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222 JCN/Volume 36, Number 4 journalofchristiannursing.com

the Whole Person By Cheryl Swanson, Audrey Thompson, Rachael Valentz, Laurie Doerner, and Kenda Jezek

Theory of Nursing for

A Distinctly Scriptural Framework

Cheryl Swanson, PhD, RN, is an associate professor at Oral Roberts University, Anna Vaughn College of Nursing (AVCON), Tulsa, Oklahoma.

Audrey Thompson, PhD, RN, is an associate professor at Oral Roberts University, AVCON.

Rachael Valentz, MSN, RN, is an instructor at and graduate of ORU AVCON, and has 14 years of critical care experience.

Laurie Doerner, MSN, RN, is a vascular access nurse at St. Francis Hospital in Tulsa, Oklahoma. She is a former assistant professor at ORU AVCON.

Kenda Jezek, PhD, RN, is Dean of the Anna Vaughn College of Nursing, Oral Roberts University.

The authors declare no conflict of interest.

Accepted by peer-review 4/5/2019.

ABSTRACT: Though unpublished in peer-reviewed literature for more than 40 years, the Theory of Nursing for the Whole Person has been, and remains, a highly useful framework for nursing practice, education, and research. Used by the College of Nursing at Oral Roberts University, the theory was developed by the founding dean, I. Tomine Tjelta. Founded on a Christian worldview, the theory is built on the basic nursing paradigm concepts, yet functions as a distinctly scriptural frame- work. The theory’s five conceptual triads describe how nursing addresses the whole- person health-illness continuum for individuals, families, and communities.

KEY WORDS: education, nursing framework, nursing theory, Oral Roberts University, Tomine Tjelta, whole-person care

F or more than a century and a half, nurses have sought to define and explain their work through the concepts of person, health, environment, and nursing. Florence Nightingale was the first, in Notes on Nursing, published in 1860. Nightingale (1969/1860) defined nursing as the act of putting “the patient in the best condition for nature to act upon him” (p. 133) and emphasized the importance of promoting a “healing” environment character- ized by fresh air, pure water, cleanliness, and

light. She recognized that “the same laws of health or of nursing, for they are in reality the same, obtain among the well as among the sick” (person) (p. 9).

Almost a century after Nightingale’s landmark publication, other nurse scholars aimed to define and explain the work of nurses through the development and testing of theories, again based on the four concepts of the nursing paradigm. In 1952, Hildegard Peplau, nursing’s second theorist, proposed a theory based on interpersonal relationships (Peplau, 1991). More nurse theorists published their ideas in the 1960s through 1980s, many refining their work in the following decades. Each nursing theorist included the four concepts of person, health, environment, and nursing, along with definitions and statements of relationships among them, as pertained to the central theme of the theory being developed. Themes central to the emerging nursing theories included adaptation (Fawcett, 2002b), human caring (Fawcett, 2002a), human becoming (Fawcett, 2015), and self-care (Orem, Taylor, & McLaughlin Renpening, 2001), among others.

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Tjelta had received these elements, she proposed definitions of the concepts and refined them with the input of the SON faculty. The definitions are built on Scripture, for as Tjelta stated, “…in theory building you take as many facts as you know to be true. For us, we believe that Scripture is truth. That source, then, became the foundation for our theoretical beliefs” (Tjelta, p. 19).

A FRAMEWORK BASED ON SCRIPTURE

Although the TNWP is structured around the same four paradigms of nursing, this framework is different than other theories developed in the 1960s and 1970s. The theory is based on the scriptural beliefs that view the individual as an eternal, spiritual being, made for communion with God (Tjelta, 1982). Within the specific definitions of man (person), health, and nursing, the TNWP is distinct.

ORIGINS OF THE THEORY In the 1970s, Dr. I. Tomine Tjelta

developed the Theory of Nursing for the Whole Person (TNWP) for Oral Roberts University (ORU). Prior to becoming the dean of the School of Nursing (SON) at ORU, Tjelta taught at the University of Washington, where Dean Mary Tschudin regarded Tjelta as the curriculum expert (Tjelta, 1982). Her professional experience exploring nursing concepts in relation to curricu- lum development was one reason that University President Oral Roberts offered Tjelta the opportunity to develop a baccalaureate program and become the founding dean of the Oral Roberts University School of Nursing. In 1972, Roberts requested that Tjelta create a school of nursing that fulfilled the University’s vision to raise up students to hear God’s voice and that educated the whole person—body, mind, and spirit.

