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“Cultural Care Diversity and Universality Theory”

(Transcultural Nursing)


 Different cultures perceive, know and practice, care in different ways, however there are
some commonalities about care among other cultures across the world.
 For culturally related care; values, beliefs, and practices are embedded in “the worldview
language, religions (or spiritual), kinships (social), political (or legal), educational, economic,
technological, ethnohistorical, and environmental context of the culture.”
 While human care is universal across cultures, caring may be demonstrated through diverse
expressions, actions, patterns, lifestyles, and meanings.
 Cultural Care is the broadest holistic means to know, explain, interpret, and predict nursing
care phenomena that serves as a guide to nursing care practices.
 There are variations in generic or folk health care practices and professional practices
among cultures and that in any culture, cultural similarities and differences exist between
care-receivers (generic) and the professional care givers.
 Care is defined as dominant, unifying, and central focus of nursing. While curing and healing
cannot occur effectively without care, care may not occur without cure. Care and caring are
essential for the survival of humans.
 Nursing is the transcultural care discipline and profession. Its central purpose is to serve
human beings in all areas of the world. Culturally based nursing care can be beneficial and
healthy if it contributes to the well-being of the client(s) as they function within the context of
their environment.
 Nursing care will be called as culturally congruent only when the client are known by the
nurse and the client’s patterns, expressions, and cultural values are used in appropriate and
meaningful ways by the nurse with the client. And if the nursing does not show
appropriateness to the client, the client may demonstrate signs of stress, noncompliance,
cultural conflict and/or ethical or moral concerns.


 Person is referred to as “human being.”
 Leininger defined person as caring and capable of being concerned against others.
 Environment was not specifically defined by leiniger however it is closely related to the
concept of culture thus it is a central matter to Leiniger’s theory. The concepts of worldview,
social culture and environmental context are discussed.

 Health is viewed as a “state of well-being”. It is culturally defined, valued and practiced. It
reflects the ability of the individual to perform their daily roles.

 Nursing is defined as a learned humanistic art and science that focuses on personalized
behaviors, functions , processes to promote and maintain health or recovery from illness. It
has physical, psycho-social and social significance for those being assisted.

 Ethnonursing
 Defined as the study of nursing belilefs, values, and practices cognitively perceived and
known by a designated culture through their direct experiences, beliefs, and value systems.


1. Transcultural Nursing
 Is defined as a learned subfield or branch of nursing which focuses on the
comparative study and analysis of culture with respect to nursing and health-
illness caring practices, beliefs, and values with the goal to provide
meaningful nursing care services to people according to their cultural values
and health-illness context.

2. Ethnonursing
 This is the study of nursing care beliefs, values, and practices as cognitively
perceived and known by a designated culture through their direct experience,
beliefs and value system (Leininger, 1979).

3. Nursing
 Is defined as a learned humanistic and scientific profession and discipline
which is focused on human care phenomena and activities in order to assist,
support, facilitate or enable individuals or groups to maintain or regain their
well-being or health in culturally meaningful and beneficial ways or to help
people face handicaps or death.

4. Professional Nursing Care (Caring)

 Is defined as formal and cognitively learned professional care knowledge and
practice skills obtained through educational institutions that are used to
provide assistive, supportive, enabling or facilitative acts to or another
individual or group in order to improve human health condition or well-being,
disability, lifeway, or to work with dying clients.

5. Cultural Congruent (Nursing) Care

 Is defines as those cognitively based assistive, supportive, facilitative, or
enabling acts or decisions that tailor-made to fit with individual, group, or
institutional cultural values, beliefs, and lifeways in order to provide or support
meaningful, beneficial, and satisfying health care, or well-being services.
6. Health
 Is a state of well-being that is culturally defines, valued, and practiced and
which reflects the ability of individuals or groups to perform their daily role
activities in culturally expressed, beneficial and patterned lifeways.

7. Human Beings
 Such are believed to be caring and to be capable of being concerned about
the needs, well-being and survival of others. Leininger also indicate that
nursing as a caring science should focused beyond traditional nurse-patient
interactions to include families, groups, communities, total cultures, and

8. Worldview
 Is the way in which people look at the world, or at the universe, and form a
“picture or value stance” about the world and their lives.

9. Cultural and Social Structure Dimensions

 Are defined as involving the dynamic patterns and features of interrelated
structural and organizational factors of a particular culture (subculture or
society) which includes religious, kinship (social), political (and legal),
economic, educational, technological, and cultural values, ethnohistorical
factors, and how these factors may be interrelated and function to influence
human behavior in different environmental contexts.

10. Environmental Context

 Is the totality of an event, situation, or particular experience that gives
meaning to human expressions, interpretations, and social interactions in
particular physical, ecological, sociopolitical, and/or cultural settings.

11. Culture
 Is the learned, shared and transmitted values, beliefs, norms and lifeways of
a particular group that guides their thinking, decisions and actions in
patterned ways.
12. Culture Care
 Is defined as the subjectively and objectively learned and transmitted values,
beliefs, and patterned lifeways that assist, support, facilitate, or enable
another individuals or group to maintain their well-being, health, improve their
human condition and lifeway, or to deal with illness, handicaps or death.

13. Culture Care Diversity

 Indicates the variabilities and/or differences in meanings, patterns, values,
lifeways, or symbols of care within or between collectives that are related to
assistive, supportive, or enabling human care expressions.

14. Culture Care Universality

 Indicates the common, similar, or dominant uniform care meanings, patterbs,
values, lifeways or symbols that are manifest among many cultures and
reflect assistive, supportive, facilitative, or enabling ways to help people.
(Leininger, 1991)


A. Aim of Nursing
 Focuses on comparative human care (caring) differences and similarities of beliefs, values
and practices of individuals or groups of similar or different cultures. Transcultural nursing’s
goal is to provide culture specific and universal nursing care practices for the health and
wellbeing of people or to help them face unfavorable human conditions, illness, or death in
culturally meaningful ways.

B. Client/Patient
 Some people may not seek Western medical treatment procedures because they do not
view the illness or disease as coming from within themselves.
 Other cultures in developing world focus of control for disease causality often is centered
outside the indivudual, while others focus of control tends to be more internally oriented.
 Some people cannot describe his/her symptoms.
 Individuals from other cultures might not follow with health-promoting or treatment
 Many individuals have specific notions about health and disease causality and treatment

C. Role of Nurses
1. The nurse should begin with an assessment by attempting to determine client’s cultural
heritage and language skills.
2. Nurses should evaluate their attitudes toward ethnic nursing care
3. Nurses must be aware of and sensitive to the clients' sociocultural background, assess
and listen carefully to their health nd illness beliefs.
4. The nursing diagnosis for clients should include potential problems in their interaction with
the health care systems and problems involving the effects of culture
5. The planning and implementation of nursing interventions should be adapted as much as
possible to the clients’ cultural background.
6. Evaluation should include the nurse’s self-evaluation of attitudes and emotions toward
providing nursing care to clients from diverse sociocultural backgrounds.

D. Source of Problems
 comes from the diversity of their beliefs their own practices towards a specific thing or
phenomena. Often caused by their own perspective, their own ways of practices like
protective practices, religious practices, traditional remedies, immigration, food choices.

E. Focus of Interventions
1. To heighten awareness of ways in which their own faith system provides resources for
encounters with illness
2. To foster understanding, respect and appreciation for the individuality and diversity of
patients’ beliefs, values, spirituality and culture.
3. To strengthen in their commitment to relationship -centered medicine.
4. To facilitate in recognizing the role of the hospital chaplain and the patient’s clergy as
partners in health care team.
5. To encourage in developing and maintaining a program of physical, emotional, and spiritual

F. Ways of Intervention
1. Cultural preservation or maintenance
2. Cultural care accommodation or negotiation
3. Cultural care repatterning or restructuring.

G. Results
 Through the help of Leininger’s theory, nurses can actually observe on how a patient’s
cultural background is related to his or her health, and use that knowledge to create a
nursing plan that will help the patient get healthy quickly while still being sensitive to his or
her cultural backgr
Summary of the Nursing Model (Humanbecoming Theory) - DR. ROSEMARIE RIZZO PARSE

I. Assumptions

The assumptions underpinning the theory were synthesized from works by European philosophers. The theory is
structured around three abiding themes: meaning, rhythmicity, and transcendence. The model makes assumptions about man and
becoming, as well as the three major assumptions about humanbecoming.

The Humanbecoming Theory makes the following assumptions about man:

 The human is coexistent while co-constituting rhythmical patterns with the universe.
 The human is open, freely choosing meaning in a situation, as well as bearing responsibilities
for decision making.
 The human is unitary, continuously co-constituting patterns of relating.
 The human is transcending multidimensionally with the possible.

The Humanbecoming Theory makes the following aussmptions about becoming.

 Becoming is unitary with human-living-health.

 Becoming is a rhythmically co-constituting the human-universe process.
 Becoming is the human’s pattern of relating value priorities.
 Becoming is an intersubjective process of transcending with the possible
 Becoming is the unitary human’s emerging.

The three major assumptions about human becoming are:

 Structuring Meaning – humanbecoming is freely choosing personal meaning in situations in the

intersubjective process of living value priorities. Man’s reality is given meaning through lived
experiences. In addition, man and environment co-create.

 Rhythmicity – humanbecoming is co-creating rhythmical patterns of relating in mutual process with the
universe. Man and environment co-create in rhythmical patterns.

 Transcendence -humanbecoming is co-transcending multidimensionality with emerging possibilities. It

refers to reaching out and beyond the limits a person sets, and one constantly transforms.

II. Metaparadigm

 Person – open being who is more than and different than the sum of parts
 Health – open process of being and becoming. It involves synthesis of values
 Nursing – a human science and art that uses an abstract body of knowledge to serve
 Environment -- everything in the person and his experience. Inseparable, complimentary to and evolving
III. Conceptual Framework

principles constitute
the humanbecoming
theory flowing from
these themes –
rhythmicity and
Each principle
contains three
concepts that
require thoughtful
exploration to
understand the
depth of the
theory. The principles are as follows:

1. Structuring meaning is the imaging and valuing of languaging.

2. Configuring rhythmical patterns is the revealing-concealing and enabling-limiting of connecting-separating.
3. Cotranscending with possible is the powering and originating of transforming.

Principle I: Structuring Meaning

"Structuring meaning is the imaging and valuing of languaging.” This principle specifies that persons structure, or choose,
the meaning of their realities, and this choosing happens with explicit-tacit knowing. Sometimes, questions are not answerable,
because people may not know why they think or feel one way or another. The first principle posits that people create their reality
illimitably with others, and they show or language their reality in the ways they speak and remain silent and in the ways they move
and stay still.
As people language their realities, they language their value priorities and meanings according to this principle which has
three concepts: (1) imaging, (2) valuing, and (3) languaging.

 Imaging
(Paradoxes: Explicit-Tacit and Reflective-Prereflective)
Imaging is the first concept of the first principle. It is a person’s explicit-tacit knowing of their personal realities. Explicit-tacit
is a paradoxical process in which explicit awareness coexists with the secreted knowing of our realities. For example, the reasons
behind certain feelings or actions may be know, or the reasons may remain a mystery. Sometimes, it is not possible to know “why?”
Imaging is a process of knowing and of coming to know as persons, accept and reject ideas, values, beliefs, and practices
consistent with their worldview. The ways persons change the meaning of their personal realities occur through processes such as
questioning, speaking about what things mean, exploring personal views, picturing cherished possibilities and comparing options and
alternative views.
For Parse, people are inherently curious and seeks answers. The answers to questions emerge as persons explore meaning
in light of reality and their view of things. Nurses cannot completely know another’s imaging, but they explore, respect, and bear
witness as people struggle with shaping, exploring, integrating, rejecting and interpreting.
 Valuing
(Paradoxes: Confirming-Not Confirming)
Valuing is the second concept of the first principle. Valuing is a process of choosing and embracing what is important. This
concept is about how persons confirm or do not confirm beliefs in light of a personal perspective or worldview. Persons are
continuously confirming-not confirming beliefs as they are making choice about how to think, act and feel. These choices may be
consistent with prior choices, or they may be radically different and require a shifting of value priorities. Sometimes people may think
about anticipated choices, and once the choice arrives they change their thinking and direction in life.
For Parse, living one’s value priorities is how an individual expresses humanbecoming. Nurses learn about persons’ values
by asking them what is the most important.

