Nursing Theory

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 nursings 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, eplaining,
predicting, and !or prescribing..
"ased on the knowledge structure levels the theoretical works in nursing can be
studied under the following headings#
$ %etaparadigm &'erson, (nvironment, )ealth * Nursing+ , &%ost abstract+
$ Nursing philosophies.
$ -onceptual models and .rand theories.
$ Nursing theories and %iddle range theories &/east abstract+
NURSING PHILOSOPHIES
Theory Key emphasis
0lorence Nightingales
/egacy of caring
0ocuses on nursing and the patient
environment relationship.
(rnestine 1iedenbach#
The helping art of clinical
nursing
)elping process meets needs through the art
of individuali2ing care.
Nurses should identify patients 3need-for ,help
by#
4bservation
5nderstanding client behaviour
6dentifying cause of discomfort
7etermining if clients can resolve problems or
have a need for help
8irginia )endersons
7efinition of Nursing
'atients re9uire help towards achieving
independence.
7erived a definition of nursing
6dentified :; basic human needs on which
nursing care is based.
0aye
..Abedellahs Typology of
twenty one Nursing
problems
'atients problems determine nursing care
/ydia (. )all #-are, -ure,
-ore model
Nursing care is person directed towards self
love.
<ean 1atsons 'hilosophy
and =cience of caring
-aring is moral ideal# mind -body , soul
engagement with one and other.
-aring is a universal, social phenomenon that
is only effective when practiced interpersonally
considering humanistic aspects and caring.
'atricia "enners 'rimacy
of caring
-aring is central to the essence of nursing. 6t
sets up what matters, enabling connection and
concern. 6t creates possibility for mutual
helpfulness.
-aring creates - possibilities of coping
possibilities for connecting with and concern
for others, possibilities for giving and receiving
help
7escribed systematically five stages of skill
ac9uisition in nursing practice , novice,
advanced beginner, competent, proficient and
epert.
CONCEPTUAL ODELS AND GRAND THEORIES
7orothea (. 4rems =elf
care deficit theory in
nursing
=elf,care maintains wholeness.
Three Theories#
Theory of =elf--are
Theory of =elf--are 7eficit
Theory of Nursing =ystems
1holly compensatory &doing for the patient+
'artly compensatory &helping the patient do
for himself or herself+
=upportive- educative &)elping patient to learn
self care and emphasi2ing on the importance
of nurses role
%yra (strin /evines# The
conservation model
)olism is maintained by conserving integrity
'roposed that the nurses use the principles of
conservation of#
-lient (nergy
'ersonal integrity
=tructural integrity
=ocial integrity
A conceptual model with three nursing theories
,
-onservation
>edundancy
Therapeutic intention
%artha (.>ogers#
=cience of unitary
human beings
'erson environment are energy fields that
evolve negentropically
%artha proposed that nursing was a basic
scientific discipline
Nursing is using knowledge for human
betterment.
The uni9ue focus of nursing is on the unitary
or irreducible human being and the
environment &both are energy fields+ rather
than health and illness
7orothy (.<ohnsons
"ehavioural system
model
6ndividuals maintain stability and balance
through adjustments and adaptation to the
forces that impinges them.
6ndividual as a behavioural system is
composed of seven subsystems.
Attachment, or the affiliative subsystems , is
the corner stone of social
organisations.
"ehavioural system also includes the
subsystems of dependency, achievement,
aggressive, ingestive-eliminative and
seual.
7isturbances in these causes nursing
problems.
=ister -allista# >oy3s
Adaptation model
=timuli disrupt an adaptive system
The individual is a biopsychosocial adaptive
system within an environment.
The individual and the environment provide
three classes of stimuli-the focal, residual and
contetual.
Through two adaptive mechanisms, regulator
and cognator, an individual demonstrates
adaptive responses or ineffective responses
re9uiring nursing interventions
"etty Neumans # )ealth
care systems model
>econstitution is a status of adaptation to
stressors
A conceptual model with two theories ?4ptimal
patient stability and prevention as
intervention@
Neumans model includes intrapersonal,
interpersonal and etrapersonal stressors.
Nursing is concerned with the whole person.
Nursing actions &'rimary, =econdary, and
Tertiary levels of prevention+ focuses on the
variables affecting the clients response to
stressors.
6mogene Aings .oal
attainment theory
Transactions provide a frame of reference
toward goal setting.
