Theory of Integral Nursing - Lippincott Williams &...

Advances in Nursing ScienceVol. 31, No. 1, pp. E52–E73Copyright c© 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Theory of Integral Nursing

Barbara Montgomery Dossey, PhD, RN, AHN-BC, FAAN

Anchored in one of the most dramatic social shifts in healthcare history, a Theory of Inte-gral Nursing can inform and shape nursing practice, education, research and policy—local toglobal—to achieve a healthy world. A Theory of Integral Nursing, informed by integral theory,presents the philosophical foundation and application of an integral worldview and process.This theory also recognizes Florence Nightingale’s philosophical foundation and legacy, heal-ing and healing research, the meta-paradigm in a nursing theory (nurse, person(s), healthand environment [society]), 6 patterns of knowing (personal, empirics, aesthetics, ethics, notknowing, sociopolitical), and other nonnursing theories. Key words: global health, healing,integral nursing, meta-paradigm in a nursing theory, micro to macro, nonlocality, pat-terns of knowing, Theory of Integral Nursing, transpersonal, transdisciplinarian, transdis-ciplinary dialogues

A Theory of Integral Nursing does not exclude or in-validate other nurse theorists who have also informedmy theory, specifically Florence Nightingale, Jean Wat-son, PhD, RN, AHN-BC, FAAN; Helen Erickson, PhD,RN, AHN-BC, FAAN; Margaret A. Newman, PhD, RN,FAAN; Patricia Benner, PhD, RN, FAAN; Rosemarie R.Parse, DNSc, RN, FAAN; Anne Boykin, PhD, RN; MarthaE. Rodgers, PhD, RN; Peggy Chinn, PhD, RN, FAAN;Afaf I. Meleis, PhD, RN, FAAN; and Madeline Leininger,PhD, RN, FAAN.

I thank H. Lea Gaydos, PhD, RN, CS, AHN-BC; CyndaH. Rushton, PhD, RN, FAAN; James Baye, BSN, RN; Bar-bara Barnum, PhD, RN, FAAN; Jennifer Reich, MA, MS,APRN-BC, ACHPN, Darlene R. Hess, PhD, NP, AHN-BC,and Geneie Everett, PhD, RN, for their suggestions forthe Theory of Integral Nursing.

Credit is given to Andrew Harvey, who coined the termsacred activism; to Patricia Hinton Walker, PhD, RN,FAAN, who coined the terms “nurses as health diplo-mats,”“integral health coaches,”and “coaching for inte-gral health;” and H. Lea Gaydos, PhD, RN, CS, AHN-BC,who introduced me to the jewel metaphor for healingand integral health.

I also acknowledge my American Holistic Nurses Asso-ciation colleagues with whom I have worked for over 2decades, particularly Cathie E. Guzzetta, PhD, RN, AHN-BC, FAAN; Lynn Keegan, PhD, RN, AHN-BC, FAAN; H. LeaGaydos, PhD, RN, CS, AHN-BC; Charlie McGuire, MSN,RN, AHN-BC; Noreen Frisch, PhD, RN, AHN-BC, FAAN;Carla Mariano, PhD, RN, AHN-BC; Charlotte Eliopou-los, PhD, RN, MPH, ND, AHN-BC; and all the members ofthe AHNA Elder Council, the former and present Journalof Holistic Nursing editors, and the former and currentAHNA Leadership Council. In November 2006 the col-lective holistic nursing endeavors were recognized as aholistic nursing specialty by the American Nurses Asso-ciation. This author believes that our challenge now isto move the holistic paradigm to an integral paradigmand language.

I acknowledge the exciting endeavors with my Nightin-gale Initiative for Global Health (NIGH) and theNightingale Declaration Campaign (NDC) colleaguesDeva-Marie Beck, PhD, RN; Cynda H. Rushton, PhD,RN, FAAN; Wayne Kines; Eleanor Kibrick, MS; WilliamRolph; and Don de Silva, and our future collaborativeendeavors that are in development and scheduledthrough 2020 (http://www.nightingaledeclaration.net).

I recognize the work of Nightingale scholars Deva-Marie Beck and Louise Selanders with whom I haveworked for over 2 decades, and who have assisted mein the Florence Nightingale Services at the WashingtonNational Cathedral in 2001 and 2004 and future ser-vices yet to be scheduled. I also recognized the dedicatedwork of Nightingale scholar Lynn McDonald, editor ofThe Collected Works of Florence Nightingale (16 vol-umes) http://www.sociology.uoguelph.ca/fnightingale.The work of Florence Nightingale scholar Alex At-tewell, former director, Florence Nightingale Mu-seum, London, is also recognized. http://www.florence-nightingale.co.uk/index.php.

I thank Ken Wilber, Diane Hamilton, Willow Pearson,Sophia Diaz, Clint Fuhs, Nicole Fegley, Kelley Beacerand the entire integral team who have challenged meto bring my Theory of Integral Nursing forward.

I express deep gratitude to Roshi Joan Halifax, PhD;Cynda H. Rushton, PhD, RN, FAAN; and the facultyand facilitation team of the Being With DyingTM Profes-sional Training Program in Compassionate End-of-LifeCare at Upaya Zen Center, Santa Fe, New Maxico, forthe wisdom we have shared in council process, bearingwitness, and mindfulness practices.

Corresponding Author: Barbara Montgomery Dossey,PhD, RN, AHN-BC, FAAN, International Co-DirectorNightingale Initiative for Global Health, 878 Paseo DelSur, Santa Fe, NM 87501 ([email protected]).The Theory of Integral Nursing Power/Point is availableon request.

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Theory of Integral Nursing E53

ATHEORY of Integral Nursing is a grandtheory that presents the science and art

of nursing. It includes an integral process, in-tegral worldview, and integral dialogues thatis Praxis—theory in action.1,2∗ An integralprocess is defined as a comprehensive wayto organize multiple phenomena of humanexperience and reality from 4 perspectives:(1) the individual interior (personal, inten-tional); (2) individual exterior (physiologic,behavioral); (3) collective interior (shared,cultural); and (4) collective exterior (systems,structures). Holistic nursing practice is in-cluded (embraced) and transcended (goes be-yond) in this integral process.1,2 An integralworldview examines values, beliefs, assump-tions, meaning, purpose, and judgments re-lated to how individuals perceive reality andrelationships from the above 4 perspectives.Integral dialogues are transformative and vi-sionary exploration of ideas and possibilitiesacross disciplines where these 4 perspectivesare considered as equally important to all ex-changes, endeavors, and outcomes.1,2 Withan increased integral awareness and an inte-gral worldview, nurses have new possibilitiesand ways to strengthen our capacities for inte-gral dialogues with each other and other dis-ciplines. We are more likely to raise our col-lective nursing voice and power to engage insocial action in our role and work of servicefor society—local to global.

To decease further fragmentation in thenursing profession, the Theory of IntegralNursing includes existing theoretical work innursing that builds on our solid holistic andmultidimensional theoretical nursing founda-tion. This theory may be used with otherholistic nursing and nonnursing caring con-cepts, theories, and research; it does not ex-clude or invalidate other nurse theorists whohave informed this theory. This is not a free-

∗Concepts specific to the Theory of Integral Nursing are

in italic throughout this article. Please consider these

words as a frame of reference and a way to explain what

you have observed or experienced with yourself and

others.

standing theory as it incorporates conceptsfrom the philosophies and various fields thatinclude holistic, multidimensionality, integral,chaos, spiral dynamics, complexity, systems,and many other paradigms.

