A theory is defined as one or more relatively concrete and specific concepts that are derived from a conceptual model, the propositions that narrowly describe those concepts, and the propositions that state relatively concrete and specific relations between two or more of the concepts. Grand theories are rather broad in scope. They are made up of concepts and propositions that are less abstract and general than the concepts and propositions of a conceptual model but are not as concrete and specific as the concepts and propositions of a middle-range theory. Middle-range theories are narrower in scope than grand theories. They are made up of a limited number of concepts and propositions that are written at a relatively concrete and specific level.
HELEN ERICKSON, EVELYN TOMLIN, AND MARY ANN SWAIN'S THEORY OF MODELING AND ROLE MODELING
Overview
A grand theory or paradigm for the practice of professional nursing that focuses on the processes by which the nurse seeks to understand the client's unique model of the world and by which the nurse understands that unique model within the context of scientific theories and plans nursing interventions that promote health. The two major concepts of the theory are:

1. 
   Modeling—an act that represents the process the nurse uses to develop an image and understand the client's world from the client's perspective. Modeling encompasses the art and science of nursing. The art of modeling is the development of a mirror image of the situation from the client's perspective, which requires communication skills that help the nurse to enter into the foreign world of the client. The science of modeling is the scientific aggregation and analysis of data collected about the client's model of the world.
   
2. 
   Role Modeling—occurs only after modeling has been accomplished. It involves the facilitation of the individual in attaining, maintaining, or promoting health through purposeful interventions, which are planned on the basis of the analysis and synthesis of data about the client's model of the world. Role modeling also encompasses the art and science of nursing. The art of role modeling occurs when the nurse plans and implements unique interventions with respect to a theoretical base for the practice of nursing. Role modeling is the essence of nurturance, the basis for the predictive and prescriptive component of nursing practice. It requires an unconditional acceptance of the client as the client is while gently encouraging and facilitating growth and development at the client's own pace and within the client's own model of the world.
   

Implications for Nursing Practice
The nursing process is an ongoing, interactive exchange of information, feelings, and behavior between nurses and clients. The nurse's goal is to nurture and support the client's self-care. Nursing practice is directed toward collection of data primarily from clients but also from families, nurses, and other health care providers. Data collection is organized into four categories:

1. 
   Description of the situation, including:
   • Overview of the situation—an overview of the client's situation from the client's perspective;
     
   • Etiology—identification of relevant etiological factors, including stressors and destressors;
     
   • Therapeutic needs—identification of possible therapeutic interventions.
     
2. 
   Immediate and long-term expectations—development of an understanding of the client's personal orientation regarding present and future expectations.
   
3. 
   Resource potential—available internal and external resources.
   
   • External—determination of the nature of the external support system, from the social network, support system, and health care system.
     
   • Internal—determination of the client's strengths, virtues, and currently available internal resources, including adaptive potential, feeling states, and psychological status.
     
4. 
   Current and future goals and life tasks—determination of the client's current developmental status so as to understand his or her personal model and to use appropriate communication skills.
   

Data collection is followed by aggregation, analysis, and synthesis of the data. Nursing diagnoses are derived from the analysis and synthesis of the data. Nursing interventions that are acceptable within the client's model of the world are then developed. The goals of nursing intervention and their associated aims are:

1. 
   Goal:Develop a trusting and functional nurse-client relationship. Aim: Build trust.
   
2. 
   Goal:Facilitate a futuristic and positive self-projection. Aim: Promote the client's positive orientation.
   
3. 
   Goal:Promote affiliated individuation with the minimum possible degree of ambivalence. Aim: Promote client's control.
   
4. 
   Goal:Promote a dynamic, adaptive, and holistic health state. Aim: Affirm and promote the client's strengths.
   
5. 
   Goal:Promote and nurture coping mechanisms that satisfy basic needs and permit growth-need satisfaction. Aim: Set mutual goals that are health-directed.
   

Implications for Nursing Education
Education of professional nursing practice requires consideration of seven factors that are required for implementation of the modeling and role modeling theory. These factors are:

1. Have confidence in nursing.
   
2. Establish a belief system.
   
3. Promote adherence.
   
4. Develop a language.
   
5. Give and get collegial support.
   
6. Be willing to take risks.
   
7. Believe in yourself.
   

References

• Erickson, H.C., Tomlin, E.M., & Swain, M.A.P. (1983). Modeling and role modeling: A theory and paradigm for nursing. Englewood Cliffs, NJ: Prentice Hall.

MADELEINE LEININGER'S THEORY OF CULTURE CARE DIVERSITY AND UNIVERSALITY
Overview
A grand theory focusing on the discovery of human care diversities and universalities and ways to provide culturally congruent care to people. The concepts of the theory are:

1. 
   Care—abstract and concrete phenomena related to assisting, supporting, or enabling experiences or behaviors toward or for others with evident or anticipated needs to ameliorate or improve a human condition or lifeway.
   
2. 
   Caring—the actions and activities directed toward assisting, supporting, or enabling another individual or group with evident or anticipated needs to ameliorate or improve a human condition or lifeway or to face death.
   
3. 
   Culture—the learned, shared, and transmitted values, beliefs, norms, and lifeways of a particular group that guide thinking, decisions, and actions in patterned ways; encompasses several cultural and social structure dimensions: technological factors, religious and philosophical factors, kinship and social factors, political and legal factors, economic factors, educational factors, and cultural values and lifeways.
   
4. 
   Language—word usages, symbols, and meanings about care.
   
5. 
   Ethnohistory—past facts, events, instances, experiences of individuals, groups, cultures, and institutions that are primarily people centered (ethno) and that describe, explain, and interpret human lifeways within particular cultural contexts and over short or long periods of time.
   
6. 
   Environmental context—the totality of an event, situation, or particular experiences that give meaning to human expressions, interpretations, and social interactions in particular physical, ecological, sociopolitical, and/or cultural settings.
   
7. 
   Health—a state of well-being that is culturally defined, 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.
   
8. 
   Worldview—the way people tend to look out on the world or their universe to form a picture of or a value stance about their life or the world around them.
   
