Nursing Theories

Nursing Theories
INTRODUCTION TO NURSING
THEORIES
INTRODUCTION
Nursing has made phenomenal achievement in the last century that has lead to
the recognition of nursing as an academic discipline and a profession. A move
towards theory-based practice has made contemporary nursing more meaningful
and significant by shifting nursing’s focus from vocation to an organised
profession. The need for knowledge-base to guide professional nursing practice
had been realised in the first half of the twentieth century and many theoretical
works have been contributed by nurses ever since, first with the goal of making
nursing a recognised profession and later with the goal of delivering care to
patients as professionals.
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)
NURSING PHILOSOPHIES
Theory Key emphasis

Florence Nightingale’s Focuses on nursing and the patient
Legacy of caring environment relationship.
Helping process meets needs through the art

of individualizing care.
Nurses should identify patients ‘need-for –

Ernestine Wiedenbach: help’ by:
The helping art of clinical
nursing Observation
Understanding client behaviour
Identifying cause of discomfort
Determining if clients can resolve problems or
have a need for help
Virginia Henderson’s Patients require help towards achieving

Definition of Nursing independence.
Derived a definition of nursing

Identified 14 basic human needs on which
nursing care is based.
Faye Patient’s problems determine nursing care

G.Abedellah’s Typology of
twenty one Nursing
problems
Lydia E. Hall :Care, Cure, Nursing care is person directed towards self
Core model love.
Jean Watson’s Philosophy Caring is moral ideal: mind -body – soul

and Science of caring 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 Caring is central to the essence of nursing. It

of caring 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 THEORIES
Dorothea E. Orem’s Self Self–care maintains wholeness.

care deficit theory in Three Theories:
nursing
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 Holism is maintained by conserving integrity

conservation model 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 Person environment are energy fields that

of unitary human beings 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 Individuals maintain stability and balance

Behavioural system model 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 Stimuli disrupt an adaptive system

Adaptation model 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 Transactions provide a frame of reference

attainment theory 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 Individuality in living.

and A.J.Tierney A model A conceptual model of nursing from which
for nursing based on a theory of goal attainment is derived.
model of living
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: Interpersonal process is maturing force for
Psychodynamic Nursing personality.
Theory 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 Interpersonal process alleviates distress.

Process Theory 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 Therapeutic human relationships.

To Human Relationship Nursing is accomplished through human to
Model 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 Growth and development of children and
Parent Child Interaction mother–infant relationships
Model 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 Parenting and maternal role attainment in

:Maternal Role Attainment diverse populations
A complex theory to explain the factors
impacting the development of maternal role
over time.
Katharine Kolcaba’s Theory Comfort is desirable holistic outcome of care.

of comfort 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 Caring is universal and varies transculturally.

Transcultural nursing, Major concepts include care, caring, culture,
culture-care theory 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 Indivisible beings and environment co-create

:Theory of human health.
becoming 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 Promoting optimum health supersedes
Health promotion; model 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
• 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.
• Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.).
Mosby, Philadelphia, 2002
• Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd
Ed. Mosby, Philadelphia, 2002.
DEVELOPMENT OF NURSING
THEORIES
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. 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: 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 & 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
1. Nursing theory aims to describe, predict and explain the phenomenon of

nursing (Chinn and Jacobs1978).
2. 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).
3. Theory is important because it helps us to decide what we know and what we
need to know (Parsons1949).
4. It helps to distinguish what should form the basis of practice by explicitly
describing nursing.
5. 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
6. The main exponent of nursing – caring – cannot be measured, it is vital to
have the theory to analyze and explain what nurses do.
7. 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.
8. 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
1. It outlines the process of growth & development of humans as orderly &

predictable, beginning with conception & ending with death.
2. The progress & behaviors of an individual within each stage are unique.
3. 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
• Nightingale (1860): To facilitate “the body’s reparative processes” by

manipulating client’s environment
• Peplau 1952: Nursing is; therapeutic interpersonal process.
• Henderson 1955: The needs often called Henderson’s 14 basic needs
• 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.
• 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.
• 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.
• Rogers 1970: to maintain and promote health, prevent illness, and care for
and rehabilitate ill and disabled client through “humanistic science of nursing”
• Orem1971: This is self-care deficit theory. Nursing care becomes necessary
when client is unable to fulfill biological, psychological, developmental, or
social needs.
• King 1971: To use communication to help client reestablish positive
adaptation to environment.
• Neuman 1972: Stress reduction is goal of system model of nursing practice.
• Roy 1979: This adaptation model is based on the physiological, psychological,
sociological and dependence-independence adaptive modes.
• 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 Function (Polit et al 2001)

Descriptive To identify the properties and
workings of a discipline
Explanatory To examine how properties relate and
thus affect the discipline
Predictive To calculate relationships between
properties and how they occur
Prescriptive To identify under which conditions

relationships occur
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.
Based on the philosophical underpinnings of the theories
■ “Needs “theories.
■ “Interaction” theories.
■ “Outcome “theories.
■ Humanistic 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 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
• 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).
Growth and Stability Models of Change
• 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 focuses
on 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:
• 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).
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 & 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:
• Imogene King’s systems interaction model, and
• 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
Environment A context “within which human beings
grow, develop, and perform daily
activities”
Health 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”
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:
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.
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.
A unique body of knowledge
• 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).
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.
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).
Summarization
1. Definition
2. Importance of Nursing Theories
3. The characteristics of theories:
4. Basic Processes in the Development Of Nursing Theories:
5. Nursing theories are often based on & influenced
6. ANA definition of Nursing Practice
7. Common concepts in Nursing Theories:
8. Historical Perspectives & Key Concepts
9. Clasification of Nursing Theories
10. Models Of Nursing
11. Growth and Stability Models of Change
12. Betty Neuman’s Health Care Systems Model
13. Stress/Adaptation Theory as a Framework
14. A unique body of knowledge
15. Criticisms of nursing theories
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
• George B. Julia , Nursing Theories- The base for professional Nursing Practice
, 3rd ed. Norwalk, Appleton & Lange.
• Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd
ed. Philadelphia, Lippincott.
• 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
Nursing Theorists
Definitions
Theory- a set of related statements that describes or explains phenomena in a
systematic way
Concept-a mental idea of a phenomenon
Construct- a phenomena that cannot be observed and must be inferred
Proposition- a statement of relationship between concepts
Conceptual model- made up of concepts and propositions
Nursing Theorists
• Florence Nightingale,
• Hildegard Peplau
• Virginia Henderson
• Fay Abdella
• Ida Jean Orlando
• Dorothy Johnson
• Martha Rogers
• Dorothea Orem
• Imogene King
• Betty Neuman
• Sister Calista Roy,
• Jean Watson
• Rosemary Rizzo Parse
• Madeleine Leininger
•
Patricia Benner
Concepts in the nursing
Metaparadigm
• Person
• Recipient of care, including physical, spiritual, psychological, and
sociocultural components
• Individual, family, or community
• Environment
• All internal and external conditions, circumstances, and influences affecting
the person
• Health
• Degree of wellness or illness experienced by the person
• Nursing
• Actions, characteristics and attributes of person giving care
Florence Nightingale- Environmental Theory
• First nursing theorist
• Unsanitary conditions posed health hazard (Notes on Nursing, 1859)
• 5 components of environment
• ventilation, light, warmth, effluvia, noise
• External influences can prevent, suppress or contribute to disease or death
Nightingale’s Concepts
• Person
o Patient who is acted on by nurse
o Affected by environment
o Has reparative powers
• Environment
o Foundation of theory. Included everything, physical, psychological,
and social
• Health
o Maintaining well-being by using a person’s powers
o Maintained by control of environment
• Nursing
o Provided fresh air, warmth, cleanliness, good diet, quiet to facilitate
person’s reparative process
Hildegard Peplau -Interpersonal Relations Model
• Based on psychodynamic nursing
• using an understanding of one’s own behavior to help others identify their
difficulties
• Applies principles of human relations
• Patient has a felt need
Peplau’s Concepts
• Person
o An individual; a developing organism who tries to reduce anxiety
caused by needs
o Lives in instable equilibrium
• Environment- Not defined
• Health
o Implies forward movement of the personality and human processes
toward creative, constructive, productive, personal, and community
living
• Nursing
o A significant, therapeutic, interpersonal process that functions
cooperatively with others to make health possible
o Involves problem-solving
Virginia Henderson -The Nature of Nursing
"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. She must in a sense,
get inside the skin of each of her patients in order to know what he needs".
Fay Abdella- Topology of 21 Nursing Problems
• A list of 21 nursing problems
• Condition presented or faced by the patient or family.
• Problems are in 3 categories
• physical, social and emotional
• The nurse must be a good problem solver
Abdella’s Concepts
• Nursing
o A helping profession
o A comprehensive service to meet patient’s needs
o Increases or restores self-help ability
o Uses 21 problems to guide nursing care
• Health
o Excludes illness
o No unmet needs and no actual or anticipated impairments
• Person
o One who has physical, emotional, or social needs
o The recipient of nursing care.
• Environment
o Did not discuss much
o Includes room, home, and community
Ida Jean Orlando- Deliberative Nursing Process
• The deliberative nursing process is set in motion by the patient’s behavior
• All behavior may represent a cry for help. Patient’s behavior can be verbal
or non-verbal.
• The nurse reacts to patient’s behavior and forms basis for determining
nurse’s acts.
• Perception, thought, feeling
• Nurses’ actions should be deliberative, rather than automatic
• Deliberative actions explore the meaning and relevance of an action.
Dorothy Johnson-Behavioral Systems Model
• The person is a behavioral system comprised of a set of organized,
interactive, interdependent, and integrated subsystems
• Constancy is maintained through biological, psychological, and sociological
factors.
• A steady state is maintained through adjusting and adapting to internal
and external forces.
Johnson’s 7 Subsystems
• Affiliative subsystem
o social bonds
• Dependency
o helping or nuturing
• Ingestive
o food intake
• Eliminative
o excretion
• Sexual
o procreation and gratification
• Aggressive
o self-protection and preservation
• Achievement
o efforts to gain mastery and control
Johnson’s Concepts
• Person
o A behavioral system comprised of subsystems constantly trying to
maintain a steady state
• Environment
o Not specifically defined but does say there is an internal and
external environment
• Health
o Balance and stability.
• Nursing
o External regulatory force that is indicated only when there is
instability.
Martha Rogers -Unitary Human Beings
• Energy fields
o Fundamental unity of things that are unique, dynamic, open, and
infinite
o Unitary man and environmental field
• Universe of open systems
o Energy fields are open, infinite, and interactive
• Pattern
o Characteristic of energy field
o A wave that changes, becomes complex and diverse
• Pandimensionality
o A nonlinear domain with out time or space
Roger’s Definitions
• Integrality
o Continuous and mutual interaction between man and environment
• Resonancy
o Continuous change longer to shorter wave patterns in human and
environmental fields
• Helicy
o Continuous, probabilistic, increasing diversity of the human and
envrionmental fields.
o Characterized by nonrepeating rhymicities
o Change
Dorothea Orem- Self-Care Model
• Self-care comprises those activities performed independently by an
individual to promote and maintain person well-being
• Self care agency is the individual’s ability to perform self care activities
• Self- care deficit occurs when the person cannot carry out self-care
• The nurse then meets the self-care needs by acting or doing for; guiding,
teaching, supporting or providing the environment to promote patient’s
ability
• Wholly compensatory nursing system-Patient dependent
• Partially compensatory- Patient can meet some needs but needs nursing
assistance
• Supportive educative-Patient can meet self care requisites, but needs
assistance with decision making or knowledge
Imogene King-Goal Attainment Theory
• Open systems framework
• Human beings are open systems in constant interaction with the
environment
• Personal System
o individual; perception, self, growth, development, time space, body
image
o Interpersonal
o Society
• Personal System
o Individual; perception, self, growth, development, time space, body
image
• Interpersonal
o Socialization; interaction, communication and transaction
• Society
o Family, religious groups, schools, work, peers
• The nurse and patient mutually communicate, establish goals and take
action to attain goals
• Each individual brings a different set of values, ideas, attitudes,
perceptions to exchange
Betty Neuman - Health Care Systems Model
• The person is a complete system, with interrelated parts
• maintains balance and harmony between internal and external
environment by adjusting to stress and defending against tension-
producing stimuli
• Focuses on stress and stress reduction
• Primarily concerned with effects of stress on health
• Stressors are any forces that alter the system’s stability
• Flexible lines of resistance
Surround basic core
Internal factors that help defend against stressors
• Normal line of resistance
Normal adaptation state
• Flexible line of defense
Protective barrier, changing, affected by variables
• Wellness is equilibrium
• Nursing interventions are activates to:
strengthen flexible lines of defense
strengthen resistance to stressors
maintain adaptation
Sister Calista Roy - Adaptation Model
• Five Interrelated Essential Elements
Patiency- The person receiving care
Goal of nursing- Adapting to change
Health-Being and becoming a whole person
Environment
Direction of nursing activities- Facilitating adaptation
• The person is an open adaptive system with input (stimuli), who adapts by
processes or control mechanisms (throughput)
• The output can be either adaptive responses or ineffective responses
Jean Watson - Philosophy and Science of Caring
• Caring can be demonstrated and practiced
• Caring consists of carative factors
• Caring promotes growth
• A caring environment accepts a person as he is and looks to what the
person may become
• A caring environment offers development of potential
• Caring promotes health better than curing
• Caring is central to nursing
Watson’s 10 Carative Factors
• Forming humanistic-altruistic value system
• Instilling faith-hope
• Cultivating sensitivity to self and others
• Developing helping-trust relationship
• Promoting expression of feelings
• Using problem-solving for decision making
• Promoting teaching-learning
• Promoting supportive environment
• Assisting with gratification of human needs
• Allowing for existential-phenomenological forces
Watson’s Concepts
• Person
o Human being to be valued, cared for, respected, nurtured,
understood and assisted
• Environment
o Society
• Health
o Complete physical, mental and social well-being and functioning
• Nursing
o Concerned with promoting and restoring health, preventing illness
Rosemary Parse - Human Becoming Theory
• Human Becoming Theory includes Totality Paradigm
o Man is a combination of biological, psychological, sociological and
spiritual factors
•
Simultaneity Paradigm
o Man is a unitary being in continuous, mutual interaction with
environment
• Originally Man-Living-Health Theory
Parse’s Three Principles
• Meaning
o Man’s reality is given meaning through lived experiences
o Man and environment cocreate
• Rhythmicity
o Man and environment cocreate ( imaging, valuing, languaging) in
rhythmical patterns
• Cotranscendence
o Refers to reaching out and beyond the limits that a person sets
o One constantly transforms
• Person
o Open being who is more than and different from the sum of the
parts
• Environment
o Everything in the person and his experiences
o Inseparable, complimentary to and evolving with
• Health
o Open process of being and becoming. Involves synthesis of values
• Nursing
o A human science and art that uses an abstract body of knowledge
to serve people
Madeleine Leininger - Culture Care Diversity and Universality
• Based on transcultural nursing, whose goal is to provide care congruent
with cultural values, beliefs, and practices
• Sunrise model consists of 4 levels that provide a base of knowledge for
delivering cultural congruent care
• Modes of nursing action
• Cultural care preservation
o help maintain or preserve health, recover from illness, or face death
• Cultural care accommodation
o help adapt to or negotiate for a beneficial health status, or face
death
• Cultural care re-patterning
o help restructure or change lifestyles that are culturally meaningful
Patricia Benner - From Novice to Expert
• Described 5 levels of nursing experience and developed exemplars and
paradigm cases to illustrate each level
• Levels reflect:
o movement from reliance on past abstract principles to the use of
past concrete experience as paradigms
o change in perception of situation as a complete whole in which
certain parts are relevant
 Novice
 Advanced beginner
 Competent
 Proficient
 Expert
Importance of Theoretical Frameworks
1. Foundation of any profession is the development of a specialized body of
knowledge. Theories should be developed in nursing, not borrow theories
form other disciplines
2. Responsibility of nurses to know and understand theorists
3. Critically analyze theoretical frameworks
Reference
Mosby, Philadelphia, 2002.
Practice , 3rd ed. Norwalk, Appleton and Lange.
Philadelphia. Lippincott Williamsand wilkins.
• Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development and
Progress 3rd ed. Philadelphia, Lippincott.
• Taylor Carol,Lillis Carol (2001)The Art and Science Of Nursing Care 4th ed.
• Potter A Patricia, Perry G Anne (1992)Fundamentals Of Nursing –Concepts
Process and Practice 3rd ed. London Mosby Year Book.
NURSING THEORIES: AN OVERVIEW
Theory
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 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"
Definition
• 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 : 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.
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.
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 )
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
Nightingale (1860): To facilitate "the body’s reparative processes" by
manipulating client’s environment
Paplau 1952: Nursing is; therapeutic interpersonal process.
Henderson 1955: The needs often called Henderson’s 14 basic needs
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.
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.
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.
Rogers 1970: to maintain and promote health, prevent illness, and care
for and rehabilitate ill and disabled client through "humanistic science of
nursing" Orem1971: This is self-care deficit theory. Nursing care becomes
necessary when client is unable to fulfill biological, psychological,
developmental, or social needs.
King 1971: To use communication to help client reestablish positive
adaptation to environment.
Neuman 1972: Stress reduction is goal of system model of nursing
practice.
Roy 1979: This adaptation model is based on the physiological,
psychological, sociological and dependence-independence adaptive modes.
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).
Growth and Stability Models of Change
• 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 focuses
on 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:
• 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).
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
1. Input (Diet teaching)
• Throughput (Assimilation of information)
• Output (Food intake)
• Feedback (Weight record ,Hb estimation etc.)
Two nursing models based on systems theory:
2. Imogene King’s systems interaction model, and
3. 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’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 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.
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)
A unique body of knowledge
• 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).
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.
• 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
• Growth and Stability Models of Change
• Betty Neuman’s Health Care Systems Model
• Stress/Adaptation Theory as a Framework
• A unique body of knowledge
• Criticisms of nursing theories
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:
1. George B. Julia , Nursing Theories- The base for professional Nursing Practice
, 3rd ed. Norwalk, Appleton and Lange.
2. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing
3. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development and Progress
4. Taylor Carol,Lillis Carol (2001)The Art and Science Of Nursing Care 4th ed.
5. Potter A Patricia, Perry G Anne (1992)Fundamentals Of Nursing –Concepts
UNDERSTANDING THE WORK OF

NURSE THEORISTS
……… Creative Beginning
Theories of Nursing
• Theory is "an internally consistent group of relational statements
(concepts, definitions and propositions) that present a systematic view
about a phenomenon and which is useful for description, explanation,
prediction and control".
• Theories are road maps that provide a framework for selecting and
organizing information:
o What to ask
o What to observe
o What to focus on
o What to think about
• Nursing theory is an organized and systematic articulation of a set of
statements related to questions in the discipline of nursing.
Uses of Theory
Theory is used to:
• Describe
• Explain
• Predict
• Prescribe
Uses of Nursing Theory
• Define relationships among the variables of a given field of inquiry
• Guide research, practice and communication
• Allow the prediction of the consequences of care
• Allow the prediction of a range of patient responses
Levels of Theory
There are four levels of theory
• Metatheory
• Grand Theory
• Middle Range Theory
• Practice Theory
Types of Theory
In Nursing there are four types of theories:
• Needs
• Interaction
• Outcome
• Humanistic
Practice value of theory
• Enhances understanding and explanation for events
• Influence our behavior.
• Makes to think differently about a problem or a situation
• Helps to try new approaches or altering behavior.
• We can gain a new perspective of events
• Basis for challenge of its speculative tenets or propositions
• Challenges subsequent discovery of new ideas or knowledge that might
explain and predict events not yet understood
In practice
• Assist nurses to describe, explain, and predict everyday experiences.
• Serve to guide assessment, intervention, 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 establish 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 defined.
• Enhance autonomy (independence and self-governance) of nursing by
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 specific field of study.
• Offer a systematic approach to identify questions for study, select
variables, interpret findings, and validate nursing interventions.
An illustration……
The germ theory
• Explains the phenomenon of disease transmission
• Means of speculative explanation and prediction of certain observable
events
• Allows us to effectively function to prevent transmission of communicable
disease.
• Viable basis upon which to make decisions about how to prevent certain
illnesses.
• There are phenomena we do not understand that are related to germ
transmission,
• Example-the communicability of cancer.
"Nursing Practice."
All experiences and events a practicing nurse encounters in the process of
providing nursing care.
Events…..
• Some may be experienced by the client,
• Others by the nurse
• Some may be observed in the environment
• May be observed in the nurse-client interaction.
• In situations of daily work or living,
…………..but as long as they are observable during the process of providing direct
nursing care, they are considered part of nursing practice.
Approaches to inter relationships between practice and theory
• How nursing practice contributes to the process of theory development..
• How theory contributes to nursing practice…
Contribution of practice to theory development
• Theory development within nursing occurs in the context of practice.
• Two activities contribute significantly to the overall process of developing
theory in nursing.
• Concept analysis and
• Practical validation of theory.
Concept analysis
• Identify and verify abstract concepts
• "what events in practice can be linked with abstract concept x"
• Application of theory in practice
• Nursing process operation of analysis of assessment data.
• Used as scientific rationale supporting judgments in nursing care plans.
Concepts
• Concepts may be (a) readily observable, or concrete, ideas such as
thermometer, rash, and lesion; (b) indirectly observable, or inferential,
ideas such as pain and temperature; or c) non-observable, or abstract,
ideas such as equilibrium, adaptation, stress, and powerlessness
• nursing theories address and specify relationships among four major
abstract concepts referred to as the metaparadigm of nursing.
• Four concepts are considered to be central to nursing :
• Person or client, the recipient of nursing care (includes individuals,
families, groups, and communities).
• Environment, the internal and external surroundings that affect the client.
This includes people in the physical environment, such as families, friends,
and significant others.
• Health, the degree of wellness or well-being that the client experiences.
• Nursing, the attributes, characteristics, and actions of the nurse providing
care on behalf of, or in conjunction with, the client
Nightingale’s environmental theory
• "the act of utilizing the environment of the patient to assist him in his
recovery"
• She linked health with five environmental factors :
• Pure or fresh air
• Pure water
• Efficient drainage
• Cleanliness
• Light, especially direct sunlight
• Deficiencies in these five factors produced lack
• Of health or illness.
Peplau’s interpersonal relations model
• Nurses enter into a personal relationship with an individual when a felt
need is present
Henderson’s definition of nursing
• Henderson conceptualized the nurse’s role as assisting sick or well
individuals to gain independence in meeting 14 fundamental needs
(Henderson)
• Breathing normally
• Eating and drinking adequately
• Eliminating body wastes
• Moving and maintaining a desirable position
• Sleeping and resting
• Selecting suitable clothes
• Maintaining body temperature within normal range by adjusting clothing
and modifying the environment.
• Keeping the body clean and well groomed to protect the integument.
• Avoiding dangers in the environment and avoiding injuring others
• Communicating with others in expressing emotions, needs, fears, or
opinions
• Worshipping according to one’s faith
• Working in such a way that one feels a sense of accomplishment
• Playing or participating in various forms of recreation.
• Learning, discovering, or satisfying the curiosity that leads to normal
development and health, and using available health facilities
Roger’s science of unitary human beings
• She states that humans are dynamic energy fields in continuous exchange
with environmental fields, both of which are infinite.
• Nurses applying Roger's theory in practice (a) focus on the person’s
wholeness, (b) seek to promote symphonic interaction between the two
energy fields (human and environment) to strengthen the coherence and
integrity of the person, c) coordinate the human field with the
rhythmicities of the environmental field, and (d) direct and redirect
patterns of interaction between the two energy fields to promote maximum
health potential
Orem’s general theory of nursing
• Orem’s self-care deficit theory explains not only when nursing is needed
but also how people can be assisted through five methods of helping:
acting or doing for, guiding, teaching, supporting, and providing an
environment that promotes the individual’s abilities to meet current and
future demands.
King’s goal attainment theory
• King’s theory offers insight into nurses’ interactions with individuals and
groups within the environment. It highlights the importance of client’s
participation in decision that influence care and focuses on both the
process of nurse-client interaction and the outcomes of care.
Neuman’s systems model
• The model is based on the individual’s relationship to stress, the reaction
to it, and reconstitution factors that are dynamic in nature.
• Betty Neuman's model of nursing is applicable to a variety of nursing
practice settings involving individuals, families, groups, and communities.
Roy’s adaptation model
• Roy focuses on the individual as a biopsychosocial adaptive system that
employs a feedback cycle of input (stimuli), throughput (control
processes), and output (behaviors or adaptive responses).
Watson’s human caring theory
• Jean Watson (1979) believes the practice of caring is central to nursing; it
is the unifying focus for practice.
• Nursing interventions related to human care are referred to as carative
factors.
• Watson’s theory of human caring has receiving worldwide recognition and
is a major force in redefining nursing as a caring-healing health model.
Parse’s human becoming theory
• Parse’s model of human becoming emphasizes how individuals choose and
bear responsibility for patterns of personal health.
Leininger’s cultural care diversity and universality theory
• She emphasizes that human caring, although a universal phenomenon,
varies among cultures in its expressions, processes, and patterns; it is
largely culturally derived.
Orem’s general theory of nursing
Assessing
• Involves collecting data about the client’s capacities (knowledge, skills, and
motivation) to perform universal, developmental, and health-deviation self-
care requisites. Determine self-care deficits.
Diagnosing
• Stated in terms of the client’s limitations for maintaining self care (a deficit
in self-care agency)
Planning
• Involves considering and designing, with the client’s participation, an
appropriate nursing system (wholly compensatory, partially compensatory,
supportive-educative, or a mix) that will help the client achieve an optimal
level of self care
Implementing
• Assisting the client
Evaluating
1. Determining the client’s level of achievement
References
1. Phipps J Wilma, Sands K Judith. Medical Surgical Nursing: concepts &
clinical practice.6th edition. Philadelphia. Mosby publications. 1996.
2. Black M. Joice, Hawks hokanson Jane. Medical Surgical Nursing: Clinical
Management for positive outcomes. St Lois, Missouri. 2005.
3. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.).
4. Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd
THEORIES & NURSING RESEARCH
Introduction
• RESEARCH – Process of inquiry

• THEORY – Product of knowledge
• SCIENCE – Result of the relationship between research & theory
• To effectively build knowledge to research process should be developed within
some theoretical structure that facilities analysis and interpretation of
findings.
• Relationship between theory and research in nursing is not well understood. It
may be give to the relative youth of the discipline and debates over
philosophical world views. (Empiricism, constructivism, etc…)
Need to Link Theory and Research
• Research without theory results in discreet information or data which does not
add to the accumulated knowledge of the discipline.
• Theory guides the research process, forms the research questions, aids in
design, analysis and interpretation.
• It enables the scientist to weave the facts together.
Theories from Nursing or Other Disciplines?

• Nursing science is blend of knowledge that is unique to nursing and
knowledge that is borrowed from other disciplines.
• Debate is whether the use of borrowed theory has hindered the development
of the discipline.
• It has contributed to problems connecting research and theory in nursing.
Historical Overview of Research and Theory in Nursing
• Florence Nightingale supported her theoretical propositions through research,

as statistical data and prepared graphs were used to depict the impact of
nursing care on the health of British soldiers.
• Afterwards, for almost century reports of nursing research were rare.
• Research and theory developed separately in nursing.
• Between 1928 and 1959 only 2 out of 152 studies reported a theoretical basis
for the research design.
• In 1970’s growing number of nurse theorists were seeking researchers to test
their models in research and clinical application
• Grand nursing theories are still not widely used. In 1990’s borrowed theories
were used more.
• Now the focus of research and theory have moved more towards middle
range theories
Purpose of Theory in Research
• To identify meaningful and relevant areas for study.

