Afaf Ibrahim Meleis, PhD, FAANMargaret Bond Simo.docx

Afaf Ibrahim Meleis, PhD, FAAN
Margaret Bond Simon Dean
Professor of Nursing and Sociology
University of Pennsylvania
School of Nursing
Philadelphia, Pennsylvania
THEORETICAL NURSING
Development and Progress
Fifth Edition
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Fifth Edition
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Library of Congress Cataloging-in-Publication Data
Meleis, Afaf Ibrahim, author.
Theoretical nursing : development and progress / Afaf Ibrahim
Meleis,
PhD, FAAN, Margaret Bond Simon Dean, Professor of Nursing
and Sociology,
University of Pennsylvania, School of Nursing, Philadelphia,

Pennsylvania. — Fifth Edition.
p. ; cm.
Includes bibliographical references and indexes.
Summary: “An additional assumption was that the processes for
theory development were new to nursing and
hence, nurses in graduate programs learned strategies for
advancing knowledge from other disciplines. This
assumption was debunked with the knowledge that nurses were
always engaged in knowledge development,
driven by their experiences in clinical practice. Because of
these assumptions, most of the early writing about
theory development was about outlining strategies that should
be used, rather than strategies that have already
been used in the discipline to develop theories. Theorists
themselves did not uncover or adequately discuss ways
by which they developed their theories, therefore the tendency
was to describe processes that were based on the-
ories developed in other disciplines, mainly the physical and
social sciences. And an implicit assumption was
made that there should be a single strategy for theory
development, some claiming to begin the process from
practice, and others believing it should be driven by research”—
Provided by publisher.
ISBN 978-1-60547-211-9 (hardback : alk. paper) 1. Nursing—
Philosophy. I. Title.
[DNLM: 1. Nursing Theory. WY 86]
RT84.5.M45 2011
610.7301—dc22
2010051628
Care has been taken to confirm the accuracy of the information
presented and to describe generally accepted

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mailto:[email protected]

In Memory of Soad Hussein Hassan, RN, PhD
A maverick—
for exemplifying humanism and commitment,
for encouraging feminism and autonomy,
for accepting challenge and diversity,
for tolerating rebellion,
for sponsoring inquisitiveness,
and for being my mother.
And
For teaching me about the courage
to face a life of challenges
and an end of life with Alzheimer’s.
LWBK821-FM_pi-xiv 1/8/11 1:30 AM Page iii
R E V I E W E R S
Patricia M. Burbank, RN, DNSc, MS
Professor
University of Rhode Island
Kingston, Rhode Island
J. Carolyn Graff, PhD, MN
Associate Professor
University of Tennessee Health Science Center
Memphis, Tennessee

Rebecca Otten, RN, EdD, MSN, BA Health
Administration
Assistant Professor
California State University — Fullerton
Fullerton, California
And
Mount St. Mary’s College
Los Angeles, California
Linda A. Streit, RN, DSN
Dean and Professor for the Graduate Program
Georgia Baptist College of Nursing of Mercer
University
Atlanta, Georgia
Cynthia Toman, RN, PhD, MScN, BScN
Assistant Professor
University of Ottawa
School of Nursing
Ottawa, Ontario, Canada
iv
LWBK821-FM_pi-xiv 1/8/11 1:30 AM Page iv
P R E F A C E
v
THROUGHOUT the many editions and revisions
of this book, I received a lot of feedback and

many responses about the ideas presented.
These arrived in writing, in person, in meet-
ings, and in e-mails. Many responses, from
many corners of the world, reflected a real
intellectual engagement in the book. Some
were inspired by our theoretical history, others
questioned our philosophical past, but most
thought the dialogues that evolved from dis-
cussing the ideas in the book reaffirmed their
identity in nursing and ignited their pride in
the profession and the discipline of nursing.
These comments, reviews, and suggestions for
revisions made me realize that the major role
of this book is empowering its readers. It has
given the readers a voice to engage, debate,
and to challenge sacred cows about how our
discipline evolved and ways by which we can
evaluate growth in the discipline.
The intent of this book, then, is to demys-
tify theory, to chart the different strategies to
use in developing and advancing theory, and to
provide tools and best practices in evaluating
progress in the discipline. It provides both an
open invitation to embark on a journey with-
out the many preconceived assumptions that
may have been a barrier to pursuing knowl-
edge development. Among these assumptions
were that a select few could engage in devel-
oping theory. Perhaps this is because, during
1950–1970, the construction of theory in nurs-
ing occupied only a select few members of
the discipline. The metatheoreticians and
their writings attracted another select group
of nurses, and they focused on suggestions
about formulating theories, defining types of

theories, and identifying sources for theories.
Subsequently, conceptualizing nursing phe-
nomena commanded the attention of a wider
circle of members of the discipline. Many
other assumptions shaped our history and
influenced our current progress in the disci-
pline. For example, there was the assumption
that a conceptual framework was essential for
advancing nursing knowledge. This assump-
tion changed as we entered the 21st century
because the discipline was better defined and
was replaced with another assumption: that
empirical knowledge and research programs
are the only means toward advancing knowl-
edge.
An additional assumption was that the
processes for theory development were new to
nursing and hence, nurses in graduate pro-
grams learned strategies for advancing knowl-
edge from other disciplines. This assumption
was debunked with the knowledge that nurses
were always engaged in knowledge develop-
ment, driven by their experiences in clinical
practice. Because of these assumptions, most
of the early writing about theory development
was about outlining strategies that should be
used, rather than strategies that have already
been used in the discipline to develop theories.
Theorists themselves did not uncover or ade-
quately discuss ways by which they developed
their theories, therefore the tendency was to
describe processes that were based on theories
developed in other disciplines, mainly the
physical and social sciences. And an implicit

assumption was made that there should be a
single strategy for theory development, some
claiming to begin the process from practice,
and others believing it should be driven by
research.
Another implicit assumption was that the-
ory development was an elitist activity, to be
engaged in only within the halls of academia.
Furthermore, it was assumed that what goes on
within the halls of academia had no resem-
blance to the clinical work that goes on in real
life. (Notice the many comments over the
years about nursing theory and the lack of cli-
nicians’ need for such theory.) Some believed
that nursing had always borrowed its theory
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vi
and that nursing was an applied field. To them,
nursing practice theory was not needed
because theories from science and ethics were
enough to guide nursing. Therefore, theory
development was an unnecessary process.
Some critics did not consider that redevelop-
ment, resynthesis, and reintegration of find-
ings, ideas, and statistical wisdom were also
processes for knowledge development.
Different eras provided different sets of
assumptions. In many instances, biomedical
sciences dominated more than biopsychologi-

cal sciences. And, as educational programs in
nursing became more biologically and med-
ically based, theories that reflect the human
sciences tended to be neglected. Therefore,
major journals in nursing tended to capture
empirical evidence based on more medically
defined outcomes of mortality and morbidity
rates as compared to quality of life, levels of
functioning, perceived health status, adapta-
tion, and energy levels.
The reader of this book will find that it
includes many arguments that dispel many of
these preconceived assumptions and that:
• Nurses have a fine and useful theoretical
heritage that is worthy of analysis. By
understanding how and why our heritage
evolved as it did, we may be in a better
position to consciously and deliberately
drive the development of theoretical nursing
to meet the mission that we have articulated
about our discipline.
• There are sources and resources by which
nurses can conceptualize different aspects
of the nursing universe for the purpose of
facilitating understanding, increasing
autonomy in their actions, and enhancing
control over their domain. The ultimate
objective is to provide quality care utilizing
the different tools and strategies for theory
development. The reader will find support
that clinicians are as valuable in advancing
nursing knowledge as theoreticians because
they articulate their practical wisdom into

