Nursing Theory in Holistic Nursing Practice

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© Olga Lyubkina/Shutterstock Nurse HealerObjectives ■ Clinical ■ ■ ■ ■ ■ ■ Theoretical cal perspective intheclinicalsetting. Apply thenursingtheoriesandatheoreti- and explorationofnewideas. as aconsequence of nursing’sexamination of IntegralAppreciate Nursing the Theory thinking. holisticnursing cansupport gral Theory spectives, Complexity Theory, and Inte- Identify how nonnursing theoretical per- ofComfort. ticularly Kolcaba’s Theory ofholisticnursing practice,par-supportive Identify theuseofmidrangetheoriesas Becoming. ofHuman sciousness; andParse’sTheory of Health as ExpandingTheory Con- HumanBeings;Newman’s ence ofUnitary ofTranspersonalory Caring;Rogers’sSci- Watson’s The- and Role-ModelingTheory; Erickson, Tomlin, andSwain’sModeling Adaptation; ofEnvironmental Theory nursingtheories:Nightingale’s established Familiarize oneself with the following elements. the isoneof and explainwhy theuseoftheory Describe theelementsofholisticnursing inthediscipline. nursing theory Understand thecurrentuseandnonuseof 111 Definitions inHolistic Nursing Theory ■ Grand theory: Framework: Abasicstructure;thecontext in Conceptual model: Concept: Anabstractidea ornotion. ■ ■ Personal Nursing theory: Aframework; aset of inter- Model: A representationof interactions Midrange theory: for nurs- Afocused theory Metatheory: develop- abouttheory Theory Metaparadigm: Concepts thatidentifythe ing care and the evaluation of that care. ing careandtheevaluationofthatcare. nurs- caninfluence Determine how theory their effect onyourtheir effect personalworldview. ortheoriesandevaluateUse thetheory tent withyour own view. vide aframework andphilosophy consis- ortheoriesthatpro- Select anursingtheory among them. among them. concepts described to suggest relationships that permits theory to be understood. tobeunderstood. that permitstheory isdeveloped; thestructurewhich theory related concepts that are testable; awayrelated concepts of that aretestable; between andamongconcepts. outcomes. concerns orthatisorientedtopatient of nurses’ing that deals with a portion abouttheory. theory ment; domain ofadiscipline. area ofthediscipline’sconcerns. oen aa Fic ad aea Potter Pamela and Frisch Cavan Noreen that covers Atheory a broad Nursing Practice A group of interrelated HPE 5 CHAPTER 25/02/15 6:08 pm 112 Chapter 5 Nursing Theory in Holistic Nursing Practice