A conceptual model of nursing from which
theory of goal attainment is derived.
0rom her major concepts &interaction,
perception, communication, transaction, role,
stress, growth and development+ derived goal
attainment theory.
B 'erceptions, <udgments and actions of the
patient and the nurse lead to reaction,
interaction, and transaction &'rocess of
nursing+.
Nancy >oper, 11./ogan
and A.<.Tierney A
model for nursing based
on a model of living
6ndividuality in living.
A conceptual model of nursing from which
theory of goal attainment is derived.
/iving is an amalgam of activities of living
&A/s+.
%ost individuals eperience significant life
events which can affect A/s 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.
)ildegard (. 'eplau#
'sychodynamic Nursing
Theory
6nterpersonal process is maturing force for
personality.
=tressed the importance of nurses ability to
understand own behaviour to help others
identify perceived difficulties.
The four phases of nurse-patient relationships
are#
:. 4rientation
C. 6dentification
D. (ploitations
;. >esolution
The si nursing roles are#
:. =tranger
C. >esource person
D. Teacher
;. /eader
E. =urrogate
F. -ounselor
6da <ean 4rlandos
Nursing 'rocess Theory
6nterpersonal process alleviates distress.
Nurses must stay connected to patients and
assure that patients get what they need,
focused on patients verbal and non verbal
epressions of need and nurses reactions to
patients behaviour to alleviate distress.
(lements of nursing situation#
:. 'atient
C. Nurse reactions
D. Nursing actions
<oyce Travelbees )uman
To )uman >elationship
%odel
Therapeutic human relationships.
Nursing is accomplished through human to
human relationships that began with# The
original encounter and then progressed
through stages of
(merging identities
7eveloping feelings of empathy and sympathy,
until the nurse and patient attained rapport in
the final stage.
Aathryn (. "arnards
'arent -hild 6nteraction
%odel
.rowth and development of children and
mother,infant relationships
6ndividual characteristics of each member
influence the parent,infant system and
adaptive behaviour modifies those
characteristics to meet the needs of the
system.
>amona T.%ercers
#%aternal >ole
Attainment
'arenting and maternal role attainment in
diverse populations
A comple theory to eplain the factors
impacting the development of maternal role
over time.
Aatharine Aolcabas
Theory of comfort
-omfort is desirable holistic outcome of care.
)ealth 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.
-omfort measures include those nursing
interventions designed to address the specific
comfort needs.
%adeleine /einingers
Transcultural nursing,
culture-care theory
-aring is universal and varies transculturally.
%ajor concepts include care, caring, culture,
cultural values and cultural variations
-aring serves to ameliorate or improve human
conditions and life base.
-are is the essence and the dominant,
distinctive and unifying feature of nursing
>osemarie >i22o
'arses #Theory of human
becoming
6ndivisible beings and environment co-create
health.
A theory of nursing derived from >ogers
conceptual model.
-lients are open, mutual and in constant
interaction with environment.
The nurse assists the client in interaction with
the environment and co creating health
Nola <.'enders #The
)ealth promotionG model
'romoting optimum health supersedes disease
prevention.
6dentifies 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. 5sing 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. 6t 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
RE!ERENCES
.eorge ". <ulia , Nursing Theories- The base for professional Nursing
'ractice, Drd ed. Norwalk, Appleton * /ange.
1ills %.(velyn, %c(wen %elanie &CHHC+. Theoretical "asis for Nursing
'hiladelphia. /ippincott 1illiams* wilkins.
%eleis 6brahim Afaf &:IIJ+ , Theoretical Nursing # 7evelopment * 'rogress
Drd ed. 'hiladelphia, /ippincott.
Taylor -arol,/illis -arol &CHH:+The Art * =cience 4f Nursing -are ;th ed.
'hiladelphia, /ippincott.
'otter A 'atricia, 'erry . Anne &:IIC+ 0undamentals 4f Nursing ,-oncepts
'rocess * 'ractice Drd ed. /ondon %osby Kear "ook.
Tomey A%, Alligood. %>. Nursing theorists and their work. &Eth ed.+.
%osby, 'hiladelphia, CHHC
Alligood %.>, Tomey. A.%. Nursing theory utili2ation and application. Cnd
(d. %osby, 'hiladelphia, CHHC.
DE"ELOPENT O! NURSING
THEORIES
Intro#u$tion
Theories are a set of interrelated concepts that give a systematic view of a
phenomenon &an observable fact or event+ that is eplanatory * predictive in nature.
