Ida Jean Orlando-Pelletier During 1958-1961, Orlando, as an associate professor and the

director of the graduate program in mental health and

(August 12, 1926 – November 28, 2007) psychiatric nursing at Yale University, used her proposed
conceptual nursing model as the foundation for the curriculum
of the program. From 1962-1972, Orlando served as a clinical
- was an internationally known psychiatric health nurse,
nurse consultant at Mclean Hospital in Belmont,
theorist and researcher who developed the “Deliberative
Massachusetts. In this position, she studied the interactions of
Nursing Process Theory.” Her theory allows nurses to
create an effective nursing care plan that can also be nurses with clients, other nurses and other staff members and
easily adapted when and if any complications arise with how these interactions affected the process of the nurse’s help
to clients. Orlando convinced the administration that an
the patient.
educational program for nurses was needed, whereupon
Mclean Hospital initiated an educational program based on her
Early Life nursing model.

Ida Jean Orlando was a first generation Irish American born  Bachelor of Science degree in public health nursing
on August 12, 1926. She dedicated her life studying nursing from St. John’s University in Brooklyn, New York
and graduated in 1947 and received a Bachelor of Science  From 1972 to 1984, she also served on the board of
degree in public health nursing in 1951. In 1954, she the Harvard Community Health Plan in Boston,
completed her Master of Arts in Mental Health consultation. Massachusetts.
While studying she also worked intermittently and sometimes  In 1981, Orlando became an educator at Boston
concurrently as a staff nurse in OB, MS, ER; as a supervisor in University School of Nursing and held administrative
a general hospital, and as an assistant director and a teacher of positions from 1984 to 1987 at Metropolitan State
several courses. And in 1961, she was married to Robert Hospital in Waltham, Massachusetts. In September
Pelletier and lived in the Boston area. 1987, she became the Assistant director of Nursing
for Education and Research at the said institution.
She was also a project consultant for the Mental
Education Health Project for Associate Degree Faculties created
by the New England Board of Higher Education.
 In 1947, she received a diploma in nursing from the Finally in 1992, Orlando retired and received the
Flower Fifth Avenue Hospital School of Nursing in Nursing Living Legend award by the Massachusetts
New York. Registered Nurse Association.
 In 1951, she received a Bachelor of Science degree in
public health nursing from St. John’s University in
Brooklyn, New York. Deliberative Nursing Process Theory
 And in 1954, Orlando received her Master of Arts
degree in mental health consultation from Teachers Ida Jean Orlando developed her theory from a study conducted
College, Columbia University. at the Yale University School of Nursing, integrating mental
health concepts into a basic nursing curriculum. She proposed
that “patients have their own meanings and interpretations of
Career and Appointments situations and therefore nurses must validate their inferences
and analyses with patients before drawing conclusions.”
Ida Jean Orlando had a diverse career, working as a
practitioner, consultant, researcher, and educator in nursing. Orlando’s nursing theory stresses the reciprocal relationship
Orlando devoted her life to mental health and psychiatric between patient and nurse. What the nurse and the patient say
nursing, working as a clinical nurse and researcher. and do affects them both. She views the professional function
of nursing as finding out and meeting the patient’s immediate
Orlando used to work in a hospital exclusive for childbirth in a need for help.
short span of time.
She also described her model as revolving around the
After receiving her master’s degree in 1954, Orlando went to following five major interrelated concepts: function of
the Yale University School of Nursing in New Haven, professional nursing, presenting behavior, immediate reaction,
Connecticut as an associate professor of mental health and nursing process discipline, and improvement. The function of
psychiatric nursing for eight years. She was awarded a federal professional nursing is the organizing principle. Presenting
grant and became a research associate and the principal project behavior is the patient’s problematic situation. The immediate
investigator of a National Institute of Mental health Institute of reaction is the internal response. The nursing process
the United States Public Health Service’s grant entitled discipline is the investigation into the patient’s needs. And
“Integration of Mental Health Concepts in a Basic lastly, improvement is the resolution to the patient’s situation.
Curriculum.” The project sought to identify those factors
relevant to the integration of psychiatric-mental health
principles into the nursing curriculum.
Goal The function of professional nursing is the organizing
principle. This means finding out and meeting the patient’s
Ida Jean Orlando’s goal is to develop a theory of effective immediate needs for help. According to Orlando, nursing is
nursing practice. The theory explains that the role of the nurse responsive to individuals who suffer, or who anticipate a sense
is to find out and meet the patient’s immediate needs for help. of helplessness. It is focused on the process of care in an
According to the theory, all patient behavior can be a cry for immediate experience, and is concerned with providing direct
help. Through these, the nurse’s job is to find out the nature of assistance to a patient in whatever setting they are found in for
the patient’s distress and provide the help he or she needs. the purpose of avoiding, relieving, diminishing, or curing the
sense of helplessness in the patient. The Nursing Process
Discipline Theory labels the purpose of nursing to supply the
MAJOR CONCEPTS help a patient needs for his or her needs to be met. That is, if
the patient has an immediate need for help, and the nurse
The nursing metaparadigm consists of four concepts: person, discovers and meets that need, the purpose of nursing has been
environment, health, and nursing. Of the four concepts, Ida achieved.
Jean Orlando only included three in her theory of Nursing
Process Discipline: person, health, and nursing. Presenting Behavior

Human Being Presenting behavior is the patient’s problematic situation.

Through the presenting behavior, the nurse finds the patient’s
Orlando uses the concept of human as she emphasizes immediate need for help. To do this, the nurse must first
individuality and the dynamic nature of the nurse-patient recognize the situation as problematic. Regardless of how the
relationship. For her, humans in need are the focus of nursing presenting behavior appears, it may represent a cry for help
practice. from the patient. The presenting behavior of the patient, which
is considered the stimulus, causes an automatic internal
response in the nurse, which in turn causes a response in the
Health patient.

