Whenever the topic of nursing theory comes up, some nurses ask, “Why do I need a theory? Isn’t being holistic enough?” These are very important questions. Nurses committed to holism are kind and compassionate nurses who share a philosophy that emphasizes a balance between self-care and the ability to care for patients using the interconnectedness of body, mind, and spirit. Theory suggests—in fact demands—that nurses reflect on philosophy and consider how their practice is working (or not working) to achieve holistic ideals. One author writes that use of theory requires reflection and is a precondition for professional practice: “Theory is a purposeful form of abstract thinking essential to a discipline and, by definition, a characteristic of the professional nurse.”⁵

The description of holistic nursing developed by the American Holistic Nurses Association (AHNA) states, “Holistic nursing practice draws on knowledge, theories, expertise, intuition, and creativity.”⁶ All five elements are necessary for the nurse to function in an ideal way: nursing knowledge is essential for the understanding of health and disease states and the various regimens required to achieve health. Theories enable one to reflect on practice and to consider carefully all alternatives of care. Expertise is necessary to perform nursing skills and for the ability to make accurate assessments and decisions about care. Intuition is needed to understand the client and to appreciate the subjective experiences of others. Creativity is helpful in solving care problems that seem insurmountable; it provides the nurse with novel ideas and ways of being with clients. Each one of these elements is as important as the others. Knowledge and theory are cognitive tools that help the nurse understand and reflect on practice. Expertise is an experiential tool that comes from practice and a significant number of encounters in nurse-client situations. Intuition and creativity are affective tools that lead the nurse to feel, experience, and follow inner guidance when working with clients.

Professional practice requires that nurses use these five elements to achieve the best possible results. A holistic nurse can move back and forth between intuitive knowing and logical reasoning, between a creative approach to care and a standard care protocol, and between a hunch of what to do and a considered direction grounded in the predictions of a theory. All of the elements of practice come only by learning how to use them. Table 5-1 presents a summary of the five elements of holistic nursing practice.

Holistic nurses entered the 21st century in a healthcare system committed to evidence-based practice as if evidence was new and all of healthcare quality issues could be remedied by a bit of attention to “evidence.” That movement has progressed and, in acknowledgment of the fact that much of what holistic nurses do does not have clear evidence, the movement has been retitled evidence-informed practice. Certainly, basing practice decisions on sound knowledge, evidence, and reasoning is very positive. No educated nurse would dispute the need to know the current literature and make use of research findings as applied to practice decisions. Nonetheless, this movement seems to have decreased the emphasis on philosophy, theory, and interpretation. This writer has had experiences where nurses assert that they have little need for theory or for understanding of the caring or holistic aspects of the discipline simply because they believe they should
attend to evidence alone. Further, some current schools of nursing have dropped their courses or emphasis on nursing theory as something no longer required for professional practice. Such developments erode the fundamental nature of our professional practice because the essence of that practice is reflection on one’s work. Once a nurse embraces the complexities of the lived experiences of clients and accepts ways of knowing that include aesthetics, personal and ethical knowledge as well as empirical knowledge, the nurse needs a means to assemble the ideas, concepts, thoughts, and feelings that originate from practice in a way that is coherent and personally meaningful. It is through the use of theory that one does just that. Theory provides the nurse with a framework from which to understand and make meaning out of complex experiences. Theory also provides guidance in practice—guidance to consider alternate explanations for what is observed and alternate ways of addressing concerns. At a time of evidence-informed practice, theory could never be more important. For the holistic nurse, practice ignoring theory is as unacceptable as practice ignoring evidence.

Theories develop over time as a theorist defines concepts, suggests relationships between concepts, tests and evaluates the relationships, and modifies the theory based on research findings. When the theorist provides definitions of the concepts and suggests possible relationships, the work is called a conceptual model. Some writers find the distinction between a theory and a conceptual model irrelevant,⁷ and for purposes of this chapter, all works are called theories. It is important, however, for nurses to understand that theories develop and mature and that they pass through the following various stages serving increasingly complex purposes:

Most nursing theories are developed to the stage of description and explanation, and theorists and researchers are currently developing nursing theories to the stages of prediction and prescription. Concepts and relationships of a theory can be evaluated and tested through research. For example, if a theory states that a person is a human energy field and suggests that there is an exchange of energy between two persons, research can be designed to evaluate such an exchange. For a theory to reach the stages of prediction and prescription, a considerable body of research is needed.