Theories are composed of concepts, definitions, models, propositions * are based on
assumptions. They are derived through two principal methodsG 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 ?organi2e the
relationship among the concepts to describe, eplain, predict, and control practice@
De%inition
-oncepts are basically vehicles of thought that involve images. -oncepts are
words that describe objects, properties, or events * are basic components of
theory.
Types# (mpirical concepts
6nferential concepts
Abstract concepts
%odels are representations of the interaction among and between the
concepts showing patterns.
'ropositions are statements that eplain the relationship between the
concepts.
'rocess it is a series of actions, changes or functions intended to bring about
a desired result. 7uring 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 3model and 3theory are often wrongly used interchangeably, which
further confounds matters.
6n nursing, models are often designed by theory authors to depict the beliefs
in their theory &/ancaster and /ancaster :IL:+.
They provide an overview of the thinking behind the theory and may
demonstrate how theory can be introduced into practice, for eample,
through specific methods of assessment.
%odels are useful as they allow the concepts in nursing theory to be
successfully applied to nursing practice &/ancaster and /ancaster :IL:+.
Their main limitation is that they are only as accurate or useful as the
underlying theory.
Importan$e o% nursing theories
:. Nursing theory aims to describe, predict and eplain the phenomenon of
nursing &-hinn and <acobs:IJL+.
C. 6t should provide the foundations of nursing practice, help to generate
further knowledge and indicate in which direction nursing should develop in
the future &"rown :IF;+.
D. Theory is important because it helps us to decide what we know and what we
need to know &'arsons:I;I+.
;. 6t helps to distinguish what should form the basis of practice by eplicitly
describing nursing.
E. 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 :IIF+. 6n addition, because
F. The main eponent of nursing , caring , cannot be measured, it is vital to
have the theory to analy2e and eplain what nurses do.
J. As medicine tries to make a move towards adopting a more multidisciplinary
approach to health care, nursing continues to strive to establish a uni9ue
body of knowledge.
L. This can be seen as an attempt by the nursing profession to maintain its
professional boundaries.
The $hara$teristi$s o% theories
Theories are
interrelating concepts in such a way as to create a different way of looking at
a particular phenomenon.
logical in nature.
generali2able.
bases for hypotheses that can be tested.
increasing the general body of knowledge within the discipline through the
research implemented to validate them.
used by the practitioners to guide and improve their practice.
consistent with other validated theories, laws, and principles but will leave
open unanswered 9uestions that need to be investigated.
&asi$ pro$esses in the #e'e(opment o% nursing theories
Nursing theories are often based on * influenced by broadly applicable processes *
theories. 0ollowing theories are basic to many nursing concepts.
Genera( System Theory
6t 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. %olecules in chemistry, cultures in sociology, and organs in Anatomy * )ealth in
Nursing.
A#aptation Theory
6t 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.
B )uman adaptation occurs on three levels #
:. The internal &self+
C. The social &others+ *
D. the physical &biochemical reactions+
De'e(opmenta( Theory
:. 6t outlines the process of growth * development of humans as orderly *
predictable, beginning with conception * ending with death.
C. The progress * behaviors of an individual within each stage are uni9ue.
D. The growth * development of an individual are influenced by heredity,
temperament, emotional, * physical environment, life eperiences * health
status.
Common $on$epts in nursing theories
0our concepts common in nursing theory that influence * determine nursing practice
are#
The person &patient+.
The environment
)ealth
Nursing &goals, roles, functions+
(ach of these concepts is usually defined * described by a nursing theorist, often
uni9uelyG although these concepts are common to all nursing theories. 4f the four
concepts, the most important is that of the person. The focus of nursing, regardless
of definition or theory, is the person.
Histori$a( perspe$ti'es an# )ey $on$epts
Nightingale &:LFH+# To facilitate ?the bodys reparative processes@ by
manipulating clients environment
'eplau :IEC# Nursing isG therapeutic interpersonal process.
)enderson :IEE# The needs often called )endersons :; basic needs
Abdellah :IFH# The nursing theory developed by 0aye Abdellah et al &:IFH+
emphasi2es delivering nursing care for the whole person to meet the physical,
emotional, intellectual, social, and spiritual needs of the client and family.
4rlando :IFC# To 6da 4rlando &:IFH+, the client is an individualG with a needG
that, when met, diminishes distress, increases ade9uacy, or enhances well-
being.
