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GARCIA, Neil A. May 12, 2009
TABOR, Yolybeth S.
BSN-2E
THEORETICAL FOUNDATIONS OF NURSING
A. ENVIRONMENTAL THEORY
“I think one’s feelings waste
themselves in words; they ought all to
be distilled into actions which bring
results.”
Florence Nightingale (1860)
Florence Nightingale defined Nursing as “the act of
utilizing the environment of the patient to assist him in
his recovery” (1860/1969), that it involves the nurse's
initiative to configure environmental settings appropriate
for the gradual restoration of the patient's health, and
that external factors associated with the patient's
surroundings affect life or biologic and physiologic
processes, and his development.
Environmental Factors Affecting Health
Defined in her environmental theory are the following
factors present in the patient’s environment:
pure or fresh air
pure water
sufficient food supplies
efficient drainage
cleanliness
light (especially direct sunlight)
Adequate ventilation has also been regarded as a factor
contributing to changes of the patient’s process of illness
recovery. Any deficiency in one or more of these factors
could lead to impaired functioning of life processes or
diminished health status.
She also emphasized in her environmental theory is the
provision of a quiet or noise-free and warm environment,
attending to patient’s dietary needs by assessment,
documentation of time of food intake, and evaluating it’s
effects on the patient.
Nightingale believed that the environment was the major
component creating illness in a patient; she regarded
disease as “the reactions of kindly nature against the
conditions in which we have placed ourselves.” Her theory
Contains three major relationships:
environment to patient
nurse to environment
nurse to patient
B. INTERACTIVE THEORIES
INTERPERSONAL RELATIONS THEORY
“The kind of person that the nurse
becomes makes a substantial difference in
what each patient will learn as he or she
receives nursing care.”
Hildegard Peplau (1952)
She defined Nursing as “an interpersonal process of
therapeutic interactions between an individual who is sick
or in need of health services and a nurse especially
educated to recognize, respond to the need for help.”
Dr. Peplau emphasized the nurse-client relationship as
the foundation of nursing practice. At the time, her
research and emphasis on the give-and-take of nurse-client
relationships was seen by many as revolutionary. She
described the nurse-patient relationship as a four-phase
phenomenon. Each phase is unique and has distinguished
contributions on the outcome of the nurse-patient
interaction.
Phases Of Nurse-Patient Relationship
1
. Orientation
Individual/family has a “felt need”
and seeks professional assistance from a
nurse (who is a stranger). This is the
problem identification phase.
Where the patient begins to have
2. Identificationfeelings of belongingness and a capacity
for dealing with the problem, creating an
optimistic attitude from which inner
strength ensues. Here happens the
selection of appropriate professional
assistance.
3. Exploitation The nurse uses communication tools
to offer services to the patient, who is
expected to take advantage of all
services.
4. Resolution
Where patient’s needs have already
been met by the collaborative efforts
between the patient and the nurse.
Therapeutic relationship is terminated
and the links are dissolved, as patient
drifts away from identifying with the
nurse as the helping person.
Nursing Roles
In the course of the nurse-patient relationship, the
nurse assumes several roles which empower and equip her in
meeting the needs of the patient.
1. Stranger Role: Receives the client the same way one
meets a stranger in other life situations; provides
an accepting climate that builds trust.
2. Resource Role: Answers questions. Interprets
clinical treatment data, gives information.
3. Teaching Role: Gives instructions and provides
training; involves analysis and synthesis of the
learner’s experience.
4. Counseling Role: Helps client understand and
integrate the meaning of current life circumstances;
provides quidance and encouragement to make changes.
5. Surrogate Role: Helps clients clarify domains of
dependence, interdependence, and independence and
acts on clients behalf as advocate.
6. Leadership Role: Helps client assume maximum
responsibility for meeting treatment goals in a
mutually satisfying way.
