Conceptual/Theoretical

Analysis of the Theory of Integrative NurseCoaching

Amy K.Moore, PhD, RN, APRN, CNM, FNP-BC, APHN-BC,HWNC-BCUniversity of Connecticut Integrative Nurse Coach, Personalized Wellness, LLCIntegrative Nurse Coach Academy

Karen Avino, EdD, RN, AHN-BC, HWNC-BCIntegrative Nurse Coach Academy University of DelawareFlorida Atlantic University

Deborah McElligott, DNP, ANP-BC, AHN-BC, HWNC-BC, CDEKatz Institute for Women’s HealthDonald and Barbara Zucker School of MedicineInternational Nurse Coach Association

The Theory of Integrative Nurse Coaching (TINC) has been analyzed according to the method of Walkerand Avant. We have found that TINC is a well-constructed mid-range theory in the discipline of nursing.Within the domain of holistic nursing, it is focused on the goal of healing the whole person, synthesizinga large amount of theoretical material related to the concept of healing and placing it within the contextof nursing as a discipline. With underpinnings in holistic nursing, it aligns with numerous grand nursingtheories via the metaparadigm, healing, and patterns of knowing. It is easily translated into holisticnursing practice, actualized in the role of the nurse coach. It describes a method of holistic nursing practicethat is suitable for use in numerous settings, including lifestyle, chronic disease, and end of life, amongothers. Although there is little published research using the theory, there is potential for application in holis-tic nursing practice, education, research, policy, and administration. We have identified numerous potentialresearch questions that would test the theory. In this time of global nursing shortage and burnout, it isnotable that this mid-range theory explicitly describes how self-care of the nurse enhances client care.

Keywords: common themes; healing; health and wellness coaching; integrative/holistic theories; nursecoaching; nursing theory

This analysis of the Theory of Integrative NurseCoaching (TINC) (Dossey, 2015b) is a systematicexamination of the theory for meaning, logical ade-quacy, usefulness, generalizability, parsimony, and testa-bility according to the method of Walker and Avant(2019). We include its relevance to holistic nursingand its implications for research, teaching, and practice.

Aim

Although there are published studies on the roleof the nurse coach and the outcomes of nurse-led

coaching programs, there is little research usingTINC as a theoretical framework (Jackson et al.,2019). Recent meta-analyses note that most studiesof nurse coaching do not have a theoretical underpin-ning and those that do are unlikely to use a nursingtheory (Xu et al., 2017; Yu-Mei Chen et al., 2019).While noting that nurses could be effective in

Authors’ Note: Please address correspondence to AmyK. Moore, PhD, RN, APRN, CNM, FNP-BC, APHN-BC,HWNC-BC, Integrative Nurse Coach, Personalized Wellness,150 Mountain Ave, Bloomfield, CT 06002, USA; e-mail: amy.kenefick.moore@uconn.edu or amoore@inursecoach.com

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numerous health outcomes, researchers recommendthe development of innovative approaches based ontheory (Tucker & Lanningham-Foster, 2015). Thepurpose of this analysis is to understand the TINCand determine its potential for contribution tonursing practice and the development of nursingknowledge.

Definitions

The TINC (Figure 1) is a mid-range nursingtheory designed to guide nurse coaching practice,education, research, and health care policy. Thetheory emphasizes, describes, and directs the practiceof nurse coaching, a recognized holistic nursingmodality (Mariano, 2016). It also aligns with thepractice of holistic nursing, defined by theAmerican Holistic Nurses Association as havinghealing as the goal of healing the whole person

(American Holistic Nurses Association, 2021a). TheTINC can guide nursing practice whenever there isneed to identify opportunities and issues related tothe client’s growth, establishing the client’s goals,and helping the client to mobilize internal strengthsand external resources (American Holistic NursesAssociation, 2021b).

In the TINC, the word “integrative” is derivedfrom the theory’s perspective on the use of variedstrategies to promote well-being. It is not distinctfrom holistic nursing. The use of the word integrativeis described as using “a whole-person approach andan ability to build patient trust and confidence…main themes are patient centeredness, health pro-motion, and holism” (Hines & McCaffery, 2016).Arising from the traditions of Florence Nightingale,integrative nurse coaching (INC) is applicable in allsettings and is seen as “as a distinct nursing rolefor assisting individuals or group to establish healthgoals, creating change in lifestyle behaviors for

Figure 1. The Theory of Integrative Nurse Coaching(© 2015 by the International Nurse Coach Association (used with permission). www.inursecoach.com).

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health promotion and disease management, andimplementing integrative modalities as appropriate”(Dossey, 2015b, p. 29).

Integrative practice is collaborative, not depen-dent. Because nursing practice is based on theTINC using information from other disciplines, col-laborating with such practitioners as needed, it isconsistent with the spirit of independent nursingpractice. Nurse coaches may use complementaryand alternative practices with their clients or mayrefer those clients to other practitioners. Forexample, the TINC knowledge base includes anunderstanding of how toxic environments and nutri-ent imbalances disrupt the human energy field. Thenurse’s work relating to lifestyle is based in part onthe belief that each individual person is a reflectionof a biochemical uniqueness. In this context, individ-uals express unique strengths and vulnerabilities.These include variations in genetically and epigenet-ically driven metabolic functions. The use of informa-tion from biochemistry and genetics is the integrativecomponent; its application in practice is the holisticnursing component.