When she arrived at ORU, Tjelta believed that she had to develop something unique that fit with the philosophy of the university, established within a Christian worldview (Tjelta, 1982). However, after spending count- less hours attempting to develop the curriculum’s framework and having nothing to show for that effort, Tjelta told President Roberts that she was blocked, had nothing, and he should find someone else to do the job. He told her to go home and pray, then wait. Later that evening, after praying and waiting on God, Tjelta received the concepts, parameters of nursing, and conceptual framework of the theory. As she reviewed the whole of what she felt the Holy Spirit had given to her, she saw that the theory was not only grounded in a Christian worldview, but also had the advantage of building on the university’s philosophy to edu- cate the whole person (Tjelta). Once

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and wholeness; and 5) promotion, maintenance, and restoration of health. Emphasis is placed on the assumption that each triad is not exclusive of any other, but that all five are interrelated (Tjelta, 1982).

The level of health and/or ill- ness experienced by an individual is predominately based on the person’s patterns of interactions with and be- tween their internal and external en- vironments. According to the TNWP, these exchanges are the foundation of assessment and diagnosis in the nurs- ing process. An individual’s internal environment is considered the interior surroundings that manifest within a person. Examples of a person’s internal environment include vari- ables associated with the body, mind, and spirit. Elements that demarcate the processes exhibited by the body include physicality, genetic predispo- sition, and neurological, endocrine, and biochemical status, among others. Essentials characterizing the indi- vidual component of the mind involve intellect, emotions, imagination, and will–volition, aspects that incorporate an individual’s thoughts, feelings, and behaviors. An individual’s spiritual as- pect is that facet which God made for communion with himself. Herein lies a person’s concept of God, which leads to the development of one’s unique relationship with God.

In contrast to the internal environ- ment, the external environment may be deemed as the peripheral atmo- sphere that presents to a person. The external environment consists of circumstances connected with outside factors that influence one’s life and health. These dynamic features include the physical location where one resides, which also entails the atmosphere of the individual’s community or neigh- borhood, and lastly, the social context (people, organizations, and relation- ships) experienced within those settings (Tjelta, 1982).

The journey or quest for whole- ness that one travels is marked by that person’s encounters between himself or herself, the family, and the community. The links created during this journey

Man, or person, is defined first as a spiritual being. The apostle Paul’s prayer in 1 Thessalonians 5:23 explicitly recognizes the three parts of a person: spirit, body, and mind. All persons have a spirit, which is their eternal aspect. Although the TNWP is grounded in a Christian worldview, the definition of spirit is not implying that a person only has a Christian spirit. Instead, the framework recognizes the part of a person that is eternal (Tjelta, 1982).

Further, the framework defines the spirit as that “part of man made for communion with God,” (Tjelta, 1982, p. 20) thus acknowledging the reality of God and his desire to have relationship with his people. A person is also defined as having a body and mind to complete the three parts of being, so that a person is “…a spiritual being who functions in an integrated biopsychosocial manner to achieve his quest for wholeness” (Tjelta, 1982, p. 20).

The body includes the processes that are physiological (biological) in nature. The mind includes those processes that can be described as emotional, voli- tional, and intellectual. Through the body and mind, the person lives and breathes, interacting with the sur- rounding environments. Integrating the biological, psychological, and social sciences within the theory of nursing provides an understanding of how a person interacts with the internal (physical, mental, and spiritual realms) and external (the individual, family, and community) environments (Tjelta, 1982). Through these interactions, an individual searches for wholeness.

