CHAPTER 5 Nursing Theory in Holistic Nursing Practice Noreen Cavan Frisch and Pamela Potter © Olga Lyubkina/Shutterstock ■ Determine how theory can influence nurs- Nurse Healer Objectives ing care and the evaluation of that care. Theoretical Personal ■ Understand the current use and nonuse of ■ Select a nursing theory or theories that pro- nursing theory in the discipline. vide a framework and philosophy consis- ■ Describe the elements of holistic nursing tent with your own view. and explain why the use of theory is one of ■ Use the theory or theories and evaluate the elements. their effect on your personal worldview. ■ Familiarize oneself with the following established nursing theories: Nightingale’s Theory of Environmental Adaptation; Definitions Erickson, Tomlin, and Swain’s Modeling and Role-Modeling Theory; Watson’s The- Concept: An abstract idea or notion. ory of Transpersonal Caring; Rogers’s Sci- Conceptual model: A group of interrelated ence of Unitary Human Beings; Newman’s concepts described to suggest relationships Theory of Health as Expanding Con- among them. sciousness; and Parse’s Theory of Human Framework: A basic structure; the context in Becoming. which theory is developed; the structure ■ Identify the use of midrange theories as that permits theory to be understood. supportive of holistic nursing practice, par- Grand theory: A theory that covers a broad ticularly Kolcaba’s Theory of Comfort. area of the discipline’s concerns. ■ Identify how nonnursing theoretical per- Metaparadigm: Concepts that identify the spectives, Complexity Theory, and Inte- domain of a discipline. gral Theory can support holistic nursing Metatheory: Theory about theory develop- thinking. ment; theory about theory. ■ Appreciate the Theory of Integral Nursing Midrange theory: A focused theory for nurs- as a consequence of nursing’s examination ing that deals with a portion of nurses’ and exploration of new ideas. concerns or that is oriented to patient outcomes. Model: A representation of interactions Clinical between and among concepts. ■ Apply the nursing theories and a theoreti- Nursing theory: A framework; a set of inter- cal perspective in the clinical setting. related concepts that are testable; a way of 111 9781284082463_CH05_PASS02.indd 111 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 frame- work 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 9781284082463_CH05_PASS02.indd 112 25/02/15 6:08 pm Challenges to the Use of Nursing Theory 113 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 out- comes has trumped any use of theory or reflec- tion, 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.