• To propose plausible approaches to health problems.
• To develop or refine theories
• Define the concepts and proposed relationships between concepts.
• To interpret research findings
• To develop clinical practice protocols.
• Generate nursing diagnosis.
Types of theory and corresponding research
Type of theory Type of research

• Descriptive or
• Descriptive explanatory
• Explanatory
• Co relational
• Predictive
• Experimental
How Theory is used in Research

Causal theory of planned behaviour
Theory Generating Research
• It is designed to develop and describe relationships between and among

phenomena without imposing preconceived notations.
• It is inductive and includes field observations and phenomenology.
• During the theory generating process, the researcher moves by logical
thought from fact to theory by means of a proposition stated as an empirical
generalization.
Grounded Theory Research
• Inductive research technique developed by Glazer and Strauss (1967)
• Grounded theory provides a way to describe what is happening and

understanding the process of why it happens.
• Methodology – The researcher observes, collects data, organizes data and
forms theory from the data at the same time.
• Data may be collected by interview, observation, records or a combination of
these techniques.
• Data are coded in preparation for analysis.
• Category development – Categories are identified and named
• Category saturation – Comparison of similar characteristics in each of the

categories
• Concept development – Defines the categories
• Search for additional categories – Continues to examine the data for
additional categories
• Category reduction – Higher order categories are selected
• Linking of categories – The researcher seeks to understand relationships
among categories
• Selective sampling of the literature
• Emergence of the core variable – Central theme are focus of the theory
• Concept modification and integration – Explaining the phenomenal
Theory testing research
• In theory testing research, theoretical statements are translated into

questions and hypothesis. It requires a deductive reasoning process.
• The interpretation determines whether the study supports are contradicts the
propositional statement.
• If a conceptual model is used as a theoretical framework for research it is not
theory testing.
• Theory testing requires detailed examination of theoretical relationships.
Theory as a conceptual framework
• Problem being investigated is fit into an existing theoretical framework, which

guides the study and enriches the value of its findings.
• The conceptual definitions are drawn from the framework
• The data collection instrument is congruent with the framework.
• Findings are interpreted in light of explanations provided by the framework.
• Implications are based on the explanatory power of a framework.
A Typology of Research
• Testing
• Analyzing
• Experimentation
• Deducting
• Deductive research
• Quantitative research
• The scientific method
• Theory / hypothesis testing
• Assaying
• Refining
• Interpreting
• Reflecting
• Inducing
• Inductive research
• Qualitative research
• Phenomenological research
• Theory generation
• ‘Divining’; ‘heuristic’ research
Guidelines for writing about a research study’s theoretical framework
In the study’s problem statement
1. Introduce the framework

2. Briefly explain why it is a good fit for the research problem area
3. At the end of the literature review
4. Thoroughly describe the framework and explain its application to the
present study.
5. Describe how the framework has been used in studies about similar
problems
6. In the study’s methodology section
7. Explain how the framework is being operationalized in the study’s
design.
8. Explain how data collection methods (such as questionnaire items)
reflect the concepts in the framework.
9. In the study’s discussion section
10. Describe how study findings are consistent (or inconsistent) with the
framework.
11. Offer suggestions for practice and further research that are congruent
with the framework’s concepts and propositions.
Conclusion
The relationship between research and theory is undeniable, and it is

important to recognize the impact of this relationships on the development of
nursing knowledge. So interface theory and research by generating theories,
testing the theories and by using it as a conceptual framework that drives the
study.
Reference
• Polit DF, Hungler BP. Nursing Research: Principles and Methods. Philadelphia:
JB Lippincott Company; 1998.
• Burns N, Grove SK. The practice of Nursing Research. 4th Ed. Philadelphia:
WB Saunders Publications; 2001.
• Treece JW, Treece EW. Elements of Research in Nursing (3rded.). St. Louis:
Mosby; 1982.
VIRGINIA HENDERSON’S NEED

THEORY
“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."
• "little Miss 3x5"
• Born in Kansas City, Missouri, in 1897 and is the 5th child of a family of 8th
children but spent her formative years in Virginia
• 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, she accepted a position teaching nursing at the Norfolk Protestant
Hospital in Virginia, where she remained for several years
• In 1929, Henderson determined that she needed more education and
entered Teachers College at Columbia University where she earned her;
Bachelor’s Degree in 1932, Master’s Degree in 1934.
• Subsequently, she joined Columbia as a member of the faculty, where she
remained until 1948(Herrmann,1998)
• Since 1953, she has been a research associate at Yale University School of
Nursing.
• Died: March 19, 1996.
Achievements
• Is the recipient of numerous recognitions for her outstanding contributions
to nursing?
• VH was a well known nursing educator and a prolific author.
• She has received honorary doctoral degrees from the
o Catholic University of America
o Pace University,
o University of Rochester,
o University of Western Ontario,
o Yale University
• Her stature as a nurse, teacher, author, researcher, and consumer health
advocate warranted an obituary in the New York Times, Friday March 22.
1996.
• In 1985, Miss Henderson was honored at the Annual Meeting of the
Nursing and Allied Health Section of the Medical Library Association.
Contribution
• In 1937 Henderson and others created a basic nursing curriculum for the
National League for Nursing in which education was “patient centered and
organized around nursing problems rather than medical diagnoses”
(Henderson,1991)
• 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)
• Although she was retired, she was a frequent visitor to nursing schools well
into her nineties.
• O’Malley (1996) states that Henderson is known as the modern-day
mother of nursing. Her work influenced the nursing profession in America
and throughout the world
• The founding members of ICIRN (Interagency Council on Information
Resources for Nursing) and a passionate advocate for the use and sharing
of health information resources.
• In 1978 the fundamental concept of nursing was revisited by Virginia
Henderson from Yale University School of Nursing ( USA ). She argued that
nurses needed to be prepared for their role by receiving the broadest
understanding of humanity and the world in which they lived.
Publications
• 1956 (with B. Harmer)-Textbook for the principles and practices of Nursing.
• 1966-The Nature of Nursing. A definition and its implication for practice,
Research and Education
• 1991- The Nature of Nursing Reflections after 20 years
Analysis of Nursing Theory
• Images of Nursing, 1950-1970
• The First School of Thought: Needs
• This school of thought includes theories that reflect an image of nursing as
meeting the needs of clients and were developed in response to such
questions as
• What do nurses do?
• What are their functions?
• What roles do nurses play?
• Answers to these questions focused on a number of theorist describing
functions and roles of nurses.
• Conceptualizing functions led theorists to consider nursing client in terms
of a Hierarchy of needs. When any of these needs are unmet and when a
person is unable to fulfill his own needs, the care provided by nurses is
required.
• Nurses then provide the necessary functions and play those roles that
could help patients meet their needs.
School of thought in Nursing Theories-1950-1970
Need theorists Interaction Outcome theorists

theorists
Abdellah King Johnson

Henderson Orlando Levine
Orem Peterson and Zderad Rogers
Paplau Roy
Travelbee
Wiedenbach
Analysis of nursing theories according to 1st School
Focus Problems
Human being A 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)
• Although her major clinical experiences were in medical-surgical
hospitals, she worked as a visiting nurse in New York City. This
experience enlarges Henderson’s view to recognize 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, p. 15).
• She was one of the first nurses to point out that nursing does not
consist of merely following physician's orders.
• 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 famous 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, p. 15).
The development of Henderson’s definition of nursing
• Two events are the basis for Henderson’s development of a definition of
nursing.
• First, she participated in the revision of a nursing textbook.
• Second, she was concerned that many states had no provision for nursing
licensure to ensure safe and competent care for the consumer.
• In the revision she recognized the need to be clear about the functions of
the nurse and she believed that this textbook serves as a main learning
source for nursing practice should present a sound and definitive
description of nursing.
• Furthermore, the principles and practice or nursing must be built upon
and derived from the definition of the profession.
• Although official statements on the nursing function were published by
the ANA in 1932 and 1937, Henderson viewed these statements as
nonspecific and unsatisfactory definitions of nursing practice.
• Then in 1955, the earlier ANA definition was modified.
• Henderson's focus on individual care is evident in that she stressed
assisting individuals with essential activities to maintain health, to
recover, or to achieve peaceful death.
• She proposed 14 components of basic nursing care to augment her
definition.
• In 1955, Henderson’s first definition of nursing was published in Bertha
Harmer’s revised nursing textbook.
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 assumption of the theory is that:
• 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
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.
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
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?
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
• Categorized
o 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
o Nurse role is,” to get inside the patient’s skin and supplement his
strength will or knowledge according to his needs.”
o 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
• Henderson views the nursing process as “really the application of the
logical approach to the solution of a problem. The steps are those of
the scientific method.”
• “Nursing process stresses the science of nursing rather than the
mixture of science and art on which it seems effective health care
service of any kind is based.”
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

Analysis: Compare data to knowledge base
of health and disease.
Nursing Diagnosis Identify individual’s ability to meet own

needs with or without assistance, taking into
consideration strength, will or knowledge.
Nursing plan 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 implementation Implementation based on the physiological

principles, age, cultural background,
emotional balance,
and physical and intellectual capacities.
Carry out treatment prescribed by the
physician.
Nursing process Henderson’s 14 components and definition of

nursing
Nursing evaluation 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 Breathe normally

needs 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

others
Belongingness Communicate with others
and love needs Worship according to faith
Esteem needs Work at something providing a sense of

accomplishment
Play or participate in various forms of recreation
Learn, discover, or satisfy curiosity
Self actualization
needs
Characteristic of Henderson’s theory

• Theories can interrelate 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 and is borrowed from other discipline.E.g..
Maslow’s Hierarchy of human needs; concept of interaction-
communication i.e. nurse-patient relationship
• Theories must be logical in nature.
• 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.
• Is the sequence of the 14 components followed by nurses in the USA
and the other countries?
• What priorities are evident in the use of the basic nursing functions?
• 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.
• Theories must be consistent with other validated theories, laws, and
principles but will leave open unanswered questions that need to be
investigated.
Philosophical claims
The philosophy reflected in Henderson's theory is an integrated approach to
scientific study that would capitalize on nursing's richness and complexity, and not
to separate the art from the science, the "doing" of nursing from the "knowing",
the psychological from the physical and the theory from clinical care.
Values and Beliefs
• Henderson believed nursing as primarily complementing the patient by
supplying what he needs in knowledge, will or strength to perform his
daily activities and to carry out the treatment prescribed for him by the
physician.
• She strongly believed in "getting inside the skin" of her patients in
order to know what he or she needs. The nurse should be the
substitute for the patient, helper to the patient and partner with the
patient. Like she said...
"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 and the knowledge
and confidence for the young mother..."
• Henderson stated that “Thorndike’s fundamental needs of man”
(Henderson, 1991, p.16) had an influence on her beliefs.
Value in extending nursing science
• From an historical standpoint, her concept of nursing enhanced nursing
science this has been particularly important in the area of nursing
education.
• Her contributions to nursing literature extended from the 1930s
through the 1990s and has had an impact on nursing research by
strengthening the focus on nursing practice and confirming the value of
tested interventions in assisting individuals to regain health.
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)
Testability
• Henderson supported nursing research, but believed that it should be
clinical research (O’Malley, 1996). Much of the research before her time
had been on educational processes and on the profession of nursing
itself, rather than on; the practice and outcomes of nursing , and she
worked to change that.
• Each of the 14 activities can be the basis for research. Although the
statements are not.
• Written in testable terms, they may be reformulated into researchable
questions. Further, the theory can guide research in any aspect of the
individual’s care needs.
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 theories
In Practice:
• 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?
Summary
1. Background
2. Achievements
3. Publications
4. Analysis of Nursing theories
5. Development of Henderson’s definition of nursing
6. 14 components
7. Major four concepts
8. Nursing process with Henderson’s theory
9. Comparison with Maslow's Hierarchy need
10. Assumptions
11. Usefulness
12. Testability
13. Characteristics
14. imitation
Conclusion
In 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.
Reference
• Timber BK. Fundamental skills and concepts in Patient Care, 7th edition,
LWW, N
Practice , 3rd ed. Norwalk, Appleton & Lange.
• Vandemark L.M. Awareness of self & expanding consciousness: using
Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul;
27(6) : 605-15
Jul;19(3):225
• Delaune SC,. Ladner PK, Fundamental of nursing, standard and practice,
2nd edition, Thomson, NY, 2002
Theory of interpersonal relations

Hildegard .E. Peplau
Introduction
• Born in Reading, Pennsylvania [1909]

• Graduated from a diploma program in Pottstown, Pennsylvania in 1931.
• Done BA in interpersonal psychology from Bennington College in 1943.
• MA in psychiatric nursing from Colombia University New York in 1947.
• EdD in curriculum development in 1953.
• Professor emeritus from Rutgers university
• Started first post baccalaureate program in nursing
• Published Interpersonal Relations in Nursing in 1952
• 1968 :interpersonal techniques-the crux of psychiatric nursing
• Worked as executive director and president of ANA.
• Worked with W.H.O, NIMH and nurse corps.
• Died in 1999.
Psychodynamic nursing
1. Understanding of ones own behavior

2. To help others identify felt difficulties
3. To apply principles of human relations to the problems that arise at all levels
of experience
4. In her book she discussed the phases of interpersonal process, roles in
nursing situations and methods for studying nursing as an interpersonal
process.
5. According to Peplau, nursing is therapeutic in that it is a healing art, assisting
an individual who is sick or in need of health care.
6. Nursing is an interpersonal process because it involves interaction between
two or more individuals with a common goal.
7. The attainment of goal is achieved through the use of a series of steps
following a series of pattern.
8. The nurse and patient work together so both become mature and
knowledgeable in the process.
Definitions
1. Person :A developing organism that tries to reduce anxiety caused by needs

2. Environment : Existing forces outside the organism and in the context of
culture
3. Health : A word symbol that implies forward movement of personality and
other ongoing human processes in the direction of creative, constructive,
productive, personal and community living.
4. Nursing: A significant therapeutic interpersonal process. It functions
cooperatively with other human process that make health possible for
individuals in communities
Roles of nurse
• Stranger: receives the client in the same way one meets a stranger in other
life situations provides an accepting climate that builds trust.
• Teacher: who imparts knowledge in reference to a need or interest
• Resource Person : one who provides a specific needed information that aids in
the understanding of a problem or new situation
• Counselors : helps to understand and integrate the meaning of current life
circumstances ,provides guidance and encouragement to make changes
• Surrogate: helps to clarify domains of dependence interdependence and
independence and acts on clients behalf as an advocate.
• Leader : 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
Theory of interpersonal relations
• Middle range descriptive classification theory

• Influenced by Harry Stack Sullivan's theory of inter personal relations (1953)
• Also influenced by Percival Symonds , Abraham Maslow's and Neal Elger
Miller
• Identified four sequential phases in the interpersonal relationship:
1. Orientation
2. Identification
3. Exploitation
4. Resolution
Orientation phase
• Problem defining phase

• Starts when client meets nurse as stranger
• Defining problem and deciding type of service needed
• Client seeks assistance ,conveys needs ,asks questions, shares
preconceptions and expectations of past experiences
• Nurse responds, explains roles to client, helps to identify problems and to use
available resources and services
Factors influencing orientation phase
Identification phase
• Selection of appropriate professional assistance

• Patient begins to have a feeling of belonging and a capability of dealing with
the problem which decreases the feeling of helplessness and hopelessness
Exploitation phase
• Use of professional assistance for problem solving alternatives

• Advantages of services are used is based on the needs and interests of the
patients
• Individual feels as an integral part of the helping environment
• They may make minor requests or attention getting techniques
• The principles of interview techniques must be used in order to explore
,understand and adequately deal with the underlying problem
• Patient may fluctuates on independence
• Nurse must be aware about the various phases of communication
• Nurse aids the patient in exploiting all avenues of help and progress is made
towards the final step
Resolution phase
• Termination of professional relationship

• The patients needs have already been met by the collaborative effect of
patient and nurse
• Now they need to terminate their therapeutic relationship and dissolve the
links between them.
• Sometimes may be difficult for both as psychological dependence persists
• Patient drifts away and breaks bond with nurse and healthier emotional
balance is demonstrated and both becomes mature individuals
Interpersonal theory and nursing process

• Both are sequential and focus on therapeutic relationship
• Both use problem solving techniques for the nurse and patient to collaborate
on, with the end purpose of meeting the patients needs
• Both use observation communication and recording as basic tools utilized by
nursing
Assessment Orientation
Data collection and Non continuous data
analysis [continuous] collection
May not be a felt need Felt need
Define needs
Nursing diagnosis Identification
Planning Interdependent goal setting
Mutually set goals
Implementation Exploitation
Plans initiated towards Patient actively seeking and
achievement of mutually drawing help
set goals Patient initiated
May be accomplished by
patient , nurse or family
Evaluation Resolution
Based on mutually Occurs after other phases are
expected behaviors completed successfully
May led to termination and Leads to termination
initiation of new plans
Peplau’s work and characteristics of a theory
Theories can interrelate concepts in such a way as to create a different way of

looking at a particular phenomenon.
Four phases interrelate the different components of each phase.
The nurse patient interaction can apply to the concepts of human

being ,health, environment and nursing.
Theories must be logical in nature
Provides a logical systematic way of viewing nursing situations
Key concepts such as anxiety, tension, goals, and frustration are

indicated with explicit relationships among them and progressive
phases
Theories should be relatively simple yet generalizable
It provides simplicity in regard to the natural progression of the NP

relationship.
Leads to adaptability in any nurse patient relationship.

The basic nature of nursing still considered an interpersonal process
Theories can be the bases for hypothesis that can be tested.
Has generated testable hypotheses.
Theories contribute to and assist in increasing the general body of

validate them.
In 1950’s two third of the nursing research concentrated on N-P

relation ship.
Theories can be utilized by practitioners to guide and improve their practice.
Peplau’s anxiety continuum is still used in anxiety patients
Theories must be consistent with other validated theories, laws, and

investigated.
Consistent with various theories
Limitations
• Intra family dynamics, personal space considerations and community social

service resources are considered less
• Health promotion and maintenance were less emphasized
• Cannot be used in a patient who doesn’t have a felt need eg. With drawn
patients, unconscious patients
• some areas are not specific enough to generate hypothesis
Research Based on Peplau’s Theory
1. Hays .D. (1961).Phases and steps of experimental teaching to patients of

a concept of anxiety: Findings revealed that when taught by the
experimental method, the patients were able to apply the concept of
anxiety after the group was terminated.
2. Burd .S.F. Develop and test a nursing intervention framework for working
with anxious patients: Students developed competency in beginning
interpersonal relationship
References
LWW, N
27(6) : 605-15
Jul;19(3):225
FAYE GLENN ABDELLAH'S THEORY
TWENTY ONE NURSING PROBLEMS
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
• Former Chief Nurse Officer for the U.S Public Health Service ,
Department of Health and human services, Washington, D.C .
• 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.
• In 1960, influenced by the desire to promote client-centred comprehensive
nursing care, Abdellah described nursing as a service to individuals, to
families, and, therefore to, to society.
• 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 a comprehensive service ,nursing includes;
• Recognizing the nursing problems of the patient
• Deciding the appropriate course of action to take in terms of
relevant nursing principles
• Providing continuous care of the individuals total needs
• Providing continuous care to relieve pain and discomfort and
provide immediate security for the individual
• Adjusting the total nursing care plan to meet the patient’s individual
needs
• Helping the individual to become more self directing in attaining or
maintaining a healthy state of mind & body
• 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
• These original premises have undergone an evolutionary process.
As result, in 1973, the item 3, - “providing continuous care of the
individual’s total health needs” was eliminated.
• From these premises, Abdellah’s theory was derived.
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
1. The language of Abdellah’s framework is readable and clear.
2. Consistent with the decade in which she was writing, 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.
3. She referred to Nursing diagnosis during a time when nurses were taught
that diagnosis was not a nurses’ prerogative.
4. Assumptions were related to
1. change and anticipated changes that affect nursing;
2. The need to appreciate the interconnectedness of social enterprises
and social problems;
3. the impact of problems such as poverty, racism, pollution,
education, and so forth on health care delivery;
4. changing nursing education
5. continuing education for professional nurses
6. development of nursing leaders from under reserved groups
5. Abdellah and colleagues developed a list of 21 nursing problems.
6. They also identified 10 steps to identify the client’s problems
7. 11 nursing skills to be used in developing a treatment typology
10 steps to identify the client’s problems
1. Learn to know the patient
2. Sort out relevant and significant data
3. Make generalizations about available data in relation to similar nursing
problems presented by other patients
4. Identify the therapeutic plan
5. Test generalizations with the patient and make additional generalizations
6. Validate the patient’s conclusions about his nursing problems
7. Continue to observe and evaluate the patient over a period of time to
identify any attitudes and clues affecting his behavior
8. Explore the patient’s and family’s reaction to the therapeutic plan and
involve them in the plan
9. Identify how the nurses feels about the patient’s nursing problems
10. Discuss and develop a comprehensive nursing care plan
11 nursing skills
1. Observation of health status
2. Skills of communication
3. Application of knowledge
4. Teaching of patients and families
5. Planning and organization of work
6. Use of resource materials
7. Use of personnel resources
8. Problem-solving
9. Direction of work of others
10. Therapeutic use of the self
11. Nursing procedures
The twenty one 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
21 NURSING PROBLEMS
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 deformities
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 21 problems are actually a model describing the "arenas" or concerns
of nursing, rather than a theory describing relationships among phenomena. In
this way, the theory distinguished the practice of nursing, with a focus on the 21
nursing problems, from the practice of medicine, with a focus on disease and
cure.
ABDELLAH’S THEORY AND NURSING
• Although Abdellah’s writings are not specific as to a theoretical statement,
such a statement can be derived by using her three major concepts of
health, nursing problems, and problem solving. Abdellah’s theory would
state that nursing is the use of the problem solving approach with key
nursing problems related to health needs of people. Such a statement
maintains problem solving as the vehicle for the nursing problems as the
client is moved toward health – the outcome
NURSING
• Acc 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.
HEALTH
• Health is a dynamic pattern of functioning whereby there is a continued
interaction with internal and external forces that results in the optimum
use of necessary resources that serve to minimize vulnerabilities
NURSING PROBLEMS
• Nursing problem presented by a client is a condition faced by the client or
client’s family that the nurse through the performance of professional
functions can assist them to meet . The problem can be either an overt or
covert nursing problem.
• An overt nursing problem is an apparent condition faced by the patient or
family, which the nurse can assist him or them to meet through the
performance of her professional functions.
• The covert nursing problem is a concealed or hidden condition faced, by
the patient or family, which the nurse can assist him or them to meet
through the performance of her professional functions
• In her attempt to bring nursing practice into its proper relationship with
restorative and preventive measures for meeting total client needs, she
seems to swing the pendulum to the opposite pole, from the disease
orientation to nursing orientation, while leaving the client somewhere in
the middle.
PROBLEM SOLVING
• The problem solving process involves identifying the problem, selecting
pertinent data, formulating hypothesis, testing hypothesis through the
collection of data, and revising hypothesis where necessary on the basis of
conclusions obtained from the data.
COMPARISON WITH OTHER THEORIES
MASLOW HENDERSON ABDELLAH

1. Breathe normally 1. To facilitate the maintenance
of a supply of oxygen to all
body cells
2. Eat and drink
adequately 2. To facilitate the maintenance
Physiological of nutrition of all body cells
needs 3. Eliminate by all
avenues of 3. To facilitate the maintenance
elimination of fluid and electrolyte
balance
4. Move & maintain
desirable posture 4. To facilitate the maintenance
of elimination
5. Sleep & rest
5. To maintain good body
6. Select suitable mechanics and prevent and
clothing correct deformities
7. Maintain body 6. To promote optimal activity:
temperature exercise , rest and sleep
8. Keep body clean and7. To facilitate the maintenance
well groomed & of regulatory mechanisms
protect the and functions
integument
8. To maintain good hygiene
and physical comfort
9. Avoid 9. To promote safety through

Safety needs environmental the prevention of accidents,
dangers & avoid injury, or other trauma and
injuring others through the prevention of
the spread of infection
10. To facilitate the maintenance
of sensory function
Belongingness10. Communicate with 11.To facilitate the maintenance

& love needs others of effective verbal and non
11. Worship according verbal communication
to faith 12. To promote the development
of productive interpersonal
relationships
13. To facilitate progress toward
achievement of personal
spiritual goals
Esteem needs 12. Work at something14. To accept the optimum
providing a sense of possible goals in the light of
accomplishment limitations, physical and
13. Play or participate emotional
in various forms of 15. To recognize the
recreation physiological responses of
14. Learn, discover, or the body to disease
satisfy curiosity conditions
16. To identify and accept
positive and negative
expressions, feelings, and
reactions
17. To identify and accept the
interrelatedness of emotions
and organic illness
18. To create and / or maintain
a therapeutic environment
19. To facilitate awareness of
self as an individual with
varying physical, emotional,
and developmental needs
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 in the
case of illness
Self
actualization
needs
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/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
Characteristic1
• 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
• The result was the statement that nursing is the use of problem solving
approach with key nursing problems related to health needs of people.
Characteristic2
• Problem solving is an activity that is inherently logical in nature
Characteristic 3
• Framework seems to focus quite heavily on nursing practice and
individuals. This somewhat limit the ability to generalize although the
problem solving approach is readily generalizable to clients with specific
health needs and specific nursing problems
Characteristic4
• One of the most important questions that arise when considering her work
is the role of client within the framework. This question could generate
hypothesis for testing and thus demonstrates the ability of Abdellah’s work
to generate hypothesis for testing
Characteristic5
• The results of testing such hypothesis would contribute to the general body
of nursing knowledge
Characteristic6
• Abdellah’s problem solving approach can easily be used by practitioners to
guide various activities within their practice. This is true when considering
nursing practice that deals with clients who have specific needs and
specific nursing problems
Characteristic7
• 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. Therefore, once the problem has been diagnosed, the goals
have been established.
• Given that these problems are called nursing problems, then it becomes
reasonable to conclude that these goals are basically nursing goals.
IMPLEMENTATION
• Using the goals as the framework, a plan is developed and appropriate
nursing interventions are determined.
EVALUATION
• According to the American Nurses’ Association Standards of Nursing
Practice, the plan is evaluated in terms of the client’s progress or lack of
progress toward the achievement of the stated goals.
• This would be extremely difficult if not impossible to do for Abdellah’s
nursing problem approach since it has been determined that the goals are
nursing goals, not the client goals.
• Thus, the most appropriate evaluation would be the nurse progress or lack
of progress toward the achievement of the stated goals.
AN illustration of the implementation of Abdellah’s framework in Ryan’s
care
Consider a case of Ryan who experienced severe crushing chest pain ‘shortness of
breath, tachycardia and profuse diaphoresis
• Stage of illness is basic to care
• Selected Abdellah nursing problem
• To maintain good hygiene and personal comfort
• Classification and approach
• Overt problem of pain; Direct and indirect method
• Selected Nursing Interventions
• administer oxygen
• elevate headrest
• reposition client
• administer prescribed analgesic
• remain with client
• Criterion measure- Amount of pain
CONCEPT OF PROGRESSIVE PATIENT CARE
1. 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
2. PPC is tailoring of hospital services to meet patients needs
3. PPC is caring for the right patient in the right bed with the right services at
the right time
4. PPC is systematic classification of patients based on their medical needs
Elements of PPC
• Intensive care
o 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
o Patients assigned to this unit are both the moderately ill and those
for whom the treatment can only be palliative
• Self care
o Ambulatory patients who are convalescencing or require diagnosis
or therapy may be cared for in this unit
• Long term care unit
o 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
o 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 PPC
PATIENT
• 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.
• Cont…
• 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
SUMMARY
• 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
CONCLUSIONS
• 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
Introduction
• Born: West Virginia
• Educated: BSN, University of Colorado, 1964, MS, University of Colorado,
1966, PhD, University of Colorado, 1973
• Dr. Jean Watson is Distinguished Professor of Nursing and holds an endowed
Chair in Caring Science at the University of Colorado Health Sciences Center.
• She is founder of the original Center for Human Caring in Colorado and is a
Fellow of the American Academy of Nursing. She previously served as Dean of
Nursing at the University Health Sciences Center and is a Past President of the
National League for Nursing
• Dr. Watson has earned undergraduate and graduate degrees in nursing and
psychiatric-mental health nursing and holds her PhD in educational
psychology and counseling.
• She is a widely published author and recipient of several awards and honors,
including an international Kellogg Fellowship in Australia, a 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”.
• Watson believes that the main focus in nursing is on carative factors. She
believes that for nurses to develop humanistic philosophies and value system,
a strong liberal arts background is necessary.
• This philosophy and value system provide a solid foundation for the science of
caring. A humanistic value system thus under grids her construction of the
science of caring.
• She asserts that the caring stance that nursing has always held is being
threatened by the tasks and technology demands of the curative factors.
The seven assumptions
Watson proposes even assumptions about the science of caring. The basic
assumptions are:
1. Caring can be effectively demonstrated and practiced only interpersonally.
2. Caring consists of carative factors that result in the satisfaction of certain
human needs.
3. Effective caring promotes health and individual or family growth.
4. Caring responses accept person not only as he or she is now but as what he
or she may become.
5. 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.
6. Caring is more “ healthogenic” than is curing. A science of caring is
complementary to the science of curing.
7. The practice of caring is central to nursing.
The ten primary carative factors
The structure for the science of caring is built upon ten carative factors.
These are:
• The formation of a humanistic- altruistic system of values.
• The installation of faith-hope.
• The cultivation of sensitivity to one’s self and to others.
• The development of a helping-trust relationship
• The promotion and acceptance of the expression of positive and negative
feelings.
• The systematic use of the scientific problem-solving method for decision
making
• The promotion of interpersonal teaching-learning.
• The provision for a supportive, protective and /or corrective mental, physical,
socio-cultural and spiritual environment.
• Assistance with the gratification of human needs.
• 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:
Congruence
Empathy
Warmth
• Communication includes verbal, nonverbal and listening in a manner which
connotes empathetic understanding.
5. The expression of feelings, both positive and negative
• According to Watson, “feelings alter thoughts and behavior, and they
need to be considered and allowed for in a caring relationship”.
• According to her such expression improves one’s level of awareness.
• 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
Example:
Bulemia, anorexia and gastro-intestinal ulcers are a just few of the disorders that
indicate a complex interaction between the physiological and psychological.
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.
• 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.
• 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.
Summary
• Watson’s theory
• Its seven assumptions
• The ten carative factors
• Watson’s theory and the four major concepts
• Watson’s theory and the nursing process
• Watson’s work and the characteristic’s of the theory
• Strengths
• Limitations
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
1. Watson provides many useful concepts for the practice of nursing.
2. 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.
3. The detailed descriptions of the carative factors can give guidance to those
who wish to employ them in practice or research.
4. Using her theory can add a dimension to practice that is both satisfying and
challenging.
Reference
• Timber BK. Fundamental skills and concepts in Patient Care, 7th edition, LWW,
N
• Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd
ed. Philadelphia, Lippincott.
• Vandemark L.M. Awareness of self & expanding consciousness: using Nursing
theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul; 27(6) :
605-15
Jul;19(3):225
• 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.
• Delaune SC,. Ladner PK, Fundamental of nursing, standard and practice, 2nd
edition, Thomson, NY, 2002.
JOHNSON’S BEHAVIOUR SYSTEM
MODEL
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. Throughout her career, Johnson has 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 (Johnson was influenced by
Buckley ,Chin and Rapport) 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.”
1. 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.
2. 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
2. “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”
3. 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”.
4. Each subsystem has a repertoire of choices or “scope of action”
1. The fourth assumption is that it produce “observable outcome” that is the
individual’s behavior.
Each subsystem has three functional requirements
2. System must be “protected" from noxious influences with which system
cannot cope”.
3. Each subsystem must be “nurtured” through the input of appropriate
supplies from the environment.
1. 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
2. Attachment or affiliative subsystem: “social inclusion intimacy and the
formation and attachment of a strong social bond.”
3. Dependency subsystem: “approval, attention or recognition and physical
assistance”
4. Ingestive subsystem: “the emphasis is on the meaning and structures of
the social events surrounding the occasion when the food is eaten”
5. 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.”
6. Sexual subsystem:" both biological and social factor affect the behavior
in the sexual subsystem”
7. 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”
1. 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
2. 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.
3. “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
4. “Health” is a purposeful adaptive response, physically mentally,
emotionally, and socially to internal and external stimuli in order to
maintain stability and comfort.
1. “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:
1. Affiliation
2. Dependency
3. Sexuality
4. Aggression
5. Elimination
6. Ingestion
7. Achievement
8. 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:
1. Insufficiency
2. Discrepancy
3. Incompatibility
4. 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.
Situation
John Smith, 6 weeks brought into the clinic for a routine check-up. He presents
with no weight gain since his check up at the age of 2 weeks .His mother stated
she feeds him but he does not seem to eat much. He sleeps 4to 5 hour between
the feedings. His mother holds him in her arms without trunk to trunk contact. As
the assessment is made the nurse notes that Mrs. Smith never looks at Johnny
and never speaks to him. She stated he was a planned baby but that she never
realized how much work a baby could be. She says, her mother told her she was
not a good mother because John is not gaining weight like he should. She states
she had not called the nurse when she knew John was not gaining weight because
she thought nurse would think she was a bad mother just like her own mother
thought she was a bad mother.
Assessment
1. Affiliative subsystem between mother and John.
2. Dependency subsystem between mother and John
3. Affiliative subsystem between Mrs.Smith and her mother.
4. Insufficiency ingesion subsystem.
Diagnosis
1. Insufficient development of the affiliative subsystem.
2. Insufficient development of the dependency subsystem
Planning and implementation
1. Increasing mother’s awareness of the baby’s clues.
2. Assisting her to talk with the baby.
3. Teach her to bring a bond between her and the baby by touch, pat and
cuddles etc.
Evaluation
1. Johnny's weight gain or weight loss will be carefully assessed.
2. The –infant interaction could be reassessed, using the nursing child
assessment feeding scale.
3. The interaction of Mrs. Smith with her mother.
Johnson’s and Characteristics of a theory
1. Interrelate concepts to create a different way of viewing a phenomenon.
2. Theories must be logical in nature.
3. Theories must be simple yet generalizable
4. Theories can be bases of hypothesis that can be tested.
5. Theories contribute to and assist in increasing the body of knowledge
within the discipline through the research implemented to validate them
6. Theories can be utilized by practitioners to guide and improve their
practice.
7. 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
• Polit DF, Hungler BP. Nursing Research: Principles and Methods. Philadelphia:
JB Lippincott Company; 1998.
• Burns N, Grove SK. The practice of Nursing Research. 4th Ed. Philadelphia:
WB Saunders Publications; 2001.
• Treece JW, Treece EW. Elements of Research in Nursing (3rded.). St. Louis:
Mosby; 1982.
IMOGENE KING: THEORY OF GOAL

ATTAINMENT
Introduction of Theorist
• 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:
personal system
Interpersonal system
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
• Proposition cont…
• 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
Nursing: is defined as “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.”
1. Action: is defined as a sequence of behaviors involving mental and
physical action.
2. Reaction: not specified, but might be considered as included in the
sequence of behaviors described in action.
3. In addition king discussed:
(a) goal
(b) domain and
(c) functions of professional nurse
4. Goal of nurse: “To help individuals to maintain their health so they can
function in their roles.”
5. Domain of nurse: “includes promoting, maintaining, and restoring
health, and caring for the sick, injured and dying.
6. 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
1. It involves to finding out weather goals are achieved or not.
2. 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
Perception, communication and

