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Advances in Nursing Science

Vol. 31, No. 1, pp. E16–E27


Copyright  c 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Focus of the Discipline


Revisited
Margaret A. Newman, PhD, RN, FAAN;
Marlaine C. Smith, PhD, RN, AHN-BC, FAAN;
Margaret Dexheimer Pharris, PhD, RN, MPH, FAAN;
Dorothy Jones, EdD, RNC, FAAN

W E have come a long way in explicat-


ing the discipline of nursing. We have
moved from an implicit acknowledgment of
a patient∗ from the UT perspective sees the
whole while attending to the part. As a mat-
ter of fact, the nurse enters into the whole
the relationship that constitutes nursing to through the part. The caring, knowing pres-
an explicit designation of the process as car- ence of a nurse taps into what is meaning-
ing in the human health experience.1 We ful for the patient and opens the way for
recognize that differences in the research as- relevant action. This article aims to summa-
cribed to nursing stem from the philosophi- rize the progress nursing has made in defining
cal assumptions underlying the methods and the discipline and to exhort members of our
practice. When first set forth, the paradigms profession to come together in a shared mean-
(labeled particulate-deterministic, interactive- ing that brings coherence to our practice.
integrative, and unitary-transformative [UT])
were considered separate categories, but as
the practice emanating from these points of THE PROCESS OF KNOWLEDGE
view was examined more closely, it became DEVELOPMENT
apparent that practice is a unified whole that
transcends the limitations of each paradigm. The worldviews that have guided our ex-
The UT paradigm can be looked upon as a ploration of knowledge include a traditional
meeting place for holistic thinking and prob- scientific approach, a multidimensional eval-
lem solving and may include deterministic uation of the interactive milieu, and, more re-
and integrative thinking. A nurse approaching cently, a unitary perspective. The unitary per-
spective represents a shift from looking at the
whole as the sum of the parts to looking at
the whole as primary, from seeking to solve
a problem to seeking to know the pattern,
Author Affiliations: University of Minnesota, and from embracing an action-reaction causal
Minneapolis, and University of Tennessee, Memphis approach to realizing the mutuality of the
(Dr Newman); Christine E Lynn College of Nursing,
Florida Atlantic University, Boca Raton (Dr Smith); unfolding, rhythmic process through which
College of St Catherine, St Paul, Minnesota (Dr insight into action arises. Nursing scholars
Pharris); and William F Connell School of Nursing,
Boston College, and Massachusetts General Hospital,
Boston, Massachusetts (Dr Jones).
Corresponding Author: Marlaine C. Smith, PhD, RN,
∗ The use of the term patient is for the sake of simplic-
AHN-BC, FAAN, Christine E. Lynn College of Nursing,
Florida Atlantic University, 777 Glades Rd, Boca Raton, ity of language and refers to the individual person and a
FL 33431 (Marlaine.Smith@fau.edu). plurality of persons, such as family or community.

