Introduction to Nursing Theories

Introduction to Nursing TheoriesThis page was last updated on February 21, 2011

INTRODUCTION

Each discipline has a unique focus for knowledge development that directs its inquiry and distinguishes it from other fields of study.(Smith & Liehr, 2008).

Nursing knowledge is the inclusive total of the philosophies, theories, research, and practice wisdom of the discipline.As a professional discipline this knowledge is important for guiding practice.(Smith & Liehr, 2008).

Theory-guided, evidence-based practice is the hallmarkof any professional discipline.

Nursing is a professional discipline (Donaldson & Crowley, 1978).

Nursing theory is the term given to the body of knowledge that is used to support nursing practice

Almost 90% of all Nursing theories are generated in the last 20 years.

Nursing models are conceptual models, constructed of theories and concepts

METAPARADIGMS IN NURSING

1. Person

Recipient of care, including physical, spiritual, psychological, and sociocultural components.

Individual, family, or community

2. Environment

All internal and external conditions, circumstances, and influences affecting the person

3. Health

Degree of wellness or illness experienced by the person

4. Nursing

Actions, characteristics and attributes of person giving care

COMPONENTS OF A THEORY

A theory is a group of related concepts that propose action that guide practice. A nursing theory is a set of concepts, definitions, relationships, and assumptions or propositions derived from nursing models or from other disciplines and project a purposive, systematic view of phenomena by designing specific inter-relationships among concepts for the purposes of describing, explaining, predicting, and /or prescribing..

Based on the knowledge structure levels the theoretical works in nursing can be studied under the following headings:

Metaparadigm (Person, Environment, Health & Nursing) – (Most abstract)

Nursing philosophies.

Conceptual models and Grand theories.

Nursing theories and Middle range theories (Least abstract)

DEFINITIONS

Definitions

Theory o a set of related statements that describes or explains

phenomena in a systematic way

Concept

o a mental idea of a phenomenon

o Concepts are the building blocks—the primary elements—of a theory.

Construct-

o a phenomena that cannot be observed and must be inferred

o Constructs are concepts developed or adopted for use in a particular theory. The key concepts of a given theory are its constructs.

Proposition

o a statement of relationship between concepts

Conceptual model-

o made up of concepts and propositions

o They epresent ways of thinking about a problem or ways of representing how complex things work the way that they do.

o Different Frameworks will emphasize different variables and outcomes and their interrelatedness.( Bordage, 2009)

o Models may draw on a number of theories to help understand a particular problem in a certain setting or context. They are not always as specified as theory.

Variables

o Variables are the operational forms of constructs. They define the way a construct is to be measured in a specific situation.

o Match variables to constructs when identifying what needs to be assessed during evaluation of a theory-driven program.

NURSING PHILOSOPHIES

Theory Key emphasis

Florence Nightingale’s Legacy of caring

Focuses on nursing and the patient environment relationship.

Ernestine Wiedenbach: The helping art of clinical nursing

Helping process meets needs through the art of individualizing care.

Nurses should identify patients ‘need-for –help’ by:

Observation Understanding client behaviour

Identifying cause of discomfort

Determining if clients can resolve problems or have a need for help

Virginia Henderson’s Definition of Nursing

Patients require help towards achieving independence.

Derived a definition of nursing

Identified 14 basic human needs on which nursing care is based.

Faye G.Abedellah’s Typology of twenty one Nursing problems

Patient’s problems determine nursing care

Lydia E. Hall :Care, Cure, Core model

Nursing care is person directed towards self love.

Jean Watson’s Philosophy and Science of caring

Caring is moral ideal: mind -body – soul engagement with one and other.

Caring is a universal, social phenomenon that is only effective when practiced interpersonally considering humanistic aspects and caring.

Patricia Benner’s Primacy of caring

Caring is central to the essence of nursing. It sets up what matters, enabling connection and concern. It creates possibility for mutual helpfulness.

Caring creates - possibilities of coping possibilities for connecting with and concern for others, possibilities for giving and receiving help

Described systematically five stages of skill acquisition in nursing practice – novice, advanced beginner, competent, proficient and expert.

CONCEPTUAL MODELS AND GRAND THEORIESDorothea E. Orem’s Self care deficit theory in nursing

Self–care maintains wholeness.

Three Theories:

Theory of Self-Care

Theory of Self-Care Deficit

Theory of Nursing Systems

Wholly compensatory (doing for the patient)

Partly compensatory (helping the patient do for himself or herself)

Supportive- educative (Helping patient to learn self care and emphasizing on the importance of nurses’ role

Myra Estrin Levine’s: The conservation model

Holism is maintained by conserving integrity

Proposed that the nurses use the principles of conservation of:

Client Energy Personal integrity

Structural integrity

Social integrity

A conceptual model with three nursing theories –

Conservation

Redundancy

Therapeutic intention

Martha E.Roger’s: Science of unitary human beings

Person environment are energy fields that evolve negentropically

Martha proposed that nursing was a basic scientific discipline

Nursing is using knowledge for human betterment.

The unique focus of nursing is on the unitary or irreducible human being and the environment (both are energy fields) rather than health and illness

Dorothy E.Johnson’s Behavioural system model

Individuals maintain stability and balance through adjustments and adaptation to the forces that impinges them.

Individual as a behavioural system is composed of seven subsystems.

Attachment, or the affiliative subsystems – is the corner stone of social organisations.

Behavioural system also includes the subsystems of dependency, achievement, aggressive, ingestive-eliminative and sexual.

Disturbances in these causes nursing problems.

Sister Callista: Roy‘s Adaptation model

Stimuli disrupt an adaptive system

The individual is a biopsychosocial adaptive system within an environment.

The individual and the environment provide three classes of stimuli-the focal, residual and contextual.

Through two adaptive mechanisms, regulator and cognator, an individual demonstrates adaptive responses or ineffective responses requiring nursing interventions

Betty Neuman’s : Health Reconstitution is a status of adaptation to

care systems model stressors

A conceptual model with two theories “Optimal patient stability and prevention as intervention”

Neuman’s model includes intrapersonal, interpersonal and extrapersonal stressors.

Nursing is concerned with the whole person.

Nursing actions (Primary, Secondary, and Tertiary levels of prevention) focuses on the variables affecting the client’s response to stressors.

Imogene King’s Goal attainment theory

Transactions provide a frame of reference toward goal setting.

A conceptual model of nursing from which theory of goal attainment is derived.

From her major concepts (interaction, perception, communication, transaction, role, stress, growth and development) derived goal attainment theory.

· Perceptions, Judgments and actions of the patient and the nurse lead to reaction, interaction, and transaction (Process of nursing).

Nancy Roper, WW.Logan and A.J.Tierney A model for nursing based on a model of living

Individuality in living.

A conceptual model of nursing from which theory of goal attainment is derived.

Living is an amalgam of activities of living (ALs).

Most individuals experience significant life events which can affect ALs causing actual and potential problems.

This affects dependence – independence

continuum which is bi-directional.

Nursing helps to maintain the individuality of person by preventing potential problems, solving actual problems and helping to cope.

Hildegard E. Peplau: Psychodynamic Nursing Theory

Interpersonal process is maturing force for personality.

Stressed the importance of nurses’ ability to understand own behaviour to help others identify perceived difficulties.

The four phases of nurse-patient relationships are:

1. Orientation

2. Identification

3. Exploitations

4. Resolution

The six nursing roles are:

1. Stranger 2. Resource person

3. Teacher

4. Leader

5. Surrogate

6. Counselor

Ida Jean Orlando’s Nursing Process Theory

Interpersonal process alleviates distress.

Nurses must stay connected to patients and assure that patients get what they need, focused on patient’s verbal and non verbal expressions of need and nurse’s reactions to patient’s behaviour to alleviate distress.

Elements of nursing situation:

1. Patient

2. Nurse reactions

3. Nursing actions

Joyce Travelbee’s Human To Human Relationship Model

Therapeutic human relationships.

Nursing is accomplished through human to human relationships that began with: The original encounter and then progressed through stages of

Emerging identities

Developing feelings of empathy and sympathy, until the nurse and patient attained rapport in the final stage.

Kathryn E. Barnard’s Parent Child Interaction Model

Growth and development of children and mother–infant relationships

Individual characteristics of each member influence the parent–infant system and adaptive behaviour modifies those characteristics to meet the needs of the system.

Ramona T.Mercer’s :Maternal Role Attainment

Parenting and maternal role attainment in diverse populations

A complex theory to explain the factors impacting the development of maternal role over time.

Katharine Kolcaba’s Theory of comfort

Comfort is desirable holistic outcome of care.

Health care needs are needs for comfort, arising from stressful health care situations that cannot be met by recipients’ traditional support system.

These needs include physical, psycho spiritual, social and environmental needs.

Comfort measures include those nursing interventions designed to address the

specific comfort needs.

Madeleine Leininger’s

Transcultural nursing, culture-care theory

Caring is universal and varies transculturally.

Major concepts include care, caring, culture, cultural values and cultural variations

Caring serves to ameliorate or improve human conditions and life base.

Care is the essence and the dominant, distinctive and unifying feature of nursing

Rosemarie Rizzo Parse’s :Theory of human becoming

Indivisible beings and environment co-create health.

A theory of nursing derived from Roger’s conceptual model.

Clients are open, mutual and in constant interaction with environment.

The nurse assists the client in interaction with the environment and co creating health

Nola J.Pender’s :The Health promotion; model

Promoting optimum health supersedes disease prevention.

Identifies cognitive, perceptual factors in clients which are modified by demographical and biological characteristics, interpersonal influences, situational and behavioural factors that help predict in health promoting behaviour

CONCLUSION

The conceptual and theoretical nursing models help to provide knowledge to improve practice, guide research and curriculum and identify the goals of nursing practice. The state of art and science of nursing theory is one of continuing growth. Using the internet the nurses of the world can share ideas and knowledge, carrying on the work begun by nursing theorists and continue the growth and development of new nursing knowledge. It is important the nursing knowledge is learnt, used, and applied in the theory based practice for the profession and the continued development of nursing and

academic discipline

REFERENCES

1. Donaldson, S. K., & Crowley, D. M. (1978). The discipline of nursing. Nursing Outlook, 26, 113–120.

2. Smith, M. J., & Liehr, P. R. (2008). Middle range theory for nursing. New York: Springer Publishing.

3. George B. Julia , Nursing Theories- The base for professional Nursing Practice, 3rd ed. Norwalk, Appleton & Lange.

4. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins.

5. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott.

6. Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

7. Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book.

8. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby, Philadelphia, 2002

9. Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed. Mosby, Philadelphia, 2002.

Development of Nursing Theories

This page was last updated on November 4, 2010============================================

Introduction

Theories are a set of interrelated concepts that give a systematic view of a phenomenon (an observable fact or event) that is explanatory & predictive in nature.

Theories are composed of concepts, definitions, models, propositions & are based on assumptions.

Theory gives planners tools for moving beyond intuition to design and evaluate health behavior and health promotion interventions based on understanding of behavior.[Robert T. Croyle (2005)].

They are derived through two principal methods; deductive reasoning and inductive reasoning.

Nursing theorists use both of these methods.

Theory is “a creative and rigorous structuring of ideas that projects a tentative, purposeful, and systematic view of phenomena”.

A theory makes it possible to “organize the relationship among the concepts to describe, explain, predict, and control practice”

Definition

Concepts are basically vehicles of thought that involve images. Concepts are words that describe objects, properties, or events & are basic components of theory.

Types:

1. Empirical concepts 2. Inferential concepts

3. Abstract concepts

Definitions

Models are representations of the interaction among and between the concepts showing patterns.

Propositions are statements that explain the relationship between the concepts.

Process it is a series of actions, changes or functions intended to bring about a desired result. During a process one takes systemic & continuous steps to meet a goal & uses both assessments & feedback to direct actions to the goal.

A particular theory or conceptual frame work directs how these actions are carried out. The delivery of nursing care within the nursing process is directed by the way specific conceptual frameworks & theories define the person (patient), the environment, health & nursing.

The terms ‘model’ and ‘theory’ are often wrongly used interchangeably, which further confounds matters.

In nursing, models are often designed by theory authors to depict the beliefs in their theory (Lancaster and Lancaster 1981).

They provide an overview of the thinking behind the theory and may demonstrate how theory can be introduced into practice, for example, through specific methods of assessment.

Models are useful as they allow the concepts in nursing theory to be successfully applied to nursing practice (Lancaster and Lancaster 1981). Their main limitation is that they are only as accurate or useful as the underlying theory.

Importance of nursing theories

Nursing theory aims to describe, predict and explain the phenomenon of nursing (Chinn and Jacobs1978).

It should provide the foundations of nursing practice, help to generate further knowledge and indicate in which direction nursing should develop in the future (Brown 1964).

Theory is important because it helps us to decide what we know and what we need to know (Parsons1949).

It helps to distinguish what should form the basis of practice by explicitly describing nursing.

The benefits of having a defined body of theory in nursing include better patient care, enhanced professional status for nurses, improved communication between nurses, and guidance for research and education (Nolan 1996).

The main exponent of nursing – caring – cannot be measured, it is vital to have the theory to analyze and explain what nurses do.

As medicine tries to make a move towards adopting a more multidisciplinary approach to health care, nursing continues to strive to establish a unique body of knowledge.

This can be seen as an attempt by the nursing profession to maintain its professional boundaries.

The characteristics of theories

Theories are:

interrelating concepts in such a way as to create a different way of looking at a particular phenomenon.

logical in nature.

generalizable.

bases for hypotheses that can be tested.

increasing the general body of knowledge within the discipline through the research implemented to validate them.

used by the practitioners to guide and improve their practice.

consistent with other validated theories, laws, and principles but will leave open unanswered questions that need to be investigated.

Basic processes in the development of nursing theories

Nursing theories are often based on & influenced by broadly applicable processes & theories. Following theories are basic to many nursing concepts.

General System Theory

It describes how to break whole things into parts & then to learn how the parts work together in “systems”. These concepts may be applied to different kinds of systems, e.g. Molecules in chemistry, cultures in sociology, and organs in Anatomy & Health in Nursing.

Adaptation Theory

It defines adaptation as the adjustment of living matter to other living things & to environmental conditions.

Adaptation is a continuously occurring process that effects change & involves interaction & response.

Human adaptation occurs on three levels :

1. The internal (self) 2. The social (others) &

3. the physical (biochemical reactions)

Developmental Theory

It outlines the process of growth & development of humans as orderly & predictable, beginning with conception & ending with death.

The progress & behaviors of an individual within each stage are unique.

The growth & development of an individual are influenced by heredity, temperament, emotional, & physical environment, life experiences & health status.

Common concepts in nursing theories

Four concepts common in nursing theory that influence & determine nursing practice are:

The person (patient). The environment

Health

Nursing (goals, roles, functions)

Each of these concepts is usually defined & described by a nursing theorist, often uniquely; although these concepts are common to all nursing theories. Of the four concepts, the most important is that of the person. The focus of nursing, regardless of definition or theory, is the person.

Historical perspectives and key concepts

1. Nightingale (1860): To facilitate “the body’s reparative processes” by manipulating client’s environment

2. Peplau 1952: Nursing is; therapeutic interpersonal process.

3. Henderson 1955: The needs often called Henderson’s 14 basic needs

4. Abdellah 1960: The nursing theory developed by Faye Abdellah et al (1960) emphasizes delivering nursing care for the whole person to meet the physical, emotional, intellectual, social, and spiritual needs of the client and family.

5. Orlando 1962: To Ida Orlando (1960), the client is an individual; with a need; that, when met, diminishes distress, increases adequacy, or enhances well-being.

6. Johnson’s Theory 1968: Dorothy Johnson’s theory of nursing 1968 focuses on how the client adapts to illness and how actual or potential stress can affect the ability to adapt. The goal of nursing to reduce stress so that; the client can move more easily through recovery.

7. Rogers 1970: to maintain and promote health, prevent illness, and care for and rehabilitate ill and disabled client through “humanistic science of nursing”

8. Orem1971: This is self-care deficit theory. Nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental, or social needs.

9. King 1971: To use communication to help client reestablish positive adaptation to environment.

10. Neuman 1972: Stress reduction is goal of system model of nursing practice.

11. Roy 1979: This adaptation model is based on the physiological, psychological, sociological and dependence-independence adaptive modes.

12. Watson’s Theory 1979: Watson’s philosophy of caring 1979 attempts to define the outcome of nursing activity in regard to the; humanistic aspects of life.

Classification of nursing theories

A. Depending On Function (Polit et al 2001)

1. Descriptive-to identify the properties and workings of a discipline2. Explanatory-to examine how properties relate and thus affect the discipline

3. Predictive-to calculate relationships between properties and how they occur

4. Prescriptive -to identify under which conditions relationships occur

B. Depending on the Generalisability of their principles

1. Metatheory: the theory of theory. Identifies specific phenomena through abstract concepts.

2. Grand theory: provides a conceptual framework under which the key concepts and

C. Principles of the discipline can be identified.

1. Middle range theory: is more precise and only analyses a particular situation with a limited number of variables.

2. Practice theory: explores one particular situation found in nursing. It identifies explicit goals and details how these goals will be achieved.

D. Based on the philosophical underpinnings of the theories

1. “Needs “theories.2. “Interaction” theories.

3. “Outcome “theories.

4. Humanistic theories.

1. “Needs” theories

These theories are based around helping individuals to fulfill their physical and mental needs. Needs theories have been criticized for relying too much on the medical model of health and placing the patient in an overtly dependent position.

2.“Interaction” theories

As described by Peplau (1988), these theories revolve around the relationships nurses form with patients.

Such theories have been criticized for largely ignoring the medical model of health and not attending to basic physical needs.

3. “Outcome” theories"

Oucome theories portray the nurse as the changing force, who enables individuals to adapt to or cope with ill health.

Outcome theories have been criticized as too abstract and difficult to implement in practice.

4. “Humanistic” Theories

Humanistic theories developed in response to the psychoanalytic thought that a person’s destiny was determined early in life.

Humanistic theories emphasize a person’s capacity for self-actualization. Humanists believe that the person contains within himself the potential for healthy &

creative growth.

Carl Rogers developed a person –centered model of psychotherapy that emphasizes the uniqueness of the individual.

The major contribution that Rogers added to nursing practice is the understandings that each client is a unique individual, so, person-centered approach now practice in nursing.

Models of nursing

A model, as an abstraction of reality, provides a way to visualize reality to simplify thinking.

A conceptual model shows how various concepts are interrelated and applies theories to predict or evaluate consequences of alternative actions.

According to Fawcett (2000),

A conceptual model “gives direction to the search for relevant questions about the phenomena of central interest to a discipline and suggests solutions to practical problems”

Four concepts are generally considered central to the discipline of nursing: the person who receives nursing care (the patient or client); the environment (society); nursing (goals, roles, functions); and health. These four concepts form a metaparadigm of nursing.

The term metaparadigm comes from the Greek prefix “meta,” which means more comprehensive or transcending, and the word Greek word “paradigm,” which means a philosophical or theoretical framework of a discipline upon which all theories, laws, and generalizations are formulated (Merriam-Webster’s Collegiate Dictionary, 1994).

Categories of Conceptual Models

Ten conceptual models of nursing have been classified according to two criteria:

the world view of change reflected by the model (growth or stability); and the major theoretical conceptual classification with which the model seems most

consistent (systems, stress/adaptation, caring, or growth/development).

1.Systems Theory as a Framework

Systems theory is concerned with changes caused by interactions among all the factors (variables)

General systems theory states

A system is defined as “a whole with interrelated parts, in which the parts have a function and the system as a totality has a function”.

A general systems approach allows for consideration of the subsystems levels of the human being, as a total human being, and as a social creature who networks himself with others in hierarchically arranged human systems of increasing complexity. Thus the human being, from the level of the individual to the level of society, can be conceptualized as the client and becomes the target system for nursing intervention (Sills & Hall, 1977).

An example of systems interaction

Input (Diet teaching) Throughput (Assimilation of information)

Output (Food intake)

Feedback (Weight record, Hb estimation etc.)