An integral understanding allows us tomore fully comprehend the complexity of hu-man nature and healing; it assists nurses tobring to healthcare and society their knowl-edge, skills, and compassion. The integral pro-cess and an integral worldview present a com-prehensive map and perspective related tothe complexity of wholeness and how to si-multaneously address the health and the well-being of nurses, the healthcare team, thepatients, families and significant others, thehealthcare system/structure, and the world.

The nursing profession asks nurses to wraparound “all of life” on so many levels withself and others that we can often feel over-whelmed. So how do we get a handle on “allof life?”The question always arises, “How canoverworked nurses and student nurses use anintegral approach or apply the Theory of In-tegral Nursing?” The answer is to start rightnow. By the time you finish reading this arti-cle I believe that you will find the answers tothe above questions. Be aware of healing, thecore concept in this theory; it is the innatenatural phenomenon that comes from withina person and describes the indivisible whole-ness, the interconnectedness of all people, allthings.

Reflect on the following clinical situation;imagine that you are taking care of a veryill patient, who needs transporting to a ra-diology procedure. The current transporta-tion protocol between the medical unit andthe radiology department lacks continuity. Inthis moment, shift your feelings and your in-terior awareness (and believe it!) to: “I amdoing the best that I can in this moment,”and “I have all the time needed to take adeep breath and relax my tight chest andshoulder muscles.” This helps you connectthese 4 perspective as follows: (1) the inte-rior self (caring for yourself in this moment);(2) the exterior self (using a research-basedrelaxation and imagery integral practice to

E54 ADVANCES IN NURSING SCIENCE/JANUARY–MARCH 2008

change your physiology); (3) the self in re-lationship to others (shifting your awarenesscreates another way of being with your pa-tient and the radiology team member); and(4) the relationship to the exterior collec-tive of systems-structures (considering howto work with the radiology team and depart-ment to improve a transportation procedurein the hospital). An integral worldview andapproach can help each nurse and studentnurse increase her or his self-awareness, aswell as the awareness of how self affects oth-ers, that is, the patient, family, colleagues,and the workplace and community. As thenurse discovers her or his own innate heal-ing from within, one is able to model self-careand how to release stress, anxiety, and fearthat manifest each day in this human journey.All nursing curriculum can be mapped in theintegral quadrants discussed later that teachesstudents to think integrally and to becomeaware of an integral perspective and howthese 4 perspectives create the whole. Theycan also learn the importance of self-care atall times as faculty also remember that theyare role models and must model self-care andthese ideas.

DEVELOPING THE THEORY OFINTEGRAL NURSING: PERSONALJOURNEY

Attending my first nursing theory confer-ence in the late 1960s as a young nurse, Iwas captivated by nursing theory and the elo-quent visionary words of these theorists asthey spoke about the science and art of nurs-ing. This opened my heart and mind to the ex-ploration and necessity to understand and touse nursing theory. Thus, I began my profes-sional commitment to address theory in all en-deavors as well as to increase my understand-ing of other disciplines that could inform meat a deeper understanding about the humanexperience. I realized that nursing was noteither “science” or “art”; but both/and. Fromthe beginning of my critical care and cardio-vascular nursing focus, I learned how to com-

bine science and technology with the art ofnursing. For example, with a patient havingsevere pain following an acute myocardial in-farction, I gave pain medication while simul-taneously guiding her or him is a relaxationor imagery practice to enhance relaxation andrelease anxiety. I also experienced a differ-ence in myself when I used this approach tocombine the science and art of nursing.

In the late 1960s, I began to study and at-tend workshops on holistic and mind-body–related ideas as well as read in other dis-ciplines such as systems theory, quantumphysics, integral, Eastern and Western mys-ticism, and more. I was also reading nursetheorists and other discipline theorists thatinformed my knowing, doing and being incaring, healing, and holism. (See acknowledg-ments for specific nurse theorists). My hus-band, an internist, who was also caring forcritically ill patients and their families, waswith me on this journey of discovery. As wecared for critically ill patients and their fami-lies, some of our greatest teachers allowed usto discuss how to blend the art of caring heal-ing modalities with the science of technologyand traditional modalities. I joined with a criti-cal care and cardiovascular nursing soul mate,Cathie Guzzetta, PhD, RN, AHN-BC, FAAN,with whom I could discuss these ideas. We be-gan to write teaching protocols and give lec-tures in critical care courses as well as writetextbooks with contributors.

My husband and I both had healthchallenges—mine was postcorneal transplantrejection and my husband’s challenge wasblinding migraine headaches. We both beganto take courses related to body-mind-spirittherapies (biofeedback, relaxation, imagery,music, meditation, and other reflectivepractices) and begin to incorporate theminto our daily lives. As we strengthened ourcapacities with self-care and self-regulationmodalities, our personal and professionalphilosophies and clinical practices changed.We took seriously teaching and integratingthese modalities into the traditional health-care setting that today is called integrativehealthcare. From this point to the present


we have always found many professional andinterdisciplinary healthcare colleagues to dis-cuss concepts and approaches for practice,education, research, healthcare protocols,and policies. This journey has led us to moreauthorship of articles, protocols, and books.See www.dosseydossey.com.

As a founding member in 1981 of the Amer-ican Holistic Nurses Association (AHNA),and with Cathie Guzzetta, PhD, RN, AHN-BC,FAAN, Lynn Keegan, PhD, RN, AHN-BC, FAAN,and many AHNA colleagues (see acknowl-edgements), our collective holistic nursingendeavors were recognized as the specialty ofholistic nursing by the American Nurses As-sociation in November 2006. The AHNA andANA Holistic Nursing: Scope and Standardsof Practice were published in June 2007.3 Ibelieve that using an integral lens can expandthis important holistic specialty.

Beginning in 1992 in London, my pri-mary, historical research of studying andsynthesizing original letters, army andpublic health documents, manuscripts,and books of Florence Nightingale, deep-ened my understanding of her relevancefor nursing, as Nightingale was indeedan integralist which is discussed later.This led to my Nightingale authorship4,5

and my collaborative Nightingale Initi-ate for Global Health,6 and the Nightin-gale Declaration,7 the first global nursingInternet signature campaign (see acknowl-edgements). My professional mission nowis to articulate and use the integral processand integral worldview in my nursing andhealthcare endeavors and to explore rituals ofhealing with many.1,2,8 My sustained nursingcareer focus with nursing colleagues onwholeness, unity, and healing, and my Flo-rence Nightingale scholarship have resultedin numerous protocols and standards forpractice, education, research, and healthcarepolicy. My integral focus since 2000 and mymany conversations with Ken Wilber andthe integral team and other interdisciplinaryintegral colleagues have led to my develop-ment of the Theory of Integral Nursing (seeacknowledgements).

Theory of integral nursing intentionsand developmental process

The intention (purpose) in a nursing the-ory is the aim of the theory. The The-ory of Integral Nursing has 3 intentions asfollows: (1) to embraces the unitary wholeperson and the complexity of the nursing pro-fession and healthcare; (2) to explore the di-rect application of an integral process and in-tegral worldview that includes 4 perspectivesof realities—the individual interior and exte-rior and the collective interior and exterior;and (3) to expand nurses’ capacities as 21st-century Nightingales, health diplomats, andintegral health coaches who are coaching forintegral health—local to global. The Theoryof Integral Nursing develops the evolutionarygrowth processes, stages, and levels of hu-man development and consciousness to movetoward a comprehensive integral philosophyand understanding. This can assist nurses tomore deeply map human capacities that beginwith healing to evolve to the transpersonalself and connection with the Divine, howeverdefined or identified, and their collective en-deavors to create a healthy world.

