Nursing Theory


Key Words: Holism, nursing theory, pain

management, caring, relationship-centered

care, theory-practice gap, nursing practice,

holistic theory, client-centered care


The use of theory to guide practice

has been advocated for decades, but the

translation of theory into practice has been

difficult for clinicians. Poor understanding

of theory and its purpose inhibits the nurse’s

ability to apply theoretical constructs in

practice, thus reducing practice to a task-

oriented enterprise rooted largely in habit.

Dossey’s (2008) theory of integral nursing

has recently emerged as a new holistic

theory that provides opportunities for

clinicians to invest in a worldview that

embraces the caring behaviors central to

the delivery of nursing care and encourages

nurses to design care that is relationship

centered and focused on healing. This

theory holds promise for application in

many care situations, though the client

experience of acute pain presents itself

as a uniquely universal opportunity to

demonstrate the prospective value of the

theory’s application.

It is widely known that pain is one of the

most common symptoms experienced by all

clients and that knowledge about effective

pain-relieving strategies is important

and essential in guiding practice. Despite

numerous advances in pain management,

pain continues to be insufficiently managed.

Inadequate understanding and use of theory

to guide pain management practice may

obscure nurses’ ability to rely on theoretical

knowledge as a basis for pain management

care. Insufficient knowledge about the

theory of integral nursing precludes

effective application of its theoretical

concepts in clinical practice, thereby

inhibiting nurses’ ability to improve pain

management practice while also inhibiting

clients’ ability to participate in the co-

creation of personalized interventions to

relieve pain. Failure of the nurse to engage

in holistic care, to capture the client’s

perspective in the design and delivery of

care, and to create a sacred space for

carrying out the holistic caring process

thwarts achievement of the mutually sought

after goal of healing. By embracing the

broader and deeper view of care offered by

the theory of integral nursing, the nurse and

client collaborate in the development of

trusting relationships as they intentionally

strive to improve client outcomes and

ultimately enhance client, nurse, and

provider satisfaction with care.


Pain management has remained enigmatic

for clients and healthcare professionals for

decades. When caring for clients, pain is the

most common symptom for which nurses

need to intervene, yet it continues to be one

for which they may be least prepared to

successfully mediate (Lui, So, & Fong,

2008; Montes-Sandoval, 1999; Wilson,

2007). Pain is a multidimensional,

subjective phenomenon and experience.

As such, the meaning and impact of any

pain experience differs for each client,

family member, nurse, and provider. Many

definitions of pain have surfaced over

the last four decades and offer multiple

interventions to alleviate clients’ pain. At the

2007 council meeting for the International

Association for the Study of Pain (IASP),

in Koyoto, Japan, the council confirmed its

1992 definition of pain as “…an unpleasant

sensory and emotional experience

associated with actual or potential tissue

damage, or described in terms of such

damage” (www.iasp-pain-org). In its

monograph on understanding, assessing,

and treating pain, the American Pain Society

supports both the IASP definition of pain

and McCaffery’s definition of pain as

“…whatever the experiencing person says

it is, existing whenever s/he says it does”

(APS, 2006, p. 4; McCaffery & Passero,

1999, p. 17). While the IASP definition

has been described as the most widely used

definition of pain, McCaffery’s definition

has gained substantial support over the past

30 years and is widely used in clinical

practice as a foundation for all types of pain

management care. Both definitions help

capture the intricate nature of the pain

experience. The IASP definition infers the

multidimensionality of the phenomenon

of pain by stating it is both physical and

emotional, though an emphasis is noted

on the sensory nature of pain. McCaffery’s

definition emphasizes the subjective nature

of the pain experience and situates clients

Exploring the Theory of Integral Nursing with Implications for Pain Management Practice Susanne M. Tracy, PhD, RN and Pamela P. DiNapoli, PhD, RN, CNL University of New Hampshire

26 International Journal for Human Caring


Inadequate attention is paid to the role of theory in guiding practice. three main factors

affect the use of theory to guide clinical practice: insufficient theory knowledge, insufficient

administrative support to encourage the development of theory-based interventions, and

the busy task-oriented climate of many nursing settings. Pain management is a vexing

problem confronting clients and healthcare professionals. the primary purpose of this

paper is to introduce scholars and clinicians to the basic tenets of Dossey’s (2008) theory of

integral nursing to aid nurses in designing client-centered pain management interventions

grounded in the theory’s main constructs of holism and healing.

272012, Vol. 16, No. 1

as the primary authority on the pain

experience, thereby prompting clinicians

to pay closer attention to clients’ description

of their lived experience of pain rather than

relying on a standardized definition of pain.

