Drawing from Mezirow’s early work (1975, 1978) in the development of adult learning theory, Rogers (1989), a Canadian nurse who is not related to the theorist who developed the Science of Unitary Human Beings, explained that perspective transformation is based on the assumption that each person has a particular meaning perspective that is used to interpret and understand the world. She defined and described perspective transformation as the process:

whereby the assumptions, values, and beliefs that constitute a given meaning perspective come to consciousness, are reflected upon, and are critically analyzed. The process involves gradually taking on a new perspective along with the corresponding assumptions, values, and beliefs. The new perspective gives rise to fundamental structural changes in the way individuals see themselves and their relationships with others, leading to a reinterpretation of their personal, social, or occupational worlds (p. 112).

Thus the process of perspective transformation involves the shift from one meaning perspective or frame of reference about nursing and nursing practice to another, from one way “of viewing and being with human beings” to another (Nagle & Mitchell, 1991, p. 22).

Rogers (1989) points out that the cognitive and emotional aspects of perspective transformation represent a major change for each nurse. Moreover, she underscores the importance of recognizing, appreciating, and acknowledging that during the process of perspective transformation, each nurse evolves from feeling “a [profound] sense of loss followed by an ultimate sense of liberation and empowerment” (Rogers, 1992b, p. 23). Clearly, perspective transformation requires considerable effort and a strong commitment to change (Nagle & Mitchell, 1991).

Perspective transformation encompasses nine phases: stability, dissonance, confusion, dwelling with uncertainty, saturation, synthesis, resolution, reconceptualization, and return to stability (Rogers, 1992b). The prevailing period of stability is disrupted when the idea of implementing nursing conceptual model–based or nursing theory–based nursing practice or changing the model or theory is introduced. Dissonance occurs as the nurse begins to examine his or her current frame of reference for practice in light of the challenge to adopt or change a conceptual model or theory. As the nurse begins to learn the content of the new conceptual model or theory, he or she begins to appreciate the discrepancy between the current way of practice and what nursing practice could be. A phase of confusion follows. As the nurse struggles to learn more about the model or theory and its implications for practice, a feeling of “lying in limbo” between frames of reference prevails (Rogers, 1992b, p. 22). Throughout the phases of dissonance and confusion, the nurse often feels anxious, angry, and unable to think. Rogers (1992b) explained that these distressing emotions “seem to arise out of the grieving of a loss of an intimate part of the self. The existing [frame of reference] no longer makes sense, yet the new [model or theory] is not sufficiently internalized to provide resolution” (p. 22).

The phase of confusion is followed by the phase of dwelling with uncertainty. At this point, the nurse acknowledges that confusion “is not a result of some personal inadequacy” (Rogers, 1992b, p. 22). As a consequence, anxiety is replaced bya “feeling of freedom to critically examine old ways and explore the new [model or theory]” (Rogers, 1992b, p. 22). The phase of dwelling with uncertainty is spent immersed in information that often seems obscure and irrelevant. It is a time of “wallowing in the obscure while waiting for moments of coherence that lead to unity of thought” (Smith, 1988, p. 3).

The phase of saturation occurs when the nurse feels that he or she “cannot think about or learn anything more about the nursing [model or theory]” (Rogers, 1992b, p. 22). The phase does not represent resistance but rather “the need to separate from the difficult process of transformation, [which] is part of the natural ebb and flow of the learning experience” (Rogers, 1992b, p. 22).

The phase of synthesis occurs as insights render the content of the new conceptual model or theory coherent and meaningful. The formerly obscure practice implications of the conceptual model or theory become clear and worthy of the implementation effort. Increasing tension is followed by exhilaration as insights illuminate the connections between the content of the conceptual model or theory and its use in nursing practice (Rogers, 1992b; Smith, 1988). As Smith (1988) explains, “These insights are moments of coherence, flashes of unity, as though suddenly the fog lifts and clarity prevails. These moments of coherence push one beyond to deepened levels of understanding” (p. 3).

The phase of resolution is characterized by “a feeling of comfort with the new nursing [model or theory]. The feelings of dissonance and discontent…are resolved and the anxiety is dissipated” (Rogers, 1992b, p. 23). During this phase, “nurses describe themselves as changed, as seeing the world differently and feeling a distinct sense of empowerment” (Rogers, 1992b, p. 23).

The phase of reconceptualization occurs as the nurse consciously reconceptualizes nursing practice using the new nursing conceptual model or theory (Rogers, 1992b). During this phase, the nurse compares the activities of practice—from patient assessment through shift reports—according to the old and new ways of thinking and changes those activities so that they are in keeping with the new model or theory. The final phase, return to stability, occurs when nursing practice is clearly based on the new nursing conceptual model or theory.