The Theory of Integral Nursing develop-ment process at this time is to strengthen our21st-century nursing endeavors and beyondso that we can more easily expand personalawareness of our integral and holistic, car-ing healing knowledge and approaches withtraditional nursing and healthcare. Nursingand healthcare are fragmented. Collaborativepractice has not been realized because onlyportions of reality are seen as being validwithin healthcare and society. Often there isa lack of respect for each other. We also donot consistently listen to the pain and suffer-ing that nurses experience within the profes-sion, nor do we consistently listen to the painand suffering of the patient and family mem-bers or our colleagues. Self-care is a low pri-ority; time is not given or valued within prac-tice settings to address basic self-care suchas short breaks for personal needs and mealswhich is made worse by short staffing andovertime. Professional burnout is extremely


high and many nurses are very discouraged.Nurse retention is at a crisis level through-out the world. As nurses integrate an inte-gral process and integral worldview and usedaily integral life practices, they will moreconsistently be healthy and model health andunderstand the complexities within healing.This will then enhances nurses’ capacities forempowerment, leadership, and being changeagents for a healthy workplace and healthyworld.

Philosophical foundation: FlorenceNightingale’s legacy

Florence Nightingale (1820–1910), the phi-losophical founder of modern secular nursingand the first recognized nurse theorist, wasan integralist.1,2,6,7 Her worldview focusedon the individual and the collective, the in-ner and outer, and human and nonhuman con-cerns. She was concerned with the most basicneeds of human beings and all aspects of theenvironment (clean air, water, food, houses,etc)—local to global.5–7 She also experiencedand recorded her personal understanding ofthe connection with the Divine or Infinite, theawareness that something greater than her,the Divine, was a major connecting link.4,5

Today we recognize Nightingale’s work asglobal nursing where she envisioned what ahealthy world might be with her integral phi-losophy and expanded capacities. Her workincluded aspects of the nursing process aswell; her achievements indeed have had animpact on us and will extend far into thefuture. Nightingale’s work was social actionthat clearly articulated the science and artof an integral worldview for nursing, health-care, and humankind. Her social action wasalso sacred activism,9 the fusion of the deep-est spiritual knowledge with radical actionin the world. Nightingale was ahead of hertime; her dedicated and focused 50 years ofwork and service still informs and impactsthe nursing profession and our global mis-sion of health and healing for humanity. Inthe 1880s, Nightingale began to write in let-ters that it would take 100 to 150 years be-fore educated and experienced nurses would

arrive to change the healthcare system. Weare that generation of 21st-century Nightin-gales who have arrived to transform health-care and carry forth her vision to create ahealthy world.

Integral foundation and theintegral model

The Theory of Integral Nursing adapts thework of Ken Wilber (1949-), one of the mostsignificant American new-paradigm philoso-phers, to strengthen the central concept ofhealing. His integral model is an elegant,4-quadrant model that has been developedover 35 years.10–15 In the 8-volume, The Col-lected Works of Ken Wilber,10,11 Wilber syn-thesizes in his monumental achievement thebest known and most influential researchers,theorists, theories, and schools of thought toshow that no individual or discipline can de-termine reality or has all the answers. Manyconcepts within the Theory of Integral Nurs-ing have been researched or are in very for-mative stages and exploration within integralmedicine, integral healthcare administration,integral business, integral healthcare educa-tion, integral psychotherapy, and more.12,13

Within the nursing profession, other nursesare also exploring integral and related theo-ries and ideas.16–24 But as of yet, there is notheory of nursing that has Nightingale’s philo-sophical foundation as an integralist com-bined with the integral process and integralworldview. When nurses use an integral lens,they are more likely to expand nurses’ rolesin interdisciplinary dialogues and to explorecommonalities and to examine differencesand how to address these across disciplines.Our challenge in nursing is to increase our in-tegral awareness as we increase our nursingcapacities, strengths, and voices in all areas ofpractice, education, research, and healthcarepolicy.

THEORY OF INTEGRAL NURSING

To present the Theory of Integral Nurs-ing, Barbara Barnum’s25 framework to cri-tique a nursing theory provides an organizing


structure that is most useful. Her approach,which examines content, context, and pro-cess, highlights what is most critical to under-stand a theory and it avoids duplication of ex-planations within the theory as presented. Inthe next section, the Theory of Integral Nurs-ing philosophical assumptions are provided.The reader is encouraged to integrate the inte-gral process concepts and to experience howthe word integral expands one’s thinking andworldview. To delete the word integral orto substitute the world holistic diminishesthe impact of the expansiveness of the inte-gral process and integral worldview and itsimplications.

Philosophical assumptions

In a Theory of Integral Nursing the philo-sophical assumptions are as follows:

1. An integral understanding recognizesthe individual as an energy field con-nected to the energy fields of othersand the wholeness of humanity; theworld is open, dynamic, interdepen-dent, fluid, and continuously interact-ing with changing variables that canlead to greater complexity and order.

2. An integral worldview is a compre-hensive way to organize multiple phe-nomena of human experience from4 perspectives of reality: (1) indi-vidual interior (subjective, personal);(2) individual exterior (objective, be-havioral); (3) collective interior (inter-subjective, cultural); and (4) collectiveexterior (interobjective, systems orstructures).

3. Healing is a process inherent in all liv-ing things; it may occur with curingof symptoms, but it is not synonymouswith curing.

4. Integral health is experienced by a per-son as wholeness with developmenttoward personal growth and expand-ing states of consciousness to deeperlevels of personal and collective un-derstanding of one’s physical, mental,emotional, social, and spiritual dimen-sions.

5. Integral nursing is founded on an inte-gral worldview using integral languageand knowledge that integrates integrallife practices and skills each day.

6. Integral nursing is broadly defined toinclude knowledge development andall ways of knowing.

7. An integral nurse is an instrument inthe healing process and facilitates heal-ing through her or his knowing, doing,and being.

8. Integral nursing is applicable in prac-tice, education, research, and health-care policy.

Content components

Content of a nursing theory includes thesubject matter and building blocks that givea theory its form. It comprises the stable el-ements that are acted on or that do the act-ing. In the Theory of Integral Nursing the sub-ject matter and building blocks are as follows:(1) healing; (2) the meta-paradigm of a nurs-ing theory; (3) patterns of knowing; (4) the4 quadrants that are adapted from Wilber’sintegral theory12: (individual interior [subjec-tive, personal or intentional], individual exte-rior [objective, behavioral], collective interior[intersubjective, cultural], and collective ex-terior [interobjective, systems or structures]);and (5) “all quadrants, all levels, all lines,”thatare adapted from Wilber.12

Content component 1: Healing

The first content component in the Theoryof Integral Nursing is healing illustrated as adiamond shape and seen in Figure 1. The The-ory of Integral Nursing enfolds from the cen-tral core concept of healing. It embraces theindividual as an energy field that is connectedwith the energy fields of all humanity and theworld. Healing is transformed when we con-sider 4 perspectives of reality in any moment:(1) the individual interior (personal, inten-tional), (2) individual exterior (physiology, be-havioral), (3) collective interior (shared, cul-tural), and (4) collective exterior (systems,structures). Using our reflective integral lensof these 4 perspectives of reality assists us to


Figure 1. Healing.

more likely experience a unitary grasp on thecomplexity that emerges in healing.

Healing includes knowing, doing, and be-ing, and is a lifelong journey and process ofbringing together aspects of oneself at deeperlevels of harmony and inner knowing leadingtoward integration.1,2,8 This healing processplaces us in a space to face our fears, to seekand express self in its fullness where we canlearn to trust life, creativity, passion, and love.Each aspect of healing has equal importanceand value that leads to more complex levelsof understanding and meaning.

