WE HAVE COME a long way since the introduction of the World Wide Web. The internet has diminished boundaries of physical space and time in a giant step toward a world of no boundaries. Views from outer space support this perspective. We experience nearly instantaneous communication in multiple directions around the world, without regard for time of day, and across barriers imposed by institutional structures. But these advances in globalization are not without ideological boundaries, in the world in general and in nursing in particular. The purpose of this article is to acknowledge the ways in which we create barriers to the understanding of nursing praxis and to recognize the connectedness of emerging nursing theories.
We have a tendency to dichotomize things. Even Florence Nightingale subtitled her classic treatise on nursing: What It Is and What It Is Not. 1 But Martha Rogers intuitively sensed the unitary nature of things. 2 Dialogue with her in the late sixties propelled consideration of health as a unitary concept. When she said that health and illness were simply expressions of the life process, my response was “oh, yes, opposite ends of the spectrum.” No, she said. I contemplated her answer and with renewed fervor posed “then opposite sides of a coin.” No, she said. Martha understood that opposites create boundaries and that there were no boundaries between health and illness. I had to give up my way of viewing things as opposites.
Ken Wilber led the way in pointing out that a world of opposites is a world of conflict and that a typical way of trying to solve the problem of opposites is to eradicate one of the opposites (eg, disease). 3 It is difficult to let go of the categories (boundaries) imposed on life, and health. Helpful, though, is the nature of rhythmic phenomena. It is possible to view body temperature, for instance, as fluctuating through highs and lows within a 24-hour period without labeling any of the measurements as pathological. The fluctuation represents a unitary pattern essential to life. Analogously one can begin to regard other so-called pathologies as fluctuations of the unitary process of health. Personal experience has taught me that health encompasses disease, and vice versa. It is strikingly clear that the old dichotomy between health and disease is no longer viable.
… we create a persistent alienation from ourselves, from others, and from the world by fracturing our present experience into different parts, separated by boundaries … each boundary we construct in our experience results in a limitation of our consciousness—a fragmentation, a conflict, a battle. 3(Preface)
That was the feeling I had while participating in some of the early nursing theory conferences in the late seventies and early eighties, a feeling that we were constructing boundaries between nursing theories, encouraging nurses to choose one and build their curriculum and practice on it. A competitive arena was created. Little attention was paid to the links between the theories. It was as if each stood alone. Since then, I have decried the boundaries imposed on nursing knowledge by conferences, organizations, and books that separate and isolate theorists of one persuasion from theorists of another, and also, that separate theorists and researchers from practitioners. Masson, a particularly wise practitioner, once wrote about her desire to be involved in research, her foray into the world of research conferences and journals, and her disappointment in not finding some practical information that could be of immediate use to her in practice. 4 The separation between theory, research, and practice has gone on far too long. The question for us today is how to go beyond the artificial barriers that separate them.
Things that we usually consider irreconcilable—the opposites—are like the crest and trough of a single wave; reality is not in the crest or the trough alone, but in the unity of one inseparable activity. Dividing lines (not boundaries) join and unite as well as divide and distinguish. Like light and dark, one cannot exist without the other. 3 Perhaps this is what was meant by Parse in her inclusion of paradox as important to nursing knowledge. 5 A line becomes a boundary when we forget that the inside coexists with the outside. We create boundaries where there are none and “these illusory boundaries, with the opposites they create, have become our impassioned battles.” 3(p27) A liberated person transcends opposites, like good and evil and life and death, moving to unity consciousness. According to Wilber, heaven is not all positives and no negatives, but no-opposites, ultimate reality as a union of opposites. At the highest level of consciousness, all opposites are reconciled. 6 Ultimate consciousness has been equated with love, which embraces all experience equally and unconditionally: pain as well as pleasure, failure as well as success, ugliness as well as beauty, disease as well as nondisease.
The convergence of various theories of nursing is becoming apparent. The crossover between theories of caring and the theory of health as expanding consciousness is remarkable. 7 Explication of the relationship between Watson's theory of caring and the science of unitary human beings has begun to illustrate the links between major perspectives of the discipline. 8 There is growing recognition that there are no real boundaries between nursing theories.
Within a unitary, transformative perspective, which Rogers introduced for nursing, 2 there are no boundaries. There are no boundaries between health and disease, between art and science, between research and practice, between nursing theory and nursing theory. In other fields, various approaches work under different circumstances, eg, ice packs to prevent swelling immediately after an injury, with heat later on to facilitate the healing process. The same is true for nursing theories: some have more immediate relevance; others enlighten and transform for the long term. So what is the transcendent unity of theories of nursing?
Before addressing that question directly, I will mention briefly 2 other dichotomies that pervade the nursing literature and bear noting. First, the question of art and science.