9. 
   Cultural care—the subjectively and objectively transmitted values, beliefs, and patterned lifeways that assist, support, or enable another individual or group to maintain well-being and health, to improve his or her human condition and lifeway, to deal with illness, handicaps, or death. The two dimensions are:
   
   • Cultural care diversity—the variabilities and/or differences in meanings, patterns, values, lifeways, or symbols of care within or between collectivities that are related to assistive, supportive, or enabling human care expressions.
     
   • Cultural care universality—the common, similar, or dominant uniform care meanings, patterns, values, lifeways, or symbols that are manifest among many cultures and reflect assistive, supportive, facilitative, or enabling ways to help people.
     
10. 
    Care systems—the values, norms, and structural features of an organization designed for serving people's health needs, concerns, or conditions. The two types of care systems are:
    
    • Generic (emic) lay care system—traditional or local indigenous health care or cure practices that have special meanings and uses to heal or assist people, which are generally offered in familiar home or community environmental contexts with their local practitioners.
      
    • Professional (etic) health care system—professional care or cure services offered by diverse health personnel who have been prepared through formal professional programs of study in special educational institutions.
      
11. 
    Culturally congruent care—culturally based care knowledge, acts, and decisions used in sensitive and knowledgeable ways to appropriately and meaningfully fit the cultural values, beliefs, and lifeways of clients for their health and well being, or to prevent illness, disabilities, or death. The three modes of culturally congruent care are:
    
    • Culture care preservation and/or maintenance refers to assistive, supportive, facilitative, or enabling professional acts or decisions that help cultures to retain, preserve, or maintain beneficial care beliefs and values or to face handicaps and death.
      
    • Culture care accommodation and/or negotiation refers to assistive, accommodating, facilitative, or enabling creative provider care actions or decisions that help cultures to adapt to or negotiate with others for culturally congruent, safe, and effective care for their health, well being, or to deal with illness or dying.
      
    • Culture care repatterning and/or restructuring refers to assistive, supportive, facilitative, or enabling professional actions and mutual decisions that would help people to reorder, change, modify, or restructure their life ways and institutions for better (or beneficial) health care patterns, practices, or outcomes.
      
12. 
    Cultural and social structure factors—Factors that influence expressions and meanings of care, including gender and class differences in religion or spirituality, kinship or social ties, politics, legal issues, education, economics, technology, philosophy of life, and cultural beliefs and values.
    

Implications for Nursing Practice
Nursing practice is directed toward improving and providing culturally congruent care to people. A practice methodology for the Theory of Culture Care Diversity and Universality is as follows:

• 
  Goals of Nursing Practice are:to improve and to provide culturally congruent care to people that is beneficial, will fit with, and be useful to the client, family, or culture group healthy lifeways; to provide culturally congruent nursing care in order to improve or offer a different kind of nursing care service to people of diverse or similar cultures.
  
• 
  Clientsinclude individuals, families, subcultures, groups, communities, and institutions.
  
• 
  Culturalogical AssessmentThe nurse maintains a holistic or total view of the client's world by using the Sunrise Model and Enablers to guide assessment of cultural beliefs, values, and lifeways.
  The nurse is aware that the client may belong to a subculture or special group that maintains its own values and beliefs that differ from the values and beliefs of the dominant culture. The nurse shows a genuine interest in the client and learns from and maintains respect for the client. The nurse asks open-ended questions and maintains the role of an active listener, learner, and reflector. The nurse shares professional knowledge only if the client asks about such knowledge.
  The nurse begins the assessment with such questions as: What would you like to share with me today about your experiences or beliefs, to help you keep well? Are there some special ideas or ways you would like nurses to care for you? The nurse gives attention to clients' gender differences, communication modes, special language terms, interpersonal relationships, and use of space and foods.
  
• 
  Nursing Judgments, Decisions, and ActionsNursing practice requires the coparticipation of nurses and clients working together to identify, plan, implement, and evaluate the appropriate mode(s) of culturally congruent care. Nursing decisions and actions encompass assisting, accommodating, supporting, facilitating, and enabling. Nurse and client select one or more mode of culturally congruent care.
  Culture Care Preservation and/or Maintenance—used when professional decisions and actions are needed to help clients of a designated culture to retain, preserve, or maintain care beliefs
  Culture Care Accommodation and/or Negotiation—used when professional decisions and actions are needed to help clients of a designated culture adapt to or negotiate with others for care.
  Culture Care Repatterning and/or Restructuring—used when professional decisions and actions are needed to help clients of a designated culture to reorder, change, modify, or restructure their life ways and institutions.
  
• 
  Clinical ProtocolsSpecific nursing practices or clinical protocols are derived from the findings of research guided by the Theory of Culture Care Diversity and Universality. The research findings are used to develop protocols for cultural-congruent care that blends with the particular cultural values, beliefs, and lifeways of the client, and is assessed to be beneficial, satisfying, and meaningful to the client.
  

Implications for Nursing Education
Professional nursing care, learned in formal educational programs, builds upon the generic care given by naturalistic lay and folk care givers. The curriculum emphasizes transcultural nursing knowledge, with formal study about different cultures in the world, as well as culture-universal and culture-specific health care needs of people and nursing care practices. Transcultural nurse generalists are prepared at the baccalaureate level for the general use of transcultural nursing concepts, principles, and practices. Transcultural nurse specialists, who are prepared at the doctoral level, have in-depth understanding of a few cultures and can function as field practitioners, teachers, researchers, or consultants. Certification is awarded by the Transcultural Nursing Society to nurses who have educational preparation in transcultural nursing or the equivalent and who demonstrate basic clinical competence in transcultural nursing.

References

• Leininger, M.M., & McFarland, M.R. (2006). Culture care diversity and universality: A worldwide nursing theory (2nd ed.). Boston: Jones and Bartlett.

