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Perspectives on the Unitary Transformative Person-Environment-Health Process for the Knowledge Base of Nursing

Smith, Mary Jane, PhD, RN, FAAN; Fitzpatrick, Joyce J., PhD, MBA, RN, FAAN

doi: 10.1097/ANS.0000000000000250
The Focus of the Discipline
Free

Nursing knowledge development continues to face significant challenges, as there is not yet widespread acceptance of the important role of nursing theory in research, education, and professional practice. The purpose of this article is to describe perspectives on person, environment, health from different levels of knowledge development for the discipline of nursing. The authors recommend continued discourse among nurse scholars to advance the discipline of nursing globally.

School of Nursing, West Virginia University, Morgantown (Dr Smith); and Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio (Dr Fitzpatrick).

Correspondence: Mary Jane Smith, PhD, RN, FAAN, School of Nursing, West Virginia University, Morgantown, WV 26506 (mjsmith@hsc.wvu.edu).

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

RECENTLY, nurse scholars have reaffirmed the need for defining the discipline-specific scientific knowledge base of nursing.1 , 2 Nursing-specific knowledge serves to guide further developments in theory, research, education, and professional practice. Nursing is a unique basic science; thus, it is imperative that the theoretical dimensions of nursing be delineated. Not only will these efforts strengthen the nursing discipline but will also reaffirm the unique perspective of nursing within interprofessional collaborative practice and interdisciplinary research.

In this article, we address the historical focus on the metaparadigm, nursing paradigms, disciplinary perspectives, and the predominant grand and middle-range theories, with particular attention to the definitions of persons, environment, and health as core concepts and the relationships among these concepts. Themes on global health, diversity, theoretical perspectives, and interdisciplinary issues extracted from the Advances in Nursing Science (ANS) 2008 issue on the discipline of nursing are discussed. We also review the perspective of the person-environment-health process underlying the models of care described by the American Academy of Nursing (AAN) Edge Runners, and global perspectives based on the work of nursing professional organizations. A synthesis of the knowledge generated by nursing science regarding the person-environment-health processes serves as a foundation for specific recommendations for the future, including those for further development of nursing science and professional practice.

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Statement of Significance

Nursing knowledge development continues to face significant challenges, as the effort to frame nursing knowledge in the context of a unique perspective over the past 50 years has not yet had widespread acceptance for the important role of nursing theory-guided research, education, and professional practice.

The authors synthesize the disciplinary perspectives to date and describe views on person-environment-health from different levels of nursing knowledge development. The unitary transformative person-environment-health process is proposed as a unique perspective for knowledge development in the discipline of nursing.

The authors recommend continued discourse through a surge of publications and presentations among nurse scholars to advance the unique perspective of the discipline of nursing.

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METAPARADIGM

Although there is attention to the metaparadigm of nursing in the literature, there are also competing views as to the necessity of a metaparadigm. A metaparadigm includes concepts and propositions that set forth the phenomena with which a discipline is concerned. A metaparadigm is the most general statement of a discipline and thus functions as a framework for the theoretical developments within the discipline.

In 1975, Yura and Torres3 reviewed the conceptual frameworks of 50 baccalaureate nursing programs to identify concepts commonly held by the faculty. They analyzed themes, topics, and threads in each conceptual framework. Based on these data, 4 concepts basic to the conceptual frameworks of baccalaureate programs in nursing were identified. These were man, society, health, and nursing. They defined the concepts as follows: man was defined as a bio-psycho-social-spiritual being, holistic and unique; society as family, community, the nation and environment; health as wellness and illness on a continuum, level, and or spectrum; and nursing as the nursing process including role and functions.3 (p22)

In 1984, Fawcett4 recognized the work of Yura and Torres and described what she labeled the metaparadigm of nursing. Fawcett's metaparadigm was composed of central concepts to provide direction for theory development. The central concepts were person, environment, health, and nursing. Subsequently, in 1996, Fawcett5 described 4 requirements for a metaparadigm. These requirements were (a) identify a distinctive disciplinary domain, (b) encompass all entities of interest, (c) not be inclusive of a particular perspective, and (d) represent an international scope. Newman and colleagues,6 Conway,7 Kim,8 and Watson9 critiqued the metaparadigm concepts. Specifically, Newman and colleagues6 indicated that the metaparadigm concepts were too narrow, unconnected, and did not raise questions nor stimulate inquiry. Conway argued that it is inappropriate to include nursing as a central concept in the metaparadigm when describing nursing.7 Kim's critique indicated that nursing knowledge should be structured with the concepts of client domain, client-nurse domain, practice domain, and environment domain.8 Based on her extensive explication of caring as a central concept for nursing, Watson9 postulated that human caring as the foundational ontological substance of nursing should be incorporated in the metaparadigm. Fawcett's rebuttal was that the various proposals for alternatives to the 4 metaparadigm concepts and propositions did not fulfill 1 or more of the requirements for a metaparadigm.5 (p95)