Assessment
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
• Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed.
• Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby,
Philadelphia, 2002
BETTY NEUMANN’S SYSTEM MODEL
INTRODUCTION
• Betty Neumann’s system model provides a comprehensive flexible holistic
and system based perspective for nursing.
• It focuses attention 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 Neumann was born in 1924, in Lowel, Ohio.
• She completed BS in nursing in 1957 and MS in Mental Health Public health
consultation, from UCLA in 1966. She holds a Ph.D. in clinical psychology
• She was a pioneer in the community mental health movement in the late
1960s.
• Betty Neumann began developing her health system model while 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
• Neumann’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.
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 (Neumann,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.
• 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
• According to Neumann’s model, prevention is 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 MAJOR CONCEPTS
PERSON
• The focus of the Neumann model is based on the philosophy that each
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.
• The internal environment exists within the client system.
• The external environment exists outside the client system.
• Neumann 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
• Neumann 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 (Neumann, 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
• Neumann 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.
NEUMANN’S SYSTEM MODEL FORMAT
Neumann’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 Neumann’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
• Neumann’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 Neumann 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.
• It has often been selected as a curriculum guide for a conceptual
framework oriented more toward wellness than toward a medical model
and has been used at various levels of nursing education.
• In the associate degree program at Indiana University.
• One of the objectives for nursing graduate is to demonstrate ability to use
the Neumann health care system in nursing practice. This helps prepare
the students for developing a frame of reference centered on holistic care.
• At northwestern State University in Shreveport, Louisiana, the faculty
determined that a systems model approach was preferred for their
master’s program because of the universality framework.
• Acceptance by the nursing community for education therefore is evident.
RESEARCH
• A study was published by Riehl and Roy to test the usefulness of the
Neumann model in nursing practice.
• There were two major objectives of the study.
o To test the model/assessment’ tool for its usefulness as a unifying
method of collecting and analyzing data for identifying client
problems.
o To test the assessment tool for its usefulness in the identification of
congruence between the client’s perception of stressors and the
care giver’s perception of client stressors.
• Results indicated that the model can help categorize data for assessing and
planning care and for guiding decision making.
• Neumann’s model can easily generate nursing research.
• It does this by providing a framework to develop goals for desired
outcomes. Acceptance by the nursing community for research applying this
model is in the beginning stages and positive.
NEUMANN’S AND THE CHARACTERISTICS OF A THEORY
• Theories connects the interrelated concepts in such a way as to
create a different way of looking at a particular phenomenon.
o The Neumann model represents a focus on nursing interest in the
total person approach to the interaction of environment and health.
o The interrelationships between the concepts of person, health,
nursing and society/environment are repeatedly mentioned
throughout the Neumann model and are considered to be basically
adequate according to the criteria.
• Theories must be logical in nature
o Neumann’s model in general presents itself as logically consistent.
o 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.
o Neumann’s model is fairly simple and straightforward in approach.
o The terms used are easily identifiable and for the most part have
definitions that are broadly accepted.
o The multiple use of the model in varied nursing situations (practice,
curriculum, and administration) is testimony in itself to its broad
applicability.
o The potential use of this model by other health care disciplines also
attests to its generalizability for use ion practice.
o One drawback in relation to simplicity is the diagrammed model
since it presents over 35 variables and tends to be awesome to the
viewer.
o Neumann’s model, due to its high level and breadth of abstraction,
lends itself to theory development.
o One are for future consideration as a beginning testable theory
might be the concept of prevention as intervention, subsequent to
basis concept refinement in the Neuman model.
knowledge within the discipline through the research implemented
to validate them.
o 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.
o The concept within the guidelines is clearly explicated and many
applications of the theory have been published, little research
explicitly derived from this model has been published to date.
• Theories can be utilized by the practitioner to guide and improve
their practice.
o One of the most significant attributes of the Neumann model is the
assessment/intervention instrument together with comprehensive
guidelines for its use with the nursing process.
o These guidelines have provided a practical resource for many
nursing practitioners and have been used extensively in a variety of
setting in nursing practice, education and administration.
• Theories must be consistent with other validated theories, laws
and principles but will leave open unanswered questions that need
to be investigated.
o In general, there is no direct conflict with other theories. There is,
however, a lack of specificity in systems concepts such as
“boundaries” which are indirectly addressed throughout the model.
Research Articles
1. “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).
1. 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.
2. These case studies illustrate how nurses' actions, directed by
Neuman's wholistic principles, integrate evidence-based practice
and generate high quality care
2. 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.
1. 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.
2. 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.
3. 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
Reference
LWW, N
Practice , 3rd ed. Norwalk, Appleton and Lange.
27(6) : 605-15
Jul;19(3):225
• 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.
LEVINE’S FOUR CONSERVATION

PRINCIPLES
Myra Estrine Levine
Introduction
• Born in Chicago, raised with a sister and a brother with whom she shared a
close loving relationship
• Also very fond of her father who was often ill and frequently hospitalized
with GI problem. This was the reason of choosing nursing as a career
• Also called as renaissance women-highly principled, remarkable and
committed to patient’s quality of care
• Died in 1996
Educational Achievement
• Diploma in nursing:-Cook county SON, Chicago, 1944
• BSN:-University of Chicago,1949
• MSN:-Wayne state University, Detroit, 1962
• Publication:-An Introduction to Clinical Nursing, 1969,1973 & 1989
• Received honorary doctorate from Loyola University in 1992
Achievements
• Clinical experience in OT technique and oncology nursing
• Civilian nurse at the Gardiner general hospital
• Director of nursing at Drexel home in Chicago
• Clinical instructor at Bryan memorial hospital in Lincoln, Nebraska
• Administrative supervisor at university of Chicago
• Chairperson of clinical nursing at cook country SON
• Visiting professor at Tel Aviv university in Israel
Conservational model
• Goal: To promote adaptation and maintain wholeness using the principles
of conservation
• Model guides the nurse to focus on the influences and responses at the
organismic level
• Nurse accomplishes the goal of model through the conservation of energy,
structure and personal and social integrity
Adaptation
• Every individual has a unique range of adaptive responses
• The responses will vary by heredity, age, gender or challenges of illness
experiences
• Example: The response to weakness of cardiac muscle is an increased
heart rate, dilation of ventricle and thickening of myocardial muscle
• While the responses are same, the timing and manifestation of organismic
responses will be unique for each individual pulse rate)
• An ongoing process of change in which patient maintains his integrity
within the realities of environment
• Achieved through the "frugal, economic, contained and controlled use of
environmental resources by individual in his or her best interest"
Wholeness
• Exist when the interaction or constant adaptations to the environment
permits the assurance of integrity
• Promoted by use of conservation principle
Conservation
• The product of adaptation
• "Keeping together "of the life systems or the wholeness of the individual
• Achieving a balance of energy supply and demand that is with in the
unique biological realities of the individual
Nursing’s paradigm
Person
• A holistic being who constantly strives to preserve wholeness and integrity
• A unique individual in unity and integrity, feeling, believing, thinking and
whole system of system
Environment
• Competes the wholeness of person
• Internal
• Homeostasis
• Homeorrhesis
• External
• Preconceptual
• Operational
• Conceptual
Internal Environment
• Homeostasis: A state of energy sparing that also provide the necessary
baselines for a multitude of synchronized physiological and psychological
factors
• A state of conservation
• Homeorrhesis: A stabilized flow rather than a static state
• Emphasis the fluidity of change within a space-time continuum
• Describe the pattern of adaptation, which permit the individual’s body to
sustain its well being with the vast changes which encroach upon it from
the environment
External Environment
• Preconceptual: Aspect of the world that individual are able to intercept
• Operational: Elements that may physically affects individuals but not
perceived by hem: radiation, micro-organism and pollution
• Conceptual: Part of person's environment including cultural patterns
characterized by spiritual existence, ideas, values, beliefs and tradition
Person and environment
• Adaptation
• Organismic response
• Conservation
Adaptation
Characteristics
Historicity: Adaptations are grounded in history and await the challenges
to which they respond
Specificity: Individual responses and their adaptive pattern varies on the
base of specific genetic structure
Redundancy: Safe and fail options available to the individual to ensure
continued adaptation
Organismic response
• A change in behavior of an individual during an attempt to adapt to the
environment
• Help individual to protect and maintain their integrity
• They co-exist
• They are four types
1. Flight or fight: An instantaneous response to real or imagined threat,
most primitive response
2. Inflammatory: response intended to provide for structural integrity
and the promotion of healing
3. Stress: Response developed over time and influenced by each stressful
experience encountered by person
4. Perceptual: Involves gathering information from the environment and
converting it in to a meaning experience
Nine models of guided assessment
• Vital’s signs
• Body movement and positioning
• Ministration of personal hygiene needs
• Pressure gradient system in nursing interventions
• Nursing determination in provision of nutritional needs
• Pressure gradient system in nursing
• Local application of heat and cold
• Administration of medicine
• Establishing an aseptic environment
Assumption
• The nurse creates an environment in which healing could occur
• A human being is more than the sum of the part
• Human being respond in a predictable way
• Human being are unique in their responses
• Human being know and appraise objects ,condition and situation
• Human being sense ,reflects, reason and understand
• human being action are self determined even when emotional
• Human being are capable of prolonging reflection through such strategists
raising questions
• Human being make decision through prioritizing course of action
• Human being must be aware and able to contemplate objects, condition
and situation
• Human being are agents who act deliberately to attain goal
• Adaptive changes involve the whole individual
• A human being has unity in his response to the environment
• Every person possesses a unique adaptive ability based on one’s life
experience which creates a unique message
• There is an order and continuity to life change is not random
• A human being respond organismically in an ever changing manner
• A theory of nursing must recognized the importance of detail of care for a
single patient with in an empiric framework that successfully describe the
requirement of the all patient
• A human being is a social animal
• A human being is an constant interaction with an ever changing society
• Change is inevitable in life
• Nursing needs existing and emerging demands of self care and dependant
care
• Nursing is associated with condition of regulation of exercise or
development of capabilities of providing care
Levine’s work & Characteristics of theory
• Theories can interrelate concepts in such a way as to create a different
way of looking at a particular phenomenon
• The concept of illness adaptation, using interventions, and the evaluation
of nursing interventions are interrelated .they are combined to look at
nursing care in a different way (more comprehensive view incorporating
total patient care) form previous time.
• Theories must be logical in nature.
• Levine’s idea about nursing care are organized in such a way as to b
sequential and logical. they can be used to explain the consequences of
nursing action
• Levine’s theory is easy to use .
• It’s major elements are easily comprehensible and the relation ship have
the potential for being complex but are easily manageable
• Certain isolated aspect of the theory are the generalizable i.e. those
related to the conservational principles
• Levine’s idea can be tested
• Hypothesis can be derived from them .
• The principle of conservation are specific enough to be testable
• Levine’s work & Characteristics of theory
validate them.
• Since Levine’s idea have not yet been widely researched ,it is hard o
determine the contribution to the general body of knowledge with in the
discipline
• Theories can be utilized by the practitioner to guide and improve their
practice.
• Paula E.Crawford-gamble :-successfully applied Levine’s theory to the
female patient undergoing surgery for the traumatic amputation of the
fingers
• These ideas lend themselves to use in practice particularly in acute care
setting
• Theories must be consistent with other validated theories, laws and
investigated .
• Levine’s ideas seem to be consistent with other theories, laws and
principles particularly those from the humanities and sciences
Conservational Principle
• Conservation of energy
• Conservation of structural integrity
• Conservation of personal integrity
• Conservation of social integrity
1. Conservation of energy
• Refers to balancing energy input and output to avoid excessive fatigue
• includes adequate rest, nutrition and exercise
Example:
availability of adequate rest
Maintenance of adequate nutrition
2. Conservation of structural integrity
• Refers to maintaining or restoring the structure of body preventing physical
breakdown And promoting healing
Example:
Assist patient in ROM exercise
Maintenance of patient’s personal hygiene
3. Conservation of personal integrity
• Recognizes the individual as one who strives for recognition, respect, self
awareness, selfhood and self determination
Example:
Recognize and protect patient’s space needs
4. Conservation of social integrity
• An individual is recognized as some one who resides with in a family, a
community ,a religious group, an ethnic group, a political system and a
nation
Example:
• Position patient in bed to foster social interaction with other patients
• Avoid sensory deprivation
• Promote patient’s use of news paper, magazines, radio. TV
• Provide support and assistance to family
Health
• Health is a wholeness and successful adaptation
• It is not merely healing of an afflicted part ,it is return to daily activities,
selfhood and the ability of the individual to pursue once more his or her
own interest without constraints
• Disease: It is unregulated and undisciplined change and must be stopped
or death will ensue
Nursing
• "nursing is a profession as well as an academic discipline, always practiced
and studied in concert with all of the disciplines that together from the
health sciences"
• The human interaction relying on communication ,rooted in the organic
dependency of the individual human being in his relationships with other
human beings
• Nursing involves engaging in "human interactions"
Goal of Nursing
• To promote wholeness, realizing that every individual requires a unique
and separate cluster of activities
• The individual integrity is his abiding concern and it is the nurse’s
responsibility to assist him to defend and to seek its realization
Nursing Process
• Assessment
• Trophicognosis
• Hypothesis
• Interventions
• Evaluation
Nursing Process
Assessment
• Collection of provocative facts through observation and interview of
challenges to the internal and external environment using four
conservation principles
• Nurses observes patient for organismic responses to illness, reads medical
reports. talks to patient and family
• Assesses factors which challenges the individual
Trophicognosis
• Nursing diagnosis-gives provocative facts meaning
• A nursing care judgment arrived at through the use of the scientific
process
• Judgment is made about patient’s needs for assistance
Hypothesis
• Planning
• Nurse proposes hypothesis about the problems and the solutions which
becomes the plan of care
• Goal is to maintain wholeness and promoting adaptation
Interventions
• Testing the hypothesis
• Interventions are designed based on the conservation principles
• Mutually acceptable
• Goal is to maintain wholeness and promoting adaptation
Evaluation
• Observation of organismic response to interventions
• It is assesses whether hypothesis is supported or not supported
• If not supported, plan is revised, new hypothesis is proposed
Conservational models
• Conservational model provides the basis for development of two theories
o Theory of redundancy
o Theory of therapeutic intention
Theory of redundancy
• Untested ,speculative theory that redefined aging and everything else that
has to do with human life
• Aging is diminished availability of redundant system necessary for effective
maintenance of physical and social well being
Theory of therapeutic intention
• Goal: To seek a way of organizing nursing interventions out of the
biological realities which the nurse has to confront
• Therapeutic regimens should support the following goals:
• Facilitate healing through natural response to disease
• Provide support for a failing auto regulatory portion of the integrated
system
• Restore individual integrity and well being
Theory of therapeutic intention
• Provide supportive measure to ensures comfort
• Balance a toxic risk against the threat of disease
• Manipulate diet and activity to correct metabolic imbalance and stimulate
physiological process
• Reinforce usual response to create a therapeutic changes
Uses
• Critical, acute or long term care unit
• Neonates, infant and young children, pregnant young adult and elderly
care unit
• Primary health care
• OT
• Community setting
Utility of Theory
• Nursing research
• Nursing education
• Nursing administration
• Nursing practice
Nursing research
• Principles of conservation have been used for data collection in various
researches
• Conservational model was used by Hanson et al.in their study of incidence
and prevalence of pressure ulcers in hospice patient
• Newport used principle of conservation of energy and social integrity for
comparing the body temperature of infant’s who had been placed on
mother’s chest immediately after birth with those who were placed in
warmer
Nursing education
• Conservational model was used as guidelines for curriculum development
• It was used to develop nursing undergraduate program at Allentown
college of St.Francis de sales, Pennsylvania
• Used in nursing education program sponsored by Kapat Holim in Israel
Nursing administration
• Taylor described an assessment guide for data collection of neurological
patients which forms basis for development of comprehensive nursing care
plan and thus evaluate nursing care
• McCall developed an assessment tool for data collection on the basis of
four conservational principles to identify nursing care needs of epileptic
patients
• Family assessment tool was designed by Lynn-Mchale and Smith for
families of patient in critical care setting
Nursing practice
• Conservational model has been used for nursing practice in different
settings
• Bayley discussed the care of a severely burned teenagers on the basis of
four conservational principles and discussed patient’s perceptual,
operational and conceptual environment
• Pond used conservation model for guiding the nursing care of homeless at
a clinic, shelters or streets
Nursing process according to Levine’s model
Mrs. Mona, a wife of an abusive husband, underwent a radical
hysterectomy. Post operatively has pain ,weight loss, nausea and inability
to empty bladder .Patient has history of smoking and stays in house which
is less than sanitary
Assessment
• Challenges to the internal env:-weight loss, nausea, loss of reproductive
ability
• Challenges to the external env:-abusive husband, insanitary condition in
home
• Energy conservation:-weight loss, nausea ,pain
• Structural integrity:-threatened by surgical procedure, inability to pass
urine
• Personal integrity:-not able to give birth to more children
• Social integrity:-Strained relationship with husband
Trophicognosis
• Inadequate nutritional status
• Pain
• Potential for wound and bladder infection
• Need to learn self catheterization
• Decreased self worth
• Potential for abuse
Hypothesis
• Nutritional consultation
• Teaching and return demonstration of urinary self catheterization
• Care of surgical wound
• Exploring concern regarding hysterectomy
Interventions
Energy conservation
• Provide medication for pain and nausea
• Allowing rest period
Structural integrity
• Administrating antibiotic for wound,
• Teaching self catheterization
Personal integrity
• Exploring her feeling about uterus removal while respecting her privacy
Social integrity
• Assess potential abuse form husband
• Support to the family
Organismic response
• Controlled pain
• Abdominal wound healing
• Improved appetite ,weight gain
• Clean urinary self catheterization
• Assistance from husband
Critiquing the theory
• She values the holistic approach to all individual, well or sick
• Values patient’s participation in nursing care
• Comprehensive content in depth
• Provides direction of nursing research , education, administration and
practice
• Logically congruent
• Shows high regard to adjunctive disciplines to develop theoretical basis for
nursing
Limitation
• Limited attention can be focused on health promotion and illness
prevention.
• Nurse has the responsibility for determining the patient ability to
participate in the care ,and if the perception of nurse and patient about the
patient ability to participate in care don’t match, this mismatch will be an
area of conflict.
• The major limitation is the focus on individual in an illness state and on the
dependency of patient.
Research Highlights
• A theory of health promotion for preterm infants based on conservational
model of nursing. Nursing science quarterly,2004 Jul,17 (3)
The article describes a new middle range theory of health promotion for
preterm infants based on Levine’s conservational model that can be used
to guide neonatal nursing practice.
Summary
• Introduction to the theorist
• Conservational model
• Concept of the model
• Adaptation
• Wholeness
• Conservation
1. Conservation principles
2. Nursing process
1. Assessment
2. Trophicogosis
3. Hypothesis
4. Interventions
5. Evaluation
3. Theory of redundancy
4. Theory of therapeutic intention
5. Utility of theory
1. Nursing research
2. Nursing education
3. Nursing administration
4. Nursing practices
References
LWW.
27(6) : 605-15
Jul;19(3):225
• 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.
2nd edition, Thomson, NY, 2002.
MARTHA ROGER’S SCIENCE OF
UNITARY HUMAN BEINGS
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 human
The 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 homeodynamic
• Resonancy
• Helicy
• 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
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 (Neumann, 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 envisions 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 explicitly 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
o Neonatal ICU
o Pediatric ICU
o Post operative unit
o Pre operative unit
o Palliative care unit
o Rehabilitation center
o Burns unit
o Adult ICU’s
o Old age homes
o Neuropsychiatric units
o 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
o Sharing knowledge
o Offering choices
o Empowering the client
o Fostering patterning
o 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
Clinical case study of Radha using Rogerian conceptual Model
Radha is a 22years old female admitted in a psychiatry unit with
severe depression secondary to diagnosis of ovarian malignancy
She becomes tearful during history taking
Radha is accompanied with her husband and 1year old child
Her husband appeared anxious but supportive and attentive …………he
is working as an accountant in their native place
Radha was diagnosed with ovarian cancer 2 months back and
underwent bilateral salphingio oopherectomy and hysterectomy………
30days ago
She is undergoing chemotherapy due to its Metastatic pattern…….
From past 3 weeks Radha started sitting lonely, decreased ADL,
repeated crying spells, decreased talks, neglects hygiene, muttering to
self, decreased sleep , appetite, neglecting her child care, complaints
of severe pain in the body,………….3 days back attempted suicide by
consuming rat poison.
Current assessment findings …….her general appearance is a teary
eyed young woman ,ill-kempt, clinging to her husband ,looking
perplexed, not talking…..poor nutritional intake, when asked about her
illness….cries inconsolably …on repeated asking expressed sadness of
mood
Nursing care of Radha with Rogers model
• With rogerian model, the process of caring Radha begins with pattern
appraisal
• Nursing care involve pattern appraisal, mutual patterning, and evaluation
Pattern appraisal
• This visible rhythmical pattern is a manifestation of evolution towards
dissonance
• Radha has pattern manifestation of dissonance……..depression with suicidal
ideation, ovarian malignancy, pain
• Radha has a low educational background
• A pattern activity of healing is noted through reports of a positive operative
course
• Patterning has to be directed towards reduction in perceived dissonance with
her personal and environmental field
• Pain is a manifestation of perceived dissonance
• Decreased environmental energy transfer is visible by decreased talking and
crying
• Radha has manifestation of fear…….her self knowledge links her illness to her
personal belief of being punished for her past sins
• Appraisal is needed in her sleep patterns, nutrition and her perception of self
• Appraisal can be grouped into exchanging patterns, communication patterns,
and relating patterns
• Time between nurse and Radha is needed to foster her healing
• During the process nurse must rely on personal intuition and insight regarding
the emerging pattern
• All this pattern forms the unitary pattern of Radha
Mutual patterning
• The process is mutual between the nurse and Radha
• The surgery performed, medication she is receiving are patterning modalities
• Patterning activities planned by the nurse for Radha ……..therapeutic touch,
humor , meditation, imagery
• Radha needs to be assessed fully regarding her ability to understand and
agree with different patterning modalities
• Therapeutic touch can be introduced to Radha
• Touch is introduced and incorporated into the management of pain, helps in
energy transmission for healing and …….helps in developing trust in the nurse
• Teach her how to center the energy and channel her energy to the area of
pain
• Use humor for increasing socialization and developing self confidence and
developing worthiness
• Human environmental patterning needs to involve the other individual who
share her environment including husband and son
• Options are introduced relating to increase communication and hygiene
patterns
• The entire family is involved in power as knowing participation in change
Evaluation
• The evaluation process centers on the perceptions of dissonance that exist
after the mutual pattern activities
• The appraisal process is repeated
• Manifestation of worry, pain, fear, sadness of moos has to be appraised with
family members
• A summary of the dissonance and/or harmony that is perceived is then
shared with Radha, and mutual patterning is modified or instituted ad
indicated based on the evaluation
Summary
• Biographical sketch of Martha Rogers
• Overview of Rogerian concepts
• Rogerian terminologies
• Rogerian theories
• Nursing concepts, nursing process
• Perspectives of nursing education, administration, nursing practice
• Contribution to nursing knowledge
• Clinical example
References
1. George B. Julia , Nursing Theories- The base for professional Nursing Practice
2. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing
3. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress
4. Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed.
5. Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts
THEORIES BASED ON INTERACTIVE
PROCESS
IMOGENE KING: THEORY OF GOAL ATTAINMENT
Major Concepts and Definitions

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
Communication
· Information from person to person
· Directly or indirectly
· Information component of interaction
Perception
· Each person’s representation of reality
Transaction
· Purposeful interaction leading to goal attainment
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
Stress
· Dynamic state
· Human being interacts with the environment
Growth and development
· Continuous changes in individuals
· At cellular, molecular and behavioural levels of activities
· Helps individuals move towards maturity
Time
· Sequence of events
· Moving onwards to the future
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
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 self
Role 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
1. All the conditions, circumstances and influences surrounding and affecting
the development and behaviour of persons or groups
References
• Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed.
• Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby,
Philadelphia, 2002.
• Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development and Progress
• Taylor Carol,Lillis Carol (2001)The Art and Science Of Nursing Care 4th ed.
Potter A Patricia, Perry G Anne (1992)Fundamentals Of Nursing –Concepts

Orem’s Theory
Introduction
One of America’s foremost nursing theorists.
Dorothea Orem earned her Bachelor of science in nursing education in
1939 and Master of science in nursing in 1945
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
Dorothea Orem as a member of a curriculum subcommittee at Catholic
University, recognized the need to continue in developing a conceptualization
of nursing.
Published first formal articulation of her ideas in Nursing: Concepts of
Practice in 1971.second in 1980,and finally 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.
1958-1960 US Department of Health, Education and Welfare where she
help publish "Guidelines for Developing Curricula for the Education of
Practical Nurses" in 1959.
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.
Continues to develop her theory after her retirement in 1984
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 environmental factors
,environmental elements, conditions ,and developmental 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 systems
Theory of Self Care
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:--
Universal
Developmental
Health deviation
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
Developmental self care requisites
Associated with developmental processes/ derived from a condition…. Or
associated with an event
E.g. adjusting to a new job
adjusting to body changes
Health deviation self care
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
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:--
Acting for and doing for others
Guiding others
Supporting another
Providing an environment promoting personal development in relation to
meet future demands
Teaching another
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
Social or interpersonal
Communication adjusted to age, health status
Maintaining interpersonal ,intragroup or intergroup 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
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
Assessment
Nursing diagnosis
Plans with scientific rationale
Implementation
evaluation
Orem’s Nursing. Process
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
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
Step 3
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 Universal Developmental Health Medical Self care

factors self care self care deviatio problem & deficits
n plan
29 yr. 32pack /yr Teenage Seeks

Female Water-no pregnancy-2 medical
restrictions OC-10 yrs attention
Early for overt
adulthood Food –nil Husband s/s
transition Wt89lb emotionally
away Aware of
Wt loss-19% disease
nauseated No
evidence
8th grade Urinary No BSE ability to Surgery on Difference

Teenage retention Infrequent manage reproductive between
pregnancy Intermittent physical effects organs knowledge
self examination base &
No work lifestyle
catheterizatio No HRT
Married n
Child-2 Poor health
Pain
Lives at Tearful EDU deprivation Will receive

mother’s Husband Oppressive RT ,perform
home. abusive living conditions intermittent
Environmen catheterizatio
t unclean Dissatisfied n
with home
Limited
resources RT
Therapeutic Adequacy Nursing Methods of helping

self care of self diagnosis
demand care
agency
Air Inadequate Potential for Guiding & directing
Maintain impaired
effective respiratory status
respiration P F fluid imbalance
Teaching
Water Actual nutritional
Adequate deficit r/t ausea
No problem
Providing physical
Food maintain support
sufficient intake Inadequate
Personal development
Hazards Inadequate P/F injury Guiding & directing

Prevent spouse
abuse Guiding & directing
Promotion of Inadequate A/d in
normalcy environment
Shared housing
Maintain Inadequate Actual delay in Guiding & directing

developmental normaldev. R/T Providing psy support
environment early parenthood
Support ed Level of education Providing physical, psy
normalcy in support
environment Inadequate
Dev deficit r/t loss
Prevent of reproductive
/manage dev organs
threat
Maintenance of Inadequate P/F contd. Guiding &
health status alterations in directing, teaching
Management of health status Guiding & directing,
Inadequate
disease process P/F UTI teaching
Adherence to Inadequate P/F ¯ adherence teaching

med regimen in self
catheterization
& OPD RT
Awareness of Inadequate teaching
potential Actual deficit in
problems awareness of
advisability of
HRT & RT effects
Adjust to loss of Inadequate Actual threat to Providing psy

reproductive self image support
ability & dev
healthy view of
illness Inadequate Actual self Guiding & directing
deficit in
Adjust life style planning for
to cope with future needs
change
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 relatively simple yet generalizable
Theories are the basis for hypothesis that can be tested
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 (Fenner 1979) 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 multiperson 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
References
• Orem, D.E. (1991). Nursing: Concepts of practice (4th ed.). St. Louis, MO:
Mosby-Year Book Inc.
• 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.
THE ROY'S ADAPTATION
MODEL
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
Persons
• Physiologic
• Self Concept
• Role Function
• Interdependence
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
• 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
1. 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
27(6) : 605-15
Jul;19(3):225
ORLANDO'S NURSING PROCESS