exemplars that may help to solve other clin-
ical problems.
• The scientific development of the discipline
of nursing has followed a unique path,
charted by members of the discipline to suit
its unique features and the context of its
nursing care complexities. The sociology
and the philosophy of nursing science are
legitimate and significant areas of investiga-
tion to discern the progress and develop-
ment of the discipline. As nurses questioned
the empiricist’s view of science and
embraced other more dynamic and chang-
ing conceptions of science, the behavior of
scientists and theoreticians, the processes of
selection of research and theories, the his-
torical environment, and the sociocultural
context for the development and utility of
the discipline’s theories become legitimate
and provide central questions for the
domain.
• And finally, our theoretical history, our
epistemology, and our domain are the bases
for our theoretical future. The novice should
be acquainted with them, the advanced
should explore and question the relation-
ships between the parts and, together with
the experienced, they should shape and
reshape nursing knowledge.
Demystifying theory and dispelling assump -
tions are essential but not sufficient conditions
for empowerment. The metaphors that describe

the current stage in theory development are
epistemic diversity and integrative process,
both of which are an acknowledgment and val-
uation of nursing history, heritage, and prac-
tice. Both of these metaphors reflect and accept
the central role of practice in advancing nurs-
ing knowledge and nurses’ ways of knowing
as vital in uncovering and developing knowl-
edge. Empowerment is also about believing
in one’s self, abilities, and capacities to
advance knowledge and about using these
capacities to become an agent for continuous
learning and creating. It is about being a criti-
cal thinker, an innovative advocate, and an
agent for change.
In this book, I present and provide sup-
port for our domain as we see it today. The
future progress of the discipline depends on
the extent to which members of the discipline
will embrace epistemic diversity and integra-
tive approaches to theory development, and
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vii
the extent to which evidence is translated,
utilized, and evaluated. The scholars of the
future are those who are as comfortable with
theorizing as with researching, practicing, and
teaching. They will be able to understand and
speak the languages of different disciplines,
translate their findings to the different practice

fields, and engage in changing policies.
In short, the major goals of this book are
to make a contribution to raising the con-
sciousness of the reader about the theoretical
development and progress of our discipline, to
acknowledge our theoretical history, to place
the present in the context of our history, and to
develop an awareness of the potential inherent
in members of the discipline, both men and
women. It is about the pride we must have in
the contributions our discipline makes to the
health and well-being of people.
I offer the ideas in this book as tentative
thoughts to provide an even platform to
enforce self-agency in students, faculty, clini-
cians, researchers, and theoreticians to drive
the development of new coherent frameworks
to advance nursing science. By knowing
equally, each may be empowered to leverage
their competency and use their expertise. A
democratization of the processes in developing
theory is an empowering process to you, the
reader, to believe in your own voice, to respect
and value the voices that came before you, but
to challenge and build on them.
Every time I work on a new edition, I feel
renewed, inspired, and regenerated. It has been
a privilege for me to be a nurse, and it is an
incredible privilege to write this book honoring
the past and envisioning the future. To readers
near and far, I thank you for dialoguing with the
ideas in this text. I truly value your responses

and comments, so keep sending them.
Afaf Ibrahim Meleis, PhD, FAAN
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REVISING and updating this book and bringing
this 5th edition to you is a testament to my
unwavering passion about its subject matter, the
progress we made in advancing knowledge in
the discipline, and the incredible support this
project received from many people.
I am grateful to Lippincott Williams &
Wilkins’ project manager, Helen Kogut, who,
knowing my schedule and commitments,
planned ahead, monitored progress, provided
reminders, respected my work priorities, and
recognized that emergencies happen. Her
patience and encouragement made it possible
to complete and publish this 5th edition.
What made this project most pleasurable in
spite of its intensity and time commitment is the
partnership that I have developed with Maria
Marconi, who oversaw the typing and organiz-
ing, seeing it through beginning to end. Watch-
ing her enthusiasm and commitment to the
quality of the project, her excitement about
learning new skills, and her pride in the project

at the completion of each phase, added tremen-
dously to the pleasure we both derived in com-
pleting it. To her, I offer my heartfelt gratitude
for her commitment, and my admiration for her
professionalism, and for the quality of her work.
I also extend my deep appreciation to
members of the Dean’s Office, who allowed me
some time flexibility to devote to this project.
My responsibilities as the Dean were well man-
aged, and the many other projects in our agenda
were completed effectively, efficiently, and on
time. That I attribute to a highly functioning,
effective, productive, and committed team,
which includes Caroline Glickman and Lucia
DiNapoli, under the leadership of Ann Marie
Franco. I am indebted to them for their expert-
ise, caring, and wonderful sense of humor.
I continue to be inspired by how far our
discipline has progressed in spite of the many
barriers and obstacles its members faced due
to gender-, occupational-, and policy-driven
inequities. The resilience, the pride, and the
commitment of nurses globally are reflected in
the many mentees who challenged my thinking
while students or junior faculty, and later, as
established scholars, extended and expanded
my horizon. I am always awed by these
mentees from around the world who continue to
be in my life. They, along with the many stu-
dents and faculty who take the time to read
what I write, and whether to extend or argue
with it, continue to influence and shape the
ideas presented in each new edition. My profes-

sional, academic, and personal lives continue to
be deepened, renewed, and enriched by each
and every one of these interactions.
My partner in life, Dr. Mahmoud Meleis,
vacillates between taking pride in all that I do,
and wishing that I would slow down to enjoy
more together-time at this stage in our lives. In
spite of this time-commitment versus time-free
paradox, his support never wavers, his advice is
always authentic, his voice is always insightful,
and his dedication to our family is emulated by
our sons, Waleed and Sherief, who are now rais-
ing their own families. They all provide a foun-
dation of family support that is most inspiring.
I am indebted to all for your support.
A.I.M.
A C K N O W L E D G M E N T S
ix
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C O N T E N T S
xi

P a r t O N E
Our Theoretical Journey 1
CHAPTER 1
POSITIONING FOR THE JOURNEY 2
Our Theoretical Heritage 3
Assumption, Goals, and Organizations 3
Organization of The Book 4
On a Personal Note 6
Reflective Questions 6
CHAPTER 2
ON BEING AND BECOMING A
SCHOLAR 7
Scholarliness in Nursing 9
Nurses as Scholars 15
Revisiting Scholarship in the 21st Century 17
Conclusion 20
CHAPTER 3
THEORY: METAPHORS, SYMBOLS,
DEFINITIONS 23
The Destination: Theory and Theoretical
Thinking 23
Definitions 25
Types of Theories 33
Theory Components 35
Uses of Theory 35

P a r t T W O
Our Theoretical Heritage 39
CHAPTER 4
FROM CAN’T TO KANT: BARRIERS AND
FORCES TOWARD THEORETICAL
THINKING 40
Barriers to Theory Development 41
Resources to Theory Development 50
Conclusion 55
CHAPTER 5
ON THE WAY TO THEORETICAL
NURSING: STAGES AND
MILESTONES 59
Stages in Nursing Progress 59
Milestones in Theory Development 67
Conclusion 80
P a r t T H R E E
Our Discipline and Its
Structure 85
CHAPTER 6