In Orlando’s theory, health is replaced by a sense of Distress

helplessness as the initiator of a necessity for nursing. She
stated that nursing deals with individuals who are in need of
The patient’s behavior reflects distress when the patient
help.
experiences a need that he cannot resolve, a sense of
helplessness occurs.
Environment
Immediate Reaction
Orlando completely disregarded environment in her theory,
only focusing on the immediate need of the patient, chiefly the
The immediate reaction is the internal response. The patient
relationship and actions between the nurse and the patient
perceives objects with his or her five senses. These
(only an individual in her theory; no families or groups were
perceptions stimulate automatic thought, and each thought
mentioned). The effect that the environment could have on the
stimulates an automatic feeling, causing the patient to act.
patient was never mentioned in Orlando’s theory.
These three items are the patient’s immediate response. The
immediate response reflects how the nurse experiences his or
Nursing her participation in the nurse-patient relationship.

Orlando speaks of nursing as unique and independent in its Nurse Reaction

concerns for an individual’s need for help in an immediate
situation. The efforts to meet the individual’s need for help are The patient behavior stimulated a nurse reaction, which marks
carried out in an interactive situation and in a disciplined the beginning of the nursing process discipline.
manner that requires proper training.
Nurse’s Action
Subconcepts
When the nurse acts, an action process transpires. This action
process by the nurse in a nurse-patient contact is called
Ida Jean Orlando described her model as revolving around the
nursing process. The nurse’s action may
following five major interrelated concepts: the function of
be automatic or deliberative.
professional nursing, presenting behavior, immediate reaction,
nursing process discipline, and improvement.
Automatic Nursing Actions are nursing actions decided upon
for reasons other than the patient’s immediate need.
Function of Professional Nursing
Deliberative Nursing Actions are actions decided upon after 5 Stages of the Deliberative Nursing Process
ascertaining a need and then meeting this need
The Deliberative Nursing Process has five stages: assessment,
The following list identifies the criteria for deliberative diagnosis, planning, implementation, and evaluation.
actions:
Assessment
 Deliberative actions result from the correct
identification of patient needs by validation of the
In the assessment stage, the nurse completes a holistic
nurse’s reaction to patient behavior.
assessment of the patient’s needs. This is done without taking
 The nurse explores the meaning of the action with
the reason for the encounter into consideration. The nurse uses
the patient and its relevance to meeting his need.
a nursing framework to collect both subjective and objective
 The nurse validates the action’s effectiveness data about the patient.
immediately after completing it.
 The nurse is free of stimuli unrelated to the
patient’s need when she acts. Diagnosis

The diagnosis stage uses the nurse’s clinical judgment about

Nursing Process Discipline
health problems. The diagnosis can then be confirmed using
links to defining characteristics, related factors, and risk
The nursing process discipline is the investigation into the factors found in the patient’s assessment.
patient’s needs. Any observation shared and explored with the
patient is immediately useful in ascertaining and meeting his
or her need, or finding out he or she has no needs at that time. Planning
The nurse cannot assume that any aspect of his or her reaction
to the patient is correct, helpful, or appropriate until he or she The planning stage addresses each of the problems identified
checks the validity of it by exploring it with the patient. The in the diagnosis. Each problem is given a specific goal or
nurse initiates this exploration to determine how the patient is outcome, and each goal or outcome is given nursing
affected by what he or she says and does. Automatic reactions interventions to help achieve the goal. By the end of this stage,
are ineffective because the nurse’s action is determined for the nurse will have a nursing care plan.
reasons other than the meaning of the patient’s behavior or the
patient’s immediate need for help. When the nurse doesn’t
explore the patient’s reaction with him or her, it is reasonably Implementation
certain that effective communication between nurse and
patient stops. In the implementation stage, the nurse begins using the
nursing care plan.
The action process in a person-to-person contact functioning
by open disclosure. The perceptions, thoughts, and feelings of Evaluation
each individual are directly available to the perception of the
other individual through the observable action.
Finally, in the evaluation stage, the nurse looks at the progress
of the patient toward the goals set in the nursing care plan.
Improvement Changes can be made to the nursing care plan based on how
well (or poorly) the patient is progressing toward the goals. If
Improvement is the resolution to the patient’s situation. In the any new problems are identified in the evaluation stage, they
resolution, the nurse’s actions are not evaluated. Instead, the can be addressed, and the process starts over again for those
result of his or her actions are evaluated to determine whether specific problems.
his or her actions served to help the patient communicate his
or her need for help and how it was met. In each contact, the
nurse repeats a process of learning how he or she can help the
patient. The nurse’s own individuality, as well as that of the
patient, requires going through this each time the nurse is
called upon to render service to those who need him or her.
JOYCE TRAVELBEE - Objective health—is an absence of discernible
disease, disability of defect as measured by physical
(Human-to-Human Relationship Model ) examination, laboratory tests and assessment by
spiritual director or psychological counselor.
(1926–1973)

