The Integrality of Situated Caring in Nursing and the Environment

Abstract

Much emphasis has been placed on the importance of the environment as a determinant of health; however, little theoretical work in nursing has specifically articulated the importance of the nursing practice environment as a factor in patient outcomes. This work advances the unitary-transformative-caring paradigm by focusing on the concept of integrality and exploring the nursing meta-paradigm concepts (nursing, environment, human being, and health) through integral philosophical inquiry.

Florence nightingale’s often quoted beliefs “that nature alone heals” and the role of nursing is to put the patient in the best environment for the natural reparative process to occur date back to the ancient Greek philosophers including Aristotle, Hippocrates, and Plato, whose writings Nightingale studied as a young adult.¹ While nursing theorists have nearly unanimously recognized optimizing the environment for patients as an essential element of nursing care, there has been considerably less emphasis on the importance of the nursing work environment for nurses to be able to provide optimal care. More than 25 years ago, the seminal work of Chandler² “The Relationship of Nursing Work Environment to Empowerment and Powerless” was grounded in Martha Rogers’ theoretical work on integrality or the continuous interaction of humans and the environment. Over the past few decades, the importance of the nursing practice environment has been explored through various research methods but is largely in the domain of health services researchers, who are exploring ways to reduce turnover and burnout among nurses and improve health outcomes for patients. The unique contribution of nursing science to advancing health research and changing norms of health care is stymied by the unfamiliarity or discomfort that many nurses associate with nursing theory, and the general tendency to ground nursing research in biomedical, sociological, or psychological frameworks.

Integrality reflects the oneness and unity or wholeness of humans and their environment. In nursing practice, integrality involves the realization that the observer is integral to what he or she is observing. The focus is on collaboration (including our patients), coevolution of knowledge and patterns of health, and unitary thinking that does not reject objective analysis but recognizes its limits.³ In the context of nursing practice, a nurse’s way of being with patients is the pattern or form of the nurse’s care (including clinical judgment). How this way of being or care is expressed and perceived or received is a reflection of the interior and exterior environments of both the nurse and the patient, which will be discussed later in this article.

The ideas presented here represent the culmination of 8 years of inquiry regarding the central question: What is the essence and experience of nursing?⁴ The essential elements of the nursing meta-paradigm (nursing, environment, human being, and health) are redefined with implications for nursing research, practice, and education. While this work is grounded in contemporary integral philosophy, the findings are consistent with the Unitary Transformative Caring paradigm and articulate a clear foundation of the core elements of nursing that can be used to ground nursing education, research, and practice.^5–10

PHILOSOPHICAL APPROACH AND EVOLUTION OF IDEAS

The philosophical inquiry approach used was grounded in contemporary integral theory and utilized an approach termed integral methodological pluralism, which aims to include all perspectives on an area of study.^11,12 Similar to Kim’s nursing epistemology,^* the organizational heuristic utilized in integral theory considers, at a minimum, the individual-interior realm of self and consciousness, the individual-exterior realm of the organism and language, the collective-interior realm of culture or worldview, and the collective-exterior realm of social systems and structures.¹³ The limitation of this method is that when there is not a solid understanding of the unitary or holonic nature of reality, the methodology can serve to further fragment rather than achieve coherence between paradigms. In addition, there can be a tendency to force data or knowledge to fit into the framework of the integral model.¹⁴ It is essential to recognize that the boundaries within the model, between categories, are “not a barrier but an interface, or region where 2 worlds are not just differentiated but joined.”^14(p29)

The integral approach (as articulated by Wilber and many others) provides something deeper than a categorical framework within which to neatly organize one’s untidy reality: it suggests a certain attitude for how one can approach knowing, conceptualizing, and theorizing. It suggests not so much what is true about the world but how people can work together to discover what is most true, just, and useful in a particular context (ie, it includes an epistemology as well as an ontology).^15(p104)

