarly research, continue to be cited in the nursing literature.

Several authors have analyzed Nightingale’s petty management concepts and actions, identifying some of the timelessness and universality of her manage- ment style (Decker & Farley, 1991; Henry, Woods, & Nagelkerk, 1990; Monteiro, 1985). More recently, Lorentzon (2003) focused specifically on Nightingale’s role as a mentor to a former student in her review and analysis of letters written between her and her former student Rachel Williams. This analysis provides a review of mentoring approaches based on Nightingale’s theories; her comments on management as offered to Rachel Williams would stimulate good discussion about the needs of nurses today for mentoring and professional development. Lannon (2007) and Naraya- nasamy and Narayanasamy (2007) based their exami- nations of nursing staff and leadership development on Nightingale’s statements about the essential need for continued learning in nursing practice.

Finally, several writers have analyzed Nightingale’s role in the suffrage movement, especially in the con- text of feminist theory development. Although she has been criticized for not actively participating in this movement, Nightingale indicated in a letter to John Stuart Mill that she could do work for women in other ways (Woodham-Smith, 1951). Her essay titled Cassandra (Nightingale 1852) reflects support for the concept that is now known as feminism. Scholars continue to assess and analyze her role in the feminist movement of this modern era (Dossey, 2000; Hektor, 1994; Holliday & Parker, 1997; Selanders, 2010; Welch, 1990). Selanders (2010) argues powerfully that Nightingale was a feminist and that her beliefs as a feminist were integral to the development of modern professional nursing.

Education Nightingale’s principles of nurse training (instruction in scientific principles and practical experience for the mastery of skills) provided a universal template for early nurse training schools, beginning with St. Thomas’s

CHAPTER 6 Florence Nightingale 69

Hospital and King’s College Hospital in London. Using the Nightingale model of nurse training, the following three experimental schools were established in the United States in 1873 (Ashley, 1976): 1. Bellevue Hospital in New York 2. New Haven Hospital in Connecticut 3. Massachusetts Hospital in Boston

The influence of this training system and of many of its principles is still evident in today’s nursing pro- grams. Although Nightingale advocated independence of the nursing school from a hospital to ensure that students would not become involved in the hospital’s labor pool as part of their training, American nursing schools were unable to achieve such independence for many years (Ashley, 1976). Nightingale (Decker & Farley, 1991) believed that the art of nursing could not be measured by licensing examinations, but she used testing methods, including case studies (notes), for nursing probationers at St. Thomas’s Hospital.

Clearly, Nightingale understood that good practice could result only from good education. This message resounds throughout her writings on nursing. Night- ingale historian Joanne Farley responded to a modern nursing student by noting that “Training is to teach a nurse to know her business . . . Training is to enable the nurse to act for the best . . . like an intelligent and responsible being” (Decker & Farley, 1991, pp. 12–13). It is difficult to imagine what the care of sick human beings would be like if Nightingale had not defined the educational needs of nurses and established these first schools.

Research Nightingale’s interest in scientific inquiry and statistics continues to define the scientific inquiry used in nurs- ing research. She was exceptionally efficient and resourceful in her ability to gather and analyze data; her ability to represent data graphically was first iden- tified in the polar diagrams, the graphical illustration style that she invented (Agnew, 1958; Cohen, 1984; McDonald, 2010b). Her empirical approach to solving problems of health care delivery is obvious in the data that she included in her numerous reports and letters.

When Nightingale’s writings are defined and ana- lyzed as theory, they are seen to present a philo- sophical approach that is applicable in modern nursing. Concepts that Nightingale identified serve as the basis for research adding to modern nursing

science and practice throughout the world. Most notable is her focus on surroundings (environment) and their importance to nursing. Finally, it is interest- ing to note that Nightingale used brief case studies, possible exemplars, to illustrate a number of the con- cepts that she discussed in Notes on Nursing (1969).

Further Development Nightingale’s philosophy and theory of nursing are stated clearly and concisely in Notes on Nursing (1969), Nightingale’s most widely known work. In this writing, she provides guidance for care of the sick and in so doing clarifies what nursing is and what it is not. The content of the text seems most amenable to theory analysis. Hardy (1978) proposed that Night- ingale formulated a grand theory that explains the totality of behavior. As knowledge of nursing theory has developed, Nightingale’s work has come to be recognized as a philosophy of nursing. Although some formulations have been tested, most often prin- ciples are derived from anecdotal situations to illus- trate their meaning and support their claims. Her work is often discussed as a theory, and it is clear that Nightingale’s premises provide a foundation for the development of both nursing practice and current nursing theories. Tourville and Ingalls (2003) de- scribed Nightingale as the trunk of the living tree of nursing theories.

Critique

Clarity Nightingale’s work is clear and easily understood. It contains the following three major relationships: 1. Environment to patient 2. Nurse to environment 3. Nurse to patient

Nightingale believed that the environment was the main factor that created illness in a patient and regarded disease as “the reactions of kindly nature against the conditions in which we have placed our- selves” (Nightingale, 1969, p. 56). Nightingale recog- nized the potential harmfulness of an environment, and she emphasized the benefit of a good environment in preventing disease.

The nurse’s practice includes manipulation of the environment in a number of ways to enhance patient

UNIT II Nursing Philosophies70

recovery. Elimination of contamination and contagion and exposure to fresh air, light, warmth, and quiet were identified as elements to be controlled or manipulated in the environment. Nightingale began to develop relationships between some of these elements in her discussions of contamination and ventilation, light and patient position in the room, cleanliness and darkness, and noise and patient stimulation. She also described the relationship between the sickroom and the rest of the house and the relationship between the house and the surrounding neighborhood.

The nurse-patient relationship may be the least well defined in Nightingale’s writings. Yet cooperation and collaboration between the nurse and patient is suggested in her discussions of a patient’s eating pat- terns and preferences, the comfort of a beloved pet to the patient, protection of the patient from emotional distress, and conservation of energy while the patient is allowed to participate in self-care. Finally, it is inter- esting to note that Nightingale discussed the concept of observation extensively, including its use to guide the care of patients and to measure improvement or lack of response to nursing interventions.

Simplicity Nightingale provides a descriptive, explanatory theory. Its environmental focus along with its epidemiological components has predictive potential. Nightingale could be said to have tested her theory in an informal manner by collecting data and verifying improvements. She intended to provide general rules and explanations that would result in good nursing care for patients. Thus her objective of setting forth general rules for the practice and development of nursing was met through this simple theory.

Generality Nightingale’s theories have been used to provide general guidelines for all nurses since she introduced them more than 150 years ago. Although some activities that she described are no longer relevant, the universality and timelessness of her concepts remain pertinent. Nurses are increasingly recogniz- ing the role of observation and measurement of outcomes as an essential component of nursing practice. Burnes Bolton and Goodenough (2003), Erlen (2007), Robb, Mackie, & Elcock (2007), and

Weir-Hughes (2007) all have written about measure- ment of patient outcomes and methods of quality improvement based on Nightingale’s notions of observation. The relation concepts (nurse, patient, and environment) remain applicable in all nursing settings today. Therefore they meet the criterion of generality.

Empirical Precision Concepts and relationships within Nightingale’s the- ory frequently are stated implicitly and are presented as truths rather than as tentative, testable statements. In contrast to her quantitative research on mortality performed in the Crimea, Nightingale advised the nurses of her day that their practice should be based on their observations and experiences. Her concepts are amenable to studies with the qualitative approaches of today as well as quantitative methods.

Derivable Consequences To an extraordinary degree, Nightingale’s writings direct the nurse to take action on behalf of the patient and the nurse. These directives encompass the areas of practice, research, and education. Her principles to shape nursing practice are the most specific. She urges nurses to provide physicians with “not your opinion, however respectfully given, but your facts” (Nightingale, 1969, p. 122). Similarly, she advises that “if you cannot get the habit of observation one way or other, you had better give up being a nurse, for it is not your calling, however kind and anxious you may be” (Nightingale, 1969, p. 113).

Nightingale’s view of humanity was consistent with her theory of nursing. She believed in a creative, uni- versal humanity with the potential and ability for growth and change (Dossey, 2000; Hektor, 1994; Palmer, 1977). Deeply religious, she viewed nursing as a means of doing the will of her God. The zeal and self-righteousness that come from being a reformer might explain some of her beliefs and the practices that she advocated. Finally, the period and place in which she lived, Victorian England, must be consid- ered if one is to understand and interpret her views.

Nightingale’s basic principles of environmental manipulation and care of the patient can be applied in contemporary nursing settings. Although subjected to some criticisms, her theory and her principles are

CHAPTER 6 Florence Nightingale 71

relevant to the professional identity and practice of nursing.

As one reads Notes on Nursing, sentences and observations made by Nightingale can have great significance for the world of nursing today. Vidrine, Owen-Smith, and Faulkner (2002) have identified one of these observations as the guiding theory for their work with equine-facilitated group psycho- therapy: “a small pet animal is often an excellent companion for the sick, for long chronic cases espe- cially” (Nightingale, 1969, p. 102). Although a horse may not qualify as a “small animal in the sickroom,” these authors have found that their therapy is suc- cessful with their patients. Indeed, Nightingale is a testament to her own theory; it is reported that she had 60 cats over her lifetime (she was chronically ill for much of her adult life and lived to 90 years of age).

Summary Florence Nightingale is a unique figure in the history of the world. Her picture appeared on the English 10-pound note for 100 years. No other woman has been and still is revered as an icon by so many people in so many diverse geographical locations. Few other figures continue to stimulate such interest in, contro- versy about, and interpretation of their lives and work. The nursing profession embraces her as the founder of modern nursing.

Nightingale defined the skills, behaviors, and knowledge required for professional nursing. Rem- nants of these descriptions serve the nursing profes- sion well today, although their origins probably are not known by today’s nurses.

Because of scientific and social changes that have occurred in the world, some of Nightingale’s observa- tions have been rejected, only to find after closer analysis that her underlying beliefs, philosophy, and observations continue to be valid. Nightingale did not consciously attempt to develop what is considered a theory of nursing; she provided the first definitions from which nurses could develop theory and the conceptual models and frameworks that inform pro- fessional nursing today. Professionals increasingly identify her as their matriarch. Mathematicians revere her for her work as an outstanding statistician.

Epidemiologists, public health professionals, and lay health care workers trace the origins of their disciplines to Nightingale’s descriptions of people who perform health promotion and disease preven- tion. Sociologists acknowledge her leadership role in defining communities and their social ills, and in working to correct problems of society as a way of improving the health of its members.

A century after Nightingale’s death, nursing com- munities throughout the world gave special attention to her life and work. In particular, the Journal of Holistic Nursing published multiple articles (cited in this chapter). Of special note is Beck’s (2010) article identifying Seven Recommendations for 21st Century Nursing Practice based on Nightingale’s philosophy offering a clarion call for nurses throughout the world to emulate the work of Nightingale.

Nurses, both students and practitioners, would be wise to become familiar with Nightingale’s original writings and to review the many books and documents that are increasingly available (McDonald, 2001 to present). If you have read Notes on Nursing, rereading it will reveal new and inspirational ideas and provide a brief look at her wry sense of humor. The logic and common sense that are embodied in Nightingale’s writings serve to stimulate productive thinking for the individual nurse and the nursing profession. To emu- late the life of Nightingale is to become a good citizen and leader in the community, the country, and the world. It is only right that Nightingale should continue to be recognized as the brilliant and creative founder of modern nursing and its first nursing theorist. What would Nightingale say about nursing today? Whatever she would say, she probably would provide an objec- tive, logical, and revealing analysis and critique.

CASE STUDY

You are caring for an 82-year-old woman who has been hospitalized for several weeks for burns that she sustained on her lower legs during a cooking accident. Before the time of her admission, she lived alone in a small apartment. The patient reported on admission that she has no surviving family. Her support system appears to be other

Continued

UNIT II Nursing Philosophies72

elders who live in her neighborhood. Because of transportation difficulties, most of them are unable to visit frequently. One of her neighbors has reported that she is caring for the patient’s dog, a Yorkshire terrier. As you care for this woman, she begs you to let her friend bring her dog to the hospital. She says that none of the other nurses have listened to her about such a visit. As she asks you about this, she begins to cry and tells you that they have never been separated. You recall that the staff discussed their concern about this woman’s well-being during report that morning. They said that she has been eating very little and seems to be depressed. Based on Nightingale’s work, identify specific interventions that you would provide in caring for this patient. 1. Describe what action, if any, you would take

regarding the patient’s request to see her dog.

Discuss the theoretical basis of your decision and action based on your understanding of Nightingale’s work.

2. Describe and discuss what nursing diagnoses you would make and what interventions you would initiate to address the patient’s nutritional status and emotional well-being.

3. As the patient’s primary nurse, identify and discuss the planning you would undertake regarding her discharge from the hospital. Identify members of the discharge team and their roles in this process. Describe how you would advocate for the patient based on Nightingale’s observations and descriptions of the role of the nurse.

CRITICAL THINKING ACTIVITIES you are practicing nursing as an employee or student.

3. You are participating in a quality improvement project in your work setting. Share how you would develop ideas to present to the group based on a Nightingale approach.

1. Your community is at risk for a specific type of natural disaster (e.g., tornado, flood, hurricane, earthquake). Use Nightingale’s principles and observations to develop an emergency plan for one of these events. Outline the items you would include in the plan.

2. Using Nightingale’s concepts of ventilation, light, noise, and cleanliness, analyze the setting in which

POINTS FOR FURTHER STUDY

Wilfred Laurier University Press. Retrieved from: http://www.sociology.uoguelph.ca/fnightingale.

n Nightingale, F. (1969). Notes on nursing: What it is and what it is not. New York: Dover (first published in 1859).

n The Florence Nightingale Museum. Retrieved from: http://www.florence-nightingale.co.uk.

n Florence Nightingale: The nurse theorists: Portraits of excellence, The Helene Fuld Health Trust (1990), Studio Three Productions, a division of Samuel Merritt College, Oakland, CA. (Video/ DVD available from Fitne, Inc., Athens, OH.)

n McDonald, L. (Ed.). (2001–present). The collected works of Florence Nightingale. Ontario, Canada:

Agnew, L. R. (1958). Florence Nightingale, statistician. American Journal of Nursing, 58, 644.

Ashley, J. A. (1976). Hospitals, paternalism, and the role of the nurse. New York: Teachers College Press.

Beck, D. M. (2010). Expanding our Nightingale hori- zon: Seven recommendations for 21st century nursing practice. Journal of Holistic Nursing, 28(4), 317–326.

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Williams, B. (2000). Florence Nightingale: a relevant heroine for nurses today? California Nurse, 96(1), 9, 27.

79

CH A P T ER 7

Jean Watson 1940 to Present

Watson’s Philosophy and Theory of Transpersonal Caring

D. Elizabeth Jesse and Martha R. Alligood

Previous authors: Ruth M. Neil, Ann Marriner Tomey, Tracey J. F. Patton, Deborah A. Barnhart, Patricia M. Bennett, Beverly D. Porter, and Rebecca S. Sloan. These authors wish to thank Dr. Jean Watson for her ongoing inspiration and support, along with her review of the content of this chapter for accuracy and her assistance in updating the references and bibliography.

“We are the light in institutional darkness, and in this model we get to return to the light of our humanity”

(Jean Watson, 7/9/2012.)

Credentials and Background of the Theorist

Margaret Jean Harman Watson, PhD, RN, AHN-BC, FAAN, was born and grew up in the small town of Welch, West Virginia, in the Appalachian Moun- tains. As the youngest of eight children, she was surrounded by an extended family–community environment.

state of Colorado. Douglas, whom Watson describes as her physical and spiritual partner, and her best friend, died in 1998. She has two grown daughters, Jennifer and Julie, and five grandchildren. Jean lives in Boulder, Colorado.

After moving to Colorado, Watson continued her nursing education and graduate studies at the Univer- sity of Colorado. She earned a baccalaureate degree in nursing in 1964 at the Boulder campus, a master’s degree in psychiatric–mental health nursing in 1966 at the Health Sciences campus, and a doctorate in educational psychology and counseling in 1973 at the Graduate School, Boulder campus. After Watson

Watson attended high school in West Virginia and then the Lewis Gale School of Nursing in Roanoke, Virginia. After graduation in 1961, she married her husband, Douglas, and moved west to his native

UNIT II Nursing Philosophies80

completed her doctoral degree, she joined the School of Nursing faculty, University of Colorado Health Sci- ences Center in Denver, where she has served in both faculty and administrative positions. In 1981 and 1982, she pursued international sabbatical studies in New Zealand, Australia, India, Thailand, and Taiwan; in 2005, she took a sabbatical for a walking pilgrimage in the Spanish El Camino.

In the 1980s, Watson and colleagues established the Center for Human Caring at the University of Colorado, the nation’s first interdisciplinary center committed to using human caring knowledge for clini- cal practice, scholarship, and administration and lead- ership (Watson, 1986). At the center, Watson and others sponsor clinical, educational, and community scholarship activities and projects in human caring. These activities involve national and international scholars in residence, as well as international connec- tions with colleagues around the world, such as Australia, Brazil, Canada, Korea, Japan, New Zealand, the United Kingdom, Scandinavia, Thailand, and Venezuela, among others. Activities such as these continue at the University of Colorado’s International Certificate Program in Caring-Healing, where Watson offers her theory courses for doctoral students.

At University of Colorado School of Nursing, Watson served as chairperson and assistant dean of the under- graduate program. She was involved in planning and implementation of the nursing PhD program and served as coordinator and director of the PhD program between 1978 and 1981. Watson was Dean of Univer- sity of Colorado School of Nursing and Associate Director of Nursing Practice at University Hospital from 1983 to 1990. During her deanship, she was in- strumental in the development of a post-baccalaureate nursing curriculum in human caring, health, and heal- ing that led to a Nursing Doctorate (ND), a professional clinical doctoral degree that in 2005 became the Doctor of Nursing Practice (DNP) degree.

During her career, Watson has been active in many community programs, such as founder and member of the Board of Boulder County Hospice, and numerous other collaborations with area health care facilities. Watson has received several research and advanced education federal grants and awards and numerous university and private grants and extramural funding for her faculty and administrative projects and scholar- ships in human caring.

The University of Colorado School of Nursing hon- ored Watson as a distinguished professor of nursing in 1992. She received six honorary doctoral degrees from universities in the United States and three Honorary Doctorates in international universities, including Göteborg University in Sweden, Luton University in London, and the University of Montreal in Quebec, Canada. In 1993, she received the National League for Nursing (NLN) Martha E. Rogers Award, which rec- ognizes nurse scholars’ significant contributions to advancing nursing knowledge and knowledge in other health sciences. Between 1993 and 1996, Watson served as a member of the Executive Committee and the Governing Board, and as an officer for the NLN, and she was elected president from 1995 to 1996. In 1997, the NLN awarded her an honorary lifetime certificate as a holistic nurse. Finally, in 1999, Watson assumed the nation’s first Murchison-Scoville Endowed Chair of Caring Science and currently is a distin- guished professor of nursing.

In 1998, Watson was recognized as a Distin- guished Nurse Scholar by New York University, and in 1999, she received the Fetzer Institute’s national Norman Cousins Award in recognition of her com- mitment to developing, maintaining, and exemplify- ing relationship-centered care practices (Watson, personal communication, August 14, 2000).

Watson is a Distinguished and/or Endowed Lec- turer at national universities, including Boston Col- lege, Catholic University, Adelphi University, Columbia University-Teachers College, State University of New York, and at universities and scholarly meetings in nu- merous foreign countries. Her international activities also include an International Kellogg Fellowship in Australia (1982), a Fulbright Research and Lecture Award to Sweden and other parts of Scandinavia (1991), and a lecture tour in the United Kingdom (1993). Watson has been involved in international projects and has received invitations to New Zealand, India, Thailand, Taiwan, Israel, Japan, Venezuela, Korea, and other places. She is featured in at least 20 nationally distributed audiotapes, videotapes, and/or CDs on nursing theory, a few of which are listed in Points for Further Study at the end of the chapter.

Jean Watson has authored 11 books, shared in au- thorship of six books, and has written countless articles in nursing journals. The following publications reflect

CHAPTER 7 Jean Watson 81

the evolution of her theory of caring from her ideas about the philosophy and science of caring.

Her first book, Nursing: The Philosophy and Science of Caring (1979), was developed from her notes for an undergraduate course taught at the University of Colorado. Yalom’s 11 curative factors stimulated Watson’s thinking about 10 carative factors, described as the organizing framework for her book (Watson, 1979), “central to nursing” (p. 9), and a moral ideal. Watson’s early work embraced the 10 carative factors but evolved to include “caritas,” making explicit con- nections between caring and love (Watson, personal correspondence, 2004). Her first book was reprinted in 1985 and translated into Korean and French.

Her second book, Nursing: Human Science and Human Care—A Theory of Nursing, published in 1985 and reprinted in 1988 and 1999, addressed her conceptual and philosophical problems in nursing. Her second book has been translated into Chinese, German, Japanese, Korean, Swedish, Norwegian, Danish, and probably other languages by now.

Her third book, Postmodern Nursing and Beyond (1999), was presented as a model to bring nursing practice into the twenty-first century. Watson describes two personal life-altering events that contributed to her writing. In 1997, she experienced an accidental injury that resulted in the loss of her left eye and soon after, in 1998, her husband died. Watson states that she is “attempting to integrate these wounds into my life and work. One of the gifts through the suffering was the privilege of experiencing and receiving my own theory through the care from my husband and loving nurse friends and colleagues” (Watson, personal communi- cation, August 31, 2000). This third book has been translated into Portuguese and Japanese. Instruments for Assessing and Measuring Caring in Nursing and Health Sciences (2002), a collection of 21 instruments to assess and measure caring, received the American Journal of Nursing Book of the Year Award.

Her fifth book, Caring Science as Sacred Science (2005), describes her personal journey to enhance understanding about caring science, spiritual practice, the concept and practice of care, and caring-healing work. In this book, she leads the reader through thought-provoking experiences and the sacredness of nursing by emphasizing deep inner reflection and personal growth, communication skills, use of self-transpersonal growth, and attention to both caring

science and healing through forgiveness, gratitude, and surrender. It received the American Journal of Nursing 2005 Book of the Year Award.

Recent books include Measuring Caring: Interna- tional Research on Caritas as Healing (Nelson & Watson, 2011), Creating a Caring Science Curriculum (Hills & Watson, 2011), and Human Caring Science: A Theory of Nursing (Watson, 2012).

Theoretical Sources Watson’s work has been called a philosophy, blueprint, ethic, paradigm, worldview, treatise, conceptual model, framework, and theory (Watson, 1996). This chapter uses the terms theory and framework interchangeably. To develop her theory, Watson (1988) defines theory as “an imaginative grouping of knowledge, ideas, and ex- perience that are represented symbolically and seek to illuminate a given phenomenon” (p. 1). She draws on the Latin meaning of theory “to see” and concludes, “It (Human Science) is a theory because it helps me ‘to see’ more broadly (clearly)” (p. 1). Watson acknowledges a phenomenological, existential, and spiritual orienta- tion from the sciences and humanities as well as philo- sophical and intellectual guidance from feminist theory, metaphysics, phenomenology, quantum phys- ics, wisdom traditions, perennial philosophy, and Bud- dhism (Watson, 1995, 1997, 1999, 2005, 2012). She cites background for her theory nursing philosophies and theorists, including Nightingale, Henderson, Leininger, Peplau, Rogers, and Newman, and also the work of Gadow, a nursing philosopher and health care ethicist (Watson, 1985, 1997, 2005, 2012). She connects Nightingale’s sense of deep commitment and calling to an ethic of human service.

Watson attributes her emphasis on the interper- sonal and transpersonal qualities of congruence, em- pathy, and warmth to the views of Carl Rogers and more recent writers of transpersonal psychology. Watson points out that Carl Rogers’ phenomenologi- cal approach, with his view that nurses are not here to manipulate and control others but rather to under- stand, was profoundly influential at a time when “clinicalization” (therapeutic control and manipula- tion of the patient) was considered the norm (Watson, personal communication, August 31, 2000). In her book, Caring Science as Sacred Science, Watson (2005) describes the wisdom of French philosopher

UNIT II Nursing Philosophies82

Emmanuael Levinas (1969) and Danish philosopher Knud Løgstrup (1995) as foundational to her work.

Watson’s main concepts include the 10 carative factors (see Major Concepts & Definitions box and Table 7-1) and transpersonal healing and transper- sonal caring relationship, caring moment, caring occasion, caring healing modalities, caring conscious- ness, caring consciousness energy, and phenomenal file/unitary consciousness. Watson expanded the cara- tive factors to a closely related concept, caritas, a Latin word that means “to cherish, to appreciate, to

give special attention, if not loving attention.” As carative factors evolved within an expanding per- spective, and as her ideas and values evolved, Watson offered a translation of the original carative factors into clinical caritas processes that suggested open ways in which they could be considered (Table 7-1).

Watson (1999) describes a “Transpersonal Caring Relationship” as foundational to her theory; it is a “special kind of human care relationship—a union with another person—high regard for the whole per- son and their being-in-the-world” (p. 63).

TABLE 7-1 Carative Factors and Caritas Processes

Carative Factors Caritas Processes

1. “The formation of a humanistic-altruistic system of values”

2. “The instillation of faith-hope”

3. “The cultivation of sensitivity to one’s self and to others”

4. “Development of a helping-trust relationship” became “development of a helping-trusting, human caring relation” (in 2004 Watson website)

5. “The promotion and acceptance of the expression of positive and negative feelings”

6. “The systematic use of the scientific problem solving method for decision making” became “systematic use of a creative problem solving caring process” (in 2004 Watson website)

7. “The promotion of transpersonal teaching-learning”

8. “The provision of supportive, protective, and (or) corrective mental, physical, societal, and spiritual environment”

9. “The assistance with gratification of human needs”

10. “The allowance for existential-phenomenological forces” became “allowance for existential-phenomenological- spiritual forces” (in 2004 Watson website)

“Practice of loving-kindness and equanimity within the context of caring consciousness”

“Being authentically present and enabling and sustaining the deep belief system and subjective life-world of self and one being cared for”

“Cultivation of one’s own spiritual practices and transpersonal self going beyond the ego self”

“Developing and sustaining a helping trusting authentic caring relationship”

“Being present to, and supportive of, the expression of positive and negative feelings as a connection with deeper spirit and self and the one-being-cared for”

“Creative use of self and all ways of knowing as part of the caring process; to engage in the artistry of caring-healing practices”

“Engaging in genuine teaching-learning experience that attends to unity of being and meaning, attempting to stay within others’ frame of reference”

“Creating healing environment at all levels (physical as well as nonphysical, subtle environment of energy and conscious- ness, whereby wholeness, beauty, comfort, dignity, and peace are potentiated)”

“Assisting with basic needs, with an intentional caring con- sciousness, administering ‘human care essentials,’ which potentiate alignment of mind body spirit, wholeness, and unity of being in all aspects of care”

“Opening and attending to spiritual-mysterious and existential dimensions of one’s own life-death; soul care for self and the one-being-cared for”

Modified from Watson, J. (1979). Nursing: The philosophy and science of caring (pp. 9–10). Boston: Little, Brown. (for original carative factors); and Watson, J. (2004). Theory of human caring (website). Denver, (CO): Jean Watson/University of Colorado School of Nursing. Retrieved from: http://hschealth.uchsc. edu/son/faculty/jw_evolution.htm (for caritas processes and revised carative factors).

CHAPTER 7 Jean Watson 83

Original 10 Carative Factors

Watson bases her theory for nursing practice on the following 10 carative factors. Each has a dynamic phenomenological component that is relative to the individuals involved in the relationship as encom- passed by nursing. The first three interdependent factors serve as the “philosophical foundation for the science of caring” (Watson, 1979, pp. 9-10). As Watson’s ideas and values have evolved, she has translated the 10 carative factors into caritas pro- cesses. Caritas processes included a decidedly spiri- tual dimension and overt evocation of love and caring. (See Table 7-1 for the original carative fac- tors and for caritas process interpretation.)

1.  Formation of a Humanistic Altruistic System  of Values

Humanistic and altruistic values are learned early in life but can be influenced greatly by nurse edu- cators. This factor can be defined as satisfaction through giving and extension of the sense of self (Watson, 1979).

 2.  Instillation of Faith-Hope

This factor, incorporating humanistic and altruistic values, facilitates the promotion of holistic nursing care and positive health within the patient popula- tion. It also describes the nurse’s role in developing effective nurse-patient interrelationships and in promoting wellness by helping the patient adopt health-seeking behaviors (Watson, 1979).

 3.  Cultivation of Sensitivity to Self and Others

The recognition of feelings leads to self- actualization through self-acceptance for both the nurse and patient. As nurses acknowledge their sensitivity and feelings, they become more genuine, authentic, and sensitive to others (Watson, 1979).

 4.  Development of a Helping-Trust Relationship

The development of a helping-trust relationship between the nurse and patient is crucial for transpersonal caring. A trusting relationship promotes and accepts the expression of both positive and negative feelings. It involves con- gruence, empathy, nonpossessive warmth, and

MAJOR CONCEPTS & DEFINITIONS

effective communication. Congruence involves being real, honest, genuine, and authentic. Empa- thy is the ability to experience and thereby under- stand the other person’s perceptions and feelings and to communicate those understandings. Non- possessive warmth is demonstrated by: a moder- ate speaking volume, a relaxed open posture, and facial expressions that are congruent with other communications. Effective communication has cognitive, affective, and behavior response com- ponents (Watson, 1979).

 5.  Promotion and Acceptance of the Expression  of Positive and Negative Feelings

The sharing of feelings is a risk-taking experience for both nurse and patient. The nurse must be prepared for either positive or negative feelings. The nurse must recognize that intellectual and emotional understandings of a situation differ (Watson, 1979).

 6.  Systematic Use of the Scientific Problem-Solving  Method for Decision Making

Use of the nursing process brings a scientific problem-solving approach to nursing care, dispel- ling the traditional image of a nurse as the doctor’s handmaiden. The nursing process is similar to the research process in that it is systematic and orga- nized (Watson, 1979).

 7.  Promotion of Interpersonal Teaching-Learning

This factor is an important concept for nursing in that it separates caring from curing. It allows the patient to be informed and shifts the responsibility for wellness and health to the patient. The nurse facilitates this process with teaching-learning techniques that are designed to enable patients to provide self-care, determine personal needs, and provide opportunities for their personal growth (Watson, 1979).

 8.  Provision for a Supportive, Protective, and   Corrective Mental, Physical, Sociocultural,   and Spiritual Environment

Nurses must recognize the influence that internal and external environments have on the health

Continued

UNIT II Nursing Philosophies84

and illness of individuals. Concepts relevant to the internal environment include the mental and spiritual well-being and sociocultural beliefs of an individual. In addition to epidemiological variables, other external variables include com- fort, privacy, safety, and clean, aesthetic sur- roundings (Watson, 1979).

 9.  Assistance with Gratification of Human Needs

The nurse recognizes the biophysical, psycho- physical, psychosocial, and intrapersonal needs of self and patient. Patients must satisfy lower-order needs before attempting to attain higher-order needs. Food, elimination, and ventilation are ex- amples of lower-order biophysical needs, whereas activity, inactivity, and sexuality are considered lower-order psychophysical needs. Achievement and affiliation are higher-order psychosocial needs. Self-actualization is a higher-order intrap- ersonal-interpersonal need (Watson, 1979).

MAJOR CONCEPTS & DEFINITIONS—cont’d

 10.  Allowance for Existential-Phenomenological  Forces

Phenomenology describes data of the immediate situation that help people understand the phe- nomena in question. Existential psychology is a science of human existence that uses phenome- nological analysis. Watson considers this factor difficult to understand. It is included to provide a thought-provoking experience, leading to a bet- ter understanding of the self and others.

Watson believes that nurses have the respon- sibility to go beyond the 10 carative factors and to facilitate patients’ development in the area of health promotion through preventive health actions. This goal is accomplished by teaching patients personal changes to promote health, providing situational support, teaching prob- lem-solving methods, and recognizing coping skills and adaptation to loss (Watson, 1979).

Use of Empirical Evidence Watson’s research into caring incorporates empiricism but emphasizes approaches that begin with nursing phenomena rather than with the natural sciences (Leininger, 1979). For example, she has used human science, empirical phenomenology, and transcendent phenomenology in her work. She has investigated metaphor and poetry to communicate, convey, and elucidate human caring and healing (Watson, 1987, 2005). In her inquiry and writing, she increasingly incorporated her conviction that a sacred relationship exists between humankind and the universe (Watson, 1997, 2005).

Major Assumptions Watson calls for joining of science with humanities so that nurses have a strong liberal arts background and understand other cultures as a requisite for using Car- ing Science and a mind-body-spiritual framework. She believes that study of the humanities expands the mind and enhances thinking skills and personal growth. Watson has compared the status of nursing with the

mythological Danaides, who attempted to fill a broken jar with water, only to see water flow through the cracks. She believed the study of sciences and humani- ties was required to seal similar cracks in the scientific basis of nursing knowledge (Watson, 1981, 1997).

Watson describes assumptions for a Transpersonal Caring Relationship extending to multidisciplinary practitioners: • Moral commitment, intentionality, and caritas

consciousness by the nurse protect, enhance, and potentiate human dignity, wholeness, and healing, thereby allowing a person to create or co-create his or her own meaning for existence.

• The conscious will of the nurse affirms the subjec- tive and spiritual significance of the patient while seeking to sustain caring in the midst of threat and despair—biological, institutional, or otherwise. The result is honoring of an I-Thou Relationship rather than an I-It Relationship.

• The nurse seeks to recognize, accurately detect, and connect with the inner condition of spirit of another through genuine presence and by being centered in the caring moment; actions, words,

CHAPTER 7 Jean Watson 85

behaviors, cognition, body language, feelings, in- tuition, thoughts, senses, the energy field, and so forth, all contribute to the transpersonal caring connection.

• The nurse’s ability to connect with another at this transpersonal spirit-to-spirit level is translated via movements, gestures, facial expressions, procedures, information, touch, sound, verbal expressions, and other scientific, technical, aesthetic, and human means of communication, into nursing human art/ acts or intentional caring-healing modalities.

• The caring-healing modalities within the context of transpersonal caring/caritas consciousness po- tentiate harmony, wholeness, and unity of being by releasing some of the disharmony, that is, the blocked energy that interferes with natural healing processes; thus the nurse helps another through this process to access the healer within, in the full- est sense of Nightingale’s view of nursing.

• Ongoing personal and professional development and spiritual growth, as well as personal spiritual practice, assist the nurse in entering into this deeper level of professional healing practice, allowing for awakening to a transpersonal condition of the world and fuller actualization of the “ontological competencies” necessary at this level of advanced practice of nursing.

• The nurse’s own life history, previous experiences, opportunities for focused study, having lived through or experienced various human conditions, and having imagined others’ feelings in various circumstances are valuable teachers for this work; to some degree, the nurse can gain the knowledge and consciousness needed through work with other cultures and study of the humanities (e.g., art; drama; literature; personal story; or narratives of illness or journeys), along with exploration of one’s own values, deep beliefs, and relationship with self, others, and one’s world.

• Other facilitators are personal growth experiences such as psychotherapy, transpersonal psychology, meditation, bioenergetics work, and other models for spiritual awakening.

• Continuous growth for developing and maturing within a transpersonal caring model is ongoing. The notion of health professionals as wounded healers is acknowledged as part of the necessary

growth and compassion called forth within this theory/philosophy (Watson, 2006b).

Theoretical Assertions

Nursing According to Watson (1988), the word nurse is both noun and verb. To her, nursing consists of “knowl- edge, thought, values, philosophy, commitment, and action, with some degree of passion” (p. 53). Nurses are interested in understanding health, illness, and the human experience; promoting and restoring health; and preventing illness. Watson’s theory calls upon nurses to go beyond procedures, tasks, and techniques used in practice settings, coined as the trim of nursing, in contrast to the core of nursing, meaning those aspects of the nurse-patient relation- ship resulting in a therapeutic outcome that are in- cluded in the transpersonal caring process (Watson, 2005; 2012). Using the original and evolving 10 cara- tive factors, the nurse provides care to various pa- tients. Each carative factor and the clinical caritas processes describe the caring process of how a patient attains or maintains health or dies a peaceful death. Conversely, Watson has described curing as a medical term that refers to the elimination of disease (Watson, 1979). As Watson’s work evolved, she increased her focus on the human care process and the transper- sonal aspects of caring-healing in a Transpersonal Caring Relationship (1999, 2005).

Watson’s evolving work continues to make explicit that humans cannot be treated as objects and that humans cannot be separated from self, other, nature, and the larger universe. The caring-healing paradigm is located within a cosmology that is both metaphysi- cal and transcendent with the co-evolving human in the universe. She asks others to be open to possibility and to put away assumptions of self and others, to learn again, and to “see” using all of one’s senses.

Personhood (Human Being) Watson uses interchangeably the terms human being, person, life, personhood, and self. She views the person as “a unity of mind/body/spirit/nature” (1996, p. 147), and she says that “personhood is tied to notions that one’s soul possess a body that is not confined by objective time and space . . .” (Watson, 1988, p. 45).

UNIT II Nursing Philosophies86

Watson states, “I make the point to use mind, body, soul or unity within an evolving emergent world view-connectedness of all, sometimes referred to as Unitary Transformative Paradigm-Holographic thinking. It is often considered dualistic because I use the three words ‘mind, body, soul.’ I do it intentionally to connote and make explicit spirit/metaphysical— which is silent in other models” (Watson, personal communication, April 12, 1994).

Health Originally, Watson’s (1979) definition of health was derived from the World Health Organization as, “The positive state of physical, mental, and social well-being with the inclusion of three elements: (1) a high level of overall physical, mental, and social functioning; (2) a general adaptive-maintenance level of daily function- ing; (3) the absence of illness (or the presence of efforts that lead to its absence)” (p. 220). Later, she defined health as “unity and harmony within the mind, body, and soul”; associated with the “degree of congruence between the self as perceived and the self as experi- enced” (Watson, 1988, p. 48). Watson (1988) stated further, “illness is not necessarily disease; [instead it is a] subjective turmoil or disharmony within a person’s inner self or soul at some level of disharmony within the spheres of the person, for example, in the mind, body, and soul, either consciously or unconsciously” (p. 47). “While illness can lead to disease, illness and health are [a] phenomenon that is not necessarily viewed on a continuum. Disease processes can also result from genetic, constitutional vulnerabilities and manifest themselves when disharmony is present. Dis- ease in turn creates more disharmony” (Watson, 1985, 1988, p. 48).

Environment In the original ten carative factors, Watson speaks to the nurse’s role in the environment as “attending to supportive, protective, and or corrective mental, physical, societal, and spiritual environments” (Watson, 1979, p. 10). In later work, she has a much broader view of environment: “the caring science is not only for sustaining humanity, but also for sustaining the planet . . . Belonging is to an infinite universal spirit world of nature and all living things; it is the primor- dial link of humanity and life itself, across time and space, boundaries and nationalities” (Watson, 2003,

p. 305). She says that “healing spaces can be used to help others transcend illness, pain, and suffering,” emphasizing the environment and person connec- tion: “when the nurse enters the patient’s room, a magnetic field of expectation is created” (Watson, 2003, p. 305).

Logical Form The framework is presented in a logical form. It con- tains broad ideas that address health-illness phenom- ena. Watson’s definition of caring as opposed to curing is to delineate nursing from medicine and classify the body of nursing knowledge as a separate science.

Since 1979, the development of the theory has been toward clarifying the person of the nurse and the person of the patient. Another emphasis has been on existential-phenomenological and spiri- tual factors. Her works (2005) remind us of the “spirit-filled dimensions of caring work and caring knowledge” (p. x).

Watson’s theory has foundational support from theorists in other disciplines, such as Rogers, Erikson, and Maslow. She is adamant that nursing education incorporate holistic knowledge from many disciplines integrating the humanities, arts, and sciences and that the increasingly complex health care systems and patient needs require nurses to have a broad, liberal education (Sakalys & Watson, 1986).

Watson incorporated dimensions of a postmodern paradigm shift throughout her theory of transper- sonal caring. Her theoretical underpinnings have been associated with concepts such as steady-state maintenance, adaptation, linear interaction, and problem-based nursing practice. The postmodern approach moves beyond this point; the redefining of such a nursing paradigm leads to a more holistic, humanistic, open system, wherein harmony, interpre- tation, and self-transcendence emerge reflecting a epistemological shift.

Application by the Nursing Community

Practice Watson’s theory has been validated in outpatient, inpatient, and community health clinical settings and with various populations, including recent ap- plications with attention to patient care essentials

CHAPTER 7 Jean Watson 87

(Pipe, Connolly, Spahr, et al., 2012), living on a ven- tilator (Lindahl, 2011), and simulating care (Diener & Hobbs, 2012). Watson and Foster (2003) de- scribed an exemplary application of theory to prac- tice; the Attending Nurse Caring Model (ANCM) is a unique pilot project in a Denver children’s hospital that is modeled after the “Attending” Physician Model. However, unlike a medical/cure model, the ANCM is concerned with the nursing care model. “It is constructed as a Nursing-Caring Science, the- ory-guided, evidence based, collaborative practice model for applying it to the conduct and oversight of pain management on a 37-bed, post surgical unit” (Watson & Foster, 2003, p. 363). Nurses who partici- pate in the project learn about Watson’s caring theory, carative factors, caring consciousness, in- tentionality, and caring-healing practices. The mis- sion of the ANCM is to have a continuous caring relationship with children in pain and their fami- lies. The ANCM is made visible in a caring-healing presence throughout the hospital. (See Watson’s website [http://www.watsoncaringscience.org] for examples of her theory in practice and further information about the many clinical agencies that use Watson’s work, such as Miami Baptist Hospital, Resurrection Health System [Chicago], Denver Veterans Administration Hospital and Children’s Hospital [Denver], Inova Health System [Virginia], Baptist Central Hospital [Kentucky], Elmhurst Hos- pital [New York], Pascak Valley Hospital [New Jersey], Sarasota Memorial Hospital and Tampa Memorial Hospital [Florida], and Scripps Memorial Hospital [California], among others.)

Administration/Leadership Watson’s theory calls for administrative practices and business models to embrace caring (Watson, 2006c), even in a health care environment of increased acuity levels of hospitalized individuals, short hospital stays, increasing complexity of technology, and rising ex- pectations in the “task” of nursing. These challenges call for solutions that address health care system reform at a deep and ethical level, and that enable nurses to follow their own professional practice model rather than short-term solutions, such as increasing numbers of beds, sign-on bonuses, and/or relocation incentives for nurses. Many hospitals seeking Magnet status, such as Central Baptist Hospital in Lexington,

Kentucky, are meeting these challenges by using Watson’s Theory of Human Caring for administra- tive change. Others call for sustaining a professional environment based on the definition of patient care essentials (Pipe, Connolly, Spahr, et al., 2012). This and other examples of caring administrative practices are described at her website and in her recent article, “Caring Theory as an Ethical Guide to Administrative and Clinical Practices” (Watson, 2006c).

Education Watson’s writings focus on educating graduate nursing students and providing them with ontological, ethical, and epistemological bases for their practice, along with research directions (Hills & Watson, 2011). Watson’s caring framework has been taught in numer- ous baccalaureate nursing curricula, including Bellar- mine College in Louisville, Kentucky; Assumption College in Worcester, Massachusetts; Indiana State University in Terre Haute; Oklahoma City Univer- sity; and Florida Atlantic University. In addition, the concepts are used in nursing programs in Australia, Japan, Brazil, Finland, Saudi Arabia, Sweden, and the United Kingdom, to name a few.

Research Qualitative, naturalistic, and phenomenological meth- ods are relevant to the study of caring and to the devel- opment of nursing as a human science (Nelson & Watson, 2011; Watson, 2012). Watson suggests that a combination of qualitative-quantitative inquiry may be useful. There is a growing body of national and in- ternational research that tests, expands, and evaluates the theory (DiNapoli, Nelson, Turkel, & Watson, 2010; Nelson & Watson, 2011). Smith (2004) published a review of 40 research studies that specifically used Watson’s theory. Persky, Nelson, Watson, and Bent’s (2008) study used a quantitative approach to deter- mine the attributes of a “Caritas nurse” as part of an effort to initiate Relationship-Based Care (RBC) at New York Presbyterian Hospital/Columbia University Medical Center. More recently, Nelson and Watson (2011) report on studies carried out in seven coun- tries. Nelson and Watson (2011) present eight caring surveys and other research tools for caritas research, such as differences among international perceptions of caring, nurse and patient relationships, and guidelines for hospitals seeking Magnet status.

UNIT II Nursing Philosophies88

Further Development Watson’s recent writings update her theory (Watson, 2012), review caring measurement (Nelson & Watson, 2011), and guide the creation of a caring science curriculum (Hills & Watson, 2011).

Critique

Clarity Watson uses nontechnical, sophisticated, fluid, and evolutionary language to artfully describe her con- cepts, such as caring-love, carative factors, and cari- tas. Paradoxically, abstract and simple concepts such as caring-love are difficult to practice, yet prac- ticing and experiencing these concepts leads to greater understanding. At times, lengthy phrases and sentences are best understood if read more than once. Watson’s inclusion of metaphors, personal reflections, artwork, and poetry make her concepts more tangible and more aesthetically appealing. She has continued to refine her theory and has revised the original carative factors as caritas processes. Critics of Watson’s work have concentrated on her use of undefined or changing/shifting definitions and terms and her focus on the psychosocial rather than the pathophysiological aspects of nursing. Watson (1985) has addressed the critiques of her work in the preface of Nursing: The Philosophy and Science of Caring (1979, 1988); in the preface of Nursing: Human Science and Human Care—A Theory of Nursing (1985),and in Caring Science as Sacred Science (Watson, 2005). Table 7-1 outlines the evolu- tion of Watson’s thinking.

Simplicity Watson draws on a number of disciplines to formu- late her theory. The theory is more about being than about doing, and the nurse must internalize it thor- oughly if it is to be actualized in practice. To under- stand the theory as it is presented, the reader does best by being familiar with the broad subject matter. This theory is viewed as complex when the existential- phenomenological nature of her work is considered, particularly for nurses who have a limited liberal arts background. Although some consider her theory complex, many find it easy to understand and to apply in practice.

Generality Watson’s theory is best understood as a moral and philosophical basis for nursing. The scope of the framework encompasses broad aspects of health- illness phenomena. In addition, the theory addresses aspects of health promotion, preventing illness and experiencing peaceful death, thereby increasing its generality. The carative factors provide guidelines for nurse-patient interactions, an important aspect of patient care.

The theory does not furnish explicit direction about what to do to achieve authentic caring-healing relationships. Nurses who want concrete guidelines may not feel secure when trying to use this theory alone. Some have suggested that it takes too much time to incorporate the caritas into practice, and some note that Watson’s personal growth emphasis is a quality “that while appealing to some may not appeal to others” (Drummond, 2005, p. 218).

Empirical Precision Watson describes her theory as descriptive; she acknowledges the evolving nature of the theory and welcomes input from others (Watson, 2012). Although the theory does not lend itself easily to research conducted through traditional scientific methods, recent qualitative nursing approaches are appropriate. Recent work on measurement reviews a broad array of international studies and provides research guidelines, design recommendations, and instruments for caring research (Nelson & Watson, 2011).

Derivable Consequences Watson’s theory continues to provide a useful and important metaphysical orientation for the delivery of nursing care (Watson, 2007). Watson’s theoretical concepts, such as use of self, patient-identified needs, the caring process, and the spiritual sense of being human, may help nurses and their patients to find meaning and harmony during a period of increasing complexity. Watson’s rich and varied knowledge of philosophy, the arts, the human sci- ences, and traditional science and traditions, joined with her prolific ability to communicate, has enabled professionals in many disciplines to share and recognize her work.

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Summary Jean Watson began developing her theory while she was assistant dean of the undergraduate program at the University of Colorado, and it evolved into plan- ning and implementation of its nursing PhD pro- gram. Her first book started as class notes that emerged from teaching in an innovative, integrated curriculum. She became coordinator and director of the PhD program when it began 1978 and served until 1981. While serving as Dean of the University of Colorado, School of Nursing, a post-baccalaureate nursing curriculum in human caring was developed that led to a professional clinical doctoral degree (ND). This curriculum was implemented in 1990 and was later merged into the Doctor of Nursing Practice (DNP) degree. Watson initiated the Center for Human Caring, the nation’s first interdisciplinary center with a commitment to develop and use knowl- edge of human caring for practice and scholarship. She worked from Yalom’s 11 curative factors to for- mulate her 10 carative factors. She modified the 10 factors slightly over time and developed the caritas processes, which have a spiritual dimension and use a more fluid and evolutionary language.

CASE STUDY

The following case study was adapted from Valerie Taylor’s (2008) clinical example for a presentation in Advanced Nursing Synthesis for the Nurse- Midwifery Concentration, East Carolina University College of Nursing (reprinted with permission).

You are a recently graduated master’s-prepared nurse-midwife working in a small 100-bed hospital, and you are committed to applying Watson’s theory to practice by building a nurse-midwife-patient relationship resulting in therapeutic outcomes. Be- cause you are new, you are slowly promoting the theory with staff, co-midwives and physicians. Today you are excited and challenged to integrate Watson’s theory into your midwifery care of Maria, a 23-year-old Hispanic female, gravida 4 para, TPAL 4004 (meaning term, preterm, abortion, and live births in her pregnancy history), who presents in labor at 39 weeks gestation. She transfers into your group’s practice from the health department

at 36 weeks, is self-pay, and receives Maternity Medicaid when she presents in labor. She cannot speak English and uses her husband, Daniel, as an interpreter, who states that he could read and write but that she cannot. She and Daniel have moved to the area for factory work, so they have little social support from family and friends, and Maria stays at home to care for their three children. Maria’s sister- in-law is caring for their three children while Maria is in the hospital. Although they are Catholic, they do not presently belong to a church. Her medical history is unremarkable, and her prenatal history is normal. Her first two children were delivered in Mexico, and her last child was delivered 1 year ago at another hospital in the United States.

As the nurse-midwife caring for Maria, Watson’s theory leads me to view Maria and her family holis- tically, wherein the body, mind, and soul are inter- related. I remember to incorporate the carative factors, caring consciousness, intentionality, and caring-healing practices, and to go beyond proce- dures, tasks, and techniques to create a mentally, physically, and spiritually healing environment, while assisting with basic needs. Watson’s theory helps me realize the importance of being authenti- cally present and developing and sustaining a help- ing, trusting, caring relationship with Maria and her husband. At 0045 today, I attend Maria for her spontaneous vaginal delivery of a healthy infant girl, Lilia, who has an Apgar score of 8 and 9. Maria’s labor is uneventful, although she is treated for group B infection. After the delivery, I place Lilia on Maria’s abdomen for skin-to-skin touch and help Maria with positioning for breastfeeding. Maria and Daniel gaze at Lilia as she latches on for the first breastfeeding. After initial bonding, infant Lilia is transported to the newborn nursery; her exam is normal and without problems. When the nurses note that Lilia has not wet a diaper in over 6 hours, the neonatologist determines that Lilia has a kid- ney problem, and she has to be transported to the Level III regional hospital for additional tests and evaluation.

From your initial plan of care, you know how important it is to maintain a reciprocal dialogue among the interpreter, obstetrician, neonatologist,

Continued

UNIT II Nursing Philosophies90

nursing staff, and social worker. You stand close as the neonatologist explains to Maria and her husband, through the interpreter, that Lilia will receive exemplary care at the tertiary hospital. Maria is tearful, and her husband appears stressed as the interpreter translates that their newborn is being prepared for immediate transport to the regional hospital for specialized assessment and care. Maria is stable and her postpartum course is normal, with the exception of her anxiety related to the unknowns of Lilia’s condition, separation from her newborn, delayed breast- feeding, and language barriers that prevent a better understanding of events pertaining to her and Lilia’s care.

You let the theory guide you as you assess Maria’s stress/anxiety related to her separation from her newborn, fear of her newborn’s progno- sis, inability to breastfeed, language barriers, and financial concerns. You know that if Maria does not have skin-to-skin touch, impairment of bonding may lead to oxytocin suppression and delays in milk production. Her stress and lack of rest also can hinder her normal recovery from a spontaneous vaginal delivery and may lead to blood loss and delayed involution. Engorgement or decreased lactogenesis may occur as the result of infrequent or interrupted breastfeeding. Maria has limited family support, with the exception of her sister-in-law, who lives 3 hours away; she lacks a friend network because of her immigra- tion from Mexico, and she has no support group to support coping. Although Maria has a Chris- tian belief system, she has no church affiliation at this time for spiritual guidance/support or fellow- ship of members. You know that Watson’s caring

theory and carative factors/caritas can potentiate successful outcomes and an optimum state of health for Maria, her husband, and their new- born daughter.

After the routine postpartum exam, you address Maria’s biophysical needs for rest and her emo- tional concerns. You encourage the neonatologist and nursery staff to let the parents bond with Lilia before her transport. Then you consult the hospital chaplain for visitation and request a Spanish- speaking priest and a hospital interpreter to be available for patient teaching for instructions and early discharge after her 24-hour stay. You speak with the social worker since she can be a liaison between mother and newborn during Lilia’s trans- port. Throughout the care of Maria, Daniel, and Lilia, you facilitate a practice of loving kindness among the caregiving staff to achieve continuous culturally sensitive care, as that guides your prac- tice. You know that the nurse-midwife–patient relationship has resulted in a therapeutic outcome because Maria and Daniel report feeling some comfort after speaking to the priest and the nurses at the tertiary care hospital. Maria is able to rest the previous night, and her postpartum examination is normal. Maria now has a breast pump, and the staff nurses explain its use. The social workers have arranged transportation for Maria and Daniel to visit their newborn at the Level III hospital after they are discharged today. Maria has spoken to her sister-in-law, and she will continue to care for the children for several more days. Maria and Daniel tell you how grateful they feel that you have been their nurse-midwife throughout their experience.

Valerie G. Taylor, MSN, CNM Hickory, North Carolina

CRITICAL THINKING ACTIVITIES

how you might incorporate the characteristics into your style of nursing practice.

3. Create a list of caring behaviors in your own nursing practice. Review Measuring Caring: International research on caritas as healing (Nelson & Watson, 2011), and compare with

1. Review the values and beliefs in your own philos- ophy of person, environment, health, and nursing to discover if your beliefs fit with Watson’s 10 carative/caritas assumptions.

2. Think of a time in your life when you felt that someone truly cared for you. Identify the major characteristics of these interactions, and describe

CHAPTER 7 Jean Watson 91

quiet music. Reflect on ways to feel compassionate, intentional, calm, and peaceful. Consider ways to incorporate ideas from your reflection into your nursing practice.

the caring behaviors from instruments designed to measure caring included in that text.

4. Plan a time and place to meditate for 10 minutes each week, closing your eyes, and listening to

POINTS FOR FURTHER STUDY

Fuld Health Trust. Available from Fitne, Inc. at: http:// www.fitne.net/.

n Watson, J. (2005). Caring science as sacred science. Philadelphia: F. A. Davis.

n Watson Caring Science Institute, International Caritas Consortium. Retrieved from: http://www. watsoncaringscience.org.

n Jesse, D. E. (2010). Watson’s philosophy in nurs- ing practice. In M. R. Alligood, Nursing theory: utilization & application (4th ed., pp. 111–136). St. Louis: Mosby-Elsevier.

n Watson, J. (2012). Human caring science: a theory of nursing. Boston: Jones & Bartlett.

n Hill, M., & Watson, J. (2011). Creating a caring sequence curriculum. New York: Springer.

n Watson, J. (1989). The nurse theorists: portraits of excellence [Videotape, CD, DVD]. New York: Helene

REFERENCES Diener, E. & Hobbs, N. (2012). Simulating care: technology-

mediated learning in twenty-first century education. Nursing Forum, 47(1), 34–38.

DiNapoli, P., Nelson, J., Turkel, M., & Watson, J. (2010). Measuring the caritas processes: caring factor survey. International Journal for Human Caring,14 (3), 17–20.

Drummond, J. (2005). Caring science as sacred science. [Book review.] Nursing Philosophy, 6, 218–220.

Hills, M., & Watson, J. (2011). Creating a caring science curriculum: an emancipatory pedagogy for nursing. New York: Springer.

Jesse, D. E. (2010). Watson’s philosophy in nursing practice. In M. R. Alligood (Ed.), Nursing theory: Utilization & ap- plication (4th ed., pp. 111–136). St. Louis: Mosby-Elsevier.

Leininger, M. (1979). Preface. In J. Watson (Ed.), Nursing: the philosophy and science of caring. Boston: Little, Brown.

Levinas, E. (1969). Totality and infinity. (A. Lingis, Trans.) Pittsburgh, (PA): Duquesne University.

Lindahl, B. (2011). Experiences of exclusion when living on a ventilator: reflections based on the application of Julia Kristev’s philosophy of caring. Nursing Philosophy,12(1), 12–21.

Løgstrup, K. E. (1995). Metaphysics, vol 1. Milwaukee: Marquette University.

Nelson, J., & Watson, J. (2011). Measuring caring: interna- tional research on caritas as healing. New York: Springer.

Persky, G. J., Nelson, J. W., Watson, J., & Bent, K. (2008). Creating a profile of a nurse effective in caring. Nursing Administration Quarterly, 32(1), 15–20.

Pipe, T., Connolly, T., Spahr, N., Lendzion, N., Buchda, V., Jury, R., et al. (2012). Bringing back the basics of nursing:

defining patient care. Nursing Administration Quarterly, 36(3), 225–233.

Sakalys, J., & Watson, J. (1986). Professional education: post-baccalaureate education for professional nursing. Journal of Professional Nursing, 2(2), 91–97.

Smith, M. (2004). Review of research related to Watson’s theory of caring. Nursing Science Quarterly, 17(1), 13–25.

Watson, J. (1979). Nursing: the philosophy and science of caring. Boston: Little, Brown.

Watson, J. (1981). Nursing’s scientific quest. Nursing Outlook, 29, 413–416.

Watson, J. (1985). Nursing: human science and human care—a theory of nursing. Norwalk, (CT): Appleton-Century-Crofts.

Watson, J. (1986, Dec.). The dean speaks out: center for human caring established. The University of Colorado School of Nursing News, 1–6.

Watson, J. (1987). Nursing on the caring edge: metaphorical vignettes. Advances in Nursing Science, 10(1), 10–18.

Watson, J. (1988). Nursing: human science and human care: a theory of nursing. New Yark: National League for Nursing.

Watson, J. (1995). Post modernism and knowledge develop- ment in nursing. Nursing Science Quarterly, 8(2), 60–64.

Watson, J. (1996). Watson’s theory of transpersonal caring. In P. J. Walker & B. Neuman (Eds.), Blueprint for use of nursing models: education, research, practice and admin- istration (pp. 141–184). New Yark: National League for Nursing Press.

Watson, J. (1997). The theory of human caring: retrospective and prospective. Nursing Science Quarterly, 10(1), 49–52.

Watson, J. (1999). Postmodern nursing and beyond. Edinburgh: Churchill Livingstone.

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Watson, J. (2003). Caring science: belonging before being as ethical cosmology. Nursing Science Quarterly, 18(4), 304–305.

Watson, J. (2005). Caring science as sacred science. Philadelphia: F. A. Davis.

Watson, J. (2006a). Walking pilgrimage as caritas action in the world. Journal of Holistic Nursing, 24(4), 289–296.

Watson, J. (2006b). Transpersonal caring and the caring moment defined. Retrieved from: http://www2.uchsc. edu/son/caring/content/transpersonal.asp.

Watson, J. (2006c). Caring theory as an ethical guide to administrative and clinical practices. Nursing Adminis- tration Quarterly, 30(1), 48–55.

Watson, J. (2007). Theoretical questions and concerns: response from a caring science framework. Nursing Science Quarterly, 20(1), 13–15.

Watson, J. (2012). Human caring science: a theory of nursing. Boston: Jones & Bartlett.

Watson, J., & Foster, R. (2003). The attending nurse caring model: integrating theory, evidence, and advanced caring-healing therapeutics for transform- ing professional practice. Journal of Clinical Nursing, 12, 360–365.

Watson Caring Science Institute, International Caritas Consor- tium. Available at: http://www.watsoncaringscience.org.

BIBLIOGRAPHY Primary Sources Books Bevis, E. O., & Watson, J. (1989). Toward a caring curriculum:

a new pedagogy for nursing. New Yark: National League for Nursing.

Bevis, E. O., & Watson, J. (2000, reprinted). Toward a caring curriculum: a new pedagogy for nursing. Sudbury, (MA): Jones & Bartlett.

Chinn, P., & Watson, J. (Eds.). (1994). Art and aesthetics of nursing. New York: National League for Nursing.

Hills, M., & Watson, J. (2011). Creating a caring science curriculum: an emancipatory pedagogy for nursing. New York: Springer.

Leininger, M., & Watson, J. (Eds.). (1990). The caring imperative in education. New Yark: National League for Nursing.

Nelson, J., & Watson, J. (2011). Measuring caring: International research on caritas as healing. New York: Springer.

Taylor, R., & Watson, J. (Eds.). (1989). They shall not hurt: human suffering and human caring. Boulder, (CO): University Press of Colorado.

Watson, J. (1979, reprinted in 1985 by University Press of Colorado). Nursing: the philosophy and science of caring. Boston: Little, Brown. [Translated into French.]

Watson, J. (1985, reprinted in 1988. Reprinted by NLN & Bartlett in 1999). Nursing: human science and human care. Norwalk, (CT): Appleton-Century-Crofts. [Trans- lated into Japanese, Swedish, Chinese, Korean, German, Norwegian, and Danish.]

Watson, J. (1985). Nursing: the philosophy and science of caring [2nd printing]. Boulder, (CO): University Press of Colorado.

Watson, J. (1988). Nursing: human science and human care [2nd printing]. New Yark: National League for Nursing. [Translated into Japanese in 1990.]

Watson, J. (Ed.). (1994). Applying the art and science of human caring. New York: National League for Nursing.

Watson, J. (1999). Postmodern nursing and beyond. Edinburgh, Scotland: Churchill Livingstone Saunders. [Translated into Japanese in 2001.]

Watson, J. (2002). Instruments for assessing and measuring caring in nursing and health sciences. New York: Springer. [American Journal of Nursing Book of the Year Award in 2002. Japanese translation in print.]

Watson, J. (2005). Caring science as sacred science. Philadelphia: F. A. Davis. (American Journal of Nursing Book of the Year Award in2005.)

Watson, J. (2012). Human caring science: a theory of nursing. Boston: Jones &Bartlett.

Watson, J., Jones, W., & Levin, J. (Eds.). (1999). Essentials of complementary alternative medicine. Philadelphia: Lippincott.

Watson, J., & Ray, M. (Eds.). (1988). The ethics of care and the ethics of cure: synthesis in chronicity. New York: National League for Nursing.

Chapters and Monographs Watson, J. (1980). Self losses. In F. Bower (Ed.), Nursing

and the concept of loss (pp. 51–84). New York: Wiley. Watson, J. (1981). Some issues related to a science of car-

ing for nursing practice. In M. Leininger (Ed.), Caring: an essential human need (pp. 61–67). Proceedings from National Caring Conference, University of Utah. Thorofare, (NJ): Charles B. Slack.