MARGARET NEWMAN'S THEORY OF HEALTH AS EXPANDING CONSCIOUSNESS
Overview
A grand theory focusing on health as the expansion of consciousness, with emphasis on the idea that every person in every situation, no matter how disordered and hopeless the situation may seem, is part of the universal process of expanding consciousness. The concepts of the theory are:

1. 
   Consciousness—the informational capacity of human beings, that is, the ability of humans to interact with their environments. Consciousness encompasses interconnected cognitive and affective awareness, physiochemical maintenance including the nervous and endocrine systems, growth processes, the immune system, and the genetic code. Consciousness can be seen in the quantity and quality of the interaction between human beings and their environments. The process of life is toward higher levels of consciousness; sometimes this process is smooth, pleasant, harmonious; other times it is difficult and disharmonious, as in disease.
   
2. 
   Pattern—a fundamental attribute of all there is and reveals unity in diversity; information that depicts the whole, understanding of the meaning of all the relationships at once; relatedness; self-organizing over time, such that it becomes more highly organized with more information. Pattern identifies particular people and is an identification of the wholeness of the person. Pattern is manifested as exchanging (interchanging matter and energy between person and environment and transforming energy from one form to another); communicating (interchanging information from one system to another); relating (connecting with other persons and the environment); valuing (assigning worth); choosing (selecting of one or more alternatives); moving (rhythmic alternating between activity and rest); perceiving (receiving and interpreting information); feeling (sensing physical and intuitive awareness); and knowing (personal recognition of self and world). Pattern encompasses three dimensions—Movement-Space-Time, Rhythm, and Diversity.
   
   • Movement-Space-Time—movement is the natural condition of life, an essential property of matter and a means of communicating; when movement ceases, it is an indication that life has gone out of the organism; movement is the means whereby one perceives reality and becomes aware of self; movement is a means whereby space and time become a reality. Space encompasses personal space, inner space, and life space as dimensions of space relevant to the individual, and territoriality, shared space, and distancing as dimensions relevant to the family. Time is a function of movement; the amount of time perceived to be passing (subjective time); clock time (objective time). Time and space have a complementary relationship.
     
   
   
   
   • 
     Rhythm—basic to movement; the rhythm of movement is an integrating experience.
     
   • 
     Diversity—seen in the parts.
     

Implications for Nursing Practice
Nursing practice is directed toward facilitating pattern recognition by connecting with the client in an authentic way, and assisting the client to discover new rules for a higher level of organization or consciousness. Newman's Research as Praxis Protocol is a research/practice methodology. The phenomenon of interest is the process of expanding consciousness.

• 
  The InterviewThe meeting of the nurse and the study participant/client occurs when there is a mutual attraction via congruent patterns, i.e., interpenetration of the two fields. The nurse and study participant/client enter into a partnership, with the mutual goal of participating in an authentic relationship, trusting that in the process of its unfolding, both will emerge at a higher level of consciousness.
  
• 
  TranscriptionThe nurse listens carefully to and transcribes the tape of the interview soon after the interview is completed. The nurse is sensitive to the relevance of the data and may omit comments made by the study participant/client that do not directly relate to his or her life pattern, with an appropriate note to the place on the tape where such comments occurred, in case those comments seem important later.
  
• 
  Development of the Narrative: Pattern RecognitionThe nurse selects the statements deemed most important to the study participant/client and arranges the key segments of the data in chronological order to highlight the most significant events and persons. The data remain the same except in the order of presentation. Natural breaks where a pattern shift occurs are noted and form the basis of the sequential patterns. Recognition of the pattern of the whole, made up of segments of the study participant/client's relationships over time, will emerge for the nurse. The nurse then transmutes the narrative into a simple diagram of the sequential pattern configurations.
  
• 
  Diagram: Pattern RecognitionThe nurse then transmutes the narrative into a simple diagram of the sequential pattern configurations.
  
• 
  Follow-Up: Pattern RecognitionThe nurse conducts a second interview with the study participant/client to share the diagram or other visual portrayal of the pattern. The nurse does not interpret the diagram. Rather, it is used simply to illustrate the study participant/ client's story in graphic form, which tends to accentuate the contrasts and repetitions in relationships over time. The mutual viewing of the graphic form is an opportunity for the study participant/client to confirm and clarify or revise the story being portrayed. The mutual viewing also is an opportunity for the nurse to clarify any aspect of the story about which he or she has any doubt.
  The nature of the pattern of person-environment interaction will begin to emerge in terms of energy flow (e.g., blocked, diffuse, disorganized, repetitive, or whatever descriptors and metaphors come to mind to describe the pattern). The study participant/client may express signs that pattern recognition is occurring (or already has occurred in the interval following the first interview) as the nurse and study participant/client reflect together on the study participant/client's life pattern. Sometimes, no signs of pattern recognition emerge, and if so, that characterizes the pattern for that person. It is not to be forced.
  
• 
  Application of Theory of Health as Expanding ConsciousnessThe nurse undertakes more intense analysis of the data in light of the Theory of Health as Expanding Consciousness after the interviews are completed. The nurse evaluates the nature of the sequential patterns of interaction in terms of quality and complexity and interprets the patterns according to the study participant/client's position on Young's spectrum of consciousness. The sequential patterns represent presentational construing or relationships. Any similarities of pattern among a group of study participants/clients having a similar experience may be designated by themes and stated in propositional form.
  

Implications for Nursing Education
Education for nursing should be the professional doctoral degree, the Doctor of Nursing (ND), which requires a strong arts and sciences background as pre-professional education. Students and practicing nurses who plan to use the Theory of Health as Expanding Consciousness have to be prepared for personal transformation in the way that they view the world and nursing.

References

• Newman, M. A. (1994). Health as expanding consciousness (2nd ed.). New York: National League for Nursing.
• Pharris, M.D. (2006). Margaret A. Newman’s theory of health as expanding consciousness and its applications. In M.E. Parker, Nursing theories and nursing practice (2nd ed., pp. 217-234). Philadelphia: F.A. Davis.
• Picard, C., & Jones, D. (Eds.). (2005). Giving voice to what we know: Margaret Newman’s theory of health as expanding consciousness in practice, research, and education. Sudbury, MA: Jones and Bartlett.

