Case Study For Grand Nursing Theories Based On Interactive And Unitary Processes

Susan Frank is a nurse in a home care agency, and she is making her initial visit to a new patient. The patient’s name, Jay Gold, looks familiar, and when she enters his home, she finds she knew him in her former job. Susan had first met Mr. Gold more than a decade ago when she was working on a medical unit at the local community hospital. At that time, Mr. Gold had been admitted to the hospital for diabetes with ketoacidosis. It was at this time that he discovered he had insulin-dependent diabetes. During his initial hospitalization, he was started on insulin and had to learn to care for his diabetes. In the weeks that followed his hospitalization, Mr. Gold returned to the medical unit to see the nurses who cared for him each time he had a visit with his dietitian and diabetes educator. As his diabetes came under control, Mr. Gold returned to his outgoing, energetic baseline. He talked to the nurses about his sales job, his wife, and his two daughters and told them how much he had learned in caring for his disorder.Susan was shocked to see Mr. Gold’s appearance now. He was lying in his bed with his back to her and did not look up when she entered the room. As she spoke to him, she noted that his color was ashen. His voice was soft as he spoke, and he appeared depressed and lethargic. He had had a right above-the-knee amputation (AKA), and Susan noted a large scar on his chest. She reviewed his record and found that Mr. Gold’s diabetes had progressed rapidly and that he had multiple complications. He had had a coronary artery bypass graft (CABG) 2 years ago and was also being monitored for decreased renal function. He had vascular problems and neuropathy, which led to the AKA. The reason for the home visit was that Mr. Gold was found to have osteomyelitis, requiring 6 weeks of intravenous antibiotics.

Mr. Gold is married. He and his wife live in a pleasant, 2-story condo in an upscale community in a quiet retirement area. His two grown daughters are married but visit often. Susan learns that Mr. Gold has not been able to work for a number of years and is relying on Social Security disability and his wife’s part-time job.

1. Select one of the nursing models/theories interactive processes and unitary process, choose one of these that will help Ms. Frank in assessing Mr. Gold and planning for his care. Why did your group select that model?

Theories:

-Imogene King: King’s Conceptual System and Theory of Goal

Attainment and Transactional Process

-Martha Rogers: The Science of Unitary and Irreducible Human Beings

 

2. Based on the model selected, what additional information would Susan want to collect/assess?

3. Based on the model selected, how would Ms. Frank initiate a plan of care for Mr. Gold?

4. Do you think that Susan would assess and plan differently for Mr. Gold’s care if she used the theory you did not select for Mr. Gold? Why or why not?

Imogene King: King’s Conceptual System and Theory of Goal

Attainment and Transactional Process

King’s theory evolved from early writings about theory development. In her first book in 1971, she

synthesized scholarship from nursing and related disciplines into a theory for nursing (King, 1971). She wrote

the Theory of Goal Attainment in 1980. The most recent edition (King, 1995a) contains further refinements

and more detailed explanation of the general nursing framework and the theory.

Background of the Theorist

Imogene King graduated from St. John’s Hospital School of Nursing in St. Louis, Missouri, with a diploma in

nursing in 1945. She received a bachelor of science in nursing education from St. Louis University in 1948

and a master’s of science in nursing from the same school in 1957. In 1961, she received the doctor of

education degree from Teacher’s College, Columbia University, in New York (Sieloff & Messmer, 2014).

She held a variety of staff nursing, educational, research, and administrative roles throughout her professional

life. She worked as a research consultant for the Division of Nursing in the Department of Health, Education,

and Welfare for several years before moving to Tampa, Florida, in 1980, assuming the position of professor at

the University of South Florida College of Nursing (Sieloff & Messmer, 2014). She remained active in

professional organizations for many years. When she died in 2008, her work was widely celebrated by her

colleagues (Mensik, 2008; Mitchell, 2008; Smith, Wright, & Fawcet, 2008; Stevens & Messmer, 2008).

Philosophical Underpinnings of the Theory

The von Bertalanffy General Systems Model is acknowledged to be the basis for King’s work. She stated that

the science of wholeness elucidated in that model gave her hope that the complexity of nursing could be

studied “as an organized whole” (King, 1995b, p. 23).

Major Assumptions, Concepts, and Relationships

King’s conceptual system and theory contain many concepts and multiple assumptions and relationships. A

few of the assumptions, concepts, and relationships are presented in the following sections. The scholar

wishing to use King’s model or theory is referred to the original writings as both the model and theory are

complex (Figure 8-2).

Figure 8-2 A model of nurse–patient interactions.