 Languaging
(Paradoxes: Speaking-Being Silent and Moving-Being Still)
Languaging is the third concept of the first principle. Languaging is a concept that is visible and relates to how humans
symbolize and express their imaged realities and their value priorities. When languaging is visible to others, it is express in patterns
that are shared with those who are close. People disclose things about themselves when they language and when they are silent and
remain still.
Nurses witness the languaging that people show, but cannot know the meaning of the languaging. To understand such,
nurses still need to ask people what their words, actions, and gestures mean. It is possible that persons still may not know the meaning
of their languaging, and in that case the nurse respects the process of coming to understand, the meaning of a situation.

Principle II: Configuring Rhythmical Patterns

The second principle of humanbecoming is “Configuring rhythmical patterns is the revealing-concealing and enabling-limiting
of connecting-separating.” This principle means that human beings create patterns in day-to-day life and these patterns tell about
personal meanings and values. In the patterns of relating that people create, many freedoms and restrictions surface with choices;
all patterns involve complex engagements and disengagements with people, ideas, and preferences. The second principle has three
concepts: (1) revealing-concealing, (2) enabling-limiting and (3) connecting-separating.

 Revealing-Concealing
(Paradox: Disclosing-Not Disclosing)
Revealing-concealing is the way persons disclose and keep hidden the persons they are becoming
with the becoming visible-invisible becoming of the emerging now. There is always more to tell and more know about self
as well as others. Human beings reveal and conceal all at once through their choices and words. Patterns of revealing-
concealing are co-created in that they vary in relation to who is present and what is happening.
Parse also links revealing-concealing to the mystery of humans and to the reality that persons are never fully
revealed; there is always more to know about others and more to discover about self.
 Enabling-Limiting
(Paradox: Potentiating-Restricting)
Enabling-limiting is the second concept of the second principle. Enabling-limiting is related to the potentials and
opportunities that surface with the restrictions and obstacles of everyday living. Every choice, even those made
prereflectively, has potentials and restrictions. It is not possible to know all consequences of any given choice; therefore
people make choice amid the reality of ambiguity.
Enabling-limiting is about choosing from the possibilities and living with the consequences of those choices.
Nurses bear witness to others as they contemplate the options and anticipated consequences of difficult choices.
 Connecting-Separating
(Paradox: Attending-Distancing)
Connecting-separating is the third concept of the second principle. This concepts relates to the ways persons
create patterns of connecting and separating with people and projects. Connecting-separating is about communion-
aloneness and the ways people separate from some to join with others. It is also about the paradox attending-distancing
and explains the way two people can be very close and yet separate.
People connect and separate with people, ideas and situations. In this way, they show their unique patterns of
human becoming. Nurses learn about persons’ patterns of connecting-separating by asking about their important
relationships and projects.

Principle III: Cotranscending with possibles

The third principle of humanbecoming is, “Contranscending with possible is the powering and originating of transforming”
(Parse, 2014, p. 36). The meaning of this principle is that persons continuously change and unfold in life as they engage with and
choose from infinite possibilities about how to be, what attitude or approach to have, whom to relate with, and what interests or
concerns to explore. Choices reflect person’s ways of moving and changing with the becoming visible-invisible becoming of the
emerging now. The three concepts of this principle are as follows: (1) powering, (2) originating, & (3) transforming.

 Powering
(Paradoxes: Pushing-Resisting, Affirming-Not Affirming, Being-Nonbeing)
Powering, the first concept of the third principle, It is a concept that conveys meaning about struggle and life and
the will to go on despite hardship and threat. Parse describes powering as pushing-resisting that is always happening and
that affirms being in light of the possibility of nonbeing. People constantly engage being and nonbeing. Nonbeing is about
loss and the risk of death and rejection. Powering is the force exerted, the pushing to act and live with purpose amid
possibilities for affirming and holding what is cherished while simultaneously living with loss and the threat of nonbeing.
There is resistance with the pushing force of powering, because persons live with others who are powering with different
possibilities in the visible-invisible becoming of the emerging now. According to Parse, conflict presents opportunities to
clarify meanings and values, and nurses enhance this process by being present with persons who are exploring issues,
conflicts, and options.

 Originating
(Paradoxes: Certainty-Uncertainty, Conforming-Not Conforming)
Originating, the second concept of the third principle, People strive to be like others, yet they also strive to be
unique. Choices about originating occur with the reality of certainty-uncertainty. It is not possible to know all that may come
from choosing to be different or from choosing to be like others. For some, there is danger in being too much life others;
for others, the danger is in being different. Each person defines and lives originating in light of their worldview and values.
Originating and creating anew is a pattern that coexists with constancy and conformity. Humans craft heir unique patterning
of originating as they engage the possibilities of everyday life. Nurses witness originating with persons choosing how they
are going to be with their changing health patterns.

 Transforming
(Paradox: Familiar-Unfamiliar)
Transforming, the third concept of the third principle, transforming is about the continuously changing and shifting
views that people have about their lives as they live what is becoming of their emerging now. People are always struggling
to integrate the unfamiliar with the familiar in living everydayness. When new discoveries are made, people change their
understanding and life patterns, and worldviews shift with insights that illuminate a familiar situation in a new light.
Transforming is the ongoing change co-created as new information and insights become visible in the emerging now.

The Symbol of Human Becoming

 Black and White – opposite paradox significant to ontology of human
becoming and green is hope.
 Center Joined – co created mutual human universe process at the ontological
level and nurse-person process.
 Green and Black swirls intertwining – universe co creation as an ongoing
process of becoming.

IV. System of Values

Nursing, for Parse, is a science, and the performing art of nursing is practiced in relationships with persons (individuals,
groups, and communities). Parse (1989) set forth the following set of fundamentals for practicing the art of nursing;

 Know and use nursing frameworks and theories.

 Be available to others.
 Value the other as a human presence.
 Respect differences in view.
 Own what you believe and be accountable for your actions.
 Move on to the new and untested.
 Connect with others.
 Take pride in self.
 Like what you do.
 Recognize the moments of joy in the struggles of living.
 Appreciate mystery and be open to new discoveries.
 Be competent in your chosen area.
 Rest and begin anew.

Also, there are values that can be acquired in the Humanbecoming theory:
A. Open-mindedness
As stated in her Metaparadigm, the Person is a open being who is more than and different than the sum
of parts, which means that the Person involved should be more open to possibilities to understand his or
her parts, to understand it as a whole.

B. Respect
Under the three principles that constitutes the humanbecoming theory, Rhythmicity; under rhythmicity has three
sub-principles, the Revealing- Concealing which states that the process human/s use to show and/or hide
personal evolution or becoming; it involves how much we share ourselves with others, which depends on how you
deal with the person wholly, and respect takes part out of it.

C. Positivity
Under the three principles that constitutes the humanbecoming theory, Transcendence; under transcendence has
three sup-principles, Powering which is the pushing-resisting process that propels in life through the difficult

V. Main Units

a. Aim of Nursing
The theory provides a transformative approach to all levels of nursing. It differs from the traditional nursing process,
particularly in that it does not seek to "fix" problems. The model gives nurses the ability to see the patient's perspective. This allows
the nurse to be "with" the patient, and guide him or her toward the health goals. The nurse-patient relationship co-creates changing
health patterns. Nurses live the art of human becoming in presences with the unfolding of meaning, synchronizing rhythms, and
The goal of practice with the human becoming theory is quality of life from the person’s perspective. Quality of life cannot be
determined by those not living the life; thus the person is the only one who can describe his or her quality of life. With the
humanbecoming practice methodology, there is no set of standards a person must meet in order to have a “good” quality of life.
The person constructs his or her own meaning of it. The humanbecoming practice methodology, which focuses on the quality of life
from the person’s perspective, flows from the principles of the theory, bring to life principles of the theory, bringing to life the belief
system through the art of practice.

b. Client/Patient
“Living quality refers to a person’s core whatness, the stuff of a life.
What is the whatness? It is the living community that each individual’s august presence is – the humanuniverse cocreation
with predecessors, contemporaries, and successors.” (Parse, 2013).
There are three core knowings of living quality:

 Persons choose ways of being according to their value priorities (Fortifying Wisdom)
 A Persons choses certain pattern preferences that creates both opportunities and restrictions all-at-once
(Discerning Witness)
 An individual ponders in silence the illimitable opportunities available to him or her for creating anew (Penetrating

Patients have the right to choose. They have the autonomy or the freedom of choice in decision making. This should be kept
in mind that patients are human beings and must be treated with dignity and respect. Their wishes must also be honored.

c. Role of Nurses
Nurses live true presence with others with an awareness of and focus on the dimensions and processes of the Human
Becoming Theory.
These dimensions and processes are as follows:

1. Illuminating meaning is explicating what was, is and will be. Explicating is making clear what is appearing
now through languaging.
2. Synchronizing rhythms is dwelling with the pitch, yaw, and roll of the human-universe process. Dwelling
with is immersing with the flow of connecting-separating.
3. Mobilizing transcendence is moving beyond the meaning moment with what is not-yet. Moving beyond is
propelling with envisioned possible of transforming.
The dimensions and processes occur all at once in the nurse-process. Nurses who utilize the Humanbecoming theory
prepare to be present with others through focused attentiveness on the moment at hand and through immersion.
Nurses have the opportunity to be with others and participate with them during times of change, struggle, upset, uncertainty,
recovery, and hope.

d. Source of Problem
The theory’s source of problem is when the patient doesn’t get the improved quality of life which is the main aim of Parse’s
humanbecoming theory. Nurses should consider patient’s perspectives to accomplish its goal and have better outcomes.
The theory does not utilize the nursing process and negates the idea that each patient engages in a unique lived experience.
It is not accessible to new nurses, and is inapplicable to acute, emergent care.

e. Focus on Intervention
The main focus of all nursing interventions is to improve the quality of life among patients who are suffering from diseases.
Unfortunately, the predominance of the biomedical model has restricted healthcare providers’ approach to a mechanistic model.
Human beings are considered machines and treatments are done to fix the faulty parts (Parse, 1996).
On the other hand, the Human Becoming theory of nursing has a distinctive approach towards patients’ care and improving
quality of life from patients’ perspectives. Parse (2006) considers humans as unitary beings, as co-authors and co-participants in
living their lives. This idea of nursing care has brought nursing practice to more client-centered care (Parse, 2006; Mitchell, 1992).

f. Ways of Intervention
The essence of living human becoming is making a commitment to be truly present with others to bear witness and to
participate with another’s unique process of becoming. Parse compares between the goal of the discipline of nursing and the goal of
the nurse living the humanbecoming theory. She states that the goal of the discipline is quality of life from the person’s perspective,
whereas the goal of the nurse living the humanbecoming theory is to be truly present with others as they experience their quality of
Nursing practice directed by the principles of human becoming, guides nurses to act differently from other nursing staff.
Parse’s nurses provide care to their patients, the way their patients desire. The humanly guided nurses understand that patients are
the masters of their own body (Parse, 2006). These nurses plan interventions based on non judgmental values, listening to clients by
giving them proper respect, and honoring patients’ wishes (Bournes, 2006). An all-at-once approach is used by Parse’s nurses to
understand patients’ priorities because patients are irreducible and changing constantly and unpredictably.
Quality of care can be enhanced in certain ways, such as true presence of the nurse involved in care, understanding the
meaning of the situation in the patients’ perspectives, going with the flow of patients’ and families’ desires, and exploring patients’
hopes, dreams, and possibilities of the future (Pilkington & Jonas-Simpson, 2009). True presence is the key to all nursing
interventions. This can be expressed by silence of the nurse or in a discussion with patients which would then be described as the
synchronizing rhythms. The nurse with true presence honors patients’ wishes to move along the situation and developing new ways
to live with their health. The true presence, practice dimensions, and processes help nurses to explore patients’ needs from their
perspective and plan for them accordingly.

g. Results
Improving the quality of life from patients’ perspectives is the prime objective of all nursing interventions (Parse, 2006).
Nurses should develop a care plan that can improve the quality of life of a patient. The role of authentic presence, using all at once
approach, and accepting perception of the situation are also helpful in dealing with the client’s distress, and meeting the client’s
perception about the quality of life.
All the nursing interventions are developed for the patients’ beneficence and better outcomes. We can expect enhanced
outcomes only if nursing plans are laid down in accordance with the national standards of practice.


Nursing Practice

A community of nurse scholars is advancing humanbecoming in living the art, sciencing, and education. The
theory has a made a difference to nurses and to persons (patient) experiencing humanbecoming professionals living true
presence. This includes nurses who work with older adults and with children. The theory guides living the art of nursing
for nurses who work with families and with persons in hospital settings, clinics, and community settings. A community-
based health action model, for instance, has been developed and has received support from the local community and
other funding agencies.