THE DISCIPLINE OF NURSING:
PERSPECTIVE AND DOMAIN 87
Nursing Perspective 88
Domain of Nursing Knowledge 94
Definition of Nursing 106
Conclusion 108
CHAPTER 7
SOURCES, RESOURCES, AND
PARADOXES FOR THEORY 113
Spinoza on Knowledge
Development 113
Sources for Theory Development 114
Classifications of Nursing Diagnosis,
Nursing Interventions, and
Decision Making 120
Resources for Theory Development 122
Identifying Domain Paradoxes 124
Conceptual Models Versus Theory 125
Nursing Theory Versus Borrowed
Theory 128
Conclusion 132
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xii
CHAPTER 8
OUR SYNTAX: AN
EPISTEMOLOGICAL ANALYSIS 136
Knowing from the Received View
to Postmodernism View 136
Truth: From Correspondence to Integrative
View of Truth 150
Conclusion 155
P a r t F O U R
Reviewing and Evaluating:
Pioneering Theories 159
CHAPTER 9
NURSING THEORIES THROUGH
MIRRORS, MICROSCOPES, OR
TELESCOPES 160
Images of Nursing, 1950–1970 162
Theories’ Primary Focus 174
Images, Metaphors, and Roles 175
Areas of Agreement Among and
Between Theorists and Schools
of Thought 175

Conclusion 177
CHAPTER 10
A MODEL FOR EVALUATION OF
THEORIES: DESCRIPTION,
ANALYSIS, CRITIQUE, TESTING,
AND SUPPORT 179
Selecting Theories for Utilization 180
Framework for Evaluating Theories 185
Description 185
Analysis 189
Critique of Theory 194
Theory Testing 200
Theory Support 202
Conclusion 203
CHAPTER 11
ON NEEDS AND SELF-CARE 207
Dorothea Orem 207
Conclusion 224
CHAPTER 12
ON INTERACTIONS 229
Imogene King—A Theory of Goal
Attainment 229
Ida Orlando 241

Josephine Paterson and Loretta Zderad 251
Joyce Travelbee 258
Ernestine Wiedenbach 265
Conclusion 271
CHAPTER 13
ON OUTCOMES 279
Dorothy Johnson 280
Myra Levine 290
Betty Neuman 300
Martha Rogers 311
Sister Callista Roy 324
Conclusion 338
P a r t F I V E
Our Theoretical Future 353
CHAPTER 14
CHALLENGES AND OPPORTUNITIES
FOR A THEORETICAL FUTURE 354
Opportunities Within Paradoxes 355
Disciplinary or Interdisciplinary
Knowledge 355
Global or Local Theories 356
Marginalized or Privileged Populations 357
Technical Nursing or Expert Nursing
Practice 357
Nursing Informatics or Medical Informatics 358

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xiii
Taxonomies or Interpretations 359
Clinical, Conceptual, or Empirical Theorizing 361
Knowing Through Research and Knowing
Through Theory 362
Integration or Isolation of Theoretical
Discourses 365
Middle-Range or Situation-Specific
Theories 367
Conclusion 368
CHAPTER 15
CONCEPT DEVELOPMENT 371
Concept Exploration 372
Concept Clarification 374
Concept Analysis 376
An Integrated Approach to Concept
Development 380
Conclusion 387
CHAPTER 16
THEORY DEVELOPMENT 391

Theory Development: Existing Strategies 394
Theory to Practice to Theory Strategy 394
Practice to Theory Strategy 396
Research to Theory Strategy 398
Theory to Research to Theory Strategy 403
Conclusion 404
CHAPTER 17
MIDDLE-RANGE AND SITUATION-
SPECIFIC THEORIES 407
The Integrative Process for Developing
Middle-Range and Situation-Specific
Theories 407
Tools for Developing Middle-Range
or Situation-Specific Theories 409
Middle-Range Theories 410
Situation-Specific Theories 419
Conclusion 423
CHAPTER 18
MEASURING PROGRESS IN A
DISCIPLINE 427
A Theory of Revolution 428
A Theory of Evolution 431
A Theory of Integration 433
Conclusion 436

P a r t S I X
Our Historical Literature 439
CHAPTER 19
HISTORICAL WRITINGS IN
THEORY 440
Section I: Abstracts of Writings in
Metatheory, 1960–1984 440
Section II: Abstracts of Writings in Nursing
Theory, 1960–1984 469
Dorothy Johnson 469
Myra Levine 478
Dorothea Orem 482
Martha Rogers 489
Sister Callista Roy 494
Joyce Travelbee 501
CHAPTER 20
HISTORICAL AND CURRENT THEORY
BIBLIOGRAPHY 502
Theory and Theorizing in Nursing 503
Nursing Theory and Theorists 548
Paradigms That Have Influenced
Nursing 616
Middle-Range Theory 631
Situation-Specific Theory 632
Video and Audio Tapes on Theory 632

AUTHOR INDEX 637
SUBJECT INDEX 663
xiii
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Our Theoretical Journey
I INVITE you, in this first part of the book, to embark on a
journey that will introduce
you to the rich theoretical underpinnings of our discipline.
Uncovering the role that
theory plays in our daily experiences as nurses is the first step
in the theoretical jour-
ney proposed in this book. In the three chapters in Part One, the
theoretical journey,
along with its symbols and scholarly destinations, is described.
In Chapter 1, you
will find assumptions on which the journey is planned, the
organizational plan for
the journey, and some of the supporting material. Chapter 2
includes scholarly goals
and the different possible destinations for the journey. The

context for the journey is
then set in Chapter 3, where the key definitions of theoretical
symbols and terms
are provided.
As with any long journey, planning is essential, but it is equally
important to
allow flexibility for personal goals to emerge from the
experience, side trips that
may distract or enrich you, and serendipitous opportunities that
may attract you. It
is the totality of these experiences that will lead to immersion,
understanding, and
innovation.
P A R T O N E
LWBK821_c01_p001-006 07/01/11 6:03 PM Page 1
C H A P T E R 1
Positioning for the Journey
Disciplines should be dynamic to respond to emerging and
changing needs of societies and to new
demands imposed by population movements, health care
reforms, and transformation of global
order. However dynamic disciplines are, they have a core set of
values, assumptions, a perspec-

tive, and a mission that maintain their stability and
effectiveness. This core is what provides conti-
nuity and progress in disciplines.
Quality care for all people continues to be nursing’s top
priority. In the 21st century, this goal
is even more urgent than it has been because of increasing
diversity and better awareness of the
changing needs of the public, the conflicting priorities in health
care systems, and the emergent
costs and reimbursement issues that patients, insurance
companies, the health care industry, and
health care professionals are confronting. Theory and
theoretical thinking may have been pro-
moted in the past as answers to the undefined roles of nursing
or the diffused nature of the profes-
sion of nursing. However, in this new era of unequal access to
health care, where disparities in
provision of health care services are becoming more recognized,
where there are emerging chal-
lenges in treating chronic illnesses and infections, and where
there is a proliferation of health care
professionals and many global dialogues about health care
reform, the role of theory has become
even more urgent and more compelling. To fully appreciate the
role of theory in shaping the future of
equitable and accessible quality health care, we must review
and analyze our theoretical past and its
influence on the present and future of health care.
By uncovering and understanding a discipline’s theoretical
journey, members of the discipline
learn and build on it. By unfolding the process used in
developing the theoretical past, we gain insights
that improve our understanding of our current progress, and we
are empowered to achieve our discipli-

nary goals. When we take a critical and reflective stance on the
current theoretical discourse, or lack
thereof, as the case may be, we see shadows of past issues and
accomplishments, as well as visions of
the future of our discipline and profession. Therefore,
reconstructing our theoretical heritage is a
process that involves reconstructing our present reality. The
intent of the historical-to-future journey
proposed in this book is to demonstrate the progress of nursing
through analyses of the philosophical
assumptions, theoretical methods, and theoretical threads that
have influenced the development of the
discipline. We will perform these analyses in ways that value
our experiences as nurses, in ways that
support and enhance our progress, and in ways that allow us to
proactively develop abstractions, exem-
plars, conceptualizations, and theories that reflect and guide our
nursing assessments and actions. Syn-
thesizing insights from and about the past, considering the
current reality of the health care systems,
analyzing the societal context, and considering the potential
future visions of quality care can enhance
creativity in the discipline of nursing, which could further its
development and progress.
Despite many crises along the path of quality care, the
development of the discipline of nursing
has progressed by leaps and bounds during the last 30 years of
the 20th century. The new century
brought with it many challenges, some new and some merely
shadows of the past. Few would dispute
the …
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Hampson (2019) advances that several companies offer
wellness, fitness and retreat services. These entities provide
competition to EcoForest Leisure. As sited in synergy