Watson, J. (1982). The nurse-client relationship. In L. Sonstegard, K. Kowalski, & B. Jennings (Eds.), Women’s health care (pp. 45–56). New York: Grune & Stratton.

Watson, J. (1983). Delivery and assurance of quality health care: a rights based foundation. In R. Luke, J. Krueger, & R. Madrow (Eds.), Organization and change in health care quality assurance (pp. 13–19). Rockville, (MD): Aspen.

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Watson, J. (1994). Poeticizing as truth through language. In P. L. Chinn & J. Watson (Eds.), Art and aesthetics in nurs- ing (pp. 3–17). New Yark: National League for Nursing.

Watson, J. (1995). Into the future. In O. Slevin & L. Basford (Eds.), Theory and practice of nursing: an integrated approach to patient care (2nd ed.). Cheltenham, UK: Nelson Thornes.

Watson, J. (1996). Art, caring, spirituality, and humanity. In E. Farmer (Ed.), Exploring the spiritual dimension of care (pp. 29–40). Wiltshire, England: Mark Allen.

Watson, J. (1996). Artistry and caring: heart and soul of nursing. In D. Marks-Maran & P. Rose (Eds.), Recon- structing nursing: beyond art and science (pp. 54–63). London: Bailliere Tindall.

Watson, J. (1996). Beyond art and science. In D. Marks- Maran & P. Rose (Eds.), Reconstructing nursing: beyond art and science. London: Bailliere Tindall.

Watson, J. (1996). Nursing, caring-healing paradigm. In D. Pesat (Ed.), Capsules of comments in psychiatric nursing. St. Louis: Mosby.

Watson, J. (1996). Poeticizing as truth on nursing inquiry. In J. Kikuchi, H. Simmons, & D. Romyn (Eds.), Truth on nursing inquiry (pp. 125–138). Thousand Oaks, (CA): Sage.

Watson, J. (1996). Watson’s theory of transpersonal caring. In P. J. Walker & B. Neuman (Eds.), Blueprint for use of nursing models: education, research, practice and adminis- tration (pp. 141–184). New Yark: National League for Nursing.

Watson, J. (1999). Postmodern nursing and beyond. In N. Chaska (Ed.), The nursing profession: nursing theories and nursing practice (pp. 343–354). Philadelphia: F. A. Davis.

Watson, J. (2000). Monograph of instruments for measuring and assessing caring. New York: Springer.

Watson, J. (2000). Postmodern nursing and beyond. In N. L. Chaska (Ed.), The nursing profession: Tomorrow’s vision and beyond (pp. 299-308). Thousand Oaks, (CA): Sage.

Watson, J. (2001). Jean Watson: theory of human caring. In M. E. Parker (Ed.), Nursing theories and nursing practice (pp. 344–354). Philadelphia: F. A. Davis.

Watson, J. (2002). Illuminating the spiritual journey: Jean Watson tells her story. In P. Burkhardt & M. G. Nagai- Jackson (Eds.), Spirituality: living our connectedness (pp. 181–186). New York: Delmar.

Watson, J. (2006). Jean Watson’s theory of human caring. In M. Parker (Ed.), Nursing theories and nursing prac- tice (2nd ed., pp. 295–301). Philadelphia: F. A. Davis.

Watson, J., & Bevis, E. (1990). Coming of age for a new age. In N. L. Chaska (Ed.), The nursing profession: turn- ing points (pp. 100–105). St. Louis: Mosby.

Watson, J. (1985). Reflection on different methodologies for the future of nursing. In M. Leininger (Ed.), Qualitative research methods in nursing (pp. 343–349). Orlando, (FL): Grune & Stratton.

Watson, J. (1987). The dream curriculum. In National League for Nursing (Ed.), Patterns in nursing: strategic planning for nursing education (pp. 91–104). New York: Author.

Watson, J. (1988). A case study: curriculum in transition. In National League for Nursing (Ed.), Curriculum revo- lution: mandate for change (pp. 1–8). New York: Author.

Watson, J. (1988). Introduction. In J. Watson & M. Ray (Eds.), The ethics of care and the ethics of cure: synthesis in chronicity (pp. 1–3). New York: National League for Nursing.

Watson, J. (1988). The professional doctorate as an entry level into practice. In National League for Nursing (Ed.), Perspectives (pp. 41–47). New York: Author.

Watson, J. (1989). Human caring and suffering: a subjec- tive model for health sciences. In R. Taylor & J. Watson (Eds.), They shall not hurt: human suffering and human caring (pp. 125–135). Boulder, (CO): University Press of Colorado.

Watson, J. (1989). Watson’s philosophy and theory of human caring in nursing. In J. Riehl-Sisca (Ed.), Conceptual models for nursing practice (3rd ed., pp. 219–236). Norwalk, (CT): Appleton & Lange.

Watson, J. (1990). Transformation in nursing: bring care back to health care. In National League for Nursing (Ed.), Curriculum revolution: redefining the student- teacher relationship (pp. 15–20). New Yark: National League for Nursing.

Watson, J. (1990). Transpersonal caring: a transcendent view of person, health, and healing. In M. Parker (Ed.), Nursing theories in practice (pp. 277–288). New Yark: National League for Nursing.

Watson, J. (1992). Notes on nursing: guidelines for caring then and now. In F. Nightingale (Ed.), Notes on nursing. Philadelphia: Lippincott.

Watson, J. (1994). A frog, a rock, a ritual: an eco-caring cosmology. In E. Schuster & C. Brown (Eds.), Caring and environmental connection. New Yark: National League for Nursing.

Watson, J. (1994). Anthology on art and esthetics. In J. Watson & P. Chinn (Eds.), Art and aesthetics as passage between centuries. New York: National League for Nursing.

Watson, J. (1994). Introduction. In J. Watson (Ed.), Apply- ing the art and science of human caring (pp. 1–10). New Yark: National League for Nursing.

Watson, J. (1994). Overview of caring theory. In J. Watson (Ed.), Applying the art and science of human caring. New Yark: National League for Nursing.

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Journal Articles Carozza, V., Congdon, J. A., & Watson, J. (1978, Nov.). An

experimental educationally sponsored pilot internship program. Journal of Nursing Education, 17, 14–20.

Fawcett, J., Watson, J., Neuman, B., & Hinton-Walker, P. (2001). On missing theories and evidence. Journal of Nursing Scholarship, 33(2), 115–119.

Krysl, M., & Watson, J. (1988). Poetry on caring and adden- dum on center for human caring. Advances in Nursing Science, 10(2), 12–17.

Persky, G. J., Nelson, J. W., Watson, J., & Bent, K. (2008). Creating a profile of a nurse effective in caring. Nursing Administration Quarterly, 32(1), 15–20.

Quinn, J., Smith, M., Swanson, K., Ritenbaugh, C., & Watson, J. (2003). The healing relationship in clinical nursing: guidelines for research. Journal of Alternative Therapies, 9(3), A65–A79.

Sakalys, J., & Watson, J. (1985). New directions in higher education: a review of trends. Journal of Professional Nursing, 1(5), 293–299.

Sakalys, J., & Watson, J. (1986). Professional education: post-baccalaureate education for professional nursing. Journal of Professional Nursing, 2(2), 91–97.

Salsberry, P. (1992). Caring, virtue theory, and a founda- tion for nursing ethics. Scholarly Inquiry for Nursing Practice: An International Journal,.(2), 155–167.

Watson, J. (1980). [Response to review of Nursing: Philosophy and science of caring.] Western Journal of Nursing Research, 2(2), 514–515.

Watson, J. (1980). [Review of Starting point: An introduc- tion to the dialectic of existence.] Western Journal of Nursing Research, 2(3), 637–638.

Watson, J. (1981). Conceptual systems of students and practicing nurses. Western Journal of Nursing Research, 3(2), 172–192.

Watson, J. (1981). Nursing’s scientific quest. Nursing Outlook, 29(7), 413–416.

Watson, J. (1981, Aug.). Professional identity crisis—is nurs- ing finally growing up? American Journal of Nursing, 81, 1488–1490.

Watson, J. (1981). Response to conceptual systems, students, practitioner. Western Journal of Nursing Research, 3(2), 197–198.

Watson, J. (1981, reprinted in 1983). The lost art of nursing. Nursing Forum, 20(3), 244–249.

Watson, J. (1982). Traditional v. tertiary: ideological shifts in nursing education. The Australian Nurses Journal, 12(2), 44–46.

Watson, J. (1983). Commentary on instructor directed research model. Western Journal of Nursing Research, 5(4), 310–311.

Watson, J. (1987). Nursing on the caring edge: metaphori- cal vignettes. Advances in Nursing Science, X(1), 10–18.

Watson, J. (1987). [Review of Health as expanding con- sciousness.] Journal of Professional Nursing, 3(5), 315.

Watson, J. (1987). [Review of Practical psychotherapy.] Journal of Psychosocial Nursing and Mental Health Services, 25(3), 42.

Watson, J. (1988). Human caring as moral context for nursing education. Nursing and Health Care, 9(8), 422–425.

Watson, J. (1988). New dimensions of human caring theory. Nursing Science Quarterly, 1(4), 175–181.

Watson, J. (1988). Of nurses, women and the devaluation of caring. [Review of Images of nurses: Perspectives for history, art, and literature.] Medical Humanities Review, 2(2), 60–62.

Watson, J. (1988). Response to caring and practice: construc- tion of the nurses’ world. Scholarly Inquiry for Nursing Practice: An International Journal, 2(3), 217–221.

Watson, J. (1989). Caring theory. Journal of Japan Academy of Nursing Science, 9(2), 29–37.

Watson, J. (1989). Keynote address: caring theory. Journal of Japan Academy of Nursing Science, 9(2), 9–37.

Watson, J. (1990). Caring knowledge and informed moral passion. Advances in Nursing Science, 13(1), 15–24.

Watson, J. (1990). Reconceptualizing nursing ethics: a response. Scholarly Inquiry for Nursing Practice: An International Journal, 4(3), 219–221.

Watson, J. (1990). The moral failure of the patriarchy. Nursing Outlook, 28(2), 62–66.

Watson, J. (1991). From revolution to renaissance. Revolu- tion: Journal of Nurse Empowerment, 1(1), 94–100.

Watson, J. (1991). Robb, Dock, and Nutting: I wish I’d been there. Nursing and Health Care, 12(4), 210.

Watson, J. (1992). Response to caring, virtue theory, and a foundation for nursing ethics. Scholarly Inquiry for Nurs- ing Practice: An International Journal, 6(2), 169–171.

Watson, J. (1993). Dr. Jean Watson with E. Henderson—an interview. Alberta Association of Registered Nurses Newsletter, 49(6), 10–12.

Watson, J. (1993). Should NPs, CNMs, and CNAs, etc., add graduate credentials? Open Mind, 2(3), 2.

Watson, J. (1994). Guest editorial. Nursing Praxis in New Zealand, 9(1), 2–5.

Watson, J. (1994). Have we arrived or are we on our way out? Promises, possibilities, and paradigms. [Invited editorial.] Image: The Journal of Nursing Scholarship, 26(2), 86.

Watson, J. (1995). Advanced nursing practice and what might be. Journal of Nursing and Health Care, 16(2), 78-83.

Watson, J. (1995). A Fulbright in Sweden: runes, academics, archetypal motifs, and other things. Image: The Journal of Nursing Scholarship, 27(1), 71–75.

Watson, J. (1995). A yearning for new debates. NLN Update, 1(3), 6–8.

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Watson, J. (1995). Nursing’s caring-healing model as an exemplar for alternative medicine. Journal of Alterna- tive Therapies in Health and Medicine, 1(3), 64–69.

Watson, J. (1995). Postmodernism and knowledge develop- ment in nursing. Nursing Science Quarterly, 8(2), 60–64.

Watson, J. (1995). President’s message: challenges and summons from within and without. Journal of Nursing and Health Care, 16(6), 340.

Watson, J. (1995). President’s message: Visioning on: to- ward action transformation. Journal of Nursing and Health Care, 16(5), 290.

Watson, J. (1995). [Review of Healing power of aromather- apy.] Journal of Alternative Therapies in Health and Medicine, 1(3), 64–69.

Watson, J. (1996). President’s message: From discipline specific to “inter” to “multi” to “transdisciplinary” health care education and practice. Journal of Nursing and Health Care, 17(2), 90–91.

Watson, J. (1996). [Review of Healing nutrition.] Journal of Alternative Therapies in Health and Medicine, 2(3), 91.

Watson, J. (1996, May). The wait, the wonder, the watch: caring in a transplant unit. Journal of Clinical Nursing, 5(3), 199–200.

Watson, J. (1996). United States of America: can nursing theory and practice survive? International Journal of Nursing Practice, 2(4), 241–243.

Watson, J. (1997). From the mountaintop to the marsh/ fens: punting on the River Cam. [Guest editorial.] Jour- nal of Clinical Nursing, 6(1), 3–4.

Watson, J. (1997). The future of nursing-scholarship. Image: The Journal of Nursing Scholarship, 29(2), 117.

Watson, J. (1997). The theory of human caring: retrospective and prospective. Nursing Science Quarterly, 10(1), 49–52.

Watson, J. (1998). Nightingale and the enduring legacy of transpersonal human caring. Journal of Holistic Nursing, 16(2), 292.

Watson, J. (1999). Aesthetic expressions of caring: private psalms—surrendering to the sacred. Personal profes- sional reflections on caring and healing. International Journal of Human Caring, 3(3), 34.

Watson, J. (2000). Leading via caring-healing: the fourfold way toward transformative leadership. Nursing Admin- istration Quarterly, 25(1), 1–6.

Watson, J. (2000). Philosophical perspectives in home care: reconsidering caring. Journal of Geriatric Nursing, 21(6), 330–331.

Watson, J. (2000). Reconsidering caring in the home. Journal of Geriatric Nursing, 21(6), 330–333.

Watson, J. (2000). Via negative: considering caring by way of non-caring. Australian Journal of Holistic Nursing, 7(1), 4–8.

Watson, J. (2001). Post-hospital nursing: shortages, shifts, and script. Nursing Administration Quarterly, 25(3), 77–82.

Watson, J. (2002). Caring and healing our living and dying. The International Nurse, 14(2), 4–5.

Watson, J. (2002). Holistic nursing and caring: a values- based approach. Journal of Japan Academy of Nursing Science, 22(2), 69–74.

Watson, J. (2002). Intentionality and caring-healing con- sciousness: a theory of transpersonal nursing. Holistic Nursing Journal, 16(4), 12–19.

Watson, J. (2002). Metaphysics of virtual caring communi- ties. International Journal of Human Caring, 6(1), 41–45.

Watson, J. (2002, Spring). Nursing: seeking its source and sur- vival. [Guest editorial.]ICU Nursing Web Journal, 9, 1–7. Retrieved from: http://www.nursing.gr/J.W.editorial.pdf.

Watson, J. (2003). Love and caring: ethics of face and hand. Nursing Administration Quarterly, 27(3), 197–202.

Watson, J. (2004). Caritas and communitas: an ethic for caring science. Journal Japan Academy of Nursing Science, 24(3), 66–67.

Watson, J. (2004). The relational core of nursing practice as partnership. [Invited commentary.] Journal of Advanced Nursing, 47(3), 241–250.

Watson, J. (2004). Caritas and communitas: an ethic for caring science. Journal Japan Academy of Nursing Science, 24(1), 66–71.

Watson, J. (2005). Caring for our future: an interview with Jean Watson. [Interview by Carla Mariano.] Beginnings (American Holistic Nurses’ Association), 25(3), 1, 12–14.

Watson, J. (2005). Caring science: belonging before being as ethical cosmology. Nursing Science Quarterly, 18(4), 304–305.

Watson, J. (2005). Commentary on Shattell, M. (2004). Nurse-patient interaction: a review of the literature. Journal of Clinical Nursing, 14, 530–532.

Watson, J. (2005). What, may I ask, is happening to nursing knowledge and professional practices? What is nursing thinking at this turn in human history? Journal of Clini- cal Nursing, 14(8), 913–914.

Watson, J. (2005). Current issues and haunting concerns for survival of nursing profession. Japanese Journal of Nursing Science, 30(11), 50–53.

Watson, J. (2005). Love and caring. [Reprinted.] Alternative Journal of Nursing, 9. Retrieved from: www.altjn.com.

Watson, J. (2005). An overview of Watson’s theory of human caring. Tokyo, Japan: Bulletin of Japanese Red Cross University College of Nursing.

Watson, J. (2006). Frontline and backstage caring: American nurse/world-wide nurses. American Nurse Today, 1(1), 24–28.

Watson, J. (2006). Carative factors—Caritas processes guide to professional nursing. Danish Clinical Nursing Journal, 20(3), 21–27.

Watson, J. (2006). Can an ethic of caring be maintained? Journal of Advanced Nursing, 54(3), 257–259.

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Watson, J. (2006). Caring theory as an ethical guide to administrative and clinical practices. JONAS Healthcare Law, Ethics and Regulation, 8(3), 87–93.

Watson, J. (2006). Caring theory as an ethical guide to administrative and clinical practices. Nursing Adminis- tration Quarterly, 30(1), 48–55.

Watson, J. (2006). Walking pilgrimage as caritas action in the world. Journal of Holistic Nursing, 24(4), 289–296.

Watson, J. (2007). Theoretical questions and concerns: response from a caring science framework. Nursing Science Quarterly, 20(1), 13–15.

Watson, J. Bauer, R., & Biley, F. (2002). Bavarian nursing secret: an inside view. Reflections on Nursing Leader- ship: Sigma Theta Tau International Magazine, 28(1), 26–28.

Watson, J., Biley, F. C., & Biley, A. M. (2001). Aesthetics, postmodern nursing, complementary therapies and more: an Internet dialogue. Theoria: Journal of Nursing Theory, 10(3), 13–16.

Watson, J., Biley, F. C., & Biley, A. M. (2002). Aesthetics, postmodern nursing, complementary therapies, and more: an Internet dialogue. Complementary Therapies in Nursing and Midwifery, 8, 81–83.

Watson, J., & Foster, R. (2003). The Attending Nurse Caring Model: integrating theory, evidence, and advanced car- ing-healing therapeutics for transforming professional practice. Journal of Clinical Nursing, 12, 360–365.

Watson, J., & Phillips, S. (1992). A call for educational reform: Colorado nursing doctorate model as exemplar. Nursing Outlook, 40, 20–26.

Watson, J., & Smith, M. C. (2002). Caring science and the science of unitary human beings: A trans-theoretical discourse for nursing knowledge development. Journal of Advanced Nursing, 7(5), 452–461.

Secondary Sources Chapters and Monographs Burns, P. (1991). Elements of spirituality and Watson’s theory

of transpersonal caring: Expansion of focus. In P. L. Chinn (Ed.), Anthology of caring (pp. 141–153). New Yark: National League for Nursing.

Duffy, J. R. (1992). The impact of nursing caring on patient outcomes. In D. Gaut (Ed.), The presence of caring in nurs- ing (pp. 113–136). New Yark: National League for Nursing.

Fawcett, J. (2000). Watson’s theory of human caring. In J. Fawcett (Ed.), Analysis and evaluation of contemporary nursing knowledge: nursing models and theories (pp. 657–687). Philadelphia: F. A. Davis.

Jesse, E. (2006). Watson’s philosophy in nursing practice. In M. R. Alligood & A.M. Tomey (Eds.). Nursing theory: Utilization & application (3rd ed., pp. 97–121). St. Louis: Mosby.

Jesse, E. (2006). La filosofia di Watson nella pratica inform- ieristica. In M. R. Alligood & A. M. Tomey, La teoria del nursing (3rd ed., pp. 91–115). [C. Calamandrei, Italian translation.] Milano, Italy: McGraw-Hill.

McGraw, M. J. (2003). Watson’s philosophy in nursing practice. In M. R. Alligood & A. M. Tomey, Nursing theory: Utilization & application (3rd ed., pp. 97–121). St. Louis: Mosby.

Morris, D. L. (1998). Watson’s human care model. In J. J. Fitzpatrick (Ed.), Encyclopedia of Nursing Research (pp. 593–595). New York: Springer.

Neil, R. M. (1990). Watson’s theory of caring in nursing: the rainbow of and for people living with AIDS. In M. E. Parker (Ed.), Nursing theories in practice (pp. 289–301). New Yark: National League for Nursing.

Neil, R. M. (1995). Evidence in support of basing a nursing center on nursing theory: the Denver nursing project in human caring. In B. Murphy (Ed.), Nursing centers: the time is now (pp. 33–46). New Yark: National League for Nursing.

Neil, R. M. (2003). Philosophy and science of caring. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (6th ed., pp. 91–115). St. Louis: Mosby.

Nyberg, J. (1994). Implementing Watson’s theory of car- ing. In J. Watson (Ed.), Applying the art and science of human caring (pp. 53–61). New Yark: National League for Nursing.

Woodward, T. K. (2006). Application of Jean Watson’s Theory of Human Caring. In M. Parker (Ed.), Nursing theories and nursing practice (2nd ed., pp. 302– 308). Philadelphia: F. A. Davis.

Journal Articles Bent, K. N. (1999). The ecologies of community caring.

Advances in Nursing Science, 21, 29–36. Biley, A. (2000). [Review ofPostmodern nursing and beyond.]

Journal of Clinical Nursing, 9, 649–653. Burchiel, R. N. (1995). The Watson theory of human care

applied to ASPO/Lamaze perinatal education. Journal of Perinatal Education, 6(1), 43–47.

Coates, C. J. (1997). The caring efficacy scale: nurses’ self- reports of caring in practice settings. Advanced Practice Nursing Quarterly, 3(1), 53–59.

Eddins, B. B., & Riley-Eddins, E. A. (1997). Watson’s theory of human caring: the twentieth century and beyond. Journal of Multicultural Nursing and Health, 3, 30–35.

Falk, R., & Adeline, R. (2000). Watson’s philosophy, science and theory of human caring as a conceptual framework for guiding community health nursing practice. Advances in Nursing Science, 23(2), 34–50.

Fawcett, J. (2002). The nurse theorists: 21st century updates— Jean Watson. Nursing Science Quarterly, 15(3), 214–219.

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From, M. A. (1995). Utilizing the home setting to teach Watson’s theory of human caring. Nursing Forum, 30, 5–11.

Horrigan, B. (2000). Regions hospital opens holistic nursing unit. Alternative Therapies, 6(4), 92–93.

Jensen, K. P., Back-Pettersson, S. R., & Segesten, K. M. (1993). The caring moment and the green-thumb phe- nomenon among Swedish nurses. Nursing Science Quarterly, 6,98–104.

Kilby, J. W. (1997). Case study: transpersonal caring theory in perinatal loss. Journal of Perinatal Education, 6(2), 45–50.

Marck, B. B. (1995). Watson’s theory of caring: a model for implementation in practice. Journal of Nursing Care Quality, 9(4), 43–54.

McNamara, S. A. (1995). Perioperative nurses’ perceptions of caring practices. AORN Journal 61(377), 380–385.

Mullaney, J. A. (2000). The lived experience of using Watson’s actual caring occasion to treat depressed women. Journal of Holistic Nursing, 18(2), 129–142.

Nelson-Marten, P., Hecomovich, K., & Pangle, M. (1998). Caring theory: a framework for advanced practice nursing. Advanced Practice Nursing Quarterly, 4,70–77.

Norred, C. (2000). Minimizing preoperative anxiety with alternative caring-healing therapies. AORN Journal, 72(3), 1–4.

Nyman, C. S., & Lutzen, K. (1999). Caring needs of patients with rheumatoid arthritis. Nursing Science Quarterly, 12(2), 164–169.

Perry, B. (1997). Beliefs of eight exemplary nurses related to Watson’s nursing theory. Canadian Oncology Nursing Journal, 8(2), 97–101.

Ray, M. A. (1997). Consciousness and the moral ideal: a transcultural analysis of Watson’s theory of transpersonal caring. Advanced Practice Nursing Quarterly, 3, 25–31.

Saewyc, E. (2000). Nursing theories of caring. Journal of Holistic Nursing, 18(2), 109–113.

Schindel-Martin, L. (1991). Using Watson’s theory to explore the dimensions of adult polycystic kidney disease. American Nephrology Nurses’ Association Journal, 18, 493–496.

Schroeder, C. (1993). Nursing’s response to the crisis of access, costs, and quality in health care. Advances in Nursing Science, 16(1), 1–20.

Schroeder, C., & Maeve, M. K. (1992). Nursing care partner- ships at the Denver nursing project in human caring: An application and extension of caring theory in practice. Advances in Nursing Science, 15(2), 25–38.

Smith, M. C. (1997). Nursing theory-guided practice: practice guided by Watson’s theory. The Denver nursing project in human caring. Nursing Science Quarterly, 10, 56–58.

Swanson, K. M. (1991). Empirical development of a middle range theory of caring. Nursing Research, 40, 161–166.

Updike, P., Cleveland, M. J., & Nyberg, J. (2000). Comple- mentary caring-healing practices of nurses caring for children with life-challenging illnesses and their families: a pilot project with case reports. Alternative Therapies, 6(4), 108–112.

Walker, C. A. (1996). Coalescing the theories of two nurse visionaries: Parse and Watson. Journal of Advanced Nursing, 24, 988–996.

Ward, S. (1998). Caring and healing in the 21st century. MCN Journal 23(4), 210–215.

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CH A P T ER 8

“Improved patient safety, infection control, reduction in medication errors, and overall quality of care in complex bureaucratic health care systems cannot occur without knowledge

and understanding of complex organizations, such as the political and economic systems, and spiritual-ethical caring, compassion and right action for all patients and professionals.”

(M. Ray, personal communication, May 15, 2012).

Marilyn Anne Ray 1938 to present

Theory of Bureaucratic Caring Sherrilyn Coffman

Credentials of the Theorist Marilyn Anne (Dee) Ray was born in Hamilton, Ontario, Canada, and grew up in a family of six chil- dren. When Ray was 15, her father became seriously ill, was hospitalized, and almost died. A nurse saved his life. Marilyn decided that she would become a nurse so that she could help others and perhaps save lives, too.

Latinos, Ray began to see how important cultures were in the development of people’s views about nurs- ing and the world.

In 1965, Ray returned to school for her BSN and MSN in maternal-child nursing at the University of Colorado School of Nursing. There she met Dr. Madeleine Leininger, who was the first nurse anthropologist and the Director of the Federal Nurse-Scientist program. Through her mentorship, Leininger influenced Ray’s life. Ray took a special interest in nursing, anthropology, childhood, and culture. She studied organizations as small cultures, and her graduate school project involved the study of a children’s hospital as a small culture. While at the University of Colorado, Ray practiced with children and adults in critical care and renal dialysis,

Photo credit: M. Dauley, Artistic Images, Littleton, CO.

In 1958, Marilyn Ray graduated from St. Joseph Hospital School of Nursing, Hamilton, and left for Los Angeles, California. She worked at the University of California, Los Angeles Medical Center on a num- ber of units, including obstetrics and gynecology, emergency department, and cardiac and critical care with adults and children from vulnerable popula- tions. While working with African Americans and

CHAPTER 8 Marilyn Anne Ray 99

From 1973 to 1977, Ray returned to Canada to be with her family. She joined the nursing faculty at McMaster University in Hamilton, Ontario, and taught in the family nurse practitioner program. This was an exciting time, because the McMaster University Health Sciences Center was initiating evidence-based teach- ing, education, and practice. Ray completed a Master of Arts in Cultural Anthropology at McMaster University and studied human relationships, decision making and conflict, and the hospital as an organizational culture. She then received a letter from Dr. Leininger asking her to apply for the first transcultural nursing doctoral program at the University of Utah. At the university, Ray’s doctoral dissertation (1981a) was a study on car- ing in the complex hospital organizational culture. From this research, the Theory of Bureaucratic Caring, the focus of this chapter, was developed.

During her doctoral studies, Ray married James L. Droesbeke, her inspiration and friend, and the love of her life. He was a constant source of support and help to her over the course of her career until his untimely death from cancer in 2001. After completing her doctorate in 1981, Ray rejoined the University of Colorado School of Nursing. At the University of Colorado, Ray worked with Dr. Jean Watson, who developed the theory and practice of human caring in nursing. With Watson and other scholars, Ray founded the International Association for Human Caring, which awarded her its Lifetime Achievement Award in 2008. In the 1980s, At the University of Colorado, Ray continued her study of phenomenol- ogy and qualitative research approaches and directed dissertation work.

In 1989, Ray accepted an appointment by Dean Anne Boykin as the Christine E. Lynn Eminent Scholar at Florida Atlantic University, College of Nursing, a position held until 1994. Florida Atlantic University developed the Center for Caring, which has been housing caring archives since the inception of the International Association for Human Caring in 1977. Ray held the position of Yingling Visiting Scholar Chair at Virginia Commonwealth University School of Nursing from 1994 to 1995, and she was a visiting professor at the University of Colorado from 1989 to 1999. Ray has been visiting professor at uni- versities in Australia, New Zealand, and Thailand, advancing the teaching and research of human caring (Ray 1994b, 2000, 2010a, 2010b; Ray & Turkel, 2000,

and in occupational health nursing with family- centered care.

In the mid 1960s, Ray became a citizen of the United States and shortly afterward was commissioned as an officer in the United States Air Force Reserve, Nurse Corps (and Air National Guard). She graduated as a flight nurse from the School of Aerospace Medi- cine at Brooks Air Force Base, San Antonio, Texas, and served as an aero-medical evacuation nurse. She cared for combat casualties and other patients on board vari- ous types of aircraft during the Viet Nam war. Ray served longer than 30 years in different positions in the U.S. Air Force—flight nurse, clinician, administrator, educator, and researcher—and held the rank of colonel. Her interest in space nursing stimulated her to attend the program for educators at Marshall Space Flight Center in Huntsville, Alabama. She remains a charter member of the Space Nursing Society. In 1990, Ray was the first nurse to go to the Soviet Union with the Aero- space Medical Association, when the former USSR opened its space operations to American space engi- neers and physicians. Ray was called to active duty during the Persian Gulf War in 1991 and was assigned to Eglin Air Force Base, Valparaiso, Florida, where she orchestrated discharge planning and conducted research in the emergency department.

Ray is the recipient of a number of medals, including Air Force commendation medals for nursing education and research developments received during her Air Force career. Most notably, in 2000 she received the Federal Nursing Services Essay Award from the Asso- ciation of Military Surgeons of the United States for research on the impact of TRICARE/Managed Care on Total Force Readiness. This award recognized her accomplishments in a research program on economics and the nurse-patient relationship that received nearly $1 million from the TriService Military Nursing Research Council. In 2008, she received the TriService Nursing Research Program Coin for excellence in nurs- ing research.

Ray’s first nursing faculty positions were at the University of California San Francisco and the University of San Francisco with Glaser and Strauss, authors of the grounded theory method. She was intrigued by the study of nursing as a culture and had opportunities to teach students from various American and Asian cul- tures. In 1971, she traveled to Mexico with colleagues to study anthropology and health.

UNIT II Nursing Philosophies100

2010). She authored several theoretical and research publications in transcultural caring, transcultural eth- ics, and caring inquiry.

Ray continues as Professor Emeritus at the Florida Atlantic University Christine E. Lynn College of Nursing as a part-time faculty member in the PhD program and faculty mentor. Ray’s interest in trans- cultural nursing remains a theme in her research, teaching, and practice. With Dr. Sherrilyn Coffman, she completed a grounded theory research study of high-risk pregnant African-American women (Coffman & Ray, 1999, 2002). Learning about vulner- able populations gave Ray a deeper understanding of their needs, particularly the importance of access to health care and caring communities. Ray was vice president of Floridians for Health Care (universal health care) from 1998 to 2000. She is a Certified Transcultural Nurse and a member of the Interna- tional Transcultural Nursing Society. She has made international presentations in China, Saudi Arabia, Sweden, Finland, England, Switzerland, Thailand, and Viet Nam. In 1984, Ray received the Leininger Transcultural Nursing Award for excellence in trans- cultural nursing. In 2005, she was named a Transcul- tural Nursing Scholar by the International Trans- cultural Nursing Society. Ray is listed in Who’s Who in America and Who’s Who in the World and gave a paper in 2010 on caring organizations at the World Universities Forum in Davos, Switzerland (Ray, 2010c). She attended a program of study at the United Nations related to implementation of the 2015 Millennium goals. Ray serves on review boards of the Journal of Transcultural Nursing and Qualita- tive Health Research. She also published Transcul- tural Caring Dynamics in Nursing and Health Care (Ray, 2010a) and, with co-editors, Nursing, Caring, and Complexity Science: For Human-Environment Well-Being, which received a 2011 American Jour- nal of Nursing Book of the Year award.

Ray’s research interests continue to focus on nurses, nurse administrators, and patients in critical care and intermediate care, and in nursing administration in complex hospital organizational cultures. She devel- oped research with Dr. Marian Turkel to study the nurse-patient relationship as an economic resource, funded by the TriService Nursing Research Program (Turkel & Ray, 2000, 2001, 2003). With Turkel, Ray has published about complex caring relational theory,

organizational transformation through caring and ethical choice making, instrument development on organizational caring, economic and political caring, and caring organization creation. They recently pro- posed renaming the nursing process to the language of caring in Nursing Science Quarterly (Turkel, Ray, & Kornblatt, 2012). Continued involvement at Florida Atlantic University has given Ray opportunities to influence complex organizations and caring organiza- tions and environments in local, national, and global contexts. Her contributions to nursing education were recognized in 2005 with an honorary degree from Nevada State College and in 2007 with the Distin- guished Alumna Award from University of Utah College of Nursing.

Theoretical Sources Ray’s interest in caring as a topic of nursing scholarship was stimulated by her work with Leininger beginning in 1968, which focused on transcultural nursing and ethnographic-ethnonursing research methods. She used ethnographic methods in combination with phe- nomenology and grounded theory to generate substan- tive and formal grounded theories, resulting in the overarching Theory of Bureaucratic Caring (Ray, 1981a, 1984, 1989, 1994b, 2010 b, 2011), which focuses on nursing in complex organizations such as hospitals. She distinguishes organizations as cultures based on anthropological study of how people behave in com- munities and the significance or meaning of work life (Louis, 1985). Organizational cultures, viewed as social constructions, are formed symbolically through mean- ing in interaction (Smircich, 1985).

Ray’s work (1981b, 1989, 2010b; Moccia, 1986) was influenced by Hegel, who posited the interrelationship among thesis, antithesis, and synthesis. In Ray’s theory, the thesis of caring (humanistic, spiritual, and ethical) and the antithesis of bureaucracy (technological, eco- nomic, political, and legal) are reconciled and synthe- sized into the unitive force, bureaucratic caring. The synthesis, as a process of becoming, is a transformation that continues to repeat itself always changing, emerg- ing, and transforming.

As she revisited and continued to develop her for- mal theory, Ray (2001, 2006; Ray & Turkel, 2010) discovered that her study findings fit well with expla- nations from chaos theory. Chaos theory describes

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simultaneous order and disorder, and order within disorder. An underlying order or interconnectedness exists in apparently random events (Peat, 2002). Mathematical studies have shown that what may seem random is actually part of a larger pattern. Ap- plication of this theory to organizations demonstrates that within a state of chaos, the system is held within boundaries that are well ordered (Wheatley, 2006). Furthermore, chaos is necessary for new creative or- dering. The creative process as described by Briggs & Peat is as follows:

“. . . when we enter the vital turbulence of life, we realize that, at bottom, everything is always new. Often we have simply failed to notice this fact. When we’re being creative, we take notice.”

(Briggs & Peat, 1999, p. 30)

Ray compares change in complex organizations with this creative process and challenges nurses to step back and renew their perceptions of everyday events, to discover the embedded meanings. This is particularly important during organizational change. Complexity is a broader concept than chaos and fo- cuses on wholeness or holonomy. Complex systems, such as organizations, have many agents that interact with each other in multiple ways. As a result, these systems are dynamic and always changing. Systems behave in nonlinear fashion because they do not react proportionately to inputs. For example, a simple in- tervention such as asking a colleague for help may be accommodated easily or may be seen as unreasonable on a busy day, making the behavior of complex sys- tems impossible to predict (Davidson, Ray, & Turkel, 2011; Vicenzi, White, & Begun, 1997). Nevertheless, chaos exists only because the entire system is holistic. Briggs and Peat (1999, pp. 156-157) describe this “chaotic wholeness” as “full of particulars, active and interactive, animated by nonlinear feedback and ca- pable of producing everything from self-organized systems to fractal self-similarity to unpredictable cha- otic disorder.” Their ideas influenced Ray’s ongoing development of bureaucratic caring theory, which suggests that multiple system inputs are intercon- nected with caring in the organizational culture (Davidson, Ray, & Turkel, 2011; Ray, Turkel, & Cohn, 2011). Ray’s idea of the Theory of Bureaucratic Caring as holographic was influenced by the revolution taking place in science based on the holographic

worldview (Davidson, Ray, & Turkel, 2011; Ray, 2001, 2006; 2010a; Ray & Turkel, 2010). The discovery of interconnectedness among apparently unrelated sub- atomic events has intrigued scientists. Scientists con- cluded that systems possess the capacity to self-organize; therefore, attention is shifting away from describing parts and instead is focusing on the totality as an actual process (Wheatley, 2006). The conceptualization of the hologram portrays how every structure interpenetrates and is interpenetrated by other structures—so the part is the whole, and the whole is reflected in every part (Talbot, 1991).

The hologram has provided scientists with a new way of understanding order. Bohm has conceptualized the universe as a kind of giant, flowing hologram (Talbot, 1991; Davidson, Ray, & Turkel, 2011). He asserted that our day-to-day reality is really an illusion, like a holo- graphic image. Bohm termed our conscious level of existence explicate, or unfolded order, and the deeper layer of reality of which humans are usually unaware implicate, or enfolded order. In the Theory of Bureau- cratic Caring, Ray compares the health care structures of political, legal, economic, educational, physiological, social-cultural, and technological with the explicate order and spiritual-ethical caring with the implicate order. An example might be a case manager’s decisions about obtaining resources for a client’s care in the home. At first, explicate structures such as the legal managed care contract or the physical needs of the client might appear to provide enough information. However, through the case manager’s caring relationship with the client, implicate issues may emerge, such as the client’s values and desires. In truth, nursing situations involve an endless enfolding and unfolding of information that may be viewed as explicate and implicate order, and important to consider in the decision-making process.

Making things work in a health care organizational system requires knowledge and understanding of bureaucracy, which is rigid, and the complexity of change. Bureaucracy and complexity may seem like the antithesis of each other, but, in reality, the structure of bureaucracy (illuminating the political, economic, legal, and technological systems in organizations) works in conjunction with the complex relational process of networks to co-create patterns of human behavior and patterns of caring. Both bureaucracy and complexity influence the ways in which diverse par- ticipants describe and intuitively live out their life

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and in other literature in 1984 and 1989. The purpose of the dissertation research was to generate a theory of the dynamic structure of caring in a complex orga- nization. Methods used were grounded theory, phe- nomenology, and ethnography to elicit the meaning of caring to study participants.

The grounded theory approach is a qualitative re- search method that uses a systematic set of procedures to develop an inductive theory of a social process (Strauss & Corbin, 1990). The process results in the evolution of substantive theory (caring data generated from experience) and formal theory (integrated syn- thesis of caring and bureaucratic structures).

Ray studied caring in all areas of a hospital, from nurs- ing practice to materials management to administration,

world experience in the system. No one thing or per- son in a system is independent; rather, they are interde- pendent. The system is holographic as the whole and the part are intertwined. Thus, bureaucracy and com- plexity co-create and transform each other. The Theory of Bureaucratic Caring is a representation of the relat- edness of system and caring factors.

Use of Empirical Evidence The Theory of Bureaucratic Caring was generated from qualitative research involving health profession- als and clients in the hospital setting. This research focused on caring in the organizational culture and first appeared in the doctoral dissertation in 1981,

MAJOR CONCEPTS & DEFINITIONS

The theoretical processes of awareness of viewing truth, or seeing the good of things (caring), and of communication are central to the theory. The dia- lectic of spiritual-ethical caring (the implicate or- der) in relation to the surrounding structures of political, legal, economic, educational, physiologi- cal, social-cultural, and technological (the explicate order) illustrates that everything is interconnected with caring and the system as a macrocosm of the culture. In the model (see Figure 8-2). everything is infused with spiritual-ethical caring (the center) by integrative and relational connection to the struc- tures of organizational life. Spiritual-ethical caring involves different political, economic, and techno- logical processes.

Holography means that everything is a whole in one context and a part in another—with each part being in the whole and the whole being in the part (Talbot, 1991). Spiritual-ethical caring is both a part and a whole. Every part secures its meaning from each part, also seen as wholes.

Caring

Caring is defined as a complex transcultural, rela- tional process grounded in an ethical, spiritual con- text. Caring is the relationship between charity and right action, between love as compassion in re- sponse to suffering and need and justice or fairness

in terms of what ought to be done. Caring occurs within a culture or society, including personal cul- ture, hospital organizational culture, and societal and global culture (Ray, 2010a, 2010b).

Spiritual-Ethical Caring

Spirituality involves creativity and choice and is re- vealed in attachment, love, and community. The ethical imperatives of caring join with the spiritual and are related to moral obligations to others. This means never treating people as a means to an end but as beings with the capacity to make choices. Spiritual-ethical caring for nursing focuses on the facilitation of choices for the good of others (Ray, 1989, 1997a, 2010a).

Educational

Formal and informal educational programs, use of audiovisual media to convey information, and other forms of teaching and sharing information are ex- amples of educational factors related to the meaning of caring (Ray, 1981a, 1989; 2010c).

Physical

Physical factors are related to the physical state of being, including biological and mental patterns. Because the mind and body are interrelated, each pattern influences the other (Ray, 2001, 2006).

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MAJOR CONCEPTS & DEFINITIONS—cont’d

Social-Cultural

Examples of social and cultural factors are ethnicity and family structures; intimacy with friends and family; communication; social interaction and sup- port; understanding interrelationships, involve- ment, and intimacy; and structures of cultural groups, community, and society (Ray, 1981a, 1989, 2001, 2006, 2010a).

Legal

Legal factors related to the meaning of caring in- clude responsibility and accountability; rules and principles to guide behaviors, such as policies and procedures; informed consent; rights to privacy; malpractice and liability issues; client, family, and professional rights; and the practice of defensive medicine and nursing (Gibson, 2008; Ray, 1981a, 1989, 2010a, 2010b).

Technological

Technological factors include nonhuman resources, such as the use of machinery to maintain the physi- ological well-being of the patient, diagnostic tests, pharmaceutical agents, and the knowledge and skill needed to utilize these resources (Davidson, Ray & Turkel, 2011; Ray, 1987, 1989). Also included with

technology are computer-assisted practice and documentation (Campling, Ray, & Lopez-Devine, 2011; Swinderman, 2011).

Economic

Factors related to the meaning of caring include money, budget, insurance systems, limitations, and guidelines imposed by managed care organizations, and, in general, allocation of scarce human and ma- terial resources to maintain the economic viability of the organization (Ray, 1981a, 1989). Caring as an interpersonal resource should be considered, as well as goods, money, and services (Turkel & Ray, 2000, 2001, 2003; Ray, Turkel & Cohn, 2011.

Political

Political factors and the power structure within health care administration influence how nursing is viewed in health care and include patterns of communication and decision making in the organization; role and gender stratification among nurses, physicians, and administrators; union activities, including negotiation and confrontation; government and insurance com- pany influences; uses of power, prestige, and privilege; and, in general, competition for scarce human and material resources (Ray, 1989, 2010a, 2010b).

including nursing administration. More than 200 respondents participated in the purposive and con- venience sample. The principal question asked was “What is the meaning of caring to you?” Through dialogue, caring evolved from in-depth interviews, participant observation, caregiving observation, and documentation (Ray, 1989).

Ray’s discovery of bureaucratic caring began as a substantive theory and evolved to a formal theory. The substantive theory emerged as Differential Caring, that the meaning of caring differentiates itself by its context. Dominant caring dimensions vary in terms of areas of practice or hospital units. For example, an in- tensive care unit has a dominant value of technological caring (e.g., monitors, ventilators, treatments, and pharmacotherapeutics), and an oncology unit has a value of a more intimate, spiritual caring (e.g., family

focused, comforting, compassionate). Staff nurses val- ued caring in relation to patients, and administrators valued caring in relation to the system, such as the economic well-being of the hospital.

The formal Theory of Bureaucratic Caring symbol- ized a dynamic structure of caring. This structure emerged from the dialectic between the thesis of car- ing as humanistic (i.e., social, education, ethical, and religious-spiritual structures) and the antithesis of caring as bureaucratic (i.e., economic, political, legal, and technological structures). The dialectic of caring illustrates that everything is interconnected and that the organization is a macrocosm of the culture.

The evolution of Ray’s theory is illustrated in Figure 8-1, with diagrams of the bureaucratic caring structure published in 1981 and 1989. In the origi- nal grounded theory (see Figure 8-1, A). political

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and economic structures occupied a larger dimen- sion to illustrate their increasing influence on the nature of institutional caring (Ray, 1981a). Subse- quent research conducted in intensive care and in- termediate care units (Ray, 1989) emphasized the differential nature of caring, as seen through its competing structures of political, legal, economic, technological-physiological, spiritual-religious, eth- ical, and educational-social elements (see Figure 8-1, B). In her 1987 article on technological caring, Ray noted that “critical care nursing is intensely human, moral, and technocratic” (p. 172). Ray encouraged other researchers to study this area to enhance nursing’s understanding of the advantages and limitations of technology in critical care. The Dimensions of Critical Care Nursing journal recognized Ray as Researcher of the Year for her groundbreaking work.

With continued reflection and analysis, com- bined with research on the economics of the nurse- patient relationship, Ray began to illuminate the ethical-spiritual realm of nursing (Figure 8-2) (Ray, 2001). Spiritual-ethical caring became a dominant modality because of discoveries that focused on the

nurse-patient relationship. Qualitatively different sys- tems, such as political, economic, social-cultural, and physiological, when viewed as open and interactive, are whole and operate through the choice making of nurses (Davidson & Ray, 1991; Ray, 1994a). Spiri- tual-ethical caring suggests how choice making for the good of others can be accomplished in nursing practice.

Ray’s research reveals that in complex organiza- tions, nursing as caring is practiced and lived out at the margin between the humanistic-spiritual dimen- sion and the systemic dimension. These findings are consistent with worldviews from the science of com- plexity, which propose that antithetical phenomena coexist (Briggs & Peat, 1999; Ray, 1998). Thus, tech- nological and humanistic systems exist together. Complexity theory explains the resolution of the paradox between differing systems (thesis and antith- esis) represented in the synthesis or the Theory of Bureaucratic Caring.

In summary, the Theory of Bureaucratic Caring emerged using a grounded theory methodology, blended with phenomenology and ethnography.

FIGURE 8-1 A, The Original Grounded Theory of Bureaucratic Caring. B, Subsequent Grounded Theory Revealing Differential Caring. (A from Ray, M. A. [1981a]. A study of caring within an institutional culture. Dissertation Abstracts International, 42[06]. [University Microfilm No. 8127787.]. B from Parker, M. E. [2006]. Nursing theories and nursing practice [3rd ed.]. Philadelphia: F. A. Davis. Graphics redrawn from originals by J. Castle and B. Jensen, Nevada State College, Henderson, NV.)

Caring

Legal

Political

Spiritual/ religious

Economic

Technological/ physiological

Educational/ social

Ethical

B

Caring

Legal

Political

Economic

Ethico- religious- humanistic

Educational

Technological

A

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Spiritual- ethical caring

Economic

Political

Social- cultural

Legal

Technological

Educational

Physical

FIGURE 8-2 The Holographic Theory of Bureaucratic Caring. (From Parker, M. E. [2006]. Nursing theories and nursing practice [3rd ed.]. Philadelphia: F. A. Davis. Graphics redrawn from originals by J. Castle and B. Jensen, Nevada State College, Henderson, NV.)

The initial theory was examined using the philoso- phy of Hegel. The theory was revisited in 2001 after continuing research, and examination in light of the science of complexity and chaos theory, resulting in the holographic Theory of Bureaucratic Caring (see Figure 8-2).

Major Assumptions

Nursing Nursing is holistic, relational, spiritual, and ethical car- ing that seeks the good of self and others in complex community, organizational, and bureaucratic cultures. Dwelling with the nature of caring reveals that love is the foundation of spiritual caring. Through knowledge of the inner mystery of the inspirational life within, love calls forth a responsible ethical life that enables the expression of concrete actions of caring in the lives of nurses. As such, caring is cultural and social. Trans- cultural caring encompasses beliefs and values of com- passion or love and justice or fairness, which has significance in the social realm, where relationships are formed and transformed. Transcultural caring serves as a unique lens through which human choices are seen, and understanding in health and healing emerges.

Thus, through compassion and justice, nursing strives toward excellence in the activities of caring through the dynamics of complex cultural contexts of relation- ships, organizations, and communities (Ray, 2010a; Davidson, Ray, & Turkel, 2011).

Person A person is a spiritual and cultural being. Persons are created by God, the Mystery of Being, and they engage co-creatively in human organizational and transcultural relationships to find meaning and value (M. Ray, personal communication, May 25, 2004).

Health Health provides a pattern of meaning for individuals, families, and communities. In all human societies, beliefs and caring practices about illness and health are central features of culture. Health is not simply the consequence of a physical state of being. People construct their reality of health in terms of biology; mental patterns; characteristics of their image of the body, mind, and soul; ethnicity and family structures; structures of society and community (political, eco- nomic, legal, and technological); and experiences of caring that give meaning to lives in complex ways. The social organization of health and illness in society (the health care system) determines the way that peo- ple are recognized as sick or well. It determines how health professionals and individuals view health and illness. Health is related to the way people in a cultural group or organizational culture or bureaucratic system construct reality and give or find meaning (Helman, 1997; Ray, 2010a).

Environment Environment is a complex spiritual, ethical, ecologi- cal, and cultural phenomenon. This conceptualization of environment embodies knowledge and conscience about the beauty of life forms and symbolic (repre- sentational) systems or patterns of meaning. These patterns are transmitted historically and are pre- served or changed through caring values, attitudes, and communication. Functional forms identified in the social structure or bureaucracy (e.g., political, legal, technological, and economic) play a role in facilitating understanding of the meaning of caring, cooperation, and conflict in human cultural groups and complex organizational environments. Nursing practice in environments embodies the elements of

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the social structure and spiritual and ethical caring patterns of meaning (Davidson, Ray, & Turkel, 2011; Ray, 2010a).

Theoretical Assertions Person, nursing, environment, and health are inte- grated into the structure of the Theory of Bureaucratic Caring. The theory implies a dialectical relationship (thesis, antithesis, synthesis) among humans (person and nurse), the dimension of spiritual-ethical caring, and the structural (nursing, environment) dimensions of the bureaucracy or organizational culture (techno- logical, economic, political, legal, and social). For Ray, the dialectic of caring and bureaucracy is synthesized into a theory of bureaucratic caring. Bureaucratic caring, the synthetic margin between the human and structural dimensions, is where nurses, patients, and administrators integrate person, nursing, health, and environment.

Theoretical assertions within the Theory of Bureau- cratic Caring are as follows: 1. The meaning of caring is highly differential,

depending on its structures (social-cultural, edu- cational, political, economic, physical, technologi- cal, legal). The substantive theory of Differential Caring discovered that caring in nursing is contex- tual and is influenced by organizational structure or culture. Thus the meaning of caring is varied in the emergency department, intensive care unit, oncology unit, and other areas of the hospital and is influenced by the role and position that a person holds. The meaning of caring emerged as differen- tial because no one definition or meaning of caring was identified (Ray, 1984, 1989; Ray, 2010b). The theoretical statement that describes the substan- tive theory of Differential Caring is formulated as:

“In a hospital, differential caring is a dynamic social process that emerges as a result of the vari- ous values, beliefs, and behaviors expressed about the meaning of caring. Differential Caring relates to competing [cooperating] educational, social, humanistic, religious/spiritual, and ethical forces as well as political, economic, legal, and techno- logical forces within the organizational culture that are influenced by the social forces within the dominant American [world] culture”

(Ray, 1989, p. 37).

2. Caring is bureaucratic as well as spiritual/ethical, given the extent to which its meaning can be un- derstood in relation to the organizational structure (Davidson, Ray, & Turkel, 2011; Ray, 1989, 2001, 2006; Ray & Turkel, 2010). In the theoretical model (see Figure 8-2). everything is infused with spiri- tual-ethical caring by its integrative and relational connection to the structures of organizational life (e.g., political, educational). Spiritual-ethical caring is both a part and a whole, just as each of the orga- nizational structures is both a part and a whole. Every part secures its purpose and meaning from the other parts. Understanding of spiritual-ethical caring in the bureaucratic organizational system, as a holographic formation, facilitates improvement in patient outcomes and transformation of human environmental well-being (M. Ray, personal com- munication, April 13, 2008; Ray, 2010a).

3. Caring is the primordial construct and conscious- ness of nursing. Spiritual-ethical caring and the organizational structures in Figure 8-2, when inte- grated, open, and interactive, are whole and oper- ate by conscious choice. Nurses’ choice making occurs with the interest of humanity at heart, uti- lizing ethical principles as the compass in delibera- tions. Ray (2001) states, “Spiritual-ethical caring for nursing does not question whether or not to care in complex systems, but intimates how sincere deliberations and ultimately the facilitation of choices for the good of others can or should be accomplished” (p. 429).

Logical Form The formal Theory of Bureaucratic Caring was in- duced primarily by comparative analysis and insight into the whole of the experience. Review of the litera- ture on nursing, philosophy, social processes, and or- ganizations was combined with the substantive the- ory, Differential Caring, that Ray discovered with ethnography, phenomenology, and grounded theory research. These ideas were analyzed and integrated through a process that was inductive and logical— inductively building on the substantive theory and logically drawing upon the philosophical argument of Hegel’s dialectic (Moccia, 1986; Ray, 1989, 2006, 2010b) and complexity science to synthesize caring and bureaucracy to a new theoretical formulation (Davidson, Ray, & Turkel, 2011; Ray, 2001).

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Acceptance by the Nursing Community

Practice The Theory of Bureaucratic Caring has direct appli- cation for nursing. In the clinical setting, staff nurses are challenged to integrate knowledge, skills, and caring (Turkel, 2001). This synthesis of behaviors and knowledge reflects the holistic nature of the Theory of Bureaucratic Caring. At the edge of chaos, con- temporary issues such as inflation of health care costs serve as the catalyst for change within corporate health care organizations. The ethical component embedded in spiritual-ethical caring (see Figure 8-2) addresses nurses’ moral obligations to others. Ray (2001) emphasizes that “transformation can occur even in the businesslike atmosphere of today if nurses reintroduce the spiritual and ethical dimensions of caring. The deep values that underlie choice to do good will be felt both inside and outside organiza- tions” (p. 429).

Deborah McCray-Stewart, a correction health service administrator at Telfair State Prison in Helena, Georgia, described how nurses in correctional health care settings integrate the Theory of Bureaucratic Car- ing into the framework of their practice (D. McCray- Stewart, personal communication, April 5, 2008). Nurses in corrections have the responsibility of car- ing for a complex special population. They must un- derstand the culture, see prisoners as human beings, and have the ability to communicate, educate, and rehabilitate in this area of health care. Their effectiveness results from incorporating the sociocul- tural, physical, educational, legal, and ethical dimen- sions of caring theory into daily practice. In the eco- nomic and political areas of the correctional system, nurses struggle with the same issues as nurses in a hospital system, such as decreasing health care costs while providing quality care. Economic strategies include conducting health services at the facility level as opposed to transporting patients to a hospital. Radiology, laboratory, and telemedicine are introduced into the system requiring nurses to work in all areas. The government provides a constitution of care for this special population.

Ray (2010a) has addressed the interface of di- verse cultures within the health care system. The Transcultural Communicative Caring Tool provides guidelines to help nurses understand the needs, adversity, problems, and questions that arise in

culturally dynamic health care situations (Ray & Turkel, 2000; Ray, 2010a). The dimensions of this tool are as follows: 1. Compassion 2. Advocacy 3. Respect 4. Interaction 5. Negotiation 6. Guidance

Administration Ray’s research has shown that nurses, patients, and administrators value the caring intentionality that is co-created in the nurse-patient or administrator- nurse relationship. By creating ethical caring relation- ships, administrators and staff can transform the work environment (Ray, Turkel, & Marino, 2002; Ray, Turkel, & Cohn, 2011). The Theory of Bureaucratic Caring suggests that organizations fostering ethical choices, respect, and trust will become the successful organizations of the future.

Miller (1995) summarized the work of Ray and other theorists and encouraged nurse executives to examine their daily caring skills and to use these skills in administrative practice. Nyberg studied with Ray and acknowledged the impact of Ray’s ideas in her book, A Caring Approach in Nursing Administration (Nyberg, 1998). Nyberg urged nurse administrators to create a caring and compassionate system, while being accountable for organizational management, costs, and economic forces. Turkel and Ray (2003) conducted a study with U.S Air Force personnel that led to increased awareness of issues between civilian and military policy makers.

Karen O’Brien, Director of Public Health Nursing in Denver, Colorado, described how public health nurse consultants developed an orientation for new nurses by incorporating the core principles of Ray’s Theory of Bureaucratic Caring (O’Brien, personal communication, April 12, 2008). The orientation curriculum includes the components of legal, tech- nological, economic, and spiritual/ethical influences on caring for whole populations. Nurses are encour- aged to use the political and economic dimensions of the theory to guide their practice. The Theory of Bureaucratic Caring provides a framework by which a nurse can view the whole population and its com- ponents to understand ways they can influence health outcomes.

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At the National University of Colombia in Bogota, Colombia, Professor Olga J. Gomez and her nursing students studied Ray’s Theory of Bureaucratic Caring, focusing on the hospital nursing administration role (Gomez, personal communication, April 5, 2008). As they studied the paradox between the concepts of human caring and economics, the students developed a framework for phenomenological research and explored the perceptions of executive nurses about the relationships among human care, economics, and control of health costs. An outcome of the study was recognition of the importance of working together in university and practice settings for empowerment and satisfaction of clients in the hospital environ- ment. Finally, the Theory of Bureaucratic Caring was adopted in 2012 by Iowa Health, Des Moines (three hospitals) for implementation as a theory guide for professional nursing practice at their hospitals in preparation for application for Magnet Recognition Status as centers for excellence (Turkel, 2004).

Education The Theory of Bureaucratic Caring is useful in nurs- ing education in terms of its broad focus on caring in nursing and its conceptualization of the health care system. The holographic theory combines differentia- tion of structures within a holistic framework. Dis- cussion of the structures or forces within complex organizations (e.g., legal, economic, social-cultural) provides an overview of factors involved in nursing situations. Infusion of these structures with spiritual- ethical caring emphasizes the moral imperatives and the choice making of nurses.

When developing a new baccalaureate nursing pro- gram at Nevada State College, the faculty was particu- larly drawn to the theory because of its description of the dimensions relevant to nursing within a philoso- phy of caring. The conceptual framework of the new nursing program combined Ray’s Theory of Bureau- cratic Caring with theoretical ideas from Watson (1985) and Johns (2000). Figure 8-3 depicts the ways nurses and clients interact in the health care system and how reflection on practice influences this process. A description of the conceptual framework for the curriculum, illustrated in Figure 8-3, is as follows:

“. . . the holographic theory of caring recognizes the interconnectedness of all things, and that

everything is a whole in one context and a part of the whole in another context. Spiritual-ethical caring, the focus for communication, infuses all nursing phenomena, including physical, social- cultural, legal, technological, economic, political, and educational forces. The arrows reflect the dynamic nature of spiritual-ethical caring by the nurse and the forces that influence the changing structure of the health care system. These forces impact both the client/patient and the nurse.”

(Nevada State College, 2010, p. 2)

In the health care system, the client-patient and the nurse come together in a dynamic transpersonal car- ing relationship (Watson, 1985). The nurse, through communication, views the person as having the capac- ity to make choices. Through reflection on experience, the nurse assesses which force has the most influence on the nursing situation (Johns, 2000). The nurse draws upon empirical, ethical, and personal knowl- edge to inform and influence the aesthetic response to the patient. Through the nurse’s caring activities within the transpersonal relationship, the goal of nursing can be achieved—the promotion of well-being through caring (Nevada State College, 2010).

The Theory of Bureaucratic Caring is being used to guide curriculum development in the master’s pro- gram in nursing administration and in the master’s and doctoral programs in theory courses at Florida Atlantic University. Structures from the theory, including ethical, spiritual, economic, technological, legal, political, and social, serve as a framework for exploration of current health care issues. Students are challenged to analyze the contemporary economic structure of health care from the perspective of car- ing. Caring within the health care delivery system is a key concept in nursing courses (Turkel, 2001; Ray, personal communication, May 2012).

Research From her research that resulted in the Theory of Bu- reaucratic Caring, Ray developed a phenomenological- hermeneutic approach and a caring inquiry approach that has continued to guide her studies (Ray, 1985, 1991, 1994b, 2011). This research approach is particu- larly significant because it is grounded in the philoso- phy of humanism and caring, and it encourages nurses to utilize phenomenological hermeneutics through the

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c s

c

c e

t c

c

c r

o w

o e

FIGURE 8-3 Nevada State College Nursing Organizing Framework. (Reprinted with permission from Nevada State College School of Nursing, Henderson, NV, 2010. Graphics redrawn from originals by J. Castle, Nevada State College, Henderson, NV.)

lens of caring. The evolution of Ray’s research methods began with ethnography-ethnonursing, grounded the- ory, and phenomenology, culminating in Caring Inquiry and Complex Caring Dynamics approaches (Ray, 2011). These approaches consist of the generation of data by inquiry into the meaning of participants’ life- world and relational experiences. Interviews and narrative discourse are the primary methods of data generation in these approaches. In Caring Inquiry, an ontology of caring is a part of the approach, in that Complex Caring Dynamics includes qualitative data generation and analysis, as well as complex quantitative research data collection and analysis techniques. The researcher dwells on the essential meanings of phe- nomena and through further reflection facilitates the interpretation of interview data, transforming data into interpretative themes and meta-themes. The ultimate

goals are to capture the unity of meaning and to syn- thesize meanings into a theory.

Based on the Theory of Bureaucratic Caring, Ray and Turkel have developed a program of research that fo- cuses on nursing in complex organizations (Davidson, Ray, & Turkel, 2011; Ray, Turkel, & Cohn, 2011). These studies further explored the meaning of caring and the nature of nursing among hospital nurses, administra- tors, and clients-patients. A TriService Nursing Research Program grant supported extensive research on nursing as an economic resource. Table 8-1 outlines publications that describe this ongoing program.

Further Development Development of the Theory of Bureaucratic Caring is ongoing in Ray’s program of research and scholarship.

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TABLE 8-1 Research Publications Related to the Theory of Bureaucratic Caring

Year Citation Research Focus and Findings

1981 Ray, M. A. Study of caring within an institutional culture. Dissertation Abstracts International, 42(06). (University Microfilm No. 8127787.)

The dissertation analyzed the meaning of caring expressions and behaviors among 192 participants in a hospital culture. The substantive theory of Differential Caring and the formal Theory of Bureaucratic Caring were abstracted.