THERE IS NO BOUNDARY BETWEEN ART AND SCIENCE
Johnson, having done a thorough review of the literature on this subject, declared art and science as complementary. 9 Johnson's analysis of what she considers to be nursing art encompasses the nurse's ability to grasp meaning in patient encounters, to establish meaningful connection with the patient, to skillfully perform nursing activities, to rationally determine an appropriate course of action, and to morally conduct nursing practice. These dimensions—pattern recognition, connectedness, technical skill, rational action, and moral imperative—have been approached also as nursing science. 10 When the emphasis shifts to nursing practice (mutual process), there is no boundary between art and science.
Mitchell and Cody, advocates of Parse's human becoming school of thought, have questioned traditional boundaries between nursing art and nursing science. 11 They see art as a unitary experience that all-at-once is reflective and prereflective, rational and intuitive, and spanning all fields of knowledge. Watson, noted nursing philosopher-theorist, asserted the convergence of art and science in the caring-healing paradigm. 12 The art and science convergence has emerged as we have begun to let go of the separation of research and practice.
THERE IS NO BOUNDARY BETWEEN RESEARCH AND PRACTICE
Wilber reminded us that the scientific endeavors of naming and counting things have created a pervasive alienation and fragmentation of our world. 3 Abstractions transcended the concrete world, and another battle was launched between quantities and qualities. These classical boundaries (of classifications and measurements) were shattered as scientists began to explore the world of subatomic particles. They found that not only did these realities not fit the old physical laws, they couldn't even be located. The atom didn't exist as a separate entity but rather as “a set of relationships that reach outward to other things (emphasis added).” 3(p37) It couldn't be located because it had no boundaries.
Reality is no longer a complex of distinct “things” but of interwoven aspects of multiple phenomena. Every entity interpenetrates every other entity. We are present in what we want to study; this interconnected web of relations reveals a network of inseparable patterns. One's sense of self envelops the All: “… there is no gap between you and your experiences … there is no gap between ‘you’ and the world which is experienced…there is no separate self.” 3(p52) This revolution in science brings us to where we are today in nursing knowledge—a world of no boundaries—and the awareness of no boundaries is unity consciousness. From a temporal perspective, reality is in the present—not what went before, or comes after: “… there is only now … the present is the only thing that has no end.” 3(p59) Being fully present in the experience of the present is the crux of unity consciousness and is requisite to nursing practice/research.
Wilber equated expanding consciousness with the dissolving of boundaries. We need to recognize that unity consciousness is entirely present now. It has no boundaries. It is omnipresent. It is everything we do, from washing dishes to reading the newspaper. It is not a future state; when we seek an experience of the future, we move away from present experience. Wilber suggested, “To move away from present experience implies that you and present experience are two different things … there is nothing but the present—no beginning, no end, nothing behind it, nothing in front of it.” 3(pp153,158) The past of memory and the future of anticipation are both seen as encompassed in the present. If we accept the omnipresence of all that there is, research regarding nursing practice must be centered in the Now of the moment, not looking back for causes or forward for predictions. Being fully in the present reveals insight and action. Cowling, a Rogerian theorist-researcher-practitioner, asserted that the purpose of nursing science is both action and theory, which occur simultaneously in the mutual process of pattern identification. 13
In 1985, when Cowling, Vail, and I set out to develop a method of identifying pattern, we found ourselves engaged in a process much like practice. 14 It was research but it was also practice. Cowling went on to develop the unitary pattern appreciation models of practice and research, 15 and I took a stand that research into the nurse-client mutual process of patterning is not separate from practice. 10,14,16 It is praxis, a melding of theory, research, and practice. The response to my insistence that this type of research was practice ranged from definite rejection, based on the premise that the objectives of research and practice are distinctly different, to welcoming acceptance, as nursing researchers demonstrated that the hermeneutic, dialectic approach is at the heart of transformative nursing practice and contributes significantly to nursing knowledge. 17–19 Heron, known for his explications of cooperative inquiry, wrote:
I participate in a unitive field of being-in-a-world … there is no gap between subject and object, between perceiver, perceiving and perceived, between consciousness and its content, … between form and process, between my being and my becoming. 20(p34)
THERE ARE NO BOUNDARIES BETWEEN NURSING THEORIES
Wilber asserted that different schools of thought “represent complementary approaches to different levels of the individual,” and opposites are “complementary aspects of one and the same reality.” 3(p23) If we can let go of the boundaries we have constructed between nursing theories and examine the literature regarding the prevailing thematic concepts of the discipline, we will begin to experience unity consciousness, and all boundaries will disappear.
