Newman the Focus of the Discipline Revisited.11

Advances in Nursing ScienceVol. 31, No. 1, pp. E16–E27Copyright c© 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Focus of the DisciplineRevisited

Margaret A. Newman, PhD, RN, FAAN;Marlaine C. Smith, PhD, RN, AHN-BC, FAAN;Margaret Dexheimer Pharris, PhD, RN, MPH, FAAN;Dorothy Jones, EdD, RNC, FAAN

WE have come a long way in explicat-ing the discipline of nursing. We have

moved from an implicit acknowledgment ofthe relationship that constitutes nursing toan explicit designation of the process as car-ing in the human health experience.1 Werecognize that differences in the research as-cribed to nursing stem from the philosophi-cal assumptions underlying the methods andpractice. When first set forth, the paradigms(labeled particulate-deterministic, interactive-integrative, and unitary-transformative [UT])were considered separate categories, but asthe practice emanating from these points ofview was examined more closely, it becameapparent that practice is a unified whole thattranscends the limitations of each paradigm.The UT paradigm can be looked upon as ameeting place for holistic thinking and prob-lem solving and may include deterministicand integrative thinking. A nurse approaching

Author Affiliations: University of Minnesota,Minneapolis, and University of Tennessee, Memphis(Dr Newman); Christine E Lynn College of Nursing,Florida Atlantic University, Boca Raton (Dr Smith);College of St Catherine, St Paul, Minnesota (DrPharris); and William F Connell School of Nursing,Boston College, and Massachusetts General Hospital,Boston, Massachusetts (Dr Jones).

Corresponding Author: Marlaine C. Smith, PhD, RN,AHN-BC, FAAN, Christine E. Lynn College of Nursing,Florida Atlantic University, 777 Glades Rd, Boca Raton,FL 33431 ([email protected]).

a patient∗ from the UT perspective sees thewhole while attending to the part. As a mat-ter of fact, the nurse enters into the wholethrough the part. The caring, knowing pres-ence of a nurse taps into what is meaning-ful for the patient and opens the way forrelevant action. This article aims to summa-rize the progress nursing has made in definingthe discipline and to exhort members of ourprofession to come together in a shared mean-ing that brings coherence to our practice.

THE PROCESS OF KNOWLEDGEDEVELOPMENT

The worldviews that have guided our ex-ploration of knowledge include a traditionalscientific approach, a multidimensional eval-uation of the interactive milieu, and, more re-cently, a unitary perspective. The unitary per-spective represents a shift from looking at thewhole as the sum of the parts to looking atthe whole as primary, from seeking to solvea problem to seeking to know the pattern,and from embracing an action-reaction causalapproach to realizing the mutuality of theunfolding, rhythmic process through whichinsight into action arises. Nursing scholars

∗The use of the term patient is for the sake of simplic-

ity of language and refers to the individual person and a

plurality of persons, such as family or community.

E16

The Focus of the Discipline Revisited E17

have contributed meaningfully to this knowl-edge base. The history of nursing epistemol-ogy reflects a receptive phase, where nurs-ing knowledge was derived mainly from otherdisciplines, a self-generative phase, in whichknowledge is concentrated on the nursing dis-cipline, and a transformative phase, in whichnursing knowledge significantly influencesother disciplines as well as nursing practice.2

Following the prevailing scientific traditions,the early nurse theorists strove to isolate, con-trol, and test relevant variables as a basis fornursing intervention; their work raised ques-tions about interventions of central concernto nursing. Broadening the context, but stillemphasizing control and predictability, thenext generation of nursing theorists empha-sized interactions of multiple factors influenc-ing health; this research inspired nurses toconsider the interpersonal approaches thatdefine the nature of the nursing relationshipin facilitating health. In 1970, Rogers’ revo-lutionary insight shifted the view to an undi-vided whole of a mutually unfolding person-environmental field.3 The theories of healthas expanding consciousness and human be-coming emanated from this perspective.4–8

Theories that originated in the interactive–integrative paradigm on caring and adap-tation have continued to evolve in waysconsistent with the UT perspective.9–17 Thecollective emphasis of the discipline is on acaring presence that is transforming for boththe patient and the nurse in revealing new vi-sion and understanding of the human healthexperience. Its relevance worldwide directsthe profession in meeting global, social, andmoral responsibilities.

