CONNECTIONS NURSING RESEARCH, THEORY PRATICE
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- CONNECTIONS NURSING RESEARCH, THEORY PRATICE
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YKAJiKU
5
«mCTI0NS
-Nu rsing R e search,
Theory,-and Practice
ANNE YOUNG, RN, EdD
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^iiiiiiaiii!itiiiiHhimW~
Associate Professor. Doctoral Pmgram Coordinator,
College of Nursing— I louston Center,
Texas W oman’s University,
Houston, Texas
SUSAN GEBHARDT TAYLOR, RN, PhD, FAAN
NEXUS sratue, arrisr Larry Y.umo
Courtesy Boone Hospital Center Board of Trustees
Professor Emerita, Sinclair Scltool of Nursing,
l.'ni' cr-irv <>l Missouri—Columbia,
< ’<Timhia. Missouri
Columbia, Missoni i
KATHERINE McLAUGHLIN-RENPENNiNG, RN, MScN
President and I’hici Nursinu Consulranr,
MCL Ediic.ilion
ices. Inc. and McLauUilm
\\ bite Rock, P'li'i-li Columbia, ( ana. la
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SALLY DECKER, PhD, RN
Professor of Nursing.
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Preface
It is not enough simply to study. First one must determine
what to study and what not to study; when to study arid
when not to study, and who to study under arid who not to
study with.
Peck, 1995
Discourse within a discipline occurs on manv levels, from the philosophical to the theo
retical and practical. In a practice discipline, discourse on the theoretical level must con
nect to the practice level. When these connections do nor occur, discourse at the theoret
ical and philosophical levels is seen as so abstract that it has little meaning for practice.
When discourse is limited to the practice level, it is hea\ ily focused on rhe hcre-and-now.
and it contributes little, it anything, to disciplinary knowledge.
In any mature discipline, scholars, scientists, and practitioners know rhe models ’bar
specify the phenomena and characteristics of rhe nature of the object or disciplinary locus.
1 hey also know rhe relationships between and among rhe phenomena of concern. They
know rhe variables based or. both universal and individual characteristic^, d hey know what
measures specific to phenomena are relevant or legitimate. They know how to use \ alid and
reliable measures to ascertain the characteristics of the situation. They develop practice
models that in turn enable practitioners to identify dimensions that arc amenable to in
tervention or change. Expert practitioners use practice models in specific nursing situa
tions to help them choose and understand theii actions.
Not ail nurses want to engage in discourse ar the philosophical and theoretical levels.
Many nurses see themsclvc' as grounded in practice, vet they want to contribute to disci
plinary knowledge. For rhe'e nurses, theory <hould be seen as a structure from which theii
research ..an gain meaning and within which that research can articulate with other work>
to fill in the ihsciplinan matrix. Many timc.> theory is taught from a historical perspective.
Although tlie >rudcnt at making benefits from knowing who has done scholarly work and
rhe nature ot ;h -r w(.rk, its wduc o .m.mni-’iicd if it does not guide research and practice.
Till•ger-, .m inie; *. ' i; c view . •: iiur-iag theoreiical systems wirhin which ra post•
r.iou ;v>c.'reli and ; ■ -vi -.'c n i h.i'i>: »r practice. T/icmeticdl svstern reieis to those theories.
• ii- ■-.h’i
■ •’. •
:
•; 1
.1! ■ lol \gies . >i modes of inquiry with:ri a < »mu .
. n:
-..i
; . h-.- . • iito u:
n.iramcicis o- rhe system. 1 re .ir'-dog'.
J co d. vii
viii
9
preface
PREFACE
i
i
tore NEXUS,
'SJePlctcd
Larry Young’s sculpshape formed from a continuous line. The v^ewer’sXT
‘S
irrCgular
sometimes directly and sometimes bv a more ■ Y■
fr°m °ne point t0 anorher,
among theory, research, and practice in the d
Like"'ise’ one can move
is often from theory to research to practice oZ
p
discipline- The movement
theory to practice or, more simply, from themv r rtlmCS’ ' m°Vement is from tesearch to
nections between and among the component^ thTT"
“ CheOry' The con'
The term modeling is used to describe the process of d
SyS'ei" enierSe ov''r time,
terns. Modeling .s rhe process of developing and rbt,these ^eorerical sysprocess is called a theoretical system which cm n
TThe Product "t this
Pons, complexes oftheor.es and model e.Li T ePT''
3nd founda-
Diversity and even controversy fioum b 7
a
’ and m0<)els for useand definitions used in this text 2, d^scribe S 7T'0"
Thercf°re dle
not be identical to those used by other aud.or N
through formal education and experiences Unit ?
comPonents may
'T?'5
" ? 1“>C
'ClS ;'"d Values are formed
cal system to assist in determining rvh.cl. perspeY'T""') i''1
°f Cilch th&>retigruent with one’s personal beliefs about,,
■
L
theoret.cal system is most conThe types of scholarly work performed withmoXh '
" I PlUCe
br°3dcr "'°Hd’
the pr.nc.pal research instruments are cr.t,oUed\ ,
''r""’ are illustratcd, and
PPmary sources. After the theoretical system w th .
"7 "
' SUhstitUte for readin«
scholarly endeavors has been chosen, the origin to
7 Pn’CtiCe’
and
scriptions, .nformat.on, and mrerpretarion T
i TTT'
C°nSulled for ful1 Jcnal, including knowing rhe unanswered ouesriT'
'"
U|ndersranding «f rhe matetheoret.cal system and the structures of J,n.c.,I s'ceJiTT'’
7"'''""'
'”Cans rhe
a better undemanding otXTthXn^Za'r-?'
C°Urs“
enX
......
Umr 1 presents a knowledt-c b ise sm. •>
i
and program administrators whose science .n I'ri.
nUrSinKstudents, clinicians,
cal practice areas. This mm explicates .or th' P
7' "1tCresrs are L-'sed in specific clim-
........ ................................ ................. *
svstems that can serve as .he disc.plmarv m ..r.y th,
'T’",
"
major theoret.cal
«’ere developed by Brem. Roger, I'„-sc
IP
W"' ‘ i"H r'‘'cricc knowledge. These
Three other .heoretical svsreim -th 7
T " ’
"om other scholars
an,U7a-™P~
o.et.cal systems are no. I.nked
,|lt.
■
''■’C.pbnory
^T.u-are developed
1,1 -’pe These three theI,eJ. THe rhei,_
ix
retical systems developed by Neuman and Watson began as specific to nursing but are now
appropriate for all healthcare disciplines.
Of these nine systems, the major studies performed within each are reviewed. The in
struments that have been developed to measure components of the particular theoretical
system are critiqued, and related information is included. The ways in which the theory- and
research articulate with and inform practice are also considered.
Readers are encouraged to explore each of the units in a quest to discover a fit for them
selves between theoretical perspectives and realities of practice. Consider the strengths
and weaknesses of the instruments presented and the practical and theoretical implica
tions of the research findings. Think about how these things might influence nursing con
ceptualizations, practice, and modes of discovery.
As Watson (1999) has noted,
One of the benefits of nursing theory and theory-guided practice (and reflective
practice-guided theory) is that it helps clinicians and scholars alike to return to
considering the ontological foundation of their practice. This ontological view
assists in examining and critiquing basic values and premises about how one views
person, humanity, environment, relationship, caring-healing, health and illness,
suffering and wholeness. It helps one examine and reexamine the role and pur
pose of nursing (p. 186).
Anne Young
Susan Gebhardt Taylor
Katherine McLaughlin-Renpenning
REFERENCES
Kinu. 1. & Fawcett. J. (Eds.I. 7 he uni,<,':ki«e n/ nKrsin.i,' theory and meiaiheory Indianapolis: Sigma Thera Tan.
Haire, l\. (1998). The singukir
"I honsand Oaks. ( A: Saye.
Peck. M.S. In search n| stones A pi/ininiare of faith. rcLisun. and disemery New York: Hyperion.
Watson, I (1999). 7’ostmodern nursing and beyond. Edinburgh: Churchhill Livingstone.
1
Contents
UNIT 1
NURSING RESEARCH, THEORY, AND PRACTICE: INTEGRATIVE DEVELOPMENT
1
Developing the Discipline of Nursing through Modeling, 3
Historical Perspective, 4
The Beginning of the Development of the Discipline, 4
The Present Stare of Development, 6
The Logical Middle, 6
Nursing as a Discipline, 7
Modeling Nursing: Philosophical Perspectives, 8
Cosmology, 8
Ontology. 9
Epistemology, 10
Modeling Nursing: Theoretic.il Perspectives, 10
Definition of a Model. 10
Definition of a Theory, 11
Definition of a Paradigm, 12
The Meaning of Metaphor in Nursing Theory. 13
Outcomes of Modeling Nursing. 1 3
Summary, 14
2
Nursing Theory and Research: Understanding the Connections, 17
Understanding the Connection. 18
Paradigms of Discovery, 18
Using Theory to Generate Research Ideas, 22
Theory-Generating Research. 23
Theory-Testing Research, 23
<Congruence Bervyeen Theory and Research, 26
Knowledge ot Theory Through Research, 26
Practical Pointers tor Evaluating Research on Instrumentation. 30
Reliahilitv, 30
Validity. 31
Siimmarv. 32
xi
F
xii
<•' O N TENTS
3
CON TENTS
xiii
1 he Structuring of Nursing Practice, 35
The Variables of Concern for Practice, 108
Describing a Population for Nursing Purposes, 112
Process Models, 113
Practice Models, 114
Implications for Administration, 117
Implications for Education, 118
Status of Theory Development, 118
Nexus, 119
Pursuing the Theory-Research-Practice Link, 36
Developing Practice within Nursing Theoretical Systems, 37
Nursing I heoretical Systems, Models, and Practice, 38
Importance of Theoretical Perspectives to Practice, 39
Human Becoming Theory, 40
Moderate Realist Perspective, 40
Critical Theory/Femi'nist Perspective, 40
Nursing as a Program, 40
Individual Practitioners, 41
Organizations and Institutions, 41
Summary. 48
4
6
The Starting Point of the Modeling Process, 124
Reason for Theory Development, 124
Phenomenon of Concern, 125
Description of Rogers’ Theoretical System, 126
Philosophical Perspectives, 126
Description of Rogers' Models and Theories, 127
Research Derived,from the Science of Unitary Human Beings, 12S
Research Instruments, 129
Review of Related P,escarch, 138
Praxis and Theory Utilization: Designing Nursing Practice Programs within the
Theoretical System of rhe Science of Unitary Human Beings, 152
The Variables of Concern for Practice, 153
Process Models, 153
Practice Models, I 54
Implications ror Administration, 155
Implications for Edik avion, 155
Nexus, 156
Integration, 51
Nursing Praxis, 52
Knowledge from Other Disciplines, 52
Selecting a Nursing Theoretical System 53
the Selection of . Theobtieai Svsten, as the Base, for Sprite
1 laaice or knowledge I >cvelopmenr, 54
Research Methods, 56
rdcihods of Quantitative Research. 57
Methods of Qualitative Research., 57
Bal.,nee Between the Two Research Methods, 58
iw^il .SZN"Inquiry’Research Merhod’and
'
.. — «
8 : l’^rct!Cl1 Ptormwc roStructure Practice, 62
Addressing rhe 1 heory-Praci
Cap, 62
Simimary, 63
UNH 2
ovEmew OF raEoPJe5. REl„ED „ESEARCH A„o pRACTm, ARpucAT]0K
5 "oX"?
Modeling Nursing From an Energy Field Perspective: Rogers' Science
of Unitary Human Beings, 123
p"'» - ““».<«
The Starting Point of the Modeling Process. 72
Reason fl)r heory Development, 72
Phenomenon of Concern. 72
Descript,,-,n ,.f Orem's Theoretic,! System, 73
1 hilosophicul Perspectives, 73
Dcs< option . a Models and Th-.mrlo, 75
Research Derived trom Self-Care Deficii N
ur.-ir.g Theory, S?
Reseaich In.-.rrumenr.s Measuring SHfR ’,
ire, 81
Review of Reijfed Rr-carJi, .89 '
Theiimti
‘
: ’ " ■:::H ' ' ' !
I r''-ooiv,. v.-m, ....
I ho vucai >y..tem -I -cir-Uare Deiicn Nursin-; M;eory. 10?
7
Modeling Nursing From Unitary and Existential Perspectives; Parse's Theory
of Human Becoming, 161
The Starting Point of the Modeling Process, 161
Reason for Theory Development, 162
Phenomenon of Concern, 162
Description of Parse's Theoretical System, 163
Philosophical Perspectives, 163
Description of Models and Theories, 165
Research Derived from the Theory of Human Becoming, 166
Review of Related Research, 169
Praxis and Theorv Utilization: Designing Nursing Practice Programs within the
Human Becoming Schno! of i bought. 180
The Variables of iConcern tor Practice, 181
Describing i Population !• -r .Xursine Purpose?-, 1'1
Expected Outcomes. 181
xiv
CONTENTS
CONTENTS
Process Models, 181
Practice Models, 183
Implications for Administration, 183
Implications for Education, 184
Nexus, 185
8
9
Modeling Nursing From a Systems Perspective: The Neuman Systems
Model, 187
The Starting Point of the Modeling Process, 187
Reason for Theory Development, 188
Phenomenon of Concern, 188
Description of Neuman’s Theoretical System. 188
Philosophical Perspectives, 188
Description of Model and Theories, 190
Research Derived from the Neuman Systems Model, 192
Research Instruments, 194
Review of Related Research, 195
Praxis and Thenrv Ul iliration: Designing Nursing Practice Programs
within Neuman’s Theoretical System, 221
I he Variable.' of Concern for Practice, 22 1
Describing a Population for Nursing Purposes, 22 1
Process Models, 226
Practice Models, 227
implications tor Administration, 227
Implications for Education, 228
Status of Theory Development, 228
Nexus, 228
Modeling Nursing From a Transactions Systems Perspective: King's
Conceptual System and Theory of Goal Attainment, 233
3 he Starring 1 oint r’f the Modeling Process, 234
Phenomenon of Concern, 2 35
Description ol King's Theoretical System, 2 35
Philosophical Perspectives, 235
Description of Model and Theory, 237
Roearch Deri ved F rom King’s Conceptual System and Theorv of Coal
Attainment, 2 38
Research Instruments, 2 38
Review of Related Research. 240
I'riv..
1 heray Uriliznrion: Des.gnrag Nursing Practice From the Perspecttve of
King - ( ...nceptual Svstem and Theory of Goal Attainment. 249
I he \ ariables of ( 'oncern for Practice, 250
Describing a Population for Nursing Purposes. 251
I.Oct. • ■ . I i luti. ,ames of Nursing, 25 I
IVocc»Moddc251
" '
’ *’
! r <’ a c M< 'do! < 2 3 5
Implications for Administration, 253
Implications for Education, 253
Status of Theory Development, 254
Nexus, 255
10
Modeling Nursing From an Adaptation Perspective: The Roy Adaptation
Model, 259
The Starting Point of the Modeling Process, 259
Reason for Theory Development, 260
Phenomenon of Concern, 260
Description of Rov’s Theoretical System, 261
Philosophical Perspectives, 261
Description of Model and Theory, 263
Research Derived from the Roy Adaptation Model, 264
Research Instruments, 264
Review of Related Research. 268
Praxis and Theory Utilization: Designing Nursing Practice Programs within the
Theoretical System of the Roy Adaptation Model. 297
The Variables of Concern for Practice. 297
Describing a Population lor Nursing Purposes, 298
Expected Outcomes of Nursing, 298
Process Models, 298
Practice Models, 300
Implications for Administration, 300
Implications for Education, 302
Status of Theory Development. 302
Nexus, 302
11
Modeling Nursing From the Perspective of Health: Pender's Health
Promotion Model, 307
The Starting Point of rhe Modeling Process, 307
Reason for Model Development, 308
Phenomenon of Concern. 308
Description of Pender’s Theoretical System, 308
Philo.ophical Perspectives, 308
Description of NhUei and 1 hcories, 309
Research. Derived from Pender’s Health Promotion Model. 310
Research Instruments. 312
Review of Related Research. 315
..xiS and Theorv L rihzation: Designing Nursing Practice 1 rograms
brom the Perspective of Pender’s Health Promotion Model. H9
The Variables of C'oncern for Practice. 3.39
i \ >c: Ting a Papiilarion tor Nursing Purpo1-. p. •.a .-.I Outc- me- of Nursing, 3
>.• Modvk 3 >9
Pm ..<• Modeh. Hl
xv
xvi
CONTENTS
CONTENTS
Implications for Administration, 341
Implications for Education, 341
Status of Theory Development, 341
Nexus, 341
12
kxs
The Starting Point of Modeling Nursing, 346
Implications for Administration, 400
Implications for Education, 401
Future Theory Development Required to Facilitate Practice, 401
Nexus, 402
H"a"
Reason for Theory Development, 346
Phenomenon of Concern, 346
Description of Peplau’s Theoretical System, 346
1 niiosophical Perspectives, 346
Description of Model and Theory 347
Review of Related Research 355
am the Perspective of
APPENDIX, 411
e anahles of Concern for Practice, 366
Expected Outcomes of Nursing, 367
Oeser,hing a Population for Nursing Purposes, 367
Process Models, 367
Practice Models, 369
Implications for Administration, 369
Implications for Education, 369
Nexus, 370
13
GLOSSARY, 483
Nursing and the TheorT o^Human CaringT?^3150"’5 TranSpersonal
The Startmg Pomt of rhe Modeling Process, 374
Reason for Theory Development, 374
1 henomenon of Concern, 374
Description of Watsons Theoretical System, 375
1 niiosophical Perspectives, 375
'’‘EZTr'"'”""”"'
.„d
H,,,,,.,,,
... ....................................... ........
Review of Related Research. 381
Wson’s Thl.o'^c'd^Cnl1W8n"lS
rhe \ari,,hlesoi Concern lor Practice, 398
' e>u,h",’~ •’ Ration for Nursing Purposes, 399
hspecrej Ou,x,|r
,y
Process Models, !W ~
Practice Models, 400
EPILOGUE: The Integration of Nursing Theory and Research
for Practice, 405
Using the Past to Create the Future: The integration of Nursing Theory
and Research for Practice, 405
Existing Theoretical Systems, 405
Nursing: A Practice Discipline with Practical Science, 405
Recognition of the Duality in the Ontology of the Discipline, 407
The Scope of Theoretical Systems, 407
Practical Usefulness, 408
Empirical Adequacy, 409
The Future, 409
within
xvii
fc
UNIT
It
NURSING RESEARCH, THEORY,
and PRACTICE
Integrative Development
The links between and among nursing research, theory, and pracrice must be tirade
plicit to interpret research findings, to establish the validity ot theoty, to aiticulatc the
outcomes of practice, and to continue to describe the discipline called nut>tng. ! he extensity of these relationships indicates rhe maturation ot the discipline ot nursiny. As
nursing researchers and scholars are able to join rhe iii<li\ i«.liial bits of knowledge co a
framework, the disciplinary matrix becomes more complete. Theory, research, and prac
tice became disconnected as rhe discipline and profession ot nursing were <le\ eloping.
Each ot these areas developed into a specialty in its own right, and a.' rhe <liscipline
matures, the contributions ot each area to integrated systems of nursiny knowledge are
important.
This unit focuses on the components of the disciplinary matrix and the linkages \\ ith ic-
search and practice. Chapter 1 describes the components of theoretical -v-teno. Thu nurs
ing knowledge that fleshes out the disciplinary matrix includes empirics, ethics, aesthetics,
and personal patterns of knowing. Integrated knowledge development usme these four pat
terns will provide a complete picture of the discipline. 1 b.i> text focuses on empiiiv-.
NuiMng theoretic.il systems provide rhe object for nursing science and f< >r research :. m-
dational to rhe practice of nursing. Research develop', \alid and reliable n'lniinr:
measuring t heoretical and practice ci instructs and make't b.um ivailablu r 'i>i
searcher.' and practitioners. The outcome is the development . ■' oair'iim rri .n.
idea' ire explained in Chapter 2 and aic presented thr-■u.-'.v hh <;■
:■
■
a.
2
CONNECTIONS
Nursing Research, Theory, and Practice
1 heory and research are important to the development of nursing practice Theory con
sider. how nursing practice should be constructed for inrervennon. Research informs prac-
n ent r ’
™de by practice program designers about how to imple
ment treatment suggest a major support for the use of theory in practice. Program theory
mcludes the specification of what must be done to achieve desired goals, other anticipated
outcomes, and how to generate these goals and impacts (Chen, 1990). The answers nurs
ing research seeks are denved from theory and practice. The results of research are inte
gramd mto practice through the development of protocols, procedures, and practice pro
grams. These ideas are developed in Chap.er 3 and throughout the book
Chapter 4 focuses on the integration of theory, research and practice. Collin (1992) de
- .bed rheoreucal integration as the power of a theory or theoretical system tZs^P
a oc and urn y our Knowledge within a particular field. Chapter 4 also summaries the
process tor selecting a theoretical system.
ummari.es tne
■ hen. I I. (1990). Thcry-driv cvu/nduonx Neuhun f’.irk. CA: Sage
C<.||-n, I- (1992). Nur<ine science
:••> fn.vrnJls«Plll-.e: Pn*|e,w .,..J challenges. \’arJ I
B2 ?.
CHAPTER
Developing the Discipline
of Nursing Through Modeling
|2( 14)
Objectives_____________________ ____________________________
• Describe the historical evolution of the nursing theoretical system.
«■ Examine the current state of nursing models, theories, and paradigms.
• Describe nursing as a discipline.
• Describe the overall process of the development of the discipline of nursing.
• Describe the value of the integral nature of nursing theoretical systems.
• Identify the importance of the object of a discipline to the development of
theoretical systems.
Discuss the role of philosophy in the development and a laiysis of nursing
theoretical systems.
« Specify the structural elements of nursing theoretical systems.
Key Terms__________
conceptual model, p. 5
cosmology, p. 8
discipline, p. 4
epistemology, p. 10
general theory, p. 12
middle-range theory, p. 12
model, p. 10
modeling, p. 4
nursing theoretical system, p. 12
object, p 7
ontology, p. 9
paradigm, p. 12
theory, p 11
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6
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 1
Developing the Discipline of Nursing Through Modeling
7
Stevens (1979), Chinn and Jacobs (1983), Fawcett (1984) Mele.s (1985) an! rl
those of Orem Rovers ■ nd R()v
h..j„
c Tt
g 'Wr5“’g the°rieS “ tO models
a,™u„„ s,
ix i’6a-
The Present State of Development
independent of thought and that it is possible to acquire knowledge of this world. T his
philosophical perspective recognizes that the reality cannot be fully known and empha
sizes analogical reasoning, often in the form of modeling. (See Chapter 5.) More recently,
Banfield (1997) conducted a philosophical inquiry of Orem’s theory, which confirmed and
elaborated on the moderate realist view. Simultaneously, a great deal of research has com
firmed and extended Orem’s work. A nursing scholar can begin from an understanding of
moderate realism, learn the views of persons and action within that philosophical tradition,
move to study Orem’s conceptualizations and general theory, explore the empirical evi
dence, generate new research, and finally apply this to practice.
NURSING AS A DISCIPLINE
disciplines to nursing theory is often expressed in mi l 11 ri
1 knowkd.^ bom other
attention. One area of discussion f?
> nuddle-range theory and receives much
lionship to theory or knowledge fr'
p
"?e9ninq <,f nursir»g theory and its rela-Ping . u.idle7>m7 thZ Sn 7 ‘AnOtht'r
" -ggests devels'.A w.11 at,e T, ;'
J :"7rP"ratl"«;h<->7
other discplim-s Ongoing re-
1-tion is rhm the ^d™ TT*^d
"mode!
’“Wtl’eory of nursing (Orem, ^wT^kawTVldliSinh ^7“
' 1
K*ca is me foeu- ol this text.
The Logical Middle
EE-
mooeh. .solar,ng and nhsr,-acting from ,-arious aspects oi re-,lit--'I
lit, "
'' ‘
"T
(p- 3c.),
in
■• •
- ■ x-uK i -elicit fheory of Nursing dlustrares tins devm-Q-.. . ......
themstginpersons needninT T - ho......
'■'Is-io care io, rnemselves.Nexr, she developed rhe concc-n.-d
H T ,
c"-^nd descriptions ,,frheoret1caleleI.1enrs.\X;l|i;,c..(|97s,; a A
"
""
seni.uixc . .f m H..- <f(.
i... ,
,
,
U 1
'•
-• ak ix-i-reft n-.lo.a Xbdcram reuh<m mgg<-sr< ib.ar a w.-i.i (......
A discipline is a structured body of knowledge about a particular segment of reality. The
structure serves as the matrix for examining relationships between concepts and proposi
tions. It presents to the researcher a view of gaps in knowledge in the field and of where
new knowledge, developed through research, articulates with current knowledge. The dis
cipline provides the practitioner and potential researcher with a framework for interpret
ing and gaining insights into questions about nursing phenomena and pract ices
The focus of a discipline is constituted by its object. Object defines the discipline; it
designates that particular aspect of reality that is rhe subject of the discipline as it is know
able and expressed. Many disciplines consider the person the subject, but the way> of know
ing and the typcs of knowledge that can be obtained in each discipline makes them differ
ent. These differences facilitate discourses related to fields and boundaries of the discipline.
This is necessary because a discipline is nor global (Bekel, 1998). Each discipline bus a dis
tinctive outlook and style of thinking as well a.' distinctive organized ideas and concepts,
methods of inquiry, and modes of understanding data (Orem, 1995). Bekd (1998' asserts
that rhe description of rhe object builds the center ol professional endeavor of a discipline
Professional endeavorcan mean rhe development of science and rhe protes-uonal pr wric
congruent with rhe disciplinary object The object is important in that it ni-uicarc- the de
ferences in scientific disciplines, rhe methods for investigating and exploring knowledge,
and the conclusions.
Kulm (1976) believed that a scientific community, which consists oi rhe practitioners
of a scientific specialty, is necessary for rhe production and validation of knowledge. I his
scientific co.'.imunirv possesses a common paradigm or disciplinary mairix discipi.'Jknv becutbc ii is the common possession nt rhe practirioners of • p'-ofessional discipline, and m.;'n.v \ic lusv ii is composed of ordered elements of \ arious sorrs. each requiring further qvc
ifi< ata n. Suppe (1976) modified this view. He suggests thai rhe only filings necessary :n
rhe dcvclopmuir of a discipline arc sufficient agreement on (1) whar theory ;o use,
(2' wh a <_( unis as good science within a particular community. (>) 'die rvlevani quc'.i. ■n>,
;4) application-of theories to nature, (5 ) what.examples from which n; work, and (6' dw
ability to communicare freely enough so that rcseaichers and scholar- s.'ri<'H c gon.-ider
.-nix . erimn characreristic problems.
I’h. -c docriprions indicate dial develop;-.’; aiming a- do- IPIH'.C I> Cl| l.l I'X idci i! ii x
o* ir t. jiiii \ c
us. sufficient agreement on that ohje.,m J (lied'.'s
.•.cir- i',d -ul'-r
am ilw .1 . The explication . r di-ciplinarv I
a ecalui i<-n;ir\ pr-e -.---. A-.vi--.u-.'
■ in ;;
•..’hji -,;
8
CONNECTIONS
Nursing Research, Theory, and Practice
varying and sometimes opposing positions will emerge. The different ontologies or theo
retical approaches described in Unit 2 reflect this.
MODELING NURSING: PHILOSOPHICAL PERSPECTIVES
Much of rhe early work in nursing theory development and evaluation emphasized rhe differenttatton of theories from conceptual models. Theorists develop models by using exist
ing knowledge about the nature of the object of the discipline. Models and the philosoph
ical underpinnings precede and guide the development of research and practice programs.
. nursing scholar must work from a nursing-specific theoretical system and model. Theory,
non<»h’iand pr!’c,ticc thar are cll‘Wuenr with that model can then be developed. Fawcett
(1999) observed that nursing will not survive as a distinct discipline if it does nor end its
romance with nonnursing disciplines. She emphasized the need for nurses to practice from
a nursing discipline-specific perspective and to conduct nursing discipline-specific research.
us does not mean that only one model or theoretical system for rhe discipline of nurs
ing exists but proposes that, regardless of the theoretical system rhe practitioner or re
searcher chooses, it should be musing discipline-specific. The ability to interpret the find
ings of research, to establish rhe validity of theory, articulate the outcomes ot practice and
to continue describing nursing relies on this specificity. The established theoretical sys
tems and models can be examined in the sense of theory evaluation and comparison
through rhe range of thuir statements regarding rhe object of the discipline Bekel (1998)
contends that rhe examination ot musing theories in the sense of rhe range of their state
ments regarding the object would retain the potential of each theoretical system The de
scriptions of theoretical systems in Unit 2 demonstrate the range of objects for rhe discipiine. eventually, a coalescing and refinement into a limited number of nursing
discipline-specific theoretical system-; with agreement on i
the object of rhe discipline could
be expected.
The develop.menr of theory is considered first in its philosophical context and then for
its specmc knowledge domams. The philosophical structure used in this text follows from
the traditional Anstoiehan classification of the various branches of philosophy namely
cosmology, onto ogy, and ep.stemologv (Wallace, 1977). The basic structures of philosophy
tor the specific theoretical systems detailed in later chapters are described in the foil.>wmg
sectionsJ fane different approaches and terms can express concepts related to theor. and
philosophy of nursing, and definitions ofthese are inclmled.Comparaove analyses of these
terms also can be found m other works, such as those of Chinn ami Kiam.er ’( 1990) .nd
King and Fawcerr (1997).
Cosmology
Cos.nologv ,5 the stub ot rhe whole uni verse, mciud.ne rheoric ut.out its orwin es Ju-
non. .structure, uid future. 1 ho rvpically includes rhe nie.urmo „;.i p|.iCe of hrunun ben- ''••rh.,n tiro universe. Ahhouyh crsrmjlngy ]ws ihe hv.dest vhnv ot reui.rv, rhe i-.
,T,
point of a,sn,olo.;v is rhe onrolotty. which is defined in rhe next
-i rhi-. h in. - T|-e
rnient .■> rl r!,«.mnl system |Wfl5
rhe venter, urounde.i m t,.,,,, e, ryrilftv mJ
expands outward to the per^ven-o.- ofrhe whole of the nnr. vr.-. .
Fhe speofK-arion of a omisT-v h .undational to a p.rrt icid i- am^mg the. .re'; d <v<.-n
i< .i recent developincm. IT w. ei. d! rheonsts work tr -r,
h
s-.?.
. ,'g,.
CHAPTER 1
Developing the Discipline of Nursing Through Modeling
9
universe, sometimes referred to as worldviews, that arc foundational to their conceptual
izations. In 1997 Roy presented rhe cosmology underpinning her theory (see Chapter 10).
She speaks directly about a god or transcendent being as an essential part of nursing the
ory, research, and practice. Watson (1999) posits a cosmology and ontology of transpersonal
caring in which “the sacred feminine archetype is considered to be the very basis ot reality"
(p. 286). Other theorists leave the cosmology that is foundational to their views of the
world to be inferred. For example, Rogers posits a universe ot open systems and energy
fields. Although she offers no further explanation or speculation about the universe’s ori
gin, she describes a theory of expanding evolution. The specific views ot theorists are de
scribed more fully in later chapters.
The meaning of cosmology to nursing is not well established in the literature; however,
the extensive literature on spirituality suggests that the meaning of a transcendent reality
is a part ot many nurses' worldviews. The introduction ot cosmology into the discussion <>f
nursing philosophy leads to a deeper exploration of the meaning ol being that surpasses
traditional considerations ot person or sell.
Religion and Cosmology. Philosophy deals with what humans can know through
experiential evidence and reason. Faith, by definition, is separated from reason; it Joes not
rest on logical proof or material evidence. Klubertanz (195 v) states that a laid) can be
held and carried out in practice, even to a very high degree ot perfection, without any
philosophy (or theology) whatsoever" (p. 278). Likewise, philosophy can be carried out
without faith. For many nurses, reality is a conjunction ot philosophy arn.1 faith. Ones faith
informs one’s philosophy—that is. it forms and shapes rhe questions and answers about
reality; it reflects rhe “unity of personality" (Klubertanz, 1953. p. _80). A person - taith
must be congruent with rationally held views <’1 reality, d his is an important consideration
for exploring nursing rheoret ical systems. It ones phih'sophical and personal views coniuct.
which will direct heliets and values about nursing’
Ontology
H-IJ or du portion
Ontology refers io the uauiicy of assumptions jbmir the nature el the world
ol realitv in oue'den. Orn -logy examines the nature ot beine- in nursin'?,, rhe prim;’.:', on
tology is the nature of person. Roy identified the person as .in adaptive system. 1 > a Orem,
the basic nature ol human beings is that ot agent, and tor Rogers, rhe human is an energy
field An ontology, according to Harre 6s Gillett (1994). is i “>\stemaric exposition ot
the assumptions about basic categories being admitted to rhe universe .n " >me <C:enr!!u
held" (p. 29). An ontology should involve a location system, a b.isic class or classes >'t en
tides, and some tvpe ot structured relations that hold all these unities together in a sin
gle world.
and modeh am deveb
ir.'in which lhc«>r
Why is it in.ponani n ■ know the onn
his qiiV'tion. He •Tatesoped? Hani' s description ( 199S)ol mnok
Ontologies are, in effect, grammars. They are specifications, some expacit. some
impheat, of ways of identifying and marking the boundaries of particulars tor
some purpose or other. Sciences are created by choosing an ontology- or more
likely, finding oneself already committed to noe in r’le way one rias beer, think
ing and <3Ctino—(hraugk the use of which phe ion ena are to be identined rma
10
CONNECTIONS
I
Nursing Research, Theory, and Practice
ordered and explanations are to be constructed. Ontologies, as expressed in
grammars, loosely fix the forms of discourse appropriate to this or that human
project, including laying out the project. Ontologies also fix methods Since on
tologies are prior to phenomena there is always a choice. In the end the choice of
°2OH9y 'S- ar9eLy,JU
'ed Pra9m3tically. how many of the phenomena of in
terest does it enable us to comprehend in a fruitful and constructive way? (p. 47)
1
eu J'Tf "'"'T
"'Iedge deVe'?PS|Within an Ont°loSy- The onri,l°W I’rovldes the lan
guage for nilk.ng about nursing. It directs the methods that can answer questions about
I henomena that interest nurses. Explanation involves identifying or linking independent
phenomena with aspects of a common ontology. Furthermore, the ontology tells us how to
( 007? ni"'SeS' i T''",'" C
Ofrlle
Practitioner. Reed
Miggorcd rh.it rhe ontology of rhe discipline of nursing be defined as an “inherent
tuman process of we -bemg. manifested by complexity and integration of human systems"
(p. 76 . Rawnsley (I998) noted a need to distinguish rhe particular ontology heim. de
scribed, smee these could differ radically or even contradict
Nurses currently use a variety of ontologies. Unit 2 describes the ontology that is idem
rihed oi that can be interred for each of the included theoretical systems. Harre noted that
the assumpnons o rhe ontology constrain rhe type of hypotheses that can be constructed
rhe\v rrl lTtS T ,n StT" :l 1 ’V'7rhesis mllst
k^ptng with ones general picture of
Hk o Id. In selecting a rhcorenca system to use tor research or practice, the theonst must
know the ontology and understand how to discuss a specific area of nursing.
Epistemology
Epistemology is the s.udy of knowledge itself: what it is, wlw its parties are. ..nd win
has these propert.es. Entomology seeks answers about the properties of truth and falsity
i
i
(T|| ,'UrU Iq-TC"' '/’t '
rh:” eVidCnCe prOC,liCCS in scicnri,k ntowledge
(Wallace, 1917). Knowledge can be speculative or practical. S/tecidume knowledCs
knowledge for its own mkc. whereas tactical knowledge exists for rhe sake <-f o/vrutnni.
e.g., the arts of making tilings,
................................ e.g., the arts of directing human activity. The de
velopmenr of knowledgile occurs through reflective thought and through science To the
extent that a [practical science engages in analysis, it can speculate and use analytical procedtires similar
.. to tho.se of the speculative sciences. A practical science seeks to produce its
[Xh neejs 'rcnr:'i' kTwleJ*e ro
,r
-us. be complemented by an an
hal it (e.g., prudence) that has as a proper concern rhe individual act in all ns c.mcrere
circumstances (Wallace, 1977).
;
MODELING NURSING: THEORETICAL PERSPECTIVES
CHAPTER 1
Developing the Discipline of Nursing Through Modeling
11
ambiguous in that they are capable of interpretation. They may be considered representa
tions of ways of understanding (observable properties) or as pictures of things that cannot
be observed (unobservable properties or processes). A model controls the abstraction of
features from the complex phenomena observed in some field of interest (Harre and Gillett,
1994). It is a system of relations used to represent another system of relations. The model
may be depicted in symbols, words, numbers, or a combination of these. In nursing, mod
els that depict the ontology are often called general models or grand models. Some
models show the relationships of variables under study. In practice, models can depict a
process, an interaction, a practice program, or a segment of such a program. Unit 2 illus
trates many of these types of models.
A model may be evaluated by its conformity to rhe part of reality it is supposed to prediet (Chen, 1990). Wallace (1996) explained a model as “an analogue or analogy that
assists or promotes the gradual understanding of something inor readily grasped in sense
experience” (p. 5). He explained that models or analogies are helpful because
we learn from things around us by noting similarities and differences. When we
encounter something new, we attempt to understand it by conceiving it after the
fashion of what is already familiar to us. We thus use things we know, or at least
think we know, to advance into the realm of the unknown (p. 5).
Many practitioners of nursing use models or analogies when instructing patients; edu
cators use models and analogies extensively in the classroom to convey new ideas. When
working with models, scientists compare properties of things and types < systems within
particular contexts (Wallace, 1996).
Modeling is the process of developing and providing an abstraction of reality—that is.
a model (Wallace, 1994). The character and result of this process depends on the model <
intended use. If the model is to provide normative guidelines—what one ought to do—it
will be deductive and may represent a very idealized view of reality. Conversely, il the
model is to describe reality, various inductive techniques are used, the most prominent be
ing statistical analysis.(Wallace, 1994). The process of modeling typically goes through the
stages of problem conceptualization or formulation, model formalization, and validation.
The resulting model is then implemented in research or practice. Although models anti
modeling are helpful or essential in understanding rhe structure and relationships of con
cepts, some limitations remain. One of these is most models inherent assumptions of nor
mality in a situation. Another limitation is that a good model may be used for rhe wrong
purpose or in the wrong situation. If the model is being used to design .1 clinical program,
these errors can cause significant problems. Chapter v presents a more derailed discussion
of the use of models in designing clinical programs.
Definition of a Model
n”'"' "T
n,oJeis: C”>'krere and abstract. For the purposes of this dis-
'
'U’1V 3f'StriKt
Tk'
- -entifu .7 ,
' TT
■' "clJ T N-’gg" >. "Vord.mS to llarry md (:,||CI, ( W4). (. cc;,rr ||
■l...1.er.vsenrJl|>eon,..|.oV. A model is a virtual or muemed .yoym i hw Iv.nv vary,noden 10,1m >mm.i:.r'.
.i.'pccisof the real world it reprcsem>. Models ire C"enriallv
Definition of a Theory
A theory simply describes the nature and workings
nkings ot
oi a m. >del. Theory is .1 frame < >1 retei ciu >.
that helps human.' [• ■ understand their world and tn tunction in it. Theory pn \ ide' 11. a ■ ailguideline-' tor analyzing a phenomenon but als<> a scheme lor underst.inding r.hu 'igiut;. an. u
of research finding' (Chen, 1990k Theory 1.' generally defined as 1 sui
mieie lam 1 isumption', principle', and/' r proposim >ns i. explain ’r guide aci ion. bo tmi ic in er a 1: . •
12
CONNECTIONS
Nursing Research, Theory, and Practice
tains many definitions of theory. One widely accepted definition is that theory is a pur
poseful systematic abstraction of reality (Chinn & Kramer, 1995). This definition is con
gruent with the vm expressed in this text. A general theory in a practice field descrip
P'
tively explains the dominant features and relationships that characterize the field's practice
situations. General theories structure what is already known and provide foundations for
the continued development, structuring, and validation of knowledge (Orem, 1991)
Other types of theories are based on the level of abstraction or scope of’variables in
cluded in the theory. These are referred to as middle-range and micro theories. A general
theory covers a broad scope, whereas these are narrower and include only a port ion of the
scope of the broader theory. King's Conceptual System includes rhe middle-range Theory
of Goal Attainment. Chinn and Kramer (1999) identified and defined many types of the
ory on the basis of scope, focus, and level ofspecificity: grand, atomistic, wholistic, macro
metamicro, middle-range, molar, molecular, empiric, etlucal. armchair, and grounded'
Tins listmg points to rhe complexity of theory work and the need ro specify rhe type of theory being used or developed.
For the purposes of this text, the important levels of nursing theory are general and
mtddle-range. General theory, explaining a general model of nursing, represents a comp etc vtew of nursing, whereas midrange or middle-range theories explain conceptual mod
els that represent a partial view of nursing practice. Middle-range theory consists of con
cepts, propositions, or relational statements from which testable hypotheses can be derived
and empinca ly measured. The development of middle-range theory can use theory or con
cepts from other dtsc.p.nes synthes,zed into a nursing discipline-specific theory to explain
TXT' , earc,h val'd-,tcs t’tttcomes and produces evidence-based nursing. Fawcett
(1997) makes a distinction between models and theories that are based on level of ahstraetton, but she does not link conceptual models and grand theories in her description
However, the distinction between conceptual models and grand theories has lumted value'
A nursing theoretical system comprises (1) a general model and theory of nursing that
ts placed w.thm a particular philosophical tradition and structures the discipline, (2) the
models and middle-range theories and empirical referents, and (3) the models that mve
direction to practice.
Definition of a Paradigm
In nursmo rheory literature, rhe term paradigm often refers ro “a worldview or ideolow ,
medunn w.rlnn which rhe theory, knowledge, and gn.cesser for knowing f ind .net.nin--rnd
colureiKc ..nd are expressed (Clnnn
Kramer, 1995. p, 76). This def.nition .s similar to
rhe detmu.on of ontologv m this text. For clarity, this text uses the term paradi^n to mean
only paradi^us o/ mquiry—that is. the following:
_
•
the operating rules about the appropriate relationship amSng theories methods
and evrdence that constitute the actual practices.of the members of a scientific
communrty, research program or tradition. [They] are the combination of theoret
ical assumptions, methodological procedures and standards of evidence that are
taken for granted in particular works, are in the foreground;(Alford, 1998, p. 2).
! .imdigm.N .n\- described rn Chapter 2
CHAPTER 1
Developing the Discipline of Nursing Through Modeling
13
The Meaning of Metaphor in Nursing Theory
Metaphor is a language structure used extensively in writing about nursing. The use of rhe
metaphor as a tool is both common and essential as new ways of looking at nursing and
nursing science develop. Metaphor, in the broadest sense, sees something from the view
point of something else; it is an attempt to integrate diverse phenomena without destroy
ing their unique differences. Metaphor transfers a term from one system of dimensional
level of meaning to another. It is the “conscious application of relationships between rhe
knower and the known. Metaphor is a connection between our consciousness and some
tangible or sensible phenomenon, whether it be in a poem or in the heuristics of a diag
nostic procedure” (Wallace, 1996, p. 41). A worldview is a product of human reason and
is presented and understood through metaphors. “Metaphors represent the ways in which
many kinds of discourses are structured and powerfully influence how we conceive things”
(Watson, 1996, p. 12) and “reflect the prevailing cosmology of the time” (Watson, 1996,
p. 59). Much of what is written about nursing is metaphorical. Watson (1999) seeks to
"deconstruct and reconstruct” metaphors in her conceptualizations and musings about nurs
ing. All theories or writings about theory contain metaphors that communicate meaning,
suggest paths for action, and enhance concept and theory development (Smith, 1992). h
is important to distinguish metaphors from science. Both are important, bur rhev arc not
the same.
OUTCOMES OF MODELING NURSING
Two major outcomes can be expected from the development of nursing theoretical s\>tems. One is scientific, systematized knowledge for nursing practice that also can be used
in designing research and curriculum. The second is a formalized statement of a philo
sophical worldview on which to base further understanding ol nursing theory. The devel
opment of knowledge fluctuates between these ends, ar one time using empirical methods
to generate a particular type of knowledge known as science and at other lime using modes
of inquiry that clarify the philosophical assumptions underlying the theory. Carper (19/>)
defined tour “patterns of knowing, namely, empirics, ethics, personal, and esthetics, each an
aspect of rhe whole of knowing, each making a unique contribution to the whole and each
equally vital to the whole of knowing” (Chinn & Kramer, 1995, p. 4). At any time, rhe de
velopment of knowledge moves dynamically between the philosophical and the scientific,
rhe empirical and the ethical, rhe speculative and rhe practical, and the formal and the per
sonal. Nursing scholars’ work reflects diverse theoretical conceptualizations, methodologies,
and meanings.
Marrmer-Tomey and Alligood (1998) identified some cbaracreristics of middle-range
nursing theory as “specific to nursing practice” and to "the area ol practice, age range of rhe
client, rhe nursing action or intervention, and the proposed outcome" ip. 33)). l awce.i
(1999) described middle-range theories as “narrower in scope than grand theories, made up
oi a limited number of concepts and propositions written at a relatively com. rete and spe- ific level, and general cd and tested by cmpiric.il research” (p.
It would seem dial gen
eral theories beget middle-range theories, whereas middle-range rhei no bezel more
middle-range theories. Lieht and Smith (1999) clarified "•me of rhe !><iic- rcgardiiiz
muldlc-range rb.eor\ Among orher things, rhev pr> 'posed caiei? ■rmng middle IT;
14
CONNECTIONS
Nursing Research, Theory, and Practice
Developing the Discipline of Nursing Through Modeling
CHAPTER 1
15
by level of abstraction (i.e., high middle, middle, low middle). They noted that all middle
range theories generated through research and published in nursing journals since 1995
included diagrammed models.
A number of general nursing theories have evolved into theoretical systems. More for
mal knowledge work is necessary to move the development of nursing as a science. The de
velopment of middle-range theories is a part of this work. Again, in addition to general
leones and conceptual models, theoretical systems include middle-range theories and
integrated knowledge. Fawcett (1999) refers to this substructure as the “conceptual
theoretical.emp.ncal structure-- (p. 31). Middle-range theory development typically be
gins witl, idennfymg a concept derived from the broader general nursing theory Concents
or theories from other disciplines often complement the development of the concept uner study. Philosophical and logical congruence between the general theory, the focal con
cept complementary theory or theories, and empirical methods is essential. Ulbrich (1999)
developed a middle-range theory ofexerc.se through triangulation of Orem’s Self-Care
Deficit Nursing Theory rhe rranstheorwical model ofexerc.se behavior, and characterisncs o a Population at risk for cardiovascular disease. (See Figure 4-1 later ,n the text for the
model used by Ulbrich to develop this middle-range theorv.)
• The focus of a discipline is constituted by its object. This facilitates discourses re
lated to fields and boundaries of the discipline. The description of the object builds
the center of professional endeavor of a discipline.
• Philosophy considers what humans can know through experiential evidence and
reason. The development of theory is considered first in its philosophical context
and then in terms of its specific knowledge domains and various branches of phi
losophy, namely, cosmology, ontology, and epistemology.
• The structural elements of nursing theoretical systems include models and theories
of general and middle-range levels of abstraction.
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Alford, R.R. (1998). The craft of inquiiA-. New York: Oxford University' Press.
Rantield. P>. (1997). A philosophical inquiry oj Orem’s sell-care deficit nursing theory. Unpublished doctoral disserta
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Bekel. (i. (1998, February-March). Statements on the object of science: A disciosion paper. Paper presented ii rhe
mecrine of the Orem Studv Group. Savannah, GA. Published in IOS Neusletter. 7 (1999) I k
k ’.irper, R.A. (1978). Fundamental patterns of knowing in nursing. Advances tn Nursmg Science. 1(1). I
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Summary___________ ____
!k
k .’hinn. P. -St Kramer, XI. (19^5). Theory and nursing: A systematic apprnaih. <4rh cd.. St. 1
M-.Jn
hui".. P. X Kramer. M. (1909). J heory and imrsing. Intctr’ated knowledge ii. iI'.opmcnt (5th ed. ■ St. i
I hekoti. J. iSs James. P. (Iu68). Oh theory development in nurung. A tli><
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(>! rlicune.'-. X’i<ahii! k.-vAnc;’ I7( ')
197-20 k
Dit k< il. I. Ck James, P. (197 U. (.'lanry to what end.’ Niosipg Research. 20(6). 499-502
I 'nu ddson. S.K. Ck Crowley, D.X1. (1978). The discipline of nursing. Nursing (. halook J‘>( 2 ;. ’ U 12
! ‘w. i.-it, |. (1984). Atutlysisand cialuution oj conceptual models o| nursing. Philadelphia FA. I '.tvi-.
• The current state of nursing models, theories and paradigms has engaged nursino
schc arsand practitioners in knowledge development through theorizing and re9
searchmg the substance and structure of knowledge that fom the discipline of
njrsmg .nd mform the practice of nursing. The meaning of nursing theory and the
c.ati unship, o tl>eory or knowledge from other disciplines to nursing theory
TIr°a9h ,1?lddle'ran9e theory are receiving much attention
• I he discipline of nursing is the structured body of knowledge unique to nursing It
mo^TdinaXnv'bTt
h0™9’ The deve,oPme^ of this knowledge
X ? I?
y V
6 Ph,,os°Phical and the scientific, the empirical and
the ethical the speculative and the practical, the formal and the personal A disc.'
yeas andaconSt'nr'Ve ° n'°f thinkin9 aS We" as di«mctive organized
■ For nursino tn hP d
a
m°deS °f understanding data ’
. or nu, sing to be described as a discipline, there must be identification of an ohiert
or focus, sufficient agreement on that object, and methods of mguby that a'e X
abeTdoma-' C pdjeCt 'A"th,rt the discipline. Development of disciplinary boundes, domains, and substantive knowledge is also necessary
’ d^in"ny K
in9 t<heOretical
ba9ins with identifying the object of the
.X ^r'na
statement of a philosophical worldview Next scientd c, systemat.zed knowledge for nursing practice can design research and
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ula for advaneng nursing ttteory.. Nursing theoretical systems .XX - ■
nurs.ng science and researckrthat is foundational to the p.actrr. of ; Xg
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ter!-.. /.’(-!'. 311 A 14.
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net. L XI. (1962). Noles en a rheorenc.il inuncw.uk ic'T nuismu resviinii. Nurshi.t; lvi . i-P
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I l.irrc. R. (199.S). The singniur scl]. Thousand O.iks, C.\: S.iije.
! I irrc. R Ck (. iillcrt, G. (1994'. 1 he clocKrsitv mind Thuiijand Oaks. (.'A: S.iyc.
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eiu li'T nurstn;; |n\ic[ice (2nd ed ) New York: Appleron-k .entiiiy-l 'rol’t>.
Kmu. I.XI. ( 1971' lun.nd u thee-A /,»- •nirsint’. New York: John Wilcv Ck Sons, hie.
Kir.e I XI < l',sl' A theory
King. . X: X Fa
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umsmt!. New York: John XVilev Ck Sims.
t I'-'St ' 1 lie
(Eds
I r >J
: 'iKi'iny theory uiid m.'Mihci
Kluberran. G.P. (195s) The p/!;'- •• .,'ihy •>/Imm.m imt.'Oc. X-:u York: Applet, mo 2e:.tur\ •(..toll -
Mihn, T. < I L' ’ >econi.l tin ught' on paradigms. In F '•uppe (Ed ). 1 he Xtiiicttne of Si .e-i!;fk T
1 rbatya I'niversitv ot lllinoo.
I..VVHU Ml
L
.i.-l'.r. I’
: 'TX Th.-'crs aiion principle' ot nursing .X'nr
n. •; 4--
1I tat'>d:tc::on -o clinical nursing Philadilph
■Smith. XI I. (1999). XtiJdlv-rangc tiieors Spinnmg
!l.-n;i:m-.i
:>t. • •
Xtfs.ng 'se;e-’.c •
•
M. dl
;■ ‘I .:i.l l<<
‘ 14< 1
-;
i-hii C
1
;n.ci.-fd-
16
CONNECTIONS
Nursing Research, Theory, and Practice
Meleis. A.I. (1997). Theoretical nursing: Development and progress. (3rd ed.). Philadelphia: Lippincott.
National League of Nursing Education. (1917, 1927, 1937). A Curriculum Guide for Schools of Nursing. New York;
Author.
Neuman, B. (1982). The Neuman systems model: Application to nursing education and practice. Norwalk, CT:
Appleton-Century-Crofts.
Nicoll, L. (1992). Perspectives on nursing theory. Philadelphia: Lippincott.
Nightingale, E (1969). Notes on nursing: What it is, and what it is not. New York: Dover.
Nursing Development Conference Group. (1973). Concept formalization in nursing. Boston: Little, Brown.
Orem, D.E. (1997). Views of human beings specific to nursing. Nursing Science Quarterly, 10( 1), 26-31.
Orem, D.E. (1971). Nursing: Concepts of practice. New York: McGraw-Hill.
Orem, D.E. (1991). Nursing: Concepts of practice. (3rd ed.). St. Louis: Mosby.
Orem, D.E. (1995). Nursing: Concepts of practice. (Sth ed.). St. Louis: Mosby.
Parse. R.R. (1981). Man-living-health: A theory of nursing. New York: John Wiley & Sons.
M
C')ntolo"y- ePistem«logy, and methodology: A clarification. Nursing Sciem Quarterly,
Reed, P. (1997). Nursing: The ontology of the discipline. Nursing Science Qiuirterly. 10(2), 76-79.
Richardson, M. (1958). Fundamentals of mathematics. New York: Macmillan.
Kogers. M.E (1961). Educational revolution tn nursing. New York: Macmillan.
Rogers, M.E. (1970). An introduction to rhe theoretical basis of nursing. Philadelphia: F.A. Dav.s.
Kogers, M E. (1990). Nursing: Science ot unitary, irreducible, human kings:’Update 1990. In E.A.M Barrett
(Ed ), Visions of Rogers' science-based nursing. New York: National League for Nursing.
Roy, C. (1970). Adaptation: A conceptual framework in nursing. Nursing Outlook, 18( 3), 42-45
Roy. C. (1976) Inin duction to nursing: An adaptation model Englewood Cliffs, NJ. Prentice-1 lall.
Smith, M.C. (1992). Metaphor in nursing theory. Nursing Science Quarterly, 5(2). 48-49.
Stevens, B. (1979). Nursmg theory: Analysis, application, evaluation. Philadelphia: Lippincott.
Suppe. E (1976). The structure of scientific theories. (2nd ed.). Urbana: University of Illinois.
Ulbnch, S.L. (1999). Nursing practice rheory of exercise as self-care. Image. 31(1), 65-70,
Walker, LO. (1971). Toward a clearer understanding of the concept of nursing theory. Nursing Research. 20(5).
428-435
Wallace, W.A. (1977). The elements of philosophy New York: Alba I louse
Wallace, W.A (1979) From a realist point of view Essays on the philosophy of science. Washington. I X ’■ I Jniversm
Press of America.
Wallace, WA. (1994). Ethnics in modeling Tarrytown. NY: Pcrgamon
Wallace. W.A. (1996). The modeling of nature. Washington, DC. The Catholic Universitx ofAmciiui.
Watson, i. (1979) Nursing: The philosophy ami science a/caring. Boston: Little. Brown.
Watson. J. (1999) Postmodeni nursing and beyond. New York: Churchill Livingstone.
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. ora. I i. & Walsh. M.B. (19/ 3). ; he nursing
.Assessing, planning, implementing. evaluating (2nd ed ) New
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1 ura. 11. & Walsh, M.B. (1978). Human needs and the nursmg /rrocess. New York: Appleton-Century ■(Tolt-
CHAPTER
Nursing Theory and Research
UNDERSTANDING the CONNECTIONS
Objectives
• Compare and contrast key characteristics of paradigms of discovery, including posi
tivism, postpositivism, critical theory, and constructivism.
• Depict the reciprocal interaction of theory and research.
• Specify how theory can be used to generate research questions.
• Examine similarities and differences between theory-generating and theory-testing
research.
• Discuss mechanisms for evaluating research studies.
• Specify essential attributes for reliability and validity of research instruments.
Key Terms
constructivism, p. 20
critical theory, p. 20
dialectical interchange, p. 20
hermeneutics, p. 20
positivism, p. 18
pcstpositivism, p. 19
reliability, p. 30
theory-generating research, p. 23
theory-testing research, p. 23
validity, p. 31
17
18
CON N ECTIONS
Nursing Research, Theory, and Practice
CHAPTER 2
Chapter I focused on the evolution of theory and
r
ing. This chapter, which discusses rhe ™
i
nt State °f theories within nursthe discussion of paradigms of discovery and 'eresearch’ wiI1 extend
inodes of discovery on nursing theory an 1
xam‘nc c
influence of specific scientific
standing what is known and how it came
be k
’
the°ry eV°lves’ under'
uing process in which new ways of thinkine mTdif
K"OW'n8 ls a continThrough research, science provides a meclvm'- f I. ' '''' “nceptual12atlorl °f reality,
about discovery influence research and th 4 'Sm T n°" 'ng' Worldviews or belief systems
tertwined with research, it is important t /ml ” '’““J'™5’ Because nursing th<tory is inand rhe dynamics surrounding d“
C°nneCt'0" be^n the two
Nursing Theory and Research: Understanding the Connections
TABLE 2-1
Characteristics of Research Paradigms
_
Positivism
Postpositivism
Critical Theory
Constructivism
Ontology
Realism
Critical realism
Historical realism
Relativism
Epistemology
Dualist
Modified dualist/
objectivist
Transactional/
subjectivist/value
mediated
Transactional/
subjectivist/created
findings
Research
Aims
Explain, pre
dict, control
Explain, predict, control
Critique, transform
Understand,
reconstruct
Nature of
Knowledge
Verified hy
potheses es
tablish facts
Nonfalsified hypotheses
establish probable facts
Structural/historical
insights transform
over time
Individual recon
structions, centered
around consensus;
subject to revision
Research
Setting
Highly
controlled
Less controlled
May use natural
setting
May use natural
setting
Research
Methods
QuantitativeExperimental
Quantitative—modified
experimental; qualitative
permitted
Primarily qualitative
Dialogical/
dialectical
Primarily qualitative
Hermeneutical/
dialectical
UNDERSTANDING THE CONNECTION
Six:xsteizsx,: r . . .
-
neetion is important. The Preface intro |u - ■ I rl ""
Ll’nnecteJ and " hy the conline that permits movement either di ec k
""T “8U,:ldy shaPcd «inuous
ory, research, and practice demonstr are- a "" C'r"" ,tOlbly- The ‘’'teraction of nursing rheformation and generation of research' oue'srim""3
hct"’een practice and theory
supporting theory, and research influencmu /,///' Tl “ SU88eSr'n" rescarch. research
aspect of nursing theory, research, and. practice ‘
' ‘nterCOnnectedness informs each
'•‘l "’|J*Ob”"'..... . -
co
conceptualization and measurement of van hl •
1 ‘i
assumptions and a philosophical worldview, -flte fluidS
'T 111 tUrn 'nay ,ead ro thc
T'j"/’'1 °funderlying
'tai to connecting theory and research k'n > -I >t
i ' '' C atcd "ldl
process is critRather, rhe process maybe irregular with disc
n°l neCessariIy Jevelop linearly,
rhen coming together again to'form a wav ofTimwin
I ri’m J'!ferCnl Jlrccll^s and
nomenon of interest.
'
°r lin^ersr;1Iiding a particular phe-
Paradigms of Discovery
...... ... ................. in
nfieJ by (luba and Lincoln 11
i’'"’ :'lrcn’',rive Pa™i*gms of mquiry iden-
C ' '
theorv, and construcrivism-have beelrt lo/' l *
ical worldviews is import idt herm
n
>
'“ 1rhesc phtlosoph-
"....................................................... .. .......................... ......
.... r
H.o
d
Post-positivism, critical
11,
1
' ,n rurn-!nf,uences nursinv rheorx
19
Modified tn>ni Giiha, E.G., & Lincoln. Y.S. (1994). (.'oinpeung paradigms in qii.ilimrit e resv.uch. In E.K. I)enY.S. Lincoln (Eds.), Himdliook <>/ qi<d/i(umv rescmvli. Thousand Oak.-. (‘A: Sage.
reality exists (Cuba Ck Lincoln, 1994). Positivism represents rhe “receivcil view,” in which
researchers unquestioningly accepted recognized methods of scientific discovery. Positivism
has dominated discovery in rhe physical and social sciences for rhe past 400 years. The on
tology is sometimes labeled "realism” and is exemplified by rhe belief in rhe existence ol a
reality driven by natural laws or mechanisms. In this view, research seeks to discover real
ity or truth and aims to explain, predict, and control phenomena. The research process at
tempts to objectify experiences, formally testing propositions and hypotheses to verify re
ality. In the positivist model truth is discovered through methods that promote freedom
from bias, have mechanisms for verification, and use reductionistic approaches. Positivist
research is quantitative and carefully controlled so .is to minimize rhe influence of con
founding variables. Rigorously prescribed procedures of study are used to prevent influence
from values or biases. Although positivism has a respected, longstanding history in the sci
entific community, these methods do nor always capture some of the practice-orientcxl pei spect ives associated with nursing (dormer, 1990).
A variation < >1 rhe positivist model, postpositivism .ittempis u- respond to s,>me of rhe
ditici>mso( positivism. Although it retains many positivi.st tenets, poopootivism hold'
■that rcaliivcan only be imperfectly understood (Guba& Lincoln. 19'-’4) In this iii.'i.uK'
the ontology o called crmc.il realism. Post,positivism considers reilitv only hk> >mpleiel\
knowable due lo flawed hum in intelleci ,mJ the ditticulrv u. >rtidv:ng phen. nidi.i. TT.
goal of research o to gain knowledge through attempt'ai t.ilsitxuig If.pi»the.'v>. Ilvporlw
se.'th.it .ire not Lil.-aiied ire ■... loidered reprv'cnr.iri*ao <-i realit\. ar Ic k o in iir.itclv .o u
I
J
I
20
CONNECTIONS
Nursing Research, Theory, and Practice
can oe known. Objectivity, with sensitivity to how findings fit within existing knowledge
and to critique by a community of peers, remains important. Inquiry occurs in less con
trolled settings, and situational information is perceived as more important. Interviews and
observations may be significant sources of data. Research methods may include modified
experimental designs and the use of qualitative methods.
Critical theory is a broad term describing several paradigms that can include neo-Marxism, feminism, materialism, and participatory inquiry (Cuba & Lincoln, 1994). Three sub
strands of critical theory include poststructuralism, postmodernism, and a combination of
both. Critical theory, ontologically called historical realism, holds that reality is shaped by
social, political, cultural, economic, ethnic, and gender factors that become crystallized
into structures (Cuba & Lincoln, 1994). Critical theory aims to critique and transform
structures that permit human exploitation. In critical theory the investigator and subjects
are linked interactively, and the investigator’s values influence the process.
The key to understanding any strand or variation of critical theory is that inquiry is
value-mediated, which means that findings are value-dependent. For example, a feminist
investigator interpreting research data filters data through a feminist lens that would ul
timately influence interpretation of research findings. This process would assist in freeing
the knower from other biases that might distort interpretation of findings. Critical theo
rists consider knowledge to be structural or historical insight that may change over time
as more informed insights or ways of thinking about the structure become available. Bar
num (1998) interprets this process as inviting rhe researcher “to exchange one interpre
tative lens for another (p. 272). Critical theorists may use a variety of research tech
niques—both quantitative and qualitative—although the dialogue between researcher
and respondent is considered a key to empowerment and change. Dialectical methods of
inquiry incorporate a dialogue that challenges individuals to transform accepted ways of
thinking to more informed ways of thinking. Researchers using feminist perspectives to
guide the research process demonstrate one example of critical social theory in nursing.
The final paradigm, constructivism, is ontologically relativist; realities are known through
mental constructions (Cuba &. Lincoln, 1994). Relativism implies that truth is relative and
may vary depending on the individual or group. Mental constructions are the ways in which
individuals perceive or construct reality. Knowledge stems from the interaction between rhe
investigator and respondents and is composed of constructions (mental interpretations) in
which a relative consensus exists. However, more than one relative consensus can exist—or
even conflict at any given time. Knowledge grows through a more sophisticated and in
formed worldview acquired when more information becomes known. Hermeneutics and di
alectical interchange are techniques of discovery used with constructivist research.
Hermeneutics focus on interpretation. Derix ed from phenomenological research approaches, hermeneutic methods are used-to discover how humans understand experience
by highlighting what is and by uncovering hidden meanings (Barnum. 199S; Welch. 1999).
Dialectical interchange compares and contrasts individual understandings and enables in
vestigators to make sense of rhe collective constructions hv wholisr icallv merging them so
thar die whole is considered Lircatcr than the' sum of the parts (Barnum, 1998; Quba <Si
Lincoln, 1994).
j
Althounh these tc»ur views-positivism. pAstpoMtn ism. cntic.rl rfu-. r\. and .nsinictivi>m---are chamcrcrixiic.illv diiiciwni. the. rrox id.; : u
lj tAidiurns lor Lrmdtn>i rrt< J:sc.ovcry of truth. Hence nurses need to examine how each >4 these m- < hani-ii'- I >rdr<c.
CHAPTER 2
Nursing Theory and Research: Understanding the Connections
21
might be reflected in the connection between theory and research. For example, an inves
tigator approaching a research problem from a positivist perspective would investigate a
narrow aspect of a phenomenon in a highly controlled setting. Thus only a piece of a theo
retical framework could be investigated within the context of one study. Knowledge from a
successive series of studies would accumulate and add to the knowledge base, permitting
generalization and establishing cause-and-effect linkages. A positivist mode appealingly of
fers extensive control and thus a sense of certainty about discoveries. However, one concern
about this perspective is the ‘blind man describing rhe elephant’ problem. Connections be
tween the individual pieces may be found, but the whole picture of the elephant may not be
discovered. On the other hand, an investigator studying a phenomenon from a constructivist
perspective would ask research questions in a broader context and study the phenomena in
natural settings. Descriptions derived regarding phenomena of interest are more whohstic
and remain interpretable as more information becomes known. However, researchers guided
by more traditional scientific paradigms consider these methods of discovery suspect.
Chinn and Kramer (1995) compare the connection between theory and research to an
interactive spiral. Fawcett (1978) envisioned the connection between theory and research
as a double helix in which theory is inextricably bound to both theory generation and the
ory testing through research. How an investigator proceeds with a particular study may de
pend on rhe purpose of the research. In theory-generating research, the investigator may
know specifics about the clinical nature of the problem under investigation. In theory
testing research, the investigator can call on an established theory to describe or predict the
outcomes of relationships. Although both processes arc theory-linked, rhe research activ
ities may differ according to the designated purpose.
This reciprocal interaction of research and theory can occur in two directions. In one di
rection, research guided by theory can clarify and extend the theory or suggest needed
modifications. This deductive approach begins with abstract propositions derived from the
ory and then moves toward more specific applications. In ibis manner, theory stimulates
thinking and directs research, permitting lheorv testing. Positivist and postp*>sitivist meth
ods of inquiry usually can be used in this process. 1 bus theory is nor formed in a vacuum
hut depends on research for concepts and propositions. Observation or measurement of se
lected phenomena through research generates theorv. T his is an inductive pioce». specific
and concrete observations build more general or abstract ideas. I ’osipositivist, critical theo
retical, or constructivist paradigms of inquiry may be useful to inductive theory genera
tion. As practitioners, nurses have a rich resi^urce of experience that can generate expla
nations of common phenomena. For theorv to be relevant and useful, practitioners and
scientists must collaborate in generating clinically applicable theories.
Phenomena of concern to nursing tend to be complex and multifaceted. 1 herclore pro
grams of research, building on previous findings and hinging on a the* uetical 'Vsrem, .ire es
sential for a research-based practice. Whether theorv is used to generate research questions
or to develop theory, research enables discovery and thus further theorization. I heorv en
riches the value and interprerabilitv of research and help' link rhe work of multiple tesearchers so that unique and common aspect^ of research .iboui a-phenomenon i mi be rec
ognized. This mechanism makes nursing research findings more broadh applwable Iheorv
cohesiveiv guides the general i« ‘U > >1 re.>cai\ h bv a-'^iming the c • a a cpru it:_.i< i* m \ i. mbk •
and suggesting potential relation>hip' nib -ng them. In turn. rc'C.irch linJing'. oclp
port or refute theoretical concept^ related m muring. Akh< ugh nui'ing loes n. ••
f
22
CONNECTIONS
Nursing Research, Theory, and Practice
unified theory, a variety of grand and middle-range theories can explain some of the com
plexities of practice.
Although theory-linked research offers many advantages over isolated research, Chinn
and Kramer (1995) warn of some pitfalls. For example, inappropriate use of theories can
cause errors in judgment or interpretation. A theory meant to describe a particular phe
nomenon within a particular context may not be automatically transferable to a related
group. Theories can become barriers if investigators permit them to become blinders and
fad to recognize deviatmns from theoretically proposed outcomes. Researchers need to en
sure that theory ls not permitted to limit thinking about the full range of possibilities found
within a phenomenon. To do so would limit the needed extension of a theoretical expla
nation of the phenomenon. Finally, the mental range of possibilities offered by theory can
potentially extend beyond those that can be ethically tested. The rights and dignity of re
search participants must always he protected to avoid unwarranted exposure to risk.
Using Theory to Generate Research Ideas
A well-developed theory is an accurate depiction of the real world useful for generating re
search questions. Fawcett (1995) suggests that good theories give researchers sufficient di
rection about research questions to ask and about the methodology io use. For example a
nurse familiar with the Neuman Systems Model might ask research quesi ions regarding lire
stressors ot illness or examine the impact of particular care strategies on reducing stressors or
improving rhe flexible lures of defense. A study simply examining stressors mighr be descnptiye, whereas one examining an intervention could be exper,mental. Chinn and Kramer
(199,) mdicate that in theory-linked research, rhe purpose, problem srarenrenr., and hy
potheses need to show the relationship between a selected theory and a specific suidv.
Recognizing that the global nature of conceptual models precludes direct tesrnre Fav celt (1999) proposes a conceprual-theoretical-empirical structure schema that links con
ceptual models to grand or middle-range theories and then to research. In this .chema re
search begins y.-,rh .1 broad conceptual model, such as Rogers' Science ot Unitary Human
icings or Roys Adaptation Model, which provides a frame of reference for, icwiire plre
nomena. From the conceptual model, either a grand theory or middle-range tlreoriT de
veloped. Il grand theories are derived from the conceptual model, the grand theories can
generate middle-range theories. Because they are narrower in scope than grand theories
nuddle-range theories are used to describe, explain, o, predict specific phenomena Tim
narrowed scope fac.litates identification of research variables to be tested, tire nature ol
the problem, the setting and source of data, research designs and instruments, methods ..
be used tor analysis, and rhe nature of rhe contributions that rhe research will make u
knowledge advancement (Fawcett, 1999).
Lirerarure review can also be valuable as research questions are de’, el. pud. ft a literature
review revea.s no information related to the phenomenon of srudv. Tu uarure ot the rc.
search design may need to be more descriptive or exploratory. In ib.e.Tx-linked n ou.n. b, Aw
investigator sh.nikl evaluate rhe theoretical back-round found m rhe liiur .lure md mio u\
leluvant iuse.uvh findings tghinn Cx Kramer, 1995) < Ten rheon--unu!;r inc rvsuarJ: du
mands additional review of the literature as Cfincept^ ur.i.i-u (mm Au J ..m. Au.h i.v. . 'rv
ceding research, thu investigator should noronlv review feuiuturu from ’
■■ .,ud "n dr
d-i 'h'add uritk].je stiidius iisinc aiter;i.irn-u,--.-i iiu,.:';:i • n - ■. ’
■ •,
.i . ■
’d''"' -v ihu ihuoruiical ideas and clarifv how and'a !i\ -peo!!.. -.dr . • m •, m •
CHAPTER 2
Nursing Theory and Research: Understanding the Connections
23
Theory-Generating Research
Theory^generating research is derived from real world observations in which the phe
nomenon of interest suggests areas to be examined (Chinn & Kramer, 1995; Fawcett,
1999). As members of a practice-based profession, nurses can observe clinical phenomena
and ask relevant research questions. In theory-generating research, methods using less
structured techniques offer a window of discovery about a selected phenomenon. Descrip
tive quantitative research or an array of qualitative methods can investigate the aspect of
interest. Central to theory-generating research is approaching the phenomenon without
imposing preconceived ideas about the concept or possible outcomes of the study. Precon
ceptions can bias the investigator and limit full exploration of a phenomenon.
Meleis (1997) proposed a research-theory strategy that could be used for developing
theories that are based on research. In this strategy, researchers select and lisr the charac
teristics of a commonly occurring phenomenon. The characteristics are measured in as
many different situations as possible. Data from the studies are analyzed to ascertain sys
tematic patterns, and any significant patterns are formalized into theoretical statements.
For nursing to maximize the use of research for theory generation, the problems identified
for study >houkl he ones unanimously considered central to the discipline of nursing
(Meleis. 1997).
The beginning point for theory-generating studies is a statement of rhe research prob-,
lent and questions. When less is known about the phenomenon ol study or when new di
rections arc sought, the problem statements may not be as explicit as those tound in
•.heorv-tesring research (Chinn (St Kramer, 1995). Additionally, the literature review may
not he complete before the beginning of the study. As concepts emerge from rhe data, ad
ditional exploration of the literature to investigate the emerging concepts may be war
ranted. I Xiring the study, the investigator should be aware of rhe literature reviewed and the
potential need to return tor additional review. For example, the investigator max uncover
sercndipitou> fmdingsor lack a rationale lor unexplained findings. Analysis of data may in
clude descriptive and nonparametric statistics in quantitative descriptive studies; if data
arc qualitative, coding and categorizing of observations arc performed.
It should be noted that research findings in themselves are nor theory; however, these
findings may motivate a scholar toward a more adequate explanation of findings within
rhe context of a new theory (Barnum, 1998). Theory evolves as relevant phenomena are
probed further. This offers insight and catalyzes new research questions. For example, in a
qualitative study using a grounded theory technique. Breckenridge (1997) investigated per
ceptions of renal dialysis patients about choices regarding their dialysis treatment modal
ity The Neuman Systems Model guided rhe study process. However, rhe end product ot the
studv was a grounded theory entitled “Patient’s ('hoice ot a Ireatment Modality versus Se
lection of a Patient’s Treatment Modality" (p. H D- Thi' model reilecteJ considerations
surr undine’ decision making about dialysis.
Theory-Testing Research
Tin I'urpasc >! thcorv-testing research i- “i o Jex clop evidence aixmi 1 n ( ■ 'Urex’ - Jen', cd
mail liworx" ' Acton. Irvin, N Hopkins, 1991. p. Al. As such, theory icsting is a deductive
. r a mon. F ''lowmc tb.eon- gencr.uion. rc.'C.irch techniques can te.-r rhe tb-.-. rv
yali
|. | A ■ i he noted th..it i ■■'.: . P • ■ • irv - -{xirricularh a gr m.Dr.co;i 1
'• *le i
;
,i-1•
\ . |p.\,■ -: inaioi'> ipi't' Jv.!i :' <<■
ic't uig. t lie1, ivlenrifv .m 1 'c. v
uv iie i of
24
CONNECTIONS
Nursing Research, Theory, and Practice
theory to test. The area selected for testing may depend on investigator interest, may be
particularly amenable to testing, and/or build on findings of previous research.
The process of theory testing offers opportunities for further theory refinement (Meleis,
1997). Following selection of a theory compatible with the domain of interest, the investi
gator selects one or more specific propositions or relational statements from the theory to be
systematically tested. In this instance, the investigator begins with broad theoretic concepts
and narrows them down to concepts measurable by specific observation. Once findings are
generated, the investigator must return to the theory and ascertain whether rhe findings
are congruent with the theoretical propositions. In some instances the findings will support
the theoretical assertions. Situations in which the theory is nor supported may call for mod
ification of the theory. In light of consistent adverse evidence, some theories may need ro be
discarded, and a new theory that reflects data findings may need to be generated. In this
manner, researchers gain further insights into the explanation of phenomena.
Fawcett (1999) suggested that three formats for theory can be associated with specific
forms of research. Descriptive theory, which is basic theory consisting of naming or classi
fying characteristics of a phenomenon, should be tested using descriptive research tech
niques. Descriptive research can answer questions regarding rhe characteristics and preva
lence of a phenomenon and the process by which the phenomenon is experienced. This
descriptive process can be either quantitative or qualitative. Explanatory theory that spec
ifies relationships among characteristics of a phenomenon should be studied with correla
tional techniques. Explanatory research helps to explain why a phenomenon exists. Fi
nal y predictive theory that predicts relationships among characteristics of a phenomenon
or differences between groups should be studied using experimental research. Research for
predictive theories could examine whether an intervention resulted in an intended effect.
Fawcett (1999) offered a specific framework for evaluating the conceptual-theoreticalempincal structures for research that addresses concerns related to using middlc-ran<>e theory
and the research testing or generating the theory. She indicated that adequate conceptualtheoretical-cmpirical linkages exist when the model is specified and the linkages between
the model, theory linkages, and propositions are stated explicitly. For example? Lowry and
Anderson (1993) used the Neuman System Model as rhe theoretical framework for their
study of ventilator dependency. First, the study addressed extrapersonal stressors as the con
cept and mechanical ventilation as the research variable. The empirical indicator or link
age was the number of failed weaning attempts. In this instance Neumans concepts were
clearly linked to the research variables and measurable indicators. Second, the study
methodology—including sample choice, instrumentation, study design, and statistical
techmques-must be related clearly to the conceptual model. The theory must be evaluated
for significance, consistency, parsimony, and testability. The research design must be assessed
for sample representativeness, validity and reliability of empirical indicators, appropriateness
of research procedures, and the ability of hypotheses ro he falsHied. Research Endings should
v evaluated for empirical adequacy to ensure congruence with empincal evidence and con
sideration of alternative explanations for findings. The urilitv.of the theory for pracnce r
considered in relationship to its practicality and feasibility of implememai ion.
Finally, evidence regarding the model’s credibility is demonstrated. For example, in a test
of Kings Theory of Goal Attainment. Froman (1995)
( 1995) hypurlv
b-. n. .rl>—:cd-dial ’die greater rhe
CHAPTER 2
Nursing Theory and Research: Understanding the Connections
25
degree of perceptual congruency between nurse and patient related ro the illness situation
and nursing care required, the greater the degree of goal attainment or satisfaction with
nursing care” (p. 225). This study tested the proposition derived from goal attainment the
ory that “the presence of perceptual congruency between nurse and client influences the
occurrence of transaction leading to goal attainment or effective nursing care." Froman s
design to test the hypothesis matched nurse-patient pairs and measured them for percep
tual congruency—which incorporated perceptions of illness, perceptions of mutual goal
setting, and perception of information communicated—and patient satisfaction. Both in
struments were deemed reliable and valid measures congruent with the Theory of Goal
Attainment. Statistical testing determined that greater perceptual congruency between
nurses and patients regarding the illness and nursing care led patients ro a greater sense of
satisfaction or goal attainment. This finding supported rhe proposition derived from King’s
Theory of Goal Attainment.
Theory testing also can be achieved through path analysis. Path analysis develops and
tests a hypothesised model based on rhe theory (Knapp, 1998). Lusk, Roms, Kerr, and At
wood (1994) developed a causal model about rhe use of hearing protection by individuals
in rhe workplace, based on Pender’s Health Promotion Model. To test their model they
designed measurements of each variable of interest and then statistically tested the data to
discover whether the predicted relationships within the proposed model actually occurred.
Investigators predicted that the use of hearing protection would be influenced by workers’
perceived control over their health, their definitions of health, and their perceived bene
fits of using hearing protection. They further hypothesized that the use of hearing protec
tion would be influenced indirectly by factors such as the work situation, gender, age. ed
ucation. and job category. In this particular study, the model developed explained almost
53% of the variance in how workers used hearing: protection. As a result of these findings,
the investigators made recommendations about rhe usefulness of rhe Health Pronunion
I romorion
Model.
Generating Hypotheses for Research. In theory-testing research, explicit statements
regarding the purpose of research, rhe research problem, and rhe hypotheses or research
questions should be stated before conducting rhe study. This process will assist m moving
from the broad intent of a theory to a more direct linkage to specific study variables (C.hinn
&. Kramer, 1995).
Following Fawcett’s (1999) proposal for techniques of theory-testing research, rhe fol
lowing kinds of research questions or hypotheses might be generated. In descriptive re
search studies., research questions may aim toward discovering what a phenomenon com
prises. In correlational studies, rhe question or hypothesis generated focuses on rhe extent
ro which two or more variables are associated with one another. The decision whether to
use research questions or hypotheses depends on the assurance with which rhe researcher
can specify the anticipated relaiionships. When using prediuive theory to generate re
search. the researcher questions whether, if rhe theory is true—or, considering the natuic
of grand theories-, if rhe rekinunJ swtenient is true—particular outcomes can he anticipated
The resulting hypothec might reflect a predicted, utcome for a given oiuation In (hi>
manner. specific hypothecs or research questions ixooaicd with the study variables are
derived.
26
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 2
Nursing Theory and Research: Understanding the Connections
27
CONGRUENCE BETWEEN THEORY AND RESEARCH
For theories to be usefill, they must guide and be guided by research (Meieis 19971 R
theories are established on current knowledge, future findings providence V
porting or refuting theoretical claims. Fawcett (1993) indicated that the rh
I
• The researcher uses the tenets of the theory to logically arrive at his or her research
questions.
• By using sufficiently specific hypotheses, the study places the theory at risk to be
falsified.
S=—
KNOWLEDGE OF THEORY THROUGH RESEARCH
(Fawcett, 1978) In renlirv ir Im r
c explanations always exists
i
... ;........ 7....
is
nursing unlimited opportunities to invcsiK-.r
research, Silva (1986) identified three 1 iff
Incorporated in es.rrcl
e l' 7
-
i
1 hls Pe' 'Pecuve offers
'Ka'r''te V a"ess use 1,1 nurW theory in
He.l been
......... ....................................................................................... ...................... .... ........
. ...... r..
S”...... ...
*• ft«•|». d« fa'
7;»h»
• The terms of the theory clearly generate the operational definitions of the study.
• The theory and research design are philosophically congruent.
• Instruments used to test the theory have been demonstrated adequate reliability and
validity.
• The theory guides the choice of samples lor the study.
• Researchers should incorporate the strongest statistics available into the study.
• In analyzing the data, the researcher should offer support for or against the theorv
and/or possible revisions to rhe theory.
• An interpretive analysis of findings related to the theory must appear in the research
report.
• The research report considers the theory’s impact on nursing.
her theoretical
• The researcher offers suggestions for more studies based on his
findings.
One shortcoming of rhe evaluative mechanisms by Silva (19So) and Acton, Irvin, and
Hopkins (1991) is the focus on quantitative methodologies from studies philosophicaih
guided by positivist and postpositivisr paradigms. Silva and Soirell > 1992) expanded on the
evaluation criteria, incorpo.raring three alternative approaches to theory testing. The eval
uation criteria found in Silva’s first article (1986) can be considered empirical testing. ( )nc
of the three additionally proposed evaluation mechanisms called lor testing theory through
critical reasoning. In this instance, verification of nursing theorv is achieved through criti
cal reasoning. Although ail methods of theory verification involve critical reasoning, Silva
and Sorrell's particular context relies on critique that incorporates judicious evaluation of
strengths and weaknesses of works, within a discipline. 1 liese critiques mav be integrative lit
erature reviews in which research in a given area is evaluated. Silva md Sovre’l (1992) sug
gest eight criteria to judge nursing theory. These include the following (p. i 7).
•
Underlying philosophic assumptions regarding what consrimrcs truth in ri
ory arc explicitly stated.
’
'K <
'' 1appropriate
’PPr'’P"ntl' manner.
"1;l,incl- Discuss
''i.cusMon
•
•
•
•
Acron, Irvin, and Hopkins (1991) built on 9i|V1\ ,v wL- D
' i
- toetu! io. eva.uarm^ rheory-tesrmtt reseat studie. Tl^tnVof V*
•
The testing of nursing theory is congruent w ith philosophic .issuinj a ions ix-gatding tiurh
The method loi testing of nursing theorv is congruent with purpose tar testing.
The purpose tor testing is death stated and advances nursing knowledge .>i method.
The testing ot nursing theory is based on rhe simplest meth>>■ I nveileJ i. •. br.im rhe m> >sr \vahd
and powerful results.
The testing of nursing theory is constructed so rhai comparable ■ : mndai wri'ic.it ion can
... ... . ............ ........... ‘iV ; ;.. .....
adequate use of models for rheorv r ■................. i...................... . .
•nK U'’,k- In the third mannci,
..... ...................... ................................................................................................... .................
tieaily from assumptions or propositions and test ■ I
Ol find.nps related back to the theoretical C.n.Xk
d he statement of purpose speltfies the.-nm-.d rctin..
'
....... -
:
I n-romPcpiVixedon the selected iIk. :
r. . ....., ....
'•ih
k-w, oi Jenvaiion of the concern ;
nJ.
.
J,
, , .
,
'
‘ i k .ii.c hr i;;ticd m i; ,c ;;cr i
•
"
icstine ut the the-
I he resting of nursing theory I n - the groundwork lor .m upplied outcome.
The overall processes used in testing exhibit internal •. >n.sisicncv. ..e- rhe: ic nniry. and < rhi-. i!
intcgriiv.
> of pcr.-onal expel iences i^ih a
Another method of testing’ theorv i> rhrou‘Ji dcscripri< m
Svirrell, 1992). In rhi< mechanism, .arc ■ pin ic:panoin p:<'\rk‘' \:i •'Akdcc ar iioiehi
28
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 2
Nursing Theory and Research: Understanding the Connections
29
that permits theory develop.ment
i
and verification of theory through the inductive strategies of qualitative techriiqiues. Silva and Sorrell proposed 10 evaluative criteria for these
search increased substantially and became more clinically focused. Studies began to demon
studies (pp. 18-19):
spective. Larger numbers of explanatory studies used increasingly sophisticated methods. It
strate more theoretical orientations; more than half explicitly identified a conceptual per
was recommended that scholars undertake more studies concerning the reliability and va
The purpose of the study is to verify relationships of described personal experiences to philo
sophical behefs and assumptions that underlie the developing nursing theory
Idennfication of the research quesrionfs) is based on an attempt to provide elaboration of
concepts related to the developing nursing theory.
cranrareriT ^3
‘"u11"’6 Sl,ffiCiCn' in dePth ^riptions of personal experiences to
capture rhe essence of the phenomenon under investigation.
Simplicity, ethical integrity, anti aesthetic presentation are integral characteristics of the de-
scribed personal experiences.
Analysis ol data incorporates a sense of wholeness of rhe described personal experiences
Formauve hypotheses and/or theory are derived inductively from qualitative analysis of the de
scribed personal experiences.
Multiple personal experiences of an individual and/or stmilar personal experiences of several
.nd, .duals about a particular phenomenon are used to validate the derived hypotheses
Analytic procedures ol data analysis and fit of rhe generated concepts to rite personal experi
ences provide indirect es-tdence ot the vahdiry (or lack thereof/ oi the developed nursin« theory
findings are d.scussed in terms ol how they related ro the developed nursin.. theory
uctiXTl'"
'''T’’ iS "T
,ra"'C 11 ri,e''ry 'IWt " tO ,,C
-I rested inductnely, both the developing and existing theories must be internally consistent and con-
lidity of measuring instruments and fewer studies on education and nurse characteristics to
advance nursing research.
Although Brown, Tanner, and Padrick’s 1984 study indicated improvement in nursing
research, other investigators indicated that nursing needed to make stronger connections
in the theory-research linkages. Moody, Wilson, Smyth, Schwartz, Tittle, and Van Corr
(1988) analyzed 720 research studies published from 1977 to 1986 in six research journals.
Investigators discovered that only 3% explicitly used and rested a conceptual or theoreti
cal framework. Silva (1986) examined 62 nursing research studies using the models of
Johnson (1980), Roy (1976), Rogers (1970), Orem (1980). and Newman (1979). She
found only nine studies that could be categorized as adequate teso of
ot some aspect of the
identified theory.
Murphy and Freston (1991) examined rhe extent to which theory and research were
related in 142 gerontological nursing studies. The randomh selected studies were published
between 1983 to 1989 in six nursing journals and focused on clinical problems in geron
tology. Investigators developed the Theory Linkage Research inventory (TLR1) using
Fawcett’s interrelationship (1978) between research and theory. In 59'A> (n — 124) ol the
studies, rhe study and the literature review were linked explicitly, whereas 17% (n = z4)
had no theoretical perspective. Sixty-six studies identified a specific theory or conceptual
grucnr with one another.
The final mechanism for theory verification suooested hy Silva and Sorrell (1992' is anpheauon through practice These studies assess whether what is purported as truth i.Gn fact,
model used to guide research or resting. Of these articles, the rheorv-rescarch linkage was
expertenced >n praettee. In this instance, the theory .s evaluated in terms of its problem-
most strongly demonstrated in the empirical phase, which was characterized by theoreti
cally related designs, sampling, instrumentation, and data collection and analysts. The
s’ ™'T?TTl ^□™CT^Ul thet’rieS dem°“ us^tn<- - chtueal p.ohlem solving.
weakest theoretical linkages were found in rhe interpretive phase. Although interpreta
‘ aiK Sorrell (1992) identify seven criteria tor evaluaring this type of theory resting
‘
which include the following (p. 20):
curred, implications for practice were rarely theory-linked.
jaarsma and Dassen (1993) reviewed research arric!e< published in. five international
Fhe purpose of the application is to demonstrate proNem-sok ing etleci ivene-s.
research journals from 1986 to 1990 to discover how often nursing theoretical modek
I he nursing theory is stated explicitly.
Specific problems are targeted for solutions in the implementation plan
•
•
•
guided research. Excluding studies concerning instrumentation, education, administration^
1 roblcms are interesting, important, and ethical f<practice
Outcomes are measured in terms of die theory’s problem-solving efWveness
Problem-solvmg effectiveness is determined in comparison uath appheano.^ m which the
theory is not used.
Findings are discussed m terms .M the theory’s instrumem.ilhv ia detininy
implementing
pt oblem -so I v i ng st ra t eg i es.
I hese addiuonal theory evak.arion methods b,™den rhe -e.-,
testing research.
tion of findings from the theoretical perspective and in light ol rhe lircrarure often oc
.f eeolu.rr.on for theory
.
nurses, blood pressure, and temperature measurement, the investigators found that 72% ol
the 428 studies reviewed did not identifiable link io theorv. Ot the 28% (121) of studies
with an identifiable theory linkage, 26% (31) identified only rhe theory; 22*’a (26) actually
linked theorv concepts to the research variables; 1 L'v (20) used the theory a.-^ an organi.ing framework for data collection; and 25% (30) tested the theorv. v>nlv (T'o (7) actually
tested an intervention- The remaining studies used rhe theory in oihci way.-'.
In a review of 20 years of pediatric nursing research published in tour pediatric practice
journals, Betz and Beal (1996) found that only 1 7 of the 302 articles used nursing theor.es.
n
Using Silva’s criteria (1986) for evaluating theory utilizari.. n in nursing research studies.
Over the past several veats, researchers have eytluateJ nursnv research
.
- ....... •i in ■'elected areas and specific time lrame>. T
brown. ’
Tanner, and Padrick (1
) .malvrcd the characterisFie*
o| C.
nursing
r
, ’ .4
n L research
h i
°VCr ,
anJ cvaIuatcJ
bn-imgs usiny enttria Prm
Betz and Beal found that <ix studies used nursing theorv minimally, eight insufficiently
•T
-
....... ...
rT ThTT
—■ Oy a-ere reviewed. Ov,., ,hi~ i
;Vi„J
-.he. ftorn
used theory, and three adequately applied nursing rheorv. I he mo>: omrnon problem was
inadequate conceptualization ot rhe problem. Thn finding mean- :!>at m- o ot these stud
ies tailed to link the variables under investigation to the the* rmic e
ing the opportunity t<i link the'pecitiK project ft a larger rese tci
mw.ork. thus •
dci.vot Fuitl ■ f.e
30
CONNECTIONS
Nursing Research, Theory, and Practice
n™”‘
CHAPTER 2
“u “ ”—'«*'■-
.......
theoretical models
nient
,hl.
.. ;...............
of„,irsmE
^search
Reliability
..... ........
ie t'I'
on the
which' t!
i,cr,rcl'’c7 ,'Tlir-|,jhwhij
.... . 0 ;■
? C
. 7''
H. m<
e.n
rcu.il'iiiL'. : t ,i
Nursing Theory and Research: Understanding the Connections
31
new instrument, and a reliability of 0.80 or greater is considered adequate. Nunnally and
Bernstein caution that satisfactory reliability depends on the instrument's use.
Stability refers to the capacity of the instrument to repeatedly measure the same phenomenon and arrive at similar scores on the instrument. Test-retest reliability assesses sta
bility. Measurements are obtained on the same group of people for at least two testings and
the scores correlated. The space of time between testings depends on the nature of the in
strument. One consideration of test-retest reliability is the time interval between tests.
The interval should be long enough to permit subjects to forget their responses to the first
testing but not so long that the construct being measured changes. Often the interval is ap
proximately 2 to 3 weeks. Walt:, Strickland, and Lenz (1991) indicate that an acceptable
value for a test/retest reliability is 0.80.
Equivalence is achieved when different raters similarly rate or score the same event.
This is necessary to ensure interrater reliability when multiple raters measure a phenome
non of interest or when there is concern as to whether one rater rates a phenomenon con
sistently (a question of intrarater reliability). Equivalence is also important when alternate
forms of an instrument arc used. Each form of rhe instrument should rate rhe event being
measured in a similar manner. Equivalence can be determined through correlation or per
centage agreement.
Validity
Validity indicates that an instrument actually perforins the intended measures. Validity of
an instrument is not established through a single study but rather is an accumulative
process. Each confirmation of validity is like adding a brick to a building, further estab
lishing the case for the instrument’s validity. Researchers can establish several types of va
lidity, including content validity, criterion-related validity, and construct validity.
Content validitv is established by sending rhe instrument to experts in the field. These
experts evaluate instrument items and indicate whether the items measure the intended
phenomena. Walt:, Strickland, and Lcn: (1991) suggest that to evaluate content validitv.
experts should work from a list of objectives that guided construction of the instrument, a
definition of terms, and a list of items to measure the designated objectives. The experts arc
asked to link rhe objective with the respective item, assess the relevance of the item, and
determine whether the items on the instrument adequately represent rhe content of the do
main of interest. Sometimes a content validity index (CV1) may be calculated. The C\ I
is the proportion of items rated by experts as relevant or very relevant to the instrument
A (.'VI of at least 0.80 is desirable.
Criterion-related validity occurs when comparing two instruments measuring rhe same
event. One form of criterion-related validity, concurrent validitv, records two measure^ ■ 't
(he event ar the same rime. Two examples include comparing the performance of a <borter
instrument to a longer, more complex instrument or comparing a new mca>urc u - i me isure rccogni:eel as a gold standard. Another form of criterion-related validity i> preda
rive validity, in which performance an one insrrumeni predicts future performance on ai
'■her measure. A major difference between concurrent validitv and predienve v.iiidnv irhe liming of the two measures. In concurrent validitv rhe two measure- are >. >inpleied i’
rhe same time: with prediciive validity one mea-ure is completed bel- re
(hv
each instance i cmrclaimn c in be u-ed ro .i.--e-< the relar i. -nship borwe
32
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 2
definition of criteria within the s.
study IS critical. Measurement of variables must be obtained independently and free of bi;
-ias. Unreliable predictor and criterion measures may resuit in lower levels of validity
sometimes used to determine whether rk •
rhe underlyma theorXl con tn
T
'
rtms lnto cacegnries, is
"" gr°UP ,nC°
Nursing Theory and Research: Understanding the Connections
33
• Theory-generating and theory-testing research are parts of the theory-researchpractice interconnection. Research offering new insights regarding practice can be
incorporated into theory, and theoretical propositions can be tested with research
techniques.
• Mechanisms for evaluating the testing of nursing theory include empirical testing,
critical reasoning, description of personal experiences, and application to nursing
practice.
• Adequate reliability and validity need to be ascertained for research instruments.
Investigators should ascertain the conditions under which these characteristics are
obtained and should also assess reliability and validity of the instruments used in
their investigations.
REFERENCES
Acron, G.J., Irvin, B.L., & Hopkins, B.A. (1991). Theory-testini; research: Bniklin.n the science Adt’tmccs in
Nursinf; Science, 14(1), 52-61.
Barnum. B.S. (1998). Nursing ihcins•: Analysis, application, evaluation. Philadelphia: Lippincott
Bet:, C.L. -St Beal, |. (1996). Use ot nursing models in pediatric nursing rocarch: A decade ol
l’iSiU’5 :n
Comprehensive Pediatric Nursing, |9( y), 15 3-167.
Breckinridge, D. (1997). Patients' perceptions ot why, how. and by whom dialvsis treatment modaln v was chosen.
ANNA Journal, 24( 3), 313-319.
Brown, J.S-, Tanner, C.A., & Padrick, K.P. (1984). Nursing's search tot soenulic knowledge. Nursing L’esearc/t.
33(1). 26-32.
Chinn, P.L. N. Kramer, M.K. (1995). Theory and nursing research: A systematic approach (4th cd.' >t Louis; Mosby.
Dickof’f, ].. James, P.. Semradek, J. (1975). A stance for nursing research—lenacitv or inquire. Nursing Research.
.... ™'"~
24(2), 84-88.
Fawcett, |. (1978). The relationship bci ween tlicorv .iiul roe.ircll: A Joublc hvl
..... ....................................-
X;
x* ..... ... .
i
dI,tlculr for :an mstrument to
............................................ .................................................................................... .
ing King's .Systems Framework ami theory oj nursing. Thousand t 'ak-. t A Sage
Gortner, S.R. (1990). Nursing's syntax revisited; A critique "1 philosophies slid
intliicii' c nursiiiLj 'het'!ic<.
International Journal of Nursing Studies. 30(6), 4 /. -488
Guba, E.G.. N. Lincoln. Y.S. (1994) Competing paradigms m ■ |ualitati\ e research. In F.K. 1 Vnr.n N \ 8. Lincoln
(Eds.), Handbook of qualitanvc research. Thousand Oaks, i IA: Sage
Jaarsma. T. N Dassen. T. (1993). The relationship >t nursing theory and rv'carch: I lie n in . 'i 'lie art. I 'itrntil >>t
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Advanced Nursing. 18(5). 783-787.
Johnson, D. (1980). The behavioral system model lor nursing. In J. Riehl Nt. IL .
:f±rry
• Research and theory inft
denTent; of
ponent generates research nupc’n
and research findings can cXe omrV
inseparable process
P
^^est or support essentia,
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formdti^. Theory
EaCh °f these pieres 15
of an integra!.’
P
Eds
’
Nursing Practice. (2nd ed.). New York: Appleton-Century Cror.'
‘ Ses?Xionlhip7thXhX1d eXaw.W™5' Pr“OOS^'ls-w’h':" theory
reality of these propositions.
X'ur'fii!; ’n’cichcc.
Fawcett, J. (1999). The relationship oj theory and research (3rd cd.). Philadelphia. 1 ’.n is.
Froman, D. (1995). Perceptual congruency between clients and nurses. In M I rev Ck C. Siclotf (Eds.), Advanc
achieve a high degree of vdidirv if ir I,
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Aih'.niii '
1(1): 49-62.
Fawcett, J. (199.3). Analysis and evaluation o/ nursing theories. Philadelphia: Pavis.
Fawcett, ]. (1995). Anrilysis and etaluation o/ conceptual models of iiiirs.mg ( nd eil > Philade'piua I hvi'
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Knapp. T. (1998). Qituntitative nursing reseaich Thousand Oaks. <. A. >age
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Lusk, S . Roms. n.. Kerr. M.. & Atwood. I i. 1O94' Test ot rhe healrh | roi:'.
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Meleis, Ad. (1997). Theoretical nursing. Detel.ipmcnt .mu pi pf
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Moody. L.E.. Wilson. M.E.. Smyth. K . Schw «ri:. R.. Tittle. XL.
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of nursing practice research; 1977-1986. Niirung |■:cworch
Murphy. E. N. Freston. XL (ll,91). An anah'is
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Newman. XI .A U'1?1' I
de:
del x .
11
>.ivi <>t
1.I|’|-I1K i 'It
?/ ;<'L L-
•’ pij'll-in' i
l-tHd
34
CONNECTIONS
Nursing Research, Theory, and Practice
Nunnally, J. & Bernstein, I. (1994). Psychomevric Theory. (3rd ed.). New York: McGraw-Hill.
Orem, D. (1980). Nursing: Concepts of Practice. (2nd ed.). New York: McGraw Hill.
Rogers, M.E. (1970). An introduction to the theoretical basis of nursing. Philadelphia: F.A. Davis.
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bil va, M.C. (1986). Research testing nursing theory. State of the art. Advances in Nursing Science 9(1) 1-11
s‘ T; M:C- ^.Soml,1’J;“' fl9?/’- re!ting of '’"rs"'8 theory: Cnnque and philosophical expansion. Advances in
Nursing Science, 14(4), 12-23.
Waltz, C S^kkjand O., & Lenz, E. (1991). Measurement in nursing research. (2nd ed.). Philadelphia: F.A. Davis.
Welch, M. (1 )92). I hcnomenology and hermeneutics. In E.C. Polifroni & M. Welch (Eds.), Perspectives on phi
losophy oj science tn nursing: An historical and contemporary anthology. Philadelphia: Lippincott
CHAPTER
The Structuring
of Nursing Practice
"Theories without practices, like man without routes, mux
he
but practices without theories, like routes without
maps, tire blind."
J.W. Gertzeis. 1960
Objectives
_
« Discuss the roie of theory in structuring nursing practice.
- Describe the impact of varying philosophical perspectives on nursing practice.
• Define conceptualizing nursing as a program.
• identify the precesses associated with developing nursing practice within a nursing
theoretical system.
• Describe the benefits of a nursing discipline-specific integrated theory, research,
and practice program.
Key Terms
practice models, p. 46
process models, p. 45
35
36
CONNECTIONS
Nursing Research, Theory, and Practice
Knowing and doing are complementary areas in nursing practice. Nursing, as a practice dis
cipline, requires nurses to generate knowledge about what they do and to act on that
knowledge. Structuring and sharing practical knowledge is essential to developing nurs
ing as a discipline. Discipline-specific theoretical systems can facilitate organizing the
knowing and doing of nursing practice.
PURSUING THE THEORY-RESEARCH-PRACTICE LINK
Strengthening the practice component depends on explicitly joining the iteratively re
lated theory development, research, and practice. Researchers and theorists need to make
this nexus relationship known to the practitioner. Denyes. O’Connor, Oakley, and Fer
guson (1989) described a process for facilitating development of this reciprocal rela
tionship. Clinical nurse specialists and academic researchers collaborated in practiceoriented research programs to facilitate the desired integration of rhe three components
of nursing. This collaborative research project demonstrated that both the theory base for
primary care and the practice bases for research and theory development were strength
ened. Project participants also described an increased understanding of the theoretical
constructs.
Reed (1996) strategired extending rhe interrelationship of practice and knowledge de
velopment with Peplau’s Theory of Interpersonal Relations (see Chapter 1 2 ). The first step
identifies rhe fundamental units of concern to nurses. This involves "assisting patients to
develop knowledge about destructive patterns and processes, and about the means for en
acting more healthy behaviors" (Reed. 1996. p. 30). The second step is to abstract concepts
from clinical knowledge—that R, from existing scientific theories and conceptual frame
works that represent phenomena observed in practice. This develops nursing knowledge
within the practice context “through syntheses of (a) existing scientific theories, clinical
observation and judgment of nursing, and (I?) knowledge and active participation of pa
tients ” (Reed, 1996. p. 31).
This book discusses a range of nursing theories useful to rhe pract itioner. These include
general theories such as Orem’s Self-Care Deficit Nursing Theory (Chapter 5) and Parse’s
Theory of Human Becoming (Chapter 7). which broadly describe rhe concerns of nurs
ing, to more limited theories such as Ponder’s health promotion model (Chapter 1 1 >. The
I'load theoretical svstems can identify the object or purpose of nursing in order to structure
nursing practic c. and the more limited theories direct particular components of practice,
Both influence pi .k tice-oi ienred lescarch I )en\cs states that rhe ‘‘value of nursing theory
for practice is predicated upon the degree
’
.—to
to \which
theory provides descriptii>n, understanding, explanation, and prediction
about
relev.
•
..................— -’ant nursing phenomena, and provides
solutions to relevant clinical nursing problems" (1993. p. 213).
Research is fundamental n. improving practice, and embedding reseaich in a nmsimtheoretical framework i- e-em.ah.o devdopmg nursing knowledge in al! dimension^
whether empirical, esjheaic, erhicii. or person.d Nursing handles rhe complex realities of
human beings \X uhm ihi> comple\tt\, rhe imr-e focuses on particular phenomena Be-
^-complex, it I- imP< s-dde to p. ify all rhe lawsth.it explain, rhe
behavior of the phenomena . irh Much nursing i- c 'ikc-ned. Theories to help describe, ex
pl tin, prediei, and/or ^dnrr. 9 i i
' ' •
1997
CHAPTER 3 The Structuring of Nursing Practice
37
DEVELOPING PRACTICE WITHIN NURSING THEORETICAL
SYSTEMS
Conceptualizing nursing as program rather than as a collection of tasks can facilitate the
health-related outcomes of nursing practice. Nursing practice begins with a mental model
of nursing and its goals. It asks the purpose of nursing in a particular situation and point in
time. Designing nursing practice programs from a theory base clarifies nursing’s objectives.
A program is a specific set of activities within a structure organized to achieve specific
outcomes. The questions of how to structure organized efforts and why such efforts suc
ceed implies that a program operates under some theory, whether implicit and unsystem
atic or explicit and systematic (Chen, 1990). Discipline-specific nursing theoretical sys
tems can provide rhe theory base for conceptualizing nursing as a program or programs.
The better developed the theoretical system, rhe more systematic and explicit rhe nursing
practice programs developed from this perspective.
Chen defines program theory "as a specification of what must be done to achieve desired
rals,
what other important impacts may also be anticipated, and how these goals and imgo.
would
be generated” (1990, p. -4 3). Program theory thus consists of two aspects: whai
pact
should be (prescriptive theory) and what is (descriptive theory). Both aspects of program
theory arc represented within the range of nursing theoretical svstems. When \ icwtd as a
practice program, nursing practice includes a normative component—what should beand a causative component that specifics the relationship between treatment or interven
tion variables and outcome variables. Nursing theory helps to direct both componcni<. h
directs examination of premises and assumptions and evaluation of the utilitv of custom
ary procedures. Nurse- incorporate into practice those components that facilitate the de
sired goals and eliminate those rh.it interfere with goal achievement. Subscquew ciutpiers
will provide examples of conceptualizing nursing as a program from the perspectives ot the
various nursing theoretical systems that illustrate the contribution of this approach to the
advancement of nursing knowledge and the improvement of practice.
In developing the practice of nursing, both process and content require «.onside:?.'r n
The late 19th centurv emphasized completing tasks, and process was related to accom
plishing those tasks. In the 1950s the empha-is changed to process. As nurses began, to de
scribe the essence of nursing as something other than a derivative of medical practice. t!u
concept of nursing process appeared in rhe literature. Nurses were encour.igcd. to deter
mine necessary nursing serx ices by using a problem-solving approach of collecriiig. refold
ing, and analyzing subj<‘crive an.i.1 objective'.lata (Weed, 1968a & 1968b; I noma. iJ._b
Little guidance for determining what d.ita to collect or how to analyze it was oftc-red Ab
dellah, Beland, and Mathency (I960), in an early attempt to specify rhe content or nurs
ing practice, described 21 patient problems
Other descriptions ot commonly .recurring patient problems and concept- associatc'i
with nursing evennialh began to appear in rhe literature (Nursing Devclopmeni 'onter
ence I ir<nip. 19? v Mm hell, 1977). Nursing students and nurses in service delivcrv ageni wed o1 !!-'■ nursing . .iiv j l.i’i- (hat included signiticam coir.ccpix .mo
Icin' (Mayci*■ lI -'72'. Ti.i- w i- an it1; .iin.-mpt to address la'th content and pnoesnri't’iicni; l b.v
! ba.-'o :• ■ -iruciunng ihe '•'iltcnt wa-derived induci • vci’, Com 'airsing
■ ihe = o- md ilk
s il s<. ietwes 'o'.il'scquen: 1 c. . riti. a. p i':. ■ md
38
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 3 The Structuring of Nursing Practice
39
!
care mapping were introduced. These also tend to be inductively derived from specific
practice situations or to address scheduling and outcomes of specific treatments. For the
most part these developments occurred outside of and without benefit of nursing theoret
ical systems.
The first conference dedicated to formalizing a classification of nursing diagnoses took
place in 1973 (Gebbie &. Lavin, 1975). At this conference the participants decided “that
theory development would nor precede terminological development” (Gebbie, 1982,
p. 9). Diagnostic labels were to be developed inductively from practice situations. Gebbie
asserted that theoretical precision should not bar clinicians’ need for basic diagnostic la
bels. Ar this point, theory development separated from rhe movement wanting to de
velop nursing diagnoses through practice. This split severely impacted theory develop
ment and rhe perceived utility of nursing theory in practice. Several nurse theorists
participated in rhe conferences as consultants, and some tried to integrate the diagnostic
categories into theory development (Roy, 1982). However, others criticized rhe theo
retical inconsistency of trying to meld nursing diagnostic activities with a broad nursing
theoretical system (Taylor, 1989).
While these developments were taking place, practitioners also tried defining nursing by
describing various roles. As nurses tried to define nursing by describing what they did,
terms such as independent, dependent, and interdependent nursing functions, primary nursing’
clinical specialist, and advanced practice nurse appeared in the literature. These developments
also focused on problem-solving proces> rather than on content, rhe development of which
requires discipline-specific theory.
NURSING THEORETICAL SYSTEMS, MODELS, AND PRACTICE
Each practitioner and administrator, nurse or nor. who is responsible for provision of nurs
ing sen ices has an implicit or explicit model of nursing. Nursing theories provide direction
for making that conceptualization of nursing oi 'mental model explicit. By clarifying rhe ob
ject and concerns of nursing, a theoretical system provides direction for differentiating
nursing knowledge and practice from rhe knowledge bases and practices of related disci"
plines. It also provides direction lor specifying the articulation between rhe nursing disci
pline and other health-related disciplines. For example, both family therapists and nurses
provide services to families. Family therapists take direction from fhmily theory and are
concerned with the whole of family functioning and interrelationships. Nurses rake direc
tion from nursing thcoryrhar incorporates aspects-of family theory. Taylor (19SQ) proposed
that the focus of nursing of famiho is derived from the functions of the family that arc
associated with self-care. Similarlv. Tavlor and .McLaughlin (1991) and Taylor and
McLaughlm-Renpenning (1995. 2001 ) describe rhe articulation of public health, com
munity, and nursing in proposing a model for community nursing practice in which the
concern of nursing is derived from rhe functions of commumrv in relation Im self-care.
Nursing theoretical svstems a.ssl>t ln describing rhe domain and boundaries of nurs
ing and the relevant phenomena of concern mthm the interdisciplinmx healthcare deli
(Nmrlrrup
( Tdv. N9>) Nursmg’s ontology can be identified, and
nur>c< can im ;
■'cyond dc-i rihinc nurse-ntriburions as’a collection of tasks.
Fawcett t
) "Ugec^red . i reciproc il r-Lfr ion>|-,ip between conccpru.il models and nur>mg practice
Antc-pinal nmdcl' is-i.o m rn-e dc' elopmenr of 'tatcmeiUs j praciice
purpose, i k m irh armn »<t: shnic.il p-..l leno, mdef-sf inding rhe c .ntenr • >1 rhe nurs-
ing process, and framing development of clinical information systems (Allison N.
McLaughlin-Renpenning, 1998; Bliss-Holtz, Taylor, N. McLaughlin, 1992). Patient clas
sification systems, measurement of outcomes, and quality assurance programs also
demonstrate the contribution of conceptual models (Walker, 1993; Riggs Ck Bliss-Holtz,
1994).
The practice arena, in turn, validates and facilitates continued development of the the
oretical systems (Mitchell, 1995; Reed, 1996). Structuring nursing practice in this manner
is referred to as theory-based nursing practice. Theory-based nursing practice is:
designed and produced for individuals and groups by nurses who have insights
about and have conceptualized the specific characteristics of the human health
service named nursing. Valid conceptualizations are in the form of descriptive ex
planations of the relationships between (1) the human variables that are inter
active in bringing about requirements for nursing, and (2) the human variables
that are interactive in the production of nursing in interpersonal or group situa
tions. The insights include knowing how given parameters of the variables affect
nursing requirements of people and, in turn, to valid and reliable designs for ap
propriate and effective systems of nursing care (Orem, 1987, p. 3).
The American Academy ol Nursing^ Expert Panel on Nursing TlhcDiV'CHiidcd Practice has delined nursing theory-guided practice as:
a human health service to society based on the discipline-specific knowledge ar
ticulated in the nursing frameworks and theories. The discipline-specific knowl
edge reflects the philosophical perspectives embedded in the ontological, epis
temological, and methodological processes that frame nursing's ethical approach
to the human-universe-health process (Nursing Science Quarterly, 2000, p. 177).
THE IMPORTANCE OF THEORETICAL PERSPECTIVES
TO PRACTICE
Knowing the philosophical foundation of a theoretical perspective is more than just schol
arly musing (Carper, 1978: Silva, Sorrell. N. Sorrell. 1995; Kikuchi N. Simmons, 1999).
Knowledge for nursing practice must be developed by nursing scholars anti practitioners.
Building on Carper’s fmir patterns >>1 kni'wing as end productsof knowledge development.
Silva. Sorrell, anti Sorrell (1995) explored how one comes to know. They argue that the
patterns arc not mutually exclusive . >i exhaustive. They introduced two new terms: the in
/vticccn. referring to ’‘what exists or reveals itself through nonlinear, meditative thinking
that moves in all direction' and depth'” (p. >),-and tlic hevond. referring to “those aspects
of realitv. meaning. an<i being that persons only come to know with dilficulry or that thc\
cann<a articulate or ever km>w (p T. ~I hese concerts enable nurse' ’ 1 address ontologi
cally issues of re ilitv. meaning, and being. L’ncox ermg the ontology frames exploration of
these i"iic'. Rc'earJ.. :• : I ■ r ' ■ ■■■
- can bertvr understand the nurse-patient rela
tionship and the ivtenria! lok" d nur'ing airhin rhe healthcare <vsrem. Understanding
>nto|i «gv is kev in cvidcncc-i'.ised pracmA i"iic.' (Lsrahrook.'. i'NS' and in determining the
best prih. iice> in nursing I he '■ ■!'
me
msion ' impin' the influence of plulosophic.u
toundarioH' indihvorctA .! jr
n pr.ictme Subsequent chapters expiind on this
1
40
CONNECTIONS
Nursing Research, Theory, and Practice
Human Becoming Theory
Human becoming theory is based in an existential-phenomenological worldview. The phe
nomenon of concern to nursing is the human-universe-health process (Parse, 1999). Nurses
engage in dialogues with patients to understand the patients’ perspectives without allow
ing their own opinions to intrude or interfere. Patients’ subjective perspectives and judg
ments are the basis for their health-related decisions (Mitchell, 1995; Parse, 1992). Parse
(1999) calls health “a continuously changing process chosen by the person” (p. 1385).
Nurses are “with individuals, families, or communities; they listen, answer questions, and
refer as necessary. They follow no standard teaching plans, since reaching is specific to rhe
patient’s questions and curiosity. There are no diagnostic labels as in medicine or as devel
oped by rhe North American Nursing Diagnosis Association (NANDA). This perspective
considers the diagnostic process reducrionistic and dehumanizing.
Moderate Realist Perspective
Kikuchi and Simmons’ (1999) moderate realist perspective on practice and knowing is
consistent with Orem’s self-care deficit nursing theory (see Chapter 5). From rhe moderate
realist perspective, it is possible to obtain an objective view of reality. One can know what
"is probably true by testing our various subjective views against reality which common
sense tells us exists, and is the wav it is regardless of how any one of us views it” (p. 45). To
greater or lesser degrees all persons have natural powers of perception, judgment, and rea
son. These powers allow comparison of various-views and facilitate judgments based on
available evidence and reason. Moderate realist.nurses consider both their perceptions of
situations and patients' views of nursing decisions to be grounded in “objectively true prin
ciples related to the pursuit of happiness” (p. 46).