“A nurse does not only seek to alleviate physical pain or

render physical care – she ministers to the whole person. The Environment
existence of the suffering whether physical, mental or spiritual
is the proper concern of the nurse.” - Environment is not clearly defined.
- She defined human conditions and life experiences
Life Story encountered by all men as sufferings, hope, pain and
illness.
 A psychiatric nurse, educator and writer born in
1926. MAJOR CONCEPTS AND DEFINITONS
 1956, she completed her BSN degree at Louisiana
State University Illness – being unhealthy, but rather explored the human
 1959, she completed her Master of Science Degree in experience of illness
Nursing at Yale University
Suffering – is a feeling of displeasure which ranges from
Working Experiences: simple transitory mental, physical or spiritual discomfort to
extreme anguish and to those phases beyond anguish—the
malignant phase of dispairful “not caring” and apathetic
 1952, Psychiatric Nursing Instructor at Depaul
indifference
Hospital Affilliate School, New Orleans.
 Also she taught at Charity Hospital School of
Nursing in Louisiana State University, New York Pain – is not observable. A unique experience. Pain is a lonely
University and University of Mississippi. experience that is difficult to communicate fully to another
 1970, the Project Director of Graduate Education at Individual.
Louisiana State University School of Nursing until
her death. Hope – the desire to gain an end or accomplish a goal
 Publications: combined with some degree of expectation that what is desired
 1963, started to publish articles and journals in or sought is attainable
nursing.
 1966 and 1971, publication of her first book entitled Hopelessness – being devoid of hope
Interpersonal Aspects of Nursing.
 1969, when she published her second book Nursing
Intervention in Psychiatric Nursing: Process in the
One-to-One Relationship. - Nursing is an interpersonal process whereby the professional
 She started Doctoral program in Florida in 1973. nurse practitioner assists an individual, family or community
Unfortunately, she was not able to finish it because to prevent or cope with experience or illness and suffering,
she died later that year. She passed away at the prime and if necessary to find meaning in these experiences.”
age of 47 after a brief sickness.
Human-to-Human Relationship Model
Nursing Metaparadigm
- humanistic revolution
Person
Interactional Phases of Human-to-Human Relationship
- Person is defined as a human being. Model:
- Both the nurse and the patient are human beings.
- A human being is a unique, irreplaceable individual 1. Original Encounter
who is in continuous process of becoming, evolving
and changing. - First impression by the nurse of the sick person and
vice-versa.
Health - Stereotyped or traditional roles
2. Emerging Identities
- Health is subjective and objective. - the time when relationship begins
- Subjective health—is an individually defined state of - the nurse and patient perceives each others
well being in accord with self-appraisal of physical- uniqueness
emotional-spiritual status.
3. Empathy
- the ability to share in the person’s experience
4. Sympathy
- when the nurse wants to lessen the cause of patient’s
suffering.
- it goes beyond empathy—“When one sympathizes,
one is involved but not incapacitated by the
involvement.”
- therapeutic use of self
5. Rapport
- Rapport is described as nursing interventions that
lessens the patient’s suffering.
- Relation as human being to human being
- “A nurse is able to establish rapport because she
possesses the necessary knowledge and skills
required to assist ill persons and because she is able
to perceive, respond to and appreciate the uniqueness
of the ill human being.”
Hildegard Elizabeth Peplau inexpensive labor. Exploitation was very common by nurse’s

employers, physicians and educational providers.

Theory of Interpersonal Relations

(September 1, 1909 – March 17, 1999) In 1931, she graduated in Pottstown, Pennsylvania School of

Nursing. Peplau earned a Bachelor’s degree in interpersonal

- was an American nurse who is the only one to serve
psychology in 1943 at Bennington College in Vermont. She
the American Nurses Association (ANA) as
studied psychological issues together with Erich Fromm,
Executive Director and later as President. She
Frieda Fromm-Reichmann, and Harry Stack Sullivan at
became the first published nursing
Chestnut Lodge, a private psychiatric hospital in Maryland.
theorist since Florence Nightingale.
Peplau held master’s and doctoral degrees from Teachers
- Peplau was well-known for her Theory of
College, Columbia University in 1947.
Interpersonal Relations, which helped to

revolutionize the scholarly work of nurses. Her

Interpersonal Relations Theory
achievements are valued by nurses all over the world

and became known to many as the “Mother of In 1952, Hildegard Peplau published her Theory of

Psychiatric Nursing” and the “Nurse of the Interpersonal Relations that was influenced by Henry Stack

Century.” Sullivan, Percival Symonds, Abraham Maslow, and Neal

Elgar Miller. Her theory is discussed further below.

Early Life
MAJOR CONCEPTS OF THE INTERPERSONAL
Hildegard Peplau was born on September 1, 1909. She was raised in Reading,
RELATIONS THEORY
Pennsylvania by her parents of German descent, Gustav and Otyllie Peplau.

She was the second daughter, having two sisters and three brothers. Though The theory explains the purpose of nursing is to help others

illiterate, her father was persevering while her mother was a perfectionist and identify their felt difficulties and that nurses should apply

oppressive. With her young age, Peplau’s eagerness to grow beyond principles of human relations to the problems that arise at all

traditional women’s roles was precise. She considers nursing was one of few levels of experience.

career choices for women during her time. In 1918, she witnessed the

devastating flu epidemic that greatly influenced her understanding of the Man

impact of illness and death on families. Peplau defines man as an organism that “strives in its own

way to reduce tension generated by needs.” The client is an

Education individual with a felt need.

When the autonomous, nursing-controlled, Nightingale era

schools came to an end in the early 1900s, schools then were Health

handled by hospitals, and the so-called formal “book learning” Health is defined as “a word symbol that implies forward
was put down. Hospitals and physicians considered women in movement of personality and other ongoing human processes
nursing as a source of free or in the direction of creative, constructive, productive, personal,

and community living.”

Society or Environment  Client seeks assistance, conveys needs, asks

questions, shares preconceptions and expectations

Although Peplau does not directly address
of past experiences
society/environment, she does encourage the nurse to consider

the patient’s culture and mores when the patient adjusts to  Nurse responds, explains roles to the client, helps

hospital routine. to identify problems and to use available

ADVERTISEMENTS resources and services

Nursing

Hildegard Peplau considers nursing to be a “significant,

therapeutic, interpersonal process.” She defines it as a “human

relationship between an individual who is sick, or in need of

health services, and a nurse specially educated to recognize

and to respond to the need for help.”