The TINC Holistic Nursing Origins

There are many ways in which the TINC revealsits underpinnings in holistic nursing. For example,its emphasis on the nurse’s personal self-care stemsfrom the holistic nursing emphasis on the “balancebetween self-care and the ability to care for patients”(Dossey et al., 2015). This is an important componentas 35–54% of nurses experience substantial symp-toms of burnout characterized by a high degree ofemotional exhaustion and depersonalization and alow sense of personal accomplishment at work. It iscommonly known that clinician well-being is essen-tial for safe and high-quality patient care (NationalAcademy of Medicine, 2021).

Consistent with holistic nursing philosophy, theTINC views persons as biopsychosocial and spiritualbeings, influenced by external and internal environ-ments. Healing is seen as being a unique journey ofthe nurse and the client, rather than a state or behav-ior. This is consistent with the holistic nursing under-standing of healing as participatory, reciprocal, andrelational concepts and characterized by order, coher-ence, balance, and compassion (Hanley et al., 2017).Patterns of knowing in nursing provide organizationfor the TINC and are part of the framework for

holistic nursing research (Hagedorn & Zahourek,2007). For example, the TINC is presented in achapter of the book, Nurse Coaching: IntegrativeApproaches for Health and Wellbeing (Dossey et al.,2015). In developing the theory, the nurse theorists’intend to “present integrative approaches thatacknowledge the complex, multidimensional, anddynamic interconnections of the person with thewhole environment” and to provide nurses “with afoundation for coaching interventions to supporthealth promotion and disease prevention across thelifespan via healthy lifestyle changes” (Bartol, 2015,p. 30). This provides the framework for a nurse coach-ing survey tool for use in practice and research, theIntegrative Health and Wellness AssessmentTM

(IHWA) (Dossey et al., 2015; McElligott et al.,2018). The IHWA is derived from the TINC. It isuseful in research and is a recommended self-assessment measure in Holistic Nursing: A Handbookfor Practice (Helming et al., 2020).

Theory Derivation

The TINC is derived inductively as a synthesis ofthe Theory of Integral Nursing (Dossey, 2008) withthe nursing metaparadigm (Fawcett, 2013) and pat-terns of knowing in nursing (Dossey, 2015a, b). Ituses an interactive–integrative paradigm in whichthe client is seen as an integrated whole interactingwith a larger environmental system. Both nursesand clients are influenced by their internal and exter-nal environments. The author wished to identify thefollowing: (1) the implications and relevance of INCfor healing, the metaparadigm in nursing theory, pat-terns of knowing in nursing, nurse coach self-development, integral perspectives for change, inte-grative lifestyle health and well-being (ILHWB),awareness and choice, energy, resilience, and trans-formation; (2) the existing nursing paradigms andworldviews that most closely explain INC; and (3)the substantive domains of health and wellnesscoaching knowledge, qualities, and competencies asseen through a Nurse Coach lens (Dossey, 2015a, b).

Nine philosophical assumptions are explicitlydescribed (Dossey, 2015a, b). Summarized, theseinclude open human and environmental energyfields; nurse coaching as a reflective developmentalprocess; health as a state or process defined by theclient, including a sense of well-being, harmony andunity; wellness as a multidimensional state of

Analysis of Integrative Nurse Coaching Theory/Moore et al. 3

integrative well-being; the integrative nurse coach asan instrument in a healing process that is facilitatedby therapeutic presence; INC as a reflective practicethat uses an integral perspective; and that nursecoaching is applicable in practice, education,research, and health care policy.

Theories are constructed in order to provide newinsights into the nature of a phenomenon, illustratingits structure and function and how it affects and isaffected by other phenomena (Walker & Avant,2019). The TINC explicates the concept of integra-tive nurse coach, describing a practice model thatplaces knowledge about healing within the contextof the nursing metaparadigm and ways of knowingin nursing (see Figure 1).

Meaning

The meaning of a theory is reflected by its con-cepts and their relationship statements. The majorconcepts provide the general setting for the theory.The major concepts in the TINC are healing, themetaparadigm of nursing, and patterns of knowingin nursing. This section includes a discussion of themajor and related concepts (known within thetheory as components) of TINC as well as their rela-tionship statements. The three major concepts andfive components of TINC have been referred to asits theoretical niches (Dossey, 2020a).

Healing

Healing is seen as distinct from “curing,” being alifelong journey rather than a state or a behavior. Inearlier work, Dossey (2013) stated that the integralhealing process incorporates an understanding ofthe unitary whole person interacting in a mutualprocess with the environment. TINC proposes thathealing occurs through a process in which nursecoaches “assist others to discover their own healingpath by incorporating integrative modalities in coach-ing sessions” (Dossey, 2015b, p. 43). Consistent withan interactive–integrative paradigm, the integrativehealing process is seen as being experienced by thenurse coach, the client individual or group, thehealth care team and community, and the collectiveprocesses of individuals and systems. Interventionssuggested by the theory affect the well-being ofboth the nurse and the client.