We are born with healing capacities. It is aprocess inherent in all living things. No onecan take healing away from life although weoften get stuck in our healing or forget that wepossess it because of life’s continuous chal-lenges and perceived barriers to wholeness.Healing can take place at all levels of humanexperience, but it may not occur simultane-ously in every realm. In truth, healing willmost likely not occur simultaneously or evenin all realms, and yet, the person may still havea perception of healing having happened.26,27

Healing is not predictable; it may occur withcuring of symptoms, but it is not synonymouswith curing. Curing may not always happen,but the potential for healing to occur is al-ways present even until one’s last breath. In-tention and intentionality are key factors inhealing.28,29 Intention is the conscious deter-mination to do a specific thing or to act in aspecific manner; it is the mental state of being

Figure 2. Healing and metaparadigm in a nursing the-ory (nurse, person(s), health, environment.

committed to, planning to, or trying to per-form an action.2 Intentionality is the qualityof an intentionally performed action.2

Content component 2: Metaparadigmof nursing theory

The second content component in the The-ory of Integral Nursing is the recognition ofthe meta-paradigm in a nursing theory—nurse, person(s), health, and environment(society)—that is shown in Figure 2. Theseconcepts are important to the Theory of Inte-gral Nursing because they are encompassedwithin the quadrants of human experience(see Content Component 4). Starting withhealing at the center, a Venn diagram sur-rounds healing and implies the interrelatedand interdependence and impact of these do-mains as each informs and influences the oth-ers; a change in one will create a degree(s) ofchange in the other(s), thus impacting healingat many levels.

An integral nurse is defined as a 21st-century Nightingale. Using terms coined byWalker,30 nurses’ endeavors of social actionand sacred activism reflect “nurses as healthdiplomats” and “integral health coaches” thatare “coaching for integral health.” As nurses


strive to be integrally informed, they are morelikely to move to a deeper experience of aconnection with the Divine or Infinite, how-ever defined or identified. Integral nursingprovides a comprehensive way to organizemultiple phenomenon of human experiencein the 4 perspectives of reality as previousdescribed. The nurse is an instrument in thehealing process where she or he brings one’swhole self into relationship to the whole selfof another or a group of significant othersthat reinforces the meaning and experienceof oneness and unity.

A person(s) is defined as an individual (pa-tient or client, family members, significantothers) who engages with a nurse in a mannerthat is respectful of a person’s subjective ex-periences about health, health beliefs, values,sexual orientation, and personal preferences.It also includes an individual nurse who in-teracts with a nursing colleague, other health-care team members, or a group of communitymembers or other groups.

Integral health is the process throughwhich we reshape basic assumptions andworldviews about well-being and see deathas a natural process of living. As seen byGaydos, integral health may be symbolicallyseen as a jewel with many facets that isreflected as a “bright gem” or a “roughstone” depending on one’s situation and per-sonal growth that influence states of health,health beliefs, and values.26,27 This jewel mayalso be seen as a spiral or as a symbol oftransformation to higher states of conscious-ness to more fully understand the essentialnature of our beingness as energy fieldsand expressions of wholeness. This includesevolving one’s state of consciousness tohigher levels of personal and collective un-derstanding of one’s physical, mental, emo-tional, social, and spiritual dimensions. Thisacknowledges the individual’s interior and ex-terior experiences and the shared collectiveinterior and exterior experiences with otherswhere authentic power is recognized withineach person. Disease and illness at the phys-ical level may manifest for many reasons andvariables. It is important not to equate physi-

cal health, mental health, and spiritual health,as they are not the same thing. They are facetsof the whole jewel of integral health.

An integral environment(s) has bothinterior and exterior aspects. The interior en-vironment includes the individual’s feelings,meaning, mental, emotional, and spiritualdimensions; it also includes a person’s brain-stem, cortex, and so on, that are an internal(inside) aspect of the exterior self. It alsoacknowledges the patterns that may notbe understood that may manifest related tovarious situations or relationships. This maybe related to living and nonliving people andthings, such as, a deceased relative, animal,lost precious object(s) through flashes ofmemories stimulated by a current situation(a touch may bring forth memories of abuseor suffering). Insights gained through dreamsand other reflective practices that revealsymbols, images, and other connections alsoinfluence one’s interior environment. Theexterior environment includes objects thatcan be seen and measured that are related tothe physical and social in some form in anyof the gross, subtle, and causal levels that areexpanded later in Component 4.

Content component 3: Patternsof knowing

The third content component in the The-ory of Integral Nursing is the recognitionof the patterns of knowing in nursing asseen in Figure 3. These 6 patterns of know-ing are personal, empirics, aesthetics, ethics,not knowing, and sociopolitical. As a wayto organize nursing knowledge, Carper,31 inher now classic 1978 article, identified the4 fundamental patterns of knowing (per-sonal, empirics, ethics, aesthetics) followedby the introduction of the pattern of notknowing in 1993 by Munhall,32 and the pat-tern of sociopolitical knowing by White33

in 1995. All of these patterns continue tobe refined and reframed with new applica-tions and interpretations.26,27,34–44 These pat-terns of knowing assist nurses in bringingthemselves into the full expression of being


Figure 3. Healing and patterns of knowing in nursing (personal, aesthetics, empirics, ethics, not knowing,sociopolitical).

present in the moment, to integrate aesthet-ics with science, and to develop the flow ofethical experience with thinking and acting.

Personal knowing is the nurse’s dynamicprocess of being whole, which focuses onthe synthesis of perceptions and being withself.41–43 It may be developed through art,meditation, dance, music, stories, and otherexpressions of the authentic and genuine selfin daily life and nursing practice.

Empirical knowing is the science of nurs-ing that focuses on formal expression, replica-tion, and validation of scientific competencein nursing education and practice.34,35 It is ex-pressed in models and theories and can beintegrated into evidence-based practice. Em-pirical indicators are accessed through theknown senses that are subject to direct obser-vation, measurement, and verification.

Aesthetic knowing is the art of nursing,that focuses on how to explore experiencesand meaning in life with self or another thatincludes authentic presence, the nurse as afacilitator of healing, and the artfulness of ahealing environment.26,27,36,44 It is the com-bination of knowledge, experience, instinct,and intuition that connects the nurse with apatient or client to explore the meaning of

a situation about the human experiences oflife, health, illness, and death. It calls forth re-sources and inner strengths from the nurse tobe a facilitator in the healing process. It is theintegration and expression of all the other pat-terns of knowing in nursing praxis.

Ethical knowing is the moral knowledge innursing, which focuses on behaviors, expres-sions, and dimensions of both morality andethics.34,35 It includes valuing and clarifyingsituations to create formal moral and ethicalbehaviors intersecting with legally prescribedduties. It emphasizes respect for the person,the family, and the community that encour-ages connectedness and relationships that en-hance attentiveness, responsiveness, commu-nication, and moral action.

Not knowing is the capacity to use heal-ing presence, to be open spontaneously tothe moment with no preconceived answersor goals to be obtained.40–44 It engages au-thenticity, mindfulness, openness, receptivity,surprise, mystery, and discovery with self andothers in the subjective space and the in-tersubjective space that allows for new solu-tions, possibilities, and insights to emerge.

Sociopolitical knowing address the impor-tant contextual variables of social, economic,


geographic, cultural, political, historical, andother key factors in theoretical, evidence-based practice, and research.33,34 This patternincludes informed critique and social justicefor the voices of the underserved in all ar-eas of society along with protocols to reducehealth disparities. [Note: As all patterns ofknowing in a Theory of Integral Nursing aresuperimposed on Wilber’s 4 quadrants inFigure 6, these patterns are primarily posi-tioned as seen; however they may also ap-pear in 1, several, or all quadrants and in-form all other quadrants].

