Key Words: Holism, nursing theory, pain
management, caring, relationship-centered
care, theory-practice gap, nursing practice,
holistic theory, client-centered care
Introduction
The use of theory to guide practice
has been advocated for decades, but the
translation of theory into practice has been
difficult for clinicians. Poor understanding
of theory and its purpose inhibits the nurse’s
ability to apply theoretical constructs in
practice, thus reducing practice to a task-
oriented enterprise rooted largely in habit.
Dossey’s (2008) theory of integral nursing
has recently emerged as a new holistic
theory that provides opportunities for
clinicians to invest in a worldview that
embraces the caring behaviors central to
the delivery of nursing care and encourages
nurses to design care that is relationship
centered and focused on healing. This
theory holds promise for application in
many care situations, though the client
experience of acute pain presents itself
as a uniquely universal opportunity to
demonstrate the prospective value of the
theory’s application.
It is widely known that pain is one of the
most common symptoms experienced by all
clients and that knowledge about effective
pain-relieving strategies is important
and essential in guiding practice. Despite
numerous advances in pain management,
pain continues to be insufficiently managed.
Inadequate understanding and use of theory
to guide pain management practice may
obscure nurses’ ability to rely on theoretical
knowledge as a basis for pain management
care. Insufficient knowledge about the
theory of integral nursing precludes
effective application of its theoretical
concepts in clinical practice, thereby
inhibiting nurses’ ability to improve pain
management practice while also inhibiting
clients’ ability to participate in the co-
creation of personalized interventions to
relieve pain. Failure of the nurse to engage
in holistic care, to capture the client’s
perspective in the design and delivery of
care, and to create a sacred space for
carrying out the holistic caring process
thwarts achievement of the mutually sought
after goal of healing. By embracing the
broader and deeper view of care offered by
the theory of integral nursing, the nurse and
client collaborate in the development of
trusting relationships as they intentionally
strive to improve client outcomes and
ultimately enhance client, nurse, and
provider satisfaction with care.
Background
Pain management has remained enigmatic
for clients and healthcare professionals for
decades. When caring for clients, pain is the
most common symptom for which nurses
need to intervene, yet it continues to be one
for which they may be least prepared to
successfully mediate (Lui, So, & Fong,
2008; Montes-Sandoval, 1999; Wilson,
2007). Pain is a multidimensional,
subjective phenomenon and experience.
As such, the meaning and impact of any
pain experience differs for each client,
family member, nurse, and provider. Many
definitions of pain have surfaced over
the last four decades and offer multiple
interventions to alleviate clients’ pain. At the
2007 council meeting for the International
Association for the Study of Pain (IASP),
in Koyoto, Japan, the council confirmed its
1992 definition of pain as “…an unpleasant
sensory and emotional experience
associated with actual or potential tissue
damage, or described in terms of such
damage” (www.iasp-pain-org). In its
monograph on understanding, assessing,
and treating pain, the American Pain Society
supports both the IASP definition of pain
and McCaffery’s definition of pain as
“…whatever the experiencing person says
it is, existing whenever s/he says it does”
(APS, 2006, p. 4; McCaffery & Passero,
1999, p. 17). While the IASP definition
has been described as the most widely used
definition of pain, McCaffery’s definition
has gained substantial support over the past
30 years and is widely used in clinical
practice as a foundation for all types of pain
management care. Both definitions help
capture the intricate nature of the pain
experience. The IASP definition infers the
multidimensionality of the phenomenon
of pain by stating it is both physical and
emotional, though an emphasis is noted
on the sensory nature of pain. McCaffery’s
definition emphasizes the subjective nature
of the pain experience and situates clients
Exploring the Theory of Integral Nursing with Implications for Pain Management Practice Susanne M. Tracy, PhD, RN and Pamela P. DiNapoli, PhD, RN, CNL University of New Hampshire
26 International Journal for Human Caring
abstract
Inadequate attention is paid to the role of theory in guiding practice. three main factors
affect the use of theory to guide clinical practice: insufficient theory knowledge, insufficient
administrative support to encourage the development of theory-based interventions, and
the busy task-oriented climate of many nursing settings. Pain management is a vexing
problem confronting clients and healthcare professionals. the primary purpose of this
paper is to introduce scholars and clinicians to the basic tenets of Dossey’s (2008) theory of
integral nursing to aid nurses in designing client-centered pain management interventions
grounded in the theory’s main constructs of holism and healing.