From a holistic perspective, all elements that

comprise the pain experience are equally

important and frame clients’ perception of

pain, the behaviors clients use to manifest

the impact of the pain experience, and

clients’ responses to varied methods used

to treat pain. Being knowledgeable about

pain management practice is an expected

competency of every registered nurse, yet

many nurses continue to describe barriers

that impede the management of clients’ pain

(Rejeh, Almadi, Mohammadi, Kazemnejad,

& Anoosheh, 2009). The literature supports

the notion that nurses’ knowledge and

attitudes about pain management is linked

to their ability to help clients successfully

manage pain; updating knowledge about

methods for relieving pain is key to improving

practice (Duignan & Dunn, 2008; Lui, So,

& Fong, 2008; Matthews & Malcolm, 2007;

Xue, Schulman-Green, Czaplinski, Harris,

& McCorkle, 2007).

Many strategies have been developed

to help bridge the gap between what nurses

know and what they actually do in practice

to help manage clients’ pain (Dihle,

Bjølseth, & Helseth, 2006). The problem

of under-treated pain persists and is likely

complicated by the lack of application of

theory to guide pain management practice.

When coupled with nurses’ uncertainty

about how to autonomously treat clients

in pain, pain relief outcomes are often

unsatisfactory. Theories, particularly

theories that have the potential to resonate

with clinicians and impact care of the whole

client, may be particularly powerful in

narrowing the theory-practice gap and

providing clues to more effective,

comprehensive pain management. The

application of a holistic philosophy of

care emphasizes the role of clinicians in

partnering with clients in the design and

implementation of mutually agreeable plans

for the relief of pain—plans that sufficiently

address the dimensions of the whole

person’s lived pain experience. Holistically,

the ultimate goals for the nurse are to better

understand the pain experience from the

client’s perspective, foster healing, and

deliver care that strives to provide the

greatest extent of pain relief possible.

Anchored in the Scope and Standards of

Holistic Nursing (2007), the five foundational

concepts of Dossey’s theory of integral

nursing articulate the qualities and way of

being that characterize the holistic, integral

nurse and prompt the nurse to attend to the

many dimensions of pain affecting the whole

client. In this way, the nurse invites the client

experiencing pain to participate in the

development of potentially transformative,

relationship-centered interactions and to

provide feedback on interventional success

or the need for further improvement.

The primary purpose of this paper is

to introduce the basic tenets of the theory

of integral nursing to aid clinicians in

designing caring interventions focused

on healing and grounded in the theory’s

holistic, relationship-centered approach.

Following the unfolding of the basic tenets

of this theory, examples of the application

of the theory to pain management are

proposed. A secondary purpose is to

stimulate scholarly interest in designing

studies that test the theory’s concepts and

holistic framework in practice. A peripheral

aim of the paper is to suggest how

application of the theory’s main concepts,

especially the concept of healing, may be

used to help define the emerging role of

the nurse in the 21st century regarding the

holistic care of the client experiencing pain.

the theory of Integral nursing

The experience of pain transcends the

physical body and requires a theory-driven,

tailored, whole-person approach to ensure

all effects of the pain experience on and in

the person; body, mind, and spirit are

addressed. The theory of integral nursing is

a composite theory developed by Barbara

Dossey in 2008 and built largely on the

work of Wilber (2000), whose integral

theory outlined the four dimensions of all

that is and represent what Wilbur believed

to be the true realities of life. Wilber posited

that understanding of these four dimensions

influences a person’s interpretation of reality

and carries the potential to affect one’s

relationships with others. Many of the

concepts within Dossey’s theory stem from

an amalgamation of concepts pivotal to

theories from within and outside of nursing.

The following commentary is a paraphrased

interpretation of Dossey’s theory with the

intent of aiding clinicians, academicians,

students, and others in understanding the

overall thrust of the theory. In this way,

partners in healthcare may find ways to

apply the theory’s core concepts to guide

the design of interventions in all areas of

practice, but especially in the area of pain

management practice. The concepts that

provide the organizing structure for the

theory of integral nursing are healing,

recognition of the metaparadigm of nursing,

patterns of knowing, quadrants, and all

quadrants/all levels (AQUAL). Appreciating

the richness and complexity of the theory

is a longitudinal process that begins with

unpacking each of the theory’s main

concepts and developing ways to apply

the concepts in clinical practice.