Additional Roles include:
1. Technical expert
2. Consultant
3. Health teacher
4. Tutor
5. Socializing agent
6. Safety agent
7. Manager of environment
8. Mediator
9. Administrator
10.Recorder observer
11.Researcher
Definition of the Unique Function of
Nursing
“The nurse is temporarily the consciousness of the
unconscious, the love of life for the suicidal, the leg of
the amputee, the eyes of the newly blind, a means of
locomotion for the infant, knowledge and confidence for the
mother, the mouthpiece for those too weak or withdrawn to
speak and so on.”
Virginia Henderson (1955)
Henderson defined Nursing as “assisting the individual,
sick or well, in the performance of those activities
contributing to health or it’s recovery (or to peaceful
death) that an individual would perform unaided if he had
the necessary strength, will or knowledge”.
She conceptualized the 14 Fundamental Needs of humans.
These needs are:
Breathing normally
Eating and drinking adequately
Eliminating body wastes
Moving and maintaining desirable position
Sleeping and resting
Selecting suitable clothes
Maintaining body temperature within normal range
Keeping the body clean and well-groomed
Avoiding dangers in the environment
Communicating with others
Worshipping according to one’s faith
Working in such a way that one feels a sense of
accomplishment
Playing/participating in various forms of recreation
Learning, discovering or satisfying the curiosity that
leads to normal development and health and using
available health facilities.
The Nurse-Patient Relationship
Henderson stated that there are three levels comprising
the nurse-patient relationship:
1. The nurse as a substitute for the patient. In times
of illness, when the patient cannot function fully,
the nurse serves as the substitute as to what the
patient lacks such, as knowledge, will, and strength
in order to make him complete, whole and independent
once again.
2. The nurse as a helper to the patient. In situations
where the patient cannot meet his basic needs, the
nurse serves as a helper to accomplish them.
3. The nurse as a partner with the patient. As partners,
the nurse and the patient formulate the care plan
together. Both as an advocate and as a resource
person, the nurse can empower the patient to make
effective decisions regarding his care plans.
Dynamic Nurse-Patient Relationship
“The role of the nurse is to find out and meet the
patient's immediate need for help. The patient's presenting
behavior may be a plea for help, however, the help needed
may not be what it appears to be.”
Ida Jean Orlando (1961)
Orlando's theory was developed in the late 1950s from
observations she recorded between a nurse and patient.
Despite her efforts, she was only able to categorize the
records as "good" or "bad" nursing. It then dawned on her
that both the formulations for "good" and "bad" nursing were
contained in the records. From these observations she
formulated the deliberative nursing process.
Therefore, nurses need to use their perception,
thoughts about the perception, or the feeling engendered
from their thoughts to explore with patients the meaning of
their behavior. This process helps the nurse find out the
nature of the distress and what help the patient needs.
Orlando's theory remains one the of the most effective
practice theories available. The use of her theory keeps the
nurse's focus on the patient. The strength of the theory is
that it is clear, concise, and easy to use. While providing
the overall framework for nursing, the use of her theory
does not exclude nurses from using other theories while
caring for the patient.
Key Concepts of Three Interlocking Circles Theory
According to Hall, Nursing is
participation in care, core and cure
aspects, where CARE is the sole
function of nurses, whereas the CORE
and CURE are shared with other
members of the health team
The major purpose of care is to
achieve an interpersonal
relationship with the individual
that will facilitate the development
of the core Lydia Hall (1961)
Human-to-Human Relationship Model
“A nurse does not only seek to alleviate physical pain
or render physical care- she ministers to the whole person.
The existence of suffering, whether physical, mental or
spiritual is the proper concern of the nurse.”
Joyce Travelbee (1966)
Travelbee's experience in initial psych nursing
practice at a Catholic charity hospital led her to believe
that the care given in these type of institutions lacked
compassion. She felt nursing needed a "humanistic
revolution" and a renewed focus on caring as central to
nursing--she warned that if this didn't happen, consumers
might seek a "new and different kind of health care worker".