272012, Vol. 16, No. 1
as the primary authority on the pain
experience, thereby prompting clinicians
to pay closer attention to clients’ description
of their lived experience of pain rather than
relying on a standardized definition of pain.
From a holistic perspective, all elements that
comprise the pain experience are equally
important and frame clients’ perception of
pain, the behaviors clients use to manifest
the impact of the pain experience, and
clients’ responses to varied methods used
to treat pain. Being knowledgeable about
pain management practice is an expected
competency of every registered nurse, yet
many nurses continue to describe barriers
that impede the management of clients’ pain
(Rejeh, Almadi, Mohammadi, Kazemnejad,
& Anoosheh, 2009). The literature supports
the notion that nurses’ knowledge and
attitudes about pain management is linked
to their ability to help clients successfully
manage pain; updating knowledge about
methods for relieving pain is key to improving
practice (Duignan & Dunn, 2008; Lui, So,
& Fong, 2008; Matthews & Malcolm, 2007;
Xue, Schulman-Green, Czaplinski, Harris,
& McCorkle, 2007).
Many strategies have been developed
to help bridge the gap between what nurses
know and what they actually do in practice
to help manage clients’ pain (Dihle,
Bjølseth, & Helseth, 2006). The problem
of under-treated pain persists and is likely
complicated by the lack of application of
theory to guide pain management practice.
When coupled with nurses’ uncertainty
about how to autonomously treat clients
in pain, pain relief outcomes are often
unsatisfactory. Theories, particularly
theories that have the potential to resonate
with clinicians and impact care of the whole
client, may be particularly powerful in
narrowing the theory-practice gap and
providing clues to more effective,
comprehensive pain management. The
application of a holistic philosophy of
care emphasizes the role of clinicians in
partnering with clients in the design and
implementation of mutually agreeable plans
for the relief of pain—plans that sufficiently
address the dimensions of the whole
person’s lived pain experience. Holistically,
the ultimate goals for the nurse are to better
understand the pain experience from the
client’s perspective, foster healing, and
deliver care that strives to provide the
greatest extent of pain relief possible.
Anchored in the Scope and Standards of
Holistic Nursing (2007), the five foundational
concepts of Dossey’s theory of integral
nursing articulate the qualities and way of
being that characterize the holistic, integral
nurse and prompt the nurse to attend to the
many dimensions of pain affecting the whole
client. In this way, the nurse invites the client
experiencing pain to participate in the
development of potentially transformative,
relationship-centered interactions and to
provide feedback on interventional success
or the need for further improvement.
The primary purpose of this paper is
to introduce the basic tenets of the theory
of integral nursing to aid clinicians in
designing caring interventions focused
on healing and grounded in the theory’s
holistic, relationship-centered approach.
Following the unfolding of the basic tenets
of this theory, examples of the application
of the theory to pain management are
proposed. A secondary purpose is to
stimulate scholarly interest in designing
studies that test the theory’s concepts and
holistic framework in practice. A peripheral
aim of the paper is to suggest how
application of the theory’s main concepts,
especially the concept of healing, may be
used to help define the emerging role of
the nurse in the 21st century regarding the
holistic care of the client experiencing pain.
the theory of Integral nursing
The experience of pain transcends the
physical body and requires a theory-driven,
tailored, whole-person approach to ensure
all effects of the pain experience on and in
the person; body, mind, and spirit are
addressed. The theory of integral nursing is
a composite theory developed by Barbara
Dossey in 2008 and built largely on the
work of Wilber (2000), whose integral
theory outlined the four dimensions of all
that is and represent what Wilbur believed
to be the true realities of life. Wilber posited
that understanding of these four dimensions
influences a person’s interpretation of reality
and carries the potential to affect one’s
relationships with others. Many of the
concepts within Dossey’s theory stem from
an amalgamation of concepts pivotal to
theories from within and outside of nursing.
The following commentary is a paraphrased
interpretation of Dossey’s theory with the
intent of aiding clinicians, academicians,
students, and others in understanding the
overall thrust of the theory. In this way,
partners in healthcare may find ways to
apply the theory’s core concepts to guide
the design of interventions in all areas of
practice, but especially in the area of pain
management practice. The concepts that
provide the organizing structure for the
theory of integral nursing are healing,
recognition of the metaparadigm of nursing,
patterns of knowing, quadrants, and all
quadrants/all levels (AQUAL). Appreciating
the richness and complexity of the theory
is a longitudinal process that begins with
unpacking each of the theory’s main
concepts and developing ways to apply
the concepts in clinical practice.
Healing