The central concept in the theory

of integral nursing is healing and is

conceptualized as a process that includes

“knowing, doing, and being” (Dossey &

Keegan, 2009, p. 21), as part of a life-long

journey toward increasing personal

harmony, harmony that is conveyed to

clients through caring actions and integral

dialogues. Integral dialogues are

transformative and visionary explorations

of ideas and possibilities within and

across disciplines. The healing process

brings clinicians to a place where they

introspectively encounter their fears, search

for and manifest their full self, and express

their full self through creativity, trust in life,

zeal, and love. No single aspect of healing

is any more important than any other. The

Exploring the Theory of Integral Nursing

28 International Journal for Human Caring

interplay between and among aspects of

healing brings greater understanding and

meaning about the complexity of illness,

wellness, and healing to interactions with

clients, families, colleagues, and others’

in one’s life. The concept of healing is

informed and transformed by the four

dimensions of reality that exist at any

moment, also known as quadrants: (a)

Individual interior (personal/intentional)—

the “I” space, (b) individual exterior

(physiological/behavioral)—the “It” space,

(c) collective interior (shared/cultural)—

the “We” space, and (d) collective exterior

(systems/structures)—the “Its” space

(Table 1). The dimensions of reality

examine values, beliefs, assumptions,

meaning, purpose, and judgments related to

how the individual structures action based

on the nature of the experience at hand

and the quadrants of reality that are most

influenced by a given situation. A personal

examination of each aspect of reality

enables the individuals to be more in touch

with their authentic self in many different

types of situations and/or environments.

A fundamental assumption of the theory

is that every human is born with healing

capabilities, so that it is not the clinician

who heals the individual but the individuals

themselves. By being open to opportunities

for healing, clients create a space for healing

to occur. Through creation of trusting, client-

centered relationships, nurses facilitate the

client’s ability to invest in self-healing. Self-

healing is not seen as some magico-religious

phenomenon, but as the process of

addressing issues that block personal

wellness. Self-healing allows the person to

be centered in the potential for the body,

mind, and spirit to work synergistically to

enhance the combined benefits of prescribed,

complementary, and safe alternative

therapies, all of which are focused on

improving health. Intentionality is a key

factor in healing and a quality of the healer

and healee that speaks to a determination or

commitment to achieve a higher level of

wellness. Without intentionality, healing

progresses less efficiently.

The Meta-Paradigm of Nursing

The theory of integral nursing

encompasses the meta-paradigm of nursing

(Fawcett, 2005), which includes person,

environment, health, and nursing. The

meta-paradigm also captures the essence

of Wilbur’s previously described quadrants

of reality, embracing both the fullness of the

human experience and the fullness of the

experience of nursing. The meta-paradigm

of nursing—person, environment, health,

and nursing—surround the theory of

integral nursing’s core concept of healing

in overlapping circles to demonstrate the

continuous nature of interactions that occur

between healing and the meta-paradigmatic

aspects of the theory of integral nursing.

Within the theory, the integral nurse

engages in care-related actions that foster

client wellness while also striving to create

a deeper, more meaningful connection

with the Divine, however interpreted

or recognized.

The concept of integral person captures

how the client interrelates with

the nurse in ways that value and respect

the life experiences of each member of the

relationship, be that of an individual, family,

colleague, or group. The idea of integral

health is viewed as a process that helps

convey ways of restructuring basic

assumptions and beliefs about well-being,

to include perceiving death as a natural part

of life. One metaphor for integral health

may be the notion of a helix, which can

be transformed into more or less complex

forms depending on the situation and one’s

personal growth. Symbolically, a more

complex helix would represent greater

growth toward higher levels of

consciousness and an increasing awareness

of the essence of the human experience of

“being.” From this view, the unique pattern

of one’s energy fields and one’s expression

of wholeness is manifested through a higher

personal and collective understanding of

the physical, emotional, mental, social,

and spiritual dimensions of health, a

homeodynamic view similar to that

espoused by Rogers (1983, 1992) in her

theory of unitary human beings. Important

to understanding integral health is the

understanding that various types of health,

such as mental health, physical health,

emotional health, and spiritual health, are

not to be viewed as separate and equal, but

as unique structural strands that create and

frame the wholeness and stability of the

metaphorical helix of health. The integral

environment consists of both internal and

external aspects. The internal aspects of

environment relate to clients’ feelings

and emotions, the meaning of events, and

the way in which the client enacts their

understanding of spirituality and caring.

Through flashes of memory, sounds,

dreams, images, and/or smells the internal

environment acknowledges and is

influenced by current and past relationships

with living and non-living people and

things, such as family members, pets, or

precious possessions. The external

environment consists of things that can be

objectively measured in the physical and

social realms of reality, such as one’s pulse,

the level of adrenaline present in one’s body

in a specific situation, skill development,

and anything one can touch or observe

scientifically in time and space. The

inextricable links between the internal

and external aspects of clients’ integral

environment shape the context in which

the client exists and help frame the meaning

of the reality of the client.