Nursing requires a three-tiered concept of practical nursing judgment. On a universal
level, prescriptive, moral, or artistic judgments rake rhe form of objective nursing principles
that apply to all nurse- at any time and place. Secondly, on a general level, judgments ap
ply to a specific, group of nurses practicing at a particular time and place. The third level ap
plies to an individual nurse practicing.in a particular place at a particular rime. Practical
nursing judgments result in principle-based nursing rules and decisions that are objectively
grounded in nursing principles hut also subjectively influenced by contingent facts.
Critical Theory/Feminist Perspective
Pr.icncc also can he structured from a critical theoretical perspective such as feminism,
(aitiual theory aims to transform structures that permit human exploitation, and critical
theorist- see the exi.-nng healthcare systeiwas stich a structure. Feminism focuses on rhe
structure- m. >-t directlv related to women. Nur-ing is one model of feminism. Watson’s
work, described in Cdhaprer 13. is developed from this perspective. The practitioner must
transform her nr ht> worldview and nurse from the view of the feminine, in which caring
is a central focijs.
NURSING AS A PROGRAM
1 .oncepruali.- ng nursing i- a pu .gram facilitates the development of practice within
a uni'mg rhe.vericaHv-ivm The- lead- the program developer to do rhe following:
• Specil\ -it- x-irialdi • ’iKcrn
CHAPTER 3 The Structuring of Nursing Practice
41
• Use those variables to describe a population for nursing purposes
• Establish the expected outcomes of nursing
• Develop process and practice models
• Undertake appropriate research and evaluation
Individual practitioners or nurses employed by organizations can accomplish these steps.
Individual Practitioners
Through formal study of the various theoretical systems and their components, individual
nurses determine the congruence between their belief systems and the nursing theories
and then model their practices accordingly. Both educational institutions and employers
have roles in facilitating theory-based practice for individual nurses. Nurses may incoqx)rate research findings into their nursing practices after participation in education programs
or reading the literature. However, most nurses work in healthcare organizations that in
large part structure their practice. Examples of how nurses practice theory-based nursing in
relation to specific theories arc described in Unit 2.
In her study of knowledge sources of registered nurses, Estabrooks (1997, 1998) found
that nurses relied most often on experience, followed by nursing school, workplace sources,
physician sources, intuition^, ■'what has worked for years,” and, lastly, rhe literature. Because
most nurses in rhe study were in their forties and thus were likely to have been educated
during a rime when nursing rheorv was less developed, the knowledge base underlying thcii
practice could be considered outdated and ungrounded in nursing science. Their knowledge
bases probably were not developed within a nursing theoretical system. As a result, the
nurses in this study most commonly read the newsletters of their provincial associations or
the Cunudiun Xnrse journal, neither of which is a major source for information about re
search or advances in nursing knowledge. Conversely, literature has been the primary man
ner in which researchers have shared their findings with the nursing world at large. If it is
valid, this study suggests that practitioners rarely arc exposed to current research.
Organizations and Institutions
Although the literature reports organizations developing theory-based nursing practice
programs, organizations and institutions need to provide specifically lor incorporating cur
rent research into nursing theor\-based practice. As with many innovations in the design
and delivery of nursing >crvices, ahccdotal support is strong. Claims include improved quaiitv of care, greater patient satisfaction, and improved job satisfaction—but little formal
evaluation of these programs has been conducted. In one study, chango in piactice oc
curred after implementing practice based in Earses Theory of Human becoming anti a ri latcd education program (Northrup
Cody. 1998). Change related to ‘‘shitting views of
human beings, altered wav> of listening, altered foci of nurse-person discussions, and per
sonal transform.nions" (p 2 H Mitchell (1995) found similar changes.
Because mariv foundational theoretical perspectives for nursing practice exist, not all
nurses will arrive at organization> ready to practice according to a particular institution’s
mission mitenwra .m-i ■•l'|c‘ tive>. Thus thev mav be unprepared to perform appropriate
patient care, koi cxainpk. . .1 a nurse ha> alwavs pracri^cd from a Ixogcriar, perspective, his
or her praciat will K
ted at pattern appraisal, mutual patterning, md cvvratio:;.
wherea> .o i .'.elf '.are pci'pectiw require- knowledge of self-care, self-care demanu an..
.'.vlf-care agcraj.. Hie ; :
ition prog rang an essential o >;npor
o: wen health, ire
42
r
CONNECTIONS
Nursing Research, Theory, and Practice
organtzat.on should include strategies that help nurses achieve the organization’s coals
including.adoption ot a theoretical viewpoint. Improving nursing through theory-based
practice requires adnunistranve support for education programs and allocation of resources
Tins includes knowledgeable support persons (Northrup & Cody, 1998). Principles de
rived from innovation diffusion theory as well as protocols derived from other theories re
ared to planned change have been demonstrated to be useful (Rogers, 1995). Horsley
i rdin C°TP
^nowlcd8e as
P-eess and product in order to link research
rI h 7 PraCt,Ce' TllekPrO.duCr iS “the r!,ckaEed research findinss in rhe form of a pro< col which once it is m that form can be treated both conceptually and empirically as an
innovation and diffusion theory applied” (Horsley, 1985 p 1 36)
Designing a Nursing Program. The mental model of nursing held by persons within an
organization .s rhe basts for design of a nursing program. The more explicit this mental
model, the more congruent the implemenranon and the more likely an organi-at.on
achieves goals related to quality service. The mental model is reflected in all of the
structural components of an organization: the mtssion statement, rhe objectives the
poltctes the procedures the protocols, rhe clinical tnftirmat.on system, rhe performance
( Ahi'™ & m7 T T PV aSS"n"lCC Pri’grjm'
rhc reSCi'rcl1 ;,nd dt'vcl>’P'"<-ni program
(Ahtson
McLaughhn-Kenpenntng, 1998). The tmsston statement should he congrtent
wtth the rheorencal framework, and rhe stab should he fatmhar with the mental tnodel
under y.ng the nursmg program. Tanslating theory mto pracr.ce requires idennfication
■ nd development of operatamaldescripiions of the earmhlesofconcernm addition to the
development of nursmg practice models and nuts,ng process models. The role of nursin..
and the relanonsh.p ot nurse variables to patmnt variables should be described clearly "
Developing the Variables of Concern for Practice Purposes, i.ach ot rhe nursin..
L'T'"" SyStemS '
‘l'S Pheflnn,cna'llThese phentimena must be studied
aga.nst the requirements of nursing practice to dcr.mnme whether they are complete m I
. dequate tor m.ict.ce 1 h,s mcludes evaluarmg rhe gate ot development of rhe substantive
struetme of each-thar is, have the specified variables been adequately described tor
purposes Of nursmg practice? Have they i-ecn moved from rheoreLnl Emulations
concrete-reality. For example Orem (see Chapter 5) refers to self-care agency, a theoretical
construct. This concept has been further developed through the work of rhe Nursmo
Development Conference Group (1979) . - include spec.hcanon of the following
'
" iZl ’C’n’',”rSC"'C!'ro
nlUk'"K' ;lnJ nCrin«) ■"'Tl.eirrc-
• ren power components (idenrificJ *cis of .ihiliries) f<ir self-care
• .i ser ot found.itional capabilities .mJ J i>posi!ions for Jeliherace action
This development moved rhe theoretic il onec-pi ■ ’f wlt'-c ue .............
agency then,
to concrete
rcalirv,
thereby providing a structiire for ,mrscs io look Io, m id.-nce tlu.t mforms
abouL'hc
................. e ex tent to winch the abilities associated with >df’-caix
• ire Icecloped and cxerciscJ. Similar
work is icquireyl within each theoretical *vsiem 11 it i
’■' pr< >\ ide direction f<'r practice. This
may I c accomplished through specific re<caich ■ >r Jc.h;
<H"ii and validated hy pr.icuce and
fu tine research. \ .in uiG-e m the phen, men.i - >r\ i ..in
md rhe development h >r practice
Of the associated van <:-L s m- discussed in refc-rcu
canons nursine theories in Unit •
After identiU inc the \ iriable*. >fconck rn,
1' ’on 'in mid include 'l ecitic djiu
collet non ,c,.i I::--. 11. a , i..: .-..t k .r; |tl re lari
■' ” i li’i.c.x m |[< pnH cdijre,. .a ■
CHAPTER 3 The Structuring of Nursing Practice
43
processes. The clinical/patient record should provide for methods of recording informa
tion about those variables. The integration of mission statement, processes and procedures,
and expected outcomes in relation to Self-Care Deficit Nursing Theory' should be described
(Allison &. McLaughlin-Renpenning, 1998). This provides the basis for evaluation.
Organizations using Self-Care Deficit Nursing Theory as a basis for practice express selfcare as a value in the mission statement. Patient assessment processes include identifying
action to accomplish self-care and evaluating patient capability in relation to that action.
Expected outcomes are expressed in relation to the extent to which self-care is accom
plished and self-care agency is developed, regulated and exercised. Subsequent chapters
provide additional examples of this type of linking with other theoretical systems.
Describing a Population for Nursing Purposes. Describing populations from a nursing
perspective is the first step in designing programs or systems of nursing. A significant
contribution of the nursing theoretical systems to nursing practice is providing a language
and schema for describing rhe characteristics of a patient population from rhe nursing
perspective. Without direction from nursing theory, nursing relies on other disciplines to
describe its populations. For example, medicine describes populations by disease entity and
medical specialty. Nursing has also used age group*, develupmenta! stages, and groups
considered epidemiologically “ar risk." However, nursing knowledge and service delivery
can be discussed from irs own perspective, using rhe language of nursing As Geden suggests
(1997a):
Defining your nursing population is a critical process in this phase of knowledge
development. ... a nursing population is a description of a subgroup of class in
need of nursing. It's defining who you nurse by the way you THINK NURSING, not
the site or place where you nurse (p. 9).
Defining a nursing population begins with determining rhe group oi persons with whom
nursing is concerned and then selecting the most meaningful and conrav niv recurring
variable(s), as derived from nursing theory- These variables' become rhe basis for the pop
ulation description. For example, nurses using Roy’s Adaptation Model might describe a
population as persons with perceived stress using inadega ite coping strategies with nonadaptive responses in the self-concept mode. Describing populations in this manner allows
nurses within an organization to explore commonalties for nursing requirements among
patients in various clinical specialties and to develop appropriate strategies. Robinson
(1987) moved from thinking of herself as a surgical-clinical nurse specialist to a facilitator
of self-care. This includes assisting in developing self-management systems and creating
nursing systems in response to processes of elimm irion and maintaining skin integrity.
With this redefinition she more accurately defined her role and could better describe and
identify her consulration abilities in surgical a- well .is other specialties.
Allison and McLaughlin-Renpenning 11998) and Tivlor and Mcl.aughlin-Renpcnning (2001) provide examples of population description based in operarional variables of
concern, and they illustrate rhe utilirv of this pr- •cc<> m dc'ign.mg nursing svstems ’‘Per
sons needing to develop neu sclf-managcmeni <vs|em' because of i change in health
state” commoniv require a nmoing system \A;liso:i X \\Laughlin-Rcnpenning.
p 70). Othei factor* '‘mclti'lc age r urge health state, health care system ijcrots. condi
tions and naiiern.' of living, self-care him; it; a.. apabi!n
'di-', re dem.mJ
44
CONNECTIONS
Nursing Research, Theory, and Practice
(p. 70). Such a population description’s use iin developing
'
' 4
a nursing system emphasizes
self-management systems, and expected outcomes refer to the effectiveness of the self
management system.
Establishing Expected Outcomes of Nursing. Conceptualizing nursing as a program
based in some nursing theoretical system provides a broad perspective for developing
expected outcomes and specifying evaluation procedures. Program theory and nursing
theory can frame decisions about establishing expected outcomes. The nature and
evaluation of the outcomes will vary with the nature and philosophical basis of rhe
theoretical system. Evaluating the effectiveness of nursing requires that the product of
nursing be known—that is, what do nurses produce? What patient-related variables are
the concerns of nursing? What arc the nurse-related variables? How do the patient-related
variables and the nurse-related variables interact? What should result from such
interaction? What treatment will produce the intended changes in rhe social system? How
can results be measured within an interdisciplinary healthcare delivery system?
From the perspective of program theory, “normative theory provides the rationale and
justification for the program structure and activities. Normative theory guides program
planning, formulation and implementation" (Chen, 1990, p. 43). Empirically based
causative theory elucidates rhe relationship between the treatment variahle(s) and rhe out
come variables of rhe program. Figure 3-1 presents a suggested-range of evaluation types in
relation to variations in nursing theory.
------ Normative theory
------ Treatment theory
------ Normative treatment
evaluation
Implementation environment
theory
Normative implementation
environment evaluation
L
Nursing
theoretical
system
Outcome theory
------Impact theory
- Causative theory
Intervening
mechanism
theory
Generalization
theory
------ Normative outcome
evaluation
------ Impact evaluation
Intervening mechanism
evaluation
Generalization
evaluation
FIGURE 3-1 Relationship
P 1
between nursing theoretical systems and basic evaluation types.
(Modified from Chen, H. (1990) Theory-driven evaluations. Newbury Park, CA: Sage.)
CHAPTER 3
The Structuring of Nursing Practice
45
Allison and McLaughlin-Rcnpenning (1998) suggest that nursing “has no consistent,
identifiable mental model or framework by which to determine and evaluate the quality of
nursing care” (p. 181). The literature rarely refers to the relationship between outcomes
and nursing theory. Consequently, the variables reviewed tend to be vicarious measures of
nursing activity. The American Nurses Association identified seven patient-related qual
ity indicators of interest to nursing: nosocomial infections, patient injury rate, patient sat
isfaction, maintenance of skin integrity, nursing staff satisfaction, staff’s mix of educational
characteristics, and total nursing care hours per day (Canavan, 1996). These variables may
or may not be primarily influenced by nursing action.
Maas, Johnson, and Morehead (1996) identified a set of nursing-sensitive outcomes as
evidence of appropriate nursing care. A nursing-sensitive outcome is “a variable patient or
family caregiver state, behavior, or perception that is responsive to nursing intervention
and conceptualized at middle levels of abstraction (e.g., mobility level, nutritional status,
health attitudes)’’ (p. 296). These outcomes presently are nor linked to a nursing diagno
sis classification system, a nursing intervention classification system, or a nursing theoret
ical system. This work remains to he completed. Currently these classification systems have
no meaning to the nurse who structures practice from rhe perspective of rhe Theory of Hu
man Becoming (Parse, 1999). Th.it nurse has no nursing diagnosis per se and docs not use
the term imen'emi<.
Critical paths arc another way organizations have tried to specify expected outcomes of
care over rime. Interdisciplinary teams generally develop these outcomes, which pertain to
specific populations often defined from a medical, rehabilitative, or developmental per
spective. These include groups such as post-operative cholecystectomy patients, patients
with spinal cord injuries, or preschool students. They identify rime frames and milestones
that patients should achieve for particular treatments and procedures. For the most part
these critical paths lack nursing perspectives. Tasks for nursing may be identified, but they
usually arc related to therapeutic goals of related disciplines such as administration ot med
ications. These outcome guidelines need ilirection from nursing theoretical systems and
theoretical research to substantiate the nursing contribution and evaluate the effective
ness of nursing parricipatii>n.
Development of Process Models. In addition to operationalizing the variable? ot
concern, translating theorv into practice requires developing nursing process models that
specify rhe nature of the intervention—that is, the relationship ot nursing to the patient
variables. Process models reproent the relationship between the nurse and patient
variables and describe rhe actions, interactions, and interpersonal processes by which the
goals of rhe relationship arc achieved.
The process models referred to here arc not synonymous with the nursing process, a term
that began to appear in the nursing literature in rhe 1960s. Thar process paralleled rhe scien tific problemsolving process oi collecting data, analyzing it, determining the nature ot
the probt:em, intervening, and cx aliiating the effectiveness of the intervention. I lowcvcr,
it was < >nly a pr> <ess. It .lid n. a dm;, i what data to collect or how to analyze it. nor did it
instruct hin > know rhe ma urc of the problem, select appropriate interventions, and evaluatc eltectivcne». All oi these lactors require some theoretical ba>i< Lacking a nursing
fr -m other disciplines; tor example, the need' ipproach burtheory ha.-c. nur-c'
nur.w' borrowed
horrrowed from the biological, muni, md psychological sciences (Hendemon, I -’OML
46
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 3
The Structuring of Nursing Practice
47
Taylor (1998) distinguishes between problem solving, a means-end deliberation, and prob
lem setting, which includes identifying, labeling, and understanding the problem from some
theoretical perspective. Early works describing nursing process set rhe problems in theories
of medicine, psychology, sociology, pathophysiology, and other disciplines related to but
different from nursing. Advances in nursing theory development have allowed rhe prob
lems to be framed in an explicit nursing perspective. Congruent with the stage of devel
opment of nursing theory, a tendency still exists to set nursing problems from rhe perspec
tive of 1 elated disciplines. Many of the critical paths lor managing patient care demonstrate
this tendency.
The process models should cohere to the theoretical frameworks from which they are
derived. A problem-solving process, for instance, is nor congruent with Parse’s Theory of
Human Becoming. A process model consistent with this theory is described in Chapter 7.
One theoretical perspective might seek to ansyver questions such as yvhy a person needs a
nurse, what nursing’s concern is, what a nurse would do first, what continuing actions a
nurse performs and why, what data a nurse needs, how data is collected, or what questions
that data will be used to answer. Another theory might focus on rhe interaction and com
munication betyveen nurse and patient. The development of rhe process model clarifies
rhe domain and boundaries of nursing and the relationship of nursing to other disciplines.
General Ideal Set of Self-Care Actions
1. "Own" a self with an objectively established structural and/or functional state.
2. "Own" a self with a need for the use of a particular technology.
3. Perform the actions needed to make use of the technology and to move self to
the structural or functional state possible by means of the technology.
4. Perform the actions necessary to keep self in the functional or structural state
produced by the technology.
5. Refrain from actions that limit the achievement of results sought through the use
of technology.
6. Take the actions needed to overcome undesirable responses that diminish thera
peutic return.
7. Monitor self for structural or functional attributes that indicate an undesirable
static state of response to the technology.
8. Monitor self for structural or functional attributes that indicate an undesirable
regressive response in the presence of the use of the technology.
9. Control factors responsible for (or productive of) a regressive or static-state re
sponse to the technology.
The developed model should specify rhe relationship between the nurse(s) and patient
and direct their ongoing action, interaction, and interrelationships. The processes associ
It >in Nursmy Devclopmcnr G’nturvncv r noup l lc'7'n In |). t 'icir. (U. ■. <
and/’n/Jii. r (2ndcil.). Bushin: Little. Bnnvn
".cci't [.mnaliau'-.ni in nnt'Mn.i;: Pnee.s'-
ated with rhe specific theoretical perspectives arc discussed in detail in Unit 2.
Development of Practice Models. A nursing practice model is a "design for nursing
action” (Orem, 1995, p. 180). It can represent what is or what should be. Derived from
analysis and study ot nursing practice situations, rhe practice model can address pariem
variables, nurse variables, and patient and nurse variables in interaction. Such
a model can
guide normative practice. Hie Jcsiim ka- treating patients during the preoperative,
miraoperative, and post.iperat ive phases ot surgery illustrate- this type of model. Rules of
nur-ing piacrice developed in association with these models guide nursing action within
situations consistent with rhe range of variation expressed by the model. For example,
preoperarive instruction for surgical patients has become a norm of nursing care. Critical
paths with the nursing contribution
in theoretical framework could be
........ grounded
...■> nursing
called a type ot nursing practice model.
Theoretical systems can facilitate deceitipmeni ol nursing practice models by system
atically organizing knowledge derived from clinical experiences with theory. The ad
vanced nurse practitioner contributes to the development of nursing knowledge when,
as .i scholar and researcher, he >r she anaiy:e>' nursing cases from a nursing theoretical
perspective, buch analvsis reveals insii’hts nor generally perceived by nurses without a
theoretical perspective (Geden. IO97h). Forex.ample. Anger, Crews, and other member.-
Ot the Nursine ix-vcl.'pmem ( onference Gcmp (NIX .G, 1979) analyzed nursing <
cases < 'l
persons on anticoagulant rherap\ and formalized rhe noram ol "the ideal generalI set’’ ol
actions necessary to regulate a rher ipv (Box v| ). XPq-reover a literature review .mJ an
analv.sis ..t cerebrovaiuiil.ir a. .. idem p inehi . haramvri-stic- and needs reveals rhai Sell
i are Nursing Deficit Them-', v.inai'lo <crvc : i-. .i KmI- for descriptive nursing practice
modeK and an orgamzat n »n ot kn. >'.vlvdec ‘ NI X < i. i o p''1
i.<r i. -n descript ion spec bi
or the therapeutic >clf-c.
knowledge and skills required by nurses caring lor that population. A seminal article by
Backscheider (1974) describes rhe contribution the analv as of mrsing situations that ad
dress some ot these same variables can make to rhe development of nursing knowledge.
The article also describes the linking of other iIu-.hic.- qvciiicallv Piagcl’.s rhec.iks of
cognitive development, u ' nursing t hc< >r\ ..-a ha.-js for dtMcn ot nursing . \>tcm> lor a par
ticular patient population
The classification ol nursing outcomes a> developed bv Maas, Johnson, and Morehead
(1996) and the clarification of nursing indicators (Bowks N Naylor, 1996) arc examples
of components of practice models, d he classilication of nursing outcomes describes the de
sired results of nursing. The classil n ation ot nursing indicators, developed from a massive
amount ot data describing current nursing, describes what nurses should investigate The
classification ol nursing outcomes and indicators structures practice but 1 icks rhe specific
description and principle- o| nursing it represent- Although they were developed from
practice, these models are not appropriate in all situations, h r example, if a nurse practices
from the perspective ■?! the Theoryv ol
neither the interventions nor
ut Hura.in
Hum.in Becoming,
Bco
the outcomes rellect thai theory’Evaluation and Research, w!
-octal program, •‘u co.u- mu-t in. Iir.k pt'. •.
.•.nd dey clopiiivn’ m ■ hj
1 hc-c ini ’del> nu hide a piipt;
c ' isc J ii in ident, •ompoi .cni
Jc-in iiid comporj.-n-< o: ■- i'-c.ire igencv. md the theoretical
>1 JcfinH!. in- .
n11;-mu jnd rhe inrerrclarionships < '*
nurse- and parient-rcl.ucd • uioi h. - .ire mi'.. l.tmciJul (. Jctcnnininu nursini; micccss
and for making ippfopri in .Tange- in pt c im dc'i'jn and di liven’ Since fiursinv is ;i
! Jir-'ii'.
u
file.
juality service. Rcscitixh
ng ■•ah ion in ■ >r . r? 17. a ion ■should he directed ;it rhe h llowinu
48
CONNECTIONS
CHAPTER 3 The Structuring of Nursing Practice
Nursing Research, Theory, and Practice
Developing programs to meet the changing requirements of the population
Determining the extent to which goals of nursing program(s) are being achieved
Designing new strategies to meet goals
Revising systems for collecting clinical data as basis for research and development
programs
• Determining costs of nursing and effectiveness of nursing services within established
budget
• Evaluating and adjusting staffing policies and budget to meet desired service quality
When the variables of concern to nursing have been identified in the mental model
and integrated into the organization’s documentation system, a basis for describing popu
lations from a nursing perspective and for determining costs of nursing services emerges.
The organization also can evaluate quality of service in relation to patient outcomes and
service provided. Finally, a basis tor designing research programs for validating or revising
the theoretical framework underlying nursing practice, evaluating the achievement of pa
tient outcomes, and implementing changes in nursing procedures and protocols to improve
patient outcomes becomes available.
•
•
•
•
49
Bowles K.H. &. Naylor D. (1996). Nursing intervention classification. Image. 28(6), 303-308.
Canavan, K. (1996). ANA asserts attacks on practice threaten patient safety. Aniericun Nurse. 28( 1), 1 -9.
Carper, B.A. (1978). FunJamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13-23.
Chen. H. (1990). Theory'driven evaluations. Newbury Park, CA: Sage.
Denyes, M.J., O’Connor, N.A., Oakley. D., Ferguson, S. (1989). Integrating nursing theory, practice and research
through collaborative research. Journal of Advanced Nursing, 14(2), 141-145.
Denyes, M.J. (1993). Response to a predictor of children’s self-care performance: Testing the theory of self-care
deficit. Scholarly Inquiry for Nursing Practice, 7(3), 21 3-217.
Estabrooks, C.A. (1997). Research utilization in nursing: An examination of formal structure and influencing factors.
Unpublished doctoral dissertation, University of Alberta, Edmonton, Alberta, Canada.
Estabrooks, C.A. (1998). A ill evidence-based nursing practice make practice perfect? Canadian Journal of Nurs
ing Research. 30( 1). 15-36.
Fawcett, J. (1992). Conceptual models and nursing practice: The reciprocal relationship. Journal of Advanced
Nursing. 17(2). 224 22>.
Gcbbie, K.M. Ck Lavin, M.A. (EJs.)
1975). i .lassificatton of mnsint! Jidjpuisis: l’i<>ceccliii.i,s <>/ the first iiduoiuu
(crence. St Louis: .Vfosbv
Gebbie. K.M. (1982). Toward the theory development lor nursing diagnosis classification (|978).Jn Ml. King <ind
D.A. Morn: (Eds.), Cljs<!/icar<";i "f nursing diagnosis. Proceedings of the third and fourth national c*inferences.
New York: McGraw Hill.
Geden. E. (1997a). Theon-based rcscmch mul Jetininy populations. The bucnuuitnuil (hen: 5<>cie'\ Xeudet'er,
5(2) 6-9.
Summary___ _________________________________________
Ge<len. E. (1997b). IL a o nursing expressed by nurse practitioners in the primary health care setting The In
Discipline-specific nursing theoretical systems frame descriptions of the domain and
boundaries of nursing and the phenomena of concern. They guide the develop
ment of process and practice models.
• The understanding and ontology of the patient and of the relationships between
the nurse and patient are derived from the philosophical perspectives from which
nurses practice.
• Conceptualizing nursing as a program involves determining the theory under
which nursing operates and making the mental model and the object of nursing
explicit.
• Developing practice within a nursing program is based on understanding
understanding aa particu
particu-
lar nursing theoretical system and developing process and practice models within
that system.
As findings of nursing research are translated into procedures, protocols, and ther
apeutic regimens, they impact the conceptualization of nursing as well as its spe
cific practices.
• Development of nursing knowledge and improvement of practice are the results of
integrating nursing practice with research framed within the same nursing theoret
ical system.
ternational Orem Soc/etv N’eu'.s/euer, 5(2), 9-11.
Gertzcls, JAV. (lvhL),) A theory and practice in educational administrat ion: An old question revisited. In R.E
Campbell N. |.M- Lipman (E<K.). Administrative theory as a guide to action Chicago: Midwest Administration
Center. University ol Chicago.
Henderson. V (196v>). /C.\ Basic principles of nursing care Geneva: International Council ol Nursing,
Horsley. J.A. (1985). I Ling research in practice: The current context. Western Journal of Nursing Research
1),
135-139.
Kikuchi. |.i'. N.
I I. 1
Practical nursing judgment: A moderate realist conception. Schoiari'- in
quiry for nursing practice L'( |). 4 3-55.
Maas. M L . John.'on. M. X Morvlic.id. S. t. i‘>1>(5). (Jassifving nursing sci^siiive patient otaeomc'. Pi'.ave -'"54),
295-301
Mayer.'. M. llv)72'. A -Astc-natk- jppr.mih ;o
McKenna. H P. tH-Wj). Theon .. id
■sni.q cure hLntnin;’ New York: Applcton-(,‘eriturv C.'rof's.
•arch: .1 link.iec («• i’enetit pniciicc. hucrihiinnui: Jnunui* o?
Sn<J-
ic<, 34(6). 431-4 3?
Mitchell, G I. \
Evaluaiioi: >l tlie human becoming theory in practice in an .Kufc care >ening. In R.R.
Parse (Ed.). 1 Luna-nuts "is The li:im.m tvoening theory in practice ind rcs.-arch New York. Nati« nal Lvamie tor
Nursing Pre".
Mitchell. P.l I. 1 i'L 7' > .. neepo bask to nursing New York: McGraw-l lill.
Northrup. IT3 . N 1 . J-.. WK 1 I'Ms' L' altimion of the human besoming theory in practice in :m ictire care psy
chiatric 'citing. Nursing 8. en, c C!,<i'icrly lit 1 23-30.
Nursing 1X-aelopmentL •omreiut. Group. 1197 3). In D. Orem (Ed.), i .oncep! t.irmalizaiien in nursing lYu." .;n.i
jirodikt Bost.-m Lirtlc. Brown
Nut sing DcvcL'pmer.i ' 01 ncreiice ir- -up ( 19‘. •’'. In I \ Yvin (lid ). I -oncc/>{ form. 2: rath
product (2tided' Bo'ion :.mL•. Brown
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BackschciJer, J.E. (1974)- Sdl’-c.iic reqnircmeMs. 'dr
iii.in.'tgemvnr dime .Xinenectn h
Bl's-i !.<!i:. | , T.i\|..r, x 1
Mel.hi.
c.ipabilino, .mJ nursing systems m ’i'w . !i mi
He.ilth. h4(12\ I ILS-1! 46.
-' Niiising fhvory
> b;ise k>r >
'u.rcu.:
nfirvnt;. /'hh < <5 .mJ
Aihe.i. ■ <r I., m
ip. • 1 tiiasitig. >,1
50
CONNECTIONS
Nursing Research, Theory, and Practice
Parse, R.R.. (1999). Nursing Science: rhe transformation of practice. Journal of Advanced Nursing Science, 30(6)
1383-1387.
Reed, P. (1996). Transforming practice knowledge into nursing knowledge-a revisionist analysis of Peplau.
Image, 28(1), 29-33.
Riggs, J. & Bliss-Holtz, J. (1994). Competency-based assessment of theory-based practi<ice. The International Orem
Society Newsletter, 2(3), 6-7.
Robinson, V. (1987). Relationship of theory based nursing and defined populations in practice in Theory'Based
Nursing Process and Product: Using Orem’s Self-Care Deficit Theory of Nursing in Practice, Education and Re
search. Papers presented at the Fifth Annual Self-Care Deficit Theoty- Conference. School of Nursing, Uni
versity of Missouri-Columbia. November 6-7, 1986. St. Louis, MO.
Rogers, E.M. (1995). Diffusion of innovations. (4th cd.). New York: The Free Press.
Roy, C. (1982). Theoretical framework for classification of nursing diagnosis (1978). In M.J. Kim and D. A. Moritz
(Eds.), Classification of Nursing Diagnosis: Proceedings of the third and fourth national conferences. New York:
McGraw-Hill.
Silva, M., Sorrell, J., <Si Sorrell, C. (1995). From Carper’s patterns of knowing to ways of being: An ontological
shift in nursing. Advances in Nursing .Science. 18(1), 1-13.
Taylor, S.G. (1989). An interpretation of family within Orem’s general theory of nursing. Nursing Science Quar
terly, 2(3), 131-137.
Taylor, S.G. (1998). Clinical decision-making from the perspective of self-care deficit nursing theory. The Inter
national Orem Society Newsletter. 6(1)? 2-6.
Taylor, S.G. <Si McLaughlin, K. (1991). Orem’s general theory of nursing and communitv nursing. Nursing Science
Quarterly .4(4), 153-160.
Taylor, S.G. McLaughlin-Renpenning, K. (1995). The practice of nursing in multi-person situations, family and
community. In D.E. Orem (Ed). Nursing. Conce/ns of practice. (5th cd). St. Louis: Mosby.
Taylor. S.G. Cx McLaughlin-Renpenning, K. (2001). The practice of nursing in multiperson situations, family
and community. In D.E. Orem (Ed.). Nursing:.Concepts of practice. (6th cd). St. Louis: Mosby.
Thoma. D. (1972). Evaluation of problem-orientedI nursing notes. Jounuil of Nursing Administration. 2(3): 50-58.
Walker. D. (1993). A nursing administrator’s perspective of use of Orem’s self-care deficit nursing theory. In M.
Parker (Ed.). Patterns o/ nursing theories in practice. New York: National League for Nursing Press.
Weed. L. (1968a). Medical records that guide and teach. New England Journal of Medicine. 2/8( 11), 593-600.
Weed, L. (1968b). Medical records that guide and teach. New England Journal of Medicine, 278(12), 652-657.
I
CHAPTER
Integration
Nursings future will be created only as the discipline
underlying nursing practices is identified, structured, and
continuously updated by 5yste?nfltic inquiry...the kinds of
knowledge contained within the discipline are identified and
an approach to its structure is proposed.
Schlotfeldt, 1999
Objectives_____________________________________________________
• Describe the role of praxis in unifying theory and practice.
• Discuss the issues associated with viewing knowledge from other disciplines
through a nursing perspective.
• Apply a systematic strategy for selecting a nursing theoretical system to use as a
guide for practice and research.
• Compare and contrast the characteristics of quantitative and qualitative research
methods, examining the appropriate use of each within different theoretical
systems.
• Specify key attributes for evaluating quantitative research instruments.
• Describe criteria for selecting a theoretical system to guide nursing practice.
• Discuss the practice benefits derived by developing research and educational pro
grams from the same theoretical perspective.
Key Terms____
_____
dialogical engagement, p. 60
emic, p. 58
ethnography, p. 58
etic, p. 58
grounded theory, p 58
phenomenology, p 57
praxiology, p. 52
01263
LIBRARY
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of Mcdica; Sciences
A, Bommasancra ir.L/.r Area
. Aral Taluk, Ban.:..: : ’ - 99
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51
52
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 4
Chapter 1 discussed the compartmentalized nature of nursing theory, research, and practice.
Integrating these areas is the next step in the evolution of the discipline and profession of
nursing. Nursing theoretical systems earn their integrity through adherence to a single ob
ject domain that is developed into a philosophically, conceptually, and logically coherent
unity. It must remain integrated even as one changes position or perspective. Like the
Nexus on the cover of this book, this integration relies on ideas and materials as well as
thoughts and feelings. These arc both abstract and conceptual. Although it is cast in
bronze, the Nexus changes as one’s viewing perspective changes. Yet it remains an ever
changing whole. Peck (1995) acknowledges the difficulty of achieving this type of inte
gration. He states, “Compartmentalization is painless; integrity never is. Integrity requires
that we fully experience the tensions of competing demands and conflicting ideas” (1995,
p. 366). Competing demands and conflicting ideas have obscured rhe need for integration
from many practicing nurses. Thus gaps between and among nursing’s parrs remain.
The theory-practice gap has been a topic of concern to nurse scientists and nurse the
oreticians for many years. Fawcett (1999a) described a helical relationship between re
search and practice. Chinn and Kramer (1999) described a “whole of knowing” that
comprises four patterns of knowing. Although it integrates knowledge development, this
model, too, fails to completely integrate a nursing framework. Some nursing scholars
consider doing research disconnected from theory unreasonable and argue that the gap
occurs because theory and research have been neglected in structuring clinical practice.
Nurses who have come to value theory through their exposure to nursing theory in their
formal education often grow frustrated with task orientation in the workplace. Con
versely, many practitioners deny the relevance of most theory and research to daily clin
ical practice. To resolve the debate and to develop nursing as a discipline and profes
sion, the intertwining of theory, research, and practice is essential. Specialty nursing
practice must embrace this nexus and ensure that their research and actions adhere to a
nursing theoretical system. This long-standing gap will nor be easily resolved, but it is an
important challenge to face.
NURSING PRAXIS
/’ruAi.s. derived from the Greek word for doing or action, is a unifying concept that can help
close this theory-practice gap. Praxiology is the study of human conduct or of efficient
action—that is, sets ot actions coordinated to achieve a common end (Kotarbinsky cited
in Orem, 1995, p. 113). \X irhin the nursing literature, praxis has taken on an additional
meaning. According to Rolle (1996), praxis indicates the inseparability of theory and prac
tice. Practice spawns theory, and theory impacts practice. Chinn and Kramer (1999)
labeled rhe “synchrony between thoughtful reflection and action” praxis (p. I ). Praxis re
quires approaching nursing as a practice discipline with both speculative and practical
knowledge developed through research and philosophical inquiry. Nursing generated
ihrough’research must be practical science—that i>, science that leads to rhe svnehrony
Chinn and Kramei described.
KNOWLEDGE FROM OTHER DISCIPLINES
Viewing nursing science as a unique creative endeavor raises the qiicsruin of
relationship b’ Hther disciplines. The current emphasis on middle-rany’e rhcory. which inre-
/'. / C-■(■>!£ - SOCHARAX^
^ot ahnngcrfa
)§)|
O'
Integration
53
grates knowledge from other disciplines into nursing science, also highlights rhe need
for discussion of this issue. Cody (1996, 1997) criticized continued use of theories from
other disciplines and argued that using this outside knowledge impedes advancement of
nursing discipline-specific knowledge. On the other hand, Rafferty (1995) advocates
mutual exchange between nursing and related fields. She holds that instead of seeking a
ratified view of nursing, nurses should embrace the work of other disciplines that helps
explain the theoretical or speculative nursing sciences, usually by analogy. This can be
achieved through identifying a nursing phenomenon, exploring a related concept or the
ory from another discipline, and reconstructing that concept into a model that generates
research questions unique to nursing (Ulbrich, 1999). The development of middle-range
theories with conceptual-rheoretical-empirical structures bridges general theory and
practice.
Fawcett (1999b) asserted nursing’s need to end the romance with nonnursing disciplines
and to focus on nursing discipline-specific knowledge. However, knowledge generated
through other human sciences cannot be ignored. Such knowledge must be recognized for
what it is—or for what it can be. For example, anatomy and physiology arc foundational to
discipline-specific nursing knowledge. Alternatively, philosophical knowledge elucidates
the nature of the patient. Bekcl’s interpretation (1998) of Wcingarmcr’s conceptualization
of object domains helpfully explains scientific disciplines’ use of different objects lor their
scientific endeavors.
Appropriate to this discussion is the concept of the application domain. Tb.is domain
describes the application of a discipline to another discipline such that the disciplines con
tinue to exist in their original form. Moreover, specialized disciplines relevant to both dis
ciplines sometimes emerge. Sentences or theoretical propositions of one discipline may be
applied to another discipline, but each discipline has a different independent object. If the
objects of the two disciplines were identical, one would be a genuine subdiscipline of the
other. That is, if nursing were understood as an application domain of psychology, it would
be a subdiscipline of psychology and not an independent discipline. Unfortunately, this is
the direction many of the so-called middle-range theories arc taking. The theories, princi
ples, or sentences from a nonnursing discipline are held as primary and are applied to nurs
ing, subordinating nursing to a subdiscipline. Using theory from other disciplines weakens
the development of nursing as a discipline. The nursing theoretical system must be pri
mary. Sentences from other disciplines may constitute a part of rhe domain ot nursing it
they arc interpreted through a specific nursing theoretical system. Ulbrich’s work exem
plifies this (Figure 4-1 )■
SELECTING A NURSING THEORETICAL SYSTEM
The first three chapters of this hook provided background information about theory, re
search. and practice and described links between and among these elements. The subse
quent chapters present some of the integrated nursing theoretical systems. Nurses should
find theoretical 'V^tems that meet their needs for developing nursing practice knowledge,
but noi all the theoretical svstems have evolved to include explicit statements ot the the
oretical <vstems’ foundational cosmologies. The movement from rhe logical middle occurm varvinu ways and ar varying speeds. To select an appropriate theoretical system, conrhe if nvii'j’ ■iue-rion- while reading and studying each cnaprer.
MJ
7-U P°l
54
CONNECTIONS
CHAPTER 4
Nursing Research, Theory, and Practice
Integration
55
L
Nursing theory
Questions Guiding Theory Choice
Central
concept
Supporting theory
COSMOLOGY/ONTOLOGY QUESTIONS
Is the object or focus of nursing specified? Is it specific to the discipline of nursing, or
could it apply to any human science or helping service?
Do the statements about the object encompass all situations of nursing or situations
Population
of nursing within my specialty area?
What is my conceptualization of person?
Is my conceptualization of person consistent with that proposed by the theory?
What is the position of person in social and physical environment or contexts?
Does the language of the theory reflect my thinking about nursing practice?
Does the language provide me with a way in which I can "talk" about my specific
Nursing practice
theory
C Research and evaluation
area of nursing?
T
Nursing knowledge !•«-
MODEL QUESTIONS
I------------------------------------- 1
i
I
I Theory development k-
1
.
Nursing science
:
---------- -
Implementation
FIGURE 4-1 Exercise as self-care: A nursing practice model. (Modified from Ulbrich, S.L.
(1999). Nursing practice theory of exercise as self-care. Image, 31(1), 65-70.)
Is there a central model that represents the ontology?
Is the model relevant to the real world of nursing?
Are the variables specified by the mode! consistent with the phenomenon with
which I am concerned?
Does the model help me understand the portion of reality it represents by showing
the relationships of variables under study?
How well does the model conform to the part of reality it is supposed to predict?
THEORY QUESTIONS
Does the narrative accompanying the model help me understand the world of nurs
ing and how nurses function within it?
Does the theory provide guidelines for analyzing a phenomenon?
METAPHOR QUESTIONS
Questions for the Selection of a Theoretical System as the
Basis for Specialty Practice or Knowledge Development
Can I visualize my nursing specialty within this framework?
What are the metaphors used to describe nursing and nursing-specific concepts?
Are these metaphors congruent with my values and beliefs about nursing?
One must first take into account one s current view of nursing practice or research. W'hat
do you consider important in a nursing theoretical system.’ Thar is, as a nurse, what must
you know.’ About what do you inquire, and what research questions do you need to ask.’
What conclusions ire valid.’ What practical meaning do you attach to the information ob
tained oi to rhe judgment1- vou make. Do you have a language to meaninglullv express
whar you know t<> patients, other nurse--, and other health workers.’ (Orem, 1995).
Conceptual-Theoretical Elements. To souk degree, rhe selection of a parricular
theoretical system is a matter of preference for rhe ontological expression, the model
RESEARCH AND PRACTICE QUESTIONS
Can questions that arise in my practice be researched from this theoretical
perspective?
With what phenomena am I concerned in my practice?
Which nursing theoretical framework reflects these phenomena?
Is there a scheme for understanding the significance of research findings?
Are nursing practice models derived from this theoretical framework adequate or
sufficient for my practice?
depiction, and rhe theoretical expression. Perceived applicability to the specialty practice
area or research questum also shapes deci-!o:>>. Thu.-you first should identify rhe cosmology
and or ontology congrueni with vour beliefs. What are your core values and beliet-.’ Arc
these captured in orwoi more of the theon-i a ai <' stems.’
Harrc (199.S) suggc-red i dual ontology tot psychology—one that permits a choice be
tween toi.indinc the science . >1 human th. ■ ught and action on molecules as basic particulars,
and founding r on people a- rhe basic particular-
■‘ '
'
'■
'
'
1
'
(p. 4< 1 This might apply to nursing
■■■..■■: gV r mhcT th in murujlb. c$
m\ m-.- mm..
: research
uid practice As you review rhe theoretical systems presented in rhe following units, conh>r example. I’epi.m's inicrpeisi'iial relasider the p> i—ibiliiv . •* -ek ci mg ; dual ontoh ’g.\
>'! iiuiMn^ <\srem> tChaptci ■>) Then ev.iitions (Chapter I ’ a:; I < ''rem ■ gcneiai '
K-i a een the t \vi >.
u.itc the phfL-ophua! md iogica 1 < i ’!!_;■ i
Thequesn m-pm-ente i m Ro■ x 4-1 ir jmde\oiir thinkimz. In reviewinp and rellectinj on \. u:
m.. - : h r’
1 J; • ■
• •
: • • ■ -ai -ppi'npri He h’r yo<t
56
CONNECTIONS
Nursing Research, Theory, and Practice
RESEARCH METHODS
Theory impacts research. Thus the theory selected should help the investigator visualize
important research questions or hypotheses. As Chapter 2 mentions, research both tests
and generates theory. Two major research approaches—quantitative and qualitative—are
used for theory testing and generation. Cuba and Lincoln (1994) suggest that these two ap
proaches evolved from competing scientific paradigms that influence methods for discov
ery of truth (see Chapter 2). These competing paradigms arc evident in several compo
nents of both types of research (Denzin &. Lincoln, 1994). Quantitative researchers attempt
to study and capture a knowable reality. Similarly, a positivist paradigm anticipates that
research findings uncover the existence of truth. Thus positivist or postpositivist paradigms
of inquiry shape much quantitative research, although a postpositivist paradigm approaches
research findings a bit more tentatively, holding that reality can only be imperfectly known.
Qualitative researchers feel that reality can never be fully understood, only approxi
mated. This perspective most reflects constructivism, hut critical theory also applies. Crit
ical theorists believe social, political, cultural, ethnic, or gender structures influence in
terpretation of reality. They are similar to postpositivists in their belief that reality can be
only approximated. From a qualitative perspective, multiple realities might exist within a
given context, whereas quantitative researchers believe in a singular reality (Haase
Myers, 1988). Both types of researchers are interested in capturing individual points of
view. However, quantitative researchers attempt the process through empirical methods
that focus on systematic and objective measurement. In contrast, qualitative researchers
try to get closer approximations of individual perspectives through less structured inter
views and observation. Qualitative research views subjective experiences as legitimate
data sources.
Both quantitative and qualitative researchers consider the constraints of everyday life.
However, quantitative researchers arc less likely to study those constraints directly. The fo
cus of quantitative research is reductionistic; the whole is broken into subparts so th ar
each of the parts can be studied. To achieve control over the research setting, the re
searcher explicitly identifies rhe research problem and attempts to limit extraneous vari
ables that might influence outcomes. In quantitative research, large numbers of randomly
selected cases are used to draw conclusions based on the probability that these cases rep
resent a larger population (Denzin &. Lincoln, 1994). Researchers attempt to limit or at
least account for data discrepancies by providing alternative explanations for rhe phe
nomenon (Haase (St Myers, 1988). On the other hand, qualitative researcher:, arc more
concerned with describing rhe phenomenon as a whole, bur they also deal wiih the
specifics of particular cases, seeking to explain both the commonalties and difference^
among participants. Qualitative research may attribute discrepancies ro rhe existence of
multiple realities.
These differences direct investigators to different modes of di>co\cry Quanotaiive re
searchers use mathematical models and statistics. Instruments measuring selected a>pccts of
the phenomena are constructed carefully ro ensure reiiabilir\ and validirv. Qualimi.ive re
searchers use a broader variety of data collection technique.", including pi-'.'-e narrative",
first-pcison accounts, photographs, lile histories, biographical and auro,I i. -graph.. al mate
rials, observation, and interviews.
i
CHAPTER 4
Integration
57
Methods of Quantitative Research
Quantitative research approaches can include descriptive, correlational, and experimental
techniques. Descriptive research uses structured or semi-structured interviews, observa
tion, surveys, and questionnaires to describe phenomena of interest. Correlational research
seeks to investigate systematic relationships between two or more variables of interest.
Correlational research does not, however, measure cause and effect; rather, it determines as
sociation among variables. A variety of measuring instruments can assess the nature of
variables of interest. Much nursing research has been descriptive or correlational. Although
these studies are useful beginnings for describing the realities of nursing, they are insuffi
cient for testing potential practice interventions.
When quantitative research moves beyond rhe descriptive or correlational realm, it be
comes some form of experimental study. Experimental studies are systematic, highly con
trolled, and predictive. They manipulate an independent variable to determine to what
degree the outcomes arc influenced. The goal of these studies is to maximize the cxpcri
mental variance while minimizing sources of error and controlling any extraneous vari
ables (Kerlinger, 1973). Because the researcher maintains greater control over the research
environment in experimental studies, these studies arc the most powerful. The clarifica
tion of experimental research is based on an investigators’ control over the events in the
study. The three elements factored into rhe structure of experimental studies arc manipu
lation of an independent variable, use of controls (usuallv a control group), and subject
assignment to groups (random assignment of subjects to groups is preferable). Including
all these elements provides the investigator the most control over the studv and greater
certainty that the findings reflect reality. Experimental studies represent positivist and post
positivist approaches to resting theory and interventions.
True experimental designs, the strongest and most controlled of experimental design, in
clude all three elements. Subjects are randomly assigned to groups: a control group is present;
the independent variable is manipulated. However, sometimes an element may be mi.v.ingIn quasi-cxperimental studies the investigator may have a control group and may be able io
manipulate the independent variable but is unable to randomly assign subiects. in this sit
uation, researchers have less control over rhe study events, which means rhe findings are !c<>
certain. Preexperimenral studies use weak designs in which only the independent ,.uiai le
is manipulated. Although a preexperimenral design mav pro\ ide a mechanism ter d;>co\vr\.
the study findings remain uncertain because poor studv control mav have allowed outside
ewnts ro influence the outcome. Although true experimental studies are valuable, they are
the most difficult ro conduct and usually involve rhe most artificial settings
Methods of Qualitative Research
Several modes of qualitative inquire arc useful for rheorv ecneration. I hrcc type." ot qual
itative research are phenomcno'ogw ethnography, and grounded rlicor.. Although . e
mechanisms for data collection in each of these types <>f research mav owrlap. rhe partic
ular t cus of each method varies.
Phenomenology focires on experiential lite in term" ot indo, iduab vu w- ind inm w tions with rhe phenomena i»f c<’nccrn in i heir everyday li \ c" i-Hoisictn X < h:i mm. I
- i.
Investigators suspend judgment about the nature of the world and ."i.iit nom "crai-Ja,
58
CONNECTIONS
Nursing Research, Theory, and Practice
focusing on the ways individuals perceive their lives and life events. Expert and reliable in
formants are used to gather data. Informants interpret their experiences for the investiga
tor, who then interprets the collective explanations of participants.
Ethnography stems from cultural anthropology. It offers a description of individuals liv
ing within cultural groups, whose members share a learned complex system of living (Boyle,
1994). Ethnography is concerned with the meaning of actions and events associated with
the cultural group. Ethnography places group description data obtained through partici
pant observations and individual interviews into a larger wholistic and contextual per
spective (Boyle, 1994). Ethnography is called reflexive because the researcher, in rhe role
of participant/observer, is a parr of the world under study. An emic perspective offers an in
sider’s view and is the goal of ethnography. An etic, or outsider s/investigator’s perspective,
helps scientifically view reality within the group under study.
The qualitative method of grounded theory specifically identifies theory generation re
garding social and psychological phenomena as its purpose (Glaser & Strauss, 1967; Strauss
&. Corbin, 1990). Grounded theory, phenomenology, and ethnography share methods of
discovery through observation and interviews. A major difference of grounded theory, how
ever, is its focus on theory generation (Strauss & Corbin, 1994). Grounded theory involves
a highly systematic set of procedures for discovery of information about a phenomenon of
interest. From this, investigators inductively develop theory. Strauss and Corbin (1994)
indicate that theory evolves through an interplay between data collection and analysis.
Grounded theory considers relationships among the concepts and then produces relevant
abstract concepts and propositions (Chenirz & Swanson, 1986). Constant comparative
analysis, a central feature of grounded theory, continually seeks similarities and differences
among participants, actions, or events. Data are coded, clustered into similar categories,
and labeled. Collection of additional data may warrant recoding and reorganization. Rela
tionships among categories are developed, and patterns among relationships are concep
tualized. Ultimately, a general theory about relationships is produced.
Balance Between the Two Research Methods
One might ask which form of research is best for building a scientific knowledge base. Very
practically, the answer is both. 1 he goal ot research and theory is an understanding that will
ultimately influence practice. Addressing rhe cyclic interaction of theory and research,
Benohel (1977) established a case for nursing research derived both from traditional sci
entific models and more naturalistic models. Beck (1997) successfully incorporated both
quantitative and qualitative research projects into a program of research on postpartum
depression. She insisted that programs of research be knowledge-directed rather than lim
ited Iw adherence to specific research methods. Silva (1977) indicated that although the
use of the scientific methods is praiseworthy for its rigor, the narrow focus of some studies
leads to trivial outcomes that fail to meaningfully advance nursing knowledge. Thus she ar
gued for a more wholixic approach to the development of nursing knowledge. Haase and
Myers (1988) suggested that because nurses must individualize care, multiple meanings
can be associated realistically with individual experiences. Conversely, because phenomena
ot interest r.. nurses are complex, considering the component parts is also helpful. Often the
choice of research model is based on the investigator's understanding of the world, which
somenmes leads to exclmn e u-e of either quantitative a qualitative research techniques.
CHAPTER 4 Integration
59
However, both quantitative and qualitative research methods contribute to an understanding of reality useful for nursing theory development, testing, and practice.
Gortner and Schultz (1988) argued that good nursing science should be characterized by
significance, theory-observation compatibility, generalizability, reproducibility, and preci
sion. These characteristics—although sometimes identified with different terms—are pres
ent in both quantitative and qualitative research approaches. Of course, these character
istics also represent good science in other disciplines. Reed (1996) suggested that nursing
scholarship should embrace a philosophical view in which each dimension—quantitative
and qualitative—informs the other in knowledge development. If nursing attends to the
contributions each can make, practice can significantly guide knowledge development,
and scientific knowledge will become embedded in nursing practice.
Triangulation permits the use of multiple research methods, theories, data, and investi
gators for studying a common phenomenon. Duffy (1987) asserted that multiple research
methods are useful in triangulating data gathered from a variety of sampling strategies. Tri
angulation assumes that the strengths of an alternate method might compensate for rhe
weakness of one method. Therefore the methods selected must be based on common as
sumptions and must complement one another (Knafl & Breitmayer, 1991). A common
type of methodological triangulation is the combination of quantitative and qualitative
research methods in a single study. The data derived are then checked tor mutual confir
mation. .Methodological triangulation incorporating qualitative and quantitative research
approaches provides “richer and more insightful analyses of complex phenomena ’ (Duffy,
1987, p. 133) and permits verification and validation of findings. Triangulation can be a
powerful tool for facilitating theory generation.
Selecting a Paradigm of Inquiry, Research Method,
and Instrumentation
Earlier, this chapter provided guidance for selecting a theoretical system. Selecting a para
digm of scientific inquiry is a similarly important step. The choice of a theoretical system
directly may influence the choice of a paradigm of inquiry. For example, some theoretical
systems, such as those by Parse (1987) and Watson (1999), strongly reflect a constructivist
paradigm of inquiry. Systems such as Orem’s (1995) may reflect a more posrpositivist para
digm. Therefore examining the theoretical system is crucial to selecting a paradigm of in
quiry. Explore the ontological concerns mentioned earlier in this chapter and consider how
the theorist posits them. What does the theorist say about persons.’ How is evidence sup
porting the theorv accumulated.’ For example, Orem (sec Chapter 5) suggests that theory
changes when new knowledge becomes available—a belief congruent with a posrpositivist
paradigm. Rogers also believed that knowledge was an evolving process but felt it must he
measured in a wholistic, acausal way.
Theoretical perspectives also influence rhe selection of research method to some de
gree. Box 4-2 presents questions to guide the selection of a research method. Some theo
rists rely primarily on quantitative approaches as mechanisms for discovery and model test
ing. Some advocate a combined approach of both quantitative and qualitative research.
Manx •'tui.lies u>ing framework.*' developed by Orem, Roy, and 1 ender primarilx u-i' oji.iititativc research coupled wuh a •'mall amount of qualitative investigation. Rew uch de
rived from Roger/ Science ot Unitary Human Beings combines quantitative and qualna-
60
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BOX 4-2
Developing Research from the Selected Theoretical System
1
RESEARCH QUESTIONS/HYPOTHESES
Can research questions or hypotheses be visualized with this theoretical perspective?
How can the phenomenon of interest within the perspective of this theory be
conceptualized?
RESEARCH METHODS
Having derived the research question from the theoretical perspective, what
method would be appropriate?
Are particular research methods more amenable to discovery within the selected
theoretical context?
What is currently known about the phenomenon of interest?
What is the state of nursing knowledge regarding the phenomenon of interest?
Would the problem be best studied in a highly controlled environment or in a more
naturalistic one?
Qualitative Methods
Quantitative Methods
What is the purpose of the
investigation?
• Description of life
experiences?
• Description of cultural
groups?
• Theory generation?
What is the purpose of the investigation?
• To describe?
• To look for associations?
• To test interventions?
Quantitative Instrument Choice
Is there an instrument that measures the phenome
non of interest?
Does the instrument possess adequate reliability?
Does the instrument possess adequate validity?
Is the instrument usable with the selected population?
tive approaches. Other theorists support using only qualitative approaches.
approaches. For
For example,
Parse would suggest that evidence be gathered only if the investigator is truly present with
rhe participant and conducts the research investigation through a process termed dialogi
cal engagement. Dialogical engagement is a process in which researchers arc truly present
with participants and arc open io discussion of the phenomenon of study. All siudies using
Parses Theory of Human Becoming as a framework are qualitative. In some wavs selec
tion of a theoretical system and a paradigm of inquire can be a cliickcn-and-cgg phenom
enon. Individuals may already have opinions that will influence their choice of a paradigm
of inquiry. For others, the theoretical system may be a drix ing factor.
Research methods also should be selected on the basis of what is-currently known and
of what needs to be discovered. It theory related to the phenomenon of study docs not ex
ist, the descriptive processes of cither quantitative or qualitative research might he a good
beginning point. Valuable nursing research stems from practice ohsciwat ions and can stim
ulate theory development or extension. Unfortunately nursing sometimes ncglccn the
proce?? of description in rhe effort to deal with practice-associated problem.?. < Vher rime?.
J
Integration
61
nursing research seems to describe a phenomenon “to death” before proceeding with ex
planatory or intervention studies. Evaluating the state of the nursing knowledge base, in
cluding a review of potentially relevant theory, is an important initial step in rhe research
process.
The nature of the problem to be studied may also be a driving factor in selecting a re
search method. Use of a naturalistic environment may be desirable for broad, in-depth
description. For other studies, using narrower foci and environments in which extrane
ous variation can be controlled at least to some extent is essential to answering the con
cern. For studies seeking in-depth description, a qualitative approach may serve the pur
pose best. When greater controls are needed, quantitative studies provide more adequate
answers.
Once a qualitative or quantitative method is selected, more decisions remain (sec Box
4-2). If investigators use qualitative research, they must determine the type of approach. For
example, a phenomenological approach best serves the purpose if the investigator wants an
in-depth understanding about the lived experience of a phenomenon. Ethnography would
be most effective in studies of cultural practices. Grounded theory is valuable for theory
generation. Once again, rhe purpose of study is important in quantitative investigations. A
study with the primary purpose of description warrants a descriptive study. A correlational
study would be used to investigate associations. Testing interventions requires some form
of experimental study.
In quantitative studies, instrumentation is also an important issue (sec Box 4-2). In
vestigators must look for instruments that will measure the phenomenon of interest. Al
ternatively, they must develop new instruments it none arc available. Instruments should
be evaluated for their reliability to ensure the accurate and dependable measurement. Be
cause the instrument needs to measure what it says it measures, validity is .ilso a concern.
Chapter 2 reviews mechanisms for evaluating reliability and validity. Finally, one must
consider the usability of the instrument in rhe population of interest. For example, an in
strument that works well in young and middle-aged populations may not work well with
older adults.
PRACTICE APPLICATIONS
All nursing practice can be called theory-based. The question is whether the rheur\ on
which practice is based is nursing discipline-specific. The advantage of structuring practice
within a nursing theoretical system is that rhe practitioner's questions can use die language
and perspective of nursing, and the related research can address the specific concerns of
nursing. Survival of the profession depends on furthering the discipline through integrated
programs of theory development, research and practice. Without such dc\e! 'pment, nurs
ing becomes merely a collection of tasks. Examples of theorv-research-practice programs in
relation to specific theories are presented in subsequent chapters. Such programs are rhe
products of researchers who deliberately set out to practice and research from a particular
nursing theoretical perspective. Individual nurses, educators, or the collective nurses in a
healthcare agency can also achieve integration of theory, research, and practice b\ prac
ticing from particular nursing theoretical perspectives. Theory becomes excglasses rhr< >egh
which to view the dilemmas of practice and identifv related research -ques-ion? (Pcn'.cs,
Tnnor. Coakley, X Ferguson, |9SQf.
CONNECTIONS
62
Nursing Research, Theory, and Practice
CHAPTER 4
I
■ISO
Developing Practice from Selected Nursing Theoretical System
i;
INDIVIDUAL PRACTICE
What is the proper object or focus of concern of nursing within this theoretical
system?
Can variables reflecting the concern of nursing practice be defined in operational
terms?
What are the characteristics of my patient population?
What should be the outcomes of my nursing practice?
What are the processes of nursing through which I can achieve the desired
outcomes?
What variations should be made to the nursing practice model in relation to my spe
cific patient populations?
ORGANIZATIONAL PERSPECTIVE
Is the selected theoretical system's conceptualization of person and beliefs about
nursing congruent with the organization's mission statement?
Are the nursing-related structural components of the organization supportive of
practice from the perspective of the selected theoretical system?
Choosing a Theoretical Perspective to Structure Practice
Choosing a theoretical perspective for practice involves studying available theoretical sys
tems and determining which are congruent with ones view of nursing; including the pa-
Integration
63
(Estabrooks, 1997). One cannot help but wonder if the gap partly originates in the intro
ductory nursing programs in which students learn social and biological theories from the
perspectives of those disciplines rather than from the perspective of nursing. In addition,
although students may be introduced to nursing theories, too commonly the nursing prac
tice before and after graduation is not embedded in rhe theories of the nursing discipline.
Structuring the clinical component of the nursing curriculum from the perspective of a
nursing discipline-specific theoretical system would begin to rectify this situation.
The lag between development of nursing theory and its influence on curriculum devel
opment means that basic education programs did not socialize many nurses to the usefulness
of theory in structuring of nursing practice. Although some essential nursing knowledge
was developed in other disciplines, nonnursing elements have tended to dominate clinical
practice. Using the knowledge developed within other disciplines and the theories from
which they are derived within the practice of nursing requires viewing them from a nursing
perspective. Donaldson and Crowley (1978) cautioned that nursing’s survival depends on
discipline development that can incorporate the knowledge from disciplines but is designed
to answer cent ral nursing concerns, such as the effects of particular educational techniques
on self-care. Donaldson and Crowley (1978) noted that nurse researchers (ended to take tar
granted that the nursing perspective is understood. This issue is still considered germane;
Kenney reproduced Donaldson and Crowlev’s original article in 19Q9. This criticism ot
nurse researchers can be extended to educators and to manv current nursing textbooks as
well. Developing a nursing perspective and using knowledge associated with related disci
plines is nor ar. innate ability It must be taught. Backscheider (19/4) provides an example
of the utility of such research for nursing practice (see Chapters 3 and d).
tiem, rhe muse, nursing actions, and nursing outcomes. The processes of nursing and the
piaciicv models developed vary with (he particular theoretical system chosen. These vari
Summary________________________________________________________________________
ations are reflected in the descriptions of patient populations served by nursing, the defi-
• Praxis requires approaching nursing as a practice discipline with both speculative
and practical knowledge developed through research and philosophical inquiry.
• Advancing the discipline of nursing requires that the nursing theoretical system be
the primary system. Other disciplines may constitute a part of the domain of nurs
ing if they are interpreted from the perspective of a specific nursing theoretical
nition ot expected outcomes of nursing, the methods by which the expccred outcomes can
be achieved and rhe documentation of data related to patients and nursing action
I he theoretical system chosen to structure nursing practice within a healthcare
' .IL’CIKV
should be consistent with the mission statement of the agency. Organ rational i
ci tin po
nents should be designed and developed to support practice from rhe chosen
pe rspcc rive,
Research programs should be designed to further rhe knowledge base about t
he phenomena of koncern. \X ir.htn educational settings, the theoretical system chosen as (he
.... trumework for developing (he students’ concepts of nursing should reflect taciilrv beliefs ah
>ut
nursing. Xursing cixirses should he structured around rhe specified phenomena
ot concern Nonnursing courses foundational to fully understanding those phenomena
shotiiJ he
otfereo.. See Box 4 > for suggested questions tor developing practice from a
leered rhe-
orvtic.il system.
Addressing the Theory-Practice Gap
I he theory-practice ^ap has concerned many nurses for-ome time. Basic nursing programs
• - •■
huviicc iiui>ing pf;Ktice. l\!li<ie< and pntcedmes >1 cm{
nsi ttuf i ns and
the I. e.m im e o| the nieda a! model m tht hcalihc.irc i eld sicmlicaniiv influence rhe
curri.. urn
: nursme procr.mo and the daily practice
a rh.e nur>c after graduation
system.
• Moving to a nursing theory-based research and clinical practice requires answering
questions about the personal theoretical bases of practice and research. An overall
philosophical and logical congruence between the general theory, the focal con
cepts), complementary theory or theories, empirical methods, and practical mean
ing is essential for successful selection and integration of theory into research and
practice.
• The chosen theoretical framework may be associated with underlying beliefs about
paradigms of inquiry. In selecting a method of discovery, nurses should consider
both the paradigm and the nature of the question.
• Key attributes such as reliability, validity, and their appropriateness for the popula
tion of study need to be considered in selecting quantitative research instruments.
’ Choice of a theoretical system hinges upon congruency between one's views of
nursing and of the patient, the nurse, nursing actions, and outcomes.
• Educational and research programs should be developed f'om the same theoretical
per mective to help close the theory-practice gap.
64
CONNECTIONS
Nursing Research, Theory, and Practice
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fiO XT®
Is
r
n
i
U N IT
OVERVIEW of THEORIES,
RELATED RESEARCH, and
PRACTICE APPLICATIONS
Objectives
• Explore the philosophical underpinnings and central characteristics of selected
nursing theoretical systems.
• Examine selected research methods and instruments used for studies guided by
nursing theories/models.
• Appraise research conducted with selected nursing theories and models.
• Conceptualize nursing as a program for structuring nursing practice
I nit
presents a selection of specific theoretical >vsiems mJ miJJle'ranye theoric'
X'
Chapter 1 stated, a nursing’ theoretical -\'tein consists of a general theory o; nursinc 'h c
can be placed within a pnib'sophical tradition tnd can .■'trudure niarsino pracriee XXXriun
theoretical systems are practical middle-ranpe rhorie' md practice niodcK Aith aiJi
middle-ranne theories can be a parr of a theoretical system, nursing also has middle
■ni.’v
theories that stand alone. Middle-range theories arc limited in range and scope from wla. h
hvp* theses can be derived and eaipiri-. allv meaoacd Th
-< a limited mind - r . e
vom epi.-, related to a specific a>pe< t of a plicnomei i"ii
included in this unit is work initialh developed in t dr .. K
■'v
C'.IITKin.
Pender. 1'eplau. and XX rison F.^l >. >1 ' i-e-.' d
67
!IYf ,7 ■
[.
120
CONNECTIONS
Nursing Research, Theory, and Practice
J
CHAPTER 5
121
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C H A P T E R
11
Modeling Nursing From an
Energy Field Perspective
ROGERS' SCIENCE of UNITARY
HUMAN BEINGS
Key Terms _
iif .!C
energy field, p. 125
helicy. p. 126
integrality, p. 126
pandimensional, p. 125
pattern, p. 125
resonancy, p. 126
unitary human being, p. 125
The Science <>l Unitary Human Beings (SUHB) tocuscs.in the wholeness of reality an.J d
human Heinos as a part ot that reality. First developed by Rogers in 196! m response ■<> the
need lor conceptual structure- in nm-mo education, it developed into a major thuoierical
system. The fir.-r dc-cript i- >n ol Roocrs’ model was published in 1970. 1 let L’eneralicationfounded continued development of knowledge about rhe unity and wholeness that she
considers the thcorerical basi< tor nur-ing.
Rogers refined her model ifrer it- publication in 1970. She wrote a number of arricles
but ncr t i revise I rhe origin, t! work, ^he po- rulatcd a theory ol accelerating evolution, revi-v d hi.' refined rhe prim, i: • . -t h- mi-a ’J', mimics (Box 6-1 1. and intn ■ I need the c< ■ncept
of pan<liinensionalit\. Other scholars tocusex! on issues including pattern, time, and peicpri >n <t human r,mc and healih B irieti, MaiinTi, ind others operationalized rhe the• aet a i! ••.enivim i.. be u -e : mpirn a!r.. c ’'rlh-i most m mably Par<e ami W.-wm.m. dew 1
nd praci nc. Boil Par-•’< Th< or. .■flbitn.in
123
124
CONNECTIONS
CHAPTER 6
Nursing Research, Theory, and Practice
Principles of Homeodynamics
• Principle of resonancy: Continuous change from lower to higher frequency wave
patterns in human and environmental fields
• Principle of helicy: Continuous innovative, unpredictable, increasing diversity of
human and environmental fields.
• Principle of integrality: The continuous mutual human field and environmental
field process.
From Rogers, M.E. (1990). Nursing: Science of unitary, irreducible human beings: Update 1990. In E.A.M.
Barrett (Ed.), Visionsoj Rogers’ science-lwised nursing. New York: National League for Nursing Press.
Becoming, and Newman’s work continue in rhe tradition of Rogerian science. Parse’s work
is presented in Chapter 7.
Coinciding with Rogers’ death in 1994, EA. Davis Co. published Martha E. Rogers: Her
Life and Her Work, a compilation that included commentary from noted Rogerian scholars
Malinski, Phillips, and Barrett (1994), who provide much information on Rogers' life and
rhe context within which her work developed. In the same book, proponents of the SUHB
describe the significance of her work.
THE STARTING POINT OF THE MODELING PROCESS
Rogers starred by looking for rhe way in which human beings could be conceptualized as
the object of nursing. She was concerned that development encompass science from a tra
ditional perspective bur be based in a concept of the human being who is integral with rhe
environment. Rogers focused on science, which she defined as “an organized abstract body
ot knowledge arrived at from scientific research and logical analysis” (1988, p. 100). She
wanted a philosophy, based in science, of the nature of human beings and the universe,
barter (1988) proposed that “Rogers’ outlook is based on the most recent theories in the bi
ological sciences, and (>n the attempts of some contemporary philosophers to include these
insights into a coherent worldview” (p. 60).
Reason for Theory Development
Rogers’ impetus for theory development appears in her early book Educational Revolution in
Nursing, published in 1961. She considered this volume groundwork for her philosophy
and for theoretical concepts in nursing. Rogers (1961) proposed significant nursing con
cepts and a theory development process that would lead to a rational framework for pro
fessional education. In a later work, Rogers (1970) noted that she was motivated bv a strong
conviction that nursing practice needed to be underwritten bv substantive knowledge.
Rogers initial work (1961) identified a foundation for nursing professional education
l'.i>ed m a substantial organized body ot theoretical knowledge fundamental to nursing”
(p. 2 >)■ Rogers felt strongly that rhe development of nursing theory was cruci.il to further
progress in rhe profess:ion. For Rogers, nursing theories are never static; they provide the opci jr h hi.iI h;i>is h>r kn. ledgeable practice. Nursing theory i> "rooted in rhe bn - id founda-
Modeling Nursing From an Energy Field Perspective
is Specific to
125
ice of Ni
Keywords
Definition___________
Energy Field
The fundamental unit of the living and the non-living. Field is a unifying concept.
Energy signifies the dynamic nature of the field. A field is in continuous motion and
is infinite.
Pattern
The distinguishing characteristic of an energy field perceived as a single wave.
Pandimensional
A nonlinear domain without spatial or temporal attributes.
Unitary Human Being
Human field
An irreducible, indivisible, pandimensional energy field identified by pattern and
manifesting characteristics specific to the whole and which cannot be predicted
from knowledge of the parts.
Environment
Environmental field
An irreducible, pandimensional energy field identified by pattern and integral with
the human field.
From Barrett. E.A.M. (Ed.). (1990). Visions of Risers' science-hased ntirsin.e New York: National League
Nursing.
tion of knowledge that characterized the liberally educated man” (p. 24). She wanted nurs
ing science to recognize rhe unitary nature of rhe person integral with rhe environment.
Rogers continued refining rhe language in order to emphasize general knowledge of rhe
universe and specific knowledge about nursing. Her work incorporated ideas from both
philosophy and science. Rogers cites such sources as Lewin, Barzun, Asimov, Bertalanffv,
Burr and Northrop, Arendt, Polanyi, deChardin, Bohm, and Gleick.
Rogers posited a number of questions related to the nature of human beings and the
universe in her early work and noted their relevance to nursing. In 1961, Rogers asked
questions that form rhe basis tor our understanding nursing: "Wh.it is man? Where does he
fit into the universe? Is he subject to the same laws that go\ern the physical world? What
is life? How can man be conceptualized, consistent with the world as we know it?” (1961,
p. 16). She introduced the idea of life as a manifestation of energy and humans as integral
parts of an expanding universe that moves on through time and space. The theoretical
content of nursing, lor Rogers, focuses on the lite process of human beings and thus is nurs
ing’s focus.
Phenomenon of Concern
Rogers consistently referred to the structure ot her work as the Science of Unitary Human
Beings from which theories will be derived. Structural elements ot the SUHB arc called
huiklmg blocks and include energy fields, a universe of open systems, pattern, and fourdimensionality, now conceptualized as pandimensionality (1992a). Rogers has iterated this
focus on nursing science a* an organized abstract system of unitary, irreducible, and mdi■ i-'iblc cncrc\ liekR m m.mv ot her writings (1988, I00?. |9Wa. 1994). The specific defi
nitions • 4 rclcvani tcims are provided in Table O-1.
126
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 6
DESCRIPTION OF ROGERS' THEORETICAL SYSTEM
Philosophical Perspectives
(K"*
127
and waves have been used metaphorically at other levels, as in Zohar and Marshall’s The
Qiumtuny Society (1994). The application of quantum physics at the human and social level
is a matter of metaphor and analogy.
Rogers used concepts of systems theory in her work. She depicted a pandimensional
universe of open systems (1981, 1988, 1992a) and used the concept of negentropy to ex
plain increasing diversity and complexity of pattern. Complexity theory, according to Ray,
is a “scientific theory of dynamical systems” (1994, p. 91). Chaos theory, a subset of com
plexity, “deals essentially with the concept of order within disorder” (p. 91). Ray credits
Rogers with being rhe first to introduce complexity to nursing. Vicenz (1994) clearly links
chaos and complexity theory to Rogers’ work.
A New Worldview. Rogers posited her work as evolving from a new worldview, rhe basis
of wh.ch .s scrence, defined as “an organized body of abstract knowledge arrived ar from
scientific research and logical analysis" (1988, p. 100) and “identified by the phenomenon
central to tts concern" (p. 99). Rogers “acknowledges the ultimate unity, or wholeness, of
the umverse (Sarter, 1988, p. 74). Rogers holds that the “energy field is integral with the
ip'
Modeling Nursing From an Energy Field Perspective
environment, while at the same time "every energy field is identified by a unique pattern
wh.ch implies that it has a personal, ontological reality” (Sarter, 1988, p. 74) Rogers refers
to man as “a unified phenomenon subject to natural laws . . . man's consciousness and
cruativ!ty me integral dimensions of man's wholeness” (1970, p. 34). The ontology of
wholeness provides the basis for Rogers’ work.
The phenomenon of concern to nursing, according ro Rogers, is people and their environmenrs whereas the purpose of nurses is to promote health and well-being for all persons, n 970. she identified the model ot the “lite process in man" as nursings conceptual
mode . She deemed nursing a humanitarian science with a focus on rhe irreducible nature
ol indnuduals-umtarv human beings-and environment. The fundamental ontological
umr is the human energv field (Sarter, 1988). Rogers described the continuous mmual
process Ivtween tire human be,ng and his or her env.ronmem in terms of resonance helicv,
and mregrahry all ol winch are homeodvnamic principles (see Box 6-1). The human beinu
IS an energv neld in constant internet mn with the environment. Postulates underlvinv rh2
system include energy held open system, pattern and patterning, pandimensionalinjand
the theoiy of accelerating evolution. 1 he theory of accelerating evolution holds that “|r|he
re.>h-..o(cvo|1,r,onnrvvhange.sexp|!e,1 X Ian's development through time reflects grow, m.
complexuy of pattern and,.rgammtim," , Rogers, 1970, p. 27). Manifestations of relative
d.veistty 'nh'-klparierning describe the conrintiotK change nr human-environment process
Language or Rogers' Theoretical System. Rogers' theoretical svsrem prefers rhe term
fawmee nmdertaes over mt. n cmi..,,..- l,eQll4;le „r rbc
;|nJ CJus:i|
U!tVi' Kr,:''c‘"’”,'rv "n"'>ilr' •'■-'dr I'oolrtv. srrch as/rreJrctron. /n-r./rnbr/n-v. oru-rrenrrtm
""si rtusis an not appropriate. 1 Inscriptions in the literature of the nurse as
human energy field in contrnuous mutual process with patient are sparse. Malinski (1994)
svnthesizcd rhe evolut., m ,9 rhe SUHB and identified rhe contemporary vocabularv..f the
work, notably /t.mernmg and fw/imcnstrnm/ity. Patterning replaces the metaphor . ,t
repatrernmg, and pandtmensionaliry replaces four-dimensionality or multidimensionality
Malinski S work perns out language's limitations in conveying Rogers' intentions. Rogers
'n'Ll"k U5cJ rl'- '■'«l'''l:'i-y Ot old paradigms
express her new worldvmw. Although
hogets concepiualovd f,, ntve.se as n nhttet.r, temporal, and nonspattal, she relied
nevertheless.,nlmct temp. .,-,1. and spatial referents u, describe human patterns. Until the
language and metaphors, mb,. n„w view ,re tden.ified md accepted, rho natural limimtrnr,
7"1;A Ai ""11 ittn 'VWB' 'lW,k
-T'-Tiu meanings are essential tor rhe
tleveh>pinu:u .-I nui'inn -.
Supporting Sciences. ■Xicnce' that support Kogers' work include quantum phvsics,
svstems, ebuo','.mJ < . mnlu in- Q"anrum phv<iC' present' the principle' t.f unpin
Jict.ii'ilirx, unviM'. mJ v !•■ : ''i 'p'n. ' ■’ M Quantum phv-i -> .ipphes the principle' w
■-i'- w .am n,-1 up.' l\-rw.-cn mJ among rhe varr u- pat icb-s
Description of Rogers' Model and Theories
Model of Unitary Human Beings. Structural elements of Rogers’ model of unitary human
beings include definitions of terms, postulates accepted as assumptions, principles of
homeoilvnamics, and correlates of human patterning (Sarter, 1988). These are presented in
Box 6-1 (principles), and Table 6-1 (definitions). No sketches or schematics are found in
the available literature. Rogers recognized the difficulty ol efforts to schematize fourdimensionalitv; she dul not develop a symbolic model but used the “Slinky” tov tn het
early work to illustrate iionrepeating. uni direct tonal rhvthmicit ics The complexity of
Rogers' model, especially .is it relates to pandimensionality. makes it difficult to present
schematic.ilk. Sarter (16S8) proposed that Rogers' model is evolutionary in that :t is “a
process of change toward higher frequency wave patterns and increasing diversity of
pattern-' in rhe Imman .md envinmmenral fields" (p. 64)Theories and Models Associated with Rogerian Science. In 1981, Rogers presented
her work a- 1 paradigm for nursing as an organized conceptual system based on unitary
man md e-w ironment . irreducible wh< des Manv rhcories are or can be derived from one
paradigm, ixog-.-r-' tdciinficd iwo theorte' from her parad.gm- -accelerating evolution (or
change) a i the paranormal ( 1992a). The theory ol accelerating evolution proposes that
rhe rate • -t evolution increases at a continually accelerating pace and that change occurs
increasingly rapidly. The paranormal is based in the vnergv field concept and attributes socalled paranormal events to varying manifestations in field pattern.
The anil of maly-'i-1 >i Rogers is the human energy field, manifested in pattern and recog
nized h\ anoi her cnerev Held through pattern recognition in rhe relative presence. Subatomic
wave md particle rhe.’tv mav t>r may not have meaning in understanding the person. Until the
science develop' more fully, scholars arc limited to metaphors and analogies to explain their
hypotheses, /aur-p.
as Rogers (1992a) defines it. consists ol energy—the “dynamic nature
ot the field'' (p. 29) and field, which R infinite, unifying, ami continually mobile. Rogers does
not address issues related ro matrer or panicles. .Another energy field’s perception of a pattern
i-ib’
i.i.i'-..•
>1 •- icncc pcrspx cr 1 \c. Tlic type'of parrerns and patterning are de
scribed bur no’ . xpl.aned b is not know u, t< >r e -aimplc, how an energy field perceive'
I’ c i' handh d :hc u-. . • c'ierg\ field theory 111 a study of family and group pattern
manifestation' ( 1992.0 As with knowledge development from any paradigm, all cxren■' ex' y. -J-o. 11'mu'i l\ ■, • ai'is'; a with t i’e basic phenomenon of c. ncern > r on.•
b’lu-V. II’
‘-■IJ MKl <
field; each has pattern and exist'
ll’ilv 4: •
I
128
CONNECTIONS
Nursing Research, Theory, and Practice
Barrett conceptualized power as “the capacity to participate knowingly in the process of
change characterizing the continuous patterning of human and environmental fields”
(1990a, p. 106). She derived this conceptual model from Rogers’ principle of helicy.
Barrett’s model is one of only a few that represent the unitary human perspective. Phillips
(1990) suggested that the perspective of human field image is one manifestation of the hu
man energy field in continuous mutual process within the pandimensional universe.
Phillips (1990) differentiates human field image (HF1) from body image, noting that HFI
synthesizes all the “changes that have occurred in the past and all projected future HFI
into what is known as the relative present HFI” (p.14). He describes a concept of health
consistent with the HFI perspective as a “eudaemonistic model of health concerned with
general well-being and self-realization" (p. 16). Barrett (1990a) developed rhe methodol
ogy of pattern manifestation appraisal and deliberative mutual patterning called practice
modalities. Thomas (1990) introduced the 1 luman Environment Encounter Model to clar
ify the nurse-patient process. Cowling (1990) constructed a template for unitary pattern
based nursing practice as an extension of Barrett’s 1988 study and identified nine con
stituents of pattern-based practice.
RESEARCH DERIVED FROM THE SCIENCE OF UNITARY
HUMAN BEINGS
...K’l
j:::n
IS
Rogers believed that knowledge development was an open-ended, evolving process. Con
cepts of pandimensionaliry and integrality collapse the space-time experience and lead re
searchers to consider change acansal. This kind of knowing is more congruent with a con
structivist than a positivist or postposirivist worldview of science, despite the fact that
Kogers began her work when positivism was a commonly accepted worldview.
Consequently, measurement of phenomena within a Rogerian worldview presents chal
lenges. The SUHB is unique because, unlike other science fields, the unitary humans the
ory is a synergistic phenomenon, the behaviors of which cannot be predicted by rhe sum of
rhe parts (Cowling, 1986a) and because it transcends accepted notions of rime and space
(Rawnslcy, 1990). This uniqueness creates difficulty because traditional positivist models
of quantification are linear and reductionistic, whereas the unitary world is conceptual
ized as wholistic and nonlinear. Critical problematic elements of rhe research process in
clude hypothesis formation, variable identification, operationalization and measurement of
variables, and research design selection (Cowling, 1986a). Hypotheses accommodating the
irreducibility of humans to parts, the premise of noncausality, and continual change arc
difficult to develop. Sherman (1997) recommended using acausal language in hypotheses
and selecting either descriptive or explanatory designs for studies. Barrett (1990a) indi
cated that quasi-experimental designs also might aid in testing unitary human field prac
tice modalities.
Carboni (1992) suggested that Rogerian research constructs must address the entire sys
tem. Additionally, rhe research process must be considered a changing and murualh pro
cessing relationship between rhe researcher and the research focus. These two aspect- are
difficult to achieve in a science that relies primarily on quantification. Although qualita
tive research methods support a more wholistic approach to the study of phenomena.
Barrett (1990a) indicated that neither quantitative nor qualitative methods capture the whole.
U nforrunarelv. ir i- dnti- all
to di'.'t
divorce
ih n>
>rc<_ th core-based studies from prevalent rc.-< areh
B.invn ' 1
rh.ii rl .■ incongruence between research metho.L .md
CHAPTER 6
Modeling Nursing From an Energy Field Perspective
129
Rogerian wholism should be acknowledged but not rejected. Barrett, Cowling, Carboni,
anef Butcher (1997) indicated that scientific methods are not paradigm-specific bur should
fit the objectives of the investigation. Barrett (1990a) emphasized that methods of science
are tools and should not be confused with the phenomenon of interest. She recommended
that the phenomenon of study, the question asked, and the congruence of methods with
Rogerian science should determine method selection. To overcome the incongruence be
tween philosophy and science, researchers should focus on manifestations of irreducible
wholes_ framing research questions in four-dimensional wholism rather than in a three-
dimensional context.
Research Instruments
Throughout rhe history of development of instruments for Rogerian studies, rhe measure
ment techniques have been controversial. Whereas early instruments tended to be quan
titative, new qualitative Rogerian methods recently have emerged. In 1978, Ference de
veloped one of rhe first instruments to measure field motion (1986a). Other quantitative
measures followed. In 1983 Barrett developed a measure of power that has undergone sub
sequent refinement (Barrett & Caroselli, 1998). As measures developed, semantic differ
entials have proven useful, and qualitative investigative techniques have also begun to
emerge. Carboni’s suggestion (1992) for investigating mutual exploration of the healing
human field-environmental field relationship used an experiential approach. Barren.
Cowling. Carboni. and Butcher (1997) suggested that pattern appreciation can be exam
ined through case study. Bultemeier (1997) developed a system of photo-disclosure, which
was based on phenomenology and visual research as for data collection and analysis. Efforts
exploring new ways to investigate Rogerian phenomena arc ongoing. The following is a de
scription of instruments and methods used to measure manifestations of patterning. Table
6-2 present-' i summary of instruments developed with rhe SUHB and offers helpful infor
mation on rhe nature of the instruments and their validity and reliability.
Human Field Motion Test. Developed in 1978. the Human Field Morion Tc<r (1IFMT)
was the first instrument specifically designed to measure human resonance. The HFMT
consist- of rwa concept-: “my motor running” and “my field expansion, which are
measured by a total of 20 semantic differential scales. Ference (1986a) investigated the
relationship between human field morion and synergistic development, which included
aspects of rime experience, creativity, and differentiation. Two dimensions were found to
account for the relationship between synergistic development and human field motion.
The complexity-diversity dimension reflects a slow-changing pattern and organization.
The human field morion dimension was considered a development characteristic that
contributed to pattern and organization and accounted fora space-rime coordinate. It also
has serx ed is a standard of comparison for other human field motion measure.- that were
developed later. Untortunatelv. published information on development of the HFMT is
limited.
Power as Knowing Participation in Change Tool. The Power as Knowing Participation
in Change Tool (PKPCT) was derived from Barrett’s power theory, which is based on
Roger-' SUHB Believing that people participate knowingly in change. Barrett (as
described m Barrett
Uaro-elh. 1998) first began work on rhe PKPl . F in 19>.Barrett
deigned dw 1'KIX H as a -eric-ol <emanrie different iai scales rhai could be ns< I
mc.i-ure
four b •!;■
uei ' ■ .crern manifestation^ ch uactcrtzing power: U ) awarene- t-’) choice-,
T'v. oa-oH o.p. iA-
3
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TABLE 6-2
m
n
Rogers* Science of Unitary Human Beings
Instrument/Description
Study/Year
Reliability and Validity
Human Field Motion
Test (HFMT)
20 semantic scales
measure two
concepts
Ference, 1986a
Five experts established content validity for initial items. Pilot testing with 43 subjects detected retest reliability of
0.77. Two concepts and 20 scales were retained. The HMFT tested 213 subjects and assessed for retest reliability and
construct validity with factor analysis. Retest reliability was 0.70. Correlations of each scale ranged from 0.51 to
0.77; the correlation of the score for each concept ("my motor running” and "my field expansion”) to the total test
score was 0.87. Three factors emerged, and each scale loaded onto at least one factor. Scale wave frequencies were
congruent with judges' predictions. Canonical correlation was used to assess the relationship between the HFMT and
synergism, as measured by the Time Metaphor Test, the Adjective Check List, and the Group Embedded Figures Test.
Two significant covariants emerged: complexity-diversity pattern, which accounted for 41% of the variance, and hu
man field motion, which accounted for 37% of the variance.
Power as KnowingParticipation in Change
(PKPCT)
PKPCT VII or Version II
48 items plus four
test-retest items us
ing 7-point semantic
differential format
Barrett, 1986, 1990b
Temporal Experience
Scale (TES)
24-item, 5-point Lik
ert scale containing
three subscales with
eight items each
Paletta, 1990
Content validity for metaphors was established by experts. Items were rated according to wave pattern by judges
and then classified into patterns using the judges' mean score. Item classification was validated by Rogers. The re
maining items were classified by a sample of 305 subjects. Subjected to principal factor analysis with oblique rota
tion, three factors emerged. Time dragging accounted for 50% variance, time racing for 29%, and timelessness for
21%. Reliabilities were: for time dragging, 0.821; time racing, 0.736; and timelessness, 0.791. The study with 120
subjects found reliabilities of: Dragging = 0.38, Racing = 0.7161, and timelessness, 0.7836, Variables of sex lan-
Perceived Field Motion
(PFM)
11-item semantic
differential with
7-point scale
Yarcheski and
Mahon, 1991
Literature review was used to extract 12 adjective pairs describing human field motion. Content validity was estab■
lished by three experts. During content validation, one pair of adjectives was deleted, for a total of 11 remaining
pairs. Principal components factor analysis assessed construct validity. Two factors emerged, with seven items
strongly loading on the first factor of motion and potency. Because only two items loaded on the second factor, the
factor was not used. Internal consistency reliability was assessed for 116 early adolescents, 116 middle adolescents,
and 116 late adolescents (alpha = 0.77, 0.79. and 0.83 for the respective adolescent groups). Reliability for the com
bined adolescent groups was 0.12.
Two judges' studies were used to establish content validity: (1) rating adjectives to describe power and then rating
43 bipolar adjective pairs; (2) experts rated four contexts of power and 38 items on a semantic differential. Items re
ceived mean ratings from 4.0 to 6.75. A pilot study of 267 adults was followed by a study of 625 adults aged 21 to
60. The reliability of the initial PKPCT ranged from 0.63 to 0.99 for the four subscales. Test-retest reliability with a
3-week interval of 25 undergraduate college students ranged from 0.71 to 0.82 for the initial PKPCT and 0.61 to
0.78 for Version II. Factor analysis revealed four factors with loadings ranging from 0.56 to 0.70. Canonical correla
tions with HFMT accounted for 40% of the variance. In other studies using the PKPCT, internal consistency estima
tions ranged from 0.81 to 0.93 for the subscales and from 0.94 to 0.97 for the total scale.
Yarcheski and
Mahon, 1995
Internal consistency reliability was assessed with 106 early, 111 middle, and 113 late adolescents. Coefficient alpha
levels were 0.80, 0.80, and 0.83, respectively.
Human Field Rhythms
1 item, 100 mm vi
sual analog scale
(VAS)
Yarcheski and
Mahon, 1991
Content validity was derived from Rogers' manifestations of frequencies of human field rhythms. One-day test-retest
reliability was reported for 10 early, 10 middle, and 10 late adolescents (r_= 0.93, 0.96, and 0.86 respectively). Verbal
end descriptors of VAS were congruent with Rogers' theoretical statements.
Mutual Exploration of
the Healing Human
Field-Environmental
Field Relationship
Carboni, 1992
Diversity of Human
Field Pattern Scale
Hastings-Tolsma,
1992 (as cited in
(DHFRS)
Watson, Barrett,
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33
CD
tn
CD
CU
A
o
QJ
□
Q.
TJ
a
2
r>
z:
>
Cl
16 item, 5-point
Likert scale
2
o
s-
=:
IQ
Hastings-Tolsma,
Johnston, &
Gueldner, 1997);
Hastings-Tolsma,
1996
The instrument was designed for experiential research. Configurations of patterns within a field determined the exis
tence of healing nurse-patient relationship. Suggestions were made for mechanisms to establish reliability and valid
ity, but no information was offered for actual use.
Face (content) validity was established by two experts. In a pilot study with 320 adults, one factor was extracted by
principal components analysis. Validity coefficients ranged from 0.36 to 0.62. Correlation of the DHFPS and the HMFT
was modest but significant at B = 0.001 (value not stated). Reliability was 0.83. The revised DHFPS was tested with
173 volunteers. Factor analysis demonstrated a unitary factor with validity coefficients ranging from 0.22 to 0.68. Co
efficient alpha was 0.81.
Z
C
82
5'
IQ
o
2
□
m
r&
IO
31
2^
Q.
?
Continued
a
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TABLE 6-2
n
.. ........................
tearch Instruments Using Rogers* Science of Unitary Human Beings—cont'd
Instrument/Description
Study/Year
Reliability and Validity
Human Field Image
Metaphor Scale
(HFIMS)
25 metaphors rated
with 5-point Likert
scale
Johnston, 1994
Metaphors were generated and validated from literature and expert consultation. The initial metaphor list was ex
panded, refined, and reduced following consultation with Rogerian scholars. A 32 item HFIMS was pilot-tested with
50 healthy subjects who completed the HFIMS, the IFE, and a demographic data sheet. Principal components analysis
revealed six factors, which were reduced to four by deleting two single-item factors. Correlation with IFE = 0.5928
(p < 0.01), Cronbach's alpha = 0.9291). In the major study of 358 healthy adults, principal component analysis re
vealed five factors that were reduced to three because two factors had insignificant loadings. Three remaining factors
(expressions of clear human field image, expressions of blurred field image, and integrality) accounted for 54.8% of
item variance. The remaining 25 items had a Cronbach's alpha of 0.9131. Correlation with IFE was 0.7056.
_____________
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g_
-i
Index of Field Energy
(IFE)
18 pairs drawings
with 7-point scale
Gueldner, Bramlett,
Johnston, and
Guillory 1996
Person-Environment
Participation Scale
(PEPS)
15-item semantic
differential with
seven gradations
Leddy, 1995
Psychometric testing was completed with two samples of 278 and 357 older adults. Composite internal consistency
reliability was reported as 0.9464, and item total correlations ranged from 0.5023 to 0.8038. The IFE has a correla
tion with the HFMT of 0.6679, with the HFIMS of 0.6647, and the PKPCT of 0.7841. Factor analysis indicates the
presence of two factors (nature not specified).
o
Psychometric testing was completed with three overlapping samples initially containing 239 ambulatory adults; six
months later with 125 adults, of which 104 had previously responded; and one year following initial testing with
136, of which 72 had been previously tested. Internal consistency reliability ranged from 0.90 to 0.94. Test-retest reli
ability with a 2-to-6-week interval was r = 0.74. Stability at 6 months was r = 0.52 and at one year was r = 0.60.
Construct validity, established through principal components factor analysis, revealed two components: expansive
ness of participation, accounting for 46.5% of variance, and ease of participation, accounting for 10% of variance.
The PEPS inversely correlated to the Fatigue Experience scale (r = -0.40) and the Symptom Experience Scale (r =
—0.42). Discriminant analysis revealed that the PEPS correctly discriminated between persons reporting one or more
health problems and those reporting none. Concurrent validity revealed a relationship between sense of coherence
and the PEPS scale (r = 0.70) and the PKPCT scale ([ = 0.69).
2
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..........
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Leddy Healthiness
Scale (LHS)
26-item, 6-point
Likert scale
Assessment of Dream
Experience (ADE)
20-item, 4-point
Likert scale
Leddy, 1999
the—
stability of the
Data were analyzed from 53 subjects who had completed all prior PEPS testings in order to assess t..
..._—
construct of mutual process. Low stability coefficients, ranging from 0.246 to 0.698, indicated the concept of partici
pation as fleeting.
Leddy, 1996
Fifteen to 20 items were generated for each of nine theoretical dimensions and yielded 72 items. Following expert re
view, 24 items were reworded and 13 replaced. CVI for revised scale items ranged from 0.97 to 0.99. The number of
items was then reduced to 36, based on corrected item total correlations. A sample of 356 adult volunteers and a
subsample of 125 were used to assess construct factor analysis and convergent and divergent validity as well as in
ternal consistency and stability. Factor analysis reduced the item total to 26. These items were composed of three fac
tors (purpose, power, and connections), which accounted for 51% of total variance. Convergent validity was obtained
by comparing: LHS to one item on well-being (r = 0.62); LHS to Sense of Coherence Scale (r = 0.70); LHS to PKPCT
Scale (r - 0.62); LHS to Physical Well-Being Scale (r 0.74); LHS to Personal Meaning Index Scale (r = 0.62). Diver
gent validity was tested after 1 year by comparing the LHS to the Fatigue Experience Scale. As fatigue increased, LHS
scores decreased (r
-0.41). Internal consistency reliability for subscales ranged from 0.66 to 0.87, and total scale
reliability ranged from 0.90 to 0.92 over measures made at baseline, 6 months and 1 year. Test-retest reliability for
2 to 6 weeks was r = 0.86, 0.58 for 6 months, and 0.61 for 1 year.
Leddy, 1997
• In a follow-up study of 53 women with cancer and 89 healthy subjects, internal consistency of the LHS was 0.93 and
test/retest reliability over 2 to 6 weeks was 0.83.
Watson, 1999
Content validity was assessed by 10 experts. Factor analysis of 100 participants revealed two factors that accounted
for 36.8% of the variance: high diversity dream experience and low diversity dream experience. Reliabilities for the
two factors were 0.823 and 0.740, respectively. Alpha coefficient for the total scale was 0.84. In the subsequent main
study the two factors accounted for 46.3% of the variance, and the alpha coefficient was 0.87.
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134
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 6
(3) freedom to act intentionally, and (4) involvement in creating change. Over the years,
the PKPCT VI—or Version 1—and the PKPCT VII—or Version II—were developed.
Version 11, now the accepted version, deleted modifications by self, family, or occupation,
which were present in the first version, because no statistically significant differences were
found (Barrett, Caroselli, Smith, &. Smith, 1997).
The PKPCT Version II is a 48-item scale containing four sets of 12 pairs of bipolar ad
jectives and four retest items, one for each dimension of power. Two types of scoring can be
used with the PKPCT. Factor scores are recommended for hypothesis testing (Barrett,
1990b). Alternatively, each power scale can be summed for a score ranging from 12 to 84,
or the total scale can be summed for a score ranging from 48 to 336. Higher scores repre
sent greater manifestations of power.
To date, the PKPCT has been used in nearly 40 power studies (Caroselli &. Barrett,
1998). Power has been commonly studied with other variables, such as reminiscence, cre
ativity, feminism, life purpose, job diversity and satisfaction, anxiety, empathy, trust, and
well-being. Version 11 has been translated into Japanese. Korean. Swedish, and Finnish
(Watson, Barrett, Hastings-Tolsma, Johnston, Ck Gueldner, 1997); however, rhe difficulty
of reading the PKPCT has led Barrett to recommend that the instrument he used only u ith
subjects who have at least a high school education (Barrett G. Caroselli. 1998). The clar
ity of rhe PKPCT’s instructions has also been questioned. Many have recommended further
siudic< io test the PKP( 'T’s sensitivity in detecting group differences and to establish norms
for various populations (Barrett Ck Caroselli, 1998). Another issue of concern is that
PKPCT ''Cores tend to be biased upward, which could be a product of social desirability in
respon>es (Barrett Ck Carobclli, 1998; Watson, Barrett, I Lisiings-Tolsma. Johnston, <k
Gueldner. 1997)
Temporal Experience Scales. The Temporal Experience Scales (TES) collectively
con>Ht of three scales: the Time Dragging Scale, rhe Time Racing Scale, and rhe
Tinielcssncs.- Scale. Each scale contains eight metaphors rated on a five-point Likert scale.
Adequate level- ot contera and construct validity were established, but the exact process
for establishing content validity was not clearly described. For a new instrument, adequate
levels of reliability for each of the three scales were demonstrated. Findings during
instrument development indicate the TES is useful for measuring sexual, lingual,
educational, and occupat i> nal biases in adults aged 20 to 50 years (Paletra, 1990). Based on
her 1990 studv of temporal experience Paletta called for additional development of the
TES instrument item configuration and determination of the groups for which rhe TES is
,
considered an adequate rest of temporal experience.
Perceived Field Motion. To measure human field morion in adolescents Vircheski and >
Mah' >n (1991) developed a test of Received Field Motion (PFM). The PFM consists of seven [
adjective pairs, and scores range from a low of seven (perceived slow morion) to a high of 49 J
^.perceived fast motion) (Yarchoki & Mahon. 1995). Internal consi-tency levels lor early,
middle, and late .idolcwenr- in two, -tudie.s (Yarcheski Si Mahon, 1991, 1995) were adequate
F- r l .e a age • ■: m.-tiument development. Unfortunately, rhe internal consistency e<timarion
for combined adolescent groups in rhe 1991 study was extremely low.
Human Field Rhythms. H.mran Fit’Ll Rhythms (FIERI repre-enr rhe dyn.imic between
rhe ui’iiied whole per- a ,ind environment. Yarcheski and Mahon 11991) developed a
visual .mak e
A- u Hie.m.ire Luman field rhythms to accomp.iir. use of rhe PFM Seale
Modeling Nursing From an Energy Field Perspective
135
This 100-mm visual analog scale contains verbal descriptors of low frequency and high
frequency at the two poles of the scale. Subjects respond by placing a mark along the analog
scale at the point that best represents their field rhythm. Scoring is accomplished by
measuring the mark location from the zero endpoint of the scale. Higher scores represent
faster human field rhythms. Content validity is derived only from theoretical frame of
reference. Tesr-retesr scores indicate strong stability, but rhe time span between retesting
was short. However, a short retest time span might be appropriate in light of the fluidity of
field rhythms.
Mutual Exploration of the Healing Human Field-Environmental Relationship.
Carboni (1992) developed the Mutual Exploration of rhe Healing Human FieldEnvironmental Relationship to measure changing configurations ol energy field patterns
that help determine the existence of a healing human field-environmental field
relationship. Based on the premise that rhe healing human field-environmental
relationship is a wholisric reflection ol a nurse-patient interaction, the Mutual Exploration
of the Human Field-Environmental Field Relationship structures joint exploration and
description of the healing relationship, ('hanging configurations reflect affirmations of
wholeness and promotion of healing through cooperative relationships between nurses and
patients within their environments.
The instrument is desimied lor experiential research in which participants contribute
not only content but also "creative thinking that generates, manages, and draws conclu
sions from the research” (Carboni. 1992; p. 119). Additionally, the researcher participates
in the activity being researched. Although mutual exploration i> a joint process, the nurse
should facilitate mutual completion. Acknowledgment of mutuality requires validation b\
both the nurse and patient. 1 he outcome of mutual exploration is a creative understand
ing of the healing human field-environmental field relationship. Verification of i heading
relationship must he evident ed by wholenes> and harmony.
Diversity of Human Field Pattern Scale. SUHB field pattern di' c:>itv reflects
individual capacitio to participate in change through involvement in creating transitions
and influencing human-environmental field connections (Hastings-Tolsma, 1996).
Greater diversity of rhe human field is thought to promote increasinglv varied and
innovative field design. To measure field potential, Hastings-Tolsma (1996) created the
Diversitv of Human Field Partem Scale (DHFPS), a 16-item, five-point Likert scale.
Potential scores range from 80 to 16, with lower scores indicating greater diversity of
human field pattern (War-on, Barrett, Hastings-Tolsma, Johnston,
Gueldner, 1997).
The HHF1 S might elucidate how individuals create change. It shows promise as a new
instrument in measuring human field potential. Additional work
>rk is needed to further refine
the measure of field pattern diversitv.
Human Field Image Metaphor Scale. According to Johnston (1994). human tickl
image encompasses ikic awareness
the infinite wholeness of the human field. Tw.
vimuain-- \\ itlun ilic human. Id image—perceived potential and integrality—are measured
bv rhe Human Held Image Metaphor Scale tHFIMS). The HF1MS rate- 25 metaph -r-on
a five-point Likert scale. >ix of the metaphors express a strong sense of potenrialitv; I 2
expiv- a p. -irr • per, •pu .-'. oi integr ilitv; five express restricted potential, in Liu 1c\p-us1 -'■ '! i^din -n. lh. . de
cin> with the stem "I iccl,” which i- fol!- u .-J b\
*‘!
::io• - me
I :<e toe-; , •mt resps.nsc> exiend In an "do nm jJentif\'
136
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 6
to “totally identify,” and scores range from 25 to 125. The HEIMS can shed light on
important strength.
(Watson, Barrett, Hastings-Tolsma, Johnston, & Gueldner., 1997; Johnston, personal
Watson's Assessment of Dream Experience. Watson’s Assessment of Dream Experi
ence (ADE) (1999) attempts to measure dreaming in a way consistent with Rogers’
communication, April 28, 1999). It is based on the premise that individuals with diverse
human field patterns have a sharper, clearer perception of human field image, enabling
conceptualization. Dreaming was a “beyond waking” experience as described By Rogers’
knowing participation in life choices and changes. Less diverse human field patterns yield
longer sleeping/longer waking/beyond waking manifestation. On the 20-item scale, 11
a blurred image and a more passive acceptance of life experiences. Initial work on reliability
items characterize high diversity dream experience, and nine indicate low diversity dream
and validity is strong. The HEIMS is available in German and Spanish and has been used
experience indicators. Participants indicate the extent to which the words on rhe ADE
to measure field image with a variety of groups, including schizophrenics (Johnston,
describe their drcams from the previous two weeks. Adequate internal consistency
personal communication, April 28, 1999).
reliabilities were found for the pilot and main study. Adequate content validity was
Index of Field Energy. 1 he Index of Field Energy (1FE) measures human field dynamics
of older adults or adults who cannot read at a high school level (Gueldner, Bramlett,
established, and a beginning basis for construct validity was demonstrated. Watson (1999)
indicated that reconsideration of the scoring mechanism may include reporting a high
Johnston, Ck Guillory, 1996). It consists of 18 pairs of black and white line drawings.
diversity score and a low diversity score. Watson (1999) recommended that the instrument
Sketches represent low or high frequency. Each sketch pair is connected with a seven-point
be used with larger and more diverse samples, because women in the instrument
scale that allows participants to indicate the point that “best describes how you feel right
development study tended to rate themselves as healthier, more active, and better educated
now." Two versions of the 1FE arc available—a pencil and paper test
rest and a board game
(Watson, Barrett, Hastings-Tolsma, Johnston, & Gueldner, 1997). Ongoing work on the
than national norms. Watson plans further refinement oi the ADE and seeks greater
exploration of the nature and meaning of “beyond waking” experiences.
IEE will add to the limited information regarding the psychometric testing of the IFE.
Photo-Disclosure. Seeking an innovative method to appraise field patterns from a
Person-Environment Participation Scale. Leddy (1995) developed the PersonEnvironment Participation Scale (PEPS) to measure mutual process, a manifestation
wholistic perspective. Bultemeier (1997) created photo-disclosure. Photo-disclosure is
based on a combination of phenomenological and photographic research techniques.
within the SUHB. Mutual process describes the integral nature of human and en
Phenomenology approaches research from a wholistic perspective, focusing on rhe lived
vironmental fields. The PEPS is perceived as an extension of available measures that
describe rhe field pattern of motion and is directed specifically toward measuring
reality of research participants. Native photography uses photographs taken by subjects,
and photo-elicitation involves participant response to photographs of themselves, their
“experienced expansiveness and ease of mutual process” (Lcddv, 1995, p. 2 3). The PEPS is
environment, or other photographs. In photo-disclosure, simultaneous native phorographv
a semantic differential with a seven-point gradation containing 1 5 bipolar adjective pairs.
and written narrative captures the phenomenon of interest. Rather than rhe photo serving
Adjectives represent continuity (integrated/fragmented). case (smooth/rurbulenr), comfort
as a probe, it becomes a data source for capturing lived experience. In Bultemeier’s study of
(calm/ agitated), influence (powcrful/powerlcss), and energy (cncrgetic/lcthargic). Scoring
women with premenstrual syndrome, women responded to the stems “The title I would
is accomplisheil by reverse scoring selected items and summing the responses for a total
give this photo is . . .
instrument score. Scores range from 15 to 105, with higher scores representing higher
“1 took this photo to show . . . ;” “When 1 took this photo I
felt. . . :' and "Right now I wish 1 could . . .” Phenomenological research techniques guided
participation.
Strong internal consistency reliability has been demonstrated psychomctrically
thematic analysts of the data. Gathering data in a wholistic manner without preset
limitations on phenomenon description is one advantage of this approach.
(Leddy, 1995). Stability scores indicate that participation is a temporary, fleeting, and
Pattern Appreciation. Believing that patterns were a distinguishing characteristic of
changing construct (Leddy, 1999). A solid ba>i> exists for initial construct validity. Leddy
energy fields. Cowling (1997) proposed pattern appreciation as a "process, an orientation,
(1995, 1999) indicates that the PEPS is useful in mc.iMiring expand vencss and case of
and an approach tor research and practice" (p. 1 H). Cowling perceives, consistently with
participation a phenomenon that could be facilitated through musing inieiventions
that pattern rhe environmental field. Examples include noninvasive modalities of ther
rhe SUHB, that human field patterns are unique. Appreciation permits sensitivity in
noticing, perceiving, and recognizing patterns and provides a “grounding context for
apeutic touch, such as reiki, music, light, or aromatherapy.
mutual sharing" (1997. p. 131). Pattern appreciation involves rhe following (Cowling.
Leddy Healthiness Scale. The Leddy Healthiness Scale (LHS) (Leddy. 199h. 1997)
measures rhe perceived purpose, connections, and p.'wcr that arc components of a dynamic
1997):
process .if healthiness. The LHS has 26 items on a six-point Liken stale, and scores can
range from a low of 26 to a high of 156. Higher scores indicate healthiness. As a new
from two studies suggest strong internal consistenc1. rcii.ihlitv (Lcddv. !99n. 'O'T’ The
three factoi ■•ubscalcs have lower levels of reliabditv. I'ur ..ilph is a •mam -i nt n lent tor a new
137
instrument. The instruments stable measurements even after 6 months to a year are an
individual health perceptions and health behaviors and might be useful for self-assessment
instrument rhe LHS demonstrates promise. Content and construe! techniques suggest
validity, and coefficient alphas for the total scale ranging from c.'ip.
p
in
Modeling Nursing From an Energy Field Perspective
•
Engagement with another for exploration of unitary human tick! patterns
•
Explicit intentions made to participants in mutually derived consent process
• Cocrcation for form and structure of engagement
I
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Documental ion of experience, perccpti.'ns, <ind expressions
Journaling ’hat includes
hides theoretical,
thev
methodok>gical. peer revica. and general reiIclO '. e note'
•
:
'prncm • U pattern appre-.
a io;
tile thr ■ugh >vn- 'pO'
138
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CONNECTIONS
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Nursing Research, Theory, and Practice
CHAPTER 6
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.i-'.C'-'-ing p< 'W
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synthesis
Pattern appreciation can be synoptic, participatory, or transformative. Synopsis seeks
the clearest picture of unitary pattern found in data. The process is participatory in that
scientist/practitioner and respondent have equal but different shared responsibility. Pat
tern appreciation is transformative in that it creates new consciousness and awareness that
can generate a context for change (Cowling, 1997).
Summary of Research Instruments. Research instruments based on the SUHB reflect
both quantitative and qualitative research methodologies. The challenges of measurement
within a Rogerian perspective have led to creative efforts such as the Mutual Exploration
of the Healing Human Field-Environmental Relationship (Carhoni, 1992), Pattern
Appreciation (Cowling, 1997), and photo-disclosure (Bultemeier, 1997). Instruments such
as the PKPCT have commonly been used in studies based on the SUHB. Other
instruments such as Carboni’s (1992) Mutual Exploration of the Healing Human
Field-Environmental Field Relationship have yet to be used substantively. Although the
SUHB’s measurement issues have not been solved, instrumentation and research method
development have evolved consistently.
.1111,1 clkiiiiic.
139
■g
Verification of pattern appreciation profile with participant
Conceptual/theoretical synthesis of pattern information
Peer review to ensure logical consistency of process
Audit procedures to review documentation if needed to increase scientific credibility
Developing a case study report that includes pattern appreciation profile and
Research usin.v Rogers’ SUHB has encompassed a range of studies describing or testing
concepts associated with the three principles of homeodynamics—helicy, resonance, and
integrality. Studies dealing with these concepts can be categorized bv power, time passing,
creativity, field morion, interactive rhythms, health, and therapeutic touch. Research stud
ies arc briefly summarized in Table 6-5, which offers the studies' purposes, measurement
methods, and findings.
An overview of Rogerian research follows. Because extensive research has been con
ducted using the SUHB. the specific studies discussed arc intended to be representative.
Priority was given to recent, published studies. This limitation is nor to negate rhe impor
tance of carlv or unpublished work but simply confines discussion ro a manageable length.
Many studies specifically described rhe SUHB and its linkage to study variables. In several
instances studies explicitly described propositions that were rested. On the whole, studies
tended ro be descriptive and/or correlational, which is congruent with thinking about appropriatc research strategies tor wholistic study. However, more recent studies employing
interventional techniques used quasiexperimcnral, repeated measures or. in two cases, ex
perimental design (Meehan, 1995; Samarel. Fawcett, Davis,
Ryan. 199S). Almost all o!
rhe studies used convenience or purposive samples. Support for the SUHB wa> mixed.
Power Studies. Power is one of rhe most significantly researched areas of helicy. It has
been investigated r the onlv variable or in conjunction with other areas such re'> 'iiaiu
integrality, lemini-an, temporal experience, spirirualiiv. health perceptions, life satisfaction.and remini>ceni
k c. Over time,
I line, Barrett s PKPUT has provided a strong mechanism for
Modeling Nursing From an Energy Field Perspective
&
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1-4
TABLE 6-3
c
Study/Year
Purpose
POWER-cont'd
McNiff, 1997
“
—
Methods
n
O
Findings
The Study investigated the relationship be-
z
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Cam
needs resP°ntfed to the PKPCT
B npL:dder'OrH-^-d index 0 We C '
8™g. Pearson corretations reused to assess
n
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Smith, 1995
-OOlrespectivefyJ.NodiffeX'bXlr
Tda s'udy^™ed to identify relanonshi be.
groups for the three variables were found.
O
ru
A positive relationship between power and
3-
established^ 0.34, B<
O-OOS). Pol,o SUrvivors did not exhibit qreater
power t ap participants who had not eZi
need a life-threatening event. Survivors ex-
o
One hundred seventy-two polio survivors and
lhePKWTSand0?adn7,,adp0'ioco'npl«ed
(SOI)
SP|nt™l Orientation Inventory
TIME
Rawnsley, 1986
□
Q.
The study tested the relationship between
nJ
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issF
second time lapse. Yot
,
. ounger subjects were
more ^f
“^"tecl. Dying persons exhibited
_______ ?■<—- :SrCater L,nl,’1PPi'
Paletta, 1990
CREATIVITY
Cowling, 1986b
Alligood, 1986
Alligood, 1991
The descriptive correlational study tested the
relationship of the magnitude of temporal
experience to human time.
The study investigated the principle of helicy,
proposing that mystical experience, differen
tiation, and creativity were related.
The study described relationships of creativ
ity and actualization with empathy.
This study continued the Alligood, 1986
study.
One hundred twenty graduate female nursing
students aged 20 to 40 years completed the TES
and the Human Time Scale (HTS).
One hundred sixty college students were as
sessed for mystical experience (Hood's Mysti
cism Scale, Factor I), differentiation (Witken's
Group Embedded Figures Test), and Creativity
(Creativity Scale from Heilburn's Adjective
Checklist).
Two hundred thirty-six volunteers aged 18 to 60
completed measures of actualization (Personal
Orientation Inventory [POI]), creativity (Similes
Preference Inventory), and empathy (Hogan
Scale).
Forty-seven additional volunteers aged 61 to 92
completed the measures of actualization, cre
ativity, and empathy.
bnrpdnm
■■ ■-
-
Correlations of the HIS with the three TES in
dicated relationships in the predicted direc
tion. The relationship between timelessness
and HTS was significant (i = 0.266, p <
0.01). In a stepwise regression the three TES
significantly predicted HTS.
n
x
>
■p
As mystical experience increased, creativity in
creased (r = 0.333, p < 0.01). Increases in
differentiation were associated with increases
in creativity (r = 0.167, p < 0.05. Multiple re
gression revealed that 14.5% of variance in
creativity was attributable to the combination
of mysticism and differentiation.
As actualization increased, empathy increased
(r = 0.269, p < 0.001). Increases in creativity
were associated with increased empathy (r =
0.391, p < 0.001. Multiple regression indi
cated combined variables of actualization,
and creativity explained 21 % of variance in
empathy.
TO
o
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C
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IQ
3
3
OJ
m
With the older sample, as creativity decreased,
empathy increased (r = -0.32, p < 0.01),
and actualization and empathy were posi
tively related (r = 0.68, p < 0.01). Creativity
and actualization combined accounted for
48% of the variance in empathy.
ft)
T.
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TABLE 6-3
on Rogers' Sci
Study/Year_____
O
Unitary
Purpose
Z
Methods
Findings
FIELD MOTION (RESONANCY)
Gueldner, 1986
The study investigated relationship between
imposed motion (rocking) and human field
motion.