THEORY
INTRODUCTION
Ida Jean Orlando, a first-generation American of Italian descent was
born in 1926.
She received her nursing diploma from New York Medical College, her
BS in public health nursing from St. John's University, NY, and her MA in
mental health nursing from Columbia University, New York.
Orlando was an Associate Professor at Yale School of Nursing where
she was Director of the Graduate Program in Mental Health Psychiatric
Nursing.
While at Yale she was project investigator of a National Institute of
Mental Health grant entitled: Integration of Mental Health Concepts in a
Basic Nursing Curriculum.
It was from this research that she developed her theory which was
published in her 1961 book, The Dynamic Nurse-Patient Relationship.
She furthered the development of her theory when at McLean
Hospital in Belmont, MA as Director of a Research Project: Two Systems of
Nursing in a Psychiatric Hospital.
The results of this research are contained in her 1972 book titled:
The Discipline and Teaching of Nursing Processes
Orlando held various positions in the Boston area, was a board
member of Harvard Community Health Plan, and served as both a national
and international consultant.
She is a frequent lecturer and conducted numerous seminars on
nursing process.
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
Questions
What prompts nursing actions?
What are the properties of dynamic nurse patient relationships that
may lead to effective care?
Answer
Nurses were prompted in their actions for reasons other than the
patients immediate experiences and needs
INTRODUCTION TO THEORY
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.
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 nurse find out the nature of the distress and what
help the patient needs.
MAJOR DIMENSIONS OF THE THEORY
Function of professional nursing - organizing principle
Presenting behavior - problematic situation
Immediate reaction - internal response
Nursing process discipline – investigation
Improvement - resolution
FUNCTIONS OF PROFESSIONAL NURSING
– ORGANIZING PRINCIPLE
Finding out and meeting the patients immediate needs for help
Nursing….is responsive to individuals who suffer or anticipate a sense
of helplessness, it is focused on the process of care in an immediate
experience, it is concerned with providing direct assistance to individuals in
whatever setting they are found for the purpose of avoiding, relieving,
diminishing or curing the individuals sense of helplessness
The purpose of nursing is to supply the help a patient requires for his
needs to be met
Nursing thought - Does the patient have an immediate need for help
or not?
If the patient has an immediate need for help and the nurse finds out
and meets that need ,the function of professional nursing is achieved
PRESENTING BEHAVIOR – PROBLEMATIC SITUATION
To find out the immediate need for help the nurse must first
recognize the situation as problematic
The presenting behavior of the patient, regardless of the form in
which it appears, may represent a plea for help
The presenting behavior of the patient, the stimulus, causes an
automatic internal response in the nurse, and the nurses behavior causes a
response in the patient
IMMEDIATE REACTION –INTERNAL RESPONSE
Person perceives with any one of his five sense organs an object or
objects
The perceptions stimulate automatic thought
Each thought stimulates an automatic feeling
Then the person acts
The first three items taken together are defined as the person’s
immediate reaction
Reflects how the nurse experiences her or his participation in the
nurse patient situation
NURSING PROCESS DISCIPLINE - INVESTIGATION
Any observation shared and explored with the patient is immediately
useful in ascertaining and meeting his need or finding out that he is not in
need at that time
The nurse does not assume that any aspect of her reaction to the
patient is correct, helpful or appropriate until she checks the validity of it in
exploration with the patient
The nurse initiates a process of exploration to ascertain how the
patient is affected by what she says or does
Automatic reactions are not effective because the nurses action is
decided upon for reasons other than the meaning of the patients behavior
or the patients immediate need for help
When the nurse does not explore with the patient her reaction it
seems reasonably certain that clear communication between them stops
IMPROVEMENT - RESOLUTION
It is not the nurses activity that is evaluated but rather its result :
whether the activity serves to help the patient communicate her or his
need for help and how it is met
In each contact the nurse repeats a process of learning how to help
the individual patient.
Her own individuality and that of the patient requires that she go
through this each time she is called upon to render service to those who
need her
ASSUMPTIONS
When patients cannot cope with their needs without help, they
become distressed with feelings of helplessness
Nursing , in its professional character , does add to the distress of the
patient
Patients are unique and individual in their responses
Nursing offers mothering and nursing analogous to an adult
mothering and nurturing of a child
Nursing deals with people, environment and health
Patient need help in communicating needs, they are uncomfortable
and ambivalent about dependency needs
Human beings are able to be secretive or explicit about their needs,
perceptions, thoughts and feelings
The nurse – patient situation is dynamic, actions and reactions are
influenced by both nurse and patient
Human beings attach meanings to situations and actions that are not
apparent to others
Patients entry into nursing care is through medicine
The patient cannot state the nature and meaning of his distress for
his need without the nurses help or without her first having established a
helpful relationship with him
Any observation shared and observed with the patient is immediately
useful in ascertaining and meeting his need or finding out that he is not in
need at that time
Nurses are concerned with needs that patients cannot meet on their
own
DOMAIN CONCEPTS
Nursing – is responsive to individuals who suffer or anticipate a sense
of helplessness
Process of care in an immediate experience….. for avoiding, relieving,
diminishing or curing the individuals sense of helplessness
Finding out meeting the patients immediate need for help
Goal of nursing – increased sense of well being, increase in ability,
adequacy in better care of self and improvement in patients behavior
Health – sense of adequacy or well being . Fulfilled needs. Sense of
comfort
Environment – not defined directly but implicitly in the immediate
context for a patient
Human being – developmental beings with needs, individuals have
their own subjective perceptions and feelings that may not be observable
directly
Nursing client – patients who are under medical care and who cannot
deal with their needs or who cannot carry out medical treatment alone
Nursing problem – distress due to unmet needs due to physical
limitations, adverse reactions to the setting or experiences which prevent
the patient from communicating his needs
Nursing process – the interaction of 1)the behavior of the patient, 2)
the reaction of the nurse and 3)the nursing actions which are assigned for
the patients benefit
Nurse – patient relations – central in theory and not differentiated
from nursing therapeutics or nursing process
Nursing therapeutics – Direct function : initiates a process of helping
the patient express the specific meaning of his behavior in order to
ascertain his distress and helps the patient explore the distress in order to
ascertain the help he requires so that his distress may be relieved.
Indirect function – calling for help of others , whatever help the
patient may require for his need to be met
Nursing therapeutics - Disciplined and professional activities –
automatic activities plus matching of verbal and nonverbal responses,
validation of perceptions, matching of thoughts and feelings with action
Automatic activities – perception by five senses, automatic thoughts,
automatic feeling, action
THEORY ANALYSIS
PARADIGMATIC ORIGINS
Paplau’s focus of interpersonal relationships in nursing
Paplau acknowledged the influence of Harry Stack Sullivan on the
development of her ideas
Symbolic interactionism – Chicago school
Use of field methodology
John Dewey’s theory of inquiry
ORLANDO'S WORK AND CHARACTERISTICS OF A THEORY
Theories can interrelate concepts in such a way in such a way as to
create a different way of looking at a particular phenomenon
Theories can be the bases for hypotheses that can be tested
validate them
Theories can be utililized by practitioners to guide and improve their
practice
Theories must be consistent with other validated theories, laws, and
investigated
INTERNAL DIMENSIONS
• Analyzed 2000 nurse – patient interactions to identify the properties,
dimensions and goals of interactions
• Use of field approach
• Focus on describing psychosocial aspects of nurse - patient interaction
• Used a mixture of operational and problematic methods of theory
development
• Focus on how to deliver care not on what care to be given
• Nursing process theory of low to medium level abstraction
STRENGTHS
• Use of her theory assures that patient will be treated as individuals and
that they will have active and constant input into their own care
• Prevents inaccurate diagnosis or ineffective plans because the nurse has to
constantly explore her reactions with the patient
• Assertion of nursing’s independence as a profession and her belief that this
independence must be based on a sound theoretical frame work
• Guides the nurse to evaluate her care in terms of objectively observable
patient outcomes
• Make evaluation a less time consuming and more deliberate function, the
results of which would be documented in patients charts
• Nursing can pursue Orlando's work for retesting and further developing her
work
THEORY CRITIQUE
• Lack of operational definitions for concepts – limits development of
research hypothesis
• Theory is more congruent in guiding nurse – patient interactions for
assessing needs and in providing nursing therapeutics deemed necessary
to patient care
• Focus on short term care, particularly aware and conscious individuals and
on the virtual absence of reference group or family members
LIMITATIONS
• Highly interactive nature Orlando's theory makes it hard to include the
highly technical and physical care that nurses give in certain settings
• Her theory struggles with the authority derived from the function of
profession and that of the employing institution’s commitment to the public
EXTERNAL COMPONENTS
• Value of nursing shifted from task oriented to patient oriented nursing
process
• Theory is culturally bound
• Misinterpretation of continuous validation as lack of knowledge and
expertise
• The uniqueness of individuals assumed by the theory could counteract
automatic responses of nurses
COMPARISON WITH NURSING PROCESS
THEORY TESTING
• Validation of perceptions, thoughts and feelings is essential for enhancing
the congruence between patient’s needs and the care given
• Results indicate unique nursing process is more effective than other
approaches in dealing with pain, in reducing stress, in understanding
patient’s needs, in relieving distress to experienced by patients during the
process of admission to a hospital
• Used in describing the responsibilities of nursing students to distressed
patients
• A number of studies focused on explicating the properties and components
of nurse – patient interactions
• Perceptions was used as a frame work to describe needs of grieving
spouses
• Gillis supported Orlando’s differentiation between presenting problems as
perceived by the nurse and those as perceived and validated by patients
• Used as a framework to research nursing administration
USES OF THEORY
• Use in Education
• Midwestern State University in Wichita Falls, Texas, is using
Orlando's theory for teaching entering nursing students.
• South Dakota State University in Brookings, SD has been using
Haggerty’s (1985) description of the communication based on
Orlando’s theory for entering nursing students as well as re-
enforcing it in their junior year
• Uses in Administration
o Schmieding successfully used Orlando's theory in two major
hospitals for both practice and administration (Lincoln General
Hospital, Lincoln, NE and Boston City Hospital, Boston, MA)..
Implementation of Orlando’s theory produced substantial benefits.
Its use increased effectiveness in meeting patient needs; improved
decision-making skills among staff nurses, including determining
what constituted nursing versus non-nursing functions; negotiated
more effectively in resolving conflict among staff nurses and
between staff and physicians; and influenced a more positive
nursing identity and unity among staff.
• Use in Research
o In an Veterans Administration (VA) ambulatory psychiatric practice
in Providence, RI Shea, McBride, Gavin, and Bauer (1987) used
Orlando’s theoretical model with patients (N = 76) having a bipolar
disorder. Their research results indicate that there were: higher
patient retention, reduction of emergency services, decreased
hospital stay, and increased satisfaction.
• In a pilot study, Potter and Bockenhauer (2000) found positive
results after implementing Orlando’s theory. These included:
positive, patient-centered outcomes, a model for staff to use to
approach patients, and a decrease in patient’s immediate distress.
• Use in Clinical Practice
o Nursing care plan
o Case studies
o Progressive patient care settings
Nursing process
• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation
SUMMARY
• Theorist – IDA JEAN ORLANDO
• Development of theory
• Dimensions of theory
• Assumptions
• Concepts
• Theory analysis
• Characteristics of a theory
• Paradigmatic origins
• Strengths and limitations
• Internal and external components
• Comparison with nursing process
• Theory testing and uses of theory
CONCLUSION TO THEORY
1. Orlando's theory remains one the of the most effective practice theories
available.
2. The use of her theory keeps the nurse's focus on the patient.
3. The strength of the theory is that it is clear, concise, and easy to use.
4. 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.
REFERENCES
27(6) : 605-15
Jul;19(3):225
APPLICATION OF IMOGENE
KING’S THEORY OF GOAL
ATTAINMENT
Objectives
1. to assess the patient condition by the various methods explained by the
nursing theory
2. to identify the needs of the patient
3. to demonstrate an effective communication and interaction with the
patient.
4. to select a theory for the application according to the need of the patient
5. to apply the theory to solve the identified problems of the patient
6. to evaluate the extent to which the process was fruitful.
Introduction
King’s theory offers insight into nurses’ interactions with individuals and groups
within the environment. It highlights the importance of client’s participation in
decision that influences care and focuses on both the process of nurse-client
interaction and the outcomes of care. Mr.Sy (74 years) was admitted in L3 ward of
...Hospital, for a herniorrhaphy on ... for his left indirect inguinal hernia and was
expecting discharge from hospital... the theory of goal attainment was used in his
nursing process.
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 behaviours
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
1. Social beings
2. Sentient beings
3. Rational beings
4. Perceiving beings
5. Controlling beings
6. Purposeful beings
7. Action – oriented beings
8. 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
Dynamic Interacting Systems
Personal system
Concepts
Perception
Self
Body image
Growth and development
Time
Space
Concepts
1. Interaction, 2. Transaction 3. Communication 4. Role 5. Stress
Social system
Concepts
1. Organization 2. Authority 3. Power 4. Status, 5. 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
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
Proposition cont…
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.
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.
The first process in nursing process is nurse meets the patient and
communicates and interacts with him. Assessment is conducted by
gathering data about the patient based on relevant concepts.
Mr. Sy is 74yrs married, got admitted in L3 ward of ...Hospital on 27/03/08 with a

diagnosis of indirect inguinal hernia underwent herniorraphy with prolene mesh
done on 30/03/08. The following areas were addressed to for gathering data.
What is the patient’s Patient says

perception of the situation? ” I have undergone surgery for hernia”. “ The
wound is getting healed, I have no other problem”
“I have pain in the area of surgery when moving”
“I’m taking medicines for hypertension for the last
7 years from here”
“I have vision problem to my left eye. I had
undergone a surgery for my right eye about 10
years back”.
What are my perceptions of Patient underwent herniorahaphy operation on 30th
the situation? March for indirect inguinal hernia which he kept
untreated for 35 years.
Patient has health maintenance related problems.
Patient is at risk of developing infection.
Patient has pain related to surgical incision.
Patient may develop hypertension related
complications in future.
What other information do I History
need to assist this patient Identification details
to achieve health? Mr. Sy is 74yrs married, male, studied up to 7th
Std is doing Business, a practicing Muslim, got
admitted in L3 ward of ...Hospital on 27/03/08 with
a diagnosis of indirect inguinal hernia underwent
herniorraphy with prolene mesh done on 30/03/08.
Present History of Illness
Abdominal swelling for 35 years with difficulty in
activities and occasional abdominal pain. He has
hypertension for seven years.
The swelling remained stable with uncomplicated
progress, getting increasing size when standing for
long and reducible on applying pressure
No h/o severe pain but increasing size for the last
few years
Relived after pressing the swelling back to position
and on taking rest and applying pressure
Past health history
Patient underwent cataract surgery about 10 years
back
On treatment for hypertension
No other significant illness
Family History
Patient’s next elder brother and next younger
brother had inguinal hernia and were operated
Elder brother underwent 3 surgeries for hernia
Socioeconomic Status
High economic status >Rs.20000/- per month
Life Style
Non vegetarian
No habit of smoking or alcoholism.
Aware about health care facilities
Physical examination
Alert, conscious and oriented
Moderately built, adequate nourishment, with BMI
of 22
Vital signs – normal except BP 140/90 mmHg
General head-to-foot examination reveals normal
finding except for the vision difficulty of the right
eye and healing surgical wound on th left inguinal
region.
Subjective problems
Pain at the surgical wound site
Lack of bowel movement for 2 days
Review of relevant systems
GI system
Inspection:
Healing wound, No infection, No redness, No
swelling
Auscultation:
Normal bowel sounds
Palpation
No pain at the site, Normal abdominal organs
Percussion:
No dull sound suggesting fluid collection or ascitis
Genito-Urinary system
Inspection:
Testicles in position, No infection, No swelling or
enlargement
Palpation
No c/o pain,No prostate enlargement
Percussion
No fluid collection in scrotum
Auscultation
Normal Bowel sounds
Laboratory Investigations
FBS - 91 mg/dl
Na(130-143mEq/dl) - 134 mEq / dl
K+ (3.5-5 mg/dl) - 3.5 mEq / dl
Urea(8-35mg/dl)-29 mg / dl
Cr (0.6-1.6 mg/ dl)- <1 mg/ dl
Other investigations
Electro cardio gram
Ant. Fascicular block
Left atrial enlargement
Normal axis
What does this information Patient neglected a health problem for 35
means to this situation? years
Patient has acute pain at the site of surgical
wound
Patient has family history of inguinal hernia
and risk for recurrence
Patient has a risk for recurrence due to
constipation.
Patient has risk for infection due to
inadequate knowledge and age.
Patient is at risk of developing complications
of hypertension
Patient requires education regarding health
maintenance
What conclusion Patient requires management for his pain
(judgement) does this Patient understands the need taking care of
patient make? health risks and agrees to work on these aspects
What conclusions Based on the assessment following nursing
(judgement) do I make? diagnoses were formulated, i.e. the clinical
Nursing diagnosis judgement about the patient’s actual and potential
The data collected problems.
by assessment are used to • Acute pain related to surgical incision
make nursing diagnosis in • Risk for infection related to surgical incision
nursing process. Acc. to
• Risk for constipation related to bed rest,
King in process of attaining
pain medication and NPO or soft diet
goal, the nurse identifies
the problems, concerns and • Deficient knowledge regarding the
disturbances about which treatment and home care
person seek help. • Ineffective health maintenance
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.
Identifying the goals and planning to achieve these goals(this step is
congruent with planning in the traditional nursing process)
What goals do I think will 1. The client will experience improved comfort, as
serve the patient’s best evidenced by:
interest? a decrease in the rating of the pain,
the ability to rest and sleep comfortably
2. The client will be free of infection as evidenced
by normal temperature, normal vital signs.
3. The client will have improved bowel
elimination, as evidenced by:
Elimination of stool without straining
4. Client will acquire adequate knowledge
regarding the treatment and home care.
5. Client will attend to health problems promptly
What are the patient’s Patient’s goals are:
goals? Freedom from pain
Rapid healing
Adequate bowel movement
Acquiring adequate knowledge regarding his
health problems
Are the patient’s goals Yes
and professional goals
are congruent?
What are the priority Relief of pain
goals? Freedom from infection
Adequate bowel movement
Improvement knowledge aspect of health conditions
Prompt attendance to health problems
What does the patient Working with the health professionals
perceives as the best way Gaining knowledge
to achieve goals? Disclosing adequate information regarding
health problems
Is the patient willing to Yes
work towards the goals?
What do I perceive to be Goal 1:
the best way to achieve Assess the characteristics of pain
the goals? Administration of prescribed medicine
Monitor the responses to drug therapy
Provide calm, efficient manner that reassures the
client and minimizes anxiety
Provide a comfortable position as per client’s
requests.
Goal 2:
Monitor vital signs
Administer antibiotics as advised
Use aseptic techniques while changing dressing
Kept the surgical wound site clean
Report surgeon regarding early signs of infection
Goal 3:
Ensure that the client has adequate bulk in diet and
adequate fluid intake
Instruct the client on prevention of straining and
avoiding valsalva manoeuvre
Consult treating physician regarding medications.
Goal 4:
Explain the treatment measures to the patient and
their benefits in a simple understandable language.
Explain demonstrate about the home care.
Clarify the doubts of the patient as the patient may
present with some matters of importance.
Repeat the information whenever necessary to
reinforce learning.
Goal 5:
Health education given about the following.
- Restriction of heavy weight lifting (more than
20kg) for 6 months
- Further management which may be
necessary
- Diet control for his hypertension
- Rehabilitation measures to promote better
living
For regular examination of the site for recurrence
of hernia
Are the goals short-term Goals are both short-term and long term
or long term?
What modifications Pain is tolerable to the patient and requires no
required based on SOS medication
mutuality? Constipation is not that severe enough to take
medication
Other interventions are mutually acceptable.
Implementations
1. In nursing process implementation involves the actual activities to achieve
the goals.
2. This step results in transactions being made.
3. Transactions occur as a result of perceiving the other person and the
situation, making judgments about those perceptions, and taking some
actions in response.
4. Reactions to action lead to transactions that reflect a shared view and
commitment
5. This step reflects implementation in the traditional nursing process.
Am I doing what the patient and I Yes
have agreed upon?
How am I carrying out the On a mutually acceptable manner in
actions? accordance with the goals set.
When do I carry out the action? According to priority, a few interventions
require immediate attention.
Other interventions are carried out during
the period of hospitalization till 5th April.
Why am I carrying out the action? Patient’s condition demands nursing car.
Is it reasonable to think that the Yes
identified goals will be reached by
carrying out the action?
Evaluation
It involves to finding out weather goals are achieved or not.
In King’s description evaluation speaks about attainment of goal and effectiveness
of nursing care.
Are my actions helping the patient Yes
achieve mutually defined goals?
How well are goals being met? Short-term goals are met before
discharge from hospital
Long-term goals are expected to be met,
because the patient is motivated to
continue home care.
What actions are not working?
What is patient’s response to my Patient is satisfied with my actions
actions?
Are other factors hindering goal Patient’s age is a hindering factor in goal
achievement? achievement regarding health
maintenance.
How should the plan be changed to Health teaching can be modified
achieve goals? according to developmental stage.
Involvement of family member in care of
the patient.
References
• Phipps J Wilma, Sands K Judith. Medical Surgical Nursing: concepts &
clinical practice.6th edition. Philadelphia. Mosby publications. 1996.
• Black M. Joice, Hawks Hokanson Jane. Medical Surgical Nursing: Clinical
Management for positive outcomes. St Lois, Missouri. 2005.
APPLICATION OF OREM'S SELF-CARE
DEFICIT THEORY IN NURSING
PRACTICE
INTRODUCTION
• The history of professional nursing begins with Florence nightingale.

• Later in last century nursing began with a strong emphasis on practice.
• Following that came the curriculum era which addressed the questions
about what the nursing students should study in order to achieve the
required standard of nursing.
• As more and more nurses began to pursue higher degrees in nursing,
there emerged the research era.
• Later graduate education and masters education was given much
importance.
• The development of the theory era was a natural outgrowth of the
research era.
• With an increased number of researches it became obvious that the
research without theory produced isolated information; however research
and theory produced the nursing sciences.
• Within the contemporary phase there is an emphasis on theory use and
theory based nursing practice and lead to the continued development of
the theories.
OBJECTIVES
 to assess the patient condition by the various methods explained by the
nursing theory
 to identify the needs of the patient
 to demonstrate an effective communication and interaction with the
patient.
 to select a theory for the application according to the need of the patient
 to apply the theory to solve the identified problems of the patient
 to evaluate the extent to which the process was fruitful.
Areas Patient details

 Name • Mrs. X
 Age • 56 years
 Sex • Female
 Education • No formal education
 Occupation • House hold
 Marital status • Married
 Religion • Hindu
 Diagnosis • Rheumatoid arthritis
 Theory applied • Orem’s theory of self
care deficit.
OREM’S THEORY OF SELF CARE DEFICIT

• The self care deficit theory proposed by Orem is a combination of three
theories, i.e. theory of self care, theory of self care deficit and the theory
of nursing systems.
• In the theory of self care, she explains self care as the activities carried
out by the individual to maintain their own health.
• The self care agency is the acquired ability to perform the self care and
this will be affected by the basic conditioning factors such as age,
gender, health care system, family system etc.
• Therapeutic self-care demand is the totality of the self care measures
required.
• The self care is carried out to fulfill the self-care requisites.
• There are mainly 3 types of self care requisites such as universal,
developmental and health deviation self care requisites.
• Whenever there is an inadequacy of any of these self care requisite, the
person will be in need of self care or will have a deficit in self care.
• The deficit is identified by the nurse through the thorough assessment of
the patient.
• Once the need is identified, the nurse has to select required nursing
systems to provide care: wholly compensatory, partly compensatory or
supportive and educative system.
• The care will be provided according to the degree of deficit the patient is
presenting with.
• Once the care is provided, the nursing activities and the use of the nursing
systems are to be evaluated to get an idea about whether the mutually
planned goals are met or not.
• Thus the theory could be successfully applied into the nursing practice.
For Mrs. X….
1. She came to the hospital with complaints of pain over all the joints,
stiffness which is more in the morning and reduces by the activities.
2. She has these complaints since 5 years and has taken treatment from
local hospital.
3. The symptoms were not reducing and came to --MC, Hospital for further
management.
4. Patient was able to do the ADL by herself but the way she performed and
the posture she used was making her prone to develop the complications
of the disease.
5. She also was malnourished and was not having awareness about the
deficiencies and effects.
DATA COLLECTION ACCORDING TO OREM’S THEORY OF SELF CARE DEFICIT
1. BASIC CONDITIONING FACTORS
Age 56 year
Gender Female
Health state Disability due to health condition, therapeutic

self care demand
Development state Ego integrity vs despair
Sociocultural No formal education, Indian, Hindu

orientation
Health care system Institutional health care
Family system Married, husband working
Patterns of living At home with partner
Environment Rural area, items for ADL not in easy reach, no

special precautions to prevent injuries
resources Husband, daughter, sister’s son
2. UNIVERSAL SELF-CARE REQUISITES:
Air Breaths without difficulty, no pallor cyanosis
Water Fluid intake is sufficient. Edema present over

ankles.
Turgor normal for the age
Food Hb – 9.6gm%, BMI = 14.Food intake is not

adequate or the diet is not nutritious.
Elimination Voids and eliminates bowel without difficulty.
Activity/ rest Frequent rest is required due to pain.

Pain not completely relieved,
Activity level ha s come down.
Deformity of the joint secondary to the disease
process and use of the joints.
Social interaction Communicates well with neighbors and calls the
daughter by phone Need for medical care is
communicated to the daughter.
Prevention of Need instruction on care of joints and prevention of

hazards falls. Need instruction on improvement of
nutritional status. Prefer to walk bare foot.
Promotion of Has good relation with daughter

normalcy
3. DEVELOPMENTAL SELF-CARE REQUISITES:
Maintenance of Able to feed self , Difficult to perform

developmental environment the dressing, toileting etc
Prevention/management of the Feels that the problems are due to her

conditions threatening the own behaviours and discusses the
normal development problems with husband and daughter.
4. HEALTH DEVIATION SELF CARE REQUISITES
Adherence to medical Reports the problems to the physician when in

regimen the hospital. Cooperates with the medication,
Not much aware about the use and side
effects of medicines
Awareness of potential Not aware about the actual disease process.

problem associated Not compliant with the diet and prevention of
with the regimen hazards. Not aware about the side effects of
the medications
Modification of self Has adapted to limitation in mobility.

image to incorporates
changes in health
status The adoption of new ways for activities leads
to deformities and progression of the disease.
Adjustment of lifestyle Adjusted with the deformities.

to accommodate Pain tolerance not achieved
changes in the health
status and medical
regimen.
5. MEDICAL PROBLEM AND PLAN:

Physician’s perspective of the condition:
Diagnosed with rheumatoid arthritis and is on the following medications:
T. Valus SR OD
T. Pan 40 mg OD
T. Tramazac 50 mg OD
T. Recofix Forte BD
T. Shelcal BD
Syp. Heamup 2tsp TID
Medical Diagnosis: Rheumatoid arthritis
Medical Treatment: Medication and physical therapy.
AREAS AND PRIORITY ACCORDING TO OREM’S THEORY OF SELF-CARE

DEFICIT: IMPORTANT FOR PRIORITIZING THE NURSING DIAGNOSIS.
a. Air
b. Water
c. Food
d. Elimination
e. Activity/ Rest
f. Solitude/ Interaction
g. Prevention of hazards
h. Promotion of normalcy
i. Maintain a developmental environment.
j. Prevent or manage the developmental threats
k. Maintenance of health status
l. Awareness and management of the disease process.
m. Adherence to the medical regimen
n. Awareness of potential problem.
o. modify self image
p. Adjust life style to accommodate health status changes and MR
Nursing care plan according to Orem’s theory of self care deficit
Nursing Outcome and Implementation Evaluation

diagnosis plan (control (regulatory
( diagnostic (Prescriptive operations) operations )
operations ) operations)
Based on self care 1. Outcome Nurse- patient 1. Effectiveness of

deficits 2. Nursing actions to the nurse patient
goal and - Promote action to
objectives patient as -Promote patient as
3. Design of self care self care agent
nursing agent - Meet self
system - Meet self care care needs
4. Appropriate needs - Decrease the
method of - Decrease the self care
helping self care deficit.
deficit. 2. Effectiveness of
the selected
nursing system to
meet the needs.
Thus in the patient Mrs. X the areas that need assistance were…
• Air
• Water
• Food
• Elimination
• Activity/ Rest(2)
• Solitude/ Interaction
• Prevention of hazards(2)
• Promotion of normalcy
• Maintain a developmental environment.
• Prevent or manage the developmental threats
• Maintenance of health status
• Awareness and management of the disease process.
• Adherence to the medical regimen
• Awareness of potential problem.
• modify self image
• Adjust life style to accommodate health status changes and medical regimen
APPLYING THE OREM’S THEORY OF SELF-CARE DEFICIT, A NURSING CARE
PLAN FOR MRS. X COULD BE PREPARED AS FOLLOWS …
Therapeutic self care demand: deficient area: food
Adequacy of self care agency: Inadequate
NURSING DIAGNOSIS
Inability to maintain the ideal nutrition related to inadequate intake and knowledge
deficit
OUTCOMES AND PLAN
a. Outcome:
improved nutrition
Maintenance of a balanced diet with adequate iron supplementation.
b. Nursing Goals and objectives
Goal: to achieve optimal levels of nutrition.
Objectives: Mrs. X will:
- state the importance of maintaining a balanced diet.
- List the food items rich in iron , that are available in the locality.
c. Design of the nursing system:
supportive educative
d. Method of helping:
guidance
support
Teaching
Providing developmental environment
IMPLEMENTATION
Mutually planned and identified the objectives and the patient were made to
understand about the required changes in the behaviour to have the requisites met.
EVALUATION
Mrs. X understood the importance of maintaining an optimum nutrition.
She told that she will select the iron rich diet for her food.
She listed the foods that are rich in iron and that are locally available.
The self care deficit in terms of food will be decreased with the initiation of the
nutritional intake.
The supportive educative system was useful for Mrs. X
--------------------------------------------------------------------------
Therapeutic self care demand: deficient area: Activity
NURSING DIAGNOSIS
Self-care deficit: dressing, toileting related to restricted joint movement, secondary
to the inflammatory process in the joints.
OUTCOMES AND PLAN
a. Outcome:
- improved self-care
- maintain the ability to perform the toileting and dressing with modification as
required.
Goal: to achieve optimal levels of ability for self care.
-perform the dressing activities within limitations
-utilize the alternative measures available for improving the toileting
-perform the other activities of daily living with minimal assistance.
c. Design of the nursing system: Partly compensatory
d. Method of helping:
Guidance:
Assess the various hindering factors for self care and how to tackle them.
Support:
Provide all the articles needed for self care, near to the patient and ask the family
members also to give the articles near to her.
Provide passive exercises and make to perform active exercises so as to promote the
mobility of the joint.
Make the patient use commodes or stools to perform toileting and insist on
avoidance of squatting position
Provide assistance whenever needed for the self care activities
Provide encouragement and positive reinforcement for minor improvement in the
activity level.
Initiate the pain relieving measures always before the patient go for any of the
activities of daily living
Make the patient to use loose fitting clothes which will be easy to wear and remove.
Teaching:
Teach the family members the limitation in the activity level the patient has and the
cooperation required
Promoting a developmental environment:
Teach the family and help them to practice how to help the patient according to her
needs
IMPLEMENTATION
Mutually planned and identified the objectives and the patient was made to
understand about the required changes in the behaviour to have the requisites met.
EVALUATION
Patient was performing some of the activities and she practiced toileting using a
commode in the hospital.
She verbalized an improved comfort and self care ability.
She performed the dressing activities with minimal assistance
Patient verbalized that she will perform the activities as instructed to get her ADL
done.
The partly compensatory system was useful for Mrs. X
----------------------------------------------------------------------
Therapeutic self care demand: deficient area: Pain control
NURSING DIAGNOSIS
• Ineffective pain control related to lack of utilization of pain relief measures
OUTCOMES AND PLAN
a. Outcome:
• - improved pain self control
• - achieve and maintain a reduction in the pain.
Goal: to achieve reduction in the pain.
describe the total plan of pharmacological and non pharmacological pain
relief
demonstrate a reduction in the pain behaviours
verbalize a reduction in the pain scale score from 7 – 4
c. Design of the nursing system: supportive educative
d. method of helping:
Guidance:
Explore the past experience of pain and methods used to manage them.
Ask the client to report the intensity, location, severity, associated and
aggravating factors.
Support:
Provide rest to the joints and avoid excessive manipulations
provide hot and cold application to have better mobility.
Encourage exercises to the joints by immersing in the warm water.
Administer T. Ultracet and Tab Diclofecac as prescribed.
Provide diversion and psychological support to the patient
Teaching:
Teach the non – pharmacological method to the patient once the pain is a
little reduced.
Providing the developmental environment:
Discuss with the patient the necessity to maintain a pain diary with all
information regarding episodes of pain and refer to that periodically
Enquire from the health team, the need for opioid analgesics or other
analgesics and get a prescription for the patient.
IMPLEMENTATION
---------------------------------------
---------------------------------------
EVALUATION
Patient still has pain over the joints and she agreed that she will use the
measures for pain relief that is told to her.
The pain scale score was 6 after the measures were provided to the patient.
She demonstrated slight reduction in the pain behaviours.
--------------------------------------------------------------
Therapeutic self care demand: deficient area: prevention of hazards.
NURSING DIAGNOSIS
Potential for fall and fractures related to rheumatoid arthritis.
OUTCOMES AND PLAN
a. Outcome:
Absence of falls and injury to the patient
Goal: prevent the falls and injury and to maintain a good body mechanics.
objectives: Mrs. X will:
-remain free from injury as evidenced by:
-absence of signs and symptoms of fall or injury
- explaining the methods to prevent the injury.
Support
Never leave the client alone in the unit
Assess the patients gait, activities and the mental status for any confusion or
disorientation
Encourage the patient to use supportive devices as required.
Provide a safe environment in the hospital by avoiding sharp objects or
wooden objects on the way and slippery floor.
Involve the family members in providing and maintaining a safe environment
in the home
Involve the family members to provide support to the patient whenever
necessary
Plan a balanced diet for the patient with a mutual interaction
IMPLEMENTATION
---------------------------------
----------------------------------
EVALUATION
Patient remained free from injury as evidenced by absence of signs and
symptoms.
Patient explained the various measures that they will take to prevent the
injury.
------------------------------------------------------------------
Therapeutic self care demand: deficient area: prevention of hazards.
NURSING DIAGNOSIS:
Potential for impaired skin integrity related to edema secondary to renal cysts.
OUTCOMES AND PLAN:
a. Outcome:
Maintenance of normal skin integrity.
b. nursing Goals and objectives
Goal: Maintain the skin integrity and take measures to prevent skin impairment.
1. maintain a normal skin integrity
2. list the measures to prevent the loss of skin integrity
3. identify the measures to relieve edema.
Support:
Assess the skin regularly for any excoriation or loss of integrity or colour changes.
Keep the skin clean always
Avoid stress or pressure over the area of edema by providing extra cushions or
padding
Monitor the lab values as well as the patient for any signs and symptoms of renal
failure.
Encourage the patient to use slippers while walking and that should not be tight
fitting.
Assess the edema for its degree, pitting or non pitting and continue the assessment
daily.
Provide a leg end elevated position or elevation of the leg on a pillow if no cardiac
abnormalities are identified.
Explain the patient the need for taking care of the edematous parts
Explain the patient to report the symptoms like decreased urine output, palpitations,
increased edema etc. to the health team
IMPLEMENTATION
----------------------------------
----------------------------------
EVALUATION
Patient remained free from impaired skin integrity
She listed the measures to prevent the loss of skin integrity
She identified the measures to relieve edema.
The supportive educative system was useful for Mrs. x
-----------------------------------------------------------------
Therapeutic self care demand: deficient area: awareness of the disease process
and management
NURSING DIAGNOSIS
Potential for complications related to rheumatoid arthritis secondary to knowledge
deficit.
OUTCOMES AND PLAN
a. Outcome:
Absence of complications and improved awareness about the disease process.
b. nursing Goals and objectives
Goal: Improve the knowledge of the patient about the disease process and the
complications.
-verbalize the various complication and their preventions
-verbalize the changes occurring with the disease process and the treatment
available
-describe the actions and side effects of the medications which she is using
c. Design of the nursing system:
supportive educative
d. Methods of helping:
• Guidance
• Teaching
• Promoting a developmental environment
IMPLEMENTATION
-------------------------------
-------------------------------
EVALUATION
Patient got adequate information regarding the disease
She verbalized what she understood about the disease and its management.
Patient has cleared her doubts regarding the medication actions and the side
effect
EVALUATION OF THE APPLICATION OF SELF CARE DEFICIT THEORY
The theory of self-care deficit when applied could identify the self care requisites of
Mrs. X from various aspects. This was helpful to provide care in a comprehensive
manner. Patient was very cooperative. the application of this theory revealed how
well the supportive and educative and partly compensatory system could be used for
solving the problems in a patient with rheumatoid arthritis.
REFERENCES
1. Alligood M R, Tomey A M. Nursing Theory: Utilization &Application .3rd ed. Missouri:
Elsevier Mosby Publications; 2002.
2. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby,
Philadelphia, 2002
3. George JB .Nursing Theories: The Base for Professional Nursing Practice .5th ed.
New Jersey :Prentice Hall;2002.
HEALTH PROMOTION MODEL