The shift to a unitary concept of health,in which pathology is relevant but not sep-arate and dominant, along with acknowledg-ment of patterning as the identifying processof the whole, allowed relationship to emergeas the central focus of the discipline. Nursinghas taken the lead in elaborating relationship-centered care, a concept sought as well byvoices outside of nursing. McLeod, citing thework of the Relationship-Centered Care Net-work, formed by a collaboration of the Fet-

zer Institute and the Pew Health ProfessionalsCommission, called for a “. . .culture of caring-of respect for relationship, and optimism fora more balanced and meaningful life” and for“. . .creating a revolution of the heart by nur-turing wholeness-honoring the fundamentalrole of relationship and connection.”18(pp37–38)

It is the nature of the nurse-patient rela-tionship that unites the practice of nursingas it occurs in myriad settings throughout theworld at every moment of every day. Whetherit be a neonatal nurse applying knowledge ofhighly technical treatments aimed at preserv-ing the life of the baby of the parents beforeher, a nurse sitting on the cot of a person dy-ing of a chronic illness in a remote village, ora nurse working with community membersfaced with an epidemic, nursing actions oc-cur within the context of a unified commit-ment. That commitment is to a caring relation-ship focused on understanding the meaningof the current situation for the people in-volved, and appreciating the pattern of evolv-ing forces shaping health, so that appropriateactions can be realized.

The development of nursing knowledgeunfolds within a participatory process. Eachnurse–patient relationship is unique, formedby the informational patterns of the nurseand the patient. Nurses bring to the situa-tion their personal knowledge and experi-ence as well as the background of liberaland professional education and experience.Patients bring to the situation their personalhistory and life experience as well as thehealth concern that often is the precipitantfor the nurse-patient meeting. The nurse’s re-sponsibility is to be fully present, seeking toknow what is meaningful to the patient, andallowing the pattern to unfold. The fruitful-ness of the encounter is a function of thenurse’s commitment to an unconditional car-ing presence, openness, and perseverance inallowing action possibilities to emerge. Therelationship is embedded in a concept ofhealth based on wholeness, evolving pattern,and transformation. Research guided by thisperspective has revealed patients’ developingunderstanding and insight regarding their

E18 ADVANCES IN NURSING SCIENCE/JANUARY–MARCH 2008

place in the world, a sense that their concernsare being addressed, and enhanced caringrelationships.19,20 Many in the UT paradigmsuggest that knowledge develops as nursingpraxis, a synthesis of theory, research, andpractice. Theory guides and informs the prac-tice experience the research process, and thegeneration of knowledge. Nursing praxis isnot only a pathway to knowledge develop-ment, but also the actualization of transforma-tional practice.

The structure of the discipline began byrecognizing the similarity of concepts of thevarious nursing theories.21,22 These connec-tions fit into a larger pattern of the disci-pline. Nursing has been through an ambigu-ous state of multiple, competing, possiblydisconnected theories, but now the disciplineis at a critical point of an emerging, overar-ching form that expands beyond the initiallinks. A consensus statement of philosophicunity was described by a group of interna-tional nurse scholars as the basic ontology ofthe discipline and its relationship to knowl-edge development and practice.23 Selectedpoints of convergence reflected by the state-ment include the following:

• The human being is characterized bywholeness, complexity, and conscious-ness.

• The essence of nursing involves thenurse’s true presence in the process ofhuman-to-human engagement.

• Nursing theory expresses the values andbeliefs of the discipline, creating a struc-ture to organize knowledge and illumi-nate nursing practice.

• The essence of nursing practice is thenurse-patient relationship.