1984 Ray, M. The development of a classifica- tion system of institutional caring. In M. Leininger (Ed.), Care: The essence of nursing and health. Thorofare, NJ: Slack.

The discussion examines the construct of caring within the cultural context of the hospital. The classification system included cultural caring symbols of psychological, practical, interactional, and philosophical factors.

1987 Ray, M. Technological caring: A new model in critical care. Dimensions in Critical Care Nursing,.(3), 166-173.

This phenomenological study examined the meaning of caring to critical care unit nurses. The study showed that ethical decisions, moral reasoning, and choice undergo a process of growth and maturation.

1989 Ray, M. A. The theory of bureaucratic caring for nursing practice in the organizational culture. Nursing Administration Quarterly, 13(2), 31-42.

Caring within the organizational culture was the focus of the study. It describes the substantive Theory of Differential Caring and the formal Theory of Bureaucratic Caring. With caring at the center of the model, the study included ethical, spiritual-religious, economic, technological-physiological, legal, political, and educational-social structures.

1989 Valentine, K. Caring is more than kindness: Modeling its complexities. Journal of Nursing Administration, 19(11), 28-34.

Nurses, patients, and corporate health managers provided quantita- tive and qualitative data to define caring. Data were organized using the categorization schema developed by Ray (1984).

1993 Ray, M. A. A study of care processes using total quality management as a framework in a USAF regional hospital emergency service and related services. Military Medicine, 158(6), 396-403.

This descriptive study investigated access to care processes in a military regional hospital emergency service using a total quality management framework. The study lends support to the need for a decentralized, coordinated health care system with greater authority and control given to local commands.

1997 Ray, M. The ethical theory of existential authenticity: The lived experience of the art of caring in nursing adminis- tration. Canadian Journal of Nursing Research, 29(1), 111-126.

Existential authenticity was uncovered as the unity of meaning of caring by nurse administrators. This was described as an ethic of living and caring for the good of nursing staff members and the good of the organization.

1998 Ray, M. A. A phenomenologic study of the interface of caring and technology in intermediate care: Toward a reflex- ive ethics for clinical practice. Holistic Nursing Practice, 12(4), 69-77.

This phenomenological study examined the meaning of caring for technologically dependent patients. Results revealed that vulnera- bility, suffering, and the ethical situations of moral blurring and moral blindness were the dynamics of caring for these patients.

2000 Turkel, M., & Ray, M. Relational complexity: A theory of the nurse- patient relationship within an economic context. Nursing Science Quarterly, 13(4), 307-313.

The formal Theory of Relational Complexity illuminated that the caring relationship is complex and dynamic, is both process and outcome, and is a function of both economic and caring variables; that, as a mutual process, is lived all at once as relational and system self-organization.

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TABLE 8-1 Research Publications Related to the Theory of Bureaucratic Caring—cont’d

Year Citation Research Focus and Findings

2001 Ray, M., & Turkel, M. Impact of TRICARE/ managed care on total force readiness. Military Medicine, 166(4), 281-289.

A phenomenological study was conducted to illuminate the life world descriptions of experiences of USAF active duty and reserve personnel with managed care in the military and civilian health care systems. The research illuminated the need for policy change to better meet the health care needs of these personnel and their families.

2001 Turkel, M., & Ray, M. Relational complex- ity: From grounded theory to instrument theoretical testing. Nursing Science Quarterly, 14(4), 281-287.

The article describes a series of studies that examined the relation- ships among caring, economics, cost, quality, and the nurse- patient relationship. The results of theory testing revealed relational caring as a process and the strongest predictor of the outcome—relational self-organization that is aimed at well-being.

2002 Ray, M., Turkel, M., & Marino, F. The transformative process for nursing in workforce redevelopment. Nursing Administration Quarterly, 26(2), 1-14.

Relational self-organization is a shared, creative response to a continuously changing and interconnected work environment. Strategies of respecting, communicating, maintaining visibility, and engaging in participative decision making are the transfor- mative processes leading to growth and transformation.

2003 Turkel, M. A journey into caring as expe- rienced by nurse managers. Interna- tional Journal for Human Caring, 7(1), 20-26.

The purpose of this phenomenological study was to capture the meaning of caring as experienced by nurse managers. Essential themes that emerged were growth, listening, support, intuition, receiving gifts, and frustration.

2003 Turkel, M., & Ray, M. A process model for policy analysis within the context of political caring. International Journal for Human Caring, 7(3), 17-25.

This phenomenological study illuminated the experiences of USAF personnel with managed care in the military and civilian health care systems. A model outlining the process of policy analysis was generated.

USAF, U.S. Air Force.

Her work is a synthesis of nursing science, ethics, philosophy, complexity science, economics, and orga- nizational management. Ray described her most recent program of research as sponsored by the TriService Nursing Research program (Turkel & Ray, 2001). It included instrument development and psy- chometric testing of the original Nurse-Patient Rela- tionship Resource Analysis Tool, now referred to as the Relational Caring Questionnaire (Professional Form) and the Relational Caring Questionnaire (Patient Form) (Watson, 2009; Watson Caring Sci- ence Institute, www.wcsi.org). These tools are Likert- type questionnaires for health care professionals (nurses and non-nurses and nurse-administrators) and patients that measure the nurse-patient relation- ship as an administrative and interpersonal resource. These tools will help researchers link the non- economic (interpersonal) resources of caring with the

administrative system resources (including eco- nomic/budgetary procedures). The tools are being translated into Swedish and are being tested. This interdisciplinary research is at the cutting edge and will lead to enhanced understanding of the concepts and relationships outlined in the Theory of Bureau- cratic Caring.

Critique

Clarity The major structures—spiritual-religious, ethical, tech- nological-physiological, social, legal, economic, political, and educational—are defined clearly in Ray’s 1989 pub- lication. These definitions are consistent with definitions commonly used by practicing nurses. They have seman- tic consistency in that concepts are used in ways consis- tent with their definitions (Chinn & Kramer, 2011).

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holistic nature of concepts and relationships. As nurses in all areas of practice study these new concep- tualizations, they may be led to question the cause- and-effect stance of older linear ideas. Therefore, the Theory of Bureaucratic Caring has the potential to change the paradigm or way of thinking of practicing nurses.

Accessibility Because the Theory of Bureaucratic Caring is generated using grounded theory and has undergone continued revisions based largely on research, empirical precision is high with concepts grounded in observable reality. The theory corresponds directly to the research data that are summarized in published reports (Ray, 1981a, 1981b, 1984, 1987, 1989, 1997b, 1998).

Ray, Turkel, and Marino use this theory in a pro- gram of research into the nurse-patient relationship as an economic resource (Ray, 1998; Ray, Turkel, & Marino, 2002; Turkel, 2003; Turkel & Ray, 2000, 2001, 2003). These studies provide guidance for nursing practice and enhance nurses’ understanding of the dynamics of health care organizations. Ray (2001) proposes that bureaucratic caring culminates “in a vision for understanding the deeper reality of nursing life” (p. 426).

Importance The issues that confront nurses today include eco- nomic constraints in the managed care environment and the effects of these constraints (e.g., staffing ra- tios) on the nurse-patient relationship. These are the very issues that the Theory of Bureaucratic Caring addresses. Nurses in administrative, research, and clinical roles can use the political and economic di- mensions of the theory as a framework to inform their practice. This theory is relevant to the contem- porary work world of nurses.

Ray and Turkel have generated middle-range theo- ries through their program of research based on the Theory of Bureaucratic Caring. Ray uncovered the Theory of Existential Authenticity (1997b) as the unity of meaning for nurse-administrator caring art, and Sor- bello adapted it more recently (2008). Nurse adminis- trators described an ethic of living, caring for the good of their staff nurses and for the good of the organiza- tion. Relational (Caring) Complexity focuses on the nurse-patient relationship within an economic context

Most terms did not change from the 1989 article to the 2001 and 2006 publications; however, some concepts combined or separated as Ray’s development of the the- ory evolved (Ray, 2010a; Ray & Turkel, 2010). Therefore, for this chapter, currently used terms were clarified with the theorist. Furthermore, the formal definitions of the terms spiritual-ethical caring, social-cultural, physical, and technological, as they relate to the theory, are pub- lished for the first time in this chapter.

The diagram presented in Figure 8-2 enhances clarity. The interrelationship of spiritual-ethical car- ing with the other structures and the openness of the system are depicted by the organization of concepts and the dynamic arrows. Ray’s description of the theory (2001, pp. 428-429; assists the reader in imag- ing the theory relationships as holographic.

Simplicity Ray’s theory simplifies the dynamics of complex bu- reaucratic organizations. From numerous descrip- tions of the inductive grounded theory study, Ray derived the integrative concept of spiritual-ethical caring and the seven interrelated concepts of physical, social-cultural, legal, technological, economic, political, and educational structures. Given the complexity of bureaucratic organizations, the number of concepts is minimal.

Generality The Theory of Bureaucratic Caring is a philosophy that addresses the nature of nursing as caring. Alligood (2010) notes, “Nursing philosophy sets forth the mean- ing of nursing phenomena through analysis, reasoning, and logical argument” (p. 69). Ray’s theory addresses questions such as “What is the nature of caring in nurs- ing?” and “What is the nature of nursing practice as caring?” Philosophies are broad and provide direction for the discipline (Alligood, 2010, p. 69). The Theory of Bureaucratic Caring proposes that nurses are choice makers guided by spiritual-ethical caring, in relation to legal, economic, technological, and other structures.

The Theory of Bureaucratic Caring provides a unique view of health care organizations and how nursing phenomena interrelate as wholes and parts of the system. Concepts are derived logically with in- ductive research. Ray’s analysis incorporates ideas from complexity science. The conceptualization of the health care system as holographic emphasizes the

CHAPTER 8 Marilyn Anne Ray 113

(Turkel & Ray, 2000, 2001; Davidson, Ray, & Turkel, 2011; Ray, Turkel, & Cohn, 2011). Study data show that relational caring between administrators, nurses, and patients are the strongest predictor of relational self-organization aimed at well-being. Relational self- organization is a shared, creative response that in- volves growth and transformation (Ray, Turkel, & Marino, 2002). Transformative processes that can lead to relational self-organization include respecting, communicating, maintaining visibility, and engaging in participative decision making in the workplace. Finally, Ray’s work emphasizes the need for reflexive ethics for clinical practice, to enhance understanding of how deep values and moral interactions shape ethi- cal decisions (Ray, 1998, 2010a).

Summary The Theory of Bureaucratic Caring challenges partici- pants in nursing to think beyond their usual frame of reference and envision the world holistically, while considering the universe as a hologram. Appreciation of the interrelatedness of persons, environments, and events is key to understanding this theory. The theory provides a unique view of how health care organiza- tions and nursing phenomena interrelate as wholes and parts in the system. Unique constructs within Ray’s theory include technological and economic car- ing. Theory development by Ray’s colleagues and other scholars continues. Ray challenges nurses to envision the spiritual and ethical dimensions of car- ing and complex organizational health care systems so the Theory of Bureaucratic Caring may inform nurse creativity and transform the work world.

CASE STUDY

Mrs. Smith was a 73-year-old widow who lived alone with no significant social support. She had been suffering from emphysema for several years and had had frequent hospitalizations for respira- tory problems. On the last hospital admission, her pneumonia quickly progressed to organ failure. Death appeared to be imminent, as she went in and out of consciousness, alone in her hospital room. The Medical-Surgical nursing staff and the Nurse Manager focused on making Mrs. Smith’s

end-of-life period as comfortable as possible. Upon consultation with the Vice President for Nursing, the Nurse Manager and the unit staff nurses decided against moving Mrs. Smith to the Palliative Care Unit, although considered more economical, because of the need to protect and nurture her as she was already experiencing signs and symptoms of the dying process. Nurses were prompted by an article they read on human caring as the “language of nursing practice” (Turkel, Ray, & Kornblatt, 2012) in their weekly caring practice meetings.

The Nurse Manager reorganized patient assign- ments. She felt that the newly assigned Clinical Nurse Leader who was working between both the Medical and Surgical Units could provide direct nurse caring and coordination at the point of care (Sherman, 2010). Over the next few hours, the Clinical Nurse Leader as well as a staff member who had volunteered her assistance provided per- sonal care for Mrs. Smith. The Clinical Nurse Leader asked the Nurse Manager to see if there was a possibility that Mrs. Smith had any close friends who could “be there” for her in her final moments. One friend was discovered and came to say goodbye to Mrs. Smith. With help from her team, the Clinical Nurse Leader turned, bathed, and suctioned Mrs. Smith. She spoke quietly, prayed, and sang hymns softly in Mrs. Smith’s room, creating a peaceful environment that ex- pressed compassion and a deep sense of caring for her. The Nurse Manager and nursing unit staff were calmed and their “hearts awakened” by the personal caring that the Clinical Nurse Leader and the volunteer nurse provided. Mrs. Smith died with caring persons at her bedside, and all mem- bers of the unit staff felt comforted that she had not died alone.

Davidson, Ray, & Turkel (2011) note that car- ing is complex, and caring science includes the art of practice, “an aesthetic which illuminates the beauty of the dynamic nurse-patient relationship, that makes possible authentic spiritual-ethical choices for transformation—healing, health, well- being, and a peaceful death” (p. xxiv). As the Clinical Nurse Leader and the nursing staff in this situation engaged in caring practice that focused

Continued

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on the well-being of the patient, they simultane- ously created a caring-healing environment that contributed to the well-being of the whole—the emotional atmosphere of the unit, the ability of the Clinical Nurse Leader and staff nurses to prac- tice caringly and competently, and the quality of care the staff were able to provide to other patients. The bureaucratic nature of the hospital included leadership and management systems that con- ferred power, authority, and control to the Nurse Manager, the Clinical Nurse Leader, as well as

nursing staff in partnership with the Vice President for Nursing. Nursing administration, Clinical Nurse Leaders, and staff ’s actions reflected values and beliefs, attitudes, and behaviors about the nursing care they would provide, how they would use technology, and how they would deal with human relationships. The ethical and spiritual choice making of the whole staff and the way they communicated their values both reflected and cre- ated a caring community in the workplace culture of the hospital unit.

CRITICAL THINKING ACTIVITIES Discuss the role and the value of the Clinical Nurse Leader on nursing units. What is the difference between the Nurse Manager and the Clinical Nurse Leader in terms of caring practice in complex hospi- tal care settings? How does a CNL fit into the Theory of Bureaucratic Caring for implementation of a caring practice?

4. What interrelationships are evident between persons in this environment, that is, how were the Vice President for Nursing, Nurse Manager, Clini- cal Nurse Leader, staff, and patient connected in this situation? Compare and contrast the traditional nursing process with Turkel, Ray, and Kornblatt’s (2012) language of caring practice within the Theory of Bureaucratic Caring.

Based on the case study above, consider the following questions. 1. What caring behaviors prompted the Nurse Manager

to assign the Clinical Nurse Leader to engage in direct caring for Mrs. Smith? Describe and explain the new Clinical Nurse Leader role established by the American Association of College of Nursing in 2004.

2. What issues (ethical, spiritual, legal, social-cultural, economic, and physical) from the structure of the Theory of Bureaucratic Caring influenced this situation? Discuss “end of life” issues in relation to the theory.

3. How did the Nurse Manager balance these issues? What considerations went into her decision making?

POINTS FOR FURTHER STUDY

n Ray, M. (2010). Transcultural caring dynamics in nursing and health care. Philadelphia: F. A. Davis.

n Santa Fe Institute, Santa Fe, NM, at: www. santafe.edu

n Watson Caring Science Institute, at www.wcsi.org

n Florida Atlantic University, Christine E. Lynn Col- lege of Nursing, Boca Raton, FL, at: www.fau.edu

n International Association for Human Caring, at: www.humancaring.org

n New England Complex Systems Institute, Cambridge, MA, at: www.necsi.edu

n Plexus Institute, Allentown, NJ, at: www. plexusinstitute.org

CHAPTER 8 Marilyn Anne Ray 115

Alligood, M. R., & Tomey, A. M. (2010). Nursing theorists and their work (7th ed.). St. Louis: Mosby.

Briggs, J., & Peat, F. D. (1999). Seven life lessons of chaos: spiritual wisdom from the science of change. New York: Harper Collins.

Chinn, P. L., & Kramer, M. K. (2011). Integrated theory and knowledge development in nursing (8th ed.). St. Louis: Mosby.

Campling, A., Ray, M., & Lopez-Devine, J. (2011). Imple- menting change in nursing informatics practice. In A. Davidson, M. Ray, & M. Turkel (Eds.), Nursing, caring, and complexity science: for human-environment well-being (pp. 325–339). New York: Springer.

Coffman, S., & Ray, M. A. (1999). Mutual intentionality: a theory of support processes in pregnant African American women. Qualitative Health Research, 9(4), 479–492.

Coffman, S., & Ray, M. A. (2002). African American women describe support processes during high-risk pregnancy and postpartum. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 31(5), 536–544.

Davidson, A., & Ray, M. (1991). Studying the human- environment phenomenon using the science of complexity. Advances in Nursing Science,14(2): 73–87.

Davidson, A., Ray, M., & Turkel, M. (2011). Nursing, caring and complexity science: for human-environment well-being. New York: Springer.

Fadiman, A. (1998). The spirit catches you and you fall down. New Yark: Farrar, Straus, & Giroux.

Gibson, S. (2008). Legal caring: preventing retraumatiza- tion of abused children through the caring nursing interview using Roach’s six Cs. International Journal for Human Caring, 12(4), 32–37.

Helman, C. (1997). Culture, health and illness (3rd ed.). Oxford, UK:Butterworth-Heinemann.

Johns, C. (2000). Becoming a reflective practitioner. Oxford, UK: Blackwell Science.

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Miller, K. (1995). Keeping the care in nursing care: our biggest challenge. Journal of Nursing Administration, 25(11), 29–32.

Moccia, P. (1986). New approaches to theory development (Pub. No. 15-1992). New Yark: National League for Nursing.

Nevada State College. (2010). Nursing organizing frame- work. Henderson, (NV): Author.

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Peat, F. (2002). From certainty to uncertainty: the story of science and ideas in the twentieth century. Washington, DC: Joseph Henry Press.

Ray, M. (1981a). A study of caring within an institutional culture. Dissertation Abstracts International, 42(06). (University Microfilms No. 8127787.)

Ray, M. (1981b). A philosophical analysis of caring within nursing. In M. Leininger (Ed.), Caring: an essential human need (pp. 25–360). Thorofare, (NJ): Slack.

Ray, M. (1984). The development of a classification system of institutional caring. In M. Leininger (Ed.), Care: the essence of nursing and health (pp. 95–112). Thorofare, (NJ): Slack.

Ray, M. (1987). Technological caring: a new model in criti- cal care. Dimensions in Critical Care Nursing, 6(3), 166– 173.

Ray, M. (1989). The Theory of Bureaucratic Caring for nursing practice in the organizational culture. Nursing Administration Quarterly, 13(2), 31–42.

Ray, M. A. (1985). A philosophical method to study nurs- ing phenomena. In M. Leininger (Ed.), Qualitative research methods in nursing (pp. 81–92). New Yark: Grune & Stratton.

Ray, M. A. (1991). Caring inquiry: the esthetic process in the way of compassion. In D. Gaut & M. Leininger (Eds.), Caring: the compassionate healer (pp. 181–189). New Yark: National League for Nursing.

Ray, M. A. (1994a). Complex caring dynamics: a unifying model for nursing inquiry. Theoretic and Applied Chaos in Nursing, 1(1), 23–32. (Journal renamed Complexity and Chaos in Nursing.)

Ray, M. A. (1994b). The richness of phenomenology: philosophic, theoretic, and methodologic concerns. In J. Morse (Ed.), Critical issues in qualitative research methods (pp. 116–135). Newbury Park, (CA): Sage.

Ray, M. A. (1997a). Consciousness and the moral ideal: a transcultural analysis of Watson’s theory of transper- sonal caring. Advanced Practice Nursing Quarterly, 3(1), 25–31.

Ray, M. A. (1997b). The ethical theory of existential authenticity: the lived experience of the art of caring in nursing administration. Canadian Journal of Nursing Research, 29(1), 111–126.

Ray, M. A. (1998). A phenomenologic study of the interface of caring and technology: a new reflexive ethics in inter- mediate care. Holistic Nursing Practice, 12(4), 71–79.

Ray, M. A. (2000). Transcultural assessment of older adults. In S. Garratt & S. Koch (Eds.), Assessing older people: a practical guide for health professionals. Sydney, Australia: MacLennan & Petty.

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Swinderman, T. (2011). Technological change in health care electronic documentation as facilitated by the science of complexity. In A. Davidson, M. Ray, & M. Turkel (Eds.), Nursing, caring, and complexity science: for human-environment well-being (pp. 309– 319). New York: Springer.

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Turkel, M. (2004). Magnet status: assessing, pursuing, and achieving nursing excellence. Marblehead, (MA): HCPro.

Turkel, M., & Ray, M. (2000). Relational complexity: a theory of the nurse-patient relationship within an economic context. Nursing Science Quarterly, 13(4), 307–313.

Turkel, M., & Ray, M. (2001). Relational complexity: from grounded theory to instrument development and theo- retical testing. Nursing Science Quarterly, 14(4), 281–287.

Turkel, M., & Ray, M. (2003). A process model for policy analysis within the context of political caring. Interna- tional Journal for Human Caring, 7(3), 17–25.

Turkel, M. C., Ray, M. A., & Kornblatt, L. (2012). Instead of reconceptualizing the nursing process let’s re-name it. Nursing Science Quarterly, 25(2), 194–198.

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Ray, M. A. (2001). The Theory of Bureaucratic Caring. In M. Parker (Ed.), Nursing theories and nursing practice (pp. 422–431). Philadelphia: F. A. Davis.

Ray, M. A. (2006). The Theory of Bureaucratic Caring. In M. Parker (Ed.), Nursing theories and nursing practice (2nd ed., pp. 360–368). Philadelphia: F. A. Davis.

Ray, M. (2010a). Transcultural caring dynamics in nursing and health care. Philadelphia: F. A. Davis.

Ray, M. (2010b). A study of caring within the institutional culture: The discovery of the Theory of Bureaucratic Caring.Saarbrucken, Germany: Lambert AcademicPress.

Ray, M. (2010c). Creating caring organizations and cul- tures through communitarian ethics. Journal of the World Universities Forum, 3(5), 41–52.

Ray, M. (2011). Complex caring dynamics: a unifying model for nursing inquiry. In A. Davidson, M. Ray, & M. Turkel (Eds.), Nursing, caring, and complexity science: For human-environment well-being. (pp. 31–52). New York: Springer.

Ray, M. A., & Turkel, M. C. (2000). Culturally based caring. In L. Dunphy & J. Winland-Brown (Eds.), Advanced practice nursing: a holistic approach (pp. 43–55). Philadelphia: F. A. Davis.

Ray, M., & Turkel, M. (2010). Marilyn Anne Ray’s Theory of Bureaucratic Caring. In M. Parker & M. Smith (Eds.), Nursing theories and nursing practice. Philadelphia: F. A. Davis.

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Primary Sources Books Davidson, A., Ray, M., & Turkel, M. (2011). Nursing, caring

and complexity science: For human-environment well- being. New York: Springer.

Ray, M. (2010). Transcultural caring dynamics in nursing and health care. Philadelphia: F. A. Davis.

Watson, J., & Ray, M. (Eds.). (1988). The ethics of care and the ethics of cure: synthesis in chronicity.New Yark: National League for Nursing. (Released 1989; translated into Swedish.)

Book Chapters Ray, M. A. (1981). A philosophical analysis of caring within

nursing. In M. Leininger (Ed.), Caring: an essential hu- man need (pp. 25–36). Thorofare, (NJ): Charles B.Slack.

Ray, M. A. (1984). The development of a nursing classifica- tion system of institutional caring. In M. Leininger (Ed.), Care: the essence of nursing and health (pp. 95–112). Thorofare, (NJ): Charles B.Slack.

Ray, M. A. (1985). A philosophical method to study nurs- ing phenomena. In M. Leininger (Ed.), Qualitative research methods in nursing (pp. 81–92). New Yark: Grune & Stratton.

Ray, M. A. (1990). Phenomenological method in nursing research. In N. Chaska (Ed.), The nursing profession: turning points (pp. 173–179). New York: McGraw-Hill.

Ray, M. A. (1991). Caring inquiry: the esthetic process in the way of compassion. In D. Gaut & M. Leininger (Eds.), Caring: the compassionate healer (pp. 181–189). New Yark: National League for Nursing.

Ray, M. A. (1992). Phenomenological method for nursing research. In J. Poindexter (Ed.), Nursing theory. Research & Practice Summer Research Conference monograph (pp. 163–174). Detroit: Wayne State University.

Ray, M. A. (1994). Environmental encountering through interiority. In E. Schuster & C. Brown (Eds.), Exploring our environmental connections (pp. 113–118). New Yark: National League for Nursing Press.

Ray, M. A. (1994). The quality of authentic presence: trans- cultural caring inquiry in primary care. In J. Wang & P. Simoni (Eds.), Proceedings of First International and Interdisciplinary Health Research Symposium (pp. 69– 72). At Peking Union Medical College Hospital, Beijing, China, and Zhejiang Medical University, Hangzhou, China (Chinese translation). Morgantown, (WV): West Virginia University.

Ray, M. A. (1994). The richness of phenomenology: philosophic, theoretic, and methodologic concerns. In J. Morse (Ed.), Critical issues in qualitative research

methods (pp. 116-135). Newbury Park, (CA): Sage. (Translated into Spanish,2004.)

Ray, M. A. (1995). Transcultural health care ethics: pathways to progress. In J. Wang (Ed.), Health care and culture (pp. 3–9). Morgantown, (WV): West Virginia University.

Ray, M. A. (1997). Illuminating the meaning of caring: unfolding the sacred art of divine love. In M. S. Roach (Ed.), Caring from the heart: the convergence between caring and spirituality (pp. 163–178). New Yark: Paulist Press.

Ray, M. A. (1999). Caring foundations of deacony. In T. Ryokas & K. Keissling (Eds.), Spiritus-Lux-Caritas (pp. 225–236). Lahti, Finland: Deaconal Institution of Lahti. (Translated into German, 1999, University of Heidelberg, Germany.)

Ray, M. A. (1999). Critical theory as a framework to enhance nursing science. In E. Polifroni & M. Welch (Eds.), Perspectives on philosophy of science in nursing (pp. 382–386). Philadelphia: Lippincott.

Ray, M. A. (2000). Transcultural assessment of older adults. In S. Koch & S. Garratt (Eds.), Assessing older people: a practical guide for health professionals. Sydney, Australia: MacLennan &Petty.

Ray, M. A. (2001). Complex culture and technology: toward a global caring communitarian ethics of nursing. In R. Locsin (Ed.), Concerning technology and caring (pp. 41–52). Westport, (CT):Greenwood.

Ray, M. A. (2001). The Theory of Bureaucratic Caring. In M. Parker (Ed.), Nursing theories and nursing practice (pp. 422–431). Philadelphia: F. A. Davis.

Ray, M. A. (2006). The Theory of Bureaucratic Caring. In M. Parker (Ed.), Nursing theories and nursing practice (2nd ed., pp. 360–368). Philadelphia: F. A. Davis.

Ray, M. (2007). Technological caring as a dynamic of com- plexity in nursing practice. In A. Barnard & R. Locsin (Eds.), Perspectives on technology and nursing practice. United Kingdom:Palgrave.

Ray, M. A., & Turkel, M. C. (2000). Culturally based caring. In L. Dunphy & J. Winland-Brown (Eds.), Advanced practice nursing: a holistic approach (pp. 43– 55). Philadelphia: F. A. Davis.

Journal Articles Davidson, A., & Ray, M. (1991). Studying the human-

environment relationship using the science of complex- ity. Advances in Nursing Science, 14(2), 73–87.

Douglas, M. K., Kemppainen, J. K., McFarland, M. R., Papadopoulos, I., Ray, M. A., Roper, J. M., et al. (2010). Chapter 10: Research methodologies for investigating cultural phenomena and evaluating interventions. Jour- nal of Transcultural Nursing, 21(4), 373S–405S.

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Ray, M. A., Didominic, V. A., Dittman, P. W., Hurst, P. A., Seaver, J. B., Sorbello, B. C., et al. (1995). The edge of chaos: caring and the bottom line. Nursing Management, 9, 48–50.

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Turkel, M., & Ray, M. (2003). A process model for policy analysis within the context of political caring. Interna- tional Journal for Human Caring, 7(3), 17–25.

Turkel, M., & Ray, M. (2004). Creating a caring practice environment through self-renewal. Nursing Administra- tion Quarterly, 28(4), 249–254.

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Turkel, M. (2006). Applications of Marilyn Ray’s Theory of Bureaucratic Caring. In M. Parker (Ed.), Nursing theories and nursing practice (2nd ed., pp. 369–379). Philadelphia: F. A. Davis.

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Bacote, J., Davidhizar, R. E., Doutrich, D., et al. (2010). Chapter 3: Theoretical basis for transcultural care. Journal of Transcultural Nursing, 21(4), 53S–136S.

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Ray, M. A. (1989). A theory of bureaucratic caring for nursing practice in the organizational culture. Nursing Administration Quarterly, 13(2), 31–42. (Also trans- lated and published in Japanese.)

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Ray, M. A. (1997). The ethical theory of Existential Authenticity: the lived experience of the art of caring in nursing administration. Canadian Journal of Nursing Research, 22(1), 111–126. (Abstract also published in French.)

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“The nurse-patient relationship is not a uniform, professionalized blueprint but rather a kaleidoscope of intimacy and distance in some of the most dramatic, poignant, and mundane moments of life.”

(Benner, 1984a)

CH A P T ER 9

Caring, Clinical Wisdom, and Ethics in Nursing Practice

Karen A. Brykczynski

Patricia Benner

range of clinical experience, including positions in acute medical-surgical, critical care, and home health care.

Benner has a rich background in research and began this part of her career in 1970 as a postgraduate nurse researcher in the School of Nursing at UCSF. Upon completion of her doctorate in 1982, Benner achieved the position of associate professor at the Department of Physiological Nursing at UCSF and tenured professor in 1989. In 2002, she moved to the Department of Social and Behavioral Sciences at UCSF, where she was the first occupant of the Thelma Shobe Cook Endowed Chair in Ethics and Spirituality. She taught at the doctoral and master’s levels and served on three to four dissertation committees per

Credentials and Background of the Philosopher

Patricia Benner was born in Hampton, Virginia, and spent her childhood in California, where she received her early and professional education. Majoring in nurs- ing, she obtained a baccalaureate of arts degree from Pasadena College in 1964. In 1970, she earned a master’s degree in nursing, with major emphasis in medical- surgical nursing, from the University of California, San Francisco (UCSF) School of Nursing. Her PhD in stress, coping, and health was conferred in 1982 at the Univer- sity of California, Berkeley, and her dissertation was published in 1984 (Benner, 1984b). Benner has a wide

Previous authors: Jullette C. Mitre, Sr., Judith E. Alexander, and Susan L. Keller. The author wishes to express appreciation to Patricia Benner for reviewing this chapter.

CHAPTER 9 Patricia Benner 121

Helen Nahm Research Lecture Award from the faculty at UCSF for her contribution to nursing science and research. Benner received an award for outstanding contributions to the profession from the National Council of State Boards of Nursing in 2002, for develop- ing an instrument, Taxonomy of Error, Root Cause and Practice (TERCAP) an electronic data collection tool to capture the sources and nature of nursing errors (Benner, Sheets, Uris, et al., 2002).

In 2002, The Institute for Nursing Healthcare Leader- ship commemorated the impact of the landmark book From Novice to Expert (1984a) with an award acknowl- edging 20 years of collecting and extending clinical wisdom, experiential learning, and caring practices and a celebration at the conference “Charting the Course: The Power of Expert Nurses to Define the Future.” Benner received the American Association of Critical Care Nurses Pioneering Spirit Award in May 2004 for her work on skill acquisition and articulating nursing knowledge in critical care. In 2007, she was selected for the UCSF School of Nursing’s Centennial Wall of Fame and was a visiting professor at the University of Pennsylvania School of Nursing in 2009. Along with her husband and colleague, Richard Benner, Patricia Benner consults around the world regarding clinical practice development models (CPDMs) (Benner & Benner, 1999). Benner was appointed Nursing Education Study Director for the Carnegie Foundation’s Preparation for the Professions Program (PPP) in March 2004. The book published from The Carnegie Foundation for the Advancement of Teaching National Nursing Education Study, Educating Nurses: A Call for Radical Transforma- tion was awarded the American Journal of Nursing Book of the Year Award for 2010, and the Prose Award for Scholarly Writing. This nationwide study was a study of professional education and the shift from technical professionalism to civic professionalism. In 2011, the American Academy of Nursing honored Patricia Benner as a Living Legend.

Philosophical Sources Benner acknowledges that her thinking in nursing has been influenced greatly by Virginia Henderson. Benner studies clinical nursing practice in an attempt to discover and describe the knowledge embedded in nursing practice. She maintains that knowledge accrues over time in a practice discipline and is developed through

year. Benner retired from full-time teaching in 2008 as professor emerita from UCSF, but continues to be involved in presentations and consultation, as well as writing and research projects. She is currently a Distinguished Visiting Professor at Seattle University School of Nursing, assisting them with a transforma- tion of their undergraduate and graduate curricula.

Benner has published extensively and has been the recipient of numerous honors and awards, the most recent being induction into the Danish Nursing Soci- ety as an Honorary Member, and the Sigma Theta Tau International Book Author award shared with her co-editors for Interpretive Phenomenology in Health Care Research (Chan, Brykczynski, Malone, & Benner, 2010). She was honored with 1984, 1989, 1996, and 1999 American Journal of Nursing Book of the Year awards for From Novice to Expert: Excellence and Power in Clinical Nursing Practice (1984a), The Primacy of Caring: Stress and Coping in Health and Illness (1989, with Wrubel), Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics (1996, with Tanner and Chesla), and Clinical Wisdom and Interventions in Critical Care: A Thinking-in-Action Approach (1999, with Hooper-Kyriakidis & Stannard), respectively. The Crisis of Care: Affirming and Restoring Caring Practices in the Helping Professions (1994), edited by Susan S. Phillips and Patricia Benner, was selected for the CHOICE list of Outstanding Academic Books for 1995. Benner’s books have been translated into 10 lan- guages as well as several of her articles. Benner received the American Journal of Nursing media CD-ROM of the year award for Clinical Wisdom and Interventions in Critical Care: A Thinking-in-Action Approach (2001, with Hooper-Kyriakidis & Stannard).

In 1985, Benner was inducted into the American Academy of Nursing. She received the National League for Nursing’s Linda Richards Award for leadership in education in 1989 and both the NLN Excellence in Leadership Award for Nursing Education and the NLN President’s Award for Creativity and Innovation in Nursing Education in 2010. In 1990, she received the Excellence in Nursing Research and Excellence in Nurs- ing Education Award from the California Organization of Nurse Executives. She also received the Alumnus of the Year Award from Point Loma Nazarene College (formerly Pasadena College) in 1993. In 1994, Benner became an Honorary Fellow in the Royal College of Nursing, United Kingdom. In 1995, she received the

UNIT II Nursing Philosophies122

experiential learning and situated thinking and reflec- tion on practice in particular practice situations. She refers to this work as articulation research, defined as: “describing, illustrating, and giving language to taken-for-granted areas of practical wisdom, skilled know-how, and notions of good practice” (Benner, Hooper-Kyriakidis, & Stannard, 1999, p. 5). One of Benner’s first philosophical distinctions was to differen- tiate between practical and theoretical knowledge. She stated that knowledge development in a practice disci- pline “consists of extending practical knowledge (know- how) through theory-based scientific investigations and through the charting of the existent ‘know-how’ devel- oped through clinical experience in the practice of that discipline” (1984a, p. 3). Benner believes that nurses have been delinquent in documenting their clinical learning, and “this lack of charting of our practices and clinical observations deprives nursing theory of the uniqueness and richness of the knowledge embedded in expert clinical practice” (Benner, 1983, p. 36). She has contributed to the description of the know-how of nurs- ing practice.

Citing Kuhn (1970) and Polanyi (1958), philoso- phers of science, Benner (1984a) emphasizes the difference between “knowing how,” a practical knowl- edge that may elude precise abstract formulations, and “knowing that,” which lends itself to theoretical explanations. Knowing that is the way an individual comes to know by establishing causal relationships between events. Clinical situations are always more varied and complicated than theoretical accounts; therefore, clinical practice is an area of inquiry and a source of knowledge development. By studying practice, nurses can uncover new knowledge. Nurses must develop the knowledge base of practice (know- how), and, through investigation and observation, begin to record and develop the know-how of clinical expertise. Ideally, practice and theory dialog creates new possibilities. Theory is derived from practice, and practice is extended by theory.

Hubert Dreyfus introduced Benner to phenomenol- ogy. Stuart Dreyfus, in operations research, and Hubert Dreyfus, in philosophy, both professors at the Univer- sity of California at Berkeley, developed the Dreyfus Model of Skill Acquisition (Dreyfus & Dreyfus, 1980; Dreyfus & Dreyfus, 1986), which Benner applied in her work, From Novice to Expert (1984a). She credits Jane Rubin’s (1984) scholarship, teaching, and colleagueship as sources of inspiration and influence, especially in

relation to the works of Heidegger (1962) and Kierkeg- aard (1962). Richard Lazarus (Lazarus & Folkman, 1984; Lazarus, 1985) mentored her in the field of stress and coping. Judith Wrubel has been a participant and co-author with Benner for years, collaborating on the ontology of caring and caring practices (Benner & Wrubel, 1989). Additional philosophical and ethical influences on Benner’s work include Joseph Dunne (1993), Knud Løgstrup (1995a, 1995b, 1997), Alistair MacIntyre (1981, 1999), Kari Martinsen (Alvsvåg, 2010), Maurice Merleau-Ponty (1962), Onora O’Neill (1996), and Charles Taylor (1971, 1982, 1989, 1991, 1993, 1994).

Benner (1984a) adapted the Dreyfus model to clini- cal nursing practice. The Dreyfus brothers developed the skill acquisition model by studying the performance of chess masters and pilots in emergency situations (Dreyfus & Dreyfus, 1980; Dreyfus & Dreyfus, 1986). Benner’s model is situational and describes five levels of skill acquisition and development: (1) novice, (2) advanced beginner, (3) competent, (4) proficient, and (5) expert. The model posits that changes in four aspects of perfor- mance occur in movement through the levels of skill acquisition: (1) movement from a reliance on abstract principles and rules to the use of past, concrete experi- ence, (2) shift from reliance on analytical, rule-based thinking to intuition, (3) change in the learner’s percep- tion of the situation from viewing it as a compilation of equally relevant bits to viewing it as an increasingly com- plex whole, in which certain parts stand out as more or less relevant, and (4) passage from a detached observer, standing outside the situation, to one of a position of involvement, fully engaged in the situation (Benner, Tanner, & Chesla, 1992).

Because the model is situation-based and is not trait-based, the level of performance is not an indi- vidual characteristic of an individual performer, but instead is a function of a given nurse’s familiarity with a particular situation in combination with her or his educational background. The performance level can be determined only by consensual validation of ex- pert judges and by assessment of the outcomes of the situation (Benner, 1984a). In applying the model to nursing, Benner noted that “experience-based skill acquisition is safer and quicker when it rests upon a sound educational base” (1984a, p. xix). Benner (1984a) defines skill and skilled practice to mean im- plementing skilled nursing interventions and clinical judgment skills in actual clinical situations. In no case

CHAPTER 9 Patricia Benner 123

does this refer to context-free psychomotor skills or other demonstrable enabling skills outside the con- text of nursing practice.

In subsequent research undertaken to further ex- plicate the Dreyfus model, Benner identified two interrelated aspects of practice that also distinguish the levels of practice from advanced beginner to expert (Benner, Tanner, & Chesla, 1992; 1996). First, clinicians at different levels of practice live in different clinical worlds, recognizing and responding to differ- ent situated needs for action. Second, clinicians develop what Benner terms agency, or the sense of responsibility toward the patient, and evolve into fully participating members of the health care team. The skills acquired through nursing experience and the perceptual awareness that expert nurses develop as decision makers from the “gestalt of the situation” lead them to follow their hunches as they search for evidence to confirm the subtle changes they observe in patients (1984a, p. xviii).

The concept that experience is defined as the out- come when preconceived notions are challenged, re- fined, or refuted in actual situations is based on the works of Heidegger (1962) and Gadamer (1970). As the nurse gains experience, clinical knowledge be- comes a blend of practical and theoretical knowledge. Expertise develops as the clinician tests and modifies principle-based expectations in the actual situation. Heidegger’s influence is evident in this and in Benner’s subsequent writings on the primacy of caring. Benner refutes the dualistic Cartesian descriptions of mind- body person and espouses Heidegger’s phenomeno- logical description of person as a self-interpreting being who is defined by concerns, practices, and life experiences. Persons are always situated, that is, they are engaged meaningfully in the context of where they are. Heidegger (1962) termed practical knowledge as the kind of knowing that occurs when an individual is involved in the situation. By virtue of being humans, we have embodied intelligence, meaning that we come to know things by being in situations. When a familiar situation is encountered, there is embodied recogni- tion of its meaning. For example, having previously witnessed someone developing a pulmonary embolus, a nurse notices qualitative nuances and has recogni- tion ability for observing it before those nurses who have never seen it. Benner and Wrubel (1989) state, “Skilled activity, which is made possible by our em- bodied intelligence, has been long regarded as ‘lower’

than intellectual, reflective activity” but argue that in- tellectual, reflective capacities are dependent on em- bodied knowing (p. 43). Embodied knowing and the meaning of being are premises for the capacity to care; things matter and “cause us to be involved in and defined by our concerns” (p. 42).

While doing her doctoral studies at Berkeley, Ben- ner was a research assistant to Richard S. Lazarus (Lazarus, 1985; Lazarus & Folkman, 1984), who is known for his stress and coping theory. As part of Lazarus’ larger study, Benner studied midcareer males’ meaning of work and coping that was pub- lished as Stress and Satisfaction on the Job: Work Meanings and Coping of Mid-Career Men (1984b). Lazarus’ Theory of Stress and Coping is described as phenomenological, that is, the person is understood to constitute and be constituted by meanings. Stress is the disruption of meanings, and coping is what the person does about the disruption. Both doing some- thing and refraining from doing something are ways of coping. Coping is bound by the meanings inherent in what the person interprets as stressful. Different possibilities arise from the way the person is in the situation. Benner used this concept to describe clini- cal nursing practice in terms of nurses making a difference by being in a situation in a caring way.

Benner’s approach to knowledge development that began with From Novice to Expert (1984a) began a growing, living tradition for learning from clinical nursing practice through collection and interpreta- tion of exemplars (Benner, 1994; Benner & Benner, 1999; Benner, Tanner & Chesla, 1996; Benner, Hooper-Kyriakidis, & Stannard, 1999). Benner and Benner (1999) stated the following:

Effective delivery of patient/family care requires collective attentiveness and mutual support of good practice embedded in a moral community of practitioners seeking to create and sustain good practice... This vision of practice is taken from the Aristotelian tradition in ethics (Aristotle, 1985) and the more recent articulation of this tradition by Alasdair MacIntyre (1981), where practice is defined as a collective endeavor that has notions of good internal to the practice... However, such col- lective endeavors must be comprised of individual practitioners who have skilled know how, craft, science, and moral imagination, who continue to create and instantiate good practice (pp. 23-24).

UNIT II Nursing Philosophies124

Novice In the novice stage of skill acquisition in the Dreyfus model, the person has no background experience of the situation in which he or she is involved. Context-free rules and objective attributes must be given to guide performance. There is difficulty discerning between relevant and irrelevant aspects of a situation. Generally, this level applies to stu- dents of nursing, but Benner has suggested that nurses at higher levels of skill in one area of practice could be classified at the novice level if placed in an area or situation completely foreign to them such as moving from general medical-surgical adult care to neonatal intensive care units (Benner, 1984a).

Advanced beginner The advanced beginner stage in the Dreyfus model develops when the person can demonstrate margin- ally acceptable performance, having coped with enough real situations to note, or to have pointed out by a mentor, the recurring meaningful compo- nents of the situation. The advanced beginner has enough experience to grasp aspects of the situation (Benner, 1984a). Unlike attributes and features, aspects cannot be objectified completely because they require experience based on recognition in the context of the situation.

Nurses functioning at this level are guided by rules and are oriented by task completion. They have difficulty grasping the current patient situation in terms of the larger perspective. However, Dreyfus and Dreyfus (1996) state the following:

“Through practical experience in concrete situ- ations with meaningful elements which neither the instructor nor student can define in terms of objective features, the advanced beginner starts intuitively to recognize these elements when they are present. We call these newly recognized elements “situational” to distinguish them from the objective elements of the skill domain that the beginner can recognize prior to seeing concrete examples (p. 38).”

Clinical situations are viewed by nurses who are in the advanced beginner stage as a test of their abilities and the demands of the situation placed on

them rather than in terms of patient needs and responses (Benner et al., 1992). Advanced beginners feel highly responsible for managing patient care, yet they still rely on the help of those who are more experienced (Benner et al., 1992). Benner places most newly graduated nurses at this level.

Competent Through learning from actual practice situations and by following the actions of others, the advanced beginner moves to the competent level (Benner, Tanner, & Chesla, 1992). The competent stage of the Dreyfus model is typified by considerable con- scious and deliberate planning that determines which aspects of current and future situations are important and which can be ignored (Benner, 1984a).

Consistency, predictability, and time management are important in competent performance. A sense of mastery is acquired through planning and predict- ability (Benner Tanner, & Chesla, 1992). The level of efficiency is increased, but “the focus is on time management and the nurse’s organization of the task world rather than on timing in relation to the patient’s needs” (Benner, Tanner, & Chesla, 1992, p. 20). The competent nurse may display hyperresponsibility for the patient, often more than is realistic, and may exhibit an ever-present and critical view of the self (Benner, Tanner, & Chesla, 1992).

The competent stage is most pivotal in clinical learning, because the learner must begin to recog- nize patterns and determine which elements of the situation warrant attention and which can be ignored. The competent nurse devises new rules and reasoning procedures for a plan, while apply- ing learned rules for action on the basis of relevant facts of that situation. To become proficient, the competent performer must allow the situation to guide responses (Dreyfus & Dreyfus, 1996). Stud- ies point to the importance of active teaching and learning in the competent stage for nurses making the transition from competency to proficiency (Benner, Tanner, & Chesla, 1996; Benner, Hooper- Kyriakidis, & Stannard, 1999; Benner, 2005; Benner, Malloch, & Sheets, 2010). The competent stage of learning is pivotal in the formation of

MAJOR CONCEPTS & DEFINITIONS

CHAPTER 9 Patricia Benner 125

MAJOR CONCEPTS & DEFINITIONS—cont’d

the everyday ethical comportment of the nurse (Benner, 2005).

Anxiety is now more tailored to the situation than it was at the novice or advanced beginner stage, when a general anxiety exists over learning and per- forming well without making mistakes. Coaching at this point should encourage competent-level nurses to follow through on a sense that things are not as usual, or even on vague feelings of foreboding or anxiety, because they have to learn to decide what is relevant with no rules to guide them . . . Nurses at this stage feel exhilarated when they perform well and feel remorse when they recognize that their performance could have been more effective or more prescient because they had paid attention to the wrong things or had missed relevant subtle signs and symptoms. These emotional responses are the formative stages of aesthetic appreciation of good practice. These feelings of satisfaction and uneasi- ness with performance act as a moral compass that guides experiential ethical and clinical learning. There is a built-in tension between the deliberate rule- and maxim-based strategies of organizing, planning, and prediction and developing a more response-based practice, as pointed out in our study of critical-care nurses (Benner, 2005. p.195).

Proficient At the proficient stage of the Dreyfus model, the performer perceives the situation as a whole (the total picture) rather than in terms of aspects, and the performance is guided by maxims. The profi- cient level is a qualitative leap beyond the compe- tent. Now the performer recognizes the most salient aspects and has an intuitive grasp of the situation based on background understanding (Benner, 1984a).

Nurses at this level demonstrate a new ability to see changing relevance in a situation, including recognition and implementation of skilled responses to the situation as it evolves. They no longer rely on preset goals for organization, and they demonstrate increased confidence in their knowledge and abilities (Benner, Tanner, & Chesla, 1992). At the proficient stage, there is much more involvement with the patient and family. The proficient stage is a

transition into expertise (Benner, Tanner, & Chesla, 1996).

Expert The fifth stage of the Dreyfus model is achieved when “the expert performer no longer relies on analytical principle (i.e., rule, guideline, maxim) to connect an understanding of the situation to an appropriate action” (Benner, 1984a, p. 31). Benner described the expert nurse as having an intuitive grasp of the situation and as being able to identify the region of the problem without losing time considering a range of alternative diagnoses and solutions. There is a qualitative change as the expert performer “knows the patient,” meaning knowing typical patterns of responses and knowing the patient as a person. Key aspects of expert practice include the following (Benner, Tanner, & Chesla, 1996): n Demonstrating a clinical grasp and resource-

based practice n Possessing embodied know-how n Seeing the big picture n Seeing the unexpected

The expert nurse has the ability to recognize pat- terns on the basis of deep experiential background. For the expert nurse, meeting the patient’s actual concerns and needs is of utmost importance, even if it means planning and negotiating for a change in the plan of care. There is almost a transparent view of the self (Benner, Tanner, & Chesla, 1992).

Aspects of a situation The aspects are the recurring meaningful situational components recognized and understood in context because the nurse has previous experience (Benner, 1984a).

Attributes of a situation The attributes are measurable properties of a situa- tion that can be explained without previous experi- ence in the situation (Benner, 1984a).

Competency Competency is “an interpretively defined area of skilled performance identified and described by its intent,

Continued

UNIT II Nursing Philosophies126

MAJOR CONCEPTS & DEFINITIONS—cont’d

functions, and meanings” (Benner, 1984a, p. 292). This term is unrelated to the competent stage of the Dreyfus model.

Domain The domain is an area of practice having a number of competencies with similar intents, functions, and meanings (Benner, 1984a).

Exemplar An exemplar is an example of a clinical situation that conveys one or more intents, meanings, functions, or outcomes easily translated to other clinical situations (Benner, 1984a).

Experience Experience is not a mere passage of time, but an active process of refining and changing preconceived theo- ries, notions, and ideas when confronted with actual situations; it implies there is a dialog between what is found in practice and what is expected (Benner & Wrubel, 1982).

Maxim Maxim is a cryptic description of skilled performance that requires a certain level of experience to recognize the implications of the instructions (Benner, 1984a).

Paradigm case A paradigm case is a clinical experience that stands out and alters the way the nurse will perceive and

understand future clinical situations (Benner, 1984a). Paradigm cases create new clinical understanding and open new clinical perspectives and alternatives.

Salience Salience describes a perceptual stance or embodied knowledge whereby aspects of a situation stand out as more or less important (Benner, 1984a).

Ethical Comportment Ethical comportment is good conduct born out of an individualized relationship with the patient. It involves engagement in a particular situation and entails a sense of membership in the relevant profes- sional group. It is socially embedded, lived, and embodied in practices, ways of being, and responses to a clinical situation that promote the well being of the patient (Day & Benner, 2002). “Clinical and ethical judgments are inseparable and must be guided by being with and understanding the human concerns and possibilities in concrete situations” (Benner, 2000, p. 305).

Hermeneutics Hermeneutics means “interpretive.” The term derives from biblical and judicial exegesis. As used in re- search, hermeneutics refers to describing and study- ing “meaningful human phenomena in a careful and detailed manner as free as possible from prior theoretical assumptions, based instead on practical understanding” (Packer, 1985, pp. 1081–1082).

Use of Empirical Evidence From 1978 to 1981, Benner was the author and project director of a federally funded grant, Achiev- ing Methods of Intraprofessional Consensus, As- sessment and Evaluation, known as the AMICAE project. This research led to the publication of From Novice to Expert (1984a). Benner directed the AMICAE project to develop evaluation methods for participating schools of nursing and hospitals in the San Francisco area. It was an interpretive, descriptive study that led to the use of Dreyfus’ five

levels of competency to describe skill acquisition in clinical nursing practice. Benner (1984a) ex- plains that the interpretive approach seeks a rich description of nursing practice from observation and narrative accounts of actual nursing practice to provide text for interpretation (hermeneutics).

Nurses’ descriptions of patient care situations in which they made a positive difference “present the uniqueness of nursing as a discipline and an art” (Benner, 1984a, p. xxvi). More than 1200 nurse par- ticipants completed questionnaires and interviews

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as part of the AMICAE project. Paired interviews with preceptors and preceptees were “aimed at dis- covering if there were distinguishable, characteristic differences in the novice’s and expert’s descriptions of the same clinical incident” (Benner, 1984a, p. 14). Additional interviews and participant observations were conducted with 51 nurse-clinicians and other newly graduated nurses and senior nursing students to “describe characteristics of nurse performance at different stages of skill acquisition” (Benner, 1984a, p. 15). The purpose “of the inquiry has been to uncover meanings and knowledge embedded in skilled practice. By bringing these meanings, skills, and knowledge into public discourse, new knowl- edge and understandings are constituted” (Benner, 1984a, p. 218).

Thirty-one competencies emerged from the analy- sis of transcripts of interviews about nurses’ detailed descriptions of patient care episodes that included their intentions and interpretations of events. From these competencies, which were identified from ac- tual practice situations, the following seven domains were derived inductively on the basis of similarity of function and intent (Benner, 1984a): 1. The helping role 2. The teaching-coaching function 3. The diagnostic and patient monitoring function 4. Effective management of rapidly changing situations 5. Administering and monitoring therapeutic inter-

ventions and regimens 6. Monitoring and ensuring the quality of health care

practices 7. Organizational work role competencies

Each domain was developed using the related competencies from actual practice situation descrip- tions. Benner presented the domains and competen- cies of nursing practice as an open-ended interpretive framework for enhancing the understanding of the knowledge embedded in nursing practice. As a result of the socially embedded, relational, and dialogical nature of clinical knowledge, domains and competen- cies should be adapted for use in each institution through the study of clinical practice at each specific locale (Benner & Benner, 1999). Such adaptations have been implemented in many institutions for nurs- ing staff in hospitals around the world (Alberti, 1991; Balasco & Black, 1988; Brykczynski, 1998; Dolan, 1984; Gaston, 1989; Gordon, 1986; Hamric, Whitworth,

& Greenfield, 1993; Lock & Gordon, 1989; Nuccio, Lingen, Burke, et al., 1996; Silver, 1986a, 1986b). The domains and competencies have also been useful for ongoing articulation of the knowledge embedded in advanced practice nursing (Brykczynski, 1999; Fenton, 1985; Fenton & Brykczynski, 1993; Lindeke, Canedy, & Kay, 1997; Martin, 1996).

Benner and Wrubel (1989) have further explained and developed the background to the ongoing study of the knowledge embedded in nursing practice in The Primacy of Caring: Stress and Coping in Health and Illness. They note that the primacy of caring is three-pronged “as the producer of both stress and coping in the lived experience of health and illness . . . as the enabling condition of nursing prac- tice (indeed any practice), and the ways that nursing practice based in such caring can positively affect the outcome of an illness” (1989, p. 7).

Benner extended the research presented in From Novice to Expert (1984a) and features this work in Expertise in Nursing Practice: Caring, Clinical Judg- ment, and Ethics (Benner, Tanner, & Chesla, 1996; 2009). This book is based on a 6-year study of 130 hospital nurses, primarily critical care nurses, examining the acquisition of clinical expertise and the nature of clinical knowledge, clinical inquiry, clinical judgment, and expert ethical comportment. The key aims of the extension of this research were as follows: • Delineate the practical knowledge embedded in

expert practice. • Describe the nature of skill acquisition in critical

care nursing practice. • Identify institutional impediments and resources for

the development of expertise in nursing practice. • Begin to identify educational strategies that en-

courage the development of expertise. In the introduction to the 1996 work, Benner

stated, “In the study we found that examining the nature of the nurse’s agency, by which we mean the sense and possibilities for acting in particular clinical situations, gave new insights about how perception and action are both shaped by a practice community” (Benner, Tanner, & Chesla, 1996, p. xiii). This study resulted in a clearer understanding of the distinctions between engagement with a problem or situation and the requisite nursing skills of interpersonal involve- ment. It appears that these nursing skills are learned

UNIT II Nursing Philosophies128

over time experientially. The skill of involvement seems central in gaining nursing expertise. Under- standing of the interlinkage of clinical and ethical decision making (i.e., how an individual’s notions of good and poor outcomes and visions of excellence shape clinical judgments and actions) was enhanced by this research. This study represents phase one of the articulation project designed to describe the nature of critical care nursing practice.

Phase two took place from 1996 to 1997 and in- cluded 76 nurses (32 of them advanced practice nurses) from six different hospitals. This work is presented in Clinical Wisdom and Interventions in Acute and Critical Care: A Thinking-in-Action Approach,which was published in 1999 and updated and enlarged in 2011 by Benner, Hooper-Kyriakidis, and Stannard.The following nine domains of critical care nursing practice were identified as broad themes in this work: 1. Diagnosing and managing life-sustaining physio-

logical functions in acute and unstable patients 2. Using the skilled know-how of managing a crisis 3. Providing comfort measures for the acute criti-

cally ill 4. Caring for patients’ families 5. Preventing hazards in a technological environ-

ment 6. Facing death: end-of-life care and decision making 7. Communicating and negotiating multiple perspec-

tives 8. Monitoring quality and managing breakdown 9. Using the skilled know-how of clinical leadership

and the coaching and mentoring of others These nine domains of critical care nursing practice

were used as broad themes to interpret the data and incorporate descriptions of the following nine aspects of clinical judgment and skillful comportment: 1. Developing a sense of salience 2. Situated learning and integration of knowledge

acquisition and knowledge use 3. Engaged reasoning-in-transition 4. Skilled know-how 5. Response-based practice 6. Agency 7. Perceptual acuity and interpersonal engagement

with patients 8. Integrating clinical and ethical reasoning 9. Developing clinical imagination

Identification of clinical grasp and clinical fore- thought (two pervasive habits of thought linked with action in nursing practice in phase two of this articulation project) enriched the understanding of clinical judgment (Benner, Hooper-Kyriakidis, & Stannard, 1999). Benner explained that clinical grasp is as follows:

“ . . . clinical inquiry in action that includes problem identification and clinical judgment across time about the particular transitions of particular patients and families. It has four components: making qualitative distinctions, engaging in detective work, recognizing chang- ing clinical relevance, and developing clinical knowledge in specific patient populations.”

(Benner, Hooper-Kyriakidis, & Stannard, 1999, p. 317)

Benner added that clinical forethought, although it plays a role in clinical grasp, “also plays an essential role in structuring the practical logic of clinicians. Clinical forethought refers to at least four habits of thought and action: future think, clinical forethought about specific diagnoses and injuries, anticipation of risks for particular patients, and seeing the unex- pected” (Benner, Hooper-Kyriakidis, & Stannard, 1999, p. 317).

Major Assumptions Benner incorporates the following assumptions (as delineated in Brykczynski’s 1985 dissertation; see also Benner 1984a) in her ongoing articulation research: • There are no interpretation-free data. This aban-

dons the assumption from natural science that there is an independent reality whose meaning can be represented by abstract terms or concepts (Taylor, 1982).

• There are no nonreactive data. This abandons the false belief from natural science that one can neutrally observe brute data (Taylor, 1982).

• Meanings are embedded in skills, practices, inten- tions, expectations, and outcomes. They are taken for granted and often are not recognized as knowl- edge. According to Polanyi (1958), a context pos- sesses existential meaning, and this distinguishes it from “denotative or, more generally, representative meaning” (p. 58). He claims that transposing a

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significant whole in terms of its constituent parts deprives it of any purpose or meaning.

• People who share a common cultural and language history have a background of common meanings that allow for understanding and interpretation. Heidegger (1962) refers to this as primordial un- derstanding, after the writings of Dilthey (1976) in the late 1800s and early 1900s, asserting that cultural organization and meanings precede and influence individual understanding.

• The meanings embedded in skills, practices, in- tentions, expectations, and outcomes cannot be made completely explicit; however, they can be interpreted by someone who shares a similar language and cultural background and can be validated consensually by participants and rele- vant practitioners. Humans are self-interpreting beings (Heidegger, 1962). Hermeneutics is the interpretation of cultural contexts and meaning- ful human action.

• Humans are integrated, holistic beings. The mind-body split is abandoned. Embodied intelli- gence enables skilled activity that is transformed through experience and mastery (Dreyfus & Dreyfus, 1980; Dreyfus & Dreyfus, 1986). Benner stated, “This model assumes that all practical sit- uations are far more complex than can be de- scribed by formal models, theories and textbook descriptions” (1984a, p. 178). The hierarchical elevation of intellectual, reflective activity above embodied skilled activity ignores the point that skilled action is a way of knowing and that the skilled body may be essential for the more highly esteemed levels of human intelligence (Dreyfus, 1979). Benner and her collaborators explicated the

themes of nursing, person, situation, and health in their publications.

Nursing Nursing is described as a caring relationship, an “en- abling condition of connection and concern” (Benner & Wrubel, 1989, p. 4). “Caring is primary because caring sets up the possibility of giving help and receiving help” (Benner & Wrubel, 1989, p. 4). “Nursing is viewed as a caring practice whose science is guided by the moral art and ethics of care and responsibility” (Benner & Wrubel, 1989, p. xi). Benner and Wrubel (1989)

understand nursing practice as the care and study of the lived experience of health, illness, and disease and the relationships among these three elements.

Person Benner and Wrubel (1989) use Heidegger’s phenom- enological description of person, which they describe as “A person is a self-interpreting being, that is, the person does not come into the world predefined but gets defined in the course of living a life. A person also has . . . an effortless and nonreflective understanding of the self in the world” (p. 41). “The person is viewed as a participant in common meanings”(Benner & Wrubel, 1989, p. 23).

Finally, the person is embodied. Benner and Wrubel (1989) conceptualized the following four major aspects of understanding that the person must deal with: 1. The role of the situation 2. The role of the body 3. The role of personal concerns 4. The role of temporality

Together, these aspects of the person make up the person in the world. This view of the person is based on the works of Heidegger (1962), Merleau-Ponty (1962), and Dreyfus (1979, 1991). Their goal is to overcome Cartesian dualism, the view that the mind and body are distinct, separate entities (Visintainer, 1988).

Benner and Wrubel (1989) define embodiment as the capacity of the body to respond to meaningful situa- tions. Based on the work of Merleau-Ponty (1962), Dreyfus (1979, 1991), and Dreyfus and Dreyfus (1986), they outline the following five dimensions of the body (Benner & Wrubel, 1989): 1. The unborn complex, unacculturated body of the

fetus and newborn baby 2. The habitual skilled body complete with socially

learned postures, gestures, customs, and skills evident in bodily skills such as sense perception and “body language” that are “learned over time through identification, imitation, and trial and error” (Benner & Wrubel, 1989, p. 71)

3. The projective body that is set (predisposed) to act in specific situations (e.g., opening a door or walking)

4. The actual projected body indicating an individu- al’s current bodily orientation or projection in a situation that is flexible and varied to fit the situa- tion, such as when an individual is skillful in using a computer

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5. The phenomenal body, the body aware of itself with the ability to imagine and describe kines- thetic sensations Benner and Wrubel (1989) point out that nurses

attend to all of these dimensions of the body and seek to understand the role of embodiment in particular situations of health, illness, and recovery.