IDA JEAN ORLANDO'S THEORY OF THE DELIBERATIVE NURSING PROCESS OVERVIEW
Overview
A middle-range predictive theory focusing on an interpersonal process that is directed toward facilitating identification of the nature of the patient's distress and his or her immediate needs for help. The concepts of the theory are:

1. 
   Patient's behavior—behavior observed by the nurse in an immediate nurse-patient situation. The two dimensions are:
   
   • Need for help—a requirement of the patient that, if supplied, relieves or diminishes immediate distress or improves immediate sense of adequacy or well-being.
     
   • Improvement—an increase in patients' mental and physical health, their well-being, and their sense of adequacy. The need for help and improvement can be expressed in both nonverbal and verbal forms. Visual manifestations of nonverbal behavior include such motor activities as eating, walking, twitching, and trembling, as well as such physiological forms as urinating, defecating, temperature and blood pressure readings, respiratory rate, and skin color. Vocal forms of nonverbal behavior—nonverbal behavior that is heard—include crying, moaning, laughing, coughing, sneezing, sighing, yelling, screaming, groaning, and singing. Verbal behavior refers to what a patient says, including complaints, requests, questions, refusals, demands, and comments or statements.
     
2. 
   Nurse's reaction—the nurse's nonobservable response to the patient's behavior. The three dimensions are:
   
   • Perception—physical stimulation of any one of the five senses by the patient's behavior.
     
   • Thought—an idea that occurs in the nurse's mind.
     
   • Feeling—a state of mind inclining the nurse toward or against a perception, thought, or action; occurs in response to the nurse's perceptions and thoughts.
     
3. 
   Nurse's activity—the observable actions taken by nurses in response to their reactions, including instructions, suggestions, directions, explanations, information, requests, and questions directed toward the patient; making decisions for the patient; handling the patient's body; administering medications or treatments; and changing the patient's immediate environment. The two dimensions of nurse's activity are:
   
   • Automatic nursing process—actions decided on by the nurse for reasons other than the patient's immediate need.
     
   • Deliberative nursing process (process discipline)—a specific set of nurse behaviors or actions directed toward the patient's behavior that ascertain or meet the patient's immediate needs for help.
     

Implications for Nursing Practice
Nursing practice is directed toward identifying and meeting the patient's immediate needs for help through use of Orlando's Practice Methodology.

• 
  Observationsencompass any and all information pertaining to a patient that the nurse acquires while on duty.
  Direct Observations are the nurse's reaction to the patient's behavior. Direct observations are any perception, thought, or feeling the nurse has from his or her own experience of the patient's behavior at any or several moments in time.
  Indirect Observations consist of any information that is derived from a source other than the patient. This information pertains to, but is not directly derived from, the patient. Actions are carried out with or for the patient
  Nurse's Activity: Deliberative Nursing Process—The process used to share and validate the nurse's direct and indirect observations is the Deliberative Nursing Process. Clinical protocols contain the specific requirements for the Deliberative Nursing Process. The nurse may express and explore any aspect of his or her reaction to the patient's behavior—perception, thought, or feeling. If exploration of one aspect of the nurse's reaction does not result in identification of the patient's need for help, then another aspect of the reaction can be explored. If exploration of all aspects of the nurse's reaction does not yield a verbal response from the patient, then the nurse may use negative expressions to demonstrate continued interest in the patient's behavior and to give the patient permission to respond with his or her own negative reaction. Examples of negative expressions by the nurse are: Is it that you don't think I'll understand? Am I wrong? It looked like that procedure was very painful, and you didn't say a word about it.
  Direct Help—The nurse meets the patient's need directly when the patient is unable to meet his or her own need and when the activity is confined to the nurse-patient contact
  Indirect Help—The nurse meets the patient's need indirectly when the activity extends to arranging the services of a person, agency, or resource that the patient cannot contact by himself or herself.
  
• 
  ReportingThe nurse receives reports about the patient's behavior from other nurses, and from other health professionals. The nurse reports his or her observations of the patient's behavior to other nurses and other health professionals.
  
• 
  RecordingThe nurse records the nursing process, including: the nurse's perception of or about the patient; the nurse's thought and/or feeling about the perception; what the nurse said and/or did to, with, or for the patient.
  

Implications for Nursing Education
Students should be trained in the use of the deliberative nursing process for all person-to-person contacts. The purpose of training is to change the nurse's activity from personal and automatic to disciplined and professional. Training is facilitated by use of process recordings that include perceptions of or about the patient, thoughts and/or feelings about the perception, and what was said and/or done to, with, or for the patient. The process discipline can be successfully taught in 6 to 12 weeks.

References

• Orlando, I. J. (1961). The dynamic nurse-patient relationship: Function, process and principles. New York: G. P. Putnam's Sons. [Reprinted 1990, New York: National League for Nursing.]
• Orlando, I. J. (1972). The discipline and teaching of nursing process: An evaluative study. New York: G. P. Putnam's Sons.

ROSEMARIE PARSE'S THEORY OF HUMAN BECOMING
Overview
A grand theory focusing on human experiences of participation with the universe in the cocreation of health. The concepts of the theory are:

1. 
   Human becoming—a unitary construct referring to the human being's living health.
   
2. 
   Meaning—the linguistic and imagined content of something and the interpretation that one gives to something.
   
3. 
   Rhythmicity—the cadent, paradoxical patterning of the human-universe mutual process.
   
4. 
   Transcendence—reaching beyond with possibles—the hopes and dreams envisioned in multidimensional experiences [and] powering the originating of transforming.
   