seeing the factors that contribute to nurs- In the past, four basic ideas (or concepts) were ing practice and nursing thought. common to all nursing theories—the concepts of Worldview: A perspective; a way of view- nursing, person, health, and environment. These ing, perceiving, and interpreting one’s concepts were thought to compose the core con- experience. tent of the discipline—the “metaparadigm” of nursing. As the discipline has matured, authors in the 1990s and 2000s suggested that the four Nursing Theory: Background and concepts were too restrictive for development of nursing knowledge,2 and some recommended Current Challenges additions to the four. Full discussion of this By definition and by history, nursing is a holis- debate is outside the scope of this chapter; how- tic practice. Nursing’s work is concerned with ever, it is important to recognize the belief that the restoration and promotion of health, the other concepts may be equally important to the prevention of disease, and the supports neces- core of nursing.3 For example, concepts such sary to help the client gain a subjective sense as caring, healing, energy fields, development, of peace and harmony. As a profession, nursing adaptation, consciousness, or nurse–client rela- has never focused solely on the physical body or tionships may be as important to describing and the disease entity. Rather, taking into account understanding nursing as the concept of health. the holistic nature of all persons, nursing is concerned with clients’ experiences of their con- ditions. In addition, nurses attend to the envi- Challenges to the Use of Nursing ronmental influences that promote recovery as well as the social and spiritual supports that Theory promote a sense of well-being for clients. Nurses Currently, however, there are three develop- have found that nursing theories help to articu- ments in nursing that consign nursing theories late the nature of nursing practice and guide to a tenuous or vulnerable place. These are (1) nursing interventions to meet client needs. omission or lack of emphasis of nursing theory in many nursing curricula, accompanied by a view from some that theory is obsolete; (2) a Nursing Theory Defined move toward interdisciplinary and interprofes- A nursing theory is a framework from which sional practice; and (3) the attention given to professional nurses can think about their work. quality, safety, and nursing outcomes that has Theory is a means of interpreting one’s obser- focused more on the “doing” of nursing than vations of the world and is an abstraction of the reflection on practice that theory demands. reality. For example, most nurses have studied Each of these will be discussed. developmental theory, which provides a framework for viewing the childhood behaviors expected with various ages and phases of child Omission of Nursing Theory from Curricula growth. Consequently, when nurses observe a In 21st-century practice, the use of nurs- toddler crying when his mother must leave him ing theories has very likely declined. A group alone with nurses in the hospital, nurses inter- of nursing educators has raised concerns that pret the child’s crying as separation anxiety, an nursing theory is no longer taught in many expected and predicted toddler behavior accord- programs and that other content required in ing to developmental theory. The theory pro- curricula (quality, safety, evidence-based prac- vides a means of understanding behavior that tice, research methodologies, and interdisciplin- otherwise might seem random and, therefore, ary collaborations) may be taking precedence is a framework from which to understand the over nursing theory.4 These authors provide a child’s actions. Thus, “a theory suggests a direc- sound rationale for maintaining nursing theory: tion in how to view facts and events.”1, p. 4 that an understanding and ability to reflect on

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the discipline is essential for the development effective. While there is nothing in this move- of nursing scholars, that knowledge of one’s ment that prohibits the use of nursing theory, own disciplinary approach is a prerequisite for use of theory is not the priority of this focus. interdisciplinary practice, and that theory assists It would seem that theory that addressed inter- professionals to learn that there are many ways professional communication (as a contribut- of developing new knowledge for nursing and of ing factor to errors), and theory that addressed understanding evidence. Nonetheless, omission health professional–patient interactions, might or lack of emphasis on nursing theory should gain more purchase than theory perceived to be give pause to holistic nurses everywhere as there one held by nurses only. Nonetheless, the very has not been a full consideration of what might important focus on quality, safety, prevention of be lost in the process. complications, and movement toward care outcomes has trumped any use of theory or reflection, now viewed as of lesser importance. Nursing and Interdisciplinary Practice The move in all health care toward truly inter- professional practice leaves those who ascribe Is There Still a Need for Theory? to nursing theory without a core group of team Nurses committed to holism are kind and com- members who even understand the use and passionate nurses who share a philosophy that meaning of theory-based practice. Nursing has emphasizes a balance between self-care and the been alone in the health professions in regard to ability to care for patients using the intercon- its theory development. Nurses have identified nectedness of body, mind, and spirit. Theory (through the writings of theorists such as Jean suggests—in fact, demands—that nurses reflect Watson) that professional practice is reflective on philosophy and consider how their practice practice. Other health professionals have simply is working (or not working) to achieve holistic not had that perspective and do not have a his- ideals. Reed and Rolfe write that use of theory tory of identifying philosophical underpinnings requires reflection and is a precondition for pro- and theoretical frameworks for their healthcare fessional practice: Theory is understood as “a practice. This development leaves many nurses purposeful form of abstract thinking essential in positions where they could be the lone nurse to a discipline and, by definition, a characteristic member of a healthcare team with the ability to of the professional nurse.”7 p. 120 express theory-to-practice applications. In addi- The description of holistic nursing devel- tion, many nurses may be working in a health oped by the American Holistic Nurses Associa- system where their immediate supervisor is a tion states, “Holistic nursing practice draws on nonnurse health professional, creating predict- knowledge, theories, expertise, intuition, and able communication challenges. creativity.”8 All five elements are necessary for the nurse to function in an ideal way: Nursing knowledge is essential for the understanding Theory in an Era of Safety, Quality, of health and disease states and the various and Evidence regimens required to achieve health. Theories With the publication of the Institute of Med- enable one to reflect on practice and to consider icine’s To Err Is Human5 and Health Professions carefully all alternatives of care. Expertise is nec- Education,6 the entire healthcare system in the essary to perform nursing skills and for the abil- United States and beyond has appropriately ity to make accurate assessments and decisions given priority attention to ensuring safe prac- about care. Intuition is needed to understand tice, providing control over errors, confirming the client and to appreciate the subjective expe- quality assurance (as defined by enacting clini- riences of others. Creativity is helpful in solv- cal practice guidelines based on best evidence ing care problems that seem insurmountable; it and/or professional consensus), and reducing provides the nurse with novel ideas and ways of regional variation on practices known to be being with clients. Each one of these elements