Content component 4: Quadrants

The fourth content component in the The-ory of Integral Nursing examines 4 perspec-tives for all known aspects of reality or ex-pressed another way, it is how we look atand/or describe anything. The Theory of In-tegral Nursing core concept of healing istransformed by adapting Ken Wilber’s integralmodel.12 Starting with healing at the centerto represent our integral nursing philosophy,human capacities, and global mission, dottedhorizontal and vertical lines are shown to il-lustrate that each quadrant can be understoodas permeable and porous, with each quad-rant experience(s) integrally informing andempowering all other quadrant experiences.Within each quadrant we see “I,” “We,” “It,”and “Its” to represent 4 perspectives of reali-ties that are already part of our everyday lan-guage and awareness.

Virtually all human languages use first-,second-, and third-person pronouns. First per-son is “the person who is speaking,”which in-cludes pronouns like I, me, mine in the singu-lar, and we, us, ours in the plural).12,13 Secondperson means “the person who is spoken to,”which includes pronouns like you and yours.Third person is “the person or thing beingspoken about,” such as she, her, he, him, orthey, it, and its. For example, if I am speak-ing about my new car, “I”am first person, and“you” are second person, and the new car isthird person. If you and I are communicat-ing, the word “we” is used to indicate that

we understand each other. “We”is technicallyfirst person plural, but if you and I are com-municating, then you are second person andmy first person are part of this extraordinary“we.” So we can simplify first, second, andthird person as “I,” “we,”“it,”and “its.”12,13

These 4 quadrants show the 4 primarydimensions or perspectives of how we ex-perience the world; these are representedgraphically as the Upper-Left (UL), Upper-Right (UR) and Lower-Left (LL), and Lower-Right (LR) quadrants. It is simply the insideand the outside of an individual and the in-side and outside of the collective. It includesexpanded states of consciousness where onefeels a connection with the Divine and thevastness of the universe, and the Infinite,that is beyond words. Integral nursing con-siders all of these areas in our personal de-velopment and any area of practice, educa-tion, research, and healthcare policy—localto global. Each quadrant, which is intricatelylinked and bound to each other, carries itsown truths and language. The specifics of thequadrants are as follows and are shown inTable 1.

• Upper-Left (UL). In this “I” space (sub-jective; the inside of the individual) canbe found the world of the individual’s in-terior experiences. These are thoughts,emotions, memories, perceptions, im-mediate sensations, and states of mind(imagination, fears, feelings, beliefs, val-ues, esteem, cognitive capacity, emo-tional maturity, moral development, andspiritual maturity). Integral nursing re-quires the development of the “I.” [Note:When working with various cultures, itis important to know that within manycultures the “I” comes last or is neververbalized or recognized as the focus ison “We”and relationships. However, thisdevelopment of the “I” and an aware-ness of one’s personal values is criti-cal for a healthy nurse and to decreaseburnout and to increase nurse renewaland nurse retention.]

• Upper-Right (UR). In this “It” (objective;the outside of the individual) space can


Table 1. Integral model and quadrants

Upper Left Upper Right

Individual interior Individual exterior

Subjective Objective

(intentional or personal) (behavioral or biological)

“I” space includes self and consciousness

(self-care, fears, feelings, beliefs, values,

esteem, cognitive capacity, emotional

maturity, moral development, spiritual

maturity, personal communication skills, etc)

“It” space includes brain and organisms,

physiology, pathophysiology (cells,

molecules, limbic system, neurotransmitters),

biochemistry, chemistry, physics, behaviors

(skill development in health, nutrition,

exercise, etc)

I IT• Interpretive

• Qualitative

• Observable

• QuantitativeWE ITS

Collective interior Collective exterior

Intersubjective Interobjective

(cultural or shared) (systems or structures)

“We” space includes the relationship to the

culture and worldview (includes shared

understanding, shared vision, shared

meaning, shared values, transdisciplinary

communication/morale, etc)

“Its” space includes the social systems and

environment, organizational structures and

systems (in healthcare financial and billing

systems), educational systems, information

technology, regulatory structures

(environmental and governmental policies,

etc)

Lower Left Lower Right

Adapted with permission from Wilber.12 Copyright 2007, Barbara M. Dossey.

be found the world of the individual’s ex-terior (an internal [inside] aspect of theexterior self). This includes the materialbody (physiology [cells, molecules, neu-rotransmitters, limbic system], biochem-istry, chemistry, physics), integral patientcare plans, skill development (health, fit-ness, exercise, nutrition etc), behaviors,leadership’s skills, and integral life prac-tices (see Process and Integral NursingPrinciples), and anything that we cantouch or observe scientifically in timeand space. Integral nursing with ournursing colleagues and healthcare teammembers includes the “It”of new behav-iors, integral assessment and care plans,leadership and skills development.

• Lower-Left (LL). In this “We” (intersub-jective; the inside of the collective)

space can be found the interior collec-tive of how we can come together toshare our cultural background, stories,values, meanings, vision, language, rela-tionships, and to form partnerships toachieve a healing mission. This can de-crease our fragmentation and enhancecollaborative practice and deep dialoguearound things that really matter. Integralnursing is built upon “We.”

• Lower-Right (LR). In this “Its” space(interobjective; the outside of the col-lective) can be found the world of thecollective, exterior things. This includessocial systems or structures, networks,organizational structures, and systems(including financial and billing systemsin healthcare), information technology,regulatory structures (environmental


Figure 4. Healing and the four quadrants (I, We, It, Its). Adapted from Wilber.12,13

and governmental policies, etc), and anyaspect of the technological environmentand in nature and the natural world.Integral nursing identifies the “Its” inthe structure that can be enhancedto create more integral awareness andintegral partnerships to achieve healthand healing—local to global.

As seen in Table 1 and Figure 4, the left-hand quadrants (UL, LL) describe aspects ofreality as subjective, interpretive and quali-tative. In contrast, the right-hand quadrants(UR, LR) describe aspects of reality as ob-jective, measurable and quantitative. Integralresearch requires a multi-modal method ap-proach to investigating phenomena, that is be-yond the scope of this article.45 When we failto consider these subjective, intersubjective,objective, and interobjective aspects of real-ity already described in each quadrant, this

is what leads our endeavors and initiativesto be fragmented and narrow and where weoften fail to reach identified outcomes andgoals. The 4 quadrants are a result of the dif-ferences and similarities in Wilber’s12–15 inves-tigation of the many aspects of identified real-ity. The model describes the territory of ourown awareness that is already present withinus and an awareness of things outside of us.These quadrants help us connect the dots ofthe actual process to more deeply understandwho we are, and how we are related to othersand all things.

Content component #5: All quadrants,all levels

The fifth content component in the The-ory of Integral Nursing is the exploration ofWilber’s “all quadrants, all levels, all lines,all states, all types” or A-Q-A-L (pronounced


Figure 5. Healing and AQAL (All Quadrants, All Levels). Adapted from Wilber.12,13

ah-qwul), as shown in Figure 5. These lev-els, lines, states, and types are important el-ements of any comprehensive map of reality.The integral model simply assists us in furtherarticulating and connecting all areas, aware-ness, and depth in these 4 quadrants. Briefly,

these levels, lines, states, and types are asfollows:12,13

• Levels: Levels of development thatbecome permanent with growth andmaturity (eg, cognitive, relational, psy-chosocial, physical, mental, emotional,


spiritual) that represents a level ofincreased organization or level of com-plexity. These levels are also referredto as waves and stages of development.Each individual possesses the masculineand feminine voice or energy. Neithermasculine nor feminine is higher or bet-ter; they are 2 equivalent types at eachlevel of consciousness and development.