Healing has seven characteristics, defined as“healing concepts” (Dossey, 2015a, b).Summarized, these include the lifelong journey ofseeking harmony and balance, an emergent processof whole systems including oneself and the body–mind–spirit-environment at deeper levels with eachhaving equal importance, deeper levels of innerknowing, integration, wholeness, and an evolvingstate of consciousness. In addition, healing is distinctfrom disease and illness and remains possible untilthe moment of death.

This conceptualization of healing is consistentwith the understanding of the concept of health.TINC defines health as “how the individual definesher/his state or process in which one experiences asense of growth, well-being, harmony, and unity”(Dossey, 2015b, p. 37). It is further defined as aprocess in which individuals reshape basic assump-tions and worldviews, including aspects of physical,mental, emotional, social, spiritual, cultural, andenvironmental well-being, and more than theabsence of disease and where death is a naturalprocess of living (Dossey, 2015a, b). Health isdescribed as a state of balance, inner harmony, resil-ience, well-being, and the ability to make life-affirming choices in the face of the universalhuman condition of vulnerability (Dossey, 2015a,b). This description of health is consistent withother well-accepted definitions of health as theabsence of illness, the capacity to adapt, the abilityto fulfill a role and the ability to incorporate theimportance of wholeness, peacefulness, and mean-ingfulness (Smith, 1981) and an actualization ofhuman potential that can be reached throughharmony with the environment, goal-directed behav-ior, competent self-care, and satisfying relationships(Pender et al., 2006).

The TINC includes numerous graphics thatdescribe the concepts and their relationships.Healing is shown at the intersection of overlappingVenn diagrams describing the metaparadigm, pat-terns of knowing, and the five components of INC(see Figure 1).

Metaparadigm

Metaparadigm concepts used in the theoryinclude nurse, health, person, and environment/society. These have been long described as the estab-lished focus of the discipline (Fawcett, 1984). Theyare commonly found in nursing theory, philosophy,

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education, and some nursing research (Bender,2018).

Patterns of Knowing

Patterns of knowing include personal, empirics,aesthetic, ethical, not knowing, and sociopolitical.These approaches describe the method of acquisitionand organization of nursing knowledge (Chinn &Kramer, 2018). The role of the nurse coach is opera-tionalized through the ways of knowing as thecoaches bring their whole self into the coachingprocess. Nurse coaches assess, create therapeuticpresence, and guide clients using their many facetsof knowing including personal, empirics, aesthetics,ethics, not knowing, and sociopolitical concepts.The TINC refers to not knowing (rather thanunknowing) to support the discovery model used incoaching. While the coach has various skills fromall ways of knowing, not knowing supports thepremise that the client alone knows what is best forthem. Not knowing also supports the coach andclient as they engage in the therapeutic encounterspontaneously, with no preconceived fixed ideas,answers, or goals. Qualities such as authenticity,mindfulness, openness, receptivity, surprise, andmystery unfold, allowing new solutions, possibilities,and insights to emerge. Not knowing acknowledgesthe patterns related to various situations or relation-ships over time, perhaps not yet understood, to man-ifest. While nurses are often experts in their variousways of knowing, the not knowing, often a newpattern is supported through personal self-development (Dossey, 2020b).

Components of the TINC

INC is defined as the art of nursing that focuseson exploring experiences and meaning in life withself or another. It includes authentic presence, thenurse as a facilitator of healing, and the artfulnessof the healing environment (Dossey, 2015a, b). TheTINC includes five components (see Figure 1): inte-grative nurse coach self-development, integral per-spectives and change, ILHWB, awareness andchoice, and listening with healing, energy, awareness,resilience, and transformation (HEART). These com-ponents exist within an internal and external healingenvironment energy field. They are seen as fully inte-grated and equal in value.

The INC concepts provide most of the structureand content for the TINC theory. The TINC compo-nents are abstract and theoretical. Like the majorconcepts, they are not inherently measurable butoperational definitions could be developed. Each ofthe components is discussed in detail and used con-sistently. Context and attributes of the componentsare described in the text. Relational statements, asimplied, are potentially testable. TINC componentsare described below.

Nurse Coach Self-development

The first TINC component, nurse coach self-development, expresses attributes of the processthat the nurse can use to develop coaching and lead-ership capacities. It includes self-reflection, self-assessment, self-evaluation, self-care, mindfulness,inner awareness, consciousness, and an intentionfor presence in order to promote an approach to theothers that reflects being with and in collaborationwith rather than doing to. Each of the aspects of self-development is described.

Integral Perspectives and Change

Within the second INC component, integral per-spectives and change, phenomena are organized in afour-quadrant model (Dossey, 2013; Wilber, 2000).The model’s quadrants are as follows: (1) individualinterior “I” (subjective and personal); (2) individualexterior “It” (objective and behavioral); (3) collectiveinterior “We” (interobjective and cultural); and (4)collective exterior “Its” (interobjective and systems/structures). The framework is to be used in thenurse’s personal life and in practice to enhanceawareness, and to appreciate pattern and the poten-tial for transcendent change.

Integrative Lifestyle Health andWell-being

The third INC component, ILHWB has sixunderlying phenomena: energy field principles anddynamics, interconnectedness, promotion of optimiz-ing internal and external healing environments,patient-centered(ness), biochemical individuality,and health on a wellness continuum. The purposeof this component is to guide understanding of pre-vention and causality.