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is as important as the others. Knowledge and meaningful. It is through use of theory that theory are cognitive tools that help the nurse the nurse can accomplish this. Theory provides understand and reflect on practice. Expertise the nurse with a framework from which to is an experiential tool that comes from prac- understand and make meaning out of complex tice and a significant number of encounters in experiences. Theory also provides guidance in nurse–client situations. Intuition and creativity practice—guidance to consider alternate expla- are affective tools that lead the nurse to feel, nations for what is observed and alternate ways experience, and follow inner guidance when of addressing concerns. At a time of emphasis working with clients. on evidence, quality, safety, and outcomes, the- Professional practice requires that nurses ory could not be more important to address the use these five elements to achieve the best pos- parts of practice—comfort, sense of security, cre- sible results. A holistic nurse can move back ation, and maintenance of a supportive external and forth between intuitive knowing and logi- environment for the patient—that most influ- cal reasoning, between a creative approach to ence care outcomes. Further, a nurse who is a care and a standard care protocol, and between a lone member of an interdisciplinary team might hunch of what to do and a considered direction well benefit from communication theories and grounded in the predictions of a theory. All of leadership theories that help in establishing the the elements of practice come only by learning perception that nursing knowledge is a valuable how to use them. Table 5-1 presents a summary contributor to the patient and family experience of the five elements of holistic nursing practice. and care outcome. For the holistic nurse today, Once a nurse adapts a holistic way of think- ignoring theory is as unacceptable as ignoring ing, embraces the complexities of the lived expe- evidence. riences of clients, and accepts ways of knowing that include aesthetics, personal and ethical Theory Development knowledge, and empirical knowledge, that nurse needs a means of assembling the ideas, concepts, Theories develop over time as a theorist defines thoughts, and feelings that originate from prac- concepts, suggests relationships between con- tice in a way that is coherent and personally cepts, tests and evaluates the relationships, and modifies the theory based on research findings. When the theorist provides definitions of the concepts and suggests possible relationships, the work is called a conceptual model. Some writ- ers find the distinction between a theory and a conceptual model irrelevant.7 It is important, TABLE 5-1 Five Elements of Holistic Nursing however, for nurses to understand that theories Practice develop and mature and that they pass through the following stages, each serving increasingly Element Domain Use in Practice complex purposes: Knowledge Cognitive Understanding health 1. Description. The theory provides definitions and disease states; of concepts, suggests a way of looking at interpreting regimens the world, and provides a framework for of care describing the phenomena of nursing. Theory Cognitive Reflection; considered 2. Explanation. The theory suggests relation- judgments ships between and among various concepts and gives the nurse a means of explaining Expertise Experiential Skilled performance observed events. Intuition Affective Subjective knowing 3. Prediction. The theory has research findings Creativity Affective Spontaneity; solving that establish clear relationships between problems or challenges aspects of nursing, and the nurse is able to predict outcomes.