Therapeutic nurse-client relationship

A professional and planned relationship between client and Factors influencing orientation phase. Click to enlarge.

nurse that focuses on the client’s needs, feelings, problems,

and ideas. It involves interaction between two or more 2. Identification Phase

individuals with a common goal. The attainment of this goal, The identification phase begins when the client works
or any goal, is achieved through a series of steps following a interdependently with the nurse, expresses feelings, and begins
sequential pattern. to feel stronger.

Four Phases of the therapeutic nurse-patient relationship:

 Selection of appropriate professional assistance

1. Orientation Phase  Patient begins to have a feeling of belonging and

a capability of dealing with the problem which

The orientation phase is directed by the nurse and involves
decreases the feeling of helplessness
engaging the client in treatment, providing explanations and
and hopelessness
information, and answering questions.

 Problem defining phase 3. Exploitation Phase

 Starts when the client meets nurse as a stranger In the exploitation phase, the client makes full use of the

services offered.
 Defining problem and deciding the type of

service needed
 In the exploitation phase, the client makes full

use of the services offered.

  Use of professional assistance for problem-  Patient drifts away and breaks the bond with the

solving alternatives nurse and healthier emotional balance is

 Advantages of services are used is based on the demonstrated and both becomes mature

needs and interests of the patients individuals

 The individual feels like an integral part of the

Subconcepts of the Interpersonal Relations Theory
helping environment
Peplau’s model has proved of great use to later nurse theorists
 They may make minor requests or attention-
and clinicians in developing more sophisticated and
getting techniques
therapeutic nursing interventions.
 The principles of interview techniques must be
The following are the roles of the Nurse in the Therapeutic
used in order to explore, understand and
relationship identified by Peplau:
adequately deal with the underlying problem
Stranger: offering the client the same acceptance and
 Patient may fluctuate on independence
courtesy that the nurse would to any stranger
 Nurse must be aware of the various phases of
Resource person: providing specific answers to questions
communication
within a larger context
 Nurse aids the patient in exploiting all avenues of
Teacher: helping the client to learn formally or informally
help and progress is made towards the final step
Leader: offering direction to the client or group

4. Resolution Phase Surrogate: serving as a substitute for another such as a parent

In the resolution phase, the client no longer needs professional or a sibling

services and gives up dependent behavior. The relationship Counselor: promoting experiences leading to health for the
ends. client such as expression of feelings

Technical Expert: providing physical care for the patient and

 In the resolution phase, the client no longer needs
operates equipment
professional services and gives up dependent

behavior. The relationship ends. Peplau also believed that the nurse could take on many other

roles but these were not defined in detail. However, they were
 Termination of professional relationship
“left to the intelligence and imagination of the readers.”
 The patients needs have already been met by the
(Peplau, 1952)
collaborative effect of patient and nurse
Additional roles include:
 Now they need to terminate their therapeutic

relationship and dissolve the links between them.  Technical expert

 Sometimes may be difficult for both as  Consultant

psychological dependence persists
 Health teacher
  Tutor relationship by using problem-solving techniques for the nurse

 Socializing agent and patient to collaborate on, with the end purpose of meeting

the patient’s needs. Both use observation communication and

 Safety agent
recording as basic tools utilized by nursing.
 Manager of environment

 Mediator Assessment Orientation

 Administrator
 Continuous data  Non-continuous
 Recorder observer collection and data collection

 Researcher analysis  Felt need

Anxiety was defined as the initial response to a psychic threat.  May not be a felt  Definite needs
There are four levels of anxiety described below. need
Nursing Identification
Diagnosis &
Planning
Four Levels of Anxiety
 Interdependent
Mild anxiety is a positive state of heightened awareness and  Mutually set goal setting
sharpened senses, allowing the person to learn new behaviors goals
and solve problems. The person can take in all available Implementation Exploitation

stimuli (perceptual field).

 Plans initiated  Patient actively
Moderate anxiety involves a decreased perceptual field
towards seeking and
(focus on immediate task only); the person can learn a new
achievement of drawing help
behavior or solve problems only with assistance. Another
mutually set  Patient-initiated
person can redirect the person to the task.
goals
Severe anxiety involves feelings of dread and terror. The  May be
person cannot be redirected to a task; he or she focuses only accomplished by
on scattered details and has physiologic symptoms of patient, nurse, or
tachycardia, diaphoresis, and chest pain. significant other.
Evaluation Resolution
Panic anxiety can involve loss of rational thought, delusions,

hallucinations, and complete physical immobility and

 Based on  Occurs after other
muteness. The person may bolt and run aimlessly, often
mutually phases are
exposing himself or herself to injury.
expected completed

behaviors successfully
Interpersonal Theory and Nursing Process  May led to  Leads to

Both Peplau’s Interpersonal Relations Theory and the Nursing termination termination