E16
The Focus of the Discipline Revisited E17

have contributed meaningfully to this knowl- zer Institute and the Pew Health Professionals
edge base. The history of nursing epistemol- Commission, called for a “. . .culture of caring-
ogy reflects a receptive phase, where nurs- of respect for relationship, and optimism for
ing knowledge was derived mainly from other a more balanced and meaningful life” and for
disciplines, a self-generative phase, in which “. . .creating a revolution of the heart by nur-
knowledge is concentrated on the nursing dis- turing wholeness-honoring the fundamental
cipline, and a transformative phase, in which role of relationship and connection.”18(pp37–38)
nursing knowledge significantly influences It is the nature of the nurse-patient rela-
other disciplines as well as nursing practice.2 tionship that unites the practice of nursing
Following the prevailing scientific traditions, as it occurs in myriad settings throughout the
the early nurse theorists strove to isolate, con- world at every moment of every day. Whether
trol, and test relevant variables as a basis for it be a neonatal nurse applying knowledge of
nursing intervention; their work raised ques- highly technical treatments aimed at preserv-
tions about interventions of central concern ing the life of the baby of the parents before
to nursing. Broadening the context, but still her, a nurse sitting on the cot of a person dy-
emphasizing control and predictability, the ing of a chronic illness in a remote village, or
next generation of nursing theorists empha- a nurse working with community members
sized interactions of multiple factors influenc- faced with an epidemic, nursing actions oc-
ing health; this research inspired nurses to cur within the context of a unified commit-
consider the interpersonal approaches that ment. That commitment is to a caring relation-
define the nature of the nursing relationship ship focused on understanding the meaning
in facilitating health. In 1970, Rogers’ revo- of the current situation for the people in-
lutionary insight shifted the view to an undi- volved, and appreciating the pattern of evolv-
vided whole of a mutually unfolding person- ing forces shaping health, so that appropriate
environmental field.3 The theories of health actions can be realized.
as expanding consciousness and human be- The development of nursing knowledge
coming emanated from this perspective.4–8 unfolds within a participatory process. Each
Theories that originated in the interactive– nurse–patient relationship is unique, formed
integrative paradigm on caring and adap- by the informational patterns of the nurse
tation have continued to evolve in ways and the patient. Nurses bring to the situa-
consistent with the UT perspective.9–17 The tion their personal knowledge and experi-
collective emphasis of the discipline is on a ence as well as the background of liberal
caring presence that is transforming for both and professional education and experience.
the patient and the nurse in revealing new vi- Patients bring to the situation their personal
sion and understanding of the human health history and life experience as well as the
experience. Its relevance worldwide directs health concern that often is the precipitant
the profession in meeting global, social, and for the nurse-patient meeting. The nurse’s re-
moral responsibilities. sponsibility is to be fully present, seeking to
The shift to a unitary concept of health, know what is meaningful to the patient, and
in which pathology is relevant but not sep- allowing the pattern to unfold. The fruitful-
arate and dominant, along with acknowledg- ness of the encounter is a function of the
ment of patterning as the identifying process nurse’s commitment to an unconditional car-
of the whole, allowed relationship to emerge ing presence, openness, and perseverance in
as the central focus of the discipline. Nursing allowing action possibilities to emerge. The
has taken the lead in elaborating relationship- relationship is embedded in a concept of
centered care, a concept sought as well by health based on wholeness, evolving pattern,
voices outside of nursing. McLeod, citing the and transformation. Research guided by this
work of the Relationship-Centered Care Net- perspective has revealed patients’ developing
work, formed by a collaboration of the Fet- understanding and insight regarding their
E18 ADVANCES IN NURSING SCIENCE/JANUARY–MARCH 2008