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4. Prescription. The theory is well developed theories are Complex Adaptive Systems Theory and permits a nurse to prescribe nurse (or simply Complexity Science) and Ken Wilber’s or client actions with confidence in the Integral Theory. These theories present impor- outcomes. tant ideas and concepts that are being brought into nursing thought and have already made Most nursing theories are developed to the stage contributions to nursing theory development. of description and explanation, and theorists These theories may provide holistic nurses with and researchers are currently developing nursing a framework to articulate care needs and pro- theories to the stages of prediction and prescrip- cesses to other members of the healthcare team, tion. Concepts and relationships of a theory as these theories may have more acceptance in can be evaluated and tested through research. team interactions than something perceived as For example, if a theory states that a person is “nursing.” In addition, both of these theories a human energy field and suggests that there permit a nurse to enter dialogue and thinking is an exchange of energy between two persons, with other health team members about theory research can be designed to evaluate such an in general and may be an entrée to discussing exchange. For a theory to reach the stages of nursing-specific theoretical perspectives that prediction and prescription, a considerable body affect the care situations at hand. For these rea- of research is needed. sons, each is discussed briefly. Theories are divided into two main catego- Complexity Science is defined as the study ries: grand theories, which are broad in scope of complex adaptive systems.10 This is a sci- and apply to all of nursing, and midrange theo- ence that addresses diverse or multifaceted ele- ries, which apply to specific specialty areas or ments that are able to change, react, and adapt particular aspects of care. Most of the theories and that are interconnected in some way. As that are presented as nursing theories are grand in Systems Theory, the elements studied from theories (Watson’s Theory of Transpersonal this theory adapt independently and affect the Caring, Parse’s Theory of Human Becoming, or whole. However, Complexity Science focuses on Erickson, Tomlin, and Swain’s Modeling and systems that have a “densely connected web of Role-Modeling Theory). Examples of midrange interacting agents, each operating from its own theories include theories of comfort, maternal- schema,”11, p. 255 addressing structures that are role attainment, self-transcendence, and the syn- self-organized, unpredictable, and ever chang- ergy model for critical care. ing. This theory is useful when working within A recent nursing textbook presents 16 theo- a structure that faces challenges of uncertainty, ries for professional nursing practice. Adding the need to act, the lack of a predictable out- some of the midrange theories could easily pro- come, and a level of complexity in which even vide a list of nearly 30 theories. Full descrip- complicated techniques such as model build- tion of these theories is beyond the scope of this ing and forecasting are inadequate to take into chapter; however, Table 5-2 presents a summary account all contingencies. Modern healthcare of the theories used most frequently in holistic organizations are a perfect example of the type nursing practice. of system requiring a new way of thinking. Complexity Science suggests that, when organizations face uncertainty, managers can best Interdisciplinary Theories of operate by distributing (rather than centraliz- ing) control and supporting individual parts (or Interest to Nursing people) of the organization who are trying to Today, there are two wide-reaching interdis- develop solutions. ciplinary theories that have proven useful in Complexity Science postulates that, in an thinking about the changing modern environ- uncertain environment, freedom to innovate, ment where a nurse can feel lost in the middle of coupled with qualities of intelligence and fast-paced action, uninterpretable observations, resourcefulness, will produce best outcomes. and situations of great human need. These two Astin and Forys suggest that following the

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TABLE 5-2 Summary of Selected Nursing Theories Used in Holistic Nursing Practice

Theory Theorist Date of First Major Concepts or Current Uses Publication Ideas Theory of Florence Nightingale 1860 Providing external supports Healthcare facility design. Environmental Louise Selanders 19989 for healing to take place. Nurse’s control of external Adaptation Emphasizing the health environment to support properties of the health and prevent environment (cleanliness, complications. fresh air, light, warmth, and order). Compelling nurses to care for nutritional needs and emotional comfort. Modeling and Helen Erickson 1983 Adaptation (striving for Used in all practice areas Role-Modeling Evelyn Tomlin equilibrium) and assessment and settings. of Adaptive Potential. Mary Ann Swain Particularly useful in Five aims of intervention: environments where the build trust, promote positive expectation is that the client orientation, promote will be in charge of his or perceived control, promote her own health decisions. strengths, and set mutual health-directed goals. Modeling the client’s world (building a model of the world from the client’s perspective). Role-modeling healthy behaviors from within the client’s worldview. Theory of Jean Watson 1979 Caring relationships between Used in all practice settings. Transpersonal nurse and client. Helpful in the evaluation Caring and Multiple truths, physical of caring as a measure of Caring Science and nonphysical realities, professional nursing. relativity of time and space. Caring ethic as foundational to all health care. Postmodern organization of healthcare settings. Science of Martha Rogers 1970 Unitary Human Beings. Used in all practice settings. Unitary Human Human energy field/ Provides a framework and Beings environmental energy field. explanation of energy-based Evolution of people in a modalities. way that is irreversible and unidirectional.