Analysis of Integrative Nurse Coaching Theory/Moore et al. 5

Awareness and Choice

The fourth INC component, awareness andchoice, is cultivated through mindfulness andincludes four qualities, loving kindness, calmness,concentration, and insight. These qualities lead tothe ability to make healthier life-affirming choices.It is thought that if individuals understand conceptsof impermanence and vulnerability, they can increasetheir ability to make life-affirming choices.

Listening With HEART

The fifth INC component, listening with HEART,includes the concepts of healing, energy, awareness,resiliency, and transformation. It is characterized bycuriosity, presence, and the lack of assumptions.

Analysis

Relational Statements

Relational statements are both stated andimplied. Because the TINC outcomes cannot bedetermined with certainty, there is no true causality.There are many associational relationships, usuallypositive, as yet untested. Below are some examplesof positive directional relational statements identifiedin the TINC. A summary matrix of relational state-ments is displayed in Table 1.

Logical Adequacy

The theory is well-integrated. Numerous majorconcept relationships are explicitly stated or can beeasily derived. They are associative although direc-tionality can be implied. For example, increasedawareness of choice is associated with innerbalance and mindfulness. Even bidirectionality sug-gests ideas for practice. For example, the nursecoach works with clients to increase their mindful-ness and they experience increased awareness ofchoice. Likewise, clients who have increased aware-ness of choice might also experience increasedmindfulness.

The TINC is based on inductive reasoning. Thenoted underlying assumptions are widely acceptedin contemporary literature. Given the descriptionsof the concepts in the model, the resulting relationalstatements make sense. The structure of the theoryallows predictions, presented in the theory as rela-tional statements. These are both stated andimplied. None of these appears to be illogical whenviewed from the perspective of the theory. As notedearlier, there are numerous unstudied relationshipsand an absence of research supporting their validity.Predictions based on the theory have face validity.The theory appears to be suitable for its aims.Psychometric testing of the IHWA was reported byMcElligott et al. (2018), demonstrating satisfactorycontent validity (does it fully represent what it pur-ports to measure?). Content and questions werereviewed during development by subject matterexperts in holistic nursing. This work would be

Table 1. Matrix of Relational Statements

INC Healing MetaparadigmPatterns ofknowing Self-development

Integralperspectives andchange ILHWB

Awarenessand choice

Healing +Metaparadigm + +Patterns of knowing + + +Self-development + + + +Integral perspectivesand change

+ + + + +

ILHWB + + + + + +Awareness andchoice

+ + + + + + +

Listening withHEART

+ + + + + + + +

Note. The symbol + denotes a positive relationship. INC = integrative nurse coaching; ILHWB = integrative lifestyle health andwell-being.

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further developed by including measures of constructvalidity (does it measure what it purports tomeasure?) and criterion validity (does the measure-ment correlate with other measures of the sameconcept?).

Usefulness

The theory provides insight into nursing activitiesassociated with healing, the core of all nursing prac-tices since the time of Nightingale. While focused onthe role of the nurse coach, the TINC is potentiallyrelevant to other kinds of nursing cares.

The usefulness of a theory is based on how ithelps one explain phenomena better or differently,to make predictions and to understand outcomes(Walker & Avant, 2019). Operationalizing theoreticalvariables for application in research or practice ischallenging. While there is little published researchon the TINC, it has been used as a model innursing education and practice (Burkhart, 2018;Ervin & Vienneau, 2019; Jackson et al., 2019;Thomas, 2017). Being based on a human energyfield model, it has the capacity to address phenomenasuch as grief, suffering, and energy imbalance andothers that are not sufficiently explained by a biomed-ical model. It, thereby, allows clarifications of theprocess of healing. Framing one’s practice in theconcept of a boundaryless human-environmentalfield does not allow prediction or the exercise ofcontrol. This may be seen as a limitation or a realmof unlimited possibility. In the TINC this unlimitedpossibility is noted, for example, by discussion ofthe development of the transpersonal self, expandingbeyond an individual, personal identity. The integra-tive nurse coach is described as practicing in a“dynamic energy flow with presence, intention, anda state of consciousness of human wholeness withnothing ‘to fix’, and to participate knowingly touncover the many levels and patterns within theclient’s story” (Dossey, 2015b, p. 41).

Generalizability

One assesses generalizability by considering howwidely the theory can be applied (Walker & Avant,2019). As a mid-range theory, the TINC’s content isapplicable to a wider group of events or populationsthan a situation-specific or practice theory. Forexample, because it is limited to the nurse coach’srole in healing, it has less of a scope than a grand

theory would have. The theory does not restrict thecontext of application. Integrative nurse coachespractice in a variety of situations with individualsand groups throughout the lifespan. The TINC is,in principle, generalizable to all of these settings.Because it describes the values and methods of prac-tice, it also has potential for use in education,research, and health care policy.