The quasiexperimental design consisted of.
three groups: (1) rocking at preferred rate (n =
10); (2) rocking at imposed rate of 34 to 36
rocking cycles per minute (n = 13); and (3) con
trol (n - 8). Following a 5-day control regimen,
the three groups participated in 5-day treat
ment regimen, consisting of 10 minutes of rock
ing at the prescribed rate or not rocking. Field
motion was measured with a modified HMFT,
and fatigue was assessed by Smith's
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Repeated ANOVA measures did not reveal any
association between rocking and field motion.
This descriptive study explored the nature of
chronic pain as a human-environmental pa‘lerning process
Of the 226 participants, 113 were placed in the
chronic pain group and 113 in the comparison
group Subjects were matched for age, race, and
sex. Groups were compared on the HFMT and
PKPCT using a MANCOVA to control for the co-
vanate of pain medication use. Differences in
HFM and PKPCT were analyzed using
MANOVA, and questions exploring pattern
manifestation within each group were analyzed
with Pearson Correlations.
Yarcheski and
Mahon, 1991
CD
r = 0.48, p < 0.01; time 2: r = 0.58, p <
0.01, and time 3: r = 0.48, p < 0.01).
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MANCOVA revealed that groups were signifi
cantly different when adjusting for opiod use.
MANOVA revealed that persons with chronic
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pain experienced lower frequency patterns
and lower power levels. Field motion and
power were highly correlated in both the pain
and comparison groups (r = 0.71, p < 0.0001
and r = 0.78, p < 0.0001), but no differences
in the direction or strength of relationship be
tween the two groups were found,
imaginative pattern, diversity of sensory phe
nomena (sentience), perception of time mov
Research Form-E, the Fast Tempo subscale from
the Time Experience Scale, and the Verran/
ing fast, and waking periods in adolescents.
Snyder-Halpern Sleep Scale. The original the
tion and sentience in middle adolescents ex
isted. When examined in distinct adolescent
ory's prediction was that as adolescents be
groups, correlations were found between
came older, their scores on each measure of
PFM, HFR, creativity, and sentience. Human
development as indexed by chronological age
frequency levels of creativity and sentience.
ZT
more rested.
Three groups of 116 adolescents (early, middle,
and late) completed the PFM, HER. Creativity
Scale of the Adjective Check List, Personality
theory, investigators predicted early adolescents
could manifest correlates of the same relative
frequency as late adolescents, and have similar
rt>
Subjects reporting high field motion were
The study examined Rogers' original and re
vised theories of correlates, consisting of per
ceived field motion, human field rhythms,
correlates would increase. To test the revised
i?
A Pearson's correlation between HFMT and
RTS scores indicated a positive relationship
between field motion and restedness (time 1:
Restedness-Tiredness Scale (RTS).
M.it.js, 1997
CQ
Findings failed to support either the original or
revised theory of correlates. No differences in
correlates among the adolescent groups were
found. A correlation between human field mo
was perceived to play a role in emergence of
manifestations of human field patterning. In
vestigators suggested that deletion of terms
implying linearity from Rogers' original theory
should occur only when clear evidence sup
porting a revised theory of correlates emerges.
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Yarcheskiand
The study examined four manifestations of
Three groups of early (n
Mahon, 1995
human environmental field patterning (field
motion, field rhythms, creativity, and sen
111), and late Ch = 113) adolescents responded
tience) in relation to perceived health status
of adolescents.
- 106), middle (n ~
to PFM, HFR, the Creativity Scale, the Sentience
Scale, the General Health Rating Index, and a
demographic questionnaire. Pearson correla
tions assessed relationships among field pat
terns and health status.
Watson, 1997
The study explored a different approach for
explaining sleep-wake cycles of older adults.
It also investigated whether diversity of sleep
rhythm and dream experience was related to
field motion.
Sixty-six women aged 60 to 83 kept a sleep
chart for two weeks and responded to the ADE,
HFMT, and TMT.
PFM was related to health status in all three
adolescent groups (r = 0.24, p < 0.05; r =
0.26, and 0.44, p.< 0.01, respectively). HFR
and creativity were related to health status
only in late adolescents (r = 0.23 and 0.20,
p < 0.05). PMF, HFR, creativity and sentience
explained 9% of variance in health status of
middle adolescents; whereas in late adoles
cents, these accounted for 22% of variance.
Most respondents slept between 6 to 8 hours
per day. Fourteen percent slept less and 9%
slept more. Most woke during the night. As
sleep-wake patterns became more diverse, di
versity in dream patterns increased (f =
0.2945, p < 0.05). No associations between
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TABLE 6-3
I Studies Based on Rogers* Science of Unitary Human Beings—cont’d
Study/Year
Purpose
INTERACTIVE RHYTHMS (INTEGRALITY)
Boyd, 1990
The study assessed the intercorrelation of
daughters' attachment to mothers, mother
daughter conflict, and dyadic identity.
Mother-daughter dyads were felt to repre
sent integrality.
HEALTH
Leddy. 1997
Methods
n
Findings
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z
An ex post facto correlational design was used
to study 81 mother-daughter dyads with the
Semantic Differential Scale, the Attachment
Scale, the Mother Daughter Conflict Scale, and
the Tennessee Self-Concept Scale. LISREL analy
sis examined the fit between the model and the
data.
Empirical support was provided for the pro
posed model. Mother-daughter identification
incorporates mutual influence and shared
identities, but daughter identity was more in
fluential in overall dyadic identity. Mother
daughter conflict over separation and per
ceived differences also mediated the
relationship, but daughter conflict was a more
powerful endogenous variable.
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The study tested relationships among health
iness, fatigue, and symptom experience in
women with and without breast cancer.
Eighty-nine healthy subjects were compared to
53 women with breast cancer that had been
treated within the past 10 years. Subjects com
pleted the Leddy Healthiness Scale, the Fatigue
Experience Scale, and the Symptom Experience
Scale (SES).
Women with breast cancer did not differ from
healthy women in terms of healthiness or fa
tigue or the relationships of healthiness, fa
tigue, and symptom experience. Breast cancer
subjects experienced more symptoms than the
healthy group (t = 2.62, df = 140, p = 0.01).
One hundred twenty-three ambulatory volun
teers completed the Person-Environment Partici
pation Scale, Perceived Stress Scale, Energy/
Fatigue Scale, Leddy Healthiness Scale, Mental
Health Index, Satisfaction with Life Scale,
Current Health Status, and Inventory of Symp
tom Distress.
Path analyses were conducted to assess the
theoretical structure. Theorized relationships
between participation, change, energy, and
healthiness were statistically supported. Paths
from participation to other proposed variables
of mental health, satisfaction with life, current
health status, and symptom distress were ,
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Leddy and
Fawcett, 1997
The study tested an explanatory theory of
healthiness based on Rogers' SUHB.
deleted.
HEALTH-RELATED
The correlational study determined whether
Andersen and
Hockman, 1997
<change in well-being and change in high-risk
drug-related behaviors related to AIDS risk.
Effects of a standard treatment protocol and
a Rogerian based protocol were compared.
Bush, 1997
The study tested the relationship of parental
health perceptions and locus of control to
healthcare follow-up for children with identi
fied health problems.
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Three hundred seventy-five drug users being
tested for HIV received a standard care
protocol—consisting of education, counseling,
and, if needed, referral. In addition to standard
care, another 369 drug users received the LIGHT
protocol incorporating bonding, assessment of
well-being, and teaching. Initial and 6-month
follow-up were completed by 454 subjects.
Data were collected through the Risk Behavior
Assessment, Global Well-Being Index, and Ad
diction Severity Index.
All subjects decreased risk behaviors.The
LIGHT group also significantly improved well
being, which was associated with a reduction
of addiction and risk behaviors. The standard
care group did not improve sense of well
being and experienced greater concerns about
employment, legal problems, and medical
concerns.
A convenience sample of 50 parents or
guardians responsible for their child's health
care completed health perceptions question
naire, Health Locus of Control Scale, and socio
economic questionnaire. Twenty-five were
parents of children who received follow-up
care, and 25 were not.
Locus of control, health beliefs, and socioeco
nomic factors did not relate to healthcare
follow-up for students receiving referrals for
healthcare problems.
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THERAPEUTIC TOUCH
The single trial, single blinded, three-group
Meehan, 1993
design assessed the influence of therapeutic
touch on postoperative pain.
One hundred eight postoperative patients were
randomly assigned to receive therapeutic touch,
a placebo control intervention, or narcotic anal
gesic for pain. A Visual Analog Scale (VAS) was
used before and 1 hour after intervention.
□
Subjects receiving pain medication experi
enced significantly greater pain relief than
therapeutic touch subjects (p = 0.001). Thera
peutic touch subjects experienced greater re
lief than the placebo control subjects, but the
difference was not significant. Placebo group
patients requested pain medication sooner
following treatment than did therapeutic ■...
touch subjects (x2 = 4.69, p < 0.05).
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TABLE 6-3
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Selected Studies Based on Rogers' Science of Unitaiy Human Beings—cont'd
Study/Year
Purpose
THERAPEUTIC TOUCH—cont'd
Peck, 1998
The study determined whether therapeutic
touch (TT) improved functional ability in
older adults with arthritis.
Saniare!, 1992
Samarel,
Fawcett, Davis,
and Ryan, 1998
Turner, Clark,
Gauthier, and
Williams, 1998
Methods
A two-group, longitudinal design with repeated
treatments assessed the efficacy of TT. Baseline
data were collected over 4 weeks, while usual
care was given. Forty-five subjects then re
ceived TT, while 37 received progressive muscle
relaxation (PMR) six times at 1-week intervals.
Subjects completed the Arthritis Impact Mea
surement Scale (AIMS 2) twice during baseline
period and following the first, third, and sixth
treatments.
Findings
TT group baseline AIMS 2 scores were com
pared to postintervention scores using paired
t-tests. The TT group significantly improved
hand function, pain, tension, mood, and satis
faction between mean baseline scores and
scores following their sixth visit. Significant
improvements were found in the PMR group
for walking and bending, pain, tension, mood,
and satisfaction. Repeated ANOVA measures
indicated that TT groups experienced greater
mobility and greater hand function.
Hie phenomenological study described
meaning and patient experiences of receiv
ing therapeutic touch.
Twenty participants describing lived experience
of receiving therapeutic touch treatments. An
initial open-ended interview and a second inter
view directed toward clarification were used for
data gathering.
Experiences prior to treatment were character
ized by unmet physiological, mental/
emotional, and spiritual needs. The experience
of treatment incorporated self-awareness re
lated to physiological relief and emotional
nurture. The therapist's roles were important,
particularly in relation to trust. Posttreatment
positive changes included improved physio
logical capabilities, renewed emotional out-
The pilot study tested efficacy of dialogue
and therapeutic touch on preop°rative and
postoperative anxiety and mood and post
operative pain.
Thirty-one women undergoing surgery for
breast cancer were randomly assigned to exper
imental or control groups. The State-Trait Anxi
ety Scale, Affects Balance Scale and Visual Ana
log Scale—Pain were completed following the
pre- and postoperative treatment episodes. Ex
perimental treatment was 10 minutes of thera
peutic touch followed by 20-minute dialogue
with nurse. Controls listened quietly to music
for 10 minutes followed by 20-minute dialogue.
MANCOVA using trait anxiety scores as the
covariate revealed that preoperative women
in the therapeutic touch group experienced
less state anxiety than the control group
(Wilks 1 [2,27] = 3.94, E = 0.03; Univariate
F [1,28] = 8.15, p = 0.008). There were no
preoperative differences in terms of pain or
mood and no postoperative differences in
anxiety, mood, or pain.
Ninety-nine adult burn patients were randomly
assigned to TT (n = 62) or sham TT (n = 37)
groups. Subjects in each group received TT or
shamTT treatments for five days Baseline ques
tionnaires included the McGill Pain Question
naire and the Credibility of Therapy Form (CTF).
On Day 3, the Visual Analog Scale for Pain
(VASP) was administered before and after treat
ment. On Day 6, the VASP, Visual Analog Scale
for Anxiety (VASA), Visual Analog Scale for Sat
isfaction with Therapy (VASS), and Effectiveness
with Therapy Form (ETF) were administered.
Eleven subjects donated blood sample drawings
for CD4+, CD8 +T-lymphocytes on Days 1
and 6.
Mean scores were adjusted, using baseline
scores as covariates. Long-term pain control
that was assessed with the McGill Pain Ques
tionnaire revealed that TT subjects had signifi
cantly less pain than the sham TT group did
(Pain rating index: t = 2.76; p = 0.004; Num
ber of words chosen: t = 2.75; p = 0.005). TT
subjects had lower anxiety levels (t = 1.90;
p = 0.031). There were no differences in satis
faction with therapy or medication usage. The
sample was too small to statistically compare
blood samples, but CD8+ cell concentrations
decreased 13% for TT patients and increased
46% for sham TT subjects. Total CD4+ con
centrations increased 15.2% forTT subjects
and increased 48.3% for the sham group.
Lymphocyte counts increased 1.1% forTT sub
jects and 38.6% for sham subjects.
The single-blinded randomized clinical trial
determined whether therapeutic touch (TT)
could produce greater pain relief than sham
touch.
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CONNECTIONS
Nursing Research, Theory, and Practice
Conceptualizing power as the “capacity to participate knowingly in the nature of
change” (p. 174), Barrett (1986) studied power in relationship to field motion concepts of
“motor running” and “field expansion.” In this process she extended work on field motion
by demonstrating that motor running and field expansion were two separate constructs.
Following a pilot study (N = 267), Barrett’s main study (N = 625) used the HFMT and
PKPCT She found that as human field motion increases, so does the ability to participate
knowingly. Her study supported conceptual links of the SUHB.
Caroselli (1995) examined the relationship between power and feminism in female
nurse executives. This study demonstrated a weak but significant relationship between
feminism and one power subscale, the freedom to act intentionally. Although this finding
is congruent with Rogerian theory, interpreting the relationship of feminism and power
requires consideration of additional factors.
In an intervention study Bramlett and Cjueldner (1993) assessed the effectiveness of
reminiscent storytelling as a method of maintaining power in the elderly. The study inter
vention stemmed from Barrett’s assertion, derived from rhe SUHB, that power comes from
an individual’s ability to gain information, make informed choices, and act on those
choices. Bramlett and Gueldner proposed that reminiscent storytelling, as a therapeutic
modality, would enhance elders perceptions of power. Three measures of power were as
sessed for both the experimental and control groups: at initiation, ar 1 week following ini
tiating of storytelling, and 5 weeks later. To make the PKPCT more manageable for elders,
a flip chart format presented rhe metaphors. Both experimental and control groups expe
rienced a small decline in power between rhe pretesting and first posttesting. Both groups
then experienced increased power between the one-week and fivc-week measures. The
value of reminiscence therapy in maintaining power remains unclear.
Several power studies centered on women with illness or significant disability. Malinski
(199?a) compared temporal experience and power in depressed and nondepressed women
and supported Rogers’ homeodynamic principles. Depressed women had lower diversity
and lower power and temporal experience. However, the findings did not support the con
cept of timelessness.
McNiff s (1997) studv of adults with long-term care needs examined the relationship of
power, perceived health, and life satisfaction. McNiff proposed that power, perceived health,
and life satisfaction were pattern manifestations emerging from rhe diverse continuous mu
tual human-environmental energy field process proposed by Rogers. She hypothesized that
these variables would he associated positively in adults with and without long-term care
needs. Findings led her to suggest that perceived health and life satisfaction may comple
ment well-being. AJult> with long-term c.irv needs participated knowingly in change, lead
ing McNiff to propose that transcendence mav he a kev step for individuals with disability
as they evolve toward greater diversity. These findings supported Roger’s contention that life
can transcend difficult circumstances and evolve to a greater diversify.
Smith (1995) investigated the relationship of power and spirituality of polio survivors
and compared survivor levels of power and spirituality to levels of persons who had not
experienced a life-thieatening illness. Her findings of a relationship !'"'twecn power and
.•'piritualirv supp,>rted Barretrs theorv of power and Rogers’ framework. Sntith suggested
spirituality grow*- through continual muru.i! pri'ce.-" and that polio survivors make more
choices associated •aith -piruu ili?v Smith iiiribmcd the ru : that hvporhesized differences
CHAPTER 6
Modeling Nursing From an Energy Field Perspective
149
in power between survivors and the non-ill failed to materialize to pattern changes over
time.
Time Studies. The concept of time passing has been the focus of several studies. In a
descriptive study, Rawnsley (1986) proposed that chronological age would influence
perceptions of time passing and that time would pass more swiftly for the dying than the
healthy. Although she could not support her hypothesis regarding chronological age, she
found that the dying perceived time as passing more quickly. Although its methodology was
criticized (Fitzpatrick, 1986), Rawnsley s study was the first to empirically test rhe SUHB.
Subsequent changes to the SUHB provided greater clarification of terms (Ference, 1986b).
In a theory-testing study, Paletta (1990) investigated rhe relationship of temporal ex
perience as measure^ by the TES to human time as measured by the Human Time Scale
(HTS). This study was based on Rogers’ postulation that human time is a manifestation of
a wholistic developmental process in which time dragging was the least complex of the
temporal patterns and timelessness was a more complex field pattern. The time dragging,
time racing, and timelessness scales were found to explain 15% of rhe variance in human
time. This study is provided early support for Rogers construct of temporal experience.
Creativity. Creativity is an aspect of unitary development described in (he SUHB.
Testing helicy. Cowling (1986b) conducted a descriptive, correlational study of 160
college-age students on mysticism, differentiation, and creativity. One strength of this
study was rhe clear relationship of \ ariables to the SUHB. Cowlings studv was based on
three conceptualizations of rhe SUHB, which included: (1) human field patterns
represent a wave, in that they move dynamically and coniinuouslv toward diversity and
innovation; (2) diversity is an identifiable characteristic of a field pattern and can be
found in mystical experience and differentiation; and (c) innovation is a charaperisric
of a human field pattern and is found in creativity. Positive associat ions between mystical
experience and creativity together accounted for a small portion of the variance in
creativity. The combination of mystical experience and creativity also acceunred for a
small portion of variance in creativity. Mystical experience accounted for a greater
portion of creativity than differentiation did. As levels of mystical experience increased,
so did creativity- As differentiation increased, so did creativity. These findings provide
support tor the principle of helicy and some tentative support for the concept of a diveise
human field pattern.
In a test of helicy, Ailigood (1986) hypothesized that creativity, acrualizaiion, and em
pathy were related, and she initially tested the relationships with a group aged 18 to 60
years. Using Rogers proposal that nature and direction of helicv is innovative. increa>
ingly diverse, and emergent from rhe continuous mutual process of humans and the envi
ronment. Ailigood (1986) proposed that empathy is a human field pattern of helicy; ere
ativity exemplifies innovation; and actualization embodies increasing diversity. Positive
relationships were found between empathv and creativiry and empathy and actualization
Creativitv and actualization combined accounted lor 21% of rhe variance in empathy. The
presence of a relationship between these variables supported rhe idea that humans and the
environment change together, which is consistent wuh rhe SUHB. Alii1.'.'>■.! (1 )91) fol
lowed her initial study with a second using simple subjek n aged ('i u o_ •. c
An invers
relarn ■n-'hip between empathy and cream itv weakened siippori tor
•.•••. nit mg change
(.21 a f living < he re lai r ’nsliip in > ’kier age gr< •up* will require ;uri 1 iv; ; ’•■•ca'x r.
150
CON NECTIONS
Nursing Research, Theory, and Practice
CHAPTER 6
eld Motion Studies. Several studies considered the concept of human field motion.
Gueldner (1986) hypothesized a positive relationship between rocking and human field
motion. He also speculated that preferred rocking rates would relate more strongly to field
motion and that perceived field motion and restedness would relate positively. This study
was based on the principle of resonancy, which contends that wave patterns emanating
from the human and environmental fields manifest continuous change from lower to
higher frequencies. Rocking was an imposed motion. Although no association was found
between rocking and field motion, a relationship between field motion and tiredness in
the e derly was found. This study did not directly support the principle of resonancy
Gueldner reported difficulty in using rhe HFMT with less educated subjects. Also small
sample sue may have impeded discerning field mor,on and rowing relationships
In a study of elderly women, Watson (1997) investigated the sleep-wake patterns of
older adults and the association of dreaming, field motion, and rime. Although rhe shared
variance of dream experience and sleep-wake cycle was only 8.75%, this studv tentatively
supports the Rogerian sleeping/longer waking/beyond waking construct. Watson reported
difficulties m scormg and interpretation of the TMT and in use of the HFMT with older
adults.
Yarcheski and Mahon (1991, 1995) moved rhe investigation of human field mor,on to
ado cscents. A comparison of Rogers’ original theory containing developmental language
to the revised theory, m which developmental language was removed, did nor vicld support
Investigators suggested that rhythms and health should be anticipated toememe developmentally. Other human lield manifestations relared ro health perceptions need' to be iden
tified in order to account for more variance associated with health status
To explore the nature of chronic pain from a Roger,an perspective. Matas (1997) compared subjects experiencing chronic pain ro a matched group without pain. Chronic pain
sufferers experienced lower field motion and lower power levels than .he,,- comparison
group. Because field motion was highly correlated to power ,n both groups, Matas’ findings
reflected Rogers concept of a single wave in an energy field. Matas further indicated that
chronic pain can be conceprualired as a pattern manifestation and that field pattern ap
praisal may be useful in describing chrome conditions and promoting intervention
Therapeutic Touch. Several studies have used the SUHB as a framework lor studying
therapeutic touch. Samarel (1992) postulated that the homeodvnamic principles of helicy
Participants expressed change in linear terms, which is potentially problem.,, ,c .or tiw
- L Hb since rhe ideal of a unitary whole is pandimensional and therefore nonlinear and
wirhour .sparial or rcmporal anrihiiLes.
In an intervention study, Samarel, Fawcett. Davis, and Rvan (1998) used rhe RUHR to
assert tha. dehhemrive mutual pntrerhjng through iherapeuric touch „,d Jialovuc would re
sult in lover anxiety, positive nm.ids. and lower pamintens,tv..ndd.stre-mn be- .nd fm.,oi'erarive breast cancer parient.s. Although women recurving rher.jvmu Mid, md di iIr’fflte preoperar.velv expenenced le- mmw.v. qu.et nme .mJ drab.-■ire.wer?-r’ o’
151
support5 Rogers’ assertion that pattern manifestation appraisal and deliberative mutual pat
terning are associated with human energy field manifestations. In this instance each of the
noninvasive modalities of therapeutic touch and dialogue and dialogue and quiet time
modified the energy manifestations of anxiety, mood, pain intensity, and distress. Contrary
to investigators’ predictions, however, therapeutic touch did not correlate more strongly
with pattern manifestations than quiet time. Whether quiet time or music followed by di
alogue also could be considered a process of patterning remains to be determined.
Proposing that patterning could change a symptom or its meaning, Peck (1998) also
envisioned therapeutic touch as a health-patterning modality. Her study investigated the
therapeutic touch in comparison to progressive muscle relaxation for treating older adults’
arthritis symptoms. Both the therapeutic touch group and progressive muscle relaxation
group demonstrated improvement. Both therapeutic touch and progressive muscle relax
ation could be considered patterning. This study supports the homeodynamic principles
of resonancy and helicy. Resonancy is represented by the fluctuations in energy fields be
tween treatments and corresponding changes in pain. Helicy is characterized by changes
in pain.
Meehan (1993) applied rhe SUHB to therapeutic touch in a slightly different manner.
She focused on pandimensionality, which suggests that no linear time or separation of hu
man and environmental fields exists. Meehan explained actions that occur at .i distance,
such as therapeutic touch, pandimensionally. Her study determined that although thera
peutic touch did nor reduce pain level, it diminished rhe need for pain medication.
Meehan called for more research to directlv test rhe relationship between therapeutic (ouch
process and propositions derived from rhe SUHB.
Suggesting that therapeutic touch is a technique can rebalance or replenish depleted,
blocked, or unbalanced energy fields affected bv illness. Turner, Clark, Gauthier, and
Williams (1998) examined the effects of therapeutic touch on burn patients. In a rigor
ously designed randomized trial, subjects were assigned to a therapeutic touch or sham ther
apeutic touch group. Researchers measured pain, anxiety, satisfaction with rreatnicni. med
ication usage, and lymphocyte counts. Therapeutic touch effectively reduced pain and
anxiety. I lowever, it did not affect medication use or satisfaction with care Total lympho
cyte concentration decreased in the therapeutic touch group, but the portion of rhe sam
ple completing physiological measures was very small. This studv supports Rogers’ con
tention nurses can intervene to balance and enhance energy fields tor ill patients.
Research Summary. Despite some mixed findings, research using a Rogerian framework
or ,i model derived from a Rogerian perspective has supported the SUHB. Rogerian
investigators have been commended for their consistent application of the SUHB. Most
studies identified strong connections between the dimensions of the SUHB and their
variables of study. Perhaps most importantly, the SI. :HB ha- provided a theoretical h.ois tor
study. Additionally, manv studies have been well planned and executed. Measuring
instruments and methods, while not problem tree, have pro\ klcd adequate mechanisms
for Rogerian discovery. Unfortunately, some SUHB studies offer limned generalizabilityDespite sufficiently large sample sizes in m.m\ 'tudk-s, participants often have been selected
too conveniently. Moreover, manv snidic' ot the M 1 IB mv unpublished di.—er.ito uv- and
what research is available docs not tend ■ m> ■■. c beyon.! a ,lc-. • pi r-- e Iw. < ! All!'.- >ugh
description provides i mctul r-mndarion. Rogerian rv-«-.m. h v!h
•i-w.l i ! -moon
inn rventtonai siudic- rh.it address the inedi
'b •gic.-. i-'Ucs i"o<i.iicd v. i’ll hneat
integrality and resonancy were congruent with the lived experience of individuals
receiving therapeutic .ouch in her phenomenological studv. Integral.tv was expressed
through awareness of relationships with others. I'arrern changes occurred before durin.,
and after treatment. They began with low frequency, and later moved to higher frequency,
n these senses, rhe pattern changes were akin to aspects of resonance and helicv I lowever
effective in m>prmm1gpo-.operwne.mx,e.x. .. ..... 1. andj'.nn k ■ n
Modeling Nursing From an Energy Field Perspective
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CONNECTIONS
Nursing Research, Theory, and Practice
measurement. Examples of such studies include Bramlett and Gueldner (1993); Samarel,
(1992); Samarel, Fawcett, Davis, and Ryan (1998); Meehan (1993); and Turner, Clark’
Gauthier, and Williams (1998).
In some areas, such as power studies and therapeutic touch, strong foundations for ad
ditional research exist. Instrumentation and study methodologies need further study, es
pecially with regard to wholistic measurement. Although research needs to continue in
populations of current concern, such as older adults and persons with disabilities, other
populations and health concerns need to be added. Children, healthy adults, and health
maintenance or illness care interventions, for example, require more research.
PRAXIS AND THEORY UTILIZATION: DESIGNING NURSING
PRACTICE PROGRAMS WITHIN THE THEORETICAL SYSTEM
OF THE SCIENCE OF UNITARY HUMAN BEINGS
The unitary nurse considers: Why is the problem occurring in this person at this
time? What can the patient do to help eliminate the problem or keep it from
happening again? How are the patient's family and co-workers involved and
how are they affected? How does the patient feel about what is happening to
him or her? Does the patient understand what is happening? (Manahan &
Manahan 1992, in Barrett, 1994.)
•• • •
.. .
in"
Rogers perspective defines nursing not only as eradicating symptoms but also as sup
porting the integral wholeness of human beings (Malinski, 1997b). This perspective al
lows nurses to extend their focus bevond physical disabilities and bodv image ro the pro
motion of human field change and human field image (Smith, 1995).
The SUHB is predicated on “a new worldview" (Rogers, 1992a, 1992b). At present,
Rogerian practitioners arc usually nurses prepared ar advanced practice levels—that is, at
rhe master’s or doctor,ire level—who sufficiently understand the new worldview that
Rogers proposes to structure practice philosophically. Chapter 3 describes rhe necessary
development that precedes nursing theory and provides direction for practice: (1) making
the language explicit, (2) specifying the focus of nursing and associated variables of con
cern, and (3) developing those variables for practice purposes. The language ro describe the
“new worldview" has not ver been developed fully nor have rhe variables been specified for
practice purposes, [-or Phillips (199/). for example, nursing practice flows from theories,
which flow from the SUHB. which in turn flows from its underlying philosophy. Rogerian
scholars believe SUHB underlies the art—that is, rhe imaginative and creative applica
tion of this foundation—of nursing (Rogers. 1992a). Phillips (1997) challenges Rogerian
scholars to
further elucidate the philosophy of the Science of Unitary-Human Beings. The
first step might be to look at the words unitary human beings. . . The elucidation
and articulation of a Rogenan philosophy requires Rogerian scholars to analyze
Rogers' writings within the context of the universe of philosophy and knowledge
to elicit the defining attributes of the concept of unitary human beings and its
philosophical base (p 16).
This step is a pTecur^T i
i Rt’Ccrian ntirsiiic practice
pol
\ 50-31>'
r
CHAPTER 6
Modeling Nursing From an Energy Field Perspective
153
The Variables of Concern for Practice
The same limitation in operationalizing variables for study discussed in the previous section
hinders development of nursing practice programs within a theoretical system. Although
some studies have informed specific practice situations, more variables need to be defined
for practice. This cannot occur, however, until the underlying SUHB is developed more fully.
Process Models
Alligood (1994) suggests that the traditional view of nursing as a problem-solving process
is not useful for practice within a Rogerian perspective. Rather, nurses provide a decision
making framework. She argues that “theory and practice are not different entities; rather,
they arc different aspects of the same phenomenon” (1994, p. 228). Because practice from
a Rogerian perspective requires knowledge gained in professional nursing education,
Alligood considers the SUHB a poor fir for task-oriented vocational nursing. Malinski
(1997b) concurs. She describes Rogerian practice as a mutual caring partnership rather
than an outcome-focused nursing process (1997b).
Barrett (1988) proposed and updated (1998) hcahh puitcrning. a practice methodology
that facilitates patients’ well-being through their knowing participation in change.
Health patterning is a creative caring partnership of mutual involvement and choices
between a patient and a nurse. Knowing participation in change is power, rhe dimensions
of which are awareness, choices, freedom to act intentionally, and involvement in cre
ating change. The processes of health patterning arc the following: (1) pattern manifes
tation knowing—or, “the continuous process of apprehending the human and environ
mental field” (p. 136), and (2) voluntary mutual patterning—“the continuous process
whereby rhe nurse assists clients to freely choose with awareness ways
wavs ro
ro panicipate
participate in
their well-being” (p. I 36).
Health-patterning modalities include m<wcmcni/dancc/imposcd motion, rest/acriviry,
music, imagery, meditation, humor, relaxation, nutrition, affirmations, therapeutic touch,
bibliotherapy, and journaling (Barrett, 1992). The Bower as Knowing Participation in
Change Tool (PKPCT) offers patients a gjimpse of their power profiles. The nurse’s role is
to help patients make informed decisions with knowledge of their options. Health pat
terning requires knowledge ot rhe SUHB. Meaningful dialogue, centering, genuineness,
trustworthiness, acceptance, and knowledgeable caring facilitate patients knowing partic
ipation and thus actualization of iheir potential well-being.
The PKPCT has been used for 15 years. Caroselli and Barrett (1998) suggest that this
tool now could be used ro design wellness programs that would enhance feelings of power
for older adults in long-term care. Programs also could he doigned to strengthen rhe power
of administrators and staff nurses.
Nursing concerns itself with the interaction between humans and their environments,
both of which are irreducible energy fieKk Pai tern mg-hc- ding modalities allow well-being
to emerge. People participate in patterning their own field-.. Phillips (199?) has identified
some modalities of patterning-healing, including meditation, visualization, imagery, thera
peutic touch, imoic/sound, prawr. art. poetry, -m .rvrelling. < ’i.-r. Immor. and motion/dance.
Phillips also has listed some characteristic^ of muiarv well l-einv awareness ot innnite
wholeness, unconditional kwing, forgiving, freed m t
>u :• ! nicipatm in cl mge
_ compii^jotajrealizmg potential.-,, pe ice. iov. integrality win. -nv uiuvvim-. rulfillment, pumose
^^ary
CWHE . SOCH/ o' vN.
m*i <o•i
-; i(ja let
; .2; d
154
CONNECTIONS
Nursing Research, Theory, and Practice
and meaning in living, recognizing the infinite significance of everything, listening to the
flow of energy, and giving-receiving.
Andersen and Smereck (1994) have used Barrett’s methodology to develop what they
call a personalized nursing process model. The goal of this model is to assist patients in at
taining an improved sense of well-being. Pattern manifestation examines well-being, being,
not being, and talents. Nurses and caregivers manifest deliberative mutual patterning
through loving the patient, intending to help, giving care gently, helping the patient im
prove well-being, and teaching the process. In turn, the patient should love him or herself,
identify concerns, set a goal, be confident and self-motivated, and take positive action.
Proponents of this model have demonstrated its utility for practice with populations of
substance abusers. They correctly hypothesized that improving well-being would reduce
directly the high risk behaviors associated indirectly with AIDS.
Practice Models
The development of practice models derived from this theoretical system is in the begin
ning stages. Further development of the variables for practice purposes and of practice the
ories will facilitate continuing development of (he models.
(..arboni (1995a) has derived a theory of Rogerian nursing practice entitled “Enfolding
Health-as-Wholencss-and-Harmony.’’ By integrating theory and practice, die attempts a
conceptual understanding required to identify and test theoretical statements. The process
of inquiry becomes an integral part of the practice. She proposes a theoretical perspective
to guide nursing practice and a research methodologv integral to th.it practice (Carboni
CHAPTER 6 Modeling Nursing From an Energy Field Perspective
155
theless indicate that field pattern appraisal is useful for describing chronic pain. With fur
ther research, this finding could provide a new direction for the treatment of such pain.
Nursing strategies developed within this framework would facilitate human growth toward
higher frequency patterning. Using music, sound and motion, meditation, dream journal
ing, nature explorations, imagery hypnosis, and therapeutic touch also are consistent with
this perspective. Matas identifies rhe following specific areas of study that have implications
for changing nursing practice (1997):
• Clinical trials using blue light to support field pattern transformation
• Exploring the use of the PKPCT and HEMT as outcome measures in studying
chronic pain
• Designing and testing interventions for chronic pain based on Barrett’s power theory
• Designing and resting strategies for chronic pain which enhance the unfolding of
human-environmental patterning process in the direction of higher frequency
patterning
Smith’s study (1995) of power and spirituality in polio survivors also could lead to a prac
tice model. This study extends rhe exploration of spirituality within Rogers’ framework to a
theory of spirituality. Spirituality is defined from a humanistic perspective, incorporating
both religious and nonreligious expressions. The findings support Barrett’s theoiy “that peo
ple who have the capacity to participate knowmglv in change . . alx have the ability to
change the nature of their participation'' (Smith, 1995, p. 1 '?T This stud\ suggests nurses
should expand their scope of activity to the promotion of power and spirituality.
1995b).
Implications for Administration
Cowling’s description (1993) of the nurse-patient relationship in the unitary model supports Carboni’s approach. He contrasts systems thinking, which has been such ;.1 dominant
force in nursing, with a unitary perspective, in winch rhe focus of nursing is on “aspects of
the situation and not on rhe relationship of parts as in systems thinking’’ (p. 202). A nurse-
In keeping with the perspectiw that there should be congruence between ontology, epis
temology and methodologv, rhe worlds of Roeerian nurse-' arc quire different from the
worlds of nurses practicing in most healthcare agencies todav. ixogcrian practice requires a
major shift in thinking about the role of nursing in an tirgaiuzai ion and ihe organizational
structure required to support that practice.
Caroselli (1994) describe' an organizaitonal structure that emanates from a philosophy
congruent with SUHB and that would support nursing practice from thi> perspective, but
she does not provide a detailed description of that nursing practice. The organization she
envisions would emphasize participatory management, from which knowing participation
in change stems. The statement of philosophy would rcflcci this value. The chief nursing
executive would function as "le.ider-a.'-rcacher." A model of .shared governance is most
congruent with Rogerian nursing pratiice since it supports the value of knowing partici
pation. A relatively ‘‘flat'’ <■;ganizaii.mal structure would comprise specialists in Ixogerian
science, change theory, and nur<ing administration as well .is rescaivh advisors responsible
for developing research programs that include all nurses;. The research advisor would work
closely with the financial ad\ noi and det.ids of the unance- .omid ’ available to all nurses
to allow their knowing parrn;pati« 'll. Piatt devek>pmcnt would pr. >cccd !!'■ -m a competency
perspective with modalities consistent with rhe Ixogcrian perspective.
patient encounter involves mutual simultaneous shaping. Interrelating is a construction
process during which both the nurse and patient interact with the human variables or phe
nomena. Cowling further suggests that these variables are more constructs than fundamen
tal aspects of reality. Observations are “rhe momentary manifestations of pattern’’ (p. 204).
Cowling (1997) integrates scientist and practitioner roles as he describes a scientist/
practitioner model of nursing facilitating knowledge development through ea.>c studies.
He suggests that in working with individuals “rhe surface display of information be con
sidered in the context of unitary patterning and that pattern be given attention as the ref
erent tor practice and lor creating a knowledge base of science for the practice of nursing”
(p. 53). He describes a process of pattern appreciation that involves being open to rhe ex
perience, perception, and expression' of a-iethcr .o represent.irivc of pattern manifesta
tions. A pattern profile i> developed b\ examining d.ua from experience, percept ion, and
expressions. The pattern profile is conicxi-ba>ed and is \ erifk\l b\ i he participant. The
pattern profile suggests possible strategics lor accomplishing rhe patient’s intent. This ac
tivity leads io practical or rheorerica! knowledge development
Defining pain as “an emergeni expression ol Imm.iii env ironmermij f ield i uTeming—
expel lo-ac.-..! e;hurt’’ ( 199?, p < I. M ,, . .Ht ...J , nkl,nh.nI v p,.!h,.
thai . m'ideo u til u , human field . rtix rh :■ : if u :■ 1
I
• h
•;
m 1 the
'
1 V' " ‘kh
' Um ted - rmple
pn
■
lu
les
.
.
nemlizmi.
r
.
■
c.
fmdincs,
tfiev
nonerk pic. !uJ.
Implications for Education
rUic and cuntinum- Jtk r. ciu-r
: . ■ thin this rhe< : ru al itji
Sli IP- :i..d -<• .k-.e'. i\ h ■ 'J
pr icticv nurs>the
156
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 6
NEXUS
school nurse referral. Issues in Gnnprehensiie Pediatric Nursing. 20( 3), 175-182.
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Carlxini, |.T. (1995a). Enfolding heahh-as-wholeness-and-harmony: A theory ot Rogerian nursing practice. Nurs
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Carboni, |.T. (1995b). A Rogerian process ot inquiry. Nursing Science Quarterly. 8(2). 22-37.
Caroselii C. (1994). Opportunities tor knowing participation: A new design tor the nursing service organization.
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Alliipa, M.R. (1991) -feting Rngcrs- rlM>,-v
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,"m T IT ; PCrS,’nS iS
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v,vw
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h,gh.n.k Jrug use an,.,„A,l„,,,
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Cowling W.R. i BNs). I, .'nitarv know mg in nursing practice. Nursing Science Qiiurie’lv. 9(4). 201-207.
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'T"'"'
New York: N.uional League lor Nursmg.
e.>ns,Jcra„ons: Complexrty and nursmg science. Nursing S«ncc Quurrcriy 11(5),
Rogers, M.E. (1961). Educmionnl revolution m nmsmg New York: Macmillan.
Rogers. M.E. (19/0). An introduction to the theoretical basis of nursing Philadelphia: F.A. Davis Co.
Kogers. M.E. (19SI)- Science of unitary man: a paradigm for nursmg. In G.E. Lasker (Ed. >. Allied systems and ey-
>emeno 5y>fenn research m healthcare, biocybemetics. and ecology. New York: Pergampn Press.
Kogers, M.E. (1968). Nursing science and art: A prospective. Nursing Science Quarterly. 1(3). 99-102.
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)O; ••
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(Ed. \ mom- of hogcix see nee-based movng New York Nanonal League tor Nursing Press.
Rogers. M.E. (1992aL Nursing w.enue and rhe T;il.e age. N./rsmg W/encu Quarter^, Sj ), 27- 54
sogers. . LE < I 9928). ^ue-age paradigm to. new frontiers m nursmg. In M E. Parker (Ed.). Nursnig Theories m
I iactu.c. New lork: National League tor Nursmg Prus>.
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p?'™";?1,
Science Quarterly. I2( 3), 245-250.
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lescents. Rese.ircli in Nursing and Health. 14(6), 447-455
Yarcheski. A. N Mahon. N.E. (1995). Rogers' pattern manifesiat inns and health in adolescents. Westeni Jountal
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Zohar, D. & Marshall, I. (|994k 7he quaniion society. New York. Morn
I ■HH
O'/ )
■
: '0)0'
C H A P "L E R
Modeling Nursing From Unitary
and Existential Perspectives
PARSE'S THEORY
of HUMAN BECOMING
.t-1
ip:.'d
IlK.n-.
Key Terms
coconstituting, p. 164
cocreating, p. 164
cotranscending, p. 164
human becoming, p. 162
meaning, p. 164
originating, p. 166
powering, p. 166
rhythmicity, p. 164
transcendence, p. 164
transforming, p. 166
Rosemarie Ixizzo Parse first introduced her theoretical conceptualization of nursing un
der the title Man-Lic/ng-Hea/t/i (1981), later known as the Theory of Human Becoming.
Parse> work proceed' from Rogers Science of Unitary Human Beings. In her first expo
sition of the lheorv. 1 ar>e created assumption.' about man and health, and she stated prin
ciples, concepts, theoretical structure.', and an overall schema of the theory (1981) Parse
icfined the theory in 199_ and 190; and she renamed her conceptualizations and changed
(he language of ihc .i."umptions n > reflect rhe more inclusive term lutman rather than man
(lai'e, 1997a). In 1992. 'he developed the Instiruicot Human Becoming to assist persons
in learning and living he,r rheorv. Ongoing ,'cholarlv work ha' established and refined the
research and practice methodologies. Parse founded and edit.' the journal Nursing Science
Qiuirtcrlv.
THE STARTING POINT OF THE MODELING PROCESS
.• i' .i ■'ccunJ-L'cncr.irn >n nursii:^ rhcon-r in rli.ir her wnrk cic.irlv extends tn>m R(h’cr>’.
H! -.ei i> ■ -he •reikal s\<icm m if>o\vn risju. Parse ( 1997h)
Ir i tsthexmie iesei . If
161
162
CONNECTIONS
Nursing Research, Theory, and Practice
Modeling Nursing From Unitary and Existential Perspectives
163
called her early work a synthesis of Rogers’ principles and concepts with existentialphenomenological tenets and concepts. Parses early work focuses on health and defines it
as “the process of becoming as experienced by a person" (1981, p. 14). The redefined focus
is on Human Becoming, a “unitary construct referring to the human being’s living health"
(1997, p. 32). In 1992 and again in 1997, Parse updated the philosophical assumptions and
later synthesized them in terms of Human Becoming.
scribed under Practice in this chapter. The specific concepts of human being and health
Reason for Theory Development
philosophical Perspectives
Parse’s theory surfaced over years of her lived experiences and interrelationships. She of
fered her work as a contribution toward a unique body of nursing knowledge. The Theory
of Human Becoming attempts to answer Rogers’ questions (sec Chapter 6). Noting the
limitations of existing perspectives, Parse wanted to "focus on moving with other possibil
ities for nursing" (1997a, p. 32). She sought a science approach for nursing grounded in the
human sciences and “rooted in rhe belief that humans participate with the universe in the
cocreation of health" (Parse, 1992, p. 32).
The Theory of Human Becoming was created as an alternative to traditional natural sci
ence nursing in response to rhe limitations inherent in the totality perspective (Parse. 1981).
The totality perspective. Parse contends, includes "viewing human beings as bio-psycho
social-spiritual organisms that interact linearly with rhe environment. Health is physical,
mental, social, and spiritual well-being that human beings strive for through manipulation of
the environment" (Fawcett, 199 j). In rhe preface to Hlumirdiiums. Parse.elaborates:
Parse describes and categorizes her worldview with the simultaneity paradigm, which is
characterized by beliefs that (1) human beings “are synergistic; more than and different
from the sum of their parts” and in “mutual rhythmical interchange with rhe environment,
and (2) “|health| is a process ot becoming; living a set of value priorities" (Fawcett, 1993,
These limitations were most visible in four major ways:
“<r!:
CHAPTER 7
•
The value priorities oi rhe person were Mibe.rd maird !.•. .i set ol n.nnis drlmcd bv medical
science.
• The nurse, rather than rhe parieni. was vomkivred rhe cxjxrr on health
• I he meamns' of lived experiences was n a ihe iocu; oi nursing; a iminan <■ icnce approach
had not yet been concepruulired.
• The potential contributions ot nursing as ,i unique discipl
.‘hfiisciiied by rhe natural
science approach to research and practice.
As an alternative to traditional, the Human Becoming Theory focuses on the
experience of humans as freely choosing beings who cocreate health in mutual
process with the universe. The person is respected as the expert on his or her own
health, and the meaning of lived experiences is honored This theory, then,
rooted in the human sciences, clearly requires a different approach to research
and practice (1997b).
Phenomenon of Concern
The object of-Human Becoming Theory is uni'.■. rs.d human health experiences that
surface in the human-unix erse process am.1 reflect being-becoming, value priorities, and
quality of life (Parse, 1992 h I he centra] locu< of pracpce i- the meaning of lived expe
riences in enhancing quahiv of hie for uniiar\ hum m I .I hc<e lix ad experiences
include paradoxical unities —<uch a< certainrv-uiv •.•rF.im■ •.. .c\■v.iiing-conccalinc. vnabling-limiting, and c 'nnetting-separating—regaided o narur.d i h-. diiib a hie. Nm-mg s goai is improved q:: 11 u v . a hte. The pri 11. 1: . m '
; 1 a a • i "i i ue prc'cib <■, . ic-
are defined in the Theory section.
DESCRIPTION OF PARSE'S THEORETICAL SYSTEM
The Theory of Human Becoming includes philosophical and theoretical levels and re
search and practice methodologies. These elements constitute the theoretical system.
p.57).
Cody (1995c) identified the goals of nursing within the simultaneity paradigm as "ori
ented toward quality of life and evolving patterns ol living lor rhe person and family”
(p. 145). Parse identified the basic rhemes of the philosophical assumptions of her theory
as "meaning, rhythmicitv, and transcendence" (1997a, p. 52). Although Parse does not
emphasize the Rogerian idea' of nonspatial, nontemporal human and cm ironment energy
fields, she does nor reject them. Parse is most concerned with the human unity and the
meaning humans assign to human-universc-healrh situations. She describes persons prop
erties through assumptions and principles. The descriptive properties of persons arc ex
sons —the nurse
pressed through lived experience. The properriex described refer to all pci
poisons
as well as rhe patient.
11
Existential Phenomenology. In rhe first published edition ol the theory
( 1981). Parse
identified rhe existential-phenomenological tenets ol inten'i-onality and human
subjectivirx along with concepts of coconstirurion, coexistence, and situated freedom.
Existential philosophy .stresses individual existence, .suhjvctiv
individual freedom, and
choice. Phenomcnologx is concerned with describing human experiences or the objecisof
experience. Phenomenological methodoktgy is described under the Research section of
this chapter. Anyone using Parse’s theoretical .system to guide research and practice needs
to be grounded in this philosophy.
Parse (1981) identified a number ot philosophers and theoiists in additutn to Rogers
whose work helped her shape rhe rheorv: Heidegger, Sartre, Husserl, and Merleau-Ponty arc
her predominant influences. T he synthesis ot their existential concepts with Rogerian prin
ciples of helicy, complementarity, anti resonanev in addition to concept of energy field,
openness, pattern and organization, anti four-dimensionality (now referred to as pandimensionalitv) resulted in nine philosophical assumptions. Three principles arc posited from
these assumptions, which in. turn give ri<e to theoretical structures Ihe essence of Parse’s
theory is found in rhe pimtiplo. concepts, and rheuierital structures (Figure < -1 I and the
evolution <>t rhe ontology of human becoming (Figure i -2).
The Language of Human Becoming. Tht menage 'oed -a dim .: ihcoictK u -.-i'm.
especially one 'har j'l'■: ose» i new uot'dview. mu>r be .-I'ccilit n that rhe< >rctical 'vstem
Because ol the t ■ >mplcxr . ■ die I r c iago u-.-J m 1 -<■ ■ die- o..
i.ivr- 'h «iild refer i
Parse's original urim > ha ' rificaih
iiicai i> . . Parse . I°9; . :i .;,-J ih .• die 1 he wx ot Human
Becoming has cleared m-v. 1 menage
IJLIC tf ■.■: dw I:-, gdmv i im uw •-i ' iw cenmd in "Px-c-.-mmg"
164
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 7
Modeling Nursing From Unitary and Existential Perspectives
165
Relationship of Principles, Coi
•ncepts, and Theoretical Struct!lures of Man-Living-Health
Science of Unitary Human Beings
Principle /. Structuring meaning
multidimensionally is cocreatinq
reality through the languaging of
valuing and imaging.
Imaging
Principle 2: Cocreating rhythmical
patterns of relating is living the
paradoxical unity of revealingconcealing and enabling-limiting
while connecting-separating.
Principle 3: Cotranscending
with the possibles is powering
unique ways of originating in
the process of transforming.
principles
Helicy
Integrality
Resonancy
Existential Phenomenology
Postulates
Energy field
Openness
Pattern
Pandimensionality
Tenets
Philosophical Assumptions
Valuing
Revealing-concealing
Languaging|\
Enabling-limiting
Powering
Originating
^/Connecting-separating
Concepts
Coconstitution
Coexistence
Situated freedom
Intentionality
Human subjectivity
1. The human is coexisting while coconstituting
rhythmical patterns with the universe.
2. The human is open, freely choosing meaning in
situation, bearing responsibility for decisions.
3. The human is unitary, continuously coconstituting
patterns of relating.
4. The human is transcending multidimensionally
with the possibles.
J
5. Becoming is unitary human-living-health.
6. Becoming is a rhythmically coconstituting
human-universe process.
7. Becoming is the human's patterns of
relating value priorities.
8. Becoming is an intersubjective process of
transcending with the possibles.
9. Becoming is unitary human's emerging.
Z'ziransforminq
Principles
Concepts in the squares:
Concepts in the ovals:
Concepts in the triangles:
Structuring meaning
multidimensionally
O7ZXemer9eS Wi,h 'he ^3 conceal
Cocreating rhythmical
patterns of relating
Cotranscending with
the possibles
emer9eS W"h 'he
~^Xw,'h,he/aW90Z
ss::s-,
Concepts
Imaging
Valuing
Languaging
--
becoming. (From Parse,
iii'"""
the experience of the person ,n the here ,n I n7 T "
.... r-..... —
l\,
|‘
phenomenological concepts and tenets inr i ,7 "
-aning. rhychmicity. and om, JX" J according to Parse, refers r.,
,
rllt t'lcorV’Otl sc.ence,
1C''1:cd Ro«er<an and existentialX
tUco m the assumptions. Meaning,
one gives to some rhmg or event. iTlhmin'm
'T""1" c”nrcnl and the interpretation
mutu.il process” (Parse, 1998 p 19) aK
b> r ic patterning of human-universe
l'"'- F..... -Oh.... conceits rel.tre X XTlX "
"rJ'™ry
■i> .1 process of becoming. Figure 7-1 inclu 1 rl
I I
Becoming Theory, written at the philosophic d P''
philosophical assumptions were svnthesred ,n ‘
(Parse, 1997a. p. 33).-
1
FIGURE 7-2 IEvolution of the ontology of human becoming. (From Parse, R.R. (1998). The
Human Becoming school of thought. Thousand Oaks, CA: Sage.)
F'\c relate to health
as^«^Ptions of the Human
d,SC°l'rSe
I997a)- These
^’mpnons about human becoming
•
I Inman becoming is cocreatiiio rhythmical patterns of relaiim; in
I han.iii her <rniiny o a ,
\
pn>ce<s nt relatin*’ value priMraw.
1
u: 'iru.itiihi in the mtersuhiecti
inutu.il process with the
universe.
•
Human hccomin*’ is coiranscviiilmi: mullidimcnsionallv
th rhe etnerning possihh
Description of Models and Theories
Theoretical Principles. The principles of rhe rheorv follow Jirecrly fro>in rhe philosophical
assumptions and are written at a thc*>rciical level of discourse. These are? (Parse, 1981, p. 69):
•
Principle I. Srruciurini: ii:*-auiim imi!tiJinivn<i< 'n.illv is cocrcari.il*’ reality through the lan-
giiayiny <>t wiluini; .mJ nn.i.qin*.'.
1 rhwiple _. (..ocreaiin*; rhvihinii ,il partem' ol relaring is livin*; the parajoxical unity ot
revcaling-concealiny and ciiahlme limirin*; while cbimecriny-wpuratin*;.
Principle 3. ( otranscendiny with the possibles o powerint’ uiii.|uv ways of originating in the
process ol transforming
The rt'lttrionship of these principle r
•
Powering
Originating
Transforming
Phcn*’'”enology. describe
human existence asdistrncr from it> essenceTh -v
'''rcnrISLS P*
concern is with
of the individual. Figure 7-2 depicts rhe reltri.n h P'"”"1'' T' re’lltyot he,n«' th*-’ nature
Betngs and exMent.a! phenoTnoT- ,nZ/rTH.™
Philosophical Level of Parse's Model
Revealing-concealing
Enabling-limiting
Connecting-separating
c-HKcpts .mJ ihcorctica! srrucuires is shown in
Figure 7 -1.
Theoretical Structures.
conccpru.ihr.umk She • .ftcred
i-'i I'.nT . :9S] ) present*-J schemata that model her
rcl.ititiM'hips of ctaiccpis that are "nondircction.il
166
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 7
propositions . . . non-causal in nature . . and consistent with the assumptions and
principles of the theory” (1992, p. 39). These propositions are called theoretical structures
•
Modeling Nursing From Unitary and Existential Perspectives
167
The researcher, through inventing, abiding with logic, and adhering to semantic consistency
during the extraction-synthesis and heuristic interpretation processes, creates structures of
Parse (1992) put these forth to guide research and practice and noted that additional
lived experiences and weaves the structure with the theory in ways that enhance the knowl
theoretical structures need to be written at lower levels of discourse. These structures—
edge base of nursing.
powering, originating, and transforming—are presented in Figure 7-1. Powering is the
“pushing-resisting process" present in all change (Parse, 1998, p. 47). Originating is
inventing or creating new ways of living with the paradoxes of daily living. Transforming
involves the human-universe process as rhe human coparticipates in changing in a
These assumptions must be congruent with rhe research method
science.
to result in good
The purpose of the Parse method is to uncover “universal lived experiences of health’'
de libera re way.
(Parse, 1994, p. 57). Parse (1997a) suggested that researchers must commit to understand
RESEARCH DERIVED FROM THE THEORY OF HUMAN
ing lived experiences. Phenomena for study are universal health experiences that surface in
BECOMING
the human-universe process. Parse (1996a) believes that universal experiences are those
Initial investigational techniques for developing Parse’s Theory of Human Becoming were
that all humans experience and would describe if given an opportunity. These experiences
qualitative—primarily
....I.. phen
-loinenological and ethnographic. Support for Parse’s theory was
reflect being-becoming, value priorities, and quality of life (Parse, 1997a). Examples Parse
I
bolstered by these <qualitative techniques and in 1987 led to a research method directly
tied to the theoretical
..J <constructs. Parse (1996a. 1997a) now describes her method as a
phenomenological aiul hermeneutic
■ ............................... tiiat values the research participants for sharing
their experiences. This approach relies
on interpretation to understand lived phenomena,
Attention to participant language is i
important because the researcheis translate rhe participants’ responses into t he language of science. P;
arse synthesized rhe works of Kaplan
(1964) with rhe artistic qualities of “order, design, <
imposition, balance, and harmony’’
into the following (Parse, 1987, p. 173):
(1996a) cites include “hope, joy-sorrow, restriction, freedom, considering tomorrow, per
severing through difficulty, grieving, and persisting while wanting to change” (p. 59). The
emerging phenomenas structures simultaneously encompass the remembered, rhe now mo
ment, and rhe not-yet.
Parses method of study includes identification of entities for study, scientific processes of
investigation, and details of processes appropriate for inquiry (Pause, 1987). Box 7-1 out
lines Parse’s research method. Specific processes of the method include participant election,
in which persons who live rhe experience arc invited to participate in rhe study. Invitees give
authentic accounts and engage in dialogue. Dialogical engagement follow- participant se
The methodology is , onstructcd to be in h.irniom with .mJ
il "I-,.I
> >h c iroin rhe < •iiU'loyicul hc-
liefsof the research tradition.
Tiie methodology is an overall design of precise processes that adhere to
•
Th,- me1h,xl..|.gv specifies rhe urder within ll'ie , n.cesses r.p,,r.|i„
search tradition.
inerh<xl<>k"_iil;iI rigor,
,, ,,|
the re-
lection. This involves researcher-parricijW discus>ion in which rhe researcher is “truly
present" with the participant (Parse. 1987). Dialogues arc unstructured; rhe direction
emerges from the nature and structure of the participant’s lived experience. Many types of
media describing rhe phenomenon of srtidv —including words, drawings, metaphors, pho
tographs. music, and movement—can be incorporated into dialogue.' (Parse, p)97al Dia
>guc' (Pan
logical engagement is a unique method ofeliciting descriprion.s
from panicipant.s.
The methodokygy is an aesrhetic composition with balance in form
Parse (1997a) considers her research method a mechanism lor enhancing the knowled.-e
base lor the d.sciplme ot nursing. This method provides a different worldview from rhe
-BOX 7-1
tradamnal natural science perspective and rs most congruent with constructivism. The fol
lowing are additional assumptions that underlie Parses research metho,I. These assump
tions, which regard human beings and their relationship to the human un.verse ,re the lol-
lowing (Parse, 1992, p. 41 ):
•
Huib.ms urc open beings in mum.il gn.cc" .'m :
to rhe hum;in-universe-hv.ilth process.
Tta-1 'iisina i /imnuu /'ctn!; refers
Human becoming is uniquely lived bv mdiv iduah. I'eLpie mak.riv<.
choices in connection with orhers and the mm^e. win, h incnm.a.
families can.describe their own experience^ in w.iv< that >h -d li
•
.
Resea re her-parncipam dialog,,J engagement uncovers ihe ; ,
maul', lived The res'.-aichcr iii rme pre'er.. .• w'd- : i, • i
mation about lived experiences.
...
uid prcivtlvciive
irmnlrh.
P^riptions of lived experiences enhance knowledge of hum ■
id
Hint; ludiv idtiiils .md
■'
imiii.1
•I i
. :i''men.i as hu-
t\ ;
.I'.i'i ici a i. Hifi)r-
'i iic.ilrh.
Processes of Parse's Research Method
• Participant selection
• Dialogical engagement
• Extraction synthesis
• Extracted from participant's language
• Written in researcher's language
• Propositions formulated from participant's essences
• Core concepts extracted and synthesized
• Structure of experience synthesized ’
• Heuristic interpretation
• Structural integration
• Conceptual interpretation
I’.
r if '.k-r
168
1^,
....
CONNECTIONS
Nursing Research, Theory, and Practice
Extraction-synthesis permits the researcher to move from participant description to a
conceptualization of phenomena in scientific language. Dialogues are tape-recorded and
transcribed, permitting the researcher to dwell on the experience. Dwelling is the process
of reflecting on the information participants shared. It allows the investigator to become
thoroughly familiar with rhe information shared. Five steps occur in extraction-synthesis
process:
1. Essences or expressions of a core idea stated in the participant’s language are ex
tracted from the transcriptions.
2. The researcher synthesizes rhe essences, trying to capture the basic nature of the
participant-described phenomenon, and then puts the description in scientific lan
guage that allows other professionals to easily understand it.
3. For each participant’s description, a joining nondirectional statement or proposition
is formulated
4. Concepts from the formulated propositions are extracted in order to capture the cen
tral meaning of the propositions.
5. Researchers synthesize the structure of rhe lived experience by developing a state
ment that conceptualizes the core concepts and answers the research question.
Heuristic interpretation is a structural anil conceptual integration of propositions con
nected to the structure of rhe theory. Heuristic interpretation is an analytical process that
involves careful examination and abstraction in which rhe structure of the lived experience
is interpreted in light of Human Becoming Theory. This interpretative process “weaves
the ideas of the structure as lived into the theory and propels it to posit ideas for research
studies and possible practice activities” (Parse, 1987, P- 177).
An excellent example of rhe explicit steps of a research study using Parse’s research
method is her study of laughing and health (Parse, 1994). Essences were extracted from
each individual discussion. For example, one participant said. “Well, 1 feel usually if 1 laugh,
1 m happy. Even it it is just for a while, vou know. joy. And I think whatever my ache or
pain is, it goes away. (Parse, 1994. p. 59). Parses extracted statement read, "rhe participant
laughs a lor and finds ir.a joy ro laugh since ir makes her feel good; it rakes away her aches
and pains and gives her a lift when she’s down" (Parse, 1994, p. 59). From this extracted
essence Parse drew a synthesized essence, which stated that “frequent mirthful episodes
with personal delight foster contentment deflecting suffering while lightening burdens”
(p. 59). The formulation of the composite is: “The lived experience of laughing and health
is delightful contentment arising through frequent mirthful engagements deflecting suf
fering while lightening burdens (p. 59). I )nce propositions were formulated for all partic
ipant essences, Parse extracted core concepts for the study.
In this study, three core concepts associated with laughing and health included "a buoy
ant vitality,” “mirthful engagements prompting an unburdening delight deflecting disheartenmenrs,” and “cmcrgimi in blissful contentment” (p. 61 ). In the heuristic interpre
tation, for the structured coiwcpi "a buoyant \ italii\." Parse identified the structural
integration as “extiberanr exhilaration" and rhe conceptual interpretation as “languaging
the enabling-limiting of powering (p. 61). Structural and conceptual integrations were
completed !• jr each ■•irucrur.il concept. T he final structural statement regarding the interc< mncctC'.lr-C" > a i lu.dung and hcalr! i was ‘’lang! ung and health i> a potent bin want viral-
CHAPTER 7
Modeling Nursing From Unitary and Existential Perspectives
169
ity sparked through mirthful engagements, prompting an unburdening delight deflecting
disheartenments while emerging with blissful contentment” (p. 59).
Review of Related Research
Research using the Human Becoming Theory is predominately qualitative. Most recent
studies specifically use Parse’s research method. Research studies engage diverse age-groups,
but older adults have been the focus of many studies. Research topics center around what
Parse would describe as universal human experiences: laughter, joy, grieving, quality of life
and suffering, aging, living with illness, homelessness, and workplace issues. Table 7-1 sum
marizes selected research studies using Parse’s Theory of Human Becoming.
Laughter/Joy-Sorrow. Parse conducted several studies of laughter and health. The
first was a phenomenological study that used van Kaams method to study descriptions of
laughter by 30 people over age 65. Parse (1993) found many similarities in descriptions of
laughing and discovered that participants related laughing and health. The structural
definition of laughing that emerged from this study was a "buoyant immersion in the
presence of unanticipated glimpsings promoting harmonious integrity, which surfaces
anew through contemplative visioning (Parse, 1993, p. 41 )• In a subsequent study, Parse
Q994) used her research method ro further rhe understanding of the interconnectedness
between laughing and health for individuals age 65 and over, and she connected her
findings to the Human Becoming Theory. Language used to describe laughtei included
“potent buoyant vitality" that reflected joy and exhilaration (p. 59). Mirthful
engagements prompting an unburdening delight deflecting disheartenments resonated
with Parse’s concept of connecting-separating in transforming imaging (p. 60). The
process was perceived as rhythmical, “being with, anil paradoxical in that it inxobes
both delight and disheartenment. The concept “emerging with blissful contentment was
identified as a product of laughter associated with health (p. 61). In these two studies,
health was nor conceived as a process of disease or its absence but rather as a process of
becoming in which values emerge and change. Laughing provided a way of becoming in
the moment and in that wav is relevant to health. Parse (1994) suggested that “buoyant
vitality" is the energy of health and that contentment is a plenitude of health that arises
through mirth (p. 62). This concept supports the Human Becoming Theory. Further
investigation into concepts of “buoyant vitality” or “blissful contentment could be
promising. New dimensions of understanding could offer unique insights about nurse
patient engagement.
Examining a different but related phenomenon, Parse (1997c) investigated the paiadoxical structure of jov/sorrow in women over age 65. Core concepts of pleasure amid ad
versity” represent patterns of transforming imaging (p. 84). “Cherished contentment re
flects treasuring or valuing, which reflects a sense of satisfaction with accomplishments
(p. 85). “Benevolent engagement” represent' connecting-separating with family, friends,
and strangers. Experience' of ]ov-sorrow consist of the ups and downs of everyday liv ing. In
this study, joy anil sorrow were found to be a pattern of health with a paradoxical rhythm
of ups and downs cocreated in the proves' of rhe human-universe This supports Human
Becoming Theory’s loncep1 ‘I p ir.idoxic.ii pun esse'. Idcmined core concepts warrant fur
ther investigation r mi n’Ust insights into ■: . uni> i tai
cd experiences.
:p.
1
LTBkAkY
TABLE 7-1
IMS
Study/Year
LAUGHTER
Parse, 1993
P.iisc, 1994
JOY-SORROW
Parse, 1997c
GRIEVING
Cody, 1991
Cody, 1995a,
1995b
SERENITY
Kruse, 1999
(TTirn
Purpose
Methods
Findings
The study uncovered structural definition of
laughing in persons over age 65.
Thirty men and women over age 65 wrote de
scriptions of laughing and all of their thoughts
and feelings associated with the experience.
Their descriptions were analyzed with van
Kaam's phenomenological method.
Four common elements emerged: buoyant im
mersion, harmonious integrity, contemplative
visioning, and unanticipated glimpsings. Syn
thesis of the final definition of laughing was
buoyant immersion in the presence of unan
ticipated glimpsings, prompting harmonious
integrity which surfaces anew in contempla
tive visioning" (p. 41).
The study uncovered the structure of lived
experience of laughing and health.
Daly, 1995
n
O
Z
z
c
5’
io
S’
l/l
OJ
Twenty men and women over age 65 partici
pated in a dialogical engagement about the ex
perience of laughing and health.
"The lived experience of laughing and health
was a potent buoyant vitality sparked through
mirthful engagements, prompting an unburden
ing delight deflecting disheartenments while
emerging with blissful contentment" (p. 58).
H
O
2
Q.
The study uncovered the structure of joy
sorrow in women over age 65.
Eleven women over 65 years of age engaged in
audiotaped and videotaped dialogues about
joy-sorrow.
Joy-sorrow is "pleasure amid adversity emerg
ing in the cherished contentment of benevo
lent engagements" (p. 84).
The study generated a structure of the lived
experience of grieving a personal loss.
Using the process of dialogical engagement,
four participants described experiences with
personal losses.
Grieving a personal loss is "intense struggling
in the flux of change, while a shifting view
fosters moving beyond the now, as different
possibilities surface in dwelling with and apart
from the absent presence and others in fight
The study specifically investigated the struc
ture of grieving for families living with AIDS.
Ten families participated in dialogical engage
ment to describe their experiences of grieving.
The families were diverse and included gay
male couples, a husband and wife, and a male
and female partner, and daughters, compan
ions, sisters, and brothers.
Four concepts were explicated; easing
intensifying with the flux of change, bearing
witness to aloneness with togetherness, possi
bilities emerging with ambiguity, and confirm
ing realms of endearment.
Ten cancer survivors described the meaning of
serenity in their lives. Parse's research method
and photos were used to facilitate description
of serenity.
The four extracted concepts included steering
yielding with the flow, savoring remembered
visions of engaging surroundings, abiding
with aloneness-togetherness, and attesting to
a loving presence.
The study investigated the meaning of seren
ity for survivors of life-threatening illness.
QUALITY OF LIFE/SUFFERING
Alkhm-Petardi,
The study described perservering through
1998
ovarian cancer.
Carson and
Mitchell, 1998
n
O
z
z
Parse's Theory of Hi
The study investigated the experience of liv
ing with persistent pain.
The study explored the experience of
suffering.
fD
n
t
>
72
Parse's research method was used with eight
women with ovarian cancer who described the
concept of perserving.
The three core concepts included deliberately
persisting, propelling fortitude, and powering
valuing.
Seventeen participants offered narratives re
garding their experiences.
Three themes emerged: forbearance surfaces
with the drain of persistent anguish; isolating
retreats coexist with comforting engage
ments; and hope for relief clarifies priorities
for daily living.
Nine participants participated in dialogical
engagement to describe their experience of
suffering.
n
Suffering is "paralyzing" anguish with
glimpses of precious possibilities emerging
with entanglements of engaging-disengaging
while struggling in pursuit of fortification"
(p.253).
o
O
IQ
z
5’
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O
2
c
2.
CD
□
Q.
rn
5.’
2
ST
w
73
rc
Continued
LA
= TT=h k
8
TABLE 7-1
■s
Study/Year______ Purpose______
QUALITY OF LIFE/SUFFERING—cont'd
Fisher and
This qualitative study examined the quality
Mitchell, 1998
of life of inpatients receiving psychiatric care.
Parse. 1996a
Baumann, 1994
its
1
The study explored the meaning of quality of
life for person's living with Alzheimer's
disease.
The study explored the experiences of moth
ers and children who were homeless.
z
z
Methods
Findings
Twenty-four psychiatric inpatients participated
in semistructured interviews. Interviews were
analyzed by tape review, thematic identifica
tion, and consideration of theoretical frame
work and literature.
Three major themes emerged: reflective mo
ments illuminate shifting priorities (remember
ing how things used to be); upset and calm
change patterns of being with and apart from_.
others (sense of discomfort in relationships);
and distant hopes fuel the relentless struggle to
carry on (reflects relentless struggle to carry on).
Five men and 20 women with beginning or
moderate Alzheimer's disease shared the mean
ings of their quality of life.
An exploratory, descriptive design guided dis
cussions of 13 mothers and 25 children living in
two shelters. Open-ended questions were used
to explore the meaning of not having a place of
their own, the unfolding of relationships, and
changing views of possibility.
n
O
______________
n
o
z
LH
Z
c
<zi
I’
S’
in
Quality of life for Alzheimer's patients was
found to be a "contentment with the remem
bered and now affiliations that arises amidst
the tedium of the commonplace, as an easyuneasy flow of transfiguring surfaces with lib
erating possibilities and confining constraints,
while desiring cherished intimacies yields with
inevitable distancing in the vicissitudes of life,
as contemplating the ambiguity of the possi
ble emerges with yearning for successes in the
moment" (p. 130).
tn
cv
n_
H
CD
O
3
Q.
S
Meaning of not having a place of one's own
was "a sense of gratitude for protection, min
gling with the discomfort of restriction and ex
posure, giving rise to fears and reassurances
as detachment from cherished others surfaces
discordance with unfamiliar patterns, while
novel engagements bring pleasure as insights
and struggles surface new possibles as well as
rt>
11TO
Baumann, 1996
The study explored the concept of "feeling
uncomfortable" as experienced by children
with no place of their own.
Parse's research methodology was used to ex
plore experiences of 16 homeless children 4 to
16 years of age. Dialogical engagement pro
vided a format for unstructured sessions.
The central finding was feeling that being un
Twelve persons 75 to 92 years of age partici
pated in dialogical engagement to describe
their experiences of restriction-freedom.
"The lived experience of restriction-freedom in
later life is anticipating limitations amidst unen
cumbered self-direction as yielding to change
fortifies resolve for moving beyond" (p. 171).
comfortable was" a disturbing uneasiness
with the unsureness of aloneness with togeth
erness amidst longing for personal joyful mo
ments" (p. 153).
>
73
AGING
Mitchell, 1995
The study generated a description of the
meaning of restriction-freedom in older
persons.
Futrell,
Wondolowski,
and Mitchell,
1993
The study elicited a structural definition of
aging from the oldest older adults living in
Scotland.
One hundred elders living in Scotland partici
pated in interviews regarding the meaning of ag
ing. Data collection and analysis were guided by
van Kaam's steps of phenomenological analysis.
The meaning of aging was "intensifying en
gagements as transfigurations signify maturity
tempering the unavoidable with buoyant
serenity" (p. 191).
Gates, 2000
The study uncovered the meaning of caring
for an elderly relative.
Nine middle-aged and older individuals were
interviewed regarding their experiencing of car
ing for a loved one. Interviews were analyzed
using van Kaam's method of phenomenological
analysis.
Five common themes were discovered: poignant
remembering (offered a historical context),
dogged continuing (effort and endurance of sit
uation), nurturant giving and confirmatory re
ceiving (caring for others contributes to quality
of life), swells of enjoyment and tides of sorrow
o
Q.
2.
£
z
c
5.
IQ
O
Mitchell, 1994a
The study uncovered the meaning of being
an elder.
Six hundred narrative stories written by Canadi
ans on personal experiences in later life were
analyzed using van Kaam's phenomenological
method. Analysis was completed from the 5000
descriptive expressions.
3
C
3.
Z
QJ
□
(moments that break routine as opposed to day-
Q.
m
to-day routine), and uplifting togetherness and
valleys of aloneness (connectedness to cared for
loved one or to others despite sense of isolation
from desired activities).
D
A structural definition being a senior was "en
gaging the now while rolling with the vicissi
tudes of life as refined astuteness surfaces a
buoyant unburdening. It is as though shifting
rhythms propel discovery through grateful abid
ing in wondering awareness as anticipation of
new possibles enlivens connectedness and al
truistic commitments affirm self amidst the
retrospective pondering of everyday" (p. 74).
Continued
r-¥
ET
S’
n
s
rilCKT
n
O
z
z
n
TABLE 7-1
o
z
ii lies Based on Parse's Theory of Human Becommg--cont,d
Study/Year______ Purpose
AGING—cont'd
Rendon, Sales,
The study explored the experience of aging
Leal, Pique, 1995
of community-dwelling elders living in Valen
cia, Spain.
Jonas, 1992
Davis and
Cannava, 1995
The study explored the meaning of being an
elder in Nepal.
The study explored the meaning of retire
ment for older persons who were performing
artists and now living in Italy.
Methods
z
Findings
van Kaam's phenomenological method was
used to study nine community-dwelling elders
regarding their lived experience of aging.
Aging for community dwelling elders was
"confirming triumphs through the forceful en
livening of bridled potency" (p. 154).
Twenty-five individuals were interviewed about
the meaning of being an older adult in Nepal.
The meaning of being and older adult in Nepal
is "cherishing necessities for survival intermin
gles with the rapture of celebration with im
portant others, as diminishing familiar pat
terns expand moments of respite, while regard
from others affirms self and changing customs
create comfort-discomfort as what-was un
folds into new possibles" (p. 174).
c
in
□’
IQ
S’
<D
£U
n
=r
o>
o
OJ
□
CL
Qj
ft
A descriptive, exploratory method was used to
interview eight artists regarding their experi
ences following retirement from the performing
arts.
8
Retirement of performing artists was the
"emerging of an unburdening lightness as es
thetic interconnections surface the was and
will-be in the now moment as the diversity of
everydayness enlivens through communion
solitude while anticipating the transposing
vistas of the inevitable prompts treasuring the
now in confirming a perpetual artistic legacy"
Ml
WORKPLACE
Mitchell and
Heidt, 1994
The study generated the structure of the ex
perience of wanting to help another.
Eight nurses who incorporated nontraditional
modalities (therapeutic touch) participated in
dialogical engagement about their desire to
help.
Janes and
Wells, 1997
Northrup und
Cody, 1998
The study described experiences of caring by
nurses using Human Becoming Theory as a
basis for practice.
The study described changes following im
plementation of Parse's Theory of Human Be
coming in a psychiatric setting.
A phenomenological approach guided 10 inter
views with persons age 65 years or older who
were hospitalized for medical problems.
Colaizzi's method for protocol analysis was
used to analyze data.
A descriptive, qualitative method was used to
discover changes on three acute-care psychi
atric units that adopted Human Becoming The
ory as a basis for practice. Interviews with
nurses, patients, unit managers, and hospital
supervisors were conducted preimplementation,
midimplementation, and postimplementation.
Written questionnaires were also completed by
nurses, unit managers, and supervisors. Chart
audits were completed at each of the three
data collection points.
, ,. . . . ®
The experience of wanting to help another
was "directing intentions to nurture amidst
uplifting affirmations with others while disso
nant constraints unfold new possibilities"
(p.123).
Emerging themes included coming together
around instrumental tasks, nurses being there
for patients, and nurse's pleasing way. Experi
ence of relating to nurses invoked "feelings of
being both cared for and looked after: One
will not be neglected or abandoned, or will
one be treated with anything less that human
kindness and respect" (p. 217).
Preimplementation nurse interviews focused
on techniques of care and functional status of
clients. Therapeutic intervention was aimed at
control and shaping more desirable behavior.
Themes changed by midinterview and postin
terview. Care became more person-focused
rather than problem-focused. Listening habits
changed as nurses became more comfortable
with permitting patients to set the tone. Topics
for discussion shifted to those the patient se
lected. Job satisfaction improved as nurses be
came more committed to applying the theory.
-T7
m
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2.
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ft
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KP’!-
176
............................ ■
ir!l.‘!q
CONNECTIONS
Nursing Research, Theory, and Practice
Grieving. Using Parse’s research method, Cody (1991) described another universal
phenomenon—grieving. Cody found that the structure of personal grieving was
characterized by four core concepts. “Intense struggling in the flux of change” incorporated
confrontation of personal mortality, struggling toward possibility, affirming self, and easing
and intensifying of immobilizing agony (p. 64). The “shifting view that fosters moving
beyond now” reflected transformation and the rise of a new view or sense of self (p. 65).
Dwelling with and apart from the absent presence and others” represented connecting
separating where there was simultaneous involvement and noninvolvement with the
absent presence and others (p. 64). “Different possibilities surfacing in light of what is
cherished” demonstrated valuing of choices and possibilities. The structure of grieving
Cody described is congruent with Parse’s principle of cotranscendence, in which power
can provide unique mechanisms for transforming. Findings indicate that grief is an ongoing
process of being and becoming in which individuals, while living among others and
cherishing involvements, move forward toward a new perspective. Further study on the
grief of the dying or on grief unrelated to death could be explored with Parse’s theory.
Broadening his study of personal grieving, Cody (1995a, 1995b) examined grieving in
families living with Autoimmune Deficiency Syndrome (AIDS). “Easing and intensifying
with the flux of change’ represented a multidimensional process in which families han
dled both welcome and unwelcome change (p. 108). “Bearing witness to aloneness with to
getherness" reflected the connections within grieving families and the options of living
with and apart from one another (p. 108). “Possibilities emerging without ambiguity" ex
emplified rhe paths chosen in grieving from multiple possibilities in light of complex rela
tionships (p. 108). Finally, “confirming realms of endearment” embodied the concept of
valuing what mattered in terms of grief and the meaning of rhe loss itself (p. 108).
1 his was rhe first study to use Parse’s research method for families rather than individ
uals. Structuring meaning through mutual reflection of cherished images, an aspect of
Parse’s concept of cocreating reality, lends credence to Human Becoming Theory. More
over, HIV families, who live in the presence of others’ grief while experiencing personal
loss, demonstrated cocreated rhythmical patterns of living in paradoxical unity. The strug
gles and joys of these families led to transformations. All of these factors provide support for
Parses theory. Areas of suggested study include examining experiences of being with and
apart from loved ones, doing the best in an impossible situation, and bearing witness to
suffering.
Serenity. Kruse (1999) documented ovarian cancer survivors’ descriptions of serenity.
1 holographs were used to enhance rhe descriptions of serenity. The resulting structural
statement was steering-yielding With the flow arising with savoring remembered visions of
engaging surroundings, as abiding with aloneness-togetherness attests to a loving presence”
(p. 147). The concept of serenity incorporates powering, a fundamental process in which
self-affirmation allows cancer patients to let go and move with the flow while still focusing
on important life aspects. Serenity for these cancer patients also reflected connecting
separating, in which patients spoke of being alone and together with others. Kruse
.suggested that this concept of serenity can guide pra. rira mcis in the nurse-to-person
procos for patients experiencing a life-threatening illness.
Quality of Life and Suffering. Quality ot life v o another phenomenon investigated
with Parse - research method (Pat'-e. N96b) in isiujx ol .Alzheimer’'-patients, four themes
f
CHAPTER 7
Modeling Nursing From Unitary and Existential Perspectives
177
supported Parse’s concept of paradoxical rhythms. “Contentment with the remembered
and now affiliations arises amidst the tedium of the commonplace” encompassed
Alzheimer's patients’ lives now as compared to their lives in the past (p. 130). The “easyuneasy flow of transfiguring surfaces with liberating possibilities and confining constraints”
represented the sometimes smooth, sometimes difficult changing patterns of living (p. 108).
“Desiring cherished intimacies yields with inevitable distancing in the vicissitudes of life”
recognized the wish for family closeness but acceptance of being apart (p. 108). Finally,
“contemplating the ambiguity of the possibles emerges with yearning for successes in the
moment” reflected participants’ consideration of their futures (p. 108).
In a different setting, Fisher and Mitchell (1998) conducted a qualitative study focusing
on the quality of life of psychiatric inpatients. This study supported Parse’s suggestion that
humans have unique realities. Mental inpatients expressed these realities through their
shifting priorities with day-to-day life changes. Reflecting on the past and present with
changing relationships offered both comfort and discomfort. Struggles in relationships
could be both upsetting and calming and thus exhibited a paradoxical rhythm. Parse’s con
cepts of transforming, originating, and powering were supported in patient descriptions of
perservering in hopes of improving their situations. Fisher and Mitchell suggest that nurses
can facilitate patient exploration of meaning, relationships, and hopes through a partici
patory practice in which nurses are truly present with patients.
Suffering is closely connected to the concept of quality of life. Daly (1995) identified
three core concepts associated with suffering: (I) “paralyzing anguish with glimpses of pos
sibility, (2) “entanglements of engaging-disengaging," and ( >) “struggling in pursuit of for
tification” (p. 253). These concepts discern rhe anguish of suffering from the positive as
pects of individuals’ lives. Possibilities remained even in the face of suffering. These
concepts reflected the valuing, connecting-separating, and powering posited in Human
Becoming Theory.
Allchin-Petardi (1998) examined a concept related to suffering—women’s persever
ance during ovarian cancer. Persevering through a difficult time was described as “deliber
ately persisting with significant engagements while shitting life patterns” (p. 174). In the
conceptual integration, persevering was described as “powering valuing in the connecting
separating of originating" (p. I 74). Powering was reflected in participants’ forging ahead in
spite of diagnosis and treatment and in reflecting and acting on values. Parse’s connecting
separating was evidenced by moving toward support systems found in significant relation
ships and away from relationships or engagements perceived to be unsupportive. Shifting
life patterns reflected Parse’s “will-bc with rhe now” concept, in which participants choose
to live in new ways. This research expanded insights about rhe concept of perseverance, a
concept that needs further description. Perseverance is not merely persisting but involves
significant human engagements.
Carson and Mitchell (1998) studied patients who live with persistent pain. The persis
tent anguish of pain was generated by physical symptoms and reflected the individual lived
realities of the sufferers. The concept of isolating retreats while also parriciparing in com
forting engagements reflects Parse's parad-‘.xical rbvthin or (.onnecting and separating as
well as revealing .ind concealing theit pain from ■ >thers i lope for reiief exemplifies Parse's
suggestion of transcendence, in which participants thought about and remembered being
pain-tree. 1 arse ' concept ot ['I'wering ■ • ' •und in the i'cisonal 'irategies used to obtain
178
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 7
relief. This study provided insight into lives of neonle n,.
.
research could examine the ways tn which these m
e,X^r,encljng Tronic pain. Further
of disclosure and obtaining pain relief.
'
* COnduct themselves in terms
(I"4'
l994studlro7ZSthIr™ndchLra
eXplored homelessness. In the
moving
bur was preferred over' being on rl^■ displacement and
"“
T3
was agonizing
but frustrated with not gert.ng out Re idendfi X Were "‘X
in a belter
policies were found to disconnect familv m
h' d'Splac"ment’ relocation, and shelter
expressed possibilities through dreams for the'f r^' M™ ' ’emSelves and others. Families
squelched by Social Services
u
L
,
MmC tek thar drea™ were
* atCempre^ to maintain control,
-'-‘‘-Hips
Originating, another focus of Parse’s rh
devdoped^ansfutrnm;X
insights and awareness. This studv
- ■1 ■ '
°f heing vvere 'nfluenced by new
of one’s own. These aspects including
.‘mpt)rtant aspects of Hving without a place
privacy, and mothers’ d ’
±X
T’3''"" frCCdom-
Baumann’s 1996 study focuX .
h
I
T.
^^^ed.
forrahle. A unique characteristic of the eT T '' ' 'ei1
rlle'r SCnSC °f feeling uncom
plain the concept of feeliim uncomforrib'l -’"ti" e'’'1'"C,nCnt "'as the use of drawings to exeasmess” which reflected an exp c me t
"distUrhil* The “unsureness ofalonenXXhfW th" > nf
"" UnC°mfi>raW‘-- <pp- ’54-1 55).
mg and uncaring engagements and losses (p 1 56) ‘ViXf30'1^ “'re dcStrL,ctive carmirrored yearning and also reflecre I w.
Ill
'
pcr'sonal J°y^ul moments”
comfortable was found tX nr- W- " f
dren IT" aff"m
elves. Feeling unory of Human Beco.nmg wM^X^s 1
SUPP°rt
longing for personal joyful moments exemnlif
Powenng. This research couZXX k ■ f^
Aging, hi addition to Parse's laughter stu li"
eCtnig C^nnecc”^'Separating, and
“ 3 part
K entlf’ed core concepts,
other studies investigated aging. Some used phen
°Ver’ SeVeral
Parses research method In i stu iv
rl
• .t)11Kn°. OL;ic,,l methods, and some used
0 995) idettified core concerns
adultS'
self-direction, and yielding to change as a fornfi -'it"'" 'T't,ir“’ns’ h'" ‘n" ‘"’encumbered
concepts and descr.pt.on ,Tv,de ? erne
T 7 fT7
7Ve ,'Cy<’nd’ These
by adjusting. They felt restneted bt h,
f
7
“
tO 'ive with change
Tins studv generated
7 el- re 7 i
by d,C ch'”Ce
-rure of the human-uX' - reh7mh7'm I
t'- p-d™^
as Pos.ted by the Thi'orv of Human Reconm re 77"st'
'p'. ;"1J ^forming
exploring turbulent times, seemg tlrures ,n . new Tr f 7'7 ’ dlrecr“’ns lncll,de
to rhe future, getting mi ohedm „
I "
^T' 'CC r'’ l'ursllL' Teams,
others, and recalling-pecial inemorie<.'
'
1'n"
gt’l’d ab<’dt helP'"g
and Mitchell H«i) .'X |' 7771‘'
'’''e''1 ri"”’ rerspectiies. Futrell. Wondolowski,
niaturirv tempering the unavoidable wrrl, g'11Ltrensnguranonssigmfv
(l994..)ol(,0,M,.ln-Ji,Vl.,
-X
?'7''ty <p’ ,91y Mitchellkstudv
S anad,.,,,, reve lled some common elements, mclud-
Modeling Nursing From Unitary and Existential Perspectives
179
■ng the ,n ensify-mgengagements which were propelled
propelled by
by an energy and enthusiasm found
‘n LatnootJhe T“Pt of bu°yancy tound in the Futrell, Wondolowski, and Mitchell
study (1993) ,s s,m,lar to Mitchell’s findings. Courage, understanding, and strength are im
portant charactensncs. Anncipation of
of possibles
possibles was important in accounting of both stud
ies Future research should be directed toward how attitudes shape experience in later life
and how those att.tudes are chosen. Exploration of how transfigurations influence health
would also provide valuable information in working with elders
Rendon Sales Leal, and P.que (1995) studied older adults being in Valencia, Spain
and found that elders described triumphs in fixing but also experienced rhe paradox of betng hnuted wlule remaining vital and alive. A sustaining resolve to move forward reflected
elements of strength and courage congruent with other studies. In this studv, confirming tri
umphs ,s linked to I arses principle of valuing; bridled potency reflects rhvthmicity; and the
paradox of revealing and conceahng while connecting/separating and forceful enlivening
reflects powering.
Nepalese older adults also described rhe paradox of aging (Jonas, 1992). For these elders
paradoxes emceed in terms of possibility and limitation, chang,ng customs but bavin., a
sense of cultural loss, and rejoicing in celebrations while struggling with dav-to-dav fife
Dams and Cannae;. (199,) studied a special segment of older adulthood -reined perorming artists Iivmg m a retirement community. Once again paradoxical themes emerged
With concern over losses bur the presence
possibilities. The retired performers feared
presence of
of new
new possibilit
losing themselves as they gave up performing but discovered new interests in passin..... . an
artistic legaev. Compared to descriptions of other older adult groups, this was a unique
manifestjrion of rhe paradoxes of a^ing.
Gates (2000) explored the experience of caring for an elderly loved one. Thematic find
ings provided msight into the experience of caregiving and support for Parse’s Theory of
Human becoming. Memor.es were a way of providing history and constructing indiv.dual
meaning to. caregiving. The endurance required for providing long-term caregiving re
flects the concept of powenng. Cotranscending was exemplified in the nurturant «itw
and coc,-eating was reflected in rhe paradoxical rhythm of the joy and sorrows embedded
m care go mg and m rhe sense ol togetherness and isolation of missed activities. This srudv
helps to provide a view of caregiving embedded within the concept of human hecomin..
Workplace. 1 arse s theory has pn,v,ded a frame of reference for practice issues. Mitchell
and kadr (I TH) explore.l the phenomenon of wanting to help another with eight nurseWho used therapeutic touch The first concept, “directing intentions to nurture,” represented
choosmg wav- of l-cmg ,n rhe helping process and shepherding others (p. 123). Parr.cipants
had longsrandmg desire, to help "Uplifting alfirmanons with others” depicted rhe learnme
changing, and connecting that occurred in rhe helping process (P 124). Tin, ..spec, wm
cherished or valued by participants. “Dissonant constraints unfold into new possibilities”
rc,lvcted the constraint of wanting m help l-ut not being able to. However, new possibilities
c'ne'-ec.l even amidst hmuations. These rmdings support Parse’s principles regardm..
pc,|Mln
, "K'' I
'K'
lcu.es theorv ...
it-.. .m..lir.mscci1dcnce.F,,1dl,1gsprov,deinsighrinrorhe nature of nurseHtJjbc <u,iro'inv< ot In mn ln lrilc presence with others.
< ‘'US' examined older ,dulr experiences of receiving care from nurses
•" Hum!” .o.miv Xur-.,.. on a medical uni, the I; id adorned
gt„de I..- yi n v s gear, kef. re ,l,g patient interview,. Punenm felt
180
CC N NF. CT 10 NS
Nursing Research, Theory, and Practice
CHAPTER 7
cared tor and treated with kindness a.,
and respect. Although time with nurses was driven by
the completion of instrumental tasks,
acc-ssibil
r
Patients appreciated the j
, ' rT’ attentlon chanced the hospital experience
ccessdulirv of the nurses and believed nurses were committed to
meeting their needs. The value of Hu
• -uman Becoming Theory was confirmed in that panents felt their values as human bci
Northrup and Cody (1998)'TfeZd T i
relatio"shiPs «'nh nurses.
acute-care psychiatric units Th v e influence of using Human Becoming Theory
on three
chart audits began before implemenTiondH1
'nterv'ews’ questionnaires, and
rice and continued ar the midpoint -ind ifr • ■ ‘T'"1 BeC‘’"’lng TheorV as basis for pracfound dramatic shifts in perspectives from nurses "’’Cntat'On'°n S”'ne ,,nits’ investigators
were viewed as people rather th in nrobl ■
" "l 'ld°PreJ the theory » tenets. Patients
Planning cate. Patients found nurses to be
"“mi
persPectlves in
Managers reported that job satisfaction md n -r "l" ''
respcctful
t,lcir views,
vestigators recommended that successful inml' „
Pans,‘’'™i’r,ons "'ere enhanced. InPractice mclude an on-s.ce laedmk^
w™
Modeling Nursing From Unitary and Existential Perspectives
181
practice. This in turn leads to an expansion of the body of nursing knowledge. Thus the
ory, research, practice and education are interrelated, which is essential to the develop
ment of nursing science and nursing knowledge.
The Variables of Concern for Practice
The variables of concern for practice within the Human Becoming school of thotmht
arc
process variables as reflected in rhe language of the theory: cocreaung, coconsiiturmg.
scendmg. Parses writings provide a complete description of the meaning of the variables.
Describing a Population for Nursing Purposes
Describing a population for nursing purposes precedes designing nursing for groups of peo
ple. No patient population desenpnons within (he perspective of the Human Becoming
school of thought were found in the literature that was reviewed
Expected Outcomes
.......... ...... .. ........................
pe tinted that ar .his tinw, 'he nimh« of ‘ H
..
Pi:::.
.Cii::.',
•p::T
Tire mrm eWted outcomes Joes no, hr well with rhe Human Becoming Theorv (Mitchell,
). he goal of rhe discipline of nursing is quality of life, and rhe goal of rhe nurse i< "rt.
be truly present with people a< they enhance rlwir quality of life” (P use NOS - (-•<;
N'lrse-patien, inrer.icfi.<houl.! aduevc the Plam. yoals, and pnorities torehanTr per
sonal patterns ot knowmp. Only the person livmu rhe l,te can describe qual.ty o, Ide
rhetefore there is no standard against which to measure quality of life, and such measuremenr is nor consistent with this theory.
in sewraI Indies. 1, should
I'arse'.S research method ,s that data analysis is ".'T' ""u
;"'vcly sinal1- A strength of
»' any qualitative research is evidence of swr'-T'"''"'” '
Cr‘''C''1 fclture
using Parse's research method presents data" from' 1
T'
StUdy rcP<>rts
rhe lonn of extracted I sseiKes m I th-i
■ 1 'K >.''1‘’P 1 :inab ',s nnd conclusions in
• mJ then
and then beur.sr.c ,uX '
h p-‘- <-re concepts
N presented. Evidenc
clearly delineated The JescriPIIV . ,, .r
A 'l'rP'>'tu.g findings is consistently and
nature <>! rl 'll'v tf <ngsean
............
pr„e„,c
;1.;:
iived experiences.
'•Vlienever a ilwoo-i ,
, Him. - it universal need
.......
1
r
“
support
his
or
her
sents a difficulty. Having the theork'nre ■ TT’"'
ller the<
Potential bias predata collection and analyse may sw r' preconceptions
y’ncePtions tied stso closely to the processes of
find
our that theory ...... cwially in.iv sway interpretation of T
Chi’ln (l"5) Poinwd
it obscun
stbility to lecognizc nc« possibilities Althoinl 'liscovery
1|'U’'Cr> when
whe‘yr
obscures an investigator’s
Process Models
Parse refers to a pract.ce mchodok.gv r.-ther than to (he nursing process. The method T
?gv .nau,.^ .lluminmmc, svrwhroninnu thvihinx ami mobilizing transcendence (B,.x
, •
J* 1 T ;.arSeidoeS n;H ?‘,Cr r° a nursin8 di«gnosisor patient problems. The knowl
edge and capab.lit.cs beneath these processes need to be specified, and education promams
or practicmg nurses need to be developed. Ar present, the richest sources of informal i.m
Srik,le? rept,rtS
researdl 111 rhe hteraiuie. and Parses own writings.
Withm the .Hluman Becoming school of thought, (he goal of nursing is being “truly pre>ent with peopl e as they enhance their quality of life" (Parse, 1998, p. 69). Parse describes
concept ■of
courages participants to reved then exo-ri: ' ■ • • ••e
VA
’* dialogical-t
d1 'engagement enterpreted are invested heax ilv in d experiences, the lenses through which findings ire in
coming. From this fw’pT we’ J AoT^'T JT''CJ 'k”'
Tl’e"ry
Be-
'll.munaring and can offer taluablc msu-'lnfor wicuc
•k-m,>n,tra(ing outcome- <>l imervention \
hmiting factor in tesrmg interventions basedT
Wh''e de:>criPr,on
provide a ha^s for
‘ i
'
Vdoes
°;S nnor
°r providc
descriptive level. This “
is 3a P°te"rially
Human Becoming Theory.
Practice Methodology Proposed by Parse
PRArnrpAo THE°RY UTILIZATION:
resigning nursing
sc™oLCEoFPRT°™”s wuhim the human
■
BECOMING
P-">e (J99S) dexrtlvd die imkim. buween ch ■ ■■
^quencciticliidiiicihiio-or!
I?
-holarly re-earch TN •
" _/ T
:
u 1 fr.m f t f
Ir\
1. Illuminating meaning ,s expl.cating what was. is, and will be. Explicating is mak
ing clear what is appearing now through languaging.
2. Synchronizing rhjthms is dwelling with the pitch, yaw, and roll of the human-universe
:C>C4K n’ Bnwttcc. and education as a
^velopmem. and
1 back Io the c<incef rual <v
ciopiucnt. lurcher research. -id
t
|
m°SSS‘ Dwe"'n9 Wlth IS '"Wrsing with the flow of connecting-separating
- MobU.zing transcendence is movmg beyond the meaning moment with what is
not yet. Movmg beyond is propelling with envisioned possibles of transforming.
if..
182
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 7
the processes related to ttrue presence and ways of changing health in true presence
as being achieved through the following actions:
• Preparation
• Focused attention on the moment at hand
• Face-to-face discussion
• Silent immersion
• Lingering presence
Changing health occurs through the following:
Creative imagining of particular changes to a situation
• Affirming personal becoming
• Recognizing the paradoxical
Mitchell (1998) describes rhe |
...
process, developed by rhe nurses ar Sunnybrook Hospital
in Toronto, Canada, for guiding practice from the |
perspective of rhe Theory of Human
Becoming (Box 7-3). Dialogue is rhe essence of this process,
As with the traditional nursmg process, consideration of the person’s lived experiences as
problems to he solved has no
place in this methodology (Mitchell, 1991). Rather, determinin'’:
g a nursing diagnosis creates an ethical dilemma lor nurses practicing from this perspective
-• as “the process of la-
J
I
I
St bTT ioT rr rr
(Mitchell
which scts the
1
p. 100). In Box 7-3, note the strong emphasis on listening claritvhv , I
MTlYTr" pa7”rs/,.rlv's CTernS' diSCUSS"1« oPtionsHeinK nonjudenAta
Mitchell, Bernardo, and Bournes (1997) relate patient views about encounters w.lh nu,T
ip:-'-;
■fi::!..,
ps:.-.
pracncins from the perspective of Human Becoming, in which the healing nurse-person rerXmTlT ;™f C ■" TCt'CC‘ The KOal °f nl,rSinR IS cn,lancil1"
-Tie tor the
pat ent. Thn ,s manifested ,n nurses' accommodating patients' wishes for variations ,n
e. ment regimens and schedules. Nurses helped patients make decisions, and patients
ZZxx:.. ...... . ................. .-~i.....
BOX 7-3,Qg
Dialogue as the Essence of Nursing Practice
1. Initiate discussions to clarify issues, concern, and Wishes as expressed by
patient/families. Seek depth about the person’s particular wishes for care and in
ClaTv T'
2.
change
S°n the indlvldual's/famiiy'' Personal meaning and views of life
individuals
discuss or
3. cTtP TPti°2' alternatwes' and anticipated consequences as seen by the person
Create open, honest, nonjudgmental engagements
4. Record descriptions of changing life situations as described by persons and
g oups. Record staff activities that support the person's wishes for change and
care. Record how individuals evaluate healthcare and how they view progression
toward their desired health and quality of life.
7
P 9 ession
I”-!- .4 chant’c.
Modeling Nursing From Unitary and Existential Perspectives
183
Descriptions of practice situations in the literature focus on “being with" the individual/
family- In addition to the dialogue process described, nurses practicing from this perspective
seek the patients and familys views of the situation while performing the technical pro
cedures. They are also conscious of and attend to their own attitudes, approaches, and in
teractions with the patient and the family. Nurses working from this perspective do not
attempt to judge another nor to direct their choices or actions. Rather, through processes
such as those described in Boxes 7-2 and 7-3, they support individuals and groups of per
sons as they clarify their own intentions, fears, and hopes.
Practice Models
Because each situation is perceived as unique, practice models and rules of practice have
not been developed from this perspective. It is possible that some guidelines for practice
that arc consistent with Human Becoming Theory will result from research studies such aCarson and Mitchell’s study (1998) of persistent pain. Within the descriptions of rhe
unique experience of living with persistent pain, the researchers found rhemes shared bv all
study parricipanrs. These included “forbearance surfaces with the dram of persistent an
guish, isolating retreats coexist with comforting engagement," and “hope for relief clari
fies priorities of dailv living" (p. 1246). The researchers suggest that these rhemes could be
investigated further to help nurses bet ter understand people’s choices about disclosing their
personal realities. This type of work might lead to related practice models.
Since there arc no practice models, reading Human Becoming research stifdics i- e-sential for nurses who wish to practice from this perspect ive. Such research has been iden
tified as rhe source of development of nursing knowledge (Parse 1997d. 1998). The focus
of research reported in the literature includes the lived experiences of persons with varvmg
health -tate> and in varying stages of dcvelopmeni.
Implications for Administration
The i>inaiii.ational <rriictiire and rhe sysicins and procedures developed bv an organization
to ensure >crvicc delivery have a major impact on the nature of nursini* practice m a health
care ayenev (Allison Ck McLau^hlin-Renpenninu, 1998: Mitchell, I99Sh Admiinsrraror>
must clearlv think through the direction for provision of care mandated bv mission state
ments. politv statements, paricnt/nursin.u standards, and similar tools of’organizations. A
major task tor administration is ensuring consistency between the values espoused bv nurses
practicing from a particular theory base and rhe systems, procedures and evaluation stan
dards developed bv the <er\ tce delivery organization. For example, evaluatin'’ the eltectivenos of nursing practiced from the perspective of the Human Becoming Theorv requires
klitterenriarinyi evidence relatin'’ to skill, outcomes associated with procedures, and service
dcliverv from knowledge that informs rhe nurse-person process. Evidence that indicates
tiic beneti; a nursine comes from the descriptions by patients and families of chanties in
h' ihh and qualitc ot life that result from nursin'! care (Mitchell, 1999).
r'rudic' < a nurse- practicing within the Human Becoming Theorv indie ire th.u nur-e- -ee
patk ius as unique |vi<- >ns in rclaiionship with orders rather than a- problem-. Fniph.
■n
the per-on rather than • n'. pn-cedure- and treatments (Mitchell. 1994b). The c <u- .
patien: di-«. U"i<'n- a;-''<-ar- i -hill fiom proceilures to relationship i—ue-. Tin- . hanccJ ! 'cuis icoimpanic'l b\ m irc.rca-e in |ob satisfaction (Northrup and Codv.
More
i
184
CONNECTIONS
Nursing Research, Theory, and Practice
some nurses expressed an increased understanding of nursing as a scientific discipline. How
ever, nurses commonly express this feeling when practice based in specific nursing theory is in
troduced; this response does not appear to be unique to any one theoretical perspective (Fitch,
Rogers, Ross, Shea, Smith, <St Tucker, 1991; Frederickson & Williams, 1997; Walker, 1993).
In reference to a community group of persons diagnosed with genital herpes, Kelly
(1995) describes the contrast between traditional nursing and practice guided by the The
ory of Human Becoming. Over the period of 10 weeks in which seven 75-minute discussion
sessions were held, the nurse developed an understanding of the experience of living with
herpes. Kelly went on to further analyze this experience and to formulate what she called
a “loose agenda for community-based practice” (p. 1 30). This included the following (Kelly
1995, p. 1.30-131):
Knowing the cycle of irresponsibility stops here brings priorities forward in action, whereas
keeping facades in relationships both protects and causes worries
• Wanting ro be “moving real" with intentions to turn your world around, yet saying the time
is not right for either reaching our or risking vulnerability because it is not easy
• Seeing rhe center of the universe a< being true to the purpose of self, yet separating from the
center to find *‘a love relationship between two persons which creates a vacuum” in regard to
the future
•
?t:::i
•<C';
Kelly went on to identify certain characteristics of a “Parse nurse ” These included be
ing respectful and nonjudgmental, honoring the importance of “facades,” and respecting
that each person knows his or her own way and that it is always evolving, and exploring joy
and spontaneity in rhe presence of suffering.
Northrup and Cody (1998) recommend that organizations implementing nursing pracii<.c from the Human becoming perspective include a facilitator knowledgeable in the the
ory at the master s or doctorate level. Adequate resources need ro be allocated for staff ed
ucation. Organizations should also ensure that management endorses practice from this
peispcctive and prov ides administrative support tor appropriate continuing education. An
ongoing program of research related to the health concerns of the population being served
is essential as research generates the knowledge base for nursing practice. Research pro^rams based in other schools of thought will have little relevance (Mitchell, 1999).
Implications for Education
CHAPTER 7
Modeling Nursing From Unitary and Existential Perspectives
185
nursing journals and newsletters—as well as the nursing science and nursing research jour
nals. In addition, continuing education programs and/or in-service education programs
need to be designed and delivered to disseminate this view and to develop the knowledge
base to support practice from this perspective.
NEXUS
With some background in philosophy, one will find that Parse’s work is simple to
grasp conceptually, the difficulty is in rhe level of knowledge necessary to use this
approach in research and practice. The basic concepts and assumptions arc philosophi
cally congruent and logically consistent. It is important to recognize the depth underlying
the ideas presented. Without a background in philosophy, the language and the ideas may
appear difficult and confusing. It is important to understand that Parse believes that one
does not simply use or apply her theory. One lives it (1997a).
REFERENCES
Ailchin-Pviardi. L. (PWSk \Vi-.ithiiaii: ; he -ti'iin Pcrseveiinq thrmiyh ;i diflicuil tunc
Scknce Qtiur-
u-r/v. 1/(4). 172-177
.Allison, S.E. Ck McLaughliln-l\cnpc:.ning. K.l" ( I 'SSI. .N’ins:ni> .Adniinisn<tti<'ii ji Kic 2/st . cntiiry .A
tk--
orv dpprniich. rhousand ( kiks, t A; Nigv.
Baumann S.L. (1994) No pl.ic c ot their own. .Xiirstng Siii’iicc Qiunicrly. 7(4). 162 -! kA
Baumann S I. (1996). K-dine tiiw.'inli >rr:il'l<- ( ’hildrm in t.unilics with no place .>1 their own. Nurs’iig Scic
Quarterly. 9(4). 152-159
I he vxi'cncncc ui In tit" with persistent p.iin. Ii 'onni e/ AJi.niccu' .X w-
Carson, M.Cj. 6: Miidiell. G.l (1
mi;. 2S(6j. 1242-1246.
Chinn, i'.L. N Kiamer. M (1995). ] hci
und nursing: .A svceniu’ic
mc/i. (4th vd.). St. Lmns: Mn-bv.
Qntntcrlv. 4(2), 61 6S.
(Jody. W. ( 1991) ( n twine a persi ’n.ii !■
.X msm.t; Xo,
C..Jy, AX'. (1995.1! The lived v.xper.i ii
>1 .:r:e' in.. Ii >; l.iii’iiics inine iviti; .A I PS. in l\ I'.ir'C (E<L ). i:<:en.hofc
/ he limn.m Ivonnmg i’leorv m
(Jody. XX . (1995b). Tiic my.mine
md locurc/i. New York: Nntional League tor Nursing Press.
T erivving tin f.inulies living with AIDS .Xu' iiu: N-
Qnjrtci.X. St i
104-114.
Cody. XX'. (1995c) About all those p.ir.idiei
M.mv in the universe, two m nursing- .Xn’sm^ X,Q'ainc’r-
<5(4). 144-146.
Daly. I. (1995) The li\cd experieiKi ot Mitiering. In R. l’ar>c (Ed ), ll/iiininiinons- 7ne Irmikin bcconiins. :ncor\ in
practice und rcscLniii New 'lork: National League for Nursing Press.
Nursing practice within the human becoming school of thought involves a specific world
view. 1 his worldview, ar present, is not generally the basis of nursing education programs
oi nursing textbooks. Although Parse (1981) described a curriculum based in Human Be
coming 3 heorv ih.n directs development oi basic and continuing education programs, this
worldview, ar present, generally i.- not (he ha.-is ot nursing education programs or text
books. An understanding ot existential phenomenology is probably necessary to practicing
from rhe perspective of the "I heory ot Human Becoming. This presupptoses at least a bac
calaureate degree that includes courses tn philosophy as a requirement for entry to practice.
Kescaii.h lit . i irure h nor a common
iircv of informatii'n for practicing nurses
(Lstabrook'. I'N.’.s) j 'is.-cuunatnig rhe body ot knowledge generated by this school of
thought b. prac- icing r.ir-V' <b.' >u!d iiklude puriu anon in what Estabrooks calls the “trade”
journals—- .
F/ie t .\mudhDi Nurse, and state and provincial
Da\ is, D K N. ( Liniui a. E. (i 995'. Thu meaning of ret irement for c<iinnuinallv-living
ircJ peril irininn .irtists.
.N'msmg Science (JimncrlX ’’i!'. ' i 6
Estabrooks. C.A. (199S). XX’dl v*.
!tji: L >urn.il
.Xnr?-
• rascii tntrsiny pr.ict
in.ike pi net ice perk
par.i.i.mn
m worldviews. XursDig Siienci' (xh<.;r!irp.. 6(2L
ing Ixescar. h .k'l 1'. i 5-56
E.nvceit. 1 (199>). Fn.m i p:e’h r
56.5S
riti h. M.. Rogers. M.. Ross. r... >1
l-Lher. M k M
11 , Muir!i. !., N. Tirkvr, D. i i,|'11). I X-wloping .< pl.ui i.-. w.il'.i k ihi '.-c
it cpieal trimiw•
hell. ■ 1 |9'>s i Rttidits'
■: ' >!<>>■.,.! ■ ■! Xi(n’’g A.ininii.ek;::. u. -( D 22 2S
-of <|u.ilitv .. 4 life: Tr.ii’-!'uiniiig'he riur-ini; ku. a IcJia b.c-e. k
ikied pr.te
Tlu R e.
CHAPTER
m q I®'
Modeling Nursing From
a Transaction Systems
Perspective
KING'S CONCEPTUAL SYSTEM and THEORY
of GOAL ATTAINMENT
a::;;
;
ii.::
i:*
Key Terms
human interaction, p. 237
interpersonal systems, p. 236
personal systems, p. 236
social systems, p. 236
transaction, p. 237
Imogene King recognized rhe need for a frame of reference tor nursing (1^04, N6S). l.K-
ing a general system fheorx approach, she formulated rhe sysreim framework io provide a
way to -elect, organize, and develop concepts for nursing. In 1971, King authored louard
a Theory o] Nursnii’. In 1981 she theorized a conceptual framework of dynamic interacting
systems. 1 his w is further dex eloped to King’s Conceptual System (King, 19o l, 1992). The
Theory of Goal Attainment and several other theories were derived from rhe conceptual
-\stem (King. 199(
ln 1997, King noted that the only changes to the conceptual system
were rhe addirii'n- of rhe concept of coping to rhe personal svstem and the concept of hu
man heing- a> spiritual.
King' tiieoretical sV'tcm comprise- three componeni-: (Ila conceptual -y>tvm con'tiikied ot interacting -\-fem.', (2) a transaction proce.— model anti I
a midc:e-ranc-.
I he. >r\ of t >o il Art immcnt 1 he language of goal attainment and -v-icm- i- tamiiim
•
233
234
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 9
attaSenth°W
King's Central Questions .
•>
SET1
1
■
'b-“ -<b- ““ »■«
■
• What T element: A Continuous throughout these changes in nursing?
ip
• WhatdrXd 9°alS °f nTin9 Similar tO those of the
half century?
ing Tudover Zn?SIOnS
**
9iven the field
nursing a unify-
•■•'uf1'
pl I
King has called information-processing systems with instant communication a hallmark
of contemporary soc.ety^Humans communicate and interact in small groups within then
nations social systems. The personal, inteqsersonal, and social systems in King’s Concep
tual System represent “interconnected links for information processing ,n a high-tech world
of healthcare and nursing and provides an approach to structure a world community of hu-
m‘'l V|L1|'7>
21
“76 ' ThC
S'slems Model (1976) and the Howland
and McDowell conceptual framework (1964) influenced King’s development of a schematic
representation of nursing.
Phenomenon of Concern
King ininally selected tour universal ideas-social systems, health, percept,on. and inter
personal relat.ons-as the conceptual bases of the nursing dimensions. The goal of nurs,ng
is to help individuals and groups attain, maintain, and restore health. If tins is not possi
ble. nurses help mdiv,duals die with dignity" ( Oh I. p. | i). N„r.scsfl,I)cri„„s ,rc
those of .he nursing process. Health is “dynamic lite experiences of a human heim. which
implies continuous admstmenr to stressors ,n rhe internal and external envininmenr
though .iptmium use of ones resources to achieve maximum potential for daily l,vin..“
(King, 1961, p. ■)).
•
T'ngbTheo^kmal.syrauunent describes nurse.pauent.nteraenonsih.u lead to goal
achievement (IVM ). The theory essent.ally models nurse-pa,enr transactions where.n Bals
are set and met (kmg. 1995). King (1961) presented a schemanc d,ngram of a Thedy of
Goal Arrmnmem that she now calls “erroneous" (personal commumcatmn. Imruary 5.
“i,tM
" TlU'"r‘' “
,"r n"rSi"S Ge'"''r“l
-™ »
New York: John W.lcy
“‘J....
ii.
jtx'i :-:
"Uerrelated SyStems functi”"eJ The outcome of King’s models is goal
’ a“XXnXOnS are nurses reqUired tO make in the “-se of their roies
“5 “SfSXSS " “b" k™“» '■
'n.l
235
SET 2
•
•Ji'
Modeling Nursing From a Transaction Systems Perspective
'ocml XhL’’ ’dhT/ ',C;'lrl1
J;
llV KrO"Th: d-el‘>Pment. and functioning in
c< i\ las strong human action and interpersonal components.
HIUiimiI
the starting point of the modeling process
(1971)"did id1 that a C°"C77al
"™ld aerate a general theory for nursing
I
.. ‘'tt""'” "■ i..............*
ing and factors that influenced th-m rl ' '
' 7P '
—X
...' T'''' ’h' ewepcon. .,,,,1
|
.
perform i ovu.<!ore health Th'
f
T'e^ons about changes in nuts-
re|adilns_^ t|1(.
.... t!;"i
|„.r
...... ... “■"»
I i ....................................................................... ^et their Basic needs■ |" '
llc‘,lrh •'nJ 'Hness; or attain, maintain, and re-
Kine-c.irlv .|ue>ii,m< •hour nursing and it> pl.
lurrhcrmg her work. The initial questions led her i. ICC in society illustrate her process for
' others directly relnred io rhe structure
,nh' "
,,f mi.-'inv Thoc are presented in Box
' l)-. •Ketlccrion on rhe>e (.|uusrions led
N'iil- I- ideniifv rhe kc. • oncepr> of her co
mccpru.il
I k-velopmenr < 4 the imme-•rkof <Vstc:m Th.. rhe Theorv o, foal Au unment and rhe
................... trans.iction process model
t m H fi'l I
I PCrS'XT1''1' rCfleCW i,Cr
,n"‘<in« kn""
— —tantly
be modified by updatmg earlier concepts (King. 1975). Tire schematic had included process
elements (agreeing to means, exploring means, and mutual goal setring) as well a« percernon and communication. The transaction process ^described later in this chapter
King y.is moved to "focus on knowledge development as an information-process,n..
goal-seeking, and decs,on-making system” (2001. r 277) Her philosophical position n
rooted m genet.,I system theory and centers on humans and their environments. Several
"ch
i Tl
' A JCVC1<’|Vj trO”' K"y'' "'rb''-"'’9 systems framework.
,j'
I
J
T'"rV
|lcr“T",:,i
"-eiaysc (1997). Freys theory offamih-, childre,,. .mJ yhron.c ,lines. (1995) and S,duff’s theory of departmental power
JJ*
- - ■' l™™ aft She considered
!’v
Zn’’ 1
T)
"-7 "Uer'em'‘’n ■ll'J thb
action> (King, 19vj;i,p H).
P-KCSS as a ‘seties of these
DESCRIPTION OF KING'S THEORETICAL SYSTEM
Philosophical Perspectives
The hu>ic ahui .ici n >n >
The tocu> of nuiAnj •
slate . r health h a mdi-.
mIF’'!rio h f|h' phei • ’Hie;’.. •
aiintm holies mtcr.icfiiili
imK 'Ahuh o ,!n tb|.r, r ?
‘ uiun .iikl hjs w.hIJ tKiny, 197i ).
uh rJicn envir.•mnuiv Ic.iJin^ to i
-Hon in >oci.il roles" ( 19S1. p. 1-p).