The process of emerging nursing knowledge is one of including and transcending that which has gone before. The literature supports the synthesis of caring and health with the underlying concepts of wholeness, pattern, mutual process, consciousness, transcendence, and transformation. The following statement, compiled from authors representing a variety of theoretical persuasions, illustrates the transcendent unity of the theories of nursing*:
The nursing mandate is to address the wholeness of the human being through caring, including a notion of health that spans all dimensions of life. 21 Health incorporates wellness, illness, well-being, and disease into a larger whole. 22 In the discipline statement, “caring in the human health experience,” caring and health can be seen as dialectically related … they merge as the process of expanding consciousness. 17 Wholeness is the starting point with caring as the moral ideal. 23 Healing is not seeking a desired wholeness but rather is realizing an inherent wholeness. 24 Healing is the process of realizing one's pattern (wholeness). 25 Pattern is central to nursing; the theories of nursing focus on life's meanings. 26 Meaning and consciousness are constitutive of person-environment integration … life has transcendent meaning. 27 Transformation comes about in the process of pattern recognition through the dialectics of theory in action. 28 Nursing as mutual process is evidenced in dialogue, which is the interpenetrability of consciousness and uniqueness of meaning in nurse-patient encounters. 29 Nursing connects with deeply felt experience and meaning, has the capacity to step into another reality, to shift experience into a different realm. 30 There is a connection between self-transcendence and personal transformation relevant to expanding consciousness. 18 Consciousness is information in the form of pattern and meaning; expanding consciousness is seen in deepening meaning, insight, new ways of relating to self and others. 19
Before leaving the focus on the discipline of nursing, I will add that there is no boundary between nursing and medicine. The acknowledgement of health as the pattern of the whole in nursing literature removes the boundary between nursing and medicine and requires a unitary perspective. This boundarylessness does not mean that there are no differences between the disciplines of nursing and medicine, but rather, as noted earlier, that they have a complementary relationship. Watson depicted nursing as the foreground and medicine as the background: “this new foreground becomes an integrating framework for the whole system.” 23(p20)
LETTING GO OF BOUNDARIES
Our nursing responsibility is to help patients let go of the artificial boundaries they have imposed on their lives and get in touch with the whole. The pattern is evolving to higher consciousness, but often one fights against it. For example, a woman who participated in one of my studies was imprisoned by the boundaries she had imposed on her life: bound by her obligations to her family, restricted and isolated from her own development as a person, feeling rejected by her children's choice of lifestyle, feeling alone and like a failure. She referred to herself as a “squirrel in a cage,” a cage of self-imposed boundaries. What she needed to do was to let go of the boundaries and allow new relationships to evolve. The need is to let go and allow the pattern to unfold.
Others support the premise of no boundaries. According to Cowling: “all things are integral—what appears to be boundary is really artificial—there is no true local event in a world of integrality.” 31(p2) Watson placed emphasis on the relational aspects of nursing, connectedness, and consciousness: “Caring and healing are about relation, not separation, about meaning …” 23(p15) Theorist Callista Roy referred to “the great gift of human consciousness” as the basis for human and environment transformations. 27(p9) Philosopher Richard Tarnas asked “How can we participate in a transformative unfolding that would lead toward a more integral world?” and answered himself: by expanding our ways of knowing and creating a hermeneutics of trust instead of suspicion. “Knowledge becomes an act of love … we are an organ of the universe's self revelation.” 32(p9) He continued: “… it is a matter of experiencing, suffering through, the struggle of opposites within our consciousness,” and “… in the spirit of Jung and Hegel, by suffering to the extreme under the great problem of opposites” to bring forth something new. 32(p10) Letting go of boundaries between theories does not eliminate their substantive contribution; rather it facilitates a coherent presentation of the discipline.
What can be said about the discipline at this point? The literature supports the following dimensions:
- caring-healing within a unitary transformative perspective
- pattern as an inclusive, transcendent phenomenon that incorporates all that has gone before and vision of the future
- interconnected theories of unfolding meaning and insight as action potential
What can each of us do to let go of the boundaries we've constructed in our knowledge and practice? For starters, one has
- to stand in the center of one's truth. This admonition comes from Jose Arguelles, the Mayan scholar who predicted the harmonic convergence. 33 It is the primary task for everyone. It involves letting go of imposed, external values and allowing one's inner voice to emerge. To do so is to fulfill one's purpose in society.
- to let go of rights and wrongs. This basic dichotomy is pervasive in society. To let go of the boundary imposed by such a distinction is to allow oneself to reach out and love others who hold values contrary to one's own and to support their action potential.
- to create a vision of a caring community from which transformation will follow. A reminder may be indicated: Transformation occurs in far from equilibrium states through disruption at the intersection between order and chaos.
As I reach the conclusion of this effort to open our hearts and minds to the boundaryless nature of nursing knowledge, I feel a deep sense of “the world is too much with us.” The world is ripe for transformation, and the profession of nursing is in a position to facilitate that transition. We must cease the binding conflict that exists in a struggle to protect false boundaries. As we explore a world of no boundaries, we will experience the compassion and creativity of unity consciousness.
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*Quotation marks have been omitted to facilitate the flow of meaning.