Travelbee's ideas have greatly influenced the hospice
movement.
In her human-to-human relationship model, the nurse and
the patient undergoes the following series of interactional
phases:
1. Original Encounter- this is described as the first
impression by the nurse of the sick person and vice-
versa The nurse and patient see each other in
stereotyped or traditional roles.
2. Emerging Identities- this phase is described by the
nurse and patient perceiving each other as unique
individual. At this time, the link of relationship
begins to form.
3. Empathy- this phase is described as the ability to
share in the person’s experience.
4. Sympathy- It happens when the nurse wants to lessen
the cause of the patient’s suffering. It goes beyond
empathy. The nurse at this time should use a
disciplined intellectual approach together with
therapeutic use of self to make helpful nursing
actions.
5. Rapport- this is described as nursing interventions
that lessens the patient’s suffering. The nurse and
the sick person are relating as human being to human
being. The sick person shows trust and confidence in
the nurse.
C. SYSTEMS THEORIES
System Model in Nursing Practice
“Health is a condition in which
all parts and subparts are in harmony
with the whole of the client”
Betty Neuman (1972)
Her theory incorporated the concept of a whole person
and an open system approach. The concept is aimed towards
the development of a person in a state of wellness having
the capacity to function optimally. The main role of the
nurse in her theory is to help a person to adapt with
environmental stimuli causing illnesses back to a state of
wellness.
Terms Related to Neuman’s System Theory
Client Variables
The clients’ variables can be one or combination of the
following: physiological, sociocultural, developmental and
spiritual. These variables function to achieve stability in
relation to the environmental stressors experienced by the
client.
Lines of Resistance
Lines of Resistance act when the Normal Line of Defense
is invaded by too much stressor, producing alterations in
the client’s health.
Normal Line of Defense
To achieve the stability of the system, the Normal Line
of Defense must act in coordination with the normal wellness
state. It must reflect the actual range of responses that is
normally acted by clients in response to any stressors. It
is the baseline in determining the level of client within
the continuum of health.
Flexible Line of Disease
It serves as a boundary for the Normal Line of Defense
to adjust to situations that threaten the imbalance within
the client’s stability.
Stressors
These are forces that produce tensions, alterations or
potential problems causing instability within the client’s
system.
Reaction
These are the outcomes or produced results of certain
stressors and actions of the lines resistance of a client.
It can be positive or negative depending on the degree of
reaction the client produces to adjust and adapt with the
situation. Neuman specified these reactions as negentropy or
entropy. Negentropy is set towards stability or wellness
while Egentropy is set towards disorganization of the system
producing illness.
Behavioral System Model
“Each individual has a predisposition
to act, with reference to the goal, in certain ways rather
than in other ways”
Dorothy Johnson (1971)
Johnson believes that each individual has a focusing
and repeating ways of acting which covers a behavioral
system distinct to that individual. These behaviors are
logical, fixed, predictable and adequately secure and
persistent to be satisfying to depiction and clarification.
Seven Behavioral Subsystems
1. The Attachment or Affiliative Subsystem is well-
known as the earliest response system to expand in
the individual. The most favorable functioning of
this subsystem allows social inclusion, closeness,
and the pattern and continuance of a strong public
bond.
2. The Dependency Subsystem are actions that trigger
nurturing behaviors from other individuals in the
environment. The product of dependency behavior is
consent, interest or appreciation, and physical
support.
3. The Ingestive Subsystem relates to the behaviors
surrounding the ingestion of food. Behaviors related
to the ingestion of food may relate more to what is
socially satisfactory in a specified culture, than
to the biological necessities of the human being.
4. The Eliminative Subsystem relates to behaviors
surrounding the secretion of waste products from the
body. Human cultures have defined different socially
acceptable behaviors for excretion of waste, but the
continuation of such an outline remains from culture
to culture.