I
236
CONNECTIONS
Nursing Research, Theory, and Practice
The dynamics of nursing are a “constant restructuring of relationships between the nurse
and patient to cope with existential problems” (King, 1971, p. 103).
King’s work is based in and developed from the perspective of general systems with an
emphasis on open systems. King identified general system theory as the philosophy of sci
ence that allowed her to study nursing as a whole system within the universe (1999). Gen
eral system theory is also the ontology of King’s Conceptual System. It provides not only
the way of viewing reality but also the structure for languaging the concepts. She described
three types of systems that interact between themselves and that interact as a whole with
the environment. These are personal, interpersonal, and social systems (Figure 9-1).
The philosophical assumptions of the conceptual system define human beings as open
systems in interaction with the environment. Human beings and environment constitute
a whole. King described human beings as “social, sentient, rational reacting, perceiving,
controlling, purposeful, action-oriented, time-oriented and spiritual beings” (1999, p. 293).
King considers personalism and realism to be foundational to her conceptual system (1981).
However, the relationship of these philosophies to general system theory is not established.
Nursing is concerned with helping patients in rhe realm of existential problems—that
is, problems arising from or associated with rhe conditions of living. The nature of human
beings is not highly developed in King’s writings. However, focusing on human nature as
an essential parr of King’s system, Whelton (1999) presented a cogent analysis of the philo
sophical core. Concepts of human nature Whelton identifies as Aristotelian and Thomistic
I
»••••
CHAPTER 9
237
Modeling Nursing From a Transaction Systems Perspective
include the integration of material and principle and powers and capabilities for human
acts. These concepts are described in Chapter 5. Within this philosophical tradition, hu
man action involves knowledge and choices. When two people meet in any situation, some
kind of action is involved (King, 1999). When the two persons are nurse and patient, the
action is interaction. A transaction occurs when mutual understanding, goals, and agree
ment on methods are achieved.
King focused on individual perception as rhe means whereby a person experiences
her or his environment. The transaction process begins with perceiving an event or ob
ject and then interacting with it. Transactions are interactions that have temporal and
spatial dimensions in which “human beings communicate with environment to achieve
goals that are values" within a shared frame of reference that consists of facts, beliefs,
experiences and preferences (King, 1981, p. 82). These concepts are congruent with a re
alist world view.
DESCRIPTION OF MODEL AND THEORY
Kings “conceptual system" is modeled in two primary diagrams: dynamic interaction sys
tems and a process ol human interaction, shown in Figures 9-1 and 9-2, respectively (19 < 1,
1981). A now retracted model that attempted to tic the concepts together was included in
her early work. The conceptual system model depicts individual systems in interaction
with rhe interpersonal and social systems, rhe interpersonal systems in interaction with
the personal and social systems, and all three systems as a whole. The dotted line indicates
the openness of rhe systems to one another and to the environment. Concepts for each
system arc identified in Box 9-2.
il?...
ii/:
Social systems
(Society)
Feedback ~
Perception
I
Interpersonal systems
(Groups)
I
" I
I
I
V
Judgment
! Personal systems ;
!
(Individuals)
Mary
A
I
I
I
I
Action
I
Interaction
Reaction
I
Action
Jan
Judgment
Perception
— Feedback
FIGURE 9-1 A conceptual system for nursing: dynamic interacting systems. (Copyright
Imogene King.)
FIGURE 9-2
A model of transaction. (Copyright Imogene King.)
Transaction
I
238
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 9
Modeling Nursing From a Transaction Systems Perspective
239
BOX!
■
Concepts in the Systems Model
PERSONAL SYSTEMS (INDIVIDUALS)
interpersonal systems
Role
Interaction
Communication
Transaction
Stress
Coping
Perception
Self
Body Image
Growth and Development
Time
Space
Instrument/Description
Study/Year_______
Family Needs
Assessment Tool
54 items
Rawlins, Rawlins, and
Horner, 1990
Reliability and Validity
Content validity was established through a literature
review, a parent panel, and two nurse experts. A sam
ple of 1,494 families with chronically ill children com
pleted the FNAT. Test/retest reliability with a two-week
interval was 0.77. Factor analysis on service needs and
information needs items yielded nine interpretable fac
tors that explained 79.6% of variance. Factors included
the following: healthcare information, growth and de
velopment information, day-respite care, special ther
apy services, information about child’s psychosocial
needs, information about meeting education needs,
counseling or psychological support services, hygiene
information, and material health support. Factor analy
sis for obstacles to treatment subscale yielded four fac
tors that accounted for 52.1% of variance. They were
the tollowing: discourteous treatment, problems with
appointments, questions about prescribed care, and
overall hassles of office/dinic visits. A second order fac
tor analysis to confirm hypothesized needs extracted
three factors, information (60% of variance in parent
need scores), obstacles to treatment (26.68% of vari
ance), and special services (11.25% of variance).
ANo?H%%yDvEg^“;LRxKiGiE^ONCEP™ALsvsTEM
nd deductive methods
T heory of Go.,I Arrain.nenr have eon„,u„-d the General Systems
I as more has become
known thiough research and practice.
Framework .„,d
Research instruments
•i:i
Two published msirumems developed us,no K,nu', (fonceptunl System , ’ '
ind rhe Theory
J. f
........ .. ....................................
I Att.nninenr by King
King (1988).
(1988).
C'T1'0'? n™'™'
To measure rhe perceive I , etG
'
T
Rawlins, and )Tomer (1990) de^lo.Gt^’^.
Measure of Goal
Attainment
4-point scale
.........
for construe, vdiduv lor the F\ \T Tl
'"''l "" L'?’r''hllsllcJ
Parents of chrome.,lb ill chddrL FtIiTqMr"' ''
referenced instrument in that it TT'm u
pcrforiiMiKG .H-G.1. Spct-in. ilh rh •
.
.u
■oral response. .„,Ju,,.,!,. Three. uK.-,k> ,reemb.|l
containtng 12 ,teu„. The
can use rhe rev,I,,,,.. J,.,. .
hy assessing the .itti'r
sure of (io,,I Att unuiem I ,
T.-.
K-Tv" 'Th
I
r
‘
"
irygiene.containmg et„ht .terns: ntovemenr „Tb
'irronM fotmdarion
V r'' “ CritCri™-
’ ,d\
d
?Us in ■re,‘,tlon
defined
if itui r.irci •■•liabdir-
An initial draft was reviewed by graduate students for
clarity and consistency. Content validity was estab
lished by two specialists (CVI = 0.88). Interrater relia
bility was established with two nurses with master's
degrees who evaluated 20 patients (total score agree
ment = 85%, physical ability subscale = 83%, behav
ior response = 84%, goal attainment = 87%). item
agreement ranged from 63% to 100%. A second sam
ple of 20 patients was evaluated by BS nurses (r =
0.99 for total scale, with subscale correlations ranging
from 0.92 to 0.99).
hrT'''T:' t'-t"™
I
I’r^laWtes.belwv.
'' ' 7' ‘
‘Ill"'e’'
ln..Nt'm7rrC|l ""'l......... '' >C
v'"lcr
X",,J d' H ”!'n. „ vs to e. ..nplete Nur.es
"
"’J ''
~
''' "'J
'<U"n!;
..............
1 ‘^itcat.
ingckimplere Jepen<|(‘ncc in performing in activin . ; J jb livjr.- u>.j , , ■ >r
fj
|
ng mdepend „ee Sgormg tor the Me. re ot G, „d Att.m.menrbTeoX'l T T i
,1'
t:t.„„eJ. Fhe Mem
........ th...
thi> fiikiii).
King, 1988
' ” l-‘''B'’
b
nuir.cd
.
?
1
t
"T
11
',:i'J-LX"!’1"lne'h>'J:nerence.!-orex.imple.irthep.,.
Z"
1
..... -I recetX
unable
r. > bathe himself
C’ ..J
'.-I mid
mtehr
be !•!•. .Hnn'rthing ni >!>.•
. ........... i ii'-n iti- gI? He
im>wci--i
.’it- . :
r|...
,1
"
, , ■ ..
• ■"!'
...
... ,.i
. ,
,
^iihentcrnigthehatht eienr were ■ictuaiiv
240
CONNECTIONS
Nursing Research, Theory, and Practice
able to achieve that goal, the item would be scored a +2. If the patient did not attain the
goal and continued to be totally dependent, the difference between the goal of 3 and the
score of 1 is —2. When a goal is achieved, the score is 0, which indicates congruence be
tween the set goal and the attained goal. King (1988) suggests converting the raw scores to
percentage scores.
1
Plhi
ipi::'
kings Conceptual System and the Theory of Goal Attainment have been used as rheoretical perspectives for a number of research studies. Several studies are based on middlerange theories derived from kings Conceptual System. King’s Conceptual System has been
used to guide research with families, women’s health, health promotion, chronic illness,
and clinical decision making. King’s Theory of Goal Attainment has guided research on
adolescents, on postoperative patients, and in multicultural settings. Examples of studies
from each of these areas are provided in the following paragraphs. Table 9-2 summarizes the
research studies.
F amilies. All hough King’s Conceptual System initially focused on individuals, family
systems can be viewed as basic structural and functional units that are both social and
interpersonal. As a result, kings framework has served in conjunction with other family
theories as a guide for research focusing on families. Studies by Hobdell (1995) and
Doornbos (1995) exemplify this concept. Work by Frey (1995) on chronic illness also deals
with family dynamics.
In a study of rhe loss of an "ideal” child, Hobdell (1995) assessed the likelihood of par
ents of children with neural tube defects accurately perceiving their children’s cognitive de
velopment. Using King’s concept of perceptions as being subjective and personal repre
sentations of reality, Hobdell hypothesized that chronic sorrow would influence parental
perceptions of cognitive development. Indeed, she found some parents inaccurately per
ceived their children’s cognitive development. This supports the concept of subjectivity in
fluencing perception within personal systems.
To test a middle-range theory of family health derived from King’s Conceptual System,
Doornbos (1995) examined the family health impact of living with a young, chronically
mentally ill family member. Doornbos proposed that the family composed an interpersonal
system influenced by stressors, coping, perceptions of the patient’s health, and time since
diagnosis of mental illness. Findings led Doornbos to propose that family health was an
outcome of family coping, particularly in terms of access to services, age of respondent,
and stressors. Stressors were mediated by the family’s perception of rhe patient’s health and
rhe time since mental illness diagnosis. Poorer perception of patient health and recent di
agnosis increased stress levels. Findings from this study support King’s assertion that fam
ily members seek assistance from a healthcare system when they are no longer able to cope
with a health problem. Additionally, Kings Conceptual System suggests that unique per
ceptions ol life events and rhe individual interpretations attributed to those events influ
ence response. Tins concept is supported by rhe influence of perception of the patient’s
health and lime since diagnosis on family members’ stress levels.
Women's Health. Sharrs-Hopko (1995; Sharts-Engel, 1987) explored factors related
to perceived health status during menopause. Menopause was viewed as a developmental
process occurring within an open >v<tems framework in which individuals have unique
le.vc C'lntinued nn f>. 246
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Review of Related Research
-:iy
C ir;
Modeling Nursing From a Transaction Systems Perspective
CHAPTER 9
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TABLE 9-2
m
n
.__Study/Year
o
Purpose
HEALTH PROMOTION
Martin, 1990
The study investigated knowledge and
attitudes about prostate and testicular
cancer following an educational
program.
Methods
2
tn
"
Findings
2
c
Four hundred forty-eight men completing a
cancer awareness program responded before
and after the program to investigatordeveloped questionnaires to measure previous
(A
5’
co
X
o
U1
(T>
a'th CanCer'early detection P^^S,
and knowledge about male-specific cancers.
CHRONIC ILLNESS
Frey, 1995
The study tested a theory of family,
children, and chronic illness derived
horn King’s Conceptual System.
Fifty children aged 10 to 16 years with diabeles mellitus and 39 ch.ldren with asthma
and then parents formed a convenience sampie. Parents completed FACES III, Coping
Health Inventory for Children, Family Inventory
o Me Events and Changes, Family lnvento,y
of Resources for Management, and Norbeck
. vuouunna.re.
^c-JaJ
Questionnaire. cmidren
Children com—
Pleted FACES III, the Denyes Self-Care Practice
------------- -'^■i-vaie ridCIIC
Instrument
Instrument (DSCPl)
(DSCPI), niah^r
Diabetes or Asthma Self-
care Practice Instrument (DiSCPI or ASCPI)
Care
.
Health^Status Instrument (DHSI), Self^epT'on
Profile
for
Children
(SPPC), and
D . .
wigu ijrruj, and
sX^Ptom Inventory (BSI). .
a>
A
zr
o
Asthmatic children tended to have fewer family ,e.
ources and greater stressors. Diabetics had their illness for fewer years; experienced greater illness sup-
□
o.
exDW7Tre
" illneSS
man^ement; and
and
less management;
S?Cial accePtance- behavioral
^petence ?B
selfater
worth,andpeK^S^
TJ
2
a
S’
HpAlrh nr rlVt
J
'
Ul 063110.
Health
predictors denved
from multiple ,e
regression
for
the
ZheHrn
7?frOm
9ress,on eal^and i? P
the f0"°win9:9enera'
. .
J
health and;,,,nes
... . s management
management hphavinre
behaviors, age at j
di-:
adanOmh'?nrat'OnKOf
femily C°heSi°n and
ppnwnc LM-.Uk r*.x.
hS^'^
Frey, 1996
-
‘t
The study examined the relationships
of general health behavior, illness man
agement behavior, and indicators of
health and illness across five samples
of youths with diabetes or asthma.
DECISION MAKING
Brooks and
The study explored characteristics of
Thomas, 1997
clinical decision making of senior bac
calaureate students.
GOAL ATTAINMENT
Caris-Verhallen,
The study explored communication be
Kerkstra, van
tween nurses and older adults in two
der Heijden,
care settings.
and Sensing,
1998
General health management was measured by
DSCPI, DISCPI or ASCPI, responsibility of care,
and satisfaction with responsibility. Health was
measured with SPPC, BSI, and DHSI. Illness
control was measured by glycosylated hemo
globin (Ghb) or Pulmonary Function Tests
(PFTS) and duration and perception of disease
severity.
General
agement behaviors. Diabetics with higher levels of
general health behaviors reported greater functional
status and positive perceptions of health. Youths ex
hibiting higher levels of general health behaviors had
higher perceptions of health status and physical and
mental status. In diabetic youth, illness management
related to perception of health. Diabetic youths with
better physical and mental status also had better
functional status and higher perception of health.
n
>
X
U3
o
Q.
Eighteen senior nursing students from three
programs participated in structured interviews
that focused on a clinical situation vignette.
Content analysis was used to identify theoreti
cal categories.
2.
An interrelationship existed between perception and
judgment occurring within intrapersonal characteris
tics of self. All responses were derived from personal
knowing or understanding of clinical situation from
the unique perspective of the self. Intrapersonal fac
tors included the following: experience, personal val
ues and beliefs, beliefs regarding pain, sources of in
trapersonal knowledge, culture and lifestyle, religion
and personal knowledge.
5’
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One hundred eighty-one videotaped encoun
ters involving 47 nurses and 109 patients were
analyzed for characteristics of communication
patterns. Communication patterns for home
care patients versus nursing home patients
were compared.
Q>
Socioemotional communication identified the follow
ing: social behavior (small talk and joking) and affec
tive (verbal attentiveness of nurse). Task-related com
munication identified the following: technical care,
hygienic care, and psychosocial care. Nurses of insti
tutionalized older adults used more social behaviors
Home care nurses used more affective and counseling
behaviors. No differences in communication about
lifestyle and emotional topics were discovered.
Continued
q
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TABLE 9-2
O
z
ont’d
Study/Year
Purpose
GOAL ATTAINMENT—cont'd
Froman, 1995
This exploratory study examined the
perceptual congruency between patient
and nurse perception of illness, nursing
care, and patient-care satisfaction.
Hanna. 1994
This exploratory descriptive study in
vestigated adolescent perceptions
about personal and interpersonal oral
contraceptive benefits and barriers.
...Aj
Methods
A convenience sample of 40 client-nurse pairs
completed the Perceptual Congruency Ques
tionnaire. Clients completed the Patient Satis
faction with Care Scale.
Twelve adolescent females seeking oral con
traceptives for first time responded to a deci
sional balance sheet and participated in a
structured interview on contraceptive benefits
and barriers. Content analysis was used to dis
cern common elements.
Hanucharurnkul and Vinyanguag, 1991
This experimental study tested the use
of a nurse-patient interaction inter
vention on outcomes of postsurgical
patients.
Forty surgical patients were randomly as
signed to an experimental or control group.
The experimental group participated in selfcare through nurse-patient interaction.
Kameoka, 1995
This study explored specific factors inter
fering with nurse-patient interactions.
The study analyzed nurse-patient interactions
with data derived from nonparticipant obser
vations on two orthopedic wards in Japanese
hospitals. Nineteen process recordings were
examined.
Long, Kee,
Graham,
Saethang, and
Dames, 1998
Specs, 1991
....
The study attempted to identify the as
sociation of selected characteristics
with medication compliance in older
hemodialysis patients and to assess the
effectiveness of teaching intervention
on compliance.
This descriptive study investigated pa
tient and family knowledge of medical
terminology.
Z
c
Findings
un
I’
1?
There were significant differences between client and
nurse perceptions of the illness and the nursing care
required. However, when congruency existed, patients
were more satisfied with care.
VI
O
Q
n
—
Twenty-five descriptions reflected perceived benefits,
whereas 19 indicated perceived barriers to oral con
traceptives. Thirty-one additional descriptions were
obtained through structured interviews. Benefits most
often mentioned were pregnancy prevention and per
sonal responsibility. Most frequently mentioned barri
ers were side effects and disapproval by others.
CD
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Pain sensation, distress, and use of analgesics was
lower for the experimental group. Ambulation on the
first three postoperative days was higher for the ex
perimental group. Complications, particularly abdomi-
. ......
Three factors interfered with nurse-patient iriterac-1 '• ’
tions: (1) differences of perceptions and inadequate
communication between nurse and patient, (2) one
sided nurse-patient relationship, and (3) lack of con
cern for patient and lack of special knowledge of
nursing.
I
-o
m
The study was initiated with 26 subjects. Sub
jects initially responded to the Iowa SelfAssessment Inventory. Medications were
checked initially, two weeks later, and two
weeks after the teaching intervention. Teaching
consisted of an individualized medication teach
ing session, in which each drug was discussed,
and written information given to patient.
The study had an 80% attrition rate with only five
subjects in the final sample. Medication compliance
rates were very low both before and after teaching.
Average compliance rates did not significantly associ
ate with economic resources, education, number of
medications, trusting others, mobility, gender, social
support, or age.
Twenty-five hospitalized patients and 25 fam
ily members responded to a 50-item question
naire on common medical terminology.
Patient scores ranged from 30 to 50. Family scores
ranged from 38 to 50. Only 9 terms were correctly
identified by all participants. Nurses overestimated
comprehension of terms.
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246
CONNECTIONS
Nursing Research, Theory, and Practice
perspectives The iniml study (Sharts-Engel, 19S7) revealed slightly poorer perceptions
revealed slightly poorer perceptions
of heath and lower life satisfaction associated with later menopausal stages. Women
CHAPTER 9
llXi
1
■C; ii'?
h:::i
:■
pausa women included current life change, perceptions of one’s mother, perceptions of
ones life partner, symptoms, perceived timing of menopause, and education level. Findings
supporter King s Conceptual System. King suggested that individual systems have unique
perspeenves within a context of personal systems that change with growth and
development. Health ,s related to rhe way individuals deal with these developmental
changes. Sharts-Hopko (1995) demonstrated that a changing internal environment and
interaction with the external environment impacted the health of women undergoing
menopause.
b
s
Health Promotion. Using the goal of health maintenance derived from King’s
I
|
I
Conceptual System, Martin (1990) investigated rhe impact of a male-specific cancer self-
I
awareness program on knowledge and attitudes of participants. Subjects indicated limited
parncparion in early detection of male-specific cancers prior to the program hut after the
piogram could express rhe importance of detection behaviors. Knowledge level re-ardino
ma e-specdic cancers significantly increased follow,ng the program. A limitation of the
study was that no mechamsm for long-term follow-up determined whether actual practices
changed king spemfied that the goal of nursing is to help maintain health of individuals
Martm also failed to address rhe study implications for King’s theory. Although these factors
me limiting, thus study supported the concept of nursing providing education programs to
maintain panent health.
°
Chronic Illness. Frey (1995) used the King’s framework
as a guide for development of a
middle-range theory of families, children, and chronic illness. Using children diagnosed
with asthma or diabems, Free found different pattern of predictors for health outcomes for
rhe iwo groups. Health outcomes for diabetic youths were related to general health, illness
management behaviors, age at diagnosis, and duration of illness. Children with diabetes
tended to better manage their d.sease than children with asthma, for whom fimilv health
variables influenced outcomes. Variables for children with asthma included adaptability
cohesion, coping, resources, stressors, and child support. This study supported Kind’s
concept of multidimensionality of health, particularly in terms of functional role. Findings
ed Hey to suggest that a theory of family, children, and chronic illness must consider how
family factors influence illness management and general health behaviors and how illness
management influences illness status.
Using ,1 composue of five samples of children with chronic illness and their families,
Hey (I 996) mvest.gated health behaviors, Alness management, and outcomes. She found
that youths with asthma and diabetes exhibited behaviors that promote general health
(such as good nurrit.on, exercise, sleep, and stress management) also better managed their
illness. General health indicators were most related to health rather than illness However, dlness management behaviors, such as treating hypoglycemia or avmding truwers for
asthma artacks, were associated with h.gh perceptions of health. Evidence oHenerd health
'fleering chrome Alness management supported King’s Conceptual Svsrem
' I1‘"
'!;,lL T" 1illness management; both
ire esx-nu.il h> bu.ihb.
247
I
experiencmg moreUife change had lower perceptions of health. In regression analysis
(Sharts-Hopko, 1995) stgnificant characteristics contributing to health status of meno-
i"
Modeling Nursing From a Transaction Systems Perspective
I
I
I
j
f
1
Clinical Decision Making. Brooks and Thomas (1997) sought to validate Brooks’
Theory of Intrapersonal Perceptual Awareness, a middle-range theory derived from King’s
framework. Brooks’ model proposed that the nurse is a whole person who engages in
clinical situations as a whole. Brooks and Thomas describe the state of wholeness as
“everything the nurse is intrapersonally, as a perceiving, judging, sensing, intuiting,
thinking, feeling, believing, and valuing person” who makes decisions (p. 52). Brooks and
Thomas’ theory extends King’s concept of perception to include intuition, perception,
judgment, and decision making in the personal system. To validate this middle-range
theory, Brooks and Thomas (1997) identified and classified factors integral to decision
making by senior baccalaureate students, hi a structured interview, student responses to a
clinical vignette revealed diversity in the ways students viewed the situation. Student views
of the vignette were highly individualized reflections of unique personal knowing or
understanding. This supported the central premise of nurses as whole persons. Perception
and judgment occurred intrapersonally as well as interpersonally. However, the interactivity
of perception and judgment within the personal system made separating rhe two difficult.
This study supported adding rhe concept of perception and judgment as an interactive
process into King’s system framework. However, the decision-making aspects of King’s
Conceptual System were nor supported because King’s decision-making focus is the
obseivablc aspects of clinical situations. Brooks and Thomas focus on the individualized
perceptual awareness in intrapersonal decision making.
Goal Attainment. Use of the Theory of Goal Attainment derived from King’s
Conceptual System has been the topic of several recent studies of transaction. Transacrions
are interchanges between nurse>. patients, and families and are used to attain goals (King.
1997b). The Theory of Goal Attainment reflects the interactive nature of nurse-patient
relationships and suggests that more goals will be attained through transactions involving
mutual goal setting and jointly establishing strategies to achieve goals. Studies using goal
attainment as a theoretical basis include those dealing with health promotion, chronic
illness, care satisfaction, postoperative recovery, and elder care. Interactions have been
examined with other cultural groups as well. Examples of these studies are presented below.
Etonian (1995) examined the congruency of patient and nurse perceptions of illness,
care needed, and patient satisfaction with care. She hypothesized that nurses’ and patients’
shared perceptions would lead to patient sttisfaction. Unfortunately, patients and nurses
significantly differed in perceptions of illness and required care. However, congruency cor
related with patient satisfaction, which supported the Theory of Goal Attainment.
In her study of adolescents requesting oral contraceptives, Hanna (1993) tested King's
concept of nurse-patient transactions. The theoretical framework for the study was aug
mented by IWnstock’s Health Belief Model (Hanna. 1993. 1995). The transactional in
tervention involved action and reaction, disturbance, and mutual goal setting. Hanna dis
cussed rhe benefits and barriers of nral contraceptives and agreed with adolescents on
tactics to avoid pregnancy. Adolescents receiving the intervention were significantly more
likely m be adherent 3 month> later. Tlu> nndmg supported King’s concept that transac
tions can -hitt perceptions and sub'equenriv alter behaviors.
In a related srudv, Hanna ( 1^-1'expiored
idole>cent perceptions c.f benefits and barripb
•th pv>
C'S ru
contraceptive- iv-th
per-na! md mterpenonal factors were considered.
I regnam.x prexention e
the ; : unary p< r- nai .md interpersonal reason tor requesting
I"'’
248
I........
,
>"l is
I;:--
, A
mil
CONNECTIONS
Nursing Research, Theory, and Practice
contraceptives. Other considerations included taking responsibility and seeking the ap
proval of others. Personally, many adolescents feared side effects, whereas interpersonally
they feared others’ disapproval. This study supports King’s concept of a dynamic interaction
between personal, interpersonal, and social systems. A nursing implication is that nurses
can potentially influence the transaction by exchanging perceptions and negotiating a par
ticular outcome.
Long, Kee, Graham, Saethang, and Dames (1998) explored medication compliance of
older hemodialysis patients, focusing on the need for mutual goal transactions. Investigators
proposed that sharing medical information would contribute to effective health mainte
nance and mutual goal transaction. The purpose of the study was twofold: to examine char
acteristics associated with medication compliance and to assess a transactive teaching pro
gram on self-administering medication. Medication compliance behaviors both before and
after teaching were substantially lower than expected. Unfortunately, the attrition rate in
this study was 80%, which left only five subjects. The Iowa Self Assessment Inventory had
not been previously validated for use with minority respondents, and this fact may also have
limited rhe study. These factors limited support for the Theory of Goal Attainment.
Specs (1991) used- King’s Theory of Goal Attainment to frame assessment of patient
and family understanding of medical terminology. Specs proposed that family members
constituted an interpersonal system that would interact to meet its basic needs. This propo
sition reflects the Theory of Goal Attainment. Communication was viewed as rhe key for
increased understanding of illness and as a mechanism for stress reduction. Findings indi
cated that nurses overestimated patient and family knowledge of medical terminology and
that family members and patients were similarly familiar with the terminology. A short
coming of this study was Specs’ failure to tie findings back to the Theory of Goal Attain
ment. However, limited understanding of medical terminology could impede nurse-patient
interactions and prevent successful transactions and goal attainment.
In an experimental study that tested a proposition from the combined frameworks of
Orem and King, Hanucharurnkul and Vinya-nguag (1991) examined whether nurse
patient interactions led to goal attainment of self-care. Investigators proposed that nurseparient interactions designed to promote patient participation in self-care would posi
tively influence postoperative recovery and increase care satisfaction. Surgical patients
undergoing pyeloiithotomy or nephrolithotomy were assigned to either an experimental
or control group. Self-care was promoted in the experimental group through the use of
nurse-patient interactions in addition to routine care. Study findings supported rhe
proposition—experimental group patients experienced less pain and distress, used fewer
analgesics, ambulated more, had fewer complications, and reported higher satisfaction.
Orem’s claim that self-care was an important goal of nursing was supported, as was King’s
assertion that nurse-patient interactions facilitated goal achievement.
In the Netherlands:, CarisA crhallcn, Kerkstra, van der Heijden, and Bensing (1998)
studied nurse-patient communication in home care and in institution.ilizcxl settings. Draw
ing on the Theorv of Goal Attainment, investigators conceived of rhe nurse-patient in
teraction as a dynamic reciprocal relationship that facilitates goal achievement. They found
that conversations between nurses and patients were socioemotional in nature. Nurses em
ployed social conversation and thus pr> wided affective support. Nurses in msiitutiona! set
tings show cd more social behaviors ihan nurses in home care, whereas home care nurses
more .-tten pr. a ided affective oippor’ such as concern and empathy. Home care pros, iders
CHAPTER 9
Modeling Nursing From a Transaction Systems Perspective
249
also offered more counseling about medical conditions and nursing care. Findings support
King’s theory' in that socioemotional communication is necessary to establish patient rela
tionships. A methodological limitation of this study was the inability to clearly distinguish
counseling behaviors of the nurse.
Kameoka (1995) used King’s classification system of nurse-patient interactions to ana
lyze interactions obtained through nonparticipant observation on two orthopedic wards
in Japan. Differences in perceptions and inadequate communication between nurse and
patient reflected mismatched between patient concerns and nurse perceptions. One-sided
nurse-patient relationships reflected an inequality of power. One-sided relationships lead to
nurse-directed rather than mutual decision making. Lack of concern for patients and lack
of special nursing knowledge was exemplified by nurses neglecting patient problems and
mutually sought alternatives. In this study, lack of essential elements suggested by Kings
Theory of Goal Attainment led to failed transactions, thus supporting rhe theory.
Research Summary. To summarize, King’s Conceptual System and her Theory of Goal
Attainment have theoretically framed a variety of studies in several cultural settings.
Several studies (Brooks & Thomas. 1997; Doornhos, 1995; Frey, 1995; 1996; Sharis-Hopko,
1995) used the systems framework for mitldle-range theory development of a specific
phenomenon. The development of middle-range theory from a broader conceptual model
coheres with Fawcett's (1999) conceptual-theorerical-empirical structuring of research
studies. Many of the recent studies specifically have used rhe aspect of goal attainment
rather than rhe general systems framework. Although most of these studies have been
descriptive, some notable exceptions exist. Using the systems framework, Martin (1990)
demonstrated that a health promotion intervention could impact awareness, knowledge,
and attitudes regarding male-specific cancers. Hanucharurnkul and Vinya-nguag (1991)
established, consistent with the Theory of Goal Attainment, that nurse-patient inter
actions can positively influence postoperative recovery. Hanna (1993) verified
achievement ot correct oral contraceptive use in adolescents through transactions based on
rhe Theory of Goal Attainment. These studies—the abstract Conceptual System and the
middle-range Theorv of Goal Attainment—demonstrate the usefulness of King’s frame
works. However, additional empirical testing on the Theorv of Goal Attainment as well as
on other middle-range theories derived from King’s Conceptual System. Future research
could include the following.
® Further testing ot developed middle-range theories
• Additional description of patient understanding ot health, illness, and care
intervention^
• Description of specific elements of transaction that permit goal achievement tor
health promotion, disease prevention, and illness intervention
• Research based on systems theory
PRAXIS AND THEORY UTILIZATION: DESIGNING NURSING
PRACTICE FROM THE PERSPECTIVE OF KING'S CONCEPTUAL
SYSTEM AND THEORY OF GOAL ATTAINMENT
King’s (Conceptual System. Theory of Goal Attainment, and the associated research
and development arc signiiiu.int contributions toward a pr.'-. iding a nursing-oriented
theorem al per<pe- ro e for nardng practice. In addition fo exploring nursing situations,
researchers haw the oj p. ro.inirx to view from a nursing perspective the concepts and
250
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 9
theories developed in other disciplines. Examples of this in the literature include em
pathy (Alligood, Evans, &. Wilt, 1995) and space (Rooke, 1995).
An understanding of general system theory is foundational to practicing nursing from
King’s conceptual framework, in which nursing consists of three interlocking systems: per
sonal, interpersonal, and social. Nurses also require an understanding of the concepts
within each system. King (1997a) identified these concepts from a review of the nursing lit
erature from 1923 to 1963 and deemed them essential knowledge for nursing as a disci
pline. Although King has initially defined some concepts, further explication of the sub
!
□escribing a Population for Nursing Purposes
Expected Outcomes of Nursing
The expected outcomes of nursing from the perspective of the Theory of Goal Attainment
include mutual goal setting, transactions, and goal achievement. These are process out
comes. The content has nor been specified, although elements of interest to nursing have
been identified in the goal-oriented nursing record (King, 1984).
Process Models
Individuals. King asserts that the goal of nursing is helping "individuals and groups attain,
maintain, and restore health” (1971, p. 84) The nursing process or method in practice is an
interrelated system ol actions assisting of assessing, diagnosing, planning, implementing,
and evaluating. The c intent or thcorx associared wirh the proves* (King, 1996) includes
perception, communication, and interaction of nurse and patient, decision making about
goals and means to accomplish goals, transactions between nurse and patient, and
evaluation of goal attainment. Effective nursing occurs .is the nurse infers rhe needs and
problems of patients trom direct and indirect observation ot patient behavior. Through a
The Variables of Concern for Practice
’1
< s/
.Cii!'1
pQ.
251
bio examples of describing a population for nursing purposes from the perspective of King’s
conceptual framework' or the Theory of Coal Attainment were found in the literature
reviewed.
stantive structure of each with accompanying theory development is essential for
application to practice.
A major contribution of King's Conceptual System to nursing practice has been rhe
Theory of Goal Attainment. 1 he emphasis on mutual goal setting between patient and
nurse makes nursing truly patient-centered. Other useful theories that have been derived
from this include a theory of families, children, and chronic illness (Frey, 1995) and a the
ory ol departmental power (Sieloff. 1995b).
i1’
Modeling Nursing From a Transaction Systems Perspective
praCt‘C® Wlth lnd,v,duals as Patient. The concepts in the
the systems
svstems model
model are idem ified in
Box
Healths central place in Kings conceptual framework demands a definition of
health in order to guide practice. King (1981) defines health as “dynamic life experiences
of a human being, which implies continuous adjustment to stressors in the internal and
external environment through optimum use of one’s resources to achieve maximum
potential foi daily living (p. 5). Although she refers to group and community health,
extending the definition of health to rhe individual is required. Winker (1995) calls for a
new definition of health within King's conceptual framework. If nursing’s goals are
series of actions, interactions and reactions, analysis and interpretations, nurses infer
patients’ health statuses. Goals are mutually established, and a plan to achieve those goals
is mutually agreed upon and implemented. Alligood’s diagram (1995) of this process is
depicted in Figure 9-3.
In support of nursing from this perspective. King (1981) developed a patient database.
This database subsequently was used to develop enregiM irations of rhe North American
Nursing Diagnosis Association (NANDA) nursing diagnoses according to the systems and
concepts of King’s conceptual framework (Coker. Fradlev, Harris, Tomarchio, Chan, &
Caton, 1995; Fawcett, Vaillancourt,
Watson, 1995). The database consists of data health
information available to any healthcare professional The work associated with this frame
work has not yet progressed to theoretical direction for specifying rhe nursing questions
about the data collected. The parameters .if what constitutes “a problem” have not been
specified beyond a mutual decision between nurse and parient/patient that one or more
health related problems exist. A problem is considered solved when the mutually deter
mined goal has been achieved. Identifying the concepts associated with rhe process of mu
tual goal setting and their relationships have been identified in the Theory of Goal At
tainment. The concepts associated with the content of tin* process for nursing purposes
have not been specified. This is j prerequisite to developing a schema for nursing diag
noses. Research is required n> v.iiid.ue rhe ti'” between King’s conceptual framework and
rhe NANDA categorization. Although King has suggested a patient database and has specifi. <1 i rhcoi\ b r-e for oic pioec". a theoiy base for tin
the content of the nursing process has
yet to be fully d'". elope.; : r nursing purp< ■e< in J published.
King and her c. Teague- (
h.■lve dc\ c! 'ped
'.i1: ■ •i ienied nursing record. The
C'. ntem tor the- iwoi.i - teiived
':1'- hn.j i.u il'
The record provides the
means for rec. rd : e
die ■ ;■•,.••• in-i nur><- k: iom n< cv«ary to attain the desired
attaining, maintaining, and restoring health and if its concerns are with personal,
interpersonal, and social systems, further explication of rhe construct and definition of
health certainly is essential to practice.
Practice with Family as Patient. Several studies extend King’s conceptual framework
from the indiv idua! to rhe family. Gonot (1986) describes rhe family as an interpersonal
system composed of a group of individuals interacting to meet their basic needs. The
concepts applicable to rhe individual therefore also apply to the family. Family health is an
additional concept. It is defined as "dynamic life experiences which imply continuous
adjustment to stressors in rhe internal and external env ironment through optimum use of
family resources io achieve maximum potential for daily living—health is the ability to
function in social roles" (I lonot. 1986, p. 35). Thus rhe health ot the family is a function
or the frimilv members management ol .-tressors. The environment is a suprasystem wirh
which the family sv<iem mreraers. Like Gonot, Wicks (1995) describes the goal of family
nursing as family health igam in terim.-i funciioning. Frey (1995) describes family health
in relation to structure and function-specifically adaptability, cohesion, coping, resources,
and stressors. Building on FreG work to srudv families of rhe young chronically mentally
ill, Doornbos (1995) defined taimlv health a* "the ability of rhe family unit to adjust to
re:>M-)rs ;,nd r<) function in their <ov ial n'les (p, 198). She measured members’ satisf icrton
'ioning. . .’b.c-ioH, .mibr, to adjust to stressor.*, and ability to manage
•-ontlic.r as m hvat.- of tamik health.
■
252
CHAPTER 9
Nursing Research, Theory, and Practice
CONNECTIONS
s-
t
Transaction
Interaction
Reaction
Action
Judgment
I
Dimension 2: Focus
Perception
Perception
Self
Practice Models
Growth and development
Continuing development ol theories derived from King’s conceptual tramevvork anil re
lated research programs are necessary to the development ot practice models. Existing the
ories include a theory of family health (Wicks, 1995), a theory of families, children, and
chronic illness (Frey, 1995) and theory development in relation to the health of families
with young chronically mentally ill children (Doornhos, 1995).
Time
Space
Role
Interaction
Stress
Communication
•< L: '
Transaction
253
Families. Gonot (1986) describes the direction the Theory of Goal Attainment
provides for the processes of nursing with the family as patient. The focus is on the family
as an interpersonal system, the individuals as subsystems, and the environment as the
suprasystem. Data about interactions, perception, communication, transaction, role, stress,
and growth and development are collected. The synthesis of assessment data and the
discipline’s knowledge base generates relevant diagnoses. Intervention begins when the
nurse begins to interact with the family, forming an interpersonal system different from
the interpersonal system of the family. Interaction clarifies rhe concerns and goals of the
family, airs the nurses’ perceptions, establishes shared goals, and identifies the means for
achieving the goals. The nurse acts as an educator, mediator, facilitator, and resource
person. Family health is achieved as family members engage in goal-directed behavior
leading to transactions.
Dimension 3: Interaction
r
' I
Modeling Nursing From a Transaction Systems Perspective
Dimension 1: Process
Assessment
Diagnosis
Implications for Administration
Planning (Mutual)
King’s Conceptual System and, more specifically, rhe Theory of Goal Attainment have tganized the development of systems of nursing service in a number of settings (Tritsch. 1998;
Laben, Sneed, and Seidel, 1995; Messmer, 1995; Hampton, 1994)- Fawcett, Vaillancourt,
and Watson (1995) describe in detail the integrating ot King’s framework in nursing prac
tice, first ensuring that the philosophies of the nursing departments reflected rhe frame
work, continuing through to developing an education program, a recording system, and
patient-care standards. Mutual goal setting is reflected not only in patient care but also in
nurse-to-nurse actions.
An organization wishing to structure nursing practice from the perspective ol King’s
Conceptual System must first decide on a definition of health. Will it he as King has de
fined it, with health limited to role function.’ Will it be as Winker (1995) expanded it,
“the ability of the individual to create meaningful symbols based on either biological or
human values within his or her cultural and individual value systems’’ (p. 42) ’ The latter
moves the practice of nursing from rhe goal of helping “individuals maintain their health
so they can function in their roles” to “restoring or maximizing health through the mutual
identification of symbols and the meaning attached to them, allowing maximum expres
sion in life or death” (King, 1981, pp. 3-4)- However, neither detinni.’n diflcrentiates
nursing from other professions, such as social work, that also mav lax claim to the <ame
goals as part of their domains. Additional theory development is required io differentiate
the goal of nursing.
Sieloff (1995a), working from King’s conceptual framework. exteivK lia . on.\ pr <if
health to social systems. She proposes health ot a social svstem can l v icfined ady
namic experiences ot a social system, which impi'iC', coniinuou- adpoii -.'-v .• --[rc>-or> :n
d'ie internal and external en\ ironment through optimum use of the -x^tcin resources to
Intervention
Evaluation
pi":i.
iiiiuiui|
J
FIGURE 9-3 Three dimensional nursing process based on King's theory. (From Alligood, M.R.
(1995). Theory of Goal Attainment: Application to adult orthopedic nursing. In M.A. Frey &
C.L. Sieloff (Eds.), Advancing King's systems framework and theory of nursing Thousand
Oaks, CA: Sage.)
goals, and evaluation of the extent of goal achievernent. The record h.i< helped nurses
practice from this perspective. Fawcett, Vaillancourt and Watson (1995) describe devel
opment ot .i record with the acronym SOGIE, which stands for suhicctii c 'Vkwuc.
impL-menuition nt nursing actions. and evaluation This record also reflects the TEc.-ry of
Goal Artaintnent.
w
254
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 9
“ of the sys.
attribUt^at
-
ministration basis for decision making.
^ggjstcd and which contribute
°ft rrOpOSes that development
3 nUrSlng rather than a business ad-
'
p™et that may be useful to
nurse adluX^
NEXUS
crease a nursing departmcnr’s\T \Cr*Vet ^r°in K‘ngs Conceptual System, attempts to in-
ll!
255
or he uses them. It is not reasonable to expect a consistent use of terms—not only within
nursing but in other disciplines as well—with so many varying definitions.
Much still could be done to relate the theoretical system to others systems. Most of the
a I?Search develoPment has been stage 2, interpretation and application (Banathy,
1926). As Chapter 8 noted, this is a reasonable expectation of systems theory work.
directedness. Research is required to further'defin ’ h' fr“t‘at'°n' lnte8rat,on. :lnd goal
nursing, and to determine the validity of the attnbures^ °f 3 SOC,alfstem’ Particularly
the greatest variance to the health of rhe > • l" ■of such theory would provide nurse admini’strir
Modeling Nursing From a Transaction Systems Perspective
nursing department's control of the-effect of envi aCtUall:ed1 p°'Ver- ln the theory h
"a
'Z.“.. ..........
Implications for Education
p-wiwmg m„smg
,|lc pcl,pccrivc (,f
G< ;1 Aimmment requm. R.ckground in general svsten s theory In"i and the T henry of
theory reand tn rhe concepts idem,Led ,n Box 9-1 needs to he developed h addition,
'
in Box 9-1 needs
’in a nursing perspec,II5d incorporated
meh mm n„rs,ngeduea,,on programs.
into nursing education
Kings Conceptual System and the Theory of Goal Attainment that is derived
from it have provided a mechanism for bringing the concept of nurse-patient
interactions into practice. These concepts are useful in working with individuals, couples,
ant groups, ing suggests that people who work toward goal achievement spend their rime
constructively (personal communication, October 29, 2000). Conceptual System and The
ory of Goal Attainment have proven useful not only in practice and education bur also in
guiding research. Noting the variety of titles given to her work, King has stated that her
cheorelic.il system should he
lied Kings Conceptual System, Theory of Goal Attainment. and Transaction Proc • Model (personal communication, October 29, 2000).
REFERENCES
An^.od^l.i;. (IWS). Thc,.n mt Goal Au.unmeni: Applicatu.n to aduh orthopedic nursing. In M.A. Free
STATUS OF THEORY DEVELOPMENT
p:::i
r.;'
I h M P7 ,r
;
,1'- 1 -L (1995)- KinK’S in,eractin« ^reniS and e"WhV- 'n M.A. Frev & CL
' 'I
R ?ioo/t a’k'”S R'-'' <
|nnncu,,,lk and
Thousand Oaks, CA: Sa»c
ana n I . (
6). A taste ot svstermes: The primer project. International society for .systems studies. URL
All s
-'i.::
< iiA
pl.cn. The Theory ol Goal AtrninmC
.denrificat.on of concepts f .m.lr'r ZA t’"
..... ..................
T>
fr.°m thiS "lodel are nor exdeVel°Ped'
aPPea' ,ieS 111 rhe
characteristics of human beings as personal Znrs hZTX’dZ'loped dimenSi‘" "
»
'ZlZm 'SiX Xt~u o" Td ■’f
“S'”=::XiZ “
c.mcepts are more h.Tlv Z'eio e 1 Iw O
Ma"V
" irhin Kings work thoiHr the obie-r f Z ThC t''"1S'1Ctl,’n nlode) is ■»<’« developed
It is inrX - , ■
tHc object of the transaction is not as clearly defined
xx:
■ :"id K7' x^d
cnv.ronment mter ,eno,
H
’T
CmphaSiS ‘>n thc P^onTfmnst stressors. K.ng , 'a Z ,,‘'’V-''-'-'.-s to protect and defend
process tor functioning within rhes ■ rhr
I
l"' K
of lcvels of systems and
........................ ..... ................................................. ......................................
R
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Brooks, E.
Thomas S (1997). The perceptton and judgment of semor baccalaureate student nurses in ehnieal
hi, i'ion making. .Xavances in .\i<rsingScience. 19(3). 50-69.
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Ums iluurx fiuineu.nk und thon-s <4 nnrsmg Thousand Oaks. CA: Sage.
Poornk.'. M (1995) U'tng KinS- <. ..nceprii.ii System to explore family health in rhe famil
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aiid
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Philadelphia: FA Davis
Ur*' I
IX
,'1.'
'
i:
11 ,he"r'
■ .•.v.-cts /rj.neuv.rk J(j
.
’n >11
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King\systenw Jromewr^k and theory of nur.M
Thousand Oak.
‘e’ " t L
' ,WS!
... ................... ....
th' critiques. Nursiiy,$«,>„ Qwer!v. 7(3).
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xnu.-ng
rn-TTldiT'TT'-TT1...
”■ LT 1 lW4t Ki”" ‘lw’ry: Cr“ique
ZzsZ *
'g'g''''
-o"-
and chr,«,e illness. In M. Frev & C. Swloli (Fd- ) Adnursing. Thousand Oak<. CA: Sage
health ind dine'' hi \<mth> with chronic, illnos. Apph.'.i
«e.
epi i.il v ''lijuenev hetwccn patient' aiu.l nurses. In M.A. Frey & C.L Sielort iE.b ' AjT
paruofir ..r.i 'hd'‘T\ ■ iiursincr Thnus;! ik! \iks, CA: S,iL.'v
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CONNECTIONS
Nursing Research, Theory, and Practice
apyfor »UrSi„g; Four
Hampton, C.C. (1994) King's The >rv
'n A L Whal1 <EJ )' Famil> ,h'r-
.
Scie"ce
Ppl,:ton'Ccntury-crofe.
7«>''™fran>ework for mana8eJ care "npie,n~ <■>
H aSe. 25(4), 285-29^'" nUn’C'P1",ent
on female adolescents' oral contraceptive adherence, lm.
Frey & C.L. Siift (E^A^Xhealth behavior. In M.A
Sage 1 ublications, Inc.
H-^^uL b. 1,989). Contparative ;millysls
‘ f amcW,,rk
Orern,
Hobdell. E. (1995). Using King’s inrenctin ‘
-be defects. In M A. Frey & C. L.
Thousand Oaks, CA: Sage.
J'"" ’
“X
’ ’
theory of nursing. Thousand Oaks, CA:
j.... .....
.... Q'wru'r/>-
1 >• H-20.
in self-care on post-
en with neural
K‘nKS S^,ems homework and Theory of Nursing
............. ....... ........ . .....
measurement ol patient care:
........
’"'<11 r,,),,,,
....
..... . -- ■' . .... -.... ......,
.....
”2 i
iiXi
hn Wiley and
<
-c1; jc;
Little. 13™™°’ ^ L°nCeprS <Or n,,rsin« rhr‘’‘'«h research. In P.J. Verhonick (Ed.). Nurs-
.ui.’• •;
IlHIII.'l
- ''
KlnXlI^Tr^Tl'T
.. .
l"-" a'i U.k"M
Kmc. |.M. (19951. The Theory of God Art "'""'"‘'7 'i"™* Somer Q"‘,rICT,T 5(1 >. 19-26
]y(r
>
K,Ilc. I.M. (19971,). KmG ThZ’.'f oTCri? ’S'On ';’r r'1C to!“’ N'™"~
................... e7^.t.'K
. ';a ^-
-
— —
^.■rF, IL()) 15 r
' 7"Afrs“"«F
In M. Purker
f
CHAPTER 9
Modeling Nursing From a Transaction Systems Percnerfiv*?
257
Messmer. P.R. ( 1995). Implementation of theory-based nursing practice. Ad.anting King's Systems Framework aad
Theory of Nursing. Thousand Oaks, CA: Sage.
Rawlins, K
P., Kawltns,
Rawlins, T,
Horner, M.
M. (1990).
(1990). Development
Developi
Rawlins
1., & Horner,
of the family needs assessment tool. Western Jour
nal of Nursing Research, 12(2), 201-214.
Rooke L (P?95)-The concept of space in Kings Conceptual System: Its implications for nursing. In M.A. Frey
C.L. Sieloff (Eds.), Advancing King's systems framework and theory of nursing. Thousand Oaks, CA: Sage.
Sharts-Engel, N. (1987). Menopausal stage, current life change, attitude toward womens roles and perceived
health status among 40- to 50-year old women. Nursing Research, 36(6), 353-357.
Sharts-Hopko, N. (1995). Using health, personal, and interpersonal system concepts within King’s Conceptual
System to explore perceived health status during menopause transition, in M. Frey &. C. Sieloff (Eds ) Ad
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Sieloff C.L. (1995b). Development of a theory of departmental power. In M. Frey & C. Sieloff (Eds.), Advancing
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Whehon, B.J. (1999). The philosophical core of King’s Conceptual Sv
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158-163.
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King s systems jramework and theory of nursing. Thousand Oaks, CA: Sage.
Winker. C.K. (1995). A systems view of health. In M. Frey & C. Sieloff (Eds.), Adwncmg Kings systems framework
and theory of nursing. Thousand Oaks, CA: Sage.
■
I
CHAPTER
SI
Modeling Nursing From an
Adaptation Perspective
ROY'S ADAPTATION MODEL
Key Terms
'.I'-1'
;;;
4:'
IH'
ixi.
JlHhMI,'
adaptation, p. 263
cognator, p. 261
contextual stimuli, p. 261
focal stimulus, p. 261
regulator, p. 261
residual stimuli, p. 261
’’L
First published in 1970, Rov'- conceptual work focused on the person, the recipiem of caiv,
as an adaptive system. Rov believed that adaptation could consider the wholistic person
(Roy <St Roberts. 1981). W ork done by Roy and by others has mox ed dynamically from the
logical middle in recent vears. The philosophical, research, and practice dimensions have
been expanded and refined. In 1991. Roy and Andrews published a '‘definitive statement"
that synthesized the work of key authors. Roy and Andrews intended this synthesis to be
come the onlv text needed: .ill others became outdated. In 1997, Rov proposed additional
major changes to her work, including an expanded definition of adaptation, revised philo
sophical and scienrifk .is-umprions. and an explicit statement on cosmolouv.
THE STARTING POINT OF THE MODELING PROCESS
Rov hciian rheory work
.i •tr.iduaic student .it the University of California-L.>s An.eele>.
She hirer used that work a? rite conceptual framework for the curriculum at M-’iuu <aiar
Marx s ( . Ilcce I Phillip-. Piuc. Brubaker, Fine. Kirsch, Papazian, Riesrcr. At S< >b:c( 11. I)
R"\ credit- I W-tiw b
i nursing scholar and Theorist at It LA. wiih in. a iv.it i: w iier
Jcvclop !r.T <oit^i-p:i :,.r.t:pib. Ro\ and Roberis believed that nur-inc needed t. ■ 'den•n\ ilv nature A ■ -e’\ .
> develop a unique boj\ of knowlcdce ( PK1
259
260
hff
CONN ECTIONS
Nursing Research, Theory, and Practice
CHAPTER 10
Modeling Nursing From an Adaptation Perspective
261
Reason for Theory Development
Roy’s goal was to develop theory that would demonstrate nursing’s impact on the health
status of the population (Roy & Roberts. 1981). Her recent work has !'een mJuvaie U
challenges she has faced in the past decade. She redefined rhe concept of adaptation a,
«nw(1997)rTH 'n
nUrSeS 3S majorsoc'al for“s - the nexl
I
i\
rLfltcts growing concern within nursing for models theories mJ
knowledge spec.fic to the field and valuable to society
' nd
In her recent expression of the cosmology, Roy argued that the development of nursin,
>g
.c.cnce and pract.ce depended on rhe inclusion of views of rationality and
progress in sei
cnee of the person and environment. Roy recognized the difficult bur
necessary challenge
<>l cons.stently articulating a value-based wholism and a view of persons
r.c.pants in rhe.r own and their environmental well-being. Nurses wh< as purposive par’ act front such a
vewpoint will be a major social force in the future.
Phenomenon of Concern
IW and Rolvro identified three major units, ba. need to be addressed in any nursing model
lii-
A description of the person who receives nursing C.1IC
A siiucnicni of the goal or purpose of nursing
A delineation of nursing intervention of activities <
>t the nurse
The goal of nursing is to promote patient adaptation in regard to the modes of adaptation
thus promoting wellness. Nursing intervention occurs in the context of the nursing process’
mobilizing regulator activity and cognator ability in order to assist the individual to inte’
grate and adapt to his or her environment. As the term would suggest, regulators are those
natural (physiological, biochemical) processes that serve to regulate human functioning.
Cognators involve conscious awareness and choice, processes rhe individual uses to create
the future. A focal stimulus is a person’s most pressing internal or external stimulus. Con
textual stimuli are all other stimuli present in a situation that contribute to the focal stim
ulus. Residual stimuli are internal or external environmental factors bur are nor the cen
ter of a persons attention or energy (Roy & Andrews, 1991).
DESCRIPTION OF ROY'S THEORETICAL SYSTEM
Philosophical Perspectives
The Focus of Nursing. The focus of nursing is rhe person as adaptive svstem. The patient
is identified as a wholistic adaptive system, with coping mechanisms of cognator and
regulator subsystems maintaining adaptation in regard to the four adaptive modes- rhe
physiological (physical, tor collectives), the self-concept (group identity tor collectives)
role function (tor individuals and collectives) and interdependence (pertaimm. to hoth)
(Roy 6t Andrews, 1999) (Figure 10-2). The identification of rhe modes of adaption and
Roy’s conceptualizations about these elements c
constitute rhe central focus of Rov’s
Adapmrion Model (RAM), us shown in Figure 10-1. When Roy begun he.Tneeptrnl”
s
o,::i i?
w"i,
3
ture 'i T'’r"’n 7 " reSpi’,1St'srress 'Vils a new ewept popular in the contemporary cul'
1rc!'cnted a'«’v viewing the person as more than biological. Roy used these loan
dnuonal concepts from Hekon (1964) in developing her conceptual homework for nursin"'
Behavior Related
to Stimuli
Person
Physio
logical
/y
/f
Self- '
Concept
B
f<Z)/
co/
-A\
Mechanisms
Coping
Mechanisms
Interde^
pendence'
_ Role
Function
^C^aptation
'-Adaptation
NK.
^valuatiqn
6
FIGURE 10-1
~
' A^Ptation
• - - - - —....Model.
...... (From Roy. C. 8 Andrews, H. (1999)
The Roy Adaptat,o„ Mode!. (2nd ed.). Stamford. CT: Appleton
----- 1 & Lange.)
FIGURE 10-2 The nursing process as it relates to Roy's description of the person. (From RoLan&ge?dreW5’ H’
Roy Adaptation Model. (2nd ed.) Stamford, CT Appleton &
Z.OZ
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 10
SKs:zssssKiT y p“” f1”'"" ‘nj ■*—»
X
into a whole. The current concenr.
un^ry and comp.es, Z
charactcr,zed ** a summation of parts
“
iogyinto
a god-figure. She holds to a cosmolog Aat “Les C >
UniVerSC and
Modeling Nursing From an Adaptation Perspective
ration, Roy noted that •'the notion front Helson that tell re.nain useful in nursing assess
tnent is that adaptanon is a pooled effect of multiple influences
and residual stimuli” (1997, p. 45).
of creation, yet infinitely more than rhe whole creation("’L?) Z'31"1 f
relatmnships between and among persons, universe u,1 '
' eXplanat,on of
Philosophical assumptions. Roy proclauns , V .. ,
'
1 G,od ;'re summarized in
k 2n J
rhe earth are at one with the earth and with rlf 'l '"H '’’'’T?''1
'vhercin the person and
presented in Box 10-1. are Jcnv . ........................... '"C_ Tllese r'ylosophical assumptions,
—
A^''
Ca'C °n
The revised definition did not r
result from research but was a response to Rov\ evolving
worldview and perception of nursing’s place
i,nJ 3,1 cic;,ril)'1-
The cosmolonv nf rhe R AM Z .
......
of previous work for congruence
...
................................................................................................................ ..... .
•1:1.
lunnan-environment relanonship and memmfoi
|.’Xi
-come
ln« Person uses conscious awareness and choice to create
,
thi
acknowleslge human values The ontolo-v f
n‘‘Ur''1 ' r 1cy ',rc now encouraged to
behalf of rhe person and on rhet^ ^Z;:,tll’nbr,r'?li;alSO
-
" irh the sured ph.Io.-I v Tin.-
called f„ -a
T
C<"’ contextuat
Description of Model and Theory
KtrhSn!? I'"7’ rCdef'nCd adaptati°n aS
cosmology and on.ology
‘
T'"?
Rather than admonishingZses to> be dl T
i" T
263
.TT^han ‘fT ZTZ hl
■!. :
•< ii.?
" ell-being of the human community (RoLl W)’Th'is'Z Parr,C,pi,te in a«ua|tting the
context of adaptation and svstem theory
|h»ni«'|
" '
.... ;
nurs,n” unh,n rhe
IWlopmenrofrheRAM model arlheres to Rovs belief rh u rh
domain concept of nursing. Roy believes that m
i * 1
Pc,M,n ls Hie primary
human meaning and articulation of values ah
'■Helson’s adapmtion-level rh'ZLnLiTtL
J
On^ °"y "rcsrs lT,,n rhe need for
Z’'1 (45)'
1
ration concept ' (Rov c< Andrews |999
'
On"in 1,1 the Rl,y ^P■■ I
A I - 33). However, ,n the revised definition of adap-
30X10-2
a
Roy s Scientific Assumptions for the 21st Century
<10-1
Roys Philosophical Assumptions for the 21st Century
^nmg^^re.
•
• God is intimately revealed in the divprc?0'41 conver9ence of the universe.
of creation
d'VerS'ty of creatlon ^d is the common destiny
Pr°9reSS * higher le“els of
’ orgaXtionatter
' Xen«s'of sae?fdandeanin9
PerS°n and --“-ent integration.
• HuXn nt
environment is rooted in thinking and feeling
. Th L dec|5‘ons are accountable for the integration of creative processes
Thinking and feeling mediate human action
' inCX“PS indUde aCC6PtanCe' PrOteCtiOn- and foste-9 of
mg the universe.
Fr.
R. .x. i
P
S
f derivirig« sustaining, and transform-
• Person ^nd
“T0" PatternS and inte9ral Nations.
264
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 10
aJirra.w. The revised essemp.lens underlying Se RAmTo ".’.
RAM more expansively
and with this vol
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Modeling Nursing From an Adaptation Perspective
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Nursing Research, Theory, and Practice
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267
fant care and occupational activities but were below 0.70 for self-care activities, house
hold activities, and social and community activities. However, Popham’s average congru
ency procedure, which was used for calculation, yields lower reliability ratings than other
procedures do. Internal consistency for the total scale sufficiently met standards for new
scale development. Tcst/retest reliability was strong, despite lower stability scores for the
household activity subscale. Construct validity testing failed to reveal predicted differences
between the vaginal and cesarean birth groups, but subscale correlations indicated that
the IFSAC was multidimensional, despite some shared variance in subscales.
Inventory of Functional Status—Antepartum Period. As a counterpart to the IFSAC,
Tulman, Fawcett, and McEvoy (1991) developed the 1FSAP, a 44-item questionnaire, tJ
assess functional status during pregnancy. The six subscales measure the extent to which
pregnant women maintain their usual household, social and community activities,
childcare, personal care, occupation, and educational activities. The mean score for each
subscale indicates functioning status. Higher scores indicate greater functional status.
Content validity using the average congruency scores was strong. Internal consistency
was variable. Personal Care Activities rated lowest. A Fishers : transformation, which was
used to estimate internal consistency, yields lower reliability estimates. No internal con
sistency reliability was reported for rhe total 1FSAP. Subscales such as the Childcare Ac
tivities Scale indicated great stability in test/retest assessments, whereas others such as the
Personal Activities Subscale demonstrated low reliability. Construct validity demonstrated
some dependence between subscales, but rhe IFSAP could differentiate between functional
status of pregnant and nonpregnant women. The IFSAP also detected differences in func
tional status between women with no pregnancy restrictions and those with various re
strictions. These findings indicate that rhe IFSAP is a potentially useful assessment.
Inventory of Functional Status—Fathers. Tulman, Fawcett, and Weiss (199T
developed the IFS-F as a counterpart to the IFSAC and to measure fathers’ changes m
household, social and community, childcare, personal care, occupation, and educational
activities. The IFS-F also measures the degree to which fathers assume infant-care
responsibilities during pregnancy and the postpartum period. This 51-item questionnaire i>
scored by calculating rhe mean score for each subscale. As with the other functional status
scales, higher scores indicate better function. Strong content validity was established.
Again, however, internal consistency reliabilities using Fisher’s : transformations for the
subscales are low. and the total scale reliability is not reported. Construct validity evaluated
I I-
■5
Modeling Nursing From an Adaptation Perspective
Content validity for the scale was strong. Internal consistency ratings were strong for in
mil
■■
CHAPTER 10
by correlation of rhe subscales indicated that most of rhe subscales are independent, except
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Inventory of Functional Status—Cancer. Tulman, lawcert, and McEvoy (19911
developed rhe 1FS-CA as a measure of functional status in women with cancer. Thu IFS-
CA is a 39-item, 4-point scale in which assessment of primary, secondary, and tertiarv r. de
I I.
..1 fl
c=; is
behaviors arc measured with tour subscales. The first subscale. Household and Familv
Acrivities. consists of 1 5 items and reflects performance of second.in rolu activities. Thu
second subscale, Social and Community Activities, has six items and muasuru> tertiarv rolu
behaviors. Thu Personal Activities subscale consists of 10 items muasurme primary role
beb.aviors such as bathing, eating, and dressing. The Occupational Activirio subs< ale.
repru^-ntittg ^ccondarv role performance, has eight items muasurme rhe mi->unt ■ i uork
268
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 10
1
P““
■>•
oi:; •■•!■ •
C: H
itx'. -■•■
n'l
:*
Ulllliu'l
accomplished at a job. Fawcett, Sidney, Riley-Law less, and Hanson (1996) modified the
IFS-CA for use with multiple sclerosis patients by substituting the words “multiple sclerosis”
for “cancer.” The acronym used for the modified instrument was IFS-MS.
Content validity for instrument items was strong. Subscale reliability was sufficient for
three subscales, but the total scale internal consistency and the Personal Care Activities
Subscale fell below acceptable reliability standards. Short-term test/retest reliability was
adequate, particularly considering that functional status may change with time for women
undergoing chemotherapy. Initial evaluation of construct validity findings indicated the
IFS-CA could differentiate between groups in active chemotherapy and those who had
completed chemotherapy.
Inventory of Functional Status—Caregiver of a Child in a Body Cast. Newman (1997)
created the IFSCCBC by drawing items from the 1FSAC and IFSAP. The 49-item
instrument has six subscales related to household activities, social and community
activities, care of child in body cast activities, care of other children, personal care
activities, and occupational activities. Content validity established by a series of expert
parent panels was adequate. Internal consistency was adequate for a new instrument. The
scale has multidimensional elements with some overlap between personal care and
occupational activities.
Self-Consistency Scale. To better measure self-consistency in older adults Zhan and
Shen (1994) used the RAM and other theories as the basis for the Self-Consistency Scale
(SCS). The SCS is a 27-item, 4-point Likert scale with a total score range from 27 to 108.
Items reflect self-esteem, private consciousness, social anxiety, and stability of self-concept.
Zhan and Shen indicate that the scale was tailored for use with older adults by including
large print and simple items relating to older people with altered health. Internal
consistency reliability levels were within acceptable ranges for a new instrument
Convergent, divergent, and construct validity using factor analysis were all well supported.
Weh over 100 studies using the RAM have been published in the past ten years. This num
ber is greater than the number of research studies that used other theorerical frameworks.
The quantity of published studies indicates the ease with which nurses can conceptually use
an adaptation model as a research guide. Many physiological, psychological, and functional
modalities lend themselves to the concept of adaptation, and the RAM has proven to be
a useful guide. Most of these studies reference the model as
as the
the theorerical
theorerical framework
framework for
rhe study, hut few specifically indicate theory testing as their function.
A strength of research efforts using RAM is rhe initiation of programs of research. In one
of the most notable programs, Fawcett, Tulman, and others conducted a series of studies
centered on aspects of childbirth. Subsequently, Samarel, Fawcett, and Tulman pursued a
related program of research on facilitating adaptation in women with breast cancer. An
other research program is Pollock’s examination (1993) o! adaptation to chronic illness
The following review explores studies from rhe established research programs and then
provides overviews of selected adaptation studies from the broad range of completed re
search. Selection of these articles is nor intended to negate other RAM research. There are
simply too many articles to include them all. Table 10-2 presents a summarv of rhe . k-ued
research studies.
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Modeling Nursing From an Adaptation Perspective
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TABLE 10-2
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Study/Year
Purpose
CHILDBIRTH—cont'd
Fawcett, Pollio,
This intervention study investigated the
Tully, Baron,
effects of incorporating information
Henklein, and
about cesarean sections in standard
Jones, 1993
childbirth preparation classes on ma
ternal reactions to unplanned cesarean
sections.
Fawcett and
Weiss, 1993
This exploratory study examined cul
tural influences on response to ce
sarean birth in Caucasian, Hispanic,
and Asian women.
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Methods
Findings
Seventy-four women in the experimental
group received cesarean information, and 48
in the control group received standard child
birth preparation information. Following deliv
ery participants responded to Pain Intensity
Scale, Distress Scale, Self-Esteem Scale, IFSAC
Feelings about Baby Scale, Relationship
'
Change Scale, and Perception of Birth Scale 1
to 2 days postpartum and at 6 weeks.
time, whereas the control group had small decline
Groups did not significantly differ on self-esteem ‘
unctional status, feelings about the baby, and
changes in quality of marital relationship.
The sample consisted of 15 women from each
ulture (Caucasian, Hispanic, and Asian) who
responded to Perception of Birth Scale and an
open-ended questionnaire within 1 to 3 days
of giving birth.
7
Caucasian and Hispanic women expressed more
physiological needs than Asian women did Hispanic
women were the only group to express seif-Z t
need due to surpnse at having cesarean deliveries All
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ceptlon of the birth experience was not different
between the two groups. No differences in pain inten
sity or physical distress were found. The experimental
W experienced a change in pain intensify over
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tants, and all expressed role function needs. Althouoh
™ny women felt nothing more could have Improved
Reichert, Baron,
and Fawcett,
1993
Fawcett,
Tulnian, and
Spedden, 1994
The study compared findings of three
qualitative studies about women's re
sponses to planned and unplanned ce
sarean sections.
The study compared the reactions of
women having vaginal births after pre
viously delivering by cesarean sections
BREAST CANCER
Samarel,
This pilot study investigated influence
Fawcett and
Tulman, 1993
of cancer support groups with coaching
on adaptation of women with breast
cancer.
£
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inducted between
thetayears
1973
1990 SngTs^mila^ues-
fertSaof
^r_subjectedtocontentan^
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identify women's responses to open-ended
questions. The adaptive modes (physiological,
self-concept, role function, and interdepen
dence) of the RAM were used to categorize
responses.
Twelve to 24 hours post-delivery, 32 women
having vaginal births after prior cesareans re
sponded to Perception of Birth Scale and Birth
Experience Questionnaire. A chi square deter
mined delivery differences. Content analysis
was used for open-ended responses.
Sixty-four women with breast cancer were ran
domly assigned to a cancer support group
(CSG) with coaching, CSG with no coaching, or
no CSG. Symptom distress was measured by
Symptom Distress Scale (SDS), emotional dis
tress measured with Profile of Mood States
Linear Analog Self-Assessment (POMS-LASA),
and functional status measured with IFS-CA.
about not having a vaginal delivery, delayed assumpt.on of parenting responsibilities, and delayed contact
with newborn. Mothers in the second study had more
adaptive responses but continued to have ineffective
responses similar to those of first study. In third study
the physiological and role function modes had more
ineffective responses, but self-concept and interde
pendence mode had more adaptive responses. How
ever, ineffective responses were again similar to those
m first study.
Women reported moderately positive perceptions of
experience of vaginal delivery and had more adaptive
responses to vaginal delivery than to the previous ce
sarean delivery. Decision making for vaginal birth was
based on recommendations from external sources be
yond women's control.
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There were no significant differences in baseline mea
sures of the 3 groups. Although the MANOVA indi
cated significant differences in symptom distress,
emotional distress, and functional status, univariate
F s did not reveal significant differences among
groups. Intervention, methods, and instrumentation
were judged appropriate for a major study.
Continued
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TABLE 10-2
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Study/Year
■
Purpose
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Methods
Findings
BREAST CANCER—cont’d
Samarel,
Fawcett and
Tulman, 1997
This major study investigated the ef
fects of CSGs on adaptation and symp
toms of women with breast cancer.
O
One hundred eighty-one women with newly
diagnosed breast cancer were randomly as
signed to CSG with coaching, CSG without
uo
tional distress, or functional status. In the CSG with
z
coaching, significant improvement in relationship
coaching, or control group. Data were col
lected using SDS, POMS-LASA, IFS-CA, and Re
quality was present following treatment, but im
lationship Change Scale at baseline. These in
provements were not sustained at the eight-week
measure.
struments were administered after treatment
and 8 weeks later. Repeated measures
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No differences were found in symptom distress, emo
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CA
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MANOVA were used for analysis.
Samarel,
The study investigated the influence of
Fawcett
support group intervention and educa
tion with coaching on adaptation of
Krippendork,
Piacentino,
tliasof, Hughes,
women with breast cancer.
Kowitski, and
Ziegler, 1998
n
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Seventy women undergoing treatment for
breast cancer were interviewed regarding
adaptation level, view of illness, physical and
emotional effects of illness, and effects of par
ticipating in research. Data were analyzed via
content analysis.
Seventy-three percent of women indicated their atti
tude toward breast cancer improved, reflected a
theme of cure, and emphasized positive feelings. Re
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search participation was positive, with women indi
cating greater adaptation, appreciating opportunity
Q.
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to verbalize, and receiving educational information.
a
Support groups facilitated physiological adaptation
by handling symptoms and promoting greater under
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standing. Self-concept responses reflected a reduction
of stress and fear. Downward comparison enhanced
well-being, and group participation facilitated nor
malization. Role function mode responses reflected
women either returning to routine duties or electing
to participate in fewer usual activities, The interdePen^nce m°de revealed improved relationships with
significant. '
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Tulman and
Fawcett, 1996
This pilot study explored the relation
ship of depression, interpersonal rela
tionships, and immune status to func
tional status of women with breast
cancer.
■
-
—
-
■-
Fourteen women responded to IFS-CA. Beck
Depression Inventory, and Psychosocial Adjustment to Illness Scale (PAIS) at 1, 7, and
13 months following diagnosis. Immune status
Women undergoing ch™otamp7 hod lower lune'
was measured each time with absolute counts
of natural killer, CD4, and CDS cells from ve
relationships had higher levels of functional status.
'
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J-__ 1
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tional Oatnc
status than
than tkrteA
those not undergoing
chemother
apy. Women with lower depression scores had higher
functional status. Women with better interpersonal
nous blood samples.
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Mock, Burke,
This experimental study examined the
Sheehan,
Creaton,
effects of a nursing rehabilitation pro
Fourteen women receiving chemotherapy ran
domly were assigned to experimental or usual
gram on adaptation of women with
breast cancer.
The experimental group increased level of walking,
whereas the control group decreased. Both groups
care group. The experimental group partici
pated in a structured exercise program and
experienced lower levels of psychosocial adjustment
over chemotherapy but had higher levels at its end.
Emotional distress decreased for the experimental
Winningham,
Mr Kenney-
support group meetings. Subjects completed
the Karnofsky Performance Status Scale,
Tedder,
Schwager, and
o
group and increased in the control group. Self
O
Inventory, Tennessee Self-Concept Scale, Body
concept remained constant for both groups over the
course of the study. Body satisfaction remained con
—
Image Visual Analogue Scale, and Symptom
Assessment Scale at baseline, midway, and at
the completion of chemotherapy.
stant in the experimental group but decreased in the
control group. Fatigue and difficulty sleeping were
12-minute Walking Test, PAIS, Brief Symptom
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present in both groups but was greater in the control
un
group. Participants reported that the rehabilitation
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program had positive effects.
Muck, Dow,
Metres, Grimm,
Dienemann,
Haisfield-Wolfe,
Quitasol,
Mitchell,
Chakravarthy,
and Gage, 1997
This experimental study evaluated the
effects of a walking program on
A two group pretest, posttest design was used.
Forty-six subjects were assigned to either an
women with breast cancer who were
receiving radiation therapy.
experimental or control group. Subjects com
pleted 12-minute Walking Test, Symptom As
sessment Scale, and Piper Fatigue Scale at the
beginning and end of radiation therapy. At
o
2
MANCOVA using baseline data as covariates and sub
sequent post hoc testing revealed that the exercise
group significantly increased their performance on
12-minute walking test. Walkers demonstrated de
mid-therapy, subjects were assessed for fa
creases in the following: fatigue, sleep difficulties,
anxiety, depression, and body dissatisfaction. Emo
tional distress decreased in the exercise group while
tigue and symptoms again. The experimental
increasing in the control group.
group was taught a walking exercise program
following the initial evaluation.
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TABLE 10-2
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Selected Studies Using the Roy Adaptation Model—cont'd
Study/Year
Purpose
__2
_____ _
Methods
Findings
Sixty-seven women responded to mailed ques
Controlling for endocrine therapy, the 25 women receiv
tionnaire regarding menopausal symptoms
and the Derogatis Sexual Functioning Inven
ing chemotherapy were more likely to report
2
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________________
BREAST CANCER—cont'd
YoungMcCaughan,
1996
The study described current sexual - •
functioning in women with breast can-
- cer, comparing women with and with
out pharmacological manipulation.
tory. Thirty women received neither chemother
apy nor endocrine therapy; 8 women received
both; 12 women received only endocrine ther
apy; and 17 received only chemotherapy.
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menopausal symptoms, sexual dysfunction, and nega
tive body image. When chemotherapy was controlled,
the twenty women undergoing endocrine therapy did
not have menopausal symptoms nor sexual dysfunction
more often than those not undergoing endocrine ther
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apy. Sixteen percent of women did not use measures to
decrease sexual dysfunction. More than half were never
CHRONIC ILLNESS
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asked about sexual issues by their healthcare providers.
n_
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Courts and
Boyette, 1998
This descriptive study compared anxi
Fifteen males receiving either home HD, in
ety, depression, and psychosocial ad
Home HD patients experienced the lowest levels of
center HD, or PD completed the Clinical Anxi
ety Scale, Generalized Contentment Scale,
anxiety, and PD experienced greatest levels. Home HD
patients had lowest depression levels while in-center
justment of patients on home he
modialysis (HD), incenter hemodialysis,
Hemodialysis Stresser Scale, PAIS-SR, and a
and peritoneal dialysis (PD).
HD patients had the highest level. Home HD patients
psychosocial interview. Five males were in
experienced higher levels of psychosocial adjustment
to illness and perceived the fewest stressors than the
other groups.
each group.
Fawcett, Sidney,
Riley-Lawless,
This exploratory study examined the ef
fects of alternative therapies on symp
and Hanson,
1996
toms severity and functional status of
respondents with multiple sclerosis.
Sixteen respondents completed telephone in
Milder symptoms were associated with greater func
terviews and mailed questionnaire regarding
functional status, Multiple Sclerosis Alternative
tional status (r = -0.51). Severity of symptoms im
proved with alternative therapies (t(15) = 6.45, p =
0.0005). Content analysis of open-ended responses
focused on beneficial effects of therapy,t need iu
to pace
Therapies Questionnaire, and severity of multi
ple sclerosis symptoms. The 13 alternative
Q.
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the r.ipies used included homeopathy, massage
Jackson,
Strauman,
Frederickson,
This descriptive study evaluated the
biopsychosocial effects of interleukin-2
therapy.
and Strauman,
1991
Wfive patients with cancTtl® was nof
treatable with conventional therapies were
measured for physiological toxicities, severity
of illness, emotional concerns, symptom dis
tress, quality of life, and financial data. Mea
sures recorded before treatment, during leukopheresis, during interleukin-2, and at 1 month
and 6 months.
Frederickson,
The study tested the RAM by examin
Strauman, and
ing biopsychosocial adaptation of can
Strauman, 1991
cer patients.
Only «
data collection. Physiological toxicities were worst''
during treatment and diminished with protocol
changes. Severity of illness and symptom distress
were greatest during treatment, and diminished after
treatment. Emotional concerns diminished following
treatment. Nursing care was the most expensive com
ponent of treatment.
Perception of symptoms positively correlated with
psychosocial adaptation (r = 0.60; p < 0.001). Per
ception was a greater factor in determining adapta
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tion than was actual physiological status.
McGill and
The study examined the relationship of
Sixty-eight older adults with cancer and 88
Paul, 1993
hope and functional status of older
adults with and without cancer.
people living in the community completed in
lated to hope. Declining physical health and lower so
struments on functional status and hope.
cioeconomic level were associated with decreased
hope. Cancer diagnosis did not diminish hope levels.
Pollock, 1986
This descriptive correlational study
identified factors associated with phys
iological and psychological adaptation.
Physical health, income, and education level were re
Three groups (n = 20 each) of adults with di
Of the three groups, significant correlations between
agnoses of diabetes, hypertension, or rheuma
physiological and psychological adaptation and har
toid arthritis responded to adaptation instru
ments (diabetes, hypertension, or arthritis),
Health-Related Hardiness Scale (HRHS), and
Psychosocial Adjustment to Illness (PAIS).
diness in the diabetic group were found (£ = 0.43;
p < 0.5; [ = 0.62; p. < 0.5). Hardiness was not a fac
tor in the arthritis group. In the hypertension group,
hardiness was related to physiological but not psy-
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TABLE 10-2
cri
Study/Year
Purpose
Pollock,
Christian, and
Sands, 1990
This comparative study examined phys
iological and psychological adaptation
ol adults with three different diagnoses
of chronic illness.
NEONATAL ADAPTATION
Shogan and
The study examined the influence of
Schumann, 1993 changes in environmental lighting on
oxygen saturation of very low birth
weight neonates.
Garcia and
White-Traut,
1993
The study examined the effect of two
interventions on preterm infants expe
riencing apneic episodes.
n
Methods
CHRONIC ILLNESS—cont'd
Pollock, 1989
This descriptive study investigated vari
ables related to physiological adapta
tion in diabetic patients.
Thirty adults with diabetes completed the
Stress Questionnaire and Revised Ways of Cop
ing Checklist, HRHS, and Physiological Adapta
tion to Diabetes Scale. Correlations and multi
ple regression were used to determine
relationships.
Two hundred eleven adults with arthritis, mul
tiple sclerosis (MS), or hypertension completed
a diagnosis specific adaptation instrument, the
Mental Health Index (MHI), HRHS, and Margin
in Life Scale (MIL), which measures ability to
tolerate change.
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Findings
m
Responses to the Stress Questionnaire were grouped
into the anticipatory category, which incorporated the
concepts of threat and challenge, and the outcome
category, consisting of harm and benefit. Diabetic pa
tients who perceived illness as a threat or challenge
were more likely to use emotion-focused coping tech
niques. Hardy individuals perceived illness as a poten
tial harmful or beneficial factor. Hardy individuals
tend not use emotion-focused coping strategies. Vari
ables explaining 56% of the variation in physiological
adaptation included outcome appraisal, a mixed fo
cus coping pattern, hardiness, patient education, and
emotion-focused coping.
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Although psychological adaptation was similar for the
three diagnostic groups, physiological adaptation var
ied. Patients with arthritis were more dependent on
their medications and were less likely to be involved in
regular physical activities than adults with hyperten
sion. Patients with arthritis experienced less psycho
logical distress than those with MS, but they were less
likely to be involved in health-promoting activities.
Twenty-seven sleeping infants were exposed
to lighting levels beginning at 10O-foot can
dles, decreasing to 5-foot candles and then re
turning to 100-foot candles. Oxygen saturation
was recorded at 1 and 5 minutes after lighting
Lowering lighting did not influence oxygen saturation
at 1 and 5 minutes. Increasing lighting generated a
4% to 7% decrease in oxygen saturation within oneminute after change.
A convenience sample of 14 nonventilated
preterm infants were compared to determine
the effectiveness of taste/smell or tactile stim
ulation during apneic episodes. Tactile stimula
tion consisted of rubbing infants' legs during
apnea. Taste/smell was administered by rub
bing with lemon-glycerine swab. Infants re
ceived each intervention twice.
Fifty six observauons (28 for each group) were
recorded for 14 infants. Infants receiving taste/smell '
intervention required intervention for a shorter period
before reinstitution of respirations. When taste/smell
intervention was used, infants were able to retain
baseline sleep state, whereas tactile intervention
moved infants from sleep to alert state.
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Kitchin and
Hutchinson,
1996
The study described touching during
preterm infant resuscitation.
CHILDREN AND ADOLESCENTS
Bournaki, 1997
The study described behavioral and
heart rate response to venipuncture.
Corser, 1996
The study described sleep patterns for
1- and 2-year-olds admitted to the
PICU. It compared patterns to those be
fore illness and determined the time
required to return to normal sleep
patterns.
Ten videos of preterm infant resuscitation were
analyzed.
Human and mechanical touching occurred. Both hu
man touch and mechanical touch were associated
with tasks, protective functions, and accidental
touching.
m
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Ninety-four children between 8 and 12 years
of age had heart rate and behavioral re
sponses recorded during venipuncture. Parents
completed survey on temperament and Modi
fied Child Rearing Practices Report. Children
completed Child Medical Fears Scale, Revised
Fear Survey Schedule for Children, Adolescent
Pediatric Pain Tool, a visual analog scale for
pain, and a word list for pain quality. Child Dis
tress Scale, pulse oximeter measure, behaviors,
and heart rate during venipuncture were
observed.
Low sensory thresholds were associated with greater
pain intensity. As perception of pain intensity in
creased so did behavioral and heart rate responses.
Age and threshold explained 12% of variance in
heart rate. Age, medical fears, distractibility, and
threshold explained 6% of variance in heart rate and
pain quality.
Twelve children aged 1 or 2 were assessed for
original sleep patterns, observed for sleep
length and disturbances, and evaluated for re
turn to original sleep patterns. Caregiver activi
ties were rated while children were in PICV.
Average sleep time for children in PICU was 453 min
utes with nine awakenings during a 12-hour night.
Sleep periods averaged 52 minutes. Sleep time de
creased with light, noise, caregiver activity, and pain.
Children received significantly less sleep and had more
awakenings when sleeping in the PICU. Sleep patterns
returned to original levels by 3'/ weeks after discharge.
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TABLE 10-2
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ejected
ant'd
Study/Year
Purpose
CHILDREN AND ADOLESCENTS—cont'd
Russell,
The study investigated the nature of
Reinbold, and
transition for adolescents with cystic fi
Maltby, 1996
brosis moving to adult care programs.
O
Methods
Seven adolescents and eight parents were in
terviewed using semistructured and openended questions. The adaptive modes of the
RAM were initially used to categorize data.
FAMILY ADAPTATION
Bokmskje, 1992
This quasiexperimental study tested the
influence of family conferences on the
anxiety levels of family members.
Fisher, 1994
Gagliardi, 1991
Kurnelasky,
1990
Niska,
Lia-Hoagberg,
and Snyder,
1997
This descriptive study identified the
needs of parents with children in pedi
atric intensive care.
The study described experiences of
having a child with Duchenne muscular
dystrophy.
The study evaluated the effectiveness
of structured home visitation on
parental anxiety and CPR knowledge
of parents with apnea-monitored
children.
This ethnographic study identified
parental concerns of new MexicanAmerican parents.
2
Findings
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Adolescents .ncreased self-identity and independence
with disease management and other life events. Adapathonohl" Parentslncluded Siting up some control,
although they were often hesitant to do so and felt
excluded. Situational transition was found to be difficult due to lack of planning and coordination. Chronic
i ness served as more of an undercurrent with treat
ment routines arranged around other life activities.
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Twenty-two family members of the neuro
science intensive care unit (NICU) admissions
completed state anxiety scale 24 hours before
infant transfer from Neuro Intensive Care and
24 hours foilowing transfer to a rehabilitation
unit. Experimental group participants (n - 15)
were a part of a family, conference prior to
transfer.
Fifteen mothers and fifteen fathers of 30 PICU
patients responded to a modified version of
the Critical Care Family Needs Inventory.
Three families with boys diagnosed with
Duchenne muscular dystrophy were followed
through 10 weekly family visits. Data were col
lected through participant observation and indepth interviews.
ANCOVA using pretest anxiety scores demonstrated
significant differences in anxiety levels between the
^vo groups (E2,1 = 30.77, p = 0.001). Family mem
bersparticipating in family conferences had lower
levels of anxiety following the conference
□
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The top five needs were the following: knowing prog
nosis, knowing wny things are done, feeling there is
Themes related to recognizing the disease were or-: ‘ '
gamzed under three major headings—disillusion
ment, working through the disease, and achieving
resolution—were identified. Disillusionment involved
realizing the impossibility of living a normal life,
physical deterioration, physical pain, self-awareness,
and social confirmation of the impossibility of nor- '
malcy. Working through the disease was character
ized by family adaptation to the disability and self
imposition of boundaries creating a smaller world.
Achieving resolution involved letting go or hanging
on and a hope that disabilities would be better so
cially tolerated in the future.
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A treatment group (n - 12) receiving home
visits was compared to a control group (n =
11) on state anxiety and CPR knowledge re
tention. Comparisons were made before and
after treatment.
Twenty-six families were followed longitudi
nally with eight home visits over first 6 months
of the infants' lives. Interviews from each
home visit were transcribed and subjected to
content analysis.
In general, both groups exhibited moderately low lev
els of state anxiety, and no significant differences be
tween treatment and control groups following home
visitation were found. No significant differences were
found in CPR knowledge retention.
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Illness of infant was the major concern of most par
ents. Providing for material needs, threatened job
loss, infant diet, concerns about rearing infant, future
threats to infant, and lack of assistance in parenting
were also important concerns.
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TABLE 10-2
■elected Studies Using the Roy Adap'won Model—cont’d
Study/Year
Purpose
O
Methods
Findings
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Twenty-three families participating in the origi
nal study were contacted and responded to 20
In family nurturing, 61 % to 70% of the families indi
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FAMILY ADAPTATION—cont'd
Niska, 1999
The study evaluated the similarity in
ways nurses and Mexican-American
couples enhanced family processes of
nurturing, support, and socialization.
Evaluated the acceptability of nursing
examples of family-enhancing interventions
that were printed on index cards. Participants
were similar to those used by their own parents. Most
I'
accepted (87%) was the technique of the nurse as
sisting family members who wished to be caretakers.
(D
Three methods of facilitating family socialization
QJ
interventions to enhance family
stacked cards according to whether the behav
ior was similar to Mexican-American parenting
processes.
behaviors. This was followed by a similar
were rated similar to current practices of Mexican-
process that assessed the acceptability of the
American families (ranging from 43% to 78%). Ac
intervention. One week later, participants com
ceptability of these practices ranged from 78% to
ro”
mented on findings of the card sorting.
96%. For family support, 83% to 100% of the 14 be
haviors were rated similar, and 35% to 96% of the
o
behaviors were considered acceptable.
□
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zr
PERIOPERATIVE
s
Leuze and
The study developed a perioperative
A random sample consisted of 20 patients (10
Nurses caring for patients with completed RAM
rj
McKenzie, 1987
assessment using the RAM and evalu
ated the circulating nurse's psychoso
control and 10 experimental) scheduled for
based assessments demonstrated greater knowledge
ro
surgery. Investigators completed RAM periop
of psychosocial and physiological aspects of the
erative assessments for the experimental
group and attached them to the OR charts that
patient.
cial knowledge when the assessment
was used.
would be reviewed by the circulating nurses.
Thirty minutes following surgery, circulating
nurses caring for study patients completed
evaluation checklists assessing their patient
■MH'
Takahashi and
This exploratory study identified char
Data were collected using observation of peri
The following assessment behaviors were observed
Bever, 1989
acteristics of perioperative assessments
80% of the time: self-introduction; verification of op
performed on ambulatory surgery and
operative nurses' preoperative assessments,
chart audits, and self-reported questionnaires
day-of-surgery admission patients.
completed by nurses. Forty-eight assessments
reactions; informing patients before activities; com
were observed.
municating information obtained from assessment to
erative procedure and site; documentation of allergic
other care providers; and documenting patient con
sent, medication history, and indicators of mental-
>
no
OO
O
emotional state. The following assessments were
observed less than 20% of the time: giving post
operative instruction, discussing physiological status
with patient, determination of patient substance
abuse, taking vital signs, soliciting information on cul
1'
tural practices or religious beliefs, communicating
c
psychosocial behaviors, ensuring waiting area quiet,
receiving verbal report from preoperative area, and
I'
2.
z
reporting deviations of diagnostic studies to other
Gaberson, 1991
ness of humorous distraction on preop
Fifteen preoperative same-day surgery patients
were divided into three groups: control, music
erative anxiety.
only group, and music plus humorous distrac
This pilot study evaluated the effective
care providers.
O
No significant differences found among the groups,
□
2
but the control group evidenced the highest anxiety
levels. A moderate treatment effect was found.
>
£■
■U
tion. Treatment occurred during a 20-minute
wait in the day surgery waiting area. Anxiety
was measured using visual analog scale.
Gaberson, 1995
This major study evaluated effective
ness of humorous distraction on preop
erative anxiety.
Forty-five preoperative same-day surgery pa
tients were divided into three groups. Treat
ment protocol and measurement were the
§
Although anxiety levels were highest for control
group, no significant differences were found between
the groups.
n
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same as in the pilot study.
Continued
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LIBRARY
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TABLE 10-2
y.
:he Roy Adaptation Model---cont,d
i
%
:r.
l/l
Study/Year
Purpose
PERIOPERATIVE—cont'd
Meeker, 1994
The study determined the impact of
structured preoperative treatment pro
gram on atelectasis and patient
satisfaction.
THEORY TESTING
Hamner. 1996
The study tested the RAM proposition
related to the interdependence of nurse
and patient. It was proposed that per
ceived control over visitation would in
fluence adequacy of seeking and re
ceiving affection.
Levesque,
Ricard,
Ducharme,
Duquette, and
Bonin, 1998
This cross-sectional study developed a
theoretical model derived from the
RAM and assessed the findings of five
studies for empirical verification of the
model.
m
QJ
Methods
Findings
Ninety-five patients received standard informal
patient education, and 49 received structured
teaching program. Atelectasis was measured
by chest x-ray report or physician notation.
Satisfaction was measured using Patient Satis
faction Inventory.
Although class evaluations indicated most felt well
prepared for surgery and had decreased anxiety, there
were no differences in episodes of atelectasis or in
patient satisfaction with teaching.
g
_
o
□
Q.
s
r*
Q
Sixty medical surgical intensive care patients
were assessed for severity of illness, perceived
control over visitation, hardiness, state anxiety,
and length of stay (LOS). Path analysis was
used to test the proposed model.
Only 18% of the variance in the model predicting LOS
was explained by the variables severity of illness, anx
iety, hardiness, and patient control over visitation.
Hardiness was associated with patient control over
visitation but was significant only at the 0.1 level.
Other paths between severity of illness and LOS, har
diness and LOS, severity of illness and anxiety, and
An aposteriori approach was used to analyze
five studies within the perspective of the con
ceptual elements of the RAM. In the first study,
265 caregivers living with a demented relative
completed the Revised Memory and Behavior
Problems Checklist, Interpersonal Relationship
Inventory (IPRI), Indices of Coping Responses,
and Brief Symptom Inventory (BSI). In the sec
ond study, 200 informal caregivers for psychiatrically ill relatives completed the Social Be
havior Assessment Scale, IPRI, Indices of
Coping Responses, and Psychiatric Symptoms
Index In the third study, 163 caregivers of
mentally ill persons at home completed the So
cial Behavior Assessment scale, IPRI, Indices of
Coping Responses, and the Psychiatric Symp
toms Index. In the fourth study, 1564 nurses
working in geriatric long-term facilities com
pleted the Nursing Stress Scale, Work Relation
ship Index, Indices of Coping Responses, and
the Psychiatric Symptoms Index. In the fifth
study, 135 community-dwelling older couples
responded to the Geriatric Social Readjustment
Rating Scale, IPRI, F-Copes, and Psychiatric
Symptoms Index.
L1SREL was used for path analysis.The initial fit was
not acceptable, so an exploratory search for a model
commenced. In the exploratory model, variance of the
psychological distress was explained for 17% of pro
fessional caregivers and 56% of caregivers to psychiatrically ill relatives. In the modified model, the con
textual stimulus of social support directly and
positively affected the focal stimulus of perceived
stress. Perceived stress triggered passive avoidance
coping strategies, which were positively linked to psy
chological distress. No linkage between gender and
available or enacted social support and perceived
stress was found. No linkage between active coping
strategies and psychological distress was found. New
paths indicated that available or enacted social sup
port and passive/avoidance coping strategies directly
and positively affected active coping strategies. Con
flicts were demonstrated to have a direct, positive ef
fect on passive coping strategies. Conflicts and per
ceived stress had a direct, positive link to
psychological distress.
5>
33
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Continued
□
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TABLE 10-2
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purpose
THEORY TESTING—cont'd
Ducharme,
The follow-up
'-up Siuuy
study io
to Levesque
Levesque,
Ricard,
Ricard, Ducharme,
Duquette
and Ronin
... ......................
’
'
•qette'andBonin
Duquette,
<’998 tested a longitudinal model de.
Levesque,
nved from the RAM on the psychosoLachance, 1998
aai determinant of adaptation in four
target groups.
z
z
n
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""
Findings
in »k tk- fSt StUdy' 161 lnformal caregivers of
o
2
givers of demented relatives, 498 professional
caregivers of older adults, and 98 older
spouses completed measures on perceived
9 es, psychological distress, and life satisfac
tion at two points in time. The second measure
occurred between 6 and 48 months
moMedr^mOde^Ommmced■A, ini,ial rneasure the
Z
c
J
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related to psychological distress. UnhypothX Y
M
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an5 oas'X f0U"d ,be,Ween
QJ
social support
n_
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3
Q.
T7
n
matory long.tudinal analysis was not achieved Ex
2
tween (1) psychological distress and conflict level f?)
...
■
Nuamah,
Cooley,
Fawcett,
and McCorkle,
1999
The study tested a RAM-based theory
of health-related quality of life in can
cer patients.
Investigators conducted a secondary analysis
of 375 cancer patients who completed the
Symptom Distress Scale, the Center for Epi
demiological Studies—Depression Scale, and
the Enforced Dependency Scale. Baseline mea
sures were made and then repeated three
months later.
defined by affective status, functional status, and
physical symptoms but somewhat less by social sup
port, which indicates that all four response models
are not related.
n
T
At baseline a model fit regarding the influence of en
vironmental factors on quality of life was achieved
(x2 = 140.97, df = 32, p < 0.001; goodness of fit =
0.945; adjusted goodness of fit = 0.866, comparative
fit index = 0.809). Hospitalization, complications,
and stage influenced illness severity. Environmental
stimuli of adjuvant treatment, severity, marital status,
race, age, income, and gender influenced healthrelated quality of life as measured by symptom dis
tress levels, functional status, and depression levels.
Environmental factors accounted for 59% of variance
in quality of life at baseline. At three months, these
factors and the baseline quality of life status influ
enced the second measure of quality of life (x2 =
262.92, df = 64, p < 0.001; goodness of fit = 0.919;
adjusted goodness of fit = 0.848; comparative fit
index = 0.835).
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3
QJ
3
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286
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CONNECTIONS
Nursing Research, Theory, and Practice
Childbirth. Tulman, Fawcett, Groblewski, and Silverman (1990) investigated changes
in functional status in 97 mothers of healthy babies for 6 months after delivery. Functional
status represented the role function mode of the RAM. The physiological mode was
measured by health variables; self-concept was measured by psychosocial variables; and
interdependence mode was measured by family variables. Although functional status
improved over the 6-month postpartum period, none of the mothers had fully assumed
functional activities after 6 months, particularly in terms of self-care. Factors influencing
resumption of activity included physical energy, type of delivery, prior occupation, maternal
confidence, support from husband, education, infant temperament, and parity. The
relationship found between functional status (role function mode) and variables in the
physiological self-concept, and interdependence adaptive modes and contextual stimuli is
congruent with Roy’s conception of a complex system necessary for adaptation. However,
these relationships were not consistent over time.
Using a subset of subjects from this longitudinal study, Tulman and Fawcett (1990) ex
amined maternal employment patterns for 6 months following childbirth. Over half of
mothers were employed within 6 months after delivery. Although employed mothers en
gaged in more roles, employed and unemployed mothers were similar in many respects. Mul
tipara mothers appeared better able to manage work following delivery than primiparas.
This led investigators to suggest that previous adaptation to multiple roles of homemaker,
mother, and employee might influence adaptation.
Cesarean births served as the subject for a series of studies using the RAM. Fawcett,
Pollio, Tully, Baron, Henklein, and Jones (1993) investigated the effects of cesarean birth
information given in childbirth preparation classes on mothers' postpartum reactions to
unplanned cesarean deliveries. The RAM model proposition that management of contex
tual stimuli promotes adaptation was not supported. The intervention failed to create any
differences between women receiving cesarean birth information and those who did nor.
Investigators postulated that the experimental and control protocols were not sufficiently
different and thus did not yield significant differences.
A subsequent study by Fawcett and Weiss (1993) examined crosscultural adaptation to
cesarean birth. No substantial differences between the cultural groups were found. Women
from all three groups exhibited a moderate level of global adaptation. This suggests that the
adaptive modes of rhe RAM are useful in different cultural groups.
Reichert, Baron, and Fawcett (1993) compared the findings of three studies regarding
women's responses to planned and unplanned cesarean sections. Content analysis was di
rectly tied to rhe adaptation modes of the RAM. Although women had both adaptive and
ineffective responses, findings suggested that women who delivered by cesarean sections re
quired sensitive care that considered special needs tor information, the presence of partners,
and early and sustained contact with their newborns. The self-concept and interdepen
dence modes-as proposed bv the RAM facilitated adaptive responses.
Fawcett, Tulman, and Spedden (I'T'H) explored vaginal delivery bv women who previ
ously had cesarean section.^ Although experiences were moderately positive, ineffective
adaptive responses included pain, fariyuc. fear ot failure, wanting to give up, and worry
about the newborn. Howe\ er. more adaptive responses, including excitement, relief, con
fidence, contiol, and interdependence, were ai>, > nuied. \X omen valued the active partic
ipation, shorter recovery lime, and rhe presence of the partner tor entire experience. Find-
CHAPTER 10 Modeling Nursing From an Adaptation Perspective
287
ings of this study contrasted those of the Reichert, Baron, and Fawcett (1993) in that it did
not find adaptive responses in the physiological, interdependence, and self-concept modes.
This study demonstrated the influence of type of delivery on adaptation and provided a
basis for directing interventions toward the physiological, and interdependence modes of
adaptation.
Finally, Tulman, Morin, and Fawcett (1998) tested the RAM proposition that focal and
contextual stimuli influence responses. In this instance investigators proposed that the fo
cal stimuli of weight before and during pregnancy and the contextual stimuli of parity and
pregnancy trimester would influence pregnant women’s physical energy and functional re
sponse to physical symptoms. Excessive weight gain was found to affect third trimester
functional status. This outcome partially supports the RAM proposition that focal and
contextual stimuli influence role function responses. The focal stimuli of weight before
pregnancy failed to influence physical symptoms and physical energy during pregnancy.
However, the focal stimuli of excessive weight gain during pregnancy influenced role func
tion, lending some support to rhe RAM. Further research needs to he completed to clarify
the role of focal stimuli m general mg role outcomes.
The composite ot these childbirth studies reveals that adaptation occurs to varying de
grees. Return to a normal functional status, even 6 months after childbirth, was not al wavs
achieved (Tulman, Fawcett, Groblewski, Cx Silverman, 1990). Mixed findings for rhe role
contextual variables played in adaptation were exhibited. Fawcett, Pollio, Tully, Baron,
Henklein, and Jones (1993) found that a contextual variable of information giving failed
to influence adaptation, whereas Tulman. Fawcett, Groblewski, and Silverman (1990)
found that contextual variables interrelated with other adaptive modes and influenced
functional status. Tulman, Morin, and Fawcett (1998) did not find that focal stimuli uni
formly influenced functional role status, nor did they find consistent relationships between
rhe coping systems over time. This may suggest a need for a longitudinal approach in future
investigations. The RAM's adaptive modes were reflected in crosscultural groups (Fawcett
& Weiss, 1993). However, different responses were found in the Reichert, Baron, and
Fawcett comparison (1993) of planned and unplanned cesarean births and in the Fawcett.
Tulman, and Spedden study (1994) of women undergoing vaginal births after previouslv
giving birth by cesarean section. Although the interdependence and self-concept modes
significantly influenced adaptation in women having planned or unplanned cesarean
births, the physiological, self-concept, and interdependence modes did not promote adap
tation in women undergoing vaginal births following cesarean sections.
Breast Cancer. As part of a continuing program of research, Samarel and Fawcett (1992)
and Samarel. Fawcett, and Tulman (1993. 1997) completed a series of studies on strategies to
enhance adaptation for women with breast cancer. In the first study, Samarel and Fawcett
(1992) initiallv proposed a framework lor research that involved modifying traditional support
groups for women with breast cancer. Drawing on successful models from childbirth and
diabetes education, Samarel and Fawcett t 1992) added coaching by a significant other to
breast cancer support groups. Considering rhe RAM, investigators proposed that level of
distre>s from diagnosis and treatment of breust cancer (physiological mode), rhe level ot
emotional distress (selt-c -ncepi model, functional status (role tunction). and relationships
with others uiHerdepcnJencv nun l. i \v<>ri< rouerher to influence adaptation. Investigators
targeted the intervention t bre.m . at.ei 't:pport groups pa local stimulus) as a mechanism
SiSSiK!
288
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 10
chronic illness. This evaluation pennitted nZ f
r
techntques for adaptation to
Samarel, Fawcett, and Tulman (1993)
'catlon° strategies for some support sessions.
mine the feasibility of a major study about the
V c°nducted a P'lot study to deterThis study compared three treatments- particinaf
°f C°achlng Kroups on adaptation,
■ng interventton, participation in ,' P
SUPP°rt grOUP with
in a support group. Although significant diff/™^.7K’Ut ct^chlnS’ and no participation
study methods, instrumentation and inre renCeb twe^n
groups were not found, the
jor study.
°n’ and ,nterve™°" ^re found to be appropriate for a ma-
••
•1;T - .
Or.... -;!-
.
””
F.X S”
suited in better relationships wit h -i<
f
SL,PPort groups (CSGs) with coaching re-
with breast cancer along with contextual stimuli
variables would influence ad mt mon Tl
ence of rhe support grot^^^
grOUP and edl,Ganon ^r women
deiWraphics and cancer treatment
Most women perceived rhe support >r
I * / 100 proV1:>ion ^or breast cancer patients,
indicated posit.ve atritudmal
intCrVentions as efifectrve. Most
tinning, self-concept, role funcrioninv ',nd ^P°rte adaPt,ve changes in physical func-
Tf>e Samarel’ Fawcett, and
—dga-rs percept,im of
ra &
Tulman (1997) study focused on quanmative finTT
what was important HLZTtl^ZoTTTT frGm
W"
rives, thus broadening perspective on this r t
Tk *
rc e^ted the -omen’s perspecstimuli influence adaptation
' ' P1C’
C StUdy reaff,rmed
idea that focal
. cl.
■;<<-
....
tienrs tended to have lower fun ri
I - . ' - / "omcn found d™r chemotherapy pachemotherapy. Women with betted intern ^tatL,>e:s L
PaUents who did not receive
tional status at 1 and 7 months after li w
^i <K1Ons np's ^ad higher levels of funcwere needed to investwate link wc.s b 't?w)SIS| I P'
lntJ,Cared dlar design changes
measure situational derather than
Ivmpho......................
r—vork for ttemsXrcl^MXk ^^17 7’nC^USed
conceptual
Techier. Schwager........1 Uehm^’ ^/"1"lngha- Penney-
program on the physic,ihnd i"vchos(.C1 J H . ■
r
tcLs (>f ■' ’Hirsing rehabilitation
breast cancer. The RAM led*inve<ti<■ idaptarion of women receiving chemotherapy for
gram that includes i walkim- \ -r
'ICClirare,y surmi^' that a rehabilitation pro« -i.kinc kxooe program and a support group would facilitate phvsi-
Modeling Nursing From an Adaptation Perspective
289
ological and psychosocial adaptation. In a subsequent study, Mock, Dow, Meares Grimm
Dienemann, Haisfield-Wolfe, Quitasol, Mitchell, Chakravarthy, and Gage (1997) found
similar positive effects of exercise on physical functioning and symptom intensity for breast
cancer patients receiving radiation therapy. Both studies clearly linked their variables to the
RAM and directly linked study variables and empirical indicators. Additionally, both stud
ies supported intervention that positively influenced physiological and psychosocial adap
tation. The interaction ot the physiological and psychological modes supports the RAM’s
concept of an integrated biopsychosocial person.
Young-McCaughan (1996) explored sexual functioning in breast cancer patients re
ceiving adjuvant therapy. The RAM was used to examine long-term effects of cancer treat
ment and subsequent attempts for adaptation. Chemotherapy was found to generate
menopausal symptoms and sexual dysfunction, but endocrine therapy was not found to
produce greater symptoms. Their healthcare providers asked fewer than 20% of women
about sexual tssues. This study provided a description of adaptation for women undergo,ng
treatment tor breast cancer. Although this study was framed using the RAM, research findings were not discussed in light of the model.
Finding of studies using the RAM in promoting adaptation for women with breast can
cer provide mixed support. In the studies by Fawcett, Tulman, and others, social support
was not found to significantly influence adaptation in breast cancer patients. However, in
studies by Mock, Burke, Sheehan, Creaton, Winningham, McKenney-Tedder, Schwager,
and Liebman (1994) and Mock, Dow, Meares, Grimm, Dienemann, Haisfield-Wolfe,
Quitasol Mitchell, Chakravarthy. and Gage (1997), a physiological (walking) and psy
chosocial support program (support group) significantly impacted adaptation. Successful in
terventions promoting adaptation, such as those found by Mock and colleagues (1994,
199/), raise further research questions, including the optimum timing and intensity for
walking, what factors facilitate adherence to walking programs, and whether similar pro
grams would work for patients with other types of cancer.
Chronic Illness. Pollock (1993) developed a program of research examining adaptation
to chronic illness. In a scries of five studies, three focused on adaptation to specific chronic
illnesses, and two were comparative studies of patients with chronic health problems. The
adaptation to chronic illness model, which used the concept of focal, contextual, and
residua stimuli derived from the RAM, theoretically framed the studies. This model
clarified concepts and specified relationships for chronic illness (Pollock, 1993).
Initially. Pollock (I9S6) studied physiological and psychological responses to chronic
illness in adults who had been diagnosed with diabetes mellitus, hypertension, or rheuma
toid arthritis in rhe previou> vear. She found that the greatest relationship in physiologi
cal and psychological adaptation wa> associated with the characteristic of hardinessin
adults with diabetes. In her I"'
I9S9 study, Pollock subsequently found that adult diaberio
who believed thev could influence
.vC events, who were committed to health-related know Iedj’e, who viewed health chane<jes as challenges, and who appraised their illnesses as poremtallv beneficial iir 1harmfu! idapted better. Perception of illness and coping strategies
were important. This >-cond >uidv provided evidence fora framework of adaptation tor
paticnr- with di ibeic-.
In the third 1 ‘I rhe '•rud\' seri'iS Pollock. ('hristian. and Sands (1990) compared the p<\
1 holocicil and phes,!. >1. .ea.fu idaptarion ot adults
-^ith rhrcc types of chronic illnc^c-
290
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 10 Modeling Nursing From an Adaptation Perspective
rheumaco.d arthr.t.s, hypertension, and multiple sclerosis. Psychological adaptation was
independent of the type of chronic illness. However, differences in physiological adaptation
were exhibited. Hardiness promoted both physiological and psychological adaptation
li!'
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Uliinix'l
e TooTn ln8 SmdleS
unPllblished but
considered in Pollock’s research
program (1993). Pollocks studies occurred over a 7-year period and included 597 adults
with chronic illnesses. From this composite perspective Pollock concluded that hardiness
the ability to tolerate stress, and participation in health promotion activities contributed
posmvely to phys.ologica and psychological adaptation. Although specific diagnoses such
as multiple sc eros.s and rheumatoid arthritis might limit physiological adaptation, persons
with vanous diagnoses of chrome illness experienced most psychosocial adaptation when
they were able to tolerate stress. Perception of disability was an important mediating
fac or in psychosocial adaptation. Based on the findings from these collective studies
Pollock concluded that the middle-range model for adaptation to chronic illness, which
was partially derived from the RAM, was supported. Interventions for chronic illness
should focus on contextual stimuli, which can mediate changes.
1 he RAM has been used is a framework lor srudymg adaptation lo other chronic tl|nesses. Air exploratory study be Fawcett. Sidney Riley-Lawless, and Hanson (1996) ex
amined the impact of alternative therapies on rhe adaptation of 16 patients with multiple
sJerose.. Respondent, reported significant improvement m symptom seventv lollowmg
. t‘-rname theiapies. 7his preliminary study supported rhe RAM proposition that focal
stimuli (alternat.ve therapies) influence adaptation responses. Additionally, rhe stro.m reanonsh.p between symptom severity (physiological mode response) and functional smtus
(role function response mode) reflects the RAM nor,on of the interrelatedness of the
respouse modes.
Several studies using the RAM as a theoretical guide spec.fically considered cancer
and cancer rheraptes. Met ,,11 and Paul (1993) found that failing physical health devreawd a sense of hope in patients with or without c.mcer. In a pair of related studies,
Jack, on, Strauman, Frederickson, and Strauman (1991) and Frederickson, Jackson
Strauman, and Strauman (1991) studied rhe adaptation of patients receiving aggressive
cancer treatment programs for cancers beyond cure with conventional therapies. Their
goal was to focus on whohsne needs and aspects of care. In a study focusing on factors
i™P<lrrannao"^nne;1tl
Strauman' Frederickson, and
trauman (19?l) found that physiological toxicities increased over treatment but that al
terations in therapy could mediate malmse and hypotension. As therapy continued ill
ness severtrv increased. It then decreased after therapy. I’m ,enr.s experienced di.mnijhed
Ttahty of life durmg treatment phases. Greater quantirie, of nursing care were required
lor parienrs in their third treatment.
Hederickson, l.icUm. Sr, ttmgm. .nd Srraum.m (R>9)) focused specifically
tesU(1g
■ ,X "
'-xannning dm ref....... tslup between pmvitosoctal adaptation and phvsiolo.,■cal symptoms and relare. do,m,,|llyl.,rmmor. found that perceived physiological ..dap■™°nrarl,e"h?n^^ hh™'-lared n.psvclm^ial adaptation, fhes^
„;i7t' I’’'1’ | “■
'^■'"■.'''’■’''G'Gmnterpree.oon. t rami.,no,,, and almrm ion
■ ■
4tl'w,k [ !1-! 'l —1
-Cd.med ,nd tr mdmed the cognator (copmg system) dependmgon p.tfient
.yen .g,
H. m„e, tl, „ .nd.e,duals form an le-mted h. .p~vJb t mI u hde u t> .il.v, vUlljlrmcJ.
291
In a small study of three types of dialysis patients, Courts and Boyette (1998) found the
greatest level of psychosocial adjustment in patients receiving home hemodialysis. These
patients experienced less anxiety and depression and perceived fewer stressors than their
counterparts. Flexibility was perceived to be a key in adaptation and is consistent with the
wholistic approach proposed by the RAM.
A summary of finding on adaptation to chronic illness affirms the RAM concept of
the person as a biopsychosocial integrated whole (Jackson, Strauman, Frederickson, &
Strauman, 1991; Frederickson, Jackson, Strauman, & Strauman, 1991; Courts & Boyette,
1998). The series of studies by Pollock and others (1986, 1990, 1993) provided a basis for
the development of a middle-range model specifically explaining adaptation to chronic
illness and suggested potential interventions to facilitate adaptation. Focal stimuli were
found to influence adaptation responses (Fawcett, Sidney, Riley-Lawless, &. Hanson, 1996).
In general, these studies support the use of the RAM to explain adaptation to chronic ill
ness and to facilitate adaptive interventions. Research opportunities exist for studying
adaptation in other chronic conditions and the possible influence of comorbid conditions.
Numerous studies could be directed toward nursing interventions that facilitate adapta
tion from a v\holistic, biopsychosocial persective.
Preterm Infant Adaptation. Several researchers have investigated rhe influence of focal
and contextual stimuli on physiological adaptation of preterm infants. In the follo.vmg
examples, the RAM guided the conceptualization of research variables. The findings from
these studies supported RAM concepts of physiological adaptation.
Shogan and Schumann (199)1 examined the effects of environmental lighting on the
oxygen saturation of preterm infants in neonatal intensive care (NICU). Focal stimuli
were related ro rhe NICU environment, whereas contextual stimuli were related to infant
prematurity. Physiological adaptation as evidenced by oxygen saturation was rhe variable
of -.onccrn. Although lowering lights did not improve infants’ oxygen saturation, incrcasc<l
lights significantly decreased oxygen saturation by 4% to 7% at 1 and 5 minutes. Rapidly
increasing lighting serves as an environmental stressor that healthcare providers can po
tentially eliminate. This study supports the RAM conception of focal stressor and their
impact on physiological adaptation.
Another local stimulus that is a stressor for preterm infants is apnea. When monitor
alarms indicate apnea, me traditional intervention is to provide tactile leg stimulation
until the episode ends. Unfortunately, this intervention wakes the infants into alertness.
Garcia and \\ hite-Traut ( 1993) anpared use of a taste/smell intervention to traditional
tactile methods and found that the apnea episode ended sooner and did not change sleep
ing state This study supported rhe facilitation of phvsiedogicai adaptation through focal
stimuli changes
Kitchin and Hutchinson (1996) explored rhe local stimulus of touch during resuscita
tion of pietcrm infants. Investigators sought to assess behaviors and stimuli that might
influence adaptation. Two types . f touch—human touch and mechanical touch were
discovered in tin 10 video> of preterm infant resusi nation. Human task touch occurred to
ensure the int.mi < surviv il and w is performed alone , >r in combination with equipment.
Example' of riii' vpe ot touch ineiuJed rv>rraining < >r repo'O ioning during a piocc.Inn or
during ca-diopmmonarv re<uscii iron Protective hum in touch shielded the mt mt from
injury mid w.i' m,>oi!-i. gv.nrle mJ cam g Ats icntal. inadvertent touching, such a>
msasssaK;
292
CON NECTIONS
Nursing Research, Theory, and Practice
CHAPTER 10
fi:
comprised equipment nokinn o d
admin'stratlon- Accidental mechanical touch
di,saszte,tsar '7”w“
during resuscitation. The failure to tie rhe 1e •
study, but investigators wet" able to t
resuscitation be reviewed to mtxX'XmTs8
•
nce adaPJlve responses of infants
tO
RAM Weakened ^e
“"b"18
'nfan'
stimuli. Tire stimuli includlTnvtonmenml hghringfa ^T^hinfIuenCcd by focal
smell, and tactile stimul .rion 4
, g (Sho8an
Schumann, 1993); taste
touching during resuscitation (Kitchin ^HuThiX? 1996) A&
199d)’ and
the adverse physiological adaptation that occurred in light if 1^ I t T of'^^udies was
rected toward the impact of neonatalfnr, I
I
j
sh focal
Researchdi-
needs and adaptation of children aged from I r I 7
M
aged
the following srud.es,
8 from 1 “ '7 yea'S °f
pediatTimeZZmlr
with sleeping and waki n a ml Zm mlZ''
patterns before illness were found
admitted to rhe PlZTTiZ
tupted rapid eye moZXX
evaluation of
h has proven useful in
’ T.adm-d
The balance of rest and a" Zrv ’"iser
,.1,
b
enV“"tal stimuli associated
. 7.™^™ with those before rhe illness,
T "'I
X
111 < t'S',ary to physiological integrity. Sleep
"T'
hea'thy chi'dra1- ChiIdten
that dis-
s
jimiH’i
was measured by changes in heart ram and" re'"pL'ament and tear- adaption co pain
quality of pain Children with I
■'
tesponses about the location, intensity, and
higher heart races and .X 1 v ' mT"
T eXpe™nCed ““d
-d had
havioral and heart n.X '
?"'Y 3 Sma" per“ntage of variation ofbe-
threshold, distmerihilitv. and niedK-d tears' Th ""f 7 iT Vaf'aW^
tor rhe RAM. bur it supported rhe need f,',- LF’F '
‘’n ''
diarric pain.