place in the world, a sense that their concerns ries, (2) consistency with knowledge devel-
are being addressed, and enhanced caring opment in other fields, and (3) utility across
relationships.19,20 Many in the UT paradigm multiple cultures. There is considerable over-
suggest that knowledge develops as nursing lap in meaning as these concepts merge as a
praxis, a synthesis of theory, research, and unified whole.
practice. Theory guides and informs the prac-
tice experience the research process, and the CONCEPTS CENTRAL TO THE
generation of knowledge. Nursing praxis is DISCIPLINE
not only a pathway to knowledge develop-
ment, but also the actualization of transforma- Health: The intent of the relationship
tional practice. Health is central to the focus of the disci-
The structure of the discipline began by pline of nursing. Many disciplines and profes-
recognizing the similarity of concepts of the sions commonly use it as the umbrella goal
various nursing theories.21,22 These connec- for those who care for people. The mean-
tions fit into a larger pattern of the disci- ings of the concept of health abound in of-
pline. Nursing has been through an ambigu- ten ambiguous or inconsistent ways such as:
ous state of multiple, competing, possibly the absence of disease; a continuum from
disconnected theories, but now the discipline wellness to illness; optimal wellness; integra-
is at a critical point of an emerging, overar- tion of body, mind, and spirit; and a holis-
ching form that expands beyond the initial tic phenomenon. Nursing literature reveals
links. A consensus statement of philosophic great diversity in the explanations of health.
unity was described by a group of interna- Donaldson and Crowley,24 held to a dichoto-
tional nurse scholars as the basic ontology of mous view of health by specifying that nurs-
the discipline and its relationship to knowl- ing is concerned with the actions or pro-
edge development and practice.23 Selected cesses by which positive changes in health
points of convergence reflected by the state- are affected. Wagner,25(p43) viewed health as
ment include the following: the ability to function independently: “adapt-
• The human being is characterized by ing successfully to life stressors,” implying
wholeness, complexity, and conscious- that through independent functioning the po-
ness. tential for achieving a full life occurs. Other
• The essence of nursing involves the definitions of health include: health as a dy-
nurse’s true presence in the process of namic life experience and a way to achieve
human-to-human engagement. potential,26 a state and process of being and
• Nursing theory expresses the values and becoming,15 an expression of unity and har-
beliefs of the discipline, creating a struc- mony of body-mind-spirit.12 From a unitary
ture to organize knowledge and illumi- perspective, the concepts of health and ill-
nate nursing practice. ness are seen as manifestations of rhythmic
• The essence of nursing practice is the fluctuations of the life process.27 This view is
nurse-patient relationship. the foundation for viewing health as a unitary
The elaboration that follows builds upon process moving through variations in order–
the unifying construct of the nurse-patient re- disorder. From this standpoint, one can no
lationship and provides a framework for its longer think of health and illness in a dichoto-
substantive content. The concepts of health, mous way, that is, health as absence of dis-
caring, consciousness, mutual process, pat- ease, or health as a continuum from wellness
terning, presence, and meaning have been to illness. According to Newman’s thesis,
selected to address the essence and dimen- health is a transforming process to higher
sions of the nursing relationship. The basis for levels of consciousness.4–6 Health and the
choosing these concepts was: (1) prevalence evolving pattern of consciousness are the
in the nursing literature across nursing theo- same.6,20 The evolving pattern of the whole
The Focus of the Discipline Revisited E19

requires a nonfragmentary view of health. Other nursing scholars have described car-
Newman referred to Bohm’s theory of the ing in various ways: as a fundamental human
implicate order to substantiate her position attribute lived out in relationship, a unique
that both disease and nondisease are ex- trait possessed by some, an affect, a moral
pressions of the whole, that is, explica- ideal that compels right action, an ethic of
tions of the underlying implicate order.5,3,28 practice, an interpersonal process, a thera-
Thus disease and nondisease are different peutic intervention, and a process of nurtur-
points of view of a larger reality. In this ing. Because of these differences, and the
way, health may be expressed and revealed lack of precision in use of the word “car-
in illness. Health in the face of illness de- ing,” some have argued that it is not a clar-
rives meaning through a caring nurse-patient ifying concept in delineating nursing’s disci-
relationship. plinary focus. It is true that there is ambiguity
in the concept of caring that obfuscates the
depth of its meaning. For this reason, under-
Caring: The nature of the relationship standing its meaning within the UT paradigm
Caring, also, is one of the defining terms of may bring clarity to its use. Smith22 identi-
the discipline and is central to nursing’s iden- fied 5 constituents of caring when viewed
tity. Newman and colleagues asserted that within the unitary paradigm: manifesting in-
nursing is about facilitating health, and that tention, attuning to dynamic flow, appreciat-
caring is the quality of relating that poten- ing pattern,32 experiencing the infinite, and
tiates a transformative connection between inviting creative emergence. From a unitary
nurse and patient.1 The establishment of car- perspective, caring is a quality of participa-
ing as a defining attribute of the discipline tive patterning. This way of being is char-
was recommended in a landmark conference acterized by holding the best intentions for
in 1989 convened by the American Academy the other and expressing them in thoughts,
of Nursing and Sigma Theta Tau. Nursing lead- words, and actions. It is sensing and moving
ers asserted that the concept “caring” should synchronously with the dynamic rhythms of
replace “nursing” in Fawcett’s29 constellation relating, following the lead of the other in
of concepts purported to define the intellec- the dance of human becoming. This way of
tual and social boundaries of the discipline. being is respecting the unique life story of
Leininger30 was the first to describe caring each person and the diversity of life choices.
as the distinguishing focus of the discipline. It is valuing and supporting what matters
She argued that care and caring were basic most to the person, family, or community.
needs essential for human growth and de- Caring is seeing the other and self as inter-
velopment, and advanced the study of car- connected to something more extensive than
ing by examining it from cultural practices. both. This way of being nurtures growth, and
Watson11 defined nursing as the art and sci- leads to self-discovery, unique self-expression,
ence of human caring and focused on the rela- and new ways of becoming and leading one’s
tional dimensions of caring and its connection life.22 For some, it is time to adopt the word
to healing. In more recent writing, she has love in describing this quality of relating in
articulated its commonalities with a unitary nursing.33,13 Teilhard de Chardin described
perspective.14,13 Boykin and Schoenhofer17 love as the energy of connection that com-
asserted that all human beings are caring, pels relationship. “Love alone is capable of
living it moment to moment. They defined uniting living beings in such a way as to
caring as “an altruistic, active expression of complete and fulfill them, for it alone takes
love. . .the intentional and embodied recogni- them and joins them by what is deepest in
tion of value and connectedness,”31(pp335–336) themselves.”34(p265) In this way, caring en-
but reminded us that it is known by experi- hances or facilitates health and healing and il-
ence and reflection and not by definition. luminates consciousness.
E20 ADVANCES IN NURSING SCIENCE/JANUARY–MARCH 2008