5. The Sexual Subsystem imitates behaviors realted to
procreation or reproduction.
6. The Aggressive Subsystem relates to behaviors
concerned with the defense and self-preservation.
7. The Achievement Subsystem contains behaviors that
attept to control the environment. Intellectual,
physical, imaginative, mechanical, and communl
skills are some of the areas that Johnson
distinguishes.
Goal Attainment Theory
“If the students can’t do the
fundamentals, how can they use advanced
knowledge.”
Imogene King (1971)
King stated that Nursing is a process of action,
reaction, and interaction whereby nurse and client share
information about their perception in the nursing situation.
Action
Action is a means of behavior or activities that are
towards the accomplishment of certain act. It is both
physical and mental.
Reaction
In King’s theory, reaction is not specified but somehow
relates reaction as part of action. According to her,
reaction is a response to a stimuli.
Interaction
Interaction, as defined by King, is any situation
wherein the nurse relates and deals with a clientele or
patient.
Open System
It is the absence of boundary existence, where a
dynamic interaction between the internal and external
environment can exchange information without barriers or
hindrances.
King proposed that the nurse interacts in the system
simultaneously at three different levels. These levels are
independent and at the same time co-exist to influence over-
all nursing practice.
Personal- how the nurse views and integrates self based
from personal goals and beliefs
Interpersonal- how the nurse interrelates with a co-
worker or patient, particularly in a nurse-patient
relationship
Social- how the nurse interacts with co-workers,
superiors, subordinates and the client environment in
general
Self-Care Theory
“Individuals, families, groups and
communities need to be taught self-
care.”
Dorothea Orem (1971)
Orem defined Nursing as “The act of assisting others in
the provision and management of self-care to
maintain/improve human functioning at home level of
effectiveness.”
The theory focuses on activities that adult individuals
perform on their own behalf to maintain life, health and
well-being. It has a strong health promotion and maintenance
focus.
She identified 3 related concepts:
1. Self-care - activities an Individual performs
independently throughout life to promote and
maintain personal well-being.
2. Self-care deficit - results when self-care agency
(Individual’s ability) is not adequate to meet the
known self-care needs.
3. Nursing System - nursing interventions needed when
Individual is unable to perform the necessary self-
care activities:
1. Wholly compensatory - nurse provides entire
self-care for the client.
Example: care of a new born, care of
client recovering from surgery in a
post-anesthesia care unit
2. Partial compensatory - nurse and client
perform care, client can perform selected
self-care activities, but also accepts care
done by the nurse for needs the client cannot
meet independently.
Example: Nurse can assist post operative
client to ambulate, Nurse can bring a
meal tray for client who can feed
himself
3. Supportive-educative - nurse’s actions are to
help the client develop/learn their own self-
care abilities through knowledge, support and
encouragement.
Example: Nurse guides a mother how to
breastfeed her baby, Counseling a
psychiatric client on more adaptive
coping strategies.
Twenty-One Nursing Problems
“I never wanted to be a medical
doctor because I could do all I wanted to
do in nursing, which is a caring
profession.”
Faye Glen Abdellah (1960)
The concept of Nursing in this theory is generally
grouped into twenty-one problem areas for nurses to work out
their judgment and appropriate care. Abdellah considers
nursing to be an all-inclusive service that is based on the
disciplines of art and science that serves individuals, sick
or well with their health needs.
Typology of Twenty-one Nursing Problems
1. To maintain good hygiene.
2. To promote optimal activity; exercise, rest and sleep.
3. To promote safety.
4. To maintain good body mechanics.
5. To facilitate the maintenance of a supply of oxygen
6. To facilitate maintenance of nutrition
7. To facilitate maintenance of elimination
8. To facilitate the maintenance of fluid and electrolyte
balance
9. To recognize the physiologic response of the body to
disease conditions
10. To facilitate the maintenance of regulatory
mechanisms and functions.