• Lines: Developmental areas that areknown as multiple intelligences: (eg, cog-nitive line [awareness of what is]; inter-personal line (how I relate socially toothers); emotional or affective line (thefull spectrum of emotions); moral line(awareness of what should be); needsline (Maslow’s hierarchy of needs); aes-thetics line (self-expression of art, beauty,and full meaning); self-identity line (whoam I?); spiritual line (where “spirit” isviewed as its own line of unfolding, andnot just as Ground and highest state),and values line [what a person considersmost important; studied by Clare Gravesand brought forward by Don Beck in hisSpiral Dynamics Integral that is beyondthe scope of this article].46

• States: Temporary changing forms ofawareness (eg, waking, dreaming, deepsleep, altered meditative states [due tomeditation, yoga, contemplative prayer,etc] altered states (due to mood swings,physiology and pathophysiology shiftswith disease or illness, seizures, cardiacarrest, low or high oxygen saturation,drug-induced); peak experiences (trig-gered by intense listening to music, walksin nature, love-making, mystical experi-ences such as hearing voice of God or thevoice of a deceased person, etc).

• Types: Differences in personality andmasculine and feminine expressions anddevelopment (eg, cultural creative types,personality types, enneagram).

This part of the Theory of Integral Nurs-ing as shown in Figure 5 starts with heal-ing at the center surrounded by 3 increasingconcentric circles with dotted lines of the 4quadrants. This aspect of the integral theory

moves to higher orders of complexity throughpersonal growth, development, expandedstages of consciousness (permanent and ac-tual milestones of growth and development),and evolution. These levels or stages of devel-opment can also be expressed as being self-absorbed (such as a child or an infant) toethnocentric (centers on group, community,tribe, nation) to world centric (care and con-cern for all peoples regardless of race, color,sex, gender, sexual orientation, creed, and tothe global level).

Starting with the UL, the “I” space, the em-phasis here is in the unfolding “awareness”from body to mind to spirit. Each increasingcircle includes the lower as it moves to thehigher level. (See Process for more details).

In the UR, the “It” space is the externalof the individual. Every state of conscious-ness has a felt energetic component thatis expressed from the wisdom traditionsas 3 recognized bodies: gross, subtle, andcausal.12,13 We can think of these 3 bodies asthe increasing capacities of a person towardhigher levels of consciousness. Each level isa specific vehicle that provides the actualsupport for any state of awareness. The grossbody is the individual physical, material,sensorimotor body that we experience in ourdaily activities. The subtle body occurs whenwe are not aware of the gross body of densematter, but of a shifting to a light, energy,emotional feelings, and fluid and flowingimages. Examples might be in our shift duringa dream, during different types of bodywork,walks in nature, or other experiences thatmove us to a profound state of bliss. Thecausal body is the body of the Infinite that isbeyond space and time. Causal also includesnonlocality where minds of individuals arenot separate in space and time. When thisis applied to consciousness, separate mindsbehave as if they are linked regardless ofhow far apart in space and time they maybe. Nonlocal consciousness may underliephenomenon such as remote healing, in-tercessory prayer, telepathy, premonitions,as well as so-called miracles. Nonlocalityalso implies that the soul does not die with


the death of the physical body—hence,immortality forms some dimension ofconsciousness.47 Nonlocality can also beboth upper and lower quadrant phenomena.

The LL, the “We” space, is the interior col-lective dimension of individuals who come to-gether. The concentric circles from the centeroutward represent increasing levels of com-plexity of our relational aspect of shared cul-tural values, as this is where teamwork andthe interdisciplinary and transpersonal disci-plinary development occur. The inner circlerepresents the individual labeled as me; thesecond circle represents a larger group la-beled us; the third circle is labeled as all of usto represent the largest group consciousnessthat expands to all people. These last 2 circlesmay include not only people, but animals, na-ture, and nonliving things that are importantto individuals.

The LR, the “Its” space, the exterior socialsystem and structures of the collective, is rep-resented with concentric circles. An examplewithin the inner circle might be a group ofhealthcare professionals in a hospital clinicor department or the complex hospital sys-tem and structure. The middle circle expandsin increased complexity to include a nation;the third concentric circle represents evengreater increased complexity to the globallevel where the health of all humanity and theworld are considered. It is also helpful to em-phasize that these groupings are the physicaldynamics such as the working structure of agroup of healthcare professionals versus therelational aspect that is a LL aspect, and thephysical and technical structural of a hospitalor a clinic.

Integral nurses strive to integrate conceptsand practices related to body, mind, and spirit(the all-levels) in self, culture, and nature (“allquadrants” part). The individual interior andexterior—“I” and “It”—as well as the collec-tive interior and exterior—“We” and “Its”—must be developed, valued, and integratedinto all aspects of culture and society. TheAQAL integral approach suggests that we con-sciously touch all of these areas and do soin relation to self, to others, and the natu-

ral world. Yet to be integrally informed doesnot mean that we have to master all of theseareas; we just need to be aware of them andchoose to integrate integral awareness and in-tegral practices. Because these areas are al-ready part of our being-in-the-world and can’tbe imposed from the outside (they are part ofour makeup from the inside), our challenge isto identify specific areas for development andfind new ways to deepen our daily integral lifepractices.

Wilber12 uses the term holon to describeanything that is itself whole or part of someother whole that creates structures from thevery smallest to the larger of increasing com-plexity. The upper half of the model rep-resents the individual holons or the microworld. The lower quadrants represent thesocial or communal holons or the macroworld. These holons create a holarcy of natu-ral evolutionary processes. As one progressesup a holarchy, the lower levels of holonsare transcended and included and thus arefoundational. All of the entities or holons inthe Right-Hand quadrants possess simple lo-cation. These are things that are perceivedwith our senses such as rocks, villages, or-ganisms, ecosystems, and planets. However,none of the entities or holons in the Left-Handquadrants possesses simple location. One can-not see feelings, concepts, states of con-sciousness, or interior illumination. They arecomplex experiences that exist in emotionalspace, conceptual space, spiritual space, andin our mutual understanding space.12,13 Thedevelopment of one’s individual conscious-ness as part of self-care is primary to the de-velopment of all other quadrants and integralthinking, application, and integration.

Structure

The structure of the Theory of IntegralNursing is shown in Figure 6. All content com-ponents are overlayed together, to create amandala to symbolize wholeness. Healing isplaced at the center, then the meta-paradigmof in a nursing theory (integral nurse, per-son(s), integral health, integral environment),


Figure 6. Theory of Integral Nursing (healing, meta-paradigm in a nursing theory, patterns of knowing in nursing,four quadrants and All Quadrants, All Levels). Copyright 2007, Barbara Dossey.

the patterns of knowing (personal, empirics,aesthetics, ethics, not knowing, sociopoliti-cal), the 4 quadrants (subjective, objective,intersubjective, interobjective), and all quad-rants and all levels of growth, development,and evolution. (Note: Although the patternsof knowing are superimposed as they are inthe various quadrants, they can also fit intoother quadrants.)