My journey to answering the question “What is the essence and experience of nursing?” began with my participation in the 2003 Nurse Manifest emancipatory study of nurses’ perceptions of practicing nursing.⁶ Not surprisingly, the dominant theme was the primacy of the nurse-patient relationship, specifically teaching, caring, and mutual growth. The most interesting finding was how closely the work environment, including workplace culture, staffing, and availability of resources seemed to correlate with nurses’ perceptions of what it was like to practice nursing.¹⁶

This led me to extensive reading and reflection on the various theories and conceptual models of nursing, with particular attention to nursing meta-language, specifically the concepts of human being, environment, health, nursing, and caring. The second project consisted of unfolding and enfolding the core concepts of nursing, using the integral model as a lens, resulting in the enactment of an integral philosophy and meta-definition of nursing as “situated caring shaped by interior and exterior environments.”¹⁷ The ideas in that article were extensively discussed with mentors, peers, and colleagues during a 1-year period prior to publication, and I have continued to integrate additional perspectives and refine the ideas over the past 4 years. Sources of knowledge or evidence include narratives of nursing practice from focus groups of nurses, a philosophical analysis of theories of nursing from the past 150 years, an analysis of the 50 US state nursing practice acts,¹⁸ international perspectives on nursing theory, and additional nursing publications including the American Association of Colleges of Nursing’s Essentials of Baccalaureate Education and the American Nurses Association (ANA) Scope and Standards of Nursing Practice.^19–23 Also included is the recently revised Scope and Standards of Nursing Practice, which now explicitly includes a standard for environmental health as a core competency of all registered nurses.²⁴ It is important to note that the ANA defines environmental health as: “Aspects of human health, including quality of life, that are determined by physical, chemical, biological, social, and psychological problems in the environment.”^24(p65)

Most recently, I have shifted my research to explore the relationship between nurses’ perceptions of the characteristics and quality of their work environments, and outcomes for nurses and patients through advanced health services research methods; performing secondary data analyses of large, linked databases. While there is criticism of the emphasis on evidence-based findings to justify what we know is true from other forms of inquiry or knowledge, the work of my quantitative-minded colleagues in this area provides the “evidence” needed by policy makers to make changes that improve nurse-patient staffing ratios and implement financial incentives to improve nursing care and care environments in acute and long-term care settings.^25–28

Effecting major change in health care requires engagement of policymakers, health care administrators, patients and their families, nurses of all levels of education, our colleagues in other professions, and the media and society at large. What I aim to present here is an updated synthesis of the very basic definitions and relationship between the central concepts of nursing that should resonate with all nurses. Since these ideas were first shared in print, the quadratic figures have been redrawn, now bounded by a circle (symbolizing wholeness and unity). Integral theory, like unitary science, maintains that the basic unit of analysis is not the atom, or the molecule, or the mathematical unit, or the interpretive perspective, or the cognitive pattern, or the historical event, or the spiritual revelation. For integral theory the unit of analysis, its basic point of explanation, analysis, reference, and “measurement” is the holon.^29(p7)

When speaking of a human being, the unitary or whole person is the holon, or whole part—a part of a whole family, culture, community, or other collective. In addition, the thoughts and beliefs of a human being are part of their inner environment and, when interacting with another human being, can impact the external environment of another, and ultimately that person’s inner environment, which, in turn, is part of their whole self.

This is especially true in health care situations where there is a cross-cultural clash between health beliefs. For example, a patient who believes in a hot-cold system, associates the properties of “hot” or “cold” with all food, medicine, and “disease.” For the patient, this is an objective truth. To illustrate, a public health campaign to encourage boiling drinking water in a rural area of Peru failed because the local, traditional belief was that boiled water (even after it had cooled) had the property of “hot” and was beneficial only in times of certain illness states that are “cold” and therefore the local population would not drink previously boiled water as a preventative measure.³⁰ In this case, it is important to note that while the hot-cold belief system would be considered part of the cultural knowledge (lower-left quadrant) or intersubjective perspective in the mind of the nurse, it is important to recognize that in the patient’s worldview, the hot-cold system is as objective as germ theory is in the biomedical worldview. As such, boundaries in the quadratic figures used on the following pages are often fluid, and “in all cases a boundary is not a barrier but an interface, or region where two worlds are not just differentiated but joined.”^14(p29)

PHILOSOPHICAL PROPOSITIONS

1. Nursing is caring situated in space, place, and time, shaped by the internal and external environments of both the nurse and the patient/client. These environments include

   1. the individual’s state of mind, intention, and personal beliefs (including personal philosophy of nursing);

   2. their level of relevant skill, training, and experience;

   3. societal and professional norms, values, and worldview;

   4. the practice environment, embedded in social, political, and economic systems (or resources, in the broadest sense).