Additional views on the metaparadigm were offered by Rawnsley,10 Malinski,11 and Cody.12 Rawnsley traced the origin of metaparadigm as a construct and found that the term was omitted from philosophers and theoreticians who had contributed to the advancement of nursing. She concluded that the term metaparadigm is “simply a synonym coined for the metaphysical connotation of a disciplinary matrix.”10 (p105) She suggested, rather than focusing on the metaparadigm used by Fawcett, we focus on formation of disciplinary matrices that would generate competing descriptions of central phenomena of the discipline.10 Further, Malinski11 advocated eliminating the focus on a nursing metaparadigm since a unifying metaparadigm needs to be so general that it becomes meaningless in providing a disciplinary perspective. And Cody12 postulated that the metaparadigm as described by Fawcett offers a narrow perspective that excludes competing views.

A search of the literature over the past 15 years using the terms nursing and metaparadigm in the title and abstract produced 7 publications in the following years: 1 in 2017, 2 in 2016, 1 in 2015, 1 in 2014, and 2 in 2013. Subjects were caring science-conscious dying,13 Chinese view,14 commentary on Chinese view,15 nursing models,16 Islamic thought on human being,17 reflection on Islamic thought,18 and professional development of RN-BSN students.19 These 7 publications on the metaparadigm represent 2 publications on the topic of caring, 1 publication on the Chinese perspective on each concept, 2 publications on Islamic thought on the human being, and 1 publication each on nursing models and professional education. Even though there are limited publications using the metaparadigm terms, the metaparadigm continues to be used by schools of nursing in offering a perspective on the knowledge base of nursing. We have found that when prospective faculty are asked about their perspective on nursing, it is the metaparadigm that they describe in a general way.

The metaparadigm proposed by Fawcett4 has been with us since 1984, 34 years, and at that time it offered a way to move nursing forward. However, given the serious critique by nurse scholars, we believe it is time to let go of the metaparadigm concepts. The metaparadigm provides a rather uncomplicated and less abstract way to describe nursing that has been taken on by members of the profession. Moving beyond will take time and strategy. The title of this article suggests the unitary person-environment-health process as a perspective for the knowledge base of nursing. Thus, the metaparadigm concepts are used and reformulated as a mutual unitary process, which changes the meaning of the metaparadigm concepts taken as singularities. This means that the person is one with the family, community, and world in which he/she lives and is the context for the person's experience of health. Furthermore, this mutual process is moving and evolving in and over time.

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NURSING PARADIGMS

A paradigm is a worldview underlying theories and methodologies of a particular scientific discipline. Paradigms are ways of viewing significant entities in a domain of study. Both Parse and Newman and colleagues described paradigms in nursing. These include Parse's delineation of 3 paradigms: totality, simultaneity, and human becoming20 , 21; and Newman and colleagues' delineation of the particulate-deterministic, interactive-integrative, and unitary-transformative paradigms in nursing.6 Parse20 described the 2 paradigms in the context of extant nursing theory in her first published work on the topic: the totality and simultaneity paradigms. In the totality paradigm, persons are described as bio-psycho-socio-spiritual organisms interacting in an environment that can be manipulated to achieve balance. Health is a dynamic state and process of physical, psychological, and spiritual well-being. The goal of nursing in the totality paradigm is a focus on health promotion, care and cure of the sick, and prevention of illness. Methods for research are primarily quantitative. In the simultaneity paradigm, persons are viewed as open beings who are more than and different from the sum of the parts and relate in an environment of patterned change. Health is a process of becoming experienced by the person. The goal of nursing is to focus on quality of life from the person's perspective. Methods for research are primarily qualitative.20 In 1991, Newman and colleagues6 identified caring in the human health experience as the focus of the discipline that could be viewed from 3 paradigms extant in nursing literature. The paradigms that they described were the particulate-deterministic, interactive-integrative, and unitary-transformative paradigms.6 According to the authors, each paradigm is rooted in a different knowledge base: particulate-deterministic stems from bio-physical sciences, interactive-integrative from social sciences, and unitary-transformative from the human sciences. In the particulate-deterministic paradigm, persons are viewed as isolatable and reducible having properties that can be measured. Change is static, linear, and causal. In the interactive-integrative paradigm, persons are viewed as having multiple interrelated parts in relation to a specific environmental context. Change is reciprocal and probabilistic. Methods for research are quantitative and descriptive. In the unitary-transformative paradigm, persons are viewed as unitary, self-organizing, and embedded in an environmental energy field. Change is unidirectional and unpredictable. Methods of inquiry are descriptive and qualitative.6 Newman's thoughts on paradigms were further developed; she subsequently embraced the transformative paradigm as the unique perspective of nursing.22 She contends that caring in the human health experience is at the metaparadigm level and this perspective on caring, along with the unitary transformative perspective of persons, serves a unique foundation for inquiry and practice in nursing.