INTRODUCTION
The health promotion model (HPM) proposed by Nola J Pender (1982; revised, 1996)
was designed to be a “complementary counterpart to models of health protection.” It
defines health as a positive dynamic state not merely the absence of disease. Health
promotion is directed at increasing a client’s level of wellbeing. The health promotion
model describes the multi dimensional nature of persons as they interact within their
environment to pursue health. The model focuses on following three areas:
Individual characteristics and experiences
Behavior-specific cognitions and affect
Behavioral outcomes
The health promotion model notes that each person has unique personal
characteristics and experiences that affect subsequent actions. The set of variables
for behavioral specific knowledge and affect have important motivational significance.
These variables can be modified through nursing actions. Health promoting behavior
is the desired behavioral outcome and is the end point in the HPM. Health promoting
behaviors should result in improved health, enhanced functional ability and better
quality of life at all stages of development. The final behavioral demand is also
influenced by the immediate competing demand and preferences, which can derail an
intended health promoting actions.
ASSUMPTIONS OF THE HEALTH PROMOTION MODEL

The HPM is based on the following assumptions, which reflect both nursing and
behavioral science perspectives:
1. Persons seek to create conditions of living through which they can express
their unique human health potential.
2. Persons have the capacity for reflective self-awareness, including
assessment of their own competencies.
3. Persons value growth in directions viewed as positive and attempts to
achieve a personally acceptable balance between change and stability.
4. Individuals seek to actively regulate their own behavior.
5. Individuals in all their biopsychosocial complexity interact with the
environment, progressively transforming the environment and being
transformed over time.
6. Health professionals constitute a part of the interpersonal environment,
which exerts influence on persons throughout their lifespan.
7. Self-initiated reconfiguration of person-environment interactive patterns is
essential to behavior change.
THEORETICAL PROPOSITIONS OF THE HEALTH PROMOTION MODEL
Theoretical statements derived from the model provide a basis for investigative work
on health behaviors. The HPM is based on the following theoretical propositions:
1. Prior behavior and inherited and acquired characteristics influence beliefs,
affect, and enactment of health-promoting behavior.
2. Persons commit to engaging in behaviors from which they anticipate
deriving personally valued benefits.
3. Perceived barriers can constrain commitment to action, a mediator of
behavior as well as actual behavior.
4. Perceived competence or self-efficacy to execute a given behavior increases
the likelihood of commitment to action and actual performance of the
behavior.
5. Greater perceived self-efficacy results in fewer perceived barriers to a
specific health behavior.
6. Positive affect toward a behavior results in greater perceived self-efficacy,
which can in turn, result in increased positive affect.
7. When positive emotions or affect are associated with a behavior, the
probability of commitment and action is increased.
8. Persons are more likely to commit to and engage in health-promoting
behaviors when significant others model the behavior, expect the behavior to
occur, and provide assistance and support to enable the behavior.
9. Families, peers, and health care providers are important sources of
interpersonal influence that can increase or decrease commitment to and
engagement in health-promoting behavior.
10. Situational influences in the external environment can increase or decrease
commitment to or participation in health-promoting behavior.
11. The greater the commitments to a specific plan of action, the more likely
health-promoting behaviors are to be maintained over time.
12. Commitment to a plan of action is less likely to result in the desired behavior
when competing demands over which persons have little control require
immediate attention. 13. Commitment to a plan of action is less likely to
result in the desired behavior when other actions are more attractive and thus
preferred over the target behavior.
13. Persons can modify cognitions, affect, and the interpersonal and physical
environment to create incentives for health actions.
THE MAJOR CONCEPTS AND DEFINITIONS OF THE HEALTH PROMOTION
MODEL
Individual Characteristics and Experience
v PRIOR RELATED BEHAVIOR
Frequency of the similar behaviour in the past. Direct and indirect effects on the
likelihood of engaging in health promoting behaviors.
v PERSONAL FACTORS
Personal factors categorized as biological, psychological and socio-cultural. These
factors are predictive of a given behavior and shaped by the nature of the target
behaviour being considered.
Personal biological factors
Include variable such as age gender body mass index pubertal status, aerobic
capacity, strength, agility, or balance.
Personal psychological factors
Include variables such as self esteem self motivation personal competence perceived
health status and definition of health.
Personal socio-cultural factors
Include variables such as race ethnicity, accuculturation, education and
socioeconomic status.
Behavioural Specific Cognition and Affect
v PERCEIVED BENEFITS OF ACTION
Anticipated positive out comes that will occur from health behaviour.
v PERCEIVED BARRIERS TO ACTION
Anticipated, imagined or real blocks and personal costs of understanding a given
behaviour
v PERCEIVED SELF EFFICACY
Judgment of personal capability to organise and execute a health-promoting
behaviour. Perceived self efficacy influences perceived barriers to action so higher
efficacy result in lowered perceptions of barriers to the performance of the behavior.
v ACTIVITY RELATED AFFECT
Subjective positive or negative feeling that occur before, during and following
behavior based on the stimulus properties of the behaviour itself. Activity-related
affect influences perceived self-efficacy, which means the more positive the
subjective feeling, the greater the feeling of efficacy. In turn, increased feelings of
efficacy can generate further positive affect.
v INTERPERSONAL INFLUENCES
Cognition concerning behaviours, beliefs, or attitudes of the others. Interpersonal
influences include: norms (expectations of significant others), social support
(instrumental and emotional encouragement) and modelling (vicarious learning
through observing others engaged in a particular behaviour). Primary sources of
interpersonal influences are families, peers, and healthcare providers.
v SITUATIONAL INFLUENCES
Personal perceptions and cognitions of any given situation or context that can
facilitate or impede behaviour. Include perceptions of options available, demand
characteristics and aesthetic features of the environment in which given health
promoting is proposed to take place. Situational influences may have direct or
indirect influences on health behaviour.
Behavioural Outcome
v COMMITMENT TO PLAN OF ACTION
The concept of intention and identification of a planned strategy leads to
implementation of health behaviour.
v IMMEDIATE COMPETING DEMANDS AND PREFERENCES
Competing demands are those alternative behaviour over which individuals have low
control because there are environmental contingencies such as work or family care
responsibilities. Competing preferences are alternative behaviour over which
individuals exert relatively high control, such as choice of ice cream or apple for a
snack
v HEALTH PROMOTING BEHAVIOUR
Endpoint or action outcome directed toward attaining positive health outcome such
as optimal well-being, personal fulfillment, and productive living.
REFERENCES
1. Marriner TA, Raile AM. Nursing theorists and their work. 5th ed. Sakraida
T.Nola J. Pender. The Health Promotion Model. St Louis: Mosby; 2005
2. Polit DF, Beck CT. Nursing research:Principles and methods. 7th ed.
Philadelphia: Lippincott Williams & Wilkins; 2007
3. Black JM, Hawks JH, Keene AM. Medical surgical nursing. 6th ed. Philadelphia:
Elsevier Mosby; 2006.
4. Potter PA, Perry AG. Fundamentals of nursing. 6th ed. St.Louis: Elsevier
Mosby; 2006.
HEALTH BELIEF MODEL (HBM)

INTRODUCTION
HBM is a popular model in nursing, especially in issues focusing on patient
compliance and preventive health care practices. the model postulates that
health-seeking behaviour is influenced by a person’s perception of a threat posed
by a health problem and the value associated with actions aimed at reducing the
threat. HBM addresses the relationship between a person’s beliefs and behaviors.
It provides a way to understanding and predicting how clients will behave in
relation to their health and how they will comply with health care therapies.
THE MAJOR CONCEPTS AND DEFINITIONS OF THE HEALTH PROMOTION
MODEL
There are six major concepts in HBM:
1. Perceived Susceptibility
2. Perceived severity
3. Perceived benefits
4. Perceived costs
5. Motivation
6. Enabling or modifying factors
1. Perceived Susceptibility: refers to a person’s perception that a health

problem is personally relevant or that a diagnosis of illness is accurate.
2. Perceived severity: even when one recognizes personal susceptibility, action

will not occur unless the individual perceives the severity to be high enough to
have serious organic or social complications.
3. Perceived benefits: refers to the patient’s belief that a given treatment will
cure the illness or help to prevent it.
4. Perceived Costs: refers to the complexity, duration, and accessibility and

accessibility of the treatment
5. Motivation: includes the desire to comply with a treatment and the belief that
people should do what
6. Modifying factors: include personality variables, patient satisfaction, and
socio-demographic factors.
REFERENCES
1. Marriner TA, Raile AM. Nursing theorists and their work. 5th ed. Sakraida
T.Nola J. Pender. The Health Promotion Model. St Louis: Mosby; 2005
2. Polit DF, Beck CT. Nursing research:Principles and methods. 7th ed.
Philadelphia: Lippincott Williams & Wilkins; 2007
3. Black JM, Hawks JH, Keene AM. Medical surgical nursing. 6th ed.
Philadelphia: Elsevier Mosby; 2006.
4. Potter PA, Perry AG. Fundamentals of nursing. 6th ed. St.Louis: Elsevier
Mosby; 2006.
5. Rosenstoch I. Historical origin of Health Belief model. Health Educ Monogr

2:334, 1974.
THEORIES USED IN COMMUNITY

HEALTH NURSING
Introduction
The concept of community is defined as "a group of people who share some
important feature of their lives and use some common agencies and institutions."
The concept of health is defined as "a balanced state of well-being resulting from
harmonious interactions of body, mind, and spirit." The term community health is
defined by meeting the needs of a community by identifying problems and managing
interactions within the community
Basic Elements
The six basic elements of nursing practice incorporated in community health

programs and services are (1) promotion of healthful living (2) prevention of health
problems (3) treatment of disorders (4) rehabilitation (5) evaluation and (6)
research.
Major Roles
The focus of nursing includes not only the individual, but also the family and the
community, meeting these multiple needs requires multiple roles. The seven major
roles of a community health nurse are (1) care provider, (2) educator, (3) advocate,
(4) manager, (5) collaborator, (6) leader, and (7) researcher.
Major Settings
Settings for community health nursing can be grouped into six categories: (1)
homes, (2) ambulatory care settings, (3) schools, (4) occupational health settings,
(5) residential institutions, and (6) the community at large. Community health
nursing practice is not limited to a specific area, but can be practiced anywhere.
Theories and Models for community health nursing
The commonly used theories are:
1. Nightingale’s theory of environment
2. Orem’s Self care model
3. Neumann’s health care system model
4. Roger’s model of the science and unitary man
5. Pender’s health promotion model
6. Roy’s adaptation model
7. Milio’s Framework of prevention
8. Salmon White’s Construct for Public health nursing
9. Block and Josten’s Ethical Theory of population focused nursing
10. Canadian Model
Milio’s Framework of prevention
Nancy Milio a nurse and leader in public health policy and public health education
developed a framework for prevention that includes concepts of community-oriented,
population focused care.(1976,1981).The basic treatise is that behavioral patterns of
populations and individuals who make up populations are a result of habitual
selection from limited choices. She challenged the common notion that a main
determinant for unhealthful behavioral choice is lack of knowledge. Governmental
and institutional policies, she said set the range of options for personal choice
making. It neglected the role of community health nursing, examining the
determinants of community health and attempting to influence those determinants
through public policy.
Salmon White’s construct for public health nursing
Mark Salmon White (1982) describes a public health as an organized societal effort
to protect, promote and restore the health of people and public health nursing as
focused on achieving and maintaining public health.
He gave 3 practice priorities i.e.; prevention of disease and poor health, protection
against disease and external agents and promotion of health. For these 3 general
categories of nursing intervention have also been put forward, they are:
11. education directed toward voluntary change in the attitude and behaviour of
the subjects
12. engineering directed at managing risk-related variables
13. enforcement directed at mandatory regulation to achieve better health.
Scope of prevention spans individual, family, community and global care.

Intervention target is in 4 categories 1.Human/Biological 2. Environmental 3.
Medical/technological/organizational 4. Social
Block and Josten’s Ethical Theory of population focused nursing
Derryl Block and Lavohn Josten, public health educators proposed this based on
intersecting fields of public health and nursing. They have given 3 essential elements
of population focused nursing that stem from these 2 fields:
1. an obligation to population
2. the primacy of prevention
3. centrality of relationship- based care
the first two are from public health and the third element from nursing. Hence it
implies to nursing that relation-based care is very important in population focused
care.
Canadian Model for community
The community health nurse works with individuals, families, groups, communities,
populations, systems and/or society, but at all times the health of the person or
community is the focus and motivation from which nursing actions flow. The
standards of practice are applied to practice in all settings where people live, work,
learn, worship and play.
The philosophical base and foundational values and beliefs that characterize
community health nursing - caring, the principles of primary health care, multiple
ways of knowing, individual/community partnerships and empowerment - are
embedded in the standards and are reflected in the development and application of
the community health nursing process.
The community health nursing process involves the traditional nursing process
components of assessment, planning, intervention and evaluation but is enhanced by
community health nurses in three dimensions: 1) individual/community participation
in each component, 2) multiple ways of knowing, each of which is necessary to
understand the complexity and diversity of nursing in the
community; knowledge and utilization of all these ways of knowing forms evidence-
based practice consistent with these standards, and 3) the inherent influence of the
broader environment on the individual/community that is the focus of care (e.g. the
community will be affected by provincial/territorial policies, its own economic status
and by the actions of its individual citizens). The standards of practice are founded
on the values and beliefs of community health nurses, and utilization of the
community health nursing process.
The model illustrates the dynamic nature of community health nursing practice,
embracing the present and projecting into the future. The values and beliefs (green
or shaded) ground practice in the present yet guide the evolution of community
health nursing practice over time. The community health nursing process provides
the vehicle through which community health nurses work with people, and supports
practice that exemplifies the standards of community health nursing. The standards
of practice revolve around both the values and beliefs and the nursing process with
the energies of community health nursing always being focused on improving the
health of people in the community and facilitating change in systems or society in
support of health. Community health nursing practice does not occur in isolation but
rather within an environmental context, such as policies within their workplace and
the legislative framework applicable to their work.
References
1. Allender J.N; Spradely B.W. Community Health Nursing Concepts and practice.
(8th edn) 2001.Lippincott,342-45.
1. Stanhope M; Lancaster J. Community Health Nursing Promoting health of

Aggregates, Families and individuals.(4th edn) 2001.Mosby,265-80.
Application of Suchman’s Stages of

illness Model
Introduction
Man is a social being. Social factors play important role in health. Social
conditions and not only promote the possibility of illness and disability, they
also enhance prospect for disease prevention and health maintenance. Health
life style and the avoidance of high-risk behaviour, advance the individual’s
potential for a longer and healthier life. The recognition of the fact that the
health of an individual is more than biological phenomena has brought in to the
forefront the significance of behavioural dimension of health.
Mr. AS, a 73 years old, Muslim, male patient admitted in ---ward of ---Hospital
with a diagnosis of prostate cancer. Data regarding psychosocial aspects of his
life and illness were collected through interview. He was cooperative and
interactive with me for most part. But later he was found to be reluctant to talk
...as he was frequently expressing his financial troubles which could not be
helped by anyone related to him.
Cancer Prostate
Prostate cancer is the fifth most common type of cancer in men and its
incidence rises with advancing years. It occurs in 1 in 10 in the men living to
the age of 70 years. Early clinical features are indistinguishable from those of
BPH and the gland may feel normal on digital examination. The PSA may be
elevated (>4 ng/ml). As the tumour grows locally it may produce bladder neck
obstruction, obstruct the ureters and rapidly lead to renal impairment. In late
disease rectal examination shows the prostate to be large, hard and irregular.
Rectal ultrasound may show the spread of the cancer and this should also be
used for directing needle or aspiration biopsy. Prostatic biopsy is important in
giving prognostic information- prognosis being poorer with poorly differentiated
tumours.
Therapy depends on staging. Early disease is treated with local radiotherapy
and more advanced disease by orchidectomy and hormone therapy with
oestrogen. It has been suggested that all men over the age of 50 years should
be screened by rectal examination, transrectal ultrasound and PSA
measurement.
General information
Name : Mr. AS
Age : 73 years
Gender : Male
Marital status : Married
Place : ---/ ----
Hosp. No. : ------
Date of admission : 1-4-08
Ward/Unit : --------
Education : No formal education
Culture & life-style
Religion : Islam, Muslim, believes in 'Durgas', and has gone
too.
Food habits : four time in a day
: Non-vegetarian once in a day
Socioeconomic condition
· Lower socioeconomic status
· Occupation
· Fisher man for 12 years
· He was a beedi worker for 10 years
· went to gulf and worked there for 4 years
· Cook for 35 years
· His son is in Gulf country, but earns only Rs.5000/month
· His residence is about 80 km away from ----,
to and fro journey costs rs.50/ person
Role in the family
· Head of the family, earning member, and father
· These role are affected due the illness “ everything is disturbed at home”
Social Support Network
· Patient has poor social support network
· There is no one to support him financially for treatment of his illness
· His daughter visited him twice in the hospital, no other person visited him
or enquired him about his illness after coming in the hospital
Patient complaints (on the first meeting)
· Pain at the genital area (on catheterization)
· Urine tube needs to be removed
· No taste for anything he eats
· No money in hand to pay the hospital bill
· No sleep at night
Identification Collection, Interpretation and

of patient observing/ analysis
needs performing
activities relating to
caring
Needs arising · “I have pain at · Patient’s main

from present genital region” complaints are pain,
illness and the · “I have problem of irritation at the site of
consequent passing urine without urinary catheter, and
response to control, that is why sleep disturbance
cope with tube is inserted”
· “I want to get this · He was a cook,
urine tube removed” working most of his life
· “Who will pay my in night time for
hospital bill of marriage parties
Rs.50,000?” · Currently, he is
· Patient complains hospitalised for cancer,
that he is not getting prostate and is
adequate sleep during receiving radiotherapy
night for the last one month
· He sleeps during
daytime
Basic physical · He is advised not · He says is a

needs to take bath till the practicing Muslim
end of radiotherapy to
avoid skin excoriation · He is taking bath
at the site means it interferes with
· He maintains his religious practices
adequate cleanliness · He is advised not to
· He visits toilet with take bath because he
assistance from his may wet the irradiation
wife area, but the cultural
issues are not
· He is catheterized addressed.
for the last 2 months
Needs related · He is a non- · His life style

to life style vegetarian related needs hindered
· But he not getting in this hospital
any non-veg food in environment
the hospital
Needs related · He does not take · As he has any

to habits tea or coffee regular habits of taking
· He does not smoke tea or coffee or drinking
or take drinks alcohol
Individual’s Patient’s Knowledge

knowledge and of Present illness
experience of Patient explains his
illness illness:
· Patient has
· “I have pain and understanding of the
urine block for the last illness as his illness is
6 months” serious.
· “My illness is · Patient underwent
serious” orchidectomy and TURP
· “I have diabetes in -------- 4 months
for the last one year” back and later referred
· “I underwent a to Manipal for further
surgery for urinary management
block and pain in ----- · Patient wants to
4 months back” know whether his illness
What the patient will get cured.
wants to know · He says he has no
about the illness? money to spend her.
“will this illness get · But his expenses are
cured” met by his daughter
“I have come here and one brother
because, doctors in
---- told me my illness
can be cured only in
Manipal”
Experience of What has been his
illness past experience
with illness?
Past Illness History
· “Earlier I went to
many local folk
doctors, they only · Patient has
made all these illness” consulted many folk
· “I have sugar doctors for minor illness
illness for the last one and never satisfied with
year” them.
· “ The doctor in · He had minor
Kundapura told me to troubles with urinary
check sugar, so I know frequency for about 4
I have sugar problem” years
· “I have not had · So he consulted
any major illness in some folk people for
my life other than some remedies
this” · But never satisfied
Family History
· No major illness
in his knowledge
Whether patient has
· Patient has
accepted his illness
accepted the illness as
· “I don’t have any some thing which he
habits, drinking, does not deserve.
smoking or taking
· He puts it on fate
even coffee since
childhood. I don’t
know why I got this
illness”
Knowledge of · He has adequate He had tried alternative

formal and information about medicines and found to
alternative formal and folk have no benefit in his
therapies medicines illness
· “I have gone to
them, but no benefits”
Knowledge at · Patient says he has · Patient has only

present and one month duration of partial knowledge of his
future course x-ray treatment illness and treatment
of action. · “nobody tells me plans
What is the what is my illness” · He is illiterate, but
treatment plan · “I’m taking nobody has explained
Does the medicines regularly” him about his treatment
person knows plans
about it
Coping with the · “What will we do?” · Patient is not
illness and its · “We have to suffer showing adaptive
outcome everything” responses
(Patient and · He has depressive
family) · He looks depressed
and tries to avoid cognitions
visitors · He has financial
· “I don’t have problems
money pay here, I
don’t know what to
do”
Analyse the · “Doctor People He is not satisfied with

individuals and come and asks how the psychological
family’s views you are? (he explains attention given to him
on sarcastically), nothing by nurse or doctor
· health team else” His wife too has the
· doctors · “They do not want same opinion
to know about my Doctor has explained
· nurses pain” about the illness to his
· “sometimes, daughter about the
nurses come asks diagnosis and prognosis
about me”
“Doctor has told
something to my
daughter”
Distinguish Patient: “they are not Patient wants to know

between the asking me anything” about his illness, and
meanings of Doctor: “he will not course of treatment, but
the patient, understand anything, doctor is preoccupied
doctor, nurse it is explained to his with the patient’s
daughter” educational status.
Nurse: “doctor has

explained everything Nursing staff is
to him, we cannot tell bothered whether they
anything to the may convey wrong
patient” message to the patient.
There is a
communication gap
exists among these
people.
Observe the What patient says has The mutual interaction

patient, doctor reason. among the treating
and nurse · Doctor has advised team and patient is
interaction him RT for 1 month, missing in this situation
so he feels there is
nothing more to talk
to the patient than
enquiring any
problems
· Nurse is largely
functionally oriented
and interact with
patient only in such
occasions
Suchman’s Stages of illness Model

Application of Suchman's Model
Conclusion
Mr. AS has been suffering form Prostate cancer for the last 1 year. But his
symptoms started about 4 years back. For about 3 years he tried folk remedies
based on the advice of other people. He approached medical advice when his
symptoms aggravated. He is currently undergoing radiotherapy for prostate
cancer and medications for diabetes and other symptoms. This case study
helps to understand the psychosocial aspects of illness development and
application illness behaviour model in nursing practice.
Reference
• Guptha MC, Mahajan B. Text book of Social Medicine, 3rd Edn. JayPee,
ND,2003
• Coe RM. Sociology of Medicine. McGraw-Hill Inc. New York, 1978.
APPLICATION OF BETTY NEUMAN'S
SYSTEMS MODEL
OBJECTIVES:
• to assess the patient condition by the various methods explained by the
nursing theory
• to identify the needs of the patient
• to demonstrate an effective communication and interaction with the
patient.
• to select a theory for the application according to the need of the patient
• to apply the theory to solve the identified problems of the patient
• to evaluate the extent to which the process was fruitful.
INTRODUCTION
SYSTEM MODEL- BETTY NEUMAN
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.
The Neuman’s system model has two major components i.e. stress and reaction
to stress. The client in the Neuman’s system model is viewed as an open system
in which repeated cycles of input, process, out put and feed back constitute a
dynamic organizational pattern. The client may be an individual, a group, a family,
a community or an aggregate. In the development towards growth and
development open system continuously become more differentiated and elaborate
or complex. As they become more complex, the internal conditions of regulation
become more complex. Exchange with the environment are reciprocal, both the
client and the environment may be affected either positively or negatively by the
other.
The system may adjust to the environment to itself. The ideal is to achieve
optimal stability. As an open system the client, the client system has propensity to
seek or maintain a balance among the various factors, both with in and out side
the system, that seek to disrupt it. Neuman seeks these forces as stressors and
views them as capable of having either positive or negative effects. Reaction to
the stressors may be possible or actual with identifiable responses and symptom.
MAJOR CONCEPTS
I. PERSON VARIABLES-
Each layer, or concentric circle, of the Neuman model is made up of the five
person variables. Ideally, each of the person variables should be considered
simultaneously and comprehensively.
1. Physiological - refers of the physicochemical structure and function of the body.
2. Psychological - refers to mental processes and emotions.
3. Sociocultural - refers to relationships; and social/cultural expectations and
activities.
4. Spiritual - refers to the influence of spiritual beliefs.
5. Developmental - refers to those processes related to development over the
lifespan.
II. CENTRAL CORE-
The basic structure, or central core, is made up of the basic survival factors that
are common to the species (Neuman, 1995, in George, 1996). These factors
include: system variables, genetic features, and the strengths and weaknesses of
the system parts. Examples of these may include: hair color, body temperature
regulation ability, functioning of body systems homeostatically, cognitive ability,
physical strength, and value systems. The person's system is an open system and
therefore is dynamic and constantly changing and evolving. 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.
III. FLEXIBLE LINES OF DEFENSE-
The flexible line of defense is the outer barrier or cushion to the normal line of
defense, the line of resistance, and the core structure. If the flexible line of
defense fails to provide adequate protection to the normal line of defense, the
lines of resistance become activated. The flexible line of defense acts as a cushion
and is described as accordion-like as it expands away from or contracts closer to
the normal line of defense. The flexible line of defense is dynamic and can be
changed/altered in a relatively short period of time.
IV. NORMAL LINE OF DEFENSE-
The normal line of defense represents system stability over time. It is considered
to be the usual level of stability in the system. The normal line of defense can
change over time in response to coping or responding to the environment. An
example is skin, which is stable and fairly constant, but can thicken into a callus
over time.
V. LINES OF RESISTANCE-
The lines of resistance protect the basic structure and become activated when
environmental stressors invade the normal line of defense. Example: activation of
the immune response after invasion of microorganisms. If the lines of resistance
are effective, the system can reconstitute and if the lines of resistance are not
effective, the resulting energy loss can result in death.
VI. RECONSTITUTION-
Reconstitution is the increase in energy that occurs in relation to the degree of
reaction to the stressor. Reconstitution begins at any point following initiation of
treatment for invasion of stressors. Reconstitution may expand the normal line of
defense beyond its previous level, stabilize the system at a lower level, or return
it to the level that existed before the illness.
VII. STRESSORS--
The Neuman Systems Model looks at the impact of stressors on health and
addresses stress and the reduction of stress (in the form of stressors). Stressors
are capable of having either a positive or negative effect on the client system. A
stressor is any environmental force which can potentially affect the stability of the
system: they may be:
• Intrapersonal - occur within person, e.g. emotions and feelings
• Interpersonal - occur between individuals, e.g. role expectations
• Extra personal - occur outside the individual, e.g. job or finance
pressures
The person has a certain degree of reaction to any given stressor at any given
time. The nature of the reaction depends in part on the strength of the lines of
resistance and defense. By means of primary, secondary and tertiary
interventions, the person (or the nurse) attempts to restore or maintain the
stability of the system.
VII. PREVENTION-
As defined by Neuman's model, prevention is the primary nursing intervention.
Prevention focuses on keeping stressors and the stress response from having a
detrimental effect on the body.
• Primary -Primary prevention occurs before the system reacts to a stressor.
On the one hand, it strengthens the person (primarily the flexible line of
defense) to enable him to better deal with stressors, and on the other
hand manipulates the environment to reduce or weaken stressors. Primary
prevention includes health promotion and maintenance of wellness.
• Secondary-Secondary prevention occurs after the system reacts to a
stressor and is provided in terms of existing systems. Secondary
prevention focuses on preventing damage to the central core by
strengthening the internal lines of resistance and/or removing the stressor.
• Tertiary -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.
NURSING METAPARADIGM
A. PERSON-
The person is a layered multidimensional being. Each layer consists of five person
variables or subsystems:
• Physical/Physiological
• Psychological
• Socio-cultural
• Developmental
• Spiritual
The layers, usually represented by concentric circle, consist of the central core,
lines of resistance, lines of normal defense, and lines of flexible defense. The basic
core structure is comprised of survival mechanisms including: organ function,
temperature control, genetic structure, response patterns, ego, and what Neuman
terms 'knowns and commonalities'. Lines of resistance and two lines of defense
protect this core. The person may in fact be an individual, a family, a group, or a
community in Neuman's model. The person, with a core of basic structures, is
seen as being in constant, dynamic interaction with the environment. Around the
basic core structures are lines of defense and resistance (shown diagrammatically
as concentric circles, with the lines of resistance nearer to the core. The person is
seen as being in a state of constant change and-as an open system-in reciprocal
interaction with the environment (i.e. affecting, and being affected by it).
B. THE 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.
• The internal environment exists within the client system.
• The external environment exists outside the client system.
• 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.
C. 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)". As the person is in a constant
interaction with the environment, the state of wellness (and by implication any
other state) is in dynamic equilibrium, rather than in any kind of steady state.
Neuman proposes a wellness-illness continuum, with the person's position on that
continuum being influenced by their interaction with the variables and the
stressors they encounter. The client system moves toward illness and death when
more energy is needed than is available. The client system moves toward wellness
when more energyis available than is needed.
D. 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 actions 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 perceptions be assessed, but so must
those of the caregiver (nurse). The role of the nurse is seen in terms of degrees of
reaction to stressors, and the use of primary, secondary and tertiary
interventions.
Neuman envisions a 3-stage nursing process:
1. Nursing Diagnosis - based of necessity in a thorough assessment, and with
consideration given to five variables in three stressor areas.
2. Nursing Goals - these must be negotiated with the patient, and take account of
patient's and nurse's perceptions of variance from wellness
3. Nursing Outcomes - considered in relation to five variables, and achieved
through primary, secondary and tertiary interventions.
NURSING PROCESS BASED ON SYSTEM MODEL
Assessment: Neuman’s first step of nursing process parallels the assessment and
nursing diagnosis of the six phase nursing process. Using system model in the
assessment phase of nursing process the nurse focuses on obtaining a
comprehensive client data base to determine the existing state of wellness and
actual or potential reaction to environmental stressors.
Nursing diagnosis- the synthesis of data with theory also provides the basis for
nursing diagnosis. The nursing diagnostic statement should reflect the entire
client condition.
Outcome identification and planning- it involves negotiation between the care
giver and the client or recipient of care. The overall goal of the care giver is to
guide the client to conserve energy and to use energy as a force to move beyond
the present.
Implementation – nursing action are based on the synthesis of a comprehensive
data base about the client and the theory that are appropriate to the client’s and
caregiver’s perception and possibilities for functional competence in the
environment. According to this step the evaluation confirms that the anticipated
or prescribed change has occurred. Immediate and long range goals are
structured in relation to the short term goals.
Evaluation – evaluation is the anticipated or prescribed change has occurred. If
it is not met the goals are reformed.
-------------------------------------------------------------------
ASSESSMENT
PATIENT PROFILE
1. Name- Mr. AM
2. Age- 66 years
3. Sex-Male
4. Marital status-married
5. Referral source- Referred from ------- Medical College, -------
STRESSORS AS PERCEIVED BY CLIENT
(Information collected from the patient and his wife)
1. Major stress area, or areas of health concern

• Patient was suffering from severe abdominal pain , nausea, vomiting,
yellowish discolorations of eye, palm, and urine, reduced appetite and
gross weight loss(8kg with in 4 months)
• Patient is been diagnosed to have Periampullary carcinoma one week back.
• Patient underwent operative procedure i.e. WHIPPLE’S PROCEDURE-
Pancreato duodenectomy on 27/3/08.
• Psychologically disturbed about his disease condition- anticipating it as a life
threatening condition. Patient is in depressive mood and does not interacting.
• Patient is disturbed by the thoughts that he became a burden to his children
with so many serious illnesses which made them to stay with him at hospital.
• Patient has pitting type of edema over the ankle region, and it is more during
the evening and will not be relieved by elevation of the affected extremities.
• He had developed BPH few months back (2008 January) and underwent
surgery TURP on January 17. Still he has mild difficulty in initiating the
stream of urine.
• Patient is a known case of Diabetes since last 28 years and for the last 4 years
he is on Inj. H.Insulin (4U-0-0). It is adding up his distress regarding his
health.
2. Life style patterns
• patient is a retired school teacher
• cares for wife and other family members
• living with his son and his family
• active in church
• participates in community group meeting i.e. local politics
• has a supportive spouse and family
• taking mixed diet
• no habits of smoking or drinking
• spends leisure time by reading news paper, watching TV, spending time with
family members and relatives
3. Have you experienced a similar problem?