Using the language of Wilber12 and DonBeck and his Spiral Dynamics Integral,46

individuals move through primitive, infan-tile consciousness to an integrated languagethat is considered first-tier thinking. As theymove up the spiral of growth, development,and evolution, and expand their integralworldview and integral consciousness, theymove into what is second-tier thinking and


participation. This is a radical leap intoholistic, systemic, and integral modes ofconsciousness.46 Wilber also expands to athird-tier of stages of consciousness that ad-dresses an even deeper level of transpersonalunderstanding that is beyond the scope of thisarticle.15

Context

Context in a nursing theory is the environ-ment in which nursing acts occur and thenature of the world of nursing. In an inte-gral nursing environment the nurse strivesto be an integralist, which means that sheor he strives to be integrally informed andis challenged to further develop an integralworldview, integral life practices, and integralcapacities, behaviors, and skills. An integralnurse values, articulates, and models the in-tegral process and integral worldview, as wellas integral life practices and self-care in nurs-ing practice, education, research, and health-care policies. The term nurse healer is usedto describe the nurse as an instrument in thehealing process and a major part of the ex-terior healing environment of a patient, fam-ily, or another. Nurses assist and facilitate theindividual person(s) (client or patient, familyand coworkers, etc) with accessing their ownhealing process and potentials; the nurses donot do the actual healing. An integral nurserecognizes oneself as a healing environmentinteracting with a person, family, or colleaguein a being with rather than an always doing toor doing for another person, and enters into ashared experience (or field of consciousness)that promotes healing potentials and an expe-rience of well-being.

A key concept in an integral healing en-vironment, both interior and exterior, ismeaning which addresses that which isindicated, referred to, or signified.48 Philo-sophical meaning is related to one’s view ofreality and the symbolic connections that canbe grasped by reason. Psychological mean-ing is related to one’s consciousness, in-tuition, and insight. Spiritual meaning isrelated to how one deepens personal expe-rience of a connection with the Divine, or

whatever mechanism or modalities are usedby an individual to feel a sense of oneness, be-longing, and connection in this human jour-ney of life. Relationship-centered care49 isvalued and integrated as a model of care-giving that is based in a vision of commu-nity where 3 types of relationships are identi-fied: (1) patient-practitioner relationship, (2)community-practitioner relationship, and (3)practitioner-practitioner relationship.

Relationship-based care50 is also valued asit provides the map and highlights the mostdirect routes to achieve the highest levels ofcare to serve patients and families.

Process

Process in a nursing theory is the methodby which the theory works. An integral heal-ing process contains both nurse processesand patient or family and healthcare workersprocesses (individual interior and individualexterior), and collective healing processes ofindividuals and of systems or structures (in-terior and exterior). This is the understand-ing of the unitary whole person interactingin mutual process with the environment. Wealso discover that by incorporating integralnursing principles discussed next we may as-sist others to discover their own healing path.The reader is referred to Figure 6 and Table 1for specifics for each principle.

Integral nursing principle 1: Nursingrequires development of the “I”

Integral Nursing Principle 1 recognizes theinterior individual “I”(subjective) space. Eachof us must value the importance of explor-ing one’s health and well-being starting withour own personal exploration and develop-ment on many levels. This includes how eachof us continually addresses our own stress,burnout, suffering, and “soul pain” as dis-cussed in the next principle. This can assistus to understand the necessity of personalhealing and self-care directly related to nurs-ing as art where we develop qualities of nurs-ing presence and inner reflection. Nurse pres-ence is also used as a way of approaching a


person that respects and honors the person’sessence; it is relating in a way that reflects aquality of “being with” and “in collaborationwith” as discussed in the next principle.41–44

Our own inner work also helps us hold deeplya conscious awareness of our own roles increating a healthy world. We recognize theimportance of addressing one’s own shadowthat is described by Jung51 as a compositeof personal characteristics and potentials thathave been denied expression in life and ofwhich a person is unaware; the ego deniesthe characteristics because they are in con-flict and incompatible with a person’s chosenconscious attitude.

In this “I” space integral self-care is val-ued, which means that integral reflectivepractices are integrated and can be trans-formative in our developmental process. Webecome more integrally conscious in ourknowing, doing, and being in all aspectsof our personal and professional endeavors.Mindfulness is the practice of giving attentionto what is happening in the present momentsuch as our thoughts, feelings, emotions, andsensations. To cultivate the capacity of mind-fulness, one may include mindfulness medi-tation practice, centering prayer, and otherreflective practices such as journaling, dreaminterpretation, art, music, or poetry that leadsto an experience of nonseparateness and love;it involves developing the qualities of stillnessand being present for one’s own sufferingwhich will also allow for full presence whenwith another.

In our personal process, we recognizeconscious dying where time and thoughtare given to contemplate one’s own death.Through a reflective practice one rehearsesand imagines one’s final breath to practicepreparing for one’s own death. This integralpractice prepares us not to be so attached tomaterial things and spending so much timethinking about the future but living in thismoment as often as we can and to live fullyuntil death comes. We are more likely to par-ticipate with deeper compassion in the deathprocess with others to become more fully en-gaged, ultimately with self. Death is seen as

the mirror in which the entire meaning andmystery of life are reflected—the moment ofliberation. Within an integral perspective thestate of transparency, the understanding thatthere is no separation between our practiceand our everyday life is recognized.1,2,43 Thisis a mature practice that is wise and empty ofa separate self.

Integral nursing principle 2: Nursingis built upon “we”

Integral Nursing Principle 2 recognizesthe importance of the “We” (intersubjective)space. Within nursing, healthcare, and soci-ety, there is much suffering, moral suffering,moral distress, and soul pain.43 We are oftencalled upon to “be with” these difficult hu-man experiences and to use our nursing pres-ence. Our sense of “We” supports us to rec-ognize the phases of suffering—“mute”suffer-ing, “expressive”suffering, and “new identity”in suffering.43 When we feel alone, as nurses,we experience mute suffering; this is an in-ability to articulate and communicate withothers one’s own suffering. Our challenge innursing is to more skillfully enter into thephase of expressive suffering where suffer-ers seek language to express their frustrationsand experiences such as in sharing stories in agroup process. Outcomes of this experienceoften move toward new identity in suffer-ing through new meaning-making where onemakes new sense of the past, interprets newmeaning in suffering, and can envision a newfuture. A shift in one’s consciousness allowsfor a shift in one’s capacity to be able to trans-form her or his suffering from causing distressto finding some new truth and meaning ofit. As we create times for sharing and givingvoice to our concerns, new levels of healingmay happen.

An integral nurse considers transpersonaldimensions. This means that interactions withothers move from conversations to a deeperdialogue that goes beyond the individual ego;it includes the acknowledgment and appre-ciation for something greater that may bereferred to as spirit, nonlocality, unity or


oneness. Transpersonal dialogues contain anintegral worldview and recognize the roleof spirituality that is the search for the sa-cred or holy that involves feelings, thoughts,experiences, rituals, meaning, value, direc-tion, and purpose as valid aspects of theuniverse.1,2,48 It is a unifying force of a per-son with all that is—the essence of being-ness and relatedness that permeates all of lifeand is manifested in one’s knowing, doing,and being; it is usually, though not univer-sally, considered the interconnectedness withself, others, nature, and God or LifeForce orAbsolute or Transcendent. From an integralperspective, spiritual care is an interfaith per-spective that takes into account dying as adevelopmental process and natural humanprocess that emphasizes meaningfulness andhuman and spiritual values.1,2,43 Religion isrecognized as the codified and ritualized be-liefs, behaviors, and rituals that take place ina community of like-minded individuals in-volved in spirituality.1,2,48 Our challenge isto enter into deep dialogue to more fullyunderstand religions different from our ownso that we may be tolerant where there aredifferences.