In 2008, Newman et al23 revisited the focus of the discipline of nursing and contended that there are limitations with each paradigm and that a holistic approach goes beyond the limitations of each paradigm. They proposed a framework of concepts essential to the nurse-patient relationship. They proposed that the nurse-patient relationship included the following: health is the intention, caring is the nature, consciousness is the information, mutual process is the unfolding, patterning is the configuration, presence is the resonance, and meaning is the importance.23 Integrating the focus of the discipline with concepts of the nurse-patient relationship, they concluded that caring in the human health experience is a mutual unfolding process patterned by presence, consciousness, and meaning.23

The third paradigm added by Parse in 2013 was named humanbecoming. In this paradigm, persons are conceptualized as humanuniverse phenomena who are indivisible, unpredictable, and everchanging.21 Health is described as living quality, which is “the ongoing incarnating of moment—to moment indivisible, unpredictable, ever-changing meaning arising with the visible-invisible becoming of the emerging now.”21 (p112) As of 2013, Parse's unique conceptual and theoretical work is represented by her proposed humanbecoming paradigm.21

The nursing discipline has been advanced through the further development of paradigmatic perspectives. We have moved beyond understandings based on the metaparadigm concepts described by Fawcett to Newman's focus of caring in the human health experience as a metaparadigm consistent with the unitary transformative paradigm. The perspective of caring in the human health experience is a unitary phenomenon of unbroken person-environment-health wholeness lived in a mutual transformative process in the expanded present. It is imperative that we accept the challenge of disseminating this perspective to the community of scholars engaging in research and practice. Beginning with doctoral students, we propose that this view be a significant part of the graduate curricula. Nurse scientists should engage in scholarship based on this disciplinary perspective, thus serving as role models not only to doctoral students but also to nurses in all levels of practice. Nurse scholars must engage in dialogue to make the case for significance based on how the research question coheres with the disciplinary perspective, how the theoretical rationale fits with the perspective, and how the findings contribute to the body of nursing knowledge.

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DISCIPLINARY PERSPECTIVES

Key disciplinary perspectives interrelating the concepts of person, health, and environment are important to note when considering the nursing disciplinary perspective. A search of the literature using CINAHL and Academic Search Complete for the terms disciplinary perspective and nursing was conducted; no listings were found. In addition, a search of the table of contents for the 4 editions of Perspectives on Nursing Theories 24–27 did not reveal additional disciplinary perspectives. Thus, the perspectives chosen by the authors for discussion in this article are believed to be known entities found in classic writings on the discipline by nurse scholars. The perspectives are presented and described according to the historical context in which they appeared in the literature.

In 1978, Donaldson and Crowley28 made the case for naming the discipline of nursing as the structured body of knowledge at the core of nursing. Three themes articulating boundaries for theory development were identified:

  1. Concern with principles and laws that govern life processes, well-being, and optimum functioning of human beings sick or well.
  2. Concern with the patterning of human behavior in interaction with the environment in critical life situations.
  3. Concern with the processes by which positive changes in health status are affected.28 (pp113-114)

These authors concluded that the discipline of nursing is concerned with human health, well-being, and quality of life grounded in the values of fostering human choice and individual independence. Persons are whole and in continuous interaction with their environment.28

In 1994, Smith29 defined the perspective of nursing as the study of healing through caring. This representation of a disciplinary focus encompasses a diversity of views and yet provides direction with boundaries for lines of inquiry.29 Healing implies a caring process of changing and evolving that facilitates health and honors human dignity. In the caring process, there is a shift in consciousness as meaning unfolds.30

In 1995, Reed proposed a metanarrative that centers on human developmental potential, transformation and self-transcendent capacity for health and healing, and recognition of the developmental histories of persons in their contexts.31 (p78) Human developmental potential happens in the mutual person-environment-process resonating with innate resources and inner healing. Thus, human beings possess a natural potential for health and healing.31