5. 
   Imaging—reflective/prereflective coming to know the explicit/tacit all-at-once.
   
6. 
   Valuing—confirming/not confirming cherished beliefs in light of a personal world view.
   
7. 
   Languaging—signifying valued images through speaking/being silent and moving/being still.
   
8. 
   Revealing/Concealing—disclosing/not disclosing all-at-once.
   
9. 
   Enabling/Limiting—living the opportunities/restrictions present in all choosings all-at-once.
   
10. 
    Connecting/Separating—being with and apart from others, ideas, objects, and situations all-at-once.
    
11. 
    Powering—the pushing/resisting process of affirming/not affirming being in light of nonbeing.
    
12. 
    Originating—inventing new ways of conforming/nonconforming in the certainty/uncertainty of living.
    
13. 
    Transforming—shifting the view of the familiar/unfamiliar, the changing of change in coconstituting anew in a deliberate way.
    

The three major principles of the theory of human becoming are:

1. 
   Structuring meaning multidimensionally is cocreating reality through the languaging of valuing and imaging—means that humans construct what is real for them from choices made at many realms of the universe.
   
2. 
   Cocreating rhythmical patterns of relating is living the paradoxical unity of revealing-concealing and enabling-limiting while connecting-separating—means that humans live in rhythm with the universe coconstituting patterns of relating.
   
3. 
   Cotranscending with the possibles is powering unique ways of originating in the process of transforming—means that humans forge unique paths with shifting perspectives as a different light is cast on the familiar.
   

Implications for Nursing Practice
Nursing practice is directed toward respecting the quality of life as perceived by the person and the family. The practice methodology is as follows:

• 
  Principle 1: Structuring meaning multidimensionally. Illuminating Meaning: explicating what was, is, and will be. Explicating: making clear what is appearing now through languaging.
  
• 
  Principle 2:Cocreating rhythmical patterns. Synchronizing rhythms: dwelling with the pitch, yaw, and roll of the human-universe process. Dwelling with: immersing with the flow of connecting/separating.
  
• 
  Principle 3: Mobilizing transcendence: moving beyond the meaning moment with what is not-yet. Moving beyond: propelling with envisioned possibles of transforming.
  
• 
  Contexts of nursingNurse-person situations and nurse-group situations. Participants include children and adults. Locations include homes, shelters, health care centers, parish halls, all departments of hospitals and clinics, rehabilitation centers, offices, and other milieus where nurses are with people.
  
• 
  Goal of discipline of nursingis quality of life from the person's, family's, and community's perspective.
  
• 
  Goal of the human becoming nurseis to be truly present with people as they enhance their quality of lives.
  
• 
  True presenceis a special way of “being with” in which the nurse is attentive to moment-to-moment changes in meaning as she or he bears witness to the person's or group's own living of value priorities.
  Coming-to-be Present is an all-at-once gentling down and lifting up. True presence begins in the coming-to-be-present moments of preparation and attention. Preparation involves: an emptying to be available to bear witness to the other or others; being flexible, not fixed but gracefully present from one's center; dwelling with the universe at the moment, considering the attentive presence about to be. Attention involves focusing on the moment at hand for immersion.
  Face-to-face discussions—Nurse and person engage in dialogue. Conversation may be through discussion in general or through interpretations of stories, films, drawings, photographs, music, metaphors, poetry, rhythmic movements, and other expressions.
  Silent immersion—A process of the quiet that does not refrain from sending and receiving messages. A chosen way of becoming in the human-universe process lived in the rhythm of speaking–being silent, moving–being still as valued images incarnate meaning. True presence without words.
  Lingering presence—Recalling a moment through a lingering presence that arises after an immediate engagement. A reflective-prereflective “abiding with” attended to through glimpses of the other person, idea, object, or situation.
  
• 
  
  
• 
  Ways of Changing Health Patterns in True Presence
  • Creative Imagining Picturing by seeing, hearing, and feeling what a situation might be like if lived in a different way.
    
  • Affirming Personal Becoming Uncovering preferred personal health patterns by critically thinking about how or who one is.
    
  • Glimpsing the paradoxical Changing one's view of a situation by recognizing incongruities in that situation.
    
  
  
• 
  
  
• 
  
  

Implications for Nursing Education
Course content flows from the three principles of the theory. Clinical courses emphasize the knowledge and skills requisite to the application of the practice methodology. Graduate education builds on baccalaureate education and prepares specialists who concentrate on creating and testing concepts of the theory of human becoming.

References

• Parse, R. R. (1992). Human becoming: Parse's theory of nursing. Nursing Science Quarterly, 5, 35–42.
• Parse, R. R. (Ed.). (1995). Illuminations: The human becoming theory in practice and research. New York: National League for Nursing.
• Parse, R. R. (1998). The human becoming school of thought: A perspective for nurses and other health care professionals. Thousand Oaks, CA: Sage.
• Parse, R.R. (2006). Part One: Rosemarie Rizzo Parse’s human becoming school of thought. In M.E. Parker, Nursing theories and nursing practice (2nd ed., pp. 187-194). Philadelphia: F.A. Davis.

NOLA PENDER'S HEALTH PROMOTION MODEL
Overview
A middle-range theory focusing on the relation of individual characteristics and experiences, behavior-specific, cognitions and affect, commitment to a plan of action, and competing demands and preferences as to health-promoting behavior. The concepts of the theory are as follows:

1. 
   Individual characteristics and experiences—prior related behavior and inherited and acquired characteristics that influence beliefs, affect, and performance of health-promoting behavior.
   
   • Prior related behavior—a behavior, enacted in the past, that is the same as or similar to the health-promoting behavior of interest.
     
   • Personal factors—inherited and acquired biological, psychological, and sociocultural characteristics.
     
     • Personal biological factors—encompass characteristics such as age, gender, body mass index, pubertal status, menopausal status, aerobic capacity, strength, agility, and balance.
       
     • Personal psychological factors—encompass characteristics such as self-esteem, self-motivation, personal competence, perceived health status, and definition of health.
       
     • Personal sociocultural factors—encompass characteristics such as race, ethnicity, acculturation, education, and socioeconomic status.
       
2. 
   Behavior-specific cognitions and affect—factors that act as motivators for commitment to a plan of action and performance of health-promoting behavior and that are modifiable through nursing actions.
   