Florence Nightingale gave nursing the first published theory by which to reflect on nursing. She presented views on concepts important to nursing and directed nurses in the provision of care. To Nightingale, the overarching goal of nursing care is putting patients in the best condition for nature to act on them. She believed that Nursing is a calling. Health is the “positive of which pathology is the negative.”^4p74 Environment is emphasized in relation to healing properties of the physical environment, such as fresh air, light, warmth, and cleanliness. Person is described in relationship to the environment; the person is the recipient of nursing care. In relation to healing, Nightingale wrote, “Nature alone cures.”^4p74

For Nightingale, the focus of nursing care was the creation of an environment so that natural healing may take place. Cleanliness, fresh air, and order are emphasized, as are the patient’s needs for nutrition. Although not stated as such in her writings, Nightingale and her nurses regularly
provided emotional and interpersonal supports. The images of Nightingale with her lamp attending to patients’ needs at night, writing letters for them, and being present as a caring nurse are as much a part of her theory of practice as preparing food and cleaning the sick room. Another important aspect of care for Nightingale is recognition of the spiritual nature of people. Deeply spiritual herself, Nightingale believed that nursing involves listening to God’s instructions, moral ideals, and devotion to humanity.⁹

Although Nightingale did not develop her theory in the same sophisticated manner as our modern theories are developed, her work stands as a remarkable treatise on reflective and thoughtful practice. Nurses today often are surprised by the accuracy of her directions in guiding current practice. The theory has been studied and modernized by nurse scholars who have described it in terms of theory development used today. Selanders first noted that “the principle of environmental alteration has served as a framework for research studies.”¹⁰ Later, Selanders noted that Nightingale’s work forms a model that is useful in practice as well as in the conceptualization of research studies.¹¹ Selanders’s notions were validated by the work of a research team that recently documented the application of the basic principles of sunlight, fresh air, and cleanliness that led to healing when working with migrant workers who had foot infections.¹² Nightingale’s theory is clearly a wonderful heritage for holistic nurses. A definitive statement on Nightingale’s life and work is available in a biography prepared by Dossey.¹³

In 1983, Helen Erickson and her colleagues published a theory and paradigm for nursing called the Modeling and Role-Modeling Theory.¹⁴ The theory draws on work from many theoretical perspectives, including Maslow’s Basic Needs, Erikson’s Stages of Development, Piaget’s Theory of Cognitive Development, and Selye’s Stress Theory. The work of the psychiatrist Milton Erickson, the father-in-law of the theory’s senior author, provided a perspective of the mind-body connection in health, healing, and disease. His work also supports the belief that the most important thing a professional can do is understand the world from the client’s perspective.

According to this theory, Nursing is a process that demands an interpersonal and interactive relationship with the client. Facilitation, nurturance, and unconditional acceptance must characterize the nurse’s caregiving. The human Person is seen as a holistic being with interacting subsystems (biological, psychological, social, and cognitive) and with an inherent genetic base and spiritual drive; the whole is greater than the sum of its parts. Health is a dynamic equilibrium between subsystems. Environment is seen as both internal and external; environment includes stressors as well as resources for adapting to them.

The client is seen as an individual with strengths that can and should be used to mobilize resources to adapt to stress. Adaptive potential is a theory-specific term used to describe conditions of adaptation-equilibrium (which can be adaptive or maladaptive), arousal, or impoverishment. The theory presents five aims of all nursing interventions: (1) to build trust, (2) to promote positive orientation, (3) to promote perceived control, (4) to promote strengths, and (5) to set mutual goals that are health directed. The nurse uses this theory by creating a model of the client’s world (modeling) and using that model to plan interventions and to demonstrate and support health-producing behaviors from within the client’s worldview (role modeling). Some of the research on the theory has focused on understanding the self-care actions and autonomy among specific populations of patients.¹⁵,¹⁶ In her reflections, Erickson emphasizes that the client’s self-knowledge should be the nurse’s primary source of information. She writes, “People have an inherent ability to grow and become the most that they can be, but they sometimes need help discovering what they are not consciously aware of but already know at some level in their being.”¹⁷ Within this theory, our ability to trust in the client’s self-care knowledge is where nursing begins.