In this “We” space nurses come togetherand are conscious of sharing their world-views, beliefs, priorities, and values related toworking together in ways to enhance integralself-care and integral healthcare. Deep listen-ing, the being present and focused with inten-tion to understand what another person is ex-pressing or not expressing, is used. Bearingwitness to others, the state achieved throughreflective and mindfulness practices, is alsovalued.1,2,43 Through mindfulness, one is ableto achieve states of equanimity that is thestability of mind that allows us to be presentwith a good and impartial heart, no matterhow beneficial or difficult the conditions; itis being present for the sufferer and suffer-ing just as it is while maintaining a spaciousmindfulness in the midst of life’s changingconditions. Compassion is an integral prac-tice where bearing witness and lovingkind-ness manifest in the face of suffering. The re-alization of the self and another as not be-

ing separate is experienced; it is the abilityto open one’s heart and be present for all lev-els of suffering so that suffering may be trans-formed for others, as well as for the self. Auseful phrase to consider is “I’m doing thebest that I can.”43 Compassionate care assistsus in living as well as when being with thedying person, the family, and others. We cantouch the roots of pain and become aware ofnew meaning in the midst of pain, chaos, loss,grief, and also in the dying process.

Integral action is the actual practice andprocess that creates the condition of trustwhere a plan of care is cocreated with thepatient and care can be given and received.Full attention and intention to the whole per-son, not merely the current presenting symp-toms, illness, crisis, or tasks to be accom-plished reinforces the person’s meaning andexperience of community and unity. Engage-ment between an integral nurse and a patientand the family or with colleagues is done ina respectful manner; each patient’s subjectiveexperience about health, health beliefs, andvalues are explored. We deeply care for othersand recognize our own mortality and that ofothers.

The integral nurse uses intention, whichis the conscious awareness of being in thepresent moment with self or another personto help facilitate the healing process; it is a vo-litional act of love.1,2,43 An awareness of therole of intuition is also recognized, whichis the perceived knowing of events, insights,and things without a conscious use of logi-cal, analytical processes; it may be informedby the senses to receive information. Integralnurses recognize love as the unconditionalunity of self with others. This love then gen-erates lovingkindness, the open, gentle, andcaring state of mindfulness that assists onewith nursing presence.

Integral communication is a free flow ofverbal and nonverbal interchange betweenand among people and pets and significant be-ings such as God or LifeForce or Absolute orTranscendent. This type of sharing leads to ex-plorations of meaning and ideas of mutual un-derstanding and growth and lovingkindness.


Intuition is a type of experience of suddeninsight into a feeling, a solution, or problemwhere time and things fit together in a uni-fied experience such as understanding aboutpain and suffering, or a moment in time withanother. This is an aspect within the patternof unknowing.

Integral nursing principle 3: “It” isabout behavior and skill development

Integral Nursing Principle 3 recognizes theimportance of the individual exterior “It”(ob-jective) space. In this “It”space of the individ-ual exterior, each person develops and inte-grates her or his integral self-care plan. Thisincludes skills, behaviors, and action stepsto achieve a fit body and to consider bodystrength training and stretching, as well asconscious eating of healthy foods. It is alsomodeling integral life skills. For the integralnurse and patient, this is also the space wherethe “doing to”and “doing for”occur. However,the integral nurse also combines her or hisnursing presence with nursing acts to assistthe patient to access personal strengths, to re-lease fear and anxiety, and to provide comfortand safety. There is awareness of consciousdying to assist the dying patient who wishesto have minimal medication and treatment tostay alert as possible while receiving comfortcare until she or he makes her or his deathtransition.

Integral nurses with other nursing col-leagues and healthcare team members com-pile the data around physiologic and patho-physiologic assessment, nursing diagnosis,outcomes, plans of care (includes medica-tions, technical procedures, monitoring, treat-ments, and protocols) implementation, andevaluation. This is also the space that in-cludes patient education and evaluation. In-tegral nurses cocreate plans of care withpatients when possible combining caring-healing interventions or modalities and in-tegral life practices that can interface andenhance the success of traditional medicaland surgical technology and treatment. Somecommon interventions are relaxation, music,

imagery, massage, touch therapies, stories,poetry, healing environment, fresh air, sun-light, flowers, soothing and calming pictures,pet therapy, and more.

Integral nursing principle 4: “Its” issystems and structures

Integral Nursing Principle 4 recognizes theimportance of the exterior collective “Its”(in-terobjective) space. In this “Its” space, inte-gral nurses and the healthcare team come to-gether to examine their work, their priori-ties, use of technologies, and any aspect ofthe technological environment, and create ex-terior healing environments that incorporatenature and the natural world such as with out-door healing gardens, green materials withsoothing colors and sounds of music and na-ture. Integral nurses identify how they mightwork together as an interdisciplinary team todeliver more effective patient care and coordi-nation of care while creating exterior healingenvironments.

Application of integral nursingprinciples

To begin applying the integral principlesin personal and professional practice, educa-tion, research, and healthcare policy endeav-ors, you can apply these 4 perspectives toany situation. Imagine that you have a difficultchallenge with a colleague, manager, physi-cian, patient, or family; reflect on these 4 per-spectives and address the situation from an in-tegral perspective. Another way is to choose1 or more integral nursing principles or con-cepts each day to focus on and use it. ForIntegral Nursing Principle 1, the “I” space,it might be to find a way that allows youto be reflective for a few minutes such asa short break at work where you focus in-ward using a relaxation and imagery exercise,or say or read an affirmation, a prayer, or ashort poem. For Integral Nursing Principle 2,it might be to reflect on the relational aspectthat you share with a colleague and acknowl-edge when she or he does something special


and to say “thank you”; this also includes thatyou take the time to receive the “thank you.”It might be to reflect on a very special mo-ment with a patient or family member wherethere seemed to be a shared experience ofhealing presence. For Integral Nursing Princi-ple 3, the “It” space, it might be to begin aself-care plan that includes one physical prac-tice such a deep breathing, stretching, or astrengthening exercise during work or a shortwalk after work. For Integral Nursing Princi-ple 4, it may be consulting with a team mem-ber about a certain floor procedure that youbelieve can be improved to increase patientsafety or to participate in evaluating anotherhospital or clinic protocol.

There are many opportunities to increaseour integral awareness, application, integralresearch and understanding each day. Reflecton all that you do each day in your work andlife—analyzing, communicating, listening, ex-changing, surveying, involving, synthesizing,investigating, interviewing, mentoring, devel-oping, creating, researching, teaching, andcreating new schemes for what is possible.Before long you will realize how all these 4quadrants and realities fit together and if youmight be completely missing a quadrant, thusan important part of reality. As we address andvalue the individual interior and exterior, the“I” and “It,” as well as the collective interior

and exterior, the “We”and “Its”a new level ofintegral understanding emerges and we mayfind that there is also more balance and har-mony each day.

CONCLUSION

A Theory of Integral Nursing addresseshow we can increase our integral awareness,our wholeness, and healing, and strengthenour personal and professional capacities tomore fully open to the mysteries of life’s jour-ney and the wondrous stages of self-discoverywith self and others. Our time demands anew paradigm and a new language where wetake the best of what we know in the scienceand art of nursing that includes holistic andhuman caring theories and modalities. Withan integral approach and worldview we arein a better position to share with others thedepth of nurses’ knowledge, expertise, andcritical-thinking capacities and skills for assist-ing others in creating health and healing. Onlyan attention to the heart of nursing, for “sa-cred”and “heart” reflect a common meaning,can we generate the vision, courage, and hoperequired to unite nurses and nursing in heal-ing. This assists us as we engage in healthcarereform to address the challenges in these trou-bled times—local to global. This is not a mat-ter of philosophy, but of survival.

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