Experiences & Synergy Jewellery (2019), one of the main
competitors is Synergy Experiences, a company specializing in
providing luxury weekends and wellness to clients in Peak
District and Staffordshire areas. Concerning fitness, Trafford
Leisure (2019) shows that the company faces stiff competition
from Trafford Leisure, which offers fitness and wellness
programs in Peak district and greater Manchester. In its niche as
a corporate retreat provider, the company faces competition
from Lowfield Farm Cottage, which provides corporate.
Environmental analysis to determine opportunities and
weaknesses
This section will utilize the PESTEL and SWOT analysis to
facilitate the analysis of the environment and identify the
weaknesses and opportunities for EcoForest Leisure.
PESTEL analysis
Political environment
The political environment allows for the thriving of the industry
because there are limited tariffs or trade restrictions designed
by the government and affect the wellness and well-being
sector. Today, Sargeant (2016) the government is focused on
cutting unemployment by removing restrictions such as age;
hence, the costs of hiring workers in the industry are low.
Economic environment
On the economic front, Lea (2018) shows that there are low
inflation rates and disposable income in the UK is high. Since
EcoForest Leisure offers premium services, the customers are
inclined to spend on their wellness and well-being, especially in
luxurious settings. Apart from this, the interest rates are
relatively low in the UK; hence, cheaper financing business is
possible. However, Chang (2018) shows that the current

uncertainty over BREXIT has adversely impacted businesses,
especially those dependent on services and products from the
European Union. For Eco Forest, this uncertainty may impact on
the company’s hiring of employees, especially non-UK citizens.
Social environment
The social and cultural shifts being experienced in the UK
favour EcoForest Leisure. Firstly, there is a growing concern
about physical and mental health in the UK (Hartley, Yeowell &
Powell, 2019). This precedent makes venturing into wellness,
fitness and well-being business lucrative. The social
environment is also characterized by shifting demographics. Ho
& Hendi (2018) report that there is an increase in population for
older people due to high life expectancy; these individuals have
begun prioritizing fitness and well-being. Lastly, Mason,
Schnackenberg & Monro, (2017) posit that the adoption of
Asian practices such as Buddhism and Yoga is on the rise in the
UK.
Technological environment
The UK presents a technologically productive climate primarily
due to the proliferation of the internet and computer
technologies. Apart from this, Page et al. (2017) shows that a
wide range of technology exists to support wellness and well-
being activities. Lastly, research and development investments
are high.
Ecological environment
Currently, McEldowney & Salter (2016) shows that there is a
sharp focus on the green environment by the government and
the public at significant, owing to climate change and extensive
environmental degradation. Hence, business entities are
required to initiate sustainable business activities and limit
pollution. Additionally, the adoption of natural and organic
products, as well as the use of renewable sources of energy for
equipment, is essential.

Legal environment
There are different legislation governing the health and safety
aspects of leisure, fitness and well-being sectors. For instance,
the provision of physical therapies such as hydrotherapy must
be undertaken by qualified personnel. Apart from these laws and
regulations on taxation, employees, work environment and
business licences are enforced promptly in the UK.
SWOT analysis
Source: Writer generated
Niche and target marketing strategy for EcoForest Leisure
EcoForest Leisure operates in a market with a wealth of
opportunities. However, weaknesses displayed by the company,
especially in its marketing strategy, means that it cannot exploit
these opportunities. Concerning this, this section will
recommend a niche and target marketing strategy that will
underpin the exploitation of the opportunities in the market.
From the case study, it is has been established that the company
intends to venture into corporate wellbeing events and other
retreat activities. Contemporarily, the company faces stiff
competition from various competitors in the segments of fitness,
wellbeing and retreats. Hence, this study recommends a niche
and target marketing strategy. Niche marketing involves three
steps of segmenting, targeting and positioning. Segmentation
entails demarcating the market into segments; in this case
demographic segmentations with respect to age will be used. As
a result, EcoForest Leisure should focus on attracting
millennials should be adopted. Lee et al. (2019) indicate that
millennials form a strong customer base for entities providing
fitness and wellbeing services. Basically, adoption of niche
marketing at EcoForest Leisure will help the company to
develop a marketing strategy that addresses the needs of a
specific niche. Akbar et al. (2017) discuss that niche marketing

streamlines marketing because the company able to exclusively
focus on a specific demographic. In this case, Eco Forest will
direct its niche marketing initiatives towards millennials.
Positioning and differentiation
The next phase of niche marketing is positioning, which aims to
provide the segment with certain marketing messages that
appeal to their unique interests and features. According Porter
(2008) a company can choose from four main generic strategies
to differentiate itself from competition and position
strategically in the minds of consumers. These include
differentiation, low costs leadership, cost focus and cost
differentiation strategy. Millennials display various unique
features, which make it difficult to marketers to target or rather
position themselves in a manner that best appeals to them.
Having grown up during the era of the economic depression,
Banerjee & Bhardwaj (2019) show that they make spending,
work, and family choices that are peculiar and making it
challenging to target. However, with unique marketing
strategies, such a group offers an important opportunity to
exploit. It is essential to note that while millennials are fond
users of the internet and digital technologies, Narang (2018)
shows that customers are quite cost sensitive. As such, Eco
Forest needs to adopt a cost-focus strategy, where the company
will position itself as a low-cost manufacturer that offers unique
designs for millennials.
The company can position itself through optimizing marketing
messages to fit mobiles and tablet applications, developing a
strong brand personality and engaging them on social media and
other online platforms such as company websites. Online
targeting will be employed at Eco-Forest Leisure through an
integrated digital marketing strategy to augment niche
marketing will be essential. This communication is informed by
the fact that millennials are the regular users of digital
technologies such as smartphones, social media and the
Internet. The plan should encompass search engine

optimization, data management, content marketing and social
media marketing. Felix, Rauschnabel, & Hinsch (2017) am apart
from being cheap, search engine optimization allows the
company’s website to standout from competition given the
strong competition in the leisure industry. Given that EcoForest
Leisure focuses on health and well-being and fitness suites, the
company has sufficient areas where it can create content for
marketing. The company can generate content such as videos,
images, articles and info-graphics to engage effectively with the
millennial generation. Lastly, Banerjee & Bhardwaj (2019)
user-generated content marketing can be used to underpin lead
generation and position for millennials as they value feedback.
Conclusion
EcoForest Leisure is a Start-up Company that has ventured into
the fitness and well-being niche, which lucrative. The niche
market has a wealth of opportunities, but the company is
saddled with competition and a weak marketing strategy. Hence,
a niche marketing strategy has been recommended. This strategy
involves segmentation, targeting and positioning of the
company in such a way that it attracts millennials. This will
involve positioning as a low cost quality manufacturer that
focuses on modern technology that fits millennials. To augment
this, application of integrated digital marketing strategy will
suffice in addressing the limitations of the current marketing
strategy at EcoForest Leisure and help the company to gain
dominance in the niche market.
References
Akbar, F., Omar, A., Wadood, F. and Yusoff, W., 2017. Niche
marketing strategy framework for SMEs: A conceptual
framework.
Ashley, Christy, and Tracy Tuten. "Creative strategies in social
media marketing: An exploratory study of branded social
content and consumer engagement." Psychology & Marketing
32.1 (2015): 15-27.