The elaboration that follows builds uponthe unifying construct of the nurse-patient re-lationship and provides a framework for itssubstantive content. The concepts of health,caring, consciousness, mutual process, pat-terning, presence, and meaning have beenselected to address the essence and dimen-sions of the nursing relationship. The basis forchoosing these concepts was: (1) prevalencein the nursing literature across nursing theo-

ries, (2) consistency with knowledge devel-opment in other fields, and (3) utility acrossmultiple cultures. There is considerable over-lap in meaning as these concepts merge as aunified whole.

CONCEPTS CENTRAL TO THEDISCIPLINE

Health: The intent of the relationship

Health is central to the focus of the disci-pline of nursing. Many disciplines and profes-sions commonly use it as the umbrella goalfor those who care for people. The mean-ings of the concept of health abound in of-ten ambiguous or inconsistent ways such as:the absence of disease; a continuum fromwellness to illness; optimal wellness; integra-tion of body, mind, and spirit; and a holis-tic phenomenon. Nursing literature revealsgreat diversity in the explanations of health.Donaldson and Crowley,24 held to a dichoto-mous view of health by specifying that nurs-ing is concerned with the actions or pro-cesses by which positive changes in healthare affected. Wagner,25(p43) viewed health asthe ability to function independently: “adapt-ing successfully to life stressors,” implyingthat through independent functioning the po-tential for achieving a full life occurs. Otherdefinitions of health include: health as a dy-namic life experience and a way to achievepotential,26 a state and process of being andbecoming,15 an expression of unity and har-mony of body-mind-spirit.12 From a unitaryperspective, the concepts of health and ill-ness are seen as manifestations of rhythmicfluctuations of the life process.27 This view isthe foundation for viewing health as a unitaryprocess moving through variations in order–disorder. From this standpoint, one can nolonger think of health and illness in a dichoto-mous way, that is, health as absence of dis-ease, or health as a continuum from wellnessto illness. According to Newman’s thesis,health is a transforming process to higherlevels of consciousness.4–6 Health and theevolving pattern of consciousness are thesame.6,20 The evolving pattern of the whole


requires a nonfragmentary view of health.Newman referred to Bohm’s theory of theimplicate order to substantiate her positionthat both disease and nondisease are ex-pressions of the whole, that is, explica-tions of the underlying implicate order.5,3,28

Thus disease and nondisease are differentpoints of view of a larger reality. In thisway, health may be expressed and revealedin illness. Health in the face of illness de-rives meaning through a caring nurse-patientrelationship.

Caring: The nature of the relationship

Caring, also, is one of the defining terms ofthe discipline and is central to nursing’s iden-tity. Newman and colleagues asserted thatnursing is about facilitating health, and thatcaring is the quality of relating that poten-tiates a transformative connection betweennurse and patient.1 The establishment of car-ing as a defining attribute of the disciplinewas recommended in a landmark conferencein 1989 convened by the American Academyof Nursing and Sigma Theta Tau. Nursing lead-ers asserted that the concept “caring” shouldreplace “nursing” in Fawcett’s29 constellationof concepts purported to define the intellec-tual and social boundaries of the discipline.Leininger30 was the first to describe caringas the distinguishing focus of the discipline.She argued that care and caring were basicneeds essential for human growth and de-velopment, and advanced the study of car-ing by examining it from cultural practices.Watson11 defined nursing as the art and sci-ence of human caring and focused on the rela-tional dimensions of caring and its connectionto healing. In more recent writing, she hasarticulated its commonalities with a unitaryperspective.14,13 Boykin and Schoenhofer17

asserted that all human beings are caring,living it moment to moment. They definedcaring as “an altruistic, active expression oflove. . .the intentional and embodied recogni-tion of value and connectedness,”31(pp335–336)

but reminded us that it is known by experi-ence and reflection and not by definition.