• The fatigue is similar to that of previous hospitalization (after the surgery of
the BPH)
• Severity of pain was some what similar in the previous time of surgery i.e.
TURP.
• Was psychologically disturbed during the previous surgery i.e. TURP.
• What helped then- family members psychological support helped him to over
come the crisis situation
4. Anticipation of the future

• Concerns about the healthy and speedy recovery.
• Anticipation of changes in the lifestyle and food habits
• Anticipating about the demands of modified life style
• Anticipating the needs of future follow up
5. What doing to help himself?

• Talking to his friends and relatives
• Reading the religious materials i.e. reading the Bible
• Instillation of positive thoughts i.e. planning about the activities to be resume
after discharge, spending time with grand children, going to the church, return
back to the social interactions etc
• Avoiding the negative thoughts i.e. diverts the attentions from the pain or
difficulties, try to eliminate the disturbing thoughts about the disease and
surgery etc
• Trying to accept the reality etc..
6. What is expected of others?

• Family members visiting the patient and spending some time with him will
help to a great extent to relieve his tension.
• Convey a warm and accepting behaviour towards him.
• Family members will help him to meet his own personal needs as much as
possible.
• Involve the patient also in taking decisions about his own care, treatment,
follow up etc
STRESSORS AS PERCEIVED BY THE CARE GIVER.
1. Major stress areas

• Persistent fatigue
• Massive weight loss i.e.( 8 kg of body weight with in 4 months)
• History of BPH and its surgery
• Persistence of urinary symptoms (difficulty in initiating the stream of urine)
and edema of the lower extremities
• Persistent disease- chronic hypertensive since last 28 years
• Depressive ideations and negative thoughts
2. Present circumstances differing from the usual pattern of living

• Hospitalization
• acute pain ( before the surgery patient had pain because of the underlying
pathology and after the surgery pain is present at the surgical site)
• nausea and vomiting which was present before the surgery and is still
persisting after the surgery also
• anticipatory anxiety concerns the recovery and prognosis of the disease
• negative thoughts that he has become a burden to his children
• Anticipatory anxiety concerning the restrictions after the surgery and the life
style modifications which are to be followed.
3. Clients past experience with the similar situations

• Patient verbalized that the severity of pain, nausea, fatigue etc was similar to
that of patient’s previous surgery. Counter checked with the family members
that what they observed.
• Psychologically disturbed previously also before the surgery. (collected from
the patient and counter checked with the relatives)
• Client perceived that the present disease condition is much more severe than
the previous condition. He thinks it is a serious form of cancer and the
recovery is very poor. So patient is psychologically depressed.
4. Future anticipations
• Client is capable of handling the situation- will need support and
encouragement to do so.
• He has the plans to go back home and to resume the activities which he was
doing prior to the hospitalization.
• He also planned in his mind about the future follow up ie continuation of
chemotherapy
5. What client can do to help himself?

• Patient is using his own coping strategies to adjust to the situations.
• He is spending time to read religious books and also spends time in talking
with others
• He is trying to clarify his own doubts in an attempt to eliminate doubts and to
instill hope.
• He sets his major goal i.e. a healthy and speedy recovery.
6. Client's expectations of family, friends and caregivers

• he sees the health care providers as a source pf information.
• He tries to consider them as a significant members who can help to over come
the stress
• He seeks both psychological and physical support from the care givers, friends
and family members
• He sees the family members as helping hands and feels
relaxed when they are with him.
Evaluation/ summary of impressions-
There is no apparent discrepancies identified between patients perception and the
care givers perceptions.
INTRAPERSONAL FACTORS
1. Physical examination and investigations
Height- 162 cm
Weight – 42 kg
TPR- 37o C, 74 b/m, 14 breaths per min
BP- 130/78 mm of Hg
• Eye- vision is normal, on examination the appearance of eye is normal.
Conjunctiva is pale in appearance. Pupils reacting to the light.
• Ear- appearance of ears normal. No wax deposition. Pinna is normal in
appearance and hearing ability is also normal.
• Respiratory system- respiratory rate is normal, no abnormal sounds on
auscultation. Respiratory rate is 16 breaths per min.
• Cardiovascular system- heart rate is 76 per min. on auscultation no
abnormalities detected. Edema is present over the left ankle which is non
pitting in nature.
• GIT- patient has the complaints of reduced appetite, nausea; vomiting etc.
food intake is very less. Mouth- on examination is normal. Bowel sounds
are reduced. Abdomen could not be palpated because of the presence of
the surgical incision. Bowel habits are not regular after the hospitalization
• Extremities- range of motion of the extremities are normal. Edema is
present over the left ankle which is non pitting in nature. Because of
weakness and fatigue he is not able to walk with out support
• Integumentary system- extremities are mild yellowish in color. No
cyanosis. Capillary refill is normal.
• Genitor urinary system- patient has difficulty in initiating the urine stream.
No complaints of painful micturation or difficulty in passing urine.
• Self acre activities- perform some of his activities, for getting up from the bed
he needs some other person’s support. To walk also he needs a support. He do
his personal care activities with the support from the others
• Immunizations- it is been told that he has taken the immunizations at the
specific periods itself and he also had taken hepatitis immunization around 8
years back
• Sleep –. He told that sleep is reduced because of the pain and other difficulties.
Sleep is reduced after the hospitalization because of the noisy environment.
• Diet and nutrition- patient is taking mixed diet, but the food intake is less
when compared to previous food intake because of the nausea and vomiting.
Usually he takes food three times a day.
• Habits- patient does not have the habit of drinking or smoking.
• Other complaints- patient has the complaints of pain fatigue, loss of appetite,
dizziness, difficulty in urination, etc...
2. Psycho- socio cultural
• Anxious about his condition
• Depressive mood
• Patient is a retired teacher and he is Christian by religion.
• Studied up to BA
• Married and has 4 children(2sons and 2 daughters)
• Congenial home environment and good relationship with wife and children
• Is active in the social activities at his native place and also actively involves in
the religious activities too.
• Good and congenial relationship with the neighbours
• Has some good and close friend at his place and he actively interact with them.
They also very supportive to him
• Good social support system is present from the family as well
as from the neighborhood
3. Developmental factors
• Patient confidently says that he had been worked for 32 years as a teacher
and he was a very good teacher for students and was a good coworker for
the friends.
• He told that he could manage the official and house hold activities very well
• He was very active after the retirement and once he go back
also he will resume the activities
4. Spiritual belief system
• Patient is Christian by religion
• He believes in got and used to go to church and also an active member in the
religious activities.
• He has a personal Bible and he used to read it min of 2 times a day and also
whenever he is worried or tensed he used to pray or read Bible.
• He has a good social support system present which helps him
to keep his mind active.
INTERPERSONAL FACTORS
• has supportive family and friends
• good social interaction with others
• good social support system is present
• active in the agricultural works at home after the retirement
• active in the religious activities.
• Good interpersonal relationship with wife and the children
• Good social adjustment present
EXTRAPERSONAL FACTORS
• All the health care facilities are present at his place
• All communication facilities, travel and transport facilities etc are present at
his own place.
• His house at a village which is not much far from the city and the facilities are
available at the place.
• Financially they are stable and are able to meet the treatment
expenses.
Summary
• Physiological- thin body built pallor of extremities, yellowish discoloration
of the mucus membrane and sclera of eye. Nausea, vomiting, reduced
appetite, reduced urinary out put. Diagnosed to have periampullary
carcinoma.
• Psycho socio cultural factors- patient is anxious abut his condition.
Depressive mood. Not interacting much with others. Good support system
is present.
• Developmental –no developmental abnormalities. Appropriate to the age.

• Spiritual- patient’s belief system has a positive contribution to his recovery
and adjustment.
CLINICAL FEATURES
• pain abdomen since 4 days
• Discoloration of urine
• Complaints of vomiting
• Fatigue
• Reduced appetite
• on and off fever
• Yellowish discoloration of eye, palms and nails
• Complaints of weight loss
• Edema over the left leg
INVESTIGATIONS
Investigations Values
Hemoglobin(13- 6.9
19g/dl)
HCT (40-50%) 21.9
WBC (4000-11000 12200

cells/cumm)
Neutrophil (40- 77.2

75%)
Lymphocyte (25- 10.5

45%)
Monocyte (2-10%) 4.5

Eosinophil (0- 2.6
10%)
Basophil (0-2%) .2
Platelet (150000- 345000

400000
cells/cumm)
ESR (0-10mm/hr) 86
RBS (60-150 148

mg/dl)
Pus C/S _
USG USG shows mild

diffuse cell
growth at the
Ampulla of Vater
which suggests
peri ampullary
carcinoma of
Grade I with out
metastasis and
gross spread.
Urea (8-35mg/dl) 28
Creatinine (0.6-1.6 1.8

mg/dl)
Sodium (130-143 136

mEq/L)
Potassium (3.5-5 4
mEq/L)
PT (patient)(11.4- 12.3
15.6 sec)
APTT- patient (24- 26.4

32.4 sec)
Blood group A+
HIV Negative
HCV Negative
HBsAg Negative
Urine Protein Negative

(negative)
Urine WBC (0-5 Nil

cells/hpf)
RBC (nil ) Nil
Epithelial cell(0-5) 4-5
Cast – granular cast Nil

(absent)
THERAPEUTIC MANAGEMENT
Initial Treatment: Post operative period

(immediate post op)
Patient got admitted to ----
Medical college for 3 days • Inj Pethedine
and the symptoms not 1mg SOS
relieved. So they asked for
discharge and came to --- • Inj Phenargan
this hospital SOS
There treated with • Inj Pantodac
• Inj Tramazac IV 40 mg IV OD
SOS • Inj Clexane 0.3
• IV fluids – DNS ml S/C OD
Treatment at this hospital... • Inj Vorth P 40
Pre operative period mg IM Q12H
• Tab Clovipas 75 • Inj calcium
mg 0-1-0 Gluconate 10
• Tab Monotrate 1- ml over 10 min
0-1 • IV fluids – DNS
• Tab Metalor XL 1- Late post op period
0-0 after 3 days of
surgery)
• Inj H Insulin S/C
• Inj H Insulin S/C
6-0-6U
6-0-6U
• Inj Tramazac 50
• Tab Pantodac 40
mg IV Q8H
mg 1-0-0
• Inj Emset 4 mg
• Cap beneficiale
Q8H
• Tab Pantodac 40 0-1-0
mg 1-0-0 • Tab Clovipas 75
• Cap beneficiale 0- mg 0-1-0
1-0 • Tab Monotrate 1-
• Syp Aristozyme 0-1
1-1-1 • Tab Metalor XL 1-
• K bind I sachet 0-0
TID Other instructions
Surgical management • Incentive
Patient underwent Whipple’s spirometry
procedure (pancreato
duodenectomy) • Steam inhalation
• Early ambulation
• Diabetic diet
NURSING PROCESS
I. NURSING DIAGNOSIS
Acute pain related to the presence of surgical wound on abdomen secondary to
periampullary carcinoma
Desired Outcome/goal : Patient will get relief from pain as evidenced by a reduction
in the pain scale score and verbalization
Nursing action
Primary Secondary prevention Tertiary prevention

prevention
• Assess • Teach the patient • Educate the

severity about the client about
of pain relaxation the
by using techniques and importance
a pain make him to do it of
scale • Encourage the cleanliness
• Check the patient to divert and
surgical his mind from pain encourage
site for any
and to engage in him to
signs of maintain
infection or pleasurable
complicatio activities like good
ns taking with others personal
• Support
hygiene.
• Do not allow the
the areas
patient to do • Involve the
with extra family
pillow to strainous
activities. And members in
allow the
normal explain to the the care of
alignment patient why those patient
and to
activities are • Encourage
prevent
strain contraindicated. relatives to
• Handle the • Involve the patient be with the
area in making client in
gently. decisions about order
Avoid
his own care and provide a
unnecessar psychologic
y handling provide a positive
psychological al well
as this will
affect the support being to
healing • Provide the patient .
process primary • Educate the
• Clean the preventive care
area
family
when ever members
around the
incision
necessary. about the
and do pain
surgical managemen
dressing at
the site of
t measures.
incision to • Provide the
prevent primary and
any form of
infections
secondary
preventive
• Provide
measures to
non-
pharmacolo the client
gical whenever
measures necessary.
for pain
relief such
as
diversional
activity
which
diverts the
patients
mind.
• Administer
the pain
medication
s as per
the
prescriptio
n by the
pain clinics
to relieve
the
severity of
pain.
• Keep the
patients
body clean
in order to
avoid
infection.
Evaluation – patient verbalized that the pain got reduced and the pain scale score
also was zero. His facial expression also reveals that he got relief from pain.
II. NURSING DIAGNOSIS
Activity intolerance related to fatigue secondary to pain at the surgery site, and dietary
restrictions
Outcome/ goals: Client will develop appropriate levels of activity free from excess
fatigue, as evidenced by normal vital signs & verbalized understanding of the
benefits of gradual increase in activity & exercise.
Nursing actions
Primary Secondary Tertiary prevention

prevention prevention
• Adequately • Instruct the • Encourage the

oxygenate client to client to do the
the client avoid the mobility
• Instruct activities exercises
the client which • Tell the family
to avoid causes members to
the extreme provide nutritious
activities fatigue. diet in a frequent
which • Advice the intervals
causes client to • Teach the patient
extreme perform and the family
fatigue exercises to about the
• Provide the strengthen importance of
necessary the psychological
articles extremities& well being in
near the promote recovery.
patients activities
• Provide the
bed side. • Tell the primary and
• Assist the client to secondary level
patient in avoid the care if necessary.
early activities
ambulation such as
straining at
• Monitor stool etc
client’s
response • Teach the
to the client about
activities in the
order to importance
reduce of early
discomfort ambulation
s. and assist
the patient
• Provide in early
nutritious ambulation
diet to the • Teach the
client. mobility
• Avoid exercises
psychologic appropriate
al distress for the
to the patient to
client. Tell improve the
the family circulation
members
to be with
him.
• Schedule
rest
periods
because it
helps to
alleviate
fatigue
Evaluation – patient verbalized that his activity level improved. He is able to do
some of his activities with assistance. Fatigue relieved and patient looks much
more active and interactive.
NURSING DIAGNOSIS-III
Impaired physical mobility related to presence of dressing, pain at the site of surgical
incision
Outcomes/goals: Patient will have improved physical mobility as evidenced by
walking with minimum support and doing the activities in limit.
Nursing action
Primary prevention Secondary prevention Tertiary prevention
• Provide active • Provide positive • Educate and

and passive reinforcement for reeducate the
exercises to even a small client and family
all the improvement to about the
extremities to increase the patients care
improve the frequency of the and recovery
muscle tone desired activity. • Support the
and strength. • Teach the patient, and
• Make the mobility exercises family towards
patient to appropriate for the attainment
perform the the patient to of the goals
breathing improve the • Coordinate the
exercises circulation and to
care activities
which will prevent
with the family
strengthen the contractures
members and
respiratory • Mobilize the other disciplines
muscle.
patient and like
• Massage the encourage him to physiotherapy.
upper and do so whenever • Teach the
lower possible
importance of
extremities • Motivate the psychological
which help to
client to involve well being which
improve the
in his own care influence
circulation.
activities indirectly the
• Provide physical
• Provide primary
articles near recovery
preventive
to the patient • Provide primary
measures
and encourage
whenever preventive
doing
necessary measures
activities
whenever
within limits
necessary
which promote
a feeling of
well being.
Evaluation – patient’s physical activity improved and he is able to move from bed
with support. Patient started doing the active and passive exercises and he
verbalized improvement.
-----------------------------------------------------------
Conclusion
The Neuman’s system model when applied in nursing practice helped in identifying
the interpersonal, intrapersonal and extra personal stressors of Mr. AM from various
aspects. This was helpful to provide care in a comprehensive manner. The application
of this theory revealed how well the primary, secondary and tertiary prevention
interventions could be used for solving the problems in the client.
References
1. Alligood M R, Tomey A M. Nursing Theory: Utilization &Application .3rd ed.
Missouri: Elsevier Mosby Publications; 2002.
Philadelphia, 2002
3. George JB .Nursing Theories: The Base for Professional Nursing Practice,5th ed.
New Jersey :Prentice Hall;2002.
APPLICATION OF ROY’S ADAPTATION
MODEL IN NURSING PRACTICE
Outline
• Introduction
• Assumptions of Roy's Adaptation Model
• Roy's Adaptation Model (RAM) –Terms
• Nursing Process
• First Level Assessment
• Second Level Assessment
• Nursing Care Plan
• Conclusion
• Reference
INTRODUCTION
 Born at Los Angeles on October 14, 1939 as the 2nd child of Mr. and Mrs.
Fabien Roy
 At age 14 she began working at a large general hospital, first as a pantry girl,
then as a maid, and finally as a nurse's aid.
 She entered the Sisters of Saint Joseph of Carondelet.
 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 & PhD in Sociology in 1973 & 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.
Sister Callista Roy (1984), Introduction to Nursing: An Adaptation Model (2nd ed)
ASSUMPTIONS OF ROY’S ADAPTATION MODEL
Scientific
 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
 Humans by their 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 relationships
 Persons and environment transformations are crated in human consciousness
 Integration of human and environment meanings results in adaptation
Philosophical
 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
PERSONS AND RELATING PERSONS
 An adaptive system with coping processes

 Described as a whole comprised of parts
 Functions as a unity for some purpose
 Includes people as individuals or in groups (families, organizations,
communities, nations, and society as a whole)
 An adaptive system with cognator and regulator subsystems acting to
maintain adaptation in the four adaptive modes: physiologic-physical, self-
concept-group identity, role function, and interdependence
ENVIRONMENT
 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
 Three kinds of stimuli: focal, contextual, and residual
 Significant stimuli in all human adaptation include stage of development,
family, and culture
HEALTH AND ADAPTATION
 Health: a state and process of being and becoming integrated and whole that
reflects person and environmental mutuality
 Adaptation: the process and outcome whereby thinking and feeling persons,
as individuals and in groups, use conscious awareness and choice to create
human and environmental integration
 Adaptive Responses: responses that promotes integrity in terms of the goals
of the human system, that is, survival, growth, reproduction, mastery, and
personal and environmental transformation
 Ineffective Responses: responses that do not contribute to integrity in terms
of the goals of the human system
 Adaptation levels represent the condition of the life processes described on
three different levels: integrated, compensatory, and compromised
NURSING
• Nursing is the science and practice that expands adaptive abilities and
enhances person and environment transformation
• Nursing goals are to promote adaptation for individuals and groups in the
four adaptive modes, thus contributing to health, quality of life, and dying
with dignity
• This is done by assessing behavior and factors that influence adaptive
abilities and by intervening to expand those abilities and to enhance
environmental interactions
ROY ADAPTATION MODEL (RAM) –TERMS
System-a set of parts connected to function as a whole for some purpose.
Stimulus-something that provokes a response, point of interaction for the human

system and the environment
• Focal Stimuli-internal or external stimulus immediately affecting the system

• Contextual Stimulus-all other stimulus present in the situation.
• Residual Stimulus-environmental factor, that effects on the situation that
are unclear.
Regulator Subsystem-automatic response to stimulus (neural, chemical, and

endocrine)
Cognator Subsystem-responds through four cognitive responds through four

cognitive-emotive channels (perceptual and information processing, learning,
judgment, and emotion)
Behavior -internal or external actions and reactions under specific circumstances
Physiologic-Physical Mode
• Behavior pertaining to the physical aspect of the human system

• Physical and chemical processes
• Nurse must be knowledgeable about normal processes
• 5 needs (Oxygenation, Nutrition, Elimination, Activity & Rest, and Protection)
Self Concept-Group Identity Mode
The composite of beliefs and feelings held about oneself at a given time. Focus on
the psychological and spiritual aspects of the human system. Need to know who one
is, so that one can exist with a state of unity, meaning, and purposefulness of 2
modes (physical self, and personal self)
Role function Mode
Set of expectations about how a person occupying one position behaves toward a
occupying another position. Basic need-social integrity, the need to know who one is
in relation to others
Interdependence Mode
Behavior pertaining to interdependent relationships of individuals and groups. Focus

on the close relationships of people and their purpose. Each relationship exists for
some reason. Involves the willingness and ability to give to others and accept from
others. Balance results in feelings of being valued and supported by others. Basic
need - feeling of security in relationships
 Adaptive Responses-promote the integrity of the human system.

 Ineffective Responses-neither promote not contribute to the integrity of
the human system
 Copping Process-innate or acquired ways innate or of interacting with the
changing of environment
NURSING PROCESS
1. A problem solving approach for gathering data, identifying the capacities and
needs of the human adaptive system, selecting and implementing
approaches for nursing care, and evaluation the outcome of care provided
• Assessment of Behavior: the first step of the nursing process which

involves gathering data about the behavior of the person as an adaptive
system in each of the adaptive modes
• Assessment of Stimuli: the second step of the nursing process which
involves the identification of internal and external stimuli that are influencing
the person’s adaptive behaviors. Stimuli are classified as: 1) Focal- those
most immediately confronting the person; 2) Contextual-all other stimuli
present that are affecting the situation and 3) Residual- those stimuli whose
effect on the situation are unclear.
• Nursing Diagnosis: step three of the nursing process which involves the
formulation of statements that interpret data about the adaptation status of
the person, including the behavior and most relevant stimuli
• Goal Setting: the forth step of the nursing process which involves the
establishment of clear statements of the behavioral outcomes for nursing
care.
• Intervention: the fifth step of the nursing process which involves the
determination of how best to assist the person in attaining the established
goals
• Evaluation: the sixth and final step of the nursing process which involves
judging the effectiveness of the nursing intervention in relation to the
behavior after the nursing intervention in comparison with the goal
established.
DEMOGRAPHIC DATA
• Name • Mr. NR
• Age
• 53 years
• Sex
• Male
• IP number
• -----
• Education
• Degree
• Occupation
• Bank clerk
• Marital status
• Married
• Religion
• Informants • Hindu
• Date of • Patient and Wife

admission • 21/01/08
FIRST LEVEL ASSESSMENT
PHYSIOLOGIC-PHYSICAL MODE
Oxygenation:
Stable process of ventilation and stable process of gas exchange. RR= 18Bpm.
Chest normal in shape. Chest expansion normal on either side. Apex beat felt on left
5th inter-costal space mid-clavicular line. Air entry equal bilaterally. No ronchi or
crepitus. NVBS. S1& S2 heard. No abnormal heart sounds. Delayed capillary refill+.
JVP0. Apex beat felt- normal rhythm, depth and rate. Dorsalis pedis pulsation of
affected limp is not palpable. All other pulsations are normal in rate, depth, tension
with regular rhythm. Cardiac dull ness heard over 3rd ICS near to sternum to left 5ht
ICS mid clavicular line. S1& S2 heard. No abnormal heart sounds. BP- Normotensive.
. Peripheral pulses felt-Normal rate and rhythm, no clubbing or cyanosis.
Nutrition
He is on diabetic diet (1500kcal). Non vegetarian. Recently his Weight reduced

markedly (10 kg/ 6 month). He has stable digestive process. He has complaints of
anorexia and not taking adequate food. No abdominal distension. Soft on palpation.
No tenderness. No visible peristaltic movements. Bowel sounds heard. Percussion
revealed dullness over hepatic area. Oral mucosa is normal. No difficulty to swallow
food
Elimination:
No signs of infections, no pain during micturation or defecation. Normal bladder

pattern. Using urinal for micturation. . Stool is hard and he complaints of
constipation.
Activity and rest:
Taking adequate rest. Sleep pattern disturbed at night due unfamiliar surrounding.
Not following any peculiar relaxation measure. Like movies and reading. No regular
pattern of exercise. Walking from home to office during morning and evening. Now,
activity reduced due to amputated wound. Mobility impaired. Walking with crutches.
Pain from joints present. No paralysis. ROM is limited in the left leg due to wound.
No contractures present. No swelling over the joints. Patient need assistance for
doing the activities.
Protection:
Left lower fore foot is amputated. Black discoloration present over the area. No
redness, discharge or other signs of infection. Nomothermic. Wound healing better
now. Walking with the use of left leg is not possible. Using crutches. Pain form knee
and hip joint present while walking. Dorsalis pedis pulsation, not present over the
left leg. Right leg is normal in length and size. Several papules present over the foot.
All peripheral pulses are present with normal rate, rhythm and depth over right leg.
Senses:
No pain sensation from the wound site. Relatively, reduced touch and pain sensation
in the lower periphery; because of neuropathy. Using spectacle for reading.
Gustatory, olfaction, and auditory senses are normal.
Fluids and electrolytes:
Drinks approximately 2000ml of water. Stable intake out put ratio. Serum electrolyte
values are with in normal limit. No signs of acidosis or alkalosis. Blood glucose
elevated
Neurological function:
He is conscious and oriented. He is anxious about the disease condition. Like to go

home as early as possible. Showing signs of stress. Touch and pain sensation
decreased in lower extremity. Thinking and memory is intact.
Endocrine function
He is on insulin. No signs and symptoms of endocrine disorders, except elevated

blood sugar value. No enlarged glands.
SELF CONCEPT MODE
Physical self:
He is anxious about changes in body image, but accepting treatment and coping
with the situation. He deprived of sexual activity after amputation.
Belongs to a Nuclear family. 5 members. Stays along with wife and three children.
Good relationship with the neighbours. Good interaction with the friends. Moderately
active in local social activities
Personal self:
Self esteem disturbed because of financial burden and hospitalization. He believes in

god and worshiping Hindu culture.
ROLE PERFORMANCE MODE:
He was the earning member in the family. His role shift is not compensated. His son
doesn’t have any work. His role clarity is not achieved.
INTERDEPENDENCE MODE:
He has good relationship with the neighbours. Good interaction with the friends
relatives. But he believes, no one is capable of helping him at this moment. He
says ”all are under financial constrains”. He was moderately active in local social
activities
SECOND LEVEL ASSESSMENT
FOCAL STIMULUS:
Non-healing wound after amputation of great and second toe of left leg- 4 week. A
wound first found on the junction between first and second toe-4 month back. The
wound was non-healing and gradually increased in size with pus collected over the
area.
He first showed in a local (---) hospital. From there, they referred to ---- medical
college; where he was admitted for 1 month and 4 days. During hospital stay great
and second toe amputated. But surgical wound turned to non- healing with pus and
black colour. So the physician suggested for below knee amputation. That made
them to come to ---Hospital, ---. He underwent a plastic surgery 3 week before.
CONTEXTUAL STIMULI:
Known case DM for past 10 years. Was on oral hypoglycemic agent for initial 2
years, but switched to insulin and using it for 8 years now. Not wearing foot wear in
house and premises.
RESIDUAL STIMULI:
He had TB attack 10 year back, and took complete course of treatment. Previously,
he admitted in ---Hospital for leg pain about 4 year back. . Mother’s brother had DM.
Mother had history of PTB. He is a graduate in humanities, no special knowledge on
health matters.
CONCLUSION
Mr.NR who was suffering with diabetes mellitus for past 10 years. Diabetic foot ulcer
and recent amputation made his life more stressful. Nursing care of this patient
based on Roy's adaptation model provided had a dramatic change in his condition.
Wound started healing and he planned to discharge on 25th april. He studied how to
use crutches and mobilized at least twice in a day. Patient’s anxiety reduced to a
great extends by proper explanation and reassurance. He gained good knowledge
on various aspect of diabetic foot ulcer for the future self care activities.
NURSING CARE PLAN
ASSESS.
ASSESSMEN
OF NURSING INTERVENTIO EVALUATIO
T OF GOAL
BEHAVIO DIAGNOSIS N N
STIMULI
UR
Ineffeciti Focal 1. Long-term § Maintain the Short term