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(Source: King, I. M. [1981]. A theory for nursing: Systems, concepts, process [p. 61]. Reprinted with permission of Sage Publications.)

Assumptions

The Theory of Goal Attainment lists several assumptions relating to individuals, nurse–client interactions, and

nursing. When describing individuals, the model shows that individuals (1) are social, sentient, rational,

reacting beings and (2) are controlling, purposeful, action oriented, and time oriented in their behavior (King,

1995b).

Regarding nurse–client interactions, King (1981) believed that (1) perceptions of the nurse and client

influence the interaction process; (2) goals, needs, and values of the nurse and client influence the interaction

process; (3) individuals have a right to knowledge about themselves; (4) individuals have a right to participate

in decisions that influence their lives, health, and community services; (5) individuals have a right to accept or

reject care; and (6) goals of health professionals and goals of recipients of health care may not be congruent.

With regard to nursing, King (1995b) wrote that (1) nursing is the care of human beings; (2) nursing is

perceiving, thinking, relating, judging, and acting vis-à-vis the behavior of individuals who come to a health

care system; (3) a nursing situation is the immediate environment in which two individuals establish a

relationship to cope with situational events; and (4) the goal of nursing is to help individuals and groups

attain, maintain, and restore health. If this is not possible, nurses help individuals die with dignity.

Concepts

King’s Theory of Goal Attainment defines the metaparadigm concepts of nursing as well as a number of

additional concepts. Table 8-4 lists some of the major concepts.

Table 8-4 Major Concepts of the Theory of Goal Attainment

Concept Definition

Nursing A process of action, reaction, and interaction whereby nurse and client share

information about their perceptions in the nursing situation. The nurse and client

share specific goals, problems, and concerns and explore means to achieve a goal.

Health A dynamic life experience of a human being, which implies continuous adjustment

to stressors in the internal and external environment through optimum use of one’s

resources to achieve maximum potential for daily living.

Individuals Social beings who are rational and sentient. Humans communicate their thoughts,

actions, customs, and beliefs through language. Persons exhibit common

characteristics such as the ability to perceive, to think, to feel, to choose between

alternative courses of action, to set goals, to select the means to achieve goals, and

to make decisions.

Environment The background for human interactions. It is both external to and internal to the

individual.

Perception The process of human transactions with environment. It involves organizing,

interpreting, and transforming information from sensory data and memory.

Communication A process by which information is given from one person to another, either directly

in face-to-face meetings or indirectly. It involves intrapersonal and interpersonal

exchanges.

Interaction A process of perception and communication between person and environment and

between person and person represented by verbal and nonverbal behaviors that are

goal-directed.

Transaction A process of interactions in which human beings communicate with the

environment to achieve goals that are valued; transactions are goal-directed human

behaviors.

Stress A dynamic state in which a human interacts with the environment to maintain

balance for growth, development, and performance; it is the exchange of

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information between human and environment for regulation and control of

stressors.

Source: King (1981).

Relationships

The Theory of Goal Attainment encompasses a great many relationships, many of them complex. King

organized them into useful propositions that enhance the understanding of the relationships of the theory. A

review of some relationships among the theory’s concepts follows:

Nurse and client are purposeful interacting systems.

Nurse and client perceptions, judgments, and actions, if congruent, lead to goal-directed transactions.

If perceptual accuracy is present in nurse–client interactions, transactions will occur.

If nurse and client make transactions, goals will be attained.

If goals are attained, satisfaction will occur.

If goals are attained, effective nursing care will occur.

If transactions are made in nurse–client interactions, growth and development will be enhanced.

If role expectations and role performance as perceived by nurse and client are congruent, transactions

will occur.

If role conflict is experienced by nurse or client or both, stress in nurse–client interactions will occur.

If nurses with special knowledge and skills communicate appropriate information to clients, mutual

goal setting and goal attainment will occur (King, 1981, pp. 61, 149).

Usefulness

King’s Theory of Goal Attainment has enhanced nursing education. For example, it served as a framework for

the baccalaureate program at the Ohio State University School of Nursing, where it determined the content

and processes taught at each level of the program (Daubenmire, 1989). Similarly, in Sweden, King’s model

was used to organize nursing education (Frey, Rooke, Sieloff, Messmer, & Kameoka, 1995). In more recent

years, King’s model has been useful in nursing education programs in Sweden, Portugal, Canada, and Japan

(Sieloff & Messmer, 2014).