Other nursing scholars have described car-ing in various ways: as a fundamental humanattribute lived out in relationship, a uniquetrait possessed by some, an affect, a moralideal that compels right action, an ethic ofpractice, an interpersonal process, a thera-peutic intervention, and a process of nurtur-ing. Because of these differences, and thelack of precision in use of the word “car-ing,” some have argued that it is not a clar-ifying concept in delineating nursing’s disci-plinary focus. It is true that there is ambiguityin the concept of caring that obfuscates thedepth of its meaning. For this reason, under-standing its meaning within the UT paradigmmay bring clarity to its use. Smith22 identi-fied 5 constituents of caring when viewedwithin the unitary paradigm: manifesting in-tention, attuning to dynamic flow, appreciat-ing pattern,32 experiencing the infinite, andinviting creative emergence. From a unitaryperspective, caring is a quality of participa-tive patterning. This way of being is char-acterized by holding the best intentions forthe other and expressing them in thoughts,words, and actions. It is sensing and movingsynchronously with the dynamic rhythms ofrelating, following the lead of the other inthe dance of human becoming. This way ofbeing is respecting the unique life story ofeach person and the diversity of life choices.It is valuing and supporting what mattersmost to the person, family, or community.Caring is seeing the other and self as inter-connected to something more extensive thanboth. This way of being nurtures growth, andleads to self-discovery, unique self-expression,and new ways of becoming and leading one’slife.22 For some, it is time to adopt the wordlove in describing this quality of relating innursing.33,13 Teilhard de Chardin describedlove as the energy of connection that com-pels relationship. “Love alone is capable ofuniting living beings in such a way as tocomplete and fulfill them, for it alone takesthem and joins them by what is deepest inthemselves.”34(p265) In this way, caring en-hances or facilitates health and healing and il-luminates consciousness.


Consciousness: The informationalpattern of the relationship

The concept of consciousness has becomecentral to the nursing discipline. A major shiftin the concept of consciousness has occurredduring the past 4 decades. International or-ganizations have been formed for the studyof consciousness along with scholarly jour-nals created for that purpose.∗ Whereas inthe first half of the 20th century the studyof consciousness focused on characteristics ofthe brain, the current movement opens widethe focus to participatory exploration of theexperience of consciousness and beyond.35

DeQuincey,36 a prominent spokesperson inthis movement, claimed that consciousnessmust be studied in relationship betweenpersons.

Grounded in a UT worldview of thephenomena of nursing and stimulated byBentov’s37 thesis that life is a process ofexpanding consciousness, Newman4 incor-porated this shift in an understanding ofthe nursing relationship by asserting thathealth is the expansion of consciousness.This view broadened the old concept of con-sciousness to include the total informationof the field (of nurse-patient-environment).Consciousness, the information of the pat-tern of the whole6 includes all forms of in-formation: sensation and physiology as wellas intellect, emotion, and intention. A per-son is identified by a pattern of conscious-ness, which includes awareness of self withina larger system of consciousness. Arguelles,38

a noted Mayan scholar, went so far as tosay that “in actuality there is only conscious-ness.”(p56) The human field is a pattern of con-sciousness within the total pattern of con-sciousness of the universe. It is constantlyreceiving and sending information and in-cludes patterns that may appear disruptive aswell as those considered harmonious. Jumpsin consciousness occur in far from equilib-

∗For example, The University of Arizona Center for Con-

sciousness Studies, Institute of Noetic Sciences, ReVision

rium states.39 These critical points may beturning points at which the pattern is trans-formed and new insights occur. A shift from amatter-based representational focus to a self-organizing field has emerged, particularly inrelation to health.

Theoretical elaborations from other nurs-ing scholars support the process of expand-ing consciousness. Mishel’s40 conceptualiza-tion of uncertainty as a growth move throughchaos to a higher level of organization sup-ports the transformation of persons facingwhat appear to be disruptive, immutable situ-ations. Reed’s41 theory of transcendence elab-orates the process of human becoming lead-ing to higher consciousness. It describes thepotential for persons to go beyond the space-time limitations of their situations to a deeperexperience of their lives. Watson12 coined theterm caring consciousness to convey a syn-thesis of the 2 concepts in the nurse’s relation-ship with the patient. Roy16 has asserted thathuman consciousness is integral to an evolv-ing, creative universe.