Health On the basis of the work of Heidegger (1962) and Merleau-Ponty (1962), Benner and Wrubel focus “on the lived experience of being healthy and being ill” (1989, p. 7). Health is defined as what can be as- sessed, whereas well-being is the human experience of health or wholeness. Well-being and being ill are understood as distinct ways of being in the world. Health is described as not just the absence of dis- ease and illness. Also, on the basis of the work of Kleinman, Eisenberg, and Good (1978), a person may have a disease and not experience illness, be- cause illness is the human experience of loss or dysfunction, whereas disease is what can be as- sessed at the physical level (Benner & Wrubel, 1989).

Situation Benner and Wrubel (1989) use the term situation rather than environment, because situation conveys a social environment with social definition and mean- ingfulness. They use the phenomenological terms be- ing situated and situated meaning, which are defined by the person’s engaged interaction, interpretation, and understanding of the situation. “Personal inter- pretation of the situation is bounded by the way the individual is in it” (Benner & Wrubel, 1989, p. 84). This means that each person’s past, present, and future, which include her or his own personal mean- ings, habits, and perspectives, influence the current situation.

Theoretical Assertions Benner (1984a) stated that there is always more to any situation than theory predicts. The skilled practice of nursing exceeds the bounds of formal theory. Concrete experience facilitates learning about the ex- ceptions and shades of meaning in a situation. The knowledge embedded in practice can lead to discovering

and interpreting theory, precedes and extends theory, and synthesizes and adapts theory in caring nursing practice. Benner has taken a hermeneutical approach to uncover the knowledge in clinical nursing practice. Dunlop (1986) stated, “As she does this, she is also uncovering the nursing-caring with which it is deeply intertwined” (p. 668). Dunlop also noted that Benner’s approach “does not provide us with any universal truths about caring in general or about nursing-caring in particular—indeed it does not make any such pre- tension” (p. 668).

As such, the competencies within each domain are in no way intended as an exhaustive list. Instead, the situation-based interpretive approach to de- scribing nursing practice seeks to overcome some of the problems of reductionism and the problem of global and overly general descriptions based on nursing process categories (Benner, 1984a). In a further description of this approach, Benner (1992) examined the role of narrative accounts for under- standing the notion of good or ethical caring in expert clinical nursing practice. “The narrative memory of the actual concrete event is taken up in embodied know-how and comportment, com- plete with emotional responses to situations. The narrative memory can evoke perceptual or sensory memories that enhance pattern recognition” (p. 16). Some of the relationship statements included in Benner’s work follow: • “Discovering assumptions, expectations, and

sets can uncover an unexamined area of practi- cal knowledge that can then be systematically studied and extended or refuted” (Benner, 1984a, p. 8).

• Clinical knowledge is embedded in perceptions rather than precepts.

• “Perceptual awareness is central to good nursing judgment and . . . [for the expert] begins with vague hunches and global assessments that ini- tially bypass critical analysis; conceptual clarity follows more often than it precedes” (Benner, 1984a, p. xviii).

• Formal rules are limited and discretionary judgment is needed in actual clinical situations.

• Clinical knowledge develops over time, and each clinician develops a personal repertoire of practice knowledge that can be shared in dialog with other clinicians.

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• “Expertise develops when the clinician tests and refines propositions, hypotheses, and principle based expectations in actual practice situations” (Benner, 1984a, p. 3).

Logical Form Through qualitative descriptive research, Benner used the Dreyfus Model of Skill Acquisition to better under- stand skill acquisition in clinical nursing practice. By following the model’s logical sequence, Benner was able to identify the performance characteristics and teaching-learning needs inherent at each skill level. In reporting her research, Benner used exemplars taken directly from interviews and observation of expert practice to help the reader form a clear picture of such practice. Guidelines for describing exemplars or clini- cal narratives, first termed “critical incidents” were presented in From Novice to Expert (1984a) and are developed further in Clinical Wisdom and Interven- tions in Acute and Critical Care: A Thinking-in-Action Approach (Benner, Hooper-Kyriakidis, & Stannard, 2011). The approach for describing clinical narratives is consistent throughout the body of Benner’s work whether the narratives are used in research, practice, or education. The goal of Benner’s research is to bring meanings and knowledge embedded in skilled practice into public discourse. Benner (1984a) claims that new knowledge and understanding are constituted by ar- ticulating meanings, skills, and knowledge that previ- ously were taken for granted and embedded in clinical practice.

Acceptance by the Nursing Community

Practice Benner describes clinical nursing practice by using an interpretive phenomenological approach. From Novice to Expert (1984a) includes several examples of the application of her work in practice settings as follows: Dolan (1984) describes its usefulness for preceptor development, orientation programs, and career development; Huntsman, Lederer, and Peterman (1984) detail their implementation of a clinical ladder to recognize and retain experienced staff nurses; Ullery (1984) presents its usefulness for conducting annual excellence symposia where nurses present their clinical narratives to recognize and

further develop clinical knowledge; and Fenton (1984) reported the use of Benner’s approach in an ethnographic study of the performance of clinical nurse-specialists.

Balasco and Black (1988) and Silver (1986a, 1986b) used Benner’s work as a basis for differentiating clinical knowledge development and career progres- sion in nursing. Neverveld (1990) used Benner’s ra- tionale and format in her development of basic and advanced preceptor workshops. Farrell and Bramadat (1990) used Benner’s paradigm case analysis in a collaborative educational project between a university school of nursing and a tertiary care teaching hospital to better understand the development of clinical rea- soning skills in actual practice situations. Crissman and Jelsma (1990) applied Benner’s findings in devel- oping a cross-training program to address staffing imbalances. They delineated specific cross-training performance objectives for novice nurses, but also provided support for the experiential judgment needed to function in unfamiliar settings by designat- ing a preceptor in the clinical area. The aim is for the novice to be able to perform more like an advanced beginner, with an experienced nurse available as a resource.

Benner’s approach continues to be used to aid in the development of clinical promotion ladders, new graduate orientation programs, and clinical knowl- edge development seminars (Benner & Benner, 1999; Benner, Tanner, & Chesla, 2009; Coyle, 2011, Hargreaves, Nichols, Shanks, & Halamak, 2010). Mauleon and colleagues (2005) conducted an inter- pretive phenomenological analysis of problematic situations experienced by nurse anesthetists in anesthesia care of elderly patients which indicated a need for ethical forums for dealing with moral dis- tress arising from their experiences. Uhrenfeldt (2009) based their study of how first-line nurse leaders care for their nursing staff on Benner and Wrubel’s (1989) caring framework. Cathcart (2010) articulated the experientially acquired knowledge, skill, and ethics embedded in nurse manager prac- tice following Benner’s approach.

Benner has been cited in nursing literature regard- ing nursing practice concerns and the role of caring in such practice. She continues to advance understand- ing of the knowledge embedded in clinical situations through her publications (Benner 1985a, 1985b, 1987;

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Benner & Tanner, 1987; Benner, Tanner, & Chesla, 1996, 2009; Benner, Hooper-Kyriakidis, & Stannard, 1999, 2011). Benner edited a clinical exemplar series in the American Journal of Nursing during the 1980s. In 2001, she began editing a series called “Current Controversies in Critical Care” in the American Jour- nal of Critical Care. Benner’s work with the National Council of State Boards of Nursing constitutes a major contribution to error recognition and enhance- ment of the safety of nursing practice (Benner, Sheets, Uris, et al., 2002). This research examines practice breakdowns from a systems perspective, with the goal of transforming the culture of blame in the health care system to dramatically reduce health care errors (Benner, Malloch, & Sheets, 2010).

Education Benner (1982) critiqued the concept of competency- based testing by contrasting it with the complexity of the proficient and expert stages described in the Dreyfus Model of Skill Acquisition and the 31 compe- tencies described in the AMICAE project (Benner, 1984a). In summary, she stated, “Competency-based testing seems limited to the less situational, less inter- actional areas of patient care where the behavior can be well defined and patient and nurse variations do not alter the performance criteria” (1982, p. 309).

Fenton (1984, 1985) applied the domains of clini- cal nursing practice as the basis for studying the skilled performance of clinical nurse specialists (CNSs). Her analysis validated that the CNSs studied demonstrated competencies in common with those skills of expert nurses reported in the AMICAE proj- ect. She also identified additional areas of skilled performance for CNSs, including the consulting role, and she delineated five preliminary categories relevant for curriculum evaluation in the graduate program. Ethical, clinical, and political dilemmas, positions, or stances that promote success or failure, and new knowledge that blends the empirical and the theoretical were among these categories.

According to Barnum (1990), it was not Benner’s development of the seven domains of nursing prac- tice that has had the greatest impact on nursing edu- cation, but the “appreciation of the utility of the Dreyfus model in describing learning and thinking in our discipline” (p. 170). As a result of Benner’s appli- cation of the Dreyfus model, nursing educators have

realized that learning needs at the early stages of clinical knowledge development are different from those required at later stages. These differences need to be acknowledged and valued to develop nursing education programs appropriate for the background experience of the students.

In Expertise in Nursing Practice, Benner, Tanner, and Chesla (1996) emphasized the importance of learning the skills of involvement and caring through practical experience, the articulation of knowledge with practice, and the use of narratives in undergraduate education. This work provides further support for the thesis that it may be better to place a new graduate with a competent nurse preceptor who can explain nursing practice in ways that the beginner comprehends, rather than with the expert, whose intuitive knowledge may elude beginners who do not have the experienced know- how to grasp the situation. This work, now in its second edition (Benner, Tanner, & Chesla, 2009), led to the development of internship and orienta- tion programs for newly graduated nurses and to clinical development programs for more experi- enced nurses.

In Clinical Wisdom in Critical Care, Benner, Hooper-Kyriakidis, and Stannard (1999) urged greater attention to experiential learning and presented the work as a guide to teaching. They designed a highly interactive CD-ROM to accompany the book (Benner, Stannard, & Hooper-Kyriakidis, 2001). The second edition (Benner, Hooper-Kyriakidis, & Stannard, 2011) includes a chapter on the educational implica- tions of this research on knowledge embedded in acute and critical care nursing and incorporating the teaching approaches recommended in Benner, Sutphen, Leonard, & Day (2010). Two major types of integrative strategies presented in the 2011 edition are multiple examples of coaching situated learning and a thinking-in-action approach to integrating classroom with clinical teaching.

A national study of nursing education was de- signed to identify and describe “signature pedago- gies” that maximize the nurse’s ability to cope with the challenges of nursing that have developed during the 30 years since the last national study of nursing edu- cation (Schwartz, 2005). The book Educating Nurses (Benner, Malloch, & Sheets 2010) reports details of this national study of nursing education, and it

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concludes that nursing education is in need of a major transformation to close the practice—that is, an edu- cation gap. An education gap is developed from the difficulty of addressing competing demands and keeping pace with the increasing complexity of practice driven by research and new technologies. The authors recommend that nurse educators make four major shifts in their focus: (1) from covering abstract knowledge to emphasizing teaching for par- ticular situations; (2) from separations between clini- cal and classroom teaching to integration of these components; (3) from critical thinking to clinical reasoning; and (4) from emphasizing socialization and role-taking to professional identity formation. These findings and recommendations have been pre- sented at national and international conferences, and to faculty at many schools of nursing.

McNiesh, Benner, and Chesla (2011) studied how students in an accelerated master’s degree entry pro- gram experientially learned the practice of nursing. They found that independent care of a patient was pivotal in the development of students’ identity and agency as nurses. Crider and McNiesh (2011) incor- porated a three-pronged apprenticeship approach (Benner, Sutphen, Leonard, & Day, 2010) that inte- grates intellectual, practical, and ethical aspects of the professional role in teaching students in psychiatric nursing to develop practical reasoning skills.

Research Benner maintains that there is excellence and power in clinical nursing practice that can be made visible through articulation research. Intricate nuanced de- scriptions of situational contexts (clinical narratives) are the essence of this research approach, which dic- tates that data be collected through situation-based dialogue and observation of actual practice. The situ- ational context guides interpretation of meanings such that there is agreement among interpreters. This is a holistic approach that emphasizes identification and description of meanings embedded in clinical practice. The holistic approach is maintained through- out the research process. The situational context is maintained as narratives are interpreted through dialog among researchers and clinicians.

Benner’s numerous research studies and projects with research colleagues and graduate students have created a community of interpretive phenomenological

scholars. Benner (1994) edited and contributed to Interpretive Phenomenology: Embodiment, Caring, and Ethics in Health and Illness, a collection of essays and studies selected from the community of interpretive phenomenological researchers that she has inspired and taught during her career. The book offers a philo- sophical introduction to interpretive phenomenology as a qualitative research method, a guide to under- standing the strategies and processes of this approach, and a varied selection of studies that convey its resemblances and variations. Interpretive phenome- nology cannot be explained as a set of procedures and techniques. Instead: “each interpreter enters the inter- pretive circle by examining preunderstandings and confronting otherness, silence, similarities, and com- monalities from his or her own particular historical, cultural, and personal stance” (Benner, 1994, p. xviii).

A second volume of interpretive phenomenologi- cal readings and studies edited by Chan, Brykczynski, Malone, and Benner (2010) arose from a Festschrift (retirement celebration for a scholar) honoring the impact and significance of the research tradition Ben- ner established. This book presents the interpretive phenomenology philosophy and research approach that continues to evolve. The first section explores theoretical and philosophical discourses and issues within the interpretive phenomenological tradition, while the second section is a collection of studies that exemplify the similarities and variations in the ap- proaches across studies.

Further Development Benner’s current research involves a large-scale collab- orative study with The Tri-Service Military Nursing Research group (De Jong, Benner, Benner, et al., 2010). They are investigating knowledge development and experiential learning from nursing practice during the Iraq and Afghanistan Wars.

Benner (2012a) discussed the progress to date in implementing recommendations from the Educating Nurses study, reporting that several states have started to implement suggested changes in nursing education and that many hospitals and health sci- ence campuses have instituted nurse residency pro- grams. Two websites have been created to facilitate the dissemination and implementation of the study recommendations as follows: Educating Nurses.com

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(http://www.educatingnurses.com) provides video- taped teaching resources, curriculum development, and teacher training resources, and NovicetoExpert. org (http://www.NovicetoExpert.org) offers online evidence-based learning and applies the recommen- dations of the Educating Nurses study. In addition, an educational newsletter was initiated to share study recommendations and create ongoing dialog with nurse educators (Benner, 2011; 2012b, 2012c; 2012d).

Critique

Clarity The clarity of Benner’s Novice to Expert model has led to its utilization among nurses around the world. An identification with the idea of clinical wisdom and varying levels of clinical expertise development pro- gressed very quickly. Benner’s work not only contrib- uted to appreciative understanding of clinical practice but also revealed nursing knowledge embedded in practice.

Simplicity Benner has developed interpretive descriptive accounts of clinical nursing practice. The concepts are the levels of skilled practice from the Dreyfus model, including novice, advanced beginner, compe- tent, proficient, and expert. She used these five concepts to describe nursing practice based on in- terviews, observations, and the analysis of tran- scripts of exemplars that nurses provided. From these descriptions, competencies were identified, and these were grouped inductively into seven do- mains of nursing practice on the basis of common intentions and meanings (Benner, 1984a). Benner and colleagues’ (1996) study of critical care nursing explored the differentiation of levels of practice in depth and suggested that nurses at different levels live in different worlds. Benner’s ongoing articula- tion research has produced nine domains of critical care nursing practice (Benner, Hooper-Kyriakidis, & Stannard,1999). The model is relatively simple with regard to the five stages of skill acquisition, and it provides a comparative guide for identifying levels of nursing practice from individual nurse descriptions and observations and interpretations validated by consensus.

A degree of complexity is encountered in the subconcepts for differentiation among the levels of competency and the need to identify meanings and intentions. This interpretive approach is designed to overcome the constraints of the rational-technical approach to the study and description of practice. Although a de-contextualized (object) description of the novice level of performance is possible, such a description of expert performance would be diffi- cult, if not impossible, and is of limited usefulness because of the limits of objectification. In other words, the philosophical problem of infinite regress would be encountered in attempts to specify all the aspects of expert practice. Rather, a holistic under- standing of the particular situation is required for expert performance.

Generality The Novice to Expert skill acquisition model has uni- versal characteristics, that is, it is not restricted by age, illness, health, or location of nursing practice. How- ever, the characteristics of theoretical universality imply properties of operationalization for prediction that are not a part of this perspective. Indeed, this phenomenological perspective critiques the limits of universality in studies of human practices. The inter- pretive model of nursing practice has the potential for universal application as a framework, but the descriptions are limited by dependence on the actual clinical nursing situations from which they must be derived. Its use depends on an understanding of the five levels of competency and the ability to identify the characteristic intentions and meanings inherent at each level of practice.

Although clinical knowledge is relational and contextual and involves local, specific, historical is- sues, it is generalizable in terms of the translation of meanings to similar situations (Guba & Lincoln, 1982). To capture the contextual and relational as- pects of practice, Benner uses narrative accounts of actual clinical situations and maintains that this approach enables the reader to recognize similar in- tents and meanings, although the objective circum- stances may be quite different. An example of generalizability or transferability as used here fol- lows: Upon reading or hearing a narrative about a nurse connecting with a family whose child is dying, other nurses can relate the knowledge and meanings

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conveyed to the experiences they may have had with families of patients of any age who were dying.

Accessibility The model was tested empirically using qualitative methods; 31 competencies, 7 domains of nursing prac- tice, and 9 domains of critical care nursing practice were derived inductively. Subsequent research suggests that the framework is applicable and useful for contin- ued development of knowledge embedded in nursing practice. This approach to knowledge development honors the primacy of caring and the central ethic of care and responsibility embedded in expert nursing practice (Benner, 1999).

The use of a qualitative process of discovering nursing knowledge is more difficult to address the body of Benner’s work for critique. The qualitative interpretive approach describes expert nursing prac- tice with exemplars. Benner’s work can be consid- ered as hypothesis generating rather than hypothesis testing. Benner provides a methodology for uncov- ering and entering into the situated meaning of ex- pert nursing care. Altmann (2007) pointed out that criticism of Benner’s work has often developed from misinterpretation of her philosophy as theory and evaluation of her qualitative research with quantita- tive parameters.

Importance Although clinical nurses around the world enthusiasti- cally received From Novice to Expert (1984a), some academicians and administrators initially interpreted it as promoting traditionalism and devaluing education and theory for nursing practice (Christman, 1985). Benner’s qualitative interpretive approach to interpre- tation of the meaning and level of nursing practice has generated questions among some researchers. An on- going debate has developed over cognitive interpreta- tions of Benner’s concepts of expertise and intuition (Benner, 1996b; Cash, 1995; Darbyshire, 1994; English, 1993; Paley, 1996). Scholarly debate around these phe- nomenological concepts contributed to clarification of the nature of the research approach.

Benner’s perspective is phenomenological, not cognitive. She stated, “Clinical judgment and caring practices require attendance to the particular patient across time, taking into account changes and what has been learned. In this vision of clinical judgment,

skilled know-how and action are linked” (Benner, 1999, p. 316). The significance of Benner’s research findings lies in her conclusion that “a nurse’s clinical knowledge is relevant to the extent to which its mani- festation in nursing skills makes a difference in pa- tient care and patient outcomes” (Benner & Wrubel, 1982, p. 11).

Generalization is approached through an under- standing of common meanings, skills, practices, and embodied capacities rather than through general ab- stract laws that explain and predict. Such common meanings, skills, and practices are socially embedded in nurse schooling and in the practice and tradition of nursing. The knowledge embedded in clinical nursing practice should be brought forth as public knowledge to further a greater understanding of nursing prac- tice. Benner (1984a) believes that the scope and complexity of nursing practice are too extensive for nurses to rely on idealized, de-contextualized views of practice or experiments. Benner (1992) stated, “The platonic quest to get to the general so that we can get beyond the vagaries of experience was a misguided turn . . . . We can redeem the turn if we subject our theories to our unedited, concrete, moral experience and acknowledge that skillful ethical comportment calls us not to be beyond experience but tempered and taught by it” (p. 19).

The generalizations possible with the interpretive approach are depicted through exemplars that dem- onstrate relational and contextually relevant intents and aspects of clinical knowledge. The applicability and relevance of the common approaches used for universality or generalization in physics and the natu- ral sciences are questioned by the interpretive ap- proach, which claims that the basis for generalization in clinical knowledge cannot be structural or mecha- nistic, but must be based on common meanings and practices. Preferred strategies for generalization in clinical practice are based on the skilled knowledge, intent, content, and notion of good in clinical knowl- edge depicted by exemplars that illustrate the role of the situation.

Benner claims that nurses need to overcome the limits of subject-object descriptions. Her call is to “increase public storytelling” to validate nursing as an ethical caring practice, and “to extend, alter, and preserve ethical distinctions and concerns” (Benner, 1992, pp. 19-20). Benner (1996a) stated, “We have

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overlooked practitioner stories that demonstrate that compassion can be wise and, in the long run, less costly than ‘defensive’ adversarial commodified tech- nocures” (pp. 35-36). Benner’s work is useful in that it frames nursing practice in the context of what nurs- ing actually is and does.

Summary Benner seeks to affirm and restore nurses’ caring practices during a time when nurses are rewarded more for efficiency, technical skills, and measurable outcomes. She maintains that caring practices are imbued with knowledge and skill about everyday human needs, and that in order to be experienced as caring, these practices must be attuned to the par- ticular person who is being cared for and to the par- ticular situation as it unfolds. Benner’s philosophy of nursing practice is a dynamic, emerging holistic perspective that holds philosophy, practice, research, and theory as interdependent, interrelated, and her- meneutic. Her hope voiced in the preface of From Novice to Expert (1984a) saying that domains and competencies would not be deified by system builders seems to have been largely realized, as those who have sought to apply these concepts have honored the con- textual background on which they are based. Benner’s work exemplifies the interrelationship of philosophy, practice, research, theory, and education.

CASE STUDY

A case study from the peer-identified nurse expert project that this author (Brykczynski, 1993-1995; 1998) conducted as part of a nursing service clinical enhancement process is selected here to illustrate Benner’s approach to knowl- edge development in clinical nursing practice. This project was undertaken to identify and describe expert staff nursing practices at our institution. Exemplars were obtained and par- ticipant observations were conducted to yield narrative text that then was interpreted through Benner’s multiphase interpretive phenomeno- logical process (Benner, 1984a; 1994). In the final phase of data analysis, Benner’s domains and competencies of nursing practice (Benner,

1984a) were incorporated as an interpretive framework. A critical aspect of using Benner’s approach is the realization that the domains and competencies form a dynamic evolving interpre- tive framework that is used in interpreting the narrative and observational data collected. The nurse who described this situation had approxi- mately 8 years of experience in critical care, and she noted that this was significant to her practice because it taught her how to integrate taking care of a family in crisis along with taking care of a critically ill patient. Thus, this was a paradigm case for the nurse, who learned many things from it that affected her future practice.

Mrs. Walsh is a pseudonym for a woman in her seventies who was in critical condition following repeat coronary artery bypass graft (CABG) sur- gery. Her family lived nearby when Mrs. Walsh had her first CABG surgery. They had moved out of town but returned to our institution, where the first surgery had been performed successfully. Mrs. Walsh remained critically ill and unstable for several weeks before her death. Her family was very anxious because of Mrs. Walsh’s unstable and deteriorating condition, and a family member was always with her 24 hours a day for the first few weeks.

The nurse became involved with this family while Mrs. Walsh was still in surgery, because fam- ily members were very anxious that the procedure was taking longer than it had the first time and made repeated calls to the critical care unit to ask about the patient. The nurse met with the family and offered to go into the operating room to talk with the cardiac surgeon so as to better inform the family of their mother’s status.

One of the helpful things the nurse did to assist this family was to establish a consistent group of nurses to work with Mrs. Walsh, so that family members could establish trust and feel more confi- dent about the care their mother was receiving. This eventually enabled family members to leave the hos- pital for intervals to get some rest. The nurse related that this was a family whose members were affluent, educated, and well informed, and that they came in prepared with lists of questions. A consistent group of nurses who were familiar with Mrs. Walsh’s

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particular situation helped both family members and nurses to be more satisfied and less anxious. The family developed a close relationship with the three nurses who consistently cared for Mrs. Walsh and shared with them details about Mrs. Walsh and her life.

The nurse related that there was a tradition in this particular critical care unit not to involve family members in care. She broke that tradition when she responded to the son’s and the daughter’s helpless feelings by teaching them some simple things that they could do for their mother. They learned to give some basic care, such as bathing her. The nurse acknowledged that involving family members in direct patient care with a critically ill patient is complex and requires knowledge and sensitivity. She believes that a developmental pro- cess is involved when nurses learn to work with families.

She noted that after a nurse has lots of experi- ence and feels very comfortable with highly tech- nical skills, it becomes okay for family members to be in the room when care is provided. She pointed out that direct observation by anxious family members can be disconcerting to those who are insecure with their skills when family members ask things like, “Why are you doing this? Nurse ‘So and So’ does it differently.” She com- mented that nurses learn to be flexible and to reset priorities. They should be able to let some things wait that do not need to be done right away to give the family some time with the patient. One of the things that the nurse did to coordinate care was to meet with the family to see what times worked best for them; then she posted family time on the patient’s activity schedule outside her cubicle to communicate the plan to others involved in Mrs. Walsh’s care.

When Mrs. Walsh died, the son and daughter wanted to participate in preparing her body. This had never been done in this unit, but after checking to see that there was no policy forbid- ding it, the nurse invited them to participate. They turned down the lights, closed the doors, and put music on; the nurse, the patient’s daugh- ter, and the patient’s son all cried together while they prepared Mrs. Walsh to be taken to the

morgue. The nurse took care of all intravenous lines and tubes while the children bathed her. The nurse provided evidence of how finely tuned her skill of involvement was with this family when she explained that she felt uncomfortable at first because she thought that the son and daughter should be sharing this time alone with their mother. Then she realized that they really wanted her to be there with them. This situation taught her that families of critically ill patients need care as well. The nurse explained that this was a paradigm case that motivated her to move into a CNS role, with expansion of her sphere of influence from her patients during her shift to other shifts, other patients and their families, and other disciplines.

Domain: The Helping Role of the Nurse This narrative exemplifies the meaning and in- tent of several competencies in this domain, in particular creating a climate for healing and pro- viding emotional and informational support to patients’ families (Benner, 1984a). Incorporating the family as participants in the care of a criti- cally ill patient requires a high level of skill that cannot be developed until the nurse feels compe- tent and confident in technical critical care skills. This nurse had many years of experience in this unit, and she felt that providing care for their mother was so important to these children that she broke tradition in her unit and taught them how to do some basic comfort and hygiene mea- sures. The nurse related that the other nurses in this critical care unit held the belief that active family involvement in care was intrusive and totally out of line. A belief such as this is based on concerns for patient safety and efficiency of care, yet it cuts the family off from being fully involved in the caring relationship. This nurse demonstrated moral courage, commitment to care, and advocacy in going against the tradition in her unit of excluding family members from direct care. She had 8 years of experience in this unit, and her peers respected her, so she was able to change practice by starting with this one patient-family situation and involving the other two nurses who were working with them.

Continued

UNIT II Nursing Philosophies138

Chesla’s (1996) research points to a gap between theory and practice with respect to including families in patient care. Eckle (1996) studied family presence with children in emer- gency situations and concluded that in times of crisis, the needs of families must be addressed to provide effective and compassionate care. The skilled practice of including the family in care emerged as significantly meaningful in the nar- rative text from the peer-identified nurse expert study. This was defined as an additional compe- tency in the domain called the helping role of the nurse and was named maximizing the family’s role in care (Brykczynski, 1998). The intent of this competency is to assess each situation as it arises and develops over time, so that family in- volvement in care can adequately address spe- cific patient-family needs, and so they are not

excluded from involvement nor do they have participation thrust upon them.

This narrative illustrates how Benner’s ap- proach is dynamic and specific for each institu- tion. The belief that being attuned to family involvement in care is in part a developmental process is supported by Nuccio and colleagues’ (1996) description of this aspect of care at their institution. They observed that novice nurses be- gin by recognizing their feelings associated with family-centered care, while expert nurses develop creative approaches to include patients and fami- lies in care. The intricate process of finely tuning the nurse’s collaboration with families in critical care is delineated further by Levy (2004) in her interpretive phenomenological study that articu- lates the practices of nurses with critically burned children and their families.

CRITICAL THINKING ACTIVITIES

this situation? What aspects stand out as salient? What would you say to the family at given points in time? How would you respond to your nursing colleagues who may question your inclusion of the family in care?

3. Using Benner’s approach, describe what is meant by the statement that caring practices, intervention skills, clinical judgment, and collaboration skills increase the visibility of nursing practice in the following three senses: (1) to the individual nurse, (2) to nursing colleagues, and (3) to the health care system.

1. Describe clinical situations from your own expe- rience that illustrate how nurses at various levels of skill development from novice to expert in- volve patients and families in care.

2. Discuss the clinical narrative provided above following the unfolding case study format to promote situated learning of clinical reasoning (Benner, Hooper-Kyriakidis, & Stannard, 2011). Regarding the various aspects of the case as they unfold over time, consider questions that encour- age thinking, increase understanding, and pro- mote dialog such as: What are your concerns in

POINTS FOR FURTHER STUDY

n Patricia Benner home page at: http://home. earthlink.net/,bennerassoc/

n The Carnegie Foundation for the Advancement of Teaching, Professional and Graduate Education at: http://www.carnegiefoundation.org

Videotapes n Benner, P., Tanner, C., & Chesla, C. (1992). From

beginner to expert: clinical knowledge in critical care nursing (Video). New York: Helene Fuld

n Brykczynski, K. A. (2002). Benner’s philosophy in nursing practice. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theory: utilization & application (2nd ed., pp. 123–148). St. Louis: Mosby.

n Benner, P. (2001). From novice to expert: com- memorative edition.Upper Saddle River, (NJ): Prentice Hall. (Re-published edition of the original 1984 work.)

n Hubert Dreyfus home page at: http://philosophy. berkeley.edu/

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Trust Fund. Available from Springer Publishing Company (see Benner home page).

n EducatingNurses.com: See Video Previews of Expert teachers.

n Moccia, R. (1987). Nursing theory: a circle of knowledge (Video). New York: National League for Nursing.

n NovicetoExpert.org: See demonstration of online clinical simulation of unfolding case studies.

CD-ROM n Benner, P., Stannard, D., & Hooper-Kyriakidis, P.

(2001). Clinical wisdom and interventions in critical care: a thinking-in-action approach (CD-ROM). Philadelphia: Saunders.

DVD n Patricia Benner, Novice to Expert (2008). The

Nurse Theorists Portraits of Excellence, Volume 2, Athens, OH: FITNE, Inc.

Alberti, A. M. (1991). Advancing the scope of primary nurses in the NICU. Journal of Perinatal and Neonatal Nursing, 5(3), 44–50.

Altmann, T. K. (2007). An evaluation of the seminal work of Patricia Benner: theory or philosophy? Contemporary Nurse, 25(1-2), 114–123.

Alvsvåg, H. (2010). Kari Martinsen: philosophy of caring. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (7th ed.). St. Louis: Mosby, 165–189.

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Benner, P. (1984a). From novice to expert: excellence and power in clinical nursing practice. Menlo Park, (CA): Addison-Wesley.

Benner, P. (1984b). Stress and satisfaction on the job: work meanings and coping of mid-career men. New York: Praeger.

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Primary Sources Books Benner, P. (2001). From novice to expert. [Commemorative

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ethics. In D. Thomasma (Ed.), The moral philosophy of Edmund Pellegrino (pp. 47-61). Dordrecht, Netherlands: Kluwer.

Benner, P. (1998). When health care becomes a commodity: the need for compassionate strangers. In J. F. Kilner, R. D. Orr, & J. A. Shelly (Eds.), The changing face of health care (pp. 119–135). Grand Rapids, (MI): William B. Eerdmans.

Benner, P. (1999). Parish nursing in the context of caring practices. In A. Solari-Twaddell (Ed.), Parish nursing. Thousand Oaks, (CA): Sage.

Benner, P. (2001). The phenomenon of care. In S. K. Tombs (Ed.), Handbook of phenomenology and medicine (pp. 351–369). Dordrecht, Netherlands: Kluwer.

Benner, P. (2002). Learning through experience and expres- sion: skillful ethical comportment in nursing practice. In E. D. Pellegrino, D. C. Thomasma, & J. L. Kissel (Eds.), The healthcare professional as friend and healer: building on the work of Edmund Pellegrino (pp. 49–64). Washington, DC: Georgetown University Press.

Benner, P. (2003). Clinical reasoning articulating experiential learning in nursing practice. In O. Slevin & L. Basford (Eds.), Theory and practice of nursing (2nd ed., pp. 176–186). London, UK: Nelson Thornes.

Benner, P. (2005). Stigma and personal responsibility: moral dimensions of a chronic illness. In R. B. Purtillo, G. M. Jensen, & R. C. Brasic (Eds.), Educating for moral action: A sourcebook in health and rehabilitation ethics. Philadelphia: F. A. Davis.

Benner, P. (2007). Experiential learning, skill acquisition and gaining clinical knowledge. In K. Osborn, A. Watson , & C. Wraa (Eds.), Medical-surgical nursing. Saddleback, (NJ): Prentice-Hall.

BIBLIOGRAPHY Benner, P. (2007). Interpretive phenomenology. In

L. M. Given (Ed.), The Sage encyclopedia of qualitative methods. Thousand Oaks, (CA): Sage.

Benner, P., & Leonard, V. W. (2005). Patient concerns and choices and clinical judgment in EBP. In B. Melnyk & E. Fineout-Overholt (Eds.), Evidence-based practice in nursing and healthcare: a guide to best practices. Philadelphia: Lippincott.

Benner, P., & Gordon, S. (1996). Caring practice. In S. Gordon, P. Benner, & N. Noddings (Eds.), Caregiving, readings in knowledge, practice, ethics and politics (pp. 40–55). Philadelphia: University of Pennsylvania Press.

Benner, P., & Leonard, V. W. (2005). Patient concerns, choices, and clinical judgment in evidence-based practice. In B. M. Mszurek (Ed.), Evidence-based practice in nursing & healthcare: a guide to best practice (pp.163–182).

Benner P., & Sutphen, M. (2007). Clinical reasoning, decision-making in action: thinking critically and clinically. In R. Hughes (Ed.), Patient safety and quality for nursing center for primary care, prevention, & clinical partnerships. Rockville, (MD): Agency for Healthcare Research and Quality.

Journal Articles* Benner, P. (1996). A dialogue between virtue ethics and

care ethics. Theoretical Medicine, 23, 1–15. Benner, P. (1996). A response by P. Benner to K. Cash,

Benner expertise in nursing: a critique. International Journal of Nursing Studies, 33(6), 669–674.

Benner, P. (2000). The roles of embodiment, emotion and lifeworld for rationality and agency in nursing practice. Nursing Philosophy, 1, 5–19.

Benner, P. (2000). The wisdom of our practice. American Journal of Nursing, 100 (10), 99–101, 103, 105.

Benner, P. (2001). Curing, caring, and healing in medicine: symbiosis and synergy or syncretism? Park Ridge Center Bulletin, 23, 11–12.

Benner, P. (2001). Developing clinical expertise in under- graduate education [in Japanese]. Expert Nurse, 12(15), 107–113.

Benner, P. (2003). [Book review for From detached concern to empathy: humanizing medical practice, J. Halpern, Ed.] The Cambridge Quarterly for Health Care Ethics, 12(1), 134–136.

Benner, P. (2004). The dangers of geneticism. Journal of Midwifery and Women’s Press, 49(3), 260–262.

*See the 5th edition (2002) of this chapter for Benner’s American Journal of Nursing “Clinical Exemplar” article series; see the 7th edition (2010) for Benner’s American Journal of Critical Care “Current Controversies in Critical Care” article series.

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Benner, P. (2011). Formation in professional education: an examination of the relationship between theories of meaning and theories of the self. Journal of Medicine and Philosophy. Special Edition on the Influence of Charles Taylor on Medical Ethics, 36, 342–353.

Benner, P., Brennan, M. R., Sr., Kessenich, C. R., & Letvak, S. A. (1996). Critique of Silva’s philosophy, science and theory: interrelationships and implica- tions for nursing research. Image: The Journal of Nursing Scholarship, 29(3), 214–215.

Benner, P., Ekegren, K., Nelson, G., Tsolinas, T., & Ferguson-Dietz, L. (1997). The nurse as a wise, skillful and compassionate stranger. American Journal of Nursing, 97(11), 27–34.

Benner P., & Sutphen, M. (2007). Learning across the professions: the clergy, a case in point. Journal of Nursing Education, 46(3), 103–108.

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2007). Learning to see and think like a nurse: clinical reasoning and caring practices. Journal of Japanese Society of Nursing Research, 30(1), 20–24.

Benner, P., Sutphen, M., Leonard, V., Day, L., (2008). Formation and ethical comportment in nursing. American Journal of Critical Care, 17(5), 173–176.

Benner, P., Stannard, D., & Hooper, P. L. (1996). “Thinking-in-action” approach to teaching clinical judgment: a classroom innovation for acute care advanced practice nurses. Advanced Practice Nursing Quarterly, 1, 70–77.

Benner, P., Tanner, C. A., & Chesla, C. A. (1996). Nurse practitioner extra: becoming an expert nurse. (Adapted with permission from Benner, Tanner, & Chesla [Eds.], Expertise in nursing practice: caring, clinical judgment, and ethics. New Yark: Springer.) American Journal of Nursing, 97(6), Contin Care Extra Ed, 16BBB, 16DDD.

Benner, P., Tanner, C. A., & Chesla, C. A. (1996). The social fabric of nursing knowledge. (Adapted with permission from Benner, Tanner, & Chesla [Eds.], Expertise in nursing practice: caring, clinical judgment, and ethics. New Yark: Springer.) American Journal of Nursing, 97(7), Nurse Pract Extra Ed, 16BBB.

Benner, P., et al. (1996). Survey reactions of nursing leaders: a grim prognosis for health care? American Journal of Nursing, 96(11), 40–44.

Brant, M., Rosen, L., & Benner, P. (1998). Nurses as skilled Samaritans: the nurse as wise, skillful, and compassionate stranger. American Journal of Nursing, 98(4), Contin Care Extra Ed, 22–23.

Cohen H., & Benner, P. (2002). Errors in nursing: individual, practice, and system causes of errors in nursing: a taxon- omy. Journal of Nursing Administration, 32(10), 50–523.

Dracup, K., Cronenwett, L., Meleis, A., & Benner, P. (2005). Reflections on the doctorate of nursing practice. Nursing Outlook, 53(4), 177–182.

Ekegren, K., Nelson, G., Tsolinas, A., Ferguson-Dietz, L., & Benner, P. (1997). The nurse as wise, skillful, and compassionate stranger. American Journal of Nursing, 97, 26–34.

Emami, A., Benner, P., & Ekman, S. L. (2001). A sociocul- tural health model for late-in-life immigrants. Journal of Transcultural Nursing, 12(1), 15–24.

Emami, A., Benner, P., Lipson, J. G., & Ekman, S. L. (2001). Health as continuity and balance in life. Western Journal of Nursing Research, 22, 812–825.

Fowler, M., & Benner, P. (2001). The new code of ethics for nurses: a dialogue with Marsha Fowler. American Journal of Critical Care, 10(6), 434–437.

Harrington, C., Crider, M. C., Benner, P., & Malone, R. (2005). Advanced nursing training in health policy: designing and implementing a new program. Policy, Politics & Nursing Practice, 6(2), 99–108.

Puntillo, K. A., Benner, P., Drought, T., Drew, B., Stotts, N., Stannard, D., et al. (2001). End-of-life issues in intensive care units: a national random survey of nurses’ knowl- edge and beliefs. American Journal of Critical Care, 10(4), 216–229.

Spichiger, E., Wallhagen, M., & Benner, P. (2005). Nursing as a caring practice from a phenomenological perspective. Scandinavian Journal of Caring Sciences, 19(4), 303–309.

Sullivan, W., & Benner, P., (2005). Challenges to profes- sionalism: work integrity and the call to renew and strengthen the social contract of the professions. American Journal of Critical Care, 14(1), 78–84.

Sunvisson, H., Haberman, B., Weiss, S., Benner, P. (2009). Augmenting the Cartesian medical discourse with an understanding of the person’s lifeworld, lived body, life story and social identity. Nursing Philosophy, 10, 241–252.

Weiss, S. M., Malone, R. E., Merighi, J. R., & Benner, P. (2002). Economism, efficiency, and the moral ecology of good nursing practice. Canadian Journal of Nursing Research, 34(2), 95–119.

Secondary Sources Doctoral Dissertations The following doctoral dissertations were supervised by

Patricia Benner: Boller, J. E. (2001). The ecology of exercise: an interpretive

phenomenological account of exercise in the lifeworld of persons on maintenance hemodialysis. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, B62/12, 5638. (University Microfilms No. 3034743.)

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Brykczynski, K. A. (1985). Exploring the clinical practice of nurse practitioners. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 46, 3789B. (University Microfilms No. DA8600592.)

Chan, G. K. (2005). E.R. 5 exit required. A philosophical, theoretical, and phenomenological investigation of care at the end-of-life in the emergency department. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, B66/06, 3054. (University Microfilms No. 3179943.)

Chesla, C. A. (1988). Parents’ caring practices and coping with schizophrenic offspring, an interpretive study. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 49-B, 2563. (University Microfilms No. AAD88-13331.)

Cho, A. (2001). Understanding the lived experience of heart transplant recipients in North America and South Korea: an interpretive phenomenological cross-cultural study. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, B62/12, 5639. (University Microfilms No. 3034721.)

Day, L. J. (1999). Nursing care of potential organ donors: an articulation of ethics, etiquette and practice. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 60-B, 5431. (University Microfilms No. AADAA-19951464.)

Doolittle, N. (1990). Life after stroke. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 51-B, 1742. (University Microfilms No. AAD90-24963.)

Dunlop, M. (1990). Shaping nursing knowledge: an interpretive analysis of curriculum documents from NSW Australia. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 51-B, 659. (University Microfilms No. AAD90-16380.)

Gordon, D. (1984). Expertise, formalism, and change in American nursing practice: a case study. Medical anthropology program. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 46-A, 738. (University Microfilms No. AAD85-09101.)

Hartfield, M. (1985). Appraisal of anger situations and subsequent coping responses in hypertensive and normotensive adults: a comparison. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 46-B, 4452. (University Microfilms No. AAD85-24005.)

Hooper, P. L. (1995). Expert titration of multiple vasoactive drugs in post-cardiac surgical patients: an interpretive study of clinical judgment and perceptual acuity. [Doctoral

dissertation, University of California, San Francisco.] Dissertation Abstracts International, 57-B, 238. (University Microfilms No. AAD85-19614338.)

Kesselring, A. (1990). The experienced body, when taken-for-grantedness falters: a phenomenological study of living with breast cancer. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 52-B, 1955. (University Microfilms No. AAD91-19579.)

Kinavey, C. (2003). Adolescents living with spina bifida: moving from parental to self-care. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International. (University Microfilms No. 3051044.)

Leonard, V. W. (1993). Stress and coping in the transition to parenthood of first time mothers with career commitments: an interpretive study. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 54-A, 3221. (University Microfilms No. AAD94-02354.)

Lionberger, H. (1986). Phenomenological study of therapeutic touch in nursing practice: an interpretive study of nurses’ practice of therapeutic touch. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 46-B, 2624. (University Microfilms No. AAD85-24008.)

MacIntyre, R. (1993). Sex, drugs, and T-cell counts in the gay community: symbolic meanings among gay men with asymptomatic HIV infections (immune deficiency). [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 54-B, 4601. (University Microfilms No. AAD94-06617.)

Mahrer-Imhof, R. (2003). Couples’ daily experiences after the onset of cardiac disease: an interpretive phenomenological study. [Doctoral dissertation, University of California, San Francisco.]

Malone, R. (1995). The almshouse revisited: heavy users of emergency services. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 56-B, 6036. (University Microfilms No. AADAA-19606591.

McKeever, L. C. (1988). Menopause: an uncertain passage. An interpretive study. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 49-B, 3677. (University Microfilms No. AAD88-24678.)

McNiesh, S. G. (2009). Formation in an accelerated nursing program: learning existential skills of nursing practice. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, B69/9, 5320. (University Microfilms No. 3324573.)

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Oakes-Greenspan, M. (2008). Running toward: reframing possibility and finitude through physicians’ stories at the end of life. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts Interna- tional, A68/11, (University Microfilms No. 3289310.)

Orsolini-Hain, L. M. (2009). An interpretive phenomenological study on the influences on associate degree prepared nurses to return to school to earn a higher degree in nursing. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, B69/09, 5321. (University Microfilms No. 3324576.)

Plager, K. A. (1995). Practical well-being in families with school-age children: An interpretive study. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 56-B, 6039. (University Microfilms No. AADAA-16906593.)

Popell, C. L. (1983). An interpretive study of stress and coping among parents of school-age developmentally disabled children. [Doctoral dissertation, Wright Institute of Graduate Psychology.] Dissertation Abstracts International, 44-B, 1604. (University Microfilms No. AAD83-20854.)

Prakke, H. (2004). Articulating maternal caregivers’ concerns, knowledge and needs. [Doctoral disserta- tion, University of California, San Francisco.] Dissertation Abstracts International. (University Microfilms No. 3149700.)

Raingruber, B. J. (1998). Moving in a climate of care: styles and patterns of interaction between nurse-therapists and clients: an interpretive study. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 58-B, 6482. (University Microfilms No. AAD98-18661.)

Rodriguez, L. (2007). Student and faculty experiences of practice breakdown and error in nursing school. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International. (University Microfilms No. 3289350.)

Schilder, E. (1986). The use of physical restraints in an acute care medical ward (immobilization). [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 47-B, 4826. (University Microfilms No. AAD87-08453.)

Smith Battle, L. (1992). Caring for teenage mothers and their children: narratives of self and ethics of intergenera- tional caregiving. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 53-B, 4594. (University Microfilms No. AAD93-03555.)

Spichiger, E. (2004). Dying patients’ and their families’ experiences of hospital end-of-life care. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International. (University Microfilms No. 3136071.)

Stannard, P. (1997). Reclaiming the house: an interpretive study of nurse-family interactions and activities in critical care. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 58-B, 4147. (University Microfilms No. AAD98-06902.)

Stevens, M. (1984). Adolescents coping with hospitalization for surgery. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 45-B, 3977. (University Microfilms No. AAD85-03742.)

Stuhlmiller, C. (1991). An interpretive study of appraisal and coping of rescue workers in an earthquake disaster: the Cypress collapse. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 52-B, 4671. (University Microfilms No. AAD92-05240.)

Warnian, L. (1987). A hermeneutical study of group psychotherapy. [Unpublished doctoral dissertation.] Berkeley, (CA): University of California, Berkeley.

Weiss, S. M. (1996). Possibility or despair: biographies of aging. [Doctoral dissertation, University of California, San Francisco.] Dissertation Abstracts International, 57-B, 3662. (University Microfilms No. AAD96-34295.)

147

CH A P T ER 10

“Nursing is founded on caring for life, on neighbourly love, . . . At the same time it is necessary that the nurse is professionally educated”

(Martinsen, 2006, p. 78).

Kari Martinsen 1943 to Present

Philosophy of Caring Herdis Alvsvåg

Credentials and Background of the Theorist

Kari Marie Martinsen, a nurse and philosopher, was born in Oslo, Norway, in 1943, during the World War II German occupation of Norway. Her parents were engaged in the Resistance Movement. After the war, moral and sociopolitical discussions dominated home life, a home that consisted of three generations: a younger sister, parents, and a grandmother. Both par- ents were economists who had been educated at the University of Oslo. Her mother worked all of her adult life outside the home.

After high school, Martinsen began her studies at Ullevål College of Nursing in Oslo, graduating in 1964. She worked in clinical practice at Ullevål hospital for

1 year, while doing preparatory studies for university entry. Before embarking upon a university degree, she specialized as a psychiatric nurse in 1966 and worked for two years at Dikemark Psychiatric Hospital near Oslo.

While practicing as a nurse, she became concerned about social inequalities in general and in the health service in particular. Health, illness, care, and treat- ment were obviously distributed unequally. She also became disturbed over perceived discrepancies be- tween health care theories, ideals, and goals on the one hand, and practical results of nursing, medicine, and the health service on the other. She began to pose questions about how a society and a profession must be constituted to support and aid the ill and the unemployed. One particularly poignant question was

Photo credit: Lars Jakob Løtvedt, Bergen, Norway. Translators: Vigdis Elisabeth Brekke, Bjørn Follevåg, and Kirsten Costain Schou.

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to address this problem. The course was established jointly by the University of Bergen, the county authorities, and three nursing colleges. A nurse with university level qualifications was needed to head the program. Martinsen was asked to be Dean of the Fac- ulty of Nursing Teachers’ Training in Bergen, which she accepted from 1976 to 1977.

Through her philosophical studies and the socio- logical issues she encountered in practical nursing and in nursing education, Martinsen developed an interest in nursing history. How did education of nurses in Norway begin, who was responsible for its inception, and what did they wish to achieve? In order to look more closely at some of these issues, Martinsen applied for and received a grant from the Norwegian Nurses’ Association in 1976. She was affiliated with the Department of Hygiene and Social Medicine at the University of Bergen, where she lec- tured to students in the nursing teachers’ training program and also students in social medicine.

At that time, an intense debate over nursing educa- tion was raging in Norway. A public commission proposed retention of the traditional 3-year degree but eventually agreed to alter this to a system of stage- based qualification. This meant that after completion of 1 year, a student became a qualified care assistant, and after 2 additional years, a qualified nurse. This implied the end of the principle of a comprehensive 3-year degree. Nurses throughout the country, with the Norwegian Nurses’ Association at the forefront, marched in protest to save the 3-year nursing degree. Sides in this debate remained rigidly opposed, and the tone of the political discourse on the issue of nursing education was heated. Martinsen threw herself into this debate. She suggested that nursing education be changed to a 4-year program, but also gave her approval to the principle of stage-based education. She sketched an educational model in which one is quali- fied as a care assistant after 2 years and as a nurse after 4 years (Martinsen, 1976). With the comprehensive 3-year degree as the stated goal for the nursing asso- ciation, her suggestion was viewed as a provocation.

In 1978, Martinsen received a grant from Norway’s General Science Research Council. At this time, she was attached to the history department at the Univer- sity of Oslo, where she worked on her new project on the social history of nursing, while lecturing master’s degree students in sociopolitical history. From 1981

how the nursing profession must operate if it is not to let down its weakest patients and those that need care the most. The obvious follow-up question was how the nurse might be able to care for the patient when medical science first and foremost relates to patient’s diseases? In other words, Martinsen wanted to know how we who represent the health services provide adequate nursing for the subjects of our care, when we are so closely allied with a science that objectifies the patient. She posed questions about whether that same objectification would increase with emphasis on a scientific base for the discipline of nursing.

These fundamental questions urged Martinsen to take up additional studies, this time for a bachelor’s degree in psychology at the University of Oslo in 1968, with the goal of obtaining a master’s degree in psychol- ogy. As a prerequisite, she needed an intermediate examination in physiology and another free credit at the intermediate level; here she chose philosophy. This encounter with philosophy and phenomenology changed her thinking drastically. She realized that philosophy rather than psychology might better illumi- nate the existential questions with which she was con- cerned. The study of phenomenology attracted her to the University of Bergen, Norway’s second largest city.

From 1972 to 1974, she attended the Department of Philosophy at the University of Bergen. In her work for the graduate degree in philosophy (Magister artium), Martinsen grappled philosophically with questions that had disturbed her as a citizen, a profes- sional, and a health care worker. The dissertation Philosophy and Nursing: A Marxist and Phenomeno- logical Contribution (Martinsen, 1975) created an instant debate and received much critical attention. The dissertation directed a critical gaze toward the nursing profession for its refusal to take seriously the consequences of the nursing discipline uncritically adopting characteristics of a profession, and uncriti- cally embracing only a scientific basis for nursing. Such a development might contribute to distancing nurses from the patients who need them most. This dissertation, the first written by a nurse in Norway, analyzed the discipline of nursing from a critical philosophical and social perspective.

During the mid-1970s, Norway experienced a marked shortage of nursing teachers. The rectors of three nursing colleges in Bergen took the initiative to establish a temporary nursing teacher–training course

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to 1985, she was a scientific assistant at the history department at the University of Bergen. In addition to conducting her own research, Martinsen lectured and supervised master’s degree students in feminist his- tory and developed a database of Norwegian feminist history.

The period from 1976 to 1986 can be described as a historical phase in Martinsen’s work (Kirkevold, 2000). She published several historical articles (Martinsen, 1977, 1978, 1979a, 1979b). Close collaborators during this phase were Anne Lise Seip, professor of social his- tory; Ida Blom, professor of feminist history; and Kari Wærness, professor of sociology. In 1979, Martinsen and Wærness published a book with the provocative title, Caring Without Care? (Martinsen & Wærness, 1979). In this book, the authors raised important questions: • Were nurses “moving away” from the sickbed? • Was caring for the ill and infirm disappearing

with the advent of increasingly technical care and treatment?

• Were nurses becoming administrators and research- ers who increasingly relinquished the concrete exe- cution of care to other occupational groups? Aiding ill and care-dependent people was consid-

ered women’s work, and this view has long historical roots. However, the existence of the professionally trained nurse is not very old in Norway, originating in the late 1800s. The deaconesses (Christian lay sisters), who were educated at different deaconess houses in Germany, were the first trained health workers in Norway. Martinsen described how these first trained nurses built up a nursing education in Norway, and how they expanded and wrote textbooks and prac- ticed nursing both in institutions and in homes. They were the forerunners of Norway’s public health sys- tem. This pioneer period was described by Martinsen in her book, History of Nursing: Frank and Engaged Deaconesses: A Caring Profession Emerges 1860-1905 (Martinsen, 1984). Based on this work, Martinsen attained her doctor of philosophy degree from the University of Bergen in 1984.

In defense of her dissertation, Martinsen had to prepare two lectures: “Health Policy Problems and Health Policy Thinking behind the Hospital Law of 1969” (Martinsen, 1989a), and “The Doctors’ Interest in Pregnancy—Part of Perinatal Care: The Period ca. 1890-1940” (Martinsen, 1989b). This work emerged from her 10-year historical phase, beginning in the

mid-70s, when she wrote about nursing’s social his- tory and feminist history, and the social history of medicine.

From 1986, Martinsen worked for 2 years as Associate Professor at the Department of Health and Social Medicine at the University of Bergen. She lectured and supervised master’s degree students, in addition to writing a series of philosophical and his- torical papers, published in 1989 under the title Car- ing, Nursing and Medicine: Historical-Philosophical Essays (Martinsen, 1989c). With this book, the threads of Martinsen’s historical phase were drawn together, marking the beginning of a more philosophical period (Kirkevold, 2000). The book has several editions, and the 2003 publication includes an inter- view with the author (Karlsson & Martinsen, 2003). Fundamental problems in caring and interpretations of the meaning of discernment are what preoccupied Martinsen from 1985 to 1990. In a Danish anthology published in 1990, she contributed a paper entitled “Moral Practice and Documentation in Practical Nursing.” Here she writes:

Moral practice is based upon caring. Caring does not merely form the value foundation of nursing; it is a fundamental precondition of our life . . . Discernment demands emotional involvement and the capacity for situational analysis in order to assess alternatives for action . . . To learn moral practice in nursing is to learn how the moral is founded in concrete situations. It is accounted for through experiential objectivity or through discretion, in action or in speech. In both cases learning good nursing is of the essence

(Martinsen, 1990, pp. 60, 64-65).

In 1990, Martinsen moved to Denmark for a 5-year period. She was employed at the University of Århus to establish master’s degree and PhD programs in nursing. Her philosophical foundation was further developed during these years mainly through encounters with Danish life philosophy (Martinsen, 2002a) and theo- logical tradition. In Caring, Nursing and Medicine: Historical-Philosophical Essays, Martinsen (1989c, 2003b) had connected the concept of caring to the German philosopher Martin Heidegger (1889-1976). While she was living in Denmark, Heidegger’s role as a Nazi sympathizer during World War II became public knowledge. At that time, a series of academic articles

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were published, which proved that Heidegger was a member of the national Socialist Party in Germany and that he had betrayed his Jewish colleagues and friends such as Edmund Husserl (1859-1938) and Hannah Arendt (1906-1975). Heidegger was banned from teaching for several years after the war because of his involvement with the Nazis (Lubcke, 1983).

Martinsen confronted Heidegger and her own thinking about his philosophy in From Marx to Løgstrup: On Morality, Social Criticism and Sensu- ousness in Nursing (Martinsen, 1993b). Precisely because life and learning cannot be separated, it became important for Martinsen to go to sources other than Heidegger to illustrate the fundamental aspects of caring. Knud E. Løgstrup (1905-1981) was the Danish theologian and philosopher who became her alternative source, although the two never met. Martinsen knew him through his books and via his wife Rosemarie Løgstrup, who was origi- nally German. She met her husband in Germany, where both were studying philosophy. She later translated his books into German.

While Martinsen lived and worked in Denmark, she met with Patricia Benner on several occasions for public dialogues in Norway and Denmark, and again in 1996 in California. One of these dialogues was later published with the title, “Ethics and Vocation, Culture and the Body” (Martinsen, 1997b); it took place at a conference at the University of Tromsø.

Martinsen also had important dialogues with Katie Eriksson, the Finnish professor of nursing. They met in Norway, Denmark, Sweden, and Finland. In the begin- ning, their discussions were tense and strained, but over time, they developed into fruitful and enlighten- ing conversations that later were published as Phenom- enology and Caring: Three Dialogues (Martinsen, 1996). Martinsen’s first chapter in this book is titled “Caring and Metaphysics—Has Nursing Science Got Room for This?” the second, “The Body and Spirit in Practical Nursing,” and the third, “The Phenomenology of Creation—Ethics and Power: Løgstrup’s Philosophy of Religion Meets Nursing Practice.” These headings employ impressive language, similar to that of the dialogues that Martinsen conducted with Benner; in her preface to the book, she elaborates:

The words about which we speak and write are compassion, hope, suffering, pain, sacrifice, shame,

violation, doubt. These are “big words.” But they are no bigger than their location in life, our every- day nursing situation. Mercy, writes the Danish theologian and philosopher Løgstrup, is the renewal of life, it is to afford others life. . . . What else is nursing but to release the patient’s possibili- ties for living a meaningful life within the life cycle we inhabit between life and death? We must ven- ture into life amongst our fellow humans in order to experience the actual meaning of these big words

(Martinsen, 1996, p. 7).

While Martinsen was teaching in Århus, she became Adjunct Professor at the Department of Nursing Science at the University of Tromsø in 1994. In 1997, she moved north and become a full-time professor. However, needing more time for her research and writings, she left after only 1 year in this position to become a freelancer in 1998.

In 2002 and for a 5-year period, Martinsen made her way back to the University of Bergen as professor at the Department of Public Health and Primary Health Care section for nursing science. Teaching master’s and doctoral students was central. She arranged doctoral courses and was much in demand in the Nordic countries as supervisor and lecturer.

The period from 1990 is characterized by philo- sophical research. Fundamental philosophical and ontological questions and their meaning for nursing dominated Martinsen’s thought. During this period, in addition to her own books, she worked on a variety of projects and published in several journals and anthologies. Books from this period have already been mentioned (Martinsen, 1993b, 1996). In 2000, The Eye and the Call (Martinsen, 2000b) was published. The chapter titles in this book ring more poetically than before: “To See with the Eye of the Heart,” “Ethics, Culture and the Vulnerability of the Flesh,” “The Calling—Can We Be Without It?” and “The Act of Love and the Call.”

Martinsen also worked with ideas about space and architecture. According to her, space and architecture influence human dignity. She first wrote about this idea in an article with the poetic title, “The House and the Song, the Tears and the Shame: Space and Architecture as Caretakers of Human Dignity” (Martinsen, 2001).

Martinsen has held positions at three nursing colleges. From 1989 to 1990, she was employed as

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researcher at Bergen Deaconess University College, Bergen, and from 2006 as an Adjunct Professor. From 1999 to 2004, she was Adjunct Professor at Lovisenberg Deaconess University College in Oslo. In 2007, she became a full-time professor at Harstad University College in northern Norway.

Ideas and academic ventures sprouted and flour- ished easily around Martinsen, and she drew others into academic projects. She edited a collection of arti- cles which several nursing college teachers contributed to, called The Thoughtful Nurse (Martinsen, 1993a). Lovisenberg Deaconess University College in Oslo, with Martinsen’s assistance, took the initiative to publish a new edition of the first Norwegian nursing textbook, which was originally published in 1877 (Nissen, 2000). In this edition, Martinsen (2000a) wrote an afterword, placing the text within a context of academic nursing. With a colleague in Oslo, Martinsen edited another collection of articles by the editors and college lecturers for a book, published as Ethics, Discipline and Refine- ment: Elizabeth Hagemann’s Ethics Book—New Readings (Martinsen & Wyller, 2003). This book provides an analysis of a text on ethics for nurses published in 1930 and used as a textbook until 1965. When the ethics text was republished in 2003, it was interpreted in the light of two French philosophers, Pierre Bourdieu (1930 to 2002) and Michel Foucault (1926 to 1984), as well as the German sociologist Max Weber (1864 to 1920). In 2012, together with colleagues at Harstad University College, Martinsen published a book about narratives and ethics in nursing (Thorsen, Mæhre, & Martinsen, 2012).

Thus historical and philosophical threads are each present in different phases of Martinsen’s thought, and they color her work differently during the differ- ent periods. In 2011, Martinsen was made Knight, First Class, of the Royal Norwegian Order of St. Olav for her very significant work, thought, and authorship in nursing science.

Theoretical Sources What is Martinsen’s theoretical background? In her analysis of the profession of nursing in the early 1970s, Martinsen looked to three philosophers in particular: German philosopher, politician, and social theorist Karl Marx (1818 to 1883); German philosopher and founder of phenomenology Edmund Husserl (1859 to

1938); and French philosopher and phenomenologist of the body Merleau-Ponty (1908 to 1961). Later, she broadened her theoretical sources to include other philosophers, theologians, and sociologists.

Karl Marx: Critical Analysis— A Transformative Practice Marxist philosophy gave Martinsen some analytical tools to describe the reality of the discipline of nurs- ing and the social crisis in which it found itself. The crisis consisted of the failure of the discipline to examine and recognize its nature as fragmented, specialized, and technically calculating, as it pretends a holistic perspective on care. She found that the discipline was part of positivism and the capitalist system, without praxis of liberation. A “reversed care–law” rules in such a way that those who need care most receive the least. Karl Marx criticized indi- vidualism and the satisfaction of the needs of the rich at the expense of the poor. Martinsen’s view is that it is important to expose this phenomenon when it occurs in health service. Such exposure of this reality can be a force for change. She maintains that we must question the nature of nursing, its content and inner structure, its historical origins, and the genesis of the profession. This questioning results in a critical nurs- ing practice as the practitioner views her occupation and profession in a historical and social context. Martinsen’s historical interest has a critical and trans- formative intention.

