Exploring the Theory of Integral Nursing with Implications for Pain Management Practice

abstract 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. 2012, Vol. 16, No. 1 27 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. Healing 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, clientcentered relationships, nurses facilitate the client’s ability to invest in self-healing. Selfhealing 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 2012, Vol. 16, No. 1 29 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 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 Personal/intentional The “I” space—the individual’s internal sense of reality Self-consciousness 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 Physiology/behavior The “IT” space—objective or tangible aspects of the individual that influence reality Brain and organisms Pathophysiology Physical sensations Neurotransmitters 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 Shared/cultural 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 Morale 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 Systems/structures 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 theorypractice 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 2012, Vol. 16, No. 1 31 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 clientnurse/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 selfcare 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 to relieve client pain. For example, in Table 1, one of the sample questions in the Individual Interior dimension asks clinicians to reflect on their openness to believing the client’s assessment of their own pain. Another question in this same dimension asks clinicians to reflect on their moral responsibility to be open to considering various pain relief options. This reflective approach requires nursing decisions about the moral and ethical delivery of care, as well as decisions about the safe and responsible use of complementary and/or alternative methods desired by clients, even if they do not possess the strength of evidence so often sought by allopathic practitioners. Caregivers and clients alike must be willing to not only talk about, but also engage in partnerships that foster healing. Before caring for others, caregivers must spend time on self-assessment and selfhealing in order to be prepared to engage clients fully in the delivery of holistic care. By listening actively and openly to client communication about the pain experience, caregivers build trust with clients, demonstrate caring and “othercenteredness,” and actively work to encourage clients to disclose more about their experience of pain. In so doing, caregivers demonstrate their willingness to validate the client’s experience of pain and open the door for teaching the client about reasonable pain evaluations, safe pain management strategies, and the benefits and limitations of pharmacological and nonpharmacological pain management options. Without these caring relationships, teaching seems inconsequential to clients (i.e., just another task the nurse has to complete) and its benefits often wither after discharge. Throughout the care experience, the use of caregiver intuition expands opportunities for nursing investigation of aspects of pain management care that may not initially be apparent. Practice expertise fosters the development of intuition. As a part of pain management, nurses’ use of intuition may help clients identify and reveal potential blocks to healing, thereby promoting active, collaborative engagement in the design and development of solutions that advance healing. The power of holistic communication cannot be overemphasized as a critical activity for promoting healing. Clients must be open to accepting the knowledge and expertise of caregivers regarding the efficacy of various treatments for pain relief but also have the responsibility for learning more about pain management and taking an active role in decision making that fosters healing. At the same time, clinicians must remain open to hearing the client’s “story,” inviting clients to partner in designing pain relief interventions, and trusting in the value of the client’s experiences of pain. Client openness to describing the meaning of the pain experience may foster their ability to address issues that have previously blocked healing. Such breakthroughs contribute to deeper integral dialogues between client and nurse, and aid the clinician in seeking the expertise of other members of the healthcare team in the restructuring of transpersonal care. To be sure, application of the dimensions of reality within quadrants does not end with the individual nurse’s holistic preparedness. Table 1 also describes the importance of applying integral knowledge within group contexts so as to transform pain management practice through integral dialogues that promote engagement with shared interdisciplinary, sociocultural, and leadership worldviews about the meaning and value of efforts to collectively address and enhance pain management care. Finally, application of the dimensions of reality within quadrants requires nurses to tap into their social consciousness about regulatory issues that may influence pain management care. Through the collective exterior dimension, nurses are compelled to work toward systematic changes in pain management policy and practice by assessing the current status of pain management structures and policies, both locally and nationally, and working to become more active in addressing identified gaps; gaps that fail to provide clients with the highest level of evidencebased pain care available. Implications for research The newness of the theory means many nurses have not yet had an opportunity to fully understand its meaning and test its integrity. Nurses must engage in a certain level of trial and error as understanding of the theory becomes more prevalent and its precepts become more integrated