In 1998, Thorne and colleagues32 presented an alternative perspective of the discipline, arguing that there should be more emphasis on the concept of illness within the disciplinary perspective. They voiced a concern about the polarization created by extreme paradigmatic positions on the concepts of person, health, environment, and nursing.32 According to these authors, human health is viewed in the holistic perspective of embodiment and bodily existence in which bodily manifestations such as illness, aging, and dying are lived. The authors asserted that nursing conceptualizations that de-emphasize illness and embodiment limit full participation of nursing in a health care system, which currently expresses its purpose within an illness/embodiment context.32 (p1260) Furthermore, they postulated that health-related quality of life that is person-oriented and participatory is essential to developing relevant conceptualizations of health for bettering the human condition.32

Newman and colleagues23 in 2008 proposed that the concepts of wholeness, consciousness, and caring are essential in leading to a unitary caring science praxis. They recommended an integration of wholeness, consciousness, and caring into a view of human life and healing. This means that wholeness incorporates health, including illness, wellness, well-being, and disease. Consciousness is a form of energy, pattern, and meaning integrated in unitary caring science. Caring is a moral imperative in the person-environment-energy process between the caregiver and one receiving care. This process is described as relational, unified, infinite, and sacred.23

Also in 2008, Litchfield and Jonsdottir33 proposed a shift in thought about the human condition in keeping with other disciplines and nations. They introduced a participatory paradigm in the context of a practice discipline that is focused on humanness of the health circumstance. Participatory is linked to practice as relational in the presence of nurses with patients, applying knowledge, and taking action. Action goes beyond performing activities to coherence in helping patients get on with life. They believe the focus on humaneness of the health circumstance is inclusive and complementary to other disciplines including medicine.33

In 2008, Willis and colleagues described a unifying focus for the discipline of nursing as facilitating humanization, meaning, choice, quality of life, and healing in living and dying.34 (32) The unifying focus was posed as the essence of the discipline of nursing. According to these authors, facilitating humanization is a process of open-minded, caring, intentional, thoughtful, and responsible unconditional acceptance of human beings as they are.34 (33) In this process, meaning is constructed giving rise to choosing what is valued and understood as quality of life.

The disciplinary perspectives present a view of the person-environment-health process as an undivided phenomenon consistent with the unitary-transformative paradigm.22 The views that persons are whole and in continuous interaction with the environment22; human development as a mutual person-environment process31; lived health/illness embodiment as process31, participation in humanness of the health circumstance33; along with 3 caring perspectives: caring in the human health experience6; healing through caring30 health as wholeness/consciousness in caring relationships23 together form a unitary perspective of the human-environment-health process. It is expected that viewing the perspectives from the unitary transformative paradigm will give direction to a unique disciplinary perspective for nursing that is inclusive. This means that the perspectives can be described in which persons are in mutual evolving process with environment. It is in this person-environment process where health is lived and where caring nurse participation in the process creates human betterment.

In an effort to synthesize knowledge in the discipline of nursing, in 2008 an entire issue of the journal, ANS was focused on the state of the nursing discipline. Thirteen articles were included in this landmark issue. In her editorial, Chinn35 noted the importance of these articles, indicating that not only did they reflect the creativity of the thought-leaders, but also proposed ways for nursing science to branch out into unchartered territory.

A review of the articles led to identification of 6 prominent themes to chart the future course of the discipline. These themes included the need to incorporate global views that go beyond Western views; the need for a stronger emphasis on diversity and related health disparities; the importance of integrating new theoretical perspectives and theories; the move toward a unique perspective essential for participating within interdisciplinary arenas; the provision of additional disciplinary perspectives and the challenge of embracing a unitary relationship-based health care process. Each of these themes is further delineated in specific articles published in this ANS issue.

Several of the ANS authors argued for including a global view of the discipline, incorporating perspectives that go beyond Western thought. Banks-Wallace and colleagues36 described how nurses have much to offer to the global struggle in addressing health issues. Litchfield and Jonsdottir33 added to this debate, arguing that there should be a shift in thinking about the human condition across disciplines and nations for a global perspective. They further described nursing as a practice discipline, focusing on the human condition across disciplines and nations centered on nurses-as-workforce.33 Alperson37 linked the tai chi philosophy to nursing knowledge development through patterns of knowing in a way that offers a distinctly different view of nursing knowledge from Western traditions.