Rogers (1989) identified several strategies that can be used to facilitate perspective transformation. These strategies are especially effective during the early phases of perspective transformation, when the nurse is moving from the original to the new frame of reference for practice.

One strategy is to use analogies to facilitate understanding of the terms conceptual model and theory. Analogies such as a chair or book can be used for concepts (conceptual), the analogy of a model home or model airplane can be used for models, and the analogy of a conjecture can be used for theory. Rogers (1989) notes that the acts of conceptualizing and theorizing can be demystified “by stating that it is not a process reserved for intellectuals but rather a cognitive process of all humans that begins in infancy as a baby puts together all the pieces to form the concept of mother” (p. 114).

Two other strategies are directed toward identification of the nurse’s existing frame of reference for nursing practice. One of those strategies is to list words thatreflect the nurse’s view of nursing practice. Similarly, the nurse could depict his or her view of nursing practice in drawings or collages of photographs. Another strategy is to think about the details of, reasons for, and outcomes of a recent interaction with a patient.

Once the nurse has gained a clear understanding of the original frame of reference, he or she needs to explore the difference between the current state of nursing practice and what practice would be like if he or she were using the new conceptual model or theory. This can be accomplished through the use of provocative strategies. One provocative strategy is to think about how situations such as childbirth and death are currently managed and how they could be managed using the new model or theory. Another strategy is to describe what is unique about nursing practice or what would be done if physicians’ orders did not need to be followed.

Rogers (1989) notes that as the nurse becomes aware of the differences between the present and the potential future practice of nursing, he or she experiences cognitive dissonance or discomfort that comes from “the awareness of the ‘what is’ versus ‘what [c]ould be’ ” (p. 115). She concludes by noting that when cognitive dissonance “has been experienced by nurses both individually or collectively, then perspective transformation can occur, and a climate for the implementation of a nursing [model or theory] will have been created” (p. 116).

Subsequent stages of perspective transformation and the implementation of conceptual model–based or theory-based nursing practice are facilitated by constant reinforcement. Accordingly, all nursing activities should be tied to the conceptual model or theory in a systematic manner. The novice user of an explicit conceptual model or theory should not become discouraged if initial experiences seem forced or awkward. Adoption of an explicit nursing conceptual model or theory requires restructuring the nurse’s way of thinking about clinical situations and use of a new vocabulary. However, repeated use of the model or theory should lead to more systematic and organized endeavors. Broncatello (1980) comments:

The nurse’s consistent use of any model [or theory] for the interpretation of observable client data is most definitely not an easy task. Much like the development of any habitual behavior, it initially requires thought, discipline, and the gradual evolvement of a mind set of what is important to observe within the guidelines of the model [or theory]. As is true of most habits, however, it makes decision making less complicated (p. 23).

Perhaps the most effective strategy for facilitating perspective transformation is the widespread use of attending nurses or patient care facilitators (PCFs). Attending nurses are nurses who are with people continually wherever they are—“in and outside of institutions, schools, homes, clinics, and community settings” (Watson, 1996, p. 163). Thus the patient always has his or her own nurse, who collaborates with other health professionals when the participant requires services from others. The Attending Nurse Caring Model, which is based on Watson’s theory of human caring (see Chapter 6), is just one example of how attending nurses might function and enhance nursing practice in service to human beings (Watson & Foster, 2003). PCFs, who are part of a model of patient care also based on Watson’s theoryof human caring, are similar to attending nurses, although their responsibilities are limited to care of hospitalized patients. More specifically, PCFs are nurses who:

provide leadership to a team of nurses assigned geographically in one segment (approximately 12-16 beds) of the [hospital], and whose primary job was to know each of the patients in this geographic area, acting as their advocate during the course of their stay…. The PCF acts as a liaison for physicians, nurses, and other involved members of the healthcare team…to coordinate the plan of care for each of the patients…. The PCF also becomes the one consistent nurse that patients and families identify with during the course of their stay (Clark, 2004, p. 107).

The methodology of nursing conceptual model–based or nursing theory–based nursing practice is operationalized by the documents and technology used to guide and direct nursing practice, to record observations and results of interventions, and to describe and evaluate nursing job performance. The methodology encompasses nursing practice standards, department and unit objectives, nursing care plans, care maps, patient database and classification tools, flow sheets, Kardex forms, computer information systems, electronic health records, quality assurance tools, nursing job description and performance appraisal tools, and other relevant documents and technologies (Fawcett, 1992; Fitch, Rogers, Ross, et al., 1991; Laurie-Shaw & Ives, 1988; Weiss & Teplick, 1993). Each existing document and all current technology must bereviewed for congruence with the nursing conceptual model or theory and revised as necessary. Although revisions often are needed and the work may seem overwhelming at the outset, the importance of having documents and technologies that are congruent with the conceptual model or theory cannot be overemphasized. Indeed, congruence may be regarded as the sine qua non of nursing conceptual model–based or nursing theory–based nursing practice. Although at least one computer software program (Bliss-Holtz, Taylor, & McLaughlin, 1992) and many practice documentation tools (Fawcett & DeSanto-Madeya, 2013; Nelson & Watson, 2012; Watson, 2009; Weiss & Teplick, 1993) have been developed, systematic research to determine the utility of the software and the reliability and validity of the tools is needed.