Two nursing models based on systems theory:

1. Imogene King’s systems interaction model, and 2. Betty Neuman’s health care systems model.

Major Concepts as Defined in King’s Model

Person (Human Being)

A personal system that interacts with interpersonal and social systems

EnvironmentA context “within which human beings grow, develop, and perform daily activities”

Healthdynamic life experiences of a human being, which implies continuous adjustment to stressors in the internal and external environment through optimum use of one’s resources to achieve maximum potential for daily living”

Nursing A process of human interaction

Imogene King’s Systems Interaction Model

In interaction model, the purpose of nursing is to help people attain, maintain, or restore health. King’s model conceptualizes three levels of dynamic interacting systems.

1. Individuals are called “personal systems.”

2. Groups (two or more persons) form “interpersonal systems.”

3. Society is composed of “social systems.”

As the person interacts with the environment, he or she must continuously adjust to stressors in the internal and external environment (King, 1981).

Health assumes achievement of maximum potential for daily living and an ability to function in social roles. It is the “dynamic life experiences of a human being, which implies continuous adjustment to stressors in the internal and external environment through optimum use of one’s resources to achieve maximum potential for daily living” (King, 1981,).

“Illness is a deviation from normal, that is, an imbalance in a person’s biological structure or in his psychological makeup, or a conflict in a person’s social relationships” (King, 1989).

“The goal of nursing is to help individuals and groups attain, maintain, and restore health”

Stress: “a dynamic state whereby a human being interacts with the environment to maintain balance for growth, development, and performance”

Betty Neuman’s Health Care Systems Model

Betty Neuman specifies that the purpose of nursing is to facilitate optimal client system stability.

Normal line of defense: an adaptational level of health considered normal for an individual

Lines of resistance: protection factors activated when stressors have penetrated the normal line of defense

Neuman’s model, organized around stress reduction, is concerned primarily with how stress and the reactions to stress affect the development and maintenance of health.

The person is a composite of physiologic, psychological, sociocultural, developmental, and spiritual variables considered simultaneously.

“Ideally the five variables function harmoniously or are stable in relation to internal and external environmental stressor influences” (Neuman, 2002).

A person is constantly affected by stressors from the internal, external, or created environment.

Stressors are tension-producing stimuli that have the potential to disturb a person’s equilibrium or normal line of defense.

This normal line of defense is the person’s “usual steady state.”

It is the way in which an individual usually deals with stressors.

Stressors may be of three types:

1. Intrapersonal: forces arising from within the person2. Interpersonal: forces arising between persons

3. Extrapersonal: forces arising from outside the person

Resistance to stressors is provided by a flexible line of defense, a dynamic protective buffer made up of all variables affecting a person at any given moment the person’s resistance to any given stressor or stressors.

If the flexible line of defense is no longer able to protect the person against a stressor, the stressor breaks through, disturbs the person’s equilibrium, and triggers a reaction. The reaction may lead toward restoration of balance or toward death.

Neuman intends for the nurse to “assist clients to retain, attain, or maintain optimal system stability” (Neuman, 1996).

Thus, health (wellness) seems to be related to dynamic equilibrium of the normal line of defense, where stressors are successfully overcome or avoided by the flexible line of defense.

Neuman defines illness as “a state of insufficiency with disrupting needs unsatisfied” (Neuman, 2002).

Illness appears to be a separate state when a stressor breaks through the normal line of defense and causes a reaction with the person’s lines of resistance.

Stress/Adaptation Theory as a Framework

In contrast to systems theory, stress and adaptation theories view change caused by person–environment interaction in terms of cause and effect.

The person must adjust to environmental changes to avoid disturbing a balanced existence. Adaptation theory provides a way to understand both how the balance is maintained and the possible effects of disturbed equilibrium.

This theory has been widely applied to explain, predict, and control biologic (physiologic and psychological) phenomenon.

Criticisms of nursing theories

To understand why nursing theory is generally neglected on the wards it is necessary to take a closer look at the main criticisms of nursing theory and the role that nurses play in contributing to its lack of prevalence in practice.

Summarization

Definition Importance of Nursing Theories

The characteristics of theories:

Basic Processes in the Development Of Nursing Theories:

Nursing theories are often based on & influenced

ANA definition of Nursing Practice

Common concepts in Nursing Theories:

Historical Perspectives & Key Concepts

Clasification of Nursing Theories

Models Of Nursing

Growth and Stability Models of Change



A unique body of knowledge


Conclusion

Theory and practice are related. A theory presents a systematic way of understanding events or situations.It is a set of concepts, definitions, and propositions that explain or predict these events or situations by illustrating the relationships between variables.Theories must be applicable to a broad variety of situations. They are, by nature, abstract, and don’t have a specified content or topic area. Like empty coffee cups, theories have shapes and boundaries, but nothing inside. They become useful when filled with practical topics, goals, and problems. [Robert T. Croyle (2005)]

Reference

1. Robert T. Croyle (2005). Theory at a Glance: Application to Health Promotion and Health Behavior (Second Edition). U.S. Department of Health and Human Services, National Institutes of Health. Available at www.thecommunityguide.org.

2. George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton & Lange.





7. Vandemark L.M. Awareness of self & expanding consciousness: using Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul; 27(6) : 605-15

8. Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006 Jul;19(3):22

Virginia Henderson's Need Theory

This page was last updated on March 1, 2011

“Nursing theories mirror different realities, throughout their development; they reflected the interests of nurses of that time.”

Introduction

“The Nightingale of Modern Nursing” “Modern-Day Mother of Nursing.”

"The 20th century Florence Nightingale."

Born in Kansas City, Missouri, in 1897.

Received a Diploma in Nursing from the Army School of Nursing at Walter Reed Hospital, Washington, D.C. in 1921.

Worked at the Henry Street Visiting Nurse Service for 2 years after graduation.

In 1923, started teaching nursing at the Norfolk Protestant Hospital in Virginia

In 1929, entered Teachers College at Columbia University for Bachelor’s Degree in 1932, Master’s Degree in 1934.

Joined Columbia as a member of the faculty, remained until 1948.

Since 1953, a research associate at Yale University School of Nursing.

recipient of numerous recognitions.

Her work influenced the nursing profession throughout the world.

a well known nursing educator and a prolific author.

honorary doctoral degrees from the Catholic University of America, Pace University, University of Rochester, University of Western Ontario, Yale University

In 1985, honored at the Annual Meeting of the Nursing and Allied Health Section of the Medical Library Association.

Died: March 19, 1996.

In 1939, she revised: Harmer’s classic textbook of nursing for its 4th edition, and later wrote the 5th; edition, incorporating her personal definition of nursing (Henderson,1991)

School of thoughts in Nursing Theories-1950-1970

Need theorists Interaction Theorists Outcome theorists

Abdellah

Henderson

Orem

King

Orlando

Peterson and Zderad

Paplau

Travelbee

Wiedenbach

Johnson

Levine

Rogers

Roy

Analysis of nursing theories according to 1st School

Focus Problems

Human beingA set of needs or problems.

A developmental being.

Patient Need Deficit

Orientation Illness, disease

Role of nurse

Dependent on medical practice.

Beginnings of independent functions

Fulfill needs requisites

Decision making Primarily health care professional

Henderson’s Theory Background

Henderson’s concept of nursing was derived form her practice and education therefore, her work is inductive..

She called her definition of nursing her “concept” (Henderson1991)

She emphasized the importance of increasing the patient’s independence so that progress after hospitalization would not be delayed (Henderson,1991)

Virginia Henderson defined nursing as "assisting individuals to gain independence in relation to the performance of activities contributing to health or its recovery" (Henderson, 1966).

She categorized nursing activities into 14 components, based on human needs.

She described the nurse's role as substitutive (doing for the person), supplementary (helping the person), complementary (working with the person), with the goal of helping the person become as independent as possible.

Her definition of nursing was one of the first statements clearly delineating nursing from medicine:

"The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible" (Henderson, 1966).

The 14 components

Breathe normally. Eat and drink adequately. Eliminate body wastes.

Move and maintain desirable postures.

Sleep and rest.

Select suitable clothes-dress and undress.

Maintain body temperature within normal range by adjusting clothing and modifying environment

Keep the body clean and well groomed and protect the integument

Avoid dangers in the environment and avoid injuring others.

Communicate with others in expressing emotions, needs, fears, or opinions.

Worship according to one’s faith.

Work in such a way that there is a sense of accomplishment.

Play or participate in various forms of recreation.

Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities.

The first 9 components are physiological. The tenth and fourteenth are psychological aspects of communicating and learning The eleventh component is spiritual and moral The twelfth and thirteenth components are sociologically oriented to occupation and recreation

Assumption

The major assumptions of the theory are:

"Nurses care for patients until patient can care for themselves once again. Patients desire to return to health, but this assumption is not explicitly stated.

Nurses are willing to serve and that “nurses will devote themselves to the patient day and night” A final assumption is that nurses should be educated at the university level in both arts and sciences.

Henderson’s theory and the four major concepts

1. Individual

Have basic needs that are component of health. Requiring assistance to achieve health and independence or a peaceful death.

Mind and body are inseparable and interrelated.

Considers the biological, psychological, sociological, and spiritual components.

The theory presents the patient as a sum of parts with biopsychosocial needs, and the patient is neither client nor consumer.

2. Environment

Settings in which an individual learns unique pattern for living. All external conditions and influences that affect life and development.

Individuals in relation to families

Minimally discusses the impact of the community on the individual and family.

Supports tasks of private and public agencies Society wants and expects nurses to act for individuals who are unable to function independently. In return she expects society to contribute to nursing education.

Basic nursing care involves providing conditions under which the patient can perform the 14 activities unaided

3. Health

Definition based on individual’s ability to function independently as outlined in the 14 components.

Nurses need to stress promotion of health and prevention and cure of disease.

Good health is a challenge. Affected by age, cultural background, physical, and intellectual capacities, and emotional balance Is the individual’s ability to meet these needs independently?

4. Nursing

Temporarily assisting an individual who lacks the necessary strength, will and knowledge to satisfy 1 or more of 14 basic needs.

Assists and supports the individual in life activities and the attainment of independence.

Nurse serves to make patient “complete” “whole", or "independent."

Henderson's classic definition of nursing:"I say that the nurse does for others what they would do for themselves if they had the strength, the will, and the knowledge. But I go on to say that the nurse makes the patient independent of him or her as soon as possible."

The nurse is expected to carry out physician’s therapeutic plan Individualized care is the result of the nurse’s creativity in planning for care.

Use nursing research

o Categorized Nursing : nursing care

o Non nursing: ordering supplies, cleanliness and serving food.

In the Nature of Nursing “ that the nurse is and should be legally, an independent practitioner and able to make independent judgments as long as s/he is not diagnosing, prescribing treatment for disease, or making a prognosis, for these are the physicians function.”

“Nurse should have knowledge to practice individualized and human care and should be a scientific problem solver.”

In the Nature of Nursing Nurse role is,” to get inside the patient’s skin and supplement his strength will or knowledge according to his needs.”

And nurse has responsibility to assess the needs of the individual patient, help individual meet their health need, and or provide an environment in which the individual can perform activity unaided

Henderson's classic definition of nursing "I say that the nurse does for others what they would do for themselves if they had the strength, the will, and the knowledge.

But I go on to say that the nurse makes the patient independent of him or her as soon as possible."

Henderson’s and Nursing Process

”Summarization of the stages of the nursing process as applied to Henderson’s definition of nursing and to the 14 components of basic nursing care.

Nursing Process Henderson’s 14 components and definition of nursing

Nursing Assessment

Henderson’s 14 components

Nursing Diagnosis Analysis: Compare data to knowledge base of health and disease.

Nursing plan Identify individual’s ability to meet own needs with or without assistance, taking into consideration strength, will or knowledge.

Nursing implementation

Document how the nurse can assist the individual, sick or well.

Nursing implementation

Assist the sick or well individual in to performance of activities in meeting human needs to maintain health, recover from illness, or to aid in peaceful death.

Nursing process Implementation based on the physiological principles, age, cultural background, emotional balance, and physical and intellectual capacities.

Carry out treatment prescribed by the physician.

Nursing evaluation

Henderson’s 14 components and definition of nursing

Use the acceptable definition of ;nursing and appropriate laws related to the practice of nursing.

The quality of care is drastically affected by the preparation and native ability of the nursing personnel rather that the amount of hours of care.

Successful outcomes of nursing care are based on the speed with which or degree to which the patient performs independently the activities of daily living

Comparison with Maslow's Hierarchy of Need

Maslow's Henderson

Physiological needs

Breathe normally

Eat and drink adequately Eliminate by all avenues of elimination Move and maintain desirable posture Sleep and rest Select suitable clothing Maintain body temperature Keep body clean and well groomed and

protect the integument

Safety Needs Avoid environmental dangers and avoid injuring other

Belongingness and love needs

Communicate with others

worship according to one's faith

Esteem needs

Work at something providing a sense of accomplishment

Play or participate in various forms of recreation

Learn, discover, or satisfy curiosity

Characteristic of Henderson’s theory

There is interrelation of concepts in such a way as to create a different way of looking at a particular phenomenon.

Concepts of fundamental human needs, biophysiology, culture, and interaction, communication are borrowed from other discipline.Eg.. Maslow’s Hierarchy of human needs; concept of interaction-communication i.e. nurse-patient relationship

Her definition and components are logical and the 14 components are a guide for the individual and nurse in reaching the chosen goal.

Theories should be relatively simple yet generalizable.

Her work can be applied to the health of individuals of all ages.

Theories can be the bases for hypotheses that can be tested. Her definition of nursing cannot be viewed as theory; therefore, it is impossible to generate testable hypotheses.

However some questions to investigate the definition of nursing and the 14 components may be useful.

Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them.

Her ideas of nursing practice are well accepted throughout the world as a basis for nursing care.

However, the impact of the definition and components has not been established through research.

Theories can be utilized by practitioners to guide and improve their practice.

Ideally the nurse would improve nursing practice by using her definition and 14 components to improve the health of individuals and thus reduce illness.

Usefulness

Nursing education has been deeply affected by Henderson’s clear vision of the functions of nurses.

The principles of Henderson’s theory were published in the major nursing textbooks used from the 1930s through the 1960s, and the principles embodied by the 14 activities are still important in evaluating nursing care in thee21st centaury.

Others concepts that Henderson (1966) proposed have been used in nursing education from the 1930s until the present O'Malley, 1996)

Limitations

Lack of conceptual linkage between physiological and other human characteristics. No concept of the holistic nature of human being.

If the assumption is made that the 14 components prioritized, the relationship among the components is unclear.

Lacks inter-relate of factors and the influence of nursing care.

Assisting the individual in the dying process she contends that the nurse helps, but there is little explanation of what the nurse does.

“Peaceful death” is curious and significant nursing role.

PURPOSES OF NURSING THEORIESIn Practice:

Assist nurses to describe, explain, and predict everyday experiences. Serve to guide assessment, interventions, and evaluation of nursing care.

Provide a rationale for collecting reliable and valid data about the health status of clients, which are essential for effective decision making and implementation.

Help to describe criteria to measure the quality of nursing care.

Help build a common nursing terminology to use in communicating with other health professionals.

Ideas are developed and words are defined.

Enhance autonomy (independence and self-governance) of nursing through defining its own independent functions.

In Education:

Provide a general focus for curriculum design Guide curricular decision making.

In Research:

Offer a framework for generating knowledge and new ideas. Assist in discovering knowledge gaps in the specific field of study.

Offer a systematic approach to identify questions for study; select variables, interpret findings, and validate nursing interventions.

Approaches to developing nursing theory

Borrowing conceptual frameworks from other disciplines.

Inductively looking at nursing practice to discover theories/concepts to explain phenomena.

Deductively looking for the compatibility of a general nursing theory with nursing practice.

Questions from practicing Nurse about using Nursing theory

Practice

Does this theory reflect nursing practice as I know it? Will it support what I believe to be excellent nursing practice?

Can this theory be considered in relation to a wide range of nursing situation?

Personal Interests, Abilities and Experiences

What will it be like to think about nursing theory in nursing practice?

Will my work with nursing theory be worth the effort?

Conclusion

Henderson provides the essence of what she believes is a definition of nursing. She didn’t intend to develop a theory of nursing but rather she attempted to define the

unique focus of nursing.

Her emphasis on basic human needs as the central focus of nursing practice has led to further theory development regarding the needs of the person and how nursing can assist in meeting those needs.

Her definition of nursing and the 14 components of basic nursing care are uncomplicated and self-explanatory.

References

1. Timber BK. Fundamental skills and concepts in Patient Care, 7th edition, LWW, N 2. George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed.

Norwalk, Appleton & Lange.







9. Delaune SC,. Ladner PK, Fundamental of nursing, standard and practice, 2nd edition, Thomson, NY, 2002

Faye Glenn Abdellah's Theory

Twenty-One Nursing Problems This page was last updated on March 1, 2011

INTRODUCTION

Faye Glenn Abdellah, pioneer nursing researcher, helped transform nursing theory, nursing care and nursing education

Birth:1919

Dr Abdellah worked as Deputy Surgeon General in US and Chief Nurse Officer for the US Public Health Service , Department of Health and human services, Washington, D.C.

She was a leader in nursing research and has over one hundred publications related to nursing care, education for advanced practice in nursing and nursing research.

According to her, nursing is based on an art and science that mould the attitudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people , sick or well, cope with their health needs.

As per Abdellah, nursing as a comprehensive service includes:

1. Recognizing the nursing problems of the patient 2. Deciding the appropriate course of action to take in terms of relevant nursing principles

3. Providing continuous care of the individuals total needs

4. Providing continuous care to relieve pain and discomfort and provide immediate security for the individual

5. Adjusting the total nursing care plan to meet the patient’s individual needs

6. Helping the individual to become more self directing in attaining or maintaining a healthy state of mind & body

7. Instructing nursing personnel and family to help the individual do for himself that which he can within his limitations

8. Helping the individual to adjust to his limitations and emotional problems

9. Working with allied health professions in planning for optimum health on local, state, national and international levels

10. Carrying out continuous evaluation and research to improve nursing techniques and to develop new techniques to meet the health needs of people

(In 1973, the item 3, - “providing continuous care of the individual’s total health needs” was eliminated.)

PHILOSOPHICAL UNDERPINNINGS OF THE THEORY

Abdellah’s patient-centred approach to nursing was developed inductively from her practice and is considered a human needs theory.

The theory was created to assist with nursing education and is most applicable to the education of nurses.

Although it was intended to guide care of those in the hospital, it also has relevance for nursing care in community settings.

MAJOR ASSUMPTIONS, CONCEPTS & RELATIONSHIPS

The language of Abdellah’s framework is readable and clear. She uses the term ‘she’ for nurses, ‘he’ for doctors and patients, and refers to the object

of nursing as ‘patient’ rather than client or consumer.

She referred to Nursing diagnosis during a time when nurses were taught that diagnosis was not a nurses’ prerogative.

Assumptions were related to

change and anticipated changes that affect nursing; the need to appreciate the interconnectedness of social enterprises and social problems;

the impact of problems such as poverty, racism, pollution, education, and so forth on health care delivery;

changing nursing education

continuing education for professional nurses

development of nursing leaders from under reserved groups

Abdellah and colleagues developed a list of 21 nursing problems.They also identified 10 steps to identify the client’s problems. 11 nursing skills to be used in developing a treatment typology

10 steps to identify the client’s problems

Learn to know the patient Sort out relevant and significant data

Make generalizations about available data in relation to similar nursing problems presented by other patients

Identify the therapeutic plan

Test generalizations with the patient and make additional generalizations

Validate the patient’s conclusions about his nursing problems

Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting his behavior

Explore the patient’s and family’s reaction to the therapeutic plan and involve them in the plan

Identify how the nurses feels about the patient’s nursing problems

Discuss and develop a comprehensive nursing care plan

11 nursing skills

Observation of health status Skills of communication

Application of knowledge

Teaching of patients and families

Planning and organization of work

Use of resource materials

Use of personnel resources

Problem-solving

Direction of work of others

Therapeutic use of the self

Nursing procedure

21 NURSING PROBLEMS

Three major categories

Physical, sociological, and emotional needs of clients Types of interpersonal relationships between the nurse and patient

Common elements of client care

BASIC TO ALL PATIENTS

To maintain good hygiene and physical comfort To promote optimal activity: exercise, rest and sleep

To promote safety through the prevention of accidents, injury, or other trauma and through the prevention of the spread of infection

To maintain good body mechanics and prevent and correct deformity

SUSTENAL CARE NEEDS

To facilitate the maintenance of a supply of oxygen to all body cells To facilitate the maintenance of nutrition of all body cells

To facilitate the maintenance of elimination

To facilitate the maintenance of fluid and electrolyte balance

To recognize the physiological responses of the body to disease conditions

To facilitate the maintenance of regulatory mechanisms and functions

To facilitate the maintenance of sensory function.