Baltes, L. P. (2015). The content marketing-the fundamental
tool of digital marketing. Bulletin of the Transilvania
University of Brasov. Economic Sciences. Series V, 8(2), 111.
Banerjee, S., & Bhardwaj, P. (2019). Aligning marketing and
sales in multi-channel marketing: Compensation design for
online lead generation and offline sales conversion. Journal of
Business Research, 105, 293-305.
Chang, W. W. (2018). Brexit and its economic consequences.
The World Economy, 41(9), 2349-2373.
Felix, R., Rauschnabel, P. A., & Hinsch, C. (2017). Elements of
strategic social media marketing: A holistic framework. Journal
of Business Research, 70, 118-126.
Hampson, L. (2019, September 4). Eleven of the best UK
wellness retreats for some well-earned R&R this autumn.
Retrieved September 19, 2019, from
https://www.standard.co.uk/lifestyle/wellness/wellness-
travel/best-wellness-retreats-uk-yoga-meditation-wellbeing-
a4095541.html
Hartley, S., Yeowell, G., & Powell, S. (2019). Promoting the
mental and physical well-being of people with mental health
difficulties through social enterprise. Mental Health Review-
Journal.
Homburg, C., Vomberg, A., Enke, M. and Grimm, P.H., 2015.
The loss of the marketing department's influence: is it
happening? And why worry?. Journal of the Academy of
Marketing Science, 43(1), pp.1-13.
Kingsnorth, S., 2019. Digital marketing strategy: an integrated

approach to online marketing. Kogan Page Publishers.
Lea, R. (2018). The UK economy: holding up remarkably well.
Arbuthnot Banking Group, 20.
Lowfield Farm Cottage. (2018, November 23). Corporate
Retreats. Retrieved October 19, 2019, from
http://www.lowfieldfarmcottages.co.uk/corporate-retreats
Mandal, P., & Joshi, N. (2017). Understanding Digital
Marketing Strategy. International Journal of Scientific Research
and Management, 5(6).
Mason, H., Schnackenberg, N., & Monro, R. (2017). Yoga and
Healthcare in the United Kingdom. International journal of yoga
therapy, 27(1), 121-126.
McEldowney, J., & Salter, D. (2016). Environmental taxation in
the UK: Climate Change Levy and policymaking. Denning LJ,
28, 37.
Narang, S. (2018). " Challenges and Opportunities for Digital
Marketing: A review analysis. International Journal, 4(3).
Page, S. J., Hartwell, H., Johns, N., Fyall, A., Ladkin, A., &
Hemingway, A. (2017). Case study: Wellness, tourism and small
business development in a UK coastal resort: Public engagement
in practice. Tourism Management, 60, 466-477.
Sargeant, M. (2016). Age discrimination: Ageism in
employment and service provision. Routledge.
Synergy Experiences & Synergy Jewellery. (2019, September
19). Synergy Experiences profile. Retrieved October 19, 2019,
from https://synergyexperiences.com/about-us
Trafford Leisure. (2019, October 12). About Us. Retrieved
October 19, 2019, from https://traffordleisure.co.uk/about-

us/#variety
Running head: Theory Critique
Marlaine smith Unitary caring theory
University of Hail
Student’s Name: Thuwaini Sultan Alshammari
Professor’s Name: Richard Dayrit
Date: May2020
Goal or Purpose of the theory
Caring is the central focus in nursing, as a discipline and
profession. However, caring can be agreed as a
multidimensional concept in the framework of practice and
perception. There appears to be a conflicting definition of what
is caring really. As such, the development of a middle range
theory was realized as anchored on the unitary-transformative
paradigm. It is important that caring is defined in various
context which should establish a common underpinnings and
bases. In the context of this theory, human beings remains in
constant mutual relationship with the environment, which is
considered an extension of the entire Universe, thus, we
participate consciously in various orders, patters, and dynamics
as how we perceive it. As such, caring becomes a mutual
concept of the individual to his or her immediate surroundings

following an established set of guidelines and protocols. More
so, this theory asserts that caring is also a process which
involves the holistic nature of the human person that helps
derive the potentialities and possibilities ascribes to it. Adding
to that, caring is a concept brought about by affirming our
minuscule existence in the entirety of the pan-dimensional
Universe.
Structural Components
Assumptions of the unitary theory of caring come from Rogers’s
science of unitary human beings (1970, 1994), Newman’s theory
of health as expanding consciousness (1994, 2008), and
Watson’s Theory of Transpersonal Caring (1985, 2005; Watson
& Smith, 2002). To fully understand the meaning of the theory,
readers will benefit from studying these sources.
· Human beings are unitary or irreducible, in mutual process
with an environment that is coextensive with the Universe,
participating knowingly in patterning, and ever-evolving
through expanding consciousness (Barrett, 1989; Newman,
1994; Rogers, 1992).
· Caring is a quality of participating knowingly in human–
environmental field patterning (M. C. Smith, 1999).
· Caring is the process through which human wholeness is
affirmed and that potentiates the emergence of innovative
patterning and possibilities (Cowling et al., 2008, E44).
· Caring is a manifestation and reflection of expanding
consciousness potentiating greater meaning, insight, and
transformative ways of relating to self and others (Cowling et
al., Smith, & Watson, 2008).
· Caring consciousness is resonating with the pandimensional
universe (Rogers, 1994; Watson, 2005; Watson & Smith, 2002).
Concepts After establishing the theoretical linkages to the
unitary-transformative paradigm, the five concepts of this
theory are explicated. The five concepts were developed from an
analysis of literature on caring and similar concepts described
by unitary scholars. The theoretical concepts have their

underpinnings in each of the assumptions.
· Manifesting intentions is the first concept in the unitary theory
of caring; it was originally defined as creating, holding, and
expressing thoughts, feelings, images, beliefs, desires, will,
purpose and actions that affirm possibilities for human health
and healing (Smith, 1999).
· Appreciating pattern is the second concept in this theory. It is
apprehending and understanding the mysteries of human
wholeness and diversity with awe.
· Attuning to dynamic flow is the third concept in this unitary
theory of caring. Attuning to dynamic flow is sensing of where
to place focus and attention in mutual process. It was originally
described as “dancing to the rhythms within continuous mutual
process” (M. C. Smith, 1999, p. 23).
· Experiencing the infinite this concept is defined as
“pandimensional awareness of coextensiveness with the
universe occurring in the context of human relating” (M. C.
Smith, 1999, p. 24).
· Inviting creative emergence it is attending the birth of
innovative, emergent patterning through affirming the potential
for change, nurturing the awareness of possibilities, imagining
new directions, and clarifying hopes and dreams.
The following are propositional statements that further clarify
concepts of the theory. Manifesting intention is:
•Preparing self to participate knowingly in cocreating an
environment for healing.
•Focusing images, thoughts and intentions for health and
healing.
•Expressing intentions in actions that support health and
healing.
Appreciating pattern is:
•Seeing wholeness in perceived fragmentation. •Valuing
uniqueness and diversity of patterning with wonder.
•Acknowledging what is without attempting to change or fix.