into everyday practice, a process likely to take time and require the involvement of nurses who are willing to be leaders and change agents. Strategies that will facilitate application of the theory of integral nursing must be seated in the current world of healthcare practice—a world often characterized by timelines, capitation Exploring the Theory of Integral Nursing 32 International Journal for Human Caring payment models, and embedded, longstanding practices. The theory brings a more open vision of the client-nurse relationship, especially as it relates to the roles of each partner who is part of the pain management experience. Many questions remain open for investigation through both qualitative and quantitative research, such as: How will nurses talk about the differences in their everyday practice when practicing from a holistic theory that views healing as the central focus of care? How will holistic pain management care be perceived by clients and families? What is the relationship between care driven by the theory of integral nursing and quality of life for clients experiencing pain? To what extent might the creation of a sacred place for care produce tangible and satisfying outcomes for clients and nurses? The nurse’s role is to carry out interventions with and for clients—interventions that manifest caring and mutual respect and promote health and healing, especially in the area of pain management care. Application of the theory of integral nursing challenges nurses to engage clients and families in their own healing and work collaboratively with clients, families, and other members of the healthcare team to design novel initiatives that advance pain management practice. Nursing needs this holistic, caring theory to return the client to the center of care and to push the envelope of grounding practice in theory. Summary The multidimensional, individualized, and complex nature of the pain experience requires nurses to design and apply new, theoretically driven pain management interventions not only rooted in the assumptions of holistic nursing, but grounded in the realities of relationshipcentered care. The theory of integral nursing offers a unique framework for nurses to collaborate with clients in mutually beneficial, interactive, and trusting relationships centered on healing. The complex nature of the pain experience requires nurses to listen carefully to clients so as to co-create theoretically driven strategies that guide nursing practice and are focused on the assumptions of client and relationship-centered care. By focusing on the integral nature of client experiences, theory-driven holistic outcomes foster a closer client-nurse relationship and press the client and nurse to strive for outcomes that help unravel the complexity of the pain experience. By substituting a holistic vision of care for the habitual, task-driven ways of managing pain, nurses partner with clients and families and come to understand the power inherent in theoretically driven, autonomous nursing interventions that create new ways of practicing while remaining focused on client healing. Designing individualized nursing interventions grounded in the assumptions and concepts central to the theory of integral nursing requires nurses to be committed to involving the client in the design of care as they collectively create new forms of care— care that emerges from the synthesis of theoretical constructs, client’s experience, and the nurse’s knowledge and expertise. Translating integral theory concepts into practice and disseminating knowledge about the theory’s usefulness in everyday care is critical to refocusing 21st century practice. The novelty of integral nursing theory mandates additional research that tests the theory’s propositions in clinical practice and encourages clinicians to describe the impact of the theory from their own perspective. We owe it to our clients to put them back in the center of care; we owe it to our profession to honor Nightingale’s long-standing foundations of practice— knowledge, care, and compassion. The theory of integral nursing holds much promise and it is up to us to apply it in practice as we refocus the humanity of nursing care in this technological age. references American Holistic Nurses Association (2007). Holistic nursing: Scope and Standards of Holistic Nursing. Flagstaff, AZ: Author. American Pain Society (APS). (2006). Pain: Current understanding of assessment, management and treatments. Glenview, IL: Educational Monograph, American Pain Society and National Pharmaceutical Council, Inc. Carper, B. (1978). Fundamental patterns of knowing in nursing. In L. Andrist, P. Nichols, & K. Wolf (Eds.), A history of nursing ideas. Sudbury, MA: Jones & Bartlett. Dihle, A., Bjølseth, G., & Helseth, S. (2006). The gap between saying and doing in postoperative pain management. Journal of Clinical Nursing, 15, 469-479. doi:10.1111/j.1365-2702.2006.01272x Dossey, B. (2008). Theory of integral nursing. Advances in Nursing Science, 31(1), E52-E73. Dossey, B., & Keegan, L. (2009). Holistic nursing: A handbook for practice (5th ed.). Sudbury, MA: Jones & Bartlett. Duignan, M., & Dunn, V. (2008). Barriers to pain management in emergency departments. Emergency Nurse, 15(9), 30-34. doi: 0.1016/j.ienj.2007.09.003 Fawcett, J. (2005). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories. Philadelphia, PA: F.A. Davis. Lui, L, So, W., & Fong, D. (2008) Knowledge and attitudes regarding pain management among nurses in Hong Kong medical units. Journal of Clinical Nursing, 17, 2014-2021. doi:10.1111/j.1365-2702.2007.02183.x Matthews, E., & Malcolm, C. (2007). Nurses’ knowledge and attitudes in pain management practice. British Journal of Nursing, 16, 174-179. McCaffery, M., & Pasero, C. (1999). Pain: Clinical manual (2nd

Exploring the Theory of Integral Nursing with Implications for Pain Management Practice

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