<ohnsons Theory :IFL# 7orothy <ohnsons theory of nursing :IFL 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 thatG the client
can move more easily through recovery.
>ogers :IJH# to maintain and promote health, prevent illness, and care for
and rehabilitate ill and disabled client through ?humanistic science of nursing@
4rem:IJ:# This is self-care deficit theory. Nursing care becomes necessary
when client is unable to fulfill biological, psychological, developmental, or
social needs.
Aing :IJ:# To use communication to help client reestablish positive
adaptation to environment.
Neuman :IJC# =tress reduction is goal of system model of nursing practice.
>oy :IJI# This adaptation model is based on the physiological, psychological,
sociological and dependence-independence adaptive modes.
1atsons Theory :IJI# 1atsons philosophy of caring :IJI attempts to define
the outcome of nursing activity in regard to theG humanistic aspects of life.
C(assi%i$ation o% nursing theories
Depen#ing On !un$tion *Po(it et a( +,,-.
7escriptive To identify the properties and
workings of a discipline
(planatory To eamine how properties relate and
thus affect the discipline
'redictive To calculate relationships between
properties and how they occur
'rescriptive

To identify under which conditions
relationships occur
Depen#ing on the Genera(isa/i(ity o% their prin$ip(es
%etatheory# the theory of theory. 6dentifies specific
phenomena through abstract concepts.
.rand theory# provides a conceptual framework under
which the key concepts and
'rinciples of the discipline can be identified.
%iddle range theory# is more precise and only analyses
a particular situation with a limited number of variables.
'ractice theory# eplores one particular situation found
in nursing. 6t identifies eplicit goals and details how
these goals will be achieved.
&ase# on the phi(osophi$a( un#erpinnings o% the theories
?Needs ?theories.
?6nteraction@ theories.
?4utcome ?theories.
)umanistic theories.
0Nee#s1 theories
These theories are based around helping individuals to fulfill their physical and
mental needs. The basis of these theories is well-illustrated in >oper, /ogan
and Tierneys %odel of Nursing &:ILH+.
Needs theories have been critici2ed for relying too much on the medical model
of health and placing the patient in an overtly dependent position.
0Intera$tion1 theories
As described by 'eplau &:ILL+, these theories revolve around the
relationships nurses form with patients.
=uch theories have been critici2ed for largely ignoring the medical model of
health and not attending to basic physical needs.
0Out$ome1 theories
These portray the nurse as the changing force, who enables individuals to
adapt to or cope with ill health &>oy :ILH+.
4utcome theories have been critici2ed as too abstract and difficult to
implement in practice &Aggleton and -halmers :ILL+.
0Humanisti$1 Theories
)umanistic theories developed in response to the psychoanalytic thought that
a persons destiny was determined early in life.
)umanistic theories emphasi2e a persons capacity for self-actuali2ation.
)umanists believe that the person contains within himself the potential for
healthy * creative growth.
-arl >ogers developed a person ,centered model of psychotherapy that
emphasi2es the uni9ueness of the individual.
The major contribution that >ogers added to nursing practice is the
understandings that each client is a uni9ue individual, so, person-centered
approach now practice in nursing.
o#e(s o% nursing
5ntil fairly recently, nursing science was derived principally from social,
biologic, and medical science theories.
)owever, from the :IEHs 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 visuali2e reality to
simplify thinking.
A conceptual model shows how various concepts are interrelated and applies
theories to predict or evaluate conse9uences of alternative actions.
According to 0awcett &CHHH+,
A conceptual model ?gives direction to the search for relevant 9uestions about
the phenomena of central interest to a discipline and suggests solutions to
practical problems@
0our concepts are generally considered central to the discipline of nursing#
the person who receives nursing care &the patient or client+G the environment
&society+G nursing &goals, roles, functions+G and health. These four concepts
form a metaparadigm of nursing.
The term metaparadigm comes from the .reek prefi ?meta,@ which means
more comprehensive or transcending, and the word .reek word ?paradigm,@
which means a philosophical or theoretical framework of a discipline upon
which all theories, laws, and generali2ations are formulated &%erriam-
1ebsters -ollegiate 7ictionary, :II;+.
Gro2th an# Sta/i(ity o#e(s o% 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@ &0awcett, :ILI,+.
1ithin the change world view, change and growth are continual and desirable,
?progress is valued, and reali2ation of ones potential is emphasi2ed@
&0awcett+.