King’s conceptual system is an organizing guide for nursing practice. In one example, Caceres (2015)

used King’s Theory of Goal Attainment to explore and expand upon the concept of functional status,

concluding that evaluation of functional status is vital and should be incorporated within mutual decisionmaking

processes from the client family’s perspective. M. L. Joseph, Laughon, and Bogue (2011) examined

the “sustainable adoption of whole-person care” (p. 989) in a Florida hospital guided by King’s Theory of

Goal Attainment. Finally, Gemmill and colleagues (2011) assessed nurses’ knowledge about and attitudes

toward ostomy care using King’s Theory of Goal Attainment to guide the research. Their findings explained

that it is difficult for staff nurses to maintain their clinical abilities when there are few opportunities.

Maintaining currency may require creative teaching interventions, such as simulations.

Testability

Parts of the Theory of Goal Attainment have been tested, and a number of research studies reported in the

literature used the model as a conceptual framework. For example, recent research includes a study by L.

Joseph (2013) who used King’s Theory of Goal Attainment to evaluate the effectiveness of a teaching

program to improve accuracy on pediatric growth measurements. In other works, Chacko, Kharde, and

Swamy (2013) used King’s theory as the framework to assess the efficacy of use of infrared lamps on

reducing pain and inflammation due to episiotomy, and Isac, Venkatesaperumal, and D’Sousa (2013) used

King’s theory to develop and evaluate the efficacy of a nurse-led information desk on assisting patients to

manage their sickle cell disease.

Parsimony

The conceptual system and theory were presented together in several versions of King’s writings and remain

largely as written in 1981. The theory is not parsimonious, having numerous concepts, multiple assumptions,

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many statements, and many relationships on a number of levels. This complexity, however, mirrors the

complexity of human transactions for goal attainment. The model is general and universal and can be the

umbrella for many midrange and practice theories.

Value in Extending Nursing Science

In addition to application in practice and research described previously, King’s work has been the basis for

development of several middle range nursing theories. For example, the Theory of Goal Attainment was used

by Rooda (1992) to develop a model for multicultural nursing practice. King’s Systems Framework was

reportedly used by Alligood and May (2000) to develop a theory of personal system empathy and by

Doornbos (2000) to derive a middle range theory of family health.

King’s conceptual system and theory have been used internationally in Australia, Brazil, Canada,

Pakistan, and Sweden, as well as in numerous university nursing programs in the United States, and have

provided a foundation for many research studies. Her work has extended nursing science by its usefulness in

education, practice, and research across international boundaries (King, 2001; Sieloff & Messmer, 2014).

Martha Rogers: The Science of Unitary and Irreducible Human Beings

Martha Rogers first described her Theory of Unitary Man in 1961, and almost from the first, there has been

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widespread controversy and debate among nursing theorists and scholars regarding her work (Phillips, 2010,

2016). Prior to Rogers, it was rare that anyone in nursing viewed human beings as anything other than the

receivers of care by nurses and physicians. Furthermore, the health care system was organized by

specialization, in which nurses and other health providers focused on discrete areas or functions (e.g., a

dressing change, medication administration, or health teaching) rather than on the whole person. As a result, it

took many professionals working in isolation, none of whom knew the whole person, to care for patients.

Rogers’s (1970) insistence that the person was a “unitary energy system” in “continuous mutual interaction

with the universal energy system” (p. 90) dramatically influenced nursing by encouraging nurses to consider

each person as a whole (a unity) when planning and delivering care. Phillips (2013) states that Rogers’s

“vision was concerned with unitary wholes, a vision she used in creating the science of unitary human beings

(SUBH) . . . ” (p. 241). A new and dramatically different ideal in health care.

Background of the Theorist

Martha Rogers was born on May 12, 1914 (the anniversary of Florence Nightingale’s birth) (Dossey, 2010),

in Dallas, Texas. She earned a diploma in nursing from Knoxville General Hospital in 1936 and a bachelor’s

degree from George Peabody College in Nashville, Tennessee, in 1937. She later received a master’s degree

in public health nursing from Teachers College, Columbia University in New York, and a master’s degree in

public health and a doctor of science from The Johns Hopkins University in Baltimore, Maryland (Gunther,

2014).

Rogers became the head of the Division of Nursing of New York University (NYU) in 1954, where she

focused on teaching and formulating and elaborating her theory (Hektor, 1989). She was teacher and mentor

to an impressive list of nursing scholars and theorists, including Newman and Parse, whose works are

described later in the chapter. Rogers continued her work and writing until her death in March 1994.

Philosophical Underpinnings of the Theory

The Science of Unitary and Irreducible Human Beings started as an abstract theory that was synthesized from

theories of numerous sciences; therefore, it was deductively derived. She drew from Einstein’s Theory of

Relativity as well as Heisenberg’s Uncertainty Principle to demonstrate the unpredictability of this universe

(Caratao-Mojica, 2015). Of particular importance was von Bertalanffy’s theory on general systems, which

contributed the concepts of entropy and negentropy and posited that open systems are characterized by

constant interaction with the environment. The work of Rapoport provided a background on open systems,

and the work of Herrick contributed to the premise of evolution of human nature (Rogers, 1994).