Patterns of Knowing

Rooted in Carper’s (1978) depiction of

the four fundamental ways of organizing

nursing knowledge and nursing’s pattern

of knowing—personal, empirics, aesthetics,

and ethics—the additional pattern of “not

knowing” proposed by Munhall (1993)

and the pattern of “socio-political knowing”

described by White (1995) create the six

patterns of knowing applied in the theory

of integral nursing. These six patterns are

superimposed on the quadrants of reality

and work to bring nurses to the fullness of

knowing and expression of being in each

caring experience. By acknowledging the

Exploring the Theory of Integral Nursing

292012, Vol. 16, No. 1

integration of science and aesthetics,

knowing and not knowing, and the influence

of socio-political knowing, nurses confirm

the value of patterns of knowing in clinical

practice. Through the patterns of knowing,

nurses are encouraged to develop a flow of

ethical experience through thinking and

acting in ways that promote self-assessment

and self-healing while generating a sacred

space for care that promotes client healing.


Quadrants in the theory of integral

nursing can be understood as dimensions

of reality that are permeable, integrally

transforming, and empowering to all other

quadrant experiences. Each quadrant is

intricately linked and bound to each other

quadrant, carrying along its own truths and

language. The language of “I,” “We,” “It,”

and “Its” that characterizes the concept

Exploring the Theory of Integral Nursing

Table 1

Dimensions of Reality within Quadrants in Pain Management

Dimension or perspective

Focus of the dimension Aspects included in the dimension Sample pain management questions by dimension

Individual Interior


The “I” space—the individual’s internal sense of reality


Self-care, self-esteem

Feelings, beliefs, values

Moral development

Cognitive capacity

Emotional maturity

Personal communication styles

Am I feeling stressed? Thinking clearly?

Am I open to the client’s assessment of their own pain?

Am I ethically assessing the client’s pain and making moral decisions about options for pain management?

Am I communicating clearly and compassionately?

Individual Exterior


The “IT” space—objective or tangible aspects of the individual that influence reality

Brain and organisms


Physical sensations


Chemistry and biochemistry

Behaviors and skill development

Am I able to envision by bodily presence changing?

Can I fully describe the sensations I feel?

Can I feel my open presence changing my client’s responses to my pain management efforts?

Do I feel more able to do my pain management work skillfully?

Collective Interior


The “WE” space—the collective sense of engagement within the individual’s reality

Relationships to others’ cultures and worldviews

Shared visions

Shared leadership

Integral dialogues


How am I relating to others involved in pain management efforts?

What is the meaning of my pain management relationships with my clients? My peers? My supervisors? Other healthcare professionals?

Am I fully engaged in using integral dialogues to enhance my pain management relationships with others?

Collective Exterior


The “ITS” space—the broader sense of being part of an external reality whose systems and structures govern practice

Relations to social systems and the environment

Organ structures and systems

Financial systems

Policy development

Regulatory structures and systems

Information technology

How do pain management policies and procedures influence my connection with my clients?

What is my group role in meeting or changing pain management regulatory guidelines?

How do I use systems and structures to improve pain management practice?

Do I allow technology to help me deliver better pain relief care or does it interfere?

Adapted from Dossey, B., & Keegan, L. (2009). Holistic nursing: A handbook for practice (5th ed.). Sudbury, MA: Jones & Bartlett.

30 International Journal for Human Caring

of quadrants are terms used in everyday

language to convey the direction of our

communication and the direction of one’s

experiences in the world. Each quadrant

helps provide a framework for interpreting

the theory and is guided by four main

principles: (a) Nursing requires the

development of the “I,” (b) the discipline of

nursing is built upon the “We,” (c) “It” is

about behavior and skill development, and

(d) systems and structures are embedded in

and frame the understanding of “Its.” Each

principle continues to remind us that being

an integral nurse is first, more than being a

holistic nurse, and, secondly, an evolving

process that becomes clearer and more

meaningful over time through ongoing

practice and reflection.