The essence of consciousness is informa-tion, and the essence of information is reso-nance. Rogers3 included resonancy, the wayinformation is shared, as a principle of the sci-ence of unitary human beings. She assertedthat the human being “experiences his envi-ronment as a resonating wave . . . uniting himwith the rest of the world.”(p101) This informa-tion is accessible to us as feeling and mean-ing. In attending to feeling, we sense the res-onance of incoming information and cocreatea resonant field. The basic way of know-ing is through attunement, resonant receptiv-ity, intuition, and revelation—a direct, unfil-tered index of communication.42 All points inspace-time have immediate access to a vaststorehouse of information. The whole orga-nizes the parts, and any event happening any-where is immediately available everywhere asinformation. The fields are conceived as be-ing unbounded by space, time, and matter.This mechanism of information transfer ex-plains the immediacy of transformation. Reso-nance implies that the transformation is a mu-tual process.


Mutual process: The way in which therelationship unfolds

Nurses are central to creating an envi-ronment that fosters relationship and health.This environment is not conceptualized asa linear communication process of send-ing and receiving. Rather, it is viewed as asimultaneous unfolding, a sharing, movingtogether. Rogers’27 principles of homeody-namics included integrality as a continuousmutual process between human and envi-ronmental fields. Mutual process occurs inthe moment of being fully present with theindividual, family, or community. In mutualprocess the patient is invited to participate,and through reflection to find opportunitiesfor new awareness, action, movement, andtransformation.43

In mutuality, the focus is on wholeness, be-ing with and in relationship.6 The unfoldingpattern that emerges within this mutual pro-cess occurs as an intentional presence as thenurse and the patient reflect on the mean-ing in the moment. The process embodiesthe experience of nurse and other over time,and through this process, pattern is revealed.True reality behind the appearance of sepa-rate, distinct entities, consists of wave-like, os-cillating possibilities, waiting to become actu-alities. These possibilities become actualitiesonce we engage in practice.12(p121)

Each interaction with the nurse and pa-tient offers in mutual process the potential fordiscovery and choice. In mutual process theunfolding of meaningful events and relation-ships in people’s lives is manifested in pattern.The mutual process with another is enhancedby the nurse’s authentic presence. The pur-poseful invitation by the nurse to dialogue in-vites trust and fosters relationships within acaring partnership.20,44 In mutual process theself and other are engaged in an experiencethat promotes awareness of self and other,and potentiates insight with new choices andactions.

The idea of human unfolding, emergence,and evolutionary transforming is significantwithin a number of nursing theories sharing

the emergent unitary paradigm.3,6–8,11,13,14,17

Rogers3 asserted that “The capacity of life totranscend itself, for new forms to emerge,for new levels of complexity to evolve, pred-icates a future that cannot be foretold.”(p57)

The mutual process of human becoming isunpredictable, but always reflects growingcomplexity.

A centerpiece of Parse’s school of thought,human becoming is described as a rhythmi-cal process lived in relationship, expressedthrough values, and “transcending with thepossibles.”8(19–20) Van Kaam,45(p10) describedthe human as both potentiality and emer-gence. Multiple potentialities are present, andthrough choice, these potentialities are ac-tualized in each moment. The mutual pro-cess of human becoming is not imposed onthe other but is always happening. Teilhardde Chardin34 stated that the direction of hu-man becoming is toward increasing complex-ity, centration, interiority, and consciousness.This path is illuminated in relationship, andthe pacing and direction of the journey on thepath is personal. When one trusts this force,he or she relinquishes any false sense of exter-nal control, having confidence that each per-son knows his or her own way. There is nopredetermined health outcome that is prefer-able for each person. The preferred outcomeemerges in the person-environment mutualprocess, through choice. Action possibilitiesarise in the context of recognizing the patternof person-environment interactions.