Rogers’s synthesis of the works of these scientists formed the basis of her proposition that human systems

are open systems embedded in larger, open environmental systems. She also brought in other concepts,

including the idea that time is unidirectional, that living systems have pattern and organization, and that man

is a sentient, thinking being capable of awareness, feeling, and choosing. From all these theories, and from her

personal study of nature, Rogers (1970) developed her original Theory of Unitary Man. She continuously

refined and elaborated her theory, which she retitled Science of Unitary Humans (Rogers, 1986) and, finally,

shortly before her death, the Science of Unitary and Irreducible Human Beings (Rogers, 1994).

Major Assumptions, Concepts, and Relationships

Assumptions

Rogers (1970) presented several assumptions about man. These are as follows:

Man is a unified whole possessing integrity and manifesting characteristics that are more than and

different from the sum of his parts (p. 47).

Man and environment are continuously exchanging matter and energy with one another (p. 54).

The life process evolves irreversibly and unidirectionally along the space–time continuum (p. 59).

Pattern and organization identify man and reflect his innovative wholeness (p. 65).

Man is characterized by the capacity for abstraction and imagery, language and thought, sensation, and

emotion (p. 73).

Rogers (1990) later revised the term man to human being to coincide with the request for gender-neutral

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language in the social sciences and nursing science.

Concepts

In Rogers’s work, the unitary human being and the environment are the focus of nursing practice. Other

central components are energy fields, openness, pandimensionality, and pattern; these she identified as the

“building blocks” (Rogers, 1970, p. 226) of her system. Rogers also derived three other components for the

model, which served as a basis of her work. These were based on principles of homeodynamics and were

termed resonancy, helicy, and integrality (Rogers, 1990) (Box 9-1). Definitions of the nursing metaparadigm

concepts and other important concepts in Rogers’s work are listed in Table 9-1.

Box 9-1 Principles of Homeodynamics Applied in Rogers’s Theory

1. Resonancy is continuous change from lower to higher frequency wave patterns in human and

environmental fields.

2. Helicy is continuous innovative, unpredictable, increasing diversity of human and environmental field

patterns.

3. Integrality is continuous mutual human and environmental field processes.

Source: Rogers (1990, p. 8).

Table 9-1 Central Concepts of Rogers’s Science of Unitary Human Beings

Concept Definition

Human–unitary human beings “Irreducible, indivisible, multidimensional energy fields identified by

pattern and manifesting characteristics that are specific to the whole

and which cannot be predicted from the knowledge of the parts” (p. 7).

Health “Unitary human health signifies an irreducible human field

manifestation. It cannot be measured by the parameters of biology or

physics or of the social sciences” (p. 10).

Nursing “The study of unitary, irreducible, indivisible human and

environmental fields: people and their world” (p. 6). Nursing is a

learned profession that is both a science and an art.

Environmental field “An irreducible, indivisible, pandimensional energy field identified by

pattern and integral with the human field” (p. 7).

Energy field “The fundamental unit of the living and the non-living. Field is a

unifying concept. Energy signifies the dynamic nature of the field; a

field is in continuous motion and is infinite” (p. 7).

Openness Refers to qualities exhibited by open systems; human beings and their

environment are open systems.

Pandimensional “A nonlinear domain without spatial or temporal attributes” (p. 28).

Pattern “The distinguishing characteristic of an energy field perceived as a

single wave” (p. 7).

Source: Rogers (1990).

Relationships

The Science of Unitary and Irreducible Human Beings is fundamentally abstract; therefore, specifically

defined relationships differ from those in more linear theories. The major components of Rogers’s model

revolve around the building blocks (energy fields, openness, pattern, and pandimensionality) and the

principles of homeodynamics (resonancy, helicy, and integrality). These explain the nature of, and direction

of, the interactions between unitary human beings and the environment.

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Among the relationships that Rogers posited are that all things are integral in that their energy fields are in

continuous mutual process and that pattern is the manifestation of the integrality of each entity and of the

environmental energy field (Rogers, 1986). Other major relationships within Rogers’s (1990) work are

contained in the following statements:

Humans and environment are interrelated in that neither “has an energy field,” both are integral energy

fields (pp. 6–7).

Manifestations of pattern emerge out of the human/environmental field mutual process and are

continuously innovative (p. 8).