•Exploring what is meaningful in the moment. •Coming to know
by listening to the other’s story.
Attuning to dynamic flow is:
•Being truly present in the flow of relating. •Attending to the
subtleties of meaning. •Synchronizing rhythms of self with
other. •Trusting intuition in the mutual process.
Experiencing the infinite is:
•Acknowledging the sacred in human relating. •Believing in
limitless possibilities. •Igniting hope in despair. •Connecting to
a pandimensional universe.
Inviting creative emergence is:
•Honoring the unique timing, pace and direction of change.
•Calling attention to possibilities and potentialities hidden from
view. •Inspiring new life to emerge in the moment. •Trusting in
the wisdom of knowing one’s own way.
Functional Components
The theory focuses holistic knowing from the unitary
perspective. There exist two main functional components for the
unitary caring theory.1. Human beings.The humans make
manifest of the capabilities it can project relative to caring and
establishing this linkage requires a satisfactory level of
interaction with one another to attain the overall goal of nursing
and the health care system. 2. Pan-dimensional environment
(Universe) Humans are merely a miniscule partition of the
entire Universe. The perceivable and knowing environment, as
we know it, is the extension of the pan-dimensional Un
Relationship between Structure and Function

readers will beneﬁt from studying these sources.Concepts are
explained clearly one by one, are consistent, well contained in
the theory and do not differentiated into sub concepts, a very
Complex to other areas packed with great information and
requires vast amount of time. It Gave so many information but
the ideas in different parts of the theory does not decrease the
clarity. Watson and Smith5 refer to a unitary caring science
that evolves from frameworks fitting within the unitary-
transformative paradigm. They also differentiate between
transformation and transcendence in their description of a
caring moment as potentiating a new human-environmental field
pattern arising from a mutual process. They depict
humankindastransformativeinnatureandaunitary caring science
that transcends all duality
Diagram of the Theory
Concepts were developed from an analysis of literature on
caring and similar concepts described by unitary scholars.
Watson and Smith5 place the frameworks of both transpersonal
caring science and the science of unitary human beings under
the umbrellaofaunitary-transformativeparadigm reflecting the
“universal oneness and connectedness of all.”(p459) Although
they do not refer to wholeness in their explication of a
synthesized view, they refer to the unitary nature of the
universe, which is congruent, if not synonymous, with
wholeness. They acknowledge “the unitary, transpersonal,
evolving nature of humankind, both immanent and transcendent
with the evolving universe.”(p459) They speak of a unitary
caring science that is deeply relational, transcending duality and

invoking the infinite. In addition, they refer to a type of
consciousness—transcending time, space, and physicality—that
is “open and continuous with the evolving unitary consciousness
of the universe.”(p459) The theory is not Visually presented and
there was no original diagram for the theory alone.
Circle of Contagiousness
The concept was developed on the basis of reviewing the
philosophical and theoretical literature on caring in nursing,
identifying meanings from this body of literature, and
classifying and naming them within a unitary perspective. A
decade later, it is important to reflect on this anew and begin to
develop theory-practice connections for unitary caring. If we
embrace a model of caring from a unitary perspective, we need
to delineate the essential ontological competencies19 that
emerge from it. The term ontological competencies has been
used by Watson,26 who refers to ontological artistry as the
creative work in nursing that reflects the sacred acts ofcaring
and healing.
The unitary theory of caring developed while studying the
literature on caring in nursing, and then analyzing this literature
through the theoretical lens of the science of unitary human
beings. Some hospitals are slowly beginning to adopt caring
philosophies. Certain hospitals such as Saint Anne's Hospital,
have adopted caring theories and applied it to their hospital
practices, and especially in their nursing practice.
Usefulness
By positing unity of wholeness, consciousness, and caring as
both higher order and deeper order concepts, it moves nursing
closer to its ethical and ontological foundations. Embedded
within these unitary concepts are new horizons for unitary
caring practices, informed by the 5 constituent meanings of
caring that Smith4 gleaned from a unitary lens, that is,
manifesting intentions, attuning to dynamic flow, appreciating
pattern, experiencing the infinite, and inviting creative
emergence. By positing unity of wholeness, consciousness, and

caring as both higher order and deeper order concepts, it moves
nursing closer to its ethical and ontological foundations.
Embedded within these unitary concepts are new horizons for
unitary caring practices, informed by the 5 constituent meanings
of caring that Smith4 gleaned from a unitary lens, that is,
emergence. Provides individual clinicians, teams of health
professionals, educators, and leaders with a relationship-centric
approach to health care.
External Components
According to her “we can never know the whole person and the
whole picture of human health through analytical, reductionist
processes of knowing". She has studied, written about, and
conducted research related to Rogers’s science of unitary human
beings, Parse’s man-living-health (now humanbecoming),
Watson’s theory of transpersonal caring, and Newman’s health
as expanding consciousness, and has written many
commentaries on issues related to nursing theory development.
She bridges together the divide between caring theorists and the
opposition, such as the Rogerians. Her work can be used by
other theorists to put greater emphasis on the aspect of caring
and how it pertains to nursing practice. Ideals and ideas for
“ontological literacy” can lead in time to “ontological design
practices.” These practices see differently—they see and honor
the whole person in a way that affirms the possibilities for
individuals and humanity; they offer new energetic heartfelt
blueprints for transformation and new fields of mutuality,
whereby the nurse becomes the healing environment, the creator
of sacred space, holding self and other in their wholeness.
Reference List
Nursing Theories & Nursing Practice Fourth Edition Marlaine
C. Smith, PhD, RN, AHN-BC, FAAN Marilyn E. Parker, PhD,
RN, FAAN
Parker, M. E., & Smith, M. C. (2010). Nursing theories and
nursing practice. Philadelphia: F.A. Davis Co.

Smith, M. C. (2013). Caring in nursing: Analysis of extant
theory. In M. C. Smith, M. C. Turkel, & Z. R. Wolf (Eds.),
Caring and
the science of unitary human beings (pp. 43-57). New York,
NY: Springer.
Smith, M. J., & Liehr, P. R. (2008). Middle range theory for
nursing. (2nd ed.). New York: Springer Publishing Company.
Smith MC. Caring and the science of unitary human beings. Adv
Nurs Sci. 1999;21(4):14–28. 5. Watson J, Smith MC. Caring
science and the science of unitary human beings. J Adv Nurs.
2002;37(5):452–461.
Smith MJ, Liehr P. Attentively embracing story: a middle-range
theory with practice and research
implications...includingcommentarybyReedPG.Sch Inq Nurs
Pract. 1999;13(3):187–210.
Quinn JF. Holding sacred space: the nurse as healing
environment. Holist Nurs Pract. 1992;6(4):26– 36. 28.
WatsonJ.CaringScienceasSacredScience.Philadelphia, PA: FA
Davis; 2004
Advances in Nursing Science Vol. 31, No. 1, pp. E41–E51
Copyright c 2008 Wolters Kluwer Health|Lippincott Williams
& Wilkins The Power of Wholeness, Consciousness, and Caring
A Dialogue on Nursing Science, Art, and Healing
W. Richard Cowling, III, PhD, RN, APRN-BC, AHN-BC;
Marlaine C. Smith, PhD, RN, AHN-BC, FAAN; Jean Watson,
PhD, RN, AHN-BC, FAAN
Running head: Theory Critique
Marlaine smith Unitary caring theory
University of Hail