REMEDIAL CARE NEEDS

To identify and accept positive and negative expressions, feelings, and reactions To identify and accept the interrelatedness of emotions and organic illness

To facilitate the maintenance of effective verbal and non verbal communication

To promote the development of productive interpersonal relationships

To facilitate progress toward achievement of personal spiritual goals

To create and / or maintain a therapeutic environment

To facilitate awareness of self as an individual with varying physical , emotional, and developmental needs

RESTORATIVE CARE NEEDS

To accept the optimum possible goals in the light of limitations, physical and emotional To use community resources as an aid in resolving problems arising from illness

To understand the role of social problems as influencing factors in the case of illness

ABDELLAH’S THEORY AND THE FOUR MAJOR CONCEPTS

NURSING

Nursing is a helping profession. In Abdellah’s model, nursing care is doing something to or for the person or providing

information to the person with the goals of meeting needs, increasing or restoring self-help ability, or alleviating impairment.

Nursing is broadly grouped into the 21 problem areas to guide care and promote use of nursing judgment.

She considers nursing to be comprehensive service that is based on art and science and aims to help people, sick or well, cope with their health needs.

PERSON

Abdellah describes people as having physical, emotional, and sociological needs. These needs may overt, consisting of largely physical needs, or covert, such as emotional and social needs.

Patient is described as the only justification for the existence of nursing.

Individuals (and families) are the recipients of nursing

Health, or achieving of it, is the purpose of nursing services.

HEALTH

In Patient–Centered Approaches to Nursing, Abdellah describes health as a state mutually exclusive of illness.

Although Abdellah does not give a definition of health, she speaks to “total health needs” and “a healthy state of mind and body” in her description of nursing as a comprehensive service.

SOCIETY AND ENVIRONMENT

Society is included in “planning for optimum health on local, state, national, and international levels”. However, as she further delineated her ideas, the focus of nursing service is clearly the individual.

The environment is the home or community from which patient comes.

ABDELLAH’S WORK AND CHARACTERISTICS OF A THEORY

Characteristic 1

Abdellah’s theory has interrelated the concepts of health, nursing problems, and problem solving as she attempts to create a different way of viewing nursing phenomenon

Nursing is the use of problem solving approach with key nursing problems related to health needs of people.

Characteristic 2

Problem solving is an activity that is inherently logical in nature.

Characteristic 3

Framework focus on nursing practice and individuals.

Characteristic 4

The role of client within the framework.

Characteristic 5

The results of testing such hypothesis would contribute to the general body of nursing knowledge

Characteristic 6

Abdellah’s problem solving approach can easily be used by practitioners to guide various activities within their practice that deals with clients who have specific needs and specific nursing problems.

Characteristic 7

Although consistency with other theories exist, many questions remain unanswered

USE OF 21 PROBLEMS IN THE NURSING PROCESS

ASSESSMENT PHASE

Nursing problems provide guidelines for the collection of data.

A principle underlying the problem solving approach is that for each identified problem, pertinent data are collected.

The overt or covert nature of the problems necessitates a direct or indirect approach, respectively.

NURSING DIAGNOSIS

The results of data collection would determine the client’s specific overt or covert problems.

These specific problems would be grouped under one or more of the broader nursing problems.

This step is consistent with that involved in nursing diagnosis

PLANNING PHASE

The statements of nursing problems most closely resemble goal statements. Once the problem has been diagnosed, the nursing goals have been established.

IMPLEMENTATION

Using the goals as the framework, a plan is developed and appropriate nursing interventions are determined.

EVALUATION

The most appropriate evaluation would be the nurse progress or lack of progress toward the achievement of the stated goals

CONCEPT OF PROGRESSIVE PATIENT CARE

PPC is defined as better patient care through the organization of hospital facilities, services and staff around the changing medical and nursing needs of the patient

PPC is tailoring of hospital services to meet patients needs

PPC is caring for the right patient in the right bed with the right services at the right time

PPC is systematic classification of patients based on their medical needs

ELEMENTS OF PPC

INTENSIVE CARE

Critically and seriously ill patients requiring highly skilled nursing care, close and frequent if not constant, nursing observation are assigned to the ICU. One patient in an ICU requires at least three nurses to observe him in 24 hrs

Intermediate care Patients assigned to this unit are both the moderately ill and those for whom the treatment can only be palliative

Self care Ambulatory patients who are convalescencing or require diagnosis or therapy may be cared for in this unit

Long term care unit This unit will provide services to certain patients now cared for in the general hospital, in nursing homes, or in their own homes and who would benefit by care in a hospital environment to achieve its maximum potential

Home care This programme makes it possible to extend needed services to the patient after he leaves the hospital and returns to his home in the community

BENEFITS OF PPCPATIENT

better attention better adjustment

minimized problems

life saving care

constant medical and nursing care

PHYSICIAN

assuring best nursing care drugs and equipments at hand

orders carried out effectively

better clinical an team service

HOSPITAL

effective and efficient use of staff improved public image

NURSING PERSONNEL

individual skills can be used more time with patient

helping pt. and family to solve problems

job satisfaction

in-service education

COMMUNITY

continuity with hospital services minimize the need of hospitalization

IMPLICATIONS OF PPC FOR NURSING EDUCATION

Many nurse educators feel that the PPC hospital where all five phases of care are available can provide clinical experience in which the nurse can learn to solve basic nursing problems in meeting patients’ needs.

The three month assignment of professional nurses may no longer be realistic in such a setting.

Organization of hospital and community services based on patients needs

In the intensive care unit, the critically ill patients are concentrated regardless of diagnosis.

These patients are under the constant audio-visual observation of the nurse, with life saving techniques and equipment immediately available

In the intermediate care unit are concentrated patients requiring a moderate amount of nursing care, not of an emergency nature, who are ambulatory for short periods, and who are beginning to participate in he planning of their own care

The self-care unit provides for patients who are physically self-sufficient and require diagnostic and convalescent care in hotel-type accommodations. This unit serves as a link between the hospital and the home.

In the long-term care unit are concentrated patients requiring prolonged care. The grouping of such patients will permit staffing patterns that are less costly

Home care, the fifth element of progressive patient care, extends hospital services into the home to assist the physician in the care of his patients

USEFULNESS

The patient centered approach was constructed to be useful to nursing practice, with impetus for it being nursing education.

Abdellah’s publications on nursing education began with her dissertation; her interest in education for nurses continues into the present.

Abdellah has also published on nursing, nursing research, and public policy related to nursing in several international publications. She has been a strong advocate for improving nursing practice through nursing research

VALUE IN EXTENDING NURSING SCIENCE

It helped to bring structure and organization to what was often a disorganized collection of lectures and experiences.

She categorized nursing problems based on the individual’s needs and developed developed a typology of nursing treatment and nursing skills..

NURSING RESEARCH

She has been a leader in nursing research and has over one hundred publications related to nursing care, education for advanced practice in nursing and nursing research.

LIMITATIONS

Very strong nursing centered orientation Little emphasis on what the client is to achieve

Her framework is inconsistent with the concept of holism Potential problems might be overlooked

CONCLUSIONS

Using Abdellah’s concepts of health, nursing problems, and problem solving, the theoretical statement of nursing that can be derived is the use of the problem solving approach with key nursing problems related to health needs of people.

From this framework, 21 nursing problems were developed

Abdellah’s theory provides a basis for determining and organizing nursing care. The problems also provide a basis for organizing appropriate nursing strategies.

It is anticipated that by solving the nursing problems, the client would be moved toward health. The nurse’s philosophical frame of reference would determine whether this theory and the 21 nursing problems could be implemented in practice.

REFERENCES

1. George Julia B. Nursing theories: The base of professional nursing practice 3rd edition. Norwalk, CN: Appleton and Lange; 1990.

2. Abdellah, F.G. The federal role in nursing education. Nursing outlook. 1987, 35(5),224-225.

3. Abdellah, F.G. Public policy impacting on nursing care of older adults .In E.M. Baines (Ed.), perspectives on gerontological nursing. Newbury, CA: Sage publications. 1991.

4. Abdellah, F.G., & Levine, E. Preparing nursing research for the 21st century. New York: Springer. 1994.

5. Abdellah, F.G., Beland, I.L., Martin, A., & Matheney, R.V. Patient-centered approaches to nursing (2nd ed.). New York: Mac Millan. 1968.

6. Abdellah, F.G. Evolution of nursing as a profession: perspective on manpower development. International Nursing Review, 1972); 19, 3..

7. Abdellah, F.G.). The nature of nursing science. In L.H. Nicholl (Ed.), perspectives on nursing theory. Boston: Little, Brown, 1986.

Jean Watson's Philosophy of Nursing

This page was last updated on February 21, 2011

Introduction

Born: West Virginia Educated: BSN, University of Colorado, 1964, MS, University of Colorado, 1966, PhD,

University of Colorado, 1973

Distinguished Professor of Nursing and endowed Chair in Caring Science at the University of Colorado Health Sciences Center.

Fellow of the American Academy of Nursing.

Previously, Dean of Nursing at the University Health Sciences Center and President of the National League for Nursing

Dr. Watson has earned undergraduate and graduate degrees in nursing and psychiatric-mental health nursing and PhD in educational psychology and counseling.

widely published author and recipient of several awards and honors, -international Kellogg Fellowship in Australia, Fulbright Research Award in Sweden and six (6) Honorary Doctoral Degrees, including 3 International Honorary Doctorates (Sweden, United Kingdom, Quebec, Canada).

Her research has been in the area of human caring and loss.

The foundation of Jean Watson’s theory of nursing was published in 1979 in nursing: “The philosophy and science of caring”

In 1988, her theory was published in “nursing: human science and human care”.

Major Concepts

-main focus in nursing is on carative factors. -for nurses to develop humanistic philosophies and value system, a strong liberal arts

background is necessary.

the caring stance that nursing has always held is being threatened by the tasks and technology demands of the curative factors

The seven assumptions Caring can be effectively demonstrated and practiced only interpersonally. Caring consists of carative factors that result in the satisfaction of certain human needs.

Effective caring promotes health and individual or family growth.

Caring responses accept person not only as he or she is now but as what he or she may become.

A caring environment is one that offers the development of potential while allowing the person to choose the best action for himself or herself at a given point in time.

Caring is more “ healthogenic” than is curing. A science of caring is complementary to the science of curing.

The practice of caring is central to nursing.

The ten primary carative factors1. The formation of a humanistic- altruistic system of values. 2. The installation of faith-hope.

3. The cultivation of sensitivity to one’s self and to others.

4. The development of a helping-trust relationship

5. The promotion and acceptance of the expression of positive and negative feelings.

6. The systematic use of the scientific problem-solving method for decision making

7. The promotion of interpersonal teaching-learning.

8. The provision for a supportive, protective and /or corrective mental, physical, socio-cultural and spiritual environment.

9. Assistance with the gratification of human needs.

10. The allowance for existential-phenomenological forces.

The first three carative factors form the “philosophical foundation” for the science of caring. The remaining seven carative factors spring from the foundation laid by these first three.

1. The formation of a humanistic- altruistic system of values

Begins developmentally at an early age with values shared with the parents. Mediated through ones own life experiences, the learning one gains and exposure to the

humanities.

Is perceived as necessary to the nurse’s own maturation which then promotes altruistic behavior towards others.

2. Faith-hope Is essential to both the carative and the curative processes. When modern science has nothing further to offer the person, the nurse can continue to

use faith-hope to provide a sense of well-being through beliefs which are meaningful to the individual.

3. Cultivation of sensitivity to one’s self and to others

Explores the need of the nurse to begin to feel an emotion as it presents itself. Development of one’s own feeling is needed to interact genuinely and sensitively with

others.

Striving to become sensitive, makes the nurse more authentic, which encourages self-growth and self-actualization, in both the nurse and those with whom the nurse interacts.

The nurses promote health and higher level functioning only when they form person to person relationship.

4. Establishing a helping-trust relationship Strongest tool is the mode of communication, which establishes rapport and caring. She has defined the characteristics needed to in the helping-trust relationship. These are:

o Congruence

o Empathy

o Warmth

Communication includes verbal, nonverbal and listening in a manner which connotes empathetic understanding.

5. The expression of feelings, both positive and negative

“feelings alter thoughts and behavior, and they need to be considered and allowed for in a caring relationship”.

Awareness of the feelings helps to understand the behavior it engenders.

6. The systematic use of the scientific problem-solving method for decision making

According to Watson, the scientific problem- solving method is the only method that allows for control and prediction, and that permits self-correction.

She also values the relative nature of nursing and supports the need to examine and develop the other methods of knowing to provide an holistic perspective.

The science of caring should not be always neutral and objective.

7. Promotion of interpersonal teaching-learning

The caring nurse must focus on the learning process as much as the teaching process. Understanding the person’s perception of the situation assist the nurse to prepare a

cognitive plan.

8. Provision for a supportive, protective and /or corrective mental, physical, socio-cultural and spiritual environment

Watson divides these into eternal and internal variables, which the nurse manipulates in order to provide support and protection for the person’s mental and physical well-being.

The external and internal environments are interdependent.

Watson suggests that the nurse also must provide comfort, privacy and safety as a part of this carative factor.

9. Assistance with the gratification of human needs

It is grounded in a hierarchy of need similar to that of the Maslow’s. She has created a hierarchy which she believes is relevant to the science of caring in

nursing.

According to her each need is equally important for quality nursing care and the promotion of optimal health.

All the needs deserve to be attended to and valued.

Watson’s ordering of needs Lower order needs (biophysical needs)

o The need for food and fluid

o The need for elimination

o The need for ventilation

Lower order needs (psychophysical needs)

o The need for activity-inactivity

o The need for sexuality

Watson’s ordering of needs

o Higher order needs (psychosocial needs)

o The need for achievement

o The need for affiliation

o Higher order need (intrapersonal-interpersonal need)

o The need for self-actualization

Research findings have established a correlation between emotional distress and illness. According to Watson, the current thinking of holistic care emphasizes that:

o Factors of the etiological component interact and produce change through complex neuro-physiological and neuro-chemical pathways

o Each psychological function has a physiological correlate

o Each physiological component has a psychological correlate

10. Allowance for existential-phenomenological forces

Phenomenology is a way of understanding people from the way things appear to them, from their frame of reference.

Existential psychology is the study of human existence using phenomenological analysis.

This factor helps the nurse to reconcile and mediate the incongruity of viewing the person holistically while at the same time attending to the hierarchical ordering of needs.

Thus the nurse assists the person to find the strength or courage to confront life or death.

Watson’s theory and the four major concepts

1. Human being She adopts a view of the human being as: “….. a valued person in and of him or herself

to be cared for, respected, nurtured, understood and assisted; in general a philosophical view of a person as a fully functional integrated self. He, human is viewed as greater than and different from, the sum of his or her parts”.

2. Health Watson believes that there are other factors that are needed to be included in the WHO

definition of health. She adds the following three elements: A high level of overall physical, mental and social functioning

A general adaptive-maintenance level of daily functioning

The absence of illness (or the presence of efforts that leads its absence)

3. Environment/society According to Watson caring (and nursing) has existed in every society. A caring attitude

is not transmitted from generation to generation. It is transmitted by the culture of the profession as a unique way of coping with its environment.

4. Nursing According to Watson “ nursing is concerned with promoting health, preventing illness,

caring for the sick and restoring health”.

It focuses on health promotion and treatment of disease. She believes that holistic health care is central to the practice of caring in nursing.

She defines nursing as…..“A human science of persons and human health-illness experiences that are mediated by professional, personal, scientific, esthetic and ethical human transactions”.

Watson’s theory and nursing process

Watson points out that nursing process contains the same steps as the scientific research process. They both try to solve a problem. Both provide a framework for decision making. Watson elaborates the two processes as:

1. Assessment Involves observation, identification and review of the problem; use of applicable

knowledge in literature. Also includes conceptual knowledge for the formulation and conceptualization of

framework.

Includes the formulation of hypothesis; defining variables that will be examined in solving the problem.

2. Plan It helps to determine how variables would be examined or measured; includes a

conceptual approach or design for problem solving. It determines what data would be collected and how on whom.

3. Intervention It is the direct action and implementation of the plan. It includes the collection of the data.

4. Evaluation Analysis of the data as well as the examination of the effects of interventions based on

the data. Includes the interpretation of the results, the degree to which positive outcome has

occurred and whether the result can be generalized.

It may also generate additional hypothesis or may even lead to the generation of a nursing theory.

Watson’s work and the characteristic of a theory

According to Watson, “a theory is an imaginative grouping of knowledge, ideas and experiences that are represented symbolically and seek to illuminate a given phenomenon”

She views nursing as,“….both a human science and an art and as such it cannot be considered qualitatively continuous with traditional, reductionistic, scientific methodology”.

She suggests that nursing might want to develop its own science that would not be related to the traditional sciences but rather would develop its own concepts, relationships and methodology.

Theories can interrelate concepts in such a way as to create a different way of looking at a particular phenomenon

The basic assumptions for the science of caring in nursing and the ten carative factors that form the structure for that concept is unique in Watson’s theory.

She describes caring in both philosophical and scientific terms.

Watson also indicates that needs are interrelated.

The science of caring suggests that the nurse recognize and assist with each of the interrelated needs in order to reach the highest order need of self-actualization.

Theories must be logical in nature Watson’s work is logical in that the factors are based on broad assumptions which

provide a supportive framework. With these carative factors she delineates nursing from other professions

These carative factors are logically derived from the assumptions and related to he hierarchy of needs.

Theories should be relatively simple yet generalizable

The theory is relatively simple as it does not use theories from other disciplines that are familiar to nursing.

The theory is simple relatively but the fact that it de-emphasizes the pathophysiological for the psychosocial diminishes its ability to be generalizable.

She discusses this in the preface of her book when she speaks of the “trim” and the “core” of nursing.

She defines trim as the clinical focus, the procedure and the techniques.

The core of the nursing is that which is intrinsic to the nurse-client interaction that produces a therapeutic result. Core mechanisms are the carative factors.

Theories can be the basis for hypotheses that can be tested

Watson’s theory is based on phenomenological studies that generally ask questions rather than state hypotheses. Its purpose is to describe the phenomena, to analyze and to gain an understanding.

Theories contribute to and assist in increasing the general body within the discipline through research implemented to validate them

According to Watson the best method to test this theory is through field study.

An example is her work in the area of loss and caring that took place in Cundeelee, Western Australia and involved a tribe of aborigines.

Theories can be utilized by practitioners to guide and improve their practice

Watson’s work can be used to guide and improve practice. It can provide the nurse with the most satisfying aspects of practice and can provide the

client with the holistic care so necessary for human growth and development.

Theories must be consistent with other validated theories, laws and principles but will leave open unanswered questions that need to be investigated

Watson’s work is supported by the theoretical work of numerous humanists, philosophers, developmentalists and psychologists.

She clearly designates the theories of stress, development, communication, teaching-learning, humanistic psychology and existential phenomenology which provide the foundation for the science of caring.

Strengths Besides assisting in providing the quality of care that client ought to receive, it also

provides the soul satisfying care for which many nurses enter the profession.As the science of caring ranges from the biophysical through the intrapersonal, each nurse becomes an active coparticipant in the client’s struggle towards self-actualization.

The client is placed in the context of the family, the community and the culture.

It places the client as the focus of practice rather than the technology.