The group field is irreducible and indivisible to itself and integral with its own environmental field (p. 8).

Nursing is concerned with maintaining and promoting health, preventing illness, and caring for those who are

sick or disabled. The purpose of nursing for Rogers (1986) is to help human beings achieve well-being within

the potential of each individual, family, or group. Because human energy fields are complex, individualizing

nursing services supports simultaneous human and environmental exchange, encouraging health (Rogers,

1990).

Usefulness

Rogers’s theory is a synthesis of phenomena that are important to nursing. It is an abstract, unified, and highly

derived framework and does not define particular hypotheses or theories. Rather, it provides a worldview

from which nurses may derive theories and hypotheses and propose relationships specific to different

situations. In essence, the theory allows many options for studying humans as individuals and groups and for

studying various situations in health as manifestations of pattern and innovation. Rogers’s model stresses the

unitary experience and provides an abstract philosophical framework that can guide nursing practice.

Rogers’s theory has been evident in nursing education, scholarship, and practice for more than four

decades. In education, among other programs, it has guided the nursing curriculum at NYU, where Rogers

was head of the Division of Nursing in the 1970s. This resulted in the education of numerous nurses who use

her theory in practice internationally (Hektor, 1989). In the area of nursing scholarship, several noted nursing

theorists (e.g., Fitzpatrick, 1989; Newman, 1994; Parse, 1998) derived theories from Rogers’s work. A

number of middle range nursing theories are based on Rogers’s work as reported by Fawcett (2015). Among

these middle range theories are Health Empowerment Theory (Shearer, 2009), Theory of the Art of Nursing

(Alligood, 2002), Theory of Self-Transcendence (Reed, 2014), Theory of Diversity of Human Field Pattern

(Hastings-Tolsma, 2006), and Theory of Intentionality (Zahourek, 2005).

In other scholarly works, Barrett (1986, 1989) derived a theory, Power as Knowing Participation in

Change, for nursing practice from Rogers’s theory. She used several of Rogers’s concepts (e.g., energy fields,

openness, pattern, and four-dimensionality [now pandimensionality]) and the principles of resonancy, helicy,

and integrality to form her theory. The Theory of Power as Knowing Participation in Change consists of

awareness, choices, freedom to act intentionally, and involvement in creating changes and was tested in

research using Barrett’s Power as Knowing Participation in Change (PKPIC) tool. Barrett’s (1989) theory

consequently has been used in research on patterning of pain and power with guided imagery by Fuller, Davis,

Servonsky, and Butcher (2012), who examined field patterns in adult substance users in rehab, and Kirton and

Morris (2012), who used Barrett’s theory to examine adherence to antiretroviral therapy in adults who are

infected with HIV. Farren (2010) found in a secondary analysis of data collected using Barrett’s PKPIC tool

with breast cancer survivors that the dimensions of power (awareness, choices, freedom to act with intention,

and involvement in creating change) were responsible for all the variance. Moreover, the breast cancer

survivors showed differing intensities of these dimensions.

In clinical settings, Rogerian practitioners employ the visible manifestations of Rogers’s science. Madrid,

Barrett, and Winstead-Fry (2010), for example, studied the feasibility of using therapeutic touch with patients

who were undergoing cerebral angiography. The design was a randomized, single blind clinical pilot study

with outcome assessments of blood pressure, pulse, and respirations. The findings of this study were

inconclusive, but the researchers followed up with exploration of the reasons and studied the implications.

Reed (2008) wrote about nursing time as a dimension of practice, research, and theory. In a nursing

educational setting, Malinski and Todaro-Franceschi (2011) studied comeditation to reduce anxiety and

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facilitate relaxation. Their data from the qualitative study suggested that the participants reported feeling

calmer, more relaxed, and balanced and centered after 1 month of practice. Their findings suggest that

comeditation may help transform education in nursing programs, most of which have reputations as being

stressful to students.

Testability

Because of the model’s abstractness, Rogers’s (1990) work is not directly testable, but it is testable in

principle (Bramlett, 2010). Numerous research studies using Rogers’s model have been completed and

reported in the nursing literature. A plethora of these studies can be found in Visions: The Journal of Rogerian

Nursing Science. Madrid and Winstead-Fry (2001) also found in a focused review of literature that from 1990

through 2000, 28 research studies on therapeutic touch were published in peer-reviewed journals, and 18 of

them were based on the Science of Unitary Human Beings, typically using Rogers’s model as explanation for

the underlying processes of therapeutic touch and its relation to energy fields and energy transfer. Examples

of some recent nursing studies using Rogers’s theory are listed in Box 9-2.

Nursing.(Practium Experience Plan)

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