The evidence needed for evidence-based nursing practice must be nurse-sensitive. That is, the evidence must connect nursing actions to patient outcomes. The documentation of nursing conceptual model–based or nursing theory–based practice can provide the required empirical evidence of nurse-sensitive patient outcomes. For example, Poster and Beliz (1988, 1992) found that 90% of the 38 adolescent psychiatric inpatients studied had an adaptive change in at least one behavioral subsystem after 1 week of Johnson’s (1990) Behavioral System Model–based nursing practice. Furthermore, on average, the patients demonstrated significant improvement in all behavioral subsystems during the discharge phase of hospitalization. Dee, van Servellen, and Brecht (1998) added empirical research evidence of Johnson’s Behavioral System Model–based nursing practice with their findings of improvement in all behavioral subsystems for inpatients under managed behavioral health care contracts. Their study results revealed statistically significant differences in the dependency, affiliative, aggressive/protective, and achievement subsystems from admission to discharge.

Another potential outcome of nursing conceptual model–based or nursing theory–based nursing practice is the nurse’s increased satisfaction with the conditions and outcomes of his or her nursing practice through an explicit focus on and identification of nursing problems and actions and through enhanced communication and documentation (Fitch, et al., 1991). Still another potential outcome is increased satisfaction by patients and their families with the nursing they receive. The evidence regarding nurse, patient, and family satisfaction is primarily in the form of anecdotal comments from a few clinical agencies (e.g., Scherer, 1988; Studio Three, 1992). However, empirical evidence has emerged. For example, Moreau, Poster, and Niemela (1993) report that Johnson’s (1990) Behavioral System Model–based nursing practice was well received by nurses and members of the multidisciplinary team. Moreover, the nurses reported an increase in job satisfaction and retention and a decrease in role conflict. Niemela, Poster, and Moreau (1992) reported that the nurses experienced increased general satisfaction and role clarity and decreased role tension. In addition, the nurses reported that they increased communication with patients’ family members.

Additional empirical evidence comes from Messmer’s (1995) report of an increase in female patients’ satisfaction with nursing on a general surgical inpatient pilot unit that implemented King’s (1981) Conceptual System–basednursing practice compared with the satisfaction of patients on two other units that were not yet using the framework. Still other empirical evidence comes from Hanucharurnkul and Vinya-nguag (1991), who found that patients who received a nursing intervention based in part on King’s (1981) Theory of Goal Attainment reported greater satisfaction with nursing than those who did not receive the intervention.

A plethora of instruments have been designed to measure nurse and patient satisfaction. However, few of these instruments (e.g., Marckx, 1995) measure satisfaction with nursing practice that is based on an explicit nursing conceptual model or theory. Thus reliable and valid instruments need to be developed before more systematic, multisite studies, which are necessary to fully document nurse, patient, and family satisfaction, are undertaken.

The literature associated with the nursing conceptual models and theories included in this text challenges nurses to consider each conceptual model and theory for possible expansion of application to a wide range of nursing specialties and for many different patient populations (see Chapters 2 and 21). Aggleton and Chalmers (1985) noted that the literature:

“might encourage some nurses to feel that it does not really matter which model of nursing is chosen to inform nursing practice within a particular care setting” (p. 39). They also noted that the literature might “encourage the view that choosing between models is something one does intuitively, as an act of personal preference. Even worse, it might encourage some nurses to feel that all their everyday problems might be eliminated were they to make the ‘right choice’ in selecting a particular model for use across a care setting” (p. 39).

However, critical appraisals of the literature have not yet revealed the extent to which the fit of the conceptual model or theory to particular patient populations might have been forced. Indeed, the issue of forced fit has not yet been addressed in the literature. This is an area for future research.

Furthermore, little attention has been given to the extent to which a particular conceptual model or theory is modified to fit a given situation (C. Germain, personal communication, October 21, 1987). Although modifications certainly are acceptable, they should be acknowledged, and serious consideration should be given to renaming the conceptual model or theory to indicate that modifications have been made. Clearly, systematic exploration of the practice implications of various conceptual models, coupled with more practical experience with each model and theory in a variety of settings, is required.