The theory was used as an overarching theoretical guide to develop a decisioning model for nurse regulators at
a state board of nursing. The theory has generated controversy and scholarly dialogue about nursing as an evolving
discipline and a distinct human science,

Nursing Education

The humanbecoming paradigm and the philosophical assumptions and theoretical beliefs specified by Parse
have fueled many scholarly dialogues about outcomes in living the art of nursing, in sciencing and in education when
different theories guide nursing endeavors. In Nursing Science Quarterly and other journals, nurses have advanced
dialogue and debate about the role of theory in nursing, the limitations of evidence-based nursing, the possibilities and
politics of human science, freedom and choice, the focus of community-based nursing, the nature of truth, leadership
and nursing theory, and the scope of mistakes in nursing.

Parse created a humanbecoming teaching-learning model that has been used in a variety of ways with students
in academic settings and practice settings. Teachers in academic and practice settings have contributed new
understanding and new processes of teaching-learning, and Parse’s theory was used as a model for explicating pros and
cons of teleapprenticeship. The humanbecoming paradigm is included in nursing courses at the undergraduate and
graduate levels in many schools of nursing.
Joyce Fitzpatrick
Life Perspective Rhythm Model

I. Assumptions

 Nursing activity focuses on enhancing the developmental process toward health.

 A central concern of nursing science and the nursing profession is the meaning attributed to life as
the basic understanding of human existence.
 The identification and labeling of concepts allows for recognition and communication with others,
and the rules for combining those concepts permits thoughts to be shared through language.

II. Metaparadigm
It refers to the transitions through basic metaparadigm concepts of person, environment, health and nursing.
a. Individual

 Person includes both self and others.

 Person is seen as an open system, a unified whole characterized by a basic human rhythm.
 The model recognizes individuals as having unique biological, psychological, emotional, social,
cultural, and spiritual attitudes

b. Health

 Health is a dynamic state of being that results from the interaction of person and the
 'a human dimension under continuous development, a heightened awareness of the
meaningfulness of life.
 Optimum health is the actualization of both innate and obtained human potential gathered from
rewarding relationships with others, goal directed behavior, and expert personal care.

c. Environment
( No Specified definition(s) mentioned)

d. Nursing Care

 "A developing discipline whose central concern is the meaning attached to life (health)

 Primary purpose of nursing is the promotion and maintenance of an optimal level of wellness.

III. Conceptual Framework

Person An open system, a unified whole characterized by a human rhythm.

Health Dynamic state of being that results from interaction of person and the
Wellness – Illness Professional nursing is rooted in the promotion of wellness practices.

Metaparadigm It refers to the transitions through basic metaparadigm concepts of person,

environment, health and nursing.

IV. System of Values

The main value of the Model is the assurance that the Client, similar to how in Martha Rogers’ theory,
experiences the environment and exchange energies with each other.

The point of which the nurse intervenes is only when the patient has need of the intervention as the theory is
based on an “as needed” basis. This is also a value in which the nurse makes sure that the recovery is
focused on the environment and the patient mainly.

Another value is the general value of which all nurses strive to achieve, the achievement of Optimal Health
of the Client, which is the end goal of every nurse’s job.

V. Main Units
a. Aim of Nursing
As Nurses, we should look for the wellness and illness of a client and let the person and
environment exchange energies to build up a more positive outcome and achieve health.
b. Client/Patient
Joyce Fitzpatrick defines client/patient as an open system individual as having a unique biological,
psychological, emotional evaluation and growth and development.

The Client/Patient is also an individual affected by the environment and society which develops their
state of wellness and health.
c. Role of Nurses
To properly identify the condition of the patient and be knowledgeable enough to determine the
proper method of handling the patient and their illness.
d. Source of Problems
The source of problems is the patient status and provide the basis for selection of nursing
interventions to achieve desired outcomes.
e. Focus of Interventions
The focus of interventions is to make sure that the patient and the environment would interact to
promote the wellness of the client and to achieve the optimal health condition of the client.

f. Ways of Intervention
Intervention, or adjustments, comes only on an “as needed” basis in order to maintain stability and
structural integrity since the intervention only comes when the client is in a state of illness.

g. Results
The result would be the achievement of optimal health of the client after the nursing process has
been implemented.
VI. Author’s Bibliography

 Born in 1944
 BSN - Georgetown University
 MS in psychiatric-mental health nursing - Ohio State University
 Bolton School’s World Health Organization Collaborating Center for Nursing
 Provided consultation on nursing education and research throughout the world, including universities and health
ministries in Africa, Asia, Australia, Europe, Latin America, and the Middle East.
 PhD in nursing - New York University and an MBA from Case Western Reserve University.
 Fellow in the American Academy of Nursing - 1981
 Presently, Elizabeth Brooks Ford Professor of Nursing, Frances Payne Bolton School of Nursing, Case Western
Reserve University, Cleveland, OH.

I. Assumptions

One: Persons are Caring by Virtue of Their Humanness
Being a person means living caring, through which being and possibilities are known to the fullest. Each
person throughout his or her life grows in the capacity to express caring. From the perspective of Nursing as
Caring, the understanding of person as caring “centers on valuing and celebrating human wholeness, the
human person as living and growing in caring, and active personal engagement with others.”

Two: Persons are Whole and Complete in the Moment

Respect for the person is communicated by the notion of a person as whole or complete in the moment.
From the perspective or Nursing as Caring, to encounter a person as less than whole fails to truly encounter
the person.

Three: Persons Live Caring, Moment to Moment

Caring is a lifetime process that is lived moment to moment, and is constantly unfolding. In the rhythm of
life experiences, we continually develop experiences of ourselves as caring persons. Actualization of the
potential to express caring varies in the moment. As competency is developed through life, we come to
understand what it means to be caring person, to live caring, and to nurture each other as caring.

Four: Personhood Is Living Life Grounded in Caring
Personhood is a process of living caring and growing in caring. It acknowledges the potential for unfolding
caring possibilities moment to moment. From the perspective of Nursing as Caring, personhood is the
universal human call. The fullness of being human is expressed in living caring uniquely day to day and is
enhanced through participation in caring relationships.

Five: Personhood is Enhanced Through Participating in Nurturing Relationships With Caring Others
The nature of relationship is transformed through caring. Caring is living in the context of relational
responsibilities and possibilities, and it acknowledges the importance of knowing the person as a person.

Six: Nursing Is Both a Discipline and a Profession
Nursing is an “exquisitely interwoven” (Boykin & Schoenhofer, 2001a, p.6) unity of aspects of the discipline
and profession of nursing. The discipline of nursing attends to the discovery, creation, development, and
refinement of knowledge needed for the practice of nursing. The profession of nursing attends to the
application of that knowledge in response to human needs.

II. Metaparadigm

a. Individual
Anne Boykin and Savina Schoenhofer’s Theory of Nursing as Caring gives emphasis in the fundamental
idea that all persons are caring; that to be a human means to be caring; and that being a person is living
in caring. Caring is innate to an individual and that a person lives their lives growing the capacity of caring.
b. Health
Boykin and Schoenhofer’s theory did not fully describe health but then it is believed that overall health
is achieved with the application of caring in all matters that deals with the patient. Since this Nursing as
Caring Theory is a grand theory, it can be used in collaboration with other theories that further help a
patient to improve the quality of nursing care given to them so that they can achieve overall health.
c. Environment
The Theory of Nursing as Caring suggest that a person should have an environment that radiates a sense
of nurturing atmosphere which helps an individual to grow in caring while revealing the richness of nursing.
d. Nursing Care
Nursing, based on the Theory of Nursing as Caring, is said to be a discipline and a profession. It focuses
on the idea of nursing as being grounded by caring and that nursing revolves around caring people not
just physically but in all aspects as well. The theory also shows that the essence of caring is most essential
in the process of providing a holistic care needed by the patient.

III. Conceptual Framework

The Theory of Nursing as Caring is a general or grand nursing theory that offers a broad philosophical
framework with practical implications for transforming practice. (Boykin, et al., 2003). From the perspective of
Nursing as Caring, the focus and aim of nursing as a discipline of knowledge and a professional service is
“nurturing persons living caring and growing in caring” (Boykin and Schoenhofer, 2001).
The theory is grounded in fundamental assumptions that (1) to be human is to be caring and (2) the
activities of the discipline and profession of nursing coalesce in coming to know persons as caring and
nurturing them as persons living and growing in caring. These assumptions give rise to the concept of respect
for persons as caring individuals and respect for what matters to them. The notion of respect grounds and
characterizes relationships and is the starting place for all nursing activities.

FIG. 1.1 The Dance of Caring Persons

Dance of Caring Persons

The Dance of Caring Persons is a visual representation of the theoretical assertion that lived
caring between the nurse and the nursed expresses underlying relationships (Fig. 1.1). The egalitarian spirit
of caring respect characterizes each participant in the Dance of Caring Persons, in which the contributions of
each dancer, including the one nursed, are honored. The Dance of Caring Persons is also a model to guide
the whole of an organization in which each person in the health care system lives caring meaningfully and has
a place of value in the system – all are caregivers.
Dancers enter the nursing situation, visualized as a circle of caring that provides organizing purpose and
integrated functioning. Each dancer brings special gifts as the nursing situation evolves. All harmonize in the
unity of the dance and the oneness of the circle. All in the nursing situation, including the nurse and the nursed,
sustain the dance, being energized ad resonating with the music of caring. Although caring is not unique to
nursing, it is uniquely lived in nursing.

Perspective of Persons as Caring

All persons are caring. Caring is lived by the person moment to moment and is an essential characteristic
of being human. Caring a process, and throughout life, each person grows in the capacity to express caring.
Person is recognized as constantly unfolding in caring.

Nursing Situation

The nursing situation is the locus of all that is known and done in nursing and is conceptualized as “the
shared, lived experience in which caring between nurse and the nursed enhances personhood.” The nursing
situation involves an expression of values, intentions and actions of two or more persons choosing to live a nursing


Personhood is the process of living that is grounded in caring. Personhood implies being oneself as
authentic caring person and being open to unfolding possibilities for caring. Respect for self as a person and
respect for other are values that affirm personhood.

Direct Invitation

Direct invitation opens the relationship to true caring between the nurse and the nursed. The direct
invitation of the nurse offers an opportunity to the nursed to share what truly matters in the moment.

Call for Nursing

Call for nursing are calls for nurturance perceived in the mind of the nurse (Boykin and Schoenhofer,
2001a, 2001b). Intentionality (Schoenhofer, 2002a) and authentic presence open the nurse to hearing calls for
nursing. The nurse responds uniquely to the one nursed with a delibrerately developed knowledge of what it means
to be human, acknowledging and affirming the person living in caring in unique ways in the immediate situation
(Boykin and Schoenhofer, 1993). Calls for nursing are uniquely situated personal expressions; they cannot be
predicted, but originate within persons who are living caring in their lives and who hold hopes and aspirations for
growing in caring.

Caring Between

Caring between, within which personhood is nurtured, is a phenomenon that rises when the nurse enters
the world of the other person with the intention of knowing the other as a caring person. Through presence and
intentionality, the nurse comes to know the one nursed, living and growing in caring. Without the caring between
the nurse and the nursed, unidirectional activity or reciprocal exchange can occur, but nursing in its fullest sense
does not occur.

Nursing Response

The nursing response is cocreated in the immediacy of what truly matters and is a specific expression of
caring nurturance to sustain and enhance the other’s living and growing in caring. Such responses are uniquely
created for the moment and cannot be predicted or applied as preplanned protocols.

Story as Method for Knowing Nursing

Story is a method for knowing nursing and a medium for all forms of nursing inquiry. Nursing stories
embody the lived experience of nursing situations involving the nurse and the nursed. As a repository of nursing
knowledge, any single nursing situation has the potential to illuminate the depth and complexity of the experience
as lived, that is, the caring that takes place between the nurse and the one nursed. This method for knowing
nursing is done aesthetically. Story as a method re-creates and represents the essence of the “experience, making
the knowledge of nursing available for further study” (Boykin & Schoenhofer, 2001a).
IV. System of Values
Roach’s “6 Cs” significantly influenced the initial development of the Nursing as Caring Theory. The “6
Cs” include:
1. Commitment - state or quality of being dedicated to a cause, activity, etc.
2. Confidence - a feeling of self-assurance arising from one's appreciation of one's own abilities or
3. Conscience - an inner feeling or voice viewed as acting as a guide to the rightness or wrongness
of one's behavior.
4. Competence - effective performance of the normal function.
5. Compassion - sympathetic pity and concern for the sufferings or misfortunes of others.
6. Comportment - behavior, or the way you act and carry yourself.
Caring in nursing is altruistic, an active expression of love is the intentional and embodied recognition of
value and connectedness.