Edmund Husserl: Phenomenology as the Natural Attitude Edmund Husserl’s phenomenology is important for Martinsen’s critiques of science and positivism. Positivism’s view of the self lies in its attitude of objec- tification and a dehumanizing and calculating attitude toward the person. Husserl viewed phenomenology as a strict science. The strict methodological processes of phenomenology produce an attitude of composed reflection over our scientific reality, so that we may uncover structures and contexts within which we oth- erwise perform taken-for-granted and unconscious work. This practice is about making the taken-for- granted problematic. By problematizing taken-for- granted self-understanding, we find opportunities to grasp “the thing itself,” which will always reveal itself perspectively. Phenomenology works with the

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prescientific, what we encounter in the natural atti- tude, when we are directed toward something with the intent to recognize and understand it meaningfully. Phenomenology insists upon context, wholeness, in- volvement, engagement, the body, and the lived life. We live in contexts, in time and space, and we live historically. The body cannot be divided into body and soul; it is a wholeness that relates to other bodies, to things in the world, and to nature.

Merleau-Ponty: The Body as the Natural Attitude Maurice Merleau-Ponty (1908 to 1961) builds upon Husserl’s thought, but focuses more than any other thinker on the human body in the world. Both Husserl and Merleau-Ponty criticized Descartes (1596 to 1650), who separates the person from the world in which one lives with other persons. The body is representing the natural attitude in the world. The nursing profession relates to the body in all of its aspects. We use our own bodies in the performance of caring, and we relate to other bodies who are in need of nursing, treatment, and care. Our bodies and those of our patients express themselves through actions, attitudes, words, tone of voice, and gestures. Phenomenology involves acts of interpretation, description, and recognition of lived life, the everyday life that people live together with oth- ers in a mutual natural world, including the profes- sional contexts in which caring is performed.

Martin Heidegger: Existential Being as Caring Martin Heidegger (1889-1976) was a German phe- nomenologist and a student of Husserl, among others. He investigated existential being, that is to say, that which is and how it is. Martinsen connects the concept of caring to Heidegger because he “has caring as a central concept in his thought. . . . The point is to try to elicit the fundamental qualities of caring, or what caring is and encompasses” (Martinsen, 1989c, p. 68). She continues: “An analysis of our practical life and an analysis of what caring is, are inseparable. To investi- gate the one is at the same time to investigate the other. Together, they form an inseparable unit. Caring is a fundamental concept in understanding the person” (Martinsen, 1989c, p. 69). With phenomenology and Heidegger as a backdrop, Martinsen gives content and substance to caring: caring will always have at least

two parts as a precondition. One is concerned and anxious for the other. Caring involves how we relate to each other, and how we show concern for each other in our daily life. Caring is the most natural and the most fundamental aspect of human existence.

As mentioned earlier, Martinsen revised her per- spective on Heidegger (Martinsen, 1993b). At the same time, she did not reject “Heidegger’s original and acute thought” (Martinsen, 1993b, p. 17). She turns back to Heidegger when she explains what it means to dwell. Heidegger had examined precisely the concept that to dwell is always to live among things (Martinsen, 2001). Here we may note that Heidegger reinforces an idea also maintained by Merleau-Ponty: that the things we surround ourselves with are not merely things for us, objectively speaking, but they actually participate in shaping our lives. We leave something of ourselves within these things when we dwell amidst them. It is the body that dwells, surrounded by an environment.

Knud Eiler Løgstrup: Ethics as a Primary Condition of Human Existence Knud Eiler Løgstrup (1905 to 1981), the Danish philosopher and theologian, became important for Martinsen in the “void” left by Heidegger. Løgstrup can be summarized through two intellectual strands: phenomenology and creation theology, the latter containing his philosophy of religion (creation the- ology should not be confused with the more recent “creationism” in the United States). As a phenome- nologist, he sought to reveal and analyze the essen- tial phenomena of human existence. Through his phenomenological investigations, Løgstrup arrived at what he termed sovereign or spontaneous life utterances: trust, hope, compassion, and the open- ness of speech. That these are essential is to say that they are precultural characteristics of our existence. As characteristics, they provide conditions for our culture, conditions for our existence; they make human community possible (Lubcke, 1983). Accord- ing to Heidegger, caring is such a characteristic. In Løgstrup’s opinion, the sovereign life utterances were the necessary characteristics for human coexistence.

Martinsen maintains that for Løgstrup, metaphysics and ethics are interwoven in the concept of creation:

They are characteristic phenomena which sustain us in such a way that caring for the other arises

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out of the condition of our having been created. Caring for the other reveals itself in human relationship through trust, open speech, hope and compassion. These phenomena, which Løg- strup also calls sovereign life utterances, are “born ethical” which means that they are essen- tially ethical. Trust, open speech, hope and com- passion are fundamentally good in themselves without requiring our justification. If we try to gain dominance over them, they will be destroyed. Metaphysics and ethics, or rather metaphysical ethics, is practical. It is linked to questions of life in which the person is stripped of omnipotence

(Martinsen, 1993b, pp. 17-18).

We must care for that which exists, not seek to control it: “Western culture is singular in its need to understand and control. It has moved away from the cradle of our culture and our religion in the nar- rative of creation from the Old Testament. In The Old Testament ‘guarding,’ ‘watching,’ and ‘caring’ on one side, and cultivating and using on the other, formed a unified opposition” (Martinsen, 1996, p. 79). That these are unified opposites is to say that they singularly and in themselves are opposites that separate and are insurmountable, but when they are adjusted to one another, they enter into an opposi- tion that unifies and creates a sound whole. To care for, guide and guard, cultivate, and make use of, that is to say, cultivate and use in a caring manner as a unified opposition, means that we do not be- come domineering and exploitative, but restrained and considerate in our dealings with one another and with nature.

The ethical question is how a society combats suf- fering and takes care of those who need help. In a nursing context, Martinsen formulates this very question like this: “How do we as nurses take care of the person’s eternal meaning, the individual’s unend- ing worth—independent of what the individual is capable of, can be useful for or can achieve? Can I bear to see the other as the other, and yet not as fundamentally different from myself?” (Martinsen, 1993b, p. 18).

Klim, the Danish publishing house, issues works by and about Løgstrup under the label The Løgstrup Library. Here Martinsen has contributed the monograph

Løgstrup og sygepleien (Martinsen, 2012b) (Løgstup and Nursing), subsequently published in Norwegian (Martinsen 2012c).

Max Weber: Vocation as the Duty to Serve One’s Neighbor through One’s Work Max Weber (1864 to 1920) was a German sociolo- gist who made a major impact on the philosophy of social science. Weber sought to understand the meaning of human action. He was also a critic of the society he saw emerging with the advent of in- dustrialization. In Weber, Martinsen found a new alliance, in addition to Marx, in the criticism of both capitalism and science. While Løgstrup was a philosopher of religion, Weber was a sociologist of religion. Weber also criticized the West for its boundless intervention and its boundless consump- tion. Science disenchants the created world precisely because it relates to what was created as objects in its objectification of all that exists (Martinsen, 2000b, 2001, 2002b).

To a great extent, Martinsen joins Weber in her explication of vocation (Martinsen, 2000b). Weber looked to Martin Luther (1483 to 1546), who dis- cussed vocation in the secular sense, as follows:

Vocation is work in the sense of a life’s occupation or a restricted field of work, in which the indi- vidual will endow his fellow person . . . The young Luther linked vocation to work, and understood it as an act of neighbourly love. Vocation is under- stood on the basis of the notion of creation, that we are created in order to care for one another through work

(Martinsen 2000b, pp. 94-95).

In other words, vocation is in the service of cre- ation. With reference to the young Luther, Martinsen wrote that vocation “means that we are placed in life contexts which demand something of us. It is a chal- lenge that I, in this my vocation, meet and attend to my neighbour. It lies in Existence as a law of life” (Martinsen, 1996, p. 91).

Michel Foucault: The Effect of His Method Intensifying Phenomenologists’ Phenomenology Phenomenologists underscore the importance of his- tory for our experience. Martinsen (1975) referred to

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Foucault in her dissertation in philosophy, but was especially concerned with this philosopher in connec- tion with her historical works from 1976 (Martinsen 1978, 1989a, 2001, 2002b, 2003a). Foucault (1926 to 1984) was a French philosopher and historian of ideas. He was concerned with the notions of fracture and difference, rather than continuity and context. He claimed that some shared common structures, systems of terms, and forms of thought that shape societies reside within each historical epoch and within the dif- ferent cultures. In this way, Foucault confronted sub- jective philosophy, which emphasizes the person as a private and independent individual. For example, Foucault asked which fundamental conditions were present during the historical epoch in which institu- tions for the insane were created. In later epochs, he defined the insane as mentally ill. Something new had happened; what did it depend on? Why did it happen and what was to be achieved in society? What actions were undertaken; were there alliances of power and did they involve establishing order and discipline? To question in this way is to dig through several layers of understanding, getting beyond the general conception in order to understand the meaning of history in a new and different way. Foucault elicits the basic social distinctions that make it possible to characterize peo- ple. They are dug out of tacit preconditions (Lubcke, 1983). In this way, Foucault’s method intensified the phenomenological process. He asked us to think anew and differently from the existing mode of thinking within the epoch and within the contexts in which we live. The gaze became not only descriptive, but also critical.

Martinsen stated that, in caring for the other, we relate to the other in a different way and look for things different from those that are looked for within natural science and objectify medicine using their “classifica- tion gaze” and “examining gaze” (Martinsen, 1989b, pp. 142-168; Martinsen, 2000a). Such gazes require spe- cial space; caring requires different types of space in order to develop different types of knowledge. The ques- tions we must bring with us into caring in the health service are these: Which disciplinary characteristics or structures are found in our practice today, in nursing practice and its spatial arrangements? What will it mean to think differently from those of our particular epoch? Do we find critical nursing here, and, if so, what are the implications for today’s health service and research?

Paul Ricoeur: The Bridge-Builder Paul Ricoeur (1913 to 2005) is a French philosopher. His position is often designated as critical hermeneu- ticsor hermeneutic phenomenology. He seeks to build a bridge between natural science and human science, between phenomenology and structuralism and other opposing positions. He focuses on topics such as time and narrative, language and history, discernment and science. Ricoeur is concerned with human communi- cation, on what it is to understand one another. He points to everyday language and its many meanings, in contrast to the language of science. Martinsen refers to parallels in the philosophy of language of Løgstrup and Ricoeur. Martinsen states:

The culture of medicine is dominated by an ab- stract conceptual language in which words are embedded in different classifications, and in which they are not always in accordance with actual practical and concrete situations. . . . In everyday language of the caring tradition on the other hand, words are followed by the manner in which they unfold in different contexts of mean- ing within concrete caring—in the company of the patient and the professional community. When spoken in everyday language, the words are distinguished by their power of expression. They strike a tone

(Martinsen, 1996, p. 103).

Empirical Evidence In Martinsen’s philosophy of caring, language and reflection involved in professional judgment and nar- rative are ways of accounting convincingly for case conditions, situations, and phenomena (Martinsen, 1997a, 2002c, 2003c, 2004b, 2005). She states that obvious perceptions must be accounted for convinc- ingly. With reference to Husserl, she points to different forms of evidence: the undoubtable (apodictic), the exhaustive, and the partial. Each type represents different evidential requirements. Facts, themes, and situations provide different forms of evidence. For example, we cannot accept mathematical evidence that is undoubtable and transfer this to physical objects and persons. In the field of caring, it is discern- ment and narrative that can clarify the empirical facts of a case in an evidentiary, enlightening, or convincing

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Martinsen is reluctant to provide definitions of terms, since definitions have a tendency to close off concepts. Rather, she maintains, the content of con- cepts should be presented. It is important to circum- scribe the meaningful content of a term, explain what the term means, but avoid having terms locked up in definitions.

Care Care “forms not only the value base of nursing, but is a fundamental precondition for our lives. Care is the positive development of the person through the Good” (Martinsen, 1990, p. 60). Care is a trinity: relational, practical, and moral simultaneously (Alvsvåg, 2003; Martinsen, 2003b, 2012b). Caring is directed outward toward the situation of the other. In professional contexts, caring requires education and training. “Without professional knowledge, con- cern for the patient becomes mere sentimentality” (Martinsen, 1990, p. 63). She is clear that guardianship negligence and sentimentality are not expressions of care.

Professional Judgment and Discernment These qualities are linked to the concrete. It is through the exercise of professional judgment in practical, living contexts that we learn clinical observation. It is “training not only to see, listen and touch clinically, but to see, listen and touch clinically in a good way” (Martinsen, 1993b, p. 147). The patient makes an impression on us, we are moved bodily, and the impression is sensuous. “Because perception has an analogue character, it evokes variation and context in the situation” (Martinsen, 1993b, p. 146). One thing is reminiscent of another, and this recollection creates a connection between the impressions in the situation, professional knowl- edge, and previous experience. Discretion expresses professional knowledge through the natural senses and everyday language (Martinsen, 2005, 2006).

Moral Practice Is Founded on Care “Moral practice is when empathy and reflection work together in such a way that caring can be expressed in nursing” (Martinsen, 1990, p. 60). Morality is present

MAJOR CONCEPTS & DEFINITIONS

in concrete situations and must be accounted for. Our actions need to be accounted for; they are learned and justified through the objectivity of empathy, which consists of empathy and reflection. This means in concrete terms to discover how the other will best be helped, and the basic conditions are recognition and empathy. Sincerity and judgment enter into moral practice (Martinsen, 1990).

Person-Oriented Professionalism Person-oriented professionalism is “to demand pro- fessional knowledge which affords the view of the patient as a suffering person, and which protects his integrity. It challenges professional competence and humanity in a benevolent reciprocation, gathered in a communal basic experience of the protection and care for life . . . It demands an engagement in what we do, so that one wants to invest something of one- self in encounters with the other, and so that one is obligated to do one’s best for the person one is to care for, watch over or nurse. It is about having an understanding of one’s position within a life context that demands something from us, and about placing the other at the centre, about the caring encounter’s orientation toward the other” (Martinsen, 2000b, pp. 12, 14).

Sovereign Life Utterances Sovereign life utterances are phenomena that accom- pany the Creation itself. They exist as precultural phenomena in all societies; they are present as poten- tials. They are beyond human control and influence, and are therefore sovereign. Sovereign life utterances are openness, mercy, trust, hope, and love. These are phenomena that we are given in the same way that we are given time, space, air, water, and food (Alvsvåg, 2003). Unless we receive them, life disintegrates. Life is self-preservation through reception (Martinsen, 2000b; 2012b). Sovereign life utterances are precondi- tions for care, simultaneously as caring actions are necessary conditions for the realization of sovereign life utterances in the concrete life. We can act in such a way that openness, trust, hope, mercy, and love are realized through our interactions, or we can shut them out. Without their presence in our actions,

Continued

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manner (Martinsen 2003c, 2004b, 2005, 2009, 2012). To exercise discretion is to interpret the impressions we get of the patient. The professional knowledge and experience one has built up give one a horizon of understanding that is flexible in en- counters with the patient’s situation (Martinsen, 1990, 2002c). The narrative can both describe and prescribe action (Kjær, 2000; Martinsen, 1997a, 2012). “A good narrative tells existential morality into being, and makes practical action unavoidable” (Martinsen, 1993b, p. 161).

Major Assumptions

Nursing Although care goes beyond nursing, caring is funda- mental to nursing and to other work of a caring na- ture. Caring involves having consideration for, taking care of, and being concerned about the other. When we speak about caring, three things must be simulta- neously present; we could call them the “trinity of caring”: caring must be relational, practical, and moral (Alvsvåg, 2011).

caring cannot be realized. At the same time, caring actions clear the way for the realization of sovereign life utterances in our personal and our professional lives. Caring can bring the patient to experience the meaning of love and mercy; caring can light hope or give it sustenance, and caring can be that which makes trust and openness foremost in relations with the nurse. In the same way, lack of care can block the other’s experience of mercy; it can create mistrust and an attitude of restraint in relation to the health service.

The Untouchable Zone This term refers to a zone that we must not interfere with in encounters with the other and encounters with nature. It refers to boundaries for which we must have respect. The untouchable zone creates a certain protective distance in the relation; it ensures impartiality and demands argumentation, theory, and professionalism. In caring, the untouchable zone is united with its opposite, which is openness, in which closeness, vulnerability, and motive have their correct place. Openness and the untouchable zone constitute a unifying contradiction in caring (Martinsen, 1990, 2006).

Vocation Vocation “is a demand life makes to me in a com- pletely human way to encounter and care for one’s fellow person. Vocation is given as a law of life con- cerning neighborly love which is foundationally

MAJOR CONCEPTS & DEFINITIONS—cont’d

human” (Martinsen, 2000b, p. 87). It is an ethical demand to take care of one’s neighbor. For this reason, nursing requires a personal refinement, in addition to professional knowledge (Malchau, 2000).

The Eye of the Heart This concept stems from the parable of the Good Samaritan. The heart says something about the exis- tence of the whole person, about being touched or moved by the suffering of the other and the situation the other experiences. In sensuousness and percep- tion, we are moved before we understand, but we are also challenged by the afterthought of understand- ing. To see and be seen with the eye of the heart is a form of participatory attention based on a recipro- cation that unifies perception and understanding, in which the eye’s understanding is led by the senses (Martinsen, 2000b, 2006).

The Registering Eye The registering eye is objectifying, and the per- spective is that of the observer. It is concerned with finding connections, systematizing, ranking, classifying, and placing in a system. The register- ing eye represents an alliance between modern natural science, technology, and industrialization. If one as a patient is exposed to, or if one as a pro- fessional employs, this gaze in a one-sided man- ner, compassion is lifted out of the situation, and the will to life is reduced (Martinsen, 2000b).

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• Relational means that caring requires at least two people. Martinsen describes it thus:

The one has concern for the other. When the one suffers, the other will “grieve” (in the sense of suffer with) and provide for the alleviation of pain. . . . Caring is the most natural and the most fundamental aspect of the person’s exis- tence. In caring, the relationship between people is the most essential element. . . . The essence of the person is that one is created for the sake of others—for one’s own sake. . . . The point here is that caring always presupposes others. Further, that I can never understand myself or realise myself alone or independent of others

(Martinsen, 1989c, p. 69).

• Caring is practical. It is about concrete and practi- cal action. Caring is trained and learned through its practice.

• Caring is also moral: “If caring is to be genuine, I must relate to the other from an attitude (mood, ‘befindlichkeit’) which acknowledges the other in light of his situation. . . . [We must] neither overes- timate nor underestimate his ability to help him- self ” (Martinsen, 1989c, p. 71). Caring requires a correct understanding of the

situation, which presupposes a good evaluation of the goals inherent in the caring situation: “Performing nursing is essentially directed towards persons not capable of self-help, who are ill and in need of care. To encounter the ill person with caring through nursing involves a set of preconditions such as knowledge, skills, and organization” (Martinsen, 1989c, p. 75). We need training in all types of caring work. We must practice and reflect alone and with others in order to develop professional judgment. Caring and profes- sional judgment are integrated in nursing (Martinsen, 1990, 1997a, 2003c, 2004b, 2005, 2006, 2012b).

Person It is the meaning-bearing fellowship of tradition that turns the individual into a person. The person cannot be torn away from the social milieu and the commu- nity of persons (Martinsen, 1975). In one way, there is a parallel between the person and the body. It is as bod- ies that we relate to ourselves, to others, and to the world (Alvsvåg, 2000; Martinsen, 1997a). The body is a

unit of soul and flesh, or spirit and flesh. The person is bodily, and as bodies we both perceive and understand.

Health Health is discussed from a sociohistorical perspective. Two rival historical health ideals, the classical Greek and the modern one of intervention and expansion, form the background when Martinsen writes: “Health does not only reflect the condition of the organism, it is also an expression of the current level of compe- tence in medicine. To put it pointedly, the tendencies of the modern concept of health are such that if one has an unnecessary ‘defect’ or an organ which ‘could’ be better, one is not completely healthy” (Martinsen, 1989c, p. 146). The modern reductionist health ideal on which modern medicine is built is both analytical and individualistic; it is oriented toward all that is not “good enough.” Combined with medicine’s autonomy and resources, it has yielded success in terms of treat- ment. Martinsen is concerned with the point that this ideology does not withstand critical examination. Medicine’s sometimes damaging effects and insuffi- cient service for people with chronic diseases and illnesses bring Martinsen to turn toward the conser- vative, classical health ideal. What is important is to cure sometimes, help often, and comfort always. This requires society to offer people the opportunity to live the best life possible and the individual to live sensi- bly; both requirements have environmental implica- tions. We must not change the environment at such a speed and to such an extent that the change exceeds our knowledge base; restraint and caution are required (Martinsen, 1989c, 2003b).

Environment: Space and Situation The person is always in a particular situation in a par- ticular space. In space are found time, ambience, and power (Martinsen, 2001, 2002b, 2002c). Martinsen asks what time, architecture, and knowledge do to the ambience of a space. Architecture, our interaction with each other, use of objects, words, knowledge, our being-in-the-room—all set the tone and color the situ- ation and the space. The person enters into universal space, natural space, but through dwelling creates cul- tural space. We build houses with rooms, and the ac- tivities of the health service take place in different rooms. “The sick-room is important as a physical,

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material and constructed place, but it is also a place we share with other people. . . . The room with its interior and objects makes visible the patient’s and the nurse’s interpretation of it” (Martinsen, 2001, pp. 175-176). Our challenge is to give patients and each other dig- nity in these spaces. What is needed then is deliberate knowledge gathered in slowed down, deliberate spaces, “space in which to perceive—smell, listen, see and care” (Martinsen, 2001, p. 176).

Theoretical Assertions People are created dependent and relational. Care is fundamental to human life. As humans, we live not merely in fellowship with one another, but we also enter into relationships with animals and with nature, and we relate to a creative force that sustains the whole. The person is fundamentally dependent upon community and the creation. To the created belong the sovereign life utterances, “These are firstly given to us, and secondly they are sovereign. That is to say it is impossible for the person to avoid their power. . . . These are phenomena which are present in the ser- vice of life. They create life, they release life’s possi- bilities” (Martinsen, 1996, p. 80).

The body is created as a whole, that is to say that need and spirit, or body and spirit, enter into a benevolent interaction, in which sensing cannot be avoided. Martinsen (1996) writes the following:

Sensing initiates interaction and maintains it. Care of the body becomes central. In this respect, nursing is secular vocational work which through professional care of the body protects and pro- vides space for the life possibilities of the patient. The vocation is seen as a demand life makes on us to care for our neighbour, in this case the patient, through our work. It is work in the service of life processes. Vocation, the body and work are seen as a counterweight to the new (bodiless) spirituality in nursing (p. 72).

Love of one’s neighbor is coupled with a concrete, practical, professional, and moral discernment. Sen- suous and experience-based knowledge is the most fundamental and essential for the practice of nursing. Caring is learned through practical experience in concrete situations under the supervision of expert and experienced nurses (Martinsen, 1993b, 2003b).

Metaphysics is not speculation about that of which we cannot know anything. It is an interpretation of phenomena we all recognize through our senses and can experience. These phenomena are prescientific and foundational.

Logical Form Martinsen’s logical form can be described as inductive and analogous. The inductive aspect of her thought has its source in that experiences in life and in health ser- vice are the starting point for her theoretical works. She turns toward philosophy and history in the hope of gaining greater insight and understanding of the con- crete work of nursing and the lived life. In her meeting with the philosophy of life and the phenomenology of creation, she encounters the ontological and meta- physical in a different way than that of traditional phi- losophy. Life utterances, the creation, time, and space are ontological and metaphysical facts. Analogy would say that we think these facts and recognize them in our concrete experiences in our practical life. They come to expression in meetings between persons, in narratives, and in the exercise of discernment. “In this way, meta- physics pries at the empirical,” writes Martinsen with reference to Løgstrup (Martinsen, 1996). Further, she states, “The narrative takes time, it is slow. It provides context through analogous forms of recognition, that is to say, it is relevant to us when we can recognize our- selves in the life phenomena it relates” (Martinsen, 2002b, p. 267).

Kirkevold (1998) writes the following:

Martinsen does not mean to present a logically constructed theory. On the contrary, she distances herself from that view of knowledge that insists theory have a logical structure of terms, principles and rules. Martinsen’s theory is an interpretive analysis of caring, upon which the author tries to shed light from several perspectives. Her treat- ment of this phenomenon must be said to be both extensive and thorough (p. 180).

Acceptance by the Nursing Community

Practice

Martinsen herself is reluctant to provide concrete direc- tions for practical nursing. However, she recommends

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that nurses “think along” and assess what she writes and speaks about in their own lives, their own practice and experience, and, against this background, imagine their own way to alternatives for action. This is how Kirkevold (1998) puts it:

Martinsen’s theory of caring is practically relevant as an overarching/general philosophy of nursing. It is clearly articulated and encompasses a precise formulation of how (one ought) to understand and approach patients and nursing. Its strength is the ability to promote reflection upon nursing practice in different contexts, in that it gives a clear picture of what the author believes must be present so that nursing may be considered caring or moral practice (p. 181).

Many of these texts have, she maintains:

. . . a normative character, and are intended to mobilize a counter-culture in nursing, which does not only revolutionize the discipline of nursing and its practice, but which also stands as a resisting force against the societal tendency in opposition to the concept of care. . . . In recent years the personal, inspiring and poetic style has become more pronounced. It communicates Martinsen’s normatively founded philosophy of caring in a gripping way, and has therefore had great impact on nurses and students

(Kirkevold, 1998, p. 204).

Martinsen herself addresses practicing nurses through their professional journal, Sykepleien. Kirkevold writes: “In choosing the journal Nursing as a main vehicle for communicating her academic work, she has under- scored her roots in practical nursing rather than in science” (Kirkevold, 1998, p. 203).

Education Most nursing colleges in Norway and Denmark make good use of Martinsen’s texts, and her works form part of the curriculum at a variety of educa- tional levels. Her books are reprinted regularly and have had considerable impact. Several prescribed texts for nursing education deal with her thought (Alvsvåg, 2011; Kirkevold, 1998; Kristoffersen, 2002; Mekki & Tollefsen, 2000; Nielsen, 2011). In addi- tion, other books have been written for nursing edu- cation in which the aim is to make Martinsen’s

thinking relevant for both nursing generally and for specific professional issues. For example, several col- lege lecturers in Norway and Denmark produced an article compilation in 2000, which gives an introduc- tion to Martinsen’s thought and for which the target group is students (Alvsvåg & Gjengedal, 2000). The book The Philosophy of Caring in Practice: Thinking with Kari Martinsen in Nursing, was published in 2002 and republished in 2010 (Austgard, 2010).

In 2003, a Danish nurse wrote a textbook of spiritual care. Central to the book is Martinsen’s thinking, in ad- dition to that of Katie Eriksson and Joyce Travelbee (Overgaard, 2003). In the Danish Encyclopedia of Nurs- ing, published in 2008, Kari Martinsen is portrayed in a separate article, while several other articles refer to her thinking on caring and judgment (Jørgensen & Lyngaa, 2008).

Research In the same way as one in practical nursing can “think along” and assess what she writes, her writings can also be applied in research. Countless dissertations based on practical, concrete, and more theoretical issues discuss the relationship between empirical experience in light of Martinsen’s terminology and philosophy. In one doctoral dissertation from 2006, the Norwegian pedagogue Pål Henning Walstad addresses Kari Martinsen’s Grundtvig-Løgstrupian influence, calling it Care for Life, and discusses this in relation to practical work and professional education (Walstad, 2006). Moreover, nursing teacher Betty- Ann Solvoll has in her 2007 doctoral dissertation done a field study of nursing education and is discuss- ing the data in relation to Martinsen’s reflections on care (Solvoll, 2007). Two Danish doctoral disserta- tions (Dahlgard, 2007; Mark 2008) reflect Martinsen’s theory applied to empirical material dealing with care for the dying, and with anorectic and diabetic patients, respectively. Similar applications are made with reference to bathing of patients (Jeanne Boge, 2008), dignified encounters in the final phase of life (Kari Gran Bøe, 2008), and the importance of space and architecture for psychiatric patients (Inger Beate Larsen, 2009). Else Foss is a preschool teacher who analyzes children’s crying in kindergartens in her doctoral dissertation (Foss, 2009). These examples of applications of Martinsen’s thought in research are even beyond those of nursing proper.

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Further Development Caring can be understood on several levels: ontologi- cal, concrete, and practical, or at the level of system or organization. In nursing, we are encouraged to act in a professional and moral manner, so that caring and life utterances are given the space they need to emerge in nurse-patient encounters. We are continuously chal- lenged to reflect critically over whether this happens or not. It would involve the manifestation of a person- oriented professionalism, the manifestation of loving deeds in the profession, over and over (Martinsen, 1993b, 2000b).

It is important, moreover, to develop a mode of thinking about caring in nursing research. Science in nursing might face certain boundaries. The challenge is to develop a type of research that does not impoverish practice, but that upgrades the available knowledge and wisdom developed through practice, in other words to develop or create a practice-oriented research, a coop- eration between researcher and practitioner (Martinsen, 1989c, 1993b). Kirkevold writes as follows:

Martinsen’s theory is especially important be- cause it is one of the few existing Norwegian nursing theories, and because it is one of the first Nordic nursing theories that gives expression to a new understanding of reality and the need for new nursing theories based upon this

(Kirkevold, 1998, p. 182).

At the organizational and social levels, the concept of care is also highly relevant. It is important to de- velop social systems and organizations, such as the health service, so that a person-oriented professional- ism can be facilitated. Martinsen writes about both a merciful and a political Samaritan (Martinsen, 1993b, 2000b, 2003b). What is important at both organiza- tional and social levels is how the political Samaritans facilitate the work of the merciful Samaritans.

Critique

Clarity Martinsen’s theory clearly states that life has been created and given to us. We have been created in dependence on each other and on nature. Caring for each other and for nature is fundamental. Our challenge as nurses is to meet patients and their

families with person-oriented professionality, and that (patient encounter) is at the heart of person- oriented professionality.

Simplicity At first glance, Martinsen’s theory seems complex. At the same time, the question must be asked whether this is because she turns so many of our familiar assumptions on their heads, for example, that we as human beings are free, independent, and boundless in our capacity for activity and interference with cre- ation. Western societies live in a culture of individual- ism. Her view of humanity can be described as collectivist. She uses a poetic and philosophical rather than a scientific mode of speaking, which might also seem alien in a scientized society. She writes about general phenomena that affect us all, and that we can easily recognize in our personal lives, either occupa- tionally or in daily life. Seen this way, the theory of caring is not hard to understand. Martinsen asks that we read slowly while imagining our own experiences in light of what she writes (Martinsen, 2000b).

Generality Because Martinsen’s nursing theory deals with essen- tial phenomena of life and nursing, phenomena pres- ent in all human situations, it can be seen as relevant to patients in general (Martinsen, 2006). Her theory of care “seems to be relevant for all patients who, because of illness or other reasons, need help and assistance” (Kirkevold, 1998, p. 181).

Accessibility The patient’s and the nurse’s worlds of experience are diverse, nuanced, and multifaceted. A nuanced and varied language is required to deal with a multifac- eted reality, one that is on par with what is to be de- scribed. This language is close to philosophy and also to everyday language; it is a poetic language. We may say that the poetic language is the most precise in describing manifold phenomena and situations open to interpretation. Reflection on professional judg- ment and professional narratives creates the contexts of a community of nursing and the tradition of nurs- ing; we recognize situations and thus find profes- sional and moral insight. This enables us to perform situation-dependent, good nursing—a professional moral practice.

CHAPTER 10 Kari Martinsen 161

Importance Martinsen’s theory of caring is a critique of the pre- vailing system and at the same time an inspiration to individuals in concrete caring situations (Gjengedal, 2000). Gjengedal writes that Martinsen’s motivation for theoretical work “has precisely a practical point of departure, a wish to understand and protect against devaluation of the aspect of care in nursing” (Gjengedal, 2000, p. 38). Devaluation of caring might occur if one uncritically accepts “a scientific perspective blind to the lived life and all that gives meaning to being” (Gjengedal, 2000, p. 54).

As persons and as nurses, we are challenged to live in a way that allows positive meaning to be expressed in our human relations, for example, in relations be- tween patients and their family members. How we express this in a concrete way in a nursing context is for us as professionals to decide, and the philosophy on which Martinsen bases her thinking provides ideas for our own reflection in specific situations. Specific situations present themselves with both pos- sibilities and limitations. Socially created structural arrangements such as lack of personnel, financial re- sources, and lack of institutional beds present serious limitations on a daily basis. Opportunities for caring become more accessible within a caring community and are shaped by politically aware people:

A caring community is not dictatorial, nor is it society’s passive extended arm. The caring com- munity exists only to the extent that we struggle for its existence. We must form it ourselves: through solidarity, through morally responsible action, through the fight for greater equality and for community and social integration. Caring is an active and radical concept

(Martinsen, 1989c, p. 62).

It is important to create conditions for good and equitable health care and living standards for all, but in the fight over limited budgetary resources, to take as our starting point those who are weakest, who most need help, it is about turning the inverted law of care around such that those who have least receive most.

Summary Martinsen has both personal and sociopolitical in- terest in the ill and in those who, for other reasons,

fall outside of society. Her theoretical stance can be called critical and phenomenological. She takes as her starting point the idea that human beings are created and are beings for whom we may have administrative responsibility. We are relational and dependent on each other and on the creation. Therefore, caring, solidarity, and moral practice are unavoidable realities for us.

In her thought on the subject of caring, Martinsen challenges society, the politics of health care, and health care workers themselves to realize the values inherent in caring through concrete policies and practical nursing. She deliberately gives few directives for action. Rather, she asks us to think ourselves into the situations of patients and family members and to arrive at the best choices for action based on a rich situational understanding, professional insight, and a caring attitude.

Martinsen’s thought has provoked, engaged, and created debate and professional development in nurs- ing in the Nordic countries over the past 30 years. Her thought challenges us to both think and act well and correctly, critically, and differently in nursing, in edu- cation, and in research. Martinsen’s “caring thought” contributes to the enlightenment of nursing and nurs- ing research through its perspectives, concepts, and insights based on historical and philosophical schol- arship and research.

CASE STUDY

As nurses, we meet patients and their family mem- bers in many different life situations. Patients may be of all age groups, acutely or chronically ill, might return to life and health, or are coming to the end of their lives and must face death as a real- ity. Nurses meet patients and family members in their homes, the hospital, the nursing home, the school health service, at the local clinic, and so forth. Some meetings with patients and family members make a greater impression on us than others, and all meetings represent situations of learning. Against this background, write a brief case study from your personal clinical experience and discuss how caring was expressed in that par- ticular case situation.

UNIT II Nursing Philosophies162

POINTS FOR FURTHER STUDY

æresbog til Staf Callewaert. [email protected] [Modernity, disenchantment and shame. A way of reading Western medicine in the modern. In K. A. Petersen & M. Høyen (Eds.), Leaving a trail on the way from Aquinas to Bordieu—honorary volume for Staf Callewaert. [email protected]]

n Martinsen, K. (2006). Care and vulnerability. Oslo: Akribe (English original).

n Martinsen, K. (2008). Modernitet, avtrylling og skam. En måte å lese vestens medisin på i det moderne. In K. A. Petersen & M. Høyen (red.), At sette spor på en vandring fra Aquinas til Bordieu—

CRITICAL THINKING ACTIVITIES 3. From the starting point of the situation in the first

item, discuss what is meant by person-oriented professionalism and moral practice.

1. Center your thinking on a concrete nursing situa- tion with which you had personal experience as an active participant or as an observer.

2. Consider the human caring aspects of the situa- tion in the first item.

Alvsvåg, H. (2000). Menneskesynet—Fra kroppsfenome- nologi til skapelsesfenomenologi. I H. Alvsvåg & E. Gjengedal (red.), Omsorgstenkning. En innføring i Kari Martinsens forfatterskap. Bergen: Fagbokforlaget. [The view of the person—from the phenomenology of the body to creation phenomenology. In H. Alvsvåg & E. Gjengedal (Eds.), Caring thought: An introduction to the writings of Kari Martinsen.Bergen: Fagbokforlaget.]

Alvsvåg, H. (2011). Omsorg—Med utgangspunkt i Kari Martinsens omsorgstenkning. I B. K. Nielsen (red.), Sygeplejebogen 3. Teori og metode. 3. opplag. København: Gads Forlag. [Caring—From the starting point of Kari Martinsen’s philosophy. In B. K. Nielsen (Ed.), Nursing textbook 3. Theoretical-methodological basis of clinical nursing. Copenhagen: Gads Forlag.]

Alvsvåg, H., & Gjengedal, E. (red.) (2000). Omsorgstenkning. En innføring i Kari Martinsens forfatterskap. Bergen: Fagbokforlaget. [Caring thought: An introduction to the writings of Kari Martinsen.Bergen: Fagbokforlaget.]

Austgard, K. (2010). Omsorgsfilosofi i praksis. A tenke med Kari Martinsen i sykepleien. Oslo: Cappelen Akademisk Forlag. [Philosophy of caring in practice. Thinking with Kari Martinsen in nursing. Oslo: Cappelen Akademisk Forlag.]

Boge, J. (2008). Kroppsvask i sjukepleia. Avhandling for philosophiae doctor (PhD). Universitetet i Bergen. [Bathing the patient. Dissertation for the degree of philosophiae doctor (PhD). University of Bergen.]

Bøe, K.G. (2008). Verdige møter mellom helsepersonale og pasienter i livets sluttfase. Avhandling for dr.art.-graden. Universitetet i Oslo.[Dignified encounters between health workers and patients in the final phase of life. Dissertation for the degree of philosophiae doctor (PhD). University of Oslo.

Dalgaard, K.M. (2007). At leve med uhelbredelig sygdom. Det samfundsvidenskabelige Fakultet, (PhD). Aalborg Universitet.[Living with incurable disease. PhD. School of Social Sciences University of Aalborg.]

Foss, E. (2009). Den omsorgsfulle væremåte. Avhandling for philosophiae doctor (PhD). Universitetet i Bergen. [The caring way of being. Dissertation for the degree of philosophiae doctor (PhD). University of Bergen.]

Gjengedal, E. (2000). Omsorg og sykepleie. I H. Alvsvåg & E. Gjengedal (red.), Omsorgstenkning: En innføring i Kari Martinsens forfatterskap.Bergen: Fagbokforlaget. [Caring and nursing. In H. Alvsvåg & E. Gjengedal (Eds.), Caring thought: an introduction to the writings of Kari Martinsen. Bergen: Fagbokforlaget.]

Jørgensen, B. B., & Lyngaa, J. (Eds.) (2008). Sygeplejeleksikon. Københagen: Munksgaard. [Encyclopedia of Nursing. Copenhagen: Munksgaard.]

Karlsson, B., & Martinsen, K. (2003). Prolog. In K. Martinsen, Omsorg, sykepleie og medisin. 2. utgave. Oslo: Universitets- forlaget. [Prologue. In K. Martinsen. Caring, nursing and medicine: historical-philosophical essays (2nd ed.). Oslo: Universitetsforlaget.]

REFERENCES*

*Norwegian titles are provided with approximate translation into English.

CHAPTER 10 Kari Martinsen 163

Kirkevold, M. (1993). Innledning. I M. Kirkevold, F. Nortvedt, & H. Alvsvåg (red.), Klokskap og kyndighet. Kari Martinsens innflytelse på norsk og dansk sykepleie. Oslo: ad Notam Gyldendal. [Introduc- tion. In M. Kirkevold, F. Nortvedt, & H. Alvsvåg (Eds.), Wisdom and skill: Kari Martinsen’s influence on Norwe- gian and Danish nursing. Oslo: ad Notam Gyldendal.]

Kirkevold, M. (1998). Sykepleieteorier—Analyse og evalu- ering. Oslo: ad Notam Gyldendal. 2. utgave. [Nursing theories—analysis and evaluation (2nd ed.). Oslo: ad Notam Gyldendal.]

Kirkevold, M. (2000). Utviklingstrekk i Kari Martinsens forfatterskap. I H. Alvsvåg & E. Gjengedal (red.), Omsorgstenkning—En innføring i Kari Martinsens forfatterskap. Bergen: Fagbokforlaget. [Developmental characteristics in the writings of Kari Martinsen. In H. Alvsvåg & E. Gjengedal (Eds.), Caring thought: an introduction to the writings of Kari Martinsen. Bergen: Fagbokforlaget.]

Kirkevold, M., Nortvedt, F., & Alvsvåg, H. (red.) (1993). Klokskap og kyndighet. Kari Martinsens innflytelse på norsk og dansk sykepleie.Oslo: Gyldendal Academisk. [Wisdom and skill. Kari Martinsen’s influence on Norwegian and Danish nursing.Oslo: Gyldendal Aca- demisk.]

Kjær, T. (2000). Fænomenologi, etikk og fortælling: I H. Alvsvåg & E. Gjengedal (red.), Omsorgstenkning—En innføring i Kari Martinsens forfatterskap. Bergen: Fagbokforlaget. [Phenomenology, ethics and narrative. In H. Alvsvåg & E. Gjengedal (Eds.), Caring thought: an introduction to the writings of Kari Martinsen.Bergen: Fagbokforlaget.]

Kristoffersen, N. J. (2002). Generell sykepleie. Oslo: Universitetsforlaget. [Fundamental nursing.Oslo: Universitetsforlaget.]

Larsen, I. B. (2009). “Det sitter i veggene” Materialitet og mennesker i distriktspsykiatriske sentra. Avhandling for philosophiae doctor (PhD). Universitetet i Bergen. [“It’s in the woodwork”—materiality and people in Regional Psychiatric Centers. Dissertation for the degree of philosophiae doctor (PhD). University of Bergen.]

Lubcke, P. (red.) (1983). Politikens filosofiske leksikon. København: Politikens Forlag. [Politiken’s philosophical lexicon. Copenhagen: Politikens Forlag.]

Malchau, S. (2000). Kaldet. I H. Alvsvåg & E. Gjengedal (red.), Omsorgstenkning—En innføring i Kari Martin- sens forfatterskap. Bergen: Fagbokforlaget. [The call. In H. Alvsvåg & E. Gjengedal (Eds.), Caring thought: An introduction to the writings of Kari Martinsen. Bergen: Fagbokforlaget.]

Mark, E. (2008). Restriktiv spising i narrativ belysning. En fænomenologisk undersøgelse af børns oplevelser af

spisning ved diabetes eller overvægt. PhD. Det humanis- tiske fakultet. Aalborg Universitet. [Restrictive eating in a narrative perspective. A phenomenological study of children’s experience of eating in relation to diabetes or obesity. PhD. School of Humanities, Aalborg University.

Martinsen K. (1975). Filosofi og sykepleie. Et marxistisk og fenomenologisk bidrag. Filosofisk institutes stensilserie nr. 34. Bergen: Universitetet i Bergen. [Philosophy and nursing: a Marxist and phenomenological contribution (Philosophical Institute’s Stencil Series No. 34). Bergen: University of Bergen.]

Martinsen, K. (1976). Historie og sykepleie—Momenter til en utdanningsdebatt. Kontrast, 7, 430-446. [History and nursing—elements of an educational debate. Contrast, 7,430–446.]

Martinsen, K. (1977). Nightingale—Ingen opprører bak myten. Sykepleien 18(65), 1022–1025. [Nightingale—no rebel behind the myth. Nursing, 18(65),1022–1025.]

Martinsen, K. (1978). Det ‘kliniske blikk’ i medisinen og i sykepleien. Sykepleien, 20(66), 1271-1272. [The ‘clinical gaze’ in medicine and in nursing. Nursing, 20(66),1271– 1272.]

Martinsen, K. (1979a). Den engelske sanitation—Bevegelsen, hygiene og synet på sykdom. I Ø. Larsen (red.), Synet på sykdom. Oslo: Seksjon for medisinsk historie, Univer- sitetet i Oslo. [The English sanitation movement, hygiene and the view of illness. In Ø. Larsen (Ed.), The view of illness. Oslo: University of Oslo (Section for medical- history).]

Martinsen, K. (1979b). Diakonissesykepleiens framvekst. Fra vekkelser og kvinneforeninger til moderhus og fat- tigomsorg. I NAVF’s sekretariat for kvinneforskning (red.), Lønnet og ulønnet omsorg. En seminarrapport. Arbeidsnotat nr. 5/79. Oslo: NAVF. [Development of the professional trained Christian nurses. From revival and woman’s charitable groups to the mother house and care of the poor. In NAVF’s Secretariat for Feminist Research (Ed.), Paid and unpaid care: a seminar report. Working paper no. 5/79. Oslo: NAVE]

Martinsen, K. (1984). Sykepleiens historie. Freidige og uforsagte diakonisser. Et omsorgsyrke vokser fram 1860–1905.Oslo: Aschehoug/Tanum-Norli. [History of nursing: frank and engaged deaconesses: a caring profession emerges 1860–1905. Oslo:Aschehoug/ Tanum-Norli.]

Martinsen, K. (1989a). Helsepolitiske problemer og helse- politisk tenkning bak sykehusloven av 1969. I K. Martin- sen, Omsorg, sykepleie og medisin. Historisk-filosofiske essays. Oslo: Tano Forlag. [Health policy problems and health policy thinking behind the hospital law of 1969. In K. Martinsen, Caring, nursing and medicine: historical- philosophical essays. Oslo: Tano Forlag.]

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Martinsen, K. (1989b). Legers interesse for svangerskapet— En del av den perinatale omsorg. Tidsrommet ca. 1890-1940. I K. Martinsen, Omsorg, sykepleie og medisin. Historisk-filosofiske essays. Oslo: Tano Forlag. [The doctor’s interest in pregnancy—part of perinatal care: The period ca. 1890–1940. In K. Martinsen, Car- ing, nursing and medicine: historical-philosophical essays.Oslo: Tano Forlag.]

Martinsen, K. (1989c). Omsorg, sykepleie og medisin. Historisk-filosofiske essays.Oslo: Tano Forlag. [Caring, nursing and medicine: historical-philosophical essays. Oslo: Tano Forlag.]

Martinsen, K. (1990). Moralsk praksis og dokumentasjon i praktisk sykepleie. I T. Jensen, L. U. Jensen, & W. C. Kim (red.), Grundlagsproblemer i sygeplejen. Etik, videnskabsteori, ledelse & samfunn. Aarhus: Philosophia. [Practice and documentation in practical nursing. In T. Jensen, L. U. Jensen, & W. C. Kim (Eds.), Founda- tional problems in nursing: ethics, theories of science, leadership and society. Aarhus: Philosophia.]

Martinsen, K. (red.) (1993a). Den omtenksomme sykepleier. Oslo: Tano. [The thoughtful nurse. Oslo: Tano.]

Martinsen, K. (1993b). Fra Marx til Løgstrup. Om moral, samfunnskritikk og sanselighet i sykepleien. Oslo: Tano Forlag. [From Marx to Løgstrup: on morality, social crit- icism and sensuousness in nursing. Oslo: Tano Forlag.]

Martinsen, K. (1996). Fenomenologi og omsorg. Tre dialoger. Oslo: Tano-Aschehoug. [Phenomenology and caring: three dialogues. Oslo:Tano-Aschehoug.]

Martinsen, K. (1997a). De etiske fortellinger. Omsorg, 1(14), 58-63. [The ethical narratives. Caring, 1(14), 58–63.]

Martinsen, K. (1997b). Etikk og kall, kultur og kropp— En dialog med Patricia Benner. I M. Sæther (red.), Sykepleiekonferanse på Nordkalottens tak. Tromsø: Universitetet i Tromsø. [Ethics and vocation, culture and the body—a dialogue with Patricia Benner. In M. Sæther (Ed.), Nursing conference on the roof of Nordkalotten. Tromsø: University of Tromsø.]

Martinsen, K. (2000a). Kjærlighetsgjerningen og kallet. Betraktninger omkring Rikke Nissens “Lærebog i Sygepleje for diakonisser”. I R. Nissen, Lœrebog i Sygepleie. Med etterord av Kari Martinsen. Oslo: Gyldendal Akademisk. [The loving act and the call. Reflections on Rikke Nissen’s textbook of nursing for deaconesses. In R. Nissen, Textbook of nursing. With afterword by Kari Martinsen. Oslo: Gyldendal Aka- demisk.]

Martinsen, K. (2000b). Øyet og kallet. Bergen: Fagbokfor- laget. [The eye and the call. Bergen:Fagbokforlaget.]

Martinsen, K. (2001). Huset og sangen, gråten og skammen. Rom og arkitektur som ivaretaker av menneskets verdighet. I T. Wyller (red.), Skam. Perspektiver på skam,

œre og skamløshet i det moderne. Bergen: Fagbokforlaget. [The house and the song, the tears and the shame: space and architecture as caretakers of human dignity. In T. Wyller (Ed.), Shame. Perspectives on shame, honor and shamelessness in modernity. Bergen: Fagbokforlaget]

Martinsen, K. (2002a). Livsfilosofiske betraktninger. Diakoninytt, 3(118), 8–12. [Reflections on the philosophy of life. Deaconry News, 3(118),8–12.]

Martinsen, K. (2002b). Rommets tid, den sykes tid, pleiens tid. I I. T. Bjørk, S. Helseth, & F. Nortvedt (red.), Møte mellom pasient og sykepleier.Oslo: Gyldendal Akademisk. [The room’s time, the ill person’s time, nursing time. In I. T. Bjørk, S. Helseth, & F. Nortvedt (Eds.), The meeting between patient and nurse. Oslo: Gyldendal Akademisk.]

Martinsen, K. (2002c). Samtalen, kommunikasjonen og sakligheten i omsorgsyrkene. Omsorg, 1(19), 14–22. [Conversation, communication and professionality in the caring professions. Caring, 1(19), 14–22.]

Martinsen, K. (2003a). Disiplin og rommelighet I K. Martinsen & T. Wyller (red.), Etikk, disiplin og dan- nelse. Elisabeth Hagemanns etikkbok—Nye lesinger. Oslo: Gyldendal Akademisk. [Discipline and spa- ciousness. In K. Martinsen & T. Wyller (Eds.), Ethics, discipline and refinement: Elizabeth Hagemann’s ethics book—new readings. Oslo: Gyldendal Akademisk.]

Martinsen, K. (2003b). Omsorg, sykepleie og medisin. Historisk-filosofiske essays. 2. utgave. Oslo: Universitets- forlaget. [Caring, nursing and medicine: historical- philosophical essays (2nd ed.). Oslo: University Press.]

Martinsen, K. (2003c). Talens åpenhet og evidens—Dialog med Jens Bydam. Klinisk Sygepleje, 4(17), 36-46. [The openness of speech and evidence—dialogue with Jens Bydam. Clinical Nursing, 4(17), 36–46.]

Martinsen, K. (2004b). Skjønn—Språk og distanse— Dialog med Jens Bydam. Klinisk Sygepleje, 2(18), 50-56. [Discernment—language and distance—dialogue with Jens Bydam. Clinical Nursing, 2(18), 50–56.]

Martinsen, K. (2005). Samtalen, skjønnet og evidensen. Oslo: Akribe. [Dialog, Discernment and the Evidence. Oslo: Akribe.]

Martinsen, K. (2006). Care and Vulnerability. Oslo: Akribe (English original).

Martinsen, K. (2009). Å se og å innse—om ulike former for evidens. Oslo: Akribe. [To see and to realize—on various forms of evidence. Oslo: Akribe.].

Martinsen, K. (2012b). Løgstrup og sykepleien. Århus: Klim Forlag. [Løgstrup and Nursing. Aarhus: Klim.]

Martinsen, K. (2012c). Løgstrup og sykepleien. Oslo: Akribe.. [Løgstrup and Nursing. Oslo: Akribe.]

Martinsen, K., & Wærness, K. (1979). Pleie uten omsorg? Oslo: Pax Forlag A/S. [Caring without care? Oslo: Pax Forlag.]

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Martinsen, K., & Wyller, T. (ed.) (2003). Etikk, disiplin og dannelse. Elisabeth Hagemanns etikkbok—Nye lesinger. Oslo: Gyldendal Akademisk. [Ethics, discipline and refinement: Elizabeth Hagemann’s ethics book—new readings. Oslo: Gyldendal Akademisk.]

Mekki, T. E., & Tollefsen, S. (2000). På terskelen. Introduks- jon til sykepleie som fag og yrke. Oslo: Akribe. [On the threshold: introduction to nursing as discipline and pro- fession. Oslo: Akribe.]

Nielsen, B. K. (Ed.) (2011). Sygeplejebogen 3. Teori og metode. 3. utg. København: Gads Forlag. [Nursing text- book 3. Theoretical-methodical basis of clinical nursing. Copenhagen: Gads.]

Nissen, R. (2000). Lœrebog i Sygepleie. Med etterord av Kari Martinsen. Oslo: Gyldendal Akademisk. [Textbook of nursing. With an afterword by Kari Martinsen. Oslo: Gyldendal Akademisk.]

Olsen, R. H. (1998). Klok av erfaring? Om sansing og oppmerksomhet, kunnskap og refleksjon i praktisk syke- pleie. Oslo: Tano Aschehoug. [Wise with experience? On sensation and attention, knowledge and reflection in practical nursing. Oslo: Tano Aschehoug.]

Overgaard, A. E. (2003). Åndelig omsorg—En lœrebog. København: Nytt Nordisk Forlag Arnold Busck. [Spiri- tual care—Textbook. Copenhagen: Nyt Nordisk Forlag Arnold Busck.]

Solvoll, B.A. (2007). Omsorgsferdigheter som pedagogisk prosjekt—en feltstudie i sykepleieutdanningen. Oslo: Universitetet i Oslo, Det medisinske fakultet, nr. 540. [Caring skills as pedagogical project—a field study in nursing education. Oslo: University of Oslo, Faculty of Medicine, Doctoral Dissertation No.540.]

Thorsen, R., Mæhre, K. S., & Martinsen, K. (eds.) (2012). Fortellinger om etikk. Bergen: Fagbokforlaget. [Narra- tives on ethics].

Walstad, P. B. (2006). Dannelse og Duelighed for livet. Dan- nelse og yrkesutdanning i den grundtvigske tradisjon. Trondheim: Norges teknisk-naturvitenskapelige univer- sitet, NTNU Doctoral dissertations 2006:88. [Education and capability for life. Education and professional training in the Grundtvigian tradition. Trondheim: Norges teknisk-naturvitenskapelige universitet, NTNU Doctoral Dissertation 2006:88.]

Primary Sources Books Martinsen K. (1975). Filosofi og sykepleie. Et marxistisk og

fenomenologisk bidrag. Filosofisk institutts stensilserie nr. 34. Bergen: Universitetet i Bergen. [Philosophy and nursing: a Marxist and phenomenological contribution. Philosophical Institute’s Stencil Series No. 34. Bergen: University of Bergen.]

Martinsen, K. (1979). Medisin og sykepleie, historie og samfunn. Oslo: Norsk Sykepleierforbund. [Medicine and nursing, history and society. Oslo: The Norwegian Nursing Association.]

Martinsen, K. (1984). Sykepleiens historie. Freidige og uforsagte diakonisser. Et omsorgsyrke vokser fram 1860– 1905. Oslo: Aschehoug/Tanum-Norli. [History of nurs- ing: frank and engaged deaconesses. a caring profession emerges 1860–1905. Oslo: Aschehoug/Tanum-Norli.]

Martinsen, K. (1989). Omsorg, sykepleie og medisin. Historisk-filosofiske essays. Oslo: Tano Forlag. [Caring, nursing and medicine. Historical-philosophical essays. Oslo: Tano Forlag.]

Martinsen, K. (red.) (1993). Den omtenksomme sykepleier. Oslo: Tano. [The thoughtful nurse. Oslo: Tano.]

Martinsen, K. (1993). Fra Marx til Løgstrup. Om moral, samfunnskritikk og sanselighet i sykepleien. Oslo: Tano

Forlag. [From Marx to Løgstrup. On morality, social criti- cism and sensuousness in nursing. Oslo: Tano Forlag.]

Martinsen, K. (1996). Fenomenologi og omsorg. Tre dialoger. Oslo: Tano-Aschehoug. [Phenomenology and caring. Three dialogues. Oslo: Tano-Aschehoug.]

Martinsen, K. (2000). Øyet og kallet. Bergen: Fagbokforlaget. [The eye and the call. Bergen: Fagbokforlaget.]

Martinsen, K. (2005). Samtalen, skjønnet og evidensen. Oslo: Akribe. Dialog, discernment and evidence. Oslo: Akribe.

Martinsen, K. (2006). Care and vulnerability. Oslo: Akribe (English original).

Martinsen, K. (2008). Å se og å innse—om ulike former for evidens. Oslo: Akribe. [To see and to realize—on various forms of evidence. Oslo: Akribe.] (In process with Katie Ericsson).

Martinsen, K. (2012). Løgstrup og sykepleien [Løgstrup and Nursing].Århus: KLIM Forlag.

Martinsen, K. (2012). Løgstrup og sykepleien [Løgstrup and Nursing]. Oslo: Akribe.

Martinsen, K., & Wærness, K. (1979). Pleie uten omsorg? Oslo: Pax Forlag A/S. [Caring without care? Oslo: Pax Forlag.]

Martinsen, K., & Wyller, T. (red.) (2003). Etikk, disiplin og dannelse. Elisabeth Hagemanns etikkbok—Nye lesinger.

BIBLIOGRAPHY*

*Norwegian titles are provided with approximate translation into English.

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Oslo: Gyldendal Akademisk. [Ethics, discipline and refine- ment. Elizabeth Hagemann’s ethics book—new readings. Oslo: Gyldendal Akademisk.]

Thorsen, R., Mæhre, K.S. & Martinsen, K. (red.) (2012). Fortellinger om etikk. [Narratives on ethics]. Bergen: Fagbokforlaget.

Book Chapters Martinsen, K. (1972). Samfunnets krise og sykepleiernes

oppgave. I I. K. Haugen, T. Malmin, S. Midtgaard, & K. Nicolaysen (red.), Pedialogen (s. 3–14). Oslo: Norsk Sykepleierforbund. [The crises of society and the nursing objectives. In I. K. Haugen, T. Malmin, S. Midtgaard, & K. Nicolaysen (Eds.), Pedialog (pp. 3–14). Oslo: Norwegian Nursing Association.]

Martinsen, K. (1972). Sykepleie som sosial-moralsk praksis. I I. K. Haugen, T. Malmin, S. Midtgaard, & K. Nicolaysen (red.), Pedialogen (s. 15–36). Oslo: Norsk Sykepleierfor- bund. [Nursing as social and moral practice. In I. K. Haugen, T. Malmin, S. Midtgaard, & K. Nicolaysen (Eds.), Pedialog (pp. 15–36). Oslo: Norwegian Nursing Association.]

Martinsen, K. (1978). Fra ufaglært fattigsykepleie til profesjonelt yrke—Konsekvenser for omsorg. I B. Persson, K. Ravn, & R. Truelsen (red.), Fokus på syge- plejen-79. Årbok (s. 128–157). København: Munksgaard. [From unskilled nursing the poor to professional occupation—consequences for nursing. In B. Persson, K. Ravn, & R. Truelsen (Eds.), Focus on nursing (Annual 79, pp. 128–157). Copenhagen: Munksgaard.]

Martinsen, K. (1979). Den engelske sanitation-bevegelsen, hygiene og synet på sykdom. I Ø. Larsen (red.), Synet på sykdom (s. 78–87). Oslo: Seksjon for medisinsk historie, Universitetet i Oslo. [The English sanitation movement: Hygiene and the view of illness. In Ø. Larsen (Ed.), The view of illness (pp. 78–87). Oslo: University of Oslo, Section for Medical History.]

Martinsen, K. (1979). Diakonissesykepleiens framvekst. Fra vekkelser og kvinneforeninger til moderhus og fattigomsorg. I NAVF’s sekretariat for kvinneforskning (red.), Lønnet og ulønnet omsorg. En seminarrapport (Arbeidsnotat nr. 5, s. 135–170). Oslo: NAVF. [Devel- opment of the professional trained Christian nurses: From revival and woman’s charitable groups to the mother house and care of the poor. In NAVF’s Secre- tariat for Feminist Research (Ed.), Paid and unpaid care: A seminar report (Working paper no. 5, pp. 135– 170). Oslo: NAVE]

Martinsen, K. (1979). Diakonissene. I E. Mehlum (red.), Bak maskinene, under fanene. Utgitt i forbindelse med “Kristiania-utstillingen” om arbeidsfolk i byen for 100

år siden (s. 54–56). Oslo: Tiden. [Deconesses. In E. Mehlum (Ed.), Behind the machines and the banners (pp. 54–56). Oslo: Tiden.] Published in connection with “The Christiania (Oslo) exhibition” on the condi- tion of workers 100 years ago.

Martinsen, K. (1979). Sykepleien, historien og den omvendte omsorgen. I R. Wendt (red.), Utveckling av omvårdnadsarbete (s. 90–102). Lund: Studentlitteratur. [Nursing, history and the converse caring. In R. Wendt (Ed.), Development of health care (pp. 90–102). Lund: Studentlitteratur.]

Martinsen, K. (1979). Sykepleien i historisk perspektiv: Fra omsorg mot egenomsorg. I M. S. Fagermoen & R. Nord (red.), Sykepleie: Teori/praksis (s. 5–23). Oslo: Norwegian Nursing Association. [Nursing in a historical perspec- tive: from care to self caring. In M. S. Fagermoen & R. Nord (Eds.), Nursing: Theory/practice (pp. 5–23). Oslo: Norwegian Nursing Association.]

Martinsen, K. (1981). Diakonisser. I H. F. Dahl, J. Elster, I. Iversen, S. Nørve, T. I. Romøren, R. Slagstad, m.fl. (red.), Pax leksikon. Oslo: Pax Forlag (s. 89–90). [Deaconessses. In H. F. Dahl, J. Elster, I. Iversen, S. Nørve, T. I. Romøren, R. Slagstad, et al. (Eds.), Pax lexicon (pp. 89–90). Oslo: Pax Forlag.]

Martinsen, K. (1981). Guldberg, Cathinka. I H. F. Dahl, J. Elster, I. Iversen, S. Nørve, T. I. Romøren, R. Slagstad, m.fl. (red.), Pax leksikon (s. 553-554). Oslo: Pax forlag. [Guldberg, Cathinka. In H. F. Dahl, J. Elster, I. Iversen, S. Nørve, T. I. Romøren, R. Slagstad, et al. (Eds.), Pax lexicon (pp. 553–554). Oslo: Pax Forlag.]

Martinsen, K. (1981). Nightingale, Florence. I H. F. Dahl, J. Elster, I. Iversen, S. Nørve, T. I. Romøren, R. Slagstad, m.fl. (red.), Pax leksikon (s. 448–449). [Nightingale, Florence. In H. F. Dahl, J. Elster, I. Iversen, S. Nørve, T. I. Romøren, R. Slagstad, et al. (Eds.), Pax lexicon (pp. 448–449). Oslo: Pax Forlag.]