Patterning: The evolving configurationof the relationship

Attention to pattern is a central aspectof nursing practice and research. Descrip-tions of patterning in the nursing litera-ture include the following: (a) each personexhibits distinguishing characteristics and aunique pattern of interactions between selfand environment3,5,32,46; (b) pattern is a char-acteristic of wholeness and gives insight intolife meaning6; (c) patterning provides deepinsight and understanding of the whole, anddetailed comprehension of the uniqueness of


the life process; (d) contrast and time are es-sential to the identification of pattern; (e) pat-terning is unpredictable and creative3; and (f)the process of pattern recognition reveals in-sights into action, an expanding horizon, andincreasing connectedness.6,47 The purpose ofattention to pattern in nursing has evolvedwith the explication of the knowledge of thediscipline–moving from diagnosis of illnessand disorder to exploration of meaning, ap-preciation of the whole, and recognition ofnew possibilities for health. Pattern conveysconnections of a meaningful whole.

The focus of pattern in nursing haschanged overtime. Ever since FlorenceNightingale developed the pie chart to ex-amine patterns of disease distribution in theenvironment, patterning has been a centralconcern and unifying concept of nursing.Many nursing theories contain frameworksthrough which nurses can assess patterns inpatients’ lives to better plan nursing care. Forexample, in the Neuman’s systems modelnurses identify the pattern of interaction be-tween the client system and the environmentto determine the impact of environmentalstressors on the client system, and to planprevention and intervention strategies tomaintain system stability.21 The theory ofcultural care diversity and universalityguides nurses to assess patterns relatingto social structures and geo-environmentalfactors to plan culturally congruent care.9

In the interactive-integrative paradigm,patterns are assessed through attentionto categories or modes and are used toguide the selection of nursing interventions.As the worldview shifted to an awareness ofthe dynamic mutually evolving nature of theperson-environment pattern, the Roy adap-tation model, for example, was modified toexpress the foundational view of persons ascoextensive with their social and physicalenvironments, with an emphasis on meaningand consciousness in the mutual relationshipbetween people and their environment.15

As nursing theories have evolved, they havefocused less on patterns of illness and dis-order as a basis for intervention, and more

on patterning as a way of partnering withpeople as they grasp the meaning of thewholeness of their life, gaining insight intonew possibilities for health.

Rogers3 identified pattern as a unifyingconcept in nursing and as ever-evolving inthe direction of increasing complexity, witheach repatterning being a revision of the im-mediately preceding pattern: “At each pointin space-time, man [sic] is what he has beenbecoming but he is not what he has been.Moreover, he cannot go back to what he hasbeen.”(p98) People’s lives go on through var-ious permutations of order and disorder; af-ter periods of chaos, their lives reorganize ata higher level of organization.

Newman described pattern as a character-istic of wholeness: “Pattern is information thatdepicts the whole, understanding the mean-ing of all the relationships at once. It is afundamental attribute of all there is and re-veals unity in diversity.”6(p71) It reveals themeaning of life. Pattern is dynamically re-lated with one’s environment, both humanand nonhuman.6 When engaging communitymembers in dialogue, centered on represen-tations of individual and family patterns, it ispossible to see the pattern of the communityand envision possibilities for transformationin the health of the community.48

Patterning reveals the evolving nature ofthe whole. As nursing embraced holism as acentral tenet of human existence, better waysto understand and respond to the whole wereneeded. Newman uses a process of patternrecognition that focuses on the evolving pat-tern of meaningful relationships and events inpeople’s lives, stressing that meaning charac-terizes pattern. The process provides insightinto potential actions.6 Cowling46 describeda similar process of pattern appreciation thatis creative, receptive, and responsive to in-dividual uniqueness; gives “primacy to thevoices of those seeking care”;and provides “acontext for human flourishing.”(p94) The prac-tice of healing from this perspective focuseson appreciating the wholeness that resideswithin the pattern32 and enhances nurses’ability to be attentive to their patients.