A second distinctive within the TNWP is the concept of health. Whole-person nursing is central to the TNWP, as people are on a quest to be complete (healthy) in all three areas of their being. Jesus’ ministry of healing, as recorded in the Gos- pels, speaks of making individuals whole (Matthew 9:21, 14:36; Mark 2:17; Luke 8:48). By following this example, the TNWP defines health as a state of wholeness in a person’s physical, mental, and spiritual aspects. Further, health is considered to ex- ist on a continuum, where one end

represents the dimension of health, whereas the other represents the dimension of illness or the state of lacking wholeness (Tjelta, 1982). The concept of a continuum illustrates the fluidity of this idiom. Health is not a frozen, motionless status; rather, it is a dynamic, volatile state of being that is constantly changing and seeking bal- ance. This quest for equilibrium leads individuals on a lifelong journey, in which they will find themselves at various points on the health-illness

continuum at any given time. It is understood that health is highly indi- vidualized, and each individual has a unique way in which he or she de- fines this concept. Like health, illness also is a dynamic state, reflective of the person’s interaction with his/her internal and external environments, and exists on a continuum of severe to minimum illness.

A nurse then performs those actions that assist the patient in his/her unique process of seeking wholeness, focusing more on the attainment of health than on confronting the problem of illness. A key belief in the TNWP is that nursing is a goal-directed service to others, directed by each nurse’s clinical judgment, and by goals developed within the nurse– patient relationship to assist the person, family, and/or community to promote, maintain, and restore a state of health and assist along the continuum toward wholeness (Tjelta, 1982).

FIVE CONCEPTUAL TRIADS The framework includes the integra-

tion of five triads, where the specifics of the core beliefs become important: 1) body, mind, and spirit; 2) individual, family, and community; 3) internal and external environments and their patterns of interaction; 4) health, illness,

“In theory building, you take as many facts as you know to be true.

For us, we believe that Scripture is truth.”

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nursing’s actions related to each triad. Fifteen theoretical statements outline nursing for the individual, the family, and the community (Table 2).

BODY-MIND-SPIRIT MODEL The conceptual framework that

Dr. Tjelta received after praying is sim- ple in its structure, but rather profound in the way the model works. As depict-

fashion the matrix of an individual’s health status and, whether positive or negative, a response is elicited. An individual’s response to the effects of the interrelatedness of these concepts ultimately determines nursing actions (Tjelta, 1982). The measures performed by the nurse fall into the categories of health promotion, maintenance, and restoration. Nursing actions focused on promotion are delivered to educate and prevent illness. Nurses are to empower clients to aim for optimal levels of health, as individually defined. Nursing actions classified as maintenance pre- serve and protect the existing, appro- priately functioning health status of the client (individual, family, or communi- ty). Restorative nursing acts are aimed at reestablishing an optimal level for a client who has experienced an altera- tion to optimal health status. Regard- less of the level of nursing action to be performed, the TNWP delineates the performance of care to be executed, utilizing the appropriate integration of these interrelated parameters (Tjelta).

The TNWP doesn’t only focus on the individual—as individuals are recognized as part of a family unit, which in turn is recognized as a part of a community. The family in the TNWP is considered the basic unit of society. The family unit is continually shaping and being shaped by the patterns of interaction that occur within the internal and external environments that exist both within the unit and the individuals who make up the unit. How the family responds to those patterns of interactions determines the health status to which that family unit ascribes. The nurse utilizes resources within the family unit and the health delivery system to facilitate promotion, maintenance, and restoration of health (Tjelta, 1982).

Similarly, the community exists on the health-illness continuum with community health being influenced by and reflecting the wholeness of the individuals and families within the populace. Nurses work within the community and health delivery systems to utilize and mobilize resources that promote, maintain, and restore health.

Central to whole-person nursing care for the individual, family, and commu- nity is the premise that the nurse can impact health in others and contribute to the wholeness of others only as long as he or she continues to grow both personally and professionally and continues a pursuit of wholeness of self (Tjelta, 1982). The classification of conceptual triads in Table 1 outlines

Table 1. Classification of TNWP Conceptual Triads Criteria Conceptual Triad

Parameters, or clientele of nursing: Individuals, families, and communities

Goals of nursing service are assisting individuals, families, and communities to:

Promote, maintain, and restore health

Desired patient–client outcomes: Health is physical, mental, and spiritual wholeness. Opposite is illness.

Basis of assessment and diagnoses: Internal environment, external environ- ment, patterns of interaction between the internal and external environments

Nature of the internal environment of the individual: Body, mind, and spirit

Source: Tjelta (1982). Used with permission.

Table 2: Theoretical Statements for TNWP Nursing for the Individual

• The individual is a spiritual being who functions in an integrated biopsychosocial manner to achieve his/her quest for wholeness.