11. To facilitate the maintenance of sensory functions
12. To identify and accept positive and negative
expressions, feelings and reactions
13. To identify and accept the interrelatedness of
emotions and illness.
14. To facilitate the maintenance of effective verbal and
non-verbal communication
15. To promote the development of productive
interpersonal relationship
16. To facilitate progress toward achievement of personal
spiritual goals
17. To create and maintain a therapeutic environment
18. To facilitate awareness of self as an individual with
varying needs.
19.To accept the optimum possible goals
20.To use community resources as an aid in resolving
problems arising from illness.
21.To understand the role of social problems as
influencing factors
Helping Art of Clinical Nursing
"My thesis is that nursing art is
not comprised of rational nor
reactionary actions but rather of
deliberative action."
Ernestine Wiedenbach (1964)
Wiedenbach conceptualizes nursing as the practice
identification of a patient’s need for help through
observation of presenting behaviors and symptoms,
exploration of the meaning of those symptoms with the
patient, determining the cause(s) of discomfort, and
determining the patient’s ability to resolve the discomfort
or if the patient has a need for help from the nurse or
other healthcare professionals.
Nursing primarily consists of identifying a patient’s
need for help. If the need for help requires intervention,
the nurse facilitates the medical plan of care and also
creates and implements a nursing plan of care based on needs
and desires of the patient. In providing care, a nurse
exercises sound judgment through deliberative, practiced,
and educated recognition of symptoms. The patient’s
perception of the situation is an important consideration to
the nurse when providing competent care.
According to Wiedenbach there are four elements to
clinical nursing: (1) philosophy, (2) purpose, (3) practice,
and (4) art.
The nurses’ philosophy was their attitude and
belief about life and how that effected reality
for them. Philosophy is what motivates the nurse
to act in a certain way.
Wiedenbach also believed that there were 3
essential components associated with a nursing
philosophy:
o Reverence for life
o Respect for the dignity, worth, autonomy and
individuality of each human being
o Resolution to act on personally and
professionally held beliefs
Nurses’ purpose is that which the nurse wants to
accomplish through what she does. It is all of
the activities directed towards the overall good
of the patient.
Practices are those observable nursing actions
that are affected by beliefs and feelings about
meeting the patient’s need for help.
The Art of nursing includes understanding
patient’s needs and concerns, developing goals and
actions intended to enhance patient’s ability and
directing the activities related to the medical
plan to improve the patient’s condition. The
nurses also focuses on prevention of complications
related to reoccurrence or development of new
concerns.
The Conservation Model
"Ethical behaviour is not the display of one's moral
rectitude in times of crisis. It is the day-to-day
expression of one's commitment to other persons and the ways
in which human beings relate to one another in their daily
interactions.”
Myra Levine (1977)
She defined nursing as supportive & therapeutic
interventions based on scientific or therapeutic knowledge.
Nursing actions based on four principles:
conservation of energy
structural integrity
personal integrity
social integrity
D. DEVELOPMENTAL THEORIES
Adaptation Model
“The model provides a way of thinking about people and
their environment that is useful in any setting. It helps
one prioritize care and challenges the nurse to move the
patient from survival to transformation.”
Sister Callista Roy (1979)
She viewed humans as biopsychosocial beings constantly
interacting with a changing environment and who cope with
their environment through Biopsychosocial adaptation
mechanisms. There are two categories of coping mechanisms
according to Roy namely the regulator and the cognator
subsystems:
Regulator Subsystem transpires through neutral,
chemical and endocrine processes like the increase in
vital signs-sympathetic response to stress.
Cognator Subsystem, on the other hand, occurs through
cognitive-emotive processes. For instance, are the
effects of prolonged hospitalization for a four-year
old child.
The degree of internal or external environmental change
and the person’s ability to cope with that change is likely
to determine the person’s health status. Nursing
interventions are aimed at promoting physiologic,
psychologic, and social functioning or adaptation.