Limitations Given the acuity of illness that leads to hospitalization, the short length stay , and the

increasing complex technology, such quality of care may be deemed impossible to give in the hospital.

While Watson acknowledges the need for biophysical base to nursing, this area receives little attention in her writings.

The ten caratiive factors primarily delineate the psychosocial needs of the person.

While the carative factors have a sound foundation based on other disciplines, they need further research in nursing to demonstrate their application to practice.

Research related to Watson’s theory Saint Joseph Hospital in Orange, California has selected Jean Watson’s theory of human

caring as the framework base for nursing practice. The effectiveness of Watson's Caring Model on the quality of life and blood pressure of

patients with hypertension. J Adv Nurs. 2003 Jan;41(2):130-9.

This study demonstrated a relationship between care given according to Watson's Caring model and increased quality of life of the patients with hypertension. Further, in those patients for whom the caring model was practised, there was a relationship between the Caring model and a decrease in patient's blood pressure. The Watson Caring Model is recommended as a guide to nursing patients with hypertension, as one means of decreasing blood pressure and increase in quality of life.

Martin, L. S. (1991). Using Watson’s theory to explore the dimensions of adult polycystic kidney disease . ANNA Journal, 18, 403-406 .

Mullaney, J. A. B. (2000). The lived experience of using Watson’s actual caring occasions to treat depressed women . Journal of Holistic Nursing, 18(2), 129-142

Martin, L. S. (1991). Using Watson’s theory to explore the dimensions of adult polycystic kidney disease . ANNA Journal, 18, 403-406

Conclusion

Watson provides many useful concepts for the practice of nursing. She ties together many theories commonly used in nursing education and does so in a

manner helpful to practioners of the art and science of nursing.

The detailed descriptions of the carative factors can give guidance to those who wish to employ them in practice or research.

Using her theory can add a dimension to practice that is both satisfying and challenging.

References

1. Timber BK. Fundamental skills and concepts in Patient Care, 7th edition, LWW, N 2. George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed.

Norwalk, Appleton & Lange.







9. Cheng MY. Using King's Goal Attainment Theory to facilitate drug compliance in a psychiatric patient. Hu Li Za Zhi. 2006 Jun;53(3):90-7.

10. Delaune SC,. Ladner PK, Fundamental of nursing, standard and practice, 2nd edition, Thomson, NY, 2002.

Johnson's Behaviour System ModelThis page was last updated on January 6, 2011

Introduction

Dorothy E. Johnson was born August 21, 1919, in Savannah, Georgia.

B. S. N. from Vanderbilt University in Nashville, Tennessee, in 1942; and her M.P.H. from Harvard University in Boston in 1948.

From 1949 until her retirement in 1978 she was an assistant professor of pediatric nursing, an associate professor of nursing, and a professor of nursing at the University of California in Los Angeles.

Dorothy Johnson has had an influence on

nursing through her publications since the 1950s.

Johnson stressed the importance of research-based knowledge about the effect of nursing care on clients.

Johnson’s behavior system model

In 1968 Dorothy first proposed her model of nursing care as fostering of “the efficient and effective behavioral functioning in the patient to prevent illness".

She also stated that nursing was “concerned with man as an integrated whole and this is the specific knowledge of order we require”.

In 1980 Johnson published her conceptualization of “behavioral system of model for nursing” this is the first work of Dorothy that explicates her definitions of the behavioral system model.

Definition of nursing

She defined nursing as “an external regulatory force which acts to preserve the organization and integration of the patients behaviors at an optimum level under those conditions in which the behaviors constitutes a threat to the physical or social health, or in which illness is found”

Based on this definition there are four goals of nursing are to assist the patient:

Whose behavior commensurate with social demands.

Who is able to modify his behavior in ways that it supports biological imperatives

Who is able to benefit to the fullest extent during illness from the physicians knowledge and skill.

Whose behavior does not give evidence of unnecessary trauma as a consequence of

illness

Assumptions of behavioral system model

There are several layers of assumptions that Johnson makes in the development of conceptualization of the behavioral system model

There are 4 assumptions of system:

1. First assumption states that there is “organization, interaction, interdependency and integration of the parts and elements of behaviors that go to make up The system ”

2. A system “tends to achieve a balance among the various forces operating within and upon it', and that man strive continually to maintain a behavioral system balance and steady state by more or less automatic adjustments and adaptations to the natural forces impinging upon him.”

3. A behavioral system, which both requires and results in some degree of regularity and constancy in behavior, is essential to man that is to say, it is functionally significant in that it serves a useful purpose, both in social life and for the individual.

4. The final assumption states “system balance reflects adjustments and adaptations that are successful in some way and to some degree.”

The integration of these assumptions provides the behavioral system with the pattern of action to form “an organized and integrated functional unit that determines and limits the interaction between the person and his environment and establishes the relation of the person to the objects, events and situations in his environment.

Assumptions about structure and function of each subsystem

“from the form the behavior takes and the consequences it achieves can be inferred what “drive” has been stimulated or what “goal” is

being sought” Each individual has a “predisposition to act

with reference to the goal, in certain ways rather than the other ways”. This predisposition is called as “set”.

Each subsystem has a repertoire of choices or “scope of action”

The fourth assumption is that it produce “observable outcome” that is the individual’s behavior.

Each subsystem has three functional requirements

System must be “protected" from noxious influences with which system cannot cope”.

Each subsystem must be “nurtured” through the input of appropriate supplies from the environment.

Each subsystem must be “stimulated” for use to enhance growth and prevent stagnation.

Johnson believes each individual has patterned, purposeful, repetitive ways of acting that comprise a behavioral system specific to that individual.

These actions and behaviors form an organized and integrated functional unit that determines and limits the interaction between the person and his environment and establishes the relationship of the person to the objects event situations in the environment.

These behaviors are “orderly, purposeful and predictable and sufficiently stable and recurrent to be amenable to description and explanation”

Johnson’s Behavioral Subsystem

Attachment or affiliative subsystem: “social inclusion intimacy and the formation and attachment of a strong social bond.”

Dependency subsystem: “approval, attention

or recognition and physical assistance”

Ingestive subsystem: “the emphasis is on the meaning and structures of the social events surrounding the occasion when the food is eaten”

Eliminative subsystem: “human cultures have defined different socially acceptable behaviors for excretion of waste ,but the existence of such a pattern remains different from culture to Culture.”

Sexual subsystem:" both biological and social factor affect the behavior in the sexual subsystem”

Aggressive subsystem: " it relates to the behaviors concerned with protection and self preservation Johnson views aggressive subsystem as one that generates defensive response from the individual when life or territory is being threatened”

Achievement subsystem: " provokes behavior that attempt to control the environment intellectual, physical, creative, mechanical and social skills achievement are some of the areas that Johnson recognizes".

Representation of Johnson's Model

Goal ----- Set --- Choice of Behavior --- Behavior

Affiliation Dependency

Sexuality

Aggression

Elimination

Ingestion

Achievement

The four major concepts

Johnson views “human being” as having two major systems, the biological system and the behavioral system. It is role of the medicine to focus on biological system where as Nursling's focus is the behavioral system.

“Society” relates to the environment on which the individual exists. According to Johnson an individual’s behavior is influenced by the events in the environment

“Health” is a purposeful adaptive response, physically mentally, emotionally, and socially to internal and external stimuli in order to maintain stability and comfort.

“Nursing” has a primary goal that is to foster equilibrium within the individual. She stated that nursing is concerned with the organized and integrated whole, but that the major focus is on maintaining a balance in the Behavior system when illness occurs in an individual.

Nursing process

Assessment

Grubbs developed an assessment tool based on Johnson’s seven subsystems plus a subsystem she labeled as restorative which focused on activities of daily living. .An assessment based on behavioral model does not easily permit the nurse to gather detailed information about the biological systems:

Affiliation Dependency

Sexuality

Aggression

Elimination

Ingestion

Achievement

Restorative

Diagnosis

Diagnosis tends to be general to the system than specific to the problem. Grubb has proposed 4 categories of nursing diagnosis derived from Johnson's behavioral system model:

Insufficiency Discrepancy

Incompatibility

Dominance

Planning and implementation

Implementation of the nursing care related to the diagnosis may be difficult because of lack of clients input in to the plan. the plan will focus on nurses actions to modify clients behavior, these plan than have a goal ,to bring about homeostasis in a subsystem, based on nursing assessment of the individuals drive, set behavior, repertoire, and observable behavior. The plan may include protection, nurturance or stimulation of the identified subsystem.

Evaluation

Evaluation is based on the attainment of a goal of balance in the identified subsystems. If the baseline data are available for an individual, the nurse may have goal for the individual to return to the baseline behavior. If the alterations in the behavior that are planned do occur, the nurse should be able to observe the return to the previous behavior patterns. Johnson's behavioral model with the nursing process is a nurse centered activity, with the nurse determining the clients needs and state behavior appropriate for that need.

Assessment

Affiliative subsystem between mother and John.

Dependency subsystem between mother and

John

Affiliative subsystem between Mrs.Kim and her mother.

Insufficiency ingestion subsystem.

Diagnosis

Insufficient development of the affiliative subsystem.

Insufficient development of the dependency subsystem

Planning and implementation

Increasing mother’s awareness of the baby’s clues.

Assisting her to talk with the baby.

Teach her to bring a bond between her and the baby by touch, pat and cuddles etc.

Evaluation

Johnny's weight gain or weight loss will be carefully assessed.

The –infant interaction could be reassessed, using the nursing child assessment feeding scale.

The interaction of Mrs. Kim with her mother.

Johnson’s and Characteristics of a theory

Interrelate concepts to create a different way of viewing a phenomenon.

Theories must be logical in nature.

Theories must be simple yet generalizable

Theories can be bases of hypothesis that can be tested.

Theories contribute to and assist in increasing the body of knowledge within the discipline through the research implemented to validate them

Theories can be utilized by practitioners to guide and improve their practice.

Theories must be consistent with other validated theories, laws and principles but will leave unanswered questions that need to be investigated.

Limitation

Johnson does not clearly interrelate her concepts of subsystems comprising the behavioral system model.

The definition of concept is so abstract that they are difficult to use.

It is difficult to test Johnson's model by development of hypothesis.

The focus on the behavioral system makes it difficult for nurses to work with physically impaired individual to use this theory.

The model is very individual oriented so the nurses working with the group have difficulty in its implementation.

The model is very individual oriented so the family of the client is only considered as an environment.

Johnson does not define the expected outcomes when one of the system is affected by the nursing implementation an implicit expectation is made that all human in all cultures will attain same outcome –homeostasis.

Johnson’s behavioral system model is not flexible.

Summary

Johnson’s Behavioral system model is a model of nursing care that advocates the fostering of efficient and effective behavioral functioning in the patient to prevent illness. The patient is defined as behavioral system composed of 7 behavioral subsystems. Each

subsystem composed of four structural characteristics i.e. drives, set, choices and observable behavior.

Three functional requirement of each subsystem includes

(1) Protection from noxious influences, (2) Provision for the nurturing environment,

and

(3) stimulation for growth.

Any imbalance in each system results in disequilibrium .it is nursing role to assist the client to return to the state of equilibrium.

Reference

1. George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton and Lange.

2. Polit DF, Hungler BP. Nursing Research: Principles and Methods. Philadelphia: JB Lippincott Company; 1998.

3. Burns N, Grove SK. The practice of Nursing Research. 4th Ed. Philadelphia: WB Saunders Publications; 2001.

4. Treece JW, Treece EW. Elements of Research in Nursing (3rded.). St. Louis: Mosby; 1982.

Imogene King's Theory of Goal Attainment

This page was last updated on January 24, 2011================================================

Introduction

Imogene King was born in 1923. Completed her Bachelor in science of nursing from St. Louis University in 1948

Completed her Master of science in nursing from St. Louis University in 1957

Completed her Doctorate from Teacher’s college, Columbia University

King’s Conceptual Framework

It includes:

Several basic assumptions Three interacting systems

Several concepts relevant for each system

Basic assumptions

Nursing focus is the care of human being Nursing goal is the health care of individuals & groups

Human beings: are open systems interacting constantly with their environment

Interacting systems:

o personal system

o Interpersonal system

o Social system

Concepts are given for each system

Concepts for Personal System

Perception Self

Growth & development

Body image

Space

Time

Concepts for Interpersonal System

Interaction Communication

Transaction

Role

Stress

Concepts for Social System

Organization Authority

Power

Status

Decision making

Major Theses of King’s conceptual framework

“Each human being perceives the world as a total person in making transactions with individuals and things in environment”

“Transaction represents a life situation in which perceiver & thing perceived are encountered and in which person enters the situation as an active participant and each is changed in the process of these experiences”

King’s Theory of Goal Attainment

Theory of goal attainment was first introduced by Imogene King in the early 1960’s. Theory describes a dynamic, interpersonal relationship in which a person grows and

develops to attain certain life goals.

Factors which affects the attainment of goal are: roles, stress, space & time

Propositions of King’s Theory

From the theory of goal attainment king developed predictive propositions, which includes:

If perceptual interaction accuracy is present in nurse-client interactions, transaction will occur

If nurse and client make transaction, goal will be attained

If goal are attained, satisfaction will occur

If transactions are made in nurse-client interactions, growth & development will be enhanced

If role expectations and role performance as perceived by nurse & client are congruent, transaction will occur

If role conflict is experienced by nurse or client or both, stress in nurse-client interaction will occur

If nurse with special knowledge skill communicate appropriate information to client, mutual goal setting and goal attainment will occur.

Major concepts of king’s theory

1. Human being /person: is social being who are rational and sentient. Person has ability to :

perceive think

feel

choose

set goals

select means to achieve goals and

to make decision

According to King, human being has three fundamental needs:

(a) The need for the health information that is unable at the time when it is needed and can be used

(b) The need for care that seek to prevent illness, and

(c) The need for care when human beings are unable to help themselves.

2. Health

According to King, health involves dynamic life experiences of a human being, which implies continuous adjustment to stressors in the internal and external environment through optimum use of one’s resources to achieve maximum potential for daily living.

3. Environment

Environment is the background for human interactions. It involves:

(a) Internal environment: transforms energy to enable person to adjust to continuous external environmental changes.

(b) External environment: involves formal and informal organizations. Nurse is a part of the patient’s environment.

4. Nursing

Definition: “A process of action, reaction and interaction by which nurse and client share information about their perception in nursing situation.” and “ a process of human interactions between nurse and client whereby each perceives the other and the situation, and through communication, they set goals, explore means, and agree on means to achieve goals.”

Action: is defined as a sequence of behaviors involving mental and physical action.

Reaction: not specified, but might be considered as included in the sequence of behaviors described in action.

In addition, king discussed:(a) goal(b) domain and(c) functions of professional nurse

Goal of nurse: “To help individuals to maintain their health so they can function in their roles.”

Domain of nurse: “includes promoting, maintaining, and restoring health, and caring for the sick, injured and dying.

Function of professional nurse: “To interpret information in nursing process to plan, implement and evaluate nursing care. King said in her theory, “A professional nurse, with special knowledge and skills, and a client in need of nursing, with knowledge of self and perception of personal problems, meet as strangers in natural environment. They interact mutually, identify problems, establish and achieve goals.

Theory of Goal Attainment and Nursing Process

Assumptions

Basic assumption of goal attainment theory is that nurse and client communicate information, set goal mutually and then act to attain those goals, is also the basic assumption of nursing process

Assessment

King indicates that assessment occur during interaction. The nurse brings special knowledge and skills whereas client brings knowledge of self

and perception of problems of concern, to this interaction.

During assessment nurse collects data regarding client (his/her growth & development, perception of self and current health status, roles etc.)

Perception is the base for collection and interpretation of data.

Communication is required to verify accuracy of perception, for interaction and transaction.

Nursing diagnosis

The data collected by assessment are used to make nursing diagnosis in nursing process. Acc. to king in process of attaining goaI the nurse identifies the problems, concerns and

disturbances about which person seek help.

Planning

After diagnosis, planning for interventions to solve those problems is done. In goal attainment planning is represented by setting goals and making decisions about

and being agreed on the means to achieve goals.

This part of transaction and client’s participation is encouraged in making decision on the means to achieve the goals.

Implementations

In nursing process implementation involves the actual activities to achieve the goals. In goal attainment it is the continuation of transaction.

Evaluation

It involves to finding out weather goals are achieved or not. In king description evaluation speaks about attainment of goal and effectiveness of

nursing care.

Nursing Process and Theory of Goal Attainment

Nursing process method Nursing process theory

A system of oriented actions A system of oriented concepts

AssessmentPerception, communication and interaction of nurse and client

Planning Decision making about the goals Be agree on the means to attain the goals

Implementation Transaction made

Evaluation Goal attained

References

1. Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed. Mosby, Philadelphia, 2002.

2. George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton & Lange.





7. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby, Philadelphia, 2002.

Betty Neuman's System ModelThis page was last updated on February 21, 2011

INTRODUCTION

Betty Neuman’s system model provides a comprehensive flexible holistic and system based perspective for nursing.

It focuses on the response of the client system to actual or potential environmental stressors and the use of primary, secondary and tertiary nursing prevention intervention for retention, attainment, and maintenance of optimal client system wellness.

HISTORY AND BACKGROUND OF THE THEORIST

Betty Neuman was born in 1924, in Lowel, Ohio. BS in nursing in 1957

MS in Mental Health Public health consultation, from UCLA in 1966.

Ph.D. in clinical psychology

a pioneer in the community mental health movement in the late 1960s.

developed the model while working as a lecturer in community health nursing at University of California, Los Angeles.

The models was initially developed in response to graduate nursing students expression of a need for course content that would expose them to breadth of nursing problems prior to focusing on specific nursing problem areas.

The model was published in 1972 as “A Model for Teaching Total Person Approach to Patient Problems” in Nursing Research.

It was refined and subsequently published in the first edition of Conceptual Models for Nursing Practice, 1974, and in the second edition in 1980.

DEVELOPMENT OF THE MODEL

Neuman’s model was influenced by a variety of sources. The philosophy writers deChardin and cornu (on wholeness in system).

Von Bertalanfy, and Lazlo on general system theory.

Selye on stress theory.

Lararus on stress and coping.

BASIC ASSUMPTIONS

Each client system is unique, a composite of factors and characteristics within a given range of responses contained within a basic structure.

Many known, unknown, and universal stressors exist. Each differ in it’s potential for disturbing a client’s usual stability level or normal LOD

The particular inter-relationships of client variables at any point in time can affect the degree to which a client is protected by the flexible LOD against possible reaction to stressors.

Each client/ client system has evolved a normal range of responses to the environment that is referred to as a normal LOD. The normal LOD can be used as a standard from which to measure health deviation.

When the flexible LOD is no longer capable of protecting the client/ client system against an environmental stressor, the stressor breaks through the normal LOD

The client whether in a state of wellness or illness, is a dynamic composite of the inter-relationships of the variables. Wellness is on a continuum of available energy to support the system in an optimal state of system stability.

Implicit within each client system are internal resistance factors known as LOR, which function to stabilize and realign the client to the usual wellness state.

Primary prevention relates to G.K. that is applied in client assessment and intervention, in identification and reduction of possible or actual risk factors.

Secondary prevention relates to symptomatology following a reaction to stressor, appropriate ranking of intervention priorities and treatment to reduce their noxious effects.

Tertiary prevention relates to adjustive processes taking place as reconstitution begins and maintenance factors move the back in circular manner toward primary prevention.

The client as a system is in dynamic, constant energy exchange with the environment.

MAJOR CONCEPTS

Content -

the variables of the person in interaction with the internal and external environment comprise the whole client system

Basic structure/Central core

common client survival factors in unique individual characteristics representing basic system energy resources.

The basis structure, or central core, is made up of the basic survival factors that are common to the species (Neuman,2002).

These factors include:- - Normal temp. range, Genetic structure.- Response pattern. Organ strength or weakness, Ego structure

Stability, or homeostasis, occurs when the amount of energy that is available exceeds that being used by the system.

A homeostatic body system is constantly in a dynamic process of input, output, feedback, and compensation, which leads to a state of balance.

Degree to reaction

the amount of system instability resulting from stressor invasion of the normal LOD.