   • Perceived benefits of action—perception of anticipated positive outcomes that will occur as a result of performing a health-promoting behavior. There is a positive relation between perceived benefits of action and commitment to a plan of action.
     
   • Perceived barriers to action—perception of anticipated, imagined, or real blocks and personal costs of performing a health-promoting behavior; a constraint on commitment to a plan of action.
     
   • Perceived self-efficacy—perception of personal capability to organize and execute a health-promoting behavior; the higher the perceived self-efficacy, the lower the perceived barriers to action and the higher the likelihood of commitment to a plan of action and actual performance of a health-promoting behavior.
     
   • Activity-related affect—subjective positive or negative feelings that occur before, during, or following performance of a health-promoting behavior. There is a reciprocal positive relation between affect toward a behavior and perceived self-efficacy, such that the more positive the affect, the greater the perceived self-efficacy and vice versa. There is a positive relation between affect toward a behavior and commitment to a plan of action and performance of a health-promoting behavior.
     
   • Interpersonal influences—cognitions about the behaviors, beliefs, or attitudes of significant others, including family, peers, and health care providers. Commitment to a plan of action and performance of health-promoting behavior is more likely to occur when significant others model the behavior, expect the behavior to occur, and provide assistance and support to enable the behavior. The cognitions include:
     
     • Norms that reflect expectations of significant others;
       
     • Social support, including instrumental and emotional encouragement;
       
     • Modeling, which refers to vicarious learning through observing others who are performing a health-promoting behavior.
       
   • Situational influences—personal perceptions and cognitions of a particular external environmental situation that can facilitate or impede performance of health-promoting behavior, including perceptions of options available, demand characteristics, and aesthetic environmental features.
     
3. 
   Commitment to a plan of action—intention to perform a health-promoting behavior and identification of a planned strategy that leads to performance of the behavior. There is a positive relation between commitment to a plan of action and maintenance of performance of a health-promoting behavior over time.
   
4. 
   Immediate competing demands and preferences—competing demands are alternative behaviors over which individuals have low control due to environmental contingencies, such as work or family care responsibilities; competing preferences are alternative behaviors over which individuals exert relatively high control, such as choice of a particular food for a snack or meal. Commitment to a plan of action is less likely to result in the desired health-promoting behavior when competing demands require immediate attention or when competing preferences are more attractive.
   
5. 
   Health-promoting behavior—action outcome directed toward attaining positive health outcomes.
   

Implications for Nursing Practice
Nursing practice is directed toward modification of cognitions, affect, and the interpersonal and physical environment to create incentives for health actions for people of all ages.
Implications for Nursing Education
Education for nursing practice focuses on promotion of health and prevention of illness and disease prevention. Health education strategies are emphasized.

References

• Pender, N.J., Murdaugh, C.L., & Parsons, M.A. (2006). Health promotion in nursing practice (5^th ed.). Upper Saddle River, NJ: Prentice Hall.

HILDEGARD PEPLAU'S THEORY OF INTERPERSONAL RELATIONS
Overview
A middle-range descriptive theory focusing on the phases of the interpersonal process that occurs when an ill person and a nurse come together to resolve a difficulty felt in relation to health. The one concept of the theory is nurse-patient relationship, which is an interpersonal process made up of four components—two persons, the professional expertise of the nurse, and the client's problem or need for which expert nursing services are sought, and which has three discernible phases; one phase has two subphases:

1. 
   Orientation—the phase in which the nurse first identifies himself or herself by name and professional status and states the purpose, nature, and time available for the patient; the phase during which the nurse conveys professional interest and receptivity to the patient, begins to know the patient as a person, obtains essential information about the patient's health condition, and sets the tone for further interactions.
   
2. 
   Working—the phase in which the major course occurs. The two subphases are:
   
   • 
     Identification—the subphase during which the patient learns how to make use of the nurse-patient relationship.
     
   • 
     Exploitation—the subphase during which the patient makes full use of available professional services.
     
3. 
   Termination—the phase in which the work accomplished is summarized and closure occurs.
   

Implications for Nursing Practice
Nursing practice is directed toward promoting favorable changes in patients, which is accomplished through the nurse-patient relationship. Within that relationship, the nurse's major function is to study the interpersonal relations between the patient/client and others. Peplau's clinical methodology, which can be used for both nursing practice and nursing research, is as follows:

• 
  Observation—Purpose is the identification, clarification, and verification of impressions about the interactive drama of the pushes and pulls in the relationship between nurse and patient, as they occur.
  Participant Observation—Nurse's Behavior includes observation of the nurse's words, voice tones, body language, and other gestural messages. Patient's Behavior includes observation of the patient's words, voice tones, body language, and other gestural messages
  Interpersonal phenomena include observation of what goes on between the patient and the nurse.
  
• 
  
  Reframing empathic linkages occurs when the nurse's and/or the patient's ability to feel in self the emotions experienced by the other person in the same situation is converted to verbal communications by the nurse asking: What are you feeling right now?
  Communication aims are the selection of symbols or concepts that convey both the reference, or meaning in the mind of the individual, and referent, the object or actions symbolized in the concept; and the wish to struggle toward the development of common understanding for words between two or more people.
  
• 
  Interpersonal techniques are verbal interventions used by nurses during nurse-patient relationships aimed at accomplishing problem resolution and competence development in patients.
  Principle of clarity—Words and sentences used to communicate are clarifying events when they occur within the frame of reference of common experiences of both or all participants, or when their meaning is established or made understandable as a result of joint and sustained effort of all parties concerned. Clarity in communication is promoted when the nurse and the patient discuss their preconceptions about the meaning of words and work toward a common understanding. Clarity is achieved when the meaning of a word to the patient is expressed and talked over and a new view is expanded in awareness.
  Principle of continuity—Continuity in communication occurs when language is used as a tool for the promotion of coherence or connections of ideas expressed and leads to discrimination of relationships or connections among ideas and the feelings, events, or themes conveyed in those ideas. Continuity is promoted when the nurse is able to pick up threads of conversation that the patient offers in the course of a conversation and over a longer period such as a week, and when he or she aids the patient to focus and to expand these threads.
  