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TABLE 5-2 Summary of Selected Nursing Theories Used in Holistic Nursing Practice (continued )

Theory Theorist Date of First Major Concepts or Current Uses Publication Ideas Theory of Health Margaret Newman 1994 Health is expanding Used in all practice settings. as Expanding consciousness that includes Work within this theory Consciousness an individual’s total pattern. focuses on the meaning and Nursing is caring—a moral purpose of living with illness. imperative. People are open systems. Health–illness as a unitary process. Research is praxis. Theory of Rosemarie Rizzo Parse 1981 A person is a unitary whole. Used in all practice settings. Human Nurses guide clients to make Work within this theory Becoming choices concerning health. focuses on intersubjective Nurses offer authentic dialogue and the client’s presence. lived experiences. Health is a process of Nurse and client co-create becoming, a personal reality. commitment, and a process related to lived experiences. Theory of Katherine Kolcaba 1991 Comfort as a holistic A midrange theory applied Comfort phenomenon. to many practice settings. Comfort reflects holistic Comfort measures are well-being. assessed by the client as Comfort is described as being in a state of comfort feelings of relief, ease, and or having been comforted. transcendence.

principles of Complexity Science permits order situation and the multiple interacting agents and creativity to emerge.12 Complexity Science that come into play simultaneously. Kramer is undoubtedly useful to healthcare leaders and and colleagues illustrated how newly licensed administrators and is perhaps especially helpful registered nurses enter practice thinking that to holistic nurse managers who may already rec- that their actions result in more predictable out- ognize the requirement to give over the control comes than is realistic.14 These authors report of actions and outcomes. Geary and Schum- that expanding nurses’ thinking to encompass acher provide an example of pairing complexity complexity provides room for innovation and theory with transition theory in the practice of creates a more supportive environment in which discharging patients from hospital to home.13 to work. The essence of applying Complexity These authors suggest that complexity the- Science is the ability to trust the process and ory gives nurses new tools to account for the the people to make the right choices and deci- unpredictable nature of the patient discharge sions and to be accountable for their actions.

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James speaks to all holistic nurses when she sug- than attempting to identify a singular cause. gests that nurses can and should lead healthcare Holistic nurses understand the need for mul- systems at the system level and become “heal- tiple modes of inquiry and multiple realities. ers of a very fragmented and siloed health care Wilber’s theory provides a scholarly framework system.”15, p. 137 She goes on to advise that “A from which to embrace new understandings of machine can be fixed with a replacement part, nursing’s work. Clark has used the theory in while an organic system must be cared for as a her teaching and explains that this model has whole.”15, p. 139 Complexity Science draws nurses helped students to care deeply for patients and to a systems level and a leadership role within to experience nursing’s art as transformative.18 the healthcare system. This may well be a first In using the integral model as a framework to step in nurses’ ability to influence the establish- view the complexities of the healthcare system ment of theoretic perspectives focusing on indi- in which we work, one observes that the current vidual patient care as well. system is dominated by thinking in the physical Integral Theory draws on ideas, concepts, and social domains and requires attention in and theories from many traditions to integrate the individual and collective internal domains. views that interpret world and life experiences The integral model calls for a more comprehen- from seemingly irreconcilable differences.16 sive understanding of the health–illness, caring, Essentially, this theory divides “all that is” into healing, mind-emotion-body, and individual– four quadrants—the four corners of the uni- cultural group relationships than are accounted verse—each quadrant representing a domain, a for in daily practices. Because holistic nurses view of reality, or a dimension of “what is.” The are at the forefront of much of the scholarship quadrants are the interior dimensions of indi- related to the internal domains, the integral viduals (feelings, meanings, beliefs), the interior model applied to nursing practice and pub- dimensions of the collective (cultural beliefs, lished in the literature provides a call for trans- shared worldviews), the exteriors of individuals lating nursing knowledge beyond the profession (the body, its organs and tissues, behaviors), and of nursing.19 See Chapter 8 for a description of the exteriors of the collective (social structures). the use of Wilber’s four quadrants as a way to Wilber embraces the notion that the domains understand the enactment of the holistic car- of each quadrant represent four true realities, ing process. Other writings provide examples of each that can be understood through differing application of Integral Theory to an individual methods of study, sources of data, and world- case study of a surgical patient.20 views. Thus, to understand human experience, one must understand all four dimensions. His theory can be easily applied to holistic health Theory of Integral Nursing because it addresses the need for a comprehen- In 2008, Barbara Dossey first presented her sive approach to treating illness and providing work on the development of a grand theory of care to people.16 Integral approaches treat the nursing that would incorporate Wilber’s the- illness, the person, and the healthcare provider— ory, particularly the use of the quadrants in going beyond the mind–body perspective and understanding the dimensions of how we per- taking a panoramic look at all modes of inquiry. ceive the world, coupled with Carper’s theory This theory can be considered a metatheory of how we come to know what we know.21 Dos- (and is so considered by Wilber and his follow- sey’s Theory of Integral Nursing (TIN) is meant ers) because it is so encompassing it can incor- to address very broad areas of the discipline’s porate the perspectives of many of our existing concerns. The TIN has shifted the paradigm in nursing theories and other psychological theo- nursing to expand our notions of whom and ries into a framework of the quadrants, iden- what we are. The reader is referred to the discus- tifying how each contributes to a panoramic sion in this text of integral and holistic nurs- whole.17 ing, from local to global, for a description of the In addition, Integral Theory examines a TIN theory and its application to nursing (see “chain of pathologies” that causes illness rather Chapter 1). Dossey’s work is a creative blending