2. Nursing impacts the health of individuals, families, groups, and populations through situated caring (or the lack of). Because of the integral (unitary) nature of human beings, physical, mental, or spiritual aspects of health may be impacted by care (or lack of care) in any dimension of their experience. For example, physical health symptoms may be impacted by psychological, spiritual, environmental, social, and cultural conditions or events.

NURSING IS SITUATED CARING

The word situated, as used in the nursing literature, means to put in context and describes the circumstances surrounding something, in this case, nursing. An integral view of nursing contextualizes the multiple pathways through which nurses receive their education or training. The various lines of development in nursing (communication, clinical competence, ethics, professional behavior) do not, by definition, proceed at an equal rate and may or may not correlate with a nurse’s highest level of education or stage of practice (academic degree, novice to expert). This conceptual model of nursing situates the different levels of nursing and types of nursing within the context of the profession as a whole. By identifying the primary orientation of an individual, organization, or culture toward a core concept such as human being or health, nursing students and practicing nurses can learn to justify and document their caring actions and intentions in a manner that will be understood by their colleagues in other disciplines and reimbursed by insurance or health financing systems.

Situated caring in nursing means that what caring “is” depends on where you are (time, space, culture) as well as one’s level of development (eg, training and experience; psychological development; moral-ethical development) and the context of the situation (disaster, high-pressure situation, routine business, relaxed, etc). A nursing encounter encompasses all these factors as well as both our patient’s perspective and our own perspective (regarding health, illness, disease, death, etc). The concept of “nursing” or “situated caring” is illustrated in Figure 1.

Figure 1.

Nursing/situated caring.

When viewed through the lens of the Right-Hand quadrants, nursing is technical actions and physical behavior. When nursing is viewed through the lens of the Left-Hand quadrants, nursing is the caring thought, feeling, and intention behind the action. These are not two different types of nursing for without caring our work would merely be tasks that could be performed by machines. On the flip side, without action our most caring intention is little more than silent prayer.^17(p89)

(Note: The quadratic figures accompanying each of the core concepts are used for illustrative (rather than prescriptive) purposes. By definition, the relevant knowledge and information for any situation are context dependent and what is considered objective in one situation or context may be considered a personal or cultural belief in another context.)

SHAPED BY THE INTERNAL AND EXTERNAL ENVIRONMENTS

Caring is situated in space and place as well as purpose and focus. Tanner³¹ writes about “noticing” as a function of the nurse’s expectations and experience, vision of excellent practice, values, workplace culture, and environment. Similarly, my research points to the importance of the internal and external environments of both the nurse and the patient/client. These environments include the individual’s state of mind, intention and personal beliefs (including personal philosophy of nursing or what nurses “do”); their level of relevant skill, training, and experience relevant to the care situation; societal and professional norms, values, and worldviews; and the practice environment, embedded in social, political, and economic systems, also referring to available resources, which might be a competent nursing assistant, working refrigerator to store perishable medication, or reliable transportation. Figure 2 presents an integrative perspective on the concept of environment and a framework to explore the holonic nature of our environment or kosmos. Kosmos refers to the entire universe in all its many dimensions: physical, emotional, mental, and spiritual. From an integral or unitary worldview, aspects of the inner environment cannot be separated from the external environment, and thoughts, beliefs, and cultural norms impact how we perceive our external environment. For example, individual or collective paranoia can impact how a government response to a health problem (such as a disease outbreak) is perceived.

Figure 2.

Environment/kosmos.