In 3 of the articles, authors recommended a stronger emphasis on diversity and related health disparities. Drevdahl and colleagues38 recommended that within the disciplinary perspective we focus on reducing racial and ethnic health disparities that exist at a population level. They further argued for the nursing discipline to provide a broader understanding of power and languages to address the broad social determinants of health.38 Lind and Smith39 presented a description of the barriers of oppressive power relationships that impede social justice in health care. Banks-Wallace and colleagues36 addressed underserved populations and the social and environmental factors that influence health. The factors they identified include health justice in the context of ethnic/racial, gender, economic, and cultural issues.36

In 9 of the ANS articles, authors argued for delivering additional theoretical perspectives and new theories. Drevdahl and colleagues recommended that culturally competent care should be abandoned and there should be dialogue and critique of the concept focused on creating equitable social, political, and economic systems for all.38 Litchfield and Jonsdottir33 proposed shifting Western thought through a participatory paradigm, articulating the human condition across nations in health service delivery. Additional theoretical perspectives that were offered to advance the thinking in nursing included appreciative inquiry39; nomadology as a way to offer resistance and politicization to disrupt the forces of biomedical discourse on nursing40; intersubjectivity as foundational to entering another's life with depth, compassion, and sensitivity41; and biopower as the next step in the development of nursing knowledge, based on power over life that introduces a sociopolitical context.42 Gehrke43 described civic engagement that includes the spheres of personal integrity, social conscience, civic involvement, and political engagement. Cowling and colleagues44 argued for a focus on wholeness, consciousness, and caring, as more abstract concepts that bring substance and coherence to nursing knowledge. A new theory of integral nursing was proposed by Dossey,45 building on Nightingale's legacy, healing, health, environment, and the patterns of knowing.

Four articles dealt with the need to move the discipline toward a unique perspective essential for participating at the interdisciplinary table. Banks-Wallace and colleagues36 indicated that nursing needed a unique body of knowledge to address research and practice issues to provide a firm a foundation for doctoral preparation. They further indicated that at interdisciplinary sessions nurses should offer new and worthwhile material grounded in the knowledge base of the discipline. According to Newman,22 without a clear sense of disciplinary knowledge in a unitary context, nursing has no meaning other than to participate in and promote the biomedical model. Cowling and colleagues44 further argued that a unitary caring science distinguishes nursing from other disciplines and strengthens interdisciplinary discourse. Dossey45 indicated that an integral approach to knowledge development positions nurses to offer holistic and caring approaches to healing in interdisciplinary endeavors.

Three of the articles described ways in which additional disciplinary perspectives could be addressed. These included the perspective of Litchfield and Jonsddottir33 on humanness of the health circumstance. Newman22 identified health, caring, consciousness, mutual process, patterning, presence, and meaning as concepts imbedded in the essence and direction of the nursing relationship. Willis and colleagues34 proposed that the nursing discipline facilitate inclusion of humanization, meaning, choice, quality of life, and healing in living and dying.

One of the most important themes from this series of ANS articles was the focus on enhancing a unitary relationship-based health care process. Lind and Smith39 proposed that the nursing discipline focus on providing health promotion with individuals, families, groups, communities, and systems. According to Newman22 the unitary transformative paradigm includes holistic thinking, problem-solving, deterministic, and integrative thinking. And Willis and colleagues34 argued that nursing's survival as a healing practice discipline depends on articulating a central unifying focus to reflect the essence of knowledge and practice.

The importance of editors of journals, and conference planners to request manuscripts and podium presentations describing research, and practice projects that center on the unitary transformative person-environment-health process can promulgate the unique perspective of nursing among practitioners and scholars. In addition, following through with the themes identified in the 2008 issue of ANS, there is a need to call for unitary perspectives that apply to global, diverse, and underserved populations. It is expected that such disseminated works can contribute to the knowledge base of nursing as a discipline with a unique perspective.

These published perspectives on the discipline of nursing were disseminated 10 years ago, and all require further elaboration. It is important that the authors take their ideas forward through continuing work so that the disciplinary knowledge is advanced in a consistent and cohesive manner. Having singular published perspectives that are not further established in the literature by the authors and by others does not extend development of the discipline of nursing.

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THEORIES FOR NURSING

More than 50 years ago, Ellis46 made the case for theories for nursing in contrast to theories of nursing (the process of nursing) or theories in nursing (again implying that the theories are embedded in the process of nursing). Ellis argued that significant theories for nursing are those that enlighten us about the patient, the recipient of nursing care. She further described significant theories as characterized by extended scope, complexity, testability, and usefulness. Significant theories for nursing according to Ellis have implicit values that can be recognized and made explicit within the discipline. Further, these theories generate information relevant to the discipline and consist of terminology that is meaningful to the phenomena observed in nursing.46 This perspective on significant theories for nursing preceded the development of nursing conceptual models and the more recent delineation of middle-range theories. Yet, it set the stage for many of the debates for the further development of nursing's disciplinary structure (ie, the focus on the individual person in interaction with the environment and the person's health).