Process are sequential and focus on the therapeutic

and initiation

of new plans
 Well-being
Self-transcendence theory - the sense of feeling whole and healthy, in accord with
one’s own criteria for wholeness and well-being”
Pamela G. Reed Moderating-mediating factors
- A variety of personal and contextual variables and their
1952 to present interactions may influence the process of self-
transcendence as it contributes to well-being.
BACKGROUND OF THE THEORIST
 Pamela G. Reed was born in Detroit, Michigan, - Examples are age, gender, cognitive ability, life
where Born in Detroit, Michigan experiences, spiritual perspectives, social environment,
and historical events.
 Baccalaureate degree from Wayne State
University-1974 MAJOR ASSUMPTIONS
 Master of science in psychiatric-mental health of
children and adolescents and in nursing Nursing
education-1976 - The role of nursing activity was to assist persons
 PhD concentration in nursing theory and (through interpersonal processes and therapeutic
research, minor in adult development and aging- management of their environments) with the skills
1982 required for promoting health and well-being.
 Dissertation research focused on relationship
between wellbeing and spiritual perspectives on Person
life and death in terminally ill and well - Persons were conceived as developing over their life
individuals. span in interaction with other persons and within an
environment of changing complexity and vibrancy that
Theoretical sources could both positively and negatively contribute to health
 Developed her Self-Transcendence Theory using and well-being.
the strategy of deductive reformulation.
 Deductive reformulation uses knowledge from - Health
non-nursing theory that is reformulated with a In the early process model, health was defined implicitly
nursing conceptual model in constructing middle- as a life process of both positive and negative experiences
range theory. from which individuals create unique values and
environments that promote well-being.
Reed describes her theory as originating from three
sources : Environment
1. The first source was the conceptualization of Family, social networks, physical surroundings, and
human development community resources were environments that
2. The second source for the theory was the early significantly contributed to health processes that nurses
work of nursing theorist Martha E. Rogers’ influenced through “managing therapeutic interactions
three principles of homeodynamics among people, objects, and [nursing] activities”
3 . The third source for the theory was evidence
from clinical experience Updated Self-Transcendence Theory proposes the
MAJOR CONCEPTS & DEFINITIONS following three sets of relationships
1. Increased vulnerability is related to increased self-
Vulnerability
transcendence.
- Vulnerability is one’s awareness of personal mortality 2. Self-transcendence is positively related to well-being
Self-transcendence and functions as a mediator between vulnerability
and well-being.
- Self-transcendence is “expansion of self-conceptual
boundaries multidimensionally:
 Inwardly -through introspective experiences),
 Outwardly - by reaching out to others, and
 Temporally - whereby past and
future are integrated into the present
- Ttranspersonally (to connect with dimensions
beyond the typically discernible world)
3. Personal and contextual factors may influence the Research findings have suggested ways in which
relationship between vulnerability and self- nurses promote self-transcendence views and behaviors in
transcendence and between self-transcendence and themselves and in their clients. Further research is
well-being. planned to examine interventions promoting self-
transcendence and studies of personal and contextual
factors that modify relationships among the theory
concepts. In addition, qualitative research approaches
assist in gaining a deeper understanding of the concept of
self-transcendence as a nursing process and as it expresses
the depth and changing complexity of human beings.

Logical form
Reed’s empirical middle-range theory was constructed
using the strategy of deductive reformulation to enhance
understanding of the end-of-life phenomenon of self-
transcendence (Reed, 1991a). The logic used was
primarily deduction, to ensure that the middle-range
theory was congruent with Rogerian and life span
principles. Analogical reasoning was also used to work
from other theories of life span development, comparing
psychology and nursing about human development and
potential for well-being in all phases of life. The key
concepts of the theory are related in a clear and logical
manner, while allowing for creativity in the way the
theory is applied, tested, and further developed. Reed’s
strategy of constructing a nursing theory—from non-
nursing theories, a nursing conceptual model, research,
and clinical and personal experiences—piqued nurses’
interest in the phenomenon of developmental maturity
and provided impetus for further theorizing into the
variety of situations where awareness of personal
mortality occurs.