V. Main Units

a. Aim of Nursing
According to Boykin and Schoenhofer, the focus of nursing is that the discipline of knowledge and
professional practice is nurturing persons living and growing in caring.
The general intention of nursing is to know persons as caring and to support and sustain them as
they live caring (Boykin & Schoenhofer, 2006). Caring is expressed in nursing and is the “intentional and
authentic presence of the nurse with another who is recognized as living in caring and growing in caring”
(Boykin & Schoenhofer, 1993, p. 24)

b. Client/Patient
Anne Boykin and Sarvina Schoenhofer’s Theory of Caring as Nursing gives emphasis in the
fundamental idea that all persons are caring; that to be a human means to be caring; and that being a
person is living in caring. Caring is innate to an individual and that a person lives their lives growing the
capacity of caring. Person is constantly unfolding in caring.

c. Role of Nurses
It is in the nursing situation that the nurse attends to calls for caring, creating caring responses
that nurture personhood. Living of nursing and the commitment nursing calls forth cannot be fully
measured. Each of us is part of the ongoing creation of nursing as we share our experience of nursing.
These attempts to share our nursing are a major part of the development of nursing as a discipline and
professional practice. Our expressions about nursing are continually challenged as part of the creating

d. Source of Problems

According to Boykin, a person is viewed as complete in the moment, which means that there is
no insufficiency, no brokenness and no absence of something. To encounter a person as less than whole
fails to truly encounter the person.

e. Focus of Interventions
The understanding of nursing as a discipline and a profession uniquely focus on caring as its
central value, its primary interest and the direct intention of practice. Nursing as caring sets forth nursing
as a unique way of living caring in the world. This theory provides a view that can be lived in all nursing
situations and can be practiced alone or in combination with other theories. The domain of nursing is
nurturing caring. The integrity, the wholeness, and the connectedness of the person simply and
assuredly is central.
f. Ways of Intervention
Formed intention and authentic presence guide the nurse in selecting and organizing empirically
based knowledge for practical use in each unique and unfolding nursing situations. Because caring is
uniquely created in the moment in response to a uniquely experienced call for nursing caring, there can
be no prescribed, expected outcome of nursing as caring since responses can be highly individualized
and varied. However, the caring that is experienced by the nursed and others in the nursing situation can
be described and valued. Sensitivity and skill in creating unique and effective ways of communicating
caring are developed through the nurse’s intention to care.

g. Results
Outcomes of Nursing Care
Outcomes of nursing care are conceptualized from values experienced in the nursing relationship,
and in the normative documentation, these outcomes are unacknowledged. Boykin and Schoenhofer
(1997) note that it is the responsibility of the courageous advanced practice nurse to “go beyond what is
currently accepted in delimiting and languaging the value expressed by persons who participate in nursing
situations.” (p. 63)


Nursing Practice

The nurse practicing nursing as caring comes to know the other as caring person in the moment. The sharing of
story can give new arise of possibilities for living nursing as caring. Practicing nursing requires acknowledgement that
knowing self as caring matters and is integral to knowing others as one can't know the other without knowing oneself first.
The practice is about knowing the other, to nurture that person in a creative way and to give support.

Nursing Education

Faculty, students and administrators dance together in the study of nursing. The model for organizational design
of nursing education is analogous to the "Dance of Caring" persons. It asserts the focus and domain of nursing as nurturing
persons living caring and growing caring that inspires, appreciates and celebrates both self and other as caring person. It
is the discipline and practices that reflect the values, focus and domain which is caring.
Carmencita M. Abaquin
I. Assumptions:

Prepare Me( Holistic Nursing Interventions) focuses on a Holistic approach in Nursing care that can be applied to all
the multi dimensional problems of cancer patient at any given setting he/she chooses to be confined into. Prepare me
have the following components:

1. Presence
Being with another person during the time in need. This includes therapeutic communication, active listening and

2. Reminisce Therapy
Recall of past experiences, feelings and thoughts to facilitate adaptation to present circumstances.

3. Prayer
A spiritual activity that involves communicating with your heart, spirit and mind in complete harmony to offer your
time to God.

4. Relaxation-Breathing
Techniques to encourage and elicit relaxation for the purpose of decreasing undesirable signs and symptoms
such as pain, muscle tension, and anxiety.

5. Meditation
Encourages an elicit form of relaxation for the purpose of altering patient’s level of awareness by focusing on an
image or thought to facilitate inner sight which helps establish connection and relationship with God. It may be
done through the use of music and other relaxation techniques.

6. Values Clarification
Assisting another individual to clarify his own values about health and illness in order to facilitate effective
decision making skills. Through this, the patient develops an open mind that will facilitate acceptance of disease
state or may help deepen or enhance values. The process of values clarification helps one become internally
consistent by achieving closer between what we do and what we feel.

PREPARE ME theory provides a framework on non-pharmacologic, non-surgical approach of care to advanced

cases of cancer patients. The focus of this is to assist the patient to explore her humanity and internal serenity while
facing the challenge of life and death. Nurses must be seen as peaceful facilitators of peaceful acceptance of
condition not just mere caregivers.
Quality of Life- MULTIFACETED construct encompasses the individual’s capacity and abilities with an aim of
enriching life when it can no longer be prolonged. a lot of aspects that make quality of life a whole ranging from
physical,psychological, social, religious, level of independence, environment and spiritual.

1. Terminally-ill patients require holistic approach of nursing that encompasses the different aspects of man namely
physical, psychological, social, religious, level of independence, environment, and spiritual. in this premise, patients with
incurable illness, specially cancer patients, require a whole faceted care that will improve the quality of their life.
2. PREPARE ME Interventions are said to be effective in improving the quality of life of cancer patients. this can be
further applied not only with terminally-ill patients but also promisingly introduced to those patients with acute and chronic
diseases and those with prolonged hospital stays.
3. The utilization of the intervention as a basic part of care given to cancer patients is recommended, as well as the
incorporation of the intervention in the basic nursing curriculum in the care of these patients. the said components of
PREPARE ME must be introduced and focused during the training of nurses both in the academe and practice to answer
the needs of this special kind of clients.
4. Development of training programs for care providers, as well as health care professionals where intervention is a part
of treatment modalities, is also recommended.
5. For patients, an honest view and feedback regarding their illness and management, and obtaining their perceptions
can lead to improvement of services and communication between patients with advanced progressive cancer, their
families and health team.
6. Supportive environment where patients with advanced progressive cancer and the terminally-ill patients can attain
dignity of dying with peace while their families are given the necessary support they need to cope up with. thus,
healthcare professionals and family members have to provide this kind of venue whether in the home of hospital setting.
This will maintain a holistic support for this special type of clients.

II. Metaparadigm: (derived from her theory)

Her theory is specific to patients in advanced stages of cancer. They are holistic being with physical, psychological,
social, religious, level of independence, and environmental aspects. Patients who are terminally-ill or those with incurable
diseases as with cancer must be approached in multifaceted care to improve their quality of life.

Just like all the other paradigms, environment was not defined accurately. Nevertheless we can assume that
environment is an aspect or dimension integrated to the cancer patient. Her quality of life can also be assessed in this
aspect thus it must be given consideration in the provision of care.

The concept of her theory revolves around illness, particularly cancer and the provision of holistic care to improve quality
of life despite their terminal cases. Quality of life is defined as a multifaceted construct that encompasses the individual’s
capabilities and abilities of enriching life when it can no longer be prolonged. This includes proper care and maintaining
integrity of the body, mind and spirit despite the limitations brought about by the present condition. The quality of life is
seen through the patient's many dimensions.
The goal of nursing care is the improvement of quality of life for advance stage cancer patients despite their current
situation. Her concept of providing holistic nursing care in addressing the multidimensional problems that cancer patients
face is summarized in the acronym PREPARE ME.

III. Conceptual Framework

IV. System of Values
Compassion- The ability of a nurse to feel the pain and the experience of the patient as it was his/her giving her
a bird’s eye view of the problem that the patient is trying to face and conquer.
Commitment- A value that is highly regarded in this theory for the patients are special in a way that they need
Physical, emotional, psychological and spiritual presence of the nurse and the support system of the patient.
Service to others – A necessity of a value in a nurse for they must know how to give service to others
especially those in need of it.

Optimism- This value can help the nurse and the patient in a way spreading good vibes and positivity making
the environment less gloomy improving the Emotional aspect of the patient.

Education- As a nurse it is also their duty to Educate, assist and facilitate the patient and the parents creating
reassurance and clearing misunderstanding of the parents and the nurse.

V. Main Units
a. Aim of Nursing

the goal of nursing is to achieve a holistic, non-pharmacologic and non-surgical nursing care to advanced cases of
cancer patients and terminally ill patients. The focus is not on cure but on assisting the patient to explore her
humanity and internal serenity as one is faced with the challenge of life and death.
b. Client/Patient

PREPARE ME Interventions are said to be effective in improving the quality of life of cancer patients. This can be
further applied not only with terminally-ill patients but also promisingly introduced to those patients with acute and
chronic diseases and those with prolonged hospital stays.

c. Role of Nurses

Focusing on assisting and facilitating the patient not just merely giving care but be with the process as well and try to
help the patient achieve acceptance and explore their humanities.

d. Source of Problems
The source of the problem can be found in different aspects it can physical, psychological, social religious, level of
independence, environment and spiritual aspect.

e. Focus of Interventions
By facilitating and assisting the parents in helping the patient cope up with the situation that he/she is in because
the main key of the theory is the parents and guardians or the support system backing the patient up in order to achieve
a peaceful death and help special client especially terminally ill and cancer patient.

f. Ways of Intervention

Praying- Bring a pastor/priest that patient is affiliated with and do some spiritual healing and promote spiritual acitivities
with the patient.
Relaxing- Facilitating activities that can help relax the patient and distract her from negative feelings that would
worsen the situation he/she is in.

g. Results

A Strong Support system can attain a peaceful death in which the families give the necessary support the patient to
cope up with the dilemma and it will also maintain the holistic support for special clients like terminally ill patient and
cancer patients.

Assumption is a thing that is accepted as true or as certain to happen, without proof.

The assumptions from this theory arise from the practical reasoning. The model is meant to provide nurses and other
health care professionals with a logical method of determining appropriate ethical actions. The following are the major
assumptions of Gladys and James Husted's Symphonological Bioethical Theory:


 " A nurse takes no actions that are not interactions "

 The nurse's ethical responsibility is to encourage and strengthen those qualities in the patient that serve life,
health and well-being through their interaction.
Person/ Patient

 Person has an individual unique character structure possessing the right to pursue vital goal as he chooses

 Survival or happiness is realized as an individual pursue and progress toward the goals of their chosen life

 " Agreement is a shared state of awareness on the basis of which interaction occurs."


Metaparadigm is defined as "the concepts that identify the phenomena of central interest to a discipline; the
propositions that describe those concepts and their relationships to each other".

Over the years, theorists like Gladys Husted and James Husted have developed a theory that provide different explanations
of the nursing discipline. Like all other theories, their Symphonological Bioethical Theory share four central or major
concepts: person, health, environment, and nursing care.

1. Person / Patient
- Defined as someone who has an individually unique character structure possessing the right to pursue vital goals
as he chooses.
- A person takes on the role of patient when he has lost or experienced decrease in agency, resulting in his inability
to take the actions required for survival or happiness.

- This inability may result from the physical or mental problems or from a lack of knowledge or experienced .

2. Health

- As defined by Husted and Husted , health is a concept applicable to every potential of a person's life. It involves
not only thriving of the physical body ,but also happiness

- Health is evident when individuals experience, express and engage in the fundamental bioethical standards.

3. Environment

- According to Gladys and James Husted, the environment established by symphonology is formed by agreement.
- Agreement is a state of awareness on the basis of which interaction occurs.
- This agreement is formed by a meeting of the professional's and the patient's needs.
- Their agreement is one in which the needs and desires of the patient is central.
- Without this, there would be no context for interaction between the two.
4. Nursing

- Nurse or any other health care professional act as the agent of the patient.

- A nurse as agent takes action for a patient, one who cannot act on his own behalf.

- Restoring the patient's capacity is the shared goal of a nurse and a patient.

-Nursing could not occur without both nurse and patient.


Decision -Making Model demonstrates the way the concepts of the theory interact with direct decision making.