In 2011, Im and Chang47 conducted an integrated literature review to determine the status of nursing theory development in the preceding decade (2001-2011). They found 257 articles related to grand theories, 84 related to middle-range theory, 13 related to situation-specific theory, 1626 related to grounded theories, and 327 related to concept analyses. To determine publications focused on grand theories, the broadest conceptualizations of nursing knowledge, they selectively entered names of those individuals who had proposed grand theories. Im and Chang found that the theories most predominant in the literature were those of Neuman, Orem, Rogers, and Roy.47 In an update of the theoretical literature (2012-2017) conducted specifically for the present article, the author used the same criteria identified and used by Im and Chang. We found 79 articles on grand theories, 42 articles related to middle-range theory, 10 related to situation-specific theories, 116 related to grounded theories, and even more articles related to concept analyses. The grand theories identified in this updated literature review included Neuman, Orem, Rogers, and Roy, but also included a number of articles based on the grand theories of Leininger and Peplau (J.J. Fitzpatrick and S. Nikowski-Keever, unpublished paper, 2017). The identification of these 6 theorists as predominant in the field was supported by the work of Roy and Hopper (C. Roy and A. Hopper, unpublished paper, 2017) with the exception of the exclusion of Rogers and the addition of Newman, Parse, and Watson in the Roy and Hopper work. Thus, the work of the 6 grand theorists that predominant the literature is included in the following discussion of definitions of person, environment, and health. These theories were chosen as they are the most predominant in the nursing literature in the last 15 years, and they are specifically identified as grand theories. It is worth noting that several other broad conceptualizations and/or grand theories appear in the literature (eg, Benner, Henderson, Levine, King, Newman, Parse, and Watson) but are not predominant. Furthermore, Parse now describes her work as a paradigm rather than a theory. Watson has broadened her conceptualization to refer to caring science that includes disciplines other than nursing; yet nursing is at the core of caring sciences according to Watson's work. Newman's theory of health as expanding consciousness has not been revised, rather she has broadened her perspective to elaborate on the paradigmatic focus of the discipline. The theories of Benner, Henderson, King and Levine have been used in specific applications, for example, Benner in relation to nursing practice, Henderson in relation to work of the International Council of Nurses, King in relation to goal attainment in the nurse-patient relationship and in nursing education, and Levine in relation to specific person-environment adaptations.

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GRAND THEORIES

Person, environment, and health have been consistently identified as the core concepts relevant to the discipline of nursing and embedded in nursing theories at all levels of abstraction. Although not all of these 3 concepts are given the same prominence in each of the theories and conceptualizations, they are all nonetheless relevant to further exploration of the discipline. In the earliest edition of Conceptual Models of Nursing: Analysis and Evaluation, Fitzpatrick and Whall48 included the definitions of each of these 3 concepts by 16 major nurse theorists, making comparisons relatively easy across conceptualizations.

Peplau's work was first published in a book, titled Interpersonal Relations in Nursing; she defined person as a self-system composed of biochemical, physical, and psychological (interpersonal) characteristics and needs.49 She emphasized the psychological dimension of persons in her theory; the basis of the nurse's work with persons is through the interpersonal relationship. Peplau addressed the environment in relation to the external factors that are essential for human development, including family, society, culture, and physical and psychological composition of the surroundings. Peplau further gives most weight to the interpersonal relationships that are part of the environment for the person. Peplau links health to human development. She describes the forward movement of the personality in the direction of creative, constructive, productive, personal, and community living.49 (12)

Rogers' book on her theory was titled An Introduction to the Theoretical Basis of Nursing; she described persons as whole, not definable by the sum of the parts, understood as greater than the sum of the parts.50 Within Rogers' conceptualization the person is an open system of energy identified by pattern. Rogers considered the environmental field in continuous interaction with the human field. For Rogers there are no boundaries between the human and environmental fields. Rogers50 considered health as a value statement unique to the cultural context of the individual. She described health and illness as manifestations of the life process.