Martinsen, K. (1981). Omsorg i sykepleie. I E. Barnes & S. Solbak (red.), Sykepleielœre 1.Lœrebok for hjelpepleiere (Kap. 3). Oslo: Aschehoug. [Care in nursing. In E. Barnes & S. Solbak (Eds.), Nursing textbook 1. Textbook for licensed practical nurses (Chapter 3). Oslo:Aschehoug.]

Martinsen, K. (1981). Sykepleier. I H. F. Dahl, J. Elster, I. Iversen, S. Nørve, T. I. Romøren, R. Slagstad, m.fl. (red.), Pax leksikon (s. 179–180). [Nurse. In H. F. Dahl, J. Elster, I. Iversen, S. Nørve, T. I. Romøren, R. Slagstad, et al. (Eds.), Pax lexicon (pp. 179–180). Oslo: PaxForlag.]

Martinsen, K. (1981). Sykepleieraksjonen 1972. I H. F. Dahl, J. Elster, I. Iversen, S. Nørve, T. I. Romøren, R. Slagstad, m.fl. (red.), Pax leksikon (s. 180–181). Oslo: Pax forlag. [Nurses on strike 1972. In H. F. Dahl, J. Elster, I. Iversen,

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S. Nørve, T. I. Romøren, R. Slagstad, et al. (Eds.), Pax lexicon (pp. 180–181). Oslo: Pax Forlag.]

Martinsen, K. (1981). Sykepleierforbund, Norsk (NSF). I H. F. Dahl, J. Elster, I. Iversen, S. Nørve, T. I. Romøren, R. Slagstad, m.fl. (red.), Pax leksikon (s. 181– 183). Oslo: Pax Forlag. [Nursing association. In H. F. Dahl, J. Elster, I. Iversen, S. Nørve, T. I. Romøren, R. Slagstad, et al. (Eds.), Pax lexicon (pp. 181–183). Oslo: Pax Forlag.]

Martinsen, K. (1981). Trekk av hjelpepleiernes historie. I E. Barnes & S. Solbak (red.), Sykepleielœre 1. Lœrebok for hjelpepleiere. (Kap. 2). Oslo: Aschehoug. [Aspects of licensed practical nurse history. In E. Barnes & S. Solbak (Eds.), Nursing textbook 1. Textbook for licensed practical nurses (Chapter 2). Oslo: Aschehoug.]

Martinsen, K. (1985). Organisering av omsorg: diakonisser i Norge. I J. Bjørgum, K. Gundersen, S. Lie, & K. Vogt (red.), Kvinnenes kulturhistorie (s. 131–134). Oslo: Universitetsforlaget. [Organization of care: deaconesses in Norway. In J. Bjørgum, K. Gundersen, S. Lie, & K. Vogt (Eds.), Woman’s cultural history (pp. 131–134). Oslo: Universitetsforlaget.]

Martinsen, K. (1986). Sykepleierne—Helsemisjonerer, oppdragere og profesjonelle yrkeskvinner. I I. Fredriksen & H. Rømer (red.), Kvinder, Mentalitet og arbejde. Kvin- dehistorisk forskning i Norden (s. 151–156). Aarhus: Aarhus universitetsforlag. [Nurses—health missionaries, educators and professional working women. In I. Fredriksen & H. Rømer (Eds.), Woman, mentality and work: research on feminist history in Nordic countries (pp. 151–156). Aarhus: Aarhus universitetsforlag.]

Martinsen, K. (1987). Ledelse og omsorgsrasjonalitet—Gir patriarkatbegrepet innsikt? I NAVFs sekretariat for kvin- neforskning (red.), Kjønn og makt: teoretiske perspektiver (s. 18–26). Arbeidsnotat nr. 2. Oslo: NAVE [Leadership and rationality of care—does the concept of patriarchy yield insight? In Gender and power: theoretical perspec- tives (Working paper no. 2, pp. 18–26). Oslo: NAVF.]

Martinsen K. (1989). Omsorg i sykepleien—In moralsk utfordring. I B. Persson, J. Petersen, & R. Truelsen (red.), Fokus på sygeplejen-90 (s. 181–200). København: Munksgaard. [Caring in nursing—a moral challenge. In B. Persson, J. Petersen, & R. Truelsen (Eds.), Focus on Nursing—90 (pp. 181–200). Copenhagen: Munksgaard.]

Martinsen, K. (1990). Fra resultater til situasjoner: Omsorg, makt og solidaritet. I Samkvind (Center for samfundsvidenskabelig kvindeforskning). Kvinder og kommuner i Norden (s. 61–82), København: Samkvind. [From results to situations: Care, power and solidarity. In Samkvind (Center for Feminist Research), Woman and municipals in Nordic countries (pp. 61–82). Copenhagen: Samkvind.]

Martinsen, K. (1990). Moralsk praksis og dokumentasjon i praktisk sykepleie. I T. Jensen, L. U. Jensen, & W. C. Kim (red.), Grundlagsproblemer i sygeplejen. Etik, videnskabsteori, ledelse & samfunn (s. 60–84). Aarhus: Philosophia. [Moral practice and documentation in practical nursing. In T. Jensen, L. U. Jensen, & W. C. Kim, Foundational problems in nursing: ethics, theories of science, leadership and society(pp. 60–84). Aarhus: Philosophia.]

Martinsen, K. (1993). Etikk og diakoni. I P. Frølich, J. Midtbø, & A. Tang, Bergen Diakonissehjem 75 år (s. 22-26). Bergen: Bergen Diakonissehjem. [Etichs and Diaconi. In P. Frølich, J. Midtbø, & A. Tang, Bergen Diakonissehjem 75 years (pp. 22–26). Bergen: Bergen Diakonissehjem.]

Martinsen, K. (1993). Omsorgens filosofi og dens praksis. I H. M. Dahl (red.), Omsorg og kjœrlighet i velfœrdsstaten (Samfundsvidenskabelig kvindefor- skning/Cekvina (s. 7–23). Århus: Universitetet i Århus. [Caring philosophy and its practice. In H. M. Dahl (Ed.), Care and love in the welfare state (Social scientifi- cally woman studies, pp. 7–23). Århus: The University ofÅrhus.]

Martinsen, K. (1995). Omsorgsfeltet i den kliniske syge- pleje. I I. Andersen & M. G. Erikstrup (red.), Statens sundhedsvidenskabelige forskningsråds sygeplejeforskn- ingsinitiativ. Betydning for sygeplejepraksis (s. 31–43). Århus: Århus Universitet. [Area for care in clinical nursing. In I. Andersen & M. G. Erikstrup (Eds.), The state’s initiative in nursing science. the significance for nursing practice (pp. 31–43). Århus: Århus University.]

Martinsen, K. (1997). Etikk og kall, kultur og kropp—En dialog med Patricia Benner. I M. Sæther (red.), Syke- pleiekonferanse på Nordkalottens tak (s. 111–157). Tromsø: Universitetet i Tromsø. [Ethics and vocation, culture and the body—a dialogue with Patricia Benner. In M. Sæther (Ed.), Nursing conference on the roof of Nordkalotten (pp. 111–157). Tromsø: University of Tromsø.]

Martinsen, K. (1999). Etikken og kulturen, og kroppens sårbarhet. I K. Christensen & L. J. Syltevik (red.), Omsorgens forvitring? En antologi om utfordringer i velferdsstaten—Tilegnet Kari Wærness (s. 241–269). Bergen: Fagbokforlaget. [Ethics and culture, and vulnerability of the body. In K. Christensen & L. J. Syltevik (Eds.), Weathering of caring? An anthology about challenges in the welfare state—dedicated to Kari Wœrness (pp. 241–269). Bergen:Fagbokforlaget.]

Martinsen, K. (2000). Kjærlighetsgjerningen og kallet. Betraktninger omkring Rikke Nissens “Lærebog i Sygepleje for diakonisser”. I R. Nissen, Lœrebog i Sygepleie. Med etterord av Kari Martinsen (s. 245–300). Oslo: Gyldendal Akademisk. [The loving act and the

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call. Reflections on Rikke Nissen’s Textbook of nursing for deaconesses. In R. Nissen, Textbook of nursing. With afterword by Kari Martinsen (pp. 245–300). Oslo: Gyldendal Akademisk.]

Martinsen, K. (2001). Huset og sangen, gråten og skammen. Rom og arkitektur som ivaretaker av menneskets verdighet. I T. Wyller (red.), Skam: Perspektiver på skam, œre og skamløshet i det moderne (s. 167–190). Bergen: Fagbokforlaget. [The house and the song, the tears and the shame: space and architecture as caretakers of human dignity. In T. Wyller (Ed.), Shame: perspectives on shame, honor and shamelessness in modernity (pp. 167–190). Bergen: Fagbokforlaget.]

Martinsen, K. (2002). Rikke Nissen. Kjærlighetsgjerningen og sykestuen. I R. Birkelund (red.), Omsorg, kald og kamp. Personer og ideer i sygeplejens historie (s. 305– 328). København: Munksgaard forlag. [The loving act and the room for the sick. In R. Birkelund (Ed.), Care, vocation and love in action and the sick-room. Persons and ideas in nursing history (pp. 305–328). Copenhagen: Munksgaard.]

Martinsen, K. (2002). Rommets tid, den sykes tid, pleiens tid. I I. T. Bjørk, S. Helseth, & F. Nortvedt (red.), Møte mellom pasient og sykepleier (s. 250–271). Oslo: Gyldendal Akademisk. [The room’s time, the ill person’s time, nursing time. In I. T. Bjørk, S. Helseth, & F. Nort- vedt (Eds.), The meeting between patient and nurse (pp. 250–271). Oslo: Gyldendal Akademisk.]

Martinsen, K. (2003). Disiplin og rommelighet. I K. Martinsen & T. Wyller (red.), Etikk, disiplin og dannelse. Elisabeth Hagemanns etikkbok—Nye lesinger (s. 51–85). Oslo: Gyldendal Akademisk. [Discipline and spaciousness. In K. Martinsen & T. Wyller (Eds.), Ethics, discipline and refinement. Elizabeth Hagemann’s ethics book—new readings (pp. 51–85). Oslo: Gyldendal Akademisk.]

Martinsen, K. (2005). Å bo på sykehuset og erfare arki- tektur. I K. Larsen (red.), Arkitektur, kropp og løring. København: Reitzels forlag. [To dwell in hospitals and experience architecture. In K. Larsen (Ed.), Architecture, body and learning. Copenhagen: Reitzels forlag.]

Martinsen, K. (2005). Sårbarheten og omveiene. Løgstrup og sykepleien. I D. Bugge, P. Bøvadt and P. Sørensen (red.). Løgstrups mange ansikter (s. 255–270). Fredriksberg: Anis. [Vulnerability and detours. Løgstrup and nursing. In D. Bugge, P. Bøvadt, and P. Sørensen (Eds.). Løgstrup’s many faces (pp. 255–270). Fredriksberg: Anis.]

Martinsen, K. (2007). Angår du meg? Etisk fordring og disiplinert godhet. I H. Alvsvåg & O. Førland (red.). Engasjement og lœring (s. 315–344). Oslo: Akribe. [Do you concern me? Ethical demand and disciplined

goodness. In H. Alvsvåg & O. Førland (Ed.), Commit- ment and learning (pp 315–344) Oslo: Akribe.]

Martinsen, K., Beedholm, K., and Fredriksen, K. (2007). Metadebatten der forsvandt. I K. Fredriksen, K. Lomborg, & U. Zeitler (red.). Perspektiver på forskning (s. 43–55). Århus: JCVU udviklingsinitiativet for syge- plejerskeuddannelsen. [The Meta debate that disap- peared. In K. Fredriksen, K. Lomborg, and U. Zeitler (Eds.). Perspectives on research (pp 43–55). Århus: JCVU udviklingsinitiativet for sygeplejerskeuddannelsen.

Martinsen, K. (2008). Modernitet, avtrylling og skam. En måte å lese vestens medisin på i det moderne. In K. A. Petersen and M. Høyen (red.). At sette spor på en vandring fra Aquinas til Bordieu—æresbog til Staf Callewaert. [email protected] [Modernity, disenchant- ment and shame. A way of reading Western medicine in the modern. In K. A. Petersen and M. Høyen (Eds.), Leaving a trail on the way from Aquinas to Bordieu— honorary volume for Staf Callewaert. [email protected]]

Martinsen, K. (2012). Skammens to sider [The two faces of shame]. In Thorsen, R., Mæhre, K. S., & Martinsen, K. (Eds.), (2012). Fortellinger om etikk [Narratives on eth- ics]. Bergen: Fagbokforlaget.

Martinsen, K. (2012). Etikk i sykepleien—mellom spon- tanitet og ettertanke [Ethics in Nursing—between spontaneity and reflection]. In: M. Pahuus & P.K. Telleus (Eds.), Antologi—Anvendt etikk—problemer og arbejdsområder [Anthology—Applied Ethics— Problems and areas of application]. Aalborg: Aalborg Univer- sitetsforlag [Aalborg University Press].

Journal Articles Martinsen, K. (1976). Historie og sykepleie—Momenter til

en utdanningsdebatt. Kontrast, 7(12), 430-446. [History and nursing—Elements of an educational debate. Con- trast, 7(12), 430–446.]

Martinsen, K. (1977). Nightingale—Ingen opprører bak myten. Sykepleien, 18(65), 1022–1025. [Nightingale— No rebel behind the myth. Nursing, 18(65),1022–1025.]

Martinsen, K. (1978). Det ‘kliniske blikk’ i medisinen og i sykepleien. Sykepleien, 20(66), 1271–1272. [The “clini- cal gaze” in medicine and in nursing. Nursing, 20(66), 1271–1272.]

Martinsen, K. (1981). Omsorgens filosofi og omsorg i praksis. Sykepleien, 8(69), 4–10. [The philosophy of caring—And the practice. Nursing, 8(69), 4-10.]

Martinsen, K. (1982). Den tvetydige veldedigheten. Sosiologi i dag, temanummer Kvinner og omsorgsarbeid, 1(12), 29-41. [The ambiguity of charity. Sociology, 1(12), 29–41.]

Martinsen, K. (1982). Diakonissene—De første faglærte sykepleiere. Sykepleien, 7(70), 6–9. [The deaconesses— The first professionally trained nurses. Nursing, 7(70), 6–9.]

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Martinsen, K. (1985). Kallsarbeidere og yrkeskvinner: Diakonissene—Våre første sykepleiere. Forskningsnytt, temanummer: Kvinner og arbeid, 1,18-23. [Women with a calling and a profession: the deaconesses—our first nurses. News in Science, 1,18–23.]

Martinsen, K. (1985). Sykepleiertradisjonen—Et nødvendig korrektiv til dagens sykepleieforskning. Sykepleien, 15(73), 6–14. [The nursing tradition—a necessary cor- rective to today’s nursing science. Nursing, 15(73), 6–14.]

Martinsen, K. (1986). Omsorg og profesjonalisering—Med fagutviklingen i sykepleien som eksempel. Nytt om kvinneforskning, 2(10), 21–32. [Care and professionalism— an example from the development in nursing. News in Woman Science, 2(10), 21–32.]

Martinsen, K. (1987). Arbeidsdeling—Kjønn og makt. Sykepleien, 1(74), 18–23. [Division of labor—gender and power. Nursing, 1(74), 18–23.]

Martinsen, K. (1987). Endret kunnskapsideal og to plei- egrupper. Sykepleien, 4(74), 20–25. [A changing para- digm and two types of nurses. Nursing, 4(74), 20–25.]

Martinsen, K. (1987). Helsepolitiske problemer og helse- politisk tenkning bak sykehusloven av 1969. Historisk tidsskrift, 3(66), 357–372. [Health policy problems and health policy thinking underlying the new hospital law. History, 3(66), 357–372.]

Martinsen, K. (1987). Ledelse og omsorgsrasjonalitet—Gir patriarkatbegrepet innsikt? Sykepleien, 1(74), 18–23. [Management and caring rationality—Does the concept of patriarchate give insight? Nursing, 1(74), 18–23.]

Martinsen, K. (1987). Legers interesse for svangerskapet— En del av den perinatale omsorg. Tidsrommet ca. 1890- 1940. Historisk tidsskrift, 3(66), 373–390. [Doctors’ in- terests in pregnancy—a part of perinatal care. History, 3(66), 373–390.]

Martinsen, K. (1987). Norsk Sykepleierskeforbund på bar- rikadene for utdanning fra første stund. Sykepleien, 3(74), 6–12. [The Norwegian Nursing Association on the barricades from day one. Nursing, 3(74), 6–12.]

Martinsen, K. (1988). Ansvar og solidaritet. En moral- filosofisk og sosialpolitisk forståelse av omsorg. Syke- pleien, 12(75), 17–21. [Responsibility and solidarity. A moral-philosophical and sociopolitical understanding of caring. Nursing, 12(75)17–21.]

Martinsen, K. (1988). Etikk og omsorgsmoral. Sykepleien, 13(75), 16–20. [Ethics and the moral practice of caring. Nursing, 13(75), 16–20.]

Martinsen, K. (1990). Diakoni er fellesskap og samhørighet. Under Ulriken, 5(30), 6–10. [Diaconi is community and fellowship. Under Ulrikken, 5(30), 6–10.]

Martinsen, K. (1991). Omsorg og makt, ord og kropp i sykepleien. Sykepleien, 2(78), 2–11, 29. [Caring and

power, word and body in nursing profession. Nursing, 2(78), 2–11,29.]

Martinsen, K. (1991). Under kjærlig forskning. Fenome- nologiens åpning for den levde erfaring i sykepleien. Perspektiv—Sygeplejersken, 36(91), 4–15. [Compassion- ate research. Phenomenology opening up for lived experience in nursing. Perspective—Nursing (Danish), 36(91), 4–15.]

Martinsen, K. (1993). Grunnforskning—Trofast og troløs forskning—Noen fenomenologiske overvei- elser. Tidsskrift for Sygeplejeforskning, 1(9), 7–28. [Basic research—Faithful and faithless research— Some phenomenological considerations. Nursing Research (Danish), 1(9), 7–28.]

Martinsen, K. (1997). De etiske fortellinger. Omsorg, 1(14), 58–63. [The ethical narratives. Caring, 1(14), 58–63.]

Martinsen, K. (1997). Kallet—Kan vi være det foruten? Tidsskrift for sygeplejeforskning, 2(13), 9–41. [The vocation—Can we do without it? Nursing Science, 2(13), 9–41.]

Martinsen, K. (1998). Det fremmede og vedkommende (I). Klinisk Sygepleje, 1(12), 13–19. [Strangeness and rele- vance (I). Clinical Nursing, 1(12), 13–19.]

Martinsen, K. (1998). Det fremmede og vedkommende (II). Klinisk Sygepleje, 1-2(12), 78–84. [Strangeness and relevance (II). Clinical Nursing, 2(12), 78–84.]

Martinsen, K. (2001). Er det mørketid for filosofien? Et svar til Marit Kirkevold. Tidsskrift for sygeplejeforskning (dansk), 1(17), 1923. [Is philosophy in shadow? A reply to Marit Kirkevold. Nursing Science (Danish), 1(17), 19–23.]

Martinsen, K. (2002). Livsfilosonske betraktninger. I Dia- koninytt, 3(118), 8–12. [Reflections on the philosophy of life. Deaconry News, 3(118), 8–12.]

Martinsen, K. (2002). Samtalen, kommunikasjonen og sakligheten i omsorgsyrkene. Omsorg, 1(19), 14–22. [Conversation, communication and professionality in the caring professions. Caring, 1(19), 14–22.]

Martinsen, K. (2003). Talens åpenhet og evidens—Dialog med Jens Bydam. Klinisk Sygepleje, 4(17), 3–46. [The openness of speech and evidence—Dialogue with Jens Bydam. Clinical Nursing, 4(17), 36–46.]

Martinsen, K. (2004). Skjønn—Språk og distanse: dialog med Jens Bydam. Klinisk Sygepleje, 2(18), 50–56. [Discernment—Language and distance: Dialogue with Jens Bydam. Clinical Nursing, 2(18), 50–56.]

Martinsen, K. (2008). Innfallet—og dets betydning i liv og arbeid. Metafysisk inspirerte overveielser over innfall- ets natur og måter å vise seg på. Klinisk Sygepleje, 1(22), [The Innfall (impulse)—and its significance in life and work. Metaphysically inspired reflections on the nature of the Innfall and its ways of showing itself. Clinical Nursing, 1(22)]

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Martinsen, K. (2012).Filosofi og fortellinger om sårbarhet [Philosophy and narratives of vulnerability]. In Klinisk Sygepleje [Clinical Nursing], 2(26), 30–37.

Sviland, R., Martinsen, K., & Råheim, M. (2007).Hvis ikke kropp og psyke—hva da? [If not body, not psyche—what then?] Fysioterapeuten [The Physiotherapeut] 12, 23–28.

Sviland, R., Råheim, M. & Martinsen, K. (2009).Å komme til seg selv – i bevegelse, sansingog forståelse [Coming to one’s senses—in moving, sensing, understanding]. Matrix; 2, 257–275.

Sviland, R., Råheim, M., & Martinsen, K. (2010).Språk— uttrykk for inntrykk [Language—expressing impressions]. Matrix, 2, 132–156.

Martinsen, K., & Wærness, K. (1976). Sykepleierrollen— En undertrykt kvinnerolle i helsesektoren (I). Sykepleien, 4(64), 220–224. [The nursing role—An oppressed female role in National Health Service. Nursing, 4(64), 220–224.]

Martinsen, K., & Wærness, K. (1976). Sykepleierrollen— En undertrykt kvinnerolle i Helsesektoren (II). Syke- pleien, 5(64), 274–275, 281–282. [The nursing role—An oppressed female role in National Health Service. Nurs- ing, 5(64), 274–275, 281–282.]

Martinsen, K., & Wærness, K. (1980). Klientomsorg og profesjonalisering. Sykepleien, 4(68), 12–14. [Client care and the professionalization. Nursing, 4(68), 12–14.]

Publications in Press Sviland, R., Råheim, M., & Martinsen, K. Touched in

sensation—moved by respiration. Embodied narrative identity—a treatment process. Scandinavian Journal of Caring Sciences.

Secondary Sources Alvsvåg, H., & Gjengedal, E. (red.) (2000). Omsorgsten-

kning. En innføring i Kari Martinsens forfatterskap. Ber- gen: Fagbokforlaget. [Caring thought: An introduction to the writings of Kari Martinsen. Bergen: Fagbokforlaget.]

Austgard, K. (2010). Omsorgsfilosofi i praksis. Å tenke med filosofen Kari Martinsen i sykepleien. Oslo: Cappelen Akademisk Forlag. [Philosophy of caring in practice: Thinking with philosopher Kari Martinsen in nursing. Oslo: Cappelen Akademisk Forlag.]

Boge, J. (2011). Kroppsvask i sjukepleie. Eit politisk og historisk perspektiv [Bathing the patient. A political and historical perspective]. Oslo: Akribe.

Jørgensen, B. B., & Lyngaa, J. (red.) (2008). Sygeplejeleksikon. København: Munksgaard. [Encyclopedia of Nursing. Copenhagen: Munksgaard.]

Mathisen, J. (2006). Sykepleiehistorie [History of Nursing]. Oslo: Gyldendal Akademisk.

Mekki, T. E., & Tollefsen, S. (2000). På terskelen. Introduk- sjon til sykepleie som fag og yrke. Oslo: Akribe. [On the threshold: An introduction to nursing as discipline and profession. Oslo: Akribe.]

Olsen, R. (1998). Klok av erfaring? Om sansing og opp-merksomhet, kunnskap og refleksjon i praktisk sykepleie. Oslo: Tano Aschehoug. [Wise with experi- ence? On sensation and attention, knowledge and reflec- tion in practical nursing. Oslo: Tano Aschehoug.]

Overgaard, A. E. (2003). Åndelig omsorg—En lœrebog. Kari Martinsen, Katie Eriksson og Joyce Travelbee i nytt lys. København: Nyt Nordisk Forlag Arnold Busck. [Spiri- tual care—A textbook. Kari Martinsen, Katie Eriksson and Joyce Travelbee in a new light. Copenhagen: Nyt Nordisk Forlag Arnold Busck.]

Walstad, P. B. (2006). Dannelse og Duelighed for livet. Dan- nelse og yrkesutdanning i den grundtvigske tradisjon. Trondheim: Norges teknisk-naturvitenskapelige univer- sitet. Doctoral dissertation 2006:88. [Education and Ca- pability for life. Education and professional training in the Grundtvigian tradition. Trondheim: Norges teknisk- naturvitenskapelige universitet, NTNU Doctoral Dis- sertations 2006:88.]

171

Katie Eriksson 1943 to Present

CH A P T ER 11

Theory of Caritative Caring Unni Å. Lindström, Lisbet Lindholm Nyström, and Joan E. Zetterlund

Credentials of the Theorist Katie Eriksson is one of the pioneers of caring science in the Nordic countries. When she started her career 30 years ago, she had to open the way for a new science. We who followed her work and progress in Finland have noticed her ability from the beginning to design caring science as a discipline, while bringing to life the abstract substance of caring.

Eriksson was born on November 18, 1943, in Jakobstad, Finland. She belongs to the Finland- Swedish minority in Finland, and her native lan- guage is Swedish. She is a 1965 graduate of the Helsinki Swedish School of Nursing, and in 1967, she completed her public health nursing specialty education at the same institution. She graduated in 1970 from the nursing teacher education program at Helsinki Finnish School of Nursing. She contin- ued her academic studies at University of Helsinki,

“Caritative caring means that we take “caritas” into use when caring for the human being in health and suffering . . . Caritative caring is a manifestation of the love that ‘just exists’ . . . Caring communion,

true caring, occurs when the one caring in a spirit of caritas alleviates the suffering of the patient” (Eriksson, 1992c, pp. 204, 207).

where she received her MA degree in philosophy in 1974 and her licentiate degree in 1976; she defended her doctoral dissertation in pedagogy (The Patient Care Process—An Approach to Curriculum Construc- tion within Nursing Education: The Development of a Model for the Patient Care Process and an Approach for Curriculum Development Based on the Process of Patient Care) in 1982 (Eriksson, 1974, 1976, 1981). In 1984, Eriksson was appointed Docent of Caring Sci- ence (part time) at University of Kuopio, the first docentship in caring science in the Nordic countries. She was appointed Professor of Caring Science at Åbo Akademi University in 1992. Between 1993 and 1999, she held a professorship in caring science at University of Helsinki, Faculty of Medicine, where she has been a docent since 2001. Since 1996, she has also served as Director of Nursing at Helsinki University Cen- tral Hospital, with responsibilities for research and

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a research program for caring science, was created. The result of her planning was the Department of Car- ing Science in 1987. It became an autonomous depart- ment within the Faculty of Education of Åbo Akademi University until 1992, when a Faculty of Social and Caring Sciences was founded. Eriksson developed an academic education for Masters and Doctoral degrees in Caring Science. The doctoral program started in 1987 under Eriksson’s direction, and 44 doctoral dis- sertations have been published.

With her staff and researchers, Eriksson has further developed the caritative theory of caring and caring science as an academic discipline. The department has a leading position in the Nordic countries with stu- dents and researchers. In addition to her work with teaching, research, and supervision, Eriksson has been the dean of the Department of Caring Science. One of her central tasks has been to develop Nordic and international contacts within caring science.

Eriksson has been a very popular guest and keynote speaker, not only in Finland, but in all the Nordic countries and at various international congresses. In 1977, she was a guest speaker at the Symposium of Medical and Nursing Education in Istanbul, Turkey; in 1978, she participated in the Foundation of Medical Care teacher education in Reykjavik, Iceland; in 1982, she presented her nursing care didactic model at the First Open Conference of the Workgroup of European Nurse-Researchers in Uppsala, Sweden; and for several years, she participated in education and advanced edu- cation of nurses at the Statens Utdanningscenter for Helsopersonell in Oslo, Norway. In 1988, Eriksson taught “Basic Research in Nursing Care Science” at the University in Bergen, Norway, and “Nursing Care Science’s Theory of Science and Research” at Umeå University in Sweden. She consulted at many educa- tional institutions in Sweden; she has been a regular lecturer at Nordiska Hälsovårdsskolan in Gothenburg, Sweden. In 1991, she was a guest speaker at the 13th International Association for Human Caring (IAHC) Conference in Rochester, New York; in 1992, she pre- sented her theory at the 14th IAHC Conference in Melbourne, Australia; and in 1993, she was the key- note speaker at the 15th IAHC Conference, Caring as Healing: Renewal Through Hope, in Portland, Oregon (Eriksson, 1994b).

Eriksson has been a yearly keynote speaker at the annual congresses for nurse managers and, since 1996,

development of caring science in connection with her professorship at Åbo Akademi University.

In the late 1960s and early 1970s, Eriksson worked in various fields of nursing practice and continued her studies at the same time. Her main area of work has been in teaching and research. Since the 1970s, Eriksson has systematically deepened her thoughts about caring, partly through development of an ideal model for caring that formed the basis for the carita- tive caring theory, and partly through the develop- ment of an autonomous, humanistically oriented caring science. Eriksson, one of the few caring sci- ence researchers in the Nordic countries, developed a caring theory and is a forerunner of basic research in caring science.

Eriksson’s scientific career and professional experi- ence comprise two periods: the years 1970 to 1986 at Helsinki Swedish School of Nursing, and the period from 1986, when she founded the Department of Caring Science at Åbo Akademi University, which she has directed since 1987.

In 1972, after teaching for 2 years at the nursing education unit at Helsinki Swedish School of Nursing, Eriksson was assigned to start and develop an educa- tional program to prepare nurse educators at that institution. Such a program taught in the Swedish lan- guage had not existed in Finland. This education program, in collaboration with University of Helsinki, was the beginning of caring science didactics. Under Eriksson’s leadership, Helsinki Swedish School of Nursing developed a leading educational program in caring science and nursing in the Nordic countries. It was the forerunner of education based on caring sci- ence and integration of research in education. Eriksson was in charge of the program for 2 years, until she became dean at Helsinki Swedish School of Nursing in 1974. She remained the dean until 1986, when she was nominated to start academic education and research at Åbo Akademi University.

Toward the end of the 1980s, nursing science be- came a university subject in Finland, and professorial chairs were established at four Finnish universities and at Åbo Akademi University, the Finland-Swedish uni- versity. In 1986, Eriksson was called to plan an educa- tion and research program within the subject of caring science at Åbo Akademi University’s Faculty of Educa- tion in Vaasa, Finland. A fully developed education program for health care, with three focus options and

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Award in Finland; in 1987, she received the Sophie Mannerheim Medal of the Swedish Nursing Associa- tion in Finland; and in 1998, she received the Caring Science Gold Mark for academic nursing care at Helsinki University Central Hospital. Also in 1998, she received an Honorary Doctorate in Public Health from the Nordic School of Public Health in Gothenburg, Sweden. Other awards include the 2001 Åland Islands Medal for caring science and the 2003 Topelius Medal, instituted by Åbo Akademi University for excellent research. In 2003, she was honored nationally as a Knight, First Class, of the Order of the White Rose of Finland.

Theoretical Sources Ever since the mid 1970s, Eriksson’s leading thoughts have been not only to develop the substance of caring, but also to develop caring science as an independent discipline (Eriksson, 1988). From the beginning, Eriksson wanted to go back to the Greek classics by Plato, Socrates, and Aristotle, from whom she found her inspiration for the development of both the sub- stance and the discipline of caring science (Eriksson, 1987a). From her basic idea of caring science as a humanistic science, she developed a meta-theory that she refers to as “the theory of science for caring science” (Eriksson, 1988, 2001).

When developing caring science as an academic discipline, Eriksson’s most important sources of inspira- tion besides Plato and Aristotle were Swedish theolo- gian Anders Nygren (1972) and Hans-Georg Gadamer (1960/1994). Nygren and later Tage Kurtén (1987) pro- vided her with support for her division of caring science into systematic and clinical caring science. Eriksson introduces Nygren’s concepts of motive research, con- text of meaning, and basic motive, which give the disci- pline structure. The aim of motive research is to find the essential context, the leading idea of caring. The idea of motive research applied to caring science is to show the characteristics of caring (Eriksson, 1992c).

The basic motive in caring science and caring for Eriksson is caritas, which constitutes the leading idea and keeps the various elements together. It gives both the substance and the discipline of caring science a distinctive character. In development of the basic motive, St. Augustine (1957) and Søren Kierkegaard (1843/1943) became important sources. In further

at the annual caring science symposia in Helsinki, Finland. In many public dialogues with Kari Martinsen from Norway, Eriksson has discussed basic questions about caring and caring science. Some dialogues have been published (Martinsen, 1996; Martinsen & Eriksson, 2009).

Eriksson worked as a leader of many symposia: the 1975 Nordic Symposium about the Nursing Care Pro- cess (the first Nordic Nursing Care Science Symposium in Finland); the 1982 Symposium in Basic Research in Nursing Care Science; the 1985 Nordic Symposium in Nursing Care Science; the 1989 Nordic Humanistic Caring Symposium; the 1991 Nordic Caring Science Conference, “Caritas & Passio in Vaasa, Finland”; and the 1993 Nordic Caring Science Conference, “To Care or Not to Care—The Key Question” in Nursing in Vaasa, Finland.

Eriksson’s caritative theory of caring came into clearer focus internationally in 1997, when the IAHC for the first time arranged its conference in a European country. The Department of Caring Science served as the host of this conference, which was arranged in Helsinki, Finland, with the topic, “Human Caring: The Primacy of Love and Existential Suffering.”

Eriksson is a member of several editorial committees for international journals in nursing and caring science. She has been invited to many universities in Finland and other Nordic countries as a faculty opponent for doctoral students and an expert consultant in her field. She is an advisor for her own research students and for research students at Kuopio and Helsinki Universities, where she is an associate professor (docent). Eriksson served as chairperson of the Nordic Academy of Caring Science from 1999 to 2002.

Eriksson has produced an extensive list of text- books, scientific reports, professional journal articles, and short papers. Her publications started in the 1970s and include about 400 titles. Some of her pub- lications have been translated into other languages, mainly into Finnish. Vårdandets Idé [The Idea of Car- ing] has been published in Braille. Her first English translation, The Suffering Human Being [Den Lidande Människan], was published in 2006 by Nordic Studies Press in Chicago.

Eriksson has received many awards and honors for her professional and academic accomplishments. In 1975, she was nominated to receive the 3M-ICN (International Council of Nurses) Nursing Fellowship

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development of the discipline, Eriksson’s thinking was influenced by sources such as Thomas Kuhn (1971) and Karl Popper (1997), and later by American philosopher Susan Langer (1942) and Finnish phi- losophers Eino Kaila (1939) and Georg von Wright (1986), all of whom support the human science idea that science cannot exist without values.

For many years, Eriksson collaborated with Håkan Törnebohm (1978), holder of the first Nordic profes- sorial chair in the theory of science at the University of Gothenburg, Sweden. It is especially Törnebohm’s research in and development of paradigms related to various scientific cultures that inspired Eriksson (Eriksson, 1989; Lindström, 1992).

The thought that concepts have both meaning and substance has been prominent in Eriksson’s scientific work. This appears through a systematic analysis of fundamental concepts with the help of a semantic method of analysis rooted in the idea of hermeneu- tics, which professor Peep Koort (1975) developed. Koort was Eriksson’s mentor and unmistakably the most important source of inspiration in her scientific work. Building on the foundation of his methodology, Eriksson subsequently developed a model for concept development that has been of great importance to many researchers in their scientific work.

In her formulation of the caritas-based caring ethic, which Eriksson conceives as an ontological

ethic, Emmanuel Lévinas’ (1988) idea that ethics pre- cedes ontology has been a guiding principle. Eriksson agrees especially with Lévinas’ thought that the call to serve precedes dialogue, that ethics is always more important in relations with other human be- ings. The fundamental substance of ethics—caritas, love, and charity—is supported further by Aristotle’s (1993), Nygren’s (1972), Kierkegaard’s (1843/1943), and St. Augustine’s (1957) ideas. In the formulation of caritative ethics, Eriksson has been inspired by Kierkegaard’s ideas of the innermost spirit of a human being as a synthesis of the eternal and temporal, and that acting ethically is to will absolutely or to will the eternal (Kierkegaard, 1843/1943). She stresses the importance of knowledge of history of ideas for the preservation of the whole of spiritual culture and finds support for this in Nikolaj Berdâev (1990), the Russian philosopher and historian. In intensifying the basic conception of the human being as body, soul, and spirit, Eriksson carries on an interesting dia- logue with several theologians such as Gustaf Wingren (1960/1996), Antonio Barbosa da Silva (1993), and Tage Kurtén (1987), while developing the subdisci- pline she refers to as caring theology.Perhaps the most prominent feature of Eriksson’s thinking has been her clear formulation of the ontological, epistemological, and ethical basic assumptions with regard to the disci- pline of caring science.

Caritas Caritas means love and charity. In caritas, eros and agapé are united, and caritas is by nature uncondi- tional love. Caritas, which is the fundamental motive of caring science, also constitutes the motive for all caring. It means that caring is an endeavor to medi- ate faith, hope, and love through tending, playing, and learning.

Caring Communion Caring communion constitutes the context of the meaning of caring and is the structure that deter- mines caring reality. Caring gets its distinctive character through caring communion (Eriksson, 1990). It is a form of intimate connection that characterizes caring. Caring communion requires

MAJOR CONCEPTS & DEFINITIONS meeting in time and space, an absolute, lasting presence (Eriksson, 1992c). Caring communion is characterized by intensity and vitality, and by warmth, closeness, rest, respect, honesty, and tol- erance. It cannot be taken for granted but pre- supposes a conscious effort to be with the other. Caring communion is seen as the source of strength and meaning in caring. Eriksson (1990) writes in Pro Caritate, referring to Lévinas:

Entering into communion implies creating op- portunities for the other—to be able to step out of the enclosure of his/her own identity, out of that which belongs to one towards that which does not belong to one and is nevertheless one’s own—it is one of the deepest forms of commu- nion (pp. 28–29).

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Joining in a communion means creating possibili- ties for the other. Lévinas suggests that considering someone as one’s own son implies a relationship “beyond the possible” (1985, p. 71; 1988). In this rela- tionship, the individual perceives the other person’s possibilities as if they were his or her own. This requires the ability to move toward that which is no longer one’s own but which belongs to oneself. It is one of the deepest forms of communion (Eriksson, 1992b). Caring communion is what unites and ties together and gives caring its significance (Eriksson, 1992a).

The Act of Caring The act of caring contains the caring elements (faith, hope, love, tending, playing, and learning), involves the categories of infinity and eternity, and invites to deep communion. The act of caring is the art of making something very special out of something less special.

Caritative Caring Ethics Caritative caring ethics comprises the ethics of car- ing, the core of which is determined by the caritas motive. Eriksson makes a distinction between caring ethics and nursing ethics. She also defines the foun- dations of ethics in care and its essential substance. Caring ethics deals with the basic relation between the patient and the nurse—the way in which the nurse meets the patient in an ethical sense. It is about the approach we have toward the patient. Nursing ethics deals with the ethical principles and rules that guide my work or my decisions. Caring ethics is the core of nursing ethics. The foundations of caritative ethics can be found not only in history, but also in the dividing line between theological and human ethics in general. Eriksson has been influenced by Nygren’s (1966) human ethics and Lévinas’ (1988) “face ethics,” among others. Ethical caring is what we actually make explicit through our approach and the things we do for the patient in practice. An approach that is based on ethics in care means that we, without prejudice, see the human being with respect, and that we confirm his or her absolute dignity. It also

MAJOR CONCEPTS & DEFINITIONS—cont’d

means that we are willing to sacrifice something of ourselves. The ethical categories that emerge as basic in caritative caring ethics are human dignity, the car- ing communion, invitation, responsibility, good and evil, and virtue and obligation. In an ethical act, the good is brought out through ethical actions (Eriksson, 1995, 2003).

Dignity Dignity constitutes one of the basic concepts of cari- tative caring ethics. Human dignity is partly absolute dignity, partly relative dignity. Absolute dignity is granted the human being through creation, while relative dignity is influenced and formed through culture and external contexts. A human being’s abso- lute dignity involves the right to be confirmed as a unique human being (Eriksson, 1988, 1995, 1997a).

Invitation Invitation refers to the act that occurs when the carer welcomes the patient to the caring communion. The concept of invitation finds room for a place where the human being is allowed to rest, a place that breathes genuine hospitality, and where the patient’s appeal for charity meets with a response (Eriksson, 1995; Eriksson & Lindström, 2000).

Suffering Suffering is an ontological concept described as a hu- man being’s struggle between good and evil in a state of becoming. Suffering implies in some sense dying away from something, and through reconciliation, the wholeness of body, soul, and spirit is re-created, when the human being’s holiness and dignity appear. Suffer- ing is a unique, isolated total experience and is not synonymous with pain (Eriksson, 1984, 1993).

Suffering Related to Illness, to Care, and to Life These are three different forms of suffering. Suffering related to illness is experienced in connection with illness and treatment. When the patient is exposed to suffering caused by care or absence of caring, the patient experiences suffering related to care, which

Continued

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Use of Empirical Evidence From the beginning development of her theory, Eriksson established it in empiricism by systemati- cally employing a hermeneutical and hypothetical deductive approach. In conformity with a human sci- ence and hermeneutical way of thinking, Eriksson developed a caring science concept of evidence (Eriksson, Nordman, & Myllymäki, 1999). Her main argument for this is that the concept of evidence in natural science is too narrow to capture and reach the depth of the complex caring reality. Her concept of evidence is derived from Gadamer’s concept of truth (Gadamer, 1960/1994), which encompasses the true, the beautiful, and the good. She points out, in accordance with Gadamer, that evidence cannot be connected solely with a method and empirical data. Evidence in a human science perspective contains two aspects: a conceptual, logical one, which she calls ontological, and an empirical one, each pre-supposing

is always a violation of the patient’s dignity. Not to be taken seriously, not to be welcome, being blamed, and being subjected to the exercise of power are various forms of suffering related to care. In the situation of being a patient, the entire life of a human being may be experienced as suffering related to life (Eriksson, 1993, 1994a; Lindholm & Eriksson, 1993).

The Suffering Human Being The suffering human being is the concept that Eriksson uses to describe the patient. The patient refers to the concept of patiens (Latin), which means “suffering.” The patient is a suffering human being, or a human being who suffers and patiently endures (Eriksson, 1994a; Eriksson & Herberts, 1992).

Reconciliation Reconciliation refers to the drama of suffering. A human being who suffers wants to be confirmed in his or her suffering and be given time and space to suffer and reach reconciliation. Reconciliation implies a change through which a new wholeness is formed of the life the human being has lost in

MAJOR CONCEPTS & DEFINITIONS—cont’d

suffering. In reconciliation, the importance of sacri- fice emerges (Eriksson, 1994a). Having achieved reconciliation implies living with an imperfection with regard to oneself and others but seeing a way forward and a meaning in one’s suffering. Reconcili- ation is a prerequisite of caritas (Eriksson, 1990).

Caring Culture Caring culture is the concept that Eriksson (1987a) uses instead of environment. It characterizes the to- tal caring reality and is based on cultural elements such as traditions, rituals, and basic values. Caring culture transmits an inner order of value preferences or ethos, and the different constructions of culture have their basis in the changes of value that ethos undergoes. If communion arises based on the ethos, the culture becomes inviting. Respect for the human being, his or her dignity and holiness, forms the goal of communion and participation in a caring culture. The origin of the concept of culture is to be found in such dimensions as reverence, tending, cultivating, and caring; these dimensions are central to the basic motive of preserving and developing a caring cul- ture (Eriksson, 1987a; Eriksson & Lindström, 2003).

the other. The evidence concept developed by Eriksson has been shown to be empirically evident when tested in two comprehensive empirical studies in which the idea was to develop evidence-based caring cultures in seven caring units in the Hospital District of Helsinki and Uusimaa (Eriksson & Nordman, 2004). A further development of evidence resulted in caring scientific evidence concept and theory (Martinsen & Eriksson, 2009).

During the 1970s, Eriksson initially developed a nursing care process model (Eriksson, 1974), which later, in her doctoral dissertation (1981), was formu- lated as a theory. Since then, Eriksson, step by step, has deepened her conceptual and logical understanding of the basic concepts and phenomena that have emerged from the theory. She has tested their validity in em- pirical contexts, where the concepts have assumed contextual and pragmatic attributes (Kärkkäinen & Eriksson, 2004b). This logical way of working, a constant

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movement between logical and empirical evidence, has been summarized by Eriksson in her model of concept development (Eriksson, 1997b). The validity of this model has been tested in several doctoral dis- sertations since 1995 (Gustafsson, 2008; Hilli, 2007; Kasén, 2002; Lassenius, 2005; Lindwall, 2004; Nåden, 1998; Näsman, 2010; Rundqvist, 2004; Sivonen, 2000; Wallinvirta, 2011; von Post, 1999). She started more comprehensive systematic as well as clinical research programs on caring when she was appointed director of the Department of Caring Science at Åbo Akademi University. All 44 doctoral dissertations written at the Department of Caring Science between 1992 and 2012 are in different ways a test and validation of her ideas and theory.

Major Assumptions Eriksson distinguishes between two kinds of major assumptions: axioms and theses. She regards axioms as fundamental truths in relation to the conception of the world; theses are fundamental statements con- cerning the general nature of caring science, and their validity is tested through basic research. Axioms and theses jointly constitute the ontology of caring science and therefore also are the foundation of its epistemol- ogy (Eriksson, 1988, 2001). The caritative theory of caring is based on the following axioms and theses, as modified and clarified from Eriksson’s basic assump- tions with her approval (Eriksson, 2002). The axioms are as follows: • The human being is fundamentally an entity of

body, soul, and spirit. • The human being is fundamentally a religious being. • The human being is fundamentally holy. Human

dignity means accepting the human obligation of serving with love, of existing for the sake of others.

• Communion is the basis for all humanity. Human beings are fundamentally interrelated to an abstract and/or concrete other in a communion.

• Caring is something human by nature, a call to serve in love.

• Suffering is an inseparable part of life. Suffering and health are each other’s prerequisites.

• Health is more than the absence of illness. Health implies wholeness and holiness.

• The human being lives in a reality that is character- ized by mystery, infinity, and eternity.

The theses are as follows: • Ethos confers ultimate meaning on the caring

context. • The basic motive of caring is the caritas motive. • The basic category of caring is suffering. • Caring communion forms the context of meaning

of caring and derives its origin from the ethos of love, responsibility, and sacrifice, namely, caritative ethics.

• Health means a movement in becoming, being, and doing while striving for wholeness and holiness, which is compatible with endurable suffering.

• Caring implies alleviation of suffering in charity, love, faith, and hope. Natural basic caring is ex- pressed through tending, playing, and learning in a sustained caring relationship, which is asymmetrical by nature.

The Human Being The conception of the human being in Eriksson’s theory is based on the axiom that the human being is an entity of body, soul, and spirit (Eriksson, 1987a, 1988). She emphasizes that the human being is funda- mentally a religious being, but all human beings have not recognized this dimension. The human being is fundamentally holy, and this axiom is related to the idea of human dignity, which means accepting the human obligation of serving with love and exist- ing for the sake of others. Eriksson stresses the necessity of understanding the human being in his ontological context. The human being is seen as in constant becoming; he is constantly in change and therefore never in a state of full completion. He is understood in terms of the dual tendencies that exist within him, engaged in a continued struggle and living in a ten- sion between being and nonbeing. Eriksson sees the human being’s conditional freedom as a dimen- sion of becoming. She links her thinking with Kierkegaard’s (1843/1943) ideas of free choice and decision in the human being’s various stages—aesthetic, ethical, and religious stages—and she thinks that the human being’s power of transcendency is the founda- tion of real freedom. The dual tendency of the human being also emerges in his effort to be unique, while he simultaneously longs for belonging in a larger communion.

The human being is fundamentally dependent on communion; he is dependent on another, and it is in the

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relationship between a concrete other (human being) and an abstract other (some form of God) that the hu- man being constitutes himself and his being (Eriksson, 1987a). The human being seeks a communion where he can give and receive love, experience faith and hope, and be aware that his existence here and now has mean- ing. According to Eriksson (1987b), the human being we meet in care is creative and imaginative, has desires and wishes, and is able to experience phenomena; therefore, a description of the human being only in terms of his needs is insufficient. When the human be- ing is entering the caring context, he or she becomes a patient in the original sense of the concept—a suffering human being (Eriksson, 1994a).

Nursing Love and charity, or caritas, as the basic motive of caring has been found in Eriksson (1987b, 1990, 2001) as a principal idea even in her early works. The caritas motive can be traced through semantics, an- thropology, and the history of ideas (Eriksson, 1992c). The history of ideas indicates that the foun- dation of the caring professions through the ages has been an inclination to help and minister to those suf- fering (Lanara, 1981).

Caritas constitutes the motive for caring, and it is through the caritas motive that caring gets its deepest formulation. This motive, according to Eriksson, is also the core of all teaching and fostering growth in all forms of human relations. In caritas, the two basic forms of love—eros and agapé (Nygren, 1966)—are combined. When the two forms of love combine, gen- erosity becomes a human being’s attitude toward life and joy is its form of expression. The motive of caritas becomes visible in a special ethical attitude in caring, or what Eriksson calls a caritative outlook, which she formulates and specifies in caritative caring ethics (Eriksson, 1995). Caritas constitutes the inner force that is connected with the mission to care. A carer beams forth what Eriksson calls claritas, or the strength and light of beauty.

Caring is something natural and original. Eriksson thinks that the substance of caring can be understood only by a search for its origin. This origin is in the origin of the concept and in the idea of natural caring. The fundamentals of natural caring are constituted by the idea of motherliness, which implies cleansing and nourishing, and spontaneous and unconditional love.

Natural basic caring is expressed through tending, playing, and learning in a spirit of love, faith, and hope. The characteristics of tending are warmth, close- ness, and touch; playing is an expression of exercise, testing, creativity, and imagination, and desires and wishes; learning is aimed at growth and change. To tend, play, and learn implies sharing, and sharing, Eriksson (1987a) says, is “presence with the human being, life and God” (p. 38). True care therefore is “not a form of behavior, not a feeling or state. It is to be there—it is the way, the spirit in which it is done, and this spirit is caritative” (Eriksson, 1998, p. 4). Eriksson brings out that caring through the ages can be seen as various expressions of love and charity, with a view toward alleviating suffering and serving life and health. In her later texts, she stresses that caring also can be seen as a search for truth, goodness, beauty, and the eternal, and for what is permanent in caring, and mak- ing it visible or evident (Eriksson, 2002). Eriksson emphasizes that caritative caring relates to the inner- most core of nursing. She distinguishes between car- ing nursing and nursing care. She means that nursing care is based on the nursing care process, and it repre- sents good care only when it is based on the innermost core of caring. Caring nursing represents a kind of car- ing without prejudice that emphasizes the patient and his or her suffering and desires (Eriksson, 1994a).

The core of the caring relationship, between nurse and patient as described by Eriksson (1993), is an open invitation that contains affirmation that the other is always welcome. The constant open invitation is involved in what Eriksson (2003) today calls the act of caring. The act of caring expresses the innermost spirit of caring and recreates the basic motive of cari- tas. The caring act expresses the deepest holy element, the safeguarding of the individual patient’s dignity. In the caring act, the patient is invited to a genuine sharing, a communion, in order to make the caring fundamentals alive and active (Eriksson, 1987a) (i.e., appropriated to the patient). The appropriation has the consequence of somehow restoring the human being and making him or her more genuinely human. In an ontological sense, the ultimate goal of caring cannot be health only; it reaches further and includes human life in its entirety. Because the mission of the human being is to serve, to exist for the sake of others, the ultimate purpose of caring is to bring the human being back to this mission (Eriksson, 1994a).

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Environment Eriksson uses the concept of ethos in accordance with Aristotle’s (1935, 1997) idea that ethics is derived from ethos. In Eriksson’s sense, the ethos of caring science, as well as that of caring, consists of the idea of love and charity and respect and honor of the holiness and dig- nity of the human being. Ethos is the sounding board of all caring. Ethos is ontology in which there is an “in- ner ought to,” a target of caring “that has its own lan- guage and its own key” (Eriksson, 2003, p. 23). Good caring and true knowledge become visible through ethos. Ethos originally refers to home, or to the place where a human being feels at home. It symbolizes a human being’s innermost space, where he appears in his nakedness (Lévinas, 1989). Ethos and ethics belong together, and in the caring culture, they become one (Eriksson, 2003). Eriksson thinks that ethos means that we feel called to serve a particular task. This ethos she sees as the core of caring culture. Ethos, which forms the basic force in caring culture, reflects the prevailing priority of values through which the basic foundations of ethics and ethical actions appear.

At the beginning of the 1990s, when Eriksson rein- troduced the idea of suffering as a basic category of caring, she returned to the fundamental historical conditions of all caring, the idea of charity as the basis of alleviating suffering (Eriksson, 1984, 1993, 1994a, 1997a). This meant a change in the view of caring real- ity to a focus on the suffering human being. Her start- ing point is that suffering is an inseparable part of human life, and that it has no distinct reason or defini- tion. Suffering as such has no meaning, but a human being can ascribe meaning to it by becoming recon- ciled to it. Eriksson makes a distinction between endurable and unendurable suffering and thinks that an unendurable suffering paralyzes the human being, preventing him or her from growing, while endurable suffering is compatible with health. Every human being’s suffering is enacted in a drama of suffering. Alleviating a human being’s suffering implies being a co-actor in the drama and confirming his or her suf- fering. A human being who suffers wants to have the suffering confirmed and be given time and space to become reconciled to it. The ultimate purpose of caring is to alleviate suffering. Eriksson has described three different forms: suffering related to illness, suf- fering related to care, and suffering related to life (Eriksson, 1993, 1994a, 1997a).

Health Eriksson considers health in many of her earlier writ- ings in accordance with an analysis of the concept in which she defines health as soundness, freshness, and well-being. The subjective dimension, or well-being, is emphasized strongly (Eriksson, 1976). In the cur- rent axiom of health, health implies being whole in body, soul, and spirit. Health means as a pure concept wholeness and holiness (Eriksson, 1984). In accor- dance with her view of the human being, Eriksson has developed various premises regarding the substance and laws of health, which have been summed up in an ontological health model. She sees health as both movement and integration. The health premise is a movement comprising various partial premises: health as movement implies a change; a human being is being formed or destroyed, but never completely; health is movement between actual and potential; health is movement in time and space; health as movement is dependent on vital force and on vitality of body, soul, and spirit; the direction of this move- ment is determined by the human being’s needs and desires; the will to find meaning, life, and love consti- tutes the source of energy of the movement; and health as movement strives toward a realization of one’s potential (Eriksson, 1984).

In the ontological conception, health is conceived as a becoming, a movement toward a deeper whole- ness and holiness. As a human being’s inner health potential is touched, a movement occurs that be- comes visible in the different dimensions of health as doing, being, and becoming with a wholeness that is unique to human beings (Eriksson, Bondas-Salonen, Fagerström, et al., 1990). In doing, the person’s thoughts concerning health are focused on healthy life habits and avoiding illness; in being, the person strives for balance and harmony; in becoming, the human being becomes whole on a deeper level of integration.

Theoretical Assertions Eriksson’s fundamental idea when formulating theo- retical assertions is that they connect four levels of knowledge: the meta-theoretical, the theoretical, the technological, and caring as art. The generation of theory takes place through dialectical movement be- tween these levels, but here deduction constitutes the

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basic epistemological idea (Eriksson, 1981). The the- ory of science for caring science, which contains the fundamental epistemological, logical, and ethical standpoints, is formed on the meta-theoretical level. Eriksson (1988), in accordance with Nygren (1972), sees the basic motive as the element that permeates the formation of knowledge at all levels and gives scientific knowledge its unique characteristics. A clearly formulated ontology constitutes the founda- tion of both the caritative caring theory and caring science as a discipline. The caritas motive, the ethos of love and charity, and the respect and reverence for human holiness and dignity, which determine the nature of caring, give the caritative caring theory its feature. This ethos, which encircles caring as science and as art, permeates caring culture and creates the preconditions for caring. The ethos is reflected in the process of nursing care, in the documentation, and in various care planning models.

Caring communion constitutes the context of mean- ing from which the concepts in the theory are to be understood. Human suffering forms the basic category of caring and summons the carer to true caring (i.e., serving in love and charity). In the act of caring, the suffering human being, or patient, is invited and wel- comed to the caring communion, where the patient’s suffering can be alleviated through the act of caring in the drama of suffering that is unique to every human being. Alleviation of suffering implies that the carer is a co-actor in the drama, confirms the patient’s suffering, and gives time and space to suffer until reconciliation is reached. Reconciliation is the ultimate aim of health or being and signifies a reestablishment of wholeness and holiness (Eriksson, 1997a).

Logical Form Meta-theory has always had a fundamental place in Eriksson’s thinking, and her epistemological work is anchored in Aristotle’s theory of knowledge (Aristotle, 1935). Searching for knowledge, which is intrinsically hermeneutic, and which takes place within the scope of an articulated theoretical perspec- tive, is understood as a search for the original text in a historical-hermeneutic tradition, that which in the old hermeneutic sense represents truth (Gadamer, 1960/1994). To achieve the depth in the development of knowledge and theory she has consistently striven

for, Eriksson has used various logical models for the hypothetical deductive method and hermeneutics guiding principles.

Eriksson stresses the importance of the logical form being created on the basis of the substance of caring (i.e., caritas), not on the basis of method. It is thus deduction combined with abduction that formed the guiding logic. The language, words, and concepts carry the content of meaning, and Eriksson stresses the necessity of choosing words, concepts, and lan- guage that correspond to human science.

In the dynamic change between the natural world and the world of science, there has constantly oc- curred a striving toward the source of the true, the beautiful, and the good—that which is evident. Eriksson (1999) shapes her theory of scientific thought, as reflection moves between patterns at different levels and interpretation is subject to the theoretical perspective. The movement takes place distinctly between doxa (empirical-perceptive knowl- edge) and episteme (rational-conceptual knowledge), and “the infinite.” Movement thus takes place between the two basic epistemological categories of the theory of knowledge: perception and conception.

Eriksson applied three forms of inference— deduction, induction, and abduction or retroduction (Eriksson & Lindström, 1997)—that give the theory a logical external structure. The substance of her car- ing theory has moved simultaneously by abductive leaps (Peirce, 1990; Eriksson & Lindström, 1997), which sometimes created a new chaos but also car- ried Eriksson’s thinking toward new discoveries. Through abduction, the ideal model for caritative caring was shaped, proceeding from historical and self-evident suppositions (Nygren, 1972). Eriksson in this way made use of old original texts that testify to caritative caring as her research material. Through induction and deduction, the validity of the theory has been tested.

Theory as conceived by Eriksson is in accordance with the Greek concept of theory, theoria, in the sense of seeing the beautiful and the good, participating in the common, and dedicating it to others (Gadamer, 2000, p. 49). Theory and practice are different aspects of the same core. The convincing force and potential of the whole theory are found in its innermost core, caritas, around which the generation of theory takes place. The caring substance is formed in a dialectical

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movement between the potential and the actual, the abstract general and the concrete individual. With the help of logical abstract thinking combined with the logic of the heart (Pascal, 1971), the Theory of Caritative Caring becomes perceptible through the art of caring.

Acceptance by the Nursing Community

Practice A characteristic feature of Eriksson’s manner of work- ing is her way of structuring abstract thinking as a natural and obvious precondition of clinical activity and an evidence-based form of caring that opens up a deeper insight. Several nursing units in the Nordic countries have based their practice and caring philoso- phy on Eriksson’s ideas and her caritative theory of caring. These include the Hospital District of Helsinki and Uusimaa in Finland, Stiftelsen Hemmet in the Åland Islands of Finland, and Stora Sköndal in Sweden. Because Eriksson’s thinking and process model of car- ing are general, the nursing care process model has proved to be applicable in all contexts of caring, from acute clinical caring and psychiatric care to health- promoting and preventive care.

Since the 1970s, Eriksson’s nursing care process model was systematically used, tested, and developed as a basis of nursing care and documentation at Helsinki University Central Hospital. From the beginning of the 1990s, Eriksson served as director of the clinical research program, “In the World of the Patient.” In various studies, Eriksson’s theory has been tested, and the results have been presented in doctoral and master’s theses and published in professional and scientific jour- nals. The study, “In the Patient’s World II: Alleviating the Patient’s Suffering—Ethics and Evidence” led to recommendations for the care of patients and is an ongoing research project that will become a handbook for clinical caring science.

Eriksson’s model has been subjected to more comprehensive academic research (Fagerström, 1999; Kärkkäinen & Eriksson, 2003, 2004; Lukander, 1995; Turtiainen, 1999). Eriksson’s thinking has been in- fluential in nursing leadership and nursing adminis- tration, where the caritative theory of nursing forms the core of the development of nursing leadership at various levels of the nursing organization. That Eriksson’s ideas about caring and her nursing care

process model work in practice has been verified by everything from a multiplicity of essays and tests of learning in clinical practice to master’s theses, licen- tiates’ theses, and doctoral dissertations produced all over the Nordic countries.

Education Since the 1970s, Eriksson’s theory has been integrated into the education of nurses at various levels, and her books have been included continuously in the exami- nation requirements in various forms of nursing edu- cation in the Nordic countries. The education for master’s and doctoral degrees that started in 1986 at the Department of Caring Science, Åbo Akademi University, has been based entirely on Eriksson’s ideas, and her caritative caring theory forms the core of the development of substance in education and research.

Development of the caring science–centered curric- ulum and caring didactics continued in the educational and research program in caring science didactics. Development of teachers within the education of nurses forms a part of the master’s degree program and has resulted in the first doctoral dissertation in the didactics of caring science (Ekebergh, 2001).

Eriksson realized at an early stage the importance of integrating academic courses in the education of nurses; nowadays, academic courses in caring science based on Eriksson’s theory are offered as part of con- tinuing education for those who work in clinical practice. Approximately 200 nurses take part annually in these academic courses.

Because Eriksson sees caring science not as profes- sion oriented but as a “pure” academic discipline, it has aroused interest among students in other disci- plines and other occupational groups, such as teach- ers, social workers, psychologists, and theologians. Eriksson stresses that it is necessary for doctors as well to study caring science, so that genuine inter- disciplinary cooperation is achieved between caring science and medicine.

Research Eriksson and her teaching and research colleagues at the Department of Caring Science designed a research program based on her caring science tradi- tion. This program comprises systematic caring sci- ence, clinical caring science, didactic caring science,

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caring administration, and interdisciplinary research. Eriksson’s caritative caring theory has been tested and further developed in various contexts with different methodological approaches, both within the depart- ment’s own research projects and in doctoral disserta- tions that have been published at the department.

Eriksson has always emphasized the importance of basic research as necessary for clinical research, and her main thesis is that substance should direct the choice of research method. In her book, Pausen (The Pause) (Eriksson, 1987b), she describes how the research object is structured, starting from the carita- tive theory of caring. In her book, Broar (Bridges) (Eriksson, 1991), she describes the research paradigm and various methodological approaches based on a human science perspective. During the first few years, the emphasis lay on basic research, with the focus on development of the basic concepts and assumptions of the theory and on the fundamentals of history and the history of ideas. An especially strong point in Eriksson’s research is the clearly formulated theoreti- cal perspective that confers explicitness and greater depth to the generation of knowledge. Development of the theory and research have always moved hand in hand with the focus on various dimensions of the theory, and, in this connection, we wish to illustrate some central results of the research.