Nurses are not the only people experiencingstress and burnout in these turbulent times. TheTINC’s emphasis on self-care and self-developmentcould be of benefit to non-nurse health careworkers who interact with patients, including butnot limited to physicians, physician assistants, socialworkers, etc. Applicability of aspects of the TINC tonon-nurses could be investigated. The use of IHWAwith non-nurse health care workers is likely to be aseffective as it is with other populations, but itremains an interesting question. The combinationof the TINCmodel and the IHWA has been especiallyuseful during the health care challenges amidCOVID. TINC and IHWA have been used in healthcare education including a 12 month institutionalclinical innovation grant funded “Advanced ClinicalProviders Integrative Certificate Program.” TheIHWA and components of TINC have also beenused in self-care retreats with interdisciplinaryteams of health care workers, and healthy living pro-grams with community members. Participants com-plete the tool as prework, document a paragraph ontheir reflective process in completing the tool, andthen discuss that reflection in small groups duringthe retreat. Themes are then generated for thelarger group to discuss (D. McElligott, personal com-munication, January 31, 2021).

Parsimony

Parsimony assesses the simplicity and efficiencyof the way that a theory explains the phenomenonof interest. Parsimonious theories often reside in anempiric domain. Nursing uses numerous approachesto try to explain complex phenomena such as humanexperience. The TINC bases its perspective on theconcept of healing, the ways of knowing, and themetaparadigm. In such a setting, parsimony is achallenge.

While based on an intricate synthesis of rich the-oretical material, the TINC itself is explained rathersimply. Graphics illustrate the theory’s phenomena,presenting the relationships in a manner that is

Analysis of Integrative Nurse Coaching Theory/Moore et al. 7

easy to understand conceptually. Because there aremultiple relationships described between complexconcepts, the best one can hope for is a largenumber of statements that are clear and brief.Relationships among the major concepts take theform of desirable, broader, and more general rela-tional statements (Walker & Avant, 2019). Althoughthe interrelationships among concepts result inoverlap, there do not appear to be any statementsthat could be eliminated.

Testability

As discussed by Walker and Avant (2019), truetestability requires the existence of instrumentationthat can be used to collect data that will support orrefute the theoretical relational statements.

The TINC is the basis for the development of theIHWA (Dossey, 2015b; McElligott et al., 2018), aninstrument designed to measure the eight dimensionsof health and wellness as defined in the TINC. Whilethe instrument may be scored, the real value lies inthe reflection on the personal journey related to theeight dimensions and the individual desire forchange (McElligott et al., 2018). The client andnurse coach may decide to focus on items with highscores or low scores. They may also decide to focuson areas of interest, independent of the score. Theycan also track scores over time, looking at changeor stability rather than absolute values.

Testability-in-principle may exist when the instru-ment does not. The TINC is testable in principlebecause it includes many testable ideas based on itswell-described concepts and relational statements.The TINC places “healing” at the intersection ofthe metaparadigm, ways of knowing, and nursecoaching components. Relational statements areimplied and may be inferred throughout the theory.Many of these are potentially testable and could beexplored through research.

While the theory has been used in clinical prac-tice, we were unable to find reports of evaluativeresearch studies. For evaluation, the conceptswould need to be operationalized. If supported byresearch the relational statements could be adoptedin practice as suggested by the theory. If not sup-ported, the theory would be modified.

The model is not predictive. It leans toward pre-scriptive in that it suggests general approaches, basedon description of desirable interventions and out-comes. Lack of causality in the model is consistent

with other work on healing that cites the unpredictabil-ity of the phenomenon (McElligott, 2010). Qualitativeapproaches such as phenomenology, ethnography, andgrounded theory would be suitable. Qualitativeresearch methods such as open or semistructuredinterviews could be used to explore these conceptsand relational statements. For example, a qualitativestudy (Frey & Ratliff, 2018) of the lived experienceof the self-development of nurses going through theIntegrative Nurse Coach Certificate Program(INCCP) can be seen as a test of the theory. In addi-tion to didactic content and supervised clinical experi-ence, the INCCP includes self-developmentexperiences as described in the TINC. The research(Frey & Ratliff, 2018) found that subjects reported apositive influence on self-development, both personaland professional. They also described enriched self-care practices, a new focus on healing and optimalrelationships, empowerment to influence health caresystems, enthusiasm for integrating nurse coachingperspectives and activities into their practice to movefrom a focus on disease to a grounding in health pro-motion and well-being.

Quantitative studies would be able to use techni-ques such as correlation, logistic regression, anddependent t-test for pretest and posttest analysis.Instrumentation to support this kind of researchincludes the Integrative Health and WellnessAssessment, known as the IHWA (Dossey, 2015a, b;McElligott et al., 2018) (see Figure 2). IHWA sup-ports a holistic perspective on outcomes, measuringphenomena including life balance and satisfaction,relationships, spirituality, mental, emotional, andphysical aspects (including nutrition, exercise,weight management, environmental and healthresponsibility). In the last 5 years, there have been∼30 requests for permission to use the IHWA forpractice, education, and research, both within theUnited States and internationally (B. M. Dossey, per-sonal communication, June 25, 2020).

Relevance to Holistic Nursing Practice,Research, and Teaching

The TINC suggests numerous lines of inquiryrelated to holistic nursing practice, research, andteaching. All of these can be described and evaluated.The TINC suggests application in practice, both in aninterdisciplinary setting such as a hospital or clinic,and in a nursing setting such as within a role, for

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example, staff nurse, or in a private practice eitherdedicated to nurse coaching or including multipleholistic nursing modalities. The TINC can be usedin education to promote self-development in bothteachers and students. It can also be taught for stu-dents to use as a framework for how they approachclients, both in simulation and in clinical practice.The theoretical framework suggests possibilities forrich, complex, and holistic questions. It is a strengthof the model that the relational statements could behypotheses. Research opportunities include testinghypotheses derived from the relational statements.Examples of research questions are shown in Table 2.