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of worldviews that include how we define, know, level of abstraction than existent nursing theo- experience, and react to our realities and how ries. These two perspectives are being used in our new understandings of our realities can healthcare practice and not only provide the influence ourselves and our work. She provides holistic nurse with tools for leadership and a framework for application of integral princi- innovation but may well establish enough inter- ples with practice domains of direct care, educa- est in theory in general for nurses to bring other tion, and research. As scholars and practitioners nursing theories into practice as well. take up this theory, there will be more learn- ings as a consequence of Dossey’s expansion of our notions of nursing. Specific concepts within Directions for Future Research our nursing worldviews will be challenged; for example, Wilber’s work includes concepts of 1. Holistic nurses should consider what is human development in stages of growth that and is not known about any theory being have been rejected by unitary nursing scholars applied to practice and evaluate the next who adhere to an evolutionary model of human steps needed to develop the theory in their change. Other issues will undoubtedly arise as own area of practice. nursing scholarship proceeds. The TIN provides 2. Evaluate theories related to the identifica- an exciting opportunity to move nursing’s work tion of specific outcomes of care. and holistic nursing in entirely new directions that we do not yet fully understand. Nurse Healer Reflections After reading this chapter, the holistic nurse Conclusion will be able to answer or to begin a process of A theory provides a means of interpreting and answering the following questions: organizing information. Nursing theories give ■■ Which of the nursing theories can I use in nurses the tools to ensure that nursing assess- my practice? ments are comprehensive and systematic and ■■ How will I determine if the theory I am that care is meaningful. While some nurses do using is acceptable to my clients? not use a theory at all, holistic nurses will use ■■ In what ways am I able and willing to theories to provide a base for that “reflective” become a nursing leader, using my back- and “cognitive” part of practice that is so impor- ground to “heal” the system? tant in holism. Because there are several theo- ■■ What is my personal plan for studying new ries, each nurse must decide which theory to use theories and learning to apply them to my and when to use an alternative perspective. In professional work? selecting a theory, a nurse should ask two questions: What theory is most comfortable for me? What theory is most comfortable for my client? The perspective selected must be comfortable NOTES for both. Many clients, as well as nurses, have 1. J. S. Hickman, “An Introduction to Nursing strong feelings and opinions about what nurs- Theory,” in Nursing Theories: A Base for Professional ing is and the type of care they wish to receive. Practice, 6th ed., ed. J. George (Upper Saddle If the theory’s perspective is not comfortable River, NJ: Prentice Hall, 2011): 1–22. for the client, the nurse is ethically obligated to 2. V. M. Malinski, “Notes on Book Review of change her or his perspective and adopt a frame- Analysis and Evaluation of Nursing Theories: work that is compatible with the client’s needs. Response,” Nursing Science Quarterly 8 (1995): 59. 3. M. E. Parker, Nursing Theories and Nursing Practice, Lastly, holistic nurses ought to give careful 2nd ed. (Philadelphia: F. A. Davis, 2006). consideration to theories of practice, such as 4. P. Donnahue-Porter, M. O. Forbes, and J. Complexity Science and Integral Theory, that H. White, “Nursing Theory in Curricula take our thinking to a systems level or a higher Today: Challenges for Faculty at All Levels of