Consciousness: The informational rium states.39 These critical points may be


pattern of the relationship turning points at which the pattern is trans-
The concept of consciousness has become formed and new insights occur. A shift from a
central to the nursing discipline. A major shift matter-based representational focus to a self-
in the concept of consciousness has occurred organizing field has emerged, particularly in
during the past 4 decades. International or- relation to health.
ganizations have been formed for the study Theoretical elaborations from other nurs-
of consciousness along with scholarly jour- ing scholars support the process of expand-
nals created for that purpose.∗ Whereas in ing consciousness. Mishel’s40 conceptualiza-
the first half of the 20th century the study tion of uncertainty as a growth move through
of consciousness focused on characteristics of chaos to a higher level of organization sup-
the brain, the current movement opens wide ports the transformation of persons facing
the focus to participatory exploration of the what appear to be disruptive, immutable situ-
experience of consciousness and beyond.35 ations. Reed’s41 theory of transcendence elab-
DeQuincey,36 a prominent spokesperson in orates the process of human becoming lead-
this movement, claimed that consciousness ing to higher consciousness. It describes the
must be studied in relationship between potential for persons to go beyond the space-
persons. time limitations of their situations to a deeper
Grounded in a UT worldview of the experience of their lives. Watson12 coined the
phenomena of nursing and stimulated by term caring consciousness to convey a syn-
Bentov’s37 thesis that life is a process of thesis of the 2 concepts in the nurse’s relation-
expanding consciousness, Newman4 incor- ship with the patient. Roy16 has asserted that
porated this shift in an understanding of human consciousness is integral to an evolv-
the nursing relationship by asserting that ing, creative universe.
health is the expansion of consciousness. The essence of consciousness is informa-
This view broadened the old concept of con- tion, and the essence of information is reso-
sciousness to include the total information nance. Rogers3 included resonancy, the way
of the field (of nurse-patient-environment). information is shared, as a principle of the sci-
Consciousness, the information of the pat- ence of unitary human beings. She asserted
tern of the whole6 includes all forms of in- that the human being “experiences his envi-
formation: sensation and physiology as well ronment as a resonating wave . . . uniting him
as intellect, emotion, and intention. A per- with the rest of the world.”(p101) This informa-
son is identified by a pattern of conscious- tion is accessible to us as feeling and mean-
ness, which includes awareness of self within ing. In attending to feeling, we sense the res-
a larger system of consciousness. Arguelles,38 onance of incoming information and cocreate
a noted Mayan scholar, went so far as to a resonant field. The basic way of know-
say that “in actuality there is only conscious- ing is through attunement, resonant receptiv-
ness.”(p56) The human field is a pattern of con- ity, intuition, and revelation—a direct, unfil-
sciousness within the total pattern of con- tered index of communication.42 All points in
sciousness of the universe. It is constantly space-time have immediate access to a vast
receiving and sending information and in- storehouse of information. The whole orga-
cludes patterns that may appear disruptive as nizes the parts, and any event happening any-
well as those considered harmonious. Jumps where is immediately available everywhere as
in consciousness occur in far from equilib- information. The fields are conceived as be-
ing unbounded by space, time, and matter.
This mechanism of information transfer ex-
plains the immediacy of transformation. Reso-
∗ Forexample, The University of Arizona Center for Con- nance implies that the transformation is a mu-
sciousness Studies, Institute of Noetic Sciences, ReVision tual process.
The Focus of the Discipline Revisited E21