Student’s Name: Thuwaini Sultan Alshammari
Professor’s Name: Richard Dayrit
Date: May2020
Goal or Purpose of the theory
Caring is the central focus in nursing, as a discipline and
profession. However, caring can be agreed as a
multidimensional concept in the framework of practice and
perception. There appears to be a conflicting definition of what
is caring really. As such, the development of a middle range
theory was realized as anchored on the unitary-transformative
paradigm. It is important that caring is defined in various
context which should establish a common underpinnings and
bases. In the context of this theory, human beings remains in
constant mutual relationship with the environment, which is
considered an extension of the entire Universe, thus, we
participate consciously in various orders, patters, and dynamics
as how we perceive it. As such, caring becomes a mutual
concept of the individual to his or her immediate surroundings
following an established set of guidelines and protocols. More
so, this theory asserts that caring is also a process which
involves the holistic nature of the human person that helps
derive the potentialities and possibilities ascribes to it. Adding
to that, caring is a concept brought about by affirming our
minuscule existence in the entirety of the pan-dimensional
Universe.
Structural Components

readers will benefit from studying these sources.
· Human beings are unitary or irreducible, in mutual process
with an environment that is coextensive with the Universe,
participating knowingly in patterning, and ever-evolving
through expanding consciousness (Barrett, 1989; Newman,
1994; Rogers, 1992).
· Caring is a quality of participating knowingly in human–
environmental field patterning (M. C. Smith, 1999).
· Caring is the process through which human wholeness is
affirmed and that potentiates the emergence of innovative
patterning and possibilities (Cowling et al., 2008, E44).
· Caring is a manifestation and reflection of expanding
consciousness potentiating greater meaning, insight, and
transformative ways of relating to self and others (Cowling et
al., Smith, & Watson, 2008).
· Caring consciousness is resonating with the pandimensional
universe (Rogers, 1994; Watson, 2005; Watson & Smith, 2002).
Concepts After establishing the theoretical linkages to the
unitary-transformative paradigm, the five concepts of this
theory are explicated. The five concepts were developed from an
analysis of literature on caring and similar concepts described
by unitary scholars. The theoretical concepts have their
underpinnings in each of the assumptions.
· Manifesting intentions is the first concept in the unitary theory
of caring; it was originally defined as creating, holding, and
expressing thoughts, feelings, images, beliefs, desires, will,
purpose and actions that affirm possibilities for human health
and healing (Smith, 1999).
· Appreciating pattern is the second concept in this theory. It is
apprehending and understanding the mysteries of human
wholeness and diversity with awe.
· Attuning to dynamic flow is the third concept in this unitary
theory of caring. Attuning to dynamic flow is sensing of where

to place focus and attention in mutual process. It was originally
described as “dancing to the rhythms within continuous mutual
process” (M. C. Smith, 1999, p. 23).
· Experiencing the infinite this concept is defined as
“pandimensional awareness of coextensiveness with the
universe occurring in the context of human relating” (M. C.
Smith, 1999, p. 24).
· Inviting creative emergence it is attending the birth of
innovative, emergent patterning through affirming the potential
for change, nurturing the awareness of possibilities, imagining
new directions, and clarifying hopes and dreams.
The following are propositional statements that further clarify
concepts of the theory. Manifesting intention is:
•Preparing self to participate knowingly in cocreating an
environment for healing.
•Focusing images, thoughts and intentions for health and
healing.
•Expressing intentions in actions that support health and
healing.
Appreciating pattern is:
•Seeing wholeness in perceived fragmentation. •Valuing
uniqueness and diversity of patterning with wonder.
•Acknowledging what is without attempting to change or fix.
•Exploring what is meaningful in the moment. •Coming to know
by listening to the other’s story.
Attuning to dynamic flow is:
•Being truly present in the flow of relating. •Attending to the
subtleties of meaning. •Synchronizing rhythms of self with
other. •Trusting intuition in the mutual process.
Experiencing the infinite is:
•Acknowledging the sacred in human relating. •Believing in
limitless possibilities. •Igniting hope in despair. •Connecting to
a pandimensional universe.
Inviting creative emergence is:
•Honoring the unique timing, pace and direction of change.

•Calling attention to possibilities and potentialities hidden from
view. •Inspiring new life to emerge in the moment. •Trusting in
the wisdom of knowing one’s own way.
Functional Components
The theory focuses holistic knowing from the unitary
perspective. There exist two main functional components for the
unitary caring theory.1. Human beings.The humans make
manifest of the capabilities it can project relative to caring and
establishing this linkage requires a satisfactory level of
interaction with one another to attain the overall goal of nursing
and the health care system. 2. Pan-dimensional environment
(Universe) Humans are merely a miniscule partition of the
entire Universe. The perceivable and knowing environment, as
we know it, is the extension of the pan-dimensional Un
Relationship between Structure and Function
readers will beneﬁt from studying these sources.Concepts are
explained clearly one by one, are consistent, well contained in
the theory and do not differentiated into sub concepts, a very
Complex to other areas packed with great information and
requires vast amount of time. It Gave so many information but
the ideas in different parts of the theory does not decrease the
clarity. Watson and Smith5 refer to a unitary caring science

that evolves from frameworks fitting within the unitary-
transformative paradigm. They also differentiate between
transformation and transcendence in their description of a
caring moment as potentiating a new human-environmental field
pattern arising from a mutual process. They depict
humankindastransformativeinnatureandaunitary caring science
that transcends all duality
Diagram of the Theory
Concepts were developed from an analysis of literature on
caring and similar concepts described by unitary scholars.
Watson and Smith5 place the frameworks of both transpersonal
caring science and the science of unitary human beings under
the umbrellaofaunitary-transformativeparadigm reflecting the
“universal oneness and connectedness of all.”(p459) Although
they do not refer to wholeness in their explication of a
synthesized view, they refer to the unitary nature of the
universe, which is congruent, if not synonymous, with
wholeness. They acknowledge “the unitary, transpersonal,
evolving nature of humankind, both immanent and transcendent
with the evolving universe.”(p459) They speak of a unitary
caring science that is deeply relational, transcending duality and
invoking the infinite. In addition, they refer to a type of
consciousness—transcending time, space, and physicality—that
is “open and continuous with the evolving unitary consciousness
of the universe.”(p459) The theory is not Visually presented and
there was no original diagram for the theory alone.
Circle of Contagiousness
The concept was developed on the basis of reviewing the
philosophical and theoretical literature on caring in nursing,
identifying meanings from this body of literature, and
classifying and naming them within a unitary perspective. A
decade later, it is important to reflect on this anew and begin to

develop theory-practice connections for unitary caring. If we
embrace a model of caring from a unitary perspective, we need
to delineate the essential ontological competencies19 that
emerge from it. The term ontological competencies has been
used by Watson,26 who refers to ontological artistry as the
creative work in nursing that reflects the sacred acts ofcaring
and healing.
The unitary theory of caring developed while studying the
literature on caring in nursing, and then analyzing this literature
through the theoretical lens of the science of unitary human
beings. Some hospitals are slowly beginning to adopt caring
philosophies. Certain hospitals such as Saint Anne's Hospital,
have adopted caring theories and applied it to their hospital
practices, and especially in their nursing practice.
Usefulness
By positing unity of wholeness, consciousness, and caring as
both higher order and deeper order concepts, it moves nursing
closer to its ethical and ontological foundations. Embedded
within these unitary concepts are new horizons for unitary
caring practices, informed by the 5 constituent meanings of
caring that Smith4 gleaned from a unitary lens, that is,
emergence. By positing unity of wholeness, consciousness, and
caring as both higher order and deeper order concepts, it moves
nursing closer to its ethical and ontological foundations.
Embedded within these unitary concepts are new horizons for
unitary caring practices, informed by the 5 constituent meanings
of caring that Smith4 gleaned from a unitary lens, that is,
emergence. Provides individual clinicians, teams of health
professionals, educators, and leaders with a relationship-centric
approach to health care.
External Components
According to her “we can never know the whole person and the