Virtually every action that a nurse takes has an ethical component. The system of values of this theory is the practice
of loving-kindness and rights of an individual which forms an ethical interaction between the individual patient and a
nurse. Values include kindness, empathy, concern, and love for self and others. They derive from childhood
experiences and are enhanced by beliefs, cultures and art. They bring meaning to one’s life through one’s belief and
relationships with other people.
The bioethical theory of Symphonology, an ethic of agreement, is a practice-based approach to help guide nurses in
caring for patients and to enhance the practice of nursing for each nurse.

Symphonology holds that all interaction between nurse and patient is ethically held together by an agreement. The
preconditions of this agreement are the bioethical standards of autonomy, freedom, objectivity, self-assertion,
beneficence, and fidelity.


a. Aim of Nursing
Symphonology holds that a nurse or any other health care professional acts as the agent of a patient.
Using the nurse’s education and experience, a nurse does for her patient what he would do for himself if he were
able. Nursing cannot occur without both nurse and patient. The aim of Nursing here is to encourage and strengthen
those qualities in the patient that serve life, health, and well-being through their interaction.

b. Client/Patient

A person takes on the role of patient when he has lost or experienced a decrease in action towards a
chosen goal, resulting in his inability to take the actions required for survival or happiness. The inability to take
action may result from physical/mental problems, or from a lack of knowledge or experience.

c. Role of Nurses

The Role of Nurses is to apply the Aim of Nursing; which is to encourage and strengthen those qualities
in the patient that serve life, health, and well-being through their interaction in order to provide quality healthcare
of the patient.

Common Roles of Nurses in the Nursing Practice:

 The nurse should assess the patient and family’s health status and needs: physical, emotional,
and psychological.
 The nurse develops an individual plan of care for patients to manage pain, improve function,
maximize independence, provide education, strengthen coping strategies, and improve access to
community resources.
 Nurses must identify and assures that treatment goals are being met.
 The nurse must have a healthcare plan which serves as a case manager to coordinate various
aspects of care and maybe involved in program planning.
 The nurse implements, administers, monitors, and educates about medications/therapies. Nurses
should also provide health teaching and health promotion and is an advocate for the patient and
family with the health care facility, the community, and legislative arena.
 And lastly, nurses should evaluate whether or not the patient's condition has improved.
Roles of Nurses in relation to the Symphonological Bioethical Theory:

 Restore the Patient’s Agency.

 Offering culturally sensitive care to patients; this is increasingly important as our health care
systems change in response to a global society.
 Recognizing the bioethical standards of patients; this is intertwined to caring because together
they provide a perfect circle of ethical justification.
 Uses Symphonology Model as a method of ensuring that ethical conclusion and actions are based
on the best interests of the individual.

d. Source of Problems

Religion, culture, beliefs, and ethnic customs can influence how patients understand health concepts, how
they take care of their health, and how they make decisions related to their health. Asking about patients' religions,
cultures, and ethnic customs can help nurses engage with their patients effectively so that, together, they can
devise treatment plans that are consistent with the patients' values.

e. Focus of Interventions

The Husteds examined traditional ideas and concepts used to guide ethical behavior. These ideas include
deontology, utilitarianism, emotivism, and social relativism.

 Deontology - a duty-based ethic in which the consequences of one’s actions are irrelevant. One
acts in accordance with preset standards regardless of the outcome.
 Utilitarian thought - acting to bring about the greatest good for the greatest number of people.
 Emotivism - promotes ethical actions in accordance with the emotions of those involved.
 Social relativism - imposes the beliefs of a society onto the individual.

The authors recognized that the inappropriateness of traditional methods of ethical reasoning brought
about the failure of the healthcare system to successfully address bioethical issues. Because traditional models
proved inadequate to guide ethical behavior, the Husteds began to conceive and develop a method by which
health care professionals might determine appropriate ethical actions. The theory was based on logical thinking,
emphasizing the provision of holistic, individualized care.

These concepts, the uniqueness of the individual and the extension of reason and rationality with insight
and discernment to create true understanding, are the foundations of the symphonological method:

1. Agency - the capacity of an agent to initiate action toward a chosen goal.

2. Context - the interweaving of the relevant facts of a situation.
3. Rights - the product of an implicit agreement among rational beings, by virtue of their rationality,
not to obtain actions or the product of actions from others except through voluntary consent,
objectively gained.
4. Ethical Standards - human qualities or character structures that can and must be recognized
and respected in the individual.
5. Bioethical Standards - autonomy, freedom, objectivity, beneficence, and fidelity are maximally
appropriate to the health care setting.
 Autonomy is the uniqueness of the individual, the singular character structure of
the individual.
 Beneficence is the capability to act to acquire desired benefits and necessary life
 Fidelity is an individual’s faithfulness to his or her own uniqueness.
 Freedom is the capability and right to take action based on the agent’s own
evaluation of the situation.
 Objectivity is the right to achieve and sustain the exercise of objective
f. Way of Intervention

A Way of Intervention is the Decision-Making Model. It demonstrates the way concepts of the theory interact with
direct decision making. It centers on health care professional’s implicit agreement with the patient/client.

The elements of ethical decision making interact in the following way:

 Each person has the right to choose and pursue, without interference, a course of
action in accordance with his needs and desires.
 Agreements between individuals are demonstrated by a shared state of awareness
toward a goal.
 The health care professional-patient agreement in directed toward preserving and
enhancing the life of the patient.
 Context is the basis for determining what actions are ethical within the health care
professional-patient agreement. In this way, there are no universal ethical principles.
 Ethical decisions are the result of reasoning from the context to a decision rather than
applying a decision or principle to a situation without regard for the context.
g. Results

Through the Symphonological Bioethical Theory, health care professionals and patients enter into an agreement
to act to achieve the patients goals.

Preconditional to this agreement are recognition and respect for each person's unique character structure and the
attendant properties of that structure which includes freedom, objectivity, beneficence and fidelity.

Symphonological Theory and the model for practice ensures an ethically justifiable, individualized decision
Dissertation: Retirement and Role Discontinuities/
Graceful Aging Theory
By: Sister Letty G. Kuan

I. Assumptions
 Physiological Age- is the endurance of cells and tissues to withstand the wear-
and-tear phenomenon of the human body. Some individuals are gifted with the
strong genetic affinity to stay young for a long time.
 Role- refers to the shared expectation focused upon a particular position. These
may include beliefs of what goals or values the position incumbent is to pursue
and the norms that will govern his behavior. It is also the set of shared
expectations from the retiree’s socialization and experiences and the values
internalized while preparing for the position as well as the adaptations to the
expectations socially defined for the position itself. For every social role, there is
complementary set of roles in the social structure among which interaction
constantly occur.
 Change of life- is the period between near retirement and post- retirement years.
In medico-physiological terms, this equates with the climacteric period adjustment
and readjustment to another tempo of life.
 Retiree- is an individual who has left the position occupied for the past years of
productive life because he/she has reached the prescribe retirement age or has
completed the required years of service.
 Role Discontinuity- is the interruption in the line of status enjoyed or role
performed. The interruption may be brought about an accident, emergency, and
change of position or retirement.
 Coping Approaches- refers to the interventions or measures applied to solve a
problematic situation or state in order to restore or maintain equilibrium and
normal functioning.

Determinants of positive perceptions in the retirement and positive reaction toward

role discontinuities:
1. Health Status- refer to physiological and mental state of the respondents, classified
as either sickly or healthy.
2. Income- (economic level) refers to the financial affluence of the respondent which
can be classifies as poor, moderate or rich.
3. Work Status (According to Webster’s Dictionary) - status of an individual
according to his/ her work.
4. Family Constellation- means the type of family composition described either close
knit or extended family where three or more generations of family live under one roof;
or distanced family whose members lived in a separate dwelling units; or nuclear
type of family where only husband, wife and children live together.
5. Self- Preparation (According to Webster’s Dictionary)-It is preparing of self to
possible outcomes in life.

II. Metaparadigm
a. Individual

(Elderly) - is a classification of age group to any person reaching the mid 70‟s up to
(Gerone) - given to people who are old but gracefully able to function as useful
citizens at home and in the community and an exemplar in fidelity to prayer life

b. Nursing – is preparing the person to have fulfillment in their retirement years, and
assisting them in their elderly years in leaving a legacy

c. Environment

d. Health - is defined as aging. It is a slow process of growth towards maturity of

mind, body and spirit. Growing old is reaching a “happy plateau” but one must
understand and accept what is aging. It brings a decreasing amount of energy
over long periods of activities; hence slowing down and moderation in our activity
involvement is one reality of aging we all must realize and accept it is a fact to
reckon with that what is desirable is to feel comfortable with one’s age and never
should one aspire to become caricatures of either age or youth . Aging is a reality
and must be accepted as a process towards fulfilment of a total self. Developing
positive attitudes towards aging while still young contributes a great deal to feeling
comfortable while growing old.

Graceful aging leads the person in leaving a legacy. Legacy is influenced by

elements of life early imprints and the factors of the aging process. Surviving the
struggles and crisis in life enables the person to leave a legacy.

e. Nursing Care-is preparing the person to have fulfillment in their retirement years,
and assisting them in their elderly years in leaving a legacy.
Conceptual Framework

Determinants of Fruitful Aging

 Prepared Retirement
 Health Status
 Income
 Family Constellation
 Self-Preparation

Retirement Outcome
Change of Life Fruitful Retirement
Role Discontinuities

(Aging Process) And Aging

III. System of Values




IV. Main Units

a. Aim of Nursing- She would like to see how people cope with the aging
process. It was a long process, that brought her to meet even the ones that at
retirement became lonely, board and sometimes crazy. She wants to find out
how many people who are retired but functioning well, happy and coping well
and on the downside. She wants to know “What makes retirement Sad, Drastic
and painful. When people after retirement goes down, regret it and soon after
b. Client/ Patient- she was always interested with old people.
c. Role of Nurse- who can give good care ,full of confidence ,calm and collected
because she is equipped .A good nurse went through a good training, a real
training in a real clinical field and acquired knowledge and experiences that
can help her in her practice.
d. Source of Problems- While the formulation of this theory gave her merits of
all sorts; it also garnered unpleasant
reactions from people, especially her peers from the academe. She had her
fair share of
discouragements and criticisms. Some would deliberately express their
disinterest by saying
that her theory is old news, that life is already like this and that she can’t
change people
anymore. But her love and devotion to know, her desire of wanting to
contribute to the general
public made all the difference. With perseverance, she had prevailed over
these obstacles
e. Focus of Interventions- Acquisition-: A good Acquisition in childhood like
good education will provide good experiences and a solid formation that will
equip you to withstand the struggles in life. Struggle: is the factor affecting you
in achieving you goals. Legacy: When do you attain Legacy? It is when you
had formed people if you are a teacher., whatever you acquire from childhood
including through formative years you will carry them to Adulthood and in
Adulthood you must have possess the Radiance of Acquisition (it is the
culmination of all experiences and knowledge you had acquired through the
years. )

f. Ways Of intervention- variables that made Retirement HAPPY. It is good

health, income, support /partner, education and resources.

g. Results- With a very happy childhood, a meaningful midlife will successfully

lead you to GRACEFUL AGING.

VI. System of Values


Acquisition Struggles Legacy

Lydia Hall

I. Assumptions
The assumptions of Hall’s Care, Cure, Core Theory are as follows:
(1) The motivation and energy necessary for healing exist within the patient, rather than in the healthcare team.
(2) The three aspects of nursing should not be viewed as functioning independently but as interrelated.
(3) The three aspects interact, and the circles representing them change size, depending on the patient’s total
course of progress.