Discussion

Mid-range theories in nursing have a specificfocus related to nursing practice. They describe,

explain, or predict clinically relevant phenomena.They are less abstract and more testable than grandtheories, but broader than practice-level orsituation-specific theories which describe a set of cir-cumstances and nursing activities related to it.Additionally, mid-range nursing theory is “broadenough to be useful in complex situations and leadsto implications for development, theory testingthrough research, and nursing practice strategies”(Smith and Parker, 2015, p. 13).

We have considered the TINC’s relationship toholistic nursing theory and practice. This theoryaligns with numerous grand nursing theories via con-cepts of healing, the nursing metaparadigm, patternsof knowing, and all abstract concepts. The addition ofthe INC components helps the theory to be viewed asa mid-range theory easily translated into holisticnursing practice, specifically in the role of the nursecoach. The TINC explicates the concept of

Figure 2. Integrative Health and Wellness Assessment(© 2015 by the International Nurse Coach Association (used with permission). www.inursecoach.com).

Analysis of Integrative Nurse Coaching Theory/Moore et al. 9

Integrative Nurse Coach, placing knowledge abouthealing within the context of the nursing metapara-digm and ways of knowing in nursing.

As a holistic nursing theory, the TINC is includedin the new editions of Dossey and Keegan’s HolisticNursing: A Handbook for Practice (Helming et al.,2020) and The Art & Science of Nurse Coaching: TheProvider’s Guide to Coaching Scope & Competencies(Southard et al., 2020). The book describes integrativeassessment as the process of going beyond the physicaland mental realms and partnering with the patient orself to reflect and identify patterns, concerns, andopportunities, in a manner that is supportive of whole-ness and meaning. It notes that the process is sup-ported by the mid-range TINC and the IHWA, longform and short form.

Conclusions

TINC is a holistic nursing theory. In this analysis,we have found it to be a well-constructed mid-rangenursing theory and useful in explaining and guidingholistic nursing practice. The TINC is a “philosophy,framework, and methodology that is praxis—theory inaction—grounded in clinical knowledge, traditionaland integrative practice, and research” (Dosseyet al., 2015, p. 11). It synthesizes a large amount oftheoretical material related to the concept ofhealing and places it within the context of nursingas a discipline. It describes a method of holisticnursing practice which is suitable for use in numer-ous settings, including lifestyle, chronic disease,and end of life, among others. While there is littlepublished literature on the theory, there is potentialfor application in practice, education, research,administration, and health care policy.

The U.S. Department of Health & HumanServices (2020) reports chronic diseases such asheart disease and stroke, cancer, or diabetes affectas many as six in 10 people. These and otherchronic diseases are not only the leading causes ofdeath and disability in the United States but arealso a leading driver of health care costs. In 2021,The World Health Report indicated that high mortal-ity, morbidity, and disability rates were attributed tomajor chronic diseases such as cardiovascular dis-eases, cancer, chronic obstructive pulmonarydisease, and Type 2 diabetes. These are linked bycommon and preventable biological risk factors,notably high blood pressure, high blood cholesteroland obesity, and by related major behavioral riskfactors including an unhealthy diet, physical inactiv-ity, and tobacco use (World Health Organization,2021). Action to prevent and control the costs ofthese major chronic diseases should focus on sup-porting lifestyle health and wellness interventions.

A theory supporting lifestyle health and wellness,the coaching process, and the healing journey is acrucial need in our present world. The nurse coach-ing process derived from the TINC transforms itsconcepts from theoretical to practical and is easilyintegrated into the practice setting.

As the TINC supports the self-care of the nurse, itsignificantly contributes to nursing practice andclient outcomes. The longstanding issues of nursingshortages and burnout have become increasinglyproblematic and critical. TINC demonstrates how

Table 2. Examples of Research Questions Derived Fromthe TINC

• What are the correlations between relationalstatements in TINC?

• Are aspects of the theory identifiable in analysis ofobserved/transcribed nurse coaching sessions?

• What is the client’s experience of INC?• What is the effectiveness of nurse coaching for people

with chronic diseases when compared to standardcare? Outcome measurements suggested by TINCinclude, for example, personal phenomena such asclient satisfaction, biochemical measurements such asblood pressure or hemoglobin A1C, and health caresystem resource utilization measurements such asoffice or ER visits, use of prescription medications, andrequirements for services such as home care.

• What is the health-related outcome measured byIHWA or others, (e.g. HgA1C) of INC (1) following anINC protocol compared with; (2) coaching followinganother protocol; (3) watching educational videos; or(4) receiving written instructions?

• How does the INC process affect client’s self-efficacyfor wellness-related change?

• How does the client describe the process of healing?• What health-related outcomes are influenced by a

healing relationship?• Is there a relationship between the nurse coach’s

integral awareness and their interest in or practice ofself-development or self-care?

• What is the relationship between self-awareness/self-care and compassion fatigue/burnout in healthcare providers?