ve stimuli: Impaired objective: wound area goal:
protectio Non-healing skin 1. amputated clean as Met: size of
n and wound after integrity area will be contamination wound
sense in amputation of related to completely affects the decreased to
physical- great and fragility of healed by healing less than 1x1
physiolog second toe of the skin 20/5/08 process. cms.
ical mode left leg- 4 secondary § Follow
to vascular 2.Skin will WBC values
week remain sterile became
insufficienc technique while
(No pain y intact with no providing cares normal on
sensation ongoing 24/4/08
from the to prevent
ulcerations. infection and
wound
site.) Short-Term delay in Long term
Objective: healing. goal:
i. Size of § Perform Partially
wound wound dressing Met: skin
decreases to with betadine partially
1x1 cm which promote intact with no
within healing and ulcerations.
24/4/08. growth of new
Continue plan
tissue.
ii. No Reassess goal
signs of § Do not and
infection overmove the interventions
the wound affected area
Unmet: not
within 1-wk frequently as it
achieved
affects the
iii. Normal complete
granulation
WBC values healing of
tissue
within 1-wk amputated
formation.
iv. Presence area.
§ Monitor for Continue plan
of healthy
signs and Reassess goal
granular symptoms of and
tissues in the infection or interventions
wound site delay in
within 1-wk healing.
§ Administer
the antibiotics
and vitamin C
supplementatio
n which will
promote the
healing
process.
Impaired Focal 2. Long term § Assess the Short term
activity stimuli: Impaired Objective: level of goal:
in During physical Patient will restriction of Met: used
physical- hospital stay mobility attain movement crutches
physiolog great and related to maximum § Provide correctly on
ical mode second toe amputation possible active and 22/4/08.
amputated. of the left physical passive he is self
But surgical forefoot mobility with exercises to all motivated in
wound turned and in 6 months. the extremities doing minor
to non- presence of to improve the
Short term excesses
healing with unhealed objective: muscle tone
pus and black wound and strength. Partially
colour. i. Met: walking
Correct use § Make the with
of crutches patient to minimum
with in perform the support.
22/4/08 ROM exercises
to lower
ii. walking extremities Long term
with which will goal:
minimum strengthen the
support- Unmet: not
muscle.
22/4/08 attained
§ Massage the maximum
iii. He will upper and possible
be self lower physical
motivated in extremities mobility-
activities- which help to Continue plan
20/4/08. improve the Reassess goal
circulation. and
§ Provide interventions
articles near to
the patient and
encourage
performing
activities within
limits which
promote a
feeling of well
being.
§ Provide
positive
reinforcement
for even a small
improvement to
increase the
frequency of
the desired
activity.
§ Measures
for pain relief
should be taken
before the
activities are
initiated as pain
can hinder with
the activity.
Alteration Contextual 3. Long term § Allow and Short term
in stimuli: Anxiety Objective: encourage the goal:
Physical Known case related to The client will client and Met:
self in DM for past hospital remain free family to ask demonstrated
Self- 10 years and admission from anxiety questions. appropriate
concept on treatment and Bring up range
mode with insulin unknown common effective
for 8 years. Outcome of Short term concerns. coping with
the disease objective: § Allow the treatment
(He is and
anxious i. client and He is able to
Residual financial family to
about demonstratin rest quietly.
stimuli: no constrains. g appropriate verbalize
changes in special
body range anxiety.
knowledge in effective Long term
image) health § Stress that
coping in the frequent goal:
matters treatment assessment are Unmet:
Change in ii. Being routine and do client not
Role able to rest not necessarily completely
performa and imply a remained free
nce deteriorating from anxiety
mode. (He iii. Asking
condition. due to
was the fewer
questions § Repeat financial
earning constrains-
member in information as
necessary Continue plan
the family. Reassess goal
His role because of the
reduced and
shift is not interventions
compensat attention span
e) of the client
and family
§ Provide
comfortable
quiet
environment for
the client and
family
Contextual 4. deficient Long term § Explain the Short term
stimuli: knowledge Objective: treatment goal:
Known case regarding Patient will measures to Met:
DM for past the foot acquire the patient and Verbalization
10 years and care, adequate their benefits in and
on treatment wound knowledge a simple demonstratio
with insulin care, regarding the understandable n of foot
for 8 years. diabetic t foot care, language. care.
------ diet, and wound care, § Explain
need of Strictly
diabetic diet, about the home following
Residual follow up and need of care. Include
stimuli: no care. diabetic diet
follow up the points like plan
special care and care of wounds,
knowledge in practice in nutrition,
health their day to activity etc. Unmet:
matters day life. Demonstratio
§ Clear the
Short term doubts of the n of wound
objective: patient as the care.
i. patient may
Verbalization present with Long term
and some matters
goal:
demonstratio of importance.
Unmet: not
n of foot § Repeat the
completely
care. information
acquired and
ii. Strictly whenever practiced the
following necessary to
required
diabetic diet reinforce knowledge.
plan learning.
Continue plan
iii. Reassess goal
Demonstratio and
n of wound interventions
care.
REFERENCE
1) Marriner TA, Raile AM. Nursing theorists and their work. 5th ed. St Louis: Mosby;
2005
2) George BJ, Nursing Theories- The Base for Nursing Practice.3rd ed. Chapter 8. Lobo
ML. Behavioral System Model. St Louis: Mosby; 2005
3) Alligood MR “Nursing Theory Utilization and Application” 5th ed. St Louis: Mosby;
2005
4) Black JM, Hawks JH, Keene AM. Medical surgical nursing. 6th ed. Philadelphia:
Elsevier Mosby; 2006.
5) Brunner LS, Suddharth DS. Text book of Medical Surgical Nursing. 6 th ed. London:
Mosby; 2002
6) Boon NA, Colledge NR, Walker BR, Hunter JAA. Davidson’s principle and practices of
medicine. 20th ed. London: Churchill Livingstone Elsevier; 2006.
APPLICATION OF INTERPERSONAL
THEORY IN NURSING PRACTICE
Outline
• Introduction
• The four phases of nurse-patient relationships are
• Overlapping phases in nurse- patient relationship
• Peplau’s theory and nursing process
• Peplau’s theory application nursing process
• Summary
• Evaluation of the theory of application
• References:
Introduction
Peplau’s theory focuses on the interpersonal processes and therapeutic relationship

that develops between the nurse and client. The interpersonal focus of Peplau’s
theory requires that the nurse attend to the interpersonal processes that occur
between the nurse and client. Interpersonal process is maturing force for personality.
Interpersonal processes include the nurse- client relationship, communication,
pattern integration and the roles of the nurse. Psychodynamic nursing is being able
to understand one’s own behavior to help others identify felt difficulties and to apply
principles of human relations to the problems that arise at all levels of experience.
This theory stressed the importance of nurses’ ability to understand own behavior to
help others identify perceived difficulties.
The four phases of nurse-patient relationships are:
1. Orientation:
During this phase, the individual has a felt need and seeks professional
assistance. The nurse helps the individual to recognize and understand his/
her problem and determine the need for help.
2. Identification
The patient identifies with those who can help him/ her. The nurse permits
exploration of feelings to aid the patient in undergoing illness as an
experience that reorients feelings and strengthens positive forces in the
personality and provides needed satisfaction.
3. Exploitation
During this phase, the patient attempts to derive full value from what he/ she
are offered through the relationship. The nurse can project new goals to be
achieved through personal effort and power shifts from the nurse to the
patient as the patient delays gratification to achieve the newly formed goals.
4. Resolution
The patient gradually puts aside old goals and adopts new goals. This is a
process in which the patient frees himself from identification with the nurse.
Overlapping phases in nurse- patient relationship
Peplau’s theory and nursing process:
Peplau defines Nursing Process as a deliberate intellectual activity that guides the
professional practice of nursing in providing care in an orderly, systematic manner.
Peplau explains 4 phases such as:
• Orientation: Nurse and patient come together as strangers; meeting

initiated by patient who expresses a “felt need”; work together to recognize,
clarify and define facts related to need.
• Identification: Patient participates in goal setting; has feeling of

belonging and selectively responds to those who can meet his or her
needs.
• Exploitation: Patient actively seeks and draws knowledge and expertise
of those who can help.
• Resolution: Occurs after other phases are completed successfully. This
leads to termination of the relationship.
In Nursing Process, the orientation phase parallels with assessment phase where
both the patient and nurse are strangers; meeting initiated by patient who expresses
a felt need. Conjointly, the nurse and patient work together, clarifies and gathers
important information. Based on this assessment the nursing diagnoses are
formulated, outcome and goal set. The interventions are planned, carried out and
evaluation done based on mutually established expected behaviours.
Peplau’s theory application nursing process:

The nursing process for Mrs. JL based on Peplau’s theory is as follows:
Mrs. JL
27 years
Diagnosis: Inter vertebral disc prolapse
Assessment Nursing Planning Implementation Evaluation
(Orientatio diagnosis (Identification (Exploitation (Resolution phase)
n phase) phase) phase)
Mrs. JL is Impaired Goal setting Carried out plans Mrs. JL was free to
on pelvic physical was done along mutually agreed express problems
traction and mobility with patient upon. regarding difficulty in
she is related to mobilizing.
restricted the
to bed. presence
of pelvic
traction.
Patient will
The need have improved
for bed rest physical
and mobility as She expressed
restriction evidenced by satisfaction when able
Provided active
was participating in to move without
and passive
discussed. self care within difficulty.
exercises to all
the limits. the extremities
Provide active
and passive
exercises to all
Made the patient
the extremities
to perform
to improve the
breathing
muscle tone
exercises
and strength.
Make the
patient to
perform the
breathing
exercises which Massaged the
will strengthen upper and lower
the respiratory extremities
muscle.
Provided article
Massage the within the reach
upper and of the patient
lower
extremities
which help to
improve the
circulation. Provided positive
reinforcement to
Provide articles the patient
near to the
patient and
encourage
doing activities
within limits.
Provide positive
reinforcement
for even a small
improvement to
increase the
frequency of
the desired
activity.
Assessmen Nursing Planning Implementation Evaluation

t diagnosis (Identification (Exploitation (Resolution phase)
(Orientatio phase) phase)
n phase)
Mrs. JL Pain related to Goal setting was Carried out plans Mrs. JL was free to
expresses the done along with mutually agreed express problems of
pain in the degenerative patient upon. pain.
low back changes in the
region. lumbar region. Mrs. JL will have
reduction in pain
as evidenced by
her verbalisation
of reduction in
pain responses.
Provide non-
Regarding pharmacological
Provided non Expressed that she
pain, measures for
pharmacological got slight relief from
discussion pain relief such
measures like pain.
was made as diversional
diversion,
to assess activity which
massaging, and
the severity diverts the
pelvic traction.
and the patients mind.
type and
duration of Give the client a
pain. Also neutral position
Provided supine
the
position to the
measures Always use back
client
to reduce support while
pain were turning the
discussed. patient that Supported the
reduces the strainback during
on the back. position change
Support the areas

with extra pillow
to allow the Used pillows to
normal alignment support the back.
and to prevent
strain.
Administer Administered Tab.

analgesics as Hifenac P and
prescribed by the Cap. Myoril 4mg
physician. as prescribed.
Given pelvic
traction and
Provide pelvic explained the
traction to the need for traction
patient
Mrs. JL Self care Goal setting Carried out plans Mrs. JL was free to
expresses deficit was done along mutually agreed express problems of
that she related to with patient upon. self care.
need the
assistance presence
to get down of pelvic
from bed. traction. Client will She used to call for
achieve and the needs and all her
maintain self needs were met
care activities appropriately
Regarding with assistance
self care of caregiver or
discussion within her
was done limits. She achieved and
and maintained self care
discussed activities within her
regarding limits
the Kept the articles
Keep all the
measures within t he reach
articles within
to solve the of the client
the reach of the
problems. patient.
Provide a call
bell to the
patient to call
in any
emergency
Frequently visited
the patient and
enquired for any
Frequently visitneeds
the patient and
enquire for any
needs.
Assisted the
client in doing her
self care activities
Assist the
patient in doing
her self care
activities. Removed the
weight as and
when needed.
Remove the
weight of the
traction as
needed by the
patient.

Mrs. JL is Anxiety Goal setting was Carried out plans Mrs. JL was free to
enquiring related to done along with mutually agreed express problems of
about the hospital patient upon. self care.
disease admission as
condition, evidenced by
its outcome verbalisation
and need and client & Client will have She asked her doubts
for surgery family reduced feeling regarding the illness
appearing of anxiety as and the diagnostic
withdrawn evidenced by procedures
Discussed asking fewer

with the questions
client She verbalized that
regarding
the disease Taught the family her anxiety has
regarding the reduced to some
process and
Teach the family disease process extent.
the findings
and client in simple
in the client
regarding the Kannada
disease process.
Explain in simple
understandable
language of the
client.
Allowed the client
and family
Allow and members to ask
encourage the questions
client and family
to ask questions.
She and her
Allow the client
husband
and family to
expressed their
verbalize anxiety.
anxiety
Stress that
frequent
assessment are
routine and do
not necessarily
imply a
deteriorating
condition.
Allow the family Allowed the

members to visit family members
the client to frequently visit
frequently the client
Mrs. JL is Deficient Goal setting was Carried out plans Mrs. JL was free to
enquiring knowledge done along with mutually agreed express problems of
about the related to patient upon. self care.
disease the
condition, treatment
its outcome measures to
and need be Patient will She expressed
for surgery continued acquire adequate acquisition of
even after knowledge knowledge regarding
the regarding the the disease and the
discharge. treatment and signs of aggravation
Discussed home care. of illness
with the
client
regarding
the disease Explained
Explain the treatment
process and treatment
the need measures and the
measures to the need for follow up
for follow patient and their
up benefits
Explained
regarding the
Explain to the signs of
client the signs aggravation of
of aggravation of disease
illness
Used simple and

Use simple and understandable
understandable terms for
terms explaining
Clarified her
doubts
Clarify all the
doubts of the
patient of
importance.
Repeated the
information
Repeat the
information
whenever
necessary to
reinforce
learning.
Summary:
1. Orientation phase
• Client is initially reluctant to talk due to pain.

• Client is expressing that while standing she is having much pain.
• Client expressed without movement and supine position gave her relief
from pain.
2. Identification
• The client participates and interdependent with the nurse

• Expresses the need for measure to get relief from pain
• Expresses need for improving the mobility
• Expresses need to know more about prognosis, discharge and home care
and follow up.
3. Exploitation
• Client explains that she gets relief of pain when lying down supine.
• Cooperates and participates actively in performing exercises.
• Client mobilizes changes position and cooperates during position changes.
4. Resolution
• Client expressed that pain has reduced a lot and she is able to tolerate it
now
• She has agreed upon to continue the exercises at home
• She also expressed that she would come for regular follow up after
discharge.
Evaluation of the theory of interpersonal relations by Peplau
With the help of the theory of interpersonal relations, the client's needs could be
assessed. It helped her to achieve them within her limits. This theory application
helped in providing comprehensive care to the client.
References:
1. Chinn P L, and Kramer M K. Theory and nursing- a systemic approach.
3rd edition. Philadelphia: Mosby year book;1991
2. George J B. Nursing theories. 5th edition. New Jersey: Prentice hall;
2002
3. Alligood M R, Tomey A M. Nursing theory- utilization and application. 3rd
edition. Missouri: Mosby Elsevier; 2006
4. Craven R F, Hirnle C J. Fundamentals of nursing – human health and
function. 5th edition. Philadelphia: Lippincott Williams and Wilkins;
2007
5. McQuiston C M and Webb A A. Foundations of nursing theory-
Contributions of 12 key theorists. New Delhi: Sage Publications; 1995
APPLICATION OF THEORY IN
NURSING PROCESS
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. They are derived through two principal methods; deductive reasoning
and inductive reasoning.
Objectives
• to assess the patient condition by the various methods explained by the

nursing theory
• to identify the needs of the patient
• to demonstrate an effective communication and interaction with the patient.
• to select a theory for the application according to the need of the patient
• to apply the theory to solve the identified problems of the patient
• to evaluate the extent to which the process was fruitful.
Definition:
Nursing theory is an organized and systematic articulation of a set of statements

related to questions in the discipline of nursing. 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..
Importance of nursing theories:
• Nursing theory aims to describe, predict and explain the phenomenon

of nursing
• It should provide the foundations of nursing practice, help to generate
further knowledge and indicate in which direction nursing should
develop in the future
• Theory is important because it helps us to decide what we know and
what we need to know
• 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
• 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
Characteristics of theories:
Theories are
• Interrelating concepts in such a way as to create a different way of

• 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.
Purposes of theory in practice:

• Serve to guide assessment, intervention, 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 establish 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
defined.
• Enhance autonomy (independence and self-governance) of nursing by
defining its own independent functions.
If theory is expected to benefit practice, it must be developed cooperatively

with people who practice nursing. People who do research and develop
theories think differently about theory when they perceive the reality of
practice. Theories do not provide the same type of procedural guidelines for
practice as do situation- specific principles and procedures or rules. Procedural
rules or principles help to standardise nursing practice and can also be useful
in achieving minimum goals of quality of care. Theory is ought to improve the
nursing practice. One of the most common ways theory has been organized in
practice is in the nursing process of analyzing assessment data.
• Application Goal Attainment Theory

• Application Orem's Self-care Deficit Theory
• Theories used in Community Health Nursing
• Application of Suchman’s Stages of Illness Mode
• Application of Betty Neuman's Systems Model in Nursing Care
REFERENCES
1. Alligood M R, Tomey A M. Nursing Theory: Utilization &Application .3rd ed. Missouri:
Elsevier Mosby Publications; 2002.
Philadelphia, 2002
3. George JB .Nursing Theories: The Base for Professional Nursing Practice .5th ed. New
Jersey :Prentice Hall;2002.
TRANSCULTURAL NURSING
Outline
• INTRODUCTION
• TRADITIONAL CONCEPTS OF HEALTH AND DISEASE
• CONCEPT OF CULTURE
• PURPOSES OF KNOWING THE PATIENTS CULTURE AND RELIGION FOR
HEALTH CARE PERSONNEL
• USE OF SUBSTANCES
• ILLNESS CAUSE AND PREVENTION RELATED TO FOOD
• ECONOMIC BARRIERS
• SOCIOCULTURAL FACTORS AND THE NURSING PROCESS
• ROLE OF NURSE
• CONCLUSION
• REFERENCES
INTRODUCTION
Transcultural nursing with established clinical approached to clients with varying

cultures are relatively new. According to Madeleine Leininger (1987) founder of
the filed of transcultural nursing in the mid 1960s. The education of nursing
students in this field is only now beginning to yield significant results.
Today nurses with a deeper appreciation of human life and values are developing
cultural sensitivity for appropriate individualized clinical approaches.
Religious and Cultural knowledge is an important ingredient in health care. If the
client do not respond as nurse expects the nurse may interpret it as unconcern or
resistance the nurse then can be anxious and frustrated in order to incorporate
cultural knowledge in care cultural knowledge in care.
It is important to understand some definition and cultural components that are
important in health care.
For a nurse to successfully provide care for a client of a different cultural or ethnic
to background, effective intercultural communication must take place.
Intercultural communication occurs when each person attempts to understand the
other’s point of view from his or her own cultural frame of reference. Effective
intercultural communication is facilitated by the nurse identification of areas of
commonalities. After reaching a cultural. understanding, the nurse must consider
cultural factor throughout the nursing process.
Major Nursing organizations have emphasized in the last decade the importance
of considering culture factors when delivering nursing care.
According to the American Nurses’ s Association (1976)”Consideration of
individual value systems and lifestyles should be included in the planning and
health care for each client Nursing curriculum recognize the contribution nursing
to the health care needs of a diverse and multi cultural society life-style may
ret1ect cultural heritage.
• Culture-Broadly defines set of values, beliefs and traditions, that are held
by a specific group of people and handed down from generation to
generation. Culture is also beliefs, habits, likes, dislikes, customs and
rituals learn from one’s family. (Specter 1991)
• Culture is the learned, shared and transmitted values, beliefs, norms and
life way practices of a particular group that guide thinking, decisions, and
actions in patterned ways.
• Religion:
• Is a set of belief in a divine or super human power (or powers) to be
obeyed and worshipped as the creator and ruler of the universe? Ethical
values and religion system of beliefs and practices, difference within the
culture and across culture are found
• Ethnic: refers to a group of people who share a common and distinctive
culture and who are members of a specific group.
• Ethnicity :a consciousness of belonging to a group.
• Cultural Identify: the sense of being part of an ethnic group or culture
• Culture-universals: commonalities of values, norms of behavior, and life
patterns that are similar among different cultures.
• Culture-specifies ; values, beliefs, and patterns of behavior that tend to
be unique to a designate culture.
• Material culture; refers to objects (dress, art, religious arti1acts)
• Non-material culture; refers to beliefs customs, languages, social
institutions. Subculture: -composed of people who have a distinct identity
but are related to a larger cultural group.
• Bicultural : a person who crosses two cultures, lifestyles, and sets of
values.
• Diversity: refers to the fact or state of being different. Diversity can occur
between cultures and within a cultural group.
• Acculturation; individuals who have taken on, usually observable,
features of another culture. People of a minority group tend to assume the
attitudes, values, beliefs, find practices of the dominant society resulting in
a blended cultural pattern.
• Cultural shock:-the state of being disoriented or unable to respond to a
different cultural environment because of its sudden strangeness,
unfamiliarity, and incompatibility to the stranger's perceptions and
expectations at is differentiated from others by symbolic markers (cultures,
biology, territory, religion).
• Ethnic groups; share a common social and cultural heritage that is
passed on to successive generations.,
• Ethnic identity;- refers to a subjective perspective of the person's
heritage and to a sense of belonging to a group that is distinguishable from
other groups.
• Race: the classification of people according to shared biologic
characteristics, genetic markers, or features. Not all people of the same
race have the same culture.
TRADITIONAL CONCEPTS OF HEALTH AND DISEASE
When viewed across a variety of multicultural groups, explanations for health and
disease that characterized, many traditional beliefs about disease causation,
treatment, and general health practices can be seen as highly complex, dynamic,
and interactive. These explanations often involve family, community, and/or
supernatural agents in cause and effect, placation, and treatment rituals to
prevent, control, or cure illness. A failure to understand and appreciate these
"differences" can have serious implications for the success of any Health
Promotion and Disease Prevention (HPDP) effort.
• Be aware that the health concepts held by many cultural, groups may
result in people choosing not to seek Western medical treatment
procedures because they do not view the illness or disease as coming from
within themselves
• Be aware that in many Eastern cultures and other cultures in the
developing world, the locus of control for disease causality often is
centered outside the individual, whereas in Western cultures, the locus of
control tends to be more internally oriented (Dim-out, 1995).
• Remember that if the more traditional person does seek Western medical
treatment, then that person might not be able to provide or describe his or
her symptoms in precise terms that the Western medical practitioner can
readily treat (Landline & Logoff, 1992).
• Recognize that individuals from other cultures might not follow through
with health-promoting or treatment recommendations because they
perceive the medical or other health- promoting encounter as a negative or
perhaps even hostile experience.
• Acknowledge that many individual patients and health care practitioners
have specific notions about health and disease causality and treatment
called explanatory models. These models are generally a conglomeration of
the respective cultural and social training, beliefs, and values; the personal
beliefs, values, and behaviors-, and the understanding of biomedical
concepts that each group holds (Klein man, 1980).
• Recognize that the more disparate the differences are between the
biomedical model and the lay/popular explanatory models, the greater the
potential for, on to encounter resistance to Western HPDP programs.
• Be aware of the need to be flexible in the design of programs, policies, and
services to meet the needs and concerns of the culturally diverse
population, groups that are likely to be encountered.
Traditional Concepts of Illness Causality
• Be aware that folk illnesses are generally learned syndromes that
individuals from particular cultural groups claim to have and from which
their culture defines the etiology, behaviors, diagnostic procedures,
prevention methods, and traditional healing or curing practices.
• Remember that most cases of lay illness have multiple causalities and may
require several different approaches to diagnosis, treatment, and cure
including folk and Western medical interventions
• Recognize that folk illnesses, which are perceived to arise from a variety of
causes, often require the services of a folk healer who may be a local
corianders, shaman, native healer, spiritualist, root doctor, or other
specialized healer.
• Recognize that the use of traditional or alternate models of health care
delivery is widely varied and may come into conflict with Western models
of health care practice.
• Understanding these differences may help us to be more sensitive to the
special beliefs and practices of multicultural target groups when planning a
program. Culture guides behavior into acceptable ways for the people in a
specific group as such culture originates and develops within the social
structure through inter personal interactions.
CONCEPT OF CULTURE
• Culture is learned by each generation through both formal and informal life
experiences. Language is primary through means of transmitting culture
• The practices of particular culture often arise because of the group's social
and physical environment
• Culture practice and beliefs are adapted over time but they mainly remain
constant as long as they satisfy needs.
Cultural awareness
It is an in-depth self-examination of one's own background, recognizing biases
and prejudices and assumptions about other people
PURPOSES OF KNOWING THE PATIENTS CULTURE AND RELIGION FOR

HEALTH CARE PERSONNEL
Cultural background affect a person's health in all dimensions, so the nurse should
consider the client's cultural background when planning care
Although basic human needs are the same for all people, the way a person seeks
to meet those needs is influenced by culture.
• To heighten awareness of ways in which their own faith system. Provides
resources for encounters with illness, suffering and death.
• To foster understanding, respect and appreciation for the individuality and
diversity of patients beliefs, values, spirituality and culture regarding
illness, its meaning, cause, treatment, and outcome.
• To strengthen in their commitment to relationship-centered medicine that
emphasizes care of the suffering person rather than attention simply more
to the pathophysiology of disease, and recognizes the physician as a
dynamic component of that relationship.
• To facilitate in recognizing the role of the hospital chaplain and the
patient's clergy as partners in the health care team in providing care for
the patient.
• To encourage in developing and maintaining a program of physical,
emotional and spiritual self-care introduce therapies from the East, such as
ayurveda and pancha karma
Leininger (1991,2002a) has defined transcultural nursing as a comparative study
of cultures to understand similarities (culture universal) and difference (culture-
specific) across human groups
Culturally congruent care;
Care that fits the people's valued life patterns and set of meanings -which is
generated from the people themselves, rather than based on predetermined
criteria. Discovering client's culture care values, meanings, beliefs and practices
as they relate to nursing and health care requires nurses to assumes the roles of
learners of client’s culture and copartners with client's and families in defining the
characteristics of meaningful and beneficial care.(Leininger,2002
Culturally competent care is the ability of the practitioner to bridge cultural
gaps in caring, work with cultural differences and enable clients and families to
achieve meaningful and supportive caring. Culturally competent care requires
specific knowledge, skills, and attitudes in the delivery of culturally congruent care
and awareness.
Pacquiato (2003) identifies three distinct levels of cultural competence at the
practitioner, organizational and social levels.
Nursing Decisions
Leininger (1991) identified three nursing decision and action modes to achieve
culturally congruent care. All three modes of professional decisions and actions
are aimed to assist, support, facilitate, or enable people of particular cultures
The three modes for congruent care, decisions, and actions proposed in the
theory are predicted to lead to health and well being, or to face illness and death.
1. Cultural preservation or maintenance: Retain and or preserve relevant care
values so that clients can maintain their well-being, recover from illness, or face
handicaps and/or death .
2.Cultural care accommodation or negotiation- Adapt or negotiate with the
others for a beneficial or satisfying health outcome
3. Cultural care repatterning or restructuring : Records, change, or greatly
modify client’s life ways for a new, different and beneficial health care pattern
PURPOSE AND GOAL OF THE THEORY
The central purpose of the theory is to discover and explain diverse and universal
culturally based care factors influencing the health, well-being, illness, or death of
individuals or groups.
The purpose and goal of the theory is to use research findings to provide
culturally congruent, safe, and meaningful care to clients of diverse or similar
cultures.
Status of Traditional Practices
Many traditional practices are used to prevent and a redemptive practice used to
prevent illness and harm treat illness, including objects and substances and
religious practices. (Morgenstern, 1966)
USE OF PROTECTIVE OBJECTS
Protective objects can be worn or carried or hung in the home. Amulets are
objects with magical powers, for all walks of life and cultural and ethnic
backgrounds is example, charms worn on a string or chain around the neck, wrist,
or waist to protect the wearer from the evil eye or evil spirits. Amulets exist in
societies all over the world and are associated with protection from trouble
(Budge, 1978)
USE OF SUBSTANCES
Substances are ingested in certain ways or amounts regimen, an effort must be
made to determine if they are worn or hung in the home. This practice uses diet
and consists of many different observances. It is believed that the body is kept in
balance or harmony by the type of food eaten so many food taboos and
combinations exist in traditional belief systems. For example, it is believed that
some food substances can be ingested to prevent illness. People from many ethnic
backgrounds eat raw garlic or onion In an effort to prevent illness or wear them
on' the body or hang them in the home.
Jews also believe that milk and meat must never be mixed or eaten at the same
meal (Steinberg, 1947) mind, and spirit, or the restoration of holistic health
RELIGIOUS PRACTICES Another traditional approach to illness prevention
female centers around religion and includes practices such as from a divine source
the burning of candles, rituals of redemption, and In many instances a heritage
consistent person may prayer. Religion strongly affects the way people attempt to
prevent illness, and it plays a strong role in rituals associated with health
protection. Religion dictates social, moral, and dietary practices designed to keep
a traditional healer (Kaptchuk and Croucherl987)
Traditional Remedies The admitted use of folk or traditional medicine
increasing, and the practice is seen among people from all walks of life and
cultural ethnic back ground Use of folk medicine is not a new practice among
heritage consistent people, so many of the remedies have been used and passed
on for generations. The pharmaceutical, must be made to determine properties of
vegetation-plants, roots, tested stems, flowers, seeds, and herbs-have been
studied tested, cataloged, and used for countless centuries. Many of these plants
are used by specific communities. Others cross ethnic and community lines and
are used in certain Geographic areas in the person's country of origin.
When patients -do not adhere to a pharmacological regimen an effort must be
made to determine the remedy if they are taking traditional remedies. Frequently,
the active ingredients of traditional remedies are unknown. If a client is believed
to be, taking them an effort must be made to determine the remedy as well as its
active in gradients Often, these ingredients can be antagonistic or synergistic to
prescribed medications. Over dose may occur.
Healer's
In the traditional context, healing is the restoration of the person to a state of
harmony between the body, Within a given community, specific people are known
to have the power to heal. The healer may be male or and is thought to have
received the gift of healing In many instances a heritage consistent person may
consult a traditional healer before, instead of, or in conjunction with a modern
health care provider. Many differences exist between the Western physician and
the Eastern A broad range of health and illness beliefs exist many of these beliefs
have roots in the culture, ethnic, religious, or social back ground .of a person
family, or community. 'When people anticipate fear or experience an illness or
crisis, they may use a modern or traditional approach toward prevention and
healing.
These approach may originate in culture, ethnicity or religion. These beliefs and
practices may be internal or personal and person may be able to define or
describe them. However, they may be due to external social forces not within the
person's control Examples of external social forces include communication
barriers, such as language differences, or economic barriers causing limited
access or lack of access to modem, health care facilities.
IMMIGRATION
Every immigrant group has its own cultural attitudes ranging beliefs and practices
regarding these areas Health and illness can be interpreted in terms of personal
experience and expectations. There are countless ways to explain health and
illness, and people base their responses on cultural, religious, and ethnic back
ground. The responses are culture specific, based on a client's experience and
perception.
Gender Roles
In many cultures, the male is dominant figure. In cultures where this is time,
males make decisions for other family members well as for themselves. For
example, no matter which family member is involved cultures where the male
dominate. The female usually is passive. In African -American families, however
as well as in many Caucasian families, the female often is dominant Knowledge of
the dominant member of the family is important consideration in planning Nursing
care folk illnesses, which are perceived to arise from a variety of causes, often
require the services of a folk healer who may be a local curandero, shaman,
native healer, spiritualist, root doctor, or other specialized healer. Recognize that
the use of traditional or alternate models of health care deliveries widely varied
and may come into conflict with Western models of health care practice.
Understanding these differences may help you to be more sensitive to the special
beliefs and practices of multicultural target groups when planning a program.
ILLNESS CAUSE AND PREVENTION RELATED TO FOOD