II. Metaparadigm
a. Individual

The individual human who is 16 years of age or older and past the acute stage of a long-term illness is the
focus of nursing care in Hall’s theory.
 The source of energy and motivation for healing is the individual care recipient, not the health care
 The individual as unique, capable of growth and learning, and requiring a total person approach.

b. Health

A state of self-awareness with conscious selection of behaviors that is optimal for that individual.
 Hall stresses the need to help the person explore the meaning of his or her behavior to identify and
overcome problems through developing self-identity and maturity.
c. Environment
Is dealt with in relation to the individual.
 Hall is credited with developing the concept of Loeb Center because she assumed that the hospital
environment during treatment of acute illness creates a difficult psychological experience for the ill
 Loeb Center focuses on providing an environment that is conducive to self-development. In such a
setting, the focus of the action of the nurses is the individual, so that any actions taken in relation to
society or environment are for the purpose of assisting the individual in attaining a personal goal.
d. Nursing Care
Is identified as consisting of participation in the care, core, and cure aspects of patient care.
 Care is the sole function of nurses, whereas core and cure are shared with other members of the health
care team
 The major purpose of care is to achieve an interpersonal relationship with the individual that will
facilitate the development of core

III. Conceptual Framework




IV. System of Values

 Compassion
 Optimism
 Determination
 Kindness

V. Main Units

a. Aim of Nursing
It aims to give comfort and provides teaching-learning activities. It also aims to provide a "motherly care"
or " mothering".
b. Client/Patient
Hall's primary targets are the adult patients who have passed the acute phase of his or her illness and
have a relatively good chance of rehabilitation.
c. Role of Nurses
Provides bodily care for the patient and helps the patient to complete such basic daily biologic activities
like eating, bathing, elimination and chewing.
d. Source of Problems
The source of the problem can be found in different aspects, but Hall believed that the patients who
suffered illnesses in the past and have not been follow up and to be taught how to maintain healthy state, so that
the patient will not come back in the hospital.
e. Focus of Interventions
Rehabilitative nursing and the role that the professional nurse played in the patient’s recovery and
f. Ways of Intervention
Exert motherly care in order for the patient to recover faster
g. Results
Hasten the caring process of the patient and give them knowledge on preventing diseases to occur
Nola J. Pender
Health Promotional Model


 Assumptions
- The assumptions reflect the behavioral science perspective and emphasize the active role of the patient in
managing health behaviors by modifying the environmental context. Through collaborative interaction with the
patient, the nurse uses the major determinants of health behaviors outlined in the model to asses and guide the
patient to achieve a healthy lifestyle. The following are the seven assumptions in this theory.

o Persons seek to create conditions of living through which they can express their unique human health
o Persons have the capacity for reflective self-awareness, including assessment of their own competencies.
o Persons value growth in directions viewed as positive and attempt to achieve a personally acceptable
balance between change and stability.
o Individuals seek to actively regulate their own behavior
o Individuals in all their biopsychosocial complexity interact with the environment, progressively
transforming the environment and being transformed over time.
o Health professionals constitute a part of the interpersonal environment, which exerts influence on persons
throughout their lifespan.
o Self-initiated reconfiguration of person-environment interactive patterns is essential to behavior change.

 Metaparadigm

o Individual
- is a biophysical organism that is partially shaped by the environment but also seeks to create an
environment in which inherent and acquired human potential can be fully expressed. Thus, the relationship
between person and environment is reciprocal. Individual characteristics as well as life experiences shape
behaviors including health behaviors. The unique individual who is the focus of the model.
o Health
- in reference to the individual is defined as the actualization of inherent and acquired human potential
through goal-directed behavior, competent self-care, and satisfying relationships with others, while
adjustments are made as needed to maintain structural integrity and harmony with relevant environments.
Health is an evolving life experience. There are definitions for family health and community health that
have been proposed by other authors. Health is also defined as a positive high-level state that is personally
o Environment
- is the social, cultural and physical context in which the life course unfolds. The environment can be
manipulated by the individual to create a positive context of cues and facilitator for health-enhancing
o Nursing care
- is collaboration with individuals, families, and communities to create the most favorable conditions for
the expression of optimal health and high-level well-being. Also defined as raising consciousness of
health-promoting behaviors and promoting self-efficacy.
o Illness
- re discrete events throughout the life span of either short (acute) or long (chronic) duration that can
hinder or facilitate one’s continuing quest for health.

 Conceptual Framework

o The Health Promotion Model (old version)

 The Health Promotion Model (revised version)

The health promotion model notes that each person has unique personal characteristics and experiences
that affect subsequent actions. The set of variables for behavioral specific knowledge and affect have
important motivational significance. These variables can be modified through nursing actions. Health
promoting behavior is the desired behavioral outcome and is the end point in the HPM. Health promoting
behaviors should result in improved health, enhanced functional ability and better quality of life at all stages
of development. The final behavioral demand is also influenced by the immediate competing demand and
preferences, which can derail an intended health promoting actions.

 Individual Characteristics and Experiences

o Prior related behavior – frequency of the same or similar health behavior in the past
o Personal factors (biological, psychological, sociocultural) – general characteristics of the
individual that influence health behavior such as age, personality structure, race, ethnicity, and
socioeconomic status.
 Behavior-Specific Cognitions and Affect
o Perceived benefits of action – perceptions of the positive or reinforcing consequences of
undertaking a health behavior
o Perceived barriers to action – perceptions of the blocks, hurdles, and personal costs of
undertaking a health behavior
o Perceived self-efficacy – judgment of personal capability to organize and execute a particular
health behavior; self-confidence in performing the health behavior successfully
o Activity-related affect – subjective feeling states or emotions occurring prior to, during and
following a specific health behavior
o Interpersonal influences (family, peers, providers): norms, social support, role models –
perceptions concerning the behaviors, beliefs, or attitudes of relevant others in regard to engaging
in a specific health behavior
o Situational influences (options, demand characteristics, aesthetics) – perceptions of the
compatibility of life context or the environment with engaging in a specific health behavior
o Commitment to a plan of action -- intention to carry out a particular health behavior including
the identification of specific strategies to do so successfully
o Immediate competing demands and preferences – alternative behaviors that intrude into
consciousness as possible courses of action just prior to the intended occurrence of a planned
health behavior
 Behavioral Outcome- Health Promoting Behavior
o Health promoting behavior – the desired behavioral end point or outcome of health decision-making
and preparation for action

 System of Values

This model has changed the focus of the role of the nurse from simply disease prevention to health promotion.
Pender’s model is useful to the nurse because it helps expands their role to promote good health as opposed to just
decreasing their risk for becoming ill (Peterson and Bredow, 2009). This model emphasizes individual perceptions which
includes the importance of health to a person, perceived control, desire for competence, self-awareness, self-esteem, the
person’s definition of health, perceived health status, and perceived benefits of health-promoting behaviours.
Health Promotion can bring about a sense of wellbeing and harmony to the individual, can increase energy, and
can also decrease social problems including violence and suicide (Peterson and Bredow, 2009). Pender outlines specific
assumptions her model is based on which overall emphasize the fact that the patient has an active role in their health
behavior. It is assumed that a patient can self-reflect, actively seek to regulate behavior, and initiate behaviors that modify
their environment. Health professionals exerts an interpersonal influence on an individual throughout their life (Pender,

HPM Theoretical Propositions

Theoretical statements derived from the model provide a basis for investigative work on health behaviors. The HPM is
based on the following theoretical propositions:
1. Prior behavior and inherited and acquired characteristics influence beliefs, affect, and enactment of health-promoting
2. Persons commit to engaging in behaviors from which they anticipate deriving personally valued benefits.
3. Perceived barriers can constrain commitment to action, a mediator of behavior as well as actual behavior.
4. Perceived competence or self-efficacy to execute a given behavior increases the likelihood of commitment to action and
actual performance of the behavior.
5. Greater perceived self-efficacy results in fewer perceived barriers to a specific health behavior.
6. Positive affect toward a behavior results in greater perceived self-efficacy.
7. When positive emotions or affect are associated with a behavior, the probability of commitment and action is increased.
8. Persons are more likely to commit to and engage in health-promoting behaviors when significant others model the
behavior, expect the behavior to occur, and provide assistance and support to enable the behavior.
9. Families, peers, and health care providers are important sources of interpersonal influence that can increase or
decrease commitment to and engagement in healthpromoting behavior.
10. Situational influences in the external environment can increase or decrease commitment to or participation in health-
promoting behavior.
11. The greater the commitment to a specific plan of action, the more likely healthpromoting behaviors are to be maintained
over time.
12. Commitment to a plan of action is less likely to result in the desired behavior when competing demands over which
persons have little control require immediate attention.
13. Commitment to a plan of action is less likely to result in the desired behavior when other actions are more attractive
and thus preferred over the target behavior.
14. Persons can modify cognitions, affect, interpersonal influences, and situational influences to create incentives for health
promoting behavior.

 Main Units

o Aim of Nursing

Health Promotion Model aims to:

 Explain disease prevention behavior
 Expands to encompass behaviors for enhancing health and applies across the life span.
 Identifies cognitive and perceptual factors as major determinants of health promoting behavior.
 Has a competence- or approach-oriented focus.
 Was formulated with the goal of integrating what is known about health-promoting behavior to
generate questions for further testing.

o Client/Patient
- Pender (1996) outlines specific assumptions her model is based on which overall emphasize the fact
that the patient has an active role in their health behavior. It is assumed that a patient can self-reflect,
actively seek to regulate behavior, and initiate behaviors that modify their environment. Pender also
discusses using contracts with the nurse or “self-contracts” so the patient can be independent in rewarding
themselves when they choose certain actions. In this case the patient “serves as the source of rewards”
instead of the nurse allowing the patient to be self sufficient (Pender, 1996).

o Role of Nurses
- Nurses have a critical and very complex role in working to promote the health of the public. Nurses
must apply skills of actively listening to individuals, getting a sense of their individual needs, constraints,
and desires. Nurses need to embrace s strong health promotion approach that includes being sensitive
to health disparities that reflect some of the inequalities in access to health promotion. Although it is
important to empower others to take responsibility for their own health, we need to simultaneously work
at a societal level to mitigate the health disparities that may influence lack of health promotion. It is clear
that the complex nursing roles involve complex understanding of all that is involved in the promotion of
health to the public. Nursing’s role is unique and invaluable in this arena.
o Source of Problems
- Impact of behaviors and characteristics.
o Focus of Intervention
- Peterson & Bredow (2009) state: “Although the model identifies foci for nursing interventions, it does
not explicitly describe how nurses can effect changes in client perceptions” (p. 296). They are correct in
that the model itself does not do this, but Pender‟s book describes specific interventions to tailor plans
to their patients including, reinforcing and identifying strengths in the individual, reiterating benefits of
change, and identifying and setting specific goals. Pender also discusses using contracts with the nurse
or “self-contracts” so the patient can be independent in rewarding themselves when they choose certain
actions. In this case the patient “serves as the source of rewards” instead of the nurse allowing the
patient to be self sufficient (Pender, 1996).
- Effect of perceived barriers and self-efficacy
o Ways of intervention
- Specific interventions to tailor plans to their patients including, reinforcing and identifying strengths in
the individual, reiterating benefits of change, and identifying and setting specific goals.
- Influence significant others and positive emotions
o Results
- Pender‟s model identifies many relationships between concepts. Health promoting behavior is
identified as the ultimate outcome of the model
- Commitment to change
Margaret A. Newman “Health as Expanding Consciousness”

I. Assumptions
The foundation for Newman’s assumptions (M. Newman, personal communication, 2000) is her definition
of health, which is grounded in Rogers’ 1970 model for nursing, specifically, the focus on wholeness,
pattern, and unidirectionality. From this, Newman developed the following assumptions that continue to
support her theory (Newman, 2008).
1. Health encompasses conditions heretofore described as illness or, in medical terms,
pathology. ( Pathology )
2. These “pathological” conditions can be considered a manifestation of the total pattern of the
( Pathological Patterns )
3. The pattern of the individual that eventually manifests itself as pathology is primary and exists
before structural or functional changes.

4. Removal of the pathology in itself will not change the pattern of the individual.
( Removal of Pathology )
5. If becoming “ill” is the only way an individual’s pattern can manifest itself, then that is health
for that person.
From these assumptions, Newman set forth her thesis: Health is the expansion of
consciousness (M. Newman, personal communication, 2008).
( Ill and Health )

Newman’s implicit assumptions about Human Nature:

1.) Being unitary

2.) Open system
3.) Interconnectedness with the universe
4.) Engaged in evolving pattern of a whole.

Unfolding Consciousness – a process that occurs regardless of what actions nurses perform (Newman,

II. Metaparadigm
 Individual
 The human is unitary, that is cannot be divided into parts, and is inseparable from the larger
unitary field
 Persons as individuals and human beings as a species are identified by their patterns of
 Persons are “centers of consciousness” within an overall pattern of expanding consciousness
 Health
 Health is expanding consciousness: “the evolving pattern of the whole, the explication of the
unfolding implicate order”. Health is a fusion of disease and non-disease. Disease and non-
disease each reflect a larger whole thus resulting to a new concept of health, “pattern of a
whole”. ( Newman, 1986, p.12). Newman (1999) elaborated her view of health further by
stating that “ health is the pattern of the whole, and wholeness is.” (p288) Wholeness cannot
be gained or lost. Within this perspective, being ill does not diminish wholeness, but
wholeness takes on a different form.
 Environment
 Although environment is not explicitly defined, it is described as being the larger whole, which
contains the consciousness of the individual. The pattern of person consciousness interacts
within the pattern of family consciousness and within the pattern of community interactions
(Newman, 1986).