Orem's theory was first published in a book titled Nursing Concepts of Practice. 51 She defined persons as self-determined, action-oriented, and goal-directed, a view that challenged the view of persons adapting to their environment. The central concept of the theory is self-care, further described through concepts of self-care agency, self-care deficit, and therapeutic self-care demands. Orem does not explicitly address the concept of environment but indirectly attends to this concept as part of the basic conditioning factors that influence self-care agency and self-care demands. These conditioning factors include social, cultural, and family dimensions of the environment. Orem described health as a state of being sound and whole, having strength, vigor, and the absence of disease; health includes structural and functional integrity. She further described well-being as distinct from health, and indicated that well-being could exist independent of structural and functional integrity.51

Roy first published her theory in a book titled Introduction to Nursing an Adaptation Model.52 She described persons as holistic adaptive systems, characterized by meaningful behavior. Persons have the capacity to adjust to the environment and can also affect the environment by their behavior and functioning. Roy defined the stimuli that are components of the environment, including focal, contextual, and residual stimuli. She described the environment is constantly changing in interaction with humans. Roy52 defined health in relation to the adaptive processes engaged in by individuals. Adaptation is reflected in the person-environment interaction, and successful adaptation is reflected in health.

Leininger's theory was first published in a book titled Transcultural Nursing: Concepts, Theories, and Practices.53 In this work individuals are considered as cultural beings. Further, she considered the use of the term person as problematic, as it is not used in some cultures. Leininger described environment as an important influence on health of individuals, families, and cultural groups. Also the context of the environment is the cultural context, including the totality of an event or experience that gives meaning to human expressions; persons can adapt and cope with changes that occur. Leininger53 considered health a state of well-being that is culturally defined, valued, and practiced. Health must be understood from the individual and the cultural perspective.

Neuman's first published book on the theory was titled The Neuman System Model (NSM): Application to Nursing Education and Practice.54 In this work persons are referred to as clients or client systems, a dynamic composite of interrelationships among physiological, psychological, sociocultural, developmental, spiritual, and basic structure dimensions. The client is further described as possessing various lines of defense and resistance, reacting to stressors in a holistic manner. Neuman referred to both the internal and external environments as consisting of stressors that lead to reactions by the client or client system. Neuman further described a created environment, unconsciously developed by the client or client system as a protective mechanism that requires energy from the system. Neuman defined health as living energy, ranging from wellness to illness. Accordingly, health is a condition determined by the degree of harmonious arrangement of the person's energy.54

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MIDDLE-RANGE THEORIES

While the above descriptions of the core concepts of the nursing discipline have been explicated in the broadest conceptualization in nursing, these same core concepts can be traced within the middle-range theories as well. Within the past 2 decades, there has been considerable substantive focus on the development of middle-range theories. Liehr and Smith55 identified 9 middle-range nursing theories that have had ongoing use within the discipline. Although there are a large number of middle-range theories that have been developed, the ongoing use of these 9 middle-range theories warrants attention. Six of these 9 middle-range theories in ongoing use are derived from a human health disciplinary perspective. These include the middle-range theories' uncertainty in illness developed by Mishel,56 , 57 self-transcendence developed by Reed,58 , 59 women's anger developed by Thomas,60 unpleasant symptoms developed by Lenz and colleagues,61–63 transitions developed by Meleis and colleagues,64–66 and inner strength developed by Roux and colleagues.67 Two of the middle-range theories with ongoing use are derived from the nurse caring disciplinary perspective: Swanson's caring68 and Kolcaba's comfort theories.69 , 70 The intellectual capital middle-range theory developed by Cowell was derived from a systems perspective.71

The person-environment-health process can be interpreted in each of these middle-range theories as follows: uncertainty in illness when persons appraise and cope with an illness situation; self-transcendence in the patterning of human development through vulnerability and well-being; women's anger that is appraised when persons evaluate their experience in the movement toward the expression of health; caring as a process of knowing the other that enables health; unpleasant symptoms as subjective phenomena occurring with persons in health and illness; transitions that occur in the multidimensional life changes in health and illness situations; comfort by attending to and strengthening human needs in health situations; inner strength as the way a person creates healing and a future perspective; and intellectual capital that comes with knowledge related to patient outcomes in the context of the health system.