• 
  Recordingis the written record of the communication between nurse and patient, that is, the data collected through participant observation and reframing of empathic linkages. The aim is to capture the exact wording of the interaction between the nurse and the patient.
  
• 
  Data analysisfocuses on testing the nurse's hypotheses, which are formulated from first impressions or hunches about the patient.
  Phases of the nurse-patient relationship—Identify the phase of nurse-patient relationship in which communication occurred.
  
• 
  Roles:Identify the roles taken by the nurse and the patient in each phase of the nurse-patient relationship.
  
• 
  Relations:Identify the connections, linkages, ties, and bonds that go on or went on between a patient and others, including family, friends, staff, or the nurse. Analyze the relations to identify their nature, origin, function, and mode.
  
• 
  Pattern integrations:Identify the patterns of the interpersonal relation between two or more people which together link or bind them and which enable the people to transform energy into patterns of action that bring satisfaction or security in the face of a recurring problem. Determine the type of pattern integration: complementary—the behavior of one person fits with and thereby complements the behavior of the other person; mutual—the same or similar behaviors are used by both persons; alternating—different behaviors used by two persons alternate between the two persons; antagonistic—the behaviors of the two persons do not fit but the relationship continues.
  

Implications for Nursing Education
Nursing is an educative instrument, a maturing force, that aims to promote forward movement of personality in the direction of creative, constructive, productive, personal, and community living. The task of each school of nursing is the fullest development of the nurse as a person who is aware of how he or she functions in a situation and as a person who wants to nurse patients in a helpful way.

References

• Peplau, H. E. (1952). Interpersonal relations in nursing. New York: G. P. Putnam's Sons. [Reprinted 1991. New York: Springer.]
• Peplau, H. E. (1992). Interpersonal relations: A theoretical framework for application in nursing practice. Nursing Science Quarterly, 5, 13–18.
• Peplau, H. E. (1997). Peplau's theory of interpersonal relations. Nursing Science Quarterly, 10, 162–167.
• Peden, A.R. (2006). Hildegard E. Peplau’s process of practice-based theory development and its applications. In M.E. Parker, Nursing theories and nursing practice (2nd ed., pp. 58-69). Philadelphia: F.A. Davis.

REVA RUBIN'S THEORY OF CLINICAL NURSING
Overview
A grand theory focusing on patients as persons undergoing subjectively involved experiences of varying degrees of tension or stress in a health problem situation. The major concepts are the situation of the patient and nursing care. Statements related to the patient situation and nursing care are:

1. Nursing care is dependent on the best estimate available of the situation of the patient.
   
2. Nursing care exists in a one-to-one relationship with the patient.
   
3. The relationship of nursing care to the situation of the patient is an ever-changing process of interaction.
   
4. The situation of the patient is expressed as a fraction or ratio that reflects the level or intensity of nursing care required.
   
   • If the situation for the patient is relatively insignificant, one that the patient can cope with quite well, then nursing care probably need not go beyond careful assessment.
     
   • If the situation for the patient is overwhelming, nursing care may have to encompass a whole series of activities to reduce the effects of the situation or reinforce the capacities of the patient in coping with the situation.
     
5. Situations within the sphere of proper nursing concern are fluid.
   

Implications for Nursing Practice
Nursing practice is directed toward helping the patient adjust to, endure, and usefully integrate the health problem situation in its many ramifications through the phenomenon of situational fluidity, which characterizes nursing care in terms of:

1. 
   Time—nursing operates within the immediate present; patient needs and behavior have an immediacy if not an urgency.
   
2. 
   Definition or diagnostic sets—nursing diagnoses are based on the definition of capacities and limitations of the persons who are patients in relation to the situations in which they find themselves.
   
3. 
   Actions—nursing actions are primarily directed toward helping the patient realign observations and expectations into a better “fit” with each other; nursing conveys a message to patients about themselves in their immediate situations.
   

Implications for Nursing Education
Education for nursing practice and nursing research emphasizes learning the naturalistic method of observation of patients in action, involved in a natural situation and setting. The learners typically are graduate students in nursing. The nurse-observer is viewed as an identifiable and functional part of the setting, as well as a helpful adjunct in the situation. The student is trained to observe while providing nursing care for the patient in a particular situation and to then record the entire nurse-patient interaction. The recorded observation serves as a database for evaluation of the quality and adequacy of nursing care as well as for generation of new theories.

References

• Rubin, R. (1968). A theory of clinical nursing. Nursing Research, 17, 210–212.
• Rubin, R. (1984). Maternal identity and the maternal experience. New York: Springer.

JEAN WATSON'S THEORY OF HUMAN CARING
Overview
A middle-range explanatory theory focusing on the human component of caring and the moment-to-moment encounters between the one who is caring and the one who is being cared for, especially the caring activities performed by nurses as they interact with others. The concepts of the theory are:

1. 
   Transpersonal caring relationship—human-to-human connectedness, whereby each person is touched by the human center of the other; a special kind of relationship involving a high regard for the whole person and his or her being-in-the world. The concept transpersonal caring relationship encompasses three dimensions:
   
   • Self—transpersonal-mindbodyspirit oneness, an embodied self, and an embodied spirit.
     
   • Phenomenal field—the totality of human experience, one's being-in-the-world.
     
   • Intersubjectivity—refers to an intersubjective human-to-human relationship in which the person of the nurse affects and is affected by the person of the other, both of whom are fully present in the moment and feel a union with the other.
     
2. 
   Caring occasion/caring moment—The coming together of nurse and other(s), which involves action and choice both by the nurse and the other. The moment of coming together in a caring occasion presents them with the opportunity to decide how to be in the relationship—what to do with the moment.
   
3. 
   Caring (healing) consciousness—A holographic dynamic that is manifest within a field of consciousness, and which exists through time and space and is dominant over physical illness.
   