Presence: The resonance of therelationship

The concept of presence has been de-scribed as genuine dialogue, commitment,full engagement and openness, the core el-ement of nursing activity, free-flowing at-tentiveness, transcendent togetherness, andtranscendent oneness.49 It demonstrates theuniqueness of the patient–nurse relationship:connecting with patients’ experience, sens-ing the current moment, going beyond scien-tific data, knowing what will work and whento act, and the sine qua non of being withthe patient.50 Presence is a nonsensory pre-hension of the being of the other. Being fullypresent is central to the relational process ofnursing:

“. . . authentic presence between patient and nurse

. . . [is] a transformation of both. Presence is a mat-

ter of consciousness and is reflected in the holistic

beings that are both nurses and patients.51(p323)

Melnechenko52 described Parse’s conceptof true presence as a way of being that val-ues the other’s dignity and freedom and con-cluded that “true presence creates the op-portunity for nurses to go where the patientis in life, to learn about the experience ofhealth as it is defined and lived, and to workwith patients as they choose the meaningof the situation.”(p23) Koerner53 stressed theimportance of active receptivity as an es-sential aspect of nursing presence, stating,“Guided by the intent to support what is inthe highest good for the person and fam-ily, we create an empty space of open ex-pectancy, which allows individuals to con-nect with their inner wisdom and innatepower to heal.”(p9)

The epistemology of presence focuses on atrust that understanding deepens explorationin relationship. The emphasis is on engage-ment rather than on measurement, on mean-ing rather than on mechanism.36 DeQuinceypointed out that “being intensely engaged inrelationship with another . . . is, perhaps, themost vital manifestation of consciousness.”It requires a shift from a world of subjects-objects, to a “view, which sees relationship asfundamental.”(p173)

Transforming presence is becoming onewith the other. This involves letting go oftime constraints, putting everything aside andfocusing completely on the patient, that is,being with the individual (family or commu-nity) with all aspects of oneself.54 One mustlet go everything else and be fully present inthe moment. Being fully present goes beyondpattern identification and is the evidence oftransformation. Becoming one with the pa-tient through presence focuses the nurse onwhat is meaningful to the patient.

Meaning: Importance of the relationship

Caring presence and intentional resonancefocus nurses on what is meaningful in the livesof patients. Searching for meaning and its mes-sage for the future is the primary motivation inpeople’s lives,55 and thus is of primary impor-tance to nurses. The focus on meaning shiftsthe nurse’s purpose from objective problem-solver to sojourner in discovery, interpre-tation, and revelation. Bohm56 describedmeaning as a dynamic process. Through re-flection on meaning, new meanings emerge.This process deepens with additional per-spectives and expands as contexts change.Meaning arouses, organizes, and gives direc-tion to energy.56 As nurses and patients reflecton the unfolding pattern of meaningful inter-actions and events in patients’ lives and on themeaning of presenting situations and the con-text, in which they occurred, new perspec-tives and deeper insights evolve. Through thisprocess, new meanings give birth to new pos-sibilities. Concentration on meaning in the lifeof the patient brings forth and directs energyinto healing that is uniquely appropriate tothe patient, demonstrating the centrality of aresonant, caring presence focused on mean-ing in people’s lives.

Several nurse theorists have asserted thatnursing springs from a focus on meaningin peoples’ lives—nursing care cannot bepredescribed or routinely applied in thesame manner across clients. Travelbee57 as-serted that nurses must go beyond helpingpeople cope with illness and suffering, tohelping people explore the unique meaning


they find in their experiences and predica-ments. Parse58 described meaning as beingilluminated and structured multidimension-ally through a cocreative process betweenthe nurse and the patient. She pointed tothe importance of dialogue, in which valuesare expressed to identify what is cherishedand imagine what is possible. Parse,58(p7)

stated, “One cocreates meaning, and themeaning changes with experiences as newimages arise, expanding possibilities. Peoplelive their treasured beliefs in the process ofevolving.”