Mutual process: The way in which the the emergent unitary paradigm.3,6–8,11,13,14,17
relationship unfolds Rogers3 asserted that “The capacity of life to
transcend itself, for new forms to emerge,
Nurses are central to creating an envi- for new levels of complexity to evolve, pred-
ronment that fosters relationship and health. icates a future that cannot be foretold.”(p57)
This environment is not conceptualized as The mutual process of human becoming is
a linear communication process of send- unpredictable, but always reflects growing
ing and receiving. Rather, it is viewed as a complexity.
simultaneous unfolding, a sharing, moving A centerpiece of Parse’s school of thought,
together. Rogers’27 principles of homeody- human becoming is described as a rhythmi-
namics included integrality as a continuous cal process lived in relationship, expressed
mutual process between human and envi- through values, and “transcending with the
ronmental fields. Mutual process occurs in possibles.”8(19–20) Van Kaam,45(p10) described
the moment of being fully present with the the human as both potentiality and emer-
individual, family, or community. In mutual gence. Multiple potentialities are present, and
process the patient is invited to participate, through choice, these potentialities are ac-
and through reflection to find opportunities tualized in each moment. The mutual pro-
for new awareness, action, movement, and cess of human becoming is not imposed on
transformation.43 the other but is always happening. Teilhard
In mutuality, the focus is on wholeness, be- de Chardin34 stated that the direction of hu-
ing with and in relationship.6 The unfolding man becoming is toward increasing complex-
pattern that emerges within this mutual pro- ity, centration, interiority, and consciousness.
cess occurs as an intentional presence as the This path is illuminated in relationship, and
nurse and the patient reflect on the mean- the pacing and direction of the journey on the
ing in the moment. The process embodies path is personal. When one trusts this force,
the experience of nurse and other over time, he or she relinquishes any false sense of exter-
and through this process, pattern is revealed. nal control, having confidence that each per-
True reality behind the appearance of sepa- son knows his or her own way. There is no
rate, distinct entities, consists of wave-like, os- predetermined health outcome that is prefer-
cillating possibilities, waiting to become actu- able for each person. The preferred outcome
alities. These possibilities become actualities emerges in the person-environment mutual
once we engage in practice.12(p121) process, through choice. Action possibilities
Each interaction with the nurse and pa- arise in the context of recognizing the pattern
tient offers in mutual process the potential for of person-environment interactions.
discovery and choice. In mutual process the
unfolding of meaningful events and relation-
ships in people’s lives is manifested in pattern. Patterning: The evolving configuration
The mutual process with another is enhanced of the relationship
by the nurse’s authentic presence. The pur- Attention to pattern is a central aspect
poseful invitation by the nurse to dialogue in- of nursing practice and research. Descrip-
vites trust and fosters relationships within a tions of patterning in the nursing litera-
caring partnership.20,44 In mutual process the ture include the following: (a) each person
self and other are engaged in an experience exhibits distinguishing characteristics and a
that promotes awareness of self and other, unique pattern of interactions between self
and potentiates insight with new choices and and environment3,5,32,46 ; (b) pattern is a char-
actions. acteristic of wholeness and gives insight into
The idea of human unfolding, emergence, life meaning6 ; (c) patterning provides deep
and evolutionary transforming is significant insight and understanding of the whole, and
within a number of nursing theories sharing detailed comprehension of the uniqueness of
E22 ADVANCES IN NURSING SCIENCE/JANUARY–MARCH 2008