whole picture of human health through analytical, reductionist
processes of knowing". She has studied, written about, and
conducted research related to Rogers’s science of unitary human
beings, Parse’s man-living-health (now humanbecoming),
Watson’s theory of transpersonal caring, and Newman’s health
as expanding consciousness, and has written many
commentaries on issues related to nursing theory development.
She bridges together the divide between caring theorists and the
opposition, such as the Rogerians. Her work can be used by
other theorists to put greater emphasis on the aspect of caring
and how it pertains to nursing practice. Ideals and ideas for
“ontological literacy” can lead in time to “ontological design
practices.” These practices see differently—they see and honor
the whole person in a way that affirms the possibilities for
individuals and humanity; they offer new energetic heartfelt
blueprints for transformation and new fields of mutuality,
whereby the nurse becomes the healing environment, the creator
of sacred space, holding self and other in their wholeness.
Reference List
Nursing Theories & Nursing Practice Fourth Edition Marlaine
C. Smith, PhD, RN, AHN-BC, FAAN Marilyn E. Parker, PhD,
RN, FAAN
Parker, M. E., & Smith, M. C. (2010). Nursing theories and
nursing practice. Philadelphia: F.A. Davis Co.
Smith, M. C. (2013). Caring in nursing: Analysis of extant
theory. In M. C. Smith, M. C. Turkel, & Z. R. Wolf (Eds.),
Caring and
the science of unitary human beings (pp. 43-57). New York,
NY: Springer.
Smith, M. J., & Liehr, P. R. (2008). Middle range theory for
nursing. (2nd ed.). New York: Springer Publishing Company.
Smith MC. Caring and the science of unitary human beings. Adv
Nurs Sci. 1999;21(4):14–28. 5. Watson J, Smith MC. Caring
science and the science of unitary human beings. J Adv Nurs.
2002;37(5):452–461.
Smith MJ, Liehr P. Attentively embracing story: a middle-range

theory with practice and research
implications...includingcommentarybyReedPG.Sch Inq Nurs
Pract. 1999;13(3):187–210.
Quinn JF. Holding sacred space: the nurse as healing
environment. Holist Nurs Pract. 1992;6(4):26– 36. 28.
WatsonJ.CaringScienceasSacredScience.Philadelphia, PA: FA
Davis; 2004
Advances in Nursing Science Vol. 31, No. 1, pp. E41–E51
Copyright c 2008 Wolters Kluwer Health|Lippincott Williams
& Wilkins The Power of Wholeness, Consciousness, and Caring
A Dialogue on Nursing Science, Art, and Healing
W. Richard Cowling, III, PhD, RN, APRN-BC, AHN-BC;
Marlaine C. Smith, PhD, RN, AHN-BC, FAAN; Jean Watson,
PhD, RN, AHN-BC, FAAN
Kingdom of Saudi Arabia
Ministry of Education
University of Hail
College of Nursing
‫ة‬ ‫عودي‬ ‫س‬ ‫ال‬ ‫ية‬ ‫عرب‬ ‫ال‬ ‫كة‬ ‫ل‬ ‫مم‬ ‫ال‬
‫يم‬ ‫ل‬ ‫ع‬ ‫ت‬ ‫ال‬ ‫وزارة‬
‫ل‬ ‫ـائ‬ ‫ح‬ ‫عـة‬ ‫امـ‬ ‫ج‬
‫ض‬ ‫تمري‬ ‫ال‬ ‫ية‬ ‫ل‬ ‫ك‬
Master of Science in Nursing (MSN) - Emergency Nursing
Exam Begins: Saturday 09/05/2020 -10:00 pm
Exam Ends: Monday 11/05/2020 - 10:00 pm
Exam Duration: 48 hours
Section: Male & Female side
Final Exam of Theoretical Foundations in Nursing (NURS 501)
Semester: 2nd Semester, AY 2019 - 2020
This exam contains (3) questions

Mark/Grade Distribution
Type of Question
Allotted Grades
Essay
5
Essay
5
Theory Critique
10
Total
20
Answer all the questions:
First Question: Essay 1 Point for Each Level of Proficiency
(Total 5 Marks).
Read the article entitled, ‘From Novice to Expert’ by Patricia
Benner found in
https://www.medicalcenter.virginia.edu/therapy-services/3%20-
%20Benner%20-%20Novice%20to%20Expert-1.pdf
Then summarize the theory.
Instructions:
1- Make a COMPREHENSIVE SUMMARY of this theory in
YOUR OWN WORDS. Focus on the five levels of proficiency
from novice to expert.
2- Your comprehensive summary should range between 500 to
1,000 words.

3- No copy and pasting of sentences from the article.
Paraphrase the sentences you will include in your
comprehensive summary.
_____________________________________________________
_____________
Second Question: Making a Theory Evaluation -1 Point for Each
item (Total 5 Marks).
Fawcett’s framework for conceptual models separates questions
for analysis from those intended for evaluation. For the
evaluation, she proposed evaluation (judgment based on
criteria) of the origins of the model, the degree of
comprehensiveness of content, the logical congruence of its
internal structure, the ability of the model to generate and test
theories, the degree to which it is credible as demonstrated in
its social utility (use, implementation), social congruency, and
significance to society.
Read Chapter 10 A Model for Evaluation of Theories:
Description, Analysis, critique, testing and Support from the e-
book Theoretical Nursing Development and Progress 5th
Edition, By Afaf Meleis. Then, MAKE COMPREHENSIVE
EVALUATION of THE SISTER CALLISTA ROY’S
ADAPTATION MODEL Using the Fawcett’s Criteria of
Nursing Models Evaluation, which includes:
· Origins
· Content
· Logical congruency
· Generation
· Credibility
Instructions: Make your evaluation of the Sister Callista Roy’s
Adaptation Model using a Fawcett’s criteria of Nursing Models

Evaluation.
Third Question: Making a Theory Critique (Total 10 Marks).
Read Chapter 4: Florence Nightingale's Legacy of Caring and
Its Applications from the e-book Nursing Theories and Nursing
Practice, Fourth Edition by Marlaine Smith and Marilyn Parker.
Then Make a COMPREHENSIVE CRITIQUE of FLORENCE
NIGHTINGALE's ENVIRONMENTAL THEORY.
Instructions: Make a COMPREHENSIVE CRITIQUE of
FLORENCE NIGHTINGALE's ENVIRONMENTAL THEORY
by combining inputs from at least two (2) critique articles from
the internet and your own viewpoint based on the following
criteria and units of analysis:
CRITERIA
UNITS OF ANALYSIS
(1) Relationship between structure and function
(1.1) Clarity
(1.2) Consistency
(1.3) Simplicity/Complexity
(1.4) Tautology/Teleology
(2) Diagram of the Theory
(2.1) Visual and Graphic Presentation
(2.2) Logical Representation
(2.3) Clarity
(3) Circle of Contagiousness
(3.1) Graphical origin of theory and geographical spread
(3.2) Influence of theorist versus theory
(4) Usefulness
(4.1) Practice

(4.2) Research
(4.3) Education
(4.4) Administration
(5) External Components of Theory
(5.1) Personal Values
(5.2) Congruence with other Professional Values
(5.3) Congruence with Social Values
(5.4) Social Significance
Page 4 of 4

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