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EDGE RUNNER INNOVATIVE NURSE-DESIGNED MODELS OF CARE

Another important contribution to an understanding of the commonalities within conceptualizations guiding nursing is the work of the AAN based on their interviews of the AAN Edge Runners. These are individuals who are known to have developed and implemented innovative models of care. Mason and colleagues72 conducted focus groups with 32 of the 39 Edge Runners. Participants were asked to identify the most important elements of their innovative model with a focus on person-environment perspective. Important findings were the commonalities that emerged regarding the conceptual understandings guiding these models of care. Four commonalities emerged: health holistically defined, individual, family, and community-centric approaches to care, relationship-based care that enables partnerships and builds patient engagement and activation, and a shift from episodic individual care to continuous group and public health approaches.72 (p540) The Edge Runner Innovative Nurse-designed Model of Care is consistent with the core disciplinary perspectives identified by Newman.22 The model emphasizes relationship-based care and individual-family-community approaches to care, which is in keeping with the Newman et al focus on caring in the human health experience.22 Furthermore, the holistic view of care presented in the model includes health as functional capacity, quality of life, personal happiness, and well-being.72 (p545) The component of relationship-based care is centered on the importance of knowing the patient and setting mutual goals for health promotion to enhance the potential for growth that extends beyond a single health event. Creating continuity of relationships over time enables participant-led care in the context of the values and expectations of the patient. These ideas in the model are congruent with Reed's metanarrative emphasizing developmental potential and the self-transcendent capacity for health and healing in the context of developmental histories.31

There are multiple significant opportunities to further the disciplinary work through the AAN Edge Runners Program as well as within other structures that influence nursing science and professional practice. Specifically, the underlying conceptualization of nursing could be a part of the application and evaluated in the selection of edge runners. Furthermore, the nursing education-accrediting agencies, the funding agencies, such as the National Institute of Nursing Research, and the professional organizations that invite scientific presentations could evaluate the inclusion of nursing conceptualizations within the criteria. Such consistency across disciplinary groups would surely propel the further advancement of the scientific development of nursing, and enhance theory-based practice.

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MATRIX ON THE DISCIPLINE OF NURSING

A summary of the above explication is included in the matrix represented in the Figure. This matrix is focused on the discipline of nursing as extracted and synthesized from the discussion on the major topics presented in this article. The matrix begins with the overarching foundational perspective stated as the person-environment-health process. Persons with environment are in continuous interchange in the evolving health process. The disciplinary perspectives that are elaborations on the foundational perspective are listed in the order in which they first appeared in the literature. Next, the grand and middle-range theories are presented that further describe person, environment, and health. The grand theories are listed based on the year in which the first book on the theory was published and the middle-range theories are listed in the order in which they first appeared in the literature. The matrix is proposed as an offering of discipline-specific knowledge that may serve to guide theory development, research, education, and practice.

Figure

Figure

It is important to point out that one of the perspectives is not more important than another, what is important is the way in which the perspective resonates with the scholar/practitioner's view about what is believed and valued about the essence of nursing having a unique perspective that is unitary and transformative. This may be facilitated by reflecting on the meaning of the perspective and critical reading on the way the author of the perspective articulates the meaning of it. It is in this way that one can come to understand and apply the unitary transformative disciplinary perspective in research and practice, thus contributing to the body of knowledge of nursing.

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GLOBAL PERSPECTIVES OF HEALTH

Many nurse scholars have called for a reframing of our disciplinary perspective to move the discipline to a global perspective, encompassing components of health and wellness that are broader those espoused by Western views of persons, environment, and health. Nursing is currently embedded in a global society. No longer can the science or professional practice of nursing be considered devoid of the global perspective. The health of all people and the work of all nurses are increasingly impacted by global environmental forces. Thus, it is important to consider global perspectives on health to inform nursing science for a global community of scholars. Within this context, working with and through global organizations, such as the World Health Organization60 and the International Council of Nurses (ICN),61 has become increasingly important as nurses advance disciplinary knowledge.

According to the World Health Organization, health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. This definition was entered into force on April 7, 1948, and remains the World Health Organization definition of health.73

The ICN is the professional body representing more than 130 countries and 20 million nurses. In the ICN Code of Ethics, 4 fundamental responsibilities of nurses were described: to promote health, to prevent illness, to restore health, and to alleviate suffering.74 This ICN description of nursing is consistent with the American Nurses Association definition of nursing as the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations.75

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SUMMARY AND CONCLUSIONS

Within the past 50 years there have been significant theoretical developments within the discipline of nursing. Across the literature there has remained a consistent focus on person, environment, and health as the core concepts for development of disciplinary knowledge. Multiple theories have been derived from the focus on these core concepts, beginning with grand theories to the current focus on middle-range theory development. Yet, we are not where we should be in developing the discipline.

There are several approaches that can be used to further develop the discipline. First is the need to accept an overarching disciplinary perspective and promulgate this widely in research, education, and professional practice. It is the conclusion of the authors that the unitary transformative person-environment-health process can serve as the foundational perspective for the discipline. Given that health care is now global, it is also important to consider a worldview of nursing and the cultural acceptance of the disciplinary perspective of nursing. Most importantly, the nursing disciplinary perspective should be infused into research, education, and professional practice to advance the discipline, and theory must be an integral component of our scientific development.

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Keywords:

discipline; paradigm; theory

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