Summary
Self-Transcendence Theory was developed initially using
deductive reformulation from life span developmental
theories, Rogers’ conceptual system of unitary human
beings, empirical research, and clinical and personal
experiences of the theorist. The theoretical concepts are
abstract, but concrete subconcepts have been developed
and studied extensively in a number of populations.
Research findings support the hypothesized relationships
among self-transcendence views, behaviors, and well-
being. These studies increase nurses’ understanding that,
no matter how desperate a health situation, people retain
a capacity for personal development that is associated
with feelings of well-being.
 Vancouver General Hospital, British Columbia, Canada.
She continued her education, earning a bachelor’s and a
Theory of Illness Trajectory master’s degree in nursing from the University of
Washington in 1971 and 1973, respectively. Dodd worked
Carolyn L. Wiener 1930-present as an instructor in nursing at University of Washington
following graduation with her master’s degree. By 1977,
Dodd returned to academe and completed a Ph.D. in
CREDENTIALS OF THE THEORISTS
nursing from Wayne State University. She then accepted
Carolyn L. Wiener was born in 1930 in San Francisco.
the position of assistant professor at UCSF. During her
She earned her bachelor’s degree in interdisciplinary
tenure there, Dodd has advanced to the rank of full
social science from San Francisco State University in
professor, serving as the director for the Center for
1972. Wiener received her master’s degree in sociology
Symptom Management at UCSF. In 2003, she was
from the University of California, San Francisco (UCSF)
awarded the Sharon A. Lamb Endowed Chair in Symptom
in 1975. She returned to UCSF to pursue her doctorate in
Management at the School of Nursing, UCSF.
sociology and completed her Ph.D. in 1978. After
Her exemplary program of research is focused in
receiving a Ph.D., Wiener accepted the position of
oncology nursing, specifically, self-care and symptom
assistant research sociologist at UCSF.
management. Dodd’s outstanding record of funded
Wiener is an adjunct professor and research sociologist
research provides evidence of the superiority and
in the Department of Social and Behavioral Sciences at
significance of her work. She has skillfully woven modest
the School of Nursing at UCSF. Her research focuses on
internal and external funding with 23 years of continuous
organization in healthcare institutions, chronic illness,
National Institutes of Health funding to advance her
and health policy. She teaches qualitative research
research. Her research trajectory has advanced
methods and has conducted numerous seminars and
impeccably as she progressively utilized both descriptive
workshops on the grounded theory method.
studies and intervention studies employing randomized
Throughout her career, Wiener’s excellence has earned
clinical trial methodologies to extend an understanding of
for her several meritorious awards and honors. Her
complex phenomena in cancer care.
intense collaborative relationship with the late Anselm
Dodd’s research was designed to test self-care
Strauss (co-originator of grounded theory methods) and
interventions (PRO-SELF Program) to manage the side
prolific experience in grounded theory methods are
effects of cancer treatment (mucositis) and symptoms of
evidenced by her invited presentations at the Celebration
cancer (fatigue, pain). This research entitled The PRO-
of the Life and Work of Anselm Strauss at UCSF in 1996
SELF: Pain Control Program—An Effective Approach
and at a conference entitled Anselm Strauss, a
for Cancer Pain Management was published in Oncology
Theoretician: The Impact of His Thinking on German and
Nursing Forum (West, Dodd, Paul, Schumacher, Tripathy
European Social Sciences in Magdeburg, Germany, in
et al., 2003). Currently, she teaches in the Oncology
1999. She is highly sought as a methodological consultant
to researchers and students from a variety of specialties. Nursing Specialty. In 2002, she instituted two new
Dissemination of research findings and methodological courses (“Biomarkers I and II”) developed by the Center
papers is a hallmark of Wiener’s work. She has produced for Symptom Management Faculty Group.
a steady stream of research and theory articles since the Dodd’s illustrious career has merited several
mid-1970s. In addition, she has authored or coauthored prestigious awards. Among these honors, she was
recognized as a fellow of the American Academy of
several books (Strauss, Fagerhaugh, Suczek, & Wiener,
Nursing (1986). Her continued excellence and significant
1997; Wiener, 1981, 2000; Wiener & Strauss,
contributions to oncology nursing are evidenced by her
1997; Wiener & Wysmans, 1990). In her early efforts, having been awarded the Oncology Nursing
Wiener focused on illness trajectories, biographies, and Society/Schering Excellence in Research Award (1993,
the evolving medical technology scene. From the late 1996), the Best Original Research Paper in Cancer
1980s to 1990s, Wiener focused on coping, uncertainty, Nursing (1994, 1996), the Oncology Nursing Society
and accountability in hospitals. Then she completed a Bristol-Myers Distinguished Researcher Career Award
study examining the quality management and redesign (1997), and the Oncology Nursing Society/Chiron
efforts in hospitals and the interplay between agencies and Excellence of Scholarship and Consistency of
hospitals around the issue of accountability (Wiener, Contribution to the Oncology Nursing Literature Career
2000). All of this work is grounded in her strong Award (2000). In 2005, Dodd received the prestigious
methodological expertise and sociological perspective. Episteme Laureate (the Nobel Prize in Nursing) Award
from the Sigma Theta Tau International Honor Society of
Marylin J. Dodd Nursing. This impressive partial listing of awards
Marylin J. Dodd was born in 1946 in Vancouver, Canada. provides a sense of the magnitude of professional respect
She qualified as a registered nurse after studying at the
and admiration that Dodd has garnered throughout her theory’s significant contribution to nursing: coping is not
career. a simple stimulus-response phenomenon that can be
Dodd’s record in research dissemination is equally isolated from the complex context of life. Because life is
illustrious. Her volume of original publications began in centered in the living body, the physiological disruptions
1975. By the early 1980s, she was publishing multiple, of illness permeate other life contexts to create a new way
focused articles each year, and that pace has only of being, a new sense of self. Responses to the disruptions
accelerated. She has authored or coauthored 130+ data- caused by illness are interwoven into the various contexts
based peer-reviewed journal articles, seven books and encountered in one’s life and the interactions with other
many book chapters, and numerous editorials, conference players in those life situations.
proceedings, and review papers (1978, 1987, 1988, 1991, From this perspective, coping is best viewed as change
1997, 2001). Her many presentations at scientific over time that is highly variable in relation to biographical
gatherings around the world accentuate this work. Dodd and sociological influences. The trajectory is this course
has been an invited speaker throughout North America, of change, of variability, that cannot be confined to or
Australia, Asia, and Europe. modeled in linear phases or stages. Rather, the trajectory
Her active service to the university, School of Nursing, of illness organizes insights to better understand the
Department of Physiological Nursing, and to numerous dynamic interplay of the disruption of illness within the
professional and public organizations and journal review changing contexts of life.
boards augments her outstanding record of service to the Within this sociological framework, Wiener and Dodd
profession of nursing. Despite the breadth and volume of address serious concerns regarding conceptual
these activities, Dodd is an active teacher and mentor. She overattribution of the role of uncertainty in the framework
is the faculty member on record for several graduate of understanding responses to living with the disruptions
courses and carries a significant advising load in the of illness (Wiener & Dodd, 1993). An old adage tells us
master’s, doctoral, and postdoctoral programs at UCSF. that nothing in life is certain, except death and taxes.
With this brief overview of but a few highlights in an Living is fraught with uncertainty, yet illness (especially
amazing career, it is clear that Dodd is an exemplar of chronic illness) compounds this uncertainty in profound
excellence in nursing scholarship. ways. Being chronically ill exaggerates the uncertainties
THEORETICAL SOURCES of living within being for those who are compromised
Being ill creates a disruption in normal life. Such (i.e., by illness) in their capability to respond to these
disruption affects all aspects of life, including uncertainties. Thus, although the concept of uncertainty
physiological functioning, social interactions, and provides a useful theoretical lens for understanding the
conceptions of self. Coping is the response to such illness trajectory, it cannot be theoretically positioned so
disruption. Although coping with illness has been of as to overshadow conceptually the dynamic context of
interest to social scientists and nursing scholars for living with chronic illness.
decades, Weiner and Dodd clearly explicate that formerly In other words, the trajectory of illness is driven by the
implicit theoretical assumptions have limited the utility of illness experience lived within contexts that are inherently
this body of work (Wiener & Dodd, 1993, 2000). Because uncertain and involve both the self and others. The
the processes surrounding the disruption of illness are dynamic flow of life contexts (both biographical and
played out in the context of living, coping responses are sociological) creates a dynamic flow of uncertainties that
inherently situated in sociological interactions with others take on different forms, meanings, and combinations
and biographical processes of self. Coping is often when living with chronic illness. Thus, tolerating
described as a compendium of strategies used to manage uncertainty is a critical theoretical strand in the illness
the disruption, attempts to isolate specific responses to trajectory theory.
one event that is lived within the complexity of life
context, or assigned value labels (e.g., good or bad) to the
responsive behaviors that are described collectively as M A J O R C O N C E P T S & D E F I N I T I O N S
coping. Yet, the complex interplay of physiological Life is situated in a biographical context. Conceptions of self are
disruption, interactions with others, and the construction rooted in the physical body and are formulated based on the perceived
capability to perform usual or expected activities to accomplish the
of biographical conceptions of the self warrants a more objectives of varied roles. Interactions with others are a major
sophisticated perspective of coping. influence on the establishment of the conception of self. As varied role
The Theory of Illness Trajectory* addresses these behaviors are enacted, the person monitors reactions of others and a
theoretical pitfalls by framing this phenomenon within a sense of self in an integrated process of establishing meaning. Identity,
temporality, and body are key elements in the biographical context, as
sociological perspective of a trajectory that emphasizes follows:
the experience of disruption related to illness within the • Identity: the conception of self at a given time that
changing contexts of interactional and sociological unifies multiple aspects of self and is situated in
processes that ultimately influence the person’s response the body
to such disruption. This theoretical approach defines this
 • Temporality: biographical time reflected in the
continuous flow of the life course events; Sources of Dimensions of
Domain
perceptions of the past, present, and possible Uncertainty Uncertainty
future interwoven into the conception of self
ways, and Skewed temporality interpretable
• Body: activities of life and derived perceptions expectations impairs the within the usual
based in the body related to the flow expected life frame of
of events course. understanding.
(temporality) are  Hope is sustained
Illness, particularly cancer, disrupts the usual or altered by disease despite changing
everyday conception of self and is compounded by the and treatment. circumstances.
perceived actions and reactions of others in the The activities of life and of living with an illness are forms of
sociological context of life. This disruption permeates the work. The sphere of work includes the person and all
interdependent elements of biography: identity, others with whom he or she interacts, including family
temporality, and body. This disruption or sense of and healthcare providers. This network of players is called
disequilibrium is marked by a sense of a loss of control, the total organization. The ill person (or patient) is the
resulting in states of uncertainty. central worker; however, all work takes place within and
is influenced by the total organization. Types of work are
organized around the following four lines of trajectory
Illness Trajectory: States of Uncertainty work performed by patients and families:
1. Illness-related work: diagnostics, symptom
management, care regimen, and crisis
Sources of Dimensions of prevention
Domain
Uncertainty Uncertainty 2. Everyday-life work: activities of daily living,
keeping a household, maintaining an
occupation, sustaining relationships, and
UNCERTAIN Life is perceived to be Loss of temporal recreation
TEMPORALITY in a constant predictability
state of flux prompts concerns 3. Biographical work: the exchange of
related to illness surrounding: information, emotional expressions, and the
and treatment. division of tasks through interactions within
 Duration: how the total organization
long 4. Uncertainty abatement work: activities
Taken-for-granted The self of the past  Pace: how fast enacted to lessen the impact of temporal,
expectations regarding is viewed  Frequency: how
the flow of life events differently (e.g., often the body, and identity uncertainty
are disrupted the way it used to experience of time
A temporal disjunction be). is distorted (i.e.,
in the biography Expectations of the stretched out,
present self are constrained, or Uncertainty Abatement Work
distorted by limitless)
illness and
treatment.
Anticipation of the
future self is Type of Activity Behavioral Manifestations
altered.