The ANA’s 2010 Scope and Standards of Nursing Practice includes a new standard (#16) “The registered nurse practices in an environmentally safe and healthy manner” that is based on the Principles of Environmental Health for Nursing Practice with Implementation Strategies.³² The principles of environmental health document is a “call to action” for nurses and builds from (a) the interpretive statements from the 8th provision of the Code of Ethics for Nurses, “The nurse has a responsibility to be aware not only of specific health needs of individual patients but also of broader health concerns such as world hunger, environmental pollution, lack of access to health care, violation of human rights, and inequitable distribution of nursing and healthcare resources” 32(Section 8.1), and (b) the World Health Organization statement, “Environmental health comprises those aspects of human health, including quality of life, that are determined by physical, chemical, biological, and social and psychological problems in the environment.”^32(p5) These documents focus primarily on the environment in a collective sense with implications at the individual level.

In contrast, the recently popular television network series Mercy provided a dramatic portrayal of how the individual, inner environment of the nurse and the patient interact during ethical dilemmas and high-pressure situations.³⁴ In one instance, Veronica Callahan, the nurse protagonist of the show, struggles to care for patients while dealing with uncontrolled symptoms of posttraumatic stress disorder. In other instances, her personal experience with grief and loss, or extensive experience with combat field medicine during a tour in Iraq, strengthens her ability to provide lifesaving counsel or emergency treatment. Unique among medical dramas, the (US) television series Mercy frequently delved into the emotional world and decision-making process of the nurses on the show and did not shy away from controversial topics or approaches to care.

While students often prefer situations where there is a clearly defined right or wrong answer, there is much to be learned from the “gray” areas of nursing that depend on the infinite nuances of a situation and require courage, risk-taking, or a sense of humor when the unexpected occurs or expectations and values clash. The idea of the environment or kosmos as inseparable or unitary with human being(s) was written about by nursing theorists including Henderson, King, Orem, Parse, Rogers, and Roy. Nightingale, Peplau, Quinn, and Halldorsdottir all wrote about the idea that the nurse creates, through her presence, intention, and actions, the environment that places the patient under his or her care in the best conditions for healing.^35–38 The point is that there is no prescription or panacea for nursing, only a context-sensitive call for nurses to practice situated caring, beginning with caring for themselves. Nurses in the emancipatory Nurse Manifest 2003 study identified 4 areas of change necessary to support ideal practice: reclaiming priorities in nursing care, obtaining needed resources, gaining respect for ourselves and from others, and finding our identity or voice.¹⁶ Each of these issues is part of the nurse’s environment, including our individual mental environments, professional and workplace culture, as well as working conditions including staffing levels and availability of material resources necessary to optimal care. Nurses must ensure and demand that their environment, both internal and external, is one that allows them to practice nursing without risk of burnout or harm to their patients (from either iatrogenic or biocidic influences).

OF BOTH THE PATIENT AND THE NURSE

Often the meta-paradigm term human being (previously person) is used to describe the patient and can refer to an individual, family, group, or population. It is important to recognize that nurses are also human beings, with basic needs that need to be met before therapeutic levels of care can be provided for an extended period of time. Nurses who have described working in survival mode provide examples of caring nurses that failed to prioritize their own self-care. In line with the American Nurses Credentialing Center’s Magnet Hospital accreditation program, current research by Aiken and colleagues^25–28,39 provides statistical evidence that working conditions and workplace culture can positively or negatively impact both nurses and the patients for whom they care for.

Figure 3 illustrates an integrative conceptualization of the concept “human being,” which can be applied to an individual, family, group, or population of patients or health care providers. While many of the major nursing theories describe the concept of a person or human being as a unitary, holistic, integrated, or unfragmented whole, they should all, theoretically, permit discussion of aspects, subsystems, or parts of a human being or a collective of human beings. Scholars in the tradition of Martha Rogers, notably Parse, often reject any labeling or discussion of aspects of a person; however, this interpretation of unitary science is similar to criticism of confusing orders of abstraction of Korzybski,⁴⁰ in which he stresses that “the map is not the territory.”

