Contributor – Julie Joseph

Authors – DaiWai Olson, PhD, RN,CCRN, and Stefany Ortega-Pérez, PhD, MSc RN,

First published – 2019

Major Concepts

Cue-Response Theory centers on the idea that patients who appear unconscious still receive, process, and respond to sensory and relational cues around them, and that nurses play an active therapeutic role in shaping those responses. The major concept is that every interaction, such as touch, voice, movement, environmental noise, and emotional tone, acts as a cue, and these cues can influence the patient’s physiologic and behavioral responses even when overt consciousness is not observable. Because the patient retains personhood and the capacity for subtle responsiveness, the nurse’s intentionality becomes essential: delivering calm, consistent, and purposeful cues. The nurse helps organize the patient’s internal experience and may support neurologic recovery. The theory, therefore, reframes unconsciousness not as an absence but as a state in which meaningful cue-response patterns persist and can be therapeutically guided through skilled nursing care.

Typology – middle range theory

Description

Cue Response Theory is a nursing-centered framework developed to guide the care of patients with acquired brain injury, particularly those with impaired or absent observable consciousness. Its central premise is that patients who appear unresponsive remain embedded in a dynamic sensory environment and may retain the capacity to perceive, process, and respond to cues from nurses, family members, and the clinical setting. The theory reframes unconsciousness not as a void but as a state in which meaningful interactions continue to occur, even if they are subtle, inconsistent, or physiologic rather than behavioral. This perspective positions the nurse as a therapeutic agent whose intentional actions can influence neurologic organization and recovery.

A foundational tenet of the theory is the concept of cues, which are the sensory, emotional, and relational signals that reach the patient. These include auditory cues such as tone of voice, familiar sounds, and spoken explanations; tactile cues such as touch, repositioning, and procedural contact; visual cues such as lighting and movement; and affective cues such as calmness, reassurance, and presence. Cue Response Theory asserts that cues are never neutral. Every interaction, whether deliberate or incidental, shapes the patient’s internal experience. Because patients with impaired consciousness cannot filter or contextualize stimuli, the quality and consistency of cues become especially important.

The second major tenet concerns responses, encompassing the patient’s reactions to cues. Responses may be physiologic (changes in heart rate, blood pressure, respiratory pattern), autonomic (sweating, flushing), motor (withdrawal, posturing, purposeful movement), or subtle behavioral indicators (eye opening, facial expression). The theory emphasizes that responses should be interpreted as meaningful even when they do not meet traditional thresholds for command following or purposeful behavior. This tenet challenges the assumption that the absence of overt behavior equals the absence of awareness.

A third tenet is the nurse–patient interaction as a therapeutic process. Nurses are not passive observers of neurologic status; they are active participants whose actions can support or hinder recovery. Routine care, such as turning, suctioning, bathing, and medication administration, becomes a series of therapeutic opportunities. The nurse’s intentionality is central: speaking before touching, explaining procedures, using consistent language, and maintaining a calm presence help organize the patient’s sensory world.

Another core tenet is continuity of personhood. Cue Response Theory affirms that patients remain whole, sentient human beings despite impaired consciousness. Their identity, dignity, and relational ties persist. This tenet reinforces ethical nursing practice by grounding care in respect, empathy, and recognition of the patient’s humanity.The theory also highlights environmental influence. The ICU is saturated with alarms, conversations, lights, and procedures. These environmental cues can overwhelm or destabilize patients with impaired consciousness. Nurses are encouraged to minimize harmful stimuli and optimize supportive ones.

Finally, the theory emphasizes pattern recognition. By observing how specific cues elicit specific responses over time, nurses can detect early signs of improvement, tailor interventions, and avoid overstimulation. This iterative process strengthens clinical judgment and supports individualized care. Together, these tenets position Cue Response Theory as a practical, humanistic, and neurologically informed framework for nursing care of patients with acquired brain injury.

Primary Source

Olson, DaiWai M.; Ortega-Pérez, Stefany. The Cue-Response Theory and Nursing Care of the Patient With Acquired Brain Injury. Journal of Neuroscience Nursing 51(1):p 43-47, February 2019. | DOI: 10.1097/JNN.0000000000000426 –

About the Authors

DaiWai Olson, PhD, RN,CCRN, FNCS, is a nationally and internationally recognized leader in neuroscience nursing, known for his rigorous scholarship, transformative mentorship, and sustained contributions to advancing neurocritical care. Dr Olson be gan his nursing career in 1986 after completing an associate degree in nursing at Scott Community College. He later earned his bachelor’s degree from Teikyo Marycrest University in 1997, demonstrating an early commitment to lifelong learning and professional growth. Beyond his academic roles, Dr. Olson is widely known for his editorial leadership. Since 2016, he has served as Editor-in-Chief of the Journal of Neuroscience Nursing, where he has championed methodological rigor, the accessibility of science, and the professional identity of neuroscience nurses worldwide. He is also a co-chair of the International Curing Coma Campaign, contributing to global efforts to advance research, awareness, and clinical innovation in the field of coma science.
Dr. Olson’s influence extends across continents; he has presented his work in dozens of U.S. states and on different continents. His career reflects a rare blend of clinical expertise, scientific rigor, and educational leadership, making him one of the most respected voices in contemporary neuroscience nursing.

Stefany Ortega-Pérez, PhD, MSc, RN
Dr. Stefany Ortega-Pérez is a nursing researcher and Assistant Professor at Universidad del Norte. Her work examines how nursing practice influences outcomes in neurocritical patients. She began her nursing career at Universidad del Norte and completed an MSc in Clinical Research at the Universidad de Barcelona, followed by a PhD in Nursing Science from the Universidad Nacional de Colombia.

With experience as an intensive care unit staff nurse, Dr. Ortega-Pérez developed a strong foundation in critical care that continues to inform her research and teaching. Her scholarly interests focus on strengthening the evidence base for nursing care in neurocritical patients and supporting the translation of that evidence into clinical practice and education.

Alongside her research, Dr. Ortega-Pérez’s work in nursing education emphasizes the development of students’ critical thinking, clinical decision-making, and clinical judgment. She promotes structured approaches to the nursing process—including care mapping—to support clinical reasoning, prioritize patient needs, and advance safe, humanized care.