Contributor – Julie Joseph MSN, RN, CCRN,
PhD Nursing Student

Light filters through a quiet grove of trees, casting long shadows across the grass, movement occurring without urgency or force. That same stillness often settles over the intensive care unit in the early morning hours. Machines hum steadily, monitors glow in the dim light, and a patient with a severe acquired brain injury (ABI) lies motionless in the bed. Their eyes remain closed, their limbs still, yet the body continues its quiet work of healing. As I begin morning care, I speak the patient’s name and narrate each step. When I wash their face, I notice a slight but distinct change in respiratory rhythm. It is subtle and easy to overlook, but it catches my attention and shapes how I proceed. This moment is not extraordinary. It is everyday nursing. Yet it reveals that something is happening, even when little appears to be happening at all.

It is within this context that Olson’s Cue Response Theory (CRT) becomes especially powerful, offering a framework for understanding the care of people with ABI as a dynamic and relational process (Olson & Ortega-Pérez, 2019). The theory describes how nurses intentionally provide cues and interpret subtle patient responses to guide care. Rather than viewing patients with impaired consciousness as passive or unreachable, CRT affirms that personhood persists through nuanced physiological and behavioral signals (Olson & Ortega-Pérez, 2019). Integrating this theory into nursing care for ABI enriches clinical practice and underscores the nurse’s role as an attentive, responsive presence that supports recovery and dignity.

CRT helps us understand the bedside interaction not as a simple exchange of stimulus and reaction but as a relational process grounded in presence and perception (Olson & Ortega-Pérez, 2019). When applied to ABI, it offers a practical and deeply human nursing framework. The nurse offers cues through touch, voice, light, and rhythm. The patient, even in altered states of consciousness, responds in subtle yet meaningful ways. A shift in respiratory pattern, a change in heart rate, or a softening of muscle tone becomes part of a feedback loop that supports neural integration and healing. The nurse notices, interprets, and responds again, creating a rhythm of care that honors the patient’s embodied presence.

This perspective challenges the assumption that patients with impaired consciousness are passive. Instead, it affirms that the person remains present even when their expression changes. The nurse’s role becomes one of attunement and relational sensitivity. Speaking to the patient during every procedure, explaining what is happening, and watching for signs of engagement become essential practices. Protecting sleep, modulating sensory input, and shaping the environment to support arousal and integration reflect the ethical and relational commitments at the heart of nursing.

CRT also reframes nursing knowledge through a philosophical lens. It validates a form of knowing that arises from embodied and relational engagement rather than detached observation. This type of embodied intelligence is a perceptual and interpretive skill grounded in experiential learning (Benner, 1982). Nurses often notice what others miss. Subtle shifts in muscle tone, micro movements, autonomic changes, and the emotional textures of the room become meaningful sources of knowledge. Nursing philosophy recognizes this as a legitimate way of knowing that is aesthetic, ethical, and personal as well as empirical.

Carper’s patterns of knowing help illuminate this understanding. CRT centers on personal knowing, which involves deep relational knowing that allows nurses to perceive the patient as a whole and a sensing person (Carper, 1978). It also draws on aesthetic knowing, which reflects an artful, intuitive grasp of patterns that emerge in practice. Chinn and Kramer’s work on ethical and emancipatory knowing further underscores that this perceptive capacity is not only clinical but also moral (Peart & MacKinnon, 2018). It reflects a commitment to seeing the patient as a person whose presence matters regardless of their ability to respond.

In nursing care for acquired brain injury, this way of knowing is essential. Consciousness is not an on-off switch. It is a dynamic and emergent process shaped by interaction. Nursing philosophy echoes this view by emphasizing that personhood is enacted in relationship rather than isolated within the body. CRT aligns with this understanding by positioning the nurse as a co-creator of the conditions that support neural integration. The cues offered by the nurse become part of the patient’s lived world. Gentle touch, a rhythmic voice, and familiar sounds shape arousal, modulate stress, and elicit responses. Nursing becomes a form of world-making in which the nurse helps construct an environment that allows the patient’s embodied self to reorient and re-emerge.

Olson’s Cue Response Theory carries a profound ethical dimension, emphasizing that nurses act as if patients can perceive and respond, even when outward signs are minimal. Caring for patients with acquired brain injury involves avoiding objectifying language, protecting the sensory environment, honoring the patient’s presence, and recognizing every cue and response, no matter how subtle, as significant (Cheng et al., 2024). This ethical stance is used in daily nursing practice, including dimming lights to safeguard sleep, speaking gently during procedures, inviting family to offer familiar cues, and interpreting subtle changes in tone or posture as engagement to guide care. Such practices illustrate that healing is not solely biological but also relational, ethical, and ontological.

Viewed through this lens, Cue Response Theory becomes more than a behavioral model. It becomes a nursing philosophy that highlights our role as relational practitioners, perceptive witnesses, and ethical agents. It affirms that nursing knowledge is generated through presence and that nursing practice is enlightened through relationship. It reminds us that nursing ethics are lived through attentiveness to the vulnerable other. In the care of people with acquired brain injury, CRT teaches that nursing is not only about doing. It is about being with. It is about offering cues that invite response and recognizing the responses that affirm presence.

References

Benner, P. (1982). From novice to expert. AJN, American Journal of Nursing, 82(3), 402–407. https://doi.org/10.1097/00000446-198282030-00004

Carper, B. A. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13–24. https://doi.org/10.1097/00012272-197810000-00004

Cheng, Y.-H., Pan, J.-D., Xu, C.-H., Mou, D., Guo, H.-L., Yan, H.-B., Chen, Q.-L., Li, W.-J., Huang, F.-A., Zhang, B.-X., Qiu, X.-Y., Lei, Q.-M., & Ling, D.-L. (2024). Nursing management of intracranial hypertension in adults with severe brain injury in a neurosurgery intensive care unit: A best practice implementation project. JBI Evidence Implementation, 24(1), 4–22. https://doi.org/10.1097/xeb.0000000000000452

Olson, D. M., & Ortega-Pérez, S. (2019). The cue-response theory and nursing care of the patient with acquired brain injury. Journal of Neuroscience Nursing, 51(1), 43–47. https://doi.org/10.1097/jnn.0000000000000426

Peart, J., & MacKinnon, K. (2018). Cultivating praxis through Chinn and Kramer’s emancipatory knowing. Advances in Nursing Science, 41(4), 351–358. https://doi.org/10.1097/ans.0000000000000232

About Julie Joseph

Julie Joseph is a critical care nurse at UT Southwestern Medical Center in Dallas and a 2nd year PhD student at Texas Woman’s University. Her work is grounded in the belief that every patient deserves to feel heard, respected, and valued. Her standpoint as both an ICU clinician and emerging nurse scholar shapes her writing, inspiring conversations around presence, ethics, and humanity in moments of vulnerability.