All Quadrants, All Levels (AQUAL)

The final concept in the theory of

integral nursing is all quadrants, all levels

(AQUAL). Wilber (2000) recognized that

the quadrants of reality are connected to

levels, lines, states, and types that help

the individual create a comprehensive map

of reality. Levels refer to aspects of the

self that change over time and become

permanent as one moves through stages

of growth and development. Lines refer

to the complex aspects of self that enrich

and enhance one’s development, such

things as multiple intelligences, cognitive

awareness, etc. States refer to temporary

and changing forms of awareness, such as

consciousness, unconsciousness, dreaming,

waking, meditative states, recollection

of peak experiences, etc. Types refer to

differences in personality and expression

that may mediate one’s experiences of

reality. Because interpretation of reality

is fluid, many human experiences, both

temporary and permanent, affect one’s

movement toward higher levels of

consciousness. Aspects such as physical

growth and development, dream states,

multiple intelligences, peak experiences,

personality, gender, shifts in physiology,

moods, etc. are considered. Through the

application of the dimensions of AQUAL,

as depicted in Table 1, individuals open

themselves to evolving insights about the

complexity of the human experience and

about the ongoing quest for higher levels

of consciousness that characterize the

integral person.

relevance to Clinical Pain

management Practice

Client reliance on the internet to provide

knowledge about care is becoming a more

common phenomenon in a technological

world. Returning to basic notions about

centering care on the client is an important

issue for the nurse in the 21st century whose

clients are becoming increasingly impatient

with the faceless, computerized nature of

care. The nurse of the 21st century must

take advantage of the power of technology

to search for and create evidence for

emerging holistic practices, understanding

that practice increasingly relies on a

growing knowledge base and a willingness

to risk implementing novel changes in

practice targeted on improving both client

outcomes and clinical nursing practice. The

theory of integral nursing offers nurses the

opportunity to act on their desire to create a

healing environment for clients through the

synthesis and application of knowledge

rooted in metaparadigmatic and quadrant

realities. Relationship-centered communication

anchored in the theoretically driven holistic

caring process is essential, especially when it

comes to the very personal experience of pain

management care.

In a world where social capital is

increasingly being lost, clients want to know

that nurses see them as individuals and

value their personal experience of pain.

For example, application of the notion of

creating a sacred space for care that is

described in the theory of integral nursing

has the potential to narrow the theory-

practice gap by emphasizing the importance

of dedicating oneself to the personalized

pain relief clients seek and nurses strive to

deliver. In this sacred space, nothing else

is allowed to interfere with the interactions

between the client and the nurse. The nurse

is totally focused on what he/she is doing

and what the client describes as their

experience of that particular episode of pain.

The theory brings a more open vision of the

client-nurse relationship, especially as it

relates to the role of each partner who is

part of the pain management experience.

Nursing’s primary role is to carry out

theoretically driven nursing interventions

with and for the client; interventions that

promote health and healing and convey

caring and respect for the individual while

facilitating pain relief. The client’s role is

to remain open to participating in their own

care, to aid the nurse and healthcare team

in the co-creation of care, and to provide

feedback to the nurse about the effects of

co-created care on their overall physical,

mental, and spiritual well-being. Nursing

process has been a blueprint for care for

many decades and is the foundation upon

which the holistic caring process has been

developed. Within the context of the holistic

caring process, the following practice

suggestions are offered.

the Holistic Caring Process

The optimal delivery of nursing care is

guided by the theory of integral nursing. The

theory’s holistic caring process expands the

assessment of clients to ensure gathering of

objective and subjective data, not only about

one’s physical status, but also regularly

gathers and integrates data about the

emotional and spiritual status of the client.

Application of the theory’s core concept of

healing facilitates conversations (integral

dialogues) between clients and physicians,

clients and nurses, nurses and physicians,

and nurses and other members of the

healthcare team. Using the pain experience

as an example, the outcomes of such

dialogues have the potential to change

practice by inviting clients to tell their pain

story (and history) so that a more useful and

meaningful plan of pain management can be

developed, a plan whose openness respects

and values the voice and experiences of

the client, as well as the knowledge and

expertise of nurses, physicians, and other

Exploring the Theory of Integral Nursing

312012, Vol. 16, No. 1

healthcare team members. Table 1 is an

exemplar that depicts the application of

the dimensions of reality within quadrants

as they apply to pain management. Each

dimension affords nurses opportunities

to center themselves on aspects of pain

management care that foster internal

reflection and wholeness in the delivery

of care. Sample pain management questions

for each dimension focus on the internal

self-assessment carried out by nurses as

they prepare to deliver personalized pain

management care anchored in the

dimensions of reality within quadrants.

Central to success in the holistic caring

process approach is a trusting client-

nurse/client-provider relationship. Openness

of each member of the integral partnership to

perceptions about pain and pain management

that may be foreign to them is critical.

When coupled with a determination to find

a mutually beneficial approach to managing

the client’s pain, this non-judgmental

approach invites clients to engage in self-

care initiatives that help free them from

issues and concerns that block healing.

Caregivers must be willing to see the pain

experience through the client’s eyes and

frame solutions in such a way as to obtain

outcomes that work …