• What is the experience of self-care practices for theintegrative nurse coach over time?

Note. ER = emergency room; INC = integrative nurse coaching;IHWA = integrative health and wellness assessment; TINC =Theory of Integrative Nurse Coaching; ILHWB = integrativelifestyle health and well-being.

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self-care enhances client care. It helps the nurse tomove from knowing into doing while supportinghealth and well-being for self and for their peers,clients, families, and communities.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respectto the research, authorship, and/or publication of this article.

ORCID iD

Amy K. Moore https://orcid.org/0000-0002-6818-4972

References

American Holistic Nurses Association. (2021a). What isholistic nursing? Retrieved March 4, 2021 from https://www.ahna.org/About-Us/What-is-Holistic-Nursing

American Holistic Nurses Association. (2021b). Coaching,health coaching, and nurse coaching. Retrieved March4, 2021 from https://www.ahna.org/Home/Resources/Nurse-Coaching

Bartol, G. M. (2015). Book review–nurse coaching:Integrative approaches for health and wellbeing.Beginnings, 35(4), 26-36.

Bender, M. (2018). Re-conceptualizing the nursing metapar-adigm: Articulating the philosophical ontology of thenursing discipline that orients inquiry and practice.Nursing Inquiry, 25(3). https://doi.org/10.1111/nin.12243

Burkhart, R. L. M. (2018). Health care reform in NewMexico: Threat or opportunity for the nurse role in com-munity health? New Mexico Nurse, 63(3), 6-8.

Chinn, P. L., & Kramer, M. K. (2018). Knowledge develop-ment in nursing: Theory and process (10th ed.). Mosby.

Dossey, B. M. (2008). Theory of integral nursing. Advances inNursing Science, 31(1), E52-E73. https://doi.org/10.1097/01.ANS.0000311536.11683.0a

Dossey, B. M. (2013). Nursing: Integral, integrative, andholistic–local to global. In B. M. Dossey, & L. Keegan(Eds.), Holistic nursing: A handbook for practice (6th ed.,pp. 1-57). Jones & Bartlett Learning.

Dossey, B. M. (2015a). Integrative health and wellnessassessment. In B. M. Dossey, S. Luck, & B. G. Schaub(Eds.), Nurse coaching: Integrative approaches for healthand wellbeing (pp. 109-122). International Nurse CoachAssociation.

Dossey, B. M. (2015b). TINC. In B. M. Dossey, S. Luck, & B.G. Schaub (Eds.), Nurse coaching: Integrative approachesfor health and wellbeing (pp. 29-49). International NurseCoach Association.

Dossey, B. M. (2020a). Barbara Dossey’s Theory of integralnursing. In M. C. Smith (Ed.), Nursing theories and nursingpractice (5th ed., pp. 211-234). F. A. Davis Company.

Dossey, B. M. (2020b). Theory of Integral Nursing.Nurseology.net. Retrieved March 4, 2021 from https://nursology.net/nurse-theorists-and-their-work/theory-of-integral-nursing/

Dossey, B. M., Luck, S., & Schaub, B. G. (Eds.). (2015).Nurse coaching: Integrative approaches for health and well-being. International Nurse Coach Association.

Ervin, D., & Vienneau, N. (2019). Battling burnout with nursecoaching: Stories from the ICU. Beginnings, 39(3), 16-34.

Fawcett, J. (1984). The metaparadigm of nursing: Presentstatus and future refinements. Image: The Journal ofNursing Scholarship, 16(3), 84-87. https://doi-org.ezproxy.lib.uconn.edu/10.1111/j.1547-5069.1984.tb01393.x

Fawcett, J. (2013). Contemporary nursing knowledge: Analysisand evaluation of nursing models and theories (3rd ed.). F.A.Davis Company.

Frey, L. M., & Ratliff, J. L. (2018). The personal and profes-sional experiences of integrative nurse coach certificateprogram graduates: A pilot study. Journal of HolisticNursing, 36(2), 134-144. https://doi-org.ezproxy.lib.uconn.edu/10.1177/0898010117704516

Hagedorn, M. E., & Zahourek, R. P. (2007). Research para-digms and methods for investigating holistic nursing con-cerns. Nursing Clinics of North America, 42(2), 335-353.

Hanley, M. A., Coppa, D., & Shields, D. (2017). A practice-based theory of healing through therapeutic touch:advancing holistic nursing practice. Journal HolisticNursing, 35(4), 369-381. https://doi.org/10.1177/0898010117721827

Helming, M. A., Shields, D. A., Avino, K., & Rosa, W. E.(Eds.). (2020). Dossey & Keegan’s holistic nursing: A hand-book for practice (8th ed.). Jones & Bartlett Learning.

Hines, M. E., & McCaffery, R. (2016). Advanced holisticnursing practice. In B. M. Dossey, L. Keegan (Authors),C. Barrere, M. A. Helming, D. Shields, & K. M. Avino(Eds.), Holistic nursing: A handbook for practice (7th ed.,p. 861). Jones & Bartlett Learning.

Jackson, K., D’avolio, D., & Gropper, S. (2019). Choosingcoaching frameworks for promoting diet modifications.British Journal of Nursing, 28(22), 1459-1460.