 Nursing
 Nursing is “caring in the human health experience”
 Nursing is seen as a partnership between the nurse and client with both grow in the “sense
of higher level of consciousness”.

III. Conceptual Framework

Parallel between Newman’s theory and Young’s stages

of human evolution

IV. System of Values

I. Nursing practice Praxis-

Mutual process between nurse and client with the intent to help. In Newman's view, the responsibility
of professional nurses is to establish a primary relationship within the client for the purpose of identifying
meaningful patterns and facilitating the client's action potential and decision-making ability (Newman,

II. Nursing Education

Newman (1986) stated that ideally, “Nurses need to be free to relate to patients in an ongoing
partnership that is not limited to a particular place or time.” (Newman 1986). Newman suggested that
nursing education revolve around pattern as a concept, substance, process, and method. Education by
this method enables nurses to be recognized as an important resource for the continued development of
health care. Newman's theory in relation to nursing education reveals that teaching the praxis research
method also teaches students a practice method that is congruent with the theory, and is a means for
students to experience transformation through pattern recognition (Newman, 2008). Newman's theory has
been used in nursing education to provide content into a model called the Healing Web. This model was
designated to integrate nursing education and nursing service with private and public education programs
for baccalaureate and associate nursing degree progrmans in South Dakota (Bunkers et al., 1992).
Sethares and Gramling (2014) demonstrated how using the theory within a clinical curriculum allowed the
students to know their patients from a more holistic perspective. This experience was transformative for
students and their patients. These experiences allow for the “possiblity of bringing this knowledge forward
into the understanding of professional nursing” (Sethares & Gramling, 2014).

III. Nursing Research

From the beginning Newman's theory of health was useful in the practice of nursing because it
contained the concepts of movement and time that are used by the nursing profession ans intrinsic to
nursing interventions such as range of motion and ambulation (Newman, 1987).

Newman and Gaudiano (1984) focused on depression in older adults and decreased subjective time.

Mentzer and Schorr (1986) used Newman's model of duration of time as a consciousness index in a
study of institutionalized older adults. Engle (1986) addressed the relationship between movement, time,
and assessment of health. Schorr and Schroeder (1989) studied differences im consciousness with regard
to time and movement, and in another study examined relationships among type A behavior, temporal
orientation, and death anxiety as manifestations of consciousness with mixed results (Schorr & Schroeder,

During the 1980s, using health as expanding consciousness, Marchione investigated the meaning of
disabling events in families in which an additional person became part of the nuclear family. The addition
was a disruptive event for the family and created disturbances in time, space, movement, and
consciousness, suggesting that Newman's work with patterns could be used to understand family
interactions (Marchione, 1986).

V. Main Units
a. Aim of Nursing

Newman views unfolding consciousness as a process that occurs of what actions nurses perform.
Nurses assist clients who are getting in touch with what is going on and in that way facilitate the process.
Newman designated “caring im the human health experience” (M. Newman, personal communication,
2004; Newman, Sime, & Corcoran-Perry, 199, p. 3) as the focus of nursing and specified this focus as the
metaparadigm of the discipline.

b. Client/Patient

“With the unitary, transformative paradigm the researcher honors and reveals the mutuality of
interaction between nurse and client with intent to help” (Newman, 2008). This process focuses “on
transformation from one point to another and incorporates the uniqueness and wholeness of pattern in
each client situation, and movement of the life process toward higher consciousness” (Newman, 2008).
“The nature of nursing practice is caring, pattern-recognizing relationship between nurse and client—a
relationship that is a transforming presence”.

c. Role of Nurses

Nurses as primary care providers who are focused completely on relationships with the individual(s)
can relate well to her view of the professional nurse role. From the Newman perspective, nursing is the
study of “Caring in the human health experience” (Newman, Lamb, & Michaels, 1991). The role of the
nurse in this experience is to help individuals recognize their patterns, which results in the illumination of
action possibilities that open the way of transformation.
Previously discussed research studies and application in nursing practice in this chapter support the
theory of health as expanding consciousness, illuminating the importance of pattern recognition in the
process of expanding consciousness. The theory has been used extensively to explore and understand
the experience of health within illness, supporting the premise of the theory, that disruptive situations
provide a catalytic effect and facilitate movement to higher levels of consciousness.

d. Source of Problems

Smith's (1995) work focused on the health of rural African American women. Yamashita (1999)
studied Japanese and Canadian family caregivers. Rosa (2006, 2016) worked witb persons living with
chronic skin wounds. Benzein, Olin, and Persson (2014) found Swedish family conversations that reflected
Newman's well-being also managed their health better. Studies have focused on patterns of persons with
rheumatoid arthritis (Brauer, 2001; Neill, 2002; Schmidt, Brauer, & Peden-McAlpine, 2003), patterns of
patients with cancer (Barron, 2005; Endo, 1998; Endo et al., 2000; Karian, Jankowski, & Beal, 1998; Kiser-
Larson, 2002; Moch, 1990; Newman, 1995) Coronary Heart Disease (Newman & Moch, 1991) Chronic
Obstructive Pulmonary Disease (Jonsdottir, 1998) Hepatitis C (Thomas, 2002) HIV and acquired immune
deficiency syndrome (AIDS) (Kamau, Rotaich, & Mwembe, 2015) Hayes (2015) used Newman's theory to
study the patterns of incarcerated women. Litchfield (1999) described the patterning of nurse-client
relationships in families with frequent illness and hospitalization of toddlers and its use in family health.

e. Focus of Interventions

A nursing intervention calls for action that evolves out of pattern recognition. That is, the recognition
of pattern provides personal insight into the meaning of the pattern and reveals the potential for action.
This nursing intervention that is based on Newman's theory was named “caring partnership” in a patient–
nurse relationship.

f. Ways of Interventions

The nurse comes together with clients at critical choice points in their lives and participates with them
in the process of expanding consciousness. The relationship is one of rhythmicity and timing, with the
nurse letting go of the need to direct rhe relationship or fix things. As the nurse relinquishes the need to
manipulate or control, there is greater ability to enter into this flunctuating, rhythmic partnership with the
client (Newman, 1999). Newman has diagrammed this nurse-client interaction of coming together and
moving apart through the processes of recognition, insight, and transformation. Nurses are partners in the
process of expanding consciousness and are also transformed and have their lives enhanced in the
dialogical process (Newman, 2008). As facilitator, the nurse helps an individual, family, or community
focus on patterns of relating (M. Newman, 2004)

g. Results

Previously discussed research studies and application in nursing practice in this chapter support the
theory of health as expanding consciousness, illuminating the importance of pattern recognition in the
process of expanding consciousness. The theory has been used extensively to explore and understand
the experience of health within illness, supporting the premise of the theory, that disruptive situations
provide a catalytic effect and facilitate movement to higher levels of consciousness.


Nursing involves two human beings who are willing to enter into an existential relationship with each other.

Nurses and patients as human beings are unique and total biopyschosocial beings with the potential for becoming
through choice and intersubjectivity.

Every encounter with another human being is an open and profound one, with a great deal of intimacy that deeply
and humanistically influences members in the encounter.

Human beings are free and are expected to be involved in their own care and in decisions involving them.

All nursing acts influence the quality of a person’s living and dying.

Nurses and patients co-exist; they are independent and interdependent.

A nurse has to “Accept and believe in the chaos of existence as lived and experience by man despite the shadows he
casts, interpreted as poise, control, order, and joy”

Human beings have an innate force that moves them to know their angular views and other’s angular views of the



Person is viewed as an “Incarnate being” always becoming in relation with man and things in a world of time and

Human beings are characterized as being capable, open to options, person with values, and unique manifestation of
their past, present and future.


Matter of personal survival.

It is a process of experiencing one’s potential for well-being and more-being, a quality of living and dying.

*Well-Being: steady state (maintenance of quality) or more than absence of disease.

*More Well-being: process of becoming all that is humanly possible. Finding meaning in life.


The objective world, of persons and things. Openness to end acceptance of the other’s inner world is essential for
true interaction between persons.

Community: the phenomenon of society or environment.

Two or more persons struggling together toward a center.

Nursing Care

Nurturing response of one person to another in a time of need that aims toward the development of well-being
and more being. Nursing is concerned with the individual’s unique being and striving towards becoming,
focusing on the whole.



The humanistic nursing theory shows the ability of a nurse to be with and endure with a patient in the process of
living and dying. In the fabric of this theory, the intentional interweaving between patient and nurse is what gives
nursing its structure, form and meaning. This theory is beneficial to supervisors and self-reflective practitioners in all
areas of nursing. Patients call to us both verbally and nonverbally, with all sorts of heath-related needs. It is
important to hear the calls and know the process that let us understand them. In hearing the calls and searching our
own experiences of who we are, our personal angular view, we may progress as humanistic nurses.


a. Aim of Nursing

Humanistic Nursing embraces more than a benevolent technically competent subject-object one-way relationship
guided by a nurse in behalf of another. Rather it dictates that nursing is a responsible searching, transactional
relationship whose meaningfulness demands conceptualization founded on nurses existential awareness of self and
of the other. Uniqueness is a universal capacity of the human species. So, “all-at-once”, while each man is unique;
paradoxically he is also like his fellows. His very uniqueness is a characteristic of his commonality with all other men.
b. Client/Patient

A person, a family, a community, or from humanity who call for help with some health-related issue. (Humanistic
Nursing Theory)

c. Roles of Nursing

Nursing is unique from other shared, authentic exchanges in that the nurse's role is to help another who needs help.

Nursing possesses a humaneness that is inseparable from the nursing role. Nursing is a "human transaction", and
thus involves all of the human limitations, emotions, and potentials of each patient, as an exchange that affects the
nurse, who in turn responds through her/his perspective and authentic being, which in turn affects the patient. Thus,
while each participant might experience a situation uniquely, they will also have experience of the shared interaction,
the "between" and its message and meaning.

For example, the nurse might experience providing care, the patient of being cared for. They will both, however, have
an experience of care-giving and care-receiving through their transaction with the other. As well, everything the
nurse does physically is shaped by her "character of being in the situation"

d. Source of problems

The sources of problems are the misconception of response form the nurse to the patient, also the delivery of call
from a patient to a nurse.

Patients willingness to open their concerns to determine their stability and also their strength and weaknesses.

Patients in terms of determining their status.

e. Focus of Interventions

DIALOGUE-Nursing a livd dialouge. It is a nurse-nursed relating creatively. What Happens during the dialogue. The
AND in the Call and Response. The Between, is Nursing.

Offering-self, active listening, acceptance, encouraging patient and even reflecting and focusing are some techniques
of therapeutic communication to promote the highest quality care.

Trust is the start of good patient-nurse relationship, by this, patient sees the nurse as one person to rely on and
nurses to act as patient advocates. Nurses provide patient the freedom to choose, think and even decide for



Nursing is a lived dialogue. It is a nurse-nursed relating creatively.

• Meeting Presence

• Response Relating

– Meeting – is characterized by the expectation that there will be a nurse and a nursed

– Relating – is a process of nurse-nursed doing with each other » Subject – Subject Relating • "I-Thou" is a coming to
know the other and the self in relation, intuitively. » Subject – Object Relating • "I-It" is an authentic analyzing,
synthesizing, and interpreting of the "I-Thou" relation through reflection.

– Presence – is the quality of being open, receptive, ready, and available to another person

– Call and Response – nurses and clients call and respond to each other both verbally and non-verbal Call and
response relationship is where the client call for assistance and the nurses hear the call and respond with their
knowledge, life experience, and skills to help the caller with the health – related need. What happens during this
dialogue, the “and” in the “call and response,” the “between,” is nursing.


Meaning comes from the realization that it is through each other that we more fully participate in and expand our
lives – Two or more persons struggling together toward a center (Paterson & Zderad, 1976)

• Through openness, sharing, and caring, we each will expand our angular views, each becoming more than before.
Subsequently, we take back into our nursing community these expanded selves, which in turn will touch our patients,
other colleagues, and the world of health care.

• According to Humanistic Nursing Theory, there is an inherent obligation of nurses to one another and to the
community of nurses. That which enhances one of us, enhances all of us.