Transcultural Theory
“Care is the heart of nursing; Care
is power; Care is essential to healing;
Care is curing; and Care is the central
and dominant focus of nursing and
transcultural nursing decisions and
actions.”
Madeleine Leininger (1985)
She stated that Nursing is a learned humanistic and
scientific profession and discipline which is focused on
human care phenomena and activities in order to assist,
support, facilitate, or enable individuals or groups to
maintain or regain their well being (or health) in
culturally meaningful and beneficial ways, or to help people
face handicaps or death.
Transcultural nursing as a learned subfield or branch
of nursing which focuses upon the comparative study and
analysis of cultures with respect to nursing and health-
illness caring practices, beliefs and values with the goal
to provide meaningful and efficacious nursing care services
to people according to their cultural values and health-
illness context. It focuses on the fact that different
cultures have different caring behaviors and different
health and illness values, beliefs, and patterns of
behaviors. Awareness of the differences allows the nurse to
design culture-specific nursing interventions.
Philosophy and Science of Caring
“Caring in nursing conveys physical
Acts but embraces the mind-body-spirit
as it reclaims the embodied spirit as
its focus attention.”
Margaret Jean Watson (1979)
Watson proposes seven assumptions about the science of
caring and ten primary carative factors to form the
framework of her theory. The basic assumptions are:
Caring can be effectively demonstrated and practiced
only interpersonally;
Effective caring promotes health and individual or
family growth;
Caring responses accept a 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. The
practice of caring integrates biophysical knowledge of
human behavior to generate or promote health and to
provide care to those who are ill. A science of caring
is therefore complementary to the science of curing.
The practice of caring is central to nursing
Ten Carative Factors
1. The promotion of a humanistic-altruistic system of
values
2. Instillation of faith-hope
3. The cultivation of sensitivity to one’s self and others
4. The development of a helping-trusting, human caring
relationship
5. Promotion and acceptance of the expression of positive
and negative feelings.
6. The systemic use of the scientific problem-solving
method for decision making
7. The promotion of interpersonal teaching-learning
8. The provision for supportive, protective and corrective
mental, physical, socio-cultural and spiritual
environment
9. Assistance with the gratification of human needs
10. The allowance for existential phenomenological
forces
The Science of Unitary Human Beings, and
Principles of Homeodynamics
“Nursing is an art and science that is
humanistic and humanitarian. It is directed
toward the unitary human and is concerned
with the nature and direction of human
development.”
Martha Rogers (1970)
Nursing interventions seek to promote harmonious
interaction between persons and their environment,
strengthen the wholeness of the individual and redirect
human and environmental patterns or organization to achieve
maximum health. There are 5 Basic Assumptions:
1. The human being is a unified whole, possessing
individual integrity and manifesting characteristics
that are more than and different from the sum of parts.
2. The individual and the environment are
continuously exchanging matter and energy with each
other
3. The life processes of human beings evolve irreversibly
and unidirectionally along a space-time continuum
4. Patterns identify human being and reflect their
innovative wholeness
5. The individual is characterized by the capacity for
abstraction and imagery, language and thought,
sensation and emotion
Theory of Human Becoming
“Nursing is a scientific discipline,
the practice of which is a performing
art.”
Rosemarie Rizzo Parse (1981)
Three assumptions about Human Becoming
Human becoming is freely choosing personal meaning
in situation in the inter-subjective process of
relating value priorities
Human becoming is co-creating rhythmic patterns or
relating in mutual process in the universe
Human becoming is co-transcending multidimensionally
with emerging possibilities.
References:
Octaviano, Eufemia F., RN, RM, MN, EdD, Balita, Carl E., RN,
RM, MAN, DrHum. “Theoretical Foundations of Nursing: The
Philippine Perspective”, 2008.
http://nursingcrib.com
http:// http://en.wikipedia.org/wiki/