the life process; (d) contrast and time are es- on patterning as a way of partnering with
sential to the identification of pattern; (e) pat- people as they grasp the meaning of the
terning is unpredictable and creative3 ; and (f) wholeness of their life, gaining insight into
the process of pattern recognition reveals in- new possibilities for health.
sights into action, an expanding horizon, and Rogers3 identified pattern as a unifying
increasing connectedness.6,47 The purpose of concept in nursing and as ever-evolving in
attention to pattern in nursing has evolved the direction of increasing complexity, with
with the explication of the knowledge of the each repatterning being a revision of the im-
discipline–moving from diagnosis of illness mediately preceding pattern: “At each point
and disorder to exploration of meaning, ap- in space-time, man [sic] is what he has been
preciation of the whole, and recognition of becoming but he is not what he has been.
new possibilities for health. Pattern conveys Moreover, he cannot go back to what he has
connections of a meaningful whole. been.”(p98) People’s lives go on through var-
The focus of pattern in nursing has ious permutations of order and disorder; af-
changed overtime. Ever since Florence ter periods of chaos, their lives reorganize at
Nightingale developed the pie chart to ex- a higher level of organization.
amine patterns of disease distribution in the Newman described pattern as a character-
environment, patterning has been a central istic of wholeness: “Pattern is information that
concern and unifying concept of nursing. depicts the whole, understanding the mean-
Many nursing theories contain frameworks ing of all the relationships at once. It is a
through which nurses can assess patterns in fundamental attribute of all there is and re-
patients’ lives to better plan nursing care. For veals unity in diversity.”6(p71) It reveals the
example, in the Neuman’s systems model meaning of life. Pattern is dynamically re-
nurses identify the pattern of interaction be- lated with one’s environment, both human
tween the client system and the environment and nonhuman.6 When engaging community
to determine the impact of environmental members in dialogue, centered on represen-
stressors on the client system, and to plan tations of individual and family patterns, it is
prevention and intervention strategies to possible to see the pattern of the community
maintain system stability.21 The theory of and envision possibilities for transformation
cultural care diversity and universality in the health of the community.48
guides nurses to assess patterns relating Patterning reveals the evolving nature of
to social structures and geo-environmental the whole. As nursing embraced holism as a
factors to plan culturally congruent care.9 central tenet of human existence, better ways
In the interactive-integrative paradigm, to understand and respond to the whole were
patterns are assessed through attention needed. Newman uses a process of pattern
to categories or modes and are used to recognition that focuses on the evolving pat-
guide the selection of nursing interventions. tern of meaningful relationships and events in
As the worldview shifted to an awareness of people’s lives, stressing that meaning charac-
the dynamic mutually evolving nature of the terizes pattern. The process provides insight
person-environment pattern, the Roy adap- into potential actions.6 Cowling46 described
tation model, for example, was modified to a similar process of pattern appreciation that
express the foundational view of persons as is creative, receptive, and responsive to in-
coextensive with their social and physical dividual uniqueness; gives “primacy to the
environments, with an emphasis on meaning voices of those seeking care”; and provides “a
and consciousness in the mutual relationship context for human flourishing.”(p94) The prac-
between people and their environment.15 tice of healing from this perspective focuses
As nursing theories have evolved, they have on appreciating the wholeness that resides
focused less on patterns of illness and dis- within the pattern32 and enhances nurses’
order as a basis for intervention, and more ability to be attentive to their patients.
The Focus of the Discipline Revisited E23