UNCERTAIN Faith in the body is

BODY shaken (body Pacing Resting or changing usual
Changes related to failure). Ambiguity in reading activities
illness and The conception of body signs Concerns
treatment the former body surrounding:
centered in one’s (the way it used
ability to perform to be) comingles
usual activities, with the altered What is being done to
involving state of the body the body
appearance, at present and the Jeopardized body Becoming Using terminology related to
physiological changed resistance “professional” illness and treatment
functions, and expectations for Efficacy and risks of patients
response to how the body treatment
treatment may perform in Disease recurrence
the future.

UNCERTAIN Body failure and  Expected life Directing care

IDENTITY difficulty reading course is
Interpretation of self the new body shattered.
is distorted as the upset the former  Evidence gleaned
body fails to conception of from reading the
perform in usual self. body is not
Type of Activity Behavioral Manifestations Type of Activity Behavioral Manifestations

Balancing expertise with super- Taking charge Asserting the right to determine
medicalization the course of treatment

Seeking reinforcing Comparing self with persons

comparisons who are in worse condition
to reassure self that it is not
as bad as it could be

Engaging in reviews Looking back to reinterpret

emergent symptoms and
interactions with others in
the organization

Setting goals Looking toward the future to

achieve desired activities

Covering up Masking signs of illness or

related emotions

Bucking up to avoid stigma or

to protect others

Finding a safe place Establishing a place where, or

to let down people with whom, true
emotions and feelings
could be expressed in a
supportive atmosphere