Eriksson has emphasized the necessity of an exhaus- tive and systematic analysis of basic concepts, and developed her own model of concept development (Eriksson, 1991, 1997b), which proved fruitful and is used by many researchers, including Nåden (1998) in his study of the art of caring, von Post (1999) in her study of the concept of natural care, Sivonen (2000) in studies of the concepts of soul and spirit, and Kasén (2002) in her study of the concept of the caring relation- ship. Other studies focused on the concept of dignity (Edlund, 2002), the concepts of power and authority (Rundqvist, 2004), and the concept of the body in a perioperative context (Lindwall, 2004).

Continued development of Eriksson’s concept of health took place in the research project Den Mång- dimensionella Hälsan (Multidimensional Health), during the years 1987 to 1992 and resulted in the on- tological health model (Eriksson, 1994a; Eriksson, Bondas-Salonen, Fagerström, et al., 1990; Eriksson & Herberts, 1992). The project resulted in a number of master’s theses. Of these, Lindholm’s study of young

people’s conception of health (1998; Lindholm & Eriksson, 1998) and Bondas’ study of women’s health during the perinatal period (2000; Bondas & Eriksson, 2001) led to doctoral dissertations.

The ontological health model subsequently formed the basis for several studies. Wärnå (2002), in her study concerning the worker’s health, related Aristotle’s the- ory of virtue to Eriksson’s ontological health model. The study opened a new line of thought in preventive health service in working environments; continued research and development are now in progress in a number of factories in the wood-processing industry in Finland.

Since the mid-1980s, when suffering as the basic category in caring was made explicit in Eriksson’s theory, examples of research related to suffering have been legion. One is Wiklund’s (2000) study of suffer- ing as struggle and drama, among both patients who had undergone coronary bypass surgery and patients addicted to drugs. In several clinical studies, Råholm focused on suffering and alleviation of suffer- ing in patients undergoing coronary bypass surgery (Råholm, Lindholm, & Eriksson, 2002; Råholm, 2003). The manifestation of suffering in a psychiatric context has been studied by Fredriksson, who illustrates the possibilities of the caring conversation in the allevia- tion of suffering (Fredriksson, 2003; Fredriksson & Eriksson, 2003; Fredriksson & Lindström, 2002). Nyback (2008) studied suffering in the Chinese cul- ture, and Lindholm (2008) focused on suffering and its connection to domestic violence. In a Norwegian study, Nilsson (2004) studied suffering in patients in psychiatric noninstitutional care units with a high degree of ill health and found that the experience of loneliness is of basic importance. Caspari (2004) in her study illustrated the importance of aesthetics for health and suffering.

In a cooperative project between researchers in Sweden and Finland, the suffering of women with breast cancer was studied. This project comprised in- tervention studies in which the importance of different forms of care for the alleviation of suffering was illus- trated (Arman, Rehnsfeldt, Lindholm, & Hamrin, 2002; Arman-Rehnsfeldt & Rehnsfeldt, 2003; Lindholm, Nieminen, Mäkelä, & Rantanen-Siljamäki, 2004). Arman-Rehnsfeldt, in her dissertation, illustrated how the drama of suffering is formed among these women (Arman, 2003).

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Continuous research has been carried out since the 1970s, with a view toward developing caring science as an academic discipline, and a theory of science for car- ing science has been formulated (Eriksson, 1988, 2001; Eriksson & Lindström, 2000, 2003; Lindström, 1992). Eriksson has developed subdisciplines of caring science, which means that researchers of caring science and other scientific disciplines enter into dialogues with each other, and constitute a research area. An example of this is the development of caritative caring ethics (Andersson, 1994; Eriksson, 1991, 1995; Fredriksson & Eriksson, 2001; Råholm & Lindholm, 1999; Råholm, Lindholm, & Eriksson, 2002). Another interesting sub- discipline that Eriksson has developed is caring theol- ogy, within which she has articulated spiritual and doctrinal questions in caring with a scientific group of themes, and in this respect has cleared the way for new thinking. Caring theology has aroused great interest among caregivers in clinical practice that can be studied in academic courses.

Further Development Eriksson continues developing her thinking and the caritative caring theory with unabated energy and constantly finds new ways, recreating and deepening what has been stated before. Systematic research and the development of caritative caring theory, as well as the discipline of caring science, take place chiefly within the scope of the research programs in her own department with her own staff and the postdoctoral group. The dissertation topics of doctoral candidates are connected with the research programs and form an important contribution of knowledge to the ongo- ing development of Eriksson’s thinking.

During the last few years, Eriksson has emphasized the necessity of basic research in clinical caring sci- ence, where she has especially stressed the under- standing of the research object, caring reality. She describes the object of research from three points of view: the experienced world, praxis as activity, and the real reality. In the real reality, which carries the attri- butes of mystery, one finds something of the deepest potential of caring, and it is a reality that can be under- stood in Gadamer’s sense, in the old Greek meaning of praxis, as a way of living, a mode of being, that is, an ontology (Gadamer, 2000). The development of knowledge in caring science becomes fundamentally

different depending on what object of knowledge con- stitutes the focus of research (Eriksson & Lindström, 2003). Another central area of interest for Eriksson (2003) is formed by the development of caritative car- ing ethics. Continued development of the caritative theory of caring also occurs, as has emerged before, through continued implementation and testing in various clinical contexts.

Critique

Clarity The strong point of Eriksson’s theory is the overall logical structure of the theory, in which every new concept becomes a part of an ever more comprehensive whole in which an element of internal logic can be seen clearly. Her main thesis has always been that basic con- ceptual clarity is needed before developing the contex- tual features of the theory. Eriksson has used concept analysis and analysis of ideas as central methods, which has led to semantic and structural clarity. It has at the same time meant that the concepts may have assumed dimensions that have been regarded as strange to those who are not familiar with the theoretical perspective in which the development of the theory has taken place. We, who have for many years had the opportunity to follow Eriksson’s work, have realized that her way of thinking forms a logical whole, where the abstract sci- entific reveals the concrete in a new understanding (i.e., provides an experience of evidence and verifies the convincing force of the theory).

Simplicity The theoretical clarity of Eriksson’s theory reflects the simplicity of the theory by showing the general in a clear and logical conceptual entirety. The hermeneutic approach has deepened the understanding of the sub- stance and thus contributed to the simplicity of the theory (Gadamer, 1960/1994). The simplicity also can be understood as an expression of Gadamer’s concept of theory by making it comprehensible that theory and practice belong together and reflect two sides of the same reality. Eriksson agrees with Gadamer’s thought that understanding includes application, and the the- ory opens the way to deeper participation and com- munion. Eriksson (2003) formulates this process by the statement that “ideals reach reality and reality reaches the ideals” (p. 26).

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Generality Eriksson’s theory is general in the sense that it aims at creating an ontological and ethical basis of caring, while at the same time it constitutes the core of the discipline and thus involves epistemology as well. Eriksson’s theory is also general as a result of the wide convincing force it receives through its theoretical core concepts and its theoretical axioms and theses. There may be a risk that a too-general theory be- comes diffuse in relation to different caring contexts. Eriksson, however, has always stressed the impor- tance of describing the core concepts on an optimal level of abstraction in order to include all of the com- plex caring reality that simultaneously carries a wealth of signification that opens up understanding in vari- ous caring contexts.

Accessibility Eriksson’s thinking as a whole has reached an under- standing that extends to other disciplines and profes- sions. She has developed a language and a rhetoric that has reached researchers as well as practitioners in the human scientific field. The empirical precision of Eriksson’s theory demonstrated in multiple deductive testings manifests a combination of the clarity, sim- plicity, and generality of the theory combined with a rich substance and clearly formulated ethos.

Importance Eriksson’s work on developing her caritative caring theory for 30 years has been successful, and particularly in the Nordic countries there is abundant evidence that her thinking is of great importance to clinical practice, research, and education, and also to the development of the caring discipline. By her development of the carita- tive theory of care, Eriksson created her own caring science tradition, a tradition that has grown strong and has set the tone for nursing advancement and caring science.

Summary Eriksson has been a guide and visionary who has gone before and “ploughed new furrows” in theory develop- ment for many years. Eriksson’s caritas-based theory and her whole caring science thinking have developed over the course of 30 years. Characteristic of her thinking is that while she is working at an abstract

level developing concepts and theory, the theory is rooted in clinical reality and teaching. The whole cari- tative theory and the caring that are built up around the theoretical core get their distinctive character and deeper meaning. The ultimate goal of caring is to alleviate suffering and serve life and health.

Knowledge formation, which Eriksson sees as a her- meneutic spiral, starts from the thought that ethics pre- cedes ontology. In a concrete sense, this implies that the thought of human holiness and dignity is always kept alive in all phases of the search for knowledge. Ethics precedes ontology in theory as well as in practice.

Eriksson’s caring science tradition and discipline of caring science form a basis for the activity at the Department of Caring Science at Åbo Akademi Univer- sity. Eriksson’s caritative caring theory and the discipline of caring science have inspired many in the Nordic countries, and they are used as the basis for research, education, and clinical practice. Many of her original textbooks, published mainly in Swedish, have been translated into Finnish, Norwegian, and Danish.

CASE STUDY

The case presented is a philosophy of practice, by Ulf Donner, leader of the Foundation Home at the psy- chiatric nursing home in Finland that for 15 years has based its practice on Eriksson’s caritative theory of caring.

Even at an early stage in our serving in caring science, we caregivers recognized ourselves in the caring science theory, which stresses the healing force of love and compassion in the form of tend- ing, playing, and learning in faith, hope, and char- ity. The caritative culture is made visible with the help of rituals, symbols, and traditions, for instance, with the stone that burns with the light of the Trinity and the daily common time for spiritual reflection. In every meeting with the suf- fering human being, the attributes of love and charity are striven for, and the day involves discus- sions of reconciliation, forgiveness, and how we as caregivers can tend by nourishing and cleansing on the level of becoming, being, and doing. In the struggle in love and compassion to reach a fellow human being who, because of suffering, has with- drawn from the communion to find common

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horizons, the sacrifice of the caregiver is con- stantly available.

We work with people who often have the feeling that they do not deserve the love they encounter and who, in various ways, try to convince us care- givers of this. We experience patients’ disappoint- ment in their destructive acts, and we constantly have to remember that it may be broken promises that produce such dynamics. Sometimes, it may be difficult to recognize that suffering expressed in this way in an abstract sense seeks an embrace that does not give way but is strong enough to give shelter to this suffering, in a way that makes a becoming movement possible. In recognizing what is bad and what is difficult, horizons in the field of force are expanded, and the possibility of bringing in a ray of light and hope is opened.

As caregivers, we constantly ask ourselves whether the words, the language we use, bring promise, and how we can create linguistic foot- holds in the void by means of images and sym- bols. In our effort to nourish and cleanse, that which constitutes the basic movement of tending,

we often recognize the importance of teaching the patient to be able to mourn disappointments and affirm the possibilities of forgiveness in the move- ment of reconciliation.

We also try to bring about the open invitation to the suffering human being to join a communion with the help of myths, legends, and tales con- cerned with human questions about evil versus good and about eternity and infinity. Reading aloud with common reflective periods often provides us caregivers a possibility of getting closer to patients without getting too close, and opens the door for the suffering the patient bears.

In the act of caring, we strive for openness with regard to the patient’s face and a confirmative attitude that responds to the appeal that we can recognize that the patient directs to us. When we as caregivers respond to the patient’s appeal for charity, we are faced with the task of confirming the holiness of the other as a human being. Our constant effort is to make it possible for the patient to reestablish his or her dignity, accomplish his or her human mission, and enter true communion.

CRITICAL THINKING ACTIVITIES 3. How have you recognized the elements of

caring—faith, hope, love and tending, playing, and learning—in a concrete caring situation? Give examples.

4. Suffering as a consequence of lack of caritative caring is a violation of a human being’s dignity. Think about a situation in which you saw this occur, and consider what can be done to prevent suffering related to care.

1. Reflect on the meaning of caritas as the ethos of caring. a. How is caritas culture formed in a care setting? b. How do caritative elements appear in caring? c. What is the nature of nursing ethics based on

caritas? 2. Health and suffering are each other’s preconditions.

Think of what this meant in the life of a patient you cared for recently.

POINTS FOR FURTHER STUDY n Eriksson, K. (2010). Concept determination as

part of the development of knowledge in caring science. Scandinavian Journal of Caring Sciences, 24, 2–11.

n Eriksson, K. (2010). Evidence—To see or not to see. Nursing Science Quarterly, 23(4), 275–279.

n For further literature and information visit our website at: http://www.abo.fi/institution/ vardvetenskap

n Eriksson, K. (2007). Becoming through suffering— The path to health and holiness. International Jour- nal for Human Caring, 11(2), 8–16.

n Eriksson, K. (2007). The theory of caritative caring: A vision. Nursing Science Quarterly, 20(3), 201–202.

n Eriksson, K. (2006). The suffering human being. Chicago: Nordic Studies Press. [English transla- tion of Den Lidande Människan. Stockholm: Liber Förlag, 1994.]

UNIT II Nursing Philosophies186

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Råholm, M-B., & Lindholm, L. (1999). Being in the world of the suffering patient: A challenge to nursing ethics. Nursing Ethics, 6, 528–539.

Råholm, M-B., Lindholm, L., & Eriksson, K. (2002). Grasping the essence of the spiritual dimension reflected through the horizon of suffering—An interpretative research syn- thesis. Australian Journal of Holistic Nursing, 9, 4–12.

Rundqvist, E. (2004). Makt som fullmakt. Ett vårdvetens- kapligt perspektiv. Doktorsavhandling, Åbo Akademis Förlag, Turku, Finland. [Power as authority. A caring science perspective. Doctoral dissertation, Åbo Akademi University Press, Turku, Finland.]

Sivonen, K. (2000). Vården och det andliga. En bestämning av begreppet ‘andlig’ ur ett vårdvetenskapligt perspektiv. Doktorsavhandling, Turku, Finland, Åbo Akademis Förlag. [Care and the spiritual dimension. A definition of the concept of “spiritual” in a caring science perspective. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

St. Augustine, A. (1957). Bekännelser. Stockholm: Söderström. [Confessions. Stockholm: Söderström.]

Törnebohm, H. (1978). Paradigm i vetenskapsteorin (Del 2. Rapport nr. 100). Gothenburg, Sweden: Institutionen för vetenskapsteori, Göteborgs universitet. [Paradigms in the theory of science (Part 2 Report nr. 100). Gothen- burg, Sweden: Institutionen för vetenskapsteori, Göteborgs universitet.]

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von Post, I. (1999). Professionell naturlig vård ur anestesi och operationassjuksköterskors perspektiv. Doktor- savhandling, Åbo Akademis Förlag, Turku, Finland. [Professional natural care from the perspective of nurse anesthetists and operating room nurses. Doctoral disser- tation, Turku, Finland, Åbo Akademi University Press.]

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Wallinvirta, E. (2011). Ansvar som klangbotten i vårdan- dets meningssammanhang. Doktorsavhandling, Turku, Finland, Åbo Akademis förlag. [Responsibility as sounding board in the caring’s context of meaning. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Wiklund, L. (2000). Lidandet som kamp och drama. Dok- torsavhandling, Turku, Finland, Åbo Akademis Förlag. [Suffering as struggle and as drama. Doctoral disserta- tion, Turku, Finland, Åbo Akademi University Press.]

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Sivonen, K., Kasén, A., & Eriksson, K. (2010). Semantic analysis according to Peep Koort—A substance-oriented research methodology. Scandinavian Journal of Caring Sciences, 24, 12–20.

von Post, I., & Eriksson, K. (2000). The ideal and practice concepts of “professional nursing care.” International Journal for Human Caring, 4(1), 14–22.

Wikberg, A., & Eriksson, K. (2008). Intercultural caring— An abductive model. Scandinavian Journal of Caring Sciences, 22(3), 485–496.

Wiklund-Gustin, L., & Eriksson, K. (2009). The drama of suffering as narrated by patients who have undergone coronary bypass surgery. International Journal for Human Caring, 13(4), 17–25.

Wikström-Grotell, C., Lindholm, L., & Eriksson, K. (2002). Det mångdimensionella rörelsebegreppet i fysioterapin— En kontextuell analys. Nordisk Fysioterapi, 6, 146–184. [The multidimensional concept of movement in physiotherapy—A contextual analysis. Nordisk Fysioterapi, 6, 146–184.]

Wärnå, C., Lindholm, L., & Eriksson, K. (2007). Virtue and health—finding meaning and joy in working life. Scandinavian Journal of Caring Sciences, 21(2), 191–198.

Wärnå, C., Lindholm, L., & Eriksson, K. (2008). Virtue and health—Describing virtue as a path to the inner domain of health. International Journal for Human Caring, 12(1), 17–24.

Articles in Compilation Works and Proceedings with Referee Practice Compilation Works Eriksson, K. (1971). En analys av sjuksköterskeutbildnin-

gen utgående från en utbildningsteknologisk model. I Sairaanhoidon vuosikirja VIII (s. 54–77). Helsinki, Finland: Sairaanhoitajien Koulutussäätiö. [An analysis of nursing education from an educational-technological model. In Health care yearbook VIII (pp. 54–77). Helsinki, Finland: Sairaanhoitajien Koulutussäätiö.]

Eriksson, K. (1974). Sairaanhoidon kehittäminen oppi- aineena. I Sairaanhoidon vuosikirja XI (s. 9–21). Helsinki, Finland: Sairaanhoitajien Koulutussäätiö. [The develop- ment of health care as a subject. In Health care yearbook XI (pp. 9–21). Helsinki, Finland: Sairaanhoitajien Koulutussäätiö.]

Eriksson, K. (1977). Hälsa—En teoretisk och begreppsana- lytisk studie om hälsa och dess nature. I Sairaanhoidon vuosikirja XIV (s. 55–195). [Health—A conceptual analysis and theoretical study of health and its nature. In Health care yearbook XIV (pp. 155–195). Helsinki, Finland: Sairaanhoitajien Koulutussäätiö.]

Eriksson, K. (1978). Modellen—Ett sätt att beskriva vårdskee- ndet. I Sairaanhoidon vuosikirja XV (s. 189–225). Helsinki,

Finland: Sairaanhoitajien Koulutussäätiö. [The model—A way of describing the act of nursing care. In Health care yearbook XV (pp. 189–225). Helsinki, Finland: Sairaan- hoitajien Koulutussäätiö.]

Eriksson, K. (1982). Den vårdvetenskapscentrerade läroplanen—Ett alternativ för dagens vårdutbildning. I Sairaanhoidon vuosikirja XIX (s. 173–187). Helsinki, Finland: Sairaanhoitajien Koulutussäätiö. [The caring science centered curriculum—An alternative for health education today. In Health care yearbook XIX (pp. 173–187). Helsinki, Finland: Sairaanhoitajien Koulutussäätiö.]

Eriksson, K. (1983). Den fullvuxna insulindiabetikern i hälsovårdens vårdprocess. I Sairaanhoidon vuosikirja XIX (s. 428–430). Helsinki, Finland: Sairaanhoitajien Koulutussäätiö. [The adult insulin-dependent diabetic in the health care nursing process. In Health care year- book XIX (pp. 428–430). Helsinki, Finland: Sairaanhoitajien Koulutussäätiö.]

Eriksson, K. (1983). Vårdområdet finner sin profil—Den vårdvetenskapliga eran har inlets. I Epione, Jubileums- skrift 1898–1983 (s. 12–17). [The area of caring finds its profile—The caring science era has begun. In Epione, Jubilee-script 1898–1983 (pp. 12–17). Helsinki, Finland: SSY-Sjuksköterskeföreningen i Finland.]

Eriksson, K. (1986). Hoito, Caring—Hoitotyön primaari substanssi. Puheenvuoro 2. I T. Martikainen & K. Man- ninen (red.), Hoitotyö ja koulutus (s. 17–41). Hämeen- linna, Finland: Sairaanhoitajien Koulutussäätiö. [Caring—The primary substance of nursing. Speech 2. In T. Martikainen & K. Manninen (Eds.), Nursing and education (pp. 17–41). Hämeenlinna, Finland: Sairaanhoitajien Koulutussäätiö.]

Eriksson, K. (1987). Vårdvetenskapen som humanistisk vetenskap. I Hoitotiede vuosikirja (s. 68–77) [Caring science as a humanistic science. Journal of Nursing Science Yearbook, 68–77.]

Eriksson, K. (1988). Vårdandets idé och ursprung. I Panakeia. Vårdvetenskaplig årsbok (s. 17–35). Stock- holm: Almqvist & Wiksell. [The origin and idea of car- ing. In Panakeia. Caring science yearbook (pp. 17–35). Stockholm: Almqvist & Wiksell.]

Eriksson, K. (1989). Ammatillisuus hoitamisessa. I Hoitoopin perusteet (2: 2 yppl., s. 125–129). Vaasa, Finland: Sairaan- hoitajien Koulutussäätiö. [Professionalism in caring. In The basics of nursing science (2nd ed., pp. 125–129). Vaasa, Finland: Sairaanhoitajien Koulutussäätiö.]

Eriksson, K. (1990). Framtidsvisioner—om utvecklingen av sjukskötarens arbete. I Epione, Jubileumsskrift 1898– 1988 (s. 28–38). Helsinki, Finland: SSY-sjuksköterske- föreningen i Finland r.f. [Future visions of the develop- ment of the nurse’s work. In Epione, Jubilee-script

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1898–1988 (pp. 28–38). Helsinki, Finland: SSY- sjuksköterske-föreningen i Finlandr.f.]

Eriksson, K. (1991). Hälsa är mera än frånvaro av sjuk- dom. I Centrum för vårdvetenskap, Vård—Utbildning— Utveckling—Forskning (s. 1–2, 29–35). Stockholm: Karolinska Institutet. [Health is more than the absence of illness. In Centrum för vårdvetenskap, Vård—Utbildning— Utveckling—Forskning (pp. 1–2, 29–35). Stockholm: Karolinska Institute.]

Eriksson, K. (1992). Nursing: The caring practice “being there.” In D. Gaut (Ed.), The practice of caring in nurs- ing (pp. 201–210). New York: National League for Nursing Press.

Eriksson, K. (1993). De första åren—Några reflektioner kring den vårdvetenskapliga eran. I Epione, Jubile- umsskrift 1898–1993 (s. 7–15). Helsinki, Finland: SSY-Sjuksköterskeföreningen. [The first years— Reflections upon the era of caring science. In Epione, Jubilee-script 1898–1993 (pp. 7–15). Helsinki, Finland: SSY-Sjuksköterskeföreningen.]

Eriksson, K. (1994). Theories of caring as health. In D. Gaut & A. Boykin (Eds.), Caring as healing: Renewal through hope (pp. 3–20). New York: National League for Nursing Press.

Eriksson, K. (1994). Vårdvetenskapen som autonom disci- pline. I H. Willman (red.), Hygieia. Hoitotyön vuosikirja 1994 (s. 87–91).). Helsinki, Finland: Kirjayhtymä. [Car- ing science as an autonomous discipline. In H. Will- man (Ed.), Hygieia. Nursing yearbook 1994 (pp. 87–91). Helsinki, Finland: Kirjayhtymä.]

Eriksson, K. (1996). Efterskrift—Om vårdvetenskapens möjligheter och gränser. I K. Martinsen (red.), Fenome- nologi og omsorg (s. 140–150). Oslo, Norway: TANO. [Postscript—About the possibilities and boundaries of caring science. In K. Martinsen (Ed.), Phenomenology and caring (pp. 140–150). Oslo, Norway: TANO.]

Eriksson, K. (1996). Om dokumentation—Vad den är och inte är. I K. Dahlberg (red.), Konsten att dokumentera omvårdnad (s. 9–13). Lund, Sweden: Studentlitteratur. [On documentation—What it is and what it is not. In K. Dahlberg (Ed.), The art of documenting care (pp. 9–13). Lund, Sweden: Studentlitteratur.]

Eriksson, K. (1996). Om människans värdighet. I T. Bjer- kreim, J. Mathinsen, & R. Nord (red.), Visjon, viten og virke. Festskrift till sykepleieren Kjellaug Lerheim, 70 år (s. 79–86). Oslo, Norway: Universitetsförlaget. [On hu- man dignity. In T. Bjerkreim, J. Mathinsen, & R. Nord (Eds.), Vision, knowledge and influence. Jubilee-script for the nurse Kjellaug Lerheim, 70 years (pp. 79–86). Oslo, Norway: Universitetsförlaget.]

Eriksson, K. (1997). Caring, spirituality and suffering. In M. S. Roach (Ed.), Caring from the heart: The convergence

between caring and spirituality (pp. 68–84). New York: Paulist Press.

Eriksson, K. (1997). Mot en vårdetisk teori. I Hoitotyön vuosikirja 1997. Pro Nursing RY:n vuosikirja, Hygieia (s. 9–23). Helsinki, Finland: Kirjayhtymä. [Toward an ethical caring theory. In Nursing yearbook 1997. Pro Nursing RY:s yearbook, Hygieia (pp. 9–23). Helsinki, Finland: Kirjayhtymä.]

Eriksson, K. (1997). Perustutkimus ja käsiteanalyysi. I M. Paunonen & K. Vehviläinen-Julkunen (red.), Hoitotieteen tutkimusmetodiikka (s. 50–75). Helsinki, Finland: WSOY. [Basic research and conceptual anal- ysis. In M. Paunonen & K. Vehviläinen-Julkunen (Eds.), The research methodology of caring science (pp. 50–75). Helsinki, Finland: WSOY.]

Eriksson, K. (1998). Epione—Vårdandets ethos. I Epione, Jubileumsskrift 1898–1998. Helsinki, Finland: SSY- Sjuksköterskeföreningen. [Epione—The ethos of caring. In Epione, Jubilee-script 1898–1998. Helsinki, Finland: SSY-Sjuksköterskeföreningen.]

Eriksson, K. (1998). Människans värdighet, lidande och lidandets ethos. I Suomen Mielenterveysseura, Tuhkaa ja linnunrata. Henkisyys mielenterveystyössä (s. 67–82). Helsinki: Suomen Mielenterveysseura, SMS-julkaisut. [Human dignity, suffering and the ethos of suffering. In Ashes and the Milky Way: Spirituality in mental health care nursing (pp. 67–82). Helsinki: Suomen Mielenter- veysseura, SMS-julkaisut.]

Eriksson, K. (1998). Understanding the world of the patient, the suffering human being: The new clinical paradigm from nursing to caring. In C. E. Guzzetta (Ed.), Essential readings in holistic nursing (pp. 3–9). Gaithersburg, (MD): Aspen.

Eriksson, K. (1999). Tillbaka till Popper och Kuhn—En evo- lutionär epistemologi för vårdvetenskapen. I J. Kinnunen, P. Meriläinen, K. Vehviläinen-Julkunen, & T. Nyberg (red.), Terveystieteiden monialainen tutkimus ja yliopistok- oulutus. Suunnistuspoluilta tiedon valtatielle. Professor Sirkka Sinkkoselle omistettu juhlakirja (s. 21–35). Kuopio, Finland: Kuopion yliopiston julkaisuja E, Yhteiskuntati- eteet 74. [Back to Popper and Kuhn—An evolutionary epistemology for caring science. In J. Kinnunen, P. Meriläinen, K. Vehviläinen-Julkunen, & T. Nyberg (Eds.), The multiscientific health science university edu- cation and research. Paths to the highway of science. A jubilee book dedicated to Professor Sirkka Sikkonen (pp. 21–35). Kuopio, Finland: Kuopion yliopiston julkaisuja E, Yhteiskuntatieteet 74.]

Eriksson, K. (1999). Vårdvetenskapen—En akademisk disciplin. I S. Janhonen, I. Lepola, M. Nikkonen, & M. Toljamo (red.), Suomalainen hoitotiede uudelle vuosituhannelle. Professori Maija Hentisen juhlakirja

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(s. 59–64). Oulu, Finland: Oulun yliopiston hoitoti- eteen ja terveyshallinnon laitoksen julkaisuja 2. [Car- ing science—An academic discipline. In S. Janhonen, I. Lepola, M. Nikkonen, & M. Toljamo (Eds.), The Finnish caring science in the new millennium. A jubilee- script dedicated to Professor Maija Hentinen (pp. 59–64). Oulu, Finland: Oulun yliopiston hoitotieteen ja terveyshallinnon laitoksen julkaisuja 2.]

Eriksson, K. (2000). Caritas et passio—Liebe und leiden— Als grundkategorien der pflegewissenschaft. I T. Strom, Diakonie an der Schwelle zum neuen Jahrtausend. Heidelberg, Germany: Diakoniewissenschaftlichen In- stituts, Universität Heidelberg. [Caritas et passio—Love and suffering as basic categories in caring science. In T. Strom, The diaconate on the threshold of the new millennium. Heidelberg, Germany: Diakoniewissen- schaftlichen Instituts, Universität Heidelberg.]

Eriksson, K. (2002). Rakkaus—Diakoniatieteen ydin ja ethos? I M. Lahtinen & T. Toikkanen (red.), Anno Do- mini. Diakoniatieteen vuosikirja 2002 (s. 155–164). Tampere, Finland: Tammerpaino. [Love—The core and ethos of deacony? In M. Lahtinen & T. Toikkanen (Eds.), Anno Domini. Diakonic yearbook 2002 (pp. 155–164). Tampere, Finland: Tammerpaino.]

Eriksson, K. (2003). Diakonian erityisyys hoitotyössä. I M. Lahtinen & T. Toikkanen (red.), Anno domini. Diakoni- atieteen vuosikirja 2003 (s. 120–126). Tampere, Finland: Tammerpaino. [The uniqueness of deacony in nursing. In M. Lahtinen & T. Toikkanen (Eds.), Anno Domini. Diakonic yearbook 2003 (pp. 120–126). Tampere, Finland: Tammerpaino.]

Eriksson, K. (2009). Evidens – Det sanna, det sköna, det goda och det eviga. I Martinsen, K., & Eriksson, K. Å se og innse. Om ulike former for evidens (s. 35–80). Oslo, Norge, Akribe. [Evidence – The true, the beautiful, the good and the eternal. In Martinsen, K., & Eriksson, K. To see and to understand. About different forms of evi- dence (pp. 35–80). Oslo, Norway, Akribe.]

Eriksson, K., & Hamrin, E. (1988). Vårdvetenskapen formas—En tillbakablick och ett framtidsperspektiv. I Panakeia, vårdvetenskaplig årsbok (s. 9–16). Stockholm: Almqvist & Wiksell. [Caring science is formed—A his- torical and futuristic perspective. In Panakeia, caring science yearbook (pp. 9–16). Stockholm: Almqvist & Wiksell.]

Eriksson, K., & Lindholm T. (2010). “Love Endures All Things?” Violence Between Spouses, Suffering, and Alleviation of Suffering—Developing a Theory Model. International Journal for Human Caring, 14(3), 72.

Eriksson, K., Nordman, T., & Kasén, A. (1998). Reflective practice: A way to the patient’s world and caring, the core of nursing. In C. Johns & D. Freshwater (Eds.),

Transforming nursing through reflective practice. Oxford: Blackwell Science.

Eriksson, K., & Willman, H. (1972). Kohti parempaa ohjausta. I Sairaanhoidon vuosikirja IX (s. 131–139). Helsinki, Finland: Sairaanhoitajien Koulutussäätiö. [Toward a better counseling. In Health care yearbook IX (pp. 131–139). Helsinki, Finland: Sairaanhoitajien Koulutussäätiö.]

Nielsen, G.B., Matilainen, D., & Eriksson, K. (2010). Caring science, clinical supervision and discourse analysis – A route forward? Nordic College of Caring Sciences confer- ence 14–16.4.2010,Vasa, Finland. Abstract book pp. 28.

Salmela, S., Eriksson, K., & Fagerström, L. (2011). A three dimensional model of leading innovation and change. International Nursing Management Conference 17– 19.11.2011, Antalya, Turkey. Abstract book pp. 43–44.

Wikberg, A., Bondas, T., & Eriksson, K. (2010). Interpret- ing empirical studies by using meta ethnography. Nor- dic College of Caring Sciences conference 14–16.4.2010, Vasa, Finland. Abstract book pp. 26.

Books and Monographs Eriksson, K. (1974). Sjuksköterskeyrket—Hantverk eller

profession? Sjuksköterskors samarbete i Norden. Rap- port från SSN: s expertgrupp för klargörande av vård- funktionsområdet. Helsinki, Finland: SSN. [The nurs- ing profession—Skill or profession? Collaboration of nurses in the Nordic countries. Report from SSN’s expert group for the clarification of nursing. Helsinki, Finland: SSN.]

Eriksson, K. (1975). Den teoretiska utgångspunkten för vårdprocessen. Rapport från SSN: s symposium i Hels- ingfors. Helsinki, Finland: SSN. [The theoretical start- ing point of the nursing care process. A report from SSN: s symposium in Helsinki. Helsinki, Finland: SSN.]

Eriksson, K. (1976). Hoitotapahtuma. Hoito-oppi 2. Helsinki, Finland: Sairaanhoitajien Koulutussäätiö. [The nursing care process. Nursing science 2. Helsinki, Finland: Sairaanhoitajien Koulutussäätiö.]

Eriksson, K. (1976). Hälsa. En teoretisk och begreppsanalyt- isk studie om hälsan och dess natur som mål för hälsovårdsedukation. Licentiatavhandling, Helsinki, Finland: Institutionen för pedagogik, Helsingfors uni- versitet. [Health. A conceptual analysis and theoretical study of health and its nature as a goal for health care education. Unpublished licentiate thesis, Helsinki, Finland: Department of Education University of Helsinki.]

Eriksson, K. (1979). Vårdprocessen. Stockholm: Almqvist & Wiksell. [The nursing care process. Stockholm: Almqvist & Wiksell.]

Eriksson, K. (1981). Vårdprocessen—En utgångspunkt för läroplanstänkande inom vårdutbildningen. Utvecklande

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av en vårdprocessmodell samt ett läroplanstänkande ut- gående från vårdprocessen (Nr. 94). Helsinki, Finland: Helsingfors universitet, Pedagogiska Institutionen. [The nursing care process—An approach to curriculum con- struction within nursing education. The development of a model for the nursing care process and an approach for curriculum development based on the process of nursing care (No. 94). Helsinki, Finland: Department of Educa- tion University of Helsinki.]

Eriksson, K. (1982). Vårdprocessen (2:a uppl.). Stockholm: Almqvist & Wiksell. [The nursing care process (2nd ed.). Stockholm: Almqvist & Wiksell.]

Eriksson, K. (1983). Introduktion till vårdvetenskap. Stock- holm: Almqvist & Wiksell. [An introduction to caring science. Stockholm: Almqvist & Wiksell.]

Eriksson, K. (1984). Hälsans idé. Stockholm: Almqvist & Wiksell. [The idea of health. Stockholm: Almqvist & Wiksell.]

Eriksson, K. (1985). Johdatus hoitotieteeseen. Helsinki, Finland: Sairaanhoitajien Koulutussäätiö. [An introduc- tion to caring science. Helsinki, Finland: Sairaanhoitajien Koulutussäätiö.]

Eriksson, K. (1985). Vårddidaktik. Stockholm: Almqvist & Wiksell. [Caring didactics. Stockholm: Almqvist & Wiksell.]

Eriksson, K. (1985). Vårdprocessen (3: e uppl.). Stockholm: Almqvist & Wiksell. [The nursing care process (3rd ed.). Stockholm: Almqvist & Wiksell.]

Eriksson, K. (1986). Hoito-opin didaktiikka. Helsinki, Finland: Sairaanhoitajien Koulutussäätiö. [The didac- tics of caring science. Helsinki, Finland: Sairaanhoitajien Koulutussäätiö.]

Eriksson, K. (1986). Introduktion till vårdvetenskap (2: a uppl.). Stockholm: Almqvist & Wiksell. [An introduc- tion to caring science (2nd ed.). Stockholm: Almqvist & Wiksell.]

Eriksson, K. (1987). Hoitamisen idea. Forssa, Finland: Sairaanhoitajien Koulutussäätiö. [The idea of caring. Forssa, Finland: Sairaanhoitajien Koulutussäätiö.]

Eriksson, K. (1987). Pausen. En beskrivning av vårdvetens- kapens kunskapsobjekt. Stockholm: Almqvist & Wiksell. [The pause. A description of the knowledge object of car- ing science. Stockholm: Almqvist & Wiksell.]

Eriksson, K. (1987). Vårdandets idé. Stockholm: Almqvist & Wiksell. [The idea of caring.Stockholm: Almqvist & Wiksell.]

Eriksson, K. (1988). Hoito tieteenä. Forssa, Sweden: Sairaanhoitajien Koulutussäätiö. [Caring as a science. Forssa, Sweden: Sairaanhoitajien Koulutussäätiö.]

Eriksson, K. (1989). Caritas-idea. Helsinki, Finland: Sairaanhoitajien Koulutussäätiö. [The idea of caritas. Helsinki, Finland: Sairaanhoitajien Koulutussäätiö.]

Eriksson, K. (1989). Hälsans idé. (2:a uppl.). Stockholm: Almqvist & Wiksell. [The idea of health (2nd ed.). Stockholm: Almqvist & Wiksell.]

Eriksson, K. (1989). Terveyden idea. Helsinki, Finland: Sairaanhoitajien Koulutussäätiö. [The idea of health. Helsinki, Finland: Sairaanhoitajien Koulutussäätiö.]

Eriksson, K. (1992). Broar. Introduktion i vårdvetenskaplig metod. Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [Bridges. Introduction to the methods of caring science. Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Eriksson, K. (1994). Den lidande människan. Stockholm: Liber Förlag. [The suffering human being. Stockholm: Liber Förlag.]

Eriksson, K. (1995). Det lidende menneske (Danish trans- lation). Copenhagen: Munksgaard. [The suffering human being (Danish translation). Copenhagen: Munksgaard.]

Eriksson, K. (1995). Den lidende menneske (Norwegian translation). Oslo: TANO. [The suffering human being (Norwegian translation). Oslo: TANO.]

Eriksson, K. (1996). Omsorgens idé (Danish translation). Copenhagen: Munksgaard. [The idea of caring (Danish translation). Copenhagen: Munksgaard.]

Eriksson, K. (1997). Vårdandets idé (Kassettband). Talboksoch punktskriftsbiblioteket. Stockholm: Almqvist & Wiksell. [The idea of caring (Audiotape). Talboksoch punktskriftsbiblioteket. Stockholm: Almqvist & Wiksell.]

Eriksson, K. (2001). Gesundheit. Ein Schlüsselbegriff der Pflegetheorie. (German translation). Bern, Germany: Verlag Hans Huber. [The idea of health (German translation). Bern, Germany: Verlag Hans Huber.]

Eriksson, K. (2006). The suffering human being. Chicago: Nordic Studies Press. [English translation of: Den lidande människan. Stockholm, Sweden: Liber Förlag.1994.]

Eriksson, K., & Barbosa da Silva, A. (Eds.). (1994). Usko ja terveys—johdatus hoitoteologiaan.(Finnish translation). Helsinki, Finland: Sairaanhoitajien Koulutussäätiö. [Caring theology (Finnish translation). Helsinki, Finland: Sairaanhoitajien Koulutussäätiö.]

Eriksson, K., Byfält, H., Leijonqvist, G-B., Nyberg, K., & Uuspää, B. (1986). Vårdteknologi. Stockholm: Almqvist & Wiksell. [Caring technology. Stockholm: Almqvist & Wiksell.]

University and Department Publications Eriksson, K. (1988). Vårdvetenskap som disciplin, forsknings-

och tillämpningsområde. Vårdforskningar 1/1988. Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [Caring science as a discipline, field of research and applica- tion. Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

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Eriksson, K. (1990). Pro Caritate. En lägesbestämning av caritativ vård. Vårdforskningar 2/1990. Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [Pro Caritate. Caritative caring—A positional analysis. Vaasa, Finland: Department of Caring Science, ÅboAkademi.]

Eriksson, K. (1991). Att lindra lidande. I K. Eriksson & A. Barbosa da Silva (red.), Vårdteologi. Vårdforskningar 3/1991 (s. 204–221). Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [To alleviate suffering. In K. Eriksson & A. Barbosa da Silva (Eds.), Caring theology (pp. 204–221). Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Eriksson, K. (1991). Vårdteologins framväxt. I K. Eriksson & A. Barbosa da Silva (red.), Vårdteologi. Vårdforsknin- gar 3/1991 (s. 1–25). [The growth of caring theology. In K. Eriksson & A. Barbosa da Silva (Eds.), Caring theol- ogy (pp. 1–25). Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Eriksson, K. (1993). Lidandets idé. I K. Eriksson (red.), Möten med lidanden. Vårdforskningar 4/1993 (s. 1–27). Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [The idea of suffering. In K. Eriksson (Ed.), Encounters with suffering (pp. 1–27). Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Eriksson, K. (red.). (1993). Möten med lidanden.Vårdfor- skning 4/1993. Vaasa, Finland: Institutionen för vård- vetenskap, Åbo Akademi. [Encounters with suffering. Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Eriksson, K. (red.). (1995). Den mångdimensionella hälsan—Verklighet och visioner. Slutrapport. Vaasa, Finland: Vasa sjukvårdsdistrikt kf. och Institutionen för vårdvetenskap, Åbo Akademi. [Multidimensional health—Visions and reality. Final report. Vaasa, Finland: Vasa sjukvårdsdistrikt kf. och Institutionen för vårdvetenskap, Åbo Akademi.]

Eriksson, K. (1995). Mot en caritativ vårdetik. I K. Eriksson (red.), Mot en caritativ vårdetik. Vårdforskning 5/1995 (s. 9–40). Vaasa, Finland: Institutionen för vårdvetens- kap, Åbo Akademi. [Toward a caritative caring ethic. In K. Eriksson (Ed.), Toward a caritative caring ethic. Caring research 5/1995. (pp. 9–40). Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Eriksson, K. (1995). Vad är vårdetik? I K. Eriksson (red.), Mot en caritativ vårdetik. Vårdforskning 5/1995 (s. 1–8). Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [What is caring ethic? In K. Eriksson (Ed.), Toward a caritative caring ethic (pp. 1–8). Vaasa, Finland: Department of Caring Science, Åbo Akademi.]. Caring research 5/1995.

Eriksson, K. (1997). Att insjukna i demens—Ett tungt lidande för patient och anhöriga. I B. Beck-Friis &

G. Grahn (red.), Leva med demenshandikapp. Lund, Sweden: Lunds universitet: Stiftelsen Silviahemmet. [Becoming ill with dementia—A burdensome suffering for the patient and his/her family. In B. Beck-Friis & G. Grahn (Eds.), Living with the handicap of dementia (Action in favor of people suffering from neurodegenera- tive diseases). Lund, Sweden: Lunds universitet, Stiftelsen Silviahemmet.]

Eriksson, K. (1998). Vårdvetenskapens framväxt som aka- demisk disciplin—Ett finlandssvenskt perspektiv. I K. Eriksson (red.), Jubileumsskrift 1987–1997 (s. 1–7). Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [The growth of caring science as an academic discipline—A Finland-Swedish perspective. In K. Eriksson (Ed.), Jubilee-script 1987–1997 (pp. 1–7). Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Eriksson, K. (2001). Vårdvetenskap som akademisk discip- lin. Vårdforskning 7/2001. Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [Caring science as an academic discipline. Caring research 7/2001. Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Eriksson, K. (2002). Den trojanske hest. Evidensbasering og sygepleje. (Danish translation). Copenhagen: Gads Förlag. [The Trojan horse. Evidence-based nursing and caring through a caring science perspective (Danish translation). Copenhagen: Gads Förlag.]

Eriksson, K. (2002). Idéhistoria som deldisciplin inom vårdvetenskapen. I K. Eriksson & D. Matilainen (red.), Vårdandets och vårdvetenskapens idéhistoria. Strövtåg i spårandet av “caritas originalis.” Vårdforskning 8/2002 (s. 1–14). Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [The history of ideas as a sub-discipline within caring science. In K. Eriksson & D. Matilainen (Eds.), The history of ideas of caring and caring science. Wanderings in search of “caritas originalis.” Caring research 8/2002 (pp. 1–14). Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Eriksson, K. (2002). Vårdandets idéhistoria. I K. Eriksson & D. Matilainen (red.), Vårdandets och vårdvetenskapens idéhistoria. Strövtåg i spårandet av “caritas originalis.” Vårdforskning 8/2002 (s. 15–34). Vaasa, Finland: Insti- tutionen för vårdvetenskap, Åbo Akademi. [The history of ideas of caring. In K. Eriksson & D. Matilainen (Eds.), The history of ideas of caring and caring science. Wanderings in search of “caritas originalis.” Caring research 8/2002 (pp. 15–34). Vaasa, Finland: Depart- ment of Caring Science, Åbo Akademi.]

Eriksson, K. (2003). Ethos. I K. Eriksson & U. Å. Lindström (red.), Gryning II. Klinisk vårdvetenskap (s. 21–34). Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [Ethos. In K. Eriksson & U. Å. Lindström (Eds.), Dawn II. Clinical caring science (pp. 21–34).

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Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Eriksson, K., & Barbosa da Silva, A. (1991). Vårdteologi som vårdvetenskapens deldisciplin. I K. Eriksson & A. Barbosa da Silva (red.), Vårdteologi. Vårdforskningar 3/1991 (s. 26–64). Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [Caring theology as a sub-discipline of caring science. In K. Eriksson & A. Barbosa da Silva (Eds.), Caring theology. Caring research 3/1991 (pp. 26–64). Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Eriksson, K., Bondas-Salonen, T., Fagerström, L., Herberts, S., & Lindholm, L. (red.). (1990). Den mångdimensionella hälsan. En pilotstudie över uppfattningar bland patien- ter, skolungdomar och lärare (Projektrapport 1). Vaasa, Finland: Vasa sjukvårdsdistrikt kf. och Institutionen för vårdvetenskap, Åbo Akademi. [Multidimensional health. A pilot study of understanding health among pa- tients, students and teachers (Project Rep. 1). Vaasa, Finland: Vasa sjukvårdsdistrikt kf. och Institutionen för vårdvetenskap, Åbo Akademi.]

Eriksson, K., & Herberts, S. (1991). Tron i hälsans tjänst. I K. Eriksson & A. Barbosa da Silva (red.), Vårdteologi. Vårdforskningar 3/1991 (s. 222–258). Vaasa Finland: Institutionen för vårdvetenskap, Åbo Akademi. [Faith in the service of health. In K. Eriksson & A. Barbosa da Silva (Eds.), Caring theology. Caring research 3/1991 (pp. 222–258). Vaasa Finland: Department of Caring Science, Åbo Akademi.

Eriksson, K., & Herberts, S. (1992). Den mångdimensio- nella hälsan. En studie av hälsobilden hos sjukvårdsle- dare och sjukvårdspersonal (Projektrapport 2). Vaasa, Finland: Vasa sjukvårdsdistrikt kf och Institutionen för vårdvetenskap, Åbo Akademi. [Multidimensional health. A study of the views of health among health care leaders and health care personnel (Project Rep. 2). Vaasa, Finland: Vasa sjukvårdsdistrikt kf och Institu- tionen för vårdvetenskap, Åbo Akademi.]

Eriksson, K., & Herberts, S. (1993). Lidande—En begrepps- analytisk studie. I K. Eriksson (red.), Möten med lidan- den. Vårdforskningar 4/1993 (s. 29–54). Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [A study of suffering—A concept analysis. In K. Eriksson (Ed.), Encounters with suffering. Caring research 4/1993 (pp. 29–54). Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Eriksson, K., Herberts, S., & Lindholm, L. (1993). Bilder av lidande—Lidande i belysning av aktuell vårdvetens- kaplig forskning. I K. Eriksson (red.), Möten med lidan- den. Vårdforskningar 4/1993 suffering (s. 55–78). Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [Views of suffering—Suffering in the light of current

caring science research. In K. Eriksson (Ed.), Encounters with suffering. Caring research 4/1993 (pp. 55–78). Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Eriksson, K., & Koort, P. (1973). Sjukvårdspedagogik (Kompendium). Helsinki, Finland: Helsingfors svenska sjukvårdsinstitut. [The pedagogy of nursing care (Compendium). Helsinki, Finland: Helsingfors svenska sjukvårdsinstitut.]

Eriksson, K., & Lindholm, L. (1993). Lidande och kärlek ur ett psykiatriskt vårdperspektiv—En casestudie av mötet mellan mänskligt lidande och kärlek. I K. Eriksson (red.), Möten med lidanden. Vårdforskningar 4/1993 suf- fering (s. 79–137). Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [Love and suffering through a psychiatric caring perspective—A case study of the encounters with human love and suffering. In K. Eriksson (Ed.), Encounters with suffering. Caring research 4/1993 (pp. 79–137). Vaasa, Finland: Depart- ment of Caring Science, Åbo Akademi.]

Eriksson, K., & Lindström, U. Å. (2000). Gryning. En vård- vetenskaplig antologi. Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [Dawn. An anthology of caring science. Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Eriksson, K., & Lindström, U. Å. (2000). Siktet, Sökandet, slu- tandet. I K. Eriksson & U. Å. Lindstöm (red.), Gryning. En vårdvetenskaplig antologi (s. 5–18). Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [Envision- ing, seeking and ending. In K. Eriksson & U. Å. Lind- ström (eds.), Dawn. An anthology of caring science (pp. 5–18). Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Eriksson, K., & Lindström, U. Å. (2003). Klinisk vård- vetenskap. I K. Eriksson & U. Å. Lindström (red.), Gryning II. Klinisk vårdvetenskap (s. 3–20). Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Aka- demi. [Clinical caring science. In K. Eriksson & U. Å. Lindström (Eds.), Dawn II. Clinical caring science (pp. 3–20). Vaasa, Finland: Department of Caring Science, Åbo Akademi.

Eriksson, K., & Lindström, U. Å. (2007). Vårdvetenskapens vetenskapsteori på hermeneutisk grund—några grund- drag. I K. Eriksson, U. Å. Lindström, D. Matilainen & L. Lindholm (red.), Gryning III. Vårdvetenskap och hermeneutik (s. 5–20). Vaasa, Finland: Enheten för vårdvetenskap, Åbo Akademi. [The theory of science for caring science on a hermeneutic foundation—some basic features. In K. Eriksson, U. Å. Lindström, D. Matilainen & L. Lindholm (Eds.), Dawn III. Caring science and hermeneutics (pp. 5–20). Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

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Eriksson, K., & Matilainen, D. (red.). (2002). Vårdandets och vårdvetenskapens idéhistoria. Strövtåg i spårandet av “caritas originalis”. Vårdforskning 8/2002. Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [Eriksson, K., & Matilainen, D. (eds.). The history of ideas of caring and caring science. Wanderings in search of “caritas originalis.” Caring research 8/2002. Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Eriksson, K., & Matilainen, D. (red.). (2004). Vårdvetens- kapens didaktik. Caritativ didaktik i vårdandets tjänst. Vårdforskningar 9/2004. Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [The didactics of caring science. Caritative didactics in the service of caring. Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Eriksson, K., & Nordman, T. (2004). Den trojanska hästen II—Utvecklande av evidensbaserade vårdande kulturer. Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [The Trojan horse II—Development of evidence-based caring cultures. Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Eriksson K., Nordman T., & Myllymäki I. (1999). Den tro- janska hästen. Evidensbaserat vårdande och vårdarbete ur ett vårdvetenskapligt perspektiv cultures (Rap. 1). Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi; Helsingfors universitetscentralsjukhus & Vasa sjukvårdsdistrikt. [The Trojan horse II— Development of evidence-based caring cultures (Rep. 1). Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi; Helsingfors universitetscentralsjukhus & Vasa sjukvårdsdistrikt.

Herberts, S., & Eriksson, K. (1995). Vårdarnas etiska profil. I K. Eriksson (red.), Mot en caritativ vårdetik. Vårdfor- skning 5/1995 (s. 41–62). Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [The ethical profile of the carers. In K. Eriksson (Ed.), Toward a caritative caring ethic. Caring research 5/1995 (pp. 41–62). Vaasa, Finland: Department of Caring Science, Åbo Akademi.]

Secondary Sources Doctoral Dissertations Andersson, M. (1994). Integritet som begrepp och prin-

cip. En studie av ett vårdetiskt ideal i utveckling. Dok- torsavhandling, Turku, Finland, Åbo Akademis Förlag. [Integrity as a concept and as a principle in health care ethics. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Arman, M. (2003). Lidande och existens i patientens värld. Kvinnors upplevelser av att leva med bröstcan- cer. Doktorsavhandling, Turku, Finland, Åbo Akademis Förlag. [Suffering and existence in the patient’s world. Women’s experiences of living with breast cancer.

Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Bondas, T. (2000). Att vara med barn: en vårdvetenskaplig studie av kvinnors upplevelser under perinatal tid. Doktorsavhandling, Turku, Finland, Åbo Akademis Förlag. [To be with child: a study of women’s lived experiences during the perinatal period from a caring science perspective. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Caspari, S. (2004). Det gyldne snitt. Den estetiske dimensjon, en kilde til helse og et etisk anliggende. Doktorsavhan- dling, Turku, Finland, Åbo Akademis Förlag. [The golden section. The aestethic dimension—a source of health. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Edlund, M. (2002). Människans värdighet-ett grundbegrepp inom vårdvetenskapen. Doktorsavhandling, Turku, Finland, Åbo Akademis Förlag. [Human dignity—A basic caring science concept. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Ekebergh, M. (2001). Tillägnandet av vårdvetenskaplig kunskap. Reflexionens betydelse för lärandet. Doktor- savhandling, Turku, Finland, Åbo Akademis Förlag. [Acquiring caring science knowledge—The importance of reflection for learning. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Fagerström, L. (1999). The patient’s caring needs. To un- derstand and to measure the unmeasurable. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.

Foss, B. (2012). Ledelse—en bevegelse i ansvar og kjær- lighet. Doktorsavhandling, Turku, Finland, Åbo Akade- mis förlag. [Leadership—A movement in responsibility and love. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Fredriksson, L. (2003). Det vårdande samtalet. Doktor- savhandling, Turku, Finland, Åbo Akademis Förlag. [The caring conversation. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.

Gustafsson, L-K. (2008). Försoning ur ett vårdvetenskap- ligt perspektiv. Doktorsavhandling, Turku, Finland, Åbo Akademis förlag. [Reconciliation—From a caring perspective. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Helin, K. (2011). Den vårdande och helande bilden— möten med bildkonst i vårdandets värld. Doktor- savhandling, Turku, Finland, Åbo Akademis förlag. [The caring and healing image—Encountering works of visual art in the caring context. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Hilli, Y. (2007). Hemmet som ethos. En idéhistorisk studie av hur hemmet som ethos blev evident i hälsosysterns

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vårdande under 1900-talets första hälft. Doktorsavhan- dling, Turku, Finland, Åbo Akademis Förlag. [The home as ethos. A history of ideas study of how the home as ethos became evident in public health nurses’ caring during the first half of the 20th century. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Karterud, D. (2006). Den etiske akten—Den caritative etikken når pasientens fordringer er av eksistensiell art. Doktorsavhandling, Turku, Finland, Åbo Akademis Förlag. [The ethical act—caring ethics when the pa- tients’ demands are existential. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Kasén, A. (2002). Den vårdande relationen. Doktorsavhan- dling, Turku, Finland, Åbo Akademis Förlag. [The car- ing relationship. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Koskinen, C. (2011). Lyssnande—en vårdvetenskaplig betraktelse. Doktorsavhandlin, Turku, Finland, Åbo Akademis förlag. [Listening—A caring science reflec- tion. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Koslander, T. (2011). Ljusets gemenskap—en gestaltning av den andliga dimensionen i vårdandet. Doktor- savhandling, Turku, Finland, Åbo Akademis förlag. [The Communion of the Light—Shaping of spiritual dimension in the caritative caring. Doctoral disserta- tion, Turku, Finland, Åbo Akademi University Press.]

Kärkkäinen, O. (2005). Documentation of Patient Care as Evidence of Caring Substance. Doctoral dissertation, Vaasa, Finland: Department of Caring Science, Åbo Akademi University.

Lassenius, E. (2005). Rummet i vårdandets värld. Doktor- savhandling, Turku, Finland, Åbo Akademis Förlag. [The space in the world of caring. Doctoral disserta- tion, Turku, Finland, Åbo Akademi University Press.]

Levy-Malmberg, R. (2010). Interpretive dialogical evalua- tion. Evaluating caring science basic research. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.

Lindholm, L. (1998). Den unga människans hälsa och lidande. Doktorsavhandling, Vaasa, Finland: Institu- tionen för vårdvetenskap, Åbo Akademi. [The young person’s health and suffering. Doctoral dissertation, Vaasa, Finland: Department of Caring Science, Åbo Akademi University.]

Lindholm, T. (2008). Kaikki se kärsii? Parisuhdeväki- valta, kärsimys ja sen lievittäminen naisten ja miesten näkökulmasta. Doktorsavhandling, Turku, Finland, Åbo Akademis förlag. [Love endures all things? Vio- lence between spouses, suffering and alleviation of suffering from the viewpoint of women and men.

Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Lindström, U. Å. (1992). De psykiatriska specialsjuk- skötarnas yrkesparadigm. Doktorsavhandling, Turku, Finland, Åbo Akademis Förlag. [The professional paradigm of the qualified psychiatric nurses. Doc- toral dissertation, Turku, Finland, Åbo Akademi University Press.]

Lindwall, L. (2004). Kroppen som bärare av hälsa och lidande. Doktorsavhandling, Turku, Finland, Åbo Akademis Förlag. [The body as a carrier of health and suffering. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Matilainen, D. (1997). Idémönster i Karin Neuman-Rahns livsgärning och författarskap—En idéhistorisk-biografisk studie i psykiatrisk vård i Finland under 1900-talets första hälft. Doktorsavhandling, Turku, Finland, Åbo Akademis Förlag. [Patterns of ideas in Karin Neuman- Rahns’ life-work and writings—A study of psychiatric care in Finland in the former part of the twentieth century, based on biography and the history of ideas. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Nilsson, B. (2004). Savnets tone i ensomhetens melodi. Ensomhet hos aleneboende personer med alvorlig psykisk lidelse. Doktorsavhandling, Turku, Finland, Åbo Akademis Förlag. [The tune of want in the loneli- ness melody. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Nordman, T. (2006). Människan som patient i en vårdande kultur. Doktorsavhandling, Vaasa, Finland: Enheten för vårdvetenskap, Åbo Akademi. [A human being as a pa- tient in a caring culture. Doctoral dissertation, Vaasa, Finland: Department of Caring Science, Åbo Akademi University.]

Nurminen, M. (2009). Tid och det tidlösa i tiden. En frambrytande vårdvetenskaplig teorigestaltning. Dok- torsavhandlin, Turku, Finland, Åbo Akademis förlag. [Time and the timeless within time—An emerging foundation for the theory of caring science. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Nyback, M-H. (2008). Generic and professional caring in a Chinese setting—an ethnographic study. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.

Nåden, D. (1998). När sykepleie er kunstutøvelse. En un- dersøkelse av noen nødvendige forutsetninger for syke- pleie som kunst. Doktorsavhandling, Vaasa, Finland: Institutionen för vårdvetenskap, Åbo Akademi. [When caring is an exercise of art. An examination of some necessary preconditions of nursing as an art. Doctoral

CHAPTER 11 Katie Eriksson 201

dissertation, Vaasa, Finland: Department of Caring Science, Åbo Akademi University.]

Näsman, Y. (2010). Hjärtats vanor, tankens välvilja och handens gärning—dygd som vårdetiskt grundbegrepp. Doktorsavhandling, Turku, Finland, Åbo Akademis förlag. [Habits of the heart, benevolence of the mind, and deeds of the hand—Virtue as a basic concept in caring ethics. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Rehnsfeldt, A. (1999). Mötet med patienten i ett livsavgörande skede. Doktorsavhandling, Turku, Finland, Åbo Akademi. [The encounter with the patient in a life-changing process. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Rosengren, A-L. (2009). Hälsans grund kan bara hjärtat förstå. Ett sökande efter kunskap om hälsa i ljuset av Blaise Pascals tänkande. Doktorsavhandling, Turku, Finland, Åbo Akademis förlag. [The foundation of health can be understood by the heart only—In pursuit of knowledge about health in the light of Blaise Pascal’s thinking. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Roxberg, Å. (2005). Vårdande och icke-vårdande tröst. Doktorsavhandling, Turku, Finland: Åbo Akademis Förlag. [Caring and non-caring consolation. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Rudolfsson, G. (2007). Den perioperativa dialogen—en gemensam värld. Doktorsavhandling, Vaasa, Finland: Enheten för vårdvetenskap, Åbo Akademi. [The periop- erative dialogue—a common world. Doctoral disserta- tion, Vaasa, Finland: Department of Caring Science, Åbo Akademi University.]

Rundqvist, E. (2004). Makt som fullmakt. Ett vårdvetens- kapligt perspektiv. Doktorsavhandling, Turku, Finland, Åbo Akademis Förlag. [Power as authority. A caring science perspective. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Rydenlund, K. (2012). Vårdandets imperativ i de yttersta livsrummen. Hermeneutiska vårdande samtal inom den rättspsykiatriska vården. Doktorsavhandling, Turku, Finland, Åbo Akademis förlag. [The imperative of caring in extreme living-spaces—Hermeneutical car- ing conversations in forensic psychiatric care. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Råholm, M-B. (2003). I kampens och modets dialektik. Doktorsavhandling, Turku, Finland, Åbo Akademis Förlag. [In the dialectic of struggle and courage. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Sæteren, B. (2006). Kampen for livet i vemodets slør. Å leve i spenningsfeltet mellom livets mulighet og dødens nødvendighet. Doktorsavhandling, Turku, Finland, Åbo Akademis Förlag. [Struggling for life in the veil of pensiveness. A life between the pressure created by the possibility of life and the necessity of death. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Sivonen, K. (2000). Vården och det andliga. En bestämning av begreppet ‘andlig’ ur ett vårdvetenskapligt perspektiv. Doktorsavhandling, Turku, Finland, Åbo Akademis Förlag. [Features of spirituality in caring. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Söderlund, M. (2004). Som drabbad av en orkan. Anhöri- gas tillvaro när en närstående drabbas av demens. Doktorsavhandling, Turku, Finland, Åbo Akademis Förlag. [As if struck by a hurricane: The situation of the relatives of someone suffering from dementia. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

von Post, I. (1999). Professionell naturlig vård ur anestesoch operationssjuksköterskors perspektiv. Doktorsavhandling, Turku, Finland, Åbo Akademis Förlag. [Professional nat- ural care from the perspective of nurse anesthetists and operating room nurses. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Wallinvirta, E. (2011). Ansvar som klangbotten i vårdan- dets meningssammanhang. Doktorsavhandling, Turku, Finland, Åbo Akademis förlag. [Responsibility as sounding board in the caring’s context of meaning. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Wiklund, L. (2000). Lidandet som kamp och drama. Doktor- savhandling, Turku, Finland, Åbo Akademis Förlag. [Suffering as struggle and as drama. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

Wärnå, C. (2002). Dygd och hälsa. Doktorsavhandling, Turku, Finland, Åbo Akademis Förlag. [Virtue and health. Doctoral dissertation, Turku, Finland, Åbo Akademi University Press.]