Entropy

a process of energy depletion and disorganization moving the system toward illness or possible death.

Flexible LOD

a protective, accordion like mechanism that surrounds and protects the normal LOD from invasion by stressors.

Normal LOD

It represents what the client has become over time, or the usual state of wellness. It is considered dynamic because it can expand or contract over time.

Line of Resistance-LOR

The series of concentric circles that surrounds the basic structure. Protection factors activated when stressors have penetrated the normal LOD, causing a

reaction symptomatology. E.g. mobilization of WBC and activation of immune system mechanism

Input- output

The matter, energy, and information exchanged between client and environment that is entering or leaving the system at any point in time.

Negentropy

A process of energy conservation that increase organization and complexity, moving the system toward stability or a higher degree of wellness.

Open system

A system in which there is continuous flow of input and process, output and feedback. It is a system of organized complexity where all elements are in interaction.

Prevention as intervention

Interventions modes for nursing action and determinants for entry of both client and nurse in to health care system.

Reconstitution

The return and maintenance of system stability, following treatment for stressor reaction, which may result in a higher or lower level of wellness.

Stability

A state of balance of harmony requiring energy exchanges as the client adequately copes with stressors to retain, attain, or maintain an optimal level of health thus preserving system integrity.

Stressors

environmental factors, intra (emotion, feeling), inter (role expectation), and extra personal (job or finance pressure) in nature, that have potential for disrupting system stability.

A stressor is any phenomenon that might penetrate both the F and N LOD, resulting either a positive or negative outcome.

Wellness/Illness

Wellness is the condition in which all system parts and subparts are in harmony with the whole system of the client.

o Illness is a state of insufficiency with disrupting needs unsatisfied (Neuman, 2002).

o Illness is an excessive expenditure of energy… when more energy is used by the system in its state of disorganization than is built and stored; the outcome may be death (Neuman, 2002).

Prevention

the primary nursing intervention. Prevention focuses on keeping stressors and the stress response from having a detrimental effect on the body.

PRIMARY PREVENTION

Primary prevention occurs before the system reacts to a stressor. On the one hand, it strengthens the person (primary the flexible LOD) to enable him to better deal with stressors

On the other hand manipulates the environment to reduce or weaken stressors.

Primary prevention includes health promotion and maintenance of wellness.

SECONDARY PREVENTION

Secondary prevention occurs after the system reacts to a stressor and is provided in terms of existing system.

Secondary prevention focuses on preventing damage to the central core by strengthening the internal lines of resistance and/or removing the stressor.

TERTIARY PREVENTION

Tertiary prevention occurs after the system has been treated through secondary prevention strategies.

Tertiary prevention offers support to the client and attempts to add energy to the system or reduce energy needed in order to facilitate reconstitution.

FOUR NURSING PARADIGMS

PERSON

human being is a total person as a client system and the person is a layered multidimensional being.

Each layer consists of five person variable or subsystems:

o Physiological- Refer of the physicochemical structure and function of the body.

o Psychological- Refers to mental processes and emotions.

o Socio-cultural- Refers to relationships; and social/cultural expectations and activities.

o Spiritual- Refers to the influence of spiritual beliefs.

o Developmental- Refers to those processes related to development over the lifespan.

ENVIRONMENT

The environment is seen to be the totality of the internal and external forces which surround a person and with which they interact at any given time.

These forces include the intrapersonal, interpersonal and extra-personal stressors which can affect the person’s normal line of defense and so can affect the stability of the system.

o The internal environment exists within the client system.

o The external environment exists outside the client system.

o Neuman also identified a created environment which is an environment that is created and developed unconsciously by the client and is symbolic of system wholeness.

HEALTH

Neuman sees health as being equated with wellness. She defines health/wellness as “the condition in which all parts and subparts (variables) are in harmony with the whole of the client (Neuman, 1995)”.

The client system moves toward illness and death when more energy is needed than is available. The client system moved toward wellness when more energy is available than is needed

NURSING

Neuman sees nursing as a unique profession that is concerned with all of the variables which influence the response a person might have to a stressor.

The person is seen as a whole, and it is the task of nursing to address the whole person.

Neuman defines nursing as “action which assist individuals, families and groups to maintain a maximum level of wellness, and the primary aim is stability of the patient/client system, through nursing interventions to reduce stressors.’’

Neuman states that, because the nurse’s perception will influence the care given, then not only must the patient/client’s perception be assessed, but so must those of the caregiver (nurse).

The role of the nurse is seen in terms of degree of reaction to stressors, and the use of primary, secondary and tertiary interventions

STAGES OF NURSING PROCESS (BY NEUMAN)

NURSING DIAGNOSIS

It depends on acquisition of appropriate database; the diagnosis identifies, assesses, classifies, and evaluates the dynamic interaction of the five variables.

Variances from wellness (needs and problems) are determined by correlations and constraints through synthesis of theory and data base.

Broad hypothetical interventions are determined, i.e. maintain flexible line of defense.

NURSING GOALS

These must be negotiated with the patient, and take account of patient’s and nurse’s perceptions of variance from wellness.

NURSING OUTCOMES

Nursing intervention using one or more preventive modes. Confirmation of prescriptive change or reformulation of nursing goals.

Short term goal outcomes influence determination of intermediate and long – term goals.

A client outcome validates nursing process.

Neuman’S SYSTEM MODEL FORMAT

Neuman’s nursing process format designates the following categories of data about the client system as the major areas of assessment.

ASSESSMENT

Potential and actual stressors. Condition and strength of basic structure factors and energy sources.

Characteristics of flexible and normal line of defenses, lines of resistance, degree of reaction and potential for reconstitution.

Interaction between client and environment.

Life process and coping factors (past, present and future) actual and potential stressors (internal and external) for optimal wellness external.

Perceptual difference between care giver and the client.

NURSING DIAGNOSIS

The data collected are then interpreted to condition and formulate the Nursing diagnosis. Health seeking behaviors.

Activity intolerance.

Ineffective coping.

Ineffective thermoregulation.

GOAL

In Neuman’s systems model the goal is to keep the client system stable.

PLANNING

Planning is focused on strengthening the lines of defense and resistance.

IMPLEMENTATION

The goal of stabilizing the client system is achieved through three modes of prevention

Primary prevention : actions taken to retain stability Secondary prevention : actions taken to attain stability

Tertiary prevention : actions taken to maintain stability

EVALUATION

The nursing process is evaluated to determine whether equilibrium is restored and a steady state maintained.

ACCEPTANCE BY THE NURSING COMMUNITY

Neuman’s model has been described as a grand nursing theory by walker and Avant. Grand theories can provide a comprehensive perspective for nursing practice, education,

and research and Neuman’s model does.

PRACTICE

The Neuman systems model has been applied and adapted to various specialties include family therapy, public health, rehabilitation, and hospital nursing.

The sub specialties include pulmonary, renal, critical care, and hospital medical units. One of the model’s strengths is that it can be used in a variety of settings

Using this conceptual model permits comparison of a nurse’s interpretation of a problem with that of the patient, so the patient and nurse do not work on two separate problems.

The role of the nurse in the model is to work with the patient to move him as far as possible along a continuum toward wellness.

Because this model requires individual interaction with the total health care system, it is indicative of the futuristic direction the nursing profession is taking.

The patient is being relabeled as a consumer with individual needs and wants.

EDUCATION

The model has also been widely accepted in academic circles.

curriculum guide for a conceptual framework at Indiana University, Northwestern State University in Shreveport, Louisiana.

RESEARCH

A study was published by Riehl and Roy to test the usefulness of the Neuman model in nursing practice.

Acceptance by the nursing community for research applying this model is in the beginning stages and positive.

NEUMAN'S SYSTEM MODEL AND THE CHARACTERISTICS OF A THEORY

Neuman's model connects the interrelated concepts in such a way as to create a different way of looking at a particular phenomenon.

Neuman’s model in general presents itself as logically consistent.

There is a logical sequence in the process of nursing wherein emphasis on the importance of accurate data assessment is basic to the sequential steps of the nursing process.

Neuman’s model is fairly simple and straightforward in approach.

The terms used are easily identifiable and for the most part have definitions that are broadly accepted.

Neuman’s model, due to its high level and breadth of abstraction, lends itself to theory development.

The model has provided clear, comprehensive guidelines for nursing education and practice in a variety of settings; this is its primary contribution to nursing knowledge.

Neuman's model is applicable in the practice as assessment/intervention instrument together with comprehensive guidelines for its use with the nursing process.

Research Articles

“Using the Neuman Systems Model for Best Practices’’--Sharon A. DeWan, Pearl N. Ume-Nwagbo, Nursing Science Quarterly, Vol. 19, No. 1, 31-35 (2006).

o The purpose of this study was to present two case studies based upon Neuman systems model; one case is directed toward family care, and the other demonstrates care with an individual. Theory-based exemplars serve as teaching tools for students and practicing nurses.

o These case studies illustrate how nurses' actions, directed by Neuman's wholistic principles, integrate evidence-based practice and generate high quality care

Melton L, Secrest J, Chien A, Andersen B. “A community needs assessment for a SANE program using Neuman's model” J Am Acad Nurse Pract. 2001 Apr;13(4):178-86.

o The purpose of the study was to present guidelines for a community needs assessment for a Sexual Assault Nurse Examiner (SANE) program using Neuman's Systems Model.

o Sexual assault is a problem faced by almost every community. A thorough community assessment is an important first step in establishing programs that adequately meet a community's needs.

o Guidelines for conducting such an assessment related to implementation of a SANE program are rare, and guidelines using a nursing model were not found in the literature

REFERENCES

1. Timber BK. Fundamental skills and concepts in Patient Care, 7th edition, LWW, NY. 2. George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed.

Norwalk, Appleton and Lange.







9. Delaune SC,. Ladner PK, Fundamental of nursing, standard and practice, 2nd edition, Thomson, NY, 2002

Martha Roger's Science of Unitary Human Beings

This page was last updated on February 21, 2011

Introduction

Born :May 12, 1914, Dallas, Texas Diploma :Knoxville General Hospital School of Nursing(1936)

Graduation in Public Health Nursing, George Peabody College, TN, 1937

MA :Teachers college, Columbia university, New York, 1945

MPH :Johns Hopkins University, Baltimore, MD, 1952

Doctorate in nursing :Johns Hopkins University, Baltimore, 1954

Fellowship: American academy of nursing

Position: Professor Emerita, Division of Nursing, New York University, Consultant, Speaker

Died : March 13 , 1994

Publications of Martha Rogers Theoretical basis of nursing (Rogers 1970) Nursing science and art :a prospective (Rogers 1988)

Nursing :science of unitary, irreducible, human beings update (Rogers 1990)

Vision of space based nursing (Rogers 1990)

Rogers nursing theory Nursing is both a science and art. the uniqueness of nursing, like that of any other science, lies in

the phenomenon central to its focus. Nurses long established concern with the people and the world they live is in a natural

forerunner of an organized abstract system encompassing people and the environments.

The irreducible nature of individuals is different from the sum of the parts.

The integral ness of people and the environment that coordinate with a multidimensional universe of open systems points to a new paradigm :the identity of nursing as a science.

The purpose of nurses is to promote health and well-being for all persons wherever they are.

Evolution of abstract system The development of the abstract system was strongly influenced by an early grounding in arts

and background of science and her keen interest in space The science of unitary human beings originated as a synthesis of facts and ideas from multiple

sources of knowledge

The uniqueness is in the central phenomena : people and environment

The Rogerian view of a causality emerges from an infinite universe of open system.

Overview of Rogerian model Rogers model provides the way of viewing the unitary human being Humans are viewed as integral with the universe

The unitary human being and the environment are one ,not dichotomous

Nursing focus on people and the manifestations that emerge from the mutual human /environmental field process

Change of pattern and organization of the human field and the environmental field is propagated by waves

The manifestations of the field patterning that emerge are observable events

The identification of the pattern provide knowledge and understanding of human experience

Basic characteristics which describes the life process of human: energy field, openness, pattern, and pan dimensionality

Basic concepts include unitary human being, environment, and homeodynamic principles

Concepts of Rogers model

Energy field

The energy field is the fundamental unit of both the living and nonliving This energy field "provide a way to perceive people and environment as irreducible wholes"

The energy fields continuously varies in intensity, density, and extent

Openness

The human field and the environmental field are constantly exchanging their energy There are no boundaries or barrier that inhibit energy flow between fields

Pattern

Pattern is defined as the distinguishing characteristic of an energy field perceived as a single waves

"pattern is an abstraction and it gives identity to the field"

Pan dimensionality

Pan dimensionality is defined as "non linear domain without spatial or temporal attributes" The parameters that human use in language to describe events are arbitrary.

The present is relative ;there is no temporal ordering of lives.

Unitary Human Being (person)

A unitary human being is an "irreducible, indivisible, pan dimensional (four-dimensional) energy field identified by pattern and manifesting characteristics that are specific to the whole and which cannot be predicted from knowledge of the parts" and "a unified whole having its own distinctive characteristics which cannot be perceived by looking at, describing, or summarizing the parts"

The people has the capacity to participate knowingly and probabilistically in the process of change

Environment

The environment is an "irreducible ,pan dimensional energy field identified by pattern and integral with the human field"

The field coexist and are integral. Manifestation emerge from this field and are perceived.

Health

Rogers defined health as an expression of the life process; they are the "characteristics and behavior emerging out of the mutual, simultaneous interaction of the human and environmental fields"

Health and illness are the part of the sane continuum.

The multiple events taking place along life's axis denote the extent to which man is achieving his maximum health potential and very in their expressions from greatest health to those conditions which are incompatible with the maintaining life process

Nursing

The concept Nursing encompasses two dimensions Independent science of nursing

An organized body of knowledge which is specific to nursing is arrived at by scientific research and logical analysis

Art of nursing practice

The creative use of science for the betterment of the humanThe creative use of its knowledge is the art of its practice

Assumptions about people and nursing Nursing exists to serve people………..it is the direct and overriding responsibility to the society The safe practice of nursing depends on the nature and amount of scientific nursing knowledge

the individual brings to practice…….the imaginative, intellectual judgment with which such knowledge is made in service to the man kind

People needs knowledgeable nursing

Homeodynamic principles

The principles of homeodynamic postulates the way of perceiving unitary human beings The fundamental unit of the living system is an energy field

Three principle of homeodynamics

o Resonancy

o Helicy

o integrality

Resonance Resonance is an ordered arrangement of rhythm characterizing both human field and

environmental field that undergoes continuous dynamic metamorphosis in the human environmental process

Helicy Helicy describes the unpredictable, but continuous, nonlinear evolution of energy fields as

evidenced by non repeating rhythmicties The principle of Helicy postulates an ordering of the humans evolutionary emergence

Integrality Integrality cover the mutual, continuous relationship of the human energy field and the

environmental field . Changes occur by by the continuous repatterning of the human and environmental fields by

resonance waves

The fields are one and integrated but unique to each other

Rogerian theories-Grand theories The theory of accelerating evolution The theory of paranormal phenomena

The theory of rhythmicities

Theory of paranormal phenomena This theory focus on the explanations for precognition, déjàvu, clairvoyance, telepathy, and

therapeutic touch Clairvoyance is rational in a four dimensional human field in continuous mutual, simultaneous

interaction with a four dimensional world; there is no linear time nor any separation of human and the environmental fields

The theory of accelerating evolution Theory postulates that evolutionary change is speeding up and that the range of diversity of life

process is widening. Rogers explained that higher wave frequencies are associated with accelerating human development

Theory of Rhythmicity Focus on the human field rhythms (these rhythms are different from the biological,

psychological rhythm) Theory deals with the manifestations of the whole unitary man as changes in human sleep wake

patterns, indices of human field motion, perception of time passing, and other rhythmic development

Theories derived from the science of unitary human beings The perspective rhythm model (Patrick 1983) Theory of health as expanding consciousness (Neuman, 1986)

Theory of creativity, actualization and empathy (Alligood 1991)

Theory of self transcendence (Reed1997)

Power as knowing participation in change (Barrett 1998)

Rogers concepts of nursing Nursing is a learned profession-it is a science and art Nursing is the study of unitary. Irreducible, indivisible human and environmental energy fields

The art of nursing involves the imaginative and creative use of nursing knowledge

The purpose of nurses is to promote health and well-being for all person and groups wherever they are using the art and science of nursing

The health services should be community based

Rogers challenges nurses to consider nursing needs of all people, including future generation of space kind ;as life continuous to evolve from earth to space and beyond.

Her view provides a different world view that encompasses a practice of nursing for the present time and for the imagined and for the yet to be imagined future

Rogers proposes a nursing practice of noninvasive modalities, such as therapeutic touch, humor, guided imagery, use of color, light, music, meditation focusing on health potential of the person.

Professional practice in nursing seeks to promote symphonic interaction between man and environment, to strengthen the coherence and integrity of the human field, and to direct and redirect patterning of the human and environmental fields for realization of maximum health potential

Nursing intervention seeks to coordinate environmental field and human field rhythmicities, participates in the process of change , to help people move toward better health

Nursing aims to assist people in achieving their maximum potential.

Nursing practice should be emphasized on pain management, supportive psychotherapy motivation for rehabilitation.

Maintenance and promotion of health, prevention of disease, nursing diagnosis, intervention, and rehabilitation encompasses the scope of nursing

Roger’s contribution to nursing knowledge Rogers was one of the first nurse scholars to identify the person (unitary man) as the central

phenomena of nursing concern Nursing abstract system is a matrix of concepts relevant to the life process in man

Rogers conceptual system provides a body of knowledge in nursing that will have relevance for all workers concerned with people, but with special relevance for nurses; because it matters to human beings; consequently to nurses

In the evolution it is properly subjected to reformulation and change as the knowledge grows, the the conceptual data will be more clearer and it will take new dimensions

The utilization of Rogerian model is used as a guide for theory development, research, nursing education, and in the direct patient care practice

Rules for nursing research guided by the Rogerian theory

Rules for research

The Rogerian research require both basic and applied research The phenomena to be studied are unitary human beings and their environmental interaction

Study participants may be any person or group, with the provision that both person and environment are taken into account

Research methodology

Qualitative and quantitative methods can be applied Experimental researches are questionable because she rejects the notion of causality

Case study and longitudinal research are better than cross sectional study

Research instruments that are directly derived from science of unitary human beings should be used

Data analysis – multivariate analysis (canonical correlation studies)

Research tools derived from science of unitary human beings

Perceived field motion scale Human field rhythm scale

Temporal experience scale

Assessment of dream experience scale

Person environment participation scale

Leddy healthiness scale

Mutual exploration of the healing human-environment field scale

Garon assessment of pain scale

Family assessment tool

Community health assessment tool

Rules for nursing education guided by Rogerian theory

Focus of the curriculum

Nursing education can be for professional nursing , technical nursing The focus is the transmission of the body of knowledge

Teaching and practicing therapeutic touch

Conducting regular in-service education

Nursing programs

Baccalaureate degree program Masters program

Doctoral program

The major concepts are – principal of Resonancy, Helicy, Integrality

The faculty in the nursing education must be prepared at doctoral level

Teaching- learning strategies

Emphasis should be on developing self awareness as an aspect of the clients environmental energy field and the dynamic role of nurse pattern manifestation on the client

Emphasis on laboratory study- the lab setting include homes, schools, industry, clinics, hospitals, other places where people lives

Importance of use of media in education

Rules for nursing administration guided by Rogerian theory

Purpose of nursing services

Nursing services is the center of any health care system The purpose of nursing services is health promotion

Characteristics of nursing personnel

The administrators should hold higher degrees in nursing and licensed Leaders must be visionary and willing to embrace innovative and creative change

Leaders should be able to identify the patterning to ensure the integrated behaviors for client and employees

Management strategies and administrative policies

Administrative policies foster an open and supportive administrative climate that enhances staff members self esteem , actualization, and freedom of choice and provide opportunity for staff development and continuing education

The ultimate goal is the clients well-being

Rules for independent practitioner guided by Rogerian model Nursing is an independent science Nurse assumes the role of potentiater of care

She proposes the independent role in various setting like school, industry, community, space (by 2050AD)

Independent practitioner is an advanced practice registered registered nurse who focus on well-being or mutual patterning of individual, family, community across the life span ,at risk for developing dissonance/illness

Rules for nursing practice guided by Rogerian theory

Areas of Rogerian model application

SETTINGS

All spheres of life School

Industry

Family

Community

Space

SPECIALITIES

Pediatrics Psychiatry

Oncology

Burns

Geriatrics

Neurology

Cardiology

Rehabilitative medicine

SPECIALIZED AREAS OF PRACTICE

Neonatal ICU Pediatric ICU

Post operative unit

Pre operative unit

Palliative care unit

Rehabilitation center

Burns unit

Adult ICU’s

Old age homes

Neuropsychiatric units

AREA WHERE ROGERIAN MODEL IS NOT APPLICABLE

o Operation theaters

Purpose of nursing practice

To promote well-being for all persons, wherever they are To assist both the client and nurse to increase their awareness of their own rhythm

Setting for practice

From community to hospital to outer space

Legitimate participants

People of all ages both as individual human energy fields and group energy fields

Nursing process- Health patterning practice method Assessment Voluntary mutual patterning

Evaluation

For the nurse

Pattern appraisal Mutual patterning of human and environmental fields

Evaluation

For the patient

Self reflection Patterning activities

Personal appraisal

Nursing process Assessment

Areas of assessment Simultaneous states of the individual and the environment

Total pattern of events at any given point in space –time

Rhythms of life process

Supplementary data

Categorical disease entities

Subsystem pathology

Pattern appraisal

It is a comprehensive assessment of:

Human field patterns of communication, exchange, rhythms, dissonance Environmental fields pattern of communication, rhythms, dissonance, harmony

Intuitive reflection of self

Validation of the appraisal

Validate with self

Validate with the client

Mutual patterning of human and environmental field

Sharing knowledge Offering choices

Empowering the client

Fostering patterning

Evaluation

Repeat pattern appraisal

Identify dissonance and harmony

Validate appraisal with the client

Self reflection for the client

Pattern appraisal include appraisal of multiple lifestyle rhythms such as:

Nutrition

Work/leisure activities

Exercise

Sleep / wake cycles

Relationships

Discomfort or pain

Fear /hopes

Patterning activities for the client

Meditation Imagery Journaling Modifying the surroundings

References 1. George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk,

Appleton & Lange. 2. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott

Williams& wilkins.