'ersistence is endurance in time
'ersistence world view emphasi2es e9uilibrium and balance.
Categories o% Con$eptua( o#e(s
Ten conceptual models of nursing have been classified according to two
criteria#
the world view of change reflected by the model &growth or stability+G
and
the major theoretical conceptual classification with which the model
seems most consistent &systems, stress!adaptation, caring, or
growth!development+.
Systems Theory as a !rame2or)
=ystems theory is concerned with changes caused by interactions among all
the factors &variables+
.eneral systems theory is emphasi2ed
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, :IJF,
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 compleity. Thus the human being, from the level of the individual
to the level of society, can be conceptuali2ed as the client and becomes the
target system for nursing intervention &=ills * )all, :IJJ+.
An e3amp(e o% systems intera$tion
6nput &7iet teaching+
Throughput &Assimilation of information+
4utput &0ood intake+
0eedback &1eight record, )b estimation etc.+
Two nursing models based on systems theory#
6mogene Aings systems interaction model, and
"etty Neumans health care systems model.
a4or Con$epts as De%ine# in King5s o#e(
'erson &human being+ A personal system that interacts with
interpersonal and social systems
(nvironment A contet ?within which human beings
grow, develop, and perform daily
activities@
)ealth dynamic life eperiences of a human
being, which implies continuous
adjustment to stressors in the internal and
eternal environment through optimum
use of ones resources to achieve
maimum potential for daily living@
Nursing A process of human interaction
Imogene King5s Systems Intera$tion o#e(
6n interaction model, the purpose of nursing is to help people attain,
maintain, or restore health. Aings model conceptuali2es three levels of
dynamic interacting systems.
:. 6ndividuals are called ?personal systems.@
C. .roups &two or more persons+ form ?interpersonal systems.@
D. =ociety is composed of ?social systems.@
As the person interacts with the environment, he or she must continuously
adjust to stressors in the internal and eternal environment &Aing, :IL:+.
)ealth assumes achievement of maimum potential for daily living and an
ability to function in social roles. 6t is the ?dynamic life eperiences of a
human being, which implies continuous adjustment to stressors in the internal
and eternal environment through optimum use of ones resources to achieve
maimum potential for daily living@ &Aing, :IL:,+.
?6llness is a deviation from normal, that is, an imbalance in a persons
biological structure or in his psychological makeup, or a conflict in a persons
social relationships@ &Aing, :ILI+.
?The goal of nursing is to help individuals and groups attain, maintain, and
restore health@
=tress# ?a dynamic state whereby a human being interacts with the
environment to maintain balance for growth, development, and performance@
&etty Neuman5s Hea(th Care Systems o#e(
"etty 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
/ines of resistance# protection factors activated when stressors have
penetrated the normal line of defense
Neumans model, organi2ed 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.
?6deally the five variables function harmoniously or are stable in relation to
internal and eternal environmental stressor influences@ &Neuman, CHHC+.
A person is constantly affected by stressors from the internal, eternal, or
created environment.
=tressors are tension-producing stimuli that have the potential to disturb a
persons e9uilibrium or normal line of defense.
This normal line of defense is the persons ?usual steady state.@
6t is the way in which an individual usually deals with stressors.
=tressors may be of three types#
6ntrapersonal# forces arising from within the person
6nterpersonal# forces arising between persons
(trapersonal# forces arising from outside the person
>esistance to stressors is provided by a fleible line of defense, a dynamic
protective buffer made up of all variables affecting a person at any given
moment the persons resistance to any given stressor or stressors.
6f the fleible line of defense is no longer able to protect the person against a
stressor, the stressor breaks through, disturbs the persons e9uilibrium, 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, :IIF+.
Thus, health &wellness+ seems to be related to dynamic e9uilibrium of the
normal line of defense, where stressors are successfully overcome or avoided
by the fleible line of defense.
Neuman defines illness as ?a state of insufficiency with disrupting needs
unsatisfied@ &Neuman, CHHC+.
6llness appears to be a separate state when a stressor breaks through the
normal line of defense and causes a reaction with the persons lines of
resistance.
Stress6A#aptation Theory as a !rame2or)
6n 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 eistence. Adaptation theory provides a way to understand both
how the balance is maintained and the possible effects of disturbed
e9uilibrium.
This theory has been widely applied to eplain, predict, and control biologic
&physiologic and psychological+ phenomenon.