Choosing a Selective sharing with

supportive individuals deemed to be
network positive supporters
 Following high school graduation in 1949, she entered the
Theory of Chronic Sorrow diploma school of nursing at the Brockville General
Georgene Gaskill Eakes Hospital, Brockville, Ontario, graduating in 1953. In
1945-present 1959, she immigrated to the United States to attend
George Peabody College for Teachers in Nashville,
Tennessee, receiving a diploma in public health nursing.
Mary Lermann Burke In 1974, she continued her education at Salve Regina
1941-present College, Newport, Rhode Island, and received a
baccalaureate degree in nursing in 1973 and a master’s
degree in psychiatric and mental health nursing from
Margaret A. Hainsworth Boston College in 1974. She received a doctoral degree in
1931-present education administration from the University of
Connecticut in 1986. In 1988, she was board certified as
a clinical specialist in psychiatric and mental health
CREDENTIALS OF THE THEORISTS nursing.
Georgene Gaskill Eakes
Georgene Gaskill Eakes was born in New Bern, North
Carolina. She received a Diploma in Nursing from Watts MAJOR CONCEPTS & DEFINITIONS
Hospital School of Nursing in Durham, North Carolina,
in 1966, and in 1977, she graduated Summa Cum Laude CHRONIC SORROW
from North Carolina Agricultural and Technical State - Chronic sorrow is the ongoing disparity resulting
University with a baccalaureate in nursing. Eakes from a loss characterized by pervasiveness and
completed an M.S.N. at the University of North Carolina permanence. Symptoms of grief recur
at Greensboro in 1980, and an Ed.D. from North Carolina periodically, and these symptoms are potentially
State University in 1988. Eakes was awarded a federal progressive.
traineeship for her graduate study at the master’s level and LOSS
a graduate fellowship from the North Carolina League for
Nursing to support her doctoral studies. She was inducted - Loss occurs as a result of disparity between the
into Sigma Theta Tau International Honor Society of “ideal” and real situations or experiences. For
Nurses in 1979 and Phi Kappa Phi Honor Society in 1988. example, there is a “perfect child” and a child
with a chronic condition who differs from that
Mary Lermann Burke ideal.
Mary Lermann Burke was born in Sandusky, Ohio, where TRIGGER EVENTS
she received her elementary and secondary education. She - Trigger events are situations, circumstances, and
was awarded her initial nursing diploma from Good conditions that highlight the disparity or the
Samaritan Hospital School of Nursing in Cincinnati in recurrent loss and initiate or exacerbate feelings
1962, followed later that year by a postgraduate of grief.
certification, from Children’s Medical Center in District
of Columbia. After several years of work experience in MANAGEMENT METHODS
pediatric nursing, Burke graduated Summa Cum Laude - Management methods are means by which
from Rhode Island College, Providence, with a bachelor’s individuals deal with chronic sorrow. These may
degree in nursing. In 1982, she received her master’s be internal (personal coping strategies) or
degree in parent-child nursing from Boston University. external (health care practitioner or other
During this program, she was also awarded a Certificate persons’ interventions).
in Parent-Child Nursing and Interdisciplinary Training in Ineffective Management
Developmental Disabilities from the Child Development - Ineffective management results from strategies
Center of Rhode Island Hospital and the Section on that increase the individual’s discomfort or
Reproductive and Developmental Medicine, Brown heighten the feelings of chronic sorrow.
University, in Providence. Her doctorate of nursing Effective Management
science in the Family Studies Cognate from Boston - Effective management results from strategies that
University followed this in 1989. lead to increased comfort of the affected
individual.
Margaret A. Hainsworth - These NCRCS studies involved the following:
Margaret A. Hainsworth was born in Brockville, Ontario, - Individuals with cancer infertility (multiple
Canada. She received her early elementary and secondary sclerosis; Hainsworth, 1994), and Parkinson’s
education in her hometown of Prescott, Ontario. disease (Lindgren, 1996)
 - Spouse caregivers of persons with chronic professional In summary, an impressive total of 196
mental illness, multiple sclerosis and interviews resulted in the middle range Theory of Chronic
Parkinson’s disease Sorrow. The theorists summarized a decade of research
- Parent caregivers of adult children with chronic with individuals with chronic sorrow and found that this
mental illness phenomenon frequently occurs in persons with chronic
Triggers conditions, in family caregivers, and in bereaved persons
Using the empirical data from these series of studies, the
NCRCS theorists identified primary events or situations
that precipitated the re-experience of initial grief feelings.
These events were labeled chronic sorrow
triggers (Eakes et al., 1993). The NCRCS compared and
contrasted the triggers of chronic sorrow in individuals
with chronic conditions, family caregivers, and bereaved
persons (Burke, Eakes, & Hainsworth, 1999). For all
populations, comparisons with norms and anniversaries
were found to trigger chronic sorrow. Both family
caregivers and persons with chronic conditions
experienced triggering with management crises. One
trigger unique for family caregivers was the requirement
of unending caregiving. The bereaved population reported
that memories and role change were unique triggers.

Management Strategies
The NCRCS posited that chronic sorrow is not
debilitating when individuals effectively manage feelings.
The management strategies were categorized as internal
or external. Self-care management strategies were
designated as internal coping strategies. The NCRCS
further designated internal coping strategies as action,
cognitive, interpersonal, and emotional.
Action coping mechanisms were used across all
subjects—individuals with chronic conditions and their
caregivers

The examples are like distraction methods commonly

used to cope with pain. For instance, “keeping busy” and
“doing something fun” are given as examples of action-
oriented coping . It was found that cognitive coping was
used frequently, and examples included “thinking
positively,” “making the most of it,” and “not trying to
fight it” .

Interpersonal coping examples included “going to a

psychiatrist,” “joined a support group,” and “talking to
others”

Emotional strategy examples included “having a good

cry” and expressing emotions
A management strategy was labeled effective when a
subject described it as helpful in decreasing feelings of re-
grief.
External management was described initially by Burke
as interventions provided by health professionals.
Healthcare professionals assist affected populations to
increase their comfort through roles of empathetic
presence, teacher-expert, and caring and competent