• The individual interacts with his/her internal and external environments wholistically. • The whole-person nursing approach focuses simultaneously on spiritual, mental, and physical

aspects of wholeness. • The nurse, through the health delivery system, facilitates the promotion, maintenance, and

restoration of individual health. • As the nurse continues the quest for personal wholeness, she or he contributes to the whole-

ness of others.

Nursing for the Family

• The family as the basic unit of society continually shapes and is shaped by the internal and external environments.

• The family pattern of interaction with environmental forces, both external and internal, deter- mines the health status of the family unit as a whole.

• Promotion, maintenance, and restoration of family health require mobilization of all re- sources within the family.

• The nurse, through the health delivery system, facilitates the promotion, maintenance, and restoration of family health.

• As the nurse continues personal and professional growth, she or he contributes to the whole- ness of the family.

Nursing for the Community

• Community health is influenced by and reflects the wholeness of persons within it. • Family health is basic to community health. • Promotion, maintenance, and restoration of community health require mobilization of all

resources within the community. • The nurse, through the health delivery system, facilitates the promotion, maintenance, and

restoration of community health. • As the nurse continues personal and professional growth, she/he contributes to the health of

the community.

Source: Oral Roberts University Anna Vaughn College of Nursing (2018), p. 11. Used with permission.

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1991; Sliep, Poggenpoel, & Gmeiner, 2001). However, during the 1980s to mid-1990s, testing of the 15 conceptual statements and constructs of the TNWP was carried out by the more than 50 students enrolled in the university’s MSN program. This work was required as the culminating master’s thesis for each student, but unfortunately their work remains archived and unpublished. However, in spite of the lack of use outside of ORU, it has continued to serve as a means to educate undergradu- ate nursing students at ORU to fully care for every aspect of the individuals, families, and communities in which they come in contact.

The following exemplars are included to amplify understanding and application of TNWP. These exemplars are not exhaustive, but give account of actual instances where ORU students utilized the TNWP.

Caring for the individual: A first- year nursing student was assigned to care for a nonverbal, older gentleman, resistant to care. He hit nursing staff and hadn’t been bathed in several days. The clinical instructor selected this

ed in Figure 1, the individual—made up of the body, mind, and spirit—is at the center of the model, along with the nurse caring for the whole person. The individual is then surrounded by the family and then the community in concentric rings. Bidirectional arrows between the rings and the center of the model allow for the TNWP to be adapted to different cultures and situations, while still being effective in providing whole-person care.

For example, in some cultures it is necessary to approach the family and the individual through the overall community. The direction of the arrows pointing inward allows the nurse to work from the community level toward the family unit and ultimately impact the individual. In other cultures, the community cannot

be impacted without starting with the individual and his/her family unit; the arrows pointing outward enable the nurse to work in this direction, as well. By understanding the interactions between levels of the model, a global focus allows for improving health and addressing health problems. No matter the avenue that must be taken for effective nursing care to take place, TNWP provides the framework necessary (Ward & Swanson, 2017).

TNWP FRAMEWORK IN PRACTICE

The TNWP is only found in limited fashion in nursing literature. An ex- tensive search reveals only two articles, both featuring authors who graduated from the Master of Science in Nursing (MSN) program at ORU (Poggenpoel,

Central to whole-person nursing care is the premise that the nurse can impact health and contribute to the wholeness of others only as long as he or she continues to grow personally and professionally and continues a pursuit of wholeness of self.

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CONCLUSION The Theory of Nursing for the Whole

Person was developed at a time when whole-person care had become a focus of nursing. A practical, Chris- tian framework, the TNWP has been used by thousands of nurses since the 1970s in practice, educa- tion, and for research. The theory is now, more than ever, a framework that can impact care provided to

individuals, families, and commu- nities worldwide. As nurses seek to

promote, maintain, and restore health in whatever situation they find themselves, the TNWP provides a framework that allows them to be the hands and feet of Christ, seeing each individual as created in the image of God, and serving indi- viduals, families, and communities in the desire to find wholeness.