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Education,” International Journal of Nursing Concepts,” Advances in Nursing Science 35, no. 3 Education Scholarship 8, no. 1 (2011): article 14. (2012): 236–248. doi:10.2202/1548-923X.2225. 14. M. Kramer, B. Brewer, D. Halfer, P. Maguire, 5. Institute of Medicine, To Err Is Human: Building S. Beausoliel, K. Claman, M. Macphee, et al., a Safer Health System (Washington, DC: National “Changing Our Lens: Seeing the Chaos of Pro- Academies Press, 2000). fessional Practice as Complexity,” Journal of Nurs- 6. Institute of Medicine, Health Professions Education: ing Management 21, no. 4 (2013): 690–704. A Bridge to Quality (Washington, DC: National 15. K. M. James, “Incorporating Complexity Science Academies Press, 2003). into Nursing Curricula,” Creative Nursing 16, no. 7. P. G. Reed and G. Rolfe, Nursing Knowledge 3 (2010): 137–142. and Nurses’ Knowledge: A Reply to Mitchell 16. K. Wilber, “Foreword to Integral Medicine: A Noetic and Bournes. Nursing Science Quarterly, 19 (2006): Reader” (2007). http://wilber.shambhala.com 120–123. /html/misc/integral-med-1.cfm. 8. American Holistic Nurses Association and Amer- 17. O. Jarrin, “An Integral Philosophy and Defini- ican Nurses Association, Holistic Nursing Practice: tion of Nursing,” AQAL: Journal of Integral Theory Scope and Standards of Practice (Silver Spring, MD: and Practice 2, no. 4 (2007): 79–101. Nursesbooks.org, 2007). 18. C. S. Clark, “An Integral Nursing Education: 9. J. George, ed., Nursing Theories: The Base for Profes- Exploration of the Wilber Quadrant Model,” sional Practice, 6th ed. (Upper Saddle River, NJ: International Journal for Human Caring 10, no. 3 Prentice Hall, 2011). (2006): 22–29. 10. B. J. Zimmerman, “Complexity Science: A Route 19. K. Fiandt, J. Forman, M. E. Megel, R. A. Paki- Through Hard Times and Uncertainty,” Health eser, and S. Burge, “Integral Nursing: An Emerg- Forum Journal 42, no. 2 (1999): 44–46, 96. ing Framework for Engaging the Evolution of 11. J. W. Begun, B. Zimmerman, and K. J. Dooley, the Profession,” Nursing Outlook 51, no. 3 (2003): “Health Care Organizations as Complex Adap- 130–137. tive Systems,” in Advances in Health Care Organiza- 20. L. Shea and N. C. Frisch, “Application of Integral tion Theory, eds. S. S. Mick and M. E. Wyttenback Theory in Holistic Nursing Practice,” 28, no. 6 (San Francisco: Jossey Bass, 2003): 253–288. (2014): 344–352. 12. J. A. Astin and K. Forys, “Psychosocial Determi- 21. B. M. Dossey, “Theory of Integral Nursing,” nants of Health and Illness: Integrating Mind, Advances in Nursing Science 31, no. 1 (2008): Body, and Spirit,” Advances in Mind-Body Medicine e52–e73. 20, no. 4 (2004): 14–21. 13. C. R. Geary and K. L. Schumacher, “Integrat- ing Transition Theory and Complexity Science

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