Presence: The resonance of the Transforming presence is becoming one


relationship with the other. This involves letting go of
The concept of presence has been de- time constraints, putting everything aside and
scribed as genuine dialogue, commitment, focusing completely on the patient, that is,
full engagement and openness, the core el- being with the individual (family or commu-
ement of nursing activity, free-flowing at- nity) with all aspects of oneself.54 One must
tentiveness, transcendent togetherness, and let go everything else and be fully present in
transcendent oneness.49 It demonstrates the the moment. Being fully present goes beyond
uniqueness of the patient–nurse relationship: pattern identification and is the evidence of
connecting with patients’ experience, sens- transformation. Becoming one with the pa-
ing the current moment, going beyond scien- tient through presence focuses the nurse on
tific data, knowing what will work and when what is meaningful to the patient.
to act, and the sine qua non of being with
the patient.50 Presence is a nonsensory pre- Meaning: Importance of the relationship
hension of the being of the other. Being fully
present is central to the relational process of Caring presence and intentional resonance
nursing: focus nurses on what is meaningful in the lives
of patients. Searching for meaning and its mes-
“. . . authentic presence between patient and nurse sage for the future is the primary motivation in
. . . [is] a transformation of both. Presence is a mat- people’s lives,55 and thus is of primary impor-
ter of consciousness and is reflected in the holistic
tance to nurses. The focus on meaning shifts
beings that are both nurses and patients.51(p323)
the nurse’s purpose from objective problem-
Melnechenko52 described Parse’s concept solver to sojourner in discovery, interpre-
of true presence as a way of being that val- tation, and revelation. Bohm56 described
ues the other’s dignity and freedom and con- meaning as a dynamic process. Through re-
cluded that “true presence creates the op- flection on meaning, new meanings emerge.
portunity for nurses to go where the patient This process deepens with additional per-
is in life, to learn about the experience of spectives and expands as contexts change.
health as it is defined and lived, and to work Meaning arouses, organizes, and gives direc-
with patients as they choose the meaning tion to energy.56 As nurses and patients reflect
of the situation.”(p23) Koerner53 stressed the on the unfolding pattern of meaningful inter-
importance of active receptivity as an es- actions and events in patients’ lives and on the
sential aspect of nursing presence, stating, meaning of presenting situations and the con-
“Guided by the intent to support what is in text, in which they occurred, new perspec-
the highest good for the person and fam- tives and deeper insights evolve. Through this
ily, we create an empty space of open ex- process, new meanings give birth to new pos-
pectancy, which allows individuals to con- sibilities. Concentration on meaning in the life
nect with their inner wisdom and innate of the patient brings forth and directs energy
power to heal.”(p9) into healing that is uniquely appropriate to
The epistemology of presence focuses on a the patient, demonstrating the centrality of a
trust that understanding deepens exploration resonant, caring presence focused on mean-
in relationship. The emphasis is on engage- ing in people’s lives.
ment rather than on measurement, on mean- Several nurse theorists have asserted that
ing rather than on mechanism.36 DeQuincey nursing springs from a focus on meaning
pointed out that “being intensely engaged in in peoples’ lives—nursing care cannot be
relationship with another . . . is, perhaps, the predescribed or routinely applied in the
most vital manifestation of consciousness.” same manner across clients. Travelbee57 as-
It requires a shift from a world of subjects- serted that nurses must go beyond helping
objects, to a “view, which sees relationship as people cope with illness and suffering, to
fundamental.”(p173) helping people explore the unique meaning
E24 ADVANCES IN NURSING SCIENCE/JANUARY–MARCH 2008