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n Nursing conceptual models are concepts and their relationships that specify a perspective and produce evidence among phenomena specific to the discipline.

n Conceptual models address broad metaparadigm concepts (human beings, health, nursing, and environment) that are central to their meaning in the context of the particular framework and the discipline of nursing.

n Nursing conceptual models provide perspectives with different foci for critical thinking about persons, families, and communities, and for making knowledgeable nursing decisions.

Nursing Conceptual Models

UNIT III

204

Credentials and Background of the Theorist*

Myra Estrin Levine enjoyed a varied career. She was a private duty nurse (1944), a civilian nurse in the U.S. Army (1945), a preclinical instructor in the physical sciences at Cook County (1947 to 1950), di- rector of nursing at Drexel Home in Chicago (1950 to 1951), and surgical supervisor at both the University of Chicago Clinics (1951 to 1952) and the Henry Ford Hospital in Detroit (1956 to 1962). Levine worked her way up the academic ranks at Bryan Memorial Hospi- tal in Lincoln, Nebraska (1951), Cook County School of Nursing (1963 to 1967), Loyola University (1967 to 1973), Rush University (1974 to 1977), and the

University of Illinois (1962 to 1963, 1977 to 1987). She chaired the Department of Clinical Nursing at Cook County School of Nursing (1963 to 1967) and coordinated the graduate nursing program in oncology at Rush University (1974 to 1977). Levine was director of the Department of Continuing Education at Evanston Hospital (March to June 1974) and consultant to the department (July 1974 to 1976). She was adjunct as- sociate professor of Humanistic Studies at the Univer- sity of Illinois (1981 to 1987). In 1987, she became a Professor Emerita, Medical Surgical Nursing, at the University of Illinois at Chicago. In 1974, Levine went to Tel-Aviv University, Israel, as a visiting associate professor and returned as a visiting professor in 1982. She also was a visiting professor at Recanati School of

“Nursing is human interaction” (Levine, 1973, p. 1).

Myra Estrin Levine 1921 to 1996

CH A P T ER 12

The Conservation Model Karen Moore Schaefer

*The information in this section is informed by Levine’s autobiographical chapter (1988a), her curriculum vitae, and the program from the Mid-Year Convocation, Loyola University, Chicago (1992). Previous authors: Karen Moore Schaefer, Gloria S. Artigue, Karen J. Foil, Tamara Johnson, Ann Marriner Tomey, Mary Carolyn Poat, LaDema Poppa, Roberta Woeste, and Susan T. Zoretich.

CHAPTER 12 Myra Estrin Levine 205

the conservation principles at nurse theory confer- ences, some of which have been audiotaped, and at the Allentown College of St. Francis de Sales (now DeSales University) Conference.

Levine (1989) published a substantial change and clarification about her theory in “The Four Conserva- tion Principles: Twenty Years Later.” She elaborated on how redundancy characterizes availability of adaptive responses when stability is threatened. Adaptation pro- cesses establish a body economy to safeguard individual stability. The outcome of adaptation is conservation.

She explicitly linked health to the process of conser- vation to clarify that the Conservation Model views health as one of its essential components (Levine, 1991). Conservation, through treatment, focuses on integrity and the reclamation of oneness of the whole person.

Levine died on March 20, 1996, at 75 years of age. She leaves a legacy as an administrator, educator, friend, mother, nurse, scholar, student of humanities, and wife (Pond, 1996). Dr. Baumhart, President of Loyola University, said the following of Levine (Mid- Year Convocation, Loyola University, 1992):

Mrs. Levine is a renaissance woman . . . who uses knowledge from several disciplines to expand the vision of health needs of persons that can be met by modern nursing. In the Talmudic tradition of her ancestors, [she] has been a forthright spokes- person for social justice and the inherent dignity of [the] human person as a child of God (p. 6).

Theoretical Sources From Beland’s (1971) presentation of the theory of specific causation and multiple factors, Levine learned historical viewpoints of diseases and learned that the way people think about disease changes over time. Beland directed Levine’s attention to numerous authors who became influential in her thinking, including Goldstein (1963), Hall (1966), Sherrington (1906), and Dubos (1961, 1965). Levine uses Gibson’s (1966) definition of perceptual systems, Erikson’s (1964) dif- ferentiation between total and whole, Selye’s (1956) stress theory, and Bates’ (1967) models of external environment. Levine was proud that Rogers (1970) was her first editor. She acknowledged Nightingale’s contri- bution to her thinking about the “guardian activity” of observation used by nurses to “save lives and increase health and comfort” (Levine, 1992, p. 42).

Nursing, Ben Gurion University of the Negev, at Beer Sheva, Israel (March to April, 1982).

Levine received numerous honors, including charter fellow of the American Academy of Nursing (1973), honorary member of the American Mental Health Aid to Israel (1976), and honorary recognition from the Illinois Nurses Association (1977). She was the first recipient of the Elizabeth Russell Belford Award for excellence in teaching from Sigma Theta Tau (1977). Both the first and second editions of her book, Introduc- tion to Clinical Nursing (Levine, 1969a; 1973) received American Journal of Nursing Book of the Year awards, and her book, Renewal for Nursing, was translated into Hebrew (Levine, 1971a). Levine was listed in Who’s Who in American Women (1977 to 1988) and in Who’s Who in American Nursing (1987). She was elected fel- low of the Institute of Medicine of Chicago (1987 to 1991). The Alpha Lambda Chapter of Sigma Theta Tau recognized Levine for her outstanding contributions to nursing in 1990. In January 1992, she was awarded an honorary doctorate of humane letters from Loyola University, Chicago (Mid-Year Convocation, Loyola University, 1992). Levine was an active leader in the American Nurses Association and the Illinois Nurses Association. After her retirement in 1987, she remained active in theory development and encouraged questions and research about her theory (Levine, 1996).

A dynamic speaker, Levine was a frequent pre- senter of programs, workshops, seminars, and panels, and a prolific writer regarding nursing and education. She also served as a consultant to hospitals and schools of nursing. Although she never intended to develop theory, she provided an organizational struc- ture for teaching medical-surgical nursing and a stim- ulus for theory development (Stafford, 1996). “The Four Conservation Principles of Nursing” was the first statement of the conservation principles (Levine, 1967a). Other preliminary work included “Adaptation and Assessment: A Rationale for Nursing Interven- tion,” “For Lack of Love Alone,” and “The Pursuit of Wholeness” (Levine, 1966b, 1967b, 1969b). The first edition of her book using the conservation principles, Introduction to Clinical Nursing, was published in 1969 (Levine, 1969a). Levine addressed the conse- quences of the four conservation principles in Holistic Nursing (Levine, 1971b). The second edition of Intro- duction to Clinical Nursing was published in 1973 (Levine, 1973). After that, Levine (1984) presented

UNIT III Nursing Conceptual Models206

The three major concepts of the Conservation Model are (1) wholeness, (2) adaptation, and (3) conservation.

Wholeness (Holism) “Whole, health, hale are all derivations of the Anglo- Saxon word hal” (Levine, 1973, p. 11). Levine based her use of wholeness on Erikson’s (1964, 1968) description of wholeness as an open system. Levine (as cited in 1969a) quotes Erikson, who states, “Wholeness emphasizes a sound, organic, progres- sive mutuality between diversified functions and parts within an entirety, the boundaries of which are open and fluent” (p. 94). Levine (1996) believed that Erikson’s definition set up the option of exploring the parts of the whole to understand the whole. Integrity means the oneness of the individuals, emphasizing that they respond in an integrated, singular fashion to environmental challenges.

Adaptation “Adaptation is a process of change whereby the indi- vidual retains his integrity within the realities of his internal and external environment” (Levine, 1973, p. 11). Conservation is the outcome. Some adapta- tions are successful and some are not. Adaptation is a matter of degree, not an all-or-nothing process. There is no such thing as maladaptation.

Levine (1991) speaks of the following three char- acteristics of adaptation: 1. Historicity 2. Specificity 3. Redundancy

She states, “. . . every species has fixed patterns of responses uniquely designed to ensure success in essential life activities, demonstrating that adaptation is both historical and specific” (p. 5). In addition, adaptive patterns may be hidden in individuals’ genetic codes. Redundancy represents the fail-safe options available to individuals to ensure adaptation. Loss of redundant choices through trauma, age, disease, or environmental conditions makes it difficult for individuals to maintain life. Levine (1991) suggests that “the possibility exists that aging itself is a consequence

MAJOR CONCEPTS & DEFINITIONS

of failed redundancy of physiological and psycho- logical processes” (p. 6).

Environment Levine (1973) also views individuals as having their own environment, both internally and externally. Nurses can relate to the internal environment as the physiological and pathophysiological aspects of the patient. Levine uses Bates’ (1967) definition of the external environment and suggests the following three levels: 1. Perceptual 2. Operational 3. Conceptual

These levels give dimension to the interactions between individuals and their environments. The perceptual level includes aspects of the world that individuals are able to intercept and interpret with their sense organs. The operational level contains things that affect individuals physically, although they cannot directly perceive them, things such as microorganisms. At the conceptual level, the envi- ronment is constructed from cultural patterns, characterized by a spiritual existence and mediated by the symbols of language, thought, and history (Levine, 1973).

Organismic Response The capacity of individuals to adapt to their envi- ronmental conditions is called the organismic re- sponse. It is divided into the following four levels of integration: 1. Fight or flight 2. Inflammatory response 3. Response to stress 4. Perceptual awareness

Treatment focuses on the management of these responses to illness and disease (Levine, 1969a).

Fight or Flight

The most primitive response is the fight or flight syndrome. Individuals perceive that they are threatened, whether or not a threat actually exists. Hospitalization, illness, and new experiences elicit a response. Individuals respond by being on the

CHAPTER 12 Myra Estrin Levine 207

alert to find more information and to ensure their safety and well-being (Levine, 1973).

Inflammatory Response

This defense mechanism protects the self from insult in a hostile environment. It is a way of heal- ing. The response uses available energy to remove or keep out unwanted irritants and pathogens. It is limited in time because it drains the individual’s energy reserves. Environmental control is impor- tant (Levine, 1973).

Response to Stress

Selye (1956) described the stress response syndrome to predictable, non–specifically induced organismic changes. The wear and tear of life is recorded on the tissues and reflects long-term hormonal responses to life experiences that cause structural change. It is characterized by irreversibility and influences the way patients respond to nursing care.

Perceptual Awareness

This response is based on the individual’s perceptual awareness. It occurs only as individuals experience the world around them. Individuals use responses to seek and maintain safety. It is the ability to gather information and convert it to a meaningful experi- ence (Levine, 1967a, 1969b).

Trophicognosis

Levine (1966a) recommended trophicognosis as an alternative to nursing diagnosis. It is a scientific method of reaching a nursing care judgment.

Conservation Conservation is from the Latin word conservatio, which means “to keep together” (Levine, 1973). “Conservation describes the way complex systems are able to continue to function even when severely challenged” (Levine, 1990, p. 192). Through conser- vation, individuals are able to confront obstacles, adapt accordingly, and maintain their uniqueness. “The goal of conservation is health and the strength to confront disability” as “. . . the rules of conserva- tion and integrity hold” in all situations in which

MAJOR CONCEPTS & DEFINITIONS—cont’d

nursing is required (Levine, 1973, pp. 193–195). The primary focus of conservation is keeping together the wholeness of individuals. Although nursing interventions may deal with one particular conser- vation principle, nurses also must recognize the influence of the other conservation principles (Levine, 1990).

Levine’s (1973) model stresses nursing interac- tions and interventions that are intended to promote adaptation and maintain wholeness. These interac- tions are based on the scientific background of the conservation principles. Conservation focuses on achieving a balance of energy supply and demand within the biological realities unique to each indi- vidual. Nursing care is based on scientific knowl- edge and nursing skills. There are four conservation principles.

Conservation Principles The goals of the Conservation Model are achieved through interventions that attend to the conservation principles.

Conservation of Energy

The individual requires a balance of energy and a constant renewal of energy to maintain life activi- ties. Processes such as healing and aging challenge that energy. This second law of thermodynamics applies to everything in the universe, including people.

Conservation of energy has long been used in nursing practice, even with the most basic proce- dures. Nursing interventions “scaled to the indi- vidual’s ability are dependent upon providing care that makes the least additional demand possible” (Levine, 1990, pp. 197–198).

Conservation of Structural Integrity

Healing is a process of restoring structural and func- tional integrity through conservation in defense of wholeness (Levine, 1991). The disabled are guided to a new level of adaptation (Levine, 1996). Nurses can limit the amount of tissue involved in disease by early recognition of functional changes and by nursing interventions.

Continued

UNIT III Nursing Conceptual Models208

Conservation of Personal Integrity

Self-worth and a sense of identity are important. The most vulnerable become patients. This begins with the erosion of privacy and the creation of anxiety. Nurses can show patients respect by calling them by name, respecting their wishes, valuing per- sonal possessions, providing privacy during proce- dures, supporting their defenses, and teaching them. “The nurse’s goal is always to impart knowl- edge and strength so that the individual can resume a private life—no longer a patient, no longer depen- dent” (Levine, 1990, p. 199). The sanctity of life is

MAJOR CONCEPTS & DEFINITIONS—cont’d

manifested through holiness, a testament to spiritu- ality in all people. “The conservation of personal integrity includes recognition of the holiness of each person” (Levine, 1996, p. 40).

Conservation of Social Integrity

Life gains meaning through social communities, and health is socially determined. Nurses fulfill professional roles, provide for family members, assist with religious needs, and use interpersonal relationships to conserve social integrity (Levine, 1967b, 1969a).

Use of Empirical Evidence Levine (1973) believed that specific nursing activities could be deducted from scientific principles. The sci- entific theoretical sources have been well researched. She based much of her work on accepted science principles.

Major Assumptions Introduction to Clinical Nursing is a text for beginning nursing students that uses the conservation principles as an organizing framework (Levine, 1969a, 1973). Although she did not state them specifically as as- sumptions, Levine (1973) valued “a holistic approach to care of all people, well or sick” (p. 151). Her respect for the individuality of each person is noted in the following statements:

Ultimately, decisions for nursing interventions must be based on the unique behavior of the individual patient. . . . Patient centered nursing care means individualized nursing care . . . and as such he requires a unique constellation of skills, techniques, and ideas designed specifically for him (1973, p. 6).

Schaefer (1996) identified the following statements as assumptions about the model: • The person can be understood only in the context

of his or her environment (Levine, 1973).

• “Every self-sustaining system monitors its own behavior by conserving the use of the resources required to define its unique identity” (Levine, 1991, p. 4).

• Human beings respond in a singular, yet integrated, fashion (Levine, 1971a).

Nursing Levine (1973) stated the following about nursing:

Nursing is a human interaction (p. 1). Professional nursing should be reserved for those few who can complete a graduate program as demanding as that expected of professionals in any other disci- pline . . . There will be very few professional nurses (Levine, 1965, p. 214).

Nursing practice is based on nursing’s unique knowledge and the scientific knowledge of other dis- ciplines adjunctive to nursing knowledge (Levine, 1988b), as follows:

It is the nurse’s task to bring a body of scientific principles, on which decisions depend, into the precise situation that she shares with the patient. Sensitive observation and the selection of rele- vant data form the basis for her assessment of his nursing requirements.

The nurse participates actively in every patient’s environment and much of what she does supports

CHAPTER 12 Myra Estrin Levine 209

his adjustments as he struggles in the predicament of illness (Levine, 1966b, p. 2452).

The essence of Levine’s theory is as follows:

. . . when nursing intervention influences adap- tation favorably, or toward renewed social well- being, then the nurse is acting in a therapeutic sense; when the response is unfavorable, the nurse provides supportive care (1966b, p. 2450).

The goal of nursing is to promote adaptation and maintain wholeness (1971b, p. 258).

Person Person is described as a holistic being; wholeness is integrity (Levine, 1991). Integrity means that the per- son has freedom of choice and movement. The person has a sense of identity and self-worth. Levine also described person as a “system of systems, and in its wholeness expresses the organization of all the con- tributing parts” (pp. 8–9). Persons experience life as change through adaptation with the goal of conserva- tion. According to Levine (1989), “The life process is the process of change” (p. 326).

Health Health is socially determined by the ability to func- tion in a reasonably normal manner (Levine, 1969b). Social groups predetermine health. Health is not just an absence of pathological conditions. Health is the return to self; individuals are free and able to pursue their own interests within the context of their own resources. Levine stressed the following:

It is important to keep in mind that health is also culturally determined—it is not an entity on its own, but rather a definition imparted by the ethos and beliefs of the groups to which individu- als belong

(M. Levine, personal communication, February 21, 1995).

Even for a single individual, the definition of health will change over time.

Environment Environment is conceptualized as the context in which individuals live their lives. It is not a passive

backdrop. “The individual actively participates in his environment” (Levine, 1973, p. 443). Levine discussed the importance of the internal and external environ- ment to the determinant of nursing interventions to promote adaptation. “All adaptations represent the accommodation that is possible between the internal and external environment” (p. 12).

Theoretical Assertions Although many theoretical assertions can be generated from Levine’s work, the four major assertions follow: 1. “Nursing intervention is based on the conserva-

tion of the individual patient’s energy” (Levine, 1967a, p. 49).

2. “Nursing intervention is based on the conserva- tion of the individual patient’s structural integrity” (Levine, 1967a, p. 56).

3. “Nursing intervention is based on the conserva- tion of the individual patient’s personal integrity” (Levine, 1967a, p. 56).

4. “Nursing intervention is based on the conservation of the individual patient’s social integrity” (Levine, 1967b, p. 179). Levine (1991) provided some thoughts about two

theories in their early stages of development. The the- ory of therapeutic intention is intended to provide the basis of nursing interventions that focus on biological realities of the patient. Although not planned as such, the theory naturally flows from the conservation prin- ciples. The theory of redundancy expands the redun- dancy domain of adaptation and offers explanations for redundant options such as those found in aging and the physiological adaptation of a failing heart.

Logical Form Levine primarily uses deductive logic. In developing her model, Levine integrates theories and concepts from the humanities and the sciences of nursing, physiology, psychology, and sociology. She uses the information to analyze nursing practice situations and describe nursing skills and activities. With the assistance of many of her students and colleagues, and through her own personal health encounters, Levine has experienced the Conservation Model and its principles operating in practice.

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Applications to the Nursing Community

Practice Levine helps define what nursing is by identifying the activities it encompasses and giving the scientific principles behind them. Conservation principles, levels of integration, and other concepts can be used in numerous contexts (Fawcett, 2000; Levine, 1990, 1991). Hirschfeld (1976) has used the principles of conservation in the care of the older adult. Savage and Culbert (1989) used the Conservation Model to establish a plan of care for infants. Dever (1991) based her care of children on the Conservation Model. Roberts, Fleming, and Yeates-Giese (1991) designed interventions for women in labor based on the Con- servation Model. Mefford (2000; Mefford & Alligood, 2011a, 2011b) tested a Middle Range Theory of Health Promotion for Preterm Infants based on Levine’s Conservation Model of nursing and found a signifi- cant inverse relationship between the consistency of the caregiver and the age at which the infant achieved health, and an inverse relationship between the use of resources by preterm infants during the initial hos- pital stay and the consistency of caregivers. Cooper (1990) developed a framework for wound care focus- ing on structural integrity while integrating all the integrities. Leach (2007) published a white paper on use of the Conservation Model to guide wound care practices. Webb (1993) used the Conservation Model to provide care for patients undergoing cancer treat- ment. Roberts, Brittin, and deClifford (1995) and Roberts, Brittin, Cook, and deClifford (1994) used the Conservation Model to study the boomerang pil- low technique effect on respiratory capacity. Jost (2000) used the model to develop an assessment of the needs of staff during the experience of change.

Conservation principles have been used as a framework for numerous practice settings in cardiol- ogy, obstetrics, gerontology, acute care (neurology), pediatrics, long-term care, emergency care, primary care, neonatology, critical care, and in the homeless community (Savage & Culbert, 1989; Schaefer & Pond, 1991).

Education Levine (1973) wrote Introduction to Clinical Nursing as a textbook for beginning students. It introduced new material into the curricula. She presented an

early discussion of death and dying and believed that women should be awakened after a breast biopsy and consulted about the next step.

Introduction to Clinical Nursing provides an orga- nizational structure for teaching medical-surgical nursing to beginning students (Levine, 1969a, 1973). In both the 1969 and 1973 editions, Levine presents a model at the end of each of the first nine chapters. Each model contains objectives, essential science con- cepts, and nursing process to give nurses a foundation for nursing activities. These models are not part of the Conservation Model. The Conservation Model is addressed in the Introduction and in Chapter 10 of the introductory text. The teachers’ manual that accompanies the text remains a timely source of edu- cational principles that may be helpful to both begin- ning and seasoned teachers (Levine, 1971c).

Although the text is labeled introductory, beginning students would have benefited from a background in physical and social sciences to use it. An emphasis of scientific principles in the second edition bridged this gap. Evidence supporting the model has been integrated successfully into undergraduate and graduate curricula (Grindley & Paradowski, 1991; Schaefer, 1991a).

Research Levine’s Model has been successfully used to develop nursing knowledge (Schaefer & Pond, 1991). However, Fawcett (1995) states that to establish credibility, “more systematic evaluations of the use of the model in vari- ous clinical situations are needed, as are studies that test conceptual-theoretical-empirical structures di- rectly derived from or linked with the conservation principles” (p. 208). Many research questions can be generated from Levine’s model (Radwin & Fawcett, 2002; Schaefer, 1991b). Graduate students and clinical researchers have used the conservation principles as a framework to guide their research (Ballard, Robley, Barrett, et al., 2006; Cox, 1988; Gagner-Tjellesen, Yurkovich, & Gragert, 2001; Mefford, 2000; Mefford & Alligood, 2011a, 2011b; Moch, St. Ours, Hall, et al., 2007). Ballard and colleagues used the model to frame their phenomenological study of how participants re- constructed their lives with paraplegia. They found that structural integrity, along with all the other integrities, was used as a basis for defining their new lives.

One of the most important questions to be asked about the model is: What are the human experiences

CHAPTER 12 Myra Estrin Levine 211

not explained by the model? This question can pro- vide guidance for continued testing of the model’s application in nursing practice. For example, as health care providers use information from the human genome project, nurse researchers will want to test the ability of the model to explain comprehensive nursing care of the client undergoing genetic counsel- ing. Based on the outcome of testing, hypotheses can be developed and tested to support the prescriptive basis of theories developed from the model.

Further Development Levine and others have worked on using the conser- vation principles as the basis for a nursing diagnosis taxonomy (Stafford, 1996; Taylor, 1989). Additional work has been done on the use of Levine’s model in administration and with the frail elderly. The model was used to develop and test the Theory of Health Promotion in Preterm Infants based on Levine’s Con- servation Model (Mefford, 2000; Mefford & Alligood, 2011a, 2011b) and has great potential for studies of sleep disorders and in the development of collabora- tive and primary care practices (Fawcett, 2000). The philosophical, ethical, and spiritual implications of the model are research challenges yet to be realized (Stafford, 1996).

Critique

Clarity Levine’s model possesses clarity. Fawcett (2000) states, “. . . Levine’s Conservation Model provides nursing with a logically congruent, holistic view of the person” (p. 189). George (2002) affirms, “this theory directs nursing actions that lead to favorable outcomes” (p. 237). The model has numerous terms; however, Levine adequately defines them for clarity.

Simplicity Although the four conservation principles appear sim- ple initially, they contain subconcepts and multiple variables. Nevertheless, this model is still one of the simpler ones developed.

Generality The four conservation principles can be used in all nursing contexts.

Accessibility Levine used deductive logic to develop her model, which can be used to generate research questions. As she lived her Conservation Model, she verified the use of inductive reasoning to further develop and in- form her model (M. Levine, personal communication, May 17, 1989).

Importance The four conservation principles defined in Levine’s model are recognized as one of the earliest nursing models used to organize and clarify elements of nurs- ing practice. Furthermore, the model continues to demonstrate evidence of its utility for nursing practice and research and is receiving increased recognition in the twenty-first century.

Summary Levine developed her Conservation Model to provide a framework within which to teach beginning nursing students. In the first chapter of her book, she intro- duces her assumptions about holism, and that the conservation principles support a holistic approach to patient care (Levine, 1969a, 1973). The model is logi- cally congruent, is externally and internally consis- tent, has breadth as well as depth, and is understood, with few exceptions, by professionals and consumers of health care. Nurses using the Conservation Model can anticipate, explain, predict, and perform patient care. However, its ability to predict outcomes must be tested further. Levine (1990) said, “. . . everywhere that nursing is essential, the rules of the conservation and the integrity hold” (p. 195).

CASE STUDY*

Yolanda is a 55-year-old married African-American mother of two adult children who has a history of breast cancer. She was diagnosed with fibromyal- gia 2 years ago, following years of unexplained muscle aches and what she thought was arthritis. The diagnosis was a relief for her; she was able to read about it and learn how to care for herself. Over the past 2 months, Yolanda stopped taking all of her medicine, because she was seeing a new physician and wanted to start her care at ground zero. In addition to her family responsibilities, she

Continued

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is completing her degree as an English major. At the time of her appointment, she told the nurse practitioner that she was having the worst pain possible.

Using Levine’s Conservation Model, the nurse practitioner completed a comprehensive assess- ment in preparation for developing a plan of care in consultation with the physician. Nursing care is organized according to the conservation princi- ples, with consideration of how the individual adapts to the internal and external environments. Yolanda’s diagnosis of fibromyalgia was based on the exclusion of other illnesses with a cluster of symptoms, including pain, fatigue, and sleepless- ness (e.g., systemic lupus erythematosus, multiple sclerosis). Laboratory and other diagnostic results all were within normal limits.

The external environment includes perceptual, operational, and conceptual factors. Perceptual factors are those that are perceived through the senses. Yolanda reported a history of unexplained fatigue and pain for years. She recently stopped her medications “to clean my body out.” However, she reported that the pain became unbearable and was making it difficult for her to sleep. She noted that when she sleeps at least 6 hours a night, her pain is less intense. With the current insomnia, her pain is very intense.

Operational factors are threats to the environment that the client cannot perceive through the senses. Yolanda reported severe pain in response to both the cold weather and changes in barometric pressure.

The conceptual environment includes cultural and personal values about health care, the meaning of health and illness, knowledge about health care, education, language use, and spiritual beliefs. In response to breast cancer, Yolanda developed her spirituality through prayer and reading the Bible. She believes that this is how she gets through the painful moments of her current illness.

Conservation of energy focuses on the balance of energy input and output to prevent excessive fatigue. Yolanda complains of a fatigue that just “comes over me.” She has difficulty doing house- work. One day of work usually means one day in bed because of extreme fatigue. Her hemoglobin level and hematocrit are normal; her arterial blood

gas results have always been within normal limits. Most diagnostic study values are within normal limits in patients with fibromyalgia, making treat- ment difficult.

Conservation of structural integrity involves maintaining the structure of the body to promote healing. Because there is no known cause of fibro- myalgia, treatment focuses on reducing symptoms. Yolanda’s symptoms could not be traced to any physical or structural alteration, yet she reports severe pain and fatigue. The nurse practitioner knows that it is important to acknowledge the reality of the symptoms and work with the client to deter- mine if activities of daily living result in changes in the pattern of illness. In addition, Yolanda thinks she is going through menopause, and she is having trouble determining if her symptoms are caused by menopause or fibromyalgia.

With continued questioning, the nurse practitio- ner learns that Yolanda was diagnosed with irritable bowel syndrome several years earlier. She is not worried about constipation but is concerned about sudden diarrhea. She is afraid to go to school; she fears embarrassment because she might have an “accident.” Yolanda was taking several medications for her discomfort. One of them made her feel so “hung over” that she stopped taking it after 2 weeks. She was given amitriptyline (Elavil) for sleep. It was the only medicine that helped her get 6 hours of continuous sleep.

Personal integrity involves the maintenance of one’s sense of personal worth and self-esteem. Yolanda reported that she lost control when she was diagnosed with breast cancer. A dear friend convinced her to go to church and encouraged her to use prayer. When feeling sorry for herself, she would go into her bedroom and read her Bible, cry by herself, and pray. She believes that prayer and Bible reading helped her heal. She continues to pray and read her Bible to gain the strength she needs to live with her illness. She also believes that she needs to be able to laugh at herself; humor helps her to feel better. She actively seeks health information, as indicated by her quest to learn about her new diagnosis of fibromyalgia. She is most upset about not being able to walk like she used to walk. One of her favorite pastimes

CHAPTER 12 Myra Estrin Levine 213

prayer, Bible reading, and humor to help her feel better, (3) discuss medication therapy and what might help her achieve restful sleep, (4) refer her for blood work to assess hormone levels, and (5) assist her with determining the meaning of the symptoms (e.g., menopause or fibromyalgia). Yolanda indicated that when she was able to get 6 hours of uninterrupted sleep, her pain was less intense and she felt better. Finding both medication- induced and nonpharmaceutical approaches to improve sleep is a high priority.

The nurse practitioner will assess the outcome of Yolanda’s care based on the organismic re- sponses. The following predicted responses suggest adaptation: n Reports comfort as a result of prayer, Bible

reading, and humor n Distinguishes symptoms of menopause from

symptoms of fibromyalgia n Reports feeling rested after 6 hours of unin-

terrupted sleep n Reports a perceived reduction in pain and

fatigue n Collaborates with health care providers to

manage symptoms of menopause

was shopping for shoes at the mall, which now is difficult for her.

Social integrity acknowledges that the patient is a social being. Yolanda is a married mother of three grown children. She keeps a lot of her feelings from her children but does share them with her husband. He is a major source of support for her. He takes her food shopping and makes sure that she gets to her appointments on time. She shared at the time of her visit that she wants to have a picnic for her birthday, but the only way she can do it is to ask her grandchildren to help her husband clean the yard.

Yolanda is a middle-aged woman with a history of severe pain, sleeplessness, and fatigue. Diagnostic studies have been unrevealing, with the exception of multiple tender points. The history of pain and positive tender points supported the diagnosis of fibromyalgia. She has stopped taking all medications and reports that she may be going through meno- pause. She reports severe pain and fatigue that make it difficult for her to sleep and to do normal house- work. Her husband and grandchildren are available to help with chores at home, and she seeks the sup- port of prayer and reading her Bible to ease her discomfort. She also finds that humor helps her to feel better.

The initial plan of care includes (1) validate the illness experience, (2) encourage continued use of

*This case study is based on raw data from a completed study (Schaefer, 2005). Yolanda is a fictitious name used to protect the privacy and anonymity of the participant.

CRITICAL THINKING ACTIVITIES

appropriate interventions using Levine’s conserva- tion principles.

4. Watch one of the following movies: City of Joy, Soul Food, The Secret Garden, Courageous, or The Descendents. Use examples from the movie to support or refute Levine’s propositional statements.

5. Apply the Conservation Model to a pathography such as Love and Other Infectious Diseases by Molly Haskell, and explain life with illness.

6. Identify what may be missing in simulation expe- riences of nursing practice from the perspective of this nursing model. Suggest how you might develop your style of nursing practice to encom- pass the total patient experience.

1. Keep a reflective journal about a personal health or illness experience or that of someone very close. Reflect on its consistency with the Conservation Model—how to modify, expand, or delimit the model to provide a context for explanation.

2. Levine stated, “Health is culturally determined; it is not an entity on its own, but rather a definition imparted by the ethos and beliefs of groups to which the individual belongs” (M. Levine, personal communication, February, 21, 1995).

3. Visit a museum, and evaluate how artistic expres- sion captures the beliefs of different ethnic groups. Then explore how these beliefs shape definitions of health and illness. On the basis of an ethnically derived definition of health, propose ethnically

UNIT III Nursing Conceptual Models214

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POINTS FOR FURTHER STUDY n Mayo Clinic—Nursing Theorist—Myra Levine at:

http://www.mayo.edu/education/nursing-research/ levine.html

n Nursing for Nurses—Levine Conservation Model (Blog) at: http://allnurses.com/forums/f76/levine- conservation-model-48040-print.html

n Nursing Theories Group E-Levine’s Conservation Model Concept at: http://nursingtheories. blogspot.com2011/07/group-e-levines-

n The nursing theorist: Portraits of excellence. Myra Levine (video, CD, or electronically), by Oakland: Studio III, Oakland, CA. Now available at Fitne, Inc., 5 Depot Street, Athens, Ohio 45701

n Cardinal Stitch University Library; Nursing Theorist: Myra Levine at: http://library.stitch.edu/ research/subjects/nursingtheorists/levine.htm

n Hahn School of Nursing and Health Science, University of San Diego at: http://www.sandiego. edu/nursing/theory/

n Karen Schaefer’s chapter, “Levine’s Conservation Nursing Model in Nursing Practice” (Chapter 10) in a companion Elsevier text, Alligood (2010). Nursing theory: Utilization & application, 4th edition.

n Leach, M. J. Using Levine’s conservation model to guide practice (white paper) at: http://www. om.com/article/6024

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system. New York: Charles Scribner’s Sons. Stafford, M. J. (1996). In tribute: Myra Estrin Levine, Pro-

fessor Emerita, MSN, RN, FAAN. Chart, 93(3), 5–6.

Taylor, J. W. (1974). Measuring the outcomes of nursing care. Nursing Clinics of North America, 9, 337–348.

Taylor, J. W. (1989). Levine’s conservation principles: Using the model for nursing diagnosis in a neurological set- ting. In J. P. Riehl-Sisca (Ed.), Conceptual models for nursing practice (3rd ed., pp. 349–358). Norwalk, (CT): Appleton & Lange.

Taylor, J. W., & Ballenger, S. (1980). Neurological dysfunc- tion and nursing interventions. New York: McGraw-Hill.

Webb, H. (1993). Holistic care following a palliative Hartmann’s procedure. British Journal of Nursing, 2(2), 128–132.

BIBLIOGRAPHY Primary Sources Books Levine, M. E. (1969). Introduction to clinical nursing.

Philadelphia: F. A. Davis. Levine, M. E. (1971). Renewal for nursing. Philadelphia:

F. A. Davis. [Translated into Hebrew, Am Oved, Jerusalem, 1978.]

Levine, M. E. (1973). Introduction to clinical nursing (2nd ed.). Philadelphia: F. A. Davis.

Book Chapters Levine, M. E. (1964). Nursing service. In M. Leeds & H.

Shore (Eds.), Geriatric institutional management. New York: Putnam.

Levine, M. E. (1973). Adaptation and assessment: A rationale for nursing intervention. In M. E. Hardy (Ed.), Theoretical foundations for nursing. New York: Irvington.

Levine, M. E. (1988). Myra Levine. In T. M. Schorr & A. Zimmerman (Eds.), Making choices, taking chances: Nursing leaders tell their stories. St. Louis: Mosby.

Levine, M. E. (1989). The four conservation principles: Twenty years later. In J. Riehl (Ed.), Conceptual models for nursing practice (3rd ed.). New York: Appleton-Century- Crofts.

Levine, M. E. (1990). Conservation and integrity. In M. Parker (Ed.), Nursing theories in practice (pp. 189–201). New York: National League for Nursing.

Levine, M. E. (1991). The conservation principles: A model for health. In K. Schaefer & J. Pond (Eds.), Levine’s Conservation Model: A framework for nursing practice (pp. 1–11). Philadelphia: F. A. Davis.

Levine, M. E. (1992). Nightingale redux. In B. S. Barnum (Ed.), Nightingale’s notes on nursing: Commemorative edi- tion with commentaries by nursing theorists. Philadelphia: Lippincott.

Levine, M. E. (1994). Some further thoughts on nursing rhetoric. In J. F. Kikuchi & H. Simmons (Eds.), Devel- oping a philosophy of nursing (pp. 104–109). Thousand Oaks, CA: Sage.

Journal Articles Levine, M. E. (1963). Florence Nightingale: The legend

that lives. Nursing Forum, 2(4), 24–35. Levine, M. E. (1964). Not to startle, though the way were

steep. Nursing Science, 2, 58–67. Levine, M. E. (1964). There need be no anonymity. First,

18(9), 4. Levine, M. E. (1965). The professional nurse and graduate

education. Nursing Science, 3, 206–214. Levine, M. E. (1965). Trophicognosis: An alternative to nurs-

ing diagnosis. ANA Regional Clinical Conferences, 2, 55–70. Levine, M. E. (1966). Adaptation and assessment: A ratio-

nale for nursing intervention. American Journal of Nursing, 66(11), 2450–2453.

Levine, M. E. (1967). For lack of love alone. Minnesota Nursing Accent, 39(7), 179–202.

Levine, M. E. (1967). Medicine-nursing dialogue belongs at patient’s bedside. Chart, 64(5), 136–137.

Levine, M. E. (1967). The four conservation principles of nursing. Nursing Forum, 6, 45–59.

Levine, M. E. (1967). This I believe: About patient-centered care. Nursing Outlook, 15, 53–55.

Levine, M. E. (1968). Knock before entering personal space bubbles (part 1). Chart, 65(2), 58–62.

Levine, M. E. (1968). Knock before entering personal space bubbles (part 2). Chart, 65(3), 82–84.

Levine, M. E. (1968). The pharmacist in the clinical setting: A nurse’s viewpoint. American Journal of Hospital Phar- macy, 25(4), 168–171. [Also translated into Japanese and published in Kyushu National Hospital Magazine for Western Japan.]

CHAPTER 12 Myra Estrin Levine 217

Levine, M. E. (1969, Feb.). Constructive student power. Chart, 66(2), 42FF.

Levine, M. E. (1969). Small hospital—Big nursing. Chart, 66(10), 265–269.

Levine, M. E. (1969). Small hospital—Big nursing. Chart, 66(11), 310–315.

Levine, M. E. (1969). The pursuit of wholeness. American Journal of Nursing, 69, 93–98.

Levine, M. E. (1970). Dilemma. ANA Clinical Conferences, 338–342.

Levine, M. E. (1970). Breaking through the medications mystique. American Journal of Hospital Pharmacy, 27(4), 294–299; American Journal of Nursing, 70(4), 799–803.

Levine, M. E. (1970). Symposium on a drug compendium: View of a nursing educator. Drug Information Journal, 4, 133–135.

Levine, M. E. (1970). The intransigent patient. American Journal of Nursing, 70, 2106–2111.

Levine, M. E. (1971). Consider implications for nursing in the use of physician’s assistant. Hospital Topics, 49, 60–63.

Levine, M. E. (1971). Holistic nursing. Nursing Clinics of North America, 6, 253–264.

Levine, M. E. (1971). The time has come to speak of health care. AORN Journal, 13, 37–43.

Levine, M. E. (1972). Benoni. American Journal of Nursing 72,(3), 466–468.

Levine, M. E. (1972). Nursing educators—An alienating elite? Chart, 69(2), 56–61.

Levine, M. E. (1973). On creativity in nursing. Image: The Journal of Nursing Scholarship, 3(3), 15–19.

Levine, M. E. (1974). The pharmacist’s clinical role in inter- disciplinary care: A nurse’s viewpoint. Hospital Formulary Management, 9, 47.

Levine, M. E. (1975). On creativity in nursing. Nursing Digest, 3, 38–40.

Levine, M. E. (1977). Nursing ethics and the ethical nurse. American Journal of Nursing, 77, 845–849.

Levine, M. E. (1978). Cancer chemotherapy: A nursing model. Nursing Clinics of North America, 13(2), 271–280.

Levine, M. E. (1978). Does continuing education improve nursing practice? Hospitals, 52(21), 138–140.

Levine, M. E. (1978). Kapklavoo and nursing, too (Editorial). Research in Nursing and Health, 1(2), 51.

Levine, M. E. (1979). Knowledge base required by general- ized and specialized nursing practice. ANA Publications, (G-127), 57–69.

Levine, M. E. (1980). The ethics of computer technology in health care. Nursing Forum, 19(2), 193–198.

Levine, M. E. (1982). Bioethics of cancer nursing. Rehabili- tation Nursing, 7, 27–31, 41.

Levine, M. E. (1982). The bioethics of cancer nursing. Journal of Enterostomal Therapy, 9, 11–13.

Levine, M. E. (1988). Antecedents from adjunctive disci- plines: Creation of nursing theory. Nursing Science Quarterly, 1(1), 16–21.

Levine, M. E. (1988). What does the future hold for nurs- ing? 25th Anniversary Address, 18th District. Illinois Nurses Association Newsletter, XXIV(6), 1–4.

Levine, M. E. (1989). Beyond dilemma. Seminars in Oncol- ogy Nursing, 5, 124–128.

Levine, M. E. (1989). Ration or rescue: The elderly in critical care. Critical Care Nursing, 12(1), 82–89.

Levine, M. E. (1989). The ethics of nursing rhetoric. Image: The Journal of Nursing Scholarship, 21(1), 4–5.

Levine, M. E. (1995). The rhetoric of nursing theory. Im- age: The Journal of Nursing Scholarship, 27(1), 11–14.

Levine, M. E. (1996). On the humanities in nursing. Cana- dian Journal of Nursing Research, 27(2), 19–23.

Levine, M. E. (1996). The conservation principles: A retro- spective. Nursing Science Quarterly, 9(1), 38–41.

Levine, M. E. (1997). On creativity in nursing. Image: The Journal of Nursing Scholarship, 29(3), 216–217.

Levine, M. E., Hallberg, C., Kathrein, M., & Cox, R. (1972). Nursing grand rounds: Congestive failure. Nursing ‘72, 2(10), 18–23.

Levine, M. E., Line, L., Boyle, A., & Kopacewski, E. (1972). Nursing grand rounds: Insulin reactions in a brittle diabetic. Nursing ‘72, 2(5), 6–11.

Levine, M. E., Moschel, P., Taylor, J., & Ferguson, G. (1972). Nursing grand rounds: Complicated case of CVA. Nursing ‘72, 2(3), 3–34.

Levine, M. E., Scanlon, M., Gregor, P., King, R., & Martin, N. (1972). Issues in rehabilitation: The quadriplegic adoles- cent. Nursing ‘72, 2, 6.

Levine, M. E., Zoellner, J., Ozmon, B., & Simunek, E. (1972). Nursing grand rounds: Severe trauma. Nursing ‘72, 2(9); 33–38.

Secondary Sources Book Reviews [Review of Introduction to clinical nursing]. (1969, Sept/

Oct.). Bedside Nurse, 2, 4. [Review of Introduction to clinical nursing]. (1970, Feb.).

Nursing Outlook, 18, 20. [Review of Introduction to clinical nursing]. (1970, Jan.).

American Journal of Nursing, 70, 99. [Review of Introduction to clinical nursing]. (1970, Oct.).

American Journal of Nursing, 70, 2220. [Review of Introduction to clinical nursing]. (1971, April).

Nursing Mirror, 132, 43. [Review of Introduction to clinical nursing]. (1971, Dec.).

Nursing Mirror, 133, 16.

UNIT III Nursing Conceptual Models218

[Review of Introduction to clinical nursing]. (1974, Feb.). American Journal of Nursing, 74, 347.

[Review of Introduction to clinical nursing]. (1974, May). Nursing Outlook, 22, 301.

[Review of Introduction to clinical nursing]. (1971, Nov.). Bedside Nurse, 4, 2.

[Review of Renewal for nursing]. (1971, Aug.). Supervisor Nurse, 2, 68.

[Review of Renewal for nursing]. (1971, Dec.). AANA Journal, 49, 495.

[Review of Renewal for nursing]. (1971, Dec.). Nursing Mirror, 133, 16.

Book Chapters Leonard, M. K. (1990). Myra Estrin Levine. In J. B. George

(Ed.), Nursing theories: The base for professional nursing practice (pp. 181–192). Englewood Cliffs, (NJ): Prentice Hall.

Meleis, A. I. (1985). Myra Levine. In A. I. Meleis (Ed.), The- oretical nursing: Development and progress (pp. 275–283). Philadelphia: Lippincott.

Peiper, B. A. (1983). Levine’s nursing model. In J. J. Fitz- patrick & A. L. Whall (Eds.), Conceptual models of nursing: Analysis and application (pp. 101–115). Bowie, (MD): Robert J. Brady.

Pond, J. B. (1990). Application of Levine’s Conservation Model to nursing the homeless community. In M. E. Parker (Ed.), Nursing theories in practice (pp. 203–215). New York: National League for Nursing.

Schaefer, K. M. (1990). A description of fatigue associated with congestive heart failure: Use of Levine’s Conserva- tion Model. In M. E. Parker (Ed.), Nursing theories in practice (pp. 217–237). New York: National League for Nursing.

Schaefer, K. M. (1996). Levine’s Conservation Model: Car- ing for women with chronic illness. In P. H. Walker & B. Neuman (Eds.), Blueprint for use of nursing models: Education, research, practice and administration (pp. 187–228). New York: National League for Nursing Press.

Schaefer, K. M. (2001). Levine’s Conservation Model: A model for the future of nursing. In Parker, M. E. (Ed.), Nursing theories and nursing practice (pp. 103–124). Philadelphia: F. A. Davis.

Schaefer, K. M. (2001). Levine’s Conservation Model: Use of the model in nursing practice. In M. R. Alligood & A. Marriner-Tomey (Eds.), Nursing theory: Utilization & application (Taiwanese ed.; pp. 89–108). St. Louis: Mosby.

Schaefer, K. M. (2002). Levine’s Conservation Model in nursing practice. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theory: Utilization & application (2nd ed., pp. 197–217). St. Louis: Mosby.

Taylor, J. W. (1989). Levine’s conservation principles: Using the model for nursing diagnosis in a neurological set- ting. In J. P. Riehl-Sisca (Ed.), Conceptual models for nursing practice (3rd ed., pp. 349–358). Norwalk, (CT): Appleton & Lange.

Journal Articles Ballard, N., Robley, L., Barrett, D., Fraser, D., & Mendoza, I.

(2006). Patients’ recollections of therapeutic paralysis in the intensive care unit. American Journal of Critical Care,15(1), 86–94.

Brunner, M. (1985). A conceptual approach to critical care nursing using Levine’s model. Focus on Critical Care, 12(2), 39–40.

Cooper, D. M. (1990). Optimizing wound healing: A prac- tice within nursing’s domain. Nursing Clinics of North America, 25(1), 165–180.

Crawford-Gamble, P. E. (1986). An application of Levine’s conceptual model. Perioperative Nursing Quarterly, 2(1), 64–70.

Fawcett, J., Brophy, S. F., Rather, M. L., & Roos, J. (1997). Commentary about Levine’s on creativity in nursing. Image: The Journal of Nursing Scholarship, 29(3), 218–219.

Fawcett, J., Tulman, L., & Samarel, N. (1995). Enhancing function in life transitions and serious illness. Advanced Practice Nursing Quarterly, 1, 50–57.

Falk, K., Swedberg, K., Gaston-Johansson, F., & Ekman, I. (2007). Fatigue is a prevalent and severe symptom as- sociated with uncertainty and sense of coherence in patients with chronic heart failure. European Journal of Cardiovascular Nursing, 6, 99–104.

Foreman, M. D. (1989). Confusion in the hospitalized el- derly: Incidence, onset, and associated factors. Research in Nursing and Health, 12(1), 21–29.

Gagner-Tjellesen, D., Yurkovich, E. E., & Gragert, M. (2001). Use of music therapy and other ITNIs in acute care. Journal of Psychosocial Nursing and Mental Health Services, 39(10), 26–37.

Hall, K. V. (1979). Current trends in the use of conceptual frameworks in nursing education. Journal of Nursing Education, 18(4), 26–29.

Happ, M. B., Williams, C. C., Strumpf, N. E., & Burger, S. G. (1996). Individualized care for frail elderly: The- ory and practice. Journal of Gerontological Nursing, 22(3), 6–14.

Hirschfeld, M. J. (1976). The cognitively impaired older adult. American Journal of Nursing, 76, 1981–1984.

Jost, S. G. (2000). An assessment and intervention strategy for managing staff needs during change. Journal of Nursing Administration, 30(1), 34–40.

Langer, V. S. (1990). Minimal handling protocol for the intensive care nursery. Neonatal Network, 9(3), 23–27.

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Lynn-McHale, D. J., & Smith, A. (1991). Comprehensive assessment of families of the critically ill. AACN Clinical Issues in Critical Care Nursing, 2(2), 195–209.

Moch, V., St. Ours, C., Hall, S., Bositis, A., Tillery, M., Belcher, A., et al. (2007). Using a conceptual model in nursing research—mitigating fatigue in cancer patients. Journal of Advanced Nursing, 58(5), 503–512.

Molchany, C. B. (1992). Ventricular septal and free wall rupture complicating acute MI. Journal of Cardiovascular Nursing, 6(4), 38–45.

Newport, M. A. (1984). Conserving thermal energy and social integrity in the newborn. Western Journal of Nursing Research, 6(2), 175–197.

O’Laughlin, K. M. (1986). Change in bladder function in the woman undergoing radical hysterectomy for cervical cancer. Journal of Obstetrical, Gynecological and Neonatal Nursing, 15(5), 380–385.

Piccoli, M., & Galvao, C. M. (2001). Perioperative nurs- ing: Identification of the nursing diagnosis infection risk based on Levine’s conceptual model (English abstract). Revista Latino-Americana de Enfermagem, 9(4), 37–43.

Roberts, K. L., Brittin, M., Cook, M., & deClifford, J. (1994). Boomerang pillows and respiratory capacity. Clinical Nursing Research, 3(2), 157–165.

Roberts, K. L., Brittin, M., & deClifford, J. (1995). Boomer- ang pillows and respiratory capacity in frail elderly women. Clinical Nursing Research, 4(4), 465–471.

Savage, T. V., & Culbert, C. (1989). Early intervention: The unique role of nursing. Journal of Pediatric Nursing, 4(5), 339–345.

Schaefer, K. M. (1997). Levine’s Conservation Model in nursing practice. In M. R. Alligood & A. Marriner Tomey (Eds.), Nursing theory: Utilization & application (pp. 89–107). St. Louis: Mosby.

Schaefer, K. M., & Pond, J. (1994). Levine’s Conservation Model as a guide to nursing practice. Nursing Science Quarterly, 7(2), 53–54.

Schaefer, K. M., & Shober-Potylycki, M. J. (1993). Fatigue in congestive heart failure: Use of Levine’s Conserva- tion Model. Journal of Advanced Nursing, 18, 260–268.

Schaefer, K. M., Swavely, D., Rothenberger, C., Hess, S., & Willistin, D. (1996). Sleep disturbances post coro- nary artery bypass surgery. Progress in Cardiovascular Nursing, 11(1), 5–14.

Stafford, M. J. (1996). In tribute: Myra Estrin Levine, Pro- fessor Emerita, MSN, RN, FAAN. Chart, 93(3), 5–6.

Tompkins, E. S. (1980). Effect of restricted mobility and dominance on perceived duration. Nursing Research, 29(6), 333–338.

Tribotti, S. (1990). Admission to the neonatal intensive care unit: Reducing the risks. Neonatal Network, 8(4), 17–22.

Webb, H. (1993). Holistic care following a palliative Hartmann’s procedure. British Journal of Nursing, 2(2), 128–132.

220

“Professional practice in nursing seeks to promote symphonic interaction between man and environ- ment, to strengthen the coherence and integrity of the human field, and to direct and redirect pat-

terning of the human and environmental fields for realization of maximum health potential” (Rogers, 1970, p. 122).

Credentials and Background of the Theorist

Martha Elizabeth Rogers, the eldest of four children of Bruce Taylor Rogers and Lucy Mulholland Keener Rogers, was born May 12, 1914, in Dallas, Texas. Soon after her birth, her family returned to Knoxville, Tennessee. She began her college education (1931 to 1933) studying science at the University of Tennessee. Receiving her nursing diploma from Knoxville Gen- eral Hospital School of Nursing (1936), she quickly obtained a BS degree from George Peabody College in Nashville, Tennessee (1937). Her other degrees

included an MA degree in public health nursing supervision from Teachers College, Columbia Uni- versity, New York (1945), and an MPH (1952) and an ScD (1954) from Johns Hopkins University in Baltimore.

Martha E. Rogers 1914 to 1994

Unitary Human Beings Mary E. Gunther

CH A P T ER 13

Previous authors: Kaye Bultemeier, Mary Gunther, Joann Sebastian Daily, Judy Sporleder Maupin, Cathy A. Murray, Martha Carole Satterly, Denise L. Schnell, and Therese L. Wallace. Earlier editions of this chapter were critiqued by Dr. Lois Meier and Dr. Martha Rogers.

Photo credit: Kathleen Leininger, Shiner, TX.

Rogers’ early nursing practice was in rural public health nursing in Michigan and in visiting nurse supervision, education, and practice in Connecticut. Rogers subsequently established the Visiting Nurse Service of Phoenix, Arizona. For 21 years (from 1954 to 1975), she was professor and head of the Division of Nursing at New York University. After 1975, she continued her duties as professor until she became

CHAPTER 13 Martha E. Rogers 221

humorous, blunt, and ethical. Rogers remains a widely recognized scholar honored for her contributions and leadership in nursing. Butcher (1999) noted, “Rogers, like Nightingale, was extremely independent, a deter- mined, perfectionist individual who trusted her vision despite skepticism” (p. 114). Colleagues consider her one of the most original thinkers in nursing as she syn- thesized and resynthesized knowledge into “an entirely new system of thought” (Butcher, 1999, p. 111). Today she is thought of as “ahead of her time, in and out of this world” (Ireland, 2000, p. 59).

Theoretical Sources Rogers’ grounding in the liberal arts and sciences is apparent in both the origin and the development of her conceptual model, published in 1970 as An Introduction to the Theoretical Basis of Nursing (Rogers, 1970). Aware of the interrelatedness of knowledge, Rogers credited scientists from multiple disciplines with influencing the development of the Science of Unitary Human Beings. Rogerian science emerged from the knowledge bases of anthropology, psychol- ogy, sociology, astronomy, religion, philosophy, history, biology, physics, mathematics, and literature to create a model of unitary human beings and the environment as energy fields integral to the life process. Within nursing, the origins of Rogerian science can be traced to Nightingale’s proposals and statistical data, placing the human being within the framework of the natural world. This “foundation for the scope of modern nurs- ing” began nursing’s investigation of the relationship between human beings and the environment (Rogers, 1970, p. 30). Newman (1997) describes the Science of Unitary Human Beings as “the study of the moving, intuitive experience of nurses in mutual process with those they serve” (p. 9).

Professor Emerita in 1979. She held this title until her death on March 13, 1994, at 79 years of age.

Rogers’ publications include three books and more than 200 articles. She lectured in 46 states, the District of Columbia, Puerto Rico, Mexico, the Netherlands, China, Newfoundland, Columbia, Brazil, and other countries (M. Rogers, personal communication, March 1988). Rogers received honorary doctorates from such renowned institutions as Duquesne University, Univer- sity of San Diego, Iona College, Fairfield University, Emory University, Adelphi University, Mercy College, and Washburn University of Topeka. The numerous awards for her contributions and leadership in nursing include citations for Inspiring Leadership in the Field of Intergroup Relations by Chi Eta Phi Sorority, In Recog- nition of Your Outstanding Contribution to Nursing by New York University, and For Distinguished Service to Nursing by Teachers College. In addition, New York University houses the Martha E. Rogers Center for the Study of Nursing Science. In 1996, Rogers was inducted posthumously into the American Nurses Association Hall of Fame.

In 1988, colleagues and students joined her in forming the Society of Rogerian Scholars (SRS) and immediately began to publish Rogerian Nursing Sci- ence News, a members’ newsletter, to disseminate the- ory developments and research studies (Malinski 2009). In 1993, the SRS began to publish a refereed journal, Visions: The Journal of Rogerian Nursing Sci- ence. The society includes a foundation that maintains and administers the Martha E. Rogers Fund. In 1995, New York University established the Martha E. Rogers Center to provide a structure for continuation of Ro- gerian research and practice.

A verbal portrait of Rogers includes such descriptive terms as stimulating, challenging, controversial, idealistic, visionary, prophetic, philosophical, academic, outspoken,

In 1970, Rogers’ conceptual model of nursing rested on a set of basic assumptions that described the life process in human beings. Wholeness, openness, unidirectionality, pattern and organization, sen- tience, and thought characterized the life process (Rogers, 1970).

MAJOR CONCEPTS & DEFINITIONS

Rogers postulates that human beings are dynamic energy fields that are integral with environmental fields. Both human and environmental fields are identified by pattern and characterized by a universe of open systems. In her 1983 paradigm, Rogers pos- tulated four building blocks for her model: energy

Continued

UNIT III Nursing Conceptual Models222

Use of Empirical Evidence Being an abstract conceptual system, the Science of Unitary Human Beings does not directly identify testable empirical indicators. Rather, it specifies a worldview and philosophy used to identify the phe- nomena of concern to the discipline of nursing. As was mentioned previously, Rogers’ model emerged from multiple knowledge sources; the most readily

field, a universe of open systems, pattern,and four- dimensionality.

Rogers consistently updated the conceptual model through revision of the homeodynamic principles. Such changes corresponded with scientific and tech- nological advances. In 1983, Rogers changed her wording from that of unitary man to unitary human being, to remove the concept of gender. Additional clarification of unitary human beings as separate and different from the term holistic stressed the unique contribution of nursing to health care. In 1992, four-dimensionality evolved into pandimension- ality. Rogers’ fundamental postulates have remained consistent since their introduction; her subsequent writings served to clarify her original ideas.

Energy Field An energy field constitutes the fundamental unit of both the living and the nonliving. Field is a unifying concept, and energy signifies the dynamic nature of the field. Energy fields are infinite and pandimen- sional. Two fields are identified: the human field and the environmental field. “Specifically human beings and environment are energy fields” (Rogers, 1986b, p. 2). The unitary human being (human field) is defined as an irreducible, indivisible, pandimen- sional energy field identified by pattern and mani- festing characteristics that are specific to the whole and that cannot be predicted from knowledge of the parts. The environmental field is defined as an irreducible, pandimensional energy field identi- fied by pattern and integral with the human field. Each environmental field is specific to its given human field. While not necessarily quantifiable, an energy field has the inherent ability to create change (Todaro-Franceschi, 2008). In this case, both

MAJOR CONCEPTS & DEFINITIONS—cont’d

human and environmental fields change continu- ously, creatively, and integrally (Rogers, 1994a).

Universe of Open Systems The concept of the universe of open systems holds that energy fields are infinite, open, and integral with one another (Rogers, 1983). The human and environmental fields are in continuous process and are open systems.

Pattern Pattern identifies energy fields. It is the distinguishing characteristic of an energy field and is perceived as a single wave. The nature of the pattern changes con- tinuously and innovatively, and these changes give identity to the energy field. Each human field pattern is unique and is integral with the environmental field (Rogers, 1983). Manifestations emerge as a human- environmental mutual process. Pattern is an abstrac- tion; it reveals itself through manifestation. A sense of self is a field manifestation, the nature of which is unique to each individual. Some variations in pat- tern manifestations have been described in phrases such as “longer versus shorter rhythms,” “pragmatic versus imaginative,” and time experienced as “fast” or “slow.” Pattern is changing continually and may manifest disease, illness, or well-being. Pattern change is continuous, innovative, and relative.

Pandimensionality Rogers defines pandimensionality as a nonlinear domain without spatial or temporal attributes, or as Phillips (2010) notes: “essentially a spaceless and timeless reality” (p. 56). The term pandimensional provides for an infinite domain without limit. It best expresses the idea of a unitary whole.

apparent of these are the nonlinear dynamics of quan- tum physics and general system theory.

Evident in her model are the influence of Einstein’s (1961) theory of relativity in relation to space-time and Burr and Northrop’s (1935) electrodynamic the- ory relating to electrical fields. By the time von Bertalanffy (1960) introduced the general system theory, theories regarding a universe of open systems

CHAPTER 13 Martha E. Rogers 223

were beginning to affect the development of knowl- edge within all disciplines. With the general system theory, the term negentropy was brought into use to signify increasing order, complexity, and heteroge- neity in direct contrast to the previously held belief that the universe was winding down. Rogers, how- ever, refined and purified the general system theory by denying hierarchical subsystems, the concept of single causation, and the predictability of a system’s behavior through investigations of its parts.

Introducing quantum theory and the theories of relativity and of probability fundamentally challenged the prevailing absolutism. As new knowledge escalated, the traditional meanings of homeostasis, steady state, adaptation,and equilibrium were questioned seriously. The closed-system, entropic model of the universe was no longer adequate to explain phenomena, and evi- dence accumulated in support of a universe of open systems (Rogers, 1994b). Continuing development within other disciplines of the acausal, nonlinear dy- namics of life validated Rogers’ model. Most notable of this development is that of chaos theory, quantum physics’ contribution to the science of complexity (or wholeness), which blurs the boundaries between the disciplines, allowing exploration and deepening of the understanding of the totality of human experience.

Major Assumptions

Nursing Nursing is a learned profession and is both a science and an art. It is an empirical science and, like other sciences, it lies in the phenomenon central to its focus. Rogerian nursing focuses on concern with people and the world in which they live—a natural fit for nursing care, as it encompasses people and their environments. The integrality of people and their environments, operating from a pandimensional uni- verse of open systems, points to a new paradigm and initiates the identity of nursing as a science. The pur- pose of nursing is to promote health and well-being for all persons. The art of nursing is the creative use of the science of nursing for human betterment (Rogers, 1994b). “Professional practice in nursing seeks to promote symphonic interaction between human and environmental fields, to strengthen the integrity of the human field, and to direct and redirect patterning of the human and environmental fields for realization of maximum health potential” (Rogers, 1970, p. 122).

Nursing exists for the care of people and the life process of humans.

Person Rogers defines person as an open system in continuous process with the open system that is the environment (integrality). She defines unitary human being as an “irreducible, indivisible, pandimensional energy field identified by pattern and manifesting characteristics that are specific to the whole” (Rogers, 1992, p. 29). Human beings “are not disembodied entities, nor are they mechanical aggregates. . . . Man is a unified whole possessing his own integrity and manifesting characteristics that are more than and different from the sum of his parts” (Rogers, 1970, pp. 46–47). Within a conceptual model specific to nursing’s con- cern, people and their environment are perceived as irreducible energy fields integral with one another and continuously creative in their evolution.

Health Rogers uses the term health in many of her earlier writings without clearly defining the term. She uses the term passive health to symbolize wellness and the absence of disease and major illness (Rogers, 1970). Her promotion of positive health connotes direction in helping people with opportunities for rhythmic consistency (Rogers, 1970). Later, she wrote that well- ness “is a much better term . . . because the term health is very ambiguous” (Rogers, 1994b, p. 34).

Rogers uses health as a value term defined by the culture or the individual. Health and illness are mani- festations of pattern and are considered “to denote behaviors that are of high value and low value” (Rogers, 1980). Events manifested in the life process indicate the extent to which a human being achieves maximum health according to some value system. In Rogerian science, the phenomenon central to nursing’s concep- tual system is the human life process. The life process has its own dynamic and creative unity that is insepa- rable from the environment and is characterized by the whole (Rogers, 1970). Using this definition as a foundation for their research, Gueldner, and colleagues (2005) postulate that a human being’s sense of well- being (wellness) manifests itself by