293
Mechanical touch was related to tasfa
-XXoSal'i
!
Modeling Nursing From an Adaptation Perspective
'
age’ temperament,
1"n"cJ support
°r a^ressivc Assessment and management of pe-
Russcll, Reinbold, and Maltby (1996) inv > rimr I i
cystic fibrosis transfernm, r > am .1 I
i n ' eX^rienc<?
because ofirslocus FZc’mnm m, i
T" T
adolescents with
«>'ide d- study
munities. Semi structured and oner"-n'lU'i,'K''' "l
groups, and com- the RAM's four inoj
T n
I qt'eStl°nS
i”“rV,C"Pa-d
parents underwem role rouFum' A IFT;1™
adoiescents and
coming more independent fro ->
Adolescents completed developmental tasks ofbetic fibrosn fachmred A 1n',"’'"|'TC,|'' “ pli"’ni"' ,l’t the future. Managing their evs-
manr consulted w.rhX ri.XTFFT
'*en pl'VS1'
nt. alone. Thev were hesmun ro rehnquidt control
Adaptation to chronic illness was a less predominant theme unless the patient experienced
a high number of acute episodes with the cystic fibrosis. Transfer to adult programs for
treatment was congruent with developmental transitions and could be facilitated throu<’h
planning by healthcare providers. Although the RAM guided this study, investigators did
not discuss their findings in light of the model. However, their findings indicated that
adaptation to a new care system occurred in both the patient and the parents.
These studies on adaptation of children and adolescents all supported rhe RAM.
Corset’s study (1996) linked environmental stimuli to adaptive behaviors of changina
sleep patterns. Bournaki’s findings (1997) on pain reaction provided limited support to?
the RAM and suggested that other factors could also affect adaptation to painful stimuli.
Russe 1, Reinhold, and Maltby’s descriptive study (1996) discovered that both parents
ind adolescent adapted to the cystic fibrosis patients’ transfer to adult care. Each of these
and
studies is descriptive, and none specifically intended to test theory. Future research can
expand to other areas, such as adolescent adaptatjpn, intervention studies, and theory
testing.
Family Adaptation. Adaprauon of families has been a concern of several studies using
the RAi as a theoretical guide. Studies focus on needs or stimuli to promote adaptation.
Fisher (1994) identified needs of parents in a pediatric intensive care unit. Knowledge
needs were particularly important for parents. These included knowing the prognosis,
knowing why things were done, knowing that child was being treated for pain, and
knowing that child might still be able to hear even if not awake. Feeling that there wa<
hope was a critically important need.
Komelasky’s intervention study (1990) of parental adaptation evaluated the impact of
home visits on retention ol cardiopulmonary resuscitation (CPR) knowledge in parents
who monitored their infants’ apnea. Home visits manipulated rhe focal stimulus of parental
need to learn CPR and monitor use. The visits were also considered contextual and resid
ual because they assisted parents in coping with the monitoring process. Home visits were
not found to significantly reduce anxiety or to promote retention of CPR knowledge One
potentially problematic area of this study is that differences in the gain scores between the
first and second testing were assessed. Use of gain scores to assess differences is less reliable
because of the potential correlation between measurement error ar each testing (Crocker
Algina. 19<S6). Therefore it is less likely that differences between groups would be dis
covered even if they existed.
In another family intervention study, Bokinskie (1992) examined rhe effects of a fam
ily conference on anxiety levels . >( family members of patients in neurointensive care units,
bamilv conference- reduced fragmentation of information and significantly reduced the
anxiety level ol family member-. This intervention facilitated an adaptive response to
'tressor-. thu.- supporting rhe RAM.
Gaghard! i i1 ) Jc-mihed the experiences of family members having a child with
Duchennejnuscular dystrophy. As a parr of analysis. Gagliardi matched the major staccanc rnlaied rheme- ro R. >\ - model. Recognition of rhemes of disillusionment and societal
confirmation of ihe impo-Tdin .f normalcy were related to rhe physiological and seif
^'ni H”' ‘^dc-. 7 heme- . .f fumib dynamics and a smaller world, exemplified H the fam“ : lu 11 ,m ’
i- rhe muscubar dystrophy progressed, were related r
'
1 *’c II'1 d lL'-' u idl d wmes of letting go. hanging on. or ixdie-cine m . hai.ge
294
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 10
Xi; X”"
sSfW’Ssaw
....... •■•xz: 'lit
tions. bus the lack of significant findings may be attributable to these factors rather than
to a weakness in the RAM.
In summary, the adapr.ve modes of rhe RAM usefully guided systematic assessments of
ant illness, providing for infant material needs, future threats ?o the infant
rowledge about child rearing, lack of parenting assistance, and threatened job loss Nurs
o n tac. tare Mexman-American parental adaption by addressmg „. °
nSSi "dT
C RAM|arP,iCah',ity tO '-k-'‘tural groups.
Ntska (1999) followed this study with another that assessed the similarity of nursin., f
terventions to ex.sting ways Mexican-American couples enhanced family processes such
■ji
r
.....
&
< E
295
category which indicates a dependence on physical assessments performed in the preoper
ative holding area and inadequate time for nursing assessments.
Gaberson (1991, 1995) conducted a pilot study and a major study assessing the influence
of humorous distraction on preoperative anxiety. The RAM suggested that anxiety was
common before surgery. Although the pilot did not demonstrate significant differences in
anxiety for subjects receiving humorous distraction, a moderate effect was calculated. Un
fortunately humor and music tapes were not found to significantly reduce anxiety, although
the control group did exhibit a higher level of anxiety.
Meeker (1994) proposed that a structured preoperative educational intervention would
influence postoperative patient outcomes of atelectasis and patient satisfaction. Meeker
proposed that preoperative education identified and controlled stimuli that affect individ
ual adaptation in the four adaptive modes suggested by the RAM. Education was conceived
as helping individuals cope and manage individual adjustment. Although participants re
ported that the classes decreased anxiety and that they felt well prepared for surgery no dif
ferences m incidence of atelecrasrs or m satisfaction with education were reported. How
ever, instruments used to measure sansfaction may not have been sufficiently sensitive to
differentiate degrees of satisfaction. Moreover, the group that received patient education
classes already exhibited a higher risk tor developing postoperative respiratory complica
if
t!:
Modeling Nursing From an Adaptation Perspective
ness of srunuh and JX
Jenim-r
mu,ricuIr*-iral applications of the RAM. Bokinskie (1992)
I
jr;
■;r'
■nd
“J .......... ... . ............
Adaptation of Surgical Patients. The RAM has guided assessment and interventions
Nurses wh
I
F
‘ls>CSi’incnt t(H,i co lhose "s'ng standard assessment techniques
........... .. .............
"npormnee A lew.l
" documentation category. This indicated rhe
s-ment activMs . M, ^d I J’s Zn W T 1
’'''''J(^ht
'4
k
time n kited to rhe biological/physical
penoperat.ve patients (Leute & McKende, 1987; Takahashi & Bever, 1989) These stud
■es support the wholism suggested by the RAM. Other nursing practice areas certainly
could benefit by systematic application of the RAM to patient assessment. The interventk’n
1 ‘991’ l995) and Mecker (l994) did
■>* '«H in supportmg rhe KAM. These studies failed to demonstrate that the RAM guided interventions in
fluenced patient outcomes. However, both studies had identifiable difficulties with
instrumentation.
Theory Testing Two studies specifically conducted to test the RAM are those of
Hamner (1996) and Levesque. Ricard, Ducharme, Duquette, and Bonin (1998). Usin« a
qX'"1’" tr°m
RAM' Ha"lner (1"6) Pr°D«ed a model of a patient's length ofsmy
(LOS) m mtenstve care. Hamner proposed that freedom of communication patterns would
positts eh influence the adequacy of seeking and receiving affection. The model suggested
that as seventy of ,llness increased, patient control over visitation would decre^e and
anx,erv would mcrease. This mcreased LOS. Higher levels of hardiness increased perceived
connol over vismmon, generating a decreased length of stay. Although severity ot illness
anxiety, hardmess, and patient-controlled nutation were shown to influence LOS the
remaining elements of the model did nor exhibit the proposed effects.
Levc-que Rrcard Dmfmme Duquette, and Bonin (1998) proposed a model derived
from the RAM and then tested tt with an apostenori analysis of five completed studies. The
mode proposed rhar three contextual stimuli (gentler, conflicts, and available social support)
'"'U 1 "1,!uenvc rl'e l"c.il -nmulus of perceived -tress. This focal stimulus would then mg;'c',vc ,lr r-.i-S'ive c.rpmc mechanisms and ulrimarelv would facilitate adaptation or nonin i k <- h >: tc ei i nit h.k [ mJ mgs m J ic.n c J supptirt for unlv < me proposition of
Hie RAM
!!1 11 ' ‘ 'l '' ' ii'fluciKc Men! simuili and result m tire promotion or
296
1
. Ir:
IIIIIIikIi
J'-
CONNECTIONS
Nursing Research, Theory, and Practice
hindrance of adaptation. The remaining two propositions were not found to be true. Passive
coping strategies directly triggered active strategies.
Ducharme, Ricard, Duquette, Levesque, and Lachance (1998) examined this derived
model in a follow-up longitudinal study. Investigators initially proposed that the contextual
stimuli of conflicts would increase the focal stimulus of perceived stress, whereas social
support would reduce stress. The focal stimulus of stress would stimulate coping strategies,
which could promote positive or negative adaptations. The exploratory longitudinal analy
sis found that people using active coping strategics during the second time measure may
have initially used passive or avoidance strategies. If people experienced high levels of dis
tress ar rhe initial measure, they tended to perceive conflict in their support relationships
and were more likely to use passive and avoidance coping strategies at the second mea
sure. The reverse was true for caregivers experiencing less distress on the initial measure.
This study’s findings indicated that the derived model was stable over rime but lacked
consistency in patterns of relationships between the studies. Few significant proposed re
lationships were found. Investigators attribute the lack of significant linkages and differ
ences between studies to the nature of stress and the difference in stress exposure for par
ticipants in each of the four studies. In other words, stressors faced by older adult spouses
are different from those of family caregivers of patients with dementia or from those of pro
fessional caregivers. Differences for the timing of the second measure also existed. The
rime ranged from 6 to 48 months. The RAM was supported in that the focal stimulus of
perceived stress triggered coping strategies. Additionally, the study’s longitudinal approach
enabled exploration of rhe circular nature of the RAM, in which variables mutually affect
one another over rime. Positive links between passive avoidance strategies, conflicts, and
psychological distress were established. This supports the RAM concept that cognator
mechanisms and contextual stimuli can influence adaptation.
Nuamah, Cooley, Fawcett, and McCorkle (1999) proposed a theory derived from the
RAM on health-related quality of life in cancer patients. In this model, health-related
quality of life was represented by the four response modes Roy identified: physiological,
self-concept, interdependence, and role function. A strength of this study is the clarity
with which the middle-range concepts were derived from the RAM and the identification
of rhe empirical indicators to measure middle-range concepts. Three propositions were
tested: (1) "the four response modes are interrelated” (p. 231), (2) environmental stimuli
influence the biopsychosocial response modes, and (3) biopsychosocial responses following
diagnosis predict biopsychosocial responses 3 months later. Findings failed to indicate rhe
interrelatedness of rhe four response modes, hut rhe nature of measurement for these modes
may have limited adequate exploration. However, environmental stimuli of receiving ad
juvant cancer treatment and severity of disease did influence biopsychosocial responses.
Investigator suggested that nurses assess the needs and demands of cancer patients re
ceiving adjuvant therapies and intervene to manage symptoms. They further suggest that
research using rhe RAM should assess environmental stimuli that could be amenable to
nursing intervention, such as nutrition and smoking cessation.
Findings from these studies (Hamner, 1996; Levesque, Ricard. Ducharme, Duquette,
Bonin.
Ducharme. Ricard. Duquette, Levesque,
Lachance. 1998; Nuamah,
t .o<’lv\. k Hvccn, N McCorkle, 1999) not only provide some support tor rhe RAM but also
introduce '■ -me intriguing p< vssibiliries about rhe direct and indirect connections between
CHAPTER 10
Modeling Nursing From an Adaptation Perspective
297
focal and contextual stimuli and adaptive responses. A strength of the studies by Levesque
Ricard, Ducharme, Duquette, and Bonin (1998) and Ducharme, Ricard, Duquette.’
Levesque, and Lachance (1998) is the pooling of data from several studies to provide more
cohesive findings. These studies pave the way for further theory-testing studies that could
validate theories or offer new insight into model reconceptualization. Further research is
needed to examine indicators of adaptation as well as the influence of various stimuli on
adaptation.
Research Summary. Research using the RAM has primarily used the framework to
guide variable selection and methods of study, but studies specifically testing the modelsuch as those described in the preceding section—have been completed. Investigators find
the model easily applicable to their research, as is demonstrated by the large number of
published studies that use the RAM. The RAM pften is used in conjunction with other
models—usually nonnursing models—as a basis for proposed research. Although several
instruments have been developed to measure adaptation, they are only infrequently used by
investigators other than their creators. Despite some programs of established research only
a few studies specifically identify model resting as a research .mm Findings from these
studies have offered mixed support for the RAM. To continue model development,
additional middle-range theory development must be derived from the theoretical system
of the RAM, and further studies must specifically test model propositions. Support for
model propositions has been mixed; focal and contextual stimuli have not consistently
influenced functional roles. These findings indicate a need for further research and
probably for further model refinement.
APPLICATION: DESIGNING NURSING PRACTICE
PROGRAMS WITHIN THE THEORETICAL SYSTEM OF THE ROY
ADAPTATION MODEL
Practicing nursing from the perspective of the RAM requires that nurses’ goals are pro
moting and facilitating adaptation and that nurses agree with Roy’s definition of adapta
tion. This definition addresses the relationship between the person and his or her envi
ronment. Underlying this revised definition of adaptation is the change in systems theory,
including the ability of all matter and energy to self-organize and to progress to higher lev
els of complex organization. This thinking replaces the previously held notion that the
system maintains itself. Roy and Andrews (1991) propose that nursing knowledge devel
opment occurs m one of three ways: nursing conceptual model development, theory con
struction and research to test and develop new theories. The conceptual model identifies
the variables with which nursing is concerned and suggests the wavs in which these vari
ables are hnked together and influence each other. The processes of theory construction,
testing through research, and development of new theories cnnche> the knowledge base
about the substant.ve structure of rhe concepts of the model and. in rum. enriches the
content associated w.th the processes of nursing. Collaboration between researcher^ and
practitioners facilitates these processes.
The Variables of Concern for Practice
Individuals. The variables of concern for practice include the Per<on with innate and
quired coping mechanism>. response behavior> that shmv coping mechamsm activity.
298
CONNECTIONS
Nursing Research, Theory, and Practice
and an adaptation level at which a person responds positively. In addition, the en
vironmental variables of focal, contextual, and residual stimuli remain important. Two
categories of coping mechanisms, the cognator subsystem and the regulator subsystem,
control the human system. The regulator subsystem responds automatically through neural,
chemical, and endocrine function. The cognator subsystem responds through perceptual/
information processing, learning, judgment, and emotion. The adaptative modes are
physiological, self-concept, role function, and interdependence (Roy &. Andrews, 1991).
Families. It has been suggested that the family, as an adaptive system, may be the
recipient of nursing care (Roy & Roberts, 1981; Roy, 1983). Roy and Roberts (1981)
suggest that the family maintains itself in regard to the physiological, self-concept, role
function, and interdependence modes. If it is viewed as an adaptive system, it is viewed as
a unit. However, in cases ip which rhe RAM has been used in relation to families, the
focus tends to be on the individual persons making up the unit rather than on rhe unit as
a whole. Schultz (1987) states that “if families, groups, organizations and communities as
interactional units with a plurality of persons as components are conceptually appropriate
extensions of rhe concepts of patient and person in nursing, then all other domain concepts
including all steps in rhe nursing process need to be specified to reflect these extended
definitions” (p. 79). Additional concept formalization and development of rhe constructs’
substructure remains crucial to extending the concepts beyond the single person to the
family, both in theory and in practice. The need for additional development also applies to
using the RAM in communities and other groups.
Describing a Population for Nursing Purposes
It should be possible to use concepts associated with the RAM to describe a population
for nursing purposes. For example, rhe adaptive modes could be used to describe subsets of
a population ol interest to nursing. This has yet to be done.
Expected Outcomes of Nursing
The expected outcomes of nursing center on promotion of adaptation, and they include in
creasing a person’s adaptive responses and decreasing the ineffective responses (Roy, 1984).
In recent writings Roy (1997) describes nursing as “acceptance, protection, and fostering
of person and environment integral relationships” (p. 47). From this description, one could
infer that an expected outcome of nursing would be an integrated person-environment re
lationship. This relationship needs to be defined further to be useful to practitioners.
Process Models
I he processes of nursing within rhe RAM reflect problem solving—gathering data, iden
tifying capacities and needs, establishing goal-', implementing ipproaches for care, and
evaluating outcomes of the care (Andrews Ck Roy. 1986; Roy &. Andrews. 1991). The spe
cific focus is on assessing behavior, collecting data, and interpreting it in relation to factors
that affect adaptation, goal setting, and intervention to promote adaptive abilities. Roy
has rccentlx added that the nurse is ako concerned with person-environment integration
(Rox; 1991 ) E'chavior is all rhe resp,mses of the human adaptive system, including capac
ities, assets, knowledge, skilfs. ihilitic-'. and >.• •mummcnt.>. The nurse evaluates the effecrixencs-of behavior in terms,.! id.ipr in.m • t nonadaprarion The patient’s perception is
CHAPTER 10 Modeling Nursing From an Adaptation Perspective
299
important in deciding whether a behavior is adaptive, nonadaptive, or ineffective. A ty
pology of indicators of positive adaptation for some of the behaviors has been developed
along with a typology of commonly recurring adaptation problems (Roy
Andrews, 1991).
Continuing development of the model should address criteria for differentiating adaptive
and nonadaptive behavior and for developing a categorization or taxonomy of such
behavior.
The nurse first collects data in relation to the lour adaptive modes: physiologicalphysical, self-concept-group identity, role function, and interdependence. Roy and her
colleagues have identified specific data to be gathered for each mode (Roy Ck Andrews,
1991, Cho, 1998).
The second step in the nursing process involves identifying internal and external stim
uli that influence behaviors. In consultation with persons involved in the situation and
through perceptive observation, measurement, and interviewing, the nurse classifies stim
uli as internal or external. Stimuli are classified as one of rhe following:
• Focal: Most immediate; for example, a pathological condition
• Contextual: All stimuli that arc evident in a situation bur that are not focal stimuli
• Residual: Stimuli that indctermin.uelv affect behavior.
When a residual stimulus demonstrably influences behavior, it is reclassified as focal or
contextual. Common stimuli affecting adaptation have been identified through research
framed from rhe perspective of the RAM and through articulation of the RAM with other
theoretical formulations (Sato, 19S4). These include such influences as culture, family,
and developmental stage.
The third step in the nursing process n inicrprcting rhe data and formulating descriptive or
diagnostic statements. These statements include identified behaviors and significant stimuli
and thus specifically direct nursing intervention. Roy and Andrews (1999) have proposed a
classification system that allows tor linking < 4 commonly recurring adaptation problems with
the diagnostic classification svstem of die \'o:ih American Nursing Diagnosis Association.
The fourth step of the nursing process involves establishing goals or behavioral out
comes of nursing care. In general, nursing intervention seeks to maintain and enhance
adaptive behavior and/or to change ineffective behavior. Goals refer to specific objectives
to be achieved and haw three parts: the behavior to be observed, rhe means for detecting
the behavior change, and rhe time frame. Patients should be involved in establishing the
goals. It is important to note that the RAM defines behavior very broadly as “actions and
reactions under specified circumstances" (Andrews N. Roy. 1986, p. 32). Behavior may be
external, as when a person laughs or cries, or it may be internal, such as a phystoL'gical re
sponse (c.g. elevated blood pressure). Therefore a goal could be that within 1 week a per
son will have mastered infecting insulin and will return to a blood pressure of 1 20780 mm
Hg within 15 liiinutcs of the injecuon.
The fifth step is intervention r. pi\ 'mote adaptation by changing the stimuli or strength
ening the adaptive procu'Sc- Stimuli max be m inaged by altering, increasing, decreasing,
removing. >r maintaining them.
mm' fir<r select rhe stimuli to be changed. In con
sultation \\ ill i rht pcrs< ms inv* dved marges I i.-'t mi mull affect ing behavior, idenritv the relw. ant coping pro(.e»e>. u d •. •n-idui u liutiwi rliu eon>.\j:ience> of changing each stimulus
v.. ild b; desirable Flic m -i •ii'pr ■' : ■ r .•
• cni ion i*'■cleCicd. md rhe mean--of achiev
ing it are dett.-rmmvd an.; carleii cm •.!
300
CONNECTIONS
Nursing Research, Theory, and Practice
The final step m the nursing process is evaluating the effectiveness of the iIllcI vtiuion
intervention
and determining whether the desired goal(s), have been achieved. This is accomplished
through observation, measurement, and interview. If goals have not been met, nurses assess
reasons for the failure.
Although the nursing process has been specified as a problem-solving process and al
though the end result of such a process is usually visualized as a definition of the problem
with proposed solutions, the picture becomes very different when the pieces of the puzzle
are put together in different ways. The process definitely is not linear, and more than one
course of action might be appropriate. Roy (1997) has suggested that nurses look at human
experience from a variety of perspectives as the experience changes with variations in stim
uli and responses, much like the changing patterns of a kaleidoscope (p. 41).
h
Practice Models
Pollock, Frederickson, Carson, Massey, and Roy (1994) analyzed research they conducted
as individual authors using the RAM. From a synthesis of their findings they developed
several middle-range theories that could become practice models after further testing and
c evelopment. Their analysis has identified support for moving beyond disease-specific nurs
I.
a-j; •■li:.;;
C.
ipfUli
'•ci
""•I
■*
ri
ing interventions to considering psychosocial factors in promoting adaptation.
A second group of researchers, who did not use the RAM to guide their original inves
tigations, subsequently analyzed five longitudinal studies within the perspective of the conceptua elements of the RAM (Levesque, Ricard, Ducharme, Duquette, & Bonin, 1998)
From this analysis they constructed a theoretical model and rested it through structural
equation analyses. Their findings indicate the importance of exploring patients’ percep
tion of environmental stimuli, because factors such as social support may hinder rather
t lan facilitate adaptation. In addition, passive/avoidance coping strategics should be ex
amined and assessed regularly. The work of this group also precedes describing practice
models as they pursue the development and evaluation of nursing interventions that focus
on conflicts, perceived stress, and coping strategies in a variety of clinical populations.
Implications for Administration
Nursing agencies interested in implementing theory-based practice have found the RAM
useful. Mastcl, Hammond, and Roberts (1982) describe the use of the RAM as a framework
for practice in an orthopedic setting. This is one of rhe earliest published reports of the
process of implementing a nursing conceptual model in an organization. It describes rhe
process of model implementation, and demonstrates the recording system to support such
practice.
Jones, Clarke, Mackay, Porter, and Ward (1991) describe the integration of the
KAM into rhe structuring of nursing practice in a 125-hed specialty hospital. Concepts
derived from the model were incorporated into the philosophy of nursing and the compo
nents of the mission statement relative to nursing practice. The model was used for devel
oping standards related to nursing assessment, care planning, implementation of nursing
care, evaluation of nursing care and professional development, and accountabilitv. Job dewere rcvI>cd to reflect
the perspectix
e...J.,
of the
rellect the nature of
of nursing practice from tht
,
i
model. This included an expecrarion that
...
rhe values and beliefs espoused hv the registered
nurse a> guiding practii wen- o.oMstenr with the RAM. This involved a major reconcep
CHAPTER 10
Modeling Nursing From an Adaptation Perspective
301
tualization of the nurse’s responsibilities from performing a variety of tasks to practicing
nursing within a particular theoretical framework. The criteria for performance as mea
sured by the performance appraisal system were revised to make explicit expectations about
use of the RAM in nursing practice. The quality-monitoring program was analyzed to de
termine consistency with and reflection of the RAM. Unsurprisingly, the major emphasis
in the quality-monitoring program was on the physiological mode, and further develop
ment of monitoring specifications for rhe self-concept, role-function, and interdependence
modes were needed.
Weiss, Hastings, Holly, and Craig (1994) reported on a study designed to examine the
utility of the RAM as a framework for nursing practice within a hospital setting. They
found varying levels of knowledge about the model and integration of the model into prac
tice among the participating nurses. This depended in parr on rhe place of the practitioner
in relation to the clinical ladder system, level of involvement with nursing models, shared
beliefs with other model supporters, and rhe environment in which rhe model implemen
tation occurs. The perceived value of the model varied. Those who found the model use
ful supported its utility tor organizing thoughts about patient care and directing rhe nurs
ing process. They commented on its comprehensiveness and wholistic nature. As in other
writings about model implementation (see Chapters 5 and 7), nurses recognized a unique
body of nursing knowledge and role in patient care.
Roy and Andrews (1999) describe the process of implementing the RAM in a regional
regional
medical center. Using the RAM to frame the implementation process, this group followed
an interesting path, which consisted of the following:
Assessing behavior and stimuli within the environment in relation to the staff and
rhe implementation process.
• Identifying internal system forces and external events that facilitated model imple
mentation and that reinforced rhe need for model based practice.
• Developing outcome statements or goals arising from rhe descriptions of the ineb
fective behaviors and their influencing factors to predict the outcomes of imple
mentation and identified intervention strategies to achieve the goals.
• Conducting education programs for managers to facilitate model implementation.
Incorporating accountability for successful implementation into performance ex
pectations for managers.
• Developing model-based nursing process tools, including an assessment tool and documentation system using strategies similar to those described by Rogers. Jones.
Clarke, Mackay, Potter, and Ward (1991).
Revising job descriptions and performance appraisal tools to reflect the model. In
keeping with using the model as the overall framework for the implementation
process, rhe job descriptions reflected the physiological, self-concept, role function,
and interdependent modes of the RAM.
° Implementing a four-step staff development (clinical ladder) program based on in
creasing expertise in application of the model.
• Instituting . ingoing evaluation of the implementation process and using the results r. >
modify and further develop the ongoing process.
Fhe literature, which includes manv examples of RAM applications, evidences the
modcD meluliie^ i.> pi icritionen (Phillips, Blue. Brubaker, Fine, Kirsch. Papzi.m, Rieoer,
LIBRARY ,
1:
01263
■. •. .. -..i Hrudayalaya
z.cal Sciences
::z ' :On?.l Area
JUZ
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 10
“ gutted
S ££ exSet'XS Xtr11 rC,atiO" tO
model requires further development if nurses are "o d f
ceptance, protection, and fosrenng of
7V'r°nmental integration. The
P^ice roles
Implications for Education
,ii'‘
t:ZLOF THEORY DE^OPMENT
continuum frJm philo^^
S'
f.
"X'i -li:J
■<
r:
.p:i;
Jw>'”l
"'“m along the
tem and of adaptive modes have been develop -1 '
‘b0'’"65 <’f PerSon as ;,daptive svs"■»rh completed since 1970 was svn.hesred
wT *
^oret.cal system. The
- atement of the RAM. The physiological mod ■ f
"
thc “definitive
ulator and cognaror processes, is highly develone I , ‘
'vith i,s emphasis on reo'■■dueTased wholism and purposive parr.c.parion
"
"
'nregri'tcd "ir‘>
new
Calvillo, E.R. Ck Flaskerud, J.H. (1993) Tk.. i
■
Model “guidecrosscult™,
t. pa,int moTd’' N,'r!'"SQ,MnCT/>' <7’nX|n’9SC‘’>pe
1" of
“ ‘Roy
'"y ’s’ Adaptation
/'d!'rtMi,,n Mo<fcl
I
C^. n. (,996).
t R"’ AA,7"CA
'tnSIV‘'l'lrefs5““"iG,mpr1.^^^
ing. 19(1), 17-31.
I o’"±y:T.T”” .. .... -........ . ...... ................. .
I
. .......... *.... ...... .. ............. . ......
adjustment of males
classical and modem
Ducharme, E. Ricard, N„ Duquerrc, A. Leves.ii,.. I <. i
model derived from rhe Ro^-adaptation model. Nm^n^Xn^C) '
teSfin"ofil ’""K'tudinal
Fawcett. ]. Tulman. I... & Mvers. S T. (19VSS) D ■ ■
,
Q'^ierly. 11(4), 149-159.
Journal ol ^ursm^Midwiferx. 33(6) M1 ’hX'
' R‘ ,nvc,',”rv l,f hincrional starus after childbirth
'■xyyTT...................
Fa-cll.
Tolocu,. ,... CS SreJ.lc-,,. H'U^ Rc,„
(Xsarean h.rrh. WAfern Journal of Nursny.
,
’• ' .icmal 1'irili
,',r,n .itrer
-"’vr (< Vsarean
:e>.„e..n .ecrion.
..
Fawcett.l., >idnev. |„ Rilcv-L.iwless k xu
allernarivedwrapi.,, Iullo,„n;,| ,,X ‘
..... .. ......... .. ........ ................... adapni-
'ra,,’r’'
' ’W"’-
Hul.suc Nursms. H(2). IIS-|2<)
'
' :"lvcrs"'' •*H^-huwttivlW,,,
adaptiVe p'stem * conjunction with
ruahmrions. Given the concept oi parrem
,'”P,’r,;,nr d""—*’ Roy's concepI '■oce.sxe.s, one might ask how the nurse intcricrs wh"
parCfeiPant in adaptive
■<nd what nursing looks like.
' ' h:K act,0,ls
appropriate for nurses.
I". J
Fret7k'"'’- k ' GV..n. BIt..’ Bauman.
S,r;,urn;|„ T.
p \ Mraum.m,
...
I H'h
X«<™f|.. Sacnce Qiumerly A4 >. I oS- i 74
Ax J nexus
The RAM significantly contribute I
i
nursing research, and to nursmu nr, ■r’ ■ 'X 'e‘’rV l>' nur5ing, to t'
54(6). 1258.1264.
Gaberson, K. ( 1995). The
apne.c episoJe.
i»>d ■•■e.de sr,n„Jur,n„ „„
|kJulnv
■u,r’-.... .
hT-h
'l',r'-hin. L. CSj Hutchinson. S ij )9o) I’,., i
..... I'l- -psVCI h .social effeers of interleukin-
i
... ; i- 'iocit.iii(1I1.
■
'
Leu-'e. M. a< Mck'en;,.-J (jo,;,. IV.....
REFERENCES
' ' 1"Mhe R. ,y Ad,t; u,
X.-.dk.CTAppleron-
^,4P(n,14M54.
r' -A
dmun.d! -r
Orme. E Duquertc,
model derived from the !<
Xlapuri.ti
31 - 39
Mas^> \| IL Hamm ndH & Rok-rp. M I' 1
'
McGill. |.
>-e ^hildre
Re-
Pau|, j
,,iiat.il Xem ork. /5(7). 45.5.]
uul (JI’R knowledge retenrrnn of p.lr-
y R,
■ ..j,..
niij'inc.d venfic.irion of a rlieoret ic.i!
S. icncc LJhdrtcrlx. I / (j .
‘
TIi, r
.A’Kni.T-' ■/.Vat-a/.,.
|
h
hm AJapmtmn Model. AuRX luumai
•f6(6k 1122-1134.
l-eves.|ue I. . R lc.ir ] \ . plK|
B,,|<in'kic.|.(|992Vp;i,tllIvi
............ ............. ..
"’xierv A pilot studv. A< )RN Joumai.
Garcia. A. & White-Tram. K. (1993) pr....
the guidance of
vvitlo
■' ” ’L
speal<s ri'Its ahilirv to hcih, ,r '
c LXrLnt 1,1 the research
''■th n nuts,ng practice. The RAM has als,, .Wtfr,
"""''Ttuahtat.on of variables
'levelopntenr studies have generated provoXr J h "1lJdlc’';?n«c
In.t.al theory
■■■nsuts that influence it.
•■■■'e d,scuss,ons ot adaptation and the tnech
I29-| 3 j
^f^aki. M. (1997). C|
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■■vetk-ciol hmnorousd.siraciiononpreoperai
ettecrof humorous and imnical diMram,
62(5). 784-7’'I
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preoperaiive anxiety. AORX
Gagliardi. 13. (j99j) y
rhe impact of Duchenne muscular dy«rorhv
‘li-49
' . ................... ....
"",SCU'ar •''murhr UU lamihcs.
JUfK-.'
■■'•ndrews
,inJ Rt
Cenrury-Crofts.
',l '•» «!«,unship
‘1"' ""'“'u I'o’l'lv «,rh .milriplv scions,, J,,,,™.,/, ,
Fisher, M.P (|994). kk,„.^ZZa'p m-im
Based......
and
easily
applicahf
. '-"■
’uy applicable
303
—-ng.
1
rhe patient as adaptive'tsumu ThL’7uld a.dd an
Adaptation Perspective
8
I
I
cnees and
puire in'dePth knowledge of the sei
dence, role functioning, and self-concept Additi^T’^"'^010^1’ interdepenadaptatton. They must be able to sy^hSeOSfr ’
^nowledTof
■n relation to adaptation. Fully functionin''. from th "
understand J
least baccalaureate-level preparation or ime.^y require at
Modeling Nursing From an
•t implernenraib ,n. /'X-
J-,,,;?;
\lOsn, ;
-
I
iiIn
Meeker. |3 :|994) Ereopermtv
non enj C,n(UH.i.r ■ _>rj,
p trienr
'!x'ur'v
rifienr oiircotnes.
Educo
•
•
.-S’'.'!!
CONNECTIONS
304
Nursing Research, Theory, and Practice
CHAPTER 10 Modeling Nursing From an Adaptation Perspective
Mock, V., Burke, M., Sheehan, P., Creaton, E., Winningham, M.. McKenney-Tedder, S., Schwager, L.,
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Mock, V., Dow, K., Meares, C., Grimm, P., Dienemann, J., Haisfield-Wolfe, M., Quitasol, W, Mitchell, S.,
Chakravarthy, A., &. Gage, 1. (1997). Effects of exercise on fatigue, physical functioning, and emotional dis
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Phillips, K., Blue, C., Brubaker, K., Fine. ).. Kirsch, M., Papazian, K., Kiester, C., (St Sobiech. (1998). Sister
Tulman, L., Fawcett, J.. -St McEvoy, M.D. (1991). Development of the inventory of functional status—cancer.
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35(2), 90-95.
chometric testing. Journal o] Nursing-Widwijery. 38(5). 276-282.
Pollock, S. (1989). Adaptive respon>e> to di.ibeie> mellitus. Western Journal of Nursing Research, i l( >), 265-280.
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ence Qutirterly, 6(2), 86-92.
Ilwioxl
Advances in Nursing Science, 10( I) ,71 -86.
Shogan, M. & Schumann, L. (1993). The effect of environmental lighting on the oxygen saturation of preterm
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:i g
. '-"I,Iii
model- (2nd ed.). Englewood Cliffs, NJ: Prentice Hall.
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<4 T
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$
s
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Samarel. N., Fawcett, J
N Tulman, I. (1993). The efleers ot coaching in breast cancel support groups' A pilot
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Samarel, N., Fawcett. J.. N Tulman. L (19971 Effect ot support groups with coaching on adaptation to early
stage breasi cancer. Research m Nursing an,.' IJcaith, 2d( 1). 1 5-26.
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T
I5"
CHAPTER
I>||!
Modeling Nursing From the
Perspective of Health
PENDER’S HEALTH PROMOTION MODEL
Key Terms
f
cognitive-perceptual factors, p. 315
modifying factors, p. 315
4.
pii
CXI.
Pender’s Health Promotion Model (HPM) deals with a phenomenon of concern to mam:
nurses, but it is not itself a model of nursing. It is one of the more popular models in use by
nurses. Its midlevel of abstraction and narrower concept make it easier to use and under
stand than the more complex nursing theoretical systems.
Pender began her work, first published in 1982. wit h rhe belief that nurses are respon
sible for “care that results in better health and more productive living for individuals and
families” (p. 182). From this belief, the HPM, a wholbtic predictive model of health
promoting behavior, was developed. The model wa> revised in 1987 and again in 1996.
Penders scholarly work encouraged a focu< on health rather than disease.
THE STARTING POINT OF THE MODELING PROCESS
The starring point for Pender's HPM wa> existin',’ psychological theory. Pender identified
a number of theories md models as hmndational to iinder>tandinj’ motivation for health
behavior (Box 11-1). The HPM creattvely ^vnthesi.x- -cial cognitive theory and
expectancy-value theory and focuses on health pinmornm bv maintaining conditions of
healthy interactions between the self and rhe envmmmcnr. All rhe models and theories
identified a>' foundational
tiTiinJanonal to or necessarv for understanding rhe HPM relate to personal
behavior or chance
change within
wirliin a social envin v imenr.
Reason for Model Development
The purpose of Pender'< book, and bv inference, rhe reason tor developing rhe model was
“(1) to provide nurses wuh a conceptual frmwaork Io;
k-rsrmJing the many furors
307
rxa
r
308
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 1 1
0“
Behave3'1'1 M°delS Foundational for Understanding Motivation for Health
• The Health Promotion Model
• Protection Motivation Theory
• Theory of Reasoned Actions
• Theory of Planned Behavior
• Social Cognitive Theory (Self-efficacy)
• The Theory of Interpersonal Behavior
• Cognitive Evaluation Theory
• The Interaction Model of Patient Health Behavior
• Relapse Prevention
r
From I cnJcT. N.J. (1996). Haikh
(irJ
■
, Sra,nfort| CT: Applwon & Lange
1
-........ ..................................................................................................................... ..
The HPM is concerned specifically with health promotion
ns a behavior of rhe nurse or
other prov.der. It is based on concepts ot health, health ^rotectu
ion, and motivation jor health
behavior of the person being served. Health is an
evolving concept, a wholistic experience,
and a multidimensional approach for human 1.....
beings as competent personal care and meaningful relationships facilitates the actualization <
of hl,rh inherent and acquired potential,
The HPM s desired outcome is a view of health a:
dynamic process inherent in the lives
T'm
'a'n,l,es- ‘,nJ
Lrmceprualnacron of health and wllneF
as priinure and pos.rne concepts could led Competence models rather than tllness models
in
healthcare. Although the HPM
I IS nor un.quelv designed for nursing, ir describes one aspect
of the object of nursing. From
original conceptualization, development has embellished
the model and its practical application.
DESCRIPTION OF PENDER' s THEORETICAL SYSTEM
Philosophical Perspectives
..... .................................. .............. ,*>
-ro m...J..... , A ,
°<
“V
4. Individuals seek to actively regulate their own behavior.
5. Individuals in all their biopsychosocial complexity, interact with the environment
Phenomenon of Concern
BlWlM'l
309
eXpr^their
tO
3
5..
•
f.. . g •
Assumptions of the Health Promotion Model
1‘ Xe’human pote^iaL n9 ““h’ thr°U9h
Z thehowXmpZtS7 fOr refleCtiVe Se'f‘awareness■ includi"9
char affect rhe health behaviors of indn iduals and families, and (2) to present specihc
•
Modeling Nursing From the Perspective of Health
T / hTd . .........
ex-recr inci x-iIh.--I,
1 ,u
M "Hegruto concepts from
’
>ry anJ social cogmttv. the^ winch consider personal behavior ra-
6 Health SS'Vef y t!'ansForm'np the environment and being transformed over time
’
6. Health professionals constitute a part of the interpersonal environment which
exerts influence on persons throughout their life spans
Z
°f P—ment interactive patterns is essen-
KL-From Pender, N.J. (1996). Heahh /manou.m in nursing l>r«cucc. (3rd ed.). Stamford, CT: Appleton & Lange.
rec.procal determmants of health.
tion, forethought, vicarious learning, self-regulation, and self-reflection T
The HPM is based
on assumptions, listed in Box 11-2. that reflect nursing and behavioral sci.
.
..
lienee perspective-^
and the patients active role. The patient shapes and maintains health behaviors and modifies the environmental context lor health behav.ors (1996). The HPM’s ontologv reflectthese assumptions in tenns of rhe person's views and relationships to rhe environment.
Description of Model and Theories
'n Fl!T' ' ' I L T '1 Cl>mf'c|renct-- or ■Tproach-or.enred model" (Pender.
. ’ ('1'
’■ ' deplCts the m^tidimenstonal nature of persons interacting with their en
vironments as thev pursue health. The model contatns three ma,or categor.es: tndividual
charactertst.cs and experiences, behavior-spec.fic cognitions and affect, and behavioral
outcome. The model deptets the vartables and interrelationships and identifies the theorettcal underp,nntngs. Although rhe model has been used to frame research, no named
theones have been advattced. Pender (1996) has nor specifically tdentified any constructs
or repositions, despite the manv inferred relationship- between elements of the model
igute 1 I -1 tdenrthes the major concepts of the model. Individual characteristics and expunt nees are umque and personal and impact subsequent act ion. This includes prior related
'
"K T'"’1''' "Cr‘T Rcll;lv"’r-Pccitic cognitions and affect arc important tv
Kitnation and provide tocal pomts tor intervention. These include perceived benefits
action, perceived barriers to action, perceived selbefficacv. acttvitv-relared affect, interpererna influence,, ami -maarional influences. The third category, behavioral outcome v
“ ■■"'‘H’frnotmg behavior directed toward armmmg positive health outcomes. Com-
"’"■‘m " 7 ' '■ "7
‘“7"
enables tnur influence this outcome.
-"Tvrmg demands and preferences are two
MaraEMrjBasifJsass?
310
CONNECTIONS
Individual
Characteristics
and Experiences
Nursing Research, Theory, and Practice
Behavior-Specific
Cognitions
and Affect
Behavioral
Outcome
Classification System for Expressions of Health
Affect
Perceived
benefits
of action
Perceived
barriers
to action
Immediate competing
demands
(low control)
and preferences
(high control)
Prior
related behavior
Perceived
self-efficacy
J
! Personal factors:
—: ,
i______
h
;
kI r
ca g '
I.
Commitment |
to a
plan of action
Interpersonal
influences
(family, peers,
providers); norms,
support, models
■...........
[
L
I__
Health-promoting
behavior
-i r
------- -----------------------------------------------------------FIGURE 11-1 P
* ■
in nursing practice. (3rd ed.). Stamford.
IVnJer (IW)
Vitality
Sensitivity
Calm
Relaxed
Peaceful
Content
Comfortable
Glowing
Happy
Joyous
Pleasant
Satisfied
Close to god-figure
Contemplative
At one with the universe
Energetic
Vigorous
Zestful
Alert
Fit
Buoyant
Exhilarated
Powerful
Courageous
Aware
Connected
Intimate
Loving
Optimism
Relevancy
Competency
Hopeful
EnthusiasticOpen
Reverent
Trustful
Useful
Contributing
Valued
Caring
Committed
Involved
Purposive
Initiating
Self-motivating
Innovative
Masterful
Challenged
Positive Life Patterns
Meaningful Work
Invigorating Play
Eating a healthy diet
Exercising regularly
Managing stress
Resting adequately
Avoiding harmful substances
Building positive relationships
Seeking and using health
information
Monitoring health
Coping constructively
Maintaining a health
strengthening
Setting realistic goals
Varying activities
Undertaking challeng
ing tasks
Assuming responsibility
for self
Collaborating with
coworkers
Receiving intrinsic or
extrinsic rewards
Having meaningful
hobbies
Engaging in satisfying
leisure activities
Planning energizing
diversions
Activity
Situational
influences:
Options
I • Demand characteristics
Aesthetics
*.
Harmony
_____ Attitudes
Activity-related
affect
Biological
Psychological
Sociocultural
ci
Serenity
|
^thPromotion
^sren, h.r the tvav Pe.,rle ex
i.veJ„nens„,„
press health (Box IM). Th.s tra.new..rk h,r st,Mane health c, anplentenrs rhe HPM ,n
that it gives content n. < me of iis major elements
MOSDELRCH DERiVED FR0M PENDER'S HEALTH PROMOTION
Self-Actualization
Growth or emergence
Personal effectiveness
Organismic efficiency
__________ Aspirations
Social Contribution
Enhancement of global harmony and interdependence
Preservation of the environment
_________ Accomplishments
The c
”
prominently in
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theoretically tramed these
Enjoyment
Creativity
Transcendence
Pleasure from daily
living
Sense of achievement
Maximum use
of capacities
Innovative contribution
Freedom
Expansion of consciousness
Optimized harmony between
man and environment
1
312
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 11
Modeling Nursing From the Perspective of Health
313
Research Instruments
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Two instruments have been developed specifically to address health promotion. The HealthPromoting Lifestyle Profile (HPLP), (Walker, Sechrist, & Pender, 1987) was revised and sub
sequently named the Health-Promoting Lifestyle Profile 11 (HPLP II) (Walker &. HillPolerecky, 1999). The Exercise Benefits/Barriers Scale (EBBS) (Sechrist, Walker, &. Pender,
1987) also measures health promotion. Many health promotion studies have used the HPLP
as a measure of health-promoting behaviors, but more recent studies use the HPLP 11. A sum
mary of the psychometric characteristics of these instruments can be found in Table 11-1.
Health Promotion Lifestyle Profile. To measure health-protecting and health
promoting behaviors that constitute a health-promoting lifestyle, Walker, Sechrist, and
Pender (1987) developed the HPLP, which derived items from the Lifestyle and Health
Habits Assessment. The 48 reported health behaviors are rated on a 4-poinr Likert scale
with options ranging from never, sometimes, often, and routinely. The six subscales represent
specific health-protecting and health-promoting behaviors suggested by the HPM and
include self-actualization, health responsibility, exercise, nutrition, interpersonal support,
and stress management. Investigators reverse score negatively stared items and then
calculate the mean responses for each subscale and total scale. Subscale and total scale
scores can range from 1 to 4. Although calculating mean scores for each subscale and rhe
total scale is rhe recommended method of scoring, some investigators have used summed
scores for their statistical analysis. Reliability and validity for the HPLP was strong for the
total scale, despite more modest subscale ratings. The subscale ratings, however, were
within acceptable parameters. In their study of African-American women, Ahijevych and
Bernhard (1994) noted that readability and applicability of the HPLP instrument might
have affected its reliability and validity in use with a diverse sample. Although they did not
assess validity, Ahijevych and Bernhard found high internal consistency for the total HPLP
at 0.95. Subscale reliabilities were lower, ranging from 0.72 for rhe nutrition subscale to
0.89 for rhe self-actualization subscale.
Translations of the HPLP have been made to Spanish and Arabic. Walker, Kerr, Pender,
and Sechrist (1990) completed the initial psychometric evaluation for the Spanish lan
guage version and found the instrument culturally relevant. Although factor analysis
demonstrated that factors were similar to that of the English language version, items failed
to load onto the factors as clearly on the Spanish language version. Reliabilitv was strong
tor the total scale bur more modest for the subscales.
Kioter and Fong (1993) conducted additional psychometric evaluation of the Spanish
language version using a predominantly Central-American sample. Although the total
scale reliability was strong, subscale scores—with the exceptions of self-actualization and
health responsibility—were lower than 0.80. Stability (test/retesr) was lower than the sam
pled rested bv Walker, Sechrist, and Pender (1987). 1 lowever, the retested sample lor this
study was small. Kuster and Fong’s findings resembled the reliability findings ot Kerr and
Ritchey (1990) in their study of migrant farm workers. Reliabilitv for the Spanish language
version of rhe HPLP in rhe Kerr and Ritchey study was 0.90 lor the total scale, with sub<calc' ranging from 0.5 i to 0.84. 1 bus although overall .scale reliahilit\ is st i. aig. subscale
<<ore' indicate th.it further work on the Spanish language HPLP 0 needed. However, it
should be noted that few Spanish language instruments to measure health behaviors are
iivailahle.
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I■
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 1 1
Modeling Nursing From the Perspective of Health
315
Haddad, Al-Ma’aitah, Cameron, and Armstrong-Stassen (1998) rested an Arabic lan
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guage version of the HPLP using 950 Jordanian adults. Principal components factor analy
sis with oblique rotation revealed six factors accounting for 39.3% of variance. Although
similarities to findings using the English language version existed, the findings were nor
identical. Although self-actualization, health responsibility, and exercise extracted in the
factor analysis were similar ro the English version, nutrition, interpersonal support, and
stress management subscales were less defined. Initial levels of internal consistency relia
bility and construct validity were demonstrated, bur further testing was recommended.
Some adaptation based on cultural considerations might he necessary.
Walker and Hill-Polerecky (1999) revised the HPLP ro include 52 items on the total
scale. The Health-Promoting Lifestyle Profile II (HPLP ll)’s six subscales measure dimen
sions of spiritual growth, interpersonal relations, nutrition, physical activity, health re
sponsibility, and stress management. The instrument is considered more adequate than its
predecessor in measuring health-promoting behavior.
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barriers of exercise, a behavior consistent with a health-promoting lifestyle. The EBBS is
a 43 item, 4-point Likert scale that consists of two subscales—a 29-item benefits <cale and
a 14-item barriers scale. The total instrument’s potential scores range from 4> to 1 72. The
benefits scale scores range from 29 to 116 and rhe barriers scale from 22 to 56. To .'Core rhe
instrument, items on the barrier scale are reverse-coded. The initial psychometric
evaluation study had adequate sample size for instrument length and was conducted
methodically. Findings for reliability and validity indicate the instrument i> internally
consistent, remains reasonably stable over short time spans, and possoso adequate
construct validity. The EBBS is a useful measure of patient perceptions of’ benefits ami
barriers to exercise, and nurses can use it to assess patient perception^ of exercise and
willingness ro exercise regularly. As model testing continues, the EBBS also mav as>ist in
research.
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Exercise Benefits/Barriers Scale. Sechrist, Walker, and Pender (1987) developed rhe
Exercise Benefits/Barriers Scale (EBBS) to measure perceived benefit' and perceived
I
Hli
Review of Related Research
A targe
large number
research studies
studies have
been conducted
conducted using
using the
the HPM
HP.M a- a lxi<i< r< i cuide
a
nunwer of
or research
have been
discovery. Many of these research studies speculate about rhe clfci t> <>f modiivinc Uigurs
and cognitive-perceptual factors in determining participation in health pr. ’mori.'n activi
ties. Modifying factors arc demographic characteristics—such a> age. income, cendcr.
education, and ethnicity—that impact health promotion participation. Cognitiveperceptual factors are motivational mechanisms such as patients’ perception' •
the im
portance of health and self-efficacy. Perceived control of health, health defimi i< -n. he mb
sratu>, benefits of health-promoting behaviors, and barriers ro health-pi.-moi m- beb.^xior> also fall in this category. Penders original concept ualirati'. i
ot the 1’PM
prop, .^.-d that cognitive-perceptual factors directly influenced particm.iu.m in hcaith-
promoUng behaviors. Pender posited that demographical. biological, inrerper-. aial. 'mution.il. and behavioral modifving facton woukl not only <lirecrlv imimm .■ 'gnitne n.-rceprion but ahi would indirectly influence health promotion. In the re\ ;-..d HP.M. I .ah
cognitive-peicepmal factors and modifving factors influence health-promoting bch ivmrs
(Pender, l^Ofd. Table 1 1-2 surnmarires rhe studio disctiS'cd in rhe ■ 'T.-,;
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TABLE 11-2
Study/Year
Research Studies Using Pender's Health Promotion Model
o
Purpose..... ,1—■ Methods__________
iz>
DETERMINANTS OF HEALTH PROMOTION BEHAVIORSAND HEALTH STATUS
Duffy, 1988
The study analyzed impact of health lo
Two hundred sixty-two women between ages
cus of control, self-esteem, and health
35 to 65 years responded to Multidimensional
status for impact on health-promoting
Health Locus of Control Scale (MHLC),
lifestyle activities of midlife women.
Rosenberg Self-Esteem Scale, Health Percep
tions Questionnaire (HPQ), and HPLP. Stepwise
multiple regression was completed, using the
total health promotion score, modifying demo
graphic variables, MHLC, Health Perception
Questionnaire subscale scores, and total
Rosenberg Self-Esteem Score. Canonical corre
lation was used to examine the relationship
between predictor variables and health promo
tion subscale scores.
Duffy, 1989
The study investigated the influence of
health locus of control, self-esteem,
and health promotion activities on
health status of employed women aged
21 to 65 years.
The sample consisted of 420 employed women
who completed MHLC, Rosenberg SelfEsteem Scale, Ware's Health Perception Ques
tionnaire, and the HPLP. Hierarchical multiple
regression analysis was used to identify health
determinants.
Duffy, 1993
The study determined the degree to
which selected health components
from Pender's HPM explained health
promotion behaviors of older adults.
The sample consisted of 477 persons aged 65
and older. Variables measured included the fol
lowing: age, gender, race, educational level,
marital status; individual perceptions of health
locus of control, self-esteem, and health status.
Health promotion practices measured included
the following: nutrition, exercise, stress
management, interpersonal support, self
actualization, and health responsibility. Canon
ical correlation analysis was used to test the
hypothesis.
Duffy. 1997
The study was based on the revised
HPM. Il determined the degree to
which selected modifying factors, locus
of control, self-efficacy, and health sta
tus explained participation in health
promotion practices.
The sample was composed of 397 MexicanAmerican women who completed mailed
packets containing Multidimensional Health
Locus of Control (MHLC), Health Perceptions
Questionnaire (HPQ), the Self-Efficacy scale,
and the Health-Promoting Lifestyle Profile
(HPLP). Analysis was conducted using canoni
cal correlation.
Z
Findings
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Twenty-five percent of the variance in health promo
tion scores was explained by chance health locus of
control, self-esteem, current health, health worry/
concern, post-high school education, and internal
health locus of control. Two canonical covariates ex
plained 72.8% of variance in subscale scores of HPLP.
Internal health locus of control, self-esteem, current
health status, and future health status accounted for
36.3% of variance in self-actualization, interpersonal
support, and exercise subscales of HPLP. Age, nega
tive chance of health locus of control, health worry/
concern, and negative prior health status explained
36.5% of health responsibility, nutrition, and stress
management subscales.
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A diagnosed problem and level of household income
initially accounted for 17.3% of variance in health
status. Major variables of study were then added to
regression equation in stepwise fashion. Internal
health locus of control, self-actualization, negative
chance health locus of control, negative health re
sponsibility, and exercise explained an additional
61 % of variance. Subjects who indicated good health
status had high self-esteem and believed health was
under their control. The second correlation was 0.51
and explained 19.6% of variance. Males with higher
incomes and self-esteem but poor health were less
likely to engage in frequent exercise and good nutri
tion. The third correlation was 0.24 and explained
7.8% of variance. Older subjects with higher incomes
and who were married and less likely to leave control
of health to chance tended to engage in health pro
motion practices of exercise, health responsibility, and
stress management.
Three canonical correlations were significant (0.68,
0.39, and 0.26) but the third covariate accounted for
a small portion of variance. The first covariate, ac
counting for 73% of variance, indicated women's be
liefs that they were personally competent and in con
trol of their health, had a good health outlook both
currently and for the future, and were more likely to
engage in six health-promoting activities. The second
covariate, accounting for 15% of variance, demon
strated that younger, more educated women who be
lieved they controlled health and felt past, current,
and future health was good were more likely to en
gage in exercise.
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TABLE 11-2
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Study/Year
Purpose
Methods
DETERMINANTS OF HEALTH PROMOTION BEHAVIORSAND HEALTH STATUS—cont'd
Fleetwood and
The study determined knowledge of
A convenience sample of 520 military officers
Packa, 1991
coronary artery disease (CAD) risk fac
completed a knowledge questionnaire for
tors, health-promoting behaviors, and
CAD, a CAD risk appraisal, the HPLP, the
relationships of health-promoting be
MHLC, and an adaptation of the health value
haviors to health locus of control, value
survey. Pearson correlations and one-way
of health, and risk factor knowledge.
ANOVA followed by Bartlett Box F test and
Scheffe procedure were used for analysis.
Gillis, 1994
Stuifheigen and
Becker, 1994
The study determined relationships be
tween health-promoting lifestyles of
adolescent females and cognitiveperceptual variables.
The study examined predictors of par
ticipation in health-promoting lifestyles
in persons with disabilities.
MODEL TESTING
FrankThis descriptive, correlational, ex post
Strornborg,
facto study tested the usefulness of the
Pender, Walker,
HPM in explaining the occurrence of
and Sechrist,
health-promoting behaviors of ambula
1990
tory cancer patients. It determined the
extent to which cognitive-perceptual
factors and modifying factors explained
the occurrence of health-promoting
behaviors.
Johnson,
Ratner,
Botlorff, and
Hayduk, 1993
The study tested the HPM and deter
mined whether LISREL was capable of
suggesting modifications to the HPM.
z
z
Findings
m
n
Significant relationships (p < 0.05) existed between
health-promoting lifestyle and internal locus of con
trol (r = 0.22), chance locus of control ([ = -0.17),
health value (r = 0.20), and knowledge of CAD ([ =
0.20). Knowledge of CAD was significantly related to
internal locus of control (r = 0.14) and chance locus
of control (r = -0.09). Internal locus of control was
related to health value (r = 0.13) and chance locus of
control (r = -0.41). Chance locus of control was re
lated to control by powerful others (r = 0.22). Indi
viduals with the best health-promoting lifestyle pro
files believed that health was controllable, either by
self or others (F(7,512) = 3.898, p < 0.5).
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The sample consisted of 184 adolescent fe
males in grades 7 through 12 and their par
ents. Variables included HPLP, Health Concep
tion Scale, Health Subscale, and General
Self-Efficacy subscale. Stepwise multiple re
gression with backward elimination was used
for analysis.
There was a weak association between health
promoting lifestyles of adolescents and mothers (r =
0.28, p < 0.01) and fathers (r = 0.16, p < 0.05).
Variables of health conception, functional health, clin
ical health, self-efficacy, health status, and ethnicity
explained 41 % of variance in adolescent participation
in health-promoting lifestyles.
A sample of 117 adults with disabilities com
pleted instruments measuring definition of
health, self-efficacy, perceived health status,
demographical and disability-related mea
sures, and the HPLP.
Most felt that their health was good or excellent
(75%). Cognitive-perceptual variables (self-rated abil
ities, self-efficacy, and definition of wellness) and
modifying factors (dependence on mechanical assis
tance and gender) accounted for 50% of variance in
health-promoting activities.^ •
v v
.
A sample of 385 ambulatory cancer patients
receiving outpatient chemotherapy or radio
therapy responded to scales measuring four of
seven cognitive-perceptual factors, including
importance of health, perceived health control,
definition of health, perceived health status,
reaction to diagnosis of cancer questionnaire,
and the HPLP.
Regression analysis revealed 23.5% of variance in
health-promoting lifestyle was explained by three
cognitive/perceptual and four modifying factors.
Cognitive-perceptual factors of positive health con
ception, health rating, and feelings of control over
health accounted for 15.8% of variance, and modify
ing factors of educational level, age, family income,
and employment status added an additional 7.7%. A
second regression incorporated illness-specific vari
ables and accounted for 24.7% of variance in health
promotion participation. Four cognitive-perceptual
variables and two modifying factors influenced
health-promoting lifestyles. Confrontation of cancer
diagnosis accounted for 3.9% of variance. Canonical
correlation produced two sets of canonical variates
that accounted for 44.4% of shared variance.
The National Survey of Health Practices and
Consequences database was used for analysis.
The database consisted of 3025 adults aged 20
to 64 years. Demographical data, indicators for
the three cognitive-perceptual factors, and in
dicators for health-promoting behaviors were
extracted from the database.
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Initial tests indicated that the model failed to fit the
data. Modifying factors for health promotion influ
enced behaviors through other mechanisms than
those specified in model. The model was modified to
reflect the direct effect of the factors of sex, age, in
come, marital status, and body mass on selected
health promotion behaviors, A marginal fit was
achieved; however, the modified model failed to ex
plain variation in participation in health-promoting
activities.
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TABLE 11-2
■esearch Studies Using Pender's Health Promotion Model—cont'd
Study/Year
Purpose
O
...... Methods
MODEL TESTING—cont'd
Lusk and
The study measured the components of
Kelemen, 1993
the HPM in preparation for testing the
larger model.
Ninety-eight metal shop workers completed
scales measuring benefits and barriers to hear
ing protection use, value of outcomes of using
hearing protection, health conception, self
rated subindex of health, and the HPLP.
z
Findings_____
Benefits of hearing protection were related to use of
protection (r = 0.29, p < 0.01) and were deterred by
barriers (r = -0.23, p < 0.05). Hearing protection
was used to keep noise out and increase sense of
well-being (r = 0.23, p < 0.05; £ = 0.24, p < 0.05).
Health-promoting factors of self-actualization and
stress management influenced workers' use of hear
ing protection (r = 0.33, p < 0.01; £ = 0.31,
p < 0.01). Regression revealed that 24% of variance
of hearing protection use was predicted by benefits,
self-actualization, and interpersonal support. Interper
sonal support diminished protection use.
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Lusk, Roms, Kerr,
and Atwood,
1994
The study tested the HPM, using it as a
causal model to predict use of hearing
protection by workers.
A sample of 561 workers responded to the
MHLC, Perceived Self-Efficacy, Clinical Health
Subscale, Nondinical Health subscale, SelfRated Health Subindex of Philadelphia Geri
atric Center Multilevel Assessment Instrument,
Benefit and Barrier Subscale, Value of Outcome
Scale, and measures of situational factors and
use of hearing protection. Structural equation
modeling was completed for both the theoreti
cal path model and two exploratory path
models.
Theoretical model fit well and explained 49% of
workers' hearing protection use. Direct effects in
cluded value of use, few barriers, high self-efficacy,
and low health competency. In the first exploratory
model, explaining 52.7% of variance, additional di
rect paths to protection use included blue-collar job
category and situational factors. In the second ex
ploratory model, explaining 50.7% of protection, all
original predictors as well as job category and situa
tional factors directly related to protection use.
Lusk, Ronis, and
Baer, 1997
The study tested the HPM as a causal
model to predict hearing protection
use by male and female blue-collar
workers.
A sample of 253 women and 251 men were
measured for situational factors, cognitiveperceptual factors, definition of health, health
status, self-efficacy, benefits, barriers, and
hearing protection use. Analysis was con
ducted using structural equation modeling
with EQS, followed by factor analysis.
Predictors accounted for 64.1% for variance in use of
hearing protection for men, 47% for women, and
52.3% for the combined group. Men's causal path of
hearing protection use was indirectly affected by situ
ational factors and age and was directly affected by
barriers, self-efficacy, and value of use. For women,
protection use was indirectly associated with situa
tional factors and minority status and was directly
associated with barriers, self-efficacy, and place of
employment.
Lusk, Ronis, and
Hogan, 1997
Pender, Walker.
Sechrist, FrankStromborg,
1990
The study tested the HPM as a causal
model to understand hearing protec
tion use by construction workers.
A sample of 359 construction workers were as
sessed for noise exposure, interpersonal influ
ence (social support, interpersonal norms, in
terpersonal support), situational factors,
control, health definition, health status, selfefficacy, benefits and barriers to use, and hear
ing protection use. Structural equation model
ing using EQS was followed by confirmatory
factor analysis to test theoretical and ex
ploratory model.
The theoretical model, which proposed direct paths
from cognitive-perceptual factors to health
promoting behaviors and direct paths from modifying
factors to cognitive-perceptual factors, accounted for
36.3% of hearing protection use. The exploratory
model, accounting for 50.6% of variance for hearing
protection use, indicated that three cognitiveperceptual factors and two modifying factors (inter
personal influence and noise) influenced hearing.
The sample consisted of 589 health promotion
program enrollees who responded to cognitiveperceptual measures of importance of health,
perceived control of health, perceived selfefficacy, perceived personal competence, defini
tion of health, and perceived health status. Par
ticipants also completed measures for behav
ioral factors and the HPLP. Measures were taken
at one and three months. Hierarchical multiple
regression was used to predict the influence of
cognitive/perceptual variables and modifying
factors on health-promoting lifestyles.
Regression revealed that cognitive-perceptual vari
ables of definition of health (wellness), health status,
and control of health (by powerful others and chance)
and modifying factors of gender, age, and phase of
exercise accounted for 31% of health promotion par
ticipation. Three months later, 25% of the variance
was accounted for by wellness, health status, internal
control, control by others, personal competence, gen
der, age, and phase of exercise. Canonical correlation
assessed the extent to which the six health
promoting dimensions contributed to lifestyle. Sixtytwo percent of the variance was explained.
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The study tested the ability of the HPM
to explain health-promoting lifestyles
of employees and investigated the use
fulness of the HPM in predicting future
health-promoting behaviors.
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TABLE 11-2
Oder's Health Promotion Modpl cont'd
Study/Year
Purpose
MODEL TESTING—cont'd
Ratner, Bottorff,
The study tested a causal model of
Johnson, and
cognitive-perceptual and modifying
Hayduk, 1994
factors on health-promoting lifestyles.
It also examined the influence of
gender.
Hainer, Bottorff,
Johnson, and
Haydtik. 1996
Weitzel. 1989
lhe study used multiple indicators to
test the multidimensionality of two
concepts of the HPM.
The study tested the HPM by examin
ing the health behaviors of blue-collar
workers.
Methods
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Findings
Data from the National Survey of Personal
Health Practices and Consequences (1979 to
1980) were used. A sample of 3025 adults
aged 20 to 64 years was examined. Indicators
for cognitive-perceptual variables of health
control, self-efficacy, and health status were
identified. Factors congruent with health
promoting lifestyle were identified. Modifying
demographics were identified. Stacked analysis
using LISREL was completed to discern gender
differences on the causal model.
A subsample of 197 males was analyzed. Mea
sures included the following- Health Locus of
Control, Health Conception Scale, reported
age, health status, and exercise. Three models
were constructed and tested. LISREL was used
to test three causal models.
A sample of 179 blue-collar workers com
pleted the MHLC, value survey, Multilevel As
sessment Instrument, General Self-Efficacy
Scale, and HPLP.
n
n
The initial model was found to be poor fit for both
men and women. The model was modified to allow
for additional interactions. Only limited variance was
explained by these models. In addition to the influ
ence of sex and marital status, education was found
to be an important indicator for women's nutrition.
Body mass index explained men's nutritional behav
ior; health control was related to exercise engage
ment for women; greater self-efficacy was related to
taking responsibility for health in men; health respon
sibility was related to exercise for men. As men age,
they perceive less control over health.
o
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rt
he first model, using single indicators for health pro
motion, fit the data. Successive models that used two
indicators for each concept and one that used three
indicators per concept demonstrated poorer fits with
the model. The model that used three indicators
failed.
z
o
3
□.
r»
Participation in health-promoting behaviors was de
termined by health status, self-efficacy, health value
and education, which accounted for 20% of variance.
Health status was a significant predictor of self
actualization, health responsibility, exercise, nutrition
interpersonal support, and stress management Psy- '
chological factors consistently had more predictive
power than demographical modifying factors for total
(T>
Hr LP and individual subscales did.
health-promoting practices
Ahijevych and
The study examined health-promoting
Bernhard, 1994
behaviors of African-American women
ages 18 to 65.
All, 1996
Foster, 1992
The study identified predictors of
osteoporosis prevention behaviors.
This descriptive correlational study in
vestigated the relationship of health
promoting behaviors to life satisfaction
and current health status.
..iiiii i imim i iw
One hundred eighty-seven African-American
women completed the HPLP and furnished
saliva samples for cotinine analysis to confirm
smoking status.
Moderate participation in health-promoting activities '
was reported (HPLP mean = 2.55).The highest sub
scale means were for self-actualization (2.89) and in
terpersonal support (2.90), whereas the lowest sub
scale mean was for exercise (1.95). Significant
correlations were found between health promotion
and the following: years of education (r = 0.19, g =
0.009), number children in home (r = -0.16, p =
0.05), income level (r = 0.25, p = 0.001), employ
ment status (r = 0.22, p = 0.006), and medical diag
nosis (r = 0.21, p = 0.004). Income explained 12%
of variance in health promotion. Presence of a med
ical diagnosis (4.3%), and employment status (2.3%)
also explained some variation.
>
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Two hundred thirty-three college students
completed questionnaires on lifestyle habits
and osteoporosis prevention behaviors, exer
cise participation, calcium intake, Exercise Ben
efits and Barriers, General Self-Efficacy, Health
Locus of Control, a health value survey, knowl
edge of healthy behaviors, and perceptions of
current body weight.
Although 88% exercised, only 3% did so regularly.
Sixty-two percent exercised irregularly, and 35% exer
cised only when they consumed a large number of
calories. Thirty-six percent of variance in calcium in
take was attributed to perception of barriers to cal
cium intake, skipping meals, and knowledge of
healthy behaviors. Internal health locus of control and
perceptions of barriers to exercise participation ex
plained only 8% variance in exercise.
in
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c
One hundred African-American adults aged 60
to 89 years responded to the HPLP, Current
Health Scale, a modified version of Life Satis
faction Index, and Two-Factor Social Position
Index Scale.
Life satisfaction was positively correlated with current
health status (r = 0.58, p = 0.001), health
promoting activities (r = 0.32, p = 0.001), age (r =
0.23, p = 0.05), and socioeconomic status (r = 0.27,
B = 0.01). An inverse relationship between health ac
tivities and smoking (r = 0.22, p = 0.01)fwas found.
No association between current health and health
promoting activities was found.
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Continued
in
6
2
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TABLE 11-2
m
S3
lies Using Pender's Health Promotion Model—cont'd
Study/Ycar
Purpose
Methods
Findings
Three hundred twenty 11 th and 12th grade
adolescents completed questionnaires that as
Students who learned to drive before implementation
of mandatory seat belt laws had a lower rate of use.
HEALTH-PROMOTING PRACTICES—cont'd
Riccio-Howe,
1991
This descriptive correlational study in
vestigated factors associated with ado
lescent safety belt use.
sessed seat belt use and benefits and barriers
to use, accident locus of control (ALOC), and a
revised health value scale.
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a
in
Higher seat belt use occurred if adolescents sat in the
front seat or if parents or friends used belts. Females
£
perceived more benefits of use, whereas males per
ceived more barriers. Benefits promoted use, and bar
in
0
OJ
riers deterred use.
A
D"
Riffle, Yoho, and
This descriptive correlational study ex
One hundred thirteen Appalachian adults aged
Health-promoting activities were positively associ
Sams, 1989
amined relationships among health
55 years or older responded to the HPLP, the
Older American Resources and Services (OARS)
ated with social support (r = 0.2968, p < 0.0008).
Health-promoting activities were positively associ
questionnaire, and the Personal Resource
ated with self-reported health (r = 0.2205,
promoting behaviors, social support,
and self-reported health
Questionnaire (PRQ2)
H
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o
□
p < 0.0103). Self-reported health was not related to
Q.
social support. Thirteen percent of variance in health
T
promoting behaviors was attributable to social sup
port and perceived health status.
Serafine and
Broom, 1998
CD
The study determined factors that pre
One hundred three pregnant women at low-
Two predictor variables accounted for 30% of vari
dicted attendance at preterm birth pre
risk for preterm birth participated. Thirty-seven
vention classes.
women attended preterm birth class. All partic
ipants answered the Fetal Health Locus of
Control Scale, Health Value Scale, a perceived
ance between women who attended or did not at
tend class. Attendees were more likely to have
planned to attend and perceived fewer barriers to
class attendance. Predicted group membership using
barrier scale, and opened-ended questions re-
those variables improved from 36% to 68% for
Three hundred forty-three
fortv-three volunteers aged
acred 55
to 93 from rural and urban locations com
pleted the MHLC, three questions on perceived
health status, and the HPLP.
Small percentages of variance In HPtP subscales were
predicted by the variables of education', income, resi
dence, health status, internal health locus of control,
chance health locus of control, and powerful others
health locus of control. Variances for predictions of
health promotion subscales included the following:
Speake, Cowart,
and Stephens,
The study compared health beliefs and
•lifestyle
i''■■■-'• practices of rural
..... and
.v' urban
1991
older adults.
Telleen, 1993
.
stress management (8%), exercise (9%), nutritional
lifestyle practices (9%), health responsibility (13%),
I
self-actualization (21%), and interpersonal support
2?
(13%).
m
73
The study compared health-promoting
practices of pregnant and nonpregnant
One hundred pregnant and 93 nonpregnant
women of childbearing age responded to the
The HPLP total score and subscale score means
ranged from 2.46 to 3.31 on a 4-point scale. Health
women.
HPLP.
promoting behaviors for pregnant and nonpregnant
women were different only with regard to nutrition
(t = 3.06, p = 0.003).
>
2
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s-=:
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c
EXERCISE
Desmond,
Conrad,
Montgomery,
and Simon,
The study identified factors associated
with physical activity of male whiteand blue-collar workers.
A convenience sample of 325 male workers
were evaluated for physical activity (work,
Job category and self-efficacy accounted for 30% of
variance for all physical activity. Fifty-six percent of
sports, and leisure), health status, self-efficacy,
variance in occupational activity was explained by in
come and job activity. Six percent of variance in
and perceived barriers. Correlation and regres
1993
sion were used to evaluate factors influencing
activity.
Bonheurand
Young,1991
The study examined differences in
self-esteem and perceived benefits and
barriers between exercisers and
nonexercisers.
Exerciser (n = 57) and nonexerciser (n = 48)
college student groups completed instruments
measuring exercise intensity, the Exercise
Benefits and Barriers Scale (EBBS), and a self-
esteem inventory.
sports activity was attributable to perceived health
status. Perceived self-efficacy and job category ac
counted for 13.5% of variance in leisure activity.
tn
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(2
Exercisers exhibited a greater degree of self-esteem
(t = -3.38, df = 100.3, p < 0.001), perceived
greater benefits of exercise (i = -6.11, df = 101.6,
P < 0.000), and fewer perceived barriers to exercise
(1 = 3.56, df = 87.6, p < 0.000). Stepwise regres
sion revealed that self-esteem, perceived benefits,
and perceived barriers accounted for 32% of differ
T)
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ence in exercise participation.
Continued
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TABLE 11-2
c
J’
Study/Year
Purpose
Methods
Findings
in
CD
OJ
HEALTH-PROMOTING PRACTICES—cont'd
Garcia. Broda,
The study investigated the influence of
The sample consisted of 286 racially diverse
Frenn. Coviak,
Pender, and
gender and developmental differences
in exercise belief and exercise behav
youth in grades 5, 6, and 8. Youths were mea
sured for exercise (Child/Adolescent Exercise
Ronis, 1995
iors of youths.
Log), Rosenberg Self-Esteem Scale, Children's
Self-Efficacy Survey, self-schema (Me Now and
Future Scale), and the Children's Perceived
Benefits/Barriers to Exercise Scale. Path analy
n
In the causal model, gender and access to facilities
explained 19.3% of variance in exercise participation.
In exploratory path analysis, 32% of variance in exer
o
cise benefits/barriers was explained by developmental
stage, perceived health status, exercise selfefficacy, social support for exercise, and exercise
□
Q.
norms.
sis was used to test causal model.
OJ
Gillis and Perry,
The study examined differences in
1991
physical activity and health-promoting
behaviors of midlife women participat
An experimental group of 52 women who
completed a 12-week program of physical ac
ing or not participating in a structured
tivity were compared to 40 control group
women for well-being, self-esteem, health lo
exercise program.
cus of control, HPLP, and health perceptions.
Measures were completed before the program,
following program completion, and 6 months
later.
xj
3)Z anu
and
....... Repeated measures ANOVA (2 zx
Neuberger,
Kasai, Smith,
Hassanein, and
DeViney, 1994
The study determined factors that pre
dicted exercise behavior and aerobic
fitness in patients with arthritis.
One hundred outpatients with arthritis com
pleted the EBBS, Arthritis Impact Measurement
Scale, Stanford 7-day Recall of Physical Activity
interview, a bicycle ergometer test, and a body
mass index calculation. Path analysis was used
to test the causal model.
The exercise group demonstrated greater increases
rn
over time in health-promoting areas of exercise (Time
2: F (1,90) = 15.87; p< 0.000;Time 3: F (1,90) =
15.55; p < 0,000) and stress management (Time
2: F (1,90) = 2.29; p < 0.04). In the exercise group,
regression indicated that wellbeing, exercise, and
stress management accounted for 52% of variance in
program adherence.
...
Poor peeved toith SSs Z asZZZiih
; '
greater severity of arthritis, longer time since diagno
sis, less education, and higher pain scores. Better per
ceived health status was associated with older age
and higher income levels. Modifying factors ac
counted for 26% of variance in health status score
and 18.4% of perceived benefits of exercise score.
Lower perceived benefits of exercise were associated
with higher arthritis scores, longer arthritis duration,
and less education, whereas higher perceived bene
fits were associated with previous exercise. Modifying
I
>
73
factors contributed to 15.6% of variance in perceived
barriers to exercise. Longer duration of arthritis,
higher arthritis scores, higher body mass index scores,
and fewer years of education were associated with
more perceived barriers. The model accounted for
20% of variance in composite exercise scores. Per
ceived benefits of exercise were associated with exer
cise participation. Poorer health status and higher
perceived barriers were associated with lower exer
cise participation.
HEALTH-PROMOTING INTERVENTIONS
Campbell and
This phenomenological study evaluated
Kreidler, 1994
personal responsibility for health
promoting behaviors and perceptions
of wellness of older adults participating
in a community-based health promo
tion program.
Thirty-three patients were interviewed during
their participation in a community-based
health promotion program that aimed to main
tain patients' independence by improving
lifestyle practices. Interventions consisted of
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Patients viewed themselves as not well and felt that
their physicians were key to indicating their level of
health status. Mobility was of key importance to a
sense of wellness. Themes of depression and hope
?
a,
I
lessness emerged for less mobile individuals.
structured educational programs, health as
rB
sessments, and home visits aimed at healthy
lifestyle choices.
I
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Continued
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328
Nursing Research, Theory, and Practice
CONNECTIONS
r
CHAPTER 1 1
Modeling Nursing From the Perspective of Health
329
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l&Packa, I991;G.llis, 1994; Sru.fbereen
& Becker. 1994) have assessed determinants of health-promoting behaviors for different
groups of various ages and affiliations. Sample age groups ranged from adolescents to older
aduks, and group affiliations included women, nursing students, and white- and blue-collar
^11 5
To examine determinants of health-promoting behaviors and health status, Dutfv (198S)
conducted a major research program in which she analyzed rhe impact of health
ocus 0 control, self-esteem, and health sratus on health-promoting lifestyle activities of
2b. m.dhie women. Subjects who reported high self-esteem, current good health, hi-h in
ternal locus ol control, and low chance health locus of control had high scores on the HPLP
subscales of self-acrualnation, nutrition exercise, and mterpersonal support. Parncipants
hr were older, bar high health worrv/concern scores, reported lower past health status
and had ow chance health locus ot control scores demonstrated high HPLP subscale scores
or health reS|sonsiM,ty nutrition, and stress management elemems of health promonon
f-mdmgs supported 1 ender's HPM, which suggests that individual percept.ons of he <lih lo
cus of comrol.selt-eoeem. and health status influence health promotion behaviors
'■'^pHeqt.ent analyse. Dultvi 1989) examined health status determinants of employed
1
.is
SK' ’■ -n.i . h..t employed women who rated them overall health smtu> a, good rti'ic.iliy had good household incomes and no diagnosed health problems Their
healrh promonon scores rndic.ired high internal locus of control, high selhactualiration.
s a i"
li-o.
s iflj
=
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rated the Hl M mto variable selection, measurement, and evaluation. Table 11-2 siimmari-es
rhe research studies included in rhe following discussion.
Determinants of Health Promotion Behaviors and Health Status. Several investi-
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Many of the systematic studies measure the cognitive-pgtceptual factors that Pender
identified. The Rokeach Values Survey or a modification of the Health Value Scale is fre
quendy used as a measure of importance of health. Control of health is often measured by
the Multidimensional Health Locus of Control Scales (MHLC). Other instrument choices
have included the Accident Locus of Control Scale (ALOC) and the Children’s Health
Locus of Control Scale. Perceived self-Eft.cacy has been measured with the General SelfEfficacy suhsca e of the Self-Efftcacy scale. The Laffrey Health Conception Scale has measured health definition. Perceived health status often is measured with rhe Current Health
Status Scale or the Health Scale, which is a subscale of the Multilevel Assessment Instrument. Although they have been inconsistently studied, a variety of instruments have measured percetved benefits and perceived barriers. The EBBS has been used for exercise beneftts and barriers. Others have used investigator-developed scales specific to
hearing
protection, safety belt use. or health promotion thr individuals with disabilities.
Several research programs centered on health promotion have determined health pro
motion and status indicators and have tested the HPM s abilny to predict healrh-pr. anotm..
behaviors. Additional studies have focused on crosscultural groups or on groups of persons
ranging m age from adolescents to older adults. Although manv stud.es have used the HELP
they were nor necessarily based on the HPM. In the following discussion, pr.ority was mven'
to stud.es that composetl a program of research. The following studies successlullv incorpo-
111
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ffh
i |“ §,
- “I s
11 ?
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cs' ■bl ‘
7riKT.',!K
^T'lnsibditv. Once again, these findings centaicnjcrs st'“'estll'n rh:,t lte,|tb l»cus of control, health promotion activ-
1'V rcf.iccu, 1 he w<Hiicn\ s<.it-.jcniiihraru»n wu> <(>nqrueni with
r
330
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_
CONNECTIONS
Nursing Research, Theory, and Practice
Pender’s conceptualization that health promotion is a method of sustaining or increasing
well-being.
Duffy (1993) investigated the degree to which selected components of Pender’s model
explained health promotion practices of persons aged 65 and over. Older healthy persons
had high esteem and internal locus of control with regard to health issues and reported us
ing five of six health promotion strategies. These typically included nutrition, exercise,
stress management, health responsibility, and self-actualization. They less often relied on
interpersonal support. Men with higher incomes and high self-esteem did not tend to use
health promotion practices as often as women did. Pender’s HPM was partially supported
by this study in that internal locus of control, high self-esteem, and positive health status
related to health promotion practices. However, with the exception of a relationship of
income to exercise and stress management to health responsibility activities, the predicted
relationships of demographic characteristics and health promotion practices were not
found In other words, this study failed to demonstrate that many of the modifying factors
indirectly influenced health-promoting activities, as Pender’s HPM had suggested.
In a final study, 1 Xiffy (1997) examined rhe degree to which modifying demographic fac
tors, cognitive-perceptual factors, and health status influenced Mexican-American women
in the six health promotion activities proposed by the revised HPM. Factors of age; educa
tion; internal sense of control; personal competence; and perception of past, present, and fu
ture health status were important in determining rhe level of participation in health pro
motion activities. In this study, marital status and household income did not impact health
promotion practices. However, the modifying factors of age and education were only small
factors in determining health promotion activities, which led Duffy to conclude that the
HPM should be modified to reflect the minor role of demographic variables.
Fleetwood and Packa (1991) investigated determinants of healrh-promoting behaviors
in military personnel. They were specifically interested in subjects’ knowledge about coro
nary artery disease (CAP) and related risk reduction behaviors. Subjects with greater
knowledge about cardiac risk factors participated in more health-promoting behaviors.
Those with rhe highest participation in health-promoting behaviors believed that health
was controllable, either by self or by others.
Gillis (1994) examined determinants of health-promoting lifestyles in adolescent fe
males. Only a weak relationship between rhe health-promoting practices of either parent
and those of the adolescent existed. Definition of health, self-efficacy, perceived health
status, and ethnicity predicted adolescent participation in health-promoting lifesty les.
Using a population that has been traditionally overlooked in health promotion,
Stuifbergen and Becker (1994) examined predictors of health-proinoting lifestyles in
persons with disabilities. Adults with disabilities were more likely to engage in health
promoting activities it they were female, possessed a high sense of self-efficacy, had a
wellness-oiiented definition of health, anil rcujuired less mechanical assistance with
daily activities. This study confirmed the value of using rhe HPM to explain health be
haviors of disabled individuals. ('ogninve-:cpiual factors accounted for at least half
of the variance associated with health pr >m a >i: l>eb.avioi’s. This finding is p.irticularly
significant tor parient- with disabilities because attitudinal factors can be changed.
In summary, study findings revealed that cogntrtx e-pcrceptual Kanables often influenced
health-promoting behaviors t Duftv. )9^,S. 19°k Gdlis. ILi94; StmTergen (Sr Becker 1994).
CHAPTER 1 1
Modeling Nursing From the Perspective of Health
331
However, the role of modifying factors was less clear. Duffy (1993, 1997) found that mod
ifying factors played only a minor role in determining health-promoting behaviors. Pender
(1996) subsequently revised the role of modifying factors in her model. The variety of peo
ple included in the samples including women (midlife, and employed versus unem
ployed), older adults, Mexican-Americans, adolescents, and persons with disabilities—is a
clear strength of all these studies of health promotion determinants.
Model Testing. Several investigators have aimed health promotion studies at
specifically testing the HPM. Cognitive-perceptualI or modifying factors’ direct or indirect
influence on health-promoting behaviors is a central issue. Findings from some of these
studies contributed toward further refinement and revision of the HPM.
Pender, Walker, Sechrist, and Frank-Stromborg (1990) investigated the HPM’s
success
in explaining health-promoting lifestyles among employees. Investigators also wanted to
determine whether the HPM would predict future health-promoting lifestyles. Those who
tended to engage in health-promoting lifestyles tended to be older, female, and selfconfident in managing life situations. They tended ro define health as possessing high lex el
wellness and believed that their personal health was good and was affected by significant
others but not by chance. This study supported the HPM in that cognitive-perceptual fac
tors, health definition, perceived control, and perceived health status influenced health
promotion activities. However, not all cognitive-perceptual factors impacted behaviors.
Moreovei, some modifying factors—gender, age, and phase of exercise program—
influenced behaviors more directly than Pender had anticipated.
Frank-Stromborg. Pender, Walker, and Sechrist (1990) also studied application of the
HfM to ambulatory cancer patients. Investigators found that better educated, older,
wealthier patients who held a wellness orientation, rated their personal health status as
high, expressed a belief that health was self-controlled, and worked outside the home
were
more likely to participate in health-promoting activities. When illness factors were in
cluded in the legression, reaction to cancer diagnosis accounted for additional variance in
health-promoting lifestyles. Once again, modifying factors—particularly education and
age—modestly hut directly contributed to participation in health-promoting behaviors.
Weitzel (1989) tested the HPM with a group or blue-collar workers. Both cognitiveperceptual factors (which Weitzel termed psychological variables) and modifying tutors of
education and income contributed modestly to heahh-promoring behaviors. The strongest
indicators of blue-collar male participation in health-promoting behaviors were feelings
of good health .status and strong senses of'sc If-efficacy. For the most parr, this group of bluecollars workers exhibited a high internal locus of control with regard to their health. How
ever, because rhe study accounted lor little variance, Weitzel concluded that other factors
must be considered in explaminig health promotion participaiion.
Using the HPM. Lusk and Kclemen (I99H: Liok.
... R<
.xonis, Kerr, and Atwood (1994);
Lusk, Ronis, and Baer (1997); and Lusk. R. m m.i I Logan (199?) conducted a series of
studies predicting workers’ use of hearing pnecua i. . I le.iring protection wa?, considered a
good measure of participation in a health j 'inoting .iciivii', bceau<c subjects worked in
noisy areas and because hearing protection s<- rcumre.- personal ie<pon>ibihty. In a preliminarv study ..oed to prep.ire foi ,iu<al m> lei n '■
ny of the HPM, Lusk and Kelemen
(1993) found that only half rhe workers um■- I’ hearing
’
protection. Lusk and Kelemen coneluded that workers who used hearing "t ■
-J,1’1 iI ' d-'cc iU'.-•-I pen c’ved benefits, rhe
332
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 11
•‘T
Modeling Nursing From the Respective of Heaith
333
equenr .study by Lusk, Ronis, Kerr, and Atwood (1994) rhe HPM nui Ml
'
participation in health-promoting behaviors. Finding of thVinitid cau'-'f17
that the HPM did not fit the data Modifying fa<m M
...s.,
i
ginal fit was discovered following causal model mo lifir >r
L 'SSt
f°r
*ndicated
A A,chough a mar-
I
be reevaluated. However, a crit.cism of this study is that only three of the ”'e , c m
perceptual factors associated with the HPM were included
”
cognuive-
i'
on pred.cr use of prorecrive be
■ng factors.
" '"‘’‘r"’" “SC' TI’"S the HPM
tht' '"’"bected direct linkages of modify
v r
'
Using the HPM, Lusk, Ronis, and Baer (1997) specific ills' idd,-,.■■ f si
pro.ect.on nt a group of male and female blue-col ar
perceptual factors would directlv infli.rn - • h
tors would directlv infl. e
prOtecr,on
support. Although ,ender s n 7
i
ft n
l""
roposmy that cognitive™d that moditvmy fac-
• •
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-
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plex group Of numerous interactions that needed to be delineated
'
multiple indicators. Investigators proposed that ,f health pXtira is , mum'
‘)f hearing protection for both mil-
Ir
i
.
* ° dmcrly explained use
•••I
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...........
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prior studies, rhe HPM provided a pred.crive rheorened mol 7 H
factors d.rectly influenced hearing protect,on use
m,’d,,V'n*
n a follow-up study. Lusk, Ronis, and Hogan (1997) used rhe HPM ,
> ■.
i
i i
-. ...............................
r
nr' tusc'barriers-
M t >onal modding and no.se exposure. Both the theoretical model mJ (hc cX
ploratory
•
models supported the HPM. S.gnificantlv, the explorm,.- m ■ I
I
fi' >n < >f rhe direct
influent
,/. | | ipfr'
m |Of ,nodifVing ^ors on health promotion wa.c( mmuem wuh
render’s
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dinindcrors .n
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d
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the influence of age on exercise wirh h >-.lrl
........... .............. :1
i i
H1^lcatGr model, testing
.................................................
.......... .........
Promoting activities (Frank-Strombor« ’ Pen I -r Y\'; Il
A'-A p,H
iparion in Pealrh.-
so r... s i ; SX;l;,’k 7 f" x xR... s
“"X.. ........... ........
..—
........
.... ........ . Z',„Z 7: ll'’r •7;f’
U'eiu's. .•...... . ........ ............ ..........
Bottom, and Hayduk (1995) and Rimer Bon rff I I
IMrncipation m ntaltn piomotion behaviors
i i*"
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v '
"in' Kj'ner-
Health-Promoting Practices. A number of dc<crirtive <rud.es 1 o • h., Jr.,; ' ■ 1
■■"
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■■■ milu-
• I ■"'•’'-oogpmcncmof vari. >u. er. mi-. (. hmupmocludc die elderli. adulr-. preAaia
334
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-
CONNECTIONS
Nursing Research, Theory, and Practice
women, and selected ethnic groups. Speake, Cowart, and Pellet (1989) examined the
relationship between healthy lifestyle and perceived health status and locus of control in
a healthy group of older adults. Participants, particularly Caucasians and those with more
education, possessed high degrees of internal locus of control over health issues. Most
participants rated their heath as good or excellent and generally felt their health had been
stable over the past 6 months. This finding was particularly true for younger, married
educated, female Caucasians. Perceived health status and internal locus of control were
associated with older adults who engaged in more health-promoting activities. This study
supports the HPM’s theoretical proposition that modifying factors of gender, race, level of
education, and age are associated with differences in the cognitive-perceptual factors of
locus of control and perceived health status. Subsequently, cognitive-perceptual factors
of locus of control and health status were associated with health-promoting lifestyle practices.
In a subsequent study Speake, Cowart, and Stephens (1991) studied the influence of
urban or rural residence on older adults’ health promotion lifestyle practices. When in
come and level of education were controlled, investigators discovered that place of resi
dence did not generate differences in health-promoting behaviors. Low income negatively
influenced health practices, whereas higher levels of education had a positive influence.
Other factors influencing health-promoting behaviors included internal locus of control
and perceived health status. It should he noted that in both studies (Speake, Cowart, &.
Pellet, 1989; Speake, Cowart, <Si Stephens, 1991), factors of education, income, and locus
of control influenced health-promoting behaviors but explained only a small percentage of
the variation. These findings indicate that other predictors need to be investigated for
their contribution to explaining health promotion practices. Pender’s HPM indicates that
other cognitive-perceptual factors are also associated with health promotion. Il is important
to consider these factors as well.
Riffle, Yoho, and Sams (1989) also investigated health-promoting behaviors—specifically,
Appalachian older adults’ relationship between health behaviors, perceived social support,
and self-reported health. Older adults engaging more health-promoting behaviors also re
ported a higher perceived health status, and those with higher levels of social support en
gaged in more health-promoting behaviors. Once again, higher levels of education and in
come positively influenced participation in health-promoting activities. Participants tended
to participate less often in self-care activities such as screening and health education. The
HPM was supported in that cognitive-perceptual factors of perceived health and social sup
port influenced participation in health-promoting activities. However, these factors onlv ex
plained a small portion of variance in participation in a health-promoting lifestyle.
Two studies specifically addressed health-promoting practices of African-Ameiicans.
Both are important because relatively few investigations have been conducted on noni 'aucasian ethnic groups and health promotion. Ahijevych and Bernhard (1994) exam
ined health-promoting praciices of African-American women between the age'' . a 1 and
65 vears. Self-actualization and interpersonal support were the strongest areas of health
promoting activity, and exercise was the lowest. Higher levels of income, rhe presence of
a medical diagno-i'. and employment positivelv influenced participation in health
promoting behavior-, landings from this >tudv differed from other- m that cxerci-e partic
ipation tigured less significantly, but women m this study assumed more health re.-ponsibility and -ought pr<Sessional assistance when needed. Participant- in other -tudies tended
CHAPTER 1 1
Modeling Nursing From the Perspective of Health
335
to be white, more educated, and wealthier. Findings indicated that women responded dif
ferently to diagnosed illness than the HPM would indicate. According to the HPM, illness
does not have motivational significance for health-promoting behaviors. In this study
women with a diagnosed illness tended to participate in more health-promoting behaviors.
Foster (1992) analyzed the relationships between health-promoting behaviors, perceived
current health status, and life satisfaction of older African-American adults. Participants re
porting greater life satisfaction also indicated greater participation in health-promoting
activities and higher socioeconomic status. Those engaging in a higher number of health
promoting activities were less likely to smoke. One finding inconsistent with the HPM
was that current health status was not associated with health promotion participation.
Telleen (1993) compared health promotion practices of pregnant and nonpregnant
women. The researcher hypothesized that pregnancy would he a modifying factor that
would influence health-promoting activities. Both groups of women had moderate partic
ipation in health promotion activities. However, pregnant women demonstrated signifi
cantly better nutritional practices than nonpregnant women did. Pregnancy as a modifying
factor for health participation affected only nutritional practices.
Four studies used the HPM to predict participation in specific health-promoting activ
ities: seat belt use (Riccio-Howe, 1991), osteoporosis prevention (Ali, 1996), contraceptive
use (Felton, 1996) and attendance at preterm birth prevention classes (Serafine
Broom.
1998). Using rhe HPM, Riccio-Howe proposed that adolescent perception of importance
of health, locus of control for accidents, and an understanding of the benefits and barriers
of seat belt use would cue safety belt use. Findings partially supported rhe proposed model
in that the proposed cues to action modified behavior. Friend or parents use of safety belts
and perception of benefits of safety belts positively influenced safety belt use. Adolescents
who perceived many barriers to use tended not to use safety belts. Locus of control and
health value did not influence safety belt behaviors. Support for the HPM was offered by
the finding that cues to action, benefits, barriers, situation, and interpersonal factors in
fluence choices about seat belt use. The finding that a high value on health and high lo
cus of control tailed to influence participation in seat belt use did not support the HPM.
Ali (1996) examined the usefulness of the HPM in determining predictors of osteo
porosis prevention behaviors of young women. Using rhe HPM, she hypothesized that
cognitive-perceptual variables of perception of benefits and barriers to calcium intake, ex
ercise participation, self-efficacy, control of health, and importance of health would posi
tivelv influence preventive activities. Women reporting the lowest calcium consumption
commonly skipped meals, consumed a large number of caffeinated drinks, were overweight,
felt health was controlled by others, and perceived barriers to calcium intake and regular
exerci>e. Conversely, women with higher calcium intakes tended to be more pleased with
their bodv weights, believed that they controlled their health, valued health, knew about
health behaviors, and perceived that benefits for calcium intake and exercise existed.
Health promotion variables contributed to rhe prediction participation in behaviors that
prevent o-teoporosis and explained more than a third of rhe variance in calcium intake
but onlv a limited amount of variance in exercise behaviors. Perception- of benefits and
barrier'' io calcium intake influenced behavior in a manner c< ngruent with the HPM.
Felton (1996) differentiated characteristics of three groups of sexually active adoles
cents who used contraceptives consistently, used them intermittentb. or did not use
336
CONNECTIONS
Nursing Research, Theory, and Practice
contraceptives. Guided by the HPM, Felton proposed that cognitive-perceptual variables
of problem solving and self-image together with modifying factors of demographical char
acteristics, sexual history, and health promotion participation would explain contracep
tive behaviors. Characteristics exhibiting the greatest discriminatory power were age at
irst coitus, prior pregnancy, and participation in health-promoting behaviors. Those^who
t it not use contraceptives were different from consistent users in that nonusers had a
higher pregnancy rate, were younger at first coitus, participated in fewer health-promoting
activities, had fewer problem-solving skills, and were younger at the time of the study
Nonusers
...
onusers differed from intermittent users
in that they were younger at first coitus, had
lower self-images, and were more likely to be African-American. In this study, both mod
ifying factors and cognitive-perceptual factors directly influenced contraceptive behavior
Health-promoting behaviors as suggested by the HPM discriminated between women us
•f
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II.-*
pj,;.. "*
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5-
ing contraceptives and those who did not. Once again, modifying factors such as race and
age played a direct role in predicting behaviors. Future research can be directed toward
testing the theoretical linkages between variables of interest and concepts of rhe HPM
Using the HPM, Serafine and Broom (1998) hypothesized that low-risk pregnant
women who valued health, perceived the benefits of health-promoting activities" and
perceived few barriers to health-promoting activities would be more likely to attend
pregnancy-related education programs. Both the group that attended and rhe group that
did not attend a class about premature birth prevention valued health. However atten
dees perceived fewer barriers. Health locus of control did not predict attendance. Accord
ingly Pender (1996) has indicated that locus of control does nor always explain specific
health behaviors.
To summarize, participation in health-promoting practices was determined by both
modifying factors and cognitive-perceptual factors (Ali, 1996; Riffle, Yoho, & Sams, 1989bpeake, Cowart, & Pellet, 1989; Speake, Cowart, & Stephens, 1991; Riccio-Howe, 1991).'
However, almost every study found some notable exceptions to HPM concepts The fail
ure of cognitive and modifying factors to account stgnificanrly for differences commonly led
researchers to conclude that unexpected, non-HPM predictors influence health promo
tion participation (Riffle, Yoho, & Sams, 1989; Speake, Cowart, & Pellet, 1989; Speake
Cowart & Stephens, 1991). The relationship of illness to health promotion partic.pation
contradicted HPM concepts (Ahijevych & Bernhard, 1994). These studies collectively
question the relationship of modifying factors to cognitive-perceptual factors and their direct or indirect relationship to the model.
Exercise Five studies have specifically considered exercise as a health promotion
acrivity. Bonheur and Young (1991) examined differences in selhesteem. perceived benefits
o exercise, and exercise barriers for university students. Exercisers demonstrated higher
self-esteem and perceived greater benefits and fewer barriers to exerose. These find.nos
are congruent with rhe HPM. In a longitudinal study, Gilln ..nd Perrv (1991) compared
deferences in health-promoting behaviors and physical activity of middle-aoed women by
participation or nonparticipation in a stmerured exercise program. Unlike rhx^c of Bonhcur
and Young, the Gillis and Perry findings suggested that self-esteem d.d not significantly
mlluence exercise participation over time. However, participann, in a structured exerc.se
prooram promoted greater participation m exercise and better stress management over
time. Likew.se, Pender’s HPM predicts that self-efficacv. as a counirix e-^rceptual variable
CHAPTER 1 1
Modeling Nursing From the Perspective of Health
337
would promote exercise participation. The conflicting findings of these studies may suggest
that multiple factors that influence health-promoting behavior and must be investigated
further.
Comparing factors associated with exercise participation between white- and bluecollar workers, Desmond, Conrad, Montgomery, and Simon (1993) found rhe composite
sum of all physical activity—comprised of work-related, sporting, and leisure activities—
was associated with higher income and higher levels of self-efficacy. Higher levels of oc
cupational activity were associated with higher income level. It should be noted that many
blue-collar workers increased their base pay through overtime, which generated higher in
come. Workers with a higher perceived health status tended more often to participate in
sports. Blue-collar workers participated in more leisure activities. Leisure activity partici
pation was also associated with higher levels of self-efficacy. This study supports rhe HPM
in that self-efficacy was associated with exercise. However, modifying factors such as in
come also demonstrated an influence.
Neuberger, Kasai, Smith, Hassanein. and De Viney (1994) nr. oi ig.ncd factors influ
encing exercise participation and aerobic fitness in outpatients with arthritis. The causal
model predicted exercise participation bur not aerobic fitness. Modifying factors such a>
age, education level, severity and duration of arthritis, and previous exercise influenced
cognitive-perceptual factors of perceived health status, perceived benefits of exercise, and
perceived barriers to exercise. In turn, these cognitive-perceptual factors explained 20% of
exercise participation. This study demonstrated some support for rhe 1IPM; however, in
vestigators indicated that rhe direct rather than indirect influence of modih mg factor’s on
health-promoting behaviors might account for a greater proportion of exercise variance.
Garcia, Broda, Frenn, Coviak, Pender, and Ronis (1995) investigated the influence of
gender and developmental differences in exercise beliefs and prediction of exercise be
haviors in youths enrolled in grades 5, 6, and 8. Researchers found that girls engaged in
fewer leisure time activities than boys, reported poorer health status, and had poorer sell
esteem. Male gender, fewer perceptions of barriers, and greater access by African-American
youth to exercise facilities positively impacted exercise habits. Older youths were less likely
rhan younger youths to report having support for exercise or exercise role models. This
study indicates a need for and examination of direct and indirect variable influence on ex
ercise in youths.
Studies of physical activity and health promotion result in a mixed picture of how mod
ifying and cognitive factors influence participation. The studies bv Bonhcur and Youn*'
(1991) and Gillis and Perrv (1991) exhibit conflictmg findings. M<Hiking tactors such a>
income (Desmond, Conrad, Montgomery. & Smion. I99D. age, education level, sexeritv
of illness (Garcia, Broda. Frenn, Coviak, Pender, C Ronis, 1995), and previous exercise
demonstrated influence on physical activity levels.
Health-Promoting Interventions. A small number of studies focused <.n the influence
of interventions aimed toward health-promoting practices. Richter. Malkiewicz. and Shaw
(198/ ) compared nursing students engaged in three different .‘duc.ii;. >ual programs < n their
participation in health-promoting activities six months after intervention. One group
completed a health promotion course, one a clinical assc-mcnr with individual;zcd
consultation on health promotion activities, and the control group m adult health nursing
course. An overall decrease in health-promoting behavior- otcufred in ill
The
338
.t!U
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<-
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•
CONNECTIONS
Nursing Research, Theory, and Practice
exercise score decreased most for the control and assessment groups. Heart rates also
increased most in the control group. In this instance, the self-awareness Pender proposed
as a health-promoting factor did not change behaviors when heavy course loads interfered
with healthy activities.
Frenn, Borgeson, Lee, and Simandl (1989) qualitatively examined generation of lifestyle
changes by patients participating in cardiac rehabilitation following an acute coronary
event. Investigators discovered that enabling and disabling factors that promoted or pre
vented change were individualized. Repatterning was facilitated by changes in beliefs, at
titudes, and plans. Two of the cognitive-perceptual factors that Pender theorized—health
protection and health promotion—influenced both enabling and disabling lifestyle change.
Pender’s behavioral and situational variables, such as family, friends, and program influ
ence, also were important in either generating or preventing lifestyle change.
Campbell anti Kreidler (1994) also used a qualitative research approach to discover
whether older persons who participated in structured health-promoting activities and
follow up b< me v is its perceived themselves as more responsible for their health behaviors.
Thev .ils< examined whether older adults perceived themselves as well when they were
able to tunction in>Jependently. The health-promoting interventions assumed that “well
ness for older adults implied maintaining or improving the ability to function indepen
dently, despite disability or chronic illness, thus maintaining or improving quality of life”
(p. 440) However, »or older adults, mobility and freedom from pain were more associated
with their perceptions of wellness than being able to function independently was. Older
adults considered themselves healthy only if they were able to perform activities they per
ceived as worthwhile .mJ were reasonably free of pain. In this sample most of the partici
pants experienced at least one chronic illness and perceived themselves as unhealthy even
when health pru. iders perceived their wellness.
1 ampbcil nJ krciJlei (1994) pointed our differences between their findings in a com
munity oiureacii urogram and the HPM. Nurses who used the HPM considered patients to
be well n thev runcrioned independently, whereas patients considered themselves health if
they were mobile and free from pain. Patients tended to leave responsibility for care to
health;.ire professionals rather than assume active roles. Chronic illnesses made patients
feel unwell.
Intcrveniion stuJie> also produced mixed findings. Cognitivc-p'erceprual variables such
as health protection .mJ health promotion influence exercise participation (Campbell &.
Kicidier, 1994; Frenn, Boigeson, Lee. & Simandl, 1989), but other factors, such as heavy
w.'ik load, also plav i iole (Richter, Malkiewicz, N. Shaw, 1987). Modifying factors such
a- chroni. illness mJ mobihrv influenced participation in exercise as well (Campbell &.
Kreidler. . ; h). J ,,
„ .J news is that these intervent ions increased exercise participa
tion; however, manv other factors facilitated or diminished exercise participation.
Research Summary. In summary, tests of the HPM have vielded mixed support In
-riidies in\'''siig;itu'he rei u onshipof in<h\ iJual v iriables related to parcicipatism in
'iib a in
, only a portion of the variance ha- been expl.lined (Huffy,
a ji)i.)
’7; Pe•nder. Walker, Sechri.-t,
Frank-Stromborg. 199C). Multi. 11 iiifi: -a ‘na 1 . x.u mi. a 1 ■ns ol I IPM <onccpis t |i>hn-on. Ratner. Bott.trfi. N I layduk, 1993;
Ramer. Botmrfi, |<'Im- 'ii. Cs Hayduk, 1994, 1996) generated link support for the HPM.
These st; In u
red f. a mcorporat iiit' .>nh' a limma! number rather than all the
CHAPTER 1 1
Modeling Nursing From the Perspective of Health
339
1
cognitive-perceptual factor into the causal models. Moreover, measures selected to discern
the cognitive-perceptual variables and health-promoting variables were somewhat
constrained in the study by Johnson, Ratner, Bottorff, & Hayduk (1993) because the
database did nor permit specific instrument selection. Causal modeling studies by Lusk and
others (1993, 1994, 1997, 1997) that used larger numbers of cognitive-perceptual factors
proposed by the HPM yielded greater support for selected health promotion behavior
participation, particularly when considered in light of Pender’s modifications (1996) to
the HPM. Revision of the HPM included identification of additional factors that directly
influence engagement in health-promoting activities. These factors include activity-related
affect, commitment to a plan of action, preferences, and immediate competing demand
The HPM has provided a useful way of thinking about motivation for participating in
health promotion. Additional research should determine whether the model revisions
adequately identify the predictors of individual health-promoting behavior- Additional
intervention research using the HPM as a basis is also needed.
PRAXIS AND THEORY UTILIZATION: DESIGNING NURSING
PRACTICE PROGRAMS FROM THE PERSPECTIVE
OF PENDER'S HEALTH PROMOTION MODEL
Penders model has been used widely by researchers seeking to better undent -mJ health
promotion and nursing’s role in relation to the construct. This work has added >igrmcantlv
to the health promotion knowledge base and can help direct related nursing -. metier.
Embedding this work in a major theoretical nursing perspective with expher .nkaoes
would aid practitioners in incorporating health promotion into their total nur-mg prac
tice. Pender's work is considered a middle-range theory, but practitioners might . Jestion
exactly to what this middle refers.
The Variables of Concern for Practice
The variables of concern for practice are named in Figure 11-1. Much work
velop the substantive structure of these named concerns.
r< > de-
Describing a Population for Nursing Purposes
No references that describe populations using the HPM were found
in the liter ■.
classification svsrem for expressions of health (see Box 11-2)
lid form the •
population description.
. The
for a
Expected Outcomes of Nursing
The desired outcomes ot nursing from the perspective of rhe HPM
are ci
.-jih ru a
plan ot action and health-promoting Behavior.
Process Models
1 ender prop.
d, .• ihc pr, >cesses of nursing include assessment, : health, he .Ith r
health hc-havi a-, development of a health-protvction-pr. m. .rr -dan: mJ
health-related life-' de. ’ hese processes relate p> individuals, families ind
. and
Assessment. l'<-ndcr 11996) defines nursing assessment as ■ -vocmatic: collect- r 4 Jala
ihour par
he . i-> •_
beliefs, .mJ hehaviurj ivIe-. t:'; r. > Jc\e
I
340
J?
t
CONNECTIONS
Nursing Research, Theory, and Practice
protection-promotion plan’’ (p. 116). These data form the basis for making decisions about
strengths, problems, nursing diagnoses, desired outcomes, and interventions. A number of
assessment tools are used and depend on a variety of patient characteristics, including
cultural orientation and developmental stages. The goal of the assessment process is to
identify health assets, lifestyle strengths, health-related beliefs, patients’ at-risk beliefs
and behaviors, and desired changes. The assessment tools selected are those deemed
appropriate to the situation. A nurse using Pender's HPM presumably would make
available to patients a collection of tools developed both by nurses and by other healthrelated professionals.
Since Pender views the family as rhe social structure in which health-related behaviors
are learned, the family is also a unit of assessment. Pender suggests that individual and fam
ily assessments are interrelated. Family assessment includes both structural and functional
components using a variety of tools that have been developed and reported in the literature
of family-related disciplines. The nurse then chooses the most suitable tool to provide data
for further decision making.
■
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2
Community assessment is also an essential component of health assessment. This
process includes collecting data to determine needs, opportunities, and resources for initi
ating community health action plans. Again, Pender suggests a number of instruments that
can facilitate this data gathering. The time available and the purpose of the data deter
mines the nature of the assessment.
Developing a Plan. Nurse and patients together identify the goals to be achieved and
plans to accomplish these goals. Presumably, during the assessment process the nurse and
the patient will develop a broadly based understanding of health stage and health behavior
patterns, risk status, belief systems, and available options. Pender outlines nine steps that
make up the health-planning process. These are summarized as follows (1996, p. 147):
1. Suinmarue data from the assessment
2. Reinforce the patient’s strengths
3. Identify health goals and behavioral change options
4. Identify outcomes that will indicate goal achievement from the patient’s perspective
Develop a behavior-change plan
6. Identify incentives for change
7. Consider environmental and interpersonal facilirat' and barrier^ ro change
8. Determine a time frame for implementing the plan
9. Commit to behavior change goals, including developing support needed to accomplish goals
Pender does not propose a comprehensive theoretical basis for these nine steps. Rather,
these steps are derived from a variety of theoretical perspectives and use forms and proce
dures selected from a number of sources.
The Action Phase. In elaborating on the action phase. Pender again draws an a number
of theoretical models and positions related to planned change. Behavioral change is
patient-controlled and patient-directed. Nur<e> facilitate the change bv providing a
supportive climate, acting as a catalyst, assisting with various >tep> or the change process,
and developing rhe patient s capacity for change. Specific strategics include c< -nsciousness
raising, self-reevaluation, cognitive restructuring, reinforcement management, modeling,
counterconditioning, and stimulus control.
CHAPTER 1 1
Modeling Nursing From the Perspective of Health
341
practice Models
Additional development is required before practice models can be described.
Implications for Administration
Health promotion is complex, and the literature associated with various aspects of
health promotion is vast. Agencies that wish to adopt Pender’s HPM must define for
themselves health, health promotion, and motivation for health behavior so that they
can select perspectives, data gathering tools, and strategies for change consistent with
their conceptualizations.
Implications for Education
The HPM has been primarily a tool of research and, to a limited extent, practice. Bringing
the HPM into a broader theoretical system would facilitate practical education and use.
STATUS OF THEORY DEVELOPMENT
The model will gain strength with the development of or linkage to philosophy, espe
cially a philosophy of person. Pender focused her work on the definition of health and did
not link it to any particular nursing theoretical system. She has recognized Orem’s selfcare conceptualizations, noting that “the nurse focusing on health promotion is primar
ily concerned with universal and developmental requisites, although health-deviation
requisites . . . must be promptly attended to if they arise” (Pender, 1982. p. 99); She also
articulates health promotion with Orem s "educative-developmental nursing system
(p. 100). In describing directions for research on self-care, Pender noted that Orem’s
theoretical work has been the driving force for empirical studies of rhe various dimen
sions of self-care and related nursing care systems. However, Pender docs not attempt to
integrate the two bodies of work. Pender does not cite rhe work of Orem and her col
leagues in her conceptualizations (1990) about health and other dimensions of her work.
The HPM has great appeal to researchers and clinicians. The variables within rhe model
are being tested empirically, and rhe outcomes of these studies have been used to modify
the HPM. It would be helpful if the work on health promotion were developed in context
of a general theory of nursing.
r
NEXUS
Health promotion has become an integral component of nursing practice. Much
gy-V I of the current thinking about health promotion has been influenced by Pender's
model, which began emerging in the 1970s. To Pender’s credit, the model has evolved
through modifications based on research finding explicated in her most recent hook
(1996). Many descriptive studies exist, whereas few intervention studies have demonstrated
the effectiveness of nursing interventions in promoting health activities More theorytesting studies have been conducted for rhe HPM than for other tb.eoru- These studies
have partially supported the HPM while also indicating rhe presence of other, still undis
covered factors that impact participation in health-promoting activity'. Continued re
search needs to discern these factors. Further research also is needed to a«e<s rhe efficacv
of nursing interventions for health promotion.
—g search. Theory. and Prartjce
$
CHAPTER 1 1
REFERENCES
Modeling Nursing From the Perspective of Health
343
Ahijevych. K. tSt Bernhard
L- (1994). Hcalth-p
Research. 43(2), 86-89.
'nca'th'P^nioting behavioi
'rS0fAfr-n-Araericnn1TOmen.W„rs,„s
20(6).°f OSteoP°rosis Prevention among college
women. A,nenca„J„1,nM(o/Hm/r/i
... ^^hQta ^Hflied Nursing Research
Pender, N.J. (1996).
Pender NJ.. Walker. S.N., Sechrist, K.R ^nTstr h N
N,<rs,nSSc.ence Quarterly, 3(3) 115 i27
APP'-n & Ltnge
’
Ratner' P
Rcsearch’ 39<6). 326-332 m
. • ^,rt^J-John.son.J.&Havduk L (1994) Th
‘ ’ 1990, PreJlcrin« health-promoting lifestyles
Oll,eradulB>™prio„sa|xlllt„.e||nc,
457-447. X krU'll>r' M
n“n.ond. A.. Conrad. K. Montgomery. A. &
....... ........ ....................... ...... * proJournal of Holistic Nursing, l4(^
V ,
.................
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I.
CHAPTER
l"
Modeling Nursing From the
Perspective of Human Relations
PEPLAU'S THEORY
of INTERPERSONAL RELATIONS
5..
Key Terms
dimensions of relations, p. 348
nurse-patient relationship, p. 346
psychodynamic nursing, p. 346
I
1:
Asked what motivated her to develop the Theory of Interpersonal Relations, Pepl
responded:
After my service in the Army Nurse Corps during World War II, it occurred to rne
that I knew things that would be worth knowing by other nurses. So I wrote the
book [Interpersonal Relations in Nursing, 1952]. The book was very controversial
at the time—publishers said no nurse should write such a book. Finally, Putnam
published it, but they were very apprehensive. It was well received. It has never
been revised. I think it was way ahead of its time. I have never really promoted
my work. I never thought of myself nor spoke of myself as a theorist My back
ground in psychology included theory. I just wrote what I knew (personal com
munication, October 7, 1997).