Theories Based on Interactive ProcessThis page was last updated on November 13, 2010

I. IMOGENE KING: THEORY OF GOAL ATTAINMENT

Major Concepts and Definitions

1. Interaction

A process of perception and communication Between person and environment

Between person and person

Represented by verbal and nonverbal behaviors

Goal-directed

Each individual brings different knowledge , needs, goals, past experiences and perceptions, which influence interaction

2. Communication

Information from person to person Directly or indirectly

Information component of interaction

3. Perception Each person’s representation of reality

4. Transaction Purposeful interaction leading to goal attainment

5. Role A set of behaviours expected of person’s occupying a position in a social system Rules that define rights and obligations in a position

6. Stress Dynamic state Human being interacts with the environment

7. Growth and development Continuous changes in individuals

At cellular, molecular and behavioural levels of activities

Helps individuals move towards maturity

8.Time Sequence of events Moving onwards to the future

9. Space Existing in all directions Same everywhere

Immediate environment (nurse and client interaction

MAJOR ASSUMPTIONS

Nursing

Observable behaviour In health care system in society

Goal – to help individuals maintain health

Interpersonal process of action; reaction, interaction and transaction

Person Social beings Sentient beings

Rational beings

Perceiving beings

Controlling beings

Purposeful beings

Action – oriented beings

Time – oriented beings

Health Dynamic state in the life cycle Continuous adaptation to stress

To achieve maximum potential for daily living

Function of nurse, patient, physicians, family and other interactions

Environment

Open system Constantly changing

Influences adjustment to life and health

Personal system

Concepts

Perception Self

Body image

Growth and development

Time

Space

Interpersonal system

Concepts

Interaction Transaction

Communication

Role

Stress

Social system

Concepts

Organization Authority

Power

Status

Decision making

ASSUMPTIONS Perceptions, goals, needs and values of the nurses and client influence interaction process

Individuals have the right to knowledge about themselves and to participate in decisions that influence their life, health and community services

Health professionals have the responsibility that helps individuals to make informed decisions about their health care

Individuals have the right to accept or reject health care

Goals of health professionals and recipients of health care may not be congruent

II. SISTER CALLISTA ROY: ADAPTATION MODEL

Introduction Begins with man Man as a biopsychosocial being

In constant interaction with his environment

Focus of nursing Man’s position on the health – illness continuum Influenced by ability to adapt to confronted stimuli

MAJOR CONCEPTS AND DEFINITIONS

System

a set of units so related or connected as to form a unit characterised by inputs, out puts, control and feedback process.

Adaptational level

a constantly changing point, made up of focal, contextual and residual stimuli represent the persons own standard of the range of stimuli, to which one can respond with

the ordinary adaptive response

Adaptation problems:

the occurrence of situations of inadequate responses to need deficits or excesses

Focal stimulus:

stimulus most immediately confronting the person must make an adaptive response

factor that precipitates behaviour

Contextual stimuli

all other stimuli present contribute to behaviour caused by the focal stimuli

Residual stimuli

factors that may be affecting behaviour effect not validated

Regulator

subsystem coping mechanism responds automatically through neural-chemical-endocrine processes

Cognator

subsystem coping mechanism cognitive – emotive process

responds through

perception, information

processing, learning

judgment and emotion

Adaptive (effector) modes

classification of ways of coping manifests regulator and cognator activity

physiologic, self concept, role function and interdependence

Adaptive responses

Promote integrity of the person in terms of the goals of survival, growth, reproduction and mastery.

Ineffective responses:

Does not contribute to adaptive goals

Physiological mode -involves body’s basic needs and ways of dealing with adaptation in relation to

Fluid and electrolytes Exercise and rest

Elimination

Nutrition

Circulation

Oxygen

-regulation includes:

The senses Temperature

Endocrine regulation

Self – concept mode:

composite of belief and feeling formed from perceptions

directs one’s behaviour

components are : the physical self the personal selfRole performance mode:

performance of duties based on given positions in society

Interdependence mode:

one’s relation with significant others support system

maintains psychic integrity

meets needs for nurturance and affection

MAJOR ASSUMPTIONS from system theory from Helson’s theory

from humanism

Assumptions from systems theory a system is a set of units so related or connected as to form a unit or whole a system is a whole that functions as a whole by virtue of the interdependence of its parts

systems have inputs, outputs and control and feedback processes

input, in the form of a standard or feedback (information)

living systems are more complex than mechanical systems and have standards and feedback to direct their functioning as a whole.

Assumptions from helson’s theory human behaviour represents adaptation to environmental and organismic forces adaptive behaviour is a function of the stimulus and adaptation level, that is, the pooled

effect of the focal, contextual and residual stimuli

adaptation is a process of responding positively to environmental changes

responses reflect the state of the organism as well as the properties of stimuli and hence are regarded as active processes.

Assumptions from humanism Persons have their own creative power A persons behaviour is purposeful and not merely a chain of cause and effect

Person is holistic

A person’s opinions and view points are of value

The interpersonal relationship is significant.

Elements

Nursing

A science and practice discipline A theoretical system of knowledge

Prescribes a process of analysis and action

Related to the care of the ill or potentially ill person

Person A biopsychosocial being A living, complex, adaptive system

With internal processes (the cognator and regulator)

Acting to maintain adaptation to the four modes

Health

A state and a process of being and becoming an integrated and whole person

Environment All the conditions, circumstances and influences surrounding and affecting the

development and behaviour of persons or groups

References 1. Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed. Mosby,

Philadelphia, 2002. 2. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby,

Philadelphia, 2002.


4. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williamsand wilkins.

5. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development and Progress 3rd ed. Philadelphia, Lippincott.

6. Taylor Carol,Lillis Carol (2001)The Art and Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

7. Potter A Patricia, Perry G Anne (1992)Fundamentals Of Nursing –Concepts Process and Practice 3rd ed. London Mosby Year Book.

Dorothea Orem's Self-Care TheoryDorothea Orem (1914-2007)

This page was last updated on January 4, 2011==========================================

INTRODUCTION

One of foremost nursing theorists. Born 1914 in Baltimore.

Earned her diploma at Providence Hospital – Washington, DC

1939 – BSN Ed., Catholic University of America

1945 – MSN Ed., Catholic University of America

Involved in nursing practice, nursing service, and nursing education

During her professional career, she worked as a staff nurse, private duty nurse, nurse educator and administrator and nurse consultant

Received honorary Doctor of Science degree in 1976

Published first formal articulation of her ideas in Nursing: Concepts of Practice in 197, second in 1980, and in 1995.

DEVELOPMENT OF THEORY

1949-1957 Orem worked for the Division of Hospital and Institutional Services of the Indiana State Board of Health.

Her goal was to upgrade the quality of nursing in general hospitals throughout the state. During this time she developed her definition of nursing practice.

1959 Orem subsequently served as acting dean of the school of Nursing and as an assistant professor of nursing education at CUA. She continued to develop her concept of nursing and self care during this time.

Orem’s Nursing: Concept of Practice was first published in 1971 and subsequently in 1980, 1985, 1991, 1995, and 2001.

MAJOR ASSUMPTIONS

People should be self-reliant and responsible for their own care and others in their family needing care

People are distinct individuals

Nursing is a form of action – interaction between two or more persons

Successfully meeting universal and development self-care requisites is an important component of primary care prevention and ill health

A person’s knowledge of potential health problems is necessary for promoting self-care behaviors

Self care and dependent care are behaviors learned within a socio-cultural context

DEFINITIONS OF DOMAIN CONCEPTS

Nursing – is art, a helping service, and a technology

Actions deliberately selected and performed by nurses to help individuals or groups under their care to maintain or change conditions in themselves or their environments

Encompasses the patient’s perspective of health condition ,the physician’s perspective , and the nursing perspective

Goal of nursing – to render the patient or members of his family capable of meeting the patient’s self care needs

To maintain a state of health

To regain normal or near normal state of health in the event of disease or injury

To stabilize ,control ,or minimize the effects of chronic poor health or disability

Health – health and healthy are terms used to describe living things …

It is when they are structurally and functionally whole or sound … wholeness or integrity. .includes that which makes a person human,…operating in conjunction with physiological and psychophysiological mechanisms and a material structure and in relation to and interacting with other human beings

Environment

environment components are enthronement factors, enthronement elements, conditions, and developed environment

Human being – has the capacity to reflect, symbolize and use symbols

Conceptualized as a total being with universal, developmental needs and capable of continuous self care

A unity that can function biologically, symbolically and socially

Nursing client

A human being who has "health related /health derived limitations that render him incapable of continuous self care or dependent care or limitations that result in ineffective / incomplete care.

A human being is the focus of nursing only when a self –care requisites exceeds self care capabilities

Nursing problem

deficits in universal, developmental, and health derived or health related conditions

Nursing process

a system to determine (1)why a person is under care (2)a plan for care ,(3)the implementation of care

Nursing therapeutics

deliberate, systematic and purposeful action

OREM’S GENERAL THEORY OF NURSING

Orem’s general theory of nursing in three related parts:-

Theory of self care

Theory of self care deficit

Theory of nursing system

A. Theory of Self Care

This theory Includes:

Self care – practice of activities that individual initiates and perform on their own behalf in maintaining life ,health and well being

Self care agency – is a human ability which is "the ability for engaging in self care" -conditioned by age developmental state, life experience sociocultural orientation health and available resources

Therapeutic self care demand – "totality of self care actions to be performed for some duration in order to meet self care requisites by using valid methods and related sets of operations and actions"

Self care requisites-action directed towards provision of self care. 3 categories of self care requisites are-

1. Universal

Developmental Health deviation

2. Universal self care requisites

Associated with life processes and the maintenance of the integrity of human structure and functioning

Common to all , ADL

Identifies these requisites as:

Maintenance of sufficient intake of air ,water, food

Provision of care assoc with elimination process

Balance between activity and rest, between solitude and social interaction

Prevention of hazards to human life well being and

Promotion of human functioning

3. Developmental self care requisites

Associated with developmental processes/ derived from a condition…. Or associated with an event

o E.g. adjusting to a new job

o adjusting to body changes

Health deviation self care

o Required in conditions of illness, injury, or disease .these include:--

o Seeking and securing appropriate medical assistance

o Being aware of and attending to the effects and results of pathologic conditions

o Effectively carrying out medically prescribed measures

o Modifying self concepts in accepting oneself as being in a particular state of health and in specific forms of health care

o Learning to live with effects of pathologic conditions

B. Theory of self care deficit

Specifies when nursing is needed Nursing is required when an adult (or in the case of a dependent, the parent) is incapable

or limited in the provision of continuous effective self care. Orem identifies 5 methods of helping:

o Acting for and doing for others

o Guiding others

o Supporting another

o Providing an environment promoting personal development in relation to meet future demands

o Teaching another

C. Theory of Nursing Systems

Describes how the patient’s self care needs will be met by the nurse , the patient, or both Identifies 3 classifications of nursing system to meet the self care requisites of the

patient:-

Wholly compensatory system

Partly compensatory system

Supportive – educative system

Design and elements of nursing system define

Scope of nursing responsibility in health care situations

General and specific roles of nurses and patients

Reasons for nurses’ relationship with patients and

The kinds of actions to be performed and the performance patterns and nurses’ and patients’ actions in regulating patients’ self care agency and in meeting their self care demand

Orem recognized that specialized technologies are usually developed by members of the health profession

A technology is systematized information about a process or a method for affecting some desired result through deliberate practical endeavor ,with or without use of materials or instruments

Categories of technologies

1. Social or interpersonal

Communication adjusted to age, health status Maintaining interpersonal, intra group or inter group relations for coordination of efforts

Maintaining therapeutic relationship in light of psychosocial modes of functioning in health and disease

Giving human assistance adapted to human needs ,action abilities and limitations

2. Regulatory technologies

Maintaining and promoting life processes Regulating psycho physiological modes of functioning in health and disease

Promoting human growth and development

Regulating position and movement in space

OREM’S THEORY AND NURSING PROCESS

Orem’s approach to the nursing process presents a method to determine the self care deficits and then to define the roles of person or nurse to meet the self care demands.

The steps within the approach are considered to be the technical component of the nursing process.

Orem emphasizes that the technological component "must be coordinated with interpersonal and social processes within nursing situations.

Comparison of Orem’s Nursing Process and the Nursing Process

Nursing Process Orem’s Nursing. Process

Assessment

Diagnosis and prescription; determine why nursing is needed. analyze and interpret –make judgment regarding care

Design of a nursing system and plan for delivery of care

Production and management of nursing systems

Step 1-collect data in six areas:-

The person’s health status The physician’s perspective of the

person’s health status

The person’s perspective of his or her health

The health goals within the context of life history ,life style, and health status

The person’s requirements for self care

The person’s capacity to perform self care

Nursing diagnosis

Plans with scientific rationale

Step 2

Nurse designs a system that is wholly or partly compensatory or supportive-educative.

The 2 actions are:-

Bringing out a good organization of the components of patients’ therapeutic self care demands

Selection of combination of ways of helping that will be effective and efficient in compensating for/ overcoming patient’s self care deficits

Implementation Step 3

evaluation

Nurse assists the patient or family in self care matters to achieve identified and described health and health related results. collecting evidence in evaluating results achieved against results specified in the nursing system design

Actions are directed by etiology component of nursing diagnosis

evaluation

Application of Orem’s theory to nursing process

Personal factors

Universal self care

Developmental self care

Health deviation

Medical problem & plan

Self care deficits

29 yr.FemaleEarly adulthood transition

32pack /yrWater-no restrictionsFood –nilWt89lbWt loss-19%nauseated

Teenage pregnancy-2OC-10 yrsHusband emotionally away

Seeks medical attention for overt s/sAware of diseaseNo evidence

8th gradeTeenage pregnancyNo workMarriedChild-2

Urinary retentionIntermittent self catheterizationPain

No BSEInfrequent physical examinationNo HRTPoor health

ability to manage effects

Surgery on reproductive organs

Difference between knowledge base & lifestyle

Lives at mother’s home. Environment uncleanLimited resources

TearfulHusband abusiveDissatisfied with homeRT

EDU deprivationOppressive living conditions

Will receive RT ,perform intermittent catheterization

Therapeutic self care demand

Adequacy of self care agency

Nursing diagnosis

Methods of helping

Air Maintain effective respirationWater No problemFood maintain sufficient intake

Inadequate

Adequate

Inadequate

Potential for impaired respiratory statusP F fluid imbalanceActual nutritional deficit r/t nausea

Guiding & directing

Teaching

Providing physical support

HazardsPrevent spouse abusePromotion of normalcy

Inadequate

Inadequate

P/F injury

A/d in environmentShared housing

Personal development

Guiding & directing

Guiding & directing

Maintain developmental environmentSupport ed normalcy in environmentPrevent /manage dev threat

Inadequate

Inadequate

Actual delay in normal dev. R/T early parenthoodLevel of education

Dev deficit r/t loss of reproductive organs

Guiding & directing Providing psy support

Providing physical, psy support

Maintenance of health statusManagement of disease process

Inadequate Inadequate

P/F contd. alterations in health status P/F UTI

Guiding & directing, teaching Guiding & directing, teaching

Adherence to med regimen

Awareness of potential problems

Inadequate

Inadequate

P/F ¯ adherence in self catheterization & OPD RT Actual deficit

teaching

teaching

in awareness of advisability of HRT & RT effects

Adjust to loss of reproductive ability & dev healthy view of illnessAdjust life style to cope with change

Inadequate

Inadequate

Actual threat to self image

Actual self deficit in planning for future needs

Providing psy support

Guiding & directing

OREM’S WORK AND THE CHARACTERISTICS OF A THEORY

Theories can interrelate concepts in such a way as to create a different way of looking at a particular phenomenon

Theories must be logical in nature

Theories must be relatively simple yet generalizable

Theories are the basis for hypothesis that can be tested

Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them

Theories can be used by the practitioners to guide and improve their practice

Theories must be consistent with other validated theories ,laws and principles

Theory Testing

Orem’s theory has been used as the basis for the development of research instruments to assist researchers in using the theory

A self care questionnaire was developed and tested by Moore(1995) for the special purpose of measuring the self care practice of children and adolescents

The theory has been used as a conceptual framework in assoc. degree programs also in many nursing schools

Strengths

Provides a comprehensive base to nursing practice It has utility for professional nursing in the areas of nursing practice nursing

curricula ,nursing education administration ,and nursing research

Specifies when nursing is needed

Also includes continuing education as part of the professional component of nursing education

Her self care approach is contemporary with the concepts of health promotion and health maintenance

Expanded her focus of individual self care to include multi person units

Limitations

In general system theory a system is viewed as a single whole thing while Orem defines a system as a single whole ,thing

Health is often viewed as dynamic and ever changing .Orem’s visual presentation of the boxed nursing systems implies three static conditions of health

Appears that the theory is illness oriented rather with no indication of its use in wellness settings

Summary

Orem’s general theory of nursing is composed of three constructs .Throughout her work ,she interprets the concepts of human beings, health, nursing and society .and has defined 3 steps of nursing process. It has a broad scope in clinical practice and to lesser extent in research ,education and administration

RESEARCH ON OREM'S THEORY

1. Self-care requirements for activity and rest: an Orem nursing focus 2. Nursing diagnoses in patients after heart catheterization--contribution of Orem

3. Self-care--the contribution of nursing sciences to health care

4. Self-care: a foundational science

5. Orem's self-care deficit nursing theory: its philosophic foundation and the state of the science

6. Dorothea E. Orem: thoughts on her theory

7. Orem's theory in practice. Hospice nursing care

8. Solving the Orem mystery: an educational strategy

9. Orem's family evaluation

REFERENCES

Orem, D.E. (1991). Nursing: Concepts of practice (4th ed.). St. Louis, MO: Mosby-Year Book Inc.

http://www.ncbi.nlm.nih.gov/pubmed/17202518










Taylor, S.G. (2006). Dorthea E. Orem: Self-care deficit theory of nursing. In A.M.