In her theory of meaning, Starck59 empha-sized the importance of engaging differentperspectives to more fully understandablemeaning, realizing that patterns of meaningmay be manifest not only through verbal re-flection, but also through spiritual and so-matic experiences. This realization focusesthe nurse–patient relationship on the mean-ing of all that the patient is experienc-ing as relevant at the moment. Meleis60 at-tributed grasping meaning to “perceptionsrather than intellect; it depends on obser-vations, feelings, imagination, and under-standing that go beyond description—it de-pends on inner experiences and is holis-tic in nature.”(p97) Watson61 invited nursesto return from the outer world of technol-ogy where meaning has been stripped, tothe inner world of healing and meaning-ful “human-to-human connections and caringmoments.”(p913) Koerner53 defined meaningas “the way in which we use a life experienceto grow and deepen as human beings;” shecalled nurses to use “slower wisdom” whichshe defined as “longitudinal examination of is-sues over time”(p208) to remove the veil of con-fusion from complex situations so that mean-ing can be revealed. Newman62 has demon-strated that it is in attending to the unfoldingpattern of patients’ lives that the meaning ofthe whole can be fully comprehended. Pat-tern and meaning are central to nursing careand give insight, one into the other.

Meaning differs from person to person andfrom time to time. There is no universal defini-tion of meaning, but rather it is uniquely man-ifest as each individual searches for it. “The

meaning of life differs from man to man [sic],from day to day, and from hour to hour. Whatmatters, therefore, is not the meaning of lifein general, but rather the specific meaningof a person’s life at a given moment.”55(p108)

Clarke63 reported that the quest for mean-ing is the most commonly occurring attributeof spirituality found in the nursing litera-ture. Drawing on the work of theologian PaulTillich, Clarke described meaning as ultimateconcern, and exhorted nurses to focus withpatients on what is at the depth of their being,rather than simply on superficial concerns.Henery64 rejected the relevance of a hierarchi-cal notion of what is most meaningful, stress-ing that nurses should not place judgment onwhat patients perceive as meaningful. Some-times what seems to be a superficial act orconcern can open a window that sheds lighton deeper meaning and insights for action.Newman65 gave the example of walking intoa patient’s room, noticing that the patient isreading a newspaper, and saying, “Readingthe want ads, huh?” This led directly to a dia-logue about the patient’s unemployment situ-ation and its meaning in the patient’s life. Thecaring, resonant presence of the nurse cre-ates the context, in which the dialogue can godeeper still. Further reflection and dialogueopens a door to deeper meaning. Newmandemonstrated the importance of entering intothe interaction where the patient is and ridingthe wave of caring presence and resonanceinto the center of what is meaningful, trustingthat the process will illuminate the directiontoward health.5,6

THE TASK BEFORE US

An issue facing the nursing profession isthe question of what knowledge will directour practice. From our perspective, nursingpractice must be first and foremost groundedin the discipline as defined by the conceptspresented here, while at the same time in-corporating relevant knowledge from otherdisciplines. The patient and the nurse bothneed access to the best evidence in mak-ing decisions about patient care. The UT


perspective expands the notion of evidenceand situates its relevance within the uniquemeaning and pattern of patients’ lives.

Peat66 offered a philosophy of wholenessthat is consistent with the UT perspectivein nursing and warned, “If we are to movetoward a more holistic and healthy world,then we must discover a way of unifyingthe statements of objective science withour personal vision of the world, and wemust do this without diluting the authentic-ity of either approach.”(p47) Watson added,“Thus, an expanded and evolved disciplinary-professional view of health, healing and qual-ity of life/living will not allow one level of ev-idence or technology to privilege itself overthe human condition and humanity itself. Theevolved future becomes large enough to holdthe paradox of both side by side.”67(p14)

Bohm,68 in writing about meaning as theroot of our whole being warned, “Without

meaning, our society will fall apart.”(p150) Fornursing, “Knowing who we are in the contextof society and other related disciplines is es-sential for our own health and well-being, andessential to our ability to serve others.”69(p14)

Without a clear sense of our nursing identityand the meaning of our mission to society, wehave no value or purpose other than to sup-port and promote the practice of medicine.Nurses are thirsting for a meaningful prac-tice, one that is based on nursing valuesand knowledge, one that is relationship-centered, enabling the expression of thedepth of our mission, and one that brings amuch needed, missing dimension to currenthealthcare. What is missing in healthcare iswhat nursing can provide when practicedfrom a disciplinary perspective. Realizingthis goal begs for consensus in the col-lective consciousness of the nursingprofession.

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