Key Words: Holism, nursing theory, pain management, caring, relationship-centered care, theory-practice gap, nursing practice, holistic theory, client-centered care

Key Words: Holism, nursing theory, pain management, caring, relationship-centered care, theory-practice gap, nursing practice, holistic theory, client-centered care

Key Words: Holism, nursing theory, pain

management, caring, relationship-centered

care, theory-practice gap, nursing practice,

holistic theory, client-centered care


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.


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


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.


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