they find in their experiences and predica- meaning of life differs from man to man [sic],
ments. Parse58 described meaning as being from day to day, and from hour to hour. What
illuminated and structured multidimension- matters, therefore, is not the meaning of life
ally through a cocreative process between in general, but rather the specific meaning
the nurse and the patient. She pointed to of a person’s life at a given moment.”55(p108)
the importance of dialogue, in which values Clarke63 reported that the quest for mean-
are expressed to identify what is cherished ing is the most commonly occurring attribute
and imagine what is possible. Parse,58(p7) of spirituality found in the nursing litera-
stated, “One cocreates meaning, and the ture. Drawing on the work of theologian Paul
meaning changes with experiences as new Tillich, Clarke described meaning as ultimate
images arise, expanding possibilities. People concern, and exhorted nurses to focus with
live their treasured beliefs in the process of patients on what is at the depth of their being,
evolving.” rather than simply on superficial concerns.
In her theory of meaning, Starck59 empha- Henery64 rejected the relevance of a hierarchi-
sized the importance of engaging different cal notion of what is most meaningful, stress-
perspectives to more fully understandable ing that nurses should not place judgment on
meaning, realizing that patterns of meaning what patients perceive as meaningful. Some-
may be manifest not only through verbal re- times what seems to be a superficial act or
flection, but also through spiritual and so- concern can open a window that sheds light
matic experiences. This realization focuses on deeper meaning and insights for action.
the nurse–patient relationship on the mean- Newman65 gave the example of walking into
ing of all that the patient is experienc- a patient’s room, noticing that the patient is
ing as relevant at the moment. Meleis60 at- reading a newspaper, and saying, “Reading
tributed grasping meaning to “perceptions the want ads, huh?” This led directly to a dia-
rather than intellect; it depends on obser- logue about the patient’s unemployment situ-
vations, feelings, imagination, and under- ation and its meaning in the patient’s life. The
standing that go beyond description—it de- caring, resonant presence of the nurse cre-
pends on inner experiences and is holis- ates the context, in which the dialogue can go
tic in nature.”(p97) Watson61 invited nurses deeper still. Further reflection and dialogue
to return from the outer world of technol- opens a door to deeper meaning. Newman
ogy where meaning has been stripped, to demonstrated the importance of entering into
the inner world of healing and meaning- the interaction where the patient is and riding
ful “human-to-human connections and caring the wave of caring presence and resonance
moments.”(p913) Koerner53 defined meaning into the center of what is meaningful, trusting
as “the way in which we use a life experience that the process will illuminate the direction
to grow and deepen as human beings;” she toward health.5,6
called nurses to use “slower wisdom” which
she defined as “longitudinal examination of is-
sues over time”(p208) to remove the veil of con- THE TASK BEFORE US
fusion from complex situations so that mean-
ing can be revealed. Newman62 has demon- An issue facing the nursing profession is
strated that it is in attending to the unfolding the question of what knowledge will direct
pattern of patients’ lives that the meaning of our practice. From our perspective, nursing
the whole can be fully comprehended. Pat- practice must be first and foremost grounded
tern and meaning are central to nursing care in the discipline as defined by the concepts
and give insight, one into the other. presented here, while at the same time in-
Meaning differs from person to person and corporating relevant knowledge from other
from time to time. There is no universal defini- disciplines. The patient and the nurse both
tion of meaning, but rather it is uniquely man- need access to the best evidence in mak-
ifest as each individual searches for it. “The ing decisions about patient care. The UT
The Focus of the Discipline Revisited E25

perspective expands the notion of evidence meaning, our society will fall apart.”(p150) For
and situates its relevance within the unique nursing, “Knowing who we are in the context
meaning and pattern of patients’ lives. of society and other related disciplines is es-
Peat66 offered a philosophy of wholeness sential for our own health and well-being, and
that is consistent with the UT perspective essential to our ability to serve others.”69(p14)
in nursing and warned, “If we are to move Without a clear sense of our nursing identity
toward a more holistic and healthy world, and the meaning of our mission to society, we
then we must discover a way of unifying have no value or purpose other than to sup-
the statements of objective science with port and promote the practice of medicine.
our personal vision of the world, and we Nurses are thirsting for a meaningful prac-
must do this without diluting the authentic- tice, one that is based on nursing values
ity of either approach.”(p47) Watson added, and knowledge, one that is relationship-
“Thus, an expanded and evolved disciplinary- centered, enabling the expression of the
professional view of health, healing and qual- depth of our mission, and one that brings a
ity of life/living will not allow one level of ev- much needed, missing dimension to current
idence or technology to privilege itself over healthcare. What is missing in healthcare is
the human condition and humanity itself. The what nursing can provide when practiced
evolved future becomes large enough to hold from a disciplinary perspective. Realizing
the paradox of both side by side.”67(p14) this goal begs for consensus in the col-
Bohm,68 in writing about meaning as the lective consciousness of the nursing
root of our whole being warned, “Without profession.

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