(T1PIU i> u>cJ prim.mlv in p<\\hoan ilyds
The Theory ot Interpersonal Relations (TTPR1
and psychotherapy. Some form> of nurse rherapv, particularly in the j ■ jct’.ccs of clini
cal specialists in psychiatric mental health nursing also have used the TIPR (Peplau.
N97 V
345
346
S'
CONNECTIONS
I
Nursing Research, Theory, and Practice
CHAPTER 12
Modeling Nursing From the Perspective of Human Relations
347
THE STARTING POINT OF MODELING NURSING
aststartSpo'T'sull^n 0953) was'notedS'?”?
Su"ivan
Which includes the impact of culturJZrce on
T 1?te'pers™al Rela^ns,
Peplau uses Sullivan's modes of experiencing as onTof h deVelOpment' for examPle,
Peplau advocated using knowledge from other di^r' I
lnterpersonai constructs,
science (1969). Her main interest was to derive con^
VieW|n8 H1’™08 35 3Pplied
other sconces to identify then congruence with nt.rs.ng praence”
a' di'ta
f™"1
Peplau s work assumes the following (Peplau, 1952, p. xii):
'■
........
................ .
■
•«
1
*
cation. Nursing
personal problems.
A third assumption, identified .is “implicit," is
"the nursing profession has legal responsibility for rhe effective use of nursing and for its
consequences
to patients" (Howls. Brophy,
Carey, Noll, Rasmussen, Searcy, & Stark, 1998, p. 339).
£
i;
,£• ... -
................ ........... -....
ru
Phenomenon of Concern
•:
~
Description of Model and Theory
The main elements in a nt.rse-panent relationship are two persons, professional experroe
and patient need. The relationship is time-limited and therefore has starting ami endmg
points that necessitate three phases: orientation, working, and resolurion. The concepts
of interpersonal relations explain psychosocial phenomena and rhe personal hehava.r of
the nurse and patient in nursing situations. Three diagrams
rhe tr.tmework of
concepts. Figure 12-3 shows rhe changing aspects of nurse-patient relation^ The t
overlapping phases in nurse-patient relationships are shown in Figure 12-4, and the ph;
;isc> .mJ
changing roles in nurse-patient relationships arc presented in Figure 12-5. Pcplau -1
m< >sr rcXX?i99^1997)nCll,dC mt)deiS/,t’’' Se- klt she °,llcJ ,he T,m u usc,ul ^eorcrwal trame-
Reason for Theory Development
p!-;
The TIPR concepts frame understanding of many of the dilemmas that patients expe
rience within the domain of professional nursing practice. Peplau considered the domain
of nursing practice congruent with the ANA definition, which identifies it as “the diagnosis
and treatment of human responses to actual and potential health problems” (1994,
pp. 6-8) The primarily subjective art of nursing seeks knowledge of the unique and highly
personal vanations of patterns of difficulty and behavior of individuals in their responses to
actual and potential health problems. Nursing art illuminates the scientific undersrandin<’
of the problem. Nursing science attempts to empirically explain and address the patterns of
difficulty and problems m human behavior. Peplau often commented that nurses need to
increase their understanding of a broad range of human problems and use both the art and
science of nursing to understand the options available for practice. Peplau and others wlentified many concepts and constructs within the scope of rhe theory. Examples of rhi- are
seen in Figure 12-1 and Figure 12-2. Peplau referred to (he TIPR as a body of knowledge
and a source of theory (1997); however, she offered no general model or statement of the
theory.
“ins-!“.. t-
. .... ..... "-i"
cep., eonteinej within hetTIPR htiinetiie""Xind'ie ee"
'"'-h" the eonpatient in nursing situations and the nsveham-' I I
r°na beI’13v,or of thc nurse and
. ................... *......... ...
.......
description OF PEPLAU'S
theoretical system
Philosophical Perspectives
the universals, the commonalities in patterns an I nr'I I
" m
sxpl.uns
croup "lie referred to thi-> i<tiv • -r
■ . ‘ * 1l-H R,l lem> of hum.ms as a
chodynamic nursin’:
’
the
P-ent as psy-
The use of self by the nurse in conjunction with rhe patient efforts produce- rhe Jeered
ei
lS l)f 1 ,‘1Vcl°pin” Per^nality and meeting human needs. Peplau was firm in her belief
tut, oveia , much of nurses work occurs during interaction with patients (1997). The
nurses roles were multiple and included that of stranger, resource person, teacher, leader, sur
rogate, counselor, consultant, tutor, safety agent, mediator, administrator, recorder obscr er
and researcher. Peplau (1992) noted that the scope of theoretical constructs reqmred toi
the practice of nursing is more comprehensive than she has presented. Peplau (195?)
ma le desenhed four phases of the nurse-pat.ent relati. .nshq—orientanon. tdcntifk „ s m
exploitalam.and resolut,on.B,,cl.uk ( 194] ) redefmed dww i-haw. .n-.cm.,,,..,, ...... kinJ
and resolution. Peplau (1952) described the following concepts „> her intnal work;
Instinctual and acquired human neetls
l:nerg\ and energy transformation
° Psychological experience.^, -uch .1- frustration
mflict. anxierv.
mJ oppimno
• I -at lb >1.>L»icdl rasks. •'iich as Ic.irnme To count on
' ■ The:-', ic-irnmu r Jcl.o >,iri'r <<. Hon, identifying oneself, and Jevelopin.e .-kills in parucipaui m
• The interlocking operations of the nursinn process . >h>ervati. m.
Ci'ininuniciii:
.mJ reci irJin.c
348
I
CONNECTIONS
I
Nursing Research, Theory, and Practice
Needs
Frustration
(One goal)
Conflict
(Opposing goals)
Modeling Nursing From the Perspective of Human Relations
Barriers
that block
progress
Steps toward a goal.
Feelings
of
satisfaction
\
Action that avoids the problem
Give up goals automatically.
Give up activity connected with
achieving goals.
Try to “forget" the difficulty.
Invest energy in operations
designed to maintain security,
feelings of safety.
3
2
1
*
I
I
Values and goals
of other
individuals
GOAL
I
I
I
349
Goal and responses to
achievement of a goal.
Feelings of
personal
inadequacy
(Provides energy that converts
into a form of action.)
Tension
Anxiety
Action that approaches the problem
Struggle to identify the “felt"
difficulty.
Identify factors related to the
difficulty.
Clarify understanding of factors.
Lower or change the goal to one
compatible with what is possible.
Struggle to get satisfaction of wants
and to achieve goals
CHAPTER 12
Feelings
of
security
Immovable
objects
I
I
I
Direct aggression
Overresponding
Euphoria
Suggestibility
Overcompensation
Destructive
aggression
< • •
pi
■ ::5
(L § c:
Normal defense dynamisms
Identification
Substitution
Compensation
Sublimation
Compromise
Rationalization
Direct attack upon the problem
Understanding the problem
Actions appropriate to that
understanding
Overresponding
by inhibition
Withdrawal
Negativistic
Self-punishment
I
Toward the
barrier
itself.
Toward objects
and individuals
resembling
the barrier.
Neuroses
Acting out
symptoms
I
Five dimensions of relations were added to Peplau s conceptualizations in 1992. These
give a broader perspective to interpersonal relation1' anti recognize many tvpes <>f relations
tor many different purposes. These dimensions are rhe following (Peplau. 1992, p. I ;
• 1 heir nature (named patterns or themes and variations)
I
I
Toward objects
and individuals
who do not
resemble the
barrier.
Toward the
self.
Possible courses of action
I
Identify the
barrier.
Psychoses
Accident proneness
Delinquency
Masochism-sadism
l
I
/ Fixation
\
/ Projection
\
/ Displacement
\
Reaction-formationX
/
FIGURE 12-1 Transformation of energy into behavior. (From Peplau, H.E. (1991). Interper
sonal relations in nursing. New York: Springer Publishing Company.)
• Their origin (history)
I
Pathological defense dynamisms
/ Re9T \
Indirect aggression
I
Relate experience to
level of aspiration
and/or to the goal.
Transformation of energy |
Discharge the
tension by
venting aggression
toward others or
self.
Give up the goal
and the response.
Strengthen
pathological defenses
in order to feel safe.
Vary the goal in
light of experience
FIGURE 12-2 Actions involved in frustration. (From Peplau, H.E. (1991). Interpersonal rela
tions in nursing. New York: Springer Publishing Company.)
350
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 12
Modeling Nursing From the Perspective of Human Relations
351
Patient: personal goals
Nurse:
Stranger
Unconditional
Mother
Surrogate
Patient:
Stranger
Infant
PATIENT
Entirely separate
goals and interests.
Both are strangers
to each other.
Individual pre
conceptions on
the meaning of
the medical
problem, the
roles of each
in the problem
atic situation.
Partially mutual
and partially
individual under
standing of the
nature of the
medical problem.
Mutual under
standing of the
nature of the
problem, roles
of nurse and
patient, and re
quirements of
nurse and patient
in the solution of
the problem.
Common, shared
health goals.
Collaborative
efforts directed
toward solving
the problem
together,
productively.
Phases in
Nursing
Relationship:
Orientation
Counselor
Resource person
Leadership
Surrogate:
Mother
Sibling
Adult person
Adolescent
Adult person
Child
Identification
-
Exploitation
- Resolution I
NURSE
Nurse; professional goals
FIGURE 12-5 Phases and changing roles in nurse-patient relationships. (From Peplau, HE.
(1991). Interpersonal relations in nursing. New York: Springer Publishing Company )
RESEARCH DERIVED FROM PEPLAU S THEORY
OF INTERPERSONAL RELATIONS
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o
| On admission
z
o
I
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co
LU
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TL
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| Convalescence and
I rehabilitation
r
; Discharge
HGURE 12-4 Overlapping phases in r------nurse-patient
relationships. (From Peplau
Interpersonal relations in nursing. New
York:
H E. (1991).
Springer Publishing Company.)
1 heir function (intent, motive, aim, -oal
purpose)
* i iieir mode (lorm, sryle)
I neir mrcemrions (linkages with .,||lcr pVr>onS' he!
fi''ns about nursing practice.
'-'"•ijonmi of
1
nwcpmali:a-
Discovery using the TIER is a dynamic process in which both the :nurse ,ind the p.iricnt
must he understood. Reality consists of individual conceptions that arc L'ontcxruiil in n<iture and potentially conflict. The T1PR has guided qualitative research n)u(hod>, >uch
observation and interviews. Quantitative roearch rh.it uses ^elected measuring instrument
such as those described in the following discussion also has been completed.
Research Instruments
lour teseaich instruments have been developed to measure aspects of mrerpcrsi’iiai rela
tionships suggested by Peplaus theory, including the Social Inretaction Inventoiv. .. ther
apeutic behavior scale, the Empathy Construct Rating Seale, .mJ the Relationship Eorm
(Table 12-1). The earliest instrument development began in Wb2. mJ the final instru
ment was developed in 1989, when Peplaus theory resurged in popularity. These instru
ments arc explained in rhe following sections.
Social Interaction Inventory. Merhven and Schlotfcldt (I'h'D designed the Soma!
Interaction Inventory to determine the nature of rhe verbal re>por.>cs that numc> u>e in
emotionally laden situations. Investigators developed the inventory b\ observing and
describing stressful occurrences in hospital situati. n> Nurong student and registered
nurses generated potential responses to rhe described situations. The Social Interaction
Inventory was derived from these sima’am- and rc<pon<e<. The Im d formar contained
30 situations that represented problems nurses encountered. Five
■'{ rep!
presented for each situation and are as follows:
• It the patient experiences an unmet need, the nurse < onv w. • 11 the patient experiences a problem, the nurx
num . -m ..-s .Vmp c
• It the patient experience-a problem, the
m
m ::c
rhe nur-!
nur<t.
problem.
s A pal ieiir c.xpre<-e- a need, bur rF,-. mu: .-.I v n.
r?
• A patient ex prea nev i. bm ■! > -a
r del..
IX
u \ C.UU 1 n UM-;
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</rt>%>
TABLE 12-1
QJ
n_
■
Research Insti
Instrument/Description
)laufs Theory of Interpersonai Relations
Study/Year
Reliability and Validity______
Social Interaction
Methven and
SSf
Inventory
Scholtfeldt, 1962
30 items with five
Er
ro
O
aTS: SeniOrhS,UdentS fa = 70)'
85 -ses (n ?
cu
diploma nurses (n = 61) Th
2
nr
mr,
nUrSeS W',h 1
□
0,C°"eSe <“ = 6°>' and ^duale
Q-
communication
responses for each
item
S
ft
s
Therapeutic Behavior
Spring and Turk,
Scale
1962
5-category rating
cons.stency, as measured by Spearman Brown
split-half coefficient, was 0.91. Construct validiXV
scale
received significantly higher therapeutic behavior scores than studen s^TsT/X 0 05)' Comelaf
behavior scores with outside judges' ratings yielded correlation.; rannin
■ •
:-------------------------------
Empathy Construct
Rating Scale (ECRS)
100-item, 6-point
............. corrHati(,n be^en
LaMonica, 1981
oT< E S O'°?' Correlatlon of therapeutic
<g q-0^
Students generated Initial items, which an expert panel then evaluated for content valid^ AddSS&^Jal^ to the pool based on expert judgment. The final instrument had five subscales that consisted of 100 items: 46 represent
ing lack of empathy and 54 representing well-developed empathy. Reliability was established for most (Form A) and
east empathetic persons (Form B), Students (N = 103) completed the ECRS. Coefficient alpha for Form A = 0.97 and
for B - 0.98. Split-half reliability using Spearman Brown correction for Form A was r = 0.89 and for Form B = 0 96
Likert scale
I
>
T>
Multitrait-multimethod validity was established with Carkhuff's Index of Communication, California Psychological Inven
TO
tory, Human-Heartedness Questionnaire, Chapin Social Insight Test, Philosophy of Human Nature, Vocabulary Test-GT,
and Tennessee Self-Concept Scale. Instrument packets were completed by 300 registered nurses and nursing students,
each of whom identified a peer and a patient who subsequently completed questionnaire packets (Total N = 900). Prin
cipal components factor analysis with varimax rotation was used to analyze responses to all instruments. A 6-factor so
lution in which empathy subscales composed the initial factor emerged. Empathy, accounting for 48% of variance did
not share variance with any of the other derived factors. Subsequent principal component analysis of ECRS using sub
ject peer, and patient responses revealed two factors—Well-Developed Empathy and Lack of Empathy. The multitraitmultimethod matrix demonstrated discriminant validity between Empathy-self and Empathy-client.
Relationship Form
One-page form de
lineating phases
of nurse-patient
relationship
Forchuk and
Brown, 1989
Content validity was established through review by three mental health clinical nurse specialists and was reviewed by
Peplau Interrater reliability was established through clinician and CNS review of 32 randomly selected records and
through rating the relationship phase of each record. With a 7-point rating scale, there was a 91 % agreement within
1 point of each rating. Perfect agreement occurred 41 % of the time and had a Kappa of 0.41.
£
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354
I •:
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::5
S""*
’i':
iC-i
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cxi
4
::
CONNECTIONS
Nursing Research, Theory, and Practice
Developers perceived that the first response of awareness and conveying concern is the
most effective. The subsequent responses limit interaction. Scoring is accomplished bv
coding the type of response selected from the five options.. Individual scores are then cal
culated to indicate the number of times each type of response was selected. Scores can
range from 0 to 30 for each response type. Each participant has five scores.
Validity was established by using known groups technique in which investigators tested
their predictions about how the groups would respond to the Social Interaction Inventory
Students, who were more informed about psychiatric nursing techniques than graduate
nurses were, selected the greatest number of therapeutic responses. Meth ven and Schlotfeldr
concluded that the Social Interaction Inventory could usefully evaluate verbal communi
^nvZtv 21 Tl,dCn? 3nd P7Ctitioners- DesP“e the relatively early development of this
inventory, only limited research measuring social interactions followed it.
Therapeutic Behavior Scale. The therapeutic behavior scale
created by Spring and
Turk (1962) was originally a 6-category scale designed to score o
observations of verbal
interactions between psychiatric nurses and patients. The six categories included approach
to patient, level at which interaction is responded to, topic, focus on patient versus
therapist, consistency, and sentence structure. Testing found that five of the six of the
categories—all but the sentence structure category—fit into a unidimensional scale
Scoring was accomplished by breaking the interaction into individual verbal units and
rating each verbal unit as therapeutic (scored as a 1) or nontherapeutic (scored as 0) in
each of the five categories. Each verbal unit could receive a score of 0 to 5. The ratings of
individual verbal units were totaled and a mean score (rhe therapeutic behavior score) was
derived Inrrarater. interrater, and internal consistency reliability were strong. Validity
resting demonstrated that the five categories of the behavior scale were unidimensional
and could yield a single therapeutic behavior score. Comparisons with outside judges and
with instructor evaluations were within acceptable limits to establish validity. Again, this
scale was developed at a time when nursing research was in its early stages. This instrument
has subsequently experienced relatively little use.
Empathy Construct Rating Scale. LaMonica (1981) created the Empathy Construct
Rating Scale (ECRS) to measure empathy through the use of positive and negative
statements on the topic. The ECRS is a 100-item, 6-point Likert scale with item scores
ranging front 3 to + 3. To score it, investigators reverse the scores on negative scales and
then add all items. Total scale scores range from -300 (lack of empathy) to +300 (welldeveloped empathy). Reliability and validity were well-established (see Table 12-1)
Findings suggested that empathy existed as a whole entity that could not be further divided
mro subscales.
Relationship Form. Forchuk and Brown (1989) developed rhe Relationship Form to
measure phases ot the nurse-patient relmionship as described by Peplau’s theory. The
-page formal includes a brief summurv <>f each phase and presents a pictorial guide to assist
in monitoring rhe relationship. Initial content validity was established. Perfect-agreement
mrenater reliability was only 41".. bur rose to 91% when scores w.rhin one point of one
another were me uded The murumenr was clm.calh useful in assessing nurse-patient
relationship-. Although miu.,1
mum of reluihilitv and validity are adequate, further
refinement is needed.
CHAPTER 12
'
I
I
I
I
|
Modeling Nursing From the Perspective of Human Relations
355
Review of Related Research
Reseated using Peplau’s model began during the early 1960s, a time when using research to
establish nursing practice was a relatively innovative idea. Early studies provided mixed
findings of support for tenets of the TIPR. It is interesting to note that research efforts
about interpersonal relationships in both psychiatric and nonpsychiatric patients and work
roles are still guided by Peplau’s conceptualizations. However, many of these conceptual
izations have not been systematically investigated. This review will focus on recent, pub-
nooy
With the mOSt cohesive Program-Forchuk’s examinations
(1|99-’ 994, 995a.’ 99:,b’ 1998) ot nurse-patient relationships. Following nurse-patient
relationships the chapter will describe studies of depression, work roles, and medication
compliance, lable 12-2 summarizes these studies.
Nurse-Patient Relationships. Studies on nurse-patient relationships encompass the
work of Forchuk and that of others studying therapeutic relationships. Nurse-patient
relationships have also been studied in nonpsychiatric patients (Vogelsang, 1990) and in
panents w.th dementia (Middleton. Steward, & Richardson. 1999) or Alzheimer's d.sease
(Wi'l.ams 61 Tappen, 1999). Following development of the Relationship Form, Forchuk's
initial work (1992) began by examining the length of the orientation phase of the nurse
patient relationship. Because Peplau established that the orientation phase represented
the first stage of therapeutic work, Forchuk examined the factors influencing the time it
took to establish trust, identify the roles of nurse and patient, and pinpoint relationship
problems to improve. Number and length of hospitalizations factored in the length of the
orientation process. Patients with the longest orientation phase had more and longer
periods of hospitalization. Some panents who had moved to a working phase reverted to“an
orientation phase when a change ol staff or worsening of psychiatric illnesses occurred
In rhe next phase of research, Forchuk (1994) tested an aspect of the TIPR concerned
with the orientation phase ot nurse-patient relationships. Peplau proposed that character
istics of both the patient and the nurse influenced evolving therapeutic relationships The
nurse s positive preconceptions of rhe patient and the patient’s positive preconceptions of
the nurse facilitated development of therapeutic relationships and tended to shorten the
orientation phase. Preconceptions developed early in rhe relationship and did nor change
substantially over the 6-month study. Other interpersonal relationships for patients influ
enced progress of therapeutic relationships. Anxiety on the part of the nurse or rhe pa
tient did not significantly influence the therapeutic relationship. Combined nurse and
patient variables influenced perceptions of evolving nurse-patient relationships. This studv
partially supported Peplau’s proposal that certain factors influence development of theta'peutic relationships. However, anxiety and the presence of other relationships may not in
fluence formation of therapeutic relationships to the degree Peplau suggested.
n subsequent secondare analyses of rhe original prospective study Forchuk (1995a.
95b) exammed factors influencing the progress of therapeutic relationships and uniqueness wirhin nurse-patienr relationships. Patients with previous lengthier hospital stavs
tended f spend more tune m the orientation phase. Shorter Orientation periods were associated with longer meetings and a greater total rime per month spent in meetm-'s
Progress m therapeutic relationships occurred more qu.cklv when nurses were older and
had more nursing experience, particularly m psvchiatnc nursing More meeting rune per
rex: conunued on p
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TABLE 12-2
w
Study/Year
z
IZ1
Methods
NURSE-PATIENT RELATIONSHIPS
Forchuk, 1992
Z
c
Purpose
This retrospective record review exam
ined the length of orientation phase of
patients and nurses in a community
mental health program.
Seventy-three patient charts were reviewed
and rated by an investigator using the Rela
tionship Form. Most common diagnoses in
cluded schizophrenia and depression.
Findings
5‘
IQ
Fifteen patients were still in the orientation phase af
in
fP
QJ
ter 1 year. The length of orientation ranged from 1 to
23 months, with an average of 5.9 months. The num
ber and length of psychiatric hospitalizations was sig
nificant in determining the length of the orientation
n
H
phase. Thirty patients reverted from the working
O
Phase to the orientation phase with a change of staff
£
cu
or worsening psychiatric illness.
Forchuk, 1994
The study tested Peplau's theory of in
fluences during the orientation phase
of the nurse-patient relationship.
A prospective, longitudinal design was used to
identify factors related to the development of
therapeutic nurse-patient relationships. Inde
pendent variables of preconceptions, interper
sonal relationships, and anxiety, and depen
dent variables of development of therapeutic
relationship were measured at initiation, at 3
months, and at 6 months. One hundred '
Wty-fou, nurse-patient dyads began the
study. Fifty-seven remained at 3 months, and
Forchuk, 1995a
Tin's secondary analysis identified fac
tors influencing the progress of thera
peutic relationships during the orienta
tion phase.
A nonprobability sample of 124 nurse-patient
dyads was used. Progress in the therapeutic re
lationship was measured by the Relationship
Form and Working Alliance Inventory.
□
Q.
idty-one of 94 nurse-patient dyads completed orien
tation. Thirty others discontinued the relationship
while still in orientation, and 13 remained in orienta
tion after 6 months. Preconceptions of both the nurse
and the patient most were significantly related to the
development of therapeutic relationship (r = 0.37
patient and 0.31 nurse, g_< 0.05). Combined nurse
Patients who stayed in orientation phase longer had
longer previous hospital stays (r — 0.43, g. < 0.007).
Patients with longer meetings with the nurse and a
greater number of meeting times per month had
shorter orientation periods (r = -0.24, p < 0.05).
rience (r = 0.24, p < 0.05), length of relationship
with the patient (r = -0.27, p < 0.02), total
monthly meeting time (r = 0.32, p < 0.01), patient's
age (r - - 0.24, p < 0.05), and number of previous
hospitalizations (r = -0.30, p < 0.03).
This secondary analysis explored the
uniqueness of therapeutic relationships
of nurses with two different patients
and patients with two different nurses.
s
and patient variables explained over 60% of the
variance in perceptions of the evoiving tapeutic
Progress in the therapeutic relationship was associ
ated with the nurse's age (r = 0.29, p < 0.02), nurs
ing experience (r = 0.26, p < 0.03), psychiatric expe
Forchuk, 1995b
TJ
OJ
r+
Thirty-eight nurses with two different patients
and 13 patients with two different nurses com
ceptions of two patients or of patients' preconcep
No significant correlations between nurses precon
posed the sample. Data from the Personal Re
tions of same nurse were found. There was a strong
source Questionnaire, Beck's Anxiety Inventory,
Working Alliance Inventory, and Relationship
correlation (r = 0.84, p < 0.001) between the num
Form were used in analysis.
nurse and with each patient. Nurses spent similar
ber of weeks for the orientation phase with same
1
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r+
amounts of time with each patient. For patients with
two nurses, no significant relationship between pa
tient preconceptions of each nurse and therapeutic
relationships were found.
in
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2.
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TABLE 12-2
---- gHtyfer
Purpose
. ....... HUj
Forchuk,
Westwell,
Martin,
Azzapardi,
KosterewaTolman, and
Hux, 1998
O
2
Methods
nurse-patient relationshipIZ^Tj
ntt?oXnCemOVenientfrOm,hf!'>ri'
to
Findings
Tta qualitative study identified factors
Z
c
Unstructured interviews were conducted with
entation phase to the working phase of
therapeutic relationships in tertiary
psychiatric settings.
===s
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able to be w™ s me n
?
and be ,isteTOd «<>.
°
un
rt>
Patient, nurse, and clinical specialist AudH
£D
anaXndterVieW!Wre'r3nSCribedi,nd
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Middleton,
Stevv-ard, and
Richardson,
1999
Vogelsang,
1990
Williams and
Tappen, 1999
This intervention study examined the
impact of ambulatory surgery patients’
continued contact with a familiar nurse
form before admission to discharge.
The study examined the feasibility of
developing a therapeutic relationship
with patient with moderate- to late
stage Alzheimer's Disease (AD).
.
oT'n9rel3,iOn-
3
Q.
C °Se' genuine- trust-
s
o
-"burses were not pemeiX^X^
o7VrmatomeS'iS3ted,heperceP,ions
menthlit 9!VerS°nSpefia'caredplon^^^'^^al
.v.
sh'P^henursePXX
mg, friendly and soci^hin tr
faction.
-
ana job
A convemence sample of 40 women—20 in
experimental and 20 in control groups—
participated.The experimental group received
contact from same nurse before admission at
postoperative awakening, and at discharge
rom the postanesthesia care unit. Interviews
were conducted 3 to 5 days after discharge.
Researchers analyzed the transcripts of 42 dents' sessions conducted by 4 adrancedliac'
Ure
re„. .................
P
to n„
nurses
(APNs’.APNi met w,,h part.dpams
3 times per week for 16 weeks. Recording oc
curred during the first, eighth, and sixteenth
weeks.
62.89, SD = 28 n7~~ n '57 than T Staff
=
tress over the dkm'n^ °’05) but exhibited less dis-
Contact group members m^rtedgreat
return home (t = 3.75. p < 0.005). Seventy-five per°
y t0 be dlschar9ed' compared to 45%
the control group. The contact group also reported
greater satisfaction with nursing care (t = 3 1
B 0.01); 80% believed that care was excellent
compared to 40% of the control group.
of
X
>
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IxJ
» PbS?
vwballzKj ,rust
2
urra distrust. During the working-identification phase
patients verbalized emotion, feeling, satisfaction and'
enjoyment of interaction, and affection for the nurse
scribed
wfork,n9-exP,oi,a'ion phase, patients de
scribed specific emotional events and desired contintitlinn h
h'PS W'th nUrSeS'Durin9 the resolutiont^re1atahipat'en,SeXPreSSedSadneSSa,endin3
O
Q.
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TABLE 12-2
LO
Selected Research Studies Using Peplau's Framework—cont'd
Study/Year
Purpose
Z
c
Methods
5’
Findings
IQ
DEPRESSION
Beeber and
Caldwell, 1996
The study examined clinical data from
a pilot intervention program to identify
pattern integrations in reciprocal inter
actions between nurse and patients ex
periencing depression.
Data were gathered from the clinical interac
tions of the investigators with six women over
four months. Each woman participated in four
to 15 intervention sessions. Through collabora
tive relationships with two primary care
zr
ro
o
and patient. The most commonly observed pattern in
tegration was "helpless persons and helper nurse," a
complementary form of interaction. Patients per
assessment and intervention. Intervention con
sisted of interpersonal relationships in which
ceived that they were unable to solve own problems
and therefore relied on the nurse. Mutual patterns
other strategies such as health practices, cog
were demonstrated by helper-helper roles, in which
the nurse directed the patient to do certain things
from 42 hours of taped intervention sessions.
LA
sponses. Consistent core elements were reviewed to
discover the nature of reciprocity between the nurse
providers, patients were referred to two psy
chiatric mental health clinical specialists for
nitive interventions, and social network
changes—were used. Analysis was derived
?
Clusters of behaviors constituting patterns for pa
tients were identified and paired with nurse re
□
Q.
s
ft
and the patient was helpful in return. The alternating
form of pursuer-distancer was embodied by either the
rt>
patient or nurse alternating pursuit or maintaining
distance in relationships or therapeutic issues. Antag
onistic patterns occurred in poor fits between patient
and nurse. The patient portrayed herself as cold, re
jecting, and critical, while the nurse remained engaged in the relationship, even when the patient de-
.
rwt
■■■
Beeberand
Charlie, 1998
This study evaluated a primary care in
tervention measure for its ability to de
crease depressive symptoms.
.....................................................................
’.
'
Thirty-three women with depression partici
pated in eight therapeutic sessions based on
the TIPR. Before and after intervention, they re
sponded to the Beck Depression Inventory, De
scribe Yourself Inventory (self-esteem), and
Tilden's Interpersonal Relationship Inventory.
Intervention consisted of assessment
(thoughts, feelings, actions, and body), devel
Depression was significantly reduced (BDl
= 233;
SO =■- 9.32; Post M = 7.03; SO = 6.23; i = 8.76,
df = 29, p = 0.000). Increases in efficacy and selfesteem were not significant. No difference in social
self-esteem was found. Satisfaction with interper
sonal relations also increased, but it did not increase
significantly.
>
m
73
opment of a problem statement and targeted
o
outcomes, contract agreement, and sessions
with a psychiatric mental health advanced
Q.
2.
practice nurse.
z
c
WORK ROLE
Morrison,
The study operationalized Peplau's
One-to-one interactions of 30 psychiatric staff
Primary work roles on the adult unit most often in
Shealy,
work roles of psychiatric staff nurses.
nurses with 62 patients were taped. Tapes
cluded counselor, resource person, and surrogate. On
were transcribed, and content was analyzed to
identify role behaviors, describe work roles,
surrogate, resource person, and friend.
Kowalski,
LaMont, and
Range, 1996
the adolescent unit primary roles included counselor,
3
and compare work roles with Peplau's concep
tualized roles.
MEDICATION COMPLIANCE
Lund and Frank,
This descriptive study compared nurses'
1991
and patients' perceptions about med
ication compliance and reasons for
noncompliance.
The sample consisted of 25 adult psychiatric
patients and 25 registered nurses who com
pleted an investigator-developed medication
compliance questionnaire.
5’
IQ
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ft)
Compliance ratings by nurses and patients were simi
lar, which indicated similar perceptions. Veteran
1?n
nurses believed noncompliance to be greater than
nurses in practice for less than 5 years. Patients and
nurses offered different reasons for noncompliance.
Almost half of the nurses believed that patients did
not perceive a need for medications. Although some
responses were congruent, patients offered reasons
for noncompliance—ranging from lack of medication
effectiveness to lack of transportation tolDharmacy—
that were not identified by nurses.
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Nursing Research, Theory, and Practice
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CHAPTER 12
Modeling Nursing From the Perspective of Human Relations
363
month also facilitated progress. Hindrances to progress in the relationship included shorter
time knowing the patient and greater number and duration of previous hospitalizations.
Examining uniqueness within relationships, Forchiik (1995b) found that the same nurse
working with two different patients had different preconceptions regarding each and thus
had different patient relationships in terms of bond, task, and goals. Patients treated by
two nurses had different preconceptions and different therapeutic relationships with each
nurse. Patients who formed new relationships with a second nurse tended to develop work
ing relationships in less than 3 months. A combination of nurse and patient factors influ
enced the quality of therapeutic relationships, and relationships tended to be unique.
In the most recent step, Forchuk, Westwell, Martin, Azzapardi, Kosterewa-Tolman, and
Hux (1998) identified influences on movements of nurse-patient dyads from the orienta
tion phase to the working phase. Progress in therapeutic relationships was facilitated by
the positive nature of planned therapeutic sessions, nurse activities between sessions on
behalf of the patient, and the nurse’s attitude. Hindrances included perceived unavailabil
ity of the nurse, lack of communication, <en^e of inequirv >T relationships, mutual with
drawal, and differences in values and realities between patient and nurse. Validation of
Peplau’s T1PR was established in that patients valued therapeutic relationships and could
identify new phases of the relationship.
Forchuk’s findings confirmed the complexity of developing therapeutic nurse-patient
' relationships. She and others have attempted to systematically rest Peplau’s formulations
about therapeutic relationships. Her findings support Peplau’s content ion that character
istics of both the nurse and the patient influence rhe relationship. However. Forchuk’s
studies did nor support Peplau’s suggestion that factors such as anxiety would influence
therapeutic relationships. Some factors that facilitated therapeutic relationships, such as
length of meetings, amount ol meeting rime per month, and lack of progress with a par
ticular therapy dyad are modifiable and have implications for practice.
In a study ot nonpsvchiairic patients, Vogelsang (1990) also focused on interpersonal re
lationships between nurses and women undergoing ambulatory surgery. Vogelsang proposed
that continued contact in the interpersonal process would result in appropriate nursing
care, in which health goals could be outlined and achieved through the patient’s interac
tion with a consistent nurse. Patients with continued contact expressed greater readiness
for discharge and greater sar isfacrion with care, thus supporting Peplau’s contentions about
the importance ot interpersonal relationships.
Noting the lack ol knowledge in long-term care regarding the development ol thera
peutic relationslnps, Middleton. Steward, and Richardson (1999) studied perceptions ot
staff members on special care units caring specifically for dementia patients and of staff on
regular long-term care units. Although rhe Fl PR suggests that therapeutic relationships
can improve interav tion< with others, siatt caring tm older adults on a long-term basis bad
little it any preparation t< a developing therapeutic relationships. I herefore the T1PR con
textualized this studv rather than guided specific study variables. Findings indicated that al
though spei i.il care units cx]'enciiccd sigiuticanrh more disruptive behavior, special care
staff experienced less distress in handling rhe behavior than other long-term care workers.
The tact that aim -- half the special care '•tatt con-i lered being hit part ot their jobs may
account tor their lower distress. Investigators suggested that the TIER be used tor further
staff devek'pmcn' m tlu- irea of interpe’S"n il relationships with dementia patients.
-
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364
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 12
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In order to investigate the possibility of developing therapeutic relationships with dementia patients, Williams and Tappen (1999) applied the TIPR to interactions with
Alzheimer’s patients. A review of the session transcripts indicated that patients with even
moderate or late Alzheimer’s disease exhibited behaviors that demonstrated the phases of
a therapeutic relationship suggested by the TIPR. Based on these findings, investigators
challenged nurses to rethink assumptions that therapeutic relationships cannot be achieved
with severely mentally impaired patients. Significantly, this study uses the TIPR on a dif
ferent population and suggests a need for continued research on its use in interventions
for patients with severe mental impairments.
Depression. Beeber (1996, 1998) and others began a series of pilot studies of depressed
women. The first of these studies considered pattern integration, and the second symptom
reversal. Pattern integrations are clusters of behaviors found in reciprocal interactions of
nurses and patients. Pattern integrations may be associated with problems in the patients’
lives and can lead to dysfunctional relationships for both the patient and rhe care provider.
Analyzing audiotaped interpersonal intervention sessions, Becher and Caldwell (1996)
investigated the nature of pattern integrations of depressed young women who were
referred from a primary care clinic to two psychiatric mental health clinical nurse
specialists. The researchers developed a clinical intervention based on the TIPR.
Four patterns emerged and were identified according to their fir with categories identi
fied by Peplau—complementary, mutual, alternating, and antagonistic. A complementary
form of pattern integration was the helpless patient’s reliance on the helper nurse to resolve
difficulties. Nurses were viewed as the provider of answers, which matched rhe hypothe
sized need of nurses to be in control and the patient’s need to accommodate others. Mutual
pattern interactions consisted of the nurse helping the patient and rhe patient helping the
nurse, which allowed the patient to avoid the anxiety of needing help. An alternate form
of pattern integration is the pursuer-distancer relationship, in which the patient periodi
cally distanced himself or herself from rhe nurse or from others in order to encourage that
person to pursue him or her our of empathy. The antagonistic form occurred when a rela
tionship was maintained in spite of a poor fit between patient and a nurse. The patient
would continue the relationship while at the same time maintaining that it was not effec
tive. Maintenance of the relationship would allow nurses to relieve personal anxiety over
ineffectiveness. Beeber and Caldwell (1996) maintained that insight into pattern integra
tions could assist nurses to create more productive therapeutic relationships. The TIPR
was demonstrated to be theoretically useful as a guide, as evidenced bv the consistency of
the identified patterns with those proposed in the TIPR.
In a study on reversing depressive symptoms of women in a primary care setting, Beeber
and Charlie (1998) used an intervention based on the TIPR. They predicted that the in
tervention would reduce symptoms, increase performance self-esteem, increase social selfesteem, and increase satisfaction with interpersonal relaticins. The purpose of the pilot
study was to test the feasibility of screening for depression and initiating intervention in a
primary care setting. Using the TIPR as a guide, researchers established a therapeutic re
lationship to assess life transitions, investigate the tide of depressive symptoms in anxiety
management, and understand depressive symptoms in rhe context oi vit and relai ionships.
One goal ot the therapeutic relationship was to help women manage anxiety differently.
Following therapeutic intervention, depression decreased significantly, but no significant
Modeling Nursing From the Perspective of Human Relations
365
‘
d
I
differences for self-esteem and satisfaction with interpersonal relationships were found.
Use of a therapeutic relationship in a primary care setting was demonstrated to be effective
for reducing depression. However, the areas of self-esteem and satisfaction with interper
sonal relationships were not as amenable to change in this study. Further investigation
needs to be completed on the best use of therapeutic relationships in primary care settings.
Work Roles. Morrison, Shealy, Kowalski, LaMont, and Range (1996) conducted a
qualitative study to operationalize Peplau’s work roles of staff nurses in psychiatric settings.
The observed roles of psychiatric nurses were compared to Peplau’s conceptualizations of
the roles. On adult units, the roles most often observed were those of counselor, resource
person, surrogate, and stranger. Roles of teacher and friend occurred infrequently, and the
leader role never emerged. On child and adolescent units, counselor remained the primary
role; the roles of surrogate, resource person, and friend followed. Leader and stranger roles
were not observed. One difficulty of the study was rhe inability to differentiate role
behaviors. For example, it was hard to distinguish between the autocratic leader role, in
which patients were told what to do, versus rhe surrogate role, in which advice was given.
Congruent with Peplau’s role conceptualizations, counselor was the central role found in
psychiatric nursing practice. However, the surrogate role conceptualization was not upheld.
Peplau contended that rhe surrogate role in nurses’ relationships with patients was
inappropriate except in cases in which patients were unable to perform activities of daily
living or needed to develop social skills. In this study, the surrogate role figured prominently
in nurses’ activities.
Medication Compliance. Using Peplau’s suggestion that the interpersonal process
focuses on patients' self-repair and renewal in meeting physiological and interpersonal
needs, Lund and Frank (1991) investigated nurse and patient perceptions about medication
compliance and hypothesized that therapeutic relationships could establish common goals
and better medication compliance. Nurses and patients similarly perceived the degree of
medication compliance. However, nurses and patients attributed different reasons to
noncompliance. Nurses’ most common explanation was that patients did not see the need
for medications. However, patients indicated reasons that included not believirm the
medication to be effective, growing tired of taking medication, liking the high feeling when
they were not medicated, opposing medication for religious reasons, fearing poisoning their
bodies, not having transportation to a pharmacy, and spouses opposing the medication.
Medication compliance was found to be multidimensional and involving both patient and
nurse interactions. Different perceptions about why medication was not taken may h.ive
generated a higher level of noncompliance.
Parenting. Jacobson (1999) proposed that parenting education and intervention tits
within the T1PR in that the therapeutic roles Peplau attributes to nurses could guide
nursing interactions with parents. Her qualitative description of positive parenting
practices sought to facilitate communication between nurses and parents and suggested
that this information would provide rhe clarity and continuity that Peplau considered
essential, to communication. Positive parenting was achieved bv clarifvmg communication
and showing mutual respect. Parents demonstrated a need for uncondirii.nal commitment
while mcetine new challenges. Interpersonal relationship?- and communication w-re
viewed as central to families, and parallels between nurse-patient relationships and parent
child relationships were drawn. This study makes a sjgmfi.anr now bv shifting Pepl pj'-
366
CONNECTIONS
Nursing Research, Theory, and Practice
ZX ThlS
CHAPTER 12 Modeling Nursing From the Perspective of Human Relations
extended by
developed dur,ng theXTZLXs been^w toSnv'k'houXZ 71
ipeutic relationships was
. . rsre
shift in'Research hL fZslS mot atre^™ on"^
Alth°Ugh *
research centers around hospitalized populations fTT77X “F Or'entation’ earlkr
program of research that supports portions of Penla, ’C
I F*"’ °ped the most continuous
orientation and working phases. Additional work is elemiy neJdJZ
'"T
therapeutic relationships continue to influpn • >
5
concepts related to
community settings.
praCC,Ce in boch institutional and
PRAXIS AND----------THEORY UTILIZATION: DESIGNING NURSING
practice from the perspective
OF INTERPERSONAL RELATIONS
OF PEPLAU'S THEORY
Peplau has drawn attention to the rich resource . th .
ing knowledge, theory, and research She c m 1
' ' •’UKe i’"13
-mal instrument that foswrsXtiX
'
< •
develoPing nursed^-
search programs (Reed, 1996).
’
tested in practice and m re-
The theorv 'lod'.wXrZ physiolo'Xcoi’' d'"'"’'17’
"f nursing pract.ce.
b*—4.-4
i;;.
be explored through other theories (rqd.tu^lX’^Tpl'm
the phenomena of concern to nursud I, ™
i
that are associated w,th the TIPR T"he di >
nurse and rhe pat,ent are^nn enr
ponents ,s also re.,uit d X
f
Describing a Population for Nursing Purposes
Without further development, the TIPR is limited in its usefulness to describe a population
for nursmg purposes, because it addresses only a portion of the concerns of nursmg
Expected Outcomes of Nursing
Forchijk a nd Voorberg (1991) identified the following expected outcomes of nursing when
• S, i'h SC
1StrUCtUre nUrSin" PraCtiCC a
-w mental health program
Establishing a therapeutic nurse-patient relationship
• Enhancing current stages of patient learning
• Maintaining or improving cop,ng effectiveness in activities of daily living
Hospitalizing appropriately
Reducing social isolation, thereby improving quality of life
Process Models
'
n "’H"’'"
,'"''"T These must
° C™mbutes
nncovering
f> undat.onal constructs for practice
kn°"'led^ and ^.Hs of both the
th«e “nr-
h1'™8'
..... ............ .................................... ... 'r“-
sequences of rhe nur-c-parient interd -n.-n 1 . -.
‘ K C c aware of the conAlthough it is particularly useful to nurses in'y1 'l'1''T"1" ,nrerPersonal transactions,
nurses in all sernnus bee iuse the
-rn
V'C 1iarr'C >errin”stheory is useful to
congruent with Peplau s goal.
1
r the 8°alsare
The Variables of Concern for Practice
The wiriables of concern n >r t'f ! r. I
i
i
•md theorv They include ,!plXAii- Nu '' " l"'^' i" thc‘WriFri'>n of the model
enerm
i e,n-,gv u
. .......' P. „ii ' ? ''"i
i'''
needs,
process operation., and the tne duncnshinsi'/relmton?’’1''1'' r,VCh<ll'’g'cai t>,:'ks' nur-'ing
. ...... . -l.-rlptu.n (lW) ..f mirsinM
„lth|Je l5riema[jon
"■
‘"U resolution. Fordwk (1991) modif ied these stages tJ
onu a ion uoikmo. and resolunon. Contending that certain transttions-such as clwn-es
m health, develop,,tent, and personal and soctal eeents-eause anx.etv ven a X
tnt rpersonal process Beeber (1998) added trans,non to the descript,r,n. Anxiety can he
u,h, red to meet,noderate challenges hut inh.b.rs more .ntense challenges. Pep u ( WI
S
existing scientific theories,
367
“xir'"iM'
Ron Pen
nursing in planning preventative mten enoon
From leplausperspect.ve, tw,sing is concerned with processes, patterns and the nrob'
kins that emerge from these processes ami patterns (Peplau 1952. 1992) The processes
include personahty development, perceiving, language-thought processes learning
piotesses. and nursmg therapeuttc processes. Al,hough they consist of separate acts par"
terns share smrtlar features and represent repeated behavior, such as tv.thdrawal from an
nxmty-Iaden s,mat,on. Pattern integration occurs in interpersonal stations Categories
pattern integration mclude mutual patterns, in which both parties use the same patterncomplemenra.y patterns, ,n which one person dominates; and antagonistic patterns such
as love-hate rekuionships (Peplau, 1992).
I-‘iicrn>, suen
Tleis-.W..1...!,,,,,,,,
..... ........................ ,Jlho„|l,
'±”,,7'"“' . ...... ......... . .....“l’“*'. ............
2. Observing, analyzing, , md interpreting patiem behavior (working)
5. Working with rhe patient to develop personalities and skills appropriate to the Siru•ition, and/or to .iccom|phsh psychological tasks associated with forming and devel''ping personality (resolution)
H.ich of these phases can he descrihed in terms of purpose, dimensions, parameters, and
cues (Peplau. 1992). In clinical
practice, nurses contribute to nursing knowledge and advancementof this theor'. a vmg aware of the understandings perceived within each cell
<»t Figure 1 2 6 and -ham ig rliis inforination with colleagues.
The areas of concern in the
•••-• mirsmgprocess include rhe following: (I ) human needs. (2 )
-ichievcmeni .mJ laci
ha interfering with goal ichiwement. ( H the associated emor>' hi> and leeluiLA, (-4' bej
nna rising fn an goal ichievemem or lack of it. and (5) p.n
pi
368
CONNECTIONS
Nursing Research, Theory, and Practice
ch APTER 1 2
re
Orientation
Working
Resolution
a
I
I
Purpose
I
Dimensions
I
Parameters
1
Modeling Nursing From the Perspective of Human Relations
369
tegrate, and utilize. Knowing the patient's stage of learning provides the
nurse with a
benchmark for designing strategies to teach new 1behaviors.
'
According to the TIPR, the
roles of the nurse include resource person, counselor, surrogate for another (su’ch
------ 1 as a
mother), and technical expert.
Extension to the Family. Forchuk and Dorsay (1995) suggest that the TIPR can be
linked with family systems nursing theory (Wright & Leahey, 1994) because both thenri
are parts of mterpersonal paradigms in which the interpersonal process is recognised as the
essence o nursmg. W.thm family systems nursing theory, both the fa.mly as a unh rmd d'e
indi .duals “ho make up the unit are the concerns of nursing. The focus is on interactions
and rec.proc.ty (Wright 6t Leahey, 1994). Additional exploration of tins .ink is important
Cues
Practice Models
FIGURE 12-6
Phases of the nurse-patient relationship related to problem solving.
tients defense mechanisms for handling those emotions and feelings. Understanding the
who, where, when, and whai of patient
r experience is essential to helping the patient to
modify behavior. Assessing the patient’s intellectual ability to know options available for
Vt
f
•<
II—•
r8
&
‘ir-
£
Beeber (1998) has begun a practice
practice model
model for
for working with depressed patients Becher
concep uahzed depmssmn as a health
model directs
d.reets rhe
the onentationTuk
health problem.
problem. This
This model
mg. and resolm,, phases ol nurse-patient contact for the advanced practice nurse Beeber
has added rhe dnnens.on of transition to Peplau's work. A transit.on is a particula s.rua
non xpenenced when there is a need for changes m seif and relation^ These c-mT
change and how to bring about change is also important (Peplau, 1964).
health-related, age-related, or based upon personal and social events. The need for ch lime
Through the stimuli, messages, inputs, and cues that nurses send to patients in rhe in
terpersonal process, they influence and facilitate changes in patient behavior. The nurse
nor only observes behav.or but also actively participates in the observation process. The behat .Ol of both rhe observer and the observed becomes a part of the data on which decisions
causes anx.etv managed through security operations, which are “rhe thoughts, feelin-s' a,? 1
actions developed to manage anxiety" (Beeber, 1998, p. 1 54).
’
aic made and courses of action are determined.
Drawing on Sull, van's work, Peplau (1992) suggests that nurses consider the phase of the
mode of experiencmg" of the patient (p. 15). In the protax.c mode, patients may be so fo
cused on the current moment that they cannot consider past or future events The
paratax.c inode relates past and present events. In this mode, similarities between past
event., and/or persons influence the interpretation of current events and distort interpre
tation ot the present. Peplau suggests that this can be resolved bv helping the patient descr.be the smularity of and specify differences between the past and the present. In the
•syntactic mode, past, present, and future are linked.
Patterns are helpful to nurses in understanding and using the interpersonal process to
change patient behav.or. Patterns may be intrapersonal—that is, an attribute of one per
son. hey may ,. su be interpersonal, in which the interaction of each person's patterns
and the relationship of these patterns are of interest.
Energy and energy transformation from the perspective of this theory are familiar con,l’ Zn T"' ThiS enerKy 15 deriVeJ fr°m anxierV anJ
bioLsofeol needs
U cplau. I )_). I ersons may engage in dysfunctional behaviors to reduce, rel.eve or pre
vent more anxiety. These are termed “relief behaviors" (p. 17). Empathic processes trans
mit anxiety from one person to another; thus nurses must be aware of and able to control
their cwt.
When working with patterns.. Beebej (199S) suggests that anxiety is a
tcncml evneepr wirhin rhis rheory.
P V1'™"' f?;rcl’ul;' S "’'"Pi'Xc'. mid Butcher (1992) outline eight stages ot.learning that
eplau considers useful to nursing; observe, describe, analyte, formulate, validate, test, in
Implications for Administration
Peplau's theory has been used extensively in nursing practice by individual, and bv omr
T h"'199 TT 'k
7 v"'Td nUrSin8’ partlCl,larlV in
psvchiatric nmsm,.
1991 Foiehuk and Voorberg reported on rhe
use of the theory in cvaluarine'a
rhe
commumtv mental health program. The TIPR was used to structure pracuce due tT
telopment of pat.enr ohjectives, and develop instruments to measure rltcome o^am
Agenc.es that wish to pracr.ce from rhe TIPR should organ.ze pol.c.es and procedures Aar
foreground the m.e.yersona relation between nurse and pat.enr or nurse and fam.lv sv'Tr A
nurse and pat.enr mterrelate, both change; development prttceeds; and behav,. „■ is mod.fied
rienu Tl'T”
“'T
NuR“ eStaHisl1
''.nes with ra
ncnt., and both nurse and pat.enr know the tunes and purposes. Forchuk, Westwell Martin
A..apard,. kosterewa-Tolman, and Hux (1998) found fewer sarisfactorv outcomes ,n relation'
daps that took longer than 6 months to move from the orientation phase to the work.iw nh tsc
Factors that .nterfere 1 w.rh movement fmm one phase to another included unaemlabdiie
.: T '
Kt‘’r |V" SUrcrtlcial
and
Pntblems. Nurses who ^rceived them"
US ■StT11 ,r tU T paticnts °r wll° diJ not
*<-' Patients as pers.,ns interfered with the
mm en.enr between rhe stages. When rhe relationship did not progress, both rhe nurse d n
n m wuhdrew emotionally The attention to nurse factors and to patient fa ctors Xdm cal setting impacts the attitude, focus, and behavior of the nurse.
Implications for Education
r™ ,1...
....................
„mpK
il(duJe
I.™.,™',”.
370
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 12
Modeling Nursing From the Perspective of Human Relations
371
NEXUS
When asked about the future, Peplau replied:
to nursing prac-
That’s^a^Zm shX^1'
nUrSeS d° tO what nurSGS knowThat s a paradigm shift of major proportions. Most of the emphasis in 1950s
was on what nurses do . . . and it's only recently—starting with my book
nurse” k^l^^
literaturG— it's a question of what
....... ..
u...
..... ’~.. .........
Pentu’H EE (I964^(!!"‘TS''T' rL‘l“""’"'"
The creation of Peplau s T1PR was groundbreaking, and the theory continues to influ
ence research and practice. Much research remains to be completed in both psychiatric
and healthy pat.ent populations. Although the TIPR has been controversial, the practical
nature ot the theoretical propositions sometimes leads nurses to assume that they are true
.< tinned testing of constructs and of practice applications needs to be completed in the
future to verify these assumptions.
1
he
REFERENCES
NCW Y°rk: GJ’ ru,nam's S‘”’s
nursmg. New York: Springer Publishing Companv
'
'
C
re''’rame""’,k tor
Beeber, L. N Caldwell, C. (1996). Pattern
■*
Nursing. 10(3), 157-164.
i r
£
-
(
"'b'"
di.-.
( Huce/xi.nis../ niadem ^ycludtry. New York: Norion
%
5 ? .
"'"'J
J.WWll
4--
:
£ S
•«-..... *
R±t^^l!;-;:r“ph“se‘’fA'nime-™
hhIZb;:.... .
What l,ci,,sj..
R.iAuC C. (1995b) Uniques u-uhin .be nur^clivn. relationship. Ardiives „/ Peeehu.ne
yd).
RadmCC & Bri,a.„. ,i (J9fW .................................. ■se.chenrrelationsh.p.^o;^^^,
' !’ ' i'WS’'
C f
-.ems nurses l„ovat(«
in theory-based
prat. tiw. .luurnal <>j Advanced Xia sing, 21(1), ] 10-1 15.
' ' ■KI',rrin’ ■K! " A--‘‘r:*r^'. W • Kosterewa-Tolman, D., 6; Hux, M. (1998) Factors
" J"‘'”.........
p.l.enrs fn,m .be ...iemaiion to the .vorking phase of rhe • , influ-
T
,.
d
"'•h'l-mpar.enl unir. I'ersj.,-. ............
''X™^,™ii';;'z.^2;9;i“v','u'".... . ....... *
Car,-. <-)( I), ifi-t-l.
nurse-
c.on^mMof
k. I... Ibopl,,. (,.H.. l arey. b.T Noll. J., Rasim,<sen. L. Searey, B., & Stark. N.L. ( !99S) Hil,|esa^ c
I’vplau- ISvchodytmmm-.sn.mm
A M.irrmm l..lllr, & M
M K
|( AUinooJ
A||y..... J (EJ.v),
(U,
.\ursinu the..
U'.’rk.s, Si Lotus:
Jacobson, C >. 11999). Parenting processes. z\ descriptive
p! in;>rt>iy study using replans the
X tosing Science
QiMrtei/-.
1). 240-244.
LaMorucj E • I 'M: I• ■ iii'.ni. i \ .iiijpv ot m cm|-.r! > instru:
■.'•nr. Rejcurch m
and Health. -/(4), 3JS9-400.
Hvlping rhe nit-dicm •: I wn
'' ii'i-- .mJ patients pcrccpi i>
ii\>ui medic,ition
urnaal i] Psychic >ctal .\utsing. _'9Vi_ 0.9
Lun I. V 6. i lank. ! ' t
■ ••m| Ii.hkc
•Anesilicsin
. .. . ' r''"r
5(5). !| 5.52C.
..... —.......
"rhLldd'i^’y n'i''1194 ’
r ’,CbllLk\(' ■77\, T7l,,u’'tl^.......................................................................... 4(n 54-60
"p-Ui.K< ■
'’|MSC ‘"tlK n"rsi'<hen!
::-
Williams, i. & Tappen R (1999) ("in
integrations in voung depressed women: Part II. Arc/tives of Psychiatric
...... . .......... ...........................
e s
X. '’.’la
•"r— N-"*
Peplau Jd.E. ( 199/) JVpIau s Theory of Interpersonal Relations
Reed, EG. (1996). Triinsiorming praciiceQ,“nterl>162167
/mage. 2S( I). 29.; 5.
knou kdge mtninto
nursmg
knowledge:
A rev.sion.M
analvs^ ..f Pepl.m.
nursing
knowledge:
A
ANA (1994) Nursmgs Md policy statement. Kansas Citv. MO. Author
^,„gclm.c.of
erCntC ,ur P^chodynmmc
Peplau, H.E. Personal Communication. October 7, 199?.
Sulh un.
,h,‘,"4h.........
°
. ......... .
A
'•'
™ -J ™o.wri,in
t_nJ eJ.)
I- i
ilh'
ft—O'
y■
a.
!
1
CHAPTER
!M
l/W'-
Modeling Nursing from a
Caring Perspective
5
WATSON'S TRANSPERSONAL NURSING
and the THEORY of HUMAN CARING
■
Key Terms
£< §
.
E:
j f-r;
>r,"
r IS
j-
/Y*.
t-’S
•I
i'Z
carative components, p. 377
caring, p. 376
mindbodyspirit, p. 375
sacred feminine archetype, p. 374
transpersonal caring, p. 399
£.
Watson s early work (1979) presented nursinn .is an an and us a science
carinn from a
human science tradition. In 1985. she inrcuraied science, art. ethics, and esihencs into
the Theory of Human Caring. In a retrospective and prospective commentarx about the
Theory of Human Caring. Watson observed that her work is 'Torh thcorv and bevond
theory ... it can be read as a philosophy, ethic, or e\ cn paradigm or worldview. It
make(s) explicit that humans cannot be treated as objects, that hum ms Lannor be sep
arated from self, other, nature, and rhe larger universe" (190. p. 50). Waison (1999)
presented a transpersonal caring-healing model that she desen'o-d .< a transformative
pa’radigm. She believes that this model is both nursing and
i 1 nursing tha
way of living or being, it can transform the whole of heahim.-re. The „ tring-healim’
model she describes "requires a radical transformation of our consciousness, our cosmol
ogy. and our being in rhe universe" (1999. p w\ i).
373
374
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 13 Modeling Nursing from a Caring Perspective
375
THE STARTING POINT OF THE MODELING PROCESS
In her 1997 retrospective, Watson noted that her work emerged from her “quest to brinp ' I
new meaning and dignity to the world of nursing and patient care” (p. 49). She combined
concepts from clinical nursing and empirical studies with her knowledge of the humanities
Strongly mfluenced by phenomenological psychology and existential philosophy, Watson’s
early work shifted toward a wholistic/humanitarian approach to developing theory
(Conway, 1985). Watson began from a traditional science perspective, claiming that “Itlhe
scientific problem-solving method is necessary for the science of caring to study guide
direct, and research knowledge and practice” (1979, P. 56). She identified basic assumn’
turns and carative factors for the science of caring. In 1999, Watson reconceptualred nurs
mg as transpersonal caring-healing manifested in a caring consciousness with an intent to
care and heal. This moved her thinking to another dimension, leaving nursing scholars to
ponder rhe effect of this reconceptualization on her earlier works and interpretations.
4
sacred. She describes the sacred in terms <of" spirit/spirituality, life’s force and energy, soul,
universal experience, the heavenly, the divine, the unitary, and the transcendent. Feminine
is described as including feelings, receptivity, subjectivity/intersubjectivity, multiplicity, nur
’■
i
I
I
turing, cooperating, intuiting, relatedness, loving, caring, and peace. The feminine is not
gender-specific. Men, too, can possess a feminine ontology; nonetheless, Watson identifies
nursing issues with womens issues. This sacred feminine archetype provides the metaphors
for understanding and shaping thought about nursing as transpersonal caring-healing.
Transpersonal conveys a human-to-human connection in which both persons are influenced
by the relationship. The persons engaged in transpersonal nursing are transformed, and nurs
ing itself will be transformed as nurses take on these reconstructed ideas.
DESCRIPTION OF WATSON'S THEORETICAL SYSTEM
s.3: ■
e: ■
S-1
“MJ
< ig
jawl
<.-3
‘Jti
’J-
Reason for Theory Development
|
Commmed to nursing’s caring-healing role and imssion, Wa.son proposed a “humanitarKin aesthetic, and spiritual” philosophy and science of caring (1997). Nursing science was
ro be developed within a human science context rather than rhe traditional natural
or physical science view. From her initial focus to her recent work. Watson has been
unwavering in her belief that caring remains rhe foundation for nursing and other health
professions.
I
Phenomenon of Concern
According to Watson, the caring dimension is the primary phenomenon of concern for
nursing. A arson s Theory of Human Caring described rhe caring phenomenon under the
umbre las of human science and art, which are intersubjective contexts that include the
mutuality of the person/self of both rhe nurse and rhe patient and concepts such as phenotnenal tick!, actual caring occasion, and transpersonal caring (1985). The Theory of
Human Caring and rhe “caring-healing” model (1999) are the basis for a
postmodern,
transformative perspective of transpersonal nursing. By 1985. Watson was
moving away
from traditional science to view science, scientific development, and theory develimment
as counrerparts ro art, the humanities, and philosophy. She wrote:
I reject methods that ascribe an increasing degree of reality to numbers and fac
tual mformat.on
. I reject definitions and interpretations of science and scien
tific inquiry that bury the quest for discovery, beauty, creativity, and a higher
sense of being-m-the-world. I want nursing to move beyond objectivism verifi
cation, rigid operations, and definitions and concern itself more with meaning
relationships, context, and patterns (1985, p. 2).
I Ins shift from science led Watson to view nursmgas a metaphor and symbol manifested
as the sacred feminine archetype (Watson, 1999). The sacred lemmine archetype ,s con
sidered ■the very basis o, reality” (Watson, 1999. p. 2Sn' An irclwrepe ,s ,n endurnm un-
C
.... .
""T-’C. original form or pattern in the human consciousness that ,s present
lnd
-'r-'o-s nine and across humanilv” (p. 2.S5). An ardv.-rype is more than a
metaphor. In describing the sacred feminine archervpc. Watson does not specificallv define
g
Philosophical Perspectives
Watson s description and discussion of postmodern nursing exemplifies movement from rhe
starting point of traditional philosophy and science to a reconstructed philosophical and
metaphoi ical description of nursing. Watson emphasized her changed worldview through
her conceptualizations about nursing. In 1985, she defined nursing as a human science of
persons and focused on human health-illness experiences that are mediated by professional,
personal, scientific, esthetic, and ethical transactions with rhe nurse as an active copartici
pant. Now Watson (1999) describes transpersonal caring-healing with a postmodern/
transpersonal \ iew of body and person. Nursing becomes the practice of transpersonal
caring-healing; nursing arts of caring and healing "tap into feelings, emotions, inner
processes, imagery, intuition and . . . consciousness" (p. 231). This reconstruction is viewed
as a model for nursing, for all of healthcare, and, moreover, for humanilv (Watson, 1999).
Cosmology and Ontology. Watson’s thinking moved to acceptance ol i he idea of an
evolving human consciousness integral to the universe and in harmony with the whole
cosmos. Caring-healing is seen as a new cosmology that views rhe person-narure-universe
as a connected whole, as a unitary consciousness—that is, a “consciousness of unity *sf
mindbodyspirit and nature" (Watson, 1999, pp. 97-98). Watson believes that this
cosmology of unity facilitates creative participation, which is characterized by ambiguity,
paradox, connectedness, and freedom with rhe universe. It supports an epistemology open
to multiple wavs of being, knowing, and doing. The basic premises lor rhe transpersonalcaring healing model are presented in Box 1 3-1. Watson asserted that this new cosmology
is contained within the "sacred feminine archetype" (1999. p. ] 3).
W .itson ( 1 )99) idemified rhe ontology as a Tckiiioiuil (uuolo^s grounded in rhe transper
sonal. In rhe sacred feminine archervpc ontology, two focal areas are considered important
to nursing: the nature of being and the meaning of caring.
Nature of Being. W arson asserted in 1999 that rhe "postmodern/transpersonal view of
body and person is still evolving" (p. 149). Within this ontology, the bodv i- rhe lived
bodx rhe lived sell, not “object bur subject—embodied subjective work!- a liwng,
breathing si.ibje<. r" (1999. P. Hl). She described rhe bod\ as:
fully manifest as physical, present in the material, objective world. At the same
time, it also manifests itself as fluid-like, as elemental vibrations of light and
376
CONNECTIONS
1
Nursing Research, Theory, and Practice
CHAPTER 1 3
Modeling Nursing from a Caring Perspective
377
IX 13-1
>X13-2
Basic Premises for the Transpersonal-Caring Healing Model
Basic Principles within Holographic Thinking
• The whole is in the part.
. Humans are inseparably interconnected with one another and with the
universe.
• Mind and consciousness are joined, and consciousness is communicated
• Acknowledgement of the human-environment energy field-life enerov field
Bohmns'seense of mn^0"5'10"50655'' UniVerSa'
On TeNhard de Chardin a"d
’ spaTe 0 COnSC,°USneSS 'S Spatia,|y extencted, and consciousness exists through
h“n’
■
Human consciousness is temporally extended, and consciousness exists through
• Caring potentiates healing, wholeness.
Nonphysical consciousness dominates over physical matter.
' excluded^'in9 m°dalities (sacred fe™™e archetype of nursing) have been
tion aree emial f'mooT
SyStemS; their develoP™nt and reintroductransform”
Postmodern, transpersonal, caring-healing models and
• Uniia™"9 Pr°CeS5eS
neSe^f anSneSS “
From Warson, J. (1988a). New dimensions of human carina theory. Nursing Science Quarterly. 1(4), 1 78.
relationshiPs
considered sacred.
WOr'dVieW and CdSmold9yviewing the con-
BOX 13-3
Carative Components or Factors
• Caring as a converging global agenda for nursing and society alike.
................................ ............... .
• Formation of a humanistic-altruistic system of values
• Instillation of faith-hope
• Cultivation of sensitivity to oneself and to others
• Development of a helping-trust relationship
• Promotion and acceptance of expressing positive and negative feelings
• Systematic use of the scientific problem-solving method for decision making
• Promotion of interpersonal teaching-learning
........... .
F-
-i .«? '5
f T i.
•
SU+PP1
°rtive' Protective, and/or corrective mental, physical, sociocul
tural, and spiritual environments
t • Assistance
with gratification of human needs
£!
• Allowance for existential-phenomenological forces
From Watson. J. (Im.
The
and
Boston: Lir.k-. B„„vn
.......................................................................................................... .............................. ..
y..j™ Itop’to“p"
phenomena are s.multaneouslv present Wmsoi ,
,
JnJ ""aVe
The Mean,ng of Caring. A relational omologv reqmres caring. Carin.. ,s
of life. It L.in he practiced intrapersonally, as within oneself, bur................ "
an essential part
coasts of transpersonal intersubject,ve attempts to protect, enhance, and preserve hum-,n,tv
and human dignity ^helping people to bnd meaning in ,heir illness, softer,ng. pam and
xLsrenLe (1993 p. 98 . The one-caring “helps another human being |the one-cared for, to
tw'n '98
' S
>nr'O^"d
l-|en5™- Back-Petrersson. & Segesren.
-' " ■
Carln8 >' guided by carat,ve components, which were referred t.. as camnve
factors ,n earlier works. These are presented in Box 13-3 and are a pan of rhe ontology of
Watson noted, “carintjcan
iiiosr cfteet,ve,Vi^nH)ns«eJ .mJ pracriceJ inrerpersonally and
nhe HP)
t
(1999,
I • Ha.). Interpersonal carme >s a more traditional new in nursin.oanJtranspersonally"
co
I considers the nurse an
•Kiivc et.participant. Transpersonal carin,u is more than mterpers..nal
■ntluenued anel changed by the relationship. Jensen, Back-Petter^ -bi a h persi >n> are
Scoesten
formulated the followmg detimrion of caring using Watson's c..,lc.r,., >n, and
,
Varing
Description of Transpersonal Caring-Healing Model and Theory
or Human Caring
J
Watson's 1999 treatise coalesced many of the concepts of caring into a Transpersonal
Car,ng-Heahngmodel (TCH). Watson sugg^rs that rhe T( d 1,nodci orim ememm..
>ng model because it is a “tuller complain .-f the mudel in uhich nursing ha> operated all
it
3;a
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 13
Future
\
!\
/
Future
/
/
\
LPresentmoment
A'f/\ )
I
I
\
\
iww
/
I
I
1
1
:■
y
/\Selp\
•: Present • moment ;
\ kA/
S /—\ z
A
Causal
past
\
\
Nurse
Causal
past
/
/
Patient
f
Causal
Causal
past
Trancnarof-in-il
Transpersonal
caring
Human care
transactions
:7g
Possible
outcomes
1
/
Carative
factors
Actual
caring
occasion
Transcendence
LActual
caring
occasion
i;
Moral
ideal
\
I
♦
Intersubjective
caring
occasion
Harmony
Transpersonal
caring
moment
Healing
I
FIGURE 13-1 The caring field and caring moment. (From Watson, J. (1988). Nursing- Humoment. (From Watson, J. (1988). Nursing:
man science and
human1 care. Sudbury, MA: National League for Nursing, Jones and Bartlett.)
-------------
•
Intersubjective
ideal
♦
al.mg" ( 1999, P. xxi). Along with this model, Watson d_
r_„
ievcloped a theory of nursing as humar. science. To accommodate her views. Watson (1985) defined theon- as
‘.m imaginative
n.pmg of knowledge, ideas, and experience tlnu are represenred svmbolicallv and seek
to
n.innaiare a g.ven phenomenon'' (p. I). This is now the Theon of Human C'-irine
• 4-< it:: £
ei
"X . /
<
ASelfX
Present iF'mohient ;
\z
I
Future
Future
:\
’
\
\
Human care
process
Modeling Nursing from a Caring Perspective
:>•
‘"‘i i:
$■
Transpersonal Caring-Healing Model. Caring requires rwo persons-one cadng and
cc.
‘Z
•.
one rece.vmg care. They come together in a moment, simultaneously transcendin'., the
tuo and connecting to the human spirit realm. A basic premise of Watson's TCH is that
rhe . onnng together of the nurse and patient in a caring connection has healing
potential. This transpersonal caring generates and potentiates rhe self-healin.. processes
FIGURE 13-2 1"
■
Watson's
Theory of Human Care. (From Sourial, S. (1996). An analysis and eval
uation of Watson's theory of human care. Journal of Advanced Nursing, 24(2), p. 401.)
Nursing ,s described as a way of being that directs knowing and doing. Transcendence
mvolves action and choice. The nurse moves to come together with, the other
and access to a deeper/higher energy source is as important to healing as are our
commun,cares caring, and assists in making choices about further action or doing’
Nms.ng/car.ng/heaiing is heed. First and foremost, nursing is /vm.—nor dom.. The
conventional treatment approaches” (1999, p. I 15).
caring field and car,ng moment arc modeled in Figure I 3-1. The T( 11 model is ?e> n as
Theory of Human Caring. Watson defines nursing as “a human science of persons and
human health-illness experiences” (198.5, p. 54). As she refined her conceptualisations,
a coimrcscence-that as, the growing together or coalescing of parts into a new whole
Zoe transpersonal canng-healing field is the concrescence of the holds of the .necari.w
mJ rhe one receiving care. A transpersonal caring relarionslnp depends , n ,
comrmtment to protect and enhance human dignity .mJ on communicar.on of rhe c mng
by maintaining rhe person as subject rather than an object. The relatmn.ship .,ho JepenT
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' A ,1"-v>ent i< called rhe c.mug m..mem. Tim., ,,-mg relationsh.p nas
to; hi’th perS°nS' WaWon cxPlmns rhat “Irlranspersonal reco..ni-es rhat
the p ww of love, t.ml,. compassmn. caring, communm. .mJ „1Ix.luion, com. iomness
nursing became “a metaphor for rhe sacred feminine archetyp.il energy” (1999, p. 1 1) as
"archetype and metaphor for woman and healer” (p. 14). She prated the AN As 1995 revised
definition of nursing—which includes attention ro the full range • if'human experiences and
responses, understanding of the subjective.’experience, and provision of a caring relarb’nship
i uar tacilirates health .mJ healing—as a more
more comprehensive
comprehensive definition
dennirion than it had >'itvr>,,i
piwiou.sly. Nursing becomes rhe pracrical art of transpersonal caring-he ilmg.
i
Watson ictet'
h1 nursing in this light as
arnsiry . Sourial (1996) dex eloped a model to illuMiarc rhe
relationship of concepts within Watson’s theorx. This h shown iFig'in. i TJ. Tht htiman
-••k. pr<»ces>e> lie ■. omprised ot curative factors >t lomponenis and I'.ora! and intersubiecrix <_■
380
CONNECTIONS
Nursing Research, Theory, and Practice
ideals. This process is the basis for the transactions that begin in the actual caring occasion
and move to transpersonal caring moment with healing as the desired outcome.
1
RESEARCH DERIVED FROM WATSON'S THEORY
OF HUMAN CARING
Watson’s method of knowing is most congruent with a critical theorist or constructivist
1
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Modeling Nursing from a Caring Perspective
Although much of the caring research is phenomenological, some quantitative instruments
the describe caring activities exist. Table 13-1 summarizes the research instruments.
Caring Behavior Inventory. In a multistep process, Wolf (1986) and Wolf, Giardino,
Osborne, and Ambrose (1994) created rhe Caring Behavior Inventory (CBI). Originally a
/5-irem instrument of caring behaviors based on extensive literature review and nurse
rankings, this instrument was reduced to 43 items rated on a d-poinr Likert scale. Following
content validation, reliability and validity were assessed with a group of nurses and patients
(see Table 13-1). Wolf, Giardino, Osborne, and Ambrose (1994) present a strong case for
both test-retest and internal consistency reliability. Additionally, the study provides
evidence for construct validity established using rhe contrasted groups technique and a
factor analysis. Contrasted groups of nurses were significantly different, and factor analysis
indicated that rhe identified dimensions explained a substantial portion of rhe variance.
The identified dimensions fit characteristics of caring as identified in Watson’s theory.
Caring Behavior Assessment. Another instrumem for measuring caring behaviors is
the Caring Behavior Assessment (CBA) developed by (.Tonin and Harrhon (1988). The
CBA consists of a list of 61 items related to nurse caring behaviors that patients can rate
on a >point Likert scale. The caring behaviors are congruent with Watson’s carative
factors. The 61 behaviors are divided into seven subscales, consisting of the folk .wing: (1)
humanism/faith-hope/sensirivity, (2) helping/trusr. (3) expression of positive/negative
feelings. (4) teaching/learning, (5) supportive/proiecrive/corrective environment. (6)
human needs assistance, and (7) existentiai/phenomcnological/spiritual forces Although
it is not specified in Cronin and HarrisonL article, coring accomplished by adding the
Likert ratings for items in each subscale and then dividing by the number of items in the
scale. The lowest MIb<cale <core is 1. and rhe highest i- 5. There r no score lor ihe total
381
TABLE 13-1
Research Instruments Based on Watson's Transpersonal Nursing and Theory
of Human Caring
Instrument/Description
Study/Year
Reliability and Validity
Caring Behavior
Assessment (CBA)
61 -item, 5-point
Likert scale
Cronin and
Harrison, 1988
Sixty-one nurse caring behaviors were grouped into seven
subscales. Content validity was established by four content
experts. Interrater reliability was assessed by a panel that
rated the congruency of each behavior with the given sub
scale. Items with interrater reliability of less than 0.75 were
recategorized. Internal consistency of subscales ranged from
0.66 to 0.90. Teaching-learning was strongest at 0.90, and ex
pression of positive/negative feelings (alpha = 0.67) and exis
tential phenomenological/spiritual forces (alpha = 0.66) were
the lowest subscales.
Caring Behavior
Inventory (CBI)
43-item, 4-point
Likert scale
Wolf, 1986,
1994
A convenience sample of 97 registered nurses ranked 75 caring
words on a 4-point Likert scale. Words with median ranks of
3.75 or lower were eliminated. The instrument was subsequently
revised to include 43 items. Test-retest reliability' was r = 0.96,
P - 0.000, rhp = 0.88, p = 0.000. Internal consistency reliabil
ity with nurses was 0.83, and with a combined sample of nurses
and patients, internal consistency reliability was 0.96. Construct
validity was established using a contrasted groups technique
that compared 278 nurses to 263 patients and indicated that the
groups were different (t = 3.01, df = 539, p = 0.003). Factor
analysis identified five dimensions that accounted for 56.8% of
the variance. The five dimensions included the following: respect
ful deference to the other, assurance of human presence, positive
connectedness, professional knowledge and skill, and attentive
ness to the other's experience.
Instruments
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orientation. According to Watson (1985), research methods need to fit the phenomena of
study. The phenomenon of caring has challenged researchers who attempt to approach it
quantifiably. Although some quantitative instruments that measure carative behaviors ex
ist, many studies exploring the phenomenon of caring have used qualitative methods—
particularly the phenomenological method. Watson indicated that phenomenological
analysis describes human meanings of experiences unapproachable through the simplistic
reduction found in traditional quantitative methods. One phenomenological method that
Watson (1985) advocates is transcendental phenomenology, in which a poetic formula
tion interprets experiential evidence. In this method, the investigator writes poetry as a
mechanism to penetrate rhe surface of rhe phenomenon and convey in a new language
the experience being described. Poetry simply provides another mechanism for conveying
the basic nature of the findings. Although it is expressively useful, it is not mandatory for
use of Watson’s theory.
CHAPTER 13
instrument. Evidence is offered only for content validity established by a panel of experts.
Adequate interrater reliability is established; however, internal consistency reliability falls
below acceptable levels on rhe two subscales of expression of positive/negative feelings and
existential/phenomenological/spiritual forces. Although this instrument has been used in
several caring studies (Cronin & Harrison, 1988; Parsons. Kee, & Grav, 1993; Marini,
1999), further work on instrumental ion needs to be completed.
Review of Related Research
To gather research studies associated with Watson s transpersonal nursinu and the 1 hei>ry
of Human (daring, a literature review was conducted using rhe ( aimulari-ve Index of Nurs
ing and Allied Health Literature (CINAHL). The following three major tvpe'- of articles
were found: ( 1) those describing caring behavua-s exhibited in nursing; (2) those describ
ing human experiences associated with living in nursing homes, dealing with chronic illnei-s, and living in a homeless shelter, ana ( )) a limned number ol discussion.-' dealing wu h
caring outcomes. Table 1 3-2 summarizes caring 'tudics that were guided Iw ft that rored
Warson > theorv.
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TABLE 13-2
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ary of Transpersonal Care
m
Purpose
nurse caring characteristics
Brown, 1986
r
This qualitative study identified themes
of patients feeling cared for by nurses.
n
Methods
Findings
s
a3 22 t0 65 were asted to <fescribe expenences in which a nurse cared for
hem' C"t'cal lnciden> sports were taped,
transcribed, and analyzed.
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on
Eight themes were identified. "Recognition of individual
q allties and needs" mvolved nurses modifying care to
meet umque needs.A "reassuring presence" ws cha
actenzed by the nurse offering comfort and support
Provision of information" reflected the mime's artto inform the patient. "Demonstration of professtoal
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and mod'I araCteriZed by administeri"9 medications
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he nurse sPend’ng extra time
with the patient. Promotion of autonomy" was charac
enzed by making the patient feel in charge of decision
deri:9„u“b"reSU''edfrOmPa,ientfeli"gP"Cronin and
Harrison, 1988
This descriptive study of myocardial in
action patients identified nursing be
haviors perceived as caring.
Twenty-two hospitalized patients were inter
viewed
completed the Caring Behaviors
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someone ,s there if I need them" (M = 4 86 fa. h' th
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rtSment(C8A)
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mportant
caring behaviors were ranked based
rt>
wh?n i1716 'eaS‘ 'nlporta^, behavior was "visit me
cording S t!^5'Subsca,es were ranked ac
cording to their mean scores.
Huma m0VJ ,0 an°ther hospital uni'" CM = 2 36)
which pa-
... Dennis, 7 991
Dietrich, 1992
Jensen, BackPettersson, and
Segcsten; 1996
This qualified study examined the components of spiritual nursing care.
This phenomenological study examined
caring practices, experience, and mean
ings of nurse-to-nurse caring, noncar
ing, and the environmental context.
this qualitative study described the es
sential characteristics of excellent
nurses as perceived by women under
going treatment for breast cancer.
Ten nurses were interviewed about spiritual.
nursing care. The eight concepts from Watson's
model were used to categorize the nurses'
responses.
Five registered nurses participated in in-depth,
open-ended interviews. The investigator com
pleted coding and content analysis of inter
view transcripts.
Ten women who underwent breast cancer
surgery and remained in secondary treatment
participated in semi-structured interviews re
garding experiences with excellent nurses and
caring situations.
essence of who we are and resides in everyone. Per
sons are unique and create their own life experiences
Nurses must be committed and ready to be fully pres
ent to others. Everyone needs spiritual care, which is
represented by a diverse spectrum. The process of spiri
tual nursing care reflects nurses' technical and intuitive
skil s and relies on experience. Varied goals range from
healing to empowerment to finding meaning. Support
ive environments influenced the amount of spiritual
care given. The nature of the exchange between nurse
and person
?n was perceived as an intersubjective flow.
Nurse-to-nurse caring involved being sensitive, offering
elp, being open, being understanding, acknowledging
coworkers' knowledge and skill, being supportive, and
having camaraderie, Nurse-to-nurse noncaring consisted of lack of respect, lack of acknowledgement, and
lack ot camaraderie. Environmental contexts that facili
tated caring included support from management. Car
ing was inhibited by limited time for interaction and
perceptions of overwhelming workloads.
Four concepts— :ompetence, compassion, courage,
and concordanci —emerged. "Competence" referred
to knowledge and practice skills about nursing, hu
man interaction, and nursing care. "Compassion" re
lated to the unconditional approach used by nurses
and the interest nurses exhibited in managing patients' life situations. "Courage" referred to infusing
hope and meaning with the nurse facing crises with
patients. "Concordance" occurred when nurses in
spired confidence, acted according to patient prefer
ences, and maintained a sense of connectedness.
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TABLE 13-2
1 Research Studies
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Study/Year______ Purpose
Lemmer, 1991
Marini, 1999
McNamara,
1995
This qualitative study explored caring
that was experienced by parents fol
lowing a perinatal loss.
This descriptive study identified nursing
staff behaviors that indicated caring.
This qualitative study determined per
ceptions of perioperative caring behav
iors by nurses.
1
Miller, Haber,
and Byrne,
1992
..................................................—
2
Methods
NURSE CARING CHARACTERISTICS—cont'd
Kerouac and
The study explored aspects of clinical
Rouillier, 1992
and administrative caring in nursing.
i
This ph^rnendgtal study examined
the experience of caring from the per
spectives of patients and nurses.
z
Findings
n
Eight 2-hour group encounters with five head
nurses were used for data collection. Activities
of the group encounters included group dis
cussion and exploration of the components of
caring found in clinical and administrative
nursing.
The sample consisted of 15 women and 13
men who had experienced perinatal loss either
through stillbirth or neonatal death. Interviews
were audiotaped and transcribed.
A convenience sample of 21 institutionalized
older adults responded to 63-item Caring Be
havior Assessment (CBA) Instrument.
Five perioperative nurses participated in semi
structured interviews that were transcribed
and analyzed.
-—
—---------------------------- .
________________________________ ____
For head nurses, incorporating caring practices into
nursing involved getting to know staff, appreciating
staff strengths, and making assignments accordingly.
Sharing difficult situations, role modeling caring be
haviors, and responding to staff needs also were as
pects of caring.
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Parent descriptions included two major categories:
"taking care of and caring for or about." Providing
expert care and information were components of be
ing taken care of. Providing emotional support; pro
viding individualized, family-centered care; acting as
a surrogate parent; facilitating the creation of memo
ries; and respecting rights of the parents composed
subcategories of "caring for or about."
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The highest ranked subscale was human needs assis
tance (M = 4.31), followed by humanism/faithhope/sensitivity (M = 4.07). Helping/trust (M = 3.57)
ranked lowest.
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Themes of caring centered around humanistic caring
by showing concern, communication, touch, and
awareness of concerns. Caring behaviors changed
from building a trusting relationship in the preopera
tive period to promoting safety and attending to
___________________________________ -
■..............
Thirteen acute-J^atients and u rturses '
five paSi themes be^LpatiS^l^^
participated in semistructured interviews
about experience of caring.
emerged; "holistic understanding," "connectedness/
shared humanness," "presence," "anticipating" and
"monitoring needs," and" beyond the mechanical."
Patient descriptions of caring involved a professional
and personal sense of caring and connection. Nurses
were courteous and always there to help but were also
human. Nurses described caring as a way of being and
established professional relationships that were also
personal. They met patients' physical expectations,
monitored patient conditions, and planned care so as to
promote positive human outcomes.
Montgomery.
1992
Parsons, Kee,
and Gray, 1993
This grounded theory study determined
the spiritual connection in nurses' per
ceptions of caring.
This study investigated perioperative
patients' perceptions of caring behav
iors and compared them to perceptions
of patients experiencing myocardial in
farction.
Thirty-five nurses participated in semistruc
tured interviews. Data were analyzed using in
terview transcripts, theoretical and method
ological notes, and a constant comparative
method.
Nineteen perioperative patients responded to
interview questions and completed a modified
version of the CBA.
The major emerging theme was spiritual transcen
dence, in which nurses described relationships with
others as a force greater than oneself. Spiritual tran
scendence consisted of a caring connection within
professional nursing relationships, as a source of en
ergy and resource for the caregiver, and as an aes
thetic of caring that guided the orchestration of car
ing experiences.
Patient perceptions of the most important caring be
haviors of nurses were ranked. They included the fol
lowing: knowing what they are doing, being kind and
considerate, treating patients as individuals, reassuring,
checking conditions closely, making patients feel that
someone was there, doing what they said they would
do, answering questions clearly, giving full attention;
treating gently, being cheerful, and knowing how to
handle equipment. Hie three subscales that were
ranked as most important by both the myocardial in
farction group and the perioperative group included
the following: human needs assistance, teaching/
learning; and humanism/faith-hope/sensitivity.
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TABLE 13-2
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Selected Rese<
Care--cont'd
Study/Year______ Purpose
n
Methods
^URS,EAfARING CHARACTER|STICS—cont'd
Ryan,
' r 1992
■'2
Findings
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11161° m°s',helpful behaviors Identified by primary
n
The study determined most and least
helpful nursing behaviors, as perceived
by primary caregivers and hospice
m
Twenty primary caregivers and five hospice
........u..,r,clCu a y-sort mat nsted 60 ran
nurses completed a Q-sort that listed 60 —
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nurses.
seven groups that ranged from most helpful to
least helpful. Behaviors were then scored from
1 (least helpful) to 7 (most helpful).
chosocial needs. Listening to the patient was ranked
on
as most helpful behavior by primary caregivers. Hos
z
pice nurses ranked assuring the caregiver of the con
stant availability as the most helpful behavior.
Swanson-
This qualitative study described the ex
Kauffman. 1986
periences and caring needs of women
experiencing unexpected pregnancy
loss.
C
Twenty women who had experienced sponta
neous abortions before 16 weeks of pregnancy
participated in two interviews regarding the
pregnancy loss.
During the "knowing" phase, women wanted to be
treated as persons experiencing loss within unique
i?
personal contexts. "Being with" entailed feeling with
the woman. "Doing for" was characterized by the
fD
DJ
n
woman s need to have others do for her during time of
duress. Enabling" was demonstrated by caring that
acilitated woman's capacity to grieve and get through
loss^ Maintaining belief" was represented by women's
Ternestedt,
1999
This grounded theory study identified
family member involvement in caring
for dying relatives, developed theoreti
cal understanding of family member in
volvement, and examined findings in
light of two caring theories.
Martin, 1991
- -
ward, an inpatient hospice ward, or a nursing
home. The Glaser and Strauss constant com-
o
givers need to know more about the patient and was
essential to further involvement in care. Knowing oc
curred through the patient, the staff, and through
° terS’
WaS a Way of bein9 Present Wlth the
patient and being in the patient's world by knowing
bJ^h5 need5 and wishes. "To do’was a task-cen-
actlons or ac-.
Ninety-two participants were interviewed us
ing a semistructured format.
n
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Three categories emerged. "To know’ reflected care
........
This qualitative study explored the ex
periences of adults with polycystic kid
ney disease.
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Six persons with dying spouses participated in
interviews during the patient's final period of
life and then 1 and 3 months after the pa
tient's death. Patients died either in a surgical
parative method was used for data analysis.
____________ -
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need to have others believe in their capacity to get
through loss and to give birth in the future.
POPULATIONS NEEDING CARE
Andershed and
H
..
.
Patients used multiple informal routes of
information—often not those of expert care
providers. The diagnosis of polycystic kidney disease
was not viewed as a "terrible" diagnosis. Divided
views existed on the use of genetic screening. Knowl
edge of a polycystic kidney disease diagnosis would
not influence family-planning decisions.
Nyman and
Lutzen, 1999
The study identified caring needs of
rheumatoid arthritis patients.
Six women participated in a conversation
guided by questions based on Watson's 10 carative factors. The sample was selected from
women being treated with acupuncture for
rheumatoid arthritis.
Discovered themes included the following: seeking
help, searching for meaning (often between grief
n
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events and illness), uncertainty about day-to-day life,
and fear of being disappointed in treatment.
m
32
Percy, 1995
This qualitative study described what
homeless children living in shelter
found meaningful.
Twelve children aged 6 to 12 used a camera to
take pictures of what was special to them. Dur
ing the initial interview, the word "special" was
discussed, and children were given cameras.
Follow-up interviews with each participant gave
children an opportunity to view and describe
their photographs. During the third interview,
Themes emerging from children aged 6 and 7 differed
from those of children aged 9 to 12 years. Two
special people. Preadolescent themes included feeling
cared for and subthemes of belonging, trusting, re
lieving stress, and a special person's always being
This qualitative study explored the ex
periences of adults aged 80 years and
older who lived in a nursing home.
Six elders living in a nursing home took part in
3 visit process, in which weekly, unstructured
interviews occurred over a 7-month period.
Each resident was visited at least five times.
Tracy, 1997
This hermeneutical, phenomenological
study examined the experience of
growing up with cystic fibrosis.
Teh adults participated in semistructured inter
views about their experiences of growing up
with cystic fibrosis.
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children ranked their five most special pictures.
Running, 1997
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themes of school-age children were having fun and
Individual vignettes of how persons came to be in a
nursing home were shared. Findings focused on pre
serving individual stories rather than on categorizing
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composite commonalities.
Thematic findings included "being different," "don't
call me terminal," "willpower," and "faith."
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The study examined the educational
wants ol prospective family caregivers
of newly disabled adults.
Eighty-throe prospective family caregivers
responded to the Matthis Educational Wants
of Family Caregivers of Disabled Adults
Questionnaire.
The greatest interest in learning needs was about as
sisting the disabled adult and learning about health
and human resources. Maintaining personal well
being was moderately important.
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TABLE 13-2
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Study/Year
'
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> Using Watson Theory of Transpersonal Care—cont'd
Purpose
OUTCOME STUDIES
Duffy, 1992
This correlational study assessed the
relationship of caring behaviors to ho?
pitalized medical and surgical patient
outcomes.
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Findings
Eighty-six randomly selected patients re
sponded to the Caring Assessment Tool, the
Patient Satisfaction Visual Analog Scale, and
the Sickness Impact Profile. The Medicus Pa
tient Classification Tool measured required
nursing hours per day. Nursing hours were
multiplied by nursing hourly salary to calculate
care cost.
As caring behaviors increased, patient satisfaction
(r = 0.46, p < 0.001) also increased. No relation
ships between nurse caring behaviors and health sta
tus, length of stay, and cost of nursing care were
found.
Seventy-five HIV positive patients who used the
services of Caring Center responded to a 26item questionnaire about satisfaction, hospital
izations, opinions about nursing care, cost ef
fectiveness of care, and qualitative comments.
Patients indicated that nurses had increased their un
derstanding of HIV/AIDS disease process, taught selfcare skills to prevent hospitalization, and helped
them follow their medical treatment plans, patients
consulted nurses before primary care providers and
received referrals to social service agencies.Costsav-
n
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Leenerts,
Koehler, and
Neil, 1996
This descriptive survey obtained patient
satisfaction and cost-effectiveness in
formation related to use of the nursing
caring partnership.
.
ir
'ncjs for the third year were.$1,590,384.
.............. .
•
'
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■
-
Neil and
Schroeder, 1992
The study used focus groups to evalu
ate the Denver Nursing Project for Hu
man Caring (DNPHC).
Fifty-one participants—including those with
HIV, significant others, and clinic staff—
responded to semistructured questions about
services at the DNPHC. A total of eight focus
groups were conducted.
Schroeder and
Maeve, 1992
The study evaluated nurse caring part
nerships developed at the DNPHC.
A focus group was formed with nursing staff
to elicit strengths and weaknesses of the pro
gram. Twenty nursing care records were ran
domly selected and reviewed for notation of
carative factors (CF). Twenty-nine patients re
sponded to a mailed survey. Three nurses and
three patients gave narrative accounts of be
ing in a Nursing Care Partnership (NCP).
Schroeder, 1993
The study examined the cost
effectiveness of the DNPHC caring
program.
2TTT'
--- --------------------------------------
Using costs of HIV/AIDS care for Colorado and
the US, the investigator computed costs for
240 patients in 1991 and 330 patients in 1992
who accessed the Caring Center.
support groups, treatments, a nondinical environ
ment, and educational information. Areas for im
provement included need for the following: longer
clinic hours, emergency support, specialized support
groups, varied support group meeting times, addi
tional educational offerings, orientation and follow
up for new patients, improved social services, conti
nuity of staff, publicity, and parking.
Nurses highly valued partnerships as method to best
interact with patients and to plan and coordinate
care. Difficulties were having undisturbed time to
plan care and role confusion. Limited documentation
of carative factors was present. The most commonly
documented CFs were the following: helping-trusting
human care relationship; creative problem-solving
caring process; supportive, protective and/or correc
tive mental, physical, societal, and spiritual environ
ment; and medically supportive care. All respondents
viewed the NCP program as supportive. Narrative ac
counts added further support for the value of NCPs.
Prevented hospital stays, shorter stays, complex med
ical treatments, and^upported home deaths provided
estimated savings of $785,744.00 for 1991 and
$1,163,912.00 for 1992.
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390
CONNECTIONS
'f
Nursing Research, Theory, and Practice
Nurses' Caring Behaviors. Caring behaviors of nurses have
been the topic of a number
of studies using Watson’s Theory of Transpersonal Care S<
’ome of these studies rely
exclusively on Watson’s theory as a guide; other studies, such as the
one by Brown (1986),
use several theorists’ perspectives on caring to form a
composite conceptualization.
Believing care to be the central focus of nursi
ing, Brown (1986) gathered critical incidents from 55 hospitalized pat.ents receiving care for medical and surgical probleT B^n
used Watson s ten carat.ve activities and caring concepts identified by other theorists to de
termme that carmg was the central focus of nursing. Caring involved a process between
nurse and patient, focusing on health attainment and maintenance or movement toward
a peaceful death. Her quahtat.ve analysis revealed eight major themes of care (see Table
- and two patterns of care that were derived from the combined themes. These patterns
included nurses demonstration of professional knowledge and skill, surveillance and re
1
ss n„g presence. The second pattern related to nurses recogmz.ng mdividual qualit s'
and i ced, pro,noting autonomy, and spending time. This indicated that interactions were
a icnt-focused rather than treatment-focused. Brown concluded that patients must first
feel confident m the nurses ability to provide physical care before more expressive carina
J
$.. i ■
I*-*!
!u:
j"
j-
-■Herns, such as listening and spending tune, could be addressed. Although Brown', work
was de.scnpr.ve m terms of caring, relating rhe findings back to Watson's theory would
have strengthened her studv. Findings are congruent w.th Watson's curative fact, s fd
velopmg a helping trust relationship and prov.dmg a supportive, protective aml/or co '
rective mental, phvs.cal, sociocultural, and spiritual environment.
van (1992) identified rhe most and least helpful caring behavmrs exhibited by nri
■nary caregivers and hospice nurses in ,. hospice home care settmg. Two of the helpful be'
MX .or- rc ared to the physical needs of emergency management and comfort. Five behav
u .» were assocuired with patient psychosocial needs-listening to the patient answering
qticstuins honestly, r.ilkmg w.th pauent io reduce fears, staying w.th the patient during
1
f” I T1^-'
TS"T" t le PUt'Cnt that nilrsing services were -’h.vav- available Thref
tclpful behaviors related ro the psychosocial needs of the caremver These inclu le I a■ng nursing serv.ee availability, prov.ding information needed for a fefoTht^X
ome ,md answering questions honestly. The highest ranked helpful behavior was hsten-
mh r .C rar'ent' 7; /ll,e kwest n,nk"J WMv>or was talking to rhe patient about guilt
Tins studv supported Watson's contenr.on that carmg is central to nut ,ng and in tht
Stance, to hosp.ee nursmg, in which both patients and primary careg.vers receive cm As
peers, pst-chosocml care, .ncludmg provision of information: active involvement of fam
elm' fo W
n"’ SU,V'”"VC ’■'"■'H’nnrents, and trusting helpful relm,unships are
■elated to Watsons carar.ve factor-. Increased awareness from both the patient's and th
.
-■■'■! Segcsic, (1996) described cssenrml chtmiererist.es of exfo C'tcm Tkhir 'T^........ ^ W 'te'^ ^menundyrgo.ngst.rgerv and treatment
I mV. ' I V T'" ' " "
rClj'ni
-ndering
V
‘
Nmsesuho ...,-J.i-om
,c ..nd
,
1
"ere 1 :'IU ■ -'■’■i'muonme. Excellen. nurse- were perceive 1 ns .vn
u.ne and respectful, bxcelk-nt nurs«' ability to be near and act in ,n I'
during chaos indicated c.'iinm.- f .......-.ia.m-w a- ■ - . '
V '
-1 "-i ii i..g ,mi ,.: t •.i.ihliJnnjj relationm m
"
CHAPTER 13
•
Modeling Nursing from a Caring Perspective
391
shtps w.th patients and in acting according to panent preferences to maintain harmonious
relanonships. Fmdmgs are congruent with Watson's identification that a humanistic and al
tnnsttc value system, courage, and the nature of the nurse patient relationship, ln which
nurses a.d pat.ents m mtegrat.ng subjective, personal experiences with their objecdve
views of the situation, are essential to caring
J
Using a quantitative approach, Marin, (1999) exammed older adult perceptions of nur<e
carmg bchav.ors. A small convenience sample of institutionalized older adults responded to
a CBA that contained seven subscales related to carat.ve behaviors. Behaviors perceived as
most mdmative of carmg were assistance with human needs, such as nurses knowing what
they were domg and callmg the physician when necessary. The second most important sub
scale was related to humanism/fmth-hope/sensit.vity, winch ind.ca.ed the .mportance of be
mg treated w.th respect and dignity The study's value was Immed bv .ts small sample sre
and its failure to relate the findings back to Watson's Theory ol Transperson 11 C ue
Two stud.es specifically examined caring practices of perioperative nurses. One b-
mT8’
' l' 95)
rCrCC|,ri™S
"1-1-
McNamara (199 ) mvestigated nurses' perceptions. The study by Parsons, Kee, and Grav
idennfied carmg bchav.ors, weighted rhe importance of the behaviors, and compared be
haviors .dent,fied by renoperanve patients to those idennfied bv pat.ents exger encin..
myocardial mfarctmn. Based on the fmdmgs, invest,gaiors
that Wat-on's tencnn
ative factors could be mcorporated into nursing practice and were applicable n-ardless'ethe settmg. Charactenstics of carmg were found to be miporranr to ge.'operar.ve pt.t.en -
TOlarlv m terms of attention to physical and emotional needs. Ahlmach , nkm.. v
rhe first three sulkies of rhe CBA were sumlar for both per.operat.ve and cr.t.cal cam
cents, rankmgs d.ffered in evaluating ,he importance of existent tai, phen menolouiX]
and spiritual forces. 1 hrs difference led investigators to conclude that these r <tors mi.T■
be more important to cr.t.cal care pattents who faced more life-rhreatenmg problem- (. >.
mg factors were found in perioperat.ve practice and were perce.ved as important ro penoperative patients. This supported Watson's supposition
McNamara’s (1995) qualitative study of perioperat.ve nurses examined perceptions. •
mg Isehaviors exhibited w.th consc.ous and unconsc.ous pot.enrs m rhe^nopenXe
f
■ C e Lments
car>nx included showing concern for patients as unique humancommumcatmg touchmg, and being sensitive to patients' experiences. Nur-es demonMaa ed concern by prov,dmgsp.riI„,.l ,md psychologieallv supporriveenvitonments.Durthe preoperat.ve permd, carmg behaviors focused on esmbl.-h.ng trust. Cmng behavrs shifted to piov.dmg safety ami profectmn, which continued through the p -roperanw
fhase. Carmg charactenst.es exlnbited by nurses val, dated the dmten.-ions. .• Watsons 1C
carat.ve factors. A l.miting factor of this study w;,s the very -mail sample
onlv five
nurses participated.
1
mixtiw
Lome., caring framework that l-,ned W.a-on'- model w.rh Lemmeer’s mode!
h 1m
"n (
de,Cribcd
■’' nurse caring be -.tumen who
Mu unexpectedly lost a pregnancy. A central gmdmg rhe-.- « .- W.t-oW c„.,1, „
the personal dignity and worth ol individuals must l-e rm.-r.-m .; ,i,c p,,. ... ,t ■ lri|, .
Cjl‘Cl;.’r arsons expertencing.m unexpected pregn.mm a mqmmd mppXw'pm'X
blending to ongoing tears, and reassurmg patients >f rheirahilirv r .v, th.. -- t lc
me proem- .md to be.,,- children .nth. -mt.,,
i ' m.-,-.... ..,1. -v . ' - I
•fi- a ir- I. Uiu, ", >wanson-
-/-r'"
392
Nursing Research, Theory, and Practice
Kauffman’s findings indicated that nurse and patient interactions must focus on two persons
striving to relate rather than maintaining separate roles.
Lemmer (1991) described carative behaviors of nurses as perceived by parents experi
encing perinatal bereavement. Parents indicated that they were “taken care of’ by nurses,
which reflected the parents’ ability to turn to nurses for knowledge and expertise to help re
gain control of rhe situation. Nurses were perceived as hands-on caregivers who attended
to the woman’s or the infant’s condition and met comfort needs. Providing information
was perceived as enormously important. Caring for or about the patients involved ad
dressing emotional and affectional needs of the mothers, interpcrsonally interacting, and
empathizing. Emotional support and family-centered care were .hallmarks of this caring.
Parents were concerned that their nurses lovingly care for their infants. Key behaviors by
nurses included furnishing tangible evidence of the infants’ lives through pictures and
handprints. Respecting parents rights, such as accommodating religious rites and provid
■
u
i
•3
3
CONNECTIONS
Ed
-/•
’A
3
ing privacy, were crucial. Noncaring behaviors were rooted in communication failures and
rime constraints. Patients descriptions of the nursing behaviors reflected transactional car
ing as Watson suggested, and noncaring behaviors tended to occur more often in nurses not
practicing from a transactional approach. A weakness of this study is iis failure ro discuss
the findings in light of Watson’s study.
Using Watsons theory as a basis, Cronin and Harrison (1988) examined indicators of
caring as perceived by coronary care patients following myocardial infarctions. These pa
tients found monitoring of their condition and demonstration of professional competence
the most important indicators of caring. In general, attentiveness to human needs was
found to be quite important. Although it was nor identified as an important carative be
havior during the curly portion of the intensive care stay, expressions of posit ive and neg
ative feelings became more important rhe longer rhe duration of the stay. This study sup
ported Watsons contention that physiological needs must be met before more qualitative
aspects of care become important.
Miller, Haber, and Byrne (1992) conducted a phenomenological study of acute-care pa
tients and nurses about their perceptions of caring. Parallel descriptions of nurse caring
were derived and indicated that caring nurses were individuals who connected with pa
tients in professional and personal relationships that permitted monitoring and interven
tion. These findings were congruent with Watson’s theory that patients value human care.
Most studies of nurse caring behaviors have focused on rhe actions of staff nurses. To
gain a different perspective. Kerouac and Rouillier (1992) examined how head nurses can
promote caring in their practices. This study was rhe outcome of a project designed to fa
cilitate caring actions. A significant component discovered was that those nurses doing
rhe caring also needed to receive care. The theoretical statement arising from the project
study was as caring is advocated by a facilirutive nursing leader within a small group ex
perience, nurse', who benefit from the experience will exhibit caring behaviors toward their
patients and peers and will interact in a healthy way within the organizational context”
(p. 98). This srud\ supports Watson’s assuniption> that caring is interpersonal, that it pro
motes growth, and that a carinc en\ ir< mment can i< ’Sier development. Thi> study demon
strates the applicahilirx <-| ihese idea- to the administrative level.
Dietrich (I99_) alsu examined the environment of caring by exploring issues related
ro curing among nurses, idenrilving nurse-ro-nurse curing and noncaring, and uncovering
CHAPTER 13
Modeling Nursing from a Caring Perspective
393
contextual factors that facilitated or inhibited caring among nurses. This study supported
Watson’s assumption that caring is interpersonal and demands connectedness, under
standing, and support. Findings from this study are also congruent with those of Kerouac
and Rouillier (1992) because both studies uncovered nurses’ need to receive care in order
to care for others.
Two studies (Dennis, 1991; Montgomery, 1992) examined the spiritual aspects of caring.
Dennis undertook an exploratory study to discover nurses’ descriptions of the components
of spiritual care. She specifically used Watson’s concepts of the spiritual aspects of human
beings to frame and guide the study. Based on her findings, Dennis suggested that nursing
is an art and a science that requires a wholistic view of care inseparable from other parts of
nursing. Many of the components of transpersonal caring relationships that Watson de
scribes were expressed in descriptions of spiritual care. Dennis (1991) asserts that two of
Watson’s tenets supported in this study of spiritual care arc that the human soul can be
undernourished and can need care and that transpersonal care is the core of nursing.
Montgomery (1992) examined a slightly different spiritual connection that focused on
spirituality as a part of caring and derived a major theme of spiritual transcendence. In this
spiritual transcendence, nurses connected with others at rhe level of the spirit, which per
mitted them to maintain involved professional relationships without succumbing to overinvolvement. Spiritual transcendence in caring provided meaning for caregivers and helped
to combat stressors. Finally, it better unified caring relationships. By focusing on rhe spiri
tual dimensions, Montgomery’s study extends descriptions of nurse caring. In doing so, the
study considers the concept of caring more whtdistically.
To summarire, several studies discussed support aspects of Watson’s Theory of Transper
sonal Caring. Human care was found to be central and valued by patients (Miller, Haber,
(St Byrne, 1992). Studies upheld W atson’s curative components of trust (Brown, 1986;
McNamara, 1995), reaching/learning (Lemmer, 1991; Ryan 1992), provision of a support
ive or protective environment (Cronin 6; Harrison, 1988; Lemmer, 1991; Ryan, 1992).
humanistic value system (Jensen, Back-Pertersson, &. Segesten, 1996; Marini, 1999), sen
sitivity to self and others (McNamara, 1995). These descriptive studies can provide in
sight about potential patient needs and concerns. Knowledge about these needs can be
instrumental in assessing and planning care.
Studies about Caring Needs and Experiences of Specific Populations. Another wav
in which Watson’s Theory of Transpersonal Care has influenced research is by philo
sophically supporting studies that investigate human experiences of residents in nursing
homes, individuals coping with chronic diseases, and homeless children. These studies
focus on caring needs experienced bv different groups and suggest ways that caring might
facilitate participant^’ well-being. These perceptions of caring are most commonly derived
from the patients. One sttklv, however, derived perceptions of caring from nurses. Two
studies (Andershcd de Ternestedt. 1999; Weeks, 1995) in this category focus on caring but
examine family members who care for a relative who is disabled or is dying. These studies
raise the issue of whether caring is unique to nursing.
Running (199( ) described rhe experience of living in a nursing home for individuals
80 vc-ars of age or older. Running’s ■'visit" method involves multiple weekly visits to resi
dents for interviews. Rather than integrating and categorizing the stories to form a com
posite of the residents, researchers allow the stories to be presented as individual vignettes.
394
CONNECTIONS
Nursing Research, Theory, and Practice
chaptcr
K-' '
coped w,th being there, investigator gained Lfcht i,"
feio ■
r
Modeling Nursing from a Caring Perspective
1
......
pp-p .j™,.±±::»d±-k..
proccss rllan in poten-
rial findings. Consequently, it is difficult to assess'th'
nng to Watson’s theory, or to provide comprehensiv ■ !>UPPOrt T' 'nsights Electively
Martin (1991) used Watson's theory to qi,X r t TXTX"™5
research
"■uh polycystic k,dney disease. Half of he s R
'
d,C «Periences of adults
77 n°7Ct d'"ly—iependenr. Based on t T in7Z
;''YSiS' a,1J
''"1
pat.ents needs for information. In congruence w
W X'F "T',’"’'"™ded sensit.v.ty to
nurses ass,st ... searching for patient peZn
"S
M"«in suggested that
Nurses need ro work within the context of rehu ,n
"7 Polycystic kidney d.sease
sl
......
this study is the focos on individuals i.tfbnning themsedves-rath A? '"'"P'"1" flnt,in8 ln
provider for information. This findino
• l
1
' C Wr r lan reh ’nS on rbe care
ing acupuncture treatment for their rhe * '
1^.7 .'
t'1eSC women were seeka trusting relationship was particularly dX'dl^fo
Carar,vc h'ctt)r developing
disappointed by traditional medicine hefor •
L
' uom(-n because many had been
Si............... -i'i--y™;;::;
............ ..... .............
ti» .he,™
,■ j
1-.T’
& -s
:=:
caring behaviors, Weeks (1995)
■.id;";;';"
The investigator proposed that the c nvtnx-.
help family members handle n-unfiil f "r
provide care. InX" e
N
T
-cnee from those without chrome illness but nor fe T
T
therC Mls " d'h
chromc problem. Most thought of themselves 7
.
7"
CrCm than
a
'""lal. " "s E.racterized by part.cipants' annciX ’| T'T '™ "D',n'r caH ™c 'er"'cared as a statistic. "Willpower and faith" were X T '”
:"’d dcsire r<>
he
teaching and learning. Weeks found that fam i '
sisr disable.! adults and to ^TorXX
their study on Leininger's suggestion (i 988
—"ts. T Xz
I
1 ■ T v ri—
'‘■<lmo|.lgcU,||Jrv,i
m.irx imp.'ll ip, .. (hl... ,
'‘'i’’.i\ ipm s.
,t
||.v .
■
1 ",CI mif'''i'.mi fiv.isi.fn-M, i |
, ,
in fricih k iipj
L, ,. .
,
.
•
--venrs mc |k . j
Uk,s'fl"’- ‘iKl ru k-1 (r.,m
• n
i
.
....... ... .... . .......
i-1 . ... . ... -... . i..«
thit' ' "’1'' lel‘’',VC5' lnves".uaiors based
ues, beliefs, and social stn.cn,r ■
praCt,ce';,re N’unJed on valWatson's bel.ef that human c tre isTle "’ ''"T < 'lr'"c' ’"''^uvators also cons.dered
cate.! that f.mtly
an J m
''--Personal process. Rnd.ngs indiknowmu, being, and doing. AnjJrshed’.'n. I Tern 'C'''lvc '
rIlree difeent wavs:
that of professional caregivers Alrli
I '
'■"KMu|r compared ta.mlv involvement to
was congruent with WatlnT
'i'1" "'* r4rr
XV
bem.-
P'tssed that having
was import..... P|.lvin ,
'’""c'UTs. School-age gh.ldren exX7!'''“,'''fo-U'''"h..n.l,.nl>.ele,;„
' TV'"'7"" .......................... ' hmang
l,,r
ULS‘’> " U’U ' prd,tK)te inferpersonal
m'’St
" kn,,'V h,,"• -
'
"’anted to karn how to maintain their own well ban"’ ^hhvT
ata
vides insight to nurses reat-bino
. c 1 .. 1n'"’A r u)u^h this inlonnarion prol«> P> W.IO.P', TIk,.,v'„(
;oX.......
*1*' Weeki l3'led
lbe’'"'t
................ .................
n.lic..,ed th.,, i.-el. ng CU...J t„r
'r"1’
or nevvdisabled adults,
educational needs would
n’leS' and "ail1 “'^nce in ’
tate caring behaviors toward fanrilv a.rTXTX' ' n’’''' ‘SJUCat'°nal neeJs w"ulJ fecilisitivity to self and others must be culriTed ind that
i T"” SUg"eSt th,'r " Sen'
c- on their goals and attempts not to become I
".
" ihingness to fo""phcat.ons based on findings and reflection on W T
P”Cy derivcd several nursing
C’Ue that nu.-ses can pract.ee w.th greater m 77 |
7 'hei’ry Qlrari'indi
examme Watson's carat.ve factor ofhum .n.su ""hr’" T"C'.S"!;«cstcJ 'hat nurses could
views and growth experiences. This would in ■
’
' '' “ systcni "> their personal
Sight would permit more altru.stic behavior to7.H
"7"'™''' a'ld thc resi,lri"«
nope should permit nurture of fa.th and hope in cl TT 7"''""''" 'l'CfOrs l,f''auh and
this xtudv are the discovery of the experienX of.
'! I’a'aents. Two strengths of
C ‘T "C
rhd fo-l"^ '"rhe carat, -e fi,et7 X , 7"
"T Chr‘'n'C
"'’d
. ',,crs t!lar
395
the*
T
X COnC'USi°nS and aPP‘ying them elsewhere howeve ‘ rariCntS’ eXpCr“ DrawM ores these aspects. Support for Watsons TheX of T
'”OrC difficUlt' Ru'ln'ng
crt.ed from the fact thar the individuality of the ,7
SPerS<’na' Car‘ng 'night be
mque. However, Watson’s theory in rhi- - ’
fractions is preserved in this tech
nonship between rhe resident »J hl
'S
rC,ared '»
nature L die rel J
as-";.
:a
13
i
.
11
■'VrriI'l’it| Xh.nMinu
s-o'.ddlidil.'d;.-;1!"":':!"!;:'"''"'I
' 'I '
.HSun s
I
I
with Wsons carative factorXT'
r'“C,1C" Doinv
D°m" "US
«>nslStem
vncic presence.
dlgn.tvand whole "T e v
"
K'<,C nc<
ting
■sisting XT
persons in niecnny basic
forthe.rdungfa.XmeX"
-1 ltnr pro. .dmg care
■s proposed 1,1
thar niir>c- uuide rclativ.
(,Mhe
the studies (Xlurrin.
(Marrin. 1991; T
Tr.K\.
i.k\. Ic>97’
1’e.- . ions-\\ '
i > >-•
the needs of pmenrs handlmg elm,., „
,T.' ,, .
— 1 ’7 '
.gated
•nil proklci
nxluded help seektng (Wman & la.men WO..T X T 'P’"
Lutzen. 1999; Tracy 1997)
I
’
,
fl'r !::'- "nng (Xvman Ck
’XXT"■;hXTXT T’:
F',rrheIesplor:,r,o„,.,JHe.,vvrrilen.r,,,.7.
‘
lcmiina 1 Tu '■■c1995)l.wors.
-
—
>!'expfrk-uing..fhcr chronic
396
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 13 Modeling Nursing from a Caring Perspective
health problems iis needed.
J. As needs become
known, evaluation of interventions to
those needs should be completed.
resolve
care are descripriv^^limUed mlmb^r ofT flT T"8 WatS°n’S concePts of transpersonal
found in Table 13-2 and described in the frll
OUt“meS’ Fourof these studies,
Nursing Project in Human Carin.. (DNPHC Z^ldZ'T
T/nZ
on outcomes of medical or surmcal patients Th
"
V
(1992) focus«
nurse caring behaviors make?, difference in Ziem
how
outcomes from a qual.tat.ve perspective (Neil & Schr .ZThoT Z StU<approacl>
1992) or descriptively explain costs (Sch
too
'
)2' Schr"eder & Maeve,
These are nor iperimenmlTX
'
Mr' & Nei'’ “W
Nursing Care Partnerships ar the DNPHC h-^
rk
r
Schroeder, 1992; Schroeder & Maeve, 1992 Schroeder
1996) that focus on the effects of mtervenXZid Z wZ’’
sonal carinn. The DNPHC is . nur in
. .
W
L
&
&
s vvork ,n rr‘in.sper-
rhe n„b .r ...............
and emphasizes collaborative connecting b hu- •.