Tomey, A. & Alligood, M. (2002). Significance of theory for nursing as a discipline and profession. Nursing Theorists and their work. Mosby, St. Louis, Missouri, United States of America.

Whelan, E. G. (1984). Analysis and application of Dorothea Orem’s Self-care Practuce Model. Retrieved October 31, 2006.

George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton & Lange.

Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins.

Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott.

Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book.

Nursing Theories: An OverviewThis page was last updated on March 1, 2011

====

INTRODUCTION

A theory is a group of related concepts that propose action that guide practice. A nursing theory is a set of concepts, definitions, relationships, and assumptions or

propositions derived from nursing models or from other disciplines and project a purposive, systematic view of phenomena by designing specific inter-relationships among concepts for the purposes of describing, explaining, predicting, and /or prescribing.

Kerlinger ---views theories as a set of interrelated concepts that give a systematic view of a phenomenon (an observable fact or event) that is explanatory and predictive in nature.

Theories are composed of concepts, definitions, models , propositions and are based on assumptions.

They are derived through two principal methods:

1) Deductive reasoning

2) Inductive reasoning.

Nursing theorists use both of these methods. Nursing Theory: Barnum(1998)---- "attempts to describe or explain the phenomenon

(process, occurrence and event) called nursing"

Theories are for professional nursing

Theory is "a creative and rigorous structuring of ideas that projects a tentative, purposeful, and systematic view of phenomena"

A theory makes it possible to "organize the relationship among the concepts to describe, explain, predict, and control practice"

DEFINITIONS

Concepts--- are basically vehicles of thought that involve images.

Concepts are words that describe objects , properties, or events and are basic components of theory.

Types of Concepts:

Empirical concepts Inferential concepts

Abstract concepts.

Models ----- are representations of the interaction among and between the concepts showing patterns.

Propositions---- are statements that explain the relationship between the concepts.

Process ---- it is a series of actions , changes or functions intended to bring about a desired result . During a process one takes systemic and continuous steps to meet a goal and uses both assessments and feedback to direct actions to the goal.

A particular theory or conceptual frame work directs how these actions are carried out . The delivery of nursing care within the nursing process is directed by the way specific conceptual frameworks and theories define the person (patient), the environment, health and nursing.

The terms ‘model’ and ‘theory’ are often wrongly used interchangeably, which further confounds matters.

In nursing, models are often designed by theory authors to depict the beliefs in their theory (Lancaster and Lancaster 1981).

They provide an overview of the thinking behind the theory and may demonstrate how theory can be introduced into practice, for example, through specific methods of assessment.

Models are useful as they allow the concepts in nursing theory to be successfully applied to nursing practice (Lancaster and Lancaster 1981).

Their main limitation is that they are only as accurate or useful as the underlying theory.

IMPORTANCE OF NURSING THEORIES

Nursing theory aims to describe, predict and explain the phenomenon of nursing (Chinn and Jacobs1978).

It should provide the foundations of nursing practice, help to generate further knowledge and indicate in which direction nursing should develop in the future (Brown 1964).

Theory is important because it helps us to decide what we know and what we need to know (Parsons1949).

It helps to distinguish what should form the basis of practice by explicitly describing nursing.

The benefits of having a defined body of theory in nursing include better patient care, enhanced professional status for nurses, improved communication between nurses, and guidance for research and education (Nolan 1996). In addition, because the main exponent of nursing – caring – cannot be measured, it is vital to have the theory to analyze and explain what nurses do.

As medicine tries to make a move towards adopting a more multidisciplinary approach to health care, nursing continues to strive to establish a unique body of knowledge.

This can be seen as an attempt by the nursing profession to maintain its professional boundaries.

THE CHARACTERISTICS OF THEORIES

Theories:

interrelate concepts in such a way as to create a different way of looking at a particular phenomenon.

are logical in nature.

are generalizable.

are the bases for hypotheses that can be tested.

increase the general body of knowledge within the discipline through the research implemented to validate them.

are used by the practitioners to guide and improve their practice.

are consistent with other validated theories, laws, and principles but will leave open unanswered questions that need to be investigated

BASIC PROCESSES IN THE DEVELOPMENT OF NURSING THEORIES

Nursing theories are often based on and influenced by broadly applicable processes and theories. Following theories are basic to many nursing concepts.

A. General System Theory:

It describes how to break whole things into parts and then to learn how the parts work together in " systems".

These concepts may be applied to different kinds of systems, e.g.. Molecules in chemistry , cultures in sociology, organs in Anatomy and health in Nursing.

B. Adaptation Theory

It defines adaptation as the adjustment of living matter to other living things and to environmental conditions.

Adaptation is a continuously occurring process that effects change and involves interaction and response.

Human adaptation occurs on three levels:

--- the internal ( self )

--- the social (others)

--- and the physical ( biochemical reactions )

C. Developmental Theory

It outlines the process of growth and development of humans as orderly and predictable, beginning with conception and ending with death.

The progress and behaviors of an individual within each stage are unique.

The growth and development of an individual are influenced by heredity , temperament, emotional, and physical environment, life experiences and health status.

COMMON CONCEPTS IN NURSING THEORIES

Four concepts common in nursing theory that influence and determine nursing practice are

-- The person( patient)

--- The environment

-- Health

--- Nursing (goals, roles, functions)

Each of these concepts is usually defined and described by a nursing theorist , Often uniquely; although these concepts are common to all nursing theories.

Of the four concepts , the most important is that of the person. The focus of nursing , regardless of definition or theory , is the person.

HISTORICAL PERSPECTIVES AND KEY CONCEPTS

1. Nightingale (1860): To facilitate "the body’s reparative processes" by manipulating client’s environment

2. Paplau 1952: Nursing is; therapeutic interpersonal process.

3. Henderson 1955: The needs often called Henderson’s 14 basic needs

4. Abdellah 1960: The nursing theory developed by Faye Abdellah et al (1960) emphasizes delivering nursing care for the whole person to meet the physical, emotional, intellectual, social, and spiritual needs of the client and family.

5. Orlando 1962: To Ida Orlando (1960), the client is an individual; with a need; that, when met, diminishes distress, increases adequacy, or enhances well-being.

6. Johnson’s Theory 1968: Dorothy Johnson’s theory of nursing 1968 focuses on how the client adapts to illness and how actual or potential stress can affect the ability to adapt. The goal of nursing to reduce stress so that; the client can move more easily through recovery.

7. Rogers 1970: to maintain and promote health, prevent illness, and care for and rehabilitate ill and disabled client through "humanistic science of nursing"

8. Orem1971: This is self-care deficit theory. Nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental, or social needs.

9. King 1971: To use communication to help client reestablish positive adaptation to environment.

10. Neuman 1972: Stress reduction is goal of system model of nursing practice.

11. Roy 1979: This adaptation model is based on the physiological, psychological, sociological and dependence-independence adaptive modes.

12. Watson’s Theory 1979: Watson’s philosophy of caring 1979 attempts to define the outcome of nursing activity in regard to the; humanistic aspects of life.

CLASSIFICATION OF NURSING THEORIES

Depending on the generalisability of their principles

Metatheory: the theory of theory. Identifies specific phenomena through abstract concepts.

Grand theory: provides a conceptual framework under which the key concepts and principles of the discipline can be identified.

Middle range theory: is more precise and only analyses a particular situation with a limited number of variables.

Practice theory: explores one particular situation found in nursing. It identifies explicit goals and details how these goals will be achieved.

Theories can also be categorised as:

"Needs "theories. "Interaction" theories.

"Outcome "theories.

"Humanistic theories"

These categories indicate the basic philosophical underpinnings of the theories

"Needs" theories

These theories are based around helping individuals to fulfill their physical and mental needs. The basis of these theories is well-illustrated in Roper, Logan and Tierney’s Model of Nursing (1980).

Needs theories have been criticized for relying too much on the medical model of health and placing the patient in an overtly dependent position.

"Interaction" theories

As described by Peplau (1988), these theories revolve around the relationships nurses form with patients.

Such theories have been criticized for largely ignoring the medical model of health and not attending to basic physical needs.

"Outcome" theories

These portray the nurse as the changing force, who enables individuals to adapt to or cope with ill health (Roy 1980).

Outcome theories have been criticized as too abstract and difficult to implement in practice (Aggleton and Chalmers 1988).

"Humanistic" Theories:

Humanistic theories developed in response to the psychoanalytic thought that a person’s destiny was determined early in life.

Humanistic theories emphasize a person’s capacity for self actualization .

Humanists believes that the person contains within himself the potential for healthy and creative growth.

Carl Rogers developed a person –centered model of psychotherapy that emphasizes the uniqueness of the individual.

The major contribution that Rogers added to nursing practice is the understanding that each client is a unique individual, so person-centered approach now practice in Nursing.

MODELS OF NURSING

Until fairly recently, nursing science was derived principally from social, biologic, and medical science theories.

However, from the 1950s to the present, an increasing number of nursing theorists have developed models of nursing that provide bases for the development of nursing theories and nursing knowledge.

A model, as an abstraction of reality, provides a way to visualize reality to simplify thinking.

A conceptual model shows how various concepts are interrelated and applies theories to predict or evaluate consequences of alternative actions.

According to Fawcett (2000),

A conceptual model "gives direction to the search for relevant questions about the phenomena of central interest to a discipline and suggests solutions to practical problems"

Four concepts are generally considered central to the discipline of nursing: the person who receives nursing care (the patient or client); the environment (society); nursing (goals, roles, functions); and health.

These four concepts form a metaparadigm of nursing.

The term metaparadigm comes from the Greek prefix "meta," which means more comprehensive or transcending, and the word Greek word "paradigm," which means a philosophical or theoretical framework of a discipline upon which all theories, laws, and generalizations are formulated (Merriam-Webster’s Collegiate Dictionary, 1994).


There are two major differences in philosophical beliefs, or world views, about the nature of change.

"The world view of change uses the growth metaphor, and the persistence view focuseson stability" (Fawcett, 1989,).

Within the change world view, change and growth are continual and desirable, "progress is valued, and realization of one’s potential is emphasized" (Fawcett).

Persistence is endurance in time

persistence world view emphasizes equilibrium and balance.

CATEGORIES OF CONCEPTUAL MODELS

Ten conceptual models of nursing have been classified according to two criteria: 1. the world view of change reflected by the model (growth or stability); and

2. the major theoretical conceptual classification with which the model seems most consistent (systems, stress/adaptation, caring, or growth/development).

Systems Theory as a Framework

Systems theory is concerned with changes caused by interactions among all the factors (variables)

General systems theory is emphasized

A system is defined as "a whole with interrelated parts, in which the parts have a function and the system as a totality has a function" (Auger, 1976)

A general systems approach allows for consideration of the subsystems levels of the human being, as a total human being, and as a social creature who networks himself with others in hierarchically arranged human systems of increasing complexity. Thus the human being, from the level of the individual to the level of society, can be conceptualized as the client and becomes the target system for nursing intervention. (Sills and Hall, 1977).

An example of systems interaction

Input (Diet teaching) Throughput (Assimilation of information)

Output (Food intake)

Feedback (Weight record ,Hb estimation etc.)

Two nursing models based on systems theory:

1. Imogene King’s systems interaction model, and 2. Betty Neuman’s health care systems model.

Imogene King’s Systems Interaction Model

interaction model, the purpose of nursing is to help people attain, maintain, or restore health

King’s model conceptualizes three levels of dynamic interacting systems.

1. Individuals are called "personal systems."

2. Groups (two or more persons) form "interpersonal systems."

3. Society is composed of "social systems."

As the person interacts with the environment, he or she must continuously adjust to stressors in the internal and external environment (King, 1981).

Health assumes achievement of maximum potential for daily living and an ability to function

in social roles. It is the "dynamic life experiences of a human being, which implies continuous

adjustment to stressors in the internal and external environment through optimum use of one’s resources to achieve maximum potential for daily living" (King, 1981,).

"Illness is a deviation from normal, that is, an imbalance in a person’s biological structure or in his psychological makeup, or a conflict in a person’s social relationships" (King, 1989).

"The goal of nursing is to help individuals and groups attain, maintain, and restore health"

Stress: "a dynamic state whereby a human being interacts with the environment to maintain balance for growth, development, and performance"


Betty Neuman specifies that the purpose of nursing is to facilitate optimal client system stability.

Normal line of defense: an adaptational level of health considered normal for an individual

Lines of resistance: protection factors activated when stressors have penetrated the normalline of defense

Neuman’s model, organized around stress reduction, is concerned primarily with how stress and the reactions to stress affect the development and maintenance of health.

The person is a composite of physiologic, psychological, sociocultural, developmental, and spiritual variables considered simultaneously.

"Ideally the five variables function harmoniously or are stable in relation to internal and external environmental stressor influences" (Neuman, 2002).

A person is constantly affected by stressors from the internal, external, or created environment.

Stressors are tension-producing stimuli that have the potential to disturb a person’s equilibrium or normal line of defense.

This normal line of defense is the person’s "usual steady state."

It is the way in which an individual usually deals with stressors.

Stressors may be of three types:

Intrapersonal: forces arising from within the person

Interpersonal: forces arising between persons

Extrapersonal: forces arising from outside the person

Resistance to stressors is provided by a flexible line of defense, a dynamic protective buffer made up of all variables affecting a person at any given moment the person’s resistance to any given stressor or stressors.

If the flexible line of defense is no longer able to protect the person against a stressor, the stressor

breaks through, disturbs the person’s equilibrium, and triggers a reaction. The reaction may lead

toward restoration of balance or toward death.

Neuman intends for the nurse to "assist clients to retain, attain, or maintain optimal system stability" (Neuman, 1996).

Thus, health (wellness) seems to be related to dynamic equilibrium of the normal line of defense, where stressors are successfully overcome or avoided by the flexible line of defense.

Neuman defines illness as "a state of insufficiency with disrupting needs unsatisfied" (Neuman, 2002).

Illness appears to be a separate state when a stressor breaks through the normal line of defense and causes a reaction with the person’s lines of resistance.


In contrast to systems theory, stress and adaptation theories view change caused by person–environment interaction in terms of cause and effect.

The person must adjust to environmental changes to avoid disturbing a balanced existence. Adaptation theory provides a way to understand

both how the balance is maintained and the possible effects of disturbed equilibrium.

This theory has been widely applied to explain, predict, and control biologic (physiologic and psychological)


The drive for a unique body of knowledge is based on the assumption that ‘borrowed’ knowledge is

less worthy.

However, nurse education is based on theory borrowed from other disciplines, such as sociology and psychology.

It has been argued that applying knowledge from different disciplines only serves to dilute nursing practice.

Nevertheless, as the occupation is focused on

humans, perhaps it is inevitable that nursing uses

knowledge from other social sciences.

It has been argued that no knowledge is exclusive, and because of nursing’s diverse nature it is impossible for it to have a unique body of knowledge and one unified body of theory (Castledine 1994, Levine 1995).


To understand why nursing theory is generally neglected on the wards it is necessary to take a closer look at the main criticisms of nursing theory and the role that nurses play in contributing to its lack of prevalence in practice.

Use of language Scott (1994) states that the crucial ingredients of nursing theory should be accessibility and clarity. However, one of the main criticisms of nursing theory is its use of overtly complex language (Kenny 1993).

It is important that the language used in the

development of nursing theory be used consistently.

Not part of everyday practice Despite theory and practice being viewed as inseparable concepts, a theory-practice gap still exists in nursing (Upton 1999).

Yet despite the availability of a vast amount of literature on the subject, nursing theory still means very little to most practicing nurses. Perhaps this is because the majority of nursing theory is developed by and for nursing academics (Lathlean 1994).

It has been recognised that traditionally nurses are used to ‘speaking with their hands’ (Levine 1995).

Therefore, many nurses have not had the training or experience to deal with the abstract concepts presented by nursing theory.

This makes it difficult for the majority of nurses to understand and apply theory to practice (Miller 1985).

Summary

Definition Importance of Nursing Theories

The characteristics of theories:

Basic Processes in the Development Of Nursing Theories:

Nursing theories are often based on and influenced

ANA definition of Nursing Practice

Common concepts in Nursing Theories:

Historical Perspectives and Key Concepts

Classification of Nursing Theories

Models Of Nursing






Conclusion:

Littlejohn (2002) comments that irrespective of nursing theories, nurses will continue to exhibit a caring response to the ‘sick and troubled’. If this is true, perhaps nurses are ‘nursing’ without the knowledge of theories and theory is irrelevant. However, theory and practice are related, and if nursing is to continue to develop, the concept of theory must be addressed. If nursing theory does not drive the development of nursing, it will continue to develop in the footsteps of other disciplines such as medicine

Reference:


2. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williamsand wilkins.

3. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development and Progress 3rd ed. Philadelphia, Lippincott.

4. Taylor Carol,Lillis Carol (2001)The Art and Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

5. Potter A Patricia, Perry G Anne (1992)Fundamentals Of Nursing –Concepts Process and Practice 3rd ed. London Mosby Year Book.

Roy's Adaptation ModelThis page was last updated on November 13, 2010

=Introduction

Sr.Callista Roy, a prominent nurse theorist, writer, lecturer, researcher and teacher Professor and Nurse Theorist at the Boston College of Nursing in Chestnut Hill

Born at Los Angeles on October 14, 1939 as the 2nd child of Mr. and Mrs. Fabien Roy

she earned a Bachelor of Arts with a major in nursing from Mount St. Mary's College, Los Angeles in 1963.

a master's degree program in pediatric nursing at the University of California ,Los Angeles in 1966.

She also earned a master’s and PhD in Sociology in 1973 and 1977 ,respectively.

Sr. Callista had the significant opportunity of working with Dorothy E. Johnson

Johnson's work with focusing knowledge for the discipline of nursing convinced Sr. Callista of the importance of describing the nature of nursing as a service to society and prompted her to begin developing her model with the goal of nursing being to promote adaptation.

She joined the faculty of Mount St. Mary's College in 1966, teaching both pediatric and maternity nursing.

She organized course content according to a view of person and family as adaptive systems.

She introduced her ideas about ‘Adaptation Nursing’ as the basis for an integrated nursing curriculum.

Goal of nursing to direct nursing education, practice and research

Model as a basis of curriculum impetus for growth--Mount St. Mary’s College

1970-The model was implemented in Mount St. Mary’s school

1971- she was made chair of the nursing department at the college.

Influencing Factors Family Education

Religious Background

Mentors

Clinical Experience

THEORY DESCRIPTION The central questions of Roy’s theory are:

o Who is the focus of nursing care?

o What is the target of nursing care?

o When is nursing care indicated?

Roy’s first ideas appeared in a graduate paper written at UCLA in 1964.

Published these ideas in "Nursing outlook" in 1970

Subsequently different components of her framework crystallized during 1970s, ’80s, and ’90s

Over the years she identified assumptions on which her theory is based.

Explicit assumptions (Roy 1989; Roy and Andrews 1991) The person is a bio-psycho-social being. The person is in constant interaction with a changing environment.

To cope with a changing world, person uses both innate and acquired mechanisms which are biological, psychological and social in origin.

Health and illness are inevitable dimensions of the person’s life.

To respond positively to environmental changes, the person must adapt.

The person’s adaptation is a function of the stimulus he is exposed to and his adaptation level

The person’s adaptation level is such that it comprises a zone indicating the range of stimulation that will lead to a positive response.

The person has 4 modes of adaptation: physiologic needs, self- concept, role function and inter-dependence.

"Nursing accepts the humanistic approach of valuing other persons’ opinions, and view points" Interpersonal relations are an integral part of nursing

There is a dynamic objective for existence with ultimate goal of achieving dignity and integrity.

Implicit assumptions A person can be reduced to parts for study and care. Nursing is based on causality.

Patient’s values and opinions are to be considered and respected.

A state of adaptation frees an individual’s energy to respond to other stimuli.