Methodology for understanding and describing nursing situations

Assumes a perceived health need by the individual who is involved in an interaction with a health care provider

Concerned with the nature of the facts and what they mean to individuals

f. Ways of Interventions

Five phases of the nursing process:

1) Preparation of the Nurse Knower For Coming to Know:

In this stage the nurse acts as investigator who willingly takes risks and has an open-mind. The nurse must be a risk-
taker and be willing to experience anything. "Accepting the decision to approach the unknown openly".

2) Nurse Knowing of the Other Intuitively:

In this stage the nurse tries to understand the other, as in the "I-thou" relationship, where the nurse as the "I" does
not superimpose themselves on the "thou" of the patient.

3) Nurse Knowing the Other Scientifically:

The nurse as the observer must observe and analyze from the outside.

At this stage, the nurse goes from intuition to analysis. Analysis is the sorting, comparing, contrasting, relating,
interpreting and categorizing.

4) Nurse Complementarily Synthesizing Known Others:

The ability of the nurse to develop or see themselves as a source of knowledge, to continually develop the nursing
community through education, and increased understanding of their owned learned experiences.

5) Succession Within the Nurse From the Many to the Paradoxical One:

In this stage the nurse takes the information gleaned and applies it in the practical clinical setting. Here the nurse
takes brings the dilemma towards resolution.

g. Results

Alleviating patient's feelings of emptiness and aloneness

To give time and presence in a patient's space

To be with and endure with a patient in the process of living and dying



I. Assumptions
l.) The patient knows of one's terminal illness and believes that no one knows the prognosis in time,
even in the absolute or mathematical sense;
2.) All individuals are unique and have their own constellation of psychological, sociological and
personality characteristics that produce behaviour;
3.) The nurse is a very significant member of the patient's environment in the hospital, as a chief
source of boosters of energy especially for patients with terminal illness.
II. Metaparadigms
a. Individual - is a multidimensional (bio-psychosocial) human
being capable of developing one's own resources to preserve
one's “wholeness.” However, at some point, one may need “external stimulants” or “boosters”
from without for one to
realize one's self-worth and self-esteem.
b. Health-
c. Environment- hospital; (otherwise not stated)
d. Nursing Care- is the process of assisting the person generates
one's (the patient's) inner resources and strengths for one to
realize self-worth and self-esteem thus enabling one to face
death peacefully.
III. Conceptual Framework


IV. System of Values

 Hope- it is the expected outcome when the person is subjected to the Hope Booster System by
the nurse. It states that one does not only hope for a cure and return to the best person possible
today but also does not let a moment escape without appreciating richness.
 Self- care- is the expected outcome when the person is subjected to the self- care booster
system as encouraged by the nurse. One practices on activities that one initiates personally.
 Personal Control- is the expected outcome when the person is subjected to the power- booster
system by the nurse. One is able to make decisions, monitor own bodily functions and control
the intrusions into one’s environment.
 Boosted self- esteem – a state where a person feels “worthwhile” respected and valued. It is the
manifestation of hope, self-care and personal control

V. Main Units
a. Aim of Nursing
 To help the nurses contribute to the enrichment of the quality of life patients with
terminal illnesses.
 To accompany patients on their journeys on earth so they may face death peacefully
when it comes.
 Goal is not curing but rather caring. Making the patient comfortable and at ease
 To help patient face death peacefully of inner joy, contentment and hope, so one will be
accepted in the next garden.

b. Client/ Patient
 Not all patients like to be told
 Some people resign themselves to fate
 Other people lose hope and isolate themselves from others
 Other individual is hard to control most especially after they will be aware that death is
inevitable for them.

c. Roles of nurses
d. Source of Problems
Problems come from patient distress, worry, and their unacceptable situation of being
terminally ill, and that an inevitable death waits in the future. Patients normally behave in fear
towards death; such as the fear of being forgotten, of cessation, of loneliness, and physical and
emotional pain.

e. Focus of Interventions
The foci of interventions are the helplessness, powerlessness, and hopelessness of the
patient which is an effect of being terminally ill and the lack of self-esteem or the impairment
thereof. The nurse comes in and aids the terminally ill patient to regain her self-esteem.
f. Ways of Interventions
The nurse assists the terminally ill patient in extracting their own inner resources and
strengths, in order for the patient to realize and regain the self-worth and esteem they have lost
in the process to acceptance of facing death peacefully.
The nurse institutes a set of strategies/activities known as the “Hope Booster System”
to help “hopeless” patients or persons draw out the said inner resources and strengths, and
recreate/restore a realistic hope.
The nurse institutes another set of strategies known as the “Self-Care Booster System”
to help the “helpless” person draw on personal resources and strengths to restore self-
care/reliance in him or herself.
The nurse lastly institutes another set of activities known as the “Power Booster
System” which is to help the “powerless” person draw on personal resources and strengths to
restore personal control.
g. Results
After the 3 “Booster Systems” have been applied, there are expected outcomes such as
restored “hope” from the Hope Booster System, personal control from the applied Power
Booster System, and last but not least, self-care from the “Self-Care Booster System”. These
three boosts the total self-esteem of the patient, then leads to a peaceful death. The patient
learns to accept death and face it peacefully; without regrets and worries. Death to the patient
should not be seen as defeat; since cure has not been the goal. The patient learns to regain joy,
contentment, hope, and have victory over death, so that the patient will be accepted happily in
“the next garden”. The patient is not left to die lonely, in pain, and agony.
Dissertation: Advance Nurse Practitioners’ COMPOSURE
Behavior and Patients’ Wellness Outcome
By: Carmelita C. Divinagracia

1. Assumptions
This study mainly attempted to determine the effects of the "COMPOSURE" behavior of the Advance
Nurse Practitioner on the wellness outcome of the selected cardiac patients. The nursing profession can
actively deliver quality care through bio-behavioral caring interventions like the "COMPOSURE BEHAVIOR"
because regardless of creed, social class, gender, age and nationality, each one needs humane, caring,
spirituality-oriented interventions that can facilitate wellness.
2. Metaparadigm
 Individual - All of us is considered as an individual human being. Individual is a person who receives
care from the nurse.
 Environment - It is where the patient can also rely its recovery because the patients situation can
also be assessed in this aspect and must be given consideration in the provision of care to help
lessen its condition of state well being.
 Health- Her theory revolves on the effects of the composure behavior of the adult cardiac patients
and to improve its state of well being despite of its terminal cases.
 D. Nursing- as a healthcare profession nursing can actively deliver quality care that each patients
need and also that can facilitate wellness of the patient.

3. Conceptual Framework

Presence and Prayer
Physiologica Biobehaviora
Understanding lOutcome l Outcome
Respect and Relaxation Physical
Vital Signs Emotional
Empathy Chest Pain Intellectual
Hemoglobin Spiritual
4. System of Values

Advance Nurse Practitioners’ COMPOSURE Behavior and Patients’ wellness outcome

It is the ability of the nurse to do something successfully and
efficiently for the clients.
The state of fact of existing, occurring, or being present in a

Presence and Prayer

place or thing and the religious service, especially a regular one.
The receptiveness to new ideas for the client.
Openmindedness Relates to the way which the nurse approach the views and
knowledge of the client.
The nurses’ encouragement of the client to develop or become
Understanding The nurses’ ability to comprehend the client’s situation.
The state of true nurse in which he/she is free from tension and
Respect and Relaxation anxiety and if he/she knows and values and knows how to honor
his/her client.
The capacity of the nurse to understand what the client is
experiencing from within their frame of reference.
Vital signs The pulse rate, temperature, respiration rate, and blood
pressure that indicate the state of a patient’s essential body
Wellness Outcome

Physiological function.
outcome Chest Pain Appears in many forms ranging from a sharp stap to a dull ache.
hemoglobin Routinely measured as part of a routine blood test termed blood
count (CBC)
physical Relating to the body of a person instead of the mind.
Emotional Relating to emotions.
Intellectual Of or relating to the ability to think in a logical way.
spiritual Relating to a person’s spirit; to a religion or religious beliefs;
having a similar values and ideas: related or joined in spirit.

5. Main Units
1. Aim of Nursing
 According to Dr. Carmilita Divinagracia, the nurse should posses COMPOSURE behavior.
Composure behaviors are set of behavior or nursing measures that the nurse demonstrated
to a specific patient to achieve its wellness status. Wellness status refers to a condition of
being in a state of well being, a coordinated and integrated living pattern that involves the
dimensions of wellness.
2. Client/Patient
 The acronym of COMPOSURE behavior stands for “COM” is for competence; ‘P’ is for
presence & prayer; ‘O’ is for opendmindedness; ‘SURE’ is for Stimulation, understanding,
respect & relaxation, and empathy. This behavior improves the state of the client’s health that
they receive from the nurse. The respondents of Dr. Carmelita Divinagracia’s dissertation
focus only on the selected cardiac patients.
3. Role of Nurses
 Nurse is the one who does the act of caring to the recipient which is the client/patient. The
role of nursing is to provide health care to individual, families, and communities. They provide
services design to promote health, prevent illness, and achieve optimal recovery from or
adaptation to health problems. They are the one who provide the need of care of a client.
They also teach clients to give instructions on how to promote wellness in their lives. They
help the clients to understand/empathize and integrate the meaning of current situation and
guide, encourage them to make changes. Providing care needs follows lot of processes
because nurses should provide different kind of care for the patients’ differences of accepting
the care.
4. Source of Problems
 Health status does not only talks about the body state of a person but also in mind. There
are different factors which affects the health of a person, it could be from environment,
heredity, random events, health care, behaviors & situations, relationships, decisions,
resistance skills, risks & resilient.
5. Focus Of Interventions
 The focus of interventions of Dr. Divinagracia’s nursing theory is to achieve a wellness
outcome of the client by the use COMPOSURE behavior in providing care to clients.
6. Ways of Intervention
 Nurses provide care to clients to get back to their original state of being. These care being
given to the client are not just a normal care that you give to a child or any individual, as
what Dr. Divinagracia stated, non-verbatim, nurses should provide care with composure
7. Results
 As an output of the care given to the specified clients, they will achieve a healthy
physiological and biobehavioral outcome.
The CASAGRA Transformative Leadership Model: Servant- Leader Formula & the Nursing Faculty’s
Transformative Leadership Behavior


 CASAGRA Transformative Leadership is a psycho-spiritual model.

 It is an effective means for faculty to become better teachers and servant-leaders.
 Care complex is a structure in the personality of the caregiver that is significantly related to the leadership
 The CASAGRA servant-leadership formula is an effective modality in enhancing the nursing faculty’s servant-
leadership behavior.
 Vitality of Care Complex of the nursing faculty is directly related to leadership behavior.

a. Individual
 A person with dynamic care complex is the cornerstone of nursing.
b. Health

c. Environment

d. Nursing Care
 Is a care complex related to the leadership behavior.



Three-Fold Transformative Leader Concept
1. Sevant-Leadership Spirituality
 Consist of a spiritual exercise, the determination of the vitality of the care complex in the personality of an
individual, and finally, a seminar workshop on transformative teaching.
2. Self-Mastery
 Consist of vibrant care complex possessed to a certain degree by all who have been through formal studies in a
care giving profession such as nursing.
3. Special- Expertise
 Is shown in a creative, caring, critical, contemplative and collegial teaching of the nurse faculty who is directly
involved with the formation of the nursing.


A. Aim of nursing
 The CASAGRA Transformative Leadership Model was designed to lead a radical change form apathy or
indifference to a spiritual person. It also aims to produce new leaders who will venture new traits and who have
gone through new information to serve the society as professional nurse.
B. Client/ Patient
This develops the relationship of the Client and the patient as for this, the nurse serves as a leader at the same time
a servant of the client but in a professional way.

C. Role of nurses
 One of the common roles taken by nurses' practitioner is leadership role. The charge nurse serves leadership
functions, and at times, serves as educators to young nurses.

D. Source of Problems
 Globalization of nursing services for the international market and urgent need of new nursing leaders to serve
society as a professional nurse.

E. Focus of interventions
The main focus of intervention of this theory is to develop nurse’s leadership behavior. By this, a developed trait of a
nurse can be applied to his community service where one becomes a servant-leader where a nurse’s knowledge can
also be acquired from his experiences through Nursing”

F. Ways of intervention
Servant-leader formula is the enrichment package prepared as interventionfor the study which has three parts that
parallel the three concepts of theCASAGRA transformative leadership model, namely: the care complexprimer, a retreat-
workshop on Servant-leadership, and a seminar-workshopon Transformative Teaching for nursing faculty

G. Results
 The theory CASAGRA transformative leadership model could be the answer in the modern world challenges in
nursing education that is centered on the teaching of Jesus, a paradigm of peace