Figure 3.

(Unitary) human being.

An integral conceptualization of the concept “human being” provides a framework for asking and answering questions at the cutting edge of nursing and medical sciences, such as recent research in genomics exploring how social isolation or lifestyle factors (diet, exercise, meditation) can change the expression of our genetic code to create or reverse illness.^41,42 Two additional examples include research on the positive effects of therapeutic touch on healthy and cancerous bone cell cultures (University of Connecticut Health Center),⁴³ and on “placebo” effects in patients with irritable bowel syndrome that were stronger than the best pharmaceutical treatment (Harvard Medical School).^44,45 The knowledge that has been documented in nursing theory for decades is beginning to be supported by a body of scientific research from other disciplines that are making discoveries that do not fit with frameworks and worldviews of the disciplines initiating the research. The US National Institute of Nursing Research strategic plan states, “The science of health encompasses the investigation of multiple health determinants—including psychological, physiological, genomic, environmental, familial, societal, and cultural factors—and their impact on the health promotion and self-management behavior of individuals within their communities.”^46(p5) This is a tacit reference to the assumption that human beings are inseparable from the environment. It is an invitation for nursing innovation in the transformation of patient care.

TO IMPROVE THE HEALTH OF INDIVIDUALS, FAMILIES, GROUPS, AND POPULATIONS

Nursing impacts the health of individuals, families, groups, and populations through situated caring. Because of the integral (unitary) nature of human beings, physical, mental, or spiritual aspects of health may be impacted by care (or lack of care) in any dimension of their experience. Physical health symptoms may impact or be impacted by psychological, spiritual, environmental, social, and cultural conditions or events (ie, by the kosmos). Consider both how the weather or an economic depression can impact an individual’s physical health symptoms and how the death of a prominent international figure (like Steve Jobs) impact the kosmos. An integrative conceptualization of health is presented in Figure 4 as experienced and measured in individuals and groups.

Figure 4.

(Unitary) health.

The major aspects of health can include an inner and outer state of wellness, integrity, and wholeness; and also take into account illness and disease from an individual and collective perspective. Individuals’ inner states are how they (or society) perceive their level of wellness. Some cultures or value systems consider this to be a function of how well the individual can fulfill their role in society (as mother, employee, husband, etc.). The outer state of wellness may refer to an individual’s physical appearance (complexion, body composition, etc.). Some cultures form their inner conception of health based on the physical measures obtained by health care professionals.^17(p87)

Again, note that this description and mapping of elements or aspects of health serve only to facilitate identification of interactions and relationships between different perspectives.

Nursing education and research related to health disparities can draw from an integrative conceptualization of health to holistically explore health issues while considering culture, power dynamics, socioeconomic conditions, and the effects of multigenerational stressors and oppression. For example, a small group of individuals who are denied human rights or civil liberties might be expected to experience greater “dis-harmony,” lower self-perception, and, probably, poorer self-care and health outcomes than the privileged majority. Alternately, an integrally informed conceptualization of health can be used to study the impact of caring and uncaring relationships as described by Halldorsdottir,³⁸ ranging from biocidic or life destroying to biogenic or life-giving relationships.

IMPIICATIONS FOR NURSING EDUCATION

The gestalt of expert nursing practice comes from more than intuition or instinct, and it is the result of a complex pattern recognition process that occurs as a patient’s presentation is subconsciously cross-referenced with the nurse’s knowledge base. It is crucial that when we speak of pattern recognition, we are not describing our abilities in terms that imply “good” nurses are telepathic, medical intuitive or that our newly licensed members are too inexperienced to respond therapeutically in complex or critical situations. Tanner³¹ refers to pattern recognition as clinical judgment and focuses on the importance of the nurse’s inner environment including past experience, the context or external environment, and the nurse-patient relationship or engagement. Recognizing, articulating, and acting on the patterns we recognize with our patients are essential for ensuring those we work with are in the best environment and position for healing/health.