ROY ADAPTATION MODEL CONCEPTS: EARLY AND REVISED Adaptation -- goal of nursing Person -- adaptive system

Environment -- stimuli

Health -- outcome of adaptation

Nursing -- promoting adaptation and health

Concepts-Adaptation Responding positively to environmental changes. The process and outcome of individuals and groups who use conscious awareness, self

reflection and choice to create human and environmental integration

Concepts-Person Bio-psycho-social being in constant interaction with a changing environment Uses innate and acquired mechanisms to adapt

An adaptive system described as a whole comprised of parts

Functions as a unity for some purpose

Includes people as individuals or in groups-families, organizations, communities, and society as a whole.

Concepts-Environment Focal - internal or external and immediately confronting the person Contextual- all stimuli present in the situation that contribute to effect of focal stimulus

Residual-a factor whose effects in the current situation are unclear

All conditions, circumstances, and influences surrounding and affecting the development and behavior of persons and groups with particular consideration of mutuality of person and earth resources, including focal, contextual and residual stimuli

Concepts-Health Inevitable dimension of person's life

Represented by a health-illness continuum

A state and a process of being and becoming integrated and whole

Concepts-Nursing To promote adaptation in the four adaptive modes To promote adaptation for individuals and groups in the four adaptive modes, thus

contributing to health, quality of life, and dying with dignity by assessing behaviors and factors that influence adaptive abilities and by intervening to enhance environmental interactions

Concepts-Subsystems Cognator subsystem — A major coping process involving 4 cognitive-emotive channels:

perceptual and information processing, learning, judgment and emotion. Regulator subsystem — a basic type of adaptive process that responds automatically

through neural, chemical, and endocrine coping channels

Relationships Derived Four Adaptive Modes 500 Samples of Patient Behavior

What was the patient doing?

What did the patient look like when needing nursing care?

Four Adaptive Modes Physiologic Needs Self Concept

Role Function

Interdependence

Four Adaptive Mode Categories Tested in practice for 10 years Criteria of significance, usefulness, and completeness were met

Sample Proposition and Hypothesis for Practice Self Concept Mode: Increased quality of social experience leads to increased feelings of

adequacy Providing support for new mothers can lead to positive parenting

THEORY DEVELOPMENT

Derived Theory

91 Propositions

Described relationships between and among regulator and cognator and four adaptive modes

12 Generic propositions

Questions Raised by 21st Century Changes How can ethics and public policy keep pace with developments in science? How can nurses focus on human needs not machines?

How can nurses contribute to creating meaning and purpose in a global society?

Scientific Assumptions for the 21st Century Systems of matter and energy progress to higher levels of complex self organization Consciousness and meaning are constitutive of person and environment integration

Awareness of self and environment is rooted in thinking and feeling

Human decisions are accountable for the integration of creative processes.

Thinking and feeling mediate human action

System relationships include acceptance, protection, and fostering of interdependence

Persons and the earth have common patterns and integral relations

Person and environment transformations are created in human consciousness

Integration of human and environment meanings results in adaptation

Philosophical Assumptions Persons have mutual relationships with the world and God Human meaning is rooted in an omega point convergence of the universe

God is intimately revealed in the diversity of creation and is the common destiny of creation

Persons use human creative abilities of awareness, enlightenment, and faith

Persons are accountable for the processes of deriving, sustaining, and transforming the universe

Adaptation and Groups Includes relating persons, partners, families, organizations, communities, nations, and

society as a whole

Adaptive Modes

A. Persons

Physiologic

Self Concept

Role Function

Interdependence

B. Groups

Physical Group Identity

Role Function

Interdependence

Role Function Mode Underlying Need of Social integrity The need to know who one is in relation to others so that one can act

The need for role clarity of all participants in group

Adaptation Level A zone within which stimulation will lead to a positive or adaptive response Adaptive mode processes described on three levels:

Integrated

Compensatory

Compromised

Integrated Life Processes Adaptation level where the structures and functions of the life processes work to meet

needs Examples of Integrated Adaptation

Stable process of breathing and ventilation

Effective processes for moral-ethical-spiritual growth

Compensatory Processes Adaptation level where the cognator and regulator are activated by a challenge to the life

processes Compensatory Adaptation Examples:

Grieving as a growth process, higher levels of adaptation and transcendence

Role transition, growth in a new role

Compromised Processes

Adaptation level resulting from inadequate integrated and compensatory life processes Adaptation problem

Compromised Adaptation Examples

Hypoxia

Unresolved Loss

Stigma

Abusive Relationships

THE NURSING PROCESS RAM offers guidelines to nurse in developing the nursing process. The elements :

First level assessment

Second level assessment

Diagnosis

Goal setting

Intervention

evaluation

Usefulness of Adaptation Model Scientific knowledge for practice Clinical assessment and intervention

Research variables

To guide nursing practice

To organize nursing education

Curricular frame work for various nursing colleges

Characteristics of the theory Theories can interrelates concepts in such a way as to present a new view of looking at a

particular phenomenon. Theories must be logical in nature

Theories should be relatively simple yet generalizable

Theories can be the basis for the hypotheses that can be tested

Theories contribute to and assist in increasing the general body of knowledge of a discipline through the research implemented to validate them

Theories can be utilized by the practitioners to guide and improve their practice

Theories must be consistent with other validated theories, laws and principles but will leave open unanswered questions that need to be investigated

Testability RAM is testable BBARNS (1999) reported that 163 studies have been conducted using this model.

RAM is complete and comprehensive

It explains the reality of client, so nursing interventions can be specifically targeted.

Research studies using RAM Middle range theories have been derived from RAM 1998-Ducharme et al described a longitudinal model of psychosocial determinants of

adaptation

1998-Levesque et al presented a MRT of psychological adaptation

1999-A MRNT , the urine control theory by Jirovec et al

Dunn, H.C. and Dunn, D. G. (1997). The Roy Adaptation Model and its application to clinical nursing practice. Journal of Ophthalmic Nursing and Technology. 6(2), 74-78.

Samarel, N., Fawcett, J., Krippendorf, K., Piacentino, J.C., Eliasof, B., Hughes, P., Kowitski, C., and Ziegler, E. (1998). Women's perception of group support and adaptation to breast cancer. Journal of Advanced Nursing. 28(6), 1259-1268.

Chiou, C. (2000). A meta-analysis of the interrelationships between the modes in Roy's adaptation model. Nursing Science Quarterly. 13(3), 252-258

Yeh, C. H. (2001). Adaptation in children with cancer: research with Roy's model. Nursing Science Quarterly. 14, 141-148.

Zhan, L. (2000). Cognitive adaptation and self-consistency in hearing-impaired older persons: testing Roy's adaptation model. Nursing Science Quarterly. 13(2), 158-165.

Summary 5 elements -person, goal of nursing, nursing activities, health and environment Persons are viewed as living adaptive systems whose behaviours may be classified as

adaptive responses or ineffective responses.

These behaviors are derived from regulator and cognator mechanisms.

These mechanisms work with in 4 adaptive modes.

The goal of nursing is to promote adaptive responses in relation to 4 adaptive modes, using information about person’s adaptation level, and various stimuli.

Nursing activities involve manipulation of these stimuli to promote adaptive responses.

Health is a process of becoming integrated and able to meet goals of survival, growth, reproduction, and mastery.

The environment consists of person’s internal and external stimuli.

References George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed.

Norwalk, Appleton & Lange. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia.

Lippincott Williams& wilkins.

Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott.

Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book.

Vandemark L.M. Awareness of self & expanding consciousness: using Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul; 27(6) : 605-15

Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006 Jul;19(3):225

Theory of Psychosocial Development

Erik H. Erikson"Healthy children will not fear life if their elders have integrity enough not to fear death."-

Erikson This page was last updated on 9/06/2010

INTRODUCTION

Erik Erikson was a psychoanalyst who developed the theory of psychosocial development.

He was born on June 15, 1902 in Karlsruhe Germany.

His classic work "Childhood and Society" set forth his theory of the life cycle.

Young Man Luther, Identity: Youth and Crisis, and Gandhi's Truth are his other influencial works.

He believed that the achievements and failures of earlier stages influence later stages, whereas later stages modify and transform earlier ones.

Erikson's conceptualization of psychosocial development based its model the epigenetic principle of organismic growth in utero.

Erikson views psychosocial growth occurs in phases.

EIGHT STAGES OF THE LIFE CYCLE

Erikson explains 8 developmental stages in which physical, cognitive, instinctual, and sexual changes combine to trigger an internal crisis whose resolution results in either psychosocial regression or growth and the development of specific virtues.

Erikson defined virtue as "inherent strength".

Psychosocial Stage Age VirtueRelated

Psychopathology

Trust vs. mistrust birth–18 months Hope

Psychosis

Addictions

Depression

Autonomy vs. shame and doubt

~18 months– Will

Paranoia

Obsessions

Compulsions

Impulsivity

Initiative vs. guilt ~3 years– Purpose

Conversion disorder

Phobia

Psychosomatic disorder

Inhibition

Industry vs. inferiority Competence Creative inhibition

Inertia

Identity vs. role confusion

~13 years– Fidelity Delinquent behavior

Gender-related identity disorders

Borderline psychotic

episodes

Intimacy vs. isolation ~20s– Love

Schizoid personality disorder

Distantiation

Generativity vs.stagnation

~40s– Care Midlife crisis

Premature invalidism

Integrity vs. despair ~60s– Wisdom Extreme alienation

Trust Versus Mistrust (Birth to About 18 Months)

The infant is taking the world in through the mouth, eyes, ears, and sense of touch. A baby whose mother is able to anticipate and respond to its needs in a consistent and

timely manner despite its oral aggression will learn to tolerate the inevitable moments of frustration and deprivation

A person who, as a result of severe disturbances in the earliest dyadic relationships, fails to develop a basic sense of trust or the virtue of hope may be predisposed as an adult to the profound withdrawal and regression characteristic of schizophrenia (Newton DS, Newton PM, 1998).

Autonomy Versus Shame and Doubt (About 18 Months to About 3 Years)

"This stage, therefore, becomes decisive for the ratio between loving good will and hateful self-insistence, between cooperation and willfulness, and between self-expression and compulsive self-restraint or meek compliance." - Erikson

This oral-sensory stage of infancy, marked by the potential development of basic trust aiming toward the achievement of a sense of hope.

Here, the child will develop an appropriate sense of autonomy, otherwise doubt and shame will undermine free will.

An individual who becomes fixated at the transition between the development of hope and autonomous will, with its residue of mistrust and doubt, may develop paranoic fears of persecution (Newton DS, Newton PM, 1998).

Other disturbances of improper transition of this stage results in perfectionism, inflexibility, stinginess and ruminative and ritualistic behavior of obsessive-compulsive personality disorder.

Initiative Versus Guilt (About 3 Years to About 5 Years)

Here, the child’s task is to develop a sense of initiative as opposed to further shame or guilt.

The lasting achievement of this stage is a sense of purpose.

The child's increasing mastery of locomotor and language skills expands its participation in the outside world and stimulates omnipotent fantasies of wider exploration and conquest

Industry Versus Inferiority (About 5 Years to About 13 Years)

Here the child is in school-age , so called stage of latency. He tries to master the crisis of industry versus inferiority aiming toward the development

of a sense of competence.

Identity Versus Role Confusion (About 13 Years to About 21 Years)

At puberty, the fifth stage, the task of adolescence is to navigate ther “identity crisis” as each individual struggles with a degree of “identity confusion.”

The lasting outcome of this stage can be a capacity for fidelity.

Intimacy Versus Isolation (About 21 Years to About 40 Years)

Young adulthood, at the stage of genitality or sixth stage, is marked by the crisis of intimacy versus isolation, out of which may come the achievement of a capacity for love.

Generativity Versus Stagnation (About 40 Years to About 60 Years)

"Generativity is primarily the concern for establishing and guiding the next generation."-Erikson

Care is the virtue that curresponding to this stage.

This failure of generativity can lead to profound personal stagnation, masked by a variety of escapisms, such as alcohol and drug abuse, and sexual and other infidelities.Mid-life crisis may occur.

Integrity Versus Despair (About 60 Years to Death)

"The acceptance of one's one and only life cycle and of the people who have become significant to it as something that had to be and that, by necessity, permitted of no substitutions."

The individual in possession of the virtue of wisdom and a sense of integrity has room to tolerate the proximity of death and to achieve.

When the attempt to attain integrity has failed, the individual may become deeply disgusted with the external world, and contemptuous of persons as well as institutions.

NURSING IMPLICATIONS

Application of Erikson's stages of psychosocial development helps in analysing patient's symptomatic behavior in the context of truamatic past experineces and struggles with current developmental tasks.

When patients' resolutions of previous psychosocial stages have been so faulty as to seriously compromise their adult development, they have the opportunity to rework early development through the relationship with the therapist. (Newton DS, Newton PM, 1998).

"The object of psychotherapy is not to head off future conflict but to assist the patient in emerging from each crisis "with an increased sense of inner unity, with an increase of good judgment, and an increase in the capacity `to do well' according to his own standards and to the standards of those who are significant to him." (Erikson in Identity: Youth and Crisis)

ERIKSON'S WORKS

Erikson E: Childhood and Society. Norton, New York, 1950. Erikson E: The dream specimen of psychoanalysis. J Am Psychoanal Assoc 2:5, 1954.

Erikson E: The first psychoanalyst. Yale Rev 46:40, 1956.

Erikson E: Freud's "The Origins of Psychoanalysis." Int J Psychoanal 36:1, 1955.

Erikson E: Gandhi's Truth. Norton, New York, 1969.

Erikson E: Hitler's imagery and German youth. Psychiatry 5:475, 1942.

Erikson E: Identity and the Life Cycle. Norton, New York, 1980.

Erikson E: Identity: Youth and Crisis. Norton, New York, 1968.

Erikson E: Insight and Responsibility. Norton, New York, 1964.

Erikson E: Life History and the Historical Moment. Norton, New York, 1975.

Erikson E: Observations on Sioux education. J Psychol 7:101, 1939.

Erikson E: The problem of ego identity. Psychol Issues 1:379, 1959.

Erikson E: Young Man Luther. Norton, New York, 1962.

Erikson E, Erikson J, Kivnick H: Vital Involvement in Old Age. Norton, New York, 1986.

REFERENCES

1. Erikson E: Insight and Responsibility. Norton, New York, 1964.2. Erikson E: Identity: Youth and Crisis. Norton, New York, 1968.

3. Newton DS, Newton PM in Kaplan HI & Sadok BJ's Synopsis of psychiatry-behavioural science or clinical psychiatry.9th edn. Hong Kong.William and Wilkinsons publications. 1998.

Maslow's Theory of Needs

This page was last updated on January 8, 2011 ==================================

Introduction

Proposed by Abraham Maslow in his 1943 paper A Theory of Human Motivation.

Maslow’s Hierarchy of Needs is a motivational theory that argues that while people aim to meet basic needs, they seek to meet successively higher needs in the form of a hierarchy.

Maslow's theoryhas been applied in nursing to guide the prioritization of patient care needs

It is often represented as a pyramid with five levels of needs.

Maslow’s hierarchy of needs

Maslow’s hierarchy of needs is a based on the theory that one level of needs must be met before moving on to the next step.

Self-actualization – e.g. morality, creativity, problem solving.

Esteem – e.g. confidence, self-esteem, achievement, respect.

Belongingness – e.g. love, friendship, intimacy, family.

Safety – e.g. security of environment, employment, resources, health, property.

Physiological – e.g. air, food, water, sex, sleep, other factors towards homeostasis.

Assumptions

Maslow’s theory maintains that a person does not feel a higher need until the needs of the current level have been satisfied.

B and D Needs

Deficiency or deprivation needs

The first four levels are considered deficiency or deprivation needs (“D-needs”) in that their lack of satisfaction causes a deficiency that motivates people to meet these needs

Growth Needs or B-Needs or Being Needs

The needs Maslow believed to be higher, healthier, and more likely to emerge in self-actualizing people were being needs, or B-needs.

Growth needs are the highest level, which is self-actualization, or the self-fulfillment.

Maslow suggested that only two percent of the people in the world achieve self actualization. E.g. Abraham Lincoln, Thomas Jefferson, Albert Einstein, Eleanor Roosevelt.

Self actualized people were reality and problem centered.

They enjoyed being by themselves, and having deeper relationships with a few people instead of more shallow relations with many people.

They tended to be spontaneous and simple.

Application in Nursing

Maslow's hierarchy of needs is a useful organizational framework that can be applied to the various nursing models for assessment of a patient’s strengths, limitations, and need for nursing interventions. (Smeltzer SC, Bare BG, 2004)

References

1. Health Care Delivery and Nursing Practice. In Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, (Edtrs. Smeltzer SC, Bare BG.) 10th Edition. Lippincott Williams and Wilkins. Philadelphia. 2003.

2. Psychiatry, Third Edition. Edited by Allan

Tasman, Jerald Kay, Jeffrey A. Lieberman, Michael B. First and Mario Maj. John Wiley & Sons, Ltd, 2008.

3. Maslow, A. H.. A Theory of Human Motivation. Psychological Review, 50, 1943. pp. 370.

Theory of Florence Nightingale

Date of last revision January 8, 2011===============================

The goal of nursing is “to put the patient in the best conditionfor nature to act upon him”. - Nightingale

Introduction

Born - 12 May 1820 Founder of mordern nursing.

The first nursing theorist.

Also known as "The Lady with the Lamp"

She explained her environmental theory in her famous book Notes on Nursing: What it is, What it is not .

She was the first to propose nursing required specific education and training.

Her contribution during Crimean war is well-known.

She was a statistician, using bar and pie charts, highlighting key points.

International Nurses Day, May 12 is observed in respect to her contribution to Nursing.

Died - 13 August 1910

Assumpations of Nightingale's Theory

Natural laws Mankind can achieve perfection

Nursing is a calling

Nursing is an art and a science

Nursing is achieved through environmental alteration

Nursing requires a specific educational base

Nursing is distinct and separate from medicine

Nightingale’s Canons: Major Concepts

1. Ventilation and warming2. Light, Noise

3. Cleanliness of rooms/walls

4. Health of houses

5. Bed and bedding

6. Personal cleanliness

7. Variety

8. Chattering hopes and advices

9. Taking food. What food?

10. Petty management/observation

Nursing Paradigms

Nightingale's documents contain her philosophical assumptions and beliefs regarding all elements found in the metaparadigm of nursing. These can be formed into a conceptual model that has great utility in the practice setting and offers a framework for research conceptualization. (Selanders LC, 2010)

Nursing

Nursing is different from medicine and the goal of nursing is to place the patient in the best possible condition for nature to act.

Nursing is the "activities that promote health (as outlined in canons) which occur in any caregiving situation. They can be done by anyone."

Person

People are multidimensional, composed of biological, psychological, social and spiritual components.

Health

Health is “not only to be well, but to be able to use well every power we have”. Disease is considered as dys-ease or the absence of comfort.

Environment

"Poor or difficult environments led to poor health and disease".

"Environment could be altered to improve conditions so that the natural laws would allow healing to occur."

Nightingale's Theory and Nursing Practice

Application of Nightingale's theory in practice:

"Patients are to be put in the best condition for nature to act on them, it is the responsibility of nurses to reduce noise, to relieve patients’ anxieties, and to help them sleep."

As per most of the nursing theories, environmental adaptation remains the basis of holistic nursing care.

Criticisms

She emphasized subservience to doctors. She focused more on physical factors than on psychological needs of patient.

Applications of Nightingale's Theory

Nightingale theory and intentional comfort touch in management of tinea pedis in vulnerable populations

Incorporating Florence Nightingale's theory of nursing into teaching a group of preadolescent children about negative peer pressure.

Conclusion

Florence Nightingale provided a professional model for nursing organization. She was the first to use a theoretical founation to nursing.

Her thoghts have influenced nursing significantly.

References

1. Nightingale, F. Notes on nursing: What it is and what it is not. 1860.2. Works by Florence Nightingale at Project Gutenberg

3. Selanders LC. The power of environmental adaptation: Florence Nightingale's original theory for nursing practice. .J Holist Nurs. 2010 Mar; 28(1):81-8.

http://www.gutenberg.org/author/Florence_Nightingale





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Introduction to Nursing Theories