.
r°,n Un CV;,lu;,tK>n study
empowerment. Patients who use rhe Carim- Cmr"
pat,enr Co :,chieve mutual
ing services and independent nursinn s m-v " «C >n atfeSS. ,nc^lca,|y supportive nursvices can include therapeutic touch
coi'v'p010 T
l|K>aling- These Ser'
mc“. emotional . ....... mt, and coordi’n;,t.o??>f servicel"18’
at'°n ah°Ut C‘,rc
Nc'1 imJ **«*«• (1992) con-
XdZiniciXXZZX^
the Mens gumps of patients, s.on.Hc m
f1
■
H "1 '<5
•Ji
Jf--
a!
i’ '^crtpttve information derived from
and weaknesses I the DNITKkprograni'lse? T.bic h'?)'T''11'5'dC’lt't'Cd tllC 5rrenSths
CHS group method for evalumon w is th >r n
/ A P°Mr,ve ‘'tircome using the fosror.es. Because of their 'emCi
I^n*
valued by being able to tell their
Zrr™ "ith
percc'vcd £o be discov^
The concept of NCPs
groups conducted by Neil
........ "<»"«
is designed so ha, jetiem " re w
T - mutua empowerment. This partnership
rh.s study ,s rhe cc,
n Cw m X
.
a"
°ne
man Caring and the pXct" tZd
ph',T>’p,’Ical
of Watsons Theory of Hu-
397
f-
timated the savings in hospital charges for prevented hospital stays, shortened lengths of
stay, complex medically supported treatments, and supported deaths at home.
COSt;effectiveness evaluation for 1991 and 1992, Leenerts, Koehler
and Ned (1996) examined the cost-effectiveness of the DNPHC for 1993 Conoruenr « >1 ’
«„Jy („W).
p„r„„iir
„„„ <d,iireJ J™'?.- J
<tlv< j|i<raneJ |ms[h of
h
t.ents were hosp.tah-ed, and prevented readmissions. These factors resulted in si.mificant
cost sav.ngs over those not receiving serv.ces from the Caring Center. Patients expr s
sat.sfact.on w.th the whol.stic nature of rhe care and preferred involving the nurs.n., re
partner m hosp.tal care and discharge planning. These studies are an exciting examT of
how a nurs.ng model dr,ven by Watsons theory can impact patient outcomes in a c sP
effective manner.
51
In an outcome studv nor related to the Denver project. Duffy (1992) focused on rhe relatamsh.p of car.nghehav.ors to outcomes of health status, sarisf.crion, length of srav and
nur .ng care cost of hosp.talized med.cal and
As predicted, a smn.
tela .onsh.p between nurse caring hehav.ors and patient sar.slact.on was present? A c
mg behav.ors mcreased. so did pattern sansfact.on. However, no relationships herwe n
carmg hehav.ors and pat, cm health status, length of stay, and nurs.ng care costs emerTd
S c y supports \\ ..tson s content.on that nurse caring promotes patient satisfaction
To summary the outcome stud.es, rhe DNPHC studies demonstrated that Watsons
theoret.cal mode cot, d he unplemented m a primary care setting and that cost sa?in.-s
co. c e ach.e.ed wh.le otlermg coordinated care. In Duffy’s study (1992)—which ex am
med car,ng behavmrs tor the.r relat.onsh.p to health status, length of stay, nurstne ^ts
and sat.stacr.on of hosp,mined medical and surgical patients-parients were more sous'
Mby names pracuemg from Watson’s theory. However, unl.ke the studies by Schroe er
19)5) and Leenerts. Koehler, and Neil (1996), cos. sas ings were no, demonstrated Further .nvesr.gat,on regard,ng spec,fie car,ng factors that influence pat.ent outcomes nel
to be completed.
Research Summary. The research review of studies us,ng Watson's theory revealed a
number of p.,bl,shed srudtes that were primar.Iy descriptive. Only five studies were aimed
h
terVCnt'”n a”J"ut“'"“’™b.al,on. Four of these studies were related to
the DN1 HC (Duffy, 1992; Leenerts, Koehler. & Neil, 1996; Neil & Schroeder 199^
bS'tnT t
lW’’ ;,nJ 1,1 tllCSC StuJ'CS a
care’,nodN
h^d on Watson sph.losophv Of human caring Clearly demonstrated positive cost-effect.ve
actenstics All methods of etalum.on?-ntZ Cn1enr‘ng a f1r(,Swm based on those charand narrative
,
"'rsc focus groups, chart rev.ew, patient survey,
term.ned that .......... .. ,de> -tb >
'
Fs- T
caring parrncrsili
parrnerships.
TF^iS study deposinveoutcomeXZCZ
implemented and that
caring can be implemented and that
outcomes. Duffy (199D demonstrated increased patient satisfaction but could not
could ,
de. no ns,, ;„CC(S,. etteenvenes.s. Although desc pt, Vv ,„tor,n.,r, on ,s v;,|„able, theses
O .mt demonstrate the value of nurse car,ng bel.av.ors. This factor is of cnZ
years I 991 and 1992 ( Whroe D,? CT"'" " 'if " ' ”P1K ' " as cst,"'ared for the
"T"'" ''
rl, lt
.tself on caring-hut ,r has ,K,r vet
''
r,',CtiCe’ RcSearch t,sir«
philosophy reflects
1 e presuppos,turns or gut .nsrincts that caring ,s lln|„,rrulir. Ilut
rT;lrcZ? r
cZ‘IW ?
' 4k
•'■IHmuch further description of
,
nW. th.
1 ’ “““■ . ....... ... ......
collaborative nurse-par.em o mnea uv procc^ Th ■ • r I V "in’UMlsc,ousness and the
fhe‘’rv-bascd caring models can improve b alI
' ',Jk
n> demonstrate that
Services. Usin» estimated > i t '
.j.. ?,Ua 11 • °r C:1,c ,,nd P^’fent use of healthcare
n. estimated eost> of care tor HIV patients in Colorado, Schroeder (1993) es-
ZT
Tlf WlrrrV-,,?''n'ruJ,CS;,rC Crir'Clllv
kJ’ h-. add,r.on. studies that
Z
T
'
il>—-I Propositions
Many Stu9.es used ., com,...... of wver,,! carmg trameworks r,. |;,v rite grsm.lwo.k tor tlv't
1;
398
CONNECTIONS
L J
Nursing Research, Theory, and Practice
CHAPTER 13
Modeling Nursing from a Caring Perspective
399
patient (Watson, 1985; Sourial, 1996). The carat.ve components presuppose a technical
Life .s not a problem to be solved but a mystery to be lived. (Watson, 1985 p ix)
xxxxiXyS:!.?scrizzr traz“' —
of Hits theory to pmct.ee
knowledge base and clin.cal competence. Watson does not elaborate on the substance of
the technical knowledge base nor on clinical competence. The carat.ve comp.mcm "are
not meant o be prescriptive but rather to guide practice philosophically. Although W.t
son states that rhe carative components direct assessment, charring, and enXt m
caring pract.ces and although the DNPHC has demonstrated their use, their suCndve
philosophy and theory based ZnZhX otoZZ^dm XTo''0'1" "“T "’ith h°th a
structure has not been developed. It presently depends on individual interpmtX "
I .S perspect,ve’ at thc ,leart of the
itri,Sr,ng’ carin^'healing rela-
group consensus.
4
“ n or
Watson (1999) also has identified intentionality, nonlocal consciousness, and quantum
nursing profession is a covenant ‘‘to develon with rl •
tionship that potentiates health and well beinn nl H
amb.gu.ty as factors significant in the practice of nuts,ng. The meaning of t| ese m r Im
other" (Watson, 1994. p. I). W.rson I
.
harmony between provider and
”
but rather as a means tor focusing on rhe h'lim'in'( '
1S''
l"' nt,rslnM Practice
- • -de ot bemg human and pi^lZZ Z'''T ' '’'""'T’
§
C"’" l" ""'a"011 “
'<■11. other, and being in the world” (Watson, 1994 p ?) The 'twh
'’'T"’"' "
!'"iny ■'?' kU*,"'inK
is as imZ
'
i"Z a'™" °f
to nursing needs to be explored further to facilitate translar.on mro nursing praerme
Describing a Population for Nursing Purposes
At this stage of development, it is not appropriate n. use the rhe.
f''' 'i ibino popula-
tions for nursing purposes.
Expected Outcomes of Nursing
5
|
and other as suhjectivelv whole, accenrin.. rl • I
* Us,'tLtlu- llu llK,c ‘ 'ewing the self
consciousness of self and ns relation to the \Xh'm 1 '7 '
'"'J ';l;i'nues rhrough greater
than physical. From a professional „i7at;±7T
C'nBoJ,mCnr “ —
■
:
ir: ‘S
::
cci if:
-
w*
The outcomes identified in the DNPHC of praet.emg nursing from this perspecr.ve ,n
eluded seemg the muqueness and wholeness of the person-lam.lv comin.'h ™ ■
Z
p'Zt! rh Tlhei,,ing’ anJ ,eelinK the —
.... ^.on--sZm h
1997, ! . 16). The possible outcomes identified by Sourial (1996) include transcendence
that is, the moment in time when nurse and anodi -r
?
'
*’’non™~caring (see Figure 1 3-1). These tnnsnerson d
;
lk n '• u.il engage in transpersonal
harmony, and healing (see Figure 15-1). Watson (198861 suggests that nurse-recipieut in'
cal. The values and beliefs of Kuh p7son-‘
te.aet.on can lacd.rare the pattern directmg energy to h.s or her ,wn healing proves
,nUrUa' <’nd reaPro'
'v
ipspec,.veofcach within the relationsh.p
^hrcetcd; the hicusof rhe nurse is ither-directed. The r i • •
.1 17 ' '7 pai,enns se^involvcmenr i> in terms of hem-’ md hr.
'l.,U ', ek> iC,p' whereas rhe nurse’s
ate distress generates in die nurse a reflect'd- pioc ‘..'fd
1 ilc Patient’s immedisharing the experience, and attempting ro heli' rlTu.-lmh
Z1'"" " "'1 thc patient'
(Watson, 1985). The curing rel.monsdp between iwrsZmTrh
'""T
rW‘>PerSOnS
tential turning point. Smnific n • Iwilm
- i i
’ * ' ()l'Ki can become an exis(Warson, 1994). Watson (1994) explains Jh-u 7r tbr' "1
(>r,gin‘Ue ,n lhis n'ming point
i '-Aj'i.nii.s mar ar tins point,
Process Models
The processes of nuts,ng cen.er on est .blish.ng and m.umainmg a suhiect-to^lwet
human-ro-buman carmg relationsh.p. The nurse possesses an .mention;.!
jeettve carmg occasion occurs in which the subject,ve worlds of rhe parttemmts in the
S^XefaiX “1
(1989 P 2 32)
be:X°XZ^Z“X SUChfr dU’he'n,C,,y 0’
ab.nty to
"
ter one's consciousness ano^'ntenbonali JV-.
to ren‘
and wholeness. Responsivity mutuality inte ' Prornote caring-healing outcomes
and expressivity of the nursedppopnate t
"ty'
e"9a9ement
paramount" (p 5)
appropnate to the car,ng needs of the other are
The Variables of Concern for Practice
yniNcs'1,o”K'cr'i:-
ine ten carari\-e C(-»:np()!!..:;H
banco and preserve human
.
nAtnursiHu^irnrhept
..
. j
p . , - f
‘
11" 111
I''' d’"''"'”C"r
r r'‘"
1 -c.tv mdude
I'ro.^.cm-
[ivv HL’mhcanceotrhe
t’U1,UU' hLa''ni: ■*I’d "’holen<-"; S‘™
a^X'nbe^th'et'XChC
lation r ih
'
m'rS'nK " '' "ns^ri<'b <’l human care transactions ,n reat on to the actual carmg occasion. When nurse and panent come together ,n intXb
'
Carin"
aCrUal‘SatKm Ol the cari,ow
theXXnXl'1' ‘'71 3
Whites transpersonal
“ buman-to-human rransacnotn”
X
d„pr that ,< based in Watsons
tneory of caring (Schroeder
Maeve, 1992) I ntTriin e.-h- rh. I
has been discontinued. The goal of nurs.n.. .t the cJn Z'
'
J JcmonSlr'lt'1’" I'-iect
n-d. bode, and soul" (SclmiedX Xw
Z
-.''Xf"Z"" j1'
nuklei k th . . 1
,
i
’
- I • -'
'■uiKl.iuienr-.i! r.' die
d??" 7
intersubjeenve carin-heainiv Mufu.d rmpnvennenr dir.^-i. ldthentic caring relationships is ro he ichie’ •• i dir
I
i
nveenmepr• i
ti
"
' d
'! 11 ‘
PHrrnershipsbecwcen parienis and nurses. The nurse, rhnm-'li e.r-.. ..Ws
•
i
• • d
>
evnilri
.
.1
......... . v
undcr<i ii : t .•
ved
^-xptritnce- 9. die recipient <4 carb-. The nui M-r....
. ..
PTS lit li. •
1
'
'
ers in ihe docunicntari, hi process.
Watson (1999) emphasises spiritual curine as rhe
a noun . >r a verb but a wav < >1 being, t J.-r riL- H o 1|1Sk
- l 1 •
l l t
rnl
i-.r
H 'b c I.lCh 'Is
r.
it nnr>irix:. i .arc b nnr
3 hrotidi c.iriui:. the
400
CONNECTIONS
Nursing Research, Theory, and Practice
CHAPTER 13
Modeling Nursing from a Caring Perspective
401
3
r
energy is shared and directed toward healing. This requires “regular spiritual, contempla
tive, meditative centering practice from the practitioner” (Watson, 1999, p. 179). The
modalities of transpersonal caring are auditory, visual, olfactory, tactile, gustatory, mentalcognitive, being, and presence.
Practice Models
The state of development of this theory does not yet support development of nursing prac
tice models within the frame of reference introduced in Chapter .3. Before such models
can be developed, study and analysis of individual cases and nursing populations is required,
as is additional research and specification of theoretical and operational variables. In ad
dition to the carative components, caring behaviors have been identified in a number of re
search studies. These have primarily been identified from the patient’s perspective. Fur
ther study and exploration may lead to the development of practice models associated with
these caring behaviors. However, because Watson does nor view rhe theory as prescrip
tive, it may not be appropriate to consider developing practice models.
*
i
at large. Watson suggests that agencies should use the language of human caring, including
the ten carative components, to guide assessment, nursing acts, recording, quality assurance
criteria, and research. Within this environment the contribution of all persons would be
equal and necessary.
The DNPHC project demonstrated a structure of nursing practice from the caring per
spective and carried this philosophy from the mission statement to individual nurse acts to
recording in the patient record and evaluating effectiveness in terms of patient and eco
nomic outcomes. They established this project as an economically viable delivery of nurs
ing services to a particular population—patients with human immunodeficiency virus (HIV)
or acquired immunodeficiency syndrome (AIDS), their partners, and their families. Within
this project, staff, clients, environment, and even their consciousnesses were considered in
terconnected, (Hecomovich, 1994).
Research in relation to caring behaviors could expand to performance appraisal guide
lines that could guide implementation of caring practice-based nursing in an organization.
Implications for Education
Implications for Administration
>-
b
:::
Implementing caring theory within an organization requires a structure that promotes the
development of nurse-patient relationships as well as caring behaviors in management
staff interactions. Such structures incorporate principles of autonomy, flexibility, and cre
ativity. Primary nursing service delivery models are preferred to functional work assign
ments. Nyberg (1994) suggests that staff development associated with implementing
Watson’s theory of caring in practice should include rhe following:
• Emphasis on self-worth
• Committing to patients and their families rather than to the delivery system, em
phasizing patients’ whole needs, and assignments that provide for continuous care
• Encouraging openness to patients’ and staff’s communications
• Prioritizing caring
• Recognizing that all people have the potential to learn and to grow
• Teaching new modalities of care such as therapeutic touch, imaging, music, art, mas
sage, and relaxation
Watson (1994) describes the following outcomes of her theory on a practice setting:
• Provision of a moral foundation that results in commitment “to preserving integrity
and wholeness of self/other in relation to patients, families, communities” (p. 5).
• Attempts by the nurse to stay within the patient’s frame of reference in order “to
promote a mutual search toward meaning and wholeness of being, while honoring di
versity and rhe inner cultural life world of the other" (p. 5).
• Preservation of the “humanity, dignity, and integrity of self and other(s)” bv the nurse
(p. 5).
• Nurses' use of modalities that include ' compassionate listening to competencies re
quired bv complex medical technologies., to advanced caring-healing derived from
the arts and humanities" (p. 5).
1 bus the theory of caring would not only be evident in the interaction between the
nurse and the patient, family, or communirv hut also would be evident in relationships and
interactions among all persons in the healthcare setting and potentially in rhe community
Watson views knowledge development and rhe teaching-learning process as more than a
cognitive rational process. It is a human process and activity (Watson, 1989). Nursing
education should proceed using methods “that attend to the moral ideals and values that
are relational, subjective inner experiences, while honoring intuition, personal, spiritual
cognitive, and physical senses alike" (Watson, 1989). Caring and healing are linked. Ed
ucators within this perspective care for their students by enabling them to “know their
own voice” (p. 53) and bv encouraging students’ self-affirmation and self-discovery. Mod
eling and dialogue arc prime modalities of education from this perspective. The relation
ship of teacher and student in rhe clinical area would involve constant demonstration of
caring behaviors and dialogue a> students learned the processes associated with human
care transactions.
Future Theory Developments Required to Facilitate Practice
The ten carative components can be used to estimate rhe state of caring-healing practices
of individual nurses, and/or of an organization. As demonstrated in the DNPHC (Schroeder
& Maeve, 1992; Watson. 1994), they can guide assessment, charring, and evaluation of
patient-care decisions and outcomes. They can indicate quality outcome measures that are
nursing- or patient-centered. They can clarify values to establish priorities and translate
them into action. They specify caring practices for patient-identified populations. They can
also provide a database for a broad spectrum of research that stems from rhe caring perspec
tive. However, agencies that wish to use Watson’s carative factors would first need to develop
rhe substantive structure of each so that all nursing staff would clearly understand the mean
ing of each. For example, what i> meant by “instilling of faith-hope”.’ How is this accom
plished? What criteria would be used to indicate that this had been accomplished?
New caring modalities arc required for practice fi\>m this perspective. What are these
modalities? \\ hat is meant bv "healing"? How is it accomplished? What are natural
healing modalities? \X hat io in\ i >1\
cd in
m the practice of
i >1 knowing
km >wing and being and
<tnd doing
do inc in
>hcj
caring relationships? How does ione devclop/perfect caring behaviors? What arc caring
behavi. >rs?
, ... Hrudax
-i
. 01263
T
t L.' / A-^ Taluk, Bangalore - >• ’
I
402
CONNECTIONS
Nursing Research, Theory, and Practice
Modeling Nursing from a Caring Perspective
CHAPTER 13
McCance, McKenna, and Boore (1999) raise the very practical question of whether
it possible to use Watson’s theory in practice without an extensive understanding of the
cxistcntial-phenomcnological-spiritual underpinnings of this theory.
£n NEXUS
r.' I
.? • 3 •
71
i
Leininger, M. (1981). Caring: An essential human need. Thorofare. NJ: Charles B. Slack.
Leininger. M.M. (1988). Care: The essence of nursing and health. In M.M. Leininger (Ed.). Care: The essence of
nursing and health. Detroit: Wayne State University Press.
Le'Nm^n^ M (199'J CUkUre
universaIU>’: A lheory "f '’1<rsing. New York: National League for
Leinmer, C (1991). Parental perceptions of caring following perinatal bereavement. Western
/Or In moving rhe caring-healing model beyond nursing, Watson obscures rhe object
gyVI of nursinga nurse comes into a professional relationship with another per
son remains in question. The distinction between human caring as a general case and nurs
ing as a particular case is not made. It seems that one must first be a nurse to understand
Watson’s concerns and to be able to transform oneself. Barker, Reynolds and Ward (1995)
.ire concerned that the focus of nursing is not expressed in the literature on caring They
find u an “unnecessary distraction from rhe continued exploration of the boundaries of
nursing” (p. 396) and from establishing the raison d'etre of nursing.
Watson noted that caring in nursing conveys bodily physical acts but emphasizes “au
thentic presencmg of being in the caring moments, carrying an intentional caring-healing
consciousness (1999, p. 10). She concluded with the statement that “the hope is that aca
demic nursing will transform its educational-practice models to prepare practitioners to
practice the more complete paradigm of nursing,.one that not only is able to integrate
medical and technological aspects into its practices but also transforms them along wkh a
totally new view of advanced nursing practice” (1999, p. 233).
403
Research, 13(4), 475-493.
Jourrud of Nursing
Marini, B. (1999). lnstirurionali:ed older adults’ perceptions of nurse caring behaviors: A pilot study, humal of
Cerontological Nursing, 2.s(->), 11-15.
Martin, L S. (1991). Using Watson’s theory to explore the dimensions of adult polvcvstic kidnev disease
1
ANNA
Jounial. 18Q). 493-499.
Mc&uce T V. McKennu, H I’. & Boore. J.R.I'. (1999). G,rinS: tl„ore.lral perspeurrvusol reley.nuu ro rnrrsine
Journal oj Advanced Nursing. 30(6), I 188-1 395.
McNamara, cS.. (1995). 1Perioperative
nurses’ perceptions
percept
jviciNdniara,
enoperative nurses
of caring pracuces. AORN lournal. 61(2) 377-IS1
384-588.
'
Miller. B„ Haber J, & Byrne M. (1992). The expenence of caring in .he acute care setting: Patient and nurse
perspectives, n^mt (Ed.) The presence oj caring in nursmg New York. National League for Nursing.
Montgomc'ry. C. (I9A). The spiritual connection: Nurses’ perceptions of the expenence of caring. In D. Gain
(td.). / fie presence oj caring in nursing. New York: National League for Nursing.
NeiL R. N Schroeder. C. (1992L Evaluation research wnhin rhe human caring framework In D Gaul (Ed )
I he presence oj caring m nursing. New York: National League for Nursing.
Nyberg. J. (1994). Implementing Watson s theory ot canng. In J. Watson (Ed.). AppNmg the art and sc.ence of hu
man caimg. New York: National League for Nursing.
NV",':"(YCY, Y?"' K' 11W' C''r,nB
"■'th
XxrMm: Sneneu Q,umerR
/z('L 104-169.
Parsons. E._ Kee, C.. & Grav. I > y 1003) Perioperative nurse canny behavior': Perceptions «.
't .'Unjicil p;nient>
AORN Journal. 57(5), I 106-11 14.
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Burljc,.
Rcvn.,Us
& Wilrd. T (19951. Tl,e |Wpt, Rkus
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:::
/nienumunal Journal of N ursmg Studies. 32(4), 386-397.
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C° Scienc^/K) ’-B-Sl
8rtatCr SPedfidty ‘n defining nUrsing’S '"^paradigm. Advances in Nursing
•i1
Cronin, S. N Harrison. B. (1988). Importance of nurse caring behaviors as
infarction. Hean-Lung. 17(4). 374-380
perceived by patients after myocardial
Dennis. P. (1991) Components <4 spiritual nursin<-care from tin muse’s perspective. Jounu! of Holistic Nursing,
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„f amng
Oierr.ch. L. (1992) The o,™,- nursing cnv.ronmvm. tn IT Cant (Ed.). The
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nutty. I, (1992). Thu unpact .,^,r,„g„n portent . ntetmes. In 1). r
(RJ.). iff/nesetKC
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Hecomovich. K. (1994). Learning to work together in a way chai nurtures our abihtv ro care. In D. Gaut (Ed )
l-he presence of caring in nursing. New York N uional League for NursimJensen. K.. Back-Pe.ter.on, < 6t Secern,.K. d-O The canng momen? and the green-thumb phenomenon
among bwedi-n nurses. Nursing Science Quarterly. P(2), 98-h'4.
lenscn. K BacCrer,e«s.,n. S.. & SutteMun. K Ot.., ;
tH,..R,jy,, l.pr„f,R. cxce|!ent
nurse NursrH-; N'li'n. e gja..:.’; >b.. 'J. ' . , ! '
Kerouac.
1< • dlier. 1. .
R..;.1X't i-
EB
i
lilies describe what is special in rheir lives. Holisuc Nursing Plaice
J I9,9,51’ Children 'n'ni
Andetshed. B. & Ternestedt. B. (IW. lnW|v.wn. of relatives m care of rhe dying in different care cultures:
i
n m-urm-!
... mg:, .-.i. ai.g. \Va i oik. Narion.il League
Levnern. M.. K... I,ler. I . .y -.. ,1. R. , , 99O Xunt.tp . .,re
of the Association ..f Nic w -n AIDS Care. 7(4). ’>7 4<)
a
lrin,- ..
Nursir.e
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In . ’ Piaui (Ed.),
wh||e rejlk.H,„
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Running, A. (1997). Sna|w.h.tots or experience Viynertcs from a numny home. Joumal ,>} Advanced Nursing. 25i I \
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c..:
a
earmy ib.Y
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*
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• th
in F.
IV... NJ \V:,r,or. .Eds' T-mir.;1
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..-TT''
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404
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Watson, J. (1999). Postmodern nursing and beyond. Edinburgh: Churchill Livingstone.
Weeks S. (1995). What are the educational needs of prospective family caregivers of newly disabled adults
Rehabilitation Nursing, 20(5), 256-260. 272, 298.
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Epilogue
THE INTEGRATION of NURSING THEORY
and RESEARCH for PRACTICE
<’•
5
1
‘ I
7
(
si ■
...
t- §
USING THE PAST TO CREATE THE FUTURE: THE INTEGRATION
OF NURSING THEORY AND RESEARCH FOR PRACTICE
The central metaphor for the integration of theory, research, and practice is the nexus.
Unit 1 described the broad concept of the nexus. The integration within each theoretical
system was the focus of Unit 2. Consideration should be given ar this time to integrating
current nursing theoretical systems into a few highly developed theoretical systems. There
are two aspects to this work: (1) rhe evaluation and organization of existing work in nurs
ing theoretical systems, and (2) a commitment to deriving further research and practice
from existing nursing theoretical systems.
EXISTING THEORETICAL SYSTEMS
Nursing: A Practice Discipline with Practical Science
It is ultimately the knowledgeable practice of nursing in service of the public that inusi
drive nursing scholars and practitioners. As the discipline develops, its knowledge must by
applied to that service. Persons who provide a particular service to the public and use
particular and unique body of knowledge characterize a profession. The development of
rhe discipline must be integrated with the development of the profession of nursing for
knowledge to have meaning. The focus of knowledge development should come from and
feed back into the general nursing theoretical systems. Developing research and knowl
edge within a rhc<'relic il system will expedite rhe progress of nursing as a discipline.
As a practice discipline, nursing is concerned with the development of knowledge and
the use of that know ledge ro structure and inform practice. Nurses can no longer be satis
fied with describing their practice in terms of what tasks they perform. The focus on out
comes and quality demand' that nurses be able to articulate knowledgeably and convinc
ingly the reasons for what they do.. To do this, nurses must first understand rhe wh\ ot what
they are doing as w
well as what they could and should be contributing to healthcare. They
need to be able ! > e«■mmunicare
.
this ro a broader public— 'hr other health profe.'sionah
405
I
ff'
406
EPILOGUE
EPi LOGUE
with whom they work, the policymakers whose decisions influence their profession anJ
!
most importantly, rhe puhl.c they serve. Professional knowledge includes awareness if th ’
condit.ons necessary for effective nursing; however, such knowledge development needs
be based in a clear understanding of the object of nursing.
‘opment needs to
|
The linking of theory and research to practice is accomplished through processes of d
t elopment and diffusion. Development makes abstract knowledge useful’in concrete wavs’
'
Using nursing research fmdmgs is not only significant in the individual nurses practice
a broader context, nursing practice improves as research findings and advances in nursin"
I
I
knowledge become rhe foundation for the development of practice procedures protocol
and programs. These advances, when diffused to a broader public, impact thi proven
and structure of healthcare. The importance of formal development prLsLs iVintegra "
mg theory and research is illustrated in Figure 14-1. The development of practice modeh
General
nursing
theory
Knowledge transmission
Research on
theory and
instrument
development
X’ - ■
4- ;
■
.3
.Ji
<
sE
.-r-'
0 S -8
g.
pJ K’ i:
f
'id.
Q
Practice
(specialty)
XX
Development
Ix
1
o
o
Clinical
research
(specialty)
|
407
should be a national or even international effort, not simply an institutional effort or the
work of individual researchers. This is both an efficient and effective approach. This
approach will also facilitate the development of policy initiatives relevant to the object
of nursing. The efforts to identify nursing interventions and outcomes and to construct
evidence-based nursing practice are examples of some broader initiatives.
Recognition of the Duality in the Ontology of the Discipline
The ontology of the discipline must include the nature of person and the nature of rela
tionships. Some theoretical systems include progressive development of both, as in the
work of Orem and Watson. Others have more high
high developed
developed one
one sine,
side, as
as in
in replan
Peplau ss emphasis on relationships. Still others focus on only
• a single
• element
within the ontology,
such as in Pender’s Health Promotion Model.
The ontology of person is necessary for understanding why a person needs or can bene
fit from nursing and tor recognizing rhe characieristics or attributes of rhe nurse. Some
theorists—notably Orem, Roy. Neuman, Pender, and Peplau—base their conceptualizations
on persons who have a capacity for deliberate action and who can modify themselves or
their environments to produce change. These theories more typically identify characteris
tics of persons than clarify the object of nursing. Others, such as Rogers, Parse, and Watson
are less specific about personal characteristics that engender change. The focus on mutual
simultaneous interaction with the environment gives as much power to the environment as
to rhe person.
Some theorists have identified the characteristics or dimensions of the patient but have
not extended these same characteristics to rhe nurse. For example, Roy described the per
son as an adaptive system from the patient’s perspective. She has yet to similarly describe
the nurse. Nursing, then, is the interaction of two adapting systems within some broader
system. Any change within one system must affect the other; this applies to both nurses and
patients. Orem. Roy. and Pender explicitly call for nurses to be engaged with patients on
that level.
An ontology of interaction is necessary to express rhe nurse-patient relationship. Nurs
ing is, in essence and in existence, interpersonal. Some theorists, such as Peplau, focus pri
marily on the interpersonal interaction. Some, such as Rogers and Parse, focus on the in
teraction of person and environment. They hold strongly ro the mutuality and simultaneity
of the person-environment interaction. Parse described the relationship as subject-tosubject engagement, a "being with" that differs from an interaction (Hoch, 1991). Others
include the interaction as an integral element of their theories. This is most notable in
rems and m Parses work. Models built on general system theory, including those of King
and Neuman, apparently assume that the nurse is a part of the system, bur rhe nurse’s role
is nor made expl.cit in their models. Watson describes the ontology of nursing as a rela
tional ontology ba>ed in a transpersonal caring-healing model.
The Scope of Theoretical Systems
Diffusion
“xxt
i
of tran5mission' deve,°pmen '■ -d
related to
Nursing and nursing rhe,irerical systems ire h»c.itvd
irhin a broader frame <>t reference,
Orem placed her work in rhe broader frame
of rhe world ot humans and their affairs
(1997). Neuman and Watson describe rheir w.
’rk b ii<cfiil ro all health protessiim-; l->r
as "beyond" nursimj
placo her work h, it.
exi'hci! i.'sm<’logy. The articulation of
i
!
I
408
EPILOGUE
EPILOGUE
.v-
i
nursing knowledge with the broader domain of knowledge of the universe, human science, and healthcare is necessary to maintain the disciplinary identity of nursing.
This text examined some theoretical systems that include the whole of nursing. Although each theorist began with different philosophical or conceptual views, each intended
to structure knowledge for the discipline of nursing. With established substantive content,
these general models provide alternate views of nursing. Other theoretical systems explain
particular aspects of nursing but not the entire discipline. These works can fit within those
described as general’ or grand theoretical systems to the extent that rhe cosmology (if one
exists) and ontology are compatible. For example, Peplau’s work is congruent with the the
ories of all but Rogers and Parse described in this text. Hanucharurnkul (1989) compared
Orem’s and King’s theories and discovered many similarities in the two works. The theo
ries complement each other and “can be used together to make nursing theory more com
plete” (p. 371). Similarly, Comley (1994) compared Orem and Peplau. Her analysis suggests
that the two are philosophically congruent and could be used together to further under
stand the nurse-patient relationship. Armstrong and Kelly (1995) compared Rogers and
Peplau and concluded that both perspectives are needed. They raise rhe discrepancy be
tween rhe two perspectives on causality and linear process and' then
’
dismiss it as nonessential. Further exploration of these differences is needed.
Some theoretical systems are limited to or include theories that are narrower in scope
and are referred to as middle-range theories. From the perspective of the discipline of nurs
ing, these theories are appropriately named when they are derived from or related to a
grand or general theory of nursing. Many middle-range theories originated in existing be
lief systems about nursing and proceeded to conceptualize and formalize one or more as
pects of that belief system. This type of work begins in the logical middle and progresses to
ward science, with limited if any movement toward philosophy. However, many
middle-range theories are not connected to nursing theory. At some point, these developing bodies of knowledge should be articulated withi or reconceptualized from a broader
nursing disciplinary matrix.
As the nursing theoretical disciplimies continue to develop, as they make explicit the
philosophical basis of the work, and as major changes to the models or theories occur, nursing scholars must continue to evaluate previous work in 1light of the new. Roy’s and
Watsons 1999 modifications of their theories demonstrate thi:
.is necessary type of change.
I-
Je 1
Practical Usefulness
Nursing theoretical systems may he useful for individual nurses as they develop personal
concepts of nursing. For many, this occurs as part of professional education. Others re
structure their existing knowledge when they first encounter a nursing theoretical system
that illuminates their practice.
Airhough personal conceptualizations of nursing are important, the development of
nursing practice programs from a nursing theoretical perspective is also important. Many
opportunities tor further development of practice from a theory-based perspective exist.
Such programs not only help io highlight the unique contribution of nursing to public
healthcare but are the basis for specifying expected outcomes of nursing activity, related in
formation systems, and costs associated with delivery of nursing services.
IS
33
1
I
f
409
Empirical Adequacy
According to Fawcett (1993), the empirical adequacy of theoretical models depends on
the composite findings of research studies. Ideally, empirical evidence is congruent with the
theoretical assertions, thus indicating support. Although the nature and adequacy of re
search varies, advances in using and supporting theoretical systems and models have been
made in multiple studies. Theory has guided research, and in turn, research has provided
supporting evidence. However, the research conducted to date is limited in that a prepon
derance of the studies have been descriptive and that far fewer have been theory-testing
studies. Some studies have insufficiently connected the variables of study and rhe theory.
Investigators have not always been careful about examining findings in the light of the re
lated theoretical propositions. Because of the nature of grand theory, only a limited aspect
of the theory can be tested at any given time.
Nevertheless, many studies have yielded support for selected aspects of theoretical sys
tems. Research findings have generated conceptual changes in some models. For example,
Pender changed her conceptualization of factors that directly influenced engagement in
health-promoting activities because research indicated that those direct connections ex
isted. Measuring instruments and research methods have continued to evolve. For exam
ple, the Self-Care Inventory is a more adequate measure than early instruments assessing
self-care. Investigators using Rogers’ Science of Unitary Human Beings have developed a
number of creative methodologies for gathering data. Perhaps the most exciting aspect of
nursing research is the emergence of some programs of research. Although many studies re
main single and isolated, some investigators have begun to publish series of studies that
build from findings of one initial study—for example, Duffy’s work on the determinants of
health promotion or the
rhe work of Fawcett, Tulman, and others on functional status. This
;
discovery method is tar more
efficient than models that were used in the early years of
nursing research.
THE FUTURE
The future of nursing as a discipline rests with those scholars and practitioners who un
derstand the need for nursing discipline-specific perspectives. Although rhe discipline fo
cuses on knowledge and use of knowledge to develop practice, it is through the profession
of nursing that interactions with other persons arc made. The nexus is completed when the
knowledge developed through theory and research is made useful for practice.
In the early twentieth century scientists attempted to define a unified view of science.
This work led to field theory, systems theory, and rhe theory of relativity. In the late twen
tieth century, the search continued. Physicists searched for a “Grand Unified Theory’" that
would unite all the forces and particles of nature into one coherent package (Gribbin,
1998). Likewise, nurses today desire a unified view of nursing. Decades have witnessed dis
cussions on one theory or many theories for nursing. In 1999, a group of nurses pur forth a
“consensus <rarement on emerging nursing knowledge’’ (Boston College, 1999). The brief
statement is limned co a values-based perspective and docs not incorponue a science-based
perspective of human being and human existence in a material world. Nursing as a disci
pline and a pnSession should integrate theory, research, and practice. But it is too early in
the process of knowledge development to seek a unified view of nursing. As nurses in
,r. i
nuLO-aniHMMilW
410
■
E PI LOG U E
1
41
-
I§
I
A
t; S-..4 ■
prac .ce know divers.ty ls an important consideration. So too is diversity in knowledge
development. Barring some major breakthrough in science, substantively different views of
the human/person and person/environment relationship will continue to develop Diverse
views of the realities ofnursing are useful in guiding research and practice.
"
Although no unified view of nursing exists, it may be possible to agree on the proper object of nursing The medical profession demonstrates the fracture that results from lack of
consensus on the proper object of the discipline. Although many agree that the object of
the medical d.sc.pl.ne is to cure disease or to make people well, numerous branches of medicme have emerged from differing beliefs on the causes of disease. These include allopathic
chiropractic, osteopathic, naturopathic, and other branches. One paradigm became pre
dominant, in part because of the quality of science but also because of the politics of the
profession. To avoid similar problems, nursing would be well advised to keep ils focus on the
science of nursing.
If nursing is to significantly impact rhe delivery of multidisoplinary healthcare, our
knowledge base needs n, be sufficen.ly def ined s.
m ,vogn.se the unique locus of nursmg mact.ce and value .t tor rhe substantive contributions „ can make to advancing it
Ji
S if:
.............................................Wa: ■URL
.................. .............................................................................................................................................. ..............................
,r- i,h'11 ... ... .
.TT
'le'el‘’rmcm .......
°"r. ..... •"ij
Huch, M.F1. Uv)-)l Perspectives <.n health. Xaryay .<-iciicc Quarterly, 4( I). 33-40
Orem. D E (1 yv. ) V,ew., ,t !uilni,n bcins,s
l(i
aS
‘"’r—s
Appendix
|
RESEARCH INSTRUMENTS
I
?
Fawccrt, J. (199 5?. Anahsrs anj evaluaium of nursing theories. Philadelplwi: FA Davis
v ’7
I
I
j
....... . ..... ...... . ............................... .....
f
I
solve to develop ir further. Opportunity awaits all nurses.
........................................................................................................................................................................ ......
v v’*’
|
Uortne. utVO) has suggested that nursing science has matured during the past 15 years
Nurs,ng has made excellent str.des in develop,ng and applving nursing knowledge. As a dis
upline, nursing should apprec.ate rhe growth of its knowledge base and strengthen ,ts re-
REFERENCES
U
'
I
|
Orem: Self-Care Deficit Theory of Nursing
Self-as-Carer Inventory (SCI), p. 420
1X2A: Dependent Care Agent Instrument Questionnaire tor Mothers, p. 425
Children’s Self-Care Performance Questionnaire, p. 428
Mental Health Self-Care Agency Sc.tic (MH-SC.A), p. 430
Rogers: Science of Unitary Human Beings
Power as Knowing Participation in Change (PKFCT). p. 433
Temporal Experience Scales (TES), p. 436
Perceived Field Motion (PFM), p. 438
Human Field Rhythms, p. 440
Human Field Image Metaphor Scale (HEIMS), p. 441
Assessment of Dream Experience (ADE), p. 443
Index of Field Energy (IFE), p. 444
Leddy Healthiness Scale (LHS), p. 450
Person-Environment Participation Scale (PEPS), p. 452
Neuman: Neuman Systems Model
Levels of Cognitive Functioning Assessment Scale (LOCFAS), p. 453
/Q( ((
?]
Roy: Roy Adaptation Model
Inventory of Functional Status—Antepartum Period (1FSAP), p. 461
Inventory of Functional Status After Childbirth (IFSAC), p. 464
Inventory of Functional Status—Fathers (1FS-F). p. 467
Inventory of Functional Status—Cancer ('
r'
(1FS-CA).
p. 471
Inventory of Functional Status—Caregiver
of Child
-............
-I in a Body Cast (IFSCCBC), p. 473
Self-Consistency Scale, p. 475
I
I
Peplau: Theory of Interpersonal Relations
The Rel; itionslup I ‘ 'rm. p. 4 /S
Watson: Transpersonal Nursing and the Theory of Human Caring
Carinu Beh.e. ior> hr ■•ni.'n o .‘Bl), i . -C '
s
B
411
I
X
412
APPENDIX
APPENDIX
I.
Complete contact information for the developer(s) of each mstrument is presented at the
end of thts sectton. Contact information is also provided for some instruments that could
not be included in the book.
H'-
THE ETIQUETTE OF USING RESEARCH INSTRUMENTS
Instrument development plays a key role in theory-related research. It provides a mecha-
smeT7 7eaSU"ng Phe"on>enon identified by the theory. Instrument development may be
penally guided by philosophical beliefs about the nature of knowing found within rhe
theoretical framework. To facilitate better communication and continuity of research this
appendix presents research mstruments denved from rhe various nursing theories discussed
in earher chapters. In some instances the complete instrument is presented for perusal- in
other instances sample items from the mstruments are provided. Sometimes only the name
and contact mfonnation for the instrument developer is included. This information is cru
cial because an invesngator planning to use an instrument developed by others must re-
quest permission. It also .nay be prudent to ensure that the author of the instrument agrees
that rhe pmpo.sed use of rhe instrument is appropriate.
When using an already developed instrument, investigators should always consider rehal dity and validity. Reliability and validity reflect the research situation in which rhe in"l11”'t5
Although reliability is necessary to establish validity, the presence of
rehabihty does not ensure validity. A reliable instrument that is used for purpose other
<
a
Te';i Uar
1
7 teS“ng may nOt be valid for measurin" a
or popl l
B
l
f n 6 G’ l991)- An inVCStigatOr " ho Selects an
a
study should weigh carefully the previously established attributes of reliability and validity
and then consider the nature of the proposed instrument use. Different circumstances may
IZ " 1
5 '7 V‘ iJit' WakZ’ StriCk‘and’ 3nd
1991) have suggested that
validity bc.detcrmmed each rime a measure is used, because random errors and individual
'S
■
I
-
uati<m,Ktb I 311 e|ilCtl7un eaCl' ad™nistration of a resc- Pretesting an msrrume.it in a sitSimilar to that of the proposed study is an excellent mechanism to ensure adequate
instrument reliability and validity for the major study.
When usmg an instrument developed by others, investigators should adhere to rhe following guidelines:
• Never use an mstrument without the written permission of the developer. Inx-csri.mror.
should always request permission, and they must note the permission in publications
of their findings. Most developers are pleased when use of their mstrument is sought
However, developers may refuse if they believe that their instrument mav be used
inappropriately. Most developers request information about rhe proposed use of the
instrument before giving permission. Although many instruments can be used free of
charge, sometimes a fee ts attached. The developer also mav limit duplication of the
instrument.
• RJMiiy mid valiJuy are characteristics of the research mstrumem in n.s mhcreni format
bi. means that the instrument cannot be modified without further work io reest ibItsh adequate levels of reliability and validity.
• I >O .yr modi/y instruments
the frermtssion of the Je, eloper Although developers
may be amenable to minor modifications to their mstruments, they have rhe rmht to
rtfu.se am modifications. Investigators must consider how
might influence
ihc instrument’s reliabilirv and validirv.
413
• Send a report of findings back to the instrument developer. Many developers make such a '
report a contingency of instrument use.
• Publish findings, crediting the instrument developer for the instrument. Making findings
available to the scientific community transmits information about research instru
ments. The reliability and validity of a measuring instrument is an ongoing concern.
One assessment of reliability and validity is not adequate. However, multiple pub
lished studies that include findings regarding reliability and validity can firmly es
tablish those characteristics for a particular measuring instrument.
REFERENCES
Pedhazur, E. <Si Schindkin, L. (1991). Measurement, design, and analysis: An nuegiiitcd npproach. Hillsdale, NJ:
Lawrence Erlbaum Associates.
Waltz, C... Strickland. O.. & Lenz, E. (1991). Measurement in nursin!' research. (2nd ed ). I'liil.kk lplii.r F.A. Das
CONTACT INFORMATION
Instruments in the Appendix
Orem: Self-Care Deficit Theory of Nursing
Self-as-Carer Inventory
Susan Taylor, PhD, FA AN
7 Gipson Court
Columbia, MO 65202
email: taylors@health.missouri.edu
Elizabeth A. Geden, PhD, RNC, FAAN
Professor
Sinclair School of Nursing
University of Missouri—Columbia
Columbia, MO 65211
emai 1: gedene@missouri.edu
DCA: Dependent Care Agent Instrument Questionnaire for Mothers
Dr. Jean Burley Moore
College of Nursing and Health Science
George Mason University
4400 University Drive
Fairfax, VA 22030
(-hildren’s Self-Care Performance Questionnaire
Dr. Jean Burley Moore
College of Nursing and Health Science
L icorge Mason Universitv
4400 University Drive
Fairfax, VA 220K
I
414
J■
APPENDIX
APPENDIX
&
Mental Health Self-Care Agency Scale
Patricia West, PhD, RN
Director of Behavioral Science
St. John Family Medical Center
24911 Little Mack, Suite C
St. Clair Shores, Michigan 48080
(810) 447-9070
Rogers: Science of Unitary Human Beings
Power as Knowing Participation in Change
Elizabeth Ann Manhart Barrett, RN, PhD, FAAN
Professor and Coordinator, Center for Nursing Research
Hunter-Bellevue School of Nursing
Hunter College of the City University of New York
425 East 25rh Street
New York, NY 10010
(212) 481-5079
or
41 5 East 85th Street, 9E
New York, NY 10028
(212) 861-8228
J
Temporal Experience Scales
Dr. Jeanne L. Palerta
3 320 Perimeter Drive
Greenacres, FL 33467-2061
(407) 433-0608
$ F'
< J!-: ,»i
fO S3
;zJ
Is
Perceived Field Motion Scale
Adela Yarcheski, PhD, FAAN
Professor, College of Nursing
Rutgers, The State University of New Jersey
University Heights
Newark, NJ 07102
(973) 35 3-5326, ext 520
email: yarcheski@nightingale.rutgers.edu
’-r;
-
i-
Noreen E. Mahon, PhD, FAAN
I rofessor. College of Nursing
Rutgers, The State University of New Jersey
University Heights
Newark, NJ 07102
(201) 64H-5388
email
I
nitycrs.edu
415
Human Field Rhythms
Adela Yarcheski, PhD, FAAN
Professor, College of Nursing
Rutgers, The State University of New Jersey
University Heights
Newark, NJ 07102
(973) 353-5326, ext 520
email: yarcheski@nightingale.rutgers.edu
Noreen E. Mahon, PhD, FAAN
Professor, College of Nursing
Rutgers, The State University of New Jersey
University Heights
Newark. NJ 07102
(201) 648-5388
email: mahon@nighringale.rutgers.edu
Human Field Image Metaphor Scale
Linda W. Johnston, RN, PhD
School of Nursing
University of South Carolina—Aiken
471 University Parkway
Aiken. SC 29801
(803) 641-3277
email: lindaj@aikcn.sc.edu
Assessment of Dream Experience
Dr. Juanita Watson
Sutton Towers A103
Collingwood, NJ 08107
(610) 499-4254
email: juanita.watson@widener.edu
Index of Field Energy
Sarah Hall Gueldner, DNS, RN, FAAN
Director and Professor, School of Nursing
Pennsylvania State University
-01 Health and Human Development East
University Park, PA 16802-6096
(814) 865-2940
fax: (814) 865-3779
email: shg9@psu.edu
I
I
I
£ 5
£
416
appendix
r
appendix
Leddy Healthiness Scale
Susan Kun Leddy, PhD, RN
Professor, School of Nursing
Widener University
One University Place
Chester, PA 19013-5792
or
609 Wilder Road
Wallingford, PA 19086
(610) 499-4207
email: pasleddy@cyber.widener.edu
f,
Oi
5i
■
J
i .3
|
f S '3
•
Person-Environment Participation Scale
Susan Kun Leddy, PhD, RN
Professor, School of Nursing
Widener University
One University Place
Chester, PA 19013-5792
or
609 Wilder Road
Wallingford, PA 19086
(610) 499-4207
email: pasleddy@cyher.widener.edu
Neuman: Neuman Systems Model
Levels of Cognitive Functioning Assessment Scale
Jeanne Flannery, DSN, ARNP, CNRN, CRRN, CCH
Florida State University
School of Nursing
Tallahassee, FL 32306'4310
(850) 644'5626
Roy: Roy Adaptation Model
Inventory of Functional Status—Antepartum Period
Dr. Lorraine Tulman
School of Nursing
University of Pennsylvania
420 Guardina Drive
Philadelphia, PA 19104-6096
Jacqueline Fawcett, PhD, FAAN
3506 Atlantic Highway
P.O. Box 1156
Waldoboro, ME 04572
(207)832-7398
email: jacqueline.fawcett@umb.edu
417
Inventory of Functional Status After Childbirth
Dr. Lorraine Tulman
School of Nursing
University of Pennsylvania
420 Guardina Drive
Philadelphia, PA 19104-6096
Jacqueline Fawcett, PhD, FAAN
3506 Atlantic Highway
P.O. Box 1156
Waldoboro, ME 04572
(207) 832-7398
email: jacqueline.fawcett@umb.edu
Inventory of Functional Status—Fathers
Dr. Lorraine Tulman
School of Nursing
University of Pennsylvania
420 Guardina Drive
Philadelphia, PA 19104-6096
Jacqueline Fawcett, PhD, FAAN
3506 Atlantic Highway
P.O. Box 1156
Waldoboro, ME 04572
(207) 832-7398
email: jacqueline.fawcert@umb.edu
Inventory of Functional Status—Cancer
Dr. Lorraine Tulman
School of Nursing
University of Pennsylvan la
420 Guardina Drive
Philadelphia, PA 19104-6096
Jacqueline Fawcett, PhD, FAAN
3506 Atlantic Highway
P-O. Box 1156
Waldoboro, ME 04572
(207) 832-7398
email: jacqueline.fawcett@umb.edu
Inventory of Functional Status—Caregiver of Child
in a B< )Jy Cast
Diana M.L. Newman. RN, EdD
P.O. Box 765
*
Chadds Ford. PA 193 I 7-0623
email: dianaml@bellatlantic.net
H
418
APPENDIX
appendix
Self-Consistency Scale
Lin Zhan, PhD, RN
Associate Professor, College of Nursing
University of Massachusetts—Boston
100 Morrissey Boulevard
Boston, MA 02125
(781) 646-1635
email: lin.zhan@umb.edu
I
Appraisal of Self-Care Agency
Dr. Marjorie Isenberg
College of Nursing
Wayne Stare University
Detroit, Ml 48202
Rogers: Science of Unitary Human Beings
Diversity of Human Field Patterns Scale
Dr. M. Hastings-Tolsma
University of Southern Maine School of Nursing
96 Falmouth Street
Portland, ME 04103
Peplau: Theory of Interpersonal Relations
The Relationship Form
Cheryl Forchuk, RN, PhD
Nurse Scientist
London Health Science Centre Research, Inc
375 South Street, Room C2O5NR
London, Ontario
CANADA N6A 465
(519) 685-8500
.
;«■ a
c-i 'E
■y.
1
fl
419
Neuman: Neuman Systems Model
Spiritual Care Scale
Pearson Educ.it ion
Maura Connor, Nursing Editor
I Lake Street
Upper Saddle River, N| 07458
Watson: Transpersonal Nursing and the Theory of Human Caring
fairing Behaviors Inventory
Dr. Zane Robinson Wolf
School of Nursing
LaSalle University
1900 West Olney Avenue
Philadelphia, PA 19141
(215)951-1432
e m a i I.- wo 1 f@ 1 asa 11 c. ed u
or
27 Haverford Road
Ardmore, PA 19003
(610)642-8473
King: King's Conceptual System and Theory of Goal Attainment
A Criterion-Referenced Measure of Goal Attainment; Assessment of Fununal Abilna
and Goal Attainment Scales
Springer Publishing Company
Permissions Coordinator
536 BroadwayNew York, NY 10012-3955
Pender: Health Promotion Model
Health Promotion Lifestyle Profile 11
Susan Noble Walker, RN, EdD
University of Nebraska Medical Center.
42nd and Dewey Avenue
Omaha, Nebraska 68105-1065
INSTRUMENTS NOT IN THE APPENDIX
Orem: Self-Care Deficit Theory of Nursing
Denyes Self-Care Agency Instrument
Dr. M.j. Denyes
College of Nursing
Wavne State University
Detroit, Ml 48202
Exercise Benefits and Barriers Scale
Susan Noble Walker, RN, EdD
University of Nebraska Medical Center.
42nd and Dewey Avenue
Omaha, Nebraska 68105-1065
I 'cn\c< Self-Care Practices Inventory
Dr. M.J. Denyes
f
(..(>1 leiie i>f Nursing
Wayne State University
Derruir. Ml 48202
•/fl-'1 ’
I
420
APPENDIX
APPENDIX
Day of your birth/Last 4 digits of your social security number
3
/
day
soc. sec. #
Day of your birth/Last 4 digits of your social security number
/
day
SELF-AS-CARER INVENTORY
soc. sec. tt
SELF-AS-CARER INVENTORY—cont’d
Instructions: Below are a number of statements about caring for yourself. (The word "self-care”
is used a lot. It means those things you do for yourself to maintain life, health, and well-being.)
Very
Inaccurate
a
£. J a
Very
Inaccurate
?■
Use a#"'
- .................
#2 pencil
to mark the number that best describes how you take care of yourself. Marking the! number “6" means the statement is a_ very accurate Statemenl about how ou care for
yourself, marking number “1" means that the statement is not at all accurate.
C U a)
421
Very
Accurate
5
6
Very
Accurate
18. I remember health care information about what I
should do for myself
1
2
3
4
5
6
19. I know how much energy I need to take care of
myself
1
2
3
4
5
6
20. To make a decision about my care, I look at both
sides of my choices
1
2
3
4
5
6
21. It matters to me that I care for myself
1. My joints are flexible enough for me to take care of
myself
1
1
2
3
4
5
6
2. I think about health information in choosing
solutions to problems in caring for myself
1
2
3
4
5
6
22. I know when I have enough energy to take care
of myself
1
2
3
4
5
6
3. The way I take care of myself fits in well with my
family life
1
2
3
4
5
6
23. I know where to find good information I need to help
me take care of myself
1
2
3
4
5
6
4. I try out new ways to take care of myself based on
information from experts
1
2
3
4
5
6
24. I think about how all the things I do fit together to
help me reach my health goals
1
2
3
4
5
6
5. My self-care routine fits in with other parts of my
life
1
2
3
4
5
6
25. I have the physical balance I need in order to take
care of myself
i
2
3
4
5
6
6. I watch for signs that tell me if I am taking good care
of myself
1
2
3
4
5
6
7. I use different ways of thinking based on the kind of
self-care problem I have
1
8. I watch for things around me that will make a
difference in how I take care of myself....
9. I am strong enough for the physical work of caring
for myself
2
4
3
2
3
4
5
6
1
2
3
4
5
6
29. I do what I know is best in taking care of myself
even though I may not like it
1
2
3
4
5
6
1
2
3
4
5
6
30. I do my self-care in several different ways
1
2
3
4
5
6
31. I follow through with decisions I make about caring
for myself
1
2
3
4
5
6
2
3
4
5
6
1
2
3
4
5
6
5
6
13. I have the necessary skills to care for myself
1
2
3
4
5
6
14. I stick to my decisions about caring for myself even
when I run into setbacks or problems
1
2
3
4
5
6
i
2
3
4
5
6
i
2
3
5
6
i
2
3
5
6
. .
17. I take care of myself because my health is important
to me
6
1
1
16. If the doctor tells me to do something. I do it
6
5
28. The way I take care of myself fits in with what I
consider important in my life
11. I plan my self-care by how much energy I have .
I
5
6
4
.
4
4
5
3
15. I know what I need to take care of myself .
3
3
4
2
j
2
2
3
1
12. lam aware of things around me that affect how I
take care of myself
1
1
2
10. I pay attention to signs telling me to change the way
I care for myself
. .
26. I fit new self-care actions into what I already do
27. My hearing and vision are good enough to allow me
to care for myself
4
32. I have a set routine for caring for myself
1
2
3
4
5
6
33. I think about how decisions I make will affect my
health and self-care
1
2
3
4
5
6
34. I knowingly spend my energies on the most
important self-care tasks
1
2
3
4
5
6
35. I use information from authorities to help me take
better care of myself
1
2
3
4
5
6
36. I have enough muscle strength to perform my
self-care
1
2
3
4
5
6
2
3
4
5
6
2
3
4
5
6
37. I think about several choices before I make a
decision about my self-care .
38. I know why I make the choices I do in order to care
for myself
1
Continued
I
I
I
1
APPENDIX
1
APPENDIX
423
Day of your birth/Last 4 digits of your social security number
day
Day of your bidh/Last 4 digits of your social security number
soc. sec. «
day
SELF-AS-CARER INVENTORY—cont’d
soc. sec. #
SELF-AS-CARER INVENTORY—cont'd
Very
Inaccurate
39. I know which actions to do first to best accomplish
my self-care
40. Once I begin to care for myself in a certain way. I
check to see if it is working
Very
Accurate
1
2
3
4
5
6
1
2
3
4
5
6
Who assists you with your self-care?
no one
me
other family member(s)
Unhealthy
1. Using a scale of 1 to 6. how would you rate your
health at this moment?
1
2
Healthy
3
4
5
friend(s)
6
nurse(s)
Unhealthy
2. Using a scale of 1 to 6, how would you rate your own
health in general?
2
1
3
4
1
2
6
5
4
5
6
------------------------ :_ _____ I
'• :■
<t.
' :!
yes
I
no
If yes, please list medications
I? <
OH
•
j □
All
3
housekeeper
other
Are you currently taking any prescription medications?
None
3. Using a scale of 1 to 6. how much of your own care
are you providing?
■f-:
.□
Healthy
PERSONAL INFORMATION
Age
Gender
<-j‘
___ ZZJH
I□
Do you need help in taking your medication?
lj
Yes
L“ No
I
If yes, please describe the help given.
Female
*w'
Male
Current living arrangement
alone
PERSONAL INFORMATION
Are you on a special diet?
with family in the same house
ont’d
TM
yes
with others in the same house
no
Ethnic group
If yes. what is the name of that diet?
American Indian/Alaskan Native
fc
Asian/Pacific Islander
I
ft
Why are you on this diet?
Hispanic
Black
___ __________
White
Other
1°
J
Last time seen by a health care professic-al
(MD. nurse. Chiropractor, etc.)? '
Month
Year
?v--
ML;
+
424
I
APPENDIX
APPENDIX
425
■t
•'.•s
Day of your birth/Last 4 digits of your social security number
day
J
DCA: DEPENDENT CARE AGENT INSTRUMENT
soc. sec. #
Questionnaire for Mothers
SELF-AS-CARER INVENTORY—cont’d
If yes, please list the problem.
This questionnaire is designed to identify activities that mothers perform with children. Please
circle the number that indicates how frequently you do each activity with your child.
What is the age of the child for whom you are answering this questionnaire?
Key
5 = Always—what you consistently do all the time.
4 = Frequently—what you usually do.
3 = Occasionally—what you sometimes do.
2 = Seldom—what you rarely do.
1 = Never—what you never do at any time.
[
List your diagnoses, if known, and length of time you have had this health problem.
*•: - *
’..T
. -c.r c:J ’
c
S
I
£ j -c
J =5’
©Curators of the University of Missouri. 1991
1. I take my child for regular health
checkups.
Always
5
4
3
2
1
Never
2. I take action to insure that my child's
home is a safe one.
Always
5
4
3
2
1
Never
3. I try to help my child have a healthy
self-image
Always
5
4
3
2
1
Never
4. I encourage my child to be in activities
with others his/her own age.
Always
5
4
3
2
1
Never
5. I make sure that my child is provided
with foods from each of the four basic
food groups.
Always
5
4
3
2
1
Never
6. I encourage periods of rest in my
child’s day.
Always
5
4
3
2
1
Never
7. Before judging his/her performance.
I take my child's limitations into
consideration.
Always
5
4
3
2
1
Never
8. I see that my child receives immuni
zations on time.
Always
5
4
3
2
1
Never
9. I make sure my child has play
opportunities.
Always
5
4
3
2
1
Never
10. I encourage my child to participate in
family activities.
Always
5
4
3
2
1
Never
11.1 make sure my child gets a good
night’s sleep.
Alwavs
5
4
3
2
1
Never
12. I evaluate my child for signs of minor
illness.
Always
5
4
3
2
1
Never
13. I remind my child io drink enough
fluid.
Always
5
4
3
2
1
Never
©E Geden & S Taylor University of Missouri - Columbia School of Nursing Columbia. MO 65211
Continued
I
i
S
f
B
426
APPENDIX
APPENDIX
J
DCA: DEPENDENT CARE AGENT INSTRUMENT—cont’d
DCA: DEPENDENT CARE AGENT INSTRUMENT—cont’d
Questionnaire for Mothers—cont’d
J
^.i
.3
.4-:
..
|
ia
i
H
14.1 help my child learn to get along with
others.
i
Always
15. When someone is smoking, I try to
get my child out of the room.
Always
16. I make sure my child develops an
understanding of the nutritional value
of food he/she eats.
Always
17. When planning meals, I pay attention
to my child's food preferences.
18. I teach my child to be aware of safety
hazards.
427
Questionnaire for Mothers—cont’d
5
4
3
2
1
Never
31. I evaluate the quality of the air my
child breathes.
Always
5
4
3
2
1
Never
5
4
3
2
1
Never
32. I help my child learn to communicate
effectively.
Always
5
4
3
2
1
Never
5
4
3
2
1
Never
33. I note how often my child has a bowel
movement.
Always
5
4
3
2
1
Never
Always
5
4
3
2
1
Never
34. I teach my child to take care of other
people's property.
Always
5
4
3
2
1
Never
Always
5
4
3
2
35. I help my child adjust to changes.
1
Never
Always
5
4
3
2
1
Never
36. I encourage my child to be a
responsible family member.
Always
5
4
3
2
1
Never
I
37. I try to know what my child is doing in
school.
Always
5
4
3
2
1
Never
I
38. I make sure that my child participates
in physical exercise.
Always
5
4
3
2
1
Never
39. When the weather is hot or when my
child has been active, I encourage
him/her to drink more liquids.
Always
5
4
3
2
1
Never
19. I assist my child in coping with
stressful events.
Always
5
4
3
20. When the doctor orders a medication
for my child, I follow the directions
carefully.
Always
5
4
3
21. I ask the doctor or nurse about compli
cations of medical treatments my child
is receiving.
Always
22. I notice how often my child urinates.
Always
5
23. I encourage social activities for my
child.
Always
24. I make judgments about whether my
child is growing and developing
normally.
Always
25. I support my child's participation in
group activities.
Always
5
26. I praise my child.
Always
27. I check places outside our home for
potential hazards for my child.
5
4
2
1
2
1
Never
Never
I
I
8
3
2
1
Never
4
3
2
1
Never
5
4
3
2
1
Never
5
4
3
2
1
Never
4
3
2
1
Never
5
4
3
2
1
Never
Always
5
4
3
2
1
Never
B
28. I make sure my child uses safety
restraints in the car.
Always
5
4
3
2
1
Never
E
29. I encourage my child to be
increasingly independent.
Always
5
4
3
2
1
Never
30. I help my child learn new words
Always
5
4
3
2
I
i
I
I
B
I
Never
Mi
APPENDIX
APPENDIX
429
: r.i -
CHILDREN’S SELF-CARE PERFORMANCE QUESTIONNAIRE
CHILDREN’S SELF-CARE PERFORMANCE QUESTIONNAIRE—cont’d
This questionnaire is designed to collect information about the activities children and
teenagers perform to promote their own health. Please answer the questions honestly and
carefully. All answers will be kept CONFIDENTIAL.
I
Directions
■
Always
5
Often
4
Sometimes
3
Rarely
2
Never
1
14. Ido things with my friends.
5
4
3
2
1
15. I ride a bike safely.
5
4
3
2
1
16. I keep away from stray animals.
5
4
3
2
1
17. I drink alcohol.
5
4
3
2
1
18. I look before I cross the street or
road.
5
4
3
2
1
19 lam careful around strangers.
5
4
3
2
1
20. I wear a seatbelt in the car.
5
4
3
2
1
21. I hand in my work on time at
school.
5
4
3
2
1
22. I play sports and games with
others.
5
4
3
2
1
23. I spend money as soon as I
get it.
5
4
3
2
1
2
Section I-
1. Please circle the number that best states how often you do the activity.
■
2. There are no right or wrong answers.
3. Please do not skip any items.
4. Feel free to write comments if you wish.
j;.
Number
Heading
Meaning
5
Always:
All of the time
4
Often:
Most of the time, frequently
3
Sometimes:
Some of the time, occasionally
2
Rarely:
Seldom, not much
1
Never:
None of the time
I
Always
5
I
:ont’d
Section II
Often
4
Sometimes
3
Rarely
2
Never
1
Section I
1. I smoke.
5
4
3
2
1
2. I drink beverages with caffeine
in them (coffee, soda, tea, etc.)
5
4
3
2
1
24. I follow the rules at home.
5
4
3
25. I follow the rules at school.
5
4
3
2
26. I am honest with my parents.
5
4
3
2
1
27. I watch too much TV.
5
4
3
2
1
28. I tell a family member where I am
going.
5
4
3
2
1
29. I do all of my homework.
5
4
3
2
1
30. I bully other children.
5
4
3
2
1
2
1
1
>«■
-
F
-B
By;..
3. I skip lunch.
• 5
4
3
2
1
4. I eat junk food.
5
4
3
2
1
5. I eat meals with food from the
four food groups.
5
4
3
2
1
6. I eat candy or other sweets.
5
4
3
2
1
7. I eat too much food.
5
8. I skip breakfast.
9. I take a bath or shower every day.
4
3
2
5
4
3
2
1
5
4
3
2
1
10. I wash my hands after going to
the bathroom.
5
4
3
2
1
11
5
4
3
2
1
5
4
3
2
1
I exercise every day.
12. I sleep at least eight hours at
night.
13. I stay up so late on school nights
that I am tired the next day.
5
4
3
2
1
1
Section III
31. I wash my hands before eating
5
4
3
32. I follow my doctor’s advice.
5
4
3
2
1
33. I tell a parent if I think I am
getting sick.
5
4
3
2
1
34. I brush my teeth.
5
4
3
2
35. I clean my cuts well, if I cut
myself.
5
4
3
2
1
I
I
!
r
430
APPENDIX
APPENDIX
431
MENTAL HEALTH SELF-CARE AGENCY SCALE
h
ID#
The Mental Health Self-Care Agency Scale (MH-SCA) was developed to measure individuals’
mental health related self-care capabilities. The development and initial testing is addressed
isenbePrgP1997) Ument Development: The Mental Heallh Self-Care Agency Srale" (West &
IS
S*or"9 Grnd elines. The original instrument had 35 items. After initial testing, three items were
dZintTa tk 1 a<Jd noth,n9 or very Mie to the reliability of the instrument, and therefore were
furtha TheS|e arGiT 41 26 and 28 of the ori9'nal instrument. They should not be included
hna y?h' F°
the Initial tes,in9 9 items were sta,ed in the negative to reduce^
response bias. These include items 3, 5, 8. 10. 11, 14, 17, 21. and 32.
9
C
To calculate a score on fhe MH-SCA, the investigators shoufd eliminate items 4 26 and 28 if
s^atedZmT Pn9?3
Then ’ h® investi9ator sh°uld reverse scoring of the negatively
stated -terns. Points are given on the basis of the respondent’s answers and totaled.
Reliability:
follows™"^ teS,in9 <WeS1' '"3| lhe reliabil'ty °'the MH-SCA and its subscales were as
MH-SCA
Affective Subscale/New
Cognitive Subscale
Pattern of Activity
Perceptual Subscale/New
Valuative Processes Subscales
Total/New Total
r J
A. . J ■
Items by content domains (original items):
Affective
Cognitive
Patterns of Activity
Perceptual
Valuative Processes
5.::
& :::
,S U,nder fhe
4**
iXligaton051
R3
i g?
!■
T
OtJ
f
h
IS®
tea
,0
.76
.66/. 73
.83
.59/. 66
.64
.93/. 94
1. 11 23. 27. 29. 33
< 8 14. 16. 21.25. 30
2. 5. 7. 10. 13. 15. 17. 19. 22. 24. 32 34
3. 6. 26.28. 31. 35
9. 12. 18. 20
of P. West (1993). Permission to use the MH-SCA
Xwin^y
MH-SCA SCALE
The following list of statements are used by people to describe themselves. Please read each
statement and then circle the number to the right which indicates how much you agree or dis
agree with the statement as a description of you. There are no right or wrong answers.
Disagree
Neither
Disagree
Nor Agree
Agree
Totally
Agree
1
2
3
4
5
2) Over the years. I have been
able to maintain at least one
close relationship
1
2
3
4
5
3) I experience a lot of confusion
about who I am.
1
2
3
4
5
4) I lack the energy to let others
know what I need from them.
1
2
3
4
5
5) I view my body pretty much as
other people do.
1
2
3
4
5
6) As things change. I remain
flexible.
1
2
3
4
5
7) I have trouble remembering
things.
1
2
3
4
5
2
3
4
5
3
4
5
Totally
Disagree
1) If I am stressed in my daily
routine. I can usually handle it.
8) At times I examine my values
to see if I need to change
9) I don’t have the energy to be
concerned about other people.
1
2
10) ! rarely enjoy my successes.
1
2
3
4
5
11)1 find time to do the things
which are important to me.
1
2
3
4
5
12) I have ways to work out
problems with others
1
2
3
4
5
13) I am easily distracted from
doing things I need to do for
myself.
1
2
3
4
5
14) I am able to laugh and enjoy
myself.
1
2
3
4
5
3
4
5
15) I regularly evaluate the choices
I make.
16) I seldom take ?me to relax.
■
3
5
Co''Tiuec
APPENDIX
APPENDIX
MH-SCA SCALE
4
f.
-g
£, J o
;ont’d
433
POWER AS KNOWING PARTICIPATION IN CHANGE
Totally
Disagree
Disagree
Neither
Disagree
Nor Agree
17) I look for ways to feel more in
tune with life around me.
1
2
3
4
5
18) I know how to get the
information I need, when
confronted with a crisis.
1
2
3
4
5
19) I have found meaning or a
purpose to my life.
1
2
3
4
5
20) I have trouble telling what’s
happening around me.
1
2
3
4
5
21) lam able to express my
sexuality in ways which are
comfortable for me.
1
2
3
4
5
22) I can express my feelings in a
healthy way, so that others
understand me.
1
2
3
4
5
23) I look for more useful ways to
resolve problems with others.
1
2
3
4
5
24) lam usually comfortable in
making decisions for myself.
1
2
3
4
5
25) I am able to wait for the things
that are important to me.
1
2
3
4
5
26) In most situations, I experience
the same feelings that other
people do.
1
2
3
4
5
27) I look for better ways to solve
problems.
1
2
3
4
5
28) When things change, I am
able to decide how I am going
to handle the situation.
1
2
3
4
5
29) I am overly dependent on
others.
1
30) I look for better ways to handle
my frustration.
1
2
3
4
5
3l il can set new priorities to meet
my responsibilities in life
1
2
3
4
5
32) I look for ways to feel good
about myself.
1
2
3
4
5
Agree
Totally
Agree
Introduction to Barrett’s PKPCT
The PKPCT is designed to help you describe the meaning of day-to-day change in your
life. Four indicators of experiencing change are:
AWARENESS
CHOICES
FREEDOM TO ACT INTENTIONALLY
INVOLVEMENT IN CREATING CHANGE
It takes about 10 minutes to complete the PKPCT.
instructions For Completing Barrett's PKPCT
For each indicator, there are 13 lines. There are words at both ends of each line. The
meaning of the words are opposite to each other. There are 7 spaces between each pair of
words which provide a range of possible responses. Place an "X” in the space along the line
that best describes the meaning of the indicator (AWARENESS. CHOICES, FREEDOM TO
ACT INTENTIONALLY, or INVOLVEMENT IN CREATING CHANGE) for you at this time
For example:
Under the indicator CHOICES, if your CHOICES are quite closely described as "informed."
your answer might look like this:
informed
l_X_J
I-------1------- 1------- 1
uninformed
If your CHOICES are quite closely described as “uninformed,” your answer might look like this:
informed ------- 1------- 1------- 1------- 1------- 1 _X_|
uninformed
If your CHOICES are equally “informed” and “uninformed," place an “X” in the middle space on
the line. Your answer might look like this:
informed
I
I
l_X_|
|
|
uninformed
REMEMBER:
• There are no right or wrong answers.
1
(-
{
• Record your first impression for each pair of words.
2
3
4
5
• You can place an "X" in any space along the line that best describes the meaning the
indicator has for you at this time.
• Mark only one “X" for each pair of words.
I
• Mark an “X” for every pair of words.
PLEASE BEGIN TO MARK YOUR X’S ON BARRETT S PKPCT
(Please go to NEXT PAGE and continue
I
434
APPENDIX
APPENDIX
435
BARRETT PKPCT, VERSION II
BARRETT PKPCT, VERSION II, PART 2
Mark an “X” as Described in the Instructions
Mark an “X” as Described In the Instructions
my AWARENESS is
profound
I
avoiding
I
valuable
.1___ I
I___ I
I
I.
I.
unintentional
I
timid
I
leading
|.
chaotic
I.
my FREEDOM TO ACT INTENTIONALLY is
■I------ J1------- 1--------superficial
I-------.11------- 1------- seeking
I------ 1.1.------- 1-------- worthless
|
------1-------1------.1. 1-------- intentional
.1
'------- 1------- 1i.------- 1------- assertive
.1
I------- 1------- 1--------1------- following
.1___ I
I------ 1------- 1------- orderly
expanding
I.
'-------1------- 1-------- 1------- 1------- shrinking
pleasant
I.
I------ 1J-------- 1------- 1--------1-------- unpleasant
uninformed-------1------- 1------- 1.1--------1____ |____ ,____ jnformed
free-------*------- 1------- 1------- 1------- 1------- 1------- constrained
unimportant
ft
unpleasant
I
|
I
I
I------- 1------- 1------- 1------- important
|
|
|
|
|
------- pleasant
I
I____ I
I-------1------- 1
I
I____ I
I-------1------- 1
informed
leading
I
I
I
I------- 1------- 1
following
I
I
I
assertive
profound
I
I
expanding
I
I------- 1------- 1-------1------ 1-------- shrinking
unimportant
I
I------- 1------- 1------- 1------ 1
valuable
I
I
I
chaotic
I
I
I------ 1------- 1------- 1------- orderly
avoiding
I
I------- 1------- 1------- 1------- 1------- seeking
I------ superficial
important
I------- 1------ 1------- worthless
free------- 1--------1------- 1------- 1------- 1------ 1-------- constrained
unintentional
I
I------- 1------- 1------- 1------ 1-------- intentional
pleasant
I
I------- 1-------1------- 1------ 1-------- unpleasant
orderly------- 1------- 1------- 1------- 1------- 1------ 1____ chaotic
Mark an “X” as Described in the Instructions
Mark an “X” as Described in the Instructions
MY CHOICES ARE
I
I
seeking------- 1
I
shrinking
|
|
my INVOLVEMENT IN CREATING CHANGE is
|
•I------- expanding
|
.1| ___ |I
I------- avoiding
assertive------- 1------- 1------- J
1-------1
------1------- 1____ tjmid
___ I
important
I
I
orderly------- 1
intentional
I
I|------- '|------- 1|------- •|--------unimportant
I------- '------- 1------- 1------- chaotic
'------- '------- 1------- 1------- '------- 1------- unintentional
unintentional-------1------- 1------- 1--------1
I
|
intentional
expanding------- 1------- 1------- 1------- 1
I
|
shrinking
profound-------1------- 1------- 1------- 1-------1
|
superficial
chaotic-------1------- 1------- 1--------1------- 1
|
orderly
free------- 1------- 1------- 1------- 1------- 1------- 1____ constrained
valuable------- 1------- 1------- 1------- 1------- 1------- 1
unpleasant
I
1------ 1------- 1------- 1------- 1------- pleasant
constrained
I
I
I
|
I------ 1--------free
worthless-------1------- 1------- 1------- 1------- 1------- 1____ va|uab|e
following-------1------- 1------- i------- 1------- 1------- 1____ |eadjng
superficial __l-------1------- 1------- 1------- 1------- 1____ profound
informed------ 1------- l__J------- 1------- 1------- 1------- uninformed
tim'd-------)------- 1------- 1------- 1------- 1------- 1------- assertive
I
j
timid
uninformed
"1984, 198?’ 1 "8|nbny E:A WnB®rr®tbA" r'9hts reserved- No duplication without written permission of author
___
Inquiries. Dr. E.A.M. Barrett, 415 East 85th Street, New York, NY 10028
(Please go to NEXT PAGE and continue)
uninformed------- 1------- 1------ 1
I
worthless
I
|
informed
avoiding-------1------- 1------- 1------- 1------- 1
|
seeking
leading------- 1------- 1------ 1
I
|
|
following
unimportant------- 1------- 1------ 1
_l
I
i
important
timid-------1------- 1------- 1------- 1------- 1------- 1____ assertive
pleasant
I
I
'-------unpleasant
superficial
I
I
i------ profound
®1984, 1987, 1998 by E.A.M. Barrett. All rights reserved. No duplication without written permission of author.
Inquiries: Dr. E.A.M. Barrett. 415 East 85th Street. New York. NY 10028
THANK YOU
?
t
436
APPENDIX
APPENDIX
TEMPORAL EXPERIENCE SCALES
hM
Metaphors
Each person experiences the movement of events in an individual
individual way.
way.
This personal experience cannot be measured by clocks or calendars, but
can be compared with the movement represented by the metaphors listed
in the Temporal Experience Scales.
Directions: Imagine the events, happenings or occurrences for each of
the listed phrases. Place an “X” in the column which best represents how
events move for you in your life.
Example: Imagine the metaphor, “a merry-go-round”. Form an image in
your mind of a merry-go-round in motion. Is this how events move for you in
your life?
If you agree that this is representative, place an “X" in the agree (A) or
I
•I
(
g
<
3!J £ '.S I
agree strongly (AS) column; if you conclude that it has no relevance for you
m your experience, place an "X" in the disagree (D) or disagree strongly
(DS) column. If you cannot decide whether the metaphor image has any
relevance in your life experience, then place an “X" in the no opinion (NO)
column.
Thus, if you decided that the image did represent how events move in
your life, your response would look like this:
Metaphor
AS
Merry-go-round
A
NO
D
DS
X
Ji
I
f
Merry-go-round
AS
A
A
NO
D
DS
1. A GALLOPING HORSEMAN
2. A GULL MOTIONLESS
IN MIDAIR
3. FLASH OF LIGHTNING
4. A SPEEDING TRAIN
5. ROLLING WAVES
6. SWINGING GATE
7. DRIFTING CLOUDS
8. SOARING KITE
9. FLAME SWIRLING UP
10. STATIC SERENITY
11. STREAM OF THOUGHT
12. QUIET, MOTIONLESS
OCEAN
13. FLOATING DRIFTWOOD
I
NO
D
15. SILENT STREAM
16. SPACE SHUTTLE
DS
17. ENDURING
X
18. CARVED IN STONE
19. AUTOMOBILE CRUSHER
20. BUTTERFLIES HOVERING
21. FREE FALLING SKYDIVERS
22. FALLING ROCK
!
23. TORNADO
I
AS
14. EMPTINESS
If you decided that the image was not at all representative of how events
move in your life, you might respond like this:
Metaphor
I
TEMPORAL EXPERIENCE SCALES—cont’d
Instructions
i
437
24. DASHING WATERFALL
Ift-
I
i
I
J-
438
appendix
appendix
439
Ft
PERCEIVED FIELD MOTION
PERCEIVED FIELD MOTION—SCORING
by a concep'-
particular concept. Let
your initial reactions guide your responses.
FIRST. THINK OF YOURSELF AS A HUMAN ENERGY FIELD MOVING
IN AN ENVIRONMENTAL ENERGY FIELD
FIRST, THINK OF YOURSELF AS A HUMAN ENERGY FIELD MOVING
IN AN ENVIRONMENTAL ENERGY FIELD
NOW, RESPOND TO THE CONCEPT
NOW, RESPOND TO THE CONCEPT
MY lElELDr MOTION
FAST
a '.;
DARK
CLEAR
.
,zl1, g -a
STRONG
LIGHT
fe s
"2
CALM
UNLIMITED
Ig
DEEP
STATIC
D
|i
b?
ACTIVE
DULL
MYTIELD” motion
SLOW
7
FAST
____ BRIGHT
6
:
5
:
2
3
7
DARK
DENSE
BRIGHT
CLEAR
WEAK
DENSE
7
STRONG
HEAVY
6
.
5
4
■
3
■27
LIGHT
__ EXCITABLE
SHALLOW
DYNAMIC
PASSIVE
SHARP
■
I
WEAK
HEAVY
CALM
LIMITED
SLOW
EXCITABLE
UNLIMITED
7
6
5
4
DEEP
7
6
5
4
STATIC
7
2
3
ACTIVE
7
6
DULL
7
2
3
2
7
LIMITED
3
2 -
7
SHALLOW
4
5
6
7
DYNAMIC
5
4
3
2 •
7
PASSIVE
3
4
5
6
■
SHARP
kyuctions fpr gcorinq the PFMsgale. The above seven (7) items comorse mrSCale
USe Qnly ,he resP°nses
'he 7 items above m mea3umWM
can score the items as indicated above, or you can score all 7 items
computer to reverse score Static-Dynamic and Dull-Sharp.
how
APPENDIX
APPENDIX
441
HUMAN FIELD RHYTHMS
K
Directions: Answer the question below by placing a vertical mark across
the answer line at the point which BEST REFLECTS YOUR OPINION.
□
€
S c
c
a
£3
8 .-8
5°
1=
Example: HAPPY
it
__ SAD
811c
O Q
ff
ra
O)
Answer the following question about your HUMAN FIELD RHYTHMS
0III
o
I
o
111
LOW
FREQUENCY
HIGH
FREQUENCY
<
o
(/)
DC
O
r
•r; -
E?°
8^
Q.
£
S
J*’
CD >.
«»_
ii
Q 0? f
CD E t-
lit
LU
'
'p.!
LU
0
r< r§
e
<
P
If’®’
sfi si
n
?.-Oo
cn-
Q
U S 13
LU
r' S' i:
E
z
<
S £■
I
i
i
M
k
D
I
I
IP st
2 c
T S oj
£ ” E
O CD
Q •O
III
iff
s
I-2 S’
HI
1
03
I
1
I
JG
LU
IX
i I
i s I
£
I J
!
.s
o
—
rc
03
i i
S
c\i
tb
co
I
03
CD
I
5
CD
Io
s
03
5
03
8
i
cri
2
i
I f f
03
1 1 i
cd
i
o
5
5
cu
sI
s
I
443
APPENDIX
APPENDIX
M2
ASSESSMENT OF DREAM EXPERIENCE
Directions: Listed below are words which may be used to describe the experience of
dreaming. Please consider what your dreams have been like over the past two weeks. Then,
using the rating scale provided, indicate the extent to which each word describes what your
dreams were generally like by placing an “X" in the appropriate space. There are no right or
Sc
wrong answers. Please be sure to rate each word.
ft
Almost
Always
Often
Sometimes
Almost
Never
1. Constrained
p
2. Boring
3. Imaginative
o
o
I
LU
■r; J
<
o
cn
x
S 2?
4. Intense
js
5. Vivid
6. Exciting
o
x
7. Simple
?
8. Vague
S
9 Colorful
UJ
0
10. Energetic
I
I
CL
LU
<
K
11. Limited
o
12. Passive
LU
iT
13. Drab
z
<
14. Active
ZD
X
8
&
15. Complex
1
2
a>
g.
o
o
cn
o
o
E
c
o
I g
s s
g
S
I I
Is
s
f
-3
5
05
1 1
LU
i £
ri
io
CD
go
c
a
I §
o
&
I
■5
!
§
rc
03
CO
I
g'
ci
.£
-J
16. Dull
1
a
I
t
17. Clear
I sI
I
<0
1
-J
S
E
18. Dramatic
ro
Ii
6?
19. Expansive
20. Unimaginative
6
444
APPENDIX
APPENDIX
INDEX OF FIELD ENERGY
DEMOGRAPHIC INFORMATION
Last four numbers of your
Social Security #
Directions:
Kindly check the boxes that best describe you. Print other information that is
requested.
1. Sex
[ ] Female
Field Dynamics Index
Today’s Date:
Month
[ ] Male
2. Age
years
Day
3. Education
[ ] No formal schooling
[ ] Grade school (completed)
Years attended (not completed)
[ ] High school (completed)
Years attended (not completed)
[ ] Vocational training (completed)
Years attended (not completed)
College:
Years attended (no degree)
College degree:
[ ] Associate
[ ] Bachelors
[ ] Masters
[ ] Doctorate
[ ] Other
Year
Your Birthday:
Month
Day
T!
t: -
Year
Sex:
. 'I
Male
Female
4 Occupation or Career
(briefly describe)
it
2
o
Z -r:
445
INSTRUCTIONS:
Look at the scale of points between each pair of pictures. Mark (X) the scale according to
which picture best describes how you feel now.
Continued
5. Current Residence:
State
Population of city/town
[ ] Less than 70,000
[ ] 70,000 to 1.000,000
[ ] More than 1.000.000
7. Check the language that you read, write and
speak best:
[ ] American-English
[ ] Other:
____
8. Check if you ingested or inhaled any stimu
lants, depressants or hallucinogens today:
[ ] None
[ ] Coffee or Tea
[ ] Other:
9. Do you practice any form of meditation?
[ ] Yes
[ ] No
10. Have you experienced a crisis during the
past 6 months?
[ ] Yes
[ ] No
11. Check the number of hours you slept last
night:
[ ] None
[ ] 3-4
[ ] 5-8
[ ] 9 or more
Was your sleep pattern last night normal for
you?
[ ] Yes
[ 1 No
12. Check the time of day when you function
best:
[ ] Morning
[ ] Afternoon
[ ] Evening
[ ] Night
6. Check the country of your birth:
[ ] U.S.A.
[ ] Other:
Continued
!
I
1
448
APPENDIX
APPENDIX
SCORING KEY
ont’d
449
SCORING KEY—cont’d
B
I 1 I
~rr~ T~ ~iT~ T~ 'll
_ 1
T|~
i
1
1
II
if ~~T ~~iT ~iT~
JJ_ H H il
I 1 I
1
1
J
f;
•Yk-
^3
an
4,
I 1 I
< K -S
■ S c
Jh
Z -r:
I
In
I 7 |
1
1
k: J
I
I 1 I
0
s
p
Continued
450
APPENDIX
APPENDIX
451
LEDDY HEALTHINESS SCALE (LHS)
LEDDY HEALTHINESS SCALE (LHS)—cont’d
Circle the number that best indicates your degree of agreement with each of the following
statements. Please answer all of the questions the way you feel right now.
i
CD
CD
JD
T
S’ I? "S :
I
£
j
s'
• : ir:
CT)
Cd
CD
CD
I
.1 t
_>>
QE
r
<
CD
CD
CD
CD
O)
I
CD
CD
O)
0>
Id
w
b
CC
OT
E
o
S'
Q
jp
cn
Q
w
in
GO
E
o
1
s
_>»
5
CD
CD
O>
OJ
I
1
t
CD
CD
.f
CD
CD
O)
CD
co
Q
>s
CD
17. I’m not what you would call a goal
oriented person.
4
3
2
1
co
E
o
5
(0
s
6
s
1. I think that I function pretty well.
6
5
4
3
2
1
18. I feel energetic.
6
5
4
3
2
1
2. I have goals that I look forward to
accomplishing in the next year.
6
5
4
3
2
1
19. I feel good about my freedom to make
choices for my life.
6
5
4
3
2
1
3. I am part of a close and supportive family.
6
5
4
3
2
1
20. I have a goal that I am trying to achieve.
6
5
4
3
2
1
4. I don’t feel there is much that is
meaningful in my life.
6
5
4
3
2
1
21. I don’t expect the future to hold much
meaning for me.
6
5
4
3
2
1
5. I have more than enough energy to do
what I want to do.
6
5
4
3
2
1
22. I like exploring new possibilities.
6
5
4
3
2
1
23. I feel full of zest and vigor.
6
5
4
3
2
1
24. I feel fine.
6
5
4
3
2
1
25. I feel pretty sure of myself.
6
5
4
3
2
1
26. I feel isolated from people.
6
5
4
3
2
1
6. I feel that I can accomplish anything I set
out to do.
6
7. There is very little that I value in my life
right now.
6
5
4
3
2
1
8. Having change(s) in my life makes me
feel uncomfortable.
6
5
4
3
2
1
9. I have rewarding relationships with
people.
6
5
4
3
2
1
10. I enjoy making plans for the future.
6
5
4
3
2
1
11.1 feel free to choose actions that are right
for me.
6
5
4
3
2
1
12. I feel like I’ve got little energy.
6
5
4
3
2
1
13. I am pleased to find that I am getting
better with age.
6
5
4
3
2
1
14. I don’t communicate much with family
or friends.
6
5
4
3
2
1
15. I get excited thinking about new projects
6
5
4
3
2
1
16. I feel good about my ability to influence
change.
6
5
4
3
2
1
5
4
3
2
1
© 1993 Dy S K. Leddy. All rights reserved. No duplication without written permission of author. Inquiries: Dr S.K Leddy. 609 Wilder
Road. Wallingford. Pennsylvania 19806
£
1
APPENDIX
APPENDIX
453
PERSON-ENVIRONMENT PARTICIPATION SCALE (PEPS)
Directions: Here are some questions about YOUR INTERACTION WITH YOUR ENVIRONMENT. Each question has answers from 1 to 7. If the word(s) under 1 are right for you circle
1; if the word(s) under 7 are right for you, circle 7. If you feel differently, circle one of the
numbers inbetween. Answer the questions the way you feel right now.
LEVELS OF COGNITIVE FUNCTIONING ASSESSMENT SCALE
Developed by Jeanne Flannery, D.S.N., A.R.N.P., CNRN, CRRN,
using Levels 1 -5 from Rancho Los Amigos Scale
Date
MY INTERACTION WITH MY ENVIRONMENT FEELS:
Time
1
Flexible
2
1
Integrated
‘1
7 £
3
5
6
7
Inflexible
7
Fragmented
Initials
Level I. NO RESPONSE
A. Attention to the Environment:
NONE
1. Appears unaware of environment; eyes usually closed
1.
3
4
5
6
7
Powerful
1
Energetic
2 •
3
4
6
7
Lethargic
2. Completely unresponsive to tactile stimuli and
position changes
2.
5
3. Completely unresponsive to auditory stimuli
3.
4. Completely unresponsive to visual stimuli
(This not to be confused with papillary
response to light, which is reflective.)
1
Laborious
2
3
4
5
6
7
Effortless
1
Empty
2
3
4
5
6
7
Full
1
Calm
2
1
Dissonant
2
3
1
Flowing
2
3
1
Smooth
2
2
3
3
3
4
4
4
4
5
6
7
Agitated
5
6
7
Harmonious
5
6
7
Clogged
5
5
6
6
7
Separated
7
Active
2
3
4
5
6
7
Turbulent
1
2
Discomforting
3
4
5
6
7
Comforting
1
Manageable
2
3
4
5
6
7
Unmanageable
1
Expanding
2
3
4
5
6
7
Shrinking
'in 995 by S K Leddy All rights'eserved ko di;piicv>or
VAjilingford, Pennsylvania 19806
L "
4
6
2
1
Passive
1
2
5
4
1
Powerless
1
Connected
I
3
_____ ____
.eduy 609 Wilde; Road
B. Response to Stimuli:
NONE
4.
□□□□□□□
□□□□□□□
0BHB
ZJBBB
5. Completely unresponsive to painful stimuli
6. Completely unresponsive to gustatory stimuli
C. Behavior Status:
REFLEXIVE
7. May have primitive responses such as snorting,
chewing, blinking, eye opening, which are
unrelated to specific stimuli
D. Ability to Process Information:
7.
□□□□□□□
NONE
E. Ability to Follow Commands:
NONE
F. Awareness of Person (Self):
NONE
G. Awareness of Time:
NONE
H. Ability to Perform Self-Care:
NONE
I. Ability to Converse:
NONE
J. Ability to Learn New Information:
NONE
*
Continued
454
APPENDIX
APPENDIX
LEVELS OF COGNITIVE FUNCTIONING ASSESSMENT SCALE
:ont’d
LEVELS OF COGNITIVE FUNCTIONING ASSESSMENT SCALE
Date
Time
Initials
'V
n
'ci 4 3 I
I
LIU
Level III. LOCALIZED RESPONSE
A. Attention to the Environment:
NONE
B. Response to Stimuli:
NONSPECIFIC, INCONSISTENT
A. Attention to the Environment:
8. May respond to external stimuli, such as position
changes, with physiologic changes such as
increased BP. P. or R, or increased perspiration
8.
9. Responds to painful stimuli with generalized reflex
action (nonpurposeful gross body movement, as
decerebration or decortication)
9.
10. Repetitive stimuli produce a change in the level of
response, either dampening or heightening it
(e g. stroking may reduce physiologic changes or
intensify response, which occurred initially)
10.
Demonstrates nonpurposeful variations in
responses to the same stimulus; delayed, limited
response
11.
C. Behavior Status:
LJ
Initials
Level II. GENERALIZED RESPONSE
11
;ont’d
Date
Time
J
455
□□□□□□□
□□□□□□□
□□□□□□□
□□□□□□□
NONE
B. Response to Stimuli:
SPECIFIC, INCONSISTENT
15. Tracks briefly a moving object in visual field when
15.
awake only if stimulus intensity gains attention:
inconsistent response
16. Demonstrates withdrawal responses or facial
grimacing to tactile stimuli (pressure, temperature,
texture) but inconsistently
16.
17 Responds specifically to the stimulus (e.g. resists
restraints, swallows food, relaxes to stroking, pulls
at NGT) but inconsistently
17.
18. Responds inconsistently to same stimulus
(e.g. turns toward or away from a sound)
18
□□□□□□□
□□□□□□□
□□□□□□□
□□□□□□□
□□□□□□□
□□□□□□□
C. Behavior Status:
AWAKE
12. May be awake but unaware of environment unless
directly stimulated
12.
13. Demonstrates inconsistent infrequent visual
fixation; may have roving eye movements, but is
incapable of visual tracking
13.
14. Behavioral response may be the same regardless
of stimulus (e.g. eye opening, startle, gross body
movement, or decerebration upon tactile, painful,
or auditory stimulus)
14.
□□□□□□□
□□□□□□□
□□□□□□□
D. Ability to Process Information:
NONE
E. Ability to Follow Commands:
NONE
F. Awareness of Person (Self):
STIMULI TO BODY PRODUCE
GENERAL RESPONSE
BEGINNING AWARENESS
19. Awakens to stimuli; has sleep/wake cycles:
19.
awakens spontaneously
20. Demonstrates purposeful visual orientation and
fixation
20.
21. Moves body parts purposefully, if able
21.
D. Ability to Process Information:
I
II
NONE
E. Ability to Follow Commands:
INCONSISTENT, DELAYED
22. Response to commands is delayed
22.
23. Responds more consistently with some persons
than with others (e.g. may look at regular caregiver
when called, but may not do it with others)
23.
24. Demonstrates inconsistent attention and language
comprehension, but when there is a response it is
unequivocally meaningful (e.g. may not respond
to command "touch your nose” when it has been
followed before)
24.
□□□□□□□
G. Awareness of Time (Present):
NONE
H. Ability to Perform Self-Care:
NONE
F. Awareness of Person (Self):
VAGUE. NOT MEASURABLE
I. Ability to Converse:
NONE
G. Awareness of Time (Present):
VAGUE. NOT MEASURABLE
J. Ability to Learn New Information:
NONE
H. Ability to Perform Self-Care:
NONE
I. Ability to Converse:
INCONSISTENT
25 May
r vocalize inconsistently to stimuli; but may be
infrequent
2o. May vocalize automatically with one or two-word
response or just make loud noises
25
26
□OODOOD !
oDomoo
ft
J. Ability to Learn New Information: NONE
Ccntiruea
fee
456
T
appendix
i
APPENDIX
1
457
LEVELS OF COGNITIVE FUNCTIONING ASSESSMENT SCALE—cont’d
LEVELS OF COGNITIVE FUNCTIONING ASSESSMENT SCALE—cont’d
Date
Date
Time
Time
Initials
Initials
Level IV. CONFUSED-AGITATED
A. Attention to the Environment:
Level IV. CONFUSED-AGITATED—cont’d
BRIEF
□□□□□□□
□□□□□□□
29. I□□□□□□□
□□□□□□□
□□□□□□□
27. Demonstrates fleeting general attention to
surroundings; unable to concentrate
28. Selective attention may be nonexistent or so brief
that is not acted upon; easily distractible
H. Ability to Perform Self-Care:
27.
28.
B. Response to Stimuli:
2 s -s I
aJ z i II
I
33. May demonstrate aggressive, hostile behavior;
has explosive or unpredictable anger; may be
self abusive
34. May show sudden changes in mood (e.g. cryinq.
laughter, anger, or sleep)
35. Performs overlearned motor activities automa
tically, but may resist commands to do these
same activities, such as “sit up"
D. Ability to Process Information:
36.
37.
38.
NONE
39. Unaware of present events; responds primarily to
own state of severe confusion
42.
43. Conversation reflects confusion and memory
deficits
43.
A. Attention to Environment:
□□□□□□□
□□□□□□□
□□□□□□□
□□□□□□□
39.
I
DISTRACTIBLE
44.
45. Has difficulty sustaining selective attention;
highly distractible; limited concentration
45.
46. Lacks ability to focus on a specific thing without
frequent redirection
46.
B. Response to Stimuli:
□□□□□□□
□□□□□□□
□□□□□□□
□□□□□□□
□□□□□□□
□□□□□□□
□□□□□□□
NONE
44. Demonstrates gross attention consistently
VARIABLE
47. Responds readily to stimuli related to self, body
comfort, family
47.
48. Use of objects in environment often inappropriate,
without direction
48.
C. Behavior Status:
ORIENTED XI
38. Is oriented to own name: aware of own body
G. Awareness of Time (Present):
35.
INCONSISTENT
37 May respond briefly or inconsistently to simple
commands when agitation is lessened
F. Awareness of Person (Self):
34.
□□□□□□□
Level V. CONFUSED—[NAPPROPRIATE, NOhbAGITATED
MINIMAL
36. Unable to understand or cooperate with treat
ment efforts; may be combative; resistant to care
will leave area, if able
E. Ability to Follow Commands:
33.
42. May confabulate (give incorrect answers to
questions about the present from unrelated long
term memory stores); lacks short-term recall
J. Ability to Learn New Information:
C. Behavior Status:
AGITATED, CONFUSED
32. In a heightened state of activity related to internal
32.
agitation (environment may be quiet and
nonstimulating); restless; pacing; rocking; rubbinqmoaning
40.
I. Ability to Converse:
PRESENT, INAPPROPRIATE
41 Verbalizes incoherently or with words unrelated
41.
to the current situation; talking may be rapid,
loud, excessive
SPECIFIC, INAPPROPRIATE
29. May respond consistently to a stimulus, but the
response is inappropriate because of internal
confusion
30. May become very agitated or yell in response to
30.
a mild stimulus and sustain response after
stimulus removed; ■’sticks” in response; low
tolerance for frustration or pain
31. Responds to presence of devices, attachments
31.
or anything confining with strong, persistent,
purposeful attempt to remove; impatient;
demanding
s
MINIMAL
40. Performs self care activities for brief periods with
maximum direction and cuing; cannot focus with
out redirection
□□□□□□□
□□□□□□□
□□□□□□□
□□□□□□□
INAPPROPRIATE
0B0B000
49. Unable to initiate functional tasks
49.
50. May demonstrate frustration and negative,
inappropriate behaviors in response to external
stimuli, usually out of proportion to stimulus
50.
51. Will tend to wander (on foot or in a wheel chair)
from unit: will not remember a command to
remain in a certain place: will not remember how
to return from a strange area to a familiar place
51.
□□□□□□□
52.
DDLIDDLJu
D. Ability to Process Information:
1
i
LIMITED TO SELF
52. May relate to conversation about own body
comfort, personal needs, momentary concerns
Continued
i
458
I
APPENDIX
APPENDIX
459
B
LEVELS OF COGNITIVE FUNCTIONING ASSESSMENT SCALE—cont’d
I
f ■ ■
h.
I
Initials
Initials
SUMMARY
53. Responds to single simple commands
consistently
53.
54. Response to a complex command becomes
fragmented, nonpurposeful, and unrelated to
command; requires redirection to follow through
54.
ORIENTED XI
55. Oriented to self; knows name, special things
about self, but not how the present self is
different from past
r
G. Awareness of Time (Present):
tt •*
r
Time
Level V. CONFUSED—INAPPROPRIATE, NON-AGITATED—cont’d
F. Awareness of Person (Self):
I
Date
Time
E. Ability to Follow Commands:
F'
55.
CONFUSED
56. Disoriented to time and place, confusing past
and present; unaware of situation
56.
57. Demonstrates severe short-term memory deficit
57.
H. Ability to Perform Self-Care:
□□□□□□□
□□□□□□□
62. Select a number from 1 to 5 which represents the
highest Cognitive Level where most of the observed
behaviors are checked at this time of observation.
Signature
Title
Initials
Signature
62.
Title
ont’d
□□□□□□□
Initials
□□□□□□□
□□□□□□□
□□□□□□□
□□□□□□□
1
□□□□□□□
i
REQUIRES MAXIMUM ASSISTANCE
58. Performs overlearned tasks with maximum
58.
structure and cuing, but does not initiate the
activity
•e.! 1/3 ■
•ei
LEVELS OF COGNITIVE FUNCTIONING ASSESSMENT SCALE
Date
-.5
I. Ability to Converse:
3
SOCIAL-AUTOMATIC
59. May converse on a social-automatic level for
short periods, as “I’m fine, how are you?", but
responses are often unrelated to specific topics
of conversation
59.
60. If not verbal, may use social-automatic gestures,
as shoulder shrug, thumbs up
60.
J. Ability to Learn New Information:
NONE
61. Unable to learn new tasks; even though tries,
listens, follows commands, outcome not
achieved.
61.
□□□□□□□
□□□□□□□
B
I
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I
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;
DIRECTIONS: PLEASE THiNK ABOUT THE TIME SINCE YOU BECAME PREGNANT. AND THEN RESPOND TO THE FOLLOW.NG ITEMS
Personal Garg. Activities
! dPX;thXXXS,n9 phrases by indicating whether the performance of an activity has decreased, remained the same, or increased
DECREASED
REMAINED
THE SAME
INCREASED
1
2
3
29 Variety of foods and beverages
eaten
30. 1 line spent on care of hail
32. Walking distances, climbing
stairs, or exercising
1
2
3
1
2
3
Household Activities
Please check all the usual household. actMties yoi
•U did p_rio_r to your pregnancy and then indicate to what extent you have continued these activities during thisjDregnancy,
j
Prjcx to my^pregnancy.
niy_usual activities 11 iciuded:
|
Lhave. continued this activity:
NOT AT ALL
PARTIALLY
Doing laundry
FULLY
1
!4 __ Ironing clothes
2
3
1
2
3
1
2
3
3.
5. __
Doing dishes
>
m
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c;
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Continued
£
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i
SAMPLE ITEMS FOR THE INVENTORY OF FUNCTIONAL STATUS—ANTEPARTUM PERIOD (IFSAP)—cont’d
>
Chjldcare Activities
IF YOU HAVE CHILDREN, PLEASE RESPOND TO THE ITEMS ON THIS PAGE
IF YOU DO NOT HAVE CHILDREN, PLEASE TURN TO THE NEXT PAGE.
aSefXfi Jou
y0U
,0 y°Ur P,e9nanCy
,hen indiCa,S ,0 Wha' eX,ent yOU have “n,inued ,hese
m
Z
o
X
Prior io thjsjDregnangy^
my usual activities
Included:
I have continued this activity:
NOT AT ALL
PARTIALLY
FULLY
18
Feeding the child(ren)
1
2
3
23
Playing with the child(ren)
1
2 •
3
25.
Helping with schoolwork/reading
to the child(ren)
1
2
3
Occupational Activities
IF YOU ARE CURRENTLY EMPLOYED, PLEASE RESPOND TO THE ITEMS ON THIS PAGE
IF YOU ARE NOT CURRENTLY EMPLOYED, PLEASE TURN TO THE NEXT PAGE.
Please respond to the following phrases by indicating whether an aspect of work has decreased, remained the same
or increased during the
Rast week or two.
DECREASED
REMAINED
THE SAME
INCREASED
35. Quality of my relationships with
work associates
1
2
3
37. Doing my job carefully and
accurately
1
2
3
38. Participating in professional
organization(s)/union
1
2
3
SAMPLE ITEMS FOR THE INVENTORY OF FUNCTIONAL STATUS—ANTEPARTUM PERIOD (IFSAP)—cont’d
j
Educatipnaj Activities
IF YOU ARE CURRENTLY GOING TO SCHOOL, PLEASE RESPOND TO THE ITEMS ON THIS PAGE.
Please respond to the following phrases by indicating whether an aspect of school has decreased, remained the same, or increased during the
past week or two.
40. Attend classes
41
Complete assignments on time
42. Sil through classes without
getting up
DECREASED
REMAINED
THE SAME
INCREASED
1
2
3
1
2
3
1
2
3
Social and Community Activities
Please check all the usual social and community activities you did prior to your pregnancy and then indicate to what extent you have continued
these activities since you became pregnant.
P rio r jto Jh is_prregriaricy,_
rny usual activities included:
I have continued this activity:
NOT AT ALL
PARTIALLY
FULLY
15.
Socializing with friends/
neighbors/coworkers
1
2
3
16.
Socializing with relatives
1
2
3
17.
Participating in social clubs
(e.g., cards, bowling, tennis,
photography)
1
2
3
>
m
z
o
X
■p*
cn
u>
I
■
A
s
SAMPLE ITEMS FOR THE INVENTORY OF FUNCTIONAL STATUS AFTER CHILDBIRTH (IFSAC)
>
DIRECTIONS: PLEASE THiNK ABOUT THE TIME SINCE THE BIHTH OF YOUR BABY, AND THEN RESPOND TO THE FOLLOWING ITEMS,
m
Z
Personal. Care Activities
Please respond to the following phrases based on
c
how your life has been during the past week or two,
X
NEVER
SOMETIMES
MOST OF THE TIME
ALL THE TIME
1
2
3
4
25 Spend much of the day
lying down
26 Sit during much of my day
1
2
27 Spend much of the day sleeping
or dozing
3
4
1
2
3
4
HousehoklActivities
10 ,he babV's birth and then indicate to what extent you have
y0U had
Prior tojhg baby's birth,
my_ usual leseonsibjlities.
included:
7.
resumed these
Lhave resumed this activity:
NOT AT ALL
JUST BEGINNING
PARTIALLY
FULLY
1
2
3
4
Household business
(paying bills, banking,
etc.)
8.
Grocery shopping
1
2
9.
3
Shopping, other than
groceries
4
1
2
3
4
SAMPLE ITEMS FOR THE INVENTORY OF FUNCTIONAL STATUS AFTER CHILDBIRTH (IFSAC)—cont'd
Infant Care Responsibilities
Please circle the_n.urnbei that indicates to what extent you have assumed your part of the following aspects of the baby’s
NOT AT ALL
JUST BEGINNING
2
20. Night feedings
1
21. Bailie the baby
1
22. Change diapers
1
2
PARTIALLY
FULLY
3
4
3
4
3
4
care.
Qccupalipna! Activities
IF YOU ARE CURRENTLY EMPLOYED, PLEASE RESPOND TO THE FOLLOWING ITEMS.
Please
phrases
ni
'"' respond
- — to the following
•
•based
----- j on hoW yoUr life alwork has been during the past week or two,
NEVER
SOMETIMES
MOST OF THE TIME
ALL THE TIME
34. Act irritable toward my
work associates (give
sharp answers, snap at
them, criticize easily, etc.)
1
2
3
4
35. Am working shorter hours
1
2
3
4
36. Am doing my job as carefully
and accurately as usual
1
2
3
4
>
m
Z
Continued
o
X
ft
in
E7?..
cn
o>
>
m
Z
o
X
SAMPLE ITEMS FOR THE INVENTORY OF FUNCTIONAL STATUS AFTER CHILDBIRTH (IFSAC)—cont’d
Social ancLComniunity Activities
Please check all the usual social and community activities
you did prior to the baby’s birth and then indicate to what extent you have resumed
these responsibilities since the baby was born.
Prior to the baby’s birth,
my_usua_l responsibilities
included;
Lhave resumed this activity:
NOT AT ALL
JUST BEGINNING
PARTIALLY
Religious organizations
1
2
3
16. ___ Socializing with friends
4
1
2
3
4
1
2
3
4
15
17.
Socializing with relatives
FULLY
SAMPLE ITEMS FOR THE INVENTORY OF FUNCTIONAL STATUS-FATHERS (IFS-F)
'
IT,EMSTI0NS PLEASE TH,NK about thb TIME SINCE YOUR WIFE BECAME PREGNANT, AND THEN RESPOND TO THE FOLLOWING
Personal Care Activities
^“hese achvX'dXt^Se^tZ
Pnor_to_my. wifei^presnancy..
myjjsual activities^
included:
'° y0Ur
™S‘ ’“e"'
,hen ind'Ca,e t0 Wha' eX,en' *ou have
I have continued this activity:
NOT AT ALL
PARTIALLY
SAME AS
BEFORE
MORE THAN
BEFORE
35.
Exercising
1
2
3
4
36.
Eating more or different
foods
1
2
3
4
37.
Listening to music
1
2
3
4
Household Activities
CheCk a!Lthe USUal
activities you had prior to your wife’s pregnancy and then indicate to what extent you have continued these
acuviuGs siricG (no pregnancy.
Prior to my wife’s pregnancy,
my.usual activities included:
>
I have continued this activity:
NOT AT ALL
PARTIALLY
SAME AS
BEFORE
MORE THAN
BEFORE
■o
m
Z
1.
Cleaning the house
1
2
3
4
o
5.
Doing dishes
1
2
3
4
X
Continued
GJ
LAIS A A ■ T
Hi
00
>
z
c
X
SAMPLE ITEMS FOR THE INVENTORY OF FUNCTIONAL STATUS
i-FATHERS (IFS-F)—cont’d
NOT AT ALL
12
SAME AS
BEFORE
PARTIALLY
MORE THAN
BEFORE
. Caring for pels
1
2
3
4
Inlant Care,Responsibilities
IF y°nS
r.es_pond to THESE items.
Plea?pUHmiA th^HnA^Ko°L^LB.E£^B0R!M’PLEASE TURN T0 THE NEXT PAGE.
Please circle the_number that indicates to what ex^enTyou
have assumed your desired part of the following aspects of the baby’s
NOT AT ALL
JUST BEGINNING
PARTIALLY
18. Daytime feedings
1
2
19. Night feedings
3
4
1
2
3
4
1
2
3
4
23. Playing with the baby
care.
FULLY
SAMPLE ITEMS FOR THE INVENTORY OF FUNCTIONAL STATUS-FATHERS (IFS-F)-confd
|
I
Childcare Activities
re™ ™.this page.
If wu Zno™
IF YOU DO NOT HAVE OTHER CHILDREN. PLEASE TURN TO THE NEXT PAGE
Flease check all the usual ch^i^S youS^^o JoZZe's
d'd R“ 10 y°Ur Wfe’S m0S' reCen'
tmued these activ tiPR sinrp thD
*—
y
Prior to my wife’s pregnancy,
niy.usuiil aclivjLies
included:
and then indicate to what extent you have con-
Lhave continued this activity:
NOT AT ALL
SAME AS
BEFORE
PARTIALLY
MORE THAN
BEFORE
24.
Feeding the child(ren)
1
2
25.
3
Getting up with the child(ren)
4
1
2
3
4
1
2
3
4
26.
Bathing the child(ren)
Occupational Activities
Ip Z app
ptZs--r -s-ond to the following ITEMS.
IF YOU ARE NOT EMPLOYED. PLEASE TURN TO THE NEXT PAGE.
Please respond to the following phrases based1 on how your life at work has been during the past week or two compared to before your wife becarne_piegna.nL
1
SAME AS
BEFORE
MORE THAN
BEFORE
NEVER
SOMETIMES
42. Accomplished usual amount of
work at my job
1
2
3
43. Achieved work goals
4
1
2
3
4
1
2
m
Z
O
3
4
X
44 Worked usual number ol hours
>
Continued
a
to
'"a
.SWBW
v“Vs
-.r-n ntf.fc cA I'Asuiv iVi
o
SAMPLE ITEMS FOR THE INVENTORY OF FUNCTIONAL STATUS-FATHERS (IFS-F)-cont’d
i
LducatipnaLActiyities
IF YOU ARE CURRENTLY GOING TO SCHOOL. PLEASE RESPOND TO THE ITEMS ON THIS PAGE
Please respond to the f-'"''
.... -—
1-------- by indicating how your life aUchoql has been during the past week or two compared to before
following
phrases
wife became pregnant.
------------------------------- ----- --T-T. your
NEVER
SOMETIMES
SAME AS
BEFORE
MORE THAN
BEFORE
48. Completing assignments on time
1
2
3
4
49. Achieving goals/learning
content
1
2
3
4
50. Participating in
extracurricular activities
1
2
3
4
>
TJ
Z
□
X
SociaLand Community Activities
Please check all the usual social and community activities you did prior to yoi
•ur wife’s pregnancy and then indicate to what extent you have continued these activities since the pregnancy.
Prior jo my wifeys pregnancy.
rny,usual activities
included.:
I have continued this activity:
NOT AT ALL
PARTIALLY
SAME AS
BEFORE
MORE THAN
BEFORE
13.
Participating in community
service organizations
(e.g., political activities,
Cub Scouts, volunteer fire
companies)
1
2
3
4
14.
Participating in religious
organizations
1
2
3
4
15
Socializing with friends
1
2
3
4
SAMPLE ITEMS FOR THE INVENTORY OF FUNCTIONAL STATUS-CANCER (IFS-CA)
FOLLOwVnG ITEMSSE TH,NK AB0UT THE TIME SINCE Y0U WERE DIAGN0SED WITH CANCER, AND THEN RESPOND TO THE
FOLLOWING ITEMS.
I
Personal Care Activities
Please respond to the following phrases based on how your life has been during the past few weeks,
1
NEVER
SOMETIMES
MOST OF
THE TIME
ALL OF
THE TIME
22. Rest or sleep more during
the day
1
2
3
4
23. Spend most of the day in my
pajamas/nightgown/bathrobe
1
2
3
4
24. Walk as much as usual
1
2
3
4
Household Activities
HvftfeTirnhe^ast^^
activities you did prior to your illness and then indicate to what extent you have continued doing these ac-
Prior to myjllness,.
my_us.uai. activities
included:
I. have continued doing this activity:
NOT AT ALL
JUST BEGINNING
PARTIALLY
FULLY
1.
Care of children
1
2
3
4
2.
Care of (husband) (wife)
1
2
3
4
4.
Cleaning the house
2
3
4
>
m
Z
0
_____
X
Continued
■ti
so
NJ
o.,.. ZZ,TEMS F0RTHE ,NVENT0W OF FU—
>
FOLLOWING ITEMS.
as been during the past few weeks
32. Accomplishing as much
as usual in rny job
33 Acting irritably toward my
work associates (give
sharp answers, snap at
them, criticize easily, etc.)
SOMETIMES
1
2
3.
4
2
3
4
1
ALL OF
THE TIME
Z
o
X
34. Working fewer hours
I
1
2
3
4
Activities
lease check all the usual social and community a.
Mes you did prior to your illness
these activities in the p_asLfew.weekiT
and then indicate to what extent you have continued doing
i
I
I
NEVER
MOST OF
THE TIME
PnoLto.myjlIni
mrusuaLactivities
included:
Lhave_cpntinued doing this activity:
16.
17.
18.
NOT AT ALL
Community service
organizations
JUST BEGINNING
1
Religious organizations
2
1
Socializing with friends
2
1
2
PARTIALLY
FULLY
3
4
3
4
3
4
INVENTORY OF FUNCTIONAL STATUS-CAREGIVER OF CHILD IN BODY CAST (SAMpTe^TEMsT'
.