4. 
   Clinical Caritas Processes—those aspects of nursing that actually potentiate therapeutic healing processes for both the one caring and the one being cared for. The 10 carative factors are:
   
   • Practice of loving kindness and equanimity within the context of caring consciousness
     
   • Being authentically present and enabling and sustaining the deep belief system and subjective life world of self and one-being-cared-for
     
   • Cultivation of one’s own spiritual practices and transpersonal self, going beyond ego self, opening to others with sensitivity and compassion
     
   • Developing and sustaining a helping-trusting, authentic caring relationship
     
   • Being present to, and supportive of, the expression of positive and negative feelings as a connection with deeper spirit of self and the one-being-cared-for
     
   • Creative use of self and all ways of knowing as part of the caring process; to engage in artistry of caring-healing practices
     
   • Engaging in genuine teaching-learning experience that attends to unity of being and meaning, attempting to stay within others’ frames of reference
     
   • Creating healing environments at all levels (physical as well as non-physical, subtle environment of energy and consciousness, whereby wholeness, beauty, comfort, dignity, and peace are potentiated)
     
   • Assisting with basic needs, with an intentional caring consciousness, administering “human care essentials,” which potentiate alignment of mind-body-spirit, wholeness, and unity of being in all aspects of care, tending to both embodied spirit and evolving spiritual emergence
     
   • Opening and attending to spiritual-mysterious, and existential dimensions of one’s own life-death; soul care for self and the one-being-cared-for
     

Implications for Nursing Practice
Nursing practice is directed toward helping persons gain a higher degree of harmony within the mind, body, and soul, which generates self-knowledge, self-reverence, self-healing, and self-care processes while increasing diversity, which is pursued through use of the 10clinical caritas processes.

• 
  Requirements for a Transpersonal Caring Relationship:
  • The nurse considers the person to be valid and whole, regardless of illness or disease, and makes a moral commitment and directs intentionality and consciousness to the protection, enhancement, and potentiation of humanity, wholeness, and healing, such that a person creates or co-creates his or her own meaning for existence, healing, wholeness, and caring.
    
  • The nurse orients intent, will, and consciousness toward affirming the subjective/ intersubjective significance of the person; a search to sustain mind-body-spirit unity and I/Thou versus I/It relationships.
    
  • The nurse has the ability to realize, accurately detect, and connect with the inner condition (spirit) of another.
    
  • The nurse recognizes that actions, words, behaviors, cognition, body language, feelings, intuition, thought, senses, and the energy field gestalt all contribute to the interconnection.
    
  • The nurse has the ability to assess and realize another's condition of being in the world and to feel a union with the other. This ability is translated via movements, gestures, facial expressions, procedures, information, touch, sound, verbal expressions, and other scientific, aesthetic, and human means of communication into nursing art acts wherein the nurse responds to, attends to, or reflects the condition of the other. Drawn from the ontological caring consciousness stance and basic competencies of the nurse, this ability expands and translates into advanced caring healing modalities, nursing arts, advanced nursing therapeutics, and healing arts.
    
  • The nurse understands that the caring healing modalities potentiate harmony, wholeness, and comfort and produce inner healing by releasing some of the disharmony and blocked energy that interfere with the natural healing processes. Transpersonal caring-healing modalities include intentional conscious use of auditory modalities (music, sounds of nature, wind, sea, chimes, chants, familiar sounds), visual modalities (light, color, form, texture, works of art), olfactory modalities (aromatherapy, breathwork, breathing fresh air, inhalation-exhalation), tactile modalities (acupressure, body therapy, caring touch, foot reflexology, shiatsu, therapeutic massage), gustatory modalities (foods in one’s diet), mental-cognitive modalities (importance of mind and imagination through story), kinesthetic modalities (basic skin care, deep massage and other body work, movement, dance, yoga, Tai Chi, applied kinesiology, chiropractic), caring consciousness modalities (physical presence, psychological presence, therapeutic presence).
    
  • The nurse understands that his or her own life history and previous experiences, including opportunities, studies, consciousness of having lived through or experienced human feelings and various human conditions, or of having imagined others' feelings in various circumstances, are valuable contributors to the transpersonal caring relationship.
    
  • 
    Authentic Presencing: The nurse is authentically present as self and other in a reflective mutuality of being and becoming and centers consciousness and intentionality on caring, healing, and wholeness, rather than on disease, problems, illness, complications, and technocures.
    The nurse attempts to stay within the other's frame of reference, join in a mutual search for meaning and wholeness of being, and potentiate comfort measures, pain control, a sense of well being, or spiritual transcendence of suffering.
    

Implications for Nursing Education
Professional nursing education should be at the postbaccalaureate level of the Doctorate of Nursing (N.D.). The nature of human life is the subject matter of nursing. The curriculum acknowledges caring as a moral ideal and incorporates philosophical theories of human caring, health, and healing. Core areas of content are the humanities, social-biomedical science, and human caring content and process. Courses should use art, music, literature, poetry, drama, and movement to facilitate understanding of responses to health and illness as well as to new caring-healing modalities.

References

• Watson, J. (1985). Nursing: Human science and human care. A theory of nursing. Norwalk, CT: Appleton-Century-Crofts. [Reprinted 1988. New York: National League for Nursing]
• Watson, J. (1996). Watson's theory of transpersonal caring. In P. Hinton Walker & B. Neuman. (Eds.), Blueprint for use of nursing models (pp. 141–184). New York: NLN Press.
• Watson, J (1997). The theory of human caring: Retrospective and prospective. Nursing Science Quarterly, 10, 49–52.
• Watson, J. (2006). Part One: Jean Watson’s theory of human caring. In M.E. Parker, Nursing theories and nursing practice (2nd ed., pp. 295-302). Philadelphia: F.A. Davis.

SOURCE: Adapted from overviews written by Jacqueline Fawcett for the videotape and CD-ROM series, The Nurse Theorists: Portraits of Excellence, produced by Studio Three, Samuel Merritt College of Nursing, Oakland, CA, and funded by the Helene Fuld Health Trust (1987–1990); and from Fawcett, J. (2005). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories. (2nd ed.). Philadelphia: F.A. Davis.