Several factors cause illness. A hot-cold imbalance, for example, is primarily
caused by improper diet. Food substances are classified as hot or cold with and
without regard to their actual temperature. This classification can vary from
person to person, but essentially, certain foods are known to be hot, and others
are known to be cold. Examples of cold food are, honey, avocados, bananas, and
lima beans. Examples of hot foods-are chocolate, coffee, com meal, garlic, kidney
beans, onions, and peas. Illness can occur if these foods are eaten in improper
combinations or amounts. .
Traditional beliefs about mental health In the traditional belief system,
mental illnesses are caused by a lack of harmony of emotions or, sometimes, by
evil spirits. Mental wellness occurs when psychological and physiologic functions
are integrated. Some elderly Asian Americans share the Buddhist belief that
problems in this life are most likely related to transgressions committed in a past
life. In addition our previous life and our future life are as much a part of the life
cycle.
ECONOMIC BARRIERS
Several economic barriers, such as unemployment, underemployment,
homelessness, lack of health insurance poverty prevent people from entering the
health care system. Poverty is by far the most critical factor. Poverty a relative
term and changes from time and place. In the United States, poverty is pervasive
and found extensively among people in certain norms geographical areas, such as
rural populations, the elderly migrant workers, and illegal aliens. Poor health,
crippling diseases, drug and alcohol abuse, poor education; and inferior are
contributing social causes of poverty.
Several programs, both governmental and private, aid people with short- and
long-tem problems. It is important for the nurse to be aware clients needs and
financial resources available in the local community.
Time orientation
It is varies for different cultures groups. A client may be late for an appointment
not because of reluctance or lack of respect for the nurse but because he is less
concerned about planning ahead to be on time than with the activity in which he
is currently engaged.
PERSONAL SPACE AND TERRITORIALITY;
Personal space involves a person's set of behaviors and attitudes toward the
space around himself. Staff members and other clients frequently encroach on a
client's territory in the hospital, which includes his room, bed, closet, and
belongings. The nurse should try, to respect the client's territory as much as
possible, especially when performing nursing procedures. The nurse should also
welcome visiting members of the family and extended family. This can remind the
client of home, lessening the effects of isolation and shock from hospitalization.
SOCIOCULTURAL FACTORS AND THE NURSING PROCESS
Religious belief that effect the care Nursing;
Belief about birth &death.
Belief about diet and food practices.
Belief regarding medical care
Comments (cremation is preferred)
ROLE OF NURSE
1. The nurse should begin the assessment by attempting to determine the
client's cultural heritage and language skills. The client should be asked if
any of his health beliefs relate to the cause of the illness or to the problem.
The nurse should then determine what, if any, home remedies the person
is taking to treat the symptoms
2. Nurses should evaluate their attitudes toward ethnic nursing care. Some
nurses may believe they should treat all clients the same and simply act
naturally, but this attitude fails to acknowledge that cultural differences do
exist and that there is no one "natural" human behavior The nurse cannot
act the same with all clients and still hope to deliver effective,
individualized ,holistic care.
3. Sometimes, inexperienced nurses are so self-conscious about cultural
differences and so afraid of making a mistake that they impede the nursing
process by not asking questions about areas of difference or by asking so
many questions that they seem to try into the client' personal life.
4. The process of self-evaluation can help the nurse become more
comfortable when providing care to clients from diverse backgrounds
5. Culture is the sum total of mores traditions & beliefs about how people
function encompasses others products of human works & thoughts.
Specific to member of an intergenerational group, community or
population.
6. Nurses have a responsibility to understand the influence of culture, race
&ethnicity on the development of social emotional relationship child rearing
practices &attitude toward health.
7. A child's self concepts evolves from ideas about his or her social roles
8. Primary groups are characterized by intimate contact mutual support and
pressure for conformity.
9. Important sub culture influences on children include ethnicity social class,
occupation school peers and mass culture
10. Socioeconomic influences play major role in ability to seek opportunity for
health promotion for wellness
11. Religious practices greatly influences health promotion belief in families.
12. Many ethnic and cultural groups in country retain the cultural heritage of
their original culture.
13. How culture influences behaviors, attitudes, and values depends on many
factors and thus is not the same for different members of a cultural group.
14. Ethnocentrism can impede the delivery of care to ethnic minority clients
and, when pervasive, can become cultural racism.
15. Stereotyping ethnic group members can lead to mistaken assumptions
about a client.
16. The nurse should have an understanding of the general characteristics of
the major ethnic groups, but should always individualize care rather than
generalize about all clients in these groups.
17. Before assessing the cultural background of a client, nurses should assess
how they are influenced by their own culture.
18. The nursing diagnosis for clients should include potential problems in their
interaction with the health care system and problems involving the effects
of culture.
19. The planning and implementation of nursing interventions should be
adapted as much as possible to the client's cultural background.
20. Evaluation should include the nurse's self-evaluation of attitudes and
emotions toward providing nursing care to clients from diverse
sociocultural backgrounds.
21. When nurses provide care to clients from a background other than their
own, they must be aware of and sensitive to the clients' sociocultural
background, assess and listen carefully to health and illness beliefs and
practices, and respect and not challenge cultural, ethnic, or religious values
and health care beliefs. The nursing process enables the nurse to provide
individualized care
22. The nurse should begin the assessment by attempting to determine the
client's cultural heritage and language skills. The client should be asked if
any of his health beliefs relate to the cause of the illness or to the problem.
The nurse should then determine what, if any, home remedies the person
is taking to treat the symptoms
23. Assessment enables the nurse to cluster relevant data and develop actual
or potential nursing diagnoses related to the cultural or ethnic need of the
client. In addition the nursing diagnosis should state the probable cause
.The identification of the cause of the problem further individualizes the
nursing care plan and encourages selection of appropriate interventions-
cultural variables as they relate to the client. The extended family should
be involved in the care the Client's strongest support group. Cultural
beliefs and practices can be in-corporate into therapy.
24. The client’s the nursing process; educational level and language skills
should be considered when planning teaching activities.
25. Explanations of and practices into nursing therapies; aspects of care
usually not questioned by acculturated clients may be required for non-
English speaking or non- acculturated clients to avoid confusion,
misunderstanding, or cultural conflict.
26. The nurse may have to alter her usual ways of interacting with clients to
avoid offend ignore alienating a client with different attitudes toward social
interaction and etiquette. A client who is modest and self-conscious about
the body may need psychological preparation before some procedures and
tests.
27. The nurse can find out what care the client considers appropriate by
involving him and his family in planning care and asking about their
expectations. This should be done in every case, even if the nursing care
cannot be modified. Because both the nurse and the client are likely to
take many aspects of their cultures for granted, questions should be clear
and explanations should be explicit.
28. Discussing cultural questions related to care with the client and family
during the planning stage helps the nurse understand how cultural
variables are related to the client's health beliefs and practices, so that
interventions can be individualized for the client.
29. The nurse evaluates the results of nursing care for ethnic clients as for all
clients, determining the extent to which the goals of care have been met.
Evaluation continues throughout the nursing process and should include feedback
from the client and family. With an ethnic minority client, however, self-evaluation
by the nurse is crucial as he or she increases skills for interaction. The nurse
should consider questions such as the following: .
• Am I open to understanding ways in which the client's values differ from
mine?
• Have I given sufficient attention to communicating with the client with
limited language skills?
• Have I have successful client's family in nursing process?
• Am I incorporating the client's traditional beliefs and practices into nursing
therapies?
• Is my therapeutic relationship with the client grounded on respect for the
client regardless of cultural differences?
CONCLUSION
Nurses need to be aware of and sensitive to the cultural needs of clients. The
body of knowledge relevant to this sensitive area is growing, and it is imperative
that nurses from all cultural backgrounds be aware of nursing implications in this
area. The practice of nursing today demands that the nurse identify and meet the
cultural needs of diverse groups, understand the social and cultural reality of the
client, family, and community, develop expertise to implement culturally
acceptable strategies to provide nursing care, and identify and use resources
acceptable to the client (Boyle, 1987).
REFERENCES
1. Boyle, JS: The practice of trans cultural nursing, Transcultural Nursing
Morgenstern, J: Rites of birth, marriage, death, and kindred occasions
2. George Julia B. Nursing theories: The base of professional nursing practice 3rd
edition. Norwalk, CN: Appleton and Lange; 1990.
3. Kozier B, Erb G, Barman A, Synder AJ. Fundamentals of nursing; concepts,
process and practice, Edn 7th, 2001.
4. Leninger M, McFarland M. Transcultural Nursing: Concepts, Theory, Research, and
Practice; Edn 3rd, McGraw-Hill Professional; New York, 2002.
5. Potter A, Perry G .Basic Nursing-Theory and Practice, Edn 3rd Mosby Company.
HELPING AND HUMAN

RELATIONSHIPS THEORY
By
ROBERT R. CARKHUFF
Introduction
When adults have reached full maturity, they can communicate fully, they have
satisfied their needs for fullness in all aspects of life and become full persons.
They are now prepared to help others to achieve their own levels of wholeness.
They will not only communicate fully with others struggling to grow and develop,
they will also teach the others the skills they need to grow and develop
themselves. They will become the models and the agents for the growth of others.
They will give their lives meaning through their productivity in living, learning and
working arenas. They will create new life through their helping skills. The cycle of
life continues.
Helping
Helping is a process leading to new behavior for the person being helped . An
effective helper is initially nourishing or responsive. This nourishment prepares
the person being helped for the more directionful or initiative behavior of the
helper. Children as they become capable of both nourishing and directionful
behavior, they assume the mantle of adulthood and later perhaps parenthood.
They can act constructively in the lives of their own and others thus we call them
fully adults or they are now helpers for they are capable of helping others as well
as themselves. Persons who are fully alive help other persons to become fully
alive. Responsive and initiative behaviours are the basic dimensions of helping
and development.
Potentially all relationships are helping relationships. It depends upon the helping
skills one has, the effects of skills depend upon how we sequence them. Thus
helping in real sense is a developmental process like child rearing. Effective
parenting involves both responsive and initiative skills. Helpers who are fully
responsive and fully initiative teach their helpees to be fully responsive and fully
initiative.
Human Relationships
Human Relationships may be facilitative or retarding effects. Like a marriage,
the consequences of all human relationships may be for better or for worse.
Consequences may be constructive or destructive, may produce persons and non
persons; health care provider-patient; employee-employer etc. The effects may
be positive or negative or any of the degrees in between these extremes. The
effects are seen in physical, emotional and intellectual functioning. With
facilitative agents the recipients may be physically energetic, emotionally
expansive and intellectually acute; with retarding agents the recipients may be
physically listless, emotionally shallow and intellectually dull.
Power and human relationships
The effects of human relationships depend upon the power relationship. If the
person is ceded the power in the relationship is functioning at a high level, then
all parties involved can benefit from the relationship. Eg. Parents. Unfortunately
power relations are developed for reasons other than functionality like tradition,
politics etc. It makes good sense that if people have not discovered themselves
they can only handicap others in finding their own way of life. The effects of the
power relationships depend upon the skills.
Skills
Most fundamentally, it is the powerful person’s level of functioning in basic human
relations skills that determines the effects of relationships. There are two sets of
skills which are the basic ingredients of all human relationships in the areas of
endeavor.
Responding and initiating skills
These skills are cycled in an individual’s personal development before his or her
interpersonal development. A person must respond to understand himself
before initiating an action program or product. There is no effective action that
is not based upon a depth of understanding.
Responsiveness
Responsiveness is the basic ingredient of human relations, which involves
empathy. Responsiveness is the most profound variable in the human
condition. To know more than that person does of her own experience, to be
able to describe and predict and influence that experience constructively, is the
test of responsive skills. Responsive skills thus involve experiencing another’s
condition and communicating to her own experience. It involves the other
person in a process leading to her own self-exploration and self-understanding.
Initiative
Initiative is the basic ingredient of human functionality. It involves
operationalizing the goal or breaking it down into it’s components. It involves
developing the steps and systems to achieve the goal, it is more than a
mechanical process. It begins with a vision of the possible, building upon our
own experience to see a goal, further it stimulates the other person to take
action to achieve the goal.
• When people share their problems, what skills do you have to truly show
that you are responding to their experience?
• How do you physically show this? Emotionally? Intellectually?
• What do you do and say that will assure the people that you are sensitively
attuned to their experience? How do you show you heard them? What
feedback do you give?
• When you are wrestling with their problems, how do you share your
experience to help them to develop achievable goals that solve their
problems?
• Now that you have responded to their experience, how do you help them
to initiate steps to get to their goals.
New Behaviour
Before we can acquire the skills of helping, we must understand the goals of
helping. New behavior is the overall goal of helping. One must explore where she
is, explore herself in relation to herself and in relation to her world. We must know
the problems before we can change the behavior. In exploring herself, the person
seeking help is attempting to understand where she is in relation to where she
wants to be. Self understanding is not real until the individual has acted upon it.
In acting the person acts upon how to get from where she is to where she wants
to be. The more accurately a person understands herself, the more constructively
she can act for herself and others.
Evolution of dimensions
Before we understand the dimensions, we must understand four things.
i. Helping Sources: There are two approaches to helping -insight and action. The
insight approach was supported by many traditional therapeutic schools,
emphasized the client’s insight as the basis for the development of an effective set
of assumptions about his or her world. The action approach has been promulgated
by the learning theory and behaviour modification schools as well as the trait and
factor school, which matches people to jobs and vice versa, who emphasized the
client’s development and implementation of rational action plans for managing his
or her world. In order to effectively help human beings to change behaviour the
insight and action approaches must be integrated into one effective helping
process.
ii. Helping Process: In order to demonstrate gain in behaviour, the helpees must
act differently from the way they did before. Thus they must have insights or
understand accurately the gaols and ways to achieve them; in order to
understand their goals, the helpees must explore their world experientially. Finally
they must act to get from where they are to where they want to be. With the
feedback they can recycle the learning process
Exploration -----------Understanding------------Action-----------Feedback
Feedback-------further exploration----self understanding--------real
understanding
Real Understanding-----------modification of action (effective action).
iii. Helper Skills: The historic dimension of empathy was complemented by
unconditional positive regard and genuineness, which were then operationalized
into accurate empathy, respect and genuineness. These were in turn
complemented by other dimensions including specificity or concreteness, self
disclosure, confrontation and immediacy; then factored into responsive and
initiative dimensions. The responsive dimensions (empathy, respect, specificity of
expression) responded to the helpee’s experience and thus facilitated the helpee’s
movement towards understanding. The initiative dimensions (genuineness, self
disclosure, confrontation, immediacy and concreteness) were generated from the
helper’s experience and stimulated the helpee’s movement toward action. The
initiative dimensions were later extended to incorporate the problem solving skills
and program development skills needed to fully help the helpee's to achieve
appropriate outcomes.
iv. Helpee Outcomes: emphasized the emotional changes or gains of he
helpee's. Since the helping methods were insight oriented, the process
emphasized helpee exploration and outcome assessments measured the changes
in the helpee’s level of emotional insights, which were restrictive because they
were assessing only one dimension of the helpee’s functioning. These were later
extended to incorporate the interpersonal functioning of the helpee's. The
dimension of physical functioning was added, to measure fitness and energy;
intellectual dimension to measure the intellectual achievement and capabilities.
Levels and styles of functioning
Carkhuff and Berenson(1967) described five levels of dimensions.
The dimensions are empathy, respect or regard, genuineness,
concreteness, warmth. Levels:
First: no empathy is taking place( no evidence of the helper characteristic)
Second: Empathizing very little and at a level that detracts from helpee
functioning(10% of time)
Third: minimum level of feeling response necessary to be efective(50% of time)
Fourth and fifth: Higher levels of helper empathy(4th – 75%; 5th – consistently
present)
The responsibility continuum:
Helping skills
The responsive and initiative factors of helping dominate the helping process
facilitating E+ U+A
That culminate in the physical, emotional and intellectual helpee outcomes. As a
result of attempts to teach they are further refined into concrete helping skills
(A+R+P+I). The attending skills are transitional between responding and
initiating.
Attending : “Being attentive to to the helpee” is made up of attending physically,
observing and listening to the helpee. The function of attending is to give them
the feelings of security that make their involvement in the helping process. By
attending physically the helper communicates interest in the helpee’s welfare, by
observing and listening, helper learns from and about the helpee. By
communicating interest in the helpee, helper establishes the conditions for the
helpee’s involvement in the helping process.
Responding: Responding to the helpee’ s expression of her experience, involves
responding to content, feeling and feeling and content together. The function of he
responding to the helpee’s experience is to facilitate self exploration. T thus she
signals her readiness for the next goal of helping- understanding, which signals
the helper to begin personalizing. They serve to stimulate the helpee’s exploration
of where he or she is in his or her experiences of the world and that the helper is
fully in tune with the helpee’s experience.
Personalizing: “To enable the helpee to understand where she is in relation to
where she wants or needs to be”, involves building a base of interchangeable
responses before personalizing the meaning, the problem, the feelings and the
goal. The purpose is to facilitate helpee self understanding in the areas of concern
to her, thus she signals readiness for using initiating. They are used to provide a
transition from responding to initiating and from exploring to acting. Personalizing
skills culminate in the helpee’s personal experience of the problem as the inability
to handle difficult situations.
Initiating: ”Finding direction in life or acting in following the direction, bringing
direction to culmination – giving life meaning in productivity and creativity”. It
involves operationalizing goals and initiating steps, schedules and reinforcements
to achieve these goals. These goals resolve helpee’s problems. Fosters the
development and implementation of the mechanical steps required to achieve the
personally meaningful goals that the helpee has developed. Initiating skills
conclude the first cycle of helping process in which helper facilitate helpee’s acting
to get to where he or she wants to be in the world.
If you have attended to to the helpee’s needs and responded to her experience,
you have facilitated her exploration of where she is. If you have personalized your
understanding of the helpee, you have facilitated her understanding of where she
is in relation to where wants to be. If you have initiated to help the helpee achieve
her goals have facilitated her acting to get from where she is to where she wants
to be. Thus you have helped her solve her problems and achieve her goals. You
have seen her grow and develop. But growth is not static, is life long learning.
Life long Learning is recycling exploring, understanding and acting. A growing
person is constantly involved in the learning person.
Growing is more than learning and helping. It is helping others to learn, which
means to explore, understand and act plus recycle. E.g. All people can do with
each other in their daily contacts, first and foremost by attending and making an
effective response to the other.
Having begun by attending and responding, over an extended period of time each
person can learn to personalize and initiate with the people with whom they are
involved
At the highest level people communicate with immediacy, which means
understanding and interpreting in the moment what is going on between you and
the helpee (highest levels of responsive and initiative behaviour). It means being
simultaneously aware of both the helpee’s and one’s own experience.
A less than whole person is never actually talking about what she seems to be
talking about, may talk in comparison or relation to other people. A whole person
is always talking about what she seems to be talking about, communicates fully.
As helpers our tasks is to become whole people. Thus helping is a process of
teaching people who do not communicate fully to communicate fully with
themselves and others. Whatever the effective helper or the whole person is
doing, she is always checking back with the helpee accuracy of the responses. She
makes this by making responses that are interchangeable with the feeling and
content expressed by the helpee, no matter how advanced is the stage of the
helping relationship. The helper is fully alive, concerned and capable of
communicating thierliving energy, concern and capability to those who are most in
need.
In fully alive communication each person may be helper to the other. But one
must initiate the helping process by communicating her openness to
understanding the other. In doing so she establishes the model for the other to
imitate, Mutual problems are resolved. There is no edge in helping. The helpee
informs us that she is ready to function as a helper by her behaviour. One clear
demonstration of the helpee’s readiness to terminate the helping process, to go
out on her own is her ability to respond to the experience of the helper. THE
CLEAR DEMONSTRATION OF THE ABILITY TO FUNCTION AS A HELPER WILL BE
ONE’S ABILITY TO RESPOND AND INITIATE EFFECTIVELY.
The Assumption
The only assumption made in developing the helping skill programs involves one’s
motivation. Other assumption is that one wants to grow, want to be like the
facilitative helpers and teachers one has experienced, one wants to become
involved in a life long learning process.- CARKHUFF
Brammer and Macdonald-
• The basic interpersonal communication processes implied by the
specialized helping relationships are similar
• People know their needs
• Basically it is a process of enabling the person to grow in the directions
that person chooses, to solve problems and to face crises.
• Voluntary quality of the helping process is a crucial point since many
persons wanting to help others have their own helping agenda and seek to
meet their own unrecognised needs.
• The act of helping people with the presumed goal of doing something for
them or changing them in some way has an arrogant quality too.
• The aim of all help is self help and self sufficiency.
• Each individual behaves in a competent and trustworthy manner if given
the freedom and encouragement to do so.
• Helper must assume some responsibility for creating conditions of trust
whereby helpeescan respond in a trusting manner and help themselves.
• Helper must be alert to the impact on the helpee of other people and of
the physical environment.
• Helping takes place over the lifespan. Each developmental period and the
transitions between usually require some form of outside help to make life
more effective and satisfying. .
• The nature of the informal agreement implies a growth contract, that
helpees will try to change under their own initiative, with minimal helper
assistance.
Basic Helping scale
I + E + U + A = New learning (behaviour)
5.0 Initiating steps
4.5 Initiating goal operationalization
4.0 Personalizing problem, feelings and goal
3.5 Personalizing meaning
3.0 Responding to feeling and content
2.5 Responding to feeling
2.0 Responding to content
1.5 Attending
1.0 Non attending
Non attending covers all behaviours, both verbal and non verbal that are
unrelated or irrelevant to the helpee’s situation or expressions.
Attending: includes the verbal and non verbal behaviours that are directly
related to involving the helpee, but do not respond to what the helpee has shared
about where she is.
Responding to content: involves summarising what the helpee has shared
concerning her situation.
Responding to feeling: involves accurately identifying a feeling word that is
interchangeable with the helpee’s experience of the situation.
Responding to feeling and content: involves the clear communication of helper
understanding of both the content and feelings expressed by the helpee.
Personalizing meaning: involves responding to identify the personal
significance or implications of the expressed situation for the helpee.
Personalizing problem, feelings and goal: involves responding to identify the
personal deficits (assets) of the helpee that are contributing to the problem or
situation, the feelings that the helpee is experiencing about her deficits (assets)
and the goal that the helpee wants to achieve.
Initiating goal operationalization: covers responses that express a clear
understanding of the helpee’s personalized problem, feelings and goal in
behavioural terms.
Initiating steps: involves responses that identify specific steps toward
accomplishing the operationalised goal.
Ingredients to secret of success
a. Skills of helping: Apply the skills then only you recognise the need for more
skills. The most of basic of all skills is learning how to learn. N ext is the
basic skill of teaching.
b. Discipline: Employ skills with discipline. The accuracy of the discriminations and
communications is the effective ingredient.
c. Work: Our real learning in life comes from working very hard, applying skills with
disciplines in a variety of human experiences. While working hard they must
protect themselves by receiving the maximum return for the minimum
investment. e.g. Once you understand the response deficits of the helpees they
will tend to employ teaching in groups as the preferred mode of treatment.
Evaluation of theory
i. 1960’s: (Eysenk, 1960, 1965; Levitt 1963; Lewis 1965) stated that
psychotherapy and counseling did not make a difference. They discovered that
both adults and children who were in control groups that were not assigned to
professional practitioners, gained as much on the average as people assigned to
professional counselors and therapists. About two thirds of the patients improved
and remained out of the hospital a year after treatment whether they were
treated or not. This research was updated in longitudinal studies in more than 50
treatment setting by Anthony(1979) who studied lasting effects of counseling,
rehabilitation and psychotherapeutic techniques. Within 3-5 years after treatment
65-75% of the patients were once again patients. The gainful employment of
patients was below 20%. Conclusion was that psychotherapy has lasting positive
effects in 17-22% of the cases.
ii. Naturalistic studies: (Rogers et al 1967, Traux and Carkhuff 1967) The clients
and patients of professional helpers demonstrated a greater range of effects than
those in professionally untreated groups. But study revealed a very distressing
conclusion that counseling and psychotherapy have a two edged effect- they may
be harmful or helpful. The effects could be determined by the levels of functioning
of the helpers on certain interpersonal dimensions such as empathy/empathetic
understanding. One who offered high level of core interpersonal dimensions
facilitated the process movement.
iii. Predictive studies: involved manipulating the levels of helpers functioning on
interpersonal dimensions such as empathy and its effects both within the helping
process and upon the helping outcomes. (Carkhuff and Alexik 1967, Holder et al
1967; Piaget et al 1968; Traux and Carkhuff 1967). Helpees of helpers
functioning at high levels of these interpersonal dimensions moved towards higher
levels of functioning (explored their problems in meaningful ways)
iv. Generalization Studies: To study the effects of teacher’s levels of interpersonal
functioning upon learner’s development. The students of teachers offering high
levels of these interpersonal dimensions demonstrated significant constructive
gains in areas of emotional, interpersonal and intellectual functioning (Aspy and
Roebuck, 1977) These effects have been generalised in all areas of helping and
human relationships where the more knowing person influences the less knowing
person, parent child relations (Carkhuff 1971, 1976); Student teacher relations
(Carkhuff 1969); counselor –client relation and therapist patient relations
v. Extension studies: Michelson and Stevic(1971) found that career information
seeking behaviour was dependent upon the helper’s levels of interpersonal
functioning in interaction with their reinforcement program Helping dimensions
were validated in predictive studies of both helping process and outcome. The
acceptance of the fundamental ingredients of helping has been widely
demonstrated in the professional literature.
The applications:
i. With credentialed counselors and therapists: Trained counselors were able to
demonstrate success rates between 74-91%. Aspy and Roebuck(1977)
demonstrated positive effects of helping skills upon student physical, emotional
and intellectual functioning.
ii. Functional Professionals: Staff personnel, such as nurses, hospital attendants,
policeman, prison guards, dormitory counselors, community volunteers were
trained and their effects in treatment studied. Lay helpers were able to elicit
significant changes in work behaviours, discharge rates, recidivism rates and a
variety of other areas including self reports, significant other reports and expert
reports.
iii. Indigenous personnel: They can work effectively with the populations from
which they are drawn. For example, new career teachers, drawn from the ranks of
unemployed have systematically helped others to learn the skills they needed in
order to get and hold meaningful jobs.
iv. Helpee population: in the kinds of skills which they need to service themselves.
Thus parents of emotionally disturbed children were systematically trained in the
skills which they needed to function effectively with themselves and their children.
Patients were trained to offer each other rewarding human relationships. The
results were significantly more positive than all other forms of treatment. The
concept of training as treatment led to the development of programs to train
entire communities to create a therapeutic milieu.
v. Science and art of helping: On implication of the research into helping is to
select persons as helpers who already possess the artful qualities and then quickly
and systematically give them basic helping skills and behaviour concepts.
vi. Self Help Groups: Hurvitz (1970) studied many groups as participant observer
and concluded saying much of their effectiveness was due to peer relationships,
inspirational methods, explicit goals, fellow ship and a variety of helping
procedures. They use many sources of help that are outside conventional helping
methods.
Helping Relationship (Brammer)
The third component of the helping relationship is described as the working
alliance, which is the agreement of helper and helpee on the goals and tasks and
the experience of an emotional bond in this mutual act. The working alliance is
considered equal in importance to helper attitudes (Gelso & Carter, 1994). Helping
relationship is dynamic at verbal and nonverbal levels, the relationship is the
principal process vehicle for both helper and helpee to express and fulfill their
needs as well as to mesh helpee problems with helper expertise. All authorities on
the helping process agree that the quality of the helping relationship is important
to effective helping(Sexton and Whiston 1994.)All agree that good working
relationship established early, yield a helping relationship. Its dimensions are
(Brammer, Abrego and Shostrom 1993) uniqueness-commonality and intellectual
– emotional content. However helping relationship is different from friendship, is
not a reciprocal relationship. The focus is on the helpee’s emotional and
intellectual issues, the helper must resist the urge to move the focus to his or her
experience.
Helping affiliations
Helping affiliations can be classified into formal and structured (professional,
paraprofessionals and volunteer helper) to informal and unstructured (friendships,
family, community& general human).
Stages in helping process
There are eight stages contained in the two basic phases of the helping process.
Phase 1: Building relationships:
• Entry: preparing the helpee and opening relationship
• Clarification: state the problem or concern and reasons for seeking help
• Structure: formulating the contract and the structure
• Relationship: building the helping relationship
Phase 2: Facilitating Positive Action
• Exploration: exploring problems, formulating goals, planning strategies,
gathering facts, expressing deeper feelings, learning new skills.
• Consolidation: exploring alternatives, working through feelings, practicing
new skills
• Planning: developing a plan of action using strategies to resolve conflicts,
reducing painful feelings, and consolidating and generalizing new skills or
behaviours to continue self-directed activities.
• Termination: evaluating outcomes and terminating the relationship.
Helping skills for understanding: of self and others
i. Listening skills
• Attending – noting verbal and nonverbal behaviours
• Paraphrasing – responding to basic messages
• Clarifying – self disclosing and focusing discussion
• Perception checking – determining accuracy of learning
ii. Leading Skills
• Indirect leading – getting started
• Direct leading – encouraging and elaborating discussion
• Focusing – controlling confusion, diffusion and vagueness
• Questioning – conducting open and closed inquiries
iii. Reflecting skills
• Reflecting feeling – responding to feelings
• Reflecting experience – responding to toal experience
• Reflecting content – repeating ideas in fresh words or for emphasis
iv. Confronting skills:
• Recognising feelings in oneself – being aware of helper experience
• Describing and sharing feelings – modeling feeling expression
• Feeding back opinions – reacting honestly to helpee expressions
• Self-confrontation
v. Interpreting skills
• INTERPRETIVE QUESTIONS – FACILITATING AWARENESS
• FANTASY AND METAPHOR- SYMBOLIZING IDEAS AND FEELINGS
vi. Informing skills
• Advising – giving suggestions and opinions based on experience
• Informing- giving valid information based on expertise
vii. Summarising Skills
• Pulling themes together.
Ethical issues in helping relationships: Informed consent
Worker self care- recognise own weak spots and work on prevention
Dual relationships- recognise them and manage them Ask following questions.
Is there a a power difference between us?
What other role obligations do I have in this situation?
How will my knowledge about you change our relationship?
Physical contact with helpees: Sexual relationships of any kind are unethical
Touching clients for support, out of compassion or to express care is controversial.
Conclusion
Our task in life is to improve the quantity and quality of human experience, our
own as well as others which is growth. Life is process, is growth and growth is
learning skills. When we use the helping skills effectively, we can be healthy and
we can help each other to actualize our human potential. The only meaning to life
is to grow for growing is life.
References
1. Carkhuff R. The art of helping. 4th ed. Amherst: Human Resource Development
press; 1983
2. Brammer L M, Macdonald G. Helping relationship process and skills. 6th ed.
Boston: Allyn and Bacon; 1996.
3. Shea C A, Pelletier L R, Poster E C, Stuart G W, Verhey M P. Advanced practice
nursing in psychiatric and mental health care. St. Louis: Mosby; 1999
4. Topalis M, Aguilera D C. Psychiatric nursing. 7th ed. St Louis: C V Mosby; 1978.
5. Morrison M. Foundations of mental health nursing. St. Louis: Mosby; 1997.
6. Taylor C, Lillis C, Le Mone P, Lynn P. Fundamentals of nursing. 6th ed.
Philadelphis: Lippincott Williams & Wilkins; 2005.
7. Dexter G, Walsh M. Psychiatric skills a pateint centred approach. 2nd ed. London:
Chapman & Hall; 1995.
8. Stuart G W, Laraia M T. Principles and practice of psychiatric nursing. St Louis:
Mosby Harcourt Pvt. Limited; 2001.
9. Boon NA, Colledge NR, Walker BR, Hunter JAA. Davidson’s principle and practices
of medicine. 20th ed. London: Churchill Livingstone Elsevier; 2006.

Nursing Theories

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Nursing Theories

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Nursing Theories

Theory Key emphasis

Helping process meets needs through the art

Nurses should identify patients ‘need-for –

Virginia Henderson’s Patients require help towards achieving

Derived a definition of nursing

Faye Patient’s problems determine nursing care

Jean Watson’s Philosophy Caring is moral ideal: mind -body – soul

Patricia Benner’s Primacy Caring is central to the essence of nursing. It

CONCEPTUAL MODELS AND GRAND THEORIES

Dorothea E. Orem’s Self Self–care maintains wholeness.

Myra Estrin Levine’s: The Holism is maintained by conserving integrity

Martha E.Roger’s: Science Person environment are energy fields that

Dorothy E.Johnson’s Individuals maintain stability and balance

Disturbances in these causes nursing

Sister Callista: Roy‘s Stimuli disrupt an adaptive system

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

Imogene King’s Goal Transactions provide a frame of reference

Nancy Roper, WW.Logan Individuality in living.

Ida Jean Orlando’s Nursing Interpersonal process alleviates distress.

Joyce Travelbee’s Human Therapeutic human relationships.

Ramona T.Mercer’s Parenting and maternal role attainment in

Katharine Kolcaba’s Theory Comfort is desirable holistic outcome of care.

Madeleine Leininger’s Caring is universal and varies transculturally.

Rosemarie Rizzo Parse’s Indivisible beings and environment co-create

Theories are a set of interrelated concepts that give a systematic view of a

• Models are representations of the interaction among and between the

Importance of nursing theories

1. Nursing theory aims to describe, predict and explain the phenomenon of

The characteristics of theories

• interrelating concepts in such a way as to create a different way of looking at

Basic processes in the development of nursing theories

General System Theory

• It defines adaptation as the adjustment of living matter to other living

1. It outlines the process of growth & development of humans as orderly &

Common concepts in nursing theories

• The person (patient).

Historical perspectives and key concepts

• Nightingale (1860): To facilitate “the body’s reparative processes” by

Classification of nursing theories

Depending On Function (Polit et al 2001)

Prescriptive To identify under which conditions

Depending on the Generalisability of their principles

• Practice theory: explores one particular situation found

• As described by Peplau (1988), these theories revolve around the

• Humanistic theories developed in response to the psychoanalytic thought that

Growth and Stability Models of Change

Categories of Conceptual Models

• Ten conceptual models of nursing have been classified according to two

Systems Theory as a Framework

• Systems theory is concerned with changes caused by interactions among all

An example of systems interaction

Major Concepts as Defined in King’s Model

Imogene King’s Systems Interaction Model

• In interaction model, the purpose of nursing is to help people attain,

• As the person interacts with the environment, he or she must continuously

Betty Neuman’s Health Care Systems Model

• Betty Neuman specifies that the purpose of nursing is to facilitate optimal

Intrapersonal: forces arising from within the person

• Resistance to stressors is provided by a flexible line of defense, a dynamic

Stress/Adaptation Theory as a Framework

• In contrast to systems theory, stress and adaptation theories view change

Criticisms of nursing theories