FOLLOWING ITEmIUT JHfc flME-SlNC-E--HAVE BEEN CARING FOR AC±IILD IN A BODY CAST, AND THEN RESPOND TO THE
WS2KS'SSSSfSSSSK
I
Pnoj to I tie.child's
oasting rny. usual activities included.;
(please check activities that were done)
household
• -haye_CQ.ntinued this activity
(please circle your response)
NQTALALL
partially
FULLY
1
MORE THAN
before
2
3
4
1
2
3
4
1
2
3
4
’•---- Cleaning the house
SOCIAL.AND .COMMUNITY
'■
Participatingin
community service
organizations
GAREQFCHlLmN BODY CAST
1. Bathing the child
Continued
z
o
X
uj
V ’3X7
>
m
INVENTORY OF FUNCTIONAL STATUS—CAREGIVER OF CHILD IN BODY CAST (SAMPLE ITEMS)—cont’d
X
Please circle the number that indicates the extent to which you do each activity
NOT AT ALL
SOMETIMES
MOST OF
THE TIME
ALL OF
THE TIME
1
2
3
4
NOTATjUL
PARTIALLY
FULLY
MORE THAN
BEFORE
1
2
3
4
NOT AT ALL
SOMETIMES
MOST OF
THE TIME
ALL OF
THE TIME
1
2
3
4
1
2
3
4
1. Clean lhe cast
z
o
CARING for other children
1. Feed the child(ren)
personalcare ACTIVITIES
Eat the right
amount of food
1.
OCCUPATIONAL AGHVITIES
1.
Maintain
Employment
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1
APPENDIX
A r F E N D |Y
SELF-CONSISTENCY SCALE-
ont’d
As I think about myself lately, I
1
SELF-CONSISTENCY SCALE—cont’d
S'
ril
pl4
■ I
^"5T. SI
CJ
.
fl* K
s *<= I
£r= g II
Lmho hnbHel0Wt frepresenls how Pe°Ple ,eel about their stability of sense of self from no chanoe
Never
Rarely
Sometimes
15. Feel mixed up about
myself
Always
1
2
3
4
16. Feel I know just what I am
like
1
2
3
4
17. Take a positive attitude
toward myself
1
2
3
4
18. Feel mixed up about what
I am really like
1
2
3
4
2
3
4
19. Feel changes like “Some
days I am happy with the
kind of person I am. Other
days I am not happy with
______ the kind of person I am”
5" ;■
477
1
20. Am satisfied with myself,
on the whole
1
21. Certainly feel useless at
times
1
22. Feel that I have a number
of good qualities
1
23. Feel changes like “Some
days I think I am one kind
of person. Other days I am
__ a different kind of person"
2
3
4
2
3
4
2
3
4
3
4
1
24. Am not much good at
anything
1
25. Know for sure how nice
I am
1
26. Feel I know just what I am
like
1
27. Change ideas about who
I am
1
2
3
4
2
3
4
2
3
4
2
3
4
-J___
J
THE SENSE OF SELF SCALF
A great deal of change
J
I
I
J
ft
No change at all
R
R
E3
Tt' S
w I
APPENDIX
H
" I
tf" I
il
THE RELATIONSHIP FORM
Phases of the Nurse-Client Relationship*
CARING BEHAVIORS INVENTORY
Date of Visit:
Below is a list of the responses that represent nurse caring. For each item, rank the
extent that a nurse or nurses made each response visible.
Name:
i
I
|
Exploitation
Resolution
|
Identification
Orientation
Working Phase
Orientation Phase
Identification
____
&
ti
£•-3 I
I •g
Makes full use of
Participates in identifying
services.
problems.
Identifies new goals.
Begins to be aware of time.
Attempts
to attain new
Responds to help.
goals.
Identifies with nurse.
Rapid shifts in behavior:
Recognizes nurse as a
dependent <—>
person.
independent.
Explores feelings.
Exploitative behavior.
Fluctuates dependence, in
Realistic
exploitation
dependence and inter
Self-directing.
dependence in relation
Develops skills in inter
ship with nurse.
personal relationships
Increases focal attention.
and problem solving.
Changes appearance (for
Displays changes in
better or worse).
manner of communi
Understands purpose of
I
l^u.^
cation (more open,
/
Respond to
meeting.
flexible).
Maintains continuity be
/
emergency
tween sessions (process
G,ve Parameters of
sp^tent).
j
meetings.
I
Explain roles
attention.
.
Continue assessment.
Gatherdata.
Meet needs as they
He'P Patient identrfy
emerge.
Problem.
y
'niiiaitan(j reason for
HOfPrnanen,P'anuse
ince.
Plans, '^avior.
or community
'eelings
Reduce anxiety
resources and
'de"t-fypositiv-y'
services
e factors.
total
hle'P Plan fOr 'y
£;°v,5ein'ormation
Faci,i’ateforwardmneeds.
°Vlc,e experiences that
^,nish feelings o a
n ^Iplessness
Focus patients
Oo "Of allow anxiety Io
Ove^elm patie^°
energies.
Clanfy preconcepHelP patit,enl ‘o focus on
and expePc,a.
cues.
t’ons of nurse.
He'PPatlent develop
U &
I
Abandons old needs.
Aspires to new goals.
Becomes indepen
dent of helping
person.
Applies new problem
solving skills.
Maintains changes
in style of commu
nication and
interaction.
Positive changes in
view of self.
Integrates illness.
Exhibits ability to
stand alone.
1. Attentively listening to the patient.
1
2
3
4
5
6
2. Giving instructions or teaching the patient.
1
2
3
4
5
6
3. Treating the patient as an individual.
1
2
3
4
5
6
4. Spending time with the patient.
1
2
3
4
5
6
5. Touching the patient to communicate caring.
1
2
3
4
5
6
6. Being hopeful for the patient.
1
2
3
4
5
6
7. Giving the patient information so that he or
she can make a decision.
1
2
3
4
5
6
8. Showing respect for the patient.
1
2
3
4
5
6
9. Supporting the patient.
1
2
3
4
5
6
10. Calling the patient by his/her preferred name.
1
2
3
4
5
6
11. Being honest with the patient.
1
2
3
4
5
6
12. Trusting the patient.
1
2
3
4
5
6
13. Being empathetic or identifying with the
patient.
1
2
3
4
5
6
14. Helping the patient grow.
1
2
3
4
5
6
15. Making the patient physically or emotionally
comfortable.
1
2
3
4
5
6
16. Being sensitive to the patient.
1
2
3
4
5
6
esAeoverlapping
17. Being patient or tireless with the patient.
1
2
3
4
5
6
_____§]gnature;
18. Helping the patient.
2
3
4
...
X . c
1 = never
2 = almost never
3 = occasionally
4 = usually
5 = almost always
6 = always
Exploitation
Client:
Seeks assistance.
Conveys educative
needs.
Asks questions.
Tests parameters.
Shares preconcep
tions and
expectations of
nurse due to past
experience.
I
ing ^Ich item 6 50316 Pr0V'ded t0 SeleCt your answer- Circle the number you select after read-
Resolution Phase
■■
IF
ASnXanda*S”°
plczngond^
Sustain relationship
as long as patient
feels necessary.
Promote family
interaction.
with goal
setting.
Teach preventive
measures.
Utilize community
agencies.
Teach self-care.
Terminate nurse
client relationship.
,, "^Ponses to cues
Use3
stimuli
'^JOTE: Phases
^!i^ompietea.
Peplau h E inf
~
_
G p. PlJ,
77
1
—---- 2ZZZZ7Z "———
--------- ------ -
«.9?3
Establishing
nurs<?
.. -...........
•° ship -Journai
Jownai pf
- ' ^oStKialNlJrSing..V72} 3034
IS®
479
5
6
19. Knowing how to give shots. IVs. etc.
1
2
3
4
5
6
20. Being confident with the patient.
1
2
3
4
5
6
2
3
4
5
21. Using a soft, gentle voice with the patient
6
___ 1
Continued
W’'
480
F
appendix
appendix
481
CARING BEHAVIORS INVENTORY—cont’d
CARING BEHAVIORS INVENTORY—cont’d
1 = never
2 = almost never
3 = occasionally
4 = usually
5 = almost always
6 = always
22 D^™onslrating Professional knowledge and
2
3
4
5
6
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
25. Being cheerful with the patient.
26. Allowing the patient to express feelings
about his or her disease and treatment.
27. Including the patient in planning his or her
care.
29. Providing a reassuring presence.
30. Returning to the patient voluntarily.
j
31. Talking with the patient.
32. Encouraging the patient to call if there are
problems.
I
I
I
’®• -';SI
2
3
4
5
6
34. Responding quickly to the patient's call.
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
?
3
4
5
6
1
2
3
4
5
6
2
3
5
6
2
3
5
6 !
37. Showing concern for the patient.
38. Giving the patient's treatments and
medications on time.
39. Paying special attention to the patient during
first times, as hospitalization, treatments.
40. Relieving the patient’s symptoms.
41. Putting the patient first.
Ki
L2
Giving good physical care.
2. male
1. single
2. married
3. divorced
4. widowed
5. separated
5. Educational Level:
4. Race: 1. African American
2. Asian
3. Caucasian
4. Hispanic
5. Native American Indian
6. Other, please specify
_
1. 1-8 grade
2. 9-12 grade
3. 1-2 years college
4 3-4 years college
5. 5 years college and over
1
7. Type of health care setting where you
were cared for by nurses:
1. university hospital
2. suburban/community hospital
3. long term care facility
4. nursing home
5. community health nursing agency
6. senior citizen center
7. other, please specify
8. Number of admissions to hospital or other health
1
36. Helping to reduce the patient's pain.
•
3. Marital Status:
33. Meeting the patient's stated and unstated
needs.
35. Appreciating the patient as a human being
•:
1. female
2. Age.
6. Highest degree earned
28. Treating patient information confidentially.
■if
1- Sex:
1
24. Managing equipment skillfully.
i
Patient ProfilePatients are asked to complete this section.
i
23. Watching over the patient.
di
Please complete the following information:
9. Reason for last admission or need foi health
i
care setting in the last 5 years
care services cf nurse
I
e
10. Number of days in hospital or other health care setting during the last admission
4
Continued
I.
«
e
482
8
APPENDIX
CARING BEHAVIORS INVENTORY
:ont’d
Nurse Profile:
Nursing staff are asked to complete this section.
1. Sex:
2. male
1. female
2. Age:
3. Marital Status:
1
1. single
2. married
3. divorced
4. widowed
5. separated
5. Educational Level:
4. Race: 1. African American
2. Asian
3. Caucasian
4. Hispanic
5. Native American Indian
6. Other, please specify
1. 1-8 grade
2. 9-12 grade
3. 1-2 years college
4. 3-4 years college
5. 5 years college and over
6. Work place (for example, hospital, nursing home, home care):
7. Highest degree earned
8. Position in nursing:
.. f
1- H
til
2»GI
1 • NA—nursing assistant staff
2. LPN—staff nurse
3. RN—staff nurse
4. RN—nurse manager
5. RN—assistant nurse manager
6. RN—supervisor __
7. RN—care coordinator
8. RN—director of nursing
9. RN—nursing faculty
10. Other, please specify
(Copyright © Zane Robinson Wolt, Z. R 1981. 1990. 1991; 10/91; 1/92; 3/92; 8/94)
Glossary
The definitions offered in this glossary
are intended to promote understanding of
terms used within this text. Many of
these terms are specific to the theorists
and represent expressions of complex
ideas. To better understand these terms,
readers should consult the chapters
within this text and the works of the the
orists themselves.
adaptation "The process and outcome
whereby the thinking and feeling per
son uses conscious awareness and
choice to create human and environ
mental integration" (Roy, 1997, p. 44).
basic conditioning factors Factors that
influence therapeutic self-care de
mand. For example, culture can be a
basic conditioning factor in influencing
sufficient food intake (Orem, 1995).
carative components Ten factors that
serve as a basis for nursing practice
founded on a transpersonal concept of
caring. These factors are essential to
satisfying certain human needs
(Watson, 1979). (See Box 13-3 for a list
of carative factors.)
caring An essential part of human life,
caring represents a moral idea about
the nature of nurse-patient relation
ships. The goal of caring relationships
is to preserve human dignity and hu
manity. Caring can be practiced intra
personally (within the self), interpersonally (the traditional relationship
between the nurse and patient), and
transpersonally (the relationship be
tween the nurse and the patient, in
which each party is influenced and
changed by the relationship) (Watson,
1999).
client/client system The object of nurs
ing, which may be an individual, fam
ily, group, or even a "social issue,"
within Neuman's theoretical system.
The client/client system is described as
"an open system in interaction and to
tal interface with the environment"
(1989, p. 23).
cocreating, coconstituting, cotranscending
The prefix "co" refers to the mutuality
of the human life process. It describes
experiences of the person in the here
and now (Parse, 1997).
cognator A coping subsystem that re
sponds to information processed,
learning, judgment, and emotion. Cognators are those processes that the in
dividual uses through conscious aware
ness and choice to create the future.
cognitive perceptual factors Motivational
mechanisms that influence decisions
about whether to engage in health
promoting behaviors. Examples of cog
nitive perceptual factors are the follow
ing: importance of health, self-efficacy,
and perceived control of health; health
definition; health status; benefits of
health-promoting behaviors; and barri
ers to health-promoting behaviors.
conceptual model "A network of con
cepts that accounts for broad nursing
phenomena" (King & Fawcett, 1997,
P-93)
483
..
8
Isi
id
■•d
tK
• I
»:
I
P -5 i
5j
HI
484
GLOSSARY
GLOSSARY
constructivism A research paradigm that
considers reality knowable through in
dividuals' mental constructions or in
terpretations. More than one relative
consensus can exist at any given time
(Cuba & Lincoln, 1994).
contextual stimuli Environmental factors
that are present in a situation; they are
not the center of attention but con
tribute to the effect of the focal stimu
lus (Roy & Andrews, 1991).
cosmology The study of the whole uni
verse, including theories about its ori
gin, evolution, structure, and future,
including the meaning and place of
human beings within the universe.
critical theory A broad research para
digm holding that reality is shaped by
social, political, cultural economic, eth
nic, and gender-related factors. The
aim of research is to critique and trans
form structures that permit human ex
ploitation (Cuba & Lincoln, 1994).
dependent-care agency The "capabilities
of persons to know and meet the ther
apeutic self-care demands of persons
socially dependent on them or to regu
late the development or exercise of
these person's self-care agency" (Orem
1995, p. 457).
dependent-care deficit The relationship
between the self-care deficit (the
required assistance) and dependent
care agency (the capabilities of the
care provider) (Orem, 1995).
dialectical interchange A dialogue be
tween individuals that challenges ac
cepted ways of thinking and promotes
more informed ways of thinking (Cuba
& Lincoln, 1994).
dialogical engagement A process
through which an investigator is truly
present with participants and is open
to discussion of the phenomenon of
study (Parse, 1987).
dimensions of relations The nature, ori
gin, function, mode, and integrations
of interpersonal relations (Peplau
1992).
fc
discipline A structured body of knowl
edge about a particular segment of re
ality; each discipline has a distinctive
outlook and style of thinking, distinc
tive organized ideas and concepts,
methods of inquiry, and modes of un
derstanding data.
energy field The "fundamental unit of
the living and the nonliving. Field is a
unifying concept. Energy signifies the
dynamic nature of the field; a field is
in continuous motion and is infinite"
(Rogers, 1990, p. 7).
emic An ethnographic term that refers
to an insider's view. An emic view is
the goal of ethnography.
epistemology The study of knowledge
itself what it is, its properties, and
why it has these properties. Epistemol
ogy seeks to answer questions about
the properties of truth and falsity, the
nature of evidence, and the certainty
that evidence produces (Wallace
1977).
ethnography A type of qualitative re
search concerned with the meaning of
actions and events associated with cul
tural groups (Boyle, 1994).
etic An ethnographic term that refers to
the outsider's perspective (such as that
of the investigators) that scientifically
views reality within a group under
study.
flexible line of defense "A protective
accordion-like mechanism that protects
the normal line of defense from inva
sion by stressors" (Neuman, 1995, p. 46).
focal stimuli Internal or external factors
that most immediately confront the
person (Roy & Andrews, 1991).
general theory The dominant features
and relationships that characterize a
practice field.
grounded theory A method of qualita
tive research concerned with theory
generation regarding social and psy
chological phenomena (Glaser &
Strauss, 1967).
helicy The "continuous, innovative, un
predictable, increasing diversity of hu
man and environmental field patterns"
(Rogers 1990, p. 8).
hermeneutics The interpretation of phe
nomena in order to depict the context
and better clarify the phenomenon of
study.
homeodynamics Three principles—resonancy, helicy, and integrality—that
deal with the state of change.
human becoming A "unitary construct
referring to the human being's living
health" (Parse, 1997, p. 32).
human interaction A process between
the nurse and patient that leads to
transactions. Perception, judgment,
and action on the parts of both the
nurse and the patient lead to a reac
tion, then to interaction, and finally to
transaction (King, 1981).
interpersonal systems Component of
King's dynamic interacting systems that
are formed through the interaction of
two or more people (King, 1995).
lines of resistance "Protection factors
activated when stressors penetrate the
normal line of defense" (Neuman,
1995, p. 46).
meaning Linguistic and imagined con
tent and the interpretation one gives
to something (Parse, 1998).
middle-range theory Theory that explains conceptual models representa
tive of a partial view of nursing prac
tice and consisting of concepts,
propositions, or relational statements
from which testable hypotheses can be
derived and empirically measured.
mindbodyspirit The connected whole of
persons (Watson, 1999).
model Virtual or imagined systems that
bear varying degrees of relevant simi
larity to aspects of the real world they
represent. A model is a system of rela
tions used to represent another system
of relations.
modeling The process of developing and
providing and abstraction of reality
(Wallace, 1994).
modifying factors Demographical char
acteristics such as age, income, gender,
education, and ethnicity, that affect
health promotion and participation.
485
normal line of defense "An adaptational level of health developed over
time and considered normal for a par
ticular individual or client system; it be
comes a standard for wellness devia
tion determination" (Neuman, 1995,
P- 46).
nurse-patient relationship The center of
nursing.
nursing agency Nurses' empowerment
to act and to know. Nursing agency re
flects nurses' ability to regulate pa
tients, assist patients in accomplishing
self-care, and achieve self-care agency
through legitimate interpersonal rela
tionships (Orem, 1995).
nursing system A system composed of
the patient(s), the nurse, and the ac
tions and interactions between the
nurse and the patient(s) (Orem, 1995).
nursing theoretical system An abstract
system consisting of the following: (1)
a general model and theory of nursing
placed within a particular philosophi
cal tradition and structuring the disci
pline of nursing; (2) the models,
middle-range theories, and empirical
referents; and (3) the models that
direct that process.
object The focus of a discipline, the ob
ject establishes the fields and bound
aries, builds the center of professional
endeavor, indicates the differences be
tween scientific disciplines, provides
the methods for investigating and ex
ploring knowledge, and determines
the conclusions in a discipline.
ontology Specifications of the ways of
identifying and marking boundaries or
particulars for a purpose.
originating Inventing or creating new
ways of living with the paradoxes of
daily living (Parse, 1998).
pandimensionality A "nonlinear domain
without spatial or temporal attributes"
(Rogers, 1990, p. 7). The shift in termi
nology from multidimensionality to
pandimensionality is discussed in
Rogers (1992).
I
I
I
I
I
8
ft IM
M
i
T
<-2 • j
ass
■
■
486
GLOSSARY
paradigms The "operating rules about
the appropriate relationships among
theories, methods, and evidence that
constitute the actual practices of the
members of a scientific community, re
search program, or tradition" (Alford,
1998, p. 2). Paradigms combine theo
retical assumptions, methodological
procedures, and standards of evidence.
pattern The "distinguishing characteris
tic of an energy field perceived as a
single wave" (Rogers, 1990, p. 7).
personal systems A component of King's
dynamic interacting systems in which
individuals exist (King, 1995).
phenomenology A qualitative research
method that focuses on individuals' ex
periential lives in terms of their views
and interactions with the phenomenon
of concern in their everyday lives
(Holstein & Gubrium, 1994).
positivism An approach to science in
which researchers assume that a dis
coverable reality exists. The goal of re
search is to discover reality in order to
explain, predict, and control (Guba &
Lincoln, 1994).
postpositivism A variation of positivist
thought, postpositivism holds that re
ality can be only imperfectly under
stood. Research seeks to gain knowl
edge by falsifying hypotheses.
powering A "pushing-resisting process"
(Parse, 1998, p. 47).
practice model A "design for nursing ac
tion" (Orem, 1995, p. 180).
praxiology The study of human conduct
or of efficient action—that is, sets of
actions coordinated toward a common
end (Kortabinsky, in Orem, 1995).
primary prevention Intervention that occurs before a reaction to stressors
(Neuman, 1995).
process model A representation of the
relationship between nurse and pa
tient variables. These models describe
the actions, interactions, and interper
sonal processes by which the goals of
the relationship are achieved.
psychodynamic nursing The active, cre
ative use of the self for the good of
the patient.
GLOSSARY
regulator A coping subsystem that physi
ologically responds through neural,
chemical, and endocrine processes (Roy
& Andrews, 1991).
reliability A measure of the accuracy and
dependability of an instrument.
residual stimuli Internal or external envi
ronmental factors, the effects of which
are unclear (Roy & Andrews, 1991).
resonancy The "continuous change from
lower to higher frequency wave pat
terns in human and environmental
fields" (Rogers, 1990, p. 8).
rhythmicity The "patterning of human
universe mutual process" (Parse, 1998,
p. 29).
sacred feminine archetype Watson's
metaphor for nursing as the basis of
reality (1999).
secondary prevention A treatment given
after symptoms caused by a reaction to
stressors (Neuman, 1995).
self-care The performance of sets of ac
tions that regulate functioning and de
velopment in order to maintain or es
tablish health (Orem, 1995).
self-care agency Persons' ability to know
and meet their continuing require
ments for self-care in order to regulate
their own human functions and devel
opment (Orem, 1995).
self-care deficit A relational construct
that expresses the disparity between
therapeutic self-care demand and selfcare agency when the self-care agency
is inadequate (Orem, 1995).
self-care systems Sequences of action
performed by individuals to meet their
self-care requisites.
social systems A component of King's
dynamic interacting systems that con
sists of groups that make up a society
(King, 1995).
stressors Environmental factors—
intrapersonal, interpersonal, and ex
trapersonal in nature—that can disrupt
the system. Stressors may penetrate
both the flexible and normal lines of
defense (Neuman, 1995).
tertiary prevention The maintenance of
optimal wellness after treatment
(Neuman. 1995)
theory The narrative that accompanies a
conceptual model, including a descrip
tion of the elements of the model and
their relationships; a frame of refer
ence that helps humans to understand
their world and to function in it; a set
of interrelated assumptions, principles,
and/or propositions to guide action.
Theory of Nursing Systems One of three
constituent theories of the Self-Care
Deficit Nursing Theory, this system de
scribes the action systems through
which nurses use their nursing agency
to promote or assist with patients' selfcare (Orem, 1995).
Theory of Self-Care One of three con
stituent theories of the Self-Care
Deficit Nursing Theory, this theory de
scribes the purpose for taking care of
self, the capacity for taking such ac
tion, and for being able to act on be
half of others (Orem, 1995).
Theory of Self-Care Deficit One of three
constituent theories of the Self-Care
Deficit Nursing Theory, this theory is
the center of the general theory and
describes the conditions that are pre
sent when people need nursing (Orem,
1995).
theory-generating research A process in
which theories are derived from real
world observations that involve the
phenomenon of interest and suggest
areas to be examined (Chinn & Kramer,
1995; Fawcett, 1999).
theory-testing research A deductive op
eration in which hypotheses are de
rived from an existing theory and then
tested. If outcomes are as predicted,
the theory is supported (Acton, Irvin, &
Hopkins, 1991).
therapeutic self-care demand A sum
mary of all the actions required over
time to meet known self-care requi
sites (Orem, 1995).
transaction Interactions that have tempo
ral and spatial dimensions in which "hu
man beings communicate with environ
ment or achieve goals that are values"
within a shared frame of reference that
comprises facts, beliefs, experiences.
and preferences (King. 1981, p 82).
487
transcendence Reaching beyond the or
dinary boundaries of a situation (Parse,
1998).
transpersonal caring The "full actualisation of the carative factors in a humanto-human transaction" (Watson, 1989,
p. 232).
transforming the human-universe
process as the human coparticipates in
change in a deliberate way (Parse,
1998).
validity An indication of whether an in
strument measures what it intends to
measure.
wholism The organization of parts or
subparts of a system into an interrelat
ing whole (Neuman, 1995).
REFERENCES
Aciihi. Li.J., Irvin, B.L.. Cx Hopkins, B.A. (1991).
Theory-restin'’ research: Building the science.
Adi a»:ccs in Xursmt; Science. I4( 1). 52-61.
Altord, R.R. (199S). The crujt nJ inqiin-s. Nev. York:
Oxlonl Umversiry Press.
Bode. I (1994'. Style.-- ot ethnography. In |. Morse
(Ed.), (.'nticul issues hi qiuditativc research methods.
Thousand Oaks. CA: Sage.
( ham. P.I.. N. Kramer. M.K. (1995). Theun: and nurs
ing research A systematic aj'l'roach (4th ed.'
St. Louis: Mosby.
Fawcett, |. (1999). The relationship oj theory and re
search, ( hd cd ). Philadelphia: Davis.
Glaser. B. N Strauss, A. (1967). The discovery o_;
cronndo! thci'Y'.
Strategies /i>r quaiitattve research.
Uhicago: Aldine.
s ni: ,i. I..C i.. St l.mi• dn. 5.S. (1994). Competing par
adigm* in qualitative research. In E.K. Dentin &
Yx. Liny.Jn iEJs.L Handbook oj qualitative rc-
'C.irch. Thousand Oaks. CA: Sage.
Hoi-rein. LA & Gubrium ].E (1994). Phenomenol-
oev. ethnotneilr. iJolugv. and interpretive prat
■ ice. in E K Demin N Y S Lincoln (Eds.), Handhonk
qualvattve •e-car. h. Thousand Oaks. CA:
Kmc. i (l'->''i i A r/i.-.cx /ui' nursing: Systems, con•
■■ W"' York John Wiley mJ S.mI'1'1"'
: a
.' •• • •- •:
c. <.
’• -.-'•■’•.i' ir.unevvvrk lor nursing. Ir.
'■
>i«. lii.'ll (EJs.). Ailrnncinc
. -x _:nJ theory oj nursing.
. l.iHi'HiiJ ■. \ik.-. i ’A. S.ige.
Kinc. I
E.i’A'xm . I t I'M"'. The language o| theci-s
m.’■
■ n-.li in i| ■ Ji<. Sigm.i Tnera Jau
I
QBav
488
GLOSSARY
Neuman, B.M. (1989). The Neuman Systems Model.
(2nd ed.). Norwalk, CT: Appleton &. Lange.
Neuman. B.M. (1995). The Neuman Systems Model.
(3rd ed.). Norwalk, CT: Appleton & Lange.
Orem, D.E. (1995). Nursing: Concepts of practice
•r.f'
41
Til
I
«I
I
h ••
Igi
I
Bl-■
3
ir^
IP
Btt
11
H. (1991). The Roy Adaptation
Model: The definitive statement. Norwalk, CT:
Parse, R.R. (1997). The Human Becoming Theory:
New York: Alba House.
Wallace. W.A. (1994). Ethics in modeling. Tarrytown.
The was, is, and will be. Nursing Science Quar
terly. 10(1), 32-38.
Parse, R.R. (1998). The Human Recoming school of
New York; Pergamon.
Watson, J. (1979). Nursing: The philosophy and science
thought. Thousand Oaks, CA: Sage.
Peplau, H. (1992). Interpersonal relations: Theoret
Watson, J. (1989). Transformative thinking and a
ical framework for application in practice. Nurs
caring curriculum. In E.O. Bevis & J. Watson
(Eds.), Toward a caring curriculum: A new peda-
Index
of caring. Boston: Little, Brown.
ing Science Quarterly, 5(1), 13-16.
Rogers. M. (1990). Nursing: Science of unitary, irre
W for nursing. New York: National League for
ducible human beings: Update 1990. In E.A.M.
Nursing.
Watson. J. (1999). Postmodern nursing and beyond.
age. Nursing Science Quarterly. 5( 1), 27-34.
■I
10(1), 42-48.
Roy, C. & Andrews, H. (1991). The Roy Adaptation
Appleton-Lange.
Wallace, W.A. (1977). The elements of philosophy.
Barrett, (Ed.), Visions of Rogers' science-based nurs
■;i
to redefine adaptation. Nursing Science Quarterly
(5th ed.). St. Louis: Mosby.
Parse, R.R. (1987). Nursing science: Major paradigms,
theories, and critiques. Philadelphia: W.B. Saunders^
ing. New York: National League for Nursing.
Kogers. M. (1992). Nursing science and the space
s:
Roy, C. (1997). Future of the Roy model: Challenge
Edinburgh: Churchill Livingstone.
A
Abortion, spontaneous, 586. 591
Abstract model, 10
Abuse, self-care research studies, 91. 102
Academic settings, Neuman Systems Model studies in.
207-208. 217-218
Accelerating evolution theorv. 127
Accident Locus of Control Scale. 529
ACL; see Adjective (?heck List
Acquired immunodeticiencv svndrome
Parse's Theory of Human Becoming research studies.
171. 176
Watson's Transpersonal Nursing studies. ’88. sup. 4,'|
Action, basic psychologic model of. 77. 79. 80
Activities of daily living. 90. 98
Activity in Pender's Health Promotion Model. 51 I
Actualization, 141. 149
AD; see .Alzheimer's disease
Adaptation, defined. 265, 487
Adaptation perspective. 259-505
administration implications. 300-502
education implications. 302
expected outcomes, 29S
model and theory description. 26 5-264
nexus, 3Q2
nursing practice. 297-302
patient population. 43. 298-500
phenomenon of concern. 2oO-26l. 297-298
philosophical perspectives. 261-263
practice models. 500
process models. 298-300
reason tor theory development, 260
research instruments. 264-268. 411.416-418. 465-481
research review. 268-297
breast cancer. 271 274, 287-289
child ami adolescent adaptation. 2777-278, 292-245
childbirth, 269-271. 286-287
chronic illness. 274 27t 2'9-2■)]
tamilv adaptation, 2 7'- 2'0. 2° 5 J Jpreterm uitant adapt.i’h . 27<’ 277
surgical patient ad.ipi.itio:.. 2'0 -2,'2
theorv testing, 282 -285. 295-29?
status of theory devel. •pmen■ '02
ADE, set Assc'sment ■fi'n.m.F
Adjective Check List. 81.1 '?
Akhecnvc R.ittng Se.ile. 2?'
Adi'lcscvni
contraceptive vise
King’* Concepui.il Sv>:crn studv. 244. 247
I’ender'i Health I'romotion Model study. 3 55-5 56
hutn.m held motiun testing. I 3], 1 54. 145. 150
I'ender's Health I'roinnuon Mudel stiiJv. 5lrt. 550
l\nv Adaptation Model <tndv. 27? 27''. 292-295
'.iletv hell ti>e. ’24. 5 ’ i
'inoking studies, 204. 2 It'-2! 7
Attect in Pender's Health I'roinotion Model. ’I I
African American population
I'endcr's Health Protnotton Model studies. ’2 5. 3 54-5’'
self-care research studies. 9*s
smoking studic', 2k'5. 2ln-2'7
Age factors
tn Parse s- Fhvorv ot Hunia Ix-c. •nimu. 173-174. 178-17°
in nine studies, 140. 14°
Agency
Jej'ciklcnt-care. 112. 487
liuinan. 75
nursing. ?(’. 112. 4S°
re. 42. 76. 109. HO. 1 | J, 490
Aging in Parse s Theorv of Huinnn Becoming. 173-174,
AIIX.
Acquircd immiint Jcticicncv <yndrc>mc
AIMS.
Arthriris Impact Mr i-u-'.-nieni Sc.ilv
AL> •li«•lism, 2'<?6
Al.lH.; 'cc Accident [.•K-uy <'t < Miuri’l Scale
Altcin.iiivc i het ip\. 274. 2'40
A itlwimcrA diwase
r.itM- - I heorv .'t I lum.in Bee* lining rc-caich -tudv. ! 72.
repl-n.- i be- el Interpers-’o.i! Relaii.my'iu.lv.
55'1. >n4
Anibiil.n.surgerx
'1 21 3
vr-.n.il Kel
A mcrh
489
1
490
INDEX
INDEX
Anxiety
chemotherapy-related, taped messages and music
intervention, 196, 202
guided imagery for baccalaureate nursing students
performing first injection, 208
influence of family conferences in neonatal intensive
care units on, 278, 293
intensive partial hospitalization program for disorders of
196-211
preoperative
humorous distraction, 281, 295
psychoeducational intervention. 197, 211
Apnea
in preterm infant. 277, 291
structured home visitation and CPR knowledge effect on
parents with children monitored for. 279, 293
Appalachian population, 3 54
Application domain. 53
Appraisal of Self-Care Agency. 84. 87-88
Archetype, sacred feminine. 374-375
Arousal state, 11 I
ARS; see Adjective Rating Scale
Arthritis
I •
?f
■
exercise studies, 327, 337
Rov Adaptation Model studies, 275. 276. 289-290
rhera['eutic touch studies, 146. 151
Watsons Transpersonal Nursing studies. 387. 595
Arthritis Impact Measurement Scale. 146. 151
ASA. sec Appraisal of Self-Care Agency
Aspirations in lender's Health I'romotion Model. 511
Assessment of Dream Ex|x-rtencv. 1 3 5. 1 57. 4 1 5. 44 5
Asthma. 242-24 3, 246
Atelectasis, 282
Attachment Scale. 144
Attitudes m Pender's Health I’mniorion Model. 511
Audiometry with tyrnpanometrv. 206. 220
B
Baccalaureate nursing proyraiii
decision making studies, 24 >. 247
guided imagery fur anxietv in nurses pertonning first
injection, 20S
Self-Gire I'Wieit Theory oi Nursing studies. 99. Ido
Back school rehabilitation program. ’OS. 209. 2 IS
Basic conditioning factors. 1 12
defined. 487
self-care research studies and. 102- 10>
Basic Conditioning I’actors Questionnaire. 97. !04
Basic psychologic model of action. 77. 79. SO
Bartering. 9|. 102
Beck Depression Inventory. 91.275. 28S
Behavun
energy transformed into. >4S
health promotum. 516-5IS. 329 - '51
nurse'-caring. i52->S6, 590-il>>
self-care. 93
Benevolent engagement. 169. 17>
Blissful contentment, in9. | 70
Body Cast, 266. 26S. 41 7. 47^—47o
Body linage in postpartum rht'vmg.
ICC
Body weight in postpartum thriving, 95, 100
Breast cancer
dialogue and therapeutic touch studies, 147, 150
Rogers' Science of Unitary Human Beings studies, 144
Roy Adaptation Medel studies, 271-274, 287-289
self-care behaviors. 93
self-care research studies, 101
Watson's Transpersonal Nursing study. 383, 390-391
Brief Symptom Inventory, 97. 104
BS1; see Brief Symptom Inventory
Buoyant vitality. 169. 170
Bum patients, therapeutic touch studies, 147, |51
Burnout, nurse. 209, 210, 219
c
CAD: see (..oronary artery disease
Cancer
attitudes following education program. 242. 246
biopsychosocial adaptation studies, 275, 290
dialogue and therapeutic touch studies, 147, 150
home care needs for outclients, 203, 215—216
interleukin-2 therapy, 275, 290
Inventory of Functional Status. 265. 267-268. 41 7
475-476
Neuman Systems Model studies, 199, 200. 212, 21 3-214
I arse s Theory of Human Becoming research studies,
171. 176
Pender's I lealth Promotion Model studies. 319, 3 51
Rogers
' of ( mt.iry Human I3eings studies. 144
Rov Adaptation Model studies. 271- 274. 287-289
self-care research studies. 92-94. 97. 100-101, 105
Watson's Transperson.il Nursing study. 383, 390- 391
Cancer support group. 271-272. 288
< ancer Survivor Questionnaire. 200
Cantril Ladder for Health. 140
C.trative comixment. 377. 395-396. 398-399. 487
Cardiac rehabiht.ition program, 328, 338
Care mapping. 3.8
Care plan. 37
*. aregiver
Neuman Systems Model studies. 203, 205. 21 5
of newly disabled adults, educational wants of. 587. 595
I'cplau's lheory of InteqK-rsonal Relations study. 358, 563
Ro\ Adaptation Model studies. 296
Caregiver ol ( hild in a Body Gist, Inventory of Functional
Status. 2('6. 268. 417. 475-476
*■ Nregivei Ret-pio.. m. Scale. '»4
5 .irutg. 576—577
defined. 487. 491
transpersona!. 49!
'• iruig Behavior Assessment. 380—381
' 'ring Behavior Inventory. 380. 381.479-482
Caring field. 378
i.tmiiu .rrat 1. 71 .m- itv,in. >ns, 4(\t—|p|
■' i‘‘‘ ■" 'is mipb........ ns. 401
future rheorv developments. 401-402
modi : and rheor. description. 377-580
Caring perspective—cont’d
nursing practice, 398-402
phenomenon of concern, 374-375, 398-399
philosophical perspectives, 375-377
practice models, 400
process models, 399—400
reason tor theory development. 374
research instruments, 380-381
research review, 381-397
caring needs and populations needing care. 386-387,
393-396
nurses'caring behavior, 382-386, 390-393
outcome studies, 388-389, 396-397
Caring-healing model, 373, 374
Causative theory. 44
CB.A; see Caring Behavior Assessment
CBI; see (haring Behavior Inventory
CCS; see Collaborative care system
Cesarean section, 270, 286
Chaos theory. 127
Chemotherapy
anxiety reduction using taped messages and music, 196.
202
self-care research studies, 92-93. 100-101
Chemotherapy Knowledge Questionnaire. 92
Cherished contentment, 169, 170
Child
ambulatory surgery stressors, 201. 21 3
asthma and diabetes melhtus in. King's (. 7 incept ual
System studies, 242-243, 246
Dependent Care Agent Questionnaire, 83. 87
Inventory of Functional Status-Caregiver of Child in :i
Body Cast. 266, 268, 417. 475-476
Parse's Theory of Human Becoming research studies.
172-173,178
Rogers' Science ot Unitary Human Beings studies. 145
Rov Adaptation Mixlel studies. 277-278. 292-293
self-care research studies. 96. 97. 103-105
Watson's Transpersonal Nursing studies, 387. 394
Child and .Adolescent Self-Care Practice Questionnaire.
85.88.413.428- 429
Childbirth
Inventory ot Functional Status After. 264. 265. 41 7.
468-470
Rov Adaptation Model research studies. 269-271,
2S6-2S7
seh-care research studies. 95. 100
Children's Health Locus <■! Control Scale. '2'1
Children's Self-Care Performance Quesrionn.vre. 88. ss.
97.428429
Chronic illness
field motion studies, 142, 150
in King's Conceptual System and Theory of Goal
\tt.iinment. 242-24 '. 24o
in .<'Tein's Selt-(l.ire Deficit The.iry. l*0-10’’
in R.a. Adaptation Model. 274--276. 2■'9-2'0
(Jironic sorrow. 240. 241
CIN'AHL; see Cumulative Index ot Nursing and Allied
! L'.i!th lareratiire
491
Client
defined, 487
interaction with nurse, 244, 245, 248, 249
in King’s Conceptual System, 235, 250
relationship with nurse in Peplau’s Theory of
Interpersonal Relations, 346, 347, 348, 349, 350,
351. 355-364
Client system, defined. 487
Client/clienr system, 188
Clinical decision making. 24 3, 247
Coconstituting, 164,487
Cocreating, 164.487
Coefficient alpha, 30
Cognator. 261.487
Cognitive function in neural tube defects, 240, 241
Cognitive-perceptual factor, 315. 318.487
( 'oll.iboratn e care system, 94. 100
Communication. 24 3, 248-249
Community
health promotion activity for older adults based in. 327,
3 38
in Neuman Systems Model, 203-206, 215—217
Communitv health nurse, safety risks. 210, 219
Compassion. 383. 390-391
C '< 'mpetence
in excellent nursing. 383. 390-391
in render's Health Promotion Model. 311
Complexitv theory, 127
1 oinplexi:\-diversity pattern, 129, 130
(..iinpliance, medication
in King’s Conceptual System, 245. 248
tn Pepl.m's Theory of Interpersonal Relations, 361. 565
Conceptual model. 5
defined. 487
nursing practice and. 38—39
in theory-based research. 22
Fawcett's rules of, 192-194
(.'onceptual System; see King's Conceptual System
C 7 nceptii.il theoretical empirical structure, 14
< Concern, phenomenon ot. 42 45
tn King's Conceptual System and Theory of Goal
Attainment, 2 55, 250
m Neuman Systems Model, 188, 221. 222-225
,n
Sell-( .'.ire Deficit Theory. 72-73. 108-112.
115-116
m Parse'' I hcorv ot Human Becoming, 162-163. 181
in Pender'.' Health Promotion Model. 308. 3 39
Peplau s Theory of Interpersonal Relations. 346. 366
in Rov Adaptation Model. 260-261.297-298
m Science of L'nirarv Human Beings. 125. 153
Watson's Transpersonal Nursing and Theory’ of
Human Caring. 374-575, 39S-399
Concordance. 'S3. 390- 5‘’l
lincrete m. Kiel. I 2
i '• ’iKurrent vahdity. ' 1 -52
< < 'n<nrutu'nal tuchirs. 11 I
Oxrucr v.tliJnv. >2
Fr
,!K'Q^
492
K
r
. j
INDEX
iNDEX
Constructivism. 19, 20. 487
Contact information.413-419
Content validity. 31
Content validity index, 31
Contentment
blissful, 169, 170
cherished. 169, 170
Contextual stimuli, 261,299. 487
Contraceptives
Kings conceptual System study, 244, 247
Penders Health Promotion Model study, 335-336
Convergent validity. 31-32
Coping, pvstsurgical, 202, 211
Coronary artery bypass graft, 196. 198
Coronary artery disease, 318. 330
Correlational research, 57
Cosmetic and Functional Impairment Ratings Scale. 97
Cosmology. 8—9
defined, 487
nursing theoretical selection and. 55
of Roy Adapt.ition Model. 262 263
of Watsons Iranspetsonal Nursing, 375
Cotranscen*ling. 164. 487
Counseling in back pain seventy. 209
Courage, 383. 390-391
w-
•V
(m-ati’-iry
r :I
u
2ss
■ ' 8' <•
in Pender's Health Promotion Mixlel. 51 i
in Science of Unitary Human Beings. 141, 149
Criterion-Referenced Measure of ( >oal Attainment
Assessment of Functional Abilities and Goal
Attainment Scales, 419
Criterion-related validity. 51
' aaiicai paths
development 01. 57-38
exp-ected outcomes and. 45
(-ritical re i.'oning, 27
Critical theory. 19, 20
2 £
defined, 487
5
nursing practice structured from. 40
Cronbnch's alpha statistic. 30
CSG; sec Cancer support group
(Cultural factors
aging studies. ’75. 174. 179
cesarean birth, 270, 286
parental concerns of new parent.', 279. 294
self-care agency. I I 1
self-care research studies
associated with pain, 95. 103
in nursing home residents, 98
smoking. 205. 216-217
Cumulative Index of Nursing and Allied Health Literature
581
Content v iliJny in lex
C.'v.A:
I
’s>?
!
D
Data collection. 42—43
OCA; see Dependent Care Agent Questionnaire
Death education program. 207, 217
Decision making, clinical. 243, 247
[defense
flexible line of. 222-225. 487
nonnal line of. 191.222-225, 489
Deliberate action, process model of. 77. 78
Delirium. 197. 212
IX-nver Nursing Project for Human Caring. 389, 396, 401
Denyes Health Status Instniment. 97. 104
Denyes Self-Care Agency Instrument. 83, 86, 102
Denves Self-Care Practice Instrument, 86, 97. 104
Dependent Care Agent Questionnaire, 83. 87 97 104
413.425-427
Dependent-care agency. 112. 487
Dependent -care deficit. 75. I 12
Depression
in breast cancer patients. 273, 288
Mental Health Self-Care Agency Scale, 85. 89
Peplaus ITeorv of Interpersonal Relations studies.
360-361. 364-365
postoperative guided imagery for. 196. 199
power studies 159.148
psychiatric home nurse visitation and readmission rates
foi. 205. 216
u.g/i I)csirtj>tive Exl>l<:tiatu>n o/ pio/vrncs <>/
De-criptivc research. 24, 2 5. 57
Descriptive theory. 24. 37
Design in Orem’s Self-Care Dehcit Theor, of Nursin11 5-116
Developmental self-care requisites, 108-109
DHH's. .,ei. Diversity of Human Field Pattern Scale
I >HM; see Denves Health Status Instniment
Diabetes mellitus
King's Conceptual System studies. 242-24 5. 246
Roy Adaptation Model studies. 275. 279. 289
self-care research studies. 97. 104
Diabetic Self-Care Practice Instrument. 97. 104
Diagnosis
classification, 58
in Neuman Svstcms Model. 226
n Orem’s Sell-Care Deficit Theory < >i Nurstny. 115-116
Diagn.rstK label. 38
Dialectical utteu hange, 20. 487
Dialogical engagement. 60. 487
Dialogue
e"ence 01 nursing practice. 182
preo|vrative in breast cancer patient,. 147. I 50 1 51
I tialv-is ■
Neuman >vstcms Model research studic'. 198 213
R n .X.lip-t
M .Jei 'tudte. 27-1. 2'*l
Discipline
defined, 4. 7. 487
nursing as, 7-8
historical perspective. 4-7
using knowledge from other disciplines. 52-53
Discovery, paradigms of, 12. 18-22
selection of. 59-61
DiSCPI; see Diabetic Self-Care Practice Instrument
Diversity of Human Field Pattern Scale. I 5I, I 35. 419
DNPHC; see IX-nver
Iknver Nursing Project for Human Caring
Documentation, 99, 106
Dream ex|vcrience
assessment of. 1 53, 1 37. 415, 447
field motion and time and, 143, 150
Drug compliance
King’s Conceptual System studies. 245. 248
Peplau's Theory of Interpersonal Relations Mudic' 561
565
DSCAI; sec Denyes Self ( arc Agency Instrument
DSCTI; see Denyes Self-Care Practice Instrument
Duchenne muscular dystrophy, 279. 293-294
Dwelling, 168
I lying
death education program influence on nurse attitudes
toward. 207. 217
tune studies. 140. 149
Watson's Transpersonal Nursing studies, 386. 503. 504
Eating Habits Confidence Scale, 91
EBBS; see Exercise Benefits and Barners Scale
lA.'RS; see Empathy Construct Rating Scale
Education of practitioners. 41 -42
death education program and care attitudes o: c
207.217
in King's Conceptual Svstem. 254
in Neuman Systems Model. 203. 216, 228
in Orem's Self-Care Deficit Tlieory. 99, 106
in Parse's Theory of Human Ik-coming. 184-185
in Peplau's Theory of Interpersonal Relations 369
in Rogers' Science of Unitary Human Beings. 155
in Roy Adaptation Modei. 302
in Science of Unitary Human Beings. I 55
EI K.S; see Eating 1 labirs Confidence Scaie
Emic, 58. 487
Empathy. 141. 149
Empathy Construct Rating Scale, 35 5. 554
Empirics, I 5
Emplovmeni
health promotion
329-330
m Pender's Health Promo’ion Model. ’I !
pistparrum. 269. J-Sf,
m Neum.i.’- mstems M .:-. i HO
•l•!<•le.^^.ent. inovuH ;■• dull . ire pr...jrann, 27s.
Wat«>n\ Transpersonal X’nr-in.a studies. 3S7. W-|
493
I ■’iincn>i..>ns or rvl.iri.
Disabled p. ■p.ilation.
tratistonnevi aito i'eh.iv
'4-Energy field, defined. 125. 12 7.->7
Enetgv field perspective. 12 3-1 59
admunstruiion unplica':
1 5'
Energy field perspective—cont d
iniklels and theories in, 127—128
nursing practice program design in. 1 52
nursing processes, 153-154
phenomenon of concern, 125, 15J
philosophical perspectives. 1 26-127
practice models, 154-155
reason tor theory development. 124-125
research instruments. 129-1 38. 41 I. 414-416, 419
4 5 3-156
Diversity of Human Field Pattern Scale. 131. I 35
Human Field Image Metaphor Scale. I 32. I 35-1 36.
415.445-446
I Inman Field Motion Test 129. I ''0
Human Field Rhythms. 131,1 34-1 38.415. 444
Index of Field Energy, I 32. I 36. 41 5. 448-453
Leddy Healthiness Scale. 1 3 3. | in | 37. 4 10. 45.|. 4S'
Mutual Exploration of ihe Healing Human FieldEm ironmenial Relationship. I 51 ] 35
Pattern -Appreciation. I 37-1 >8
Perceived Field Motion. 1 31. | 34. 414. 442-44 3
Per'on Environment Participation Scale, i >2 ! 3 3.
I 56.416.456
Photo-Disclosure. 137
Power as Knowing Participation m ■- .bange To ■!.
I2l)-| 34.414.433-435
iciupor.il ExperieiKc Stales’. I 3X'. . ;4. 414.4’ ’ 441
W u-.on > Assessment of Dre un Ex;
research review, 1 38-1 52
sreaiivirv, 141. 149
field morion studies. 142 -14 3. ■ 5.'
power studies. I 58—149
'herapeutK .-ouch. 145-147. | 5^ ■ ;
tune st.idies. 140-141. 149
Eiifi'lding Hvalth-as-\X’holenes» and H tnramv. I 5a
Enjovmvnr. 511
Environment
in Neuman Svstcms Model. 222
pain relief tn hospitalized child. 96. I ' 5
Perceived Environmental ( ncr iint- index.
Environmental field, defined, 125
Environmental lighting in oxygen saturation of; rm
infant.'. 291
Epistemology. 10. 19. 487
ESt .’A; see kxerci'C of Self-t ’ itv \gencv <.• ikEstherics i 3
Etlmogr.iphv. 58. 4?.?
Eric. 5s qs"
Ev iluariop.. 47-48
Exercise
tn Pender'Heahli l':omoti«>n Model. ' ? '27.
as -el- .
54
C-
494
-
INDEX
I■ ■
INDEX
Ml I
FILE; see Family Inventory of Life Events and Changes
nursiog practice program design in. 180-181
nursing processes in. 181-185
philosophical perspectives. 163-165
practice models. 183
reason for theory development. 162
health-promoting interventions, 327-328, 337-338
Focal stimuli. 261. 299
health-promoting practices, 323-325, 333-336
homelessness, 178
model testing, 319-322. 331-333
joy/sorrow, 169, 170
laughter. 169, 170
quality of life/suffering, 171-173, 176-178
Ftxxl Habits Questionnaire, 91
laughter. 169. I7Q
G
I lealth-Related Hardiness Scale, 275
administration implications, 400-401
Gender
I fearing protection in workers. 320-321. 531-332
education implications, 401
exercise beliefs and khaviors and. 326. 5 37
Heart rate res,x>nse to venipuncture. 277. 292
future theory developments, 401—402
m Pender’s Health Promotion M.xlel studies.
I leal therapy for postoperative shivering. 199. 21 I
nuxlel .iml theory description. 377-380
Helicv. 124, 126
nexus. 402
Health-Promoting Lifestyle Profile, 101
Health-promoting practices. 323-325. 333-336
176-178
Experimental research. 57
322. 333
General ideal set of self-care actions. 46-47
Explahatorv research. 24
General Survey Index. 97. 104
Experience, self-care agency and. 111
defined, 487
research studies. 141. 149
Explanatory theory. 24
General theory. 12. 487
I lemixli.ilvsis, 274. 291
Exploitation. 350. 551
Generic factors, 111
1 k-rmciicurii_J. 4>7
Genital heqvs. 184
Herpes, genital, I 84
Goal attainment
111'1; sec Human field image
F
m King’s Conceptual System, 24 5-245 '47- ’49
FACES 11;
Family Adaptability and Cohesmn
Evaluation Scales
Factor analysis, 32
Fa,th. 9
Family
King’s Conceptual System .md Theory of Goal
251-252
workplace. 175, 179-180
Human Caring Theory. 373-404
nursing practice. 398-402
phenomenon of concern. 374- 575. 398- 599
philosophical pcrspeclives. 375-577
practice nxxleis. 400
ptixtess models, 399-400
reason for theory development, 374
HFIMS; see Human Field Image Metaphor Scale
research instruments. 380 381
HFMT; see Human Field Motion Test
research review. 381-397
H1R. see Human Field Rhythms
theory of; sec Theory of Goal Attainment
serenity, 171. 176
Grand theory, 22
Hierarchy of interlocking 'vsicms. 76
Grieving. 170-171. 176
Hip surgery. 197, 2 I 2
Grounded theory. 58. 487
H1stor1c.1l pcr-pectivc, 4-6
caring needs anil populations needing care. 586-587.
393-396
nurses' caring behavior. 382-586, 390-595
outcome siudies, >88-589. 596-397
Anainmeni studies, 240, .’41,250. 25 5
m Pepl.m’s Iheon ot Interpersonal Relations. 569
( 'SI; see ( ieneral Survey Index
1 listofical realism. 20
Guglielmmos Self-Directed Learning Readmess Scale. 81.82
111V; xc Hum.in immune‘JcticietKy
Human field image. 128
m Roy Adaptation M.xlel. 278-280. 293-294. 298
Ou idea inuigery
Hogan Scale, 141
Human Field Image Metaphor Scale, 1 32. 1 55-1 56
Human field motion studies. 139. 142-14 3. |J8. ] 50
Human field, defined. 125
Family Adaptability and Cohesion Evah.au. -n Sc.des. 494
for baccalaureate nursing students anxiety performing
Hollingshead Four Factor Index. 97. 104
Family Crisis Oriented Personal Scales. 241
first injection. 208
for postoperative depressmn in older adult. 196. 199
Holographic thinking, 577
Human Field Morion Test. 129, 1 30
11< •mclessness
Human Field Rhythms. I 51. 1 34-1 55
Family Environment Scale. 241
Faindy Inventory of Life Events and Changes Scale ’41
Family Needs Assessment T<h>|. 2 38. 2 59
Fathers. Inventory of Functional Status. 265. 267 41 7
Neuman Systems Model qudies. 204. 211
H
Parses I heorv of Human Becoming studies, 178
Harmony. 3] |
Watson's Transpersonal Nursing studies. 587. 394
4 ■ I -474
Fatigue Experience Scale. I 5 5
11D-SC; see Health deviation self-care
Homeodynainics. 124, 487
Head injury, 205. 215
Hope. 275. 290
i-UOPES; see Family Cnsm Ouenu-d Personal Scales
Health
Hospitalization
Female population
abuse-, sell-care research studies. 9|. [0>
African Amencan, Penders Health Promotion M.xlel
.-rudies, 32 >. 3 54-3 55
'lepresMon. power studies. I 39. |j8
•nip.K- of self-esteem on health promotion acnvtttes
516. 529-530
Orem’s Self-Care Deficit Theory studies. 75. 90-103
Rogers' Science "t Unitary Human Beings studies, 144
171. 176
Rogers’Science of Unitary Human Beings studies. 145
Watson s Transpersonal Nursing studies. 388. 96. 401
Human interaction, 237, 489
spirituality needs, 198. 212
Watson's Transpersonal Nursing studies. >88. 39?
Human relations perspective. >45-371
administration implications. 369
education implications, 569
requisites, 108-109
Health Patterning. 153
HPM. sec I le.ihh Promotior. Model
model and theory description. 347-350, 351
IIR1 IS. ige I lealth-Related Hardiness Scale
nexus, 370
Health promotion in Kings Conceptual System
I Inman agency. 75
and
smoking studies. 205, 216-21 7
Health Promotion Mvxlel. 307-54?
reman vl. |99. 2 I 1
FerctKe. 19X0.1 I Ju [ 30
Parses Thei>rv of Human Becoming research studies,
HPLI'; sec Hcalth-Promotihg Lifestyle Profile
King's Conci-ptuai System studies.
nursing pracnce structured from. 40
I'owcr studies and. I 59. 148
Human immunodeficiency virus
Health deviation self-care. 97. 104
Theory of Goa! Attainment. 242. 246
I lealth Promotion Lifestyle Profile. ’ 1 2- 51 3. 410
Feminism. 20
nursing practice, 566-369
Human becoming. 162. 4S9
patient population. 567
Human Becoming Theorv. 40
phenomenon of concern. 546. 566
adimiustratioii implications. IS >-184
philosophical I'crspectivrs. 546-347, 348. 349
model and theeTies description. 3p9-3|0. 31[
education implx atioits. I ■'4-185
practice models, 569
nexus. 541
mixlels and rheoties in. lt‘5-166
process models. 3o7->69
nursing practice. 3 59-34]
phenomenon of concern. 508. 5 59
nexus. 185
reason for theory ilevelopment. 346
nursing practice program design tn. 180- lSi
research instruments. 351- >54. 418. 482
• <5
'hilt^.phical perspective'. 508- '?9
'iur'ing prixesses m. IS-
' ES; <ee Famib. I nviroimsi-nt Seal-.-
C.ison for model development. 508
pii<'ineiiim • ’ lOncerr.. : J In>. iS1
depression. '6C-3i>!
H Ii0- .c-t |- ...J Habits Que<iii ■nna,:.-
esearch instruments. 512 - 5 ’ A 41 ■)
pl,;!., i.•phi..c perspective'.
mcilication compliance. 561. >65
Fiber Te-rary. 201.21 I
eseareh review. 315-3 39
rea'. i. ter rheotv dcvcli'pinent. 162
parenting. 362. 365-366
Field m..ti..n studio, I 39. 142->4}. 14s
a
Health-promoting interventions, 327-328, 337-338
Frustration, 349
workplace, 175, 179-180
Expected outcomes. 44-45
»•
Health Value Scale, 329
homelessness, 178
quality of life/suffcring. 171-173,
h
Ftxxl diary, 91
aging. 173-174. 178-179
grieving. 170-171, 176
joy/sorrow, 169. 170
seremry, 171. 176
i,.5r
i
rr
status of theory development. 341
in neonatal adaptation, 292
loot'd
research review—cont’d
exercise. 325—327. 336-337
aging, 173-174, 178-179
I
Human Becoming Theory
Fluid intake, 201. 211
defined, 487
grieving, 170-171. 176
:ont’d
research review—cont’d
FNAT; see Family Needs Assessment Tool
research review. 169-180
I
Health Promotion Model
Scale
Flexible line of defense. 222-225, 487
phenomenon of concern. 162-163, 181
I
495
Existential perspective—cont’d
determinants of health promotton behaviors and
health status, 316-318. 329-35|
research review, 555-566
>64-365
nurse-patienr rc-’arion-hips. 355-364
Tf-varrh rcviv.v. !6i - IS*
work roles. 361, 365
Humorous distraction on preopetatr.e anxiety 2"'’
.'■-'5
496
INDEX
I N DEX
-Vi
Hypertension, 275, 276. 289-290
Hypothesis, generating for research, 25
I
IDDM; see Insulin -dependent self-care
Ideal general set of self-care actions. 46-47 114
Identification in Peplau’s Theory of Interpersonal
Relations, 350. 351
'E Ocak-; see Rotters Internal-External Locus of Control
IFE; see Index of Field Energy
IFSAC; see Inventory of Functional Status After
Childbirth
IFSAP; see Inventory of Functional Status-Antepartum
Period
IFS-CA; see Inventory of Functional Status-Cancer
IFSCCBC; ,s<ee Inventory of Funct ional Staius-Caregiver of
Child1 >n a I3»xly Cast
IFS-F; see Inventory of Functional Status-Fathers
Illness
I
fl
'i
in King's Conceptual System and Theory of Goal
Attainment. 242-24 3. 246
m Orem’s Self-Care Deficit Theory. 90-103
m Roy Adiiptation Model. 274-276. 289-291
Immune function. 273. 288
Inbetween, term. 39
Index of Field Energy. I >2. 1 56
Infant, preterm
adaptation. 276-277. 29 J -292
•S‘j-
maternal attendance at classes to prevent. 524. 5 36
Infarction, myocardial
41
nurses caring behavior studies.
591. 592
Mudies, 582. 585, 591,
self-care research studies, 91. 101-102
Injury
head, caregiver needs. 205. 2 i 5
3|J
■- S' i
-I
-i
54 t' g
1
motor vehicle accident. 204
spinal cord, chronic pain management. 201. 212
Inpatient issues in Neuman Systems Model research
studies. 196-215
ln<|uiry. paradigms of. 12. 18-22
selection of. 59-61
Instrumentarion. 411-486
contact information. 41 5-419
etiquette of using. 412-413
m King's Conceptual System. 2 58-240. 419
m Neuman Svstem> Model. 194. |95. 41 I. 416. 419
457—164
m Orem's Self-C; Defktt Thc<
SI S9.41I.
415-414. 418-419. 422 4 5|
Appraisal of Self-Care Agency. 84. s? -88. 419
Child and Adolescent Self-Care Prac tice
Questionnaire. 85. 'S. 4j i.q’.x g
Denves Svlt-t.are Agency Instrument. S3. 86. 4] s
I knves Sel;-(„ire Practice Instrument. 86, 4]8
Dependent < are Agent Questioimaire. 83, s; j| ;
Exercise of S<-||-t ?are Ag.-nc Seale SI 86
i
a
3
Mental | Ivalth
Instrumentation—conr’d
in Penders Health Promotion Model. 312-315. 419
■n Peplau’s Theory of Interpersonal Relations, 351-354
418,482
%
Interpersonal Relations Theory rent'd
practice models, 369
process models, 367-369
reason for theory development, 346
research instruments, 351-354. 418, 482
research review, 355-366
depression, 360-361, 364-365
medication compliance. 361. 365
nurse-patient relationships. 355-364
parenting, 362. 365-366
work roles, 361, 365
Interpersonal system, 236, 238, 489
Inventory of Functional Status After Childbirth. 264, 265,
417.464-466
Inventory of Functional Status-Antepartum Period, 265.
267.416. 461-463
Inventory of Functional Status-Cancer. 265. 267-268. 417
471-472
Inventory of Functional Status-Caregiver of Child in a
Rxly Cast. 266. 268, 417.47 3-474
Inventory of Functional Status-Fathers. 265, 267. 417.
467-470
I TH I’. see Intensive partial hospitalirarion program
research evaluation on. 30—32
in Rogers' Science of Unitary Human Beings. 129-138
411.414-416,419.433-456
Diversity of Human Field Pattern Scale, 131, 135
Human Field Image Metaphor Scale. 132. 135-136
415. 445-446
Human Field Morion Test, 129, 130
Human Field Rhythms, 131. 134-1 35,415, 444
Index of Field Energy. 132. 136, 41 5. 448-453
Leddy Healthiness Scale. I 33. 136-1 37. 416, 454-455
Mutual Exploration of the Healing Human FieldEnvironmental Relationship, 131, 135
Pattern Appreciation, 137-138
Perceived Field Mot
>"on. 1 31. 134. 414. 442-44 5
Pers. m-Environment Participation Scale. I 32-1 33,
136.416.456
Photo-Disclosure. 137
Power as Knowing Participation in Change Tool
129-134.414,433-435
Temporal Exivrience Scales. I 30. 134. 414, 436-441
Watson's Assessment of Dream Experience. 13 3. I 37
>n Roy Adaptation Model. 264-268. 41 1416-418
465-481
selection of. 59-61
tn Watson’s Transpersonal Nursing and Theory of
Human Caring, 380- 381,483-486
Insulin-dependent self-care. 97, 104
Integrality. 124. 126. 144
Intensive care unit
neonatal
J
loy/sormw, 169, | 70
K
Karnotskv Performance Statu- Scale. 9 3, 101
Kat: Index of Activities of Daily Living, 90. 98
Kidney disease. |X»lycysric. 387. 594
King’s Conceptual System. 2 5 >-257
.administration implication.-. 25 5-254
education implications. 254
expected outcomes. 2 51
models and theories, 2 >7. 2 38
nexus, 255
nursing practice. 249-254
nursing process. 251 252
patient ['opulation, 251
phenomenon of concern. 2 35. 250
philosophical perspectr. e>. 2 35-2 3?
practice models. 253
research instruments, 2 >8-240. 419
research review. 240-249
chronic illness, 242-24 >. 246
clinical decision making. 24 5. 247
families. 240. 241.25 5
goal attainment. 24 '-245. 247-249
health promotion. 242, 246
women'' health. 24'.' 246
status ot theory development. 254 -25'
environmental lighting in oxygen saturation of
preterm infants, 291
'■"inly conferences and anxiety level study. 278, 293
parent support needs. 197, 213
pediatric
needs of parents in, 278. 293
sleep patterns in. 277. 292
bHcnso-e partial h.isp.talization program for anxiety
disorders, 196-21 I
Interaction
human. 2 57
defined, 489
nurse-patient. 244. 245. 248. 249
Interactive rhythm studies, 144
lntcih-ukin-2 therapy. 275, 290
Internal consistency. 50
Internal-External Locus; of (Control. 81
liUerperson.il Relations Theory. 545-571
administration implications, 369
education implications, 569
Uh-del U hheorv description. 547-550. 351
it l are
414.430-432
Perceived Self-Care /Aeerv. Qtiesiionnaire. 85, Sn 87
S lr-As (/arer Inventory.
nursing pr-ictive. 566-369
patient population. 567
phenome non of concern. 346. 366
co ' - -L al pe--pesrnes. 546-547. 348. 349
n.ittire-'r ::i r-'-c.irch p.iriditiin,'. I 8
■r-.•:;! other .li'ciplino, 52-^ 5
j
497
Knowledge—cont’d
study of, 10
of theory through research, 26-30
L
Laffrey Health Conception Scale, 329
Laughter, 168-169, 170
Laxative use in nursing home residents. 201. 211
Leddy Healthiness Scale. 1 53. 1 36-1 3?
Level of Cognitive Functioning Scale. 194, 195.416,
453-460
LHS; see Leddy Healthiness Scale
Lifestyle patterns in postpartum thriving, 95. 100
Liken Scale
in Orem's Self-Care Deficit 73kleery of Nursine. 81,82.
83. 84. 85, 86-87. 88-89
tn Pender's Health Promotion Model. 312. 515. 314
m Rogers'Science of Unitary Human Beings. 1 32. 1
I 35. 136
in Roy Adaptation .Model, 265
in Warsens Transpersonal Nursing. 580. 581
Lines of defense, 222-225. 487
Lines of resistance. 191, 222-225, 489
Literature review. 22-23
LOCFAS; see Level of Cognitr Hincnohinii Scale
Logical middle, 6-7
Lung cancer, 199. ’ 12
M
Male population, prostate and testicular cancer attitudes
following education program. 242. 246
Marlowe-Crowne Social Desirability Scale. 85
Materialism. 20
Maternal Role Involvement Questionnaire. 207
Matrix, disciplinary, 7
Meaning. 164,489
Measure of Goal Attainment, 2 38-240
Mechanical ventilation studies, 192. 200. 212-215
Medical terminology, 245. 248
.Medication compliance
King’s Conceptual System study. 245. 248
Peplau’s Theory of Interpersonal Relations stud-,. >61. 5r;
Menopause. 240-246
Mental Health Self-Care Agency Scale. 85, 88-89. 414.
4 30-4 32
Mental illness
impact on tamilv health. 240. 24 1
Parse's Tlieory of Human Becoming research studies.
172. 175. 177. ISO
PeplauS Theorv of Interpersonal Relations
>55.
556. >58. >63
self-care research studies, 95. 102
Mental nudel of nursing, 42
Meperidine. 199, 211
Metaphor. | 5. 55
Mexican-American popul it ion
tamilv-enhancmg intervention.'. 280. 294
Pender's Health Promotion Model study. 317. ''?
•yli car.-re.-varch study <"oci;ite.l w:r:i p.nn. "'5 i.
■rude ot parental con. ern--at new "arenr,. 27‘J. 29-
498
INDEX
INDEX
MHLCjseeM'-'
Multidimensional Health Locus of Control
MH-SCA; see Mental Health Self-C;'are Agency Scale
MI; see Myocardial infarction
Micro theory, 12
Middle-range theory, 6. 12. 52-53
characteristics of, 13-14
defined, 489
in Neuman Systems Model, 192
in theory-based research. 22
Mindbtxlyspirit, 375, 489
Mini Mental Status Examination. 197
Mission statement. 42
Mode of experience, 368
Model
defined. 10-11.489
nursing theoretical selection and. 55
Modeling
defined. 4. Ill, 489
nursing development through. 3-16. 38-39
historical perspective. 4-7
■
h
i
I
fl
nursing as a discipline. 7-8
outcomes of. 15-14
philosophical perspectives. 8-9
theoretical perspectives. 10-1 3
Modeling nursing
components of. 12
cosmology foundational to. 8-9
expected outcomes. I 3-14. 44
Kings (aincgptu.il Svstem and Theory of Goal
Attainment. 2 3 3-257
Neuman Systems Model, 187-2 31
nursing practice development within, .57- 39
Orems Self-Care Deficit Nursing Theory, 71-122
outcomes of. 13-14
Parse s Theory of Human Becoming. 161-186
Pender’s Health Promotion Model. 507-54 3
Peplau s Theory of Interpersonal Relations. 545-371
philosophical perspectives. .8-9
Roy Adaptation Model. 2 59- 505
Science of Unitary I Inman Beings. 123-159
selection of. 53-6 5
conceptual-theoretical elements, 54-55
paradigm of inquire and instrumentation. 59-6]
practice applications and. 61-63
research meth.xls and. 56-61
theoretical perspectives. 10-13
using knowledge from other disciplines. 52 3. 54
Watson’s Transpersonal Nursing and Thcorv of Human
Caring. 373-404
M.k/e/s ,ind Rides /or .Nursing I’ractuc. I i’S
Mndeh .m.; R,des /.r I’lotmon of .\’ltrsmg/,„■ /’opidmiuns.
H8
Miklerate realism. 6- 7
m Orem’s Self-Care Deficit rhc.rv or Nursing, 7 5
Moderate realist perspective on praciiee. 40
Modifying factor. 515, 489
Mother Daughter < ’ .nth-, r Scale, 144
M.ithets whi> arc ils,, undents. 207, 217-218
Motor vehicle accident. 204
MRIQ-. see Maternal Role Involvement Questionnaire
Multidimensional Health Loci:us of Control. 93, 101, 200,
316, 329
Multiple sclerosis
alternative therapies, 274, 290
Roy Adaptation Model studies, 276, 289-290
Multitrait, multimethod validity evaluation, 32
Muscle relaxation, progressive, 210, 218
Muscular dystrophy, Duchenne, 279, 293-294
Music therapy, 196, 202
Mutual Exploration of the Healing Human FieldEnvironmental Relationship, 131, IJ5
Mutual process, 156
Myocardial infarction
nurses'caring behavior studies, 582, 585. 591, 592
self-care research studies, 91, 101-102
Mystical experience. 141, 149
N
NANDA; see North American Nursing Diagnosis
Association
National League for Nursing Education. 4
NlX.C; see Nursing Development Conference Group
Neo-Marxism, 20
Neonatal adaptation. 276-277. 291-292
Neonatal death, 584, 592
Neonatal intensive care unit
environmental lighting in oxygen saturation of preterm
infants. 291
family conferences and anxiety level study, 278. 293
parent support needs. 197, 21 5
Neuman Systems Model. 187-231
administration implications. 227-228
education implications, 228
models and theories in. 190. 191. 192
nexus. 228
patient population, 221-226
phenomenon of concern. 188. 189. 221, 222-225
phikisophical perspectives. 188-190
practice models, 227
process models, 226-227
reason for development. 188
research instruments. 194, 195, 411.416. 419
457-464
research review. 195-221
tn academic settings. 207-208. 217-218
m community settings. 205-206. 215-2 I 7
inpatient issues. 196-215
workplace studies. 208-210. 218-220
theory development status, 228
Neural rube defect. 240. 241
■Nexus. 18
Kings Conceptual Svstem and Theory of Goal
Attainment. 255
Neuman Systems Model. 22.8
Orem s Self-Care Deficit Theory, i 19
Parse s Theory of Hyman Becoming. 1S5
1 enders Health Promotion Model. HI
Peplau s Theory or Interpersonal Relations. 370
Rov Adaptation Model. 302
Nexus—cont'd
Science of Unitary Human Beings, 156
Watson's Transpersonal Nursing and Theory of Human
Caring, 402
NICU; see Neonatal intensive care unit
Nightingale, 4-5
Norbeck Social Support Questionnaire, 101, 207
Normal line of defense, 191,222-225, 489
Normalcy, 102
Normative theory. 44
North American Nursing Diagnosi Associarion, 251
NSM; see Neuman Systems Model
NSSQ; sec Norlx-ck SiKial Support Questionnaire
NTO; see Nursing Theories Opinionnaire
Nurse
actions of io alleviate pain in hospitalised child, 96,
103-104
caring behavior of . 382- 586. 390-593
communication with older adult', 24 5. 248-249
routine cyclosporine A administration by. 209, 218-219
work stress, hardiness, and burnout of. 209, 219
Nurse Attitudes Instrument. 99
Nurse-patient relationship
defined. 489
King's Conceptual Svstem studies. 244. 245. 248, 249
in Peplati's Theory of Interpersonal Relations. 346.
355-364
Nursing
development through modeling. 3-16
historical perspective. 4-7
nursing as a discipline. 7-8
outcome' ot. I 5-14
philosophical perspectives. S-9
theoretical perspectives. 10-1 5
mental model ot. 42
Orem s conceptual framework for. 77
as a program. 40-41
designing. 42
psychodynamic. 346. 490
Nursing agency. 76. 112, 489
Nursing care partnership. 599 .
Nursing care plan. ’7
Nmsnti; (kiscs .ind Their Nutuml History. I IS
Nur'ing Development Conference Group
ideal general set of 'elf-care action'. 46—47
Orem s Self-Gary Deficit Theon ot Nursing practice
mislels, 114
on 'vli-^are agenev. 42. 109. i '.111
Nur'ing di.ignosi' c!.i"itic.iti. >n.
Nur'ing hoiiie residents
laxative use studies. 201. 2 11
'clt-C.ire rc'carcb. studies, 98. ; .'5-106
3X it'on- rianspers,inal Nutsitie'ludu-', ''7. ’9’-3i)J
Nursuig practice
ii tlogue as essence of. I 82
nut'ing 'heorv md research m'-.-gr mon lor. 405-410
c.-n. vptu:d nuvlfl .mJ. ?''-59
u cc.ii
stems. 37-38
Nursing practice—cont'd
structuring of—cont’d
evaluation and research, 47-48
expected outcomes establishment. 44-45
human becoming theory, 40
individual practitioners and, 41
nuxlerate realist perspective, 40
nursing as a program, 40-41
nursing program designing, 42
patient population description, 43-44
practice models development, 46—47
process models development, 45-46
pursuing the theory-research-practice link. 56
theoretical perspectives in. 39-40. 62
using Orem’s Self-Care Deficit Theory. 107-1 IS
variables of concern development. 42-4 3
Nursing praxis, 52
Nursing process, 37. 45
in Orem's Self-Care Deficit Theory of Nursing. 115
Nursing science, 80-81
Nursing Stress Scale. 209
Nursing system, 107, 108, 489
Nursing theoretical system
components of, 12
cosmology foundational to. 8-9
defined. 489
existing, 405-409
exjvcrcil outcomes. I 3-14. 44
King’s (’oneeptual System and Theory of Goal
Attainment, 233-257
Neuman Systems Mcxlel. 187-231
nursing practice development within. 37- 59
Orem’s Self-Care Deficit.Nursing Theon, 71-122
outcomes of, 13-14
Parse’s Theory of Human Becoming, 161-186
Pender’s Health Promotion Model. 307- 34 3
Peplau’s Theory of Interpersonal Relation.'. 545-37!
philosophical perspectives. 8 -9
Roy Adaptation Model. 259-305
Science of Unitary Human Beings, 123-159
selection of. 53-63
conceptual-theoretical elements, 54-55
paradigm ot inquiry and instrumentation. 59-6]
practice applications and. 61-63
research methods and. 56-61
theoretical perspectives, 10-13
using knowledge from other disciplines. 52-5 3. G
Watson s Transpersiin.il Nur'ing and Thcorv of; lur.'..
Caring. 373-404
Nursing Theories Opinionnaire. 20'
Nursing theon’
connection to research. I 7-34. 405-410
congruence between theon and research, 2n
knowledge ot theory through research. 2(.— 50
paradigms of discovery. 18-22
research evaluation on insrruirent irto;■. '
theory-generating research. 22. 2 3
theory-testing research. 23-2 5
historv of, 4
metaphors in. I ’
499
yt*
3; 7
500
INDEX
7'
Orem's Self-Care Deficit Nursing Theory
middle-range. 6, 12, 52-53
defined, 489
Appraisal of Self-Care Agency. 84, 87-88, 419
in Neuman Systems Mtxlel. 192
Child and Adolescent Self-Care Practice
Questionnaire, 85. 88, 41 3, 428-429
in theory-based research, 22
Denyes Self-Care Agency Instrument. 83. 86. 418
relationship to theory or knowledge from other
lk-nyes Self-Care Practice Instrument. 86. 418
IX-pendent Care Agent Questionnaire. 83, 87. 41 3
disciplines, 6
verification of, 26-30
425-427
Nursing theory-guided practice. 39
Exercise of Self-Care Agency Scale. 81-86
Nutrition. 101-102
Mental Health Self-Cai
o
414,430-432
Perceiyed ^-If-Care Agency Questionnaire. 83. 86-87
dticumenration, 99. 106
oltler adults. 98. 105-106
in Kings< onceptual System, 245, 248
m Peplau's Theoty of Interpersonal Relations. 361. 365
arses Theory ot Human Becoming research srudies
169. 170
1 endet s Health Promotion Model studies. 3|7. 3 3Q
planned tersu.s unplanned hip surgery. 19/. _’/ >
in Neuman Systems Model, 221-226
.
in Orem's Self-Care IX-ficit Theory. 112-111
in Pender’s Health Promotion Model, 119
in Peplau's Theory of Interpersonal Relations, 167
Pain
in Roy Adaptation Model, 29,S-1(\1
(. 'Biology, 9- 10 19
after Panned versus unplanned hir replacement surgery,
duality recognition in. 407
Of human becoming, 165
of Roy Adaptation M.kIcI. 262-261
ix'stoperative. therapeutic touch studies. 145. 15|
self-care research studies, 95-96, 103-104
74-75
of Watson’s Transpersonal Nursing. 375
Pattern Appreciation, I 17 -1 18
Pearson Education. 419
Pediatric intensive care unit
characteristics of. 18-22
defined, 12, 489
Oral contraceptives, 244. 247
selection of, 59-61
Orem's Self-t. 2.re 1 X f,clf Nursmg The.
71-122
ai implicarioio. I | 7- i I 8
devek-pr.h
iKing logical middle. (>-7
models and theories m. V 75-77 '.s 79
needs ot parents in. 278, 291
sleep patterns m. 277. 292
Pender’s Health Promotion Model. >0? 143
Paranormal. 127
Parent
needs ot
model and theories description. 109-llv. 3|[
nexus. >41
nursing practice. 1 >9- U |
phenomenon of concern. 108. > jq
m net-natal intensive care units. 197. 21 >
m pediatric intensive care unns. 278. 29 3
nexus. I 19
patient population. I I 2-1 I 1
- phenomenon of concern. 72-73. 108-1 12. 1 15-116
pain relief in hospitalization child and. 96.
pedtarnc .imhulatory surgery stressors srudy. 22!. 2 i >
363 366
practice models. | ]4-! i 7
i arse . Theory of Human Becoming. |6| -H6
;i„
. J. .rik.ni -
...g;)
philosophical perspectives. 108->09
;
m Peplau's Theory of Interpersonal Relations ?6 ’
pnilosoptiic.d ptTspecii-.es. 73-75
,i;
a-imim.'tr irion implications, |.43_' '-I
t-ducation implications, 184-|S5
models and iheones in, 165-166
Patterning, 126
Patterns of knowledge, 11
PD; see Peritoneal dialysis
Pandimensionaliry, 125, 126.489
Paradigm. 18-22
o™'. Seir.G,„. I
.
spinal cord injury. 201, 212
H 3. 114. 115-.| 16
Optimism. 311
420-4 31
i'.ittern, defined. I 25. 489
Pattern integration in depression. 360, 164
nursing theoretical selection and. 54-55
<>f Orem's Self-Care Defictr Theory of Nursim
I-..-1
m Wats.m's Transpersonal Nursing and Theory >f
Human < I iring. 5,,iJ
171.177 178
defined, 489
'
"
Peplau’s Theory of Interpersonal Relations, 345-371
administration implications, 369
education implications, 369
model and theory description, 147-350, 351
nexus, 370
nursing practice, 366-369
patient population, 367
phenomenon of concern. 346, 366
philosophical pers|>ectives, 346-347, 348, 349
practice models, 369
prixess models, 367-369
reason for theory development. 546
research instruments. 351-354,418. 482
research review, 355-166
depression, 160-161. 364-165
medication compliance, 3(>|. 165
nurse-patient relationships, 155-364
Attainment. 251
Osteoporosis, 32 3. 3 35
Parse's Theory of Human Becoming reseaa h studies
ijs
workplace, 175. 179-180
in King's Conceptual System ami Theory of Coal
chronic, field motion studies, 142, 150
reason i-.f
serenity, 171, 176
Patient population. 41-44
M7.35O.3ti| 355.356. 357.367,368
< Originating. 165, 166.489
V fntoiogical arti-try, 379
proccxsm..J.-ls. | ] 3. | H
laughter, 169, 170
quality of life/suffenng. 171 -173, 176-178
151, 155-164
P
ti.crapeutic touch srudies. 146. |5|
I
f
joy/sorrow, 169. 170
in Parse's Theory of Human Becoming, 181
■deep-wake cycles in. 143. I 50
admini>tr:
homelessness, 178
Interpersonal Relations. >46. 147, >48. 149 150
status of theory development. 118
Oriemu,,,,,,
rerl.>rt Tlm,„
Ovarian cancer. I 71. I 76
grieving, 170-171. 176
relationship with nurse in Peplati's Theory of
Oxygen saturation in preterm infants, 291
pi'Wl .'Indies. 1 39, 148
-eit c ire research studies. 98. 105-106
research review, 169-180
in King's Conceptual System. 215, 250
usefulness of theory to research. 106-107
niciiiciituni c»iiupliiince
reason for theory development, 162
interaction with nurse. 244. 245. 248, 249
'‘clt-carc and children. 97. 104-105
health-promoting interventions. 327. U.S
practice models, 183
Patient
pain, 95-96. 10 i- IO4
Q’5. .3.34
philosophical perspectives, 163-165
Path analysis, 25
health and illness. 90-103
health beliefs and lifestyle pracnces of rural versus m/xm
nursing processes in, 181-185
phenomenon of concern, 162-163, 181
I'iirticiputory inquiry, 20
education, 99, 106
196. |99
-
Agency Scale. 85. 88-89.
8H.-lt-As-C.arer Inventory, 84. 88, 41 3. 420-425
research review. 89-107
communication with nurses, 24 1, 248-249
guided imagery for postoperanve depression in
Parse’s Theory of Human Becoming—cont’d
aging, 173-174, 178-179
Nursing-sensitive outcomes. 45
Older adult
■r Li*
:ont'd '
research instruments—cont’d
characteristics of, 13-14
Object, 7-8, 489
d
501
Nursing theory—cont’d
f
I ■,
I
INDEX
reason tor model ic\t |o| m-m. 108
icscarch insriunient'. 112-115. 419
research res lew. >15-1 3’J
Jeterimnanis o! health pt 'motion behavioo and
healrh status, >|fi-3| S '2 J-1>!
he lii h-; ;. -n :.
parenting. 162. 365-166
work roles, 361. 365
PEPS; see Person-Environ me nt Participation Scale
Perceived Environmental Constraints Index, 90. 9s'
Perceived Field Motion. Hl. 134
Perceived Multiple Role Stress Scale. 207
Perceived Self-Care Agency Questionnaire 81. 86-87
Performing artists, retirement of. 174. ) 79
Perioperam e client
.imhulatory
pediatric, stressors in. 201, 211
Peplau's Theory of Interpersonal Relati-.
adult. 196, 199
Neuman Systems Model studies. Jv,-. 202. 211
i '
nurse-patient interaction intervention, 244. 248
|H>sto|KT.itive coping. 202. 21 !
Rov Adaptation Model studies. 280 -282. 294-295
therapeutic touch and dialogue studies. 47. 150-151
Watson's Transpersonal Nursing studies. >84. 385. 188
391. 397
Peritoneal dialysis, 274, 291
Personal experience. 28
Personal knowledge, I >
Personal Meaning Index Scale. 1 3 3
Personal Orientation inventory. 141
Personal system. 2 36. 2 Is. 490
Personal \ ieus Survey. 209
Personalism. 7 3 -74. 7t>
Ferson-Envuoninenr Participation Scale. 132-133. I 36
PE>: see Progress Evalu.ition Scale
PEN; see Perceived Field Motion
Phenomenoiogv. 57-58
defined, 4'\'
isistentiai. 163
Phenomenei’. ot concern
.fevvlopmeni of . 4." -4 >
m King - < , ■nceptiial Sy >tem md Thy1 tv ot < i. '.d
Ait.iT.menr. 2 1^ Jlf
nexus. 185
cursing j’ractice program design m.
»ns >rii<lv, 15^.
361
guided nn.igery lor postoperative dvpressron in older
•:i < ^retii'x *
11'.
u nK .--.
I'ilU
502
INDEX
INDEX
bi
1’’^
h..
a
VIi
I
K
■
II
161
Hi
Phenomenon of concern—cont’d
in Parse’s Theory of Human Becoming, 162-163, 181
in Pender’s Health Promotion Model, 308, 339
in Peplau's Theory of Interpersonal Relations, 346, 366
in Roy Adaptation Model, 260-261, 297-298
in Science of Unitary Human Beings, 125, 153
in Watson's Transpersonal Nursing and Theory’ of
Human Caring, 374-375, 398-399
Photo-Disclosure, 137
Physical Coping Behavior Scale, 202
Physical Well-Being Scale, 13 3
PICU; see Pediatric intensive care unit
Piers-Harris Children’s Self-Concept Scale. 97
PKPCT; see Power as Knowing Participation in Change
Tool
Planning in Orem's Self-Care Deficit Theorv of Nursing
115-116
Play, 311
PMR; see Progressive muscle relaxation
PMRS; see Perceived Multiple Role Stress Scale
POI; see Personal Orientation Inventory
Polio survivor power studies, 140, 148-149
Polycystic kidneydisease. 387. 394
POMS: see Profile of Mi.kh.1 State
Population, 4 3-44
in King’s Conceptual System and Theory of Goal
Attainment, 251
in Neuman Systems Model. 221 -226
in Orem's Self-Care I leficit Theory, 112-113
in Parse’s Theory of Human Kcoming, 181
in Pender's Health Promotion Model, 339
in Peplau's Theory of Interpersonal Relations. 367
tn Rov Adaptation Model, 298-300
m Watson's Transpersonal Nursing and Theorv of
Human Caring. 399
Positivism. 18-19. 21,490
Postanesthesia shivering, 199, 2 11
Postmodernism, 20
Postoperative pain. 145, 151
Postpartum self-care research studies, 95. 100
Postpositivism, 19-20. 21. 490
Poststructuralism. 20
Postsurgical coping. 202. 211
Power as Knowing Participation in Change Twl, 129-1 34,
153
Power studies, 138-149
Powering, 165. 166.490
Practical knowledge, 10
Pracric.il science. 80—81
Practice
dialogue as essence of, 182
nursing theorv .1 nd research ureur.irion for. 405-410
structuring of, 35-50. 41-48. 61-63
conceptual model and. 38-39
critic il theory feminist perspective. 40
development within nursing theoretical systems. 37-38
ev.ilu mon and research. 47-48
expected outc.uiies establishment, 44—15
human Incoming theory. 40
individual pracritioners and. 41
Practice—cont’d
structuring of—cont’d
moderate realist perspective, 40
nursing as a program, 40-41
nursing program designing, 42
patient population description, 43-44
practice models development, 46-47
priKess models development, 45—46
pursuing the theory-research-practice link, 36
theoretical perspectives in, 39-40, 62
using Orem’s Self-Care Deficit Theory, 107-118
variables of concern development, 42—4 3
Practice methodology in Parse's Theory of Human
Becoming, 181
Practice modalities, 126
Practice mtxlel, 46-47
defined, 490
in Orem's Self-Care Deficit Theory. 114 117
Praxiology, 52. 490
Praxis, 52
Predictive theory, 25
Predictive validity. 31-32
Pregnancy
Inventory of Functional Status-Anteparrum Peruxl ’65
267
Pender's Health Promotion Mcxlel studies. 325. 335
Roy Adaptation Model research studies. 269-271
286-287
self-care research studies. 95, 100
spiintaneous abortion. Watson's Transpersonal Nursing
studies, 386, 391
Prescription in Orem's Self-C; Deficit Theorv of
Nursing, 115-116
Prescriptive the<
37
Preterm infant
adaptation, 276-277, 291-292
maternal attendance at classes to prevent, 324. 336
Prevention
defined. 490
in Neuman Systems Model. 189. |9|
Primary prevenrion
defined. 490
in Neuman Systems Model. 189. 191
Problem setting, 46
Problem solving, 46
Process model. 45—46
defined, 490
in Orem's Self-Care IWicit Theory. 77. 78. 11 3 114
115-116
Production m Orem's Self-Care Deficit ITeorv of Nursin..
115-116
Profile ot Mood State. 101
Program
defined, 37
nursing as. 40-41.42
Program theorv. defined. 37
Progress Evaluarion Scale, 24!
Progressive muscle relaxation. 210, 218
Prostate cancer. 242. 246
PS( A. see Perceived Self-C.-are Agency QueMionnatre
Psychiatric units; see Mental illness
Psychodynamic nursing, 346, 490
Psychologic model of action, 77, 79. 80
Psychological factors in Neuman Systems Model, 222-225
Psychophysiological Coping Behavior Scale. 202
Psychosocial factors in postpartum thriving, 95, 100
Puerto Rican population, 205, 216-217
Pulmonary cancer, 199, 212
Pure tone threshold audiometry, 206
Q
Qualitative research, 56-61
Quality ot life
tn lung cancer patients, Neuman Systems Model studies,
199.212
in Parse's Theory of Human Incoming, 171-173,
176-178
Quantitative research. 56-61
R
Radiant heat tor |x>sto|XTative shivering, 199. 211
Radiation therapy
breast cancer, walking programs and. 275. 289
.'elf-care research studies, 94
RAM; see Rov Adaptation Mixlel
Realism
historical. 20
moderate. ('-7
in Oreni ' Self-Care Deficit Theory of Nursing. 73
Realist perspective. 71-122
administration implications. 117-118
models and theories in. 70, 75-77. 78, 79 •
patient pipulation. 112-113
phenomenon ot concern, 72-73. 108—112
philosophical perspectives, 73-75
practice models, 114-117
process models, 113, 114, II5-116
reason for theory development. 72
research instruments. 81 -89. 411.413—414,418-419.
420-431
Appraisal of Self-Care Agency. 84, 87-88, 419
Child and Adolescent Self-Care Practice
Questionnaire, 85. 88. 413, 428-429
Denyes >elt-Care Agency Instrument. 83. 86. 418
Fienyes Self-Care Practice Instrument. 86. 418
Ik-pendenr Care Agent Questionnaire. S3. 87. 41 3.
Exercise ot Self-Care Agency Scale. 81-86
Mental Health SelfA.'are Agency Scale. 85. 88-89.
414, 4-30-452
Perceived 8elt-Care Agencv Questionnaire. 83, 86-87
Self A<-Carer Invcr.rorv. 84. SS. 413. 420-425
research review. 89-107
documentation. 99, 106
education. 99. 106
i!:b. mJ
‘>0- 10’
older adult-.’»<. 105- 106
pain. 95-96. 103-104
'fit <.are and children. 97. 104-105
'tani' -r rhe ,rv J-. -.eiopment. 1.18
503
Reasoning, critical, 27
Reconstitution, 189
Regulator. 261. 490
Rehabilitation program
back scluxtl, 208, 209, 218
breast cancer. 273, 288-289
cardiac. 328. 338
Relational ontology, 375
Relations, dimensions of, 348-350
Relationship Form. 353, 354. 418, 478
Relaxation, progressive muscle, 210, 218
Relevancy in Pender's Health Promotion Model. 311
Reliability. 30-31. 490
Religion. 9
Reminiscent srorvtelling, 139. 148
Research
connection to nursine theorv, 17- 34. 405-410
congruence between theorv and research. 2o
knowledge of theorv through res<- itch, 26-30
paradigms of discovers. 18-22
research v. .ilu.ition on instrumentation, 30-32
theory-generating research. 22. 23
theory-testing research. 2 3 -25
descriptive. 24. 25
explanatory. 24
generating hypotheses tor. 25
methods of. 56-61
Research instruments, 41 1—486
contact information. 41 '—119
etiquette of using, 41 2- 41 3
in King's Conceptual Svstem. 238-240. 419
in Neuman Svstems Model. 194. 195. 411. 4io. 419.
457-464
in Orem's Self-Care Dettcit Theorv. 81-89, 411.
413-414.418-419. 420-431
Appraisal of Self-Care Agency, 84. 87-88. 419
Child and Adolescent Self-Care Practice
Questionnaire. 85. SS. 4! 3. 428-429
Denyes Self-Care Agency Instrument. 8 3. 86. 418
Denyes Self-Care Practice Instrument. 86. -18
Dependent Care Agent Questionnaire. 83. >7. 413,
425-427
Exercise ot Self-Care Agencv Scale. 81-86
Mental Health Selt-l 'are Agencv Scale. 85. >>-89.
414.43^4 32
Perceived >cit-C.i:e Agency Questionnaire. ? >. 80-'
Selt-.-\s-Circr Inventory, 84, 88. 41 ’. 420—425
in Petiyler's Health Proinorum Model. 312-315. 411*
in Pepl.iu\ Fheory of Irci-rpersonal Relations. 5s I _; sc
research evaluation on. ’.'-32
in Rogers' Science ot Lnitan Human Beings. 129-1 3e.
41 I.414-416. 419. 435-456
Diversit’. ot Human Field Pattern Scale. 131. 135
Human Field Image Metaphor Scale. 1 32. 135 -1 36
Human l ieki Mota'ii Fol. 129. I »•.'
Human Field Rhythms. 131, 134-1 >5, 41 5. 444
Index ot Held Enercn. ! ’J. ! 3h. 4!^. 448—4' ’
leddv He.Hnme-s-x
I H. I i6-l ‘7 41-.’. -?
11I
if :- - •
f-
I
!
f-
:: J
rd
'J: • ’ ■ I
-^■5 I
1J
h
B
■
504
INDEX
Research instruments—cont'd
in Rogers' Science of Unitary Human Beings—cont'd
Mutual Exploration of the Healing Human FieldEnvironmental Relationship, 1.31, 135
Pattern Appreciation. 137-138
Perceived Field Motion, 131, 134. 414, 442-443
Person-Environment Participation Scale, 132-133,
136,416,456
Photo-Disclosure, I 37
Power as Knowing Participation in Change Tool.
129-134.414.433-435
TemjHsr.il Experience Scales. 130. I 34. 414, 4 36-441
Watson's Assessment of Dream Experience. 133, 137
in Roy Adaptation Model. 264-268. 411.416-418,
465-481
selection of. 59-61
in Watson's Transpersonal Nursing and Theory of
Human Caring, 380-381.483-486
Residual stimuli. 261, 299. 490
Resistance, lines of. 191,222-225, 489
Resolution, 347. 350. 351, 367. 368
Rest •nancy. 124. 126
defined. 490
research ,'tmlies. 142 !4 3. 150
Resuscitation, preterm. 277. 29|- 2J2
Retirement of performing artist.-. 17A 179
Rheumatoid arthritis
R.w Adapt.mon Mixle! studies, 275. 289
V-Uson'-Ir.inspci-oii.il Nur-uig-Kidies. >87. >95
Rhvihmiiu’.. i('4. 4‘>C
Rocking, human field motion anil, 142. 1 50
Rogers' Science of Unitaiy Human Beings, 123-159
adiHinfstr.irion implications. 155
eduiation implications. 155
m. dels anil theories in. 127-128
nexus 156
nursing practice ptog.-am design in. I152
nursing pm, esses. 15 >-l 54
phenomenon of concern. 125. 15 >
philosophical perspectives 126- 127
practice modcis. 154-1 55
reason tor theory . cvelopmenr. i 24-125
research i:.stnimyn)•. !29-l 38. 411.414-416. 419.
433-456
Diversity of Human Field Pattcm Scale, 1 H. i 35
Human Field Image Metaphor >v.ile. I 32. I 35_[ V>.
445-446
‘3
-
p
I
s
I
I
I
liuman Field Motion lest, 129 ‘ ip
Human Fiei i Rhythms. ! >l. 154- | >5.444
hi.lex .g Field Energy, i >2 1
448 45 •
Leddv I le.iithihess Scale. I 5 >. I >t>-l j“. 454-455
Mutual Exploration . f the Healing Human FieldFm :mni::ent.>! RyLitionship. ! >i. 13?
I'arrern Appn'ii:irn>B. ! >7-1 >S
Perceived Field Mot m. 131. 1 >4. 442-44 >
rc-r-i'n-Environmcnt Pirncipation Scale. I >2 I > '.
l'huh.’-i )is<h.stirv, . i ?
I'i'uer is Knowiiit!
? 29- 134.4'3-4'-’
icirartnn m < .L.ini!.- T-hJ.
INDEX
Rogers’ Science of Unitary Human Bcings- :ont'd
research instruments—cont'd
Temporal Experience Scales, 130, ! 34, 436-441
Watson s Assessment of Dream Experience, 133, 137
research review, 138-152
creativity, 141, 149
field motion studies, 142-143. 150
power studies, 138-149
therapeutic touch, 145-147, 150-151
time studies. 140-141. 149
Rokeach Values Survey, 329
Role deprivation in students. 207, 217
Rotters Internal-External Locus of Control, 81
Roy and Andrews (1998), 301
Roy Adaptation M.hIcI, 259-305
administration implications. 300-302
education implications, 302
expected outcomes, 298
model and theory description, 263-264
nexus. 302
nursing practice. 297-302
patient population. 4 3. 298-300
phenomenon of concern, 260-261, 297-298
philosophical perspectives. 261-263
practice models, 300
process models. 298-300
leason for theory development. 260
research instruments. 264-268, 41 1.416-418. 465-481
research review. 268- 297
hre.ist cancer. 271-274. 287-289
child an<l adolescent adaptation, 277-278, 292-29.3
childbirth, 269-271, 286-287
chronic illness. 274-276, 289-291
family adaptation. 278-280. 293-294
preterm infant’.idaptation, 276-277, 291-292
surgical patient adaptation. 280-282, 294-295
theory testing, 282-285, 295-297
status of theory development. 302
Rural older adult. 325, 334
s
Sacred feminine archetype. 374—375, 490
Safety, community health nurse. 2 10, 219
Safety belt use, adolescent, 324. 335
St .13; see Self -Care Behavior Log
SCDNT; see Self-Care Deficit Nursing Theorv
St.I; sc,.- Self-A.s-Carer Inventory
Science >t Unitary Human Beings, 5, 123-159
administration implications. 155
education implications, 155
models and theories tn. 127-1 28
nexus. 1 56
nursing practice program design in. i152
nursing processes. 15 3-154
phenomenon of concern. 125. 153
philosophical perspectives. 126-127
reason tor theory development, i 24-125
ryse i-ch instruments. I 29-1 38, 411.414-416. 419.
Science of Unitary Human Beings- :ont’d
research instruments—cont'd
Diversity of Human Field Pattern Scale, 131, 135
Human Field Image Metaphor Scale. 132, I 35-1 36,
415.445-446
Human Field Motion Test. 129, 130
Human Field Rhythms. 1 31,1 34-1 35. 415, 444
Index of Field Energy. I 32, 1 36, 415, 448-453
Leddy Healthiness Scale. 133. 1 36-1 37, 416, 454-455
Mutual Exploration of the Healing Human Field-
Environmental Relationship. 131, 135
Pattern Appreciation, 137-1 38
Perceived Field Motion. 13|. 1 34, 414, 442-443
Person-Environment Participation Scale, 1 32-1 3 3.
136.416.456
Photo-Disc losute, 1 >7
Power as Knowing Participation in Change Tool.
129-134.414.433-435
Temporal Experience Scales. I 30, I >4. 414. 4 >(>-441
Watson s Assessment ot Dream Experience, 113. | 37
research review, 138-152
creativity. 141. I49
tield moi ion studies. 1-2- 14), 150
power studies. 1 >8 -149
thc ipeutic touch. I45-147. 150-151
time studies. Hi' 141. 149
Scler 'sis. multiple
.iliernative therapies. 2 7J. 290
Roy Adaptation Mode! studies, 276. 289-290
Sl.,QB; sec Si If-Care Iseh.n iot Quest k uin.iirc
SCS; see Spiritual Cure Scale
SI 'LRS. see Self-Directed Le-.iming Readiness Scale
Seci’ndarv pre', vniion
defined. 490
■n Net.rti.m Sv-rems Model. 189. 191
Svif-jctii liiintti'i;. ’ 1 I
Self-Ar-I,arer Invent,>rv.
SS. 413, 420-425
Self-care
defined. 72. 73. 490
health deviation. 9f 104
universal. 97, K'4
Self-care agency. 42. 76. JOS*, i 10. 111. 490
>ell-C.ire Behavi. i Clivckk k'i
Self-Cate Behavi<>r L-’g. 9>. ■ <'!
Self-Care Bch.ivt.'t Q’lc-r
Seli-i.ire detieir, I! 2. 49?
Self ■I .'are Defic.’ Xur-tv.g 7'h-.
.idinmisn.iiii■:. imphc.iri.
development using iogicai middle, o-7
models and theories in 72. 75-77. 78.
patient popuLitt,
phen, immon . ‘f
t'lul,u,.,! pcT
I r.icticc models. I i 4-117
505
Self-Care Deficit Nursing Theory :ont'd
research instruments—cont'd
Appraisal of Self-Care Agency, 84, 87-88, 419
Child and Adolescent Self-Care Practice
Questionnaire, 85, 88. 413. 428-429
Denyes Self-Care Agency Instrument, S3, 86,
418
Denyes Self-Care Practice Instrument, 86, 418
De|Tendent Care Agent Questionnaire, 83, 87, 413,
425-427
Exercise of Self-Care Agency Scale. 81-86
Mental Health Self-Care Agency Scale. 85. 88-89,
414.430-432
Perceived Sell-Care Agency Questionnaire, 83,
86-87
Selt-As-( 2aarer Inventory, 84. 88, 413. 420—425
research review, 89-107
documentation, 99, 106
education. 99. 106
health and illness. 90-103
older adults, 98. 105-106
pain, 95-96.103-104
self-care and children, 97. 104-105
usefulness of theorv io research, 106-107
status of theory development. 118
Self-care rci|iiiMics. 108-109
Self-care system. 112. 490
Self-concept, self care and. 97. IC4-IO5
Self-1 ionsistenev Scale. 266. 268. 418. 475-477
Sell-Directed Learning Readiness Scale. xi. S2
Self-esteem, impact on health piomotion activities
exercise. 325. 336-3.37
in older adults, 317. 3 30
in women. >16. 329-330'
Sell-Perception rrotiie for Children. 104
Setnamii Differential Scale, 144
SEMT; see Side effect management techniques
Sense of Coherence Scale. 13 3
Sensitivity, .311
Serenity
in Parse's Theory of Human Becoming. 171. 1 7o
in Pender's Health Promotion Model. 311
Sexual function, 274. 289
Shivering. I'ostanvsthcric. 199. 2 11
Short Portable Mental Status Questionnaire, i 39
Silk* effect management techniques, 92. 9 3
Similes Preference Inventory. ’41
Sleep patterns
in older adulis, ’. 4 '. I 50
in pediatric intensive care unit. 277, 292
.liter planned versus unplanned hip replacement surgen.
197 212
Slosson hveiligenc-e Test. 24!
Smcll/'.i-ie intersentutn in preterm infant apnea. 27.. _9i
Smoking. 205, 216-217
Social l.icrors. I 11
;si .’.54.
li :i Intel.ii tit •:> ho j:
Siki ti ''•ipp<trt Qu<
;
506
11
iI I
ri
to
to
0
S
INDEX
SOG1E, 252
Sorrow
chronic, 240, 241
in Parse’s Theory of Human Becoming, 169, 170
Spearman-Brown Prophecy formula, 30—31
Speculative knowledge. 10
Spielberger State Anxiety Inventory, 202
Spinal cord injury, 201, 212
Spiritual Care Scale. 194, 195,419
Spiritual Orientation Inventory. 140
Spirituality
in Neuman Systems Model. 190, 222-225
research studies in hospitalized patients, 198, 212
nurse hardiness and well-being and, 210, 219
in nursing care, 583, 385. 593
in polio survivors, 140. 148-149
Split-half reliability, 30
Spontaneous abortion, 386. 391
SPI’C; see Self-Perception Profile for Children
SRI; see Stress Response Index
SRIQ; sec Student Role Involvement Questionnaire
SSAI; see Spielberger Stare Anxiety Inventory
SSQ; see Social Support Questionnaire
Stability, 31
S7AI; see Stare-Trait Anxiety Inventory
State-Trait Anxiety Inventory. 95, 101, 197
Stillbirth. 384, 392
Storytelling, lemmiseent. I 59, 148
Stress Questionnaire. 276
Stress Response Index, 210
Stressor
defined. 490
in Neuman Systems Model. 189, 191. 222
in pediatric imhulatory surgery. 201.21 3
Student Role Involvement Questionnaire. 207
Suffering, 17!-173, 176-178
SUHB; see Rogers Science ot Unitary Human Beings
Support group, breast cancer. 271-272. 288
Support needs ot parents in neonatal intensive care units,
197.215
Surgery
ambulatory
pediatric, stressors in, 201, 215
Peplau’s Theon ol inter; er-.< na! Relations study 559
565
guided imagen tor postoperative depression in older
adult. 196, 199
hip. Neuman System.' M. del studies. 197. 212
nur'C-patient interaction intervention following ’44
248
|H.sroperative coping. Neuman Systems Model studies
202. 211
Ko> Adaptation Mixlel studies. 280-282. 294-295
rherapcutic touch and dialogue studies. 47, I 50-151
3X .irson s Transpersonal Nursing studies 584 385 388
■'91. 597
Svmptom CJheckhst. 9!
Sympf ,m Experience S. .1'. ,
>vncrgi129. I H'
System, defined, 188
System theory, defined, 188
Systems perspective, 187-231
administration implications, 227-228
education implications, 228
models and theories in, 190, 191, 192
nexus, 228
patient population, 221-226
phenomenon of concern, 188, 189, 221, 222-225
philosophical perspectives. 188-190
practice models, 227
process models. 226-227
reason for development. 188
research instruments. 194. 195, 411.416. 419. 457-464
research review. 195-221
in academic settings, 207-208. 217-218
in community settings. 20 5-206, 215-217
inpatient issues. 196 215
workplace studies. 208-210. 21S-220
theory development status. 228
7
INDEX
Theory—conr'd
human becoming, 40
meraphors in, 13
middle-range, 6, 12. 52-53
characteristics of, 13-14
defined. 489
in Neuman Systems Model, 192
in theory-based research, 22
predictive. 25
verification of. 26-30
Theory Linkage Research Inventory, 29
Theory of Goal Attainment. 2.33-257
administration implications. 253-254
education implications. 254
expected outcomes. 251
models and theories. 2 37. 2 58
nexus, 255
nursing practice, 249-254
nursing process. 251 -252
patient |\>piilation, 251
phenomenon of concern. 2 55, 250
philosophical perspectives. 2 55-23?
practice models. 25 3
research instruments. 2 38-240, 419
research review. 240-249
chronic illness. 242-24’. 246
clinical decision making. 243. 247
families. 240. 241.253
goal attainment. 243-245. 247-249
health promoti. >11. 242. 246
ivoiiien's health, 240-246
status of theory development. 254-255
Theory of Human Becoming."l61-l.S6
administration implications. 183-184
education implication^. 184-185
titpdels and theories in, 165-166
nexus, 185
T
Taped messages tor chemotherapy-related anxiety. 196. 202
Taste/smell intervention in preterm infant apnea. 277. 291
TCH; see Tran.s|x.-rsona| Caring-Healing M.xkl
Technological system. 76
Tedium Burnout Scale. 209
Temporal experience. 1 59. 141, 148. 149
Temporal Experience Scales. 130. 154
Tennessee Self-Concept Scale, 91. 102, 144
Terminology, medical. 245. 248
Tertiary prevention
defined. 490
in Neuman Systems Model. 189. 19|
TES; see Temporal Experience Scales
Testicular cancer, 242. 246
Test-retesr reliability. 31
The beyond, term, 39
The Relationship Form. 418. 482
Theoretical perspectiyes
modeling nursing development and. 10-15
nursing practice structuring through. 62
in research method selection. 59-<>0
Theory
chaos, 127
complexity, 127
connection to research, ! 7-34. 4Q5_4|2'
congruence between theory and research. 2(>
knowledge of theory through research. 26- >2
paradigms of discovery. IS-22
research evaluation ,>n instrument.iti.
50- 52
rheory-generating research. 22. 2 >
theory-resting research. 2 3-25
critical. 19. 20
nursing practice srructmed from. 40
defined, 5. 11-12. 490
descriptive. 24
explanaron. 24
grounded. 58
■
I
I
I
I
507
Theory of Human Gtring—coin’d
practice models. 400
process models, 399-400
reason tor theory development, 374
research instruments, 380-381
research review, 381-397
caring needs and populations needing care, 386-387,
393-396
nurses’ caring Khavior, 382-386. 390-393
outcome studies. 388-389. 396-397
Theory of Interpersonal Relations, 545-371
administration implications. 369
education implications. 569
miKlel and theory description. 547-550. 551
nexus. 570
nursing practice. 566-569
patient population, 567
phenomenon ol concern. 546. 566
philosophical pcrsj'ective', 3:46-547. 548, 549
practice models. 369
process models, 567—569
reason for theory development. 546
research instruinents, 551- 554. 418. 482
research review. 3 55-566
ilepression. 360 -56!, >64- 565
medication compliance. >61. 565
nurse-patient relationships, 555- 564
parenting, 362. 365-566
work roles. 361. 565
Theory of nursing system. 75. 76, 491
Theory of self-care. 75. 491
Theory of self-care deficit. 75. 491
3 heory-based nursing practice. 59
rheory-generating research. 22. 23. 491
Theory-practice gap. 62-6 ’
Theory-testing research. 23-25
defined. 491
evaluation of, 26-27
Therapeutic Behavior Scale. 352. 354
Therapeutic sclt-care demano, 108. 49!
Therapeutic touch
Parse's Theory of Human Becoming research studies.
175,179
Science of Unitary Human Beings research studies.
145-147. 150-151
Thriving. jH>sfpanimi. 95. 100
Time Dragging Scale. 1 '0. 1 >4
Time Metaphor Test, i 30
Time Racing Scale. 1 '0. 154
Time studies. 140-141. ] 49
Timclessness Scale. 1 50. I 54
T1PR. see Hicoryot Interpersonal Relations
TLRh see Theory Linkage Research Inventory
Totahtv perspecm e. i‘>2
Touch
during preterm inf.irr resux.il.iti- c.. 7". 1-292
therapeutic
Parse' 1 heory ot t him in Becoming tcseaich -nim,'
175. 179
>« ivnci e I'm: ,-. Iha .•... ,
nursing practice program design in, 180-181
nursing processes in. 181-185
phenomenon of concern. 162-163, 181
phdosophic.il perspectives. 165-165
practice models. 183
reason toi theory devclopnutent. 162
research review, 169-ISO
aging, 173-1 74. i 78-1 79
grieving. ' 70- 1 71. 176
homclessnes'. 178
lov'sorrow. 169, 170
laughter. 1'"‘. | 70
lu.ilii1. •: life,suttering. 171-173. 176-178
screimv. ! 7 i. ! 7<’
workplace. 175. 179-ISO
Theory ot Humai' < aftiig. '75-404
admifistrati.m imphc in.ms
education implications. 401
t'.irurc the<'tv vlix’eliipmenrs. 401-402
'■
/
a
I
508
i
I
1
II
hi
41 i
r9
If
INDEX
INDEX
Unitary perspective, 161 — 186
administration implications, 183-184
education implications. 184-185
models and theories in. 165-166
nexus, 185
nursing practice program design in, 180-181
nursing processes in. 181-185
phenomenon of concern, 162-163, 181
philosophical perspectives. 163-165
practice models, 183
reason for theory development, 162
research review, 169-180
aging. 173-174, 178-179
grieving, 170-171. 176
homelessness, 178
joy/sorrow, 169, 170
laughter, 169, 170
quality of life/suifertng, 171-173, 176-178
serenity. 171. 176
workplace, 175, 179-180
Universal self-care. 97, 104
reviuisites, 108-109
Urban-older adult. 325, 3 34
U-SC-.-sve Universal self-care
Transaction, 237, 491
Transaction systems perspective, 233-257
administration implications, 253-254
education implications, 254
expected outcomes, 251
models and theories, 237, 238
nexus, 255
nursing practice, 249-254
nursing process, 251-252
patient population, 251
phenomenon of concern. 235, 250
philosophical perspectives, 2 35-237
practice models, 253
research instruments, 238-240. 419
research review. 240-249
chronic illness, 242-243. 246
clinical decision making, 243. 247
families. 240. 241. 25 3
goal attainment. 243-245. 247-249
health promotion. 242, 246
women’s health. 240-246
status of theory development, 254-255
Transcendence, 164
defined. 491
in Pender’s Health Promotion Model. 31 1
spiritual, 385, 393
in Watson's Transpersonal Nursing, 378
Transforming. 165. 166.491
Transpersonal t iling. 377. >99.491
Transpersonal (Taring-Healing Model. 3; 3-404
administration implications, 400-401
education implications, 401
future theory developments. 40! -402
model and theory description. >77-380
nexus. 402
nursing practice. 398-402
phenomenon •’con.crii. ; 4-i. >. i'.,’S--399
philosophical perspectives. >75- >77
practice models, 400
process nuxlels, 399 -400
reason tor theory development. >74
research instruments. 580-381
research review. >81 >97
caring needs md populati. ins needing
■. J86-5S7.
395-396
nurses'canng Ivhavi.a. 382->86. 390-39 3
outcome studies. >88 >89. >96 -397
Trauma
head, caregiver needs. 205, 2 i 5
motor vehicle accident. 204
spinal cord injury, chronic pain management. 201. 212
Turning, postoperative .n cor,.n.irv ar:en bypass graft
clients. 196. 198
24-hour food diary. 91
Tympanomerrv. audiometry with, 206. 220
\V
Walking program in breast cancer patients. 2 < 289
Watson's Assessment ol Dream Experience, 133. 137. 41 5.
447
'X arson's Transpersonal Nursing, 573-404
•^ministration implications. 400-401
• !i. art, :i i.npiu..i:i->n>. 401
rinure theory developments. 401 -402
mode! md theory description. 377-380
u
J
iQx_402
S
Wellness model, 190
Wholism, 190.491
Women; see Female population
Work in Pender's Health Promotion Model, 311
Work roles in Peplau’s Theory of Interpersonal Relations,
365
Working phase in Peplau’s Theory of Interpersonal
Relations. 347, 358, 363, 367, 368
Workplace studies
in Neuman Systems Mixlel, 208-210, 218-220
in Parse’s Theory of Human Becoming. 175, 179-180
in Pender's Health Promotion Model. 320-321, 322,
331-332,333
Worldview. 9
in Rogers' Science of Unitary Human Beings, I 26
01263
LIBRARY
V
Validity. 31-32,491
van Kaatn’s phenomenological method. 169, 1,0. 1 74
Variables of concern
development of. 42-4 3
in King’s Conceptual System and Theory of Goal
Attainment. 235, 250
in Neuman Systems Model, 188. 221,222-225
in Orem's Self-Care Beticir Theory. 72-73. 108-112.
115-116
in I'arse's Theorv of Human Becoming. 162-163. 181
in Pender's Health Promotion Model, 308, 3 59
tn Peplau’s Theory of Interpersonal Relations. 346.
366
in Roy Adaptation Model, 260-261, 297-298
tn Science of Unitary Human Beings. 125, 153
in Watson's Transpersonal Nursing and Theory of
Human Caring, 374-375, 398-599
V'arutrn»:s <>] Nursing Elements and Reldtuinship J/S
VAS; see Visual Analog Scale
Venipuncture. 277. 292
Ventilator studies. 192, 200. 212-21 >
Visual Analog Scale. 145
Vitality. 311
t Unitary human bcinj;
kletincJ. i25
Rogers' sciei’AC •. Ih.m,in
Watson’s Transpersonal Nursing—conr'd
phenomenon of concern, 374-375, 398-399
philosophical perspectives, 375-377
practice models. 400
process models, 399-400
reason for theory development, 374
research instruments, 380-381,483-486
research review, 381-397
caring needs and populations needing care, 386-387.
393-396
nurses'canng behavior, 382-386, 390-393
i utcome studies, 388-389, 396-397
Weight gain during pregnancy, 269, 287
Weight in postparruin thriving. 95. 100
Wellbeing. 73
509
Nnrayana Hrudayalaya
Ins •••/■e of Medical Sciences
‘•‘ommasandra Industrial Area
•J Taluk, Bangalore - 99
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