Mariano, C. (2016). Holistic nursing: Scope and standards ofpractice. In B. M. Dossey, L. Keegan, C. Barrere,M. Helming, & D. Shields (Eds.), Holistic nursing: A hand-book for practice (pp. 53-76). Jones & Bartlett Learning.

McElligott, D. (2010). Healing: The journey from concept tonursing practice. Journal of Holistic Nursing, 28(4), 251-259. https://doi.org/10.1177/0898010110376321

McElligott, D., Eckardt, S., Montgomery Dossey, B., Luck,S., & Eckardt, P. (2018). Instrument developmentof integrative health and wellness assessment™.J Holist Nurs, 36(4), 374-384. https://doi.org/10.1177/0898010117747752

Analysis of Integrative Nurse Coaching Theory/Moore et al. 11

National Academy ofMedicine. (2021). Action collaborative onclinician well-being and reilience. National Academy ofSciences. https://nam.edu/initiatives/clinician-resilience-and-well-being/

Pender, N., Murdaugh, C., & Parsons, M. (2006).Health pro-motion in nursing practice (4th ed.). Prentice Hall.

Smith, J. (1981). The idea of health: A philosophical inquiry.Advances in Nursing Science, 3(3), 43-50.

Smith, M. C., & Parker, M. E. (Eds). (2015). Nursing theoryand the discipline of nursing. In Nursing theories andnursing practice (4th ed., pp. 3–18). F. A. Davis Company.

Southard, M. E., Dossey, B. M., Bark, L., & Gulino-Schaub,B. (2020). The art and science of nurse coaching: The pro-vider’s guide to coaching scope and competencies (2nd ed.).American Nurses Association, Nursing Knowledge Center.

Thomas,M.M. (2017). The role of integrative nurse coaching inreducing chronic disease. Washington Nurse, 43(4), 16-18.

Tucker, S., & Lanningham-Foster, L. M. (2015). Nurse-ledschool-based child obesity prevention. Journal of SchoolNursing, 31(6), 450-466. https://doi-org.ezproxy.lib.uconn.edu/10.1177/1059840515574002

Walker, L. O., & Avant, K. C. (2019). Strategies for theory con-struction in nursing (6th ed.). Pearson.

Wilber, K. (2000). Integral psychology: Consciousness, spirit,psychology, therapy. Shambhala.

World Health Organization. (2021). Chronic disease and healthpromotion. Integrated chronic disease prevention andcontrol. https://www.who.int/chp/about/integrated_cd/en/

Xu, H., Mou, L., & Cai, Z. (2017). A nurse-coordinatedmodel of care versus usual care for chronic kidneydisease: meta-analysis. Journal of Clinical Nursing,26(11-12), 1639-1649. https://doi-org.ezproxy.lib.uconn.edu/10.1111/jocn.13533

Yu-Mei Chen, D., Wu, X. V., Chan, E. Y., & Goh, Y. S. (2019).Nurse-led tele-coaching on modifiable cardiovascularrisk factors in people with type 2 diabetes mellitus: Asystematic review and meta-analysis. Worldviews onEvidence-Based Nursing, 16(6), 424-432. https://doi.org/10.1111/wvn.12409

Author Biographies

Amy K. Moore, PhD, RN, APRN, CNM, FNP-BC, APHN-BC,HWNC-BC, is board-certified as a Nurse Midwife, FamilyNurse Practitioner, Advanced Practice Holistic Nurse andHealth and Wellness Nurse Coach. She is a clinical facultymember for the Integrative Nurse Coach Academy and has aprivate practice, personalized wellness, LLC. She taughtnursing theory and statistical analysis of health-related data atthe University of Connecticut for more than 20 years. DrMoore’s practice includes integrative nurse coaching for individ-uals and groups, specializing in serious illness and end-of-life.She presents and consults regarding theory-based nursingresearch and practice. Dr Moore is the author of the HolisticTheory of Unpleasant Symptoms.

Karen Avino, EdD, RN, AHN-BC, HWNC-BC, is the Director ofEducation for the Integrative Nurse Coach Academy and theInternational Nurse Coach Association (INCA). INCA providesonline and onsite continuing education programs for nurses. Asa consultant, Karen helps healthcare organizations createoptimal healing environments, integrate holistic nursing intopractice and develop integrative health centers. Karen is facultyat the University of Delaware and Florida Atlantic University,teaching Holistic Nursing, Integrative Health, and Coaching. DrAvino is an author and editor of Holistic Nursing: A Handbookfor Practice (2016, 2020) and Core Curriculum for HolisticNursing (2014).

Deborah McElligott, DNP, ANP-BC, AHN-BC, HWNC-BC,CDE, is a board-certified Adult and Holistic Nurse Practitioner,an Integrative Health and Wellness Coach and a CertifiedDiabetes Educator who works at the Northwell Center forWellness and Integrative Medicine (Roslyn, NY). She is aClinical Assistant Professor at the Donald & Barbara ZuckerSchool of Medicine at Hofstra–Northwell and Associate Facultywith the International Nurse Coach Association. Dr McElligotthas been the primary investigator in nursing research studiesinvolving imagery, massage, and three studies focusing onhealth promotion and wellness. She has published these studiesand book chapters on self-care, reflection, and research and pre-sented findings internationally.

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