Appreciating and building upon the wealth of knowledge that beginning students already have about what it means to care and be cared for would provide a unifying entry point for nursing studies, especially for programs that are currently organized using a body system/disease framework. Situated caring provides a rationale for everything from bed making to highly technical tasks. It provides a reason for holding someone’s hand or making sure a draw sheet is wrinkle free and for calling an interdisciplinary team meeting or family conference to discuss how care could be best provided in challenging situations. Situated caring provides a motivating force for nurses to engage in political and policy issues, in their institutions and communities and at the state and national levels. Situated caring becomes a philosophy, a theory, and a context. In education, theory is often seen as divorced from practice, at least within the eyes of the students. Situated caring has the potential to become a part of every action, thought and perspective of each student and nurse. Theory is not divorced from but is integral to nursing praxis.

An approach to discussing situated caring that would be especially appropriate for schools that emphasize evidence-based practice is to have students gather the “evidence” for nursing, as a discipline distinct from medicine, psychology, or social work. As a beginning exercise, this forces students and faculty to consider broadly what constitutes knowledge and evidence for practice. Evidence-based practice in nursing has been defined as patient-centered care that integrates “the evidence available, nursing expertise, and the values and preferences of the individuals, families, and communities who are served.”^47(P69) This takes place within the context of the practitioner-patient interaction and relationship, which involves knowing the patient, empathy, and trust.⁴⁸

Concept-based education is not new and has been used effectively for decades to teach integrated nursing care related to concepts including aging, behavior change, comfort, culture, fluid and electrolyte imbalance, infection control, shock, spirituality, and transitions. Curricular changes in nursing are progressively resulting in the elimination of courses and content in nursing theory and history at the undergraduate level. In actuality, knowledge and application of nursing theories, especially those that explicitly emphasize the unitary relationship between human beings and their internal and external environments, should be used to ground the introduction of courses such as genomics.

The response to concerns about a lack of a theoretical base for nursing has created the current emphasis on mid-level theories related to concepts, including the model of behavior change of Prochaska and colleagues⁴⁹ or the theory of experiencing transitions of Meleis.⁵⁰ While mid-range theories are considered more accessible to researchers and clinicians, they still require a nursing perspective that considers phenomena holistically, dynamically, and within context.⁵⁰ The meta-language of nursing contains the basic building blocks or foundation for the discipline and profession of nursing. The basic elements (human being, environment/kosmos, nursing/situated caring, and health) of the discipline need to be explored from an integral or holistic nursing perspective throughout nursing education programs and especially in introductory and fundamentals courses. How students conceptualize human beings and health, appreciate the impact of environment, and view the role of nursing are critical to their formation as nurses and essential to the development of health care providers with a unique and distinct perspective and approach to care within the multidisciplinary team. Through an emphasis on integrality within the nursing meta-paradigm we can achieve the radical transformation called for in the Carnegie Foundation report on nursing education that called for nursing students to learn to “put their patients’ experience in context, including the cultural background, the patient’s environment, illness experience, and relationships with the patient and the family.”^51(p48)

FINAL THOUGHTS

My early research with the Nurse Manifest project highlighted fragmentation within the paradigms and profession of nursing. Later, I viewed the fragmentation as different perspectives that must be transcended and included to create a coherent foundation for the future of the nursing profession. This integral vision is especially needed now to preserve the unique contribution of nursing while working with a health care system that is currently focused on applications of information technology, research that includes “biomarkers,” evidence-based practice, and interprofessional education. Through an integral lens, the meta-paradigm of nursing is caring that is situated in space, place, and time and influenced by the interior and exterior environments of the nurse and the patient. Nursing care (or lack of care) impacts the health of individuals, families, groups, and populations. For these reasons, it is essential that we, as a profession and society, ensure that nurses are provided with optimal work environments and resources to create the best conditions for their patients to heal.

I hope that this article invites new discourse and dialogue about the current state of thinking within nursing theory and expanding views that allow new thinking and reflection. May this work be forever useful to students and faculty in all levels of nursing education and serve to assist scholars in other disciplines appreciate what is special and unique about nursing.