Fawcett, J. (2002a). The nurse theorists: 21st-century updates—Jean Watson. Nursing Science Quarterly, 15(3), 214–219. doi:10.1177/089431840201500307

Fawcett, J. (2002b). The nurse theorists: 21st-century updates—Callista Roy. Nursing Science Quarterly, 15(4), 308–310. doi:10.1177/089431802236795

Fawcett, J. (2015). Evolution of the science of unitary human beings: The conceptual system, theory develop- ment, and research and practice methodologies. Visions: The Journal of Rogerian Nursing Science, 21(1), 9–16.

Nightingale, F. (1969). Notes on nursing: What it is and what it is not. New York, NY: Dover Publications (Original work published 1860).

Oral Roberts University Anna Vaughn College of Nurs- ing. (2018). Oral Roberts University Anna Vaughn College of Nursing student handbook 2018-2019. Tulsa, OK: Author.

Orem, D. E., Taylor, S., & McLaughlin Renpening, K. (2001). Nursing: Concepts of practice (6th ed.). St. Louis, MO: Mosby.

Peplau, H. (1991). Interpersonal relations in nursing: A conceptual frame of reference for psychodynamic nursing. New York, NY: Springer Publishing Company.

Poggenpoel, M. (1991). Nursing research education in the United States of America: One approach. Curationis, 14(3), 15–19. doi:10.4102/curationis.v14i3.332

Sliep, Y., Poggenpoel, M., & Gmeiner, A. (2001). A care counselling model for HIV reactive patients in rural Malawi—Part II. Curationis, 24(3), 66–74. doi:10.4102/ curationis.v24i3.855

Tjelta, I. T. (1982, October). Development of the theoretical framework of Nursing for the Whole Person at Oral Roberts University. In Oral Roberts University (Ed.), Proposal for Dr. Tjelta’s papers from annual theory con- ferences 1982-1991 (pp. 3–27). Tulsa, OK: Oral Roberts University.

Ward, E., & Swanson, C. (2017). The theory of nursing for the whole person and its impact on the practice of nursing school graduates (Unpublished senior research project). Oral Roberts University Anna Vaughn College of Nurs- ing, Tulsa, OK.

opportunity to demonstrate principles of the TNWP and asked a few students to join in bathing this patient. After ex- plaining to the patient what they were going to do, the students began to prepare the water and linens for the bath. Talking to the patient, providing a caring touch, and even singing a hymn as they worked, changed the way the patient responded. Not only did the patient allow for the bath, but opened his eyes and thanked the students for their care, asking them to pray with him before they left the room. As the instructor relayed, the care provided for the patient’s spirit allowed the care for his body and even produced a measurable outcome of verbalization, opening of the eyes, and cessation of resistance to care.

Caring for the community: Stu- dents participating in their community clinical rotation receive assignments to nontraditional clinical sites and perform comprehensive assessments of internal and external environmental factors to develop a community health proposal that benefits the targeted population. For example, a nonprofit agency serving justice-involved fe- males was the clinical site for a pair of senior nursing students. The students planned an overall goal of developing a community health program to assist the women in experiencing optimal levels of health. Assessment of the organization included a one-to-one interview with the agency’s execu- tive director, questionnaires com- pleted by staff, and a focus group with participants in the program. Students developed a health fair that focused on physical, mental, and spiritual needs of

interest identified by the population. Agency staff members discussed the need for physical activity among this population because the women were not frequently exposed to physical exercise and lacked access or resources for gym memberships. During the health fair, students set up an area to engage the ladies in intermittent periods of 15 minutes of low-impact aerobics.

Caring for individuals, families, and communities cross-culturally: Students participating in an international clinical experience wished to offer health teaching that benefited individuals who suffered from a variety of chronic diseases. Most community residents were wary of the students and would not speak with them. Realizing that they needed to work from the com- munity level to engage the families and individuals, the students collaborated with healthcare workers within the community. These community officials provided valuable input regarding the greatest health needs. Students also received an introduction to the town mayor. By working through commu- nity leaders who endorsed the students’ efforts, the health fair went forward. With public announcements about the health fair, which was held in the town square, the majority of the community attended the fair and received valuable health information about promoting their wellness.

Figure 1: Theory of Nursing for the Whole-Person Conceptual Model

Community Family

Indi vidual

SPIRIT

M IN

BO DY

Nursing for the Whole

Person

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