A uni7ue /o#y o% )no2(e#ge
The drive for a uni9ue body of knowledge is based on the assumption that
3borrowed knowledge is less worthy.
)owever, nurse education is based on theory borrowed from other disciplines,
such as sociology and psychology.
6t 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.
6t has been argued that no knowledge is eclusive, and because of nursings
diverse nature it is impossible for it to have a uni9ue body of knowledge and
one unified body of theory &-astledine :II;, /evine :IIE+.
Criti$isms o% 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 o% (anguage
=cott &:II;+ states that the crucial ingredients of nursing theory should be
accessibility and clarity. )owever, one of the main criticisms of nursing theory
is its use of overtly comple language &Aenny :IID+. 6t is important that the
language used in the development of nursing theory be used consistently.
Not part o% e'ery#ay pra$ti$e
7espite theory and practice being viewed as inseparable concepts, a theory-
practice gap still eists in nursing &5pton :III+. Ket despite the availability
of a vast amount of literature on the subject, nursing theory still means very
little to most practicing nurses. 'erhaps this is because the majority of
nursing theory is developed by and for nursing academics &/athlean :II;+. 6t
has been recognised that traditionally nurses are used to 3speaking with their
hands &/evine :IIE+. Therefore, many nurses have not had the training or
eperience 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 &%iller :ILE+.
Summari8ation
:. 7efinition
C. 6mportance of Nursing Theories
D. The characteristics of theories#
;. "asic 'rocesses in the 7evelopment 4f Nursing Theories#
E. Nursing theories are often based on * influenced
F. ANA definition of Nursing 'ractice
J. -ommon concepts in Nursing Theories#
L. )istorical 'erspectives * Aey -oncepts
I. -lasification of Nursing Theories
:H. %odels 4f Nursing
::. .rowth and =tability %odels of -hange
:C. "etty Neumans )ealth -are =ystems %odel
:D. =tress!Adaptation Theory as a 0ramework
:;. A uni9ue body of knowledge
:E. -riticisms of nursing theories
Con$(usion
/ittlejohn &CHHC+ comments that, irrespective of nursing theories nurses will continue
to ehibit a caring response to the 3sick and troubled. 6f this is true, perhaps nurses
are 3nursing without the knowledge of theories and theory is irrelevant. )owever,
theory and practice are related, and if nursing is to continue to develop, the concept
of theory must be addressed. 6f nursing theory does not drive the development of
nursing, it will continue to develop in the footsteps of other disciplines such as
medicine
Re%eren$e
'ractice , D
rd
ed. Norwalk, Appleton * /ange.
%eleis 6brahim Afaf &:IIJ+ , Theoretical Nursing # 7evelopment * 'rogress D
rd
ed. 'hiladelphia, /ippincott.
Taylor -arol,/illis -arol &CHH:+The Art * =cience 4f Nursing -are ;
th
ed.
'rocess * 'ractice D
rd
ed. /ondon %osby Kear "ook.
8andemark /.%. Awareness of self * epanding consciousness# using Nursing
theories to prepare nurse ,therapists %ent )ealth Nurs. CHHF <ulG CJ&F+ #
FHE-:E
>eed '., The force of nursing theory guided- practice. Nurs =ci M. CHHF
<ulG:I&D+#CCE
Nursing Theorists
De%initions
Theory- a set of related statements that describes or eplains phenomena in a
systematic way
-oncept-a mental idea of a phenomenon
-onstruct- a phenomena that cannot be observed and must be inferred
'roposition- a statement of relationship between concepts
-onceptual model- made up of concepts and propositions
Nursing Theorists
0lorence Nightingale,
)ildegard 'eplau
8irginia )enderson
0ay Abdella
6da <ean 4rlando
7orothy <ohnson
%artha >ogers
7orothea 4rem
6mogene Aing
"etty Neuman
=ister -alista >oy,
<ean 1atson
>osemary >i22o 'arse
%adeleine /eininger
'atricia "enner
Con$epts in the nursing
%etaparadigm
Person
>ecipient of care, including physical, spiritual, psychological, and
sociocultural components
6ndividual, family, or community
En'ironment
All internal and eternal conditions, circumstances, and influences affecting
the person
Hea(th
7egree of wellness or illness eperienced by the person
Nursing
Actions, characteristics and attributes of person giving care
0lorence Nightingale- (nvironmental Theory
0irst nursing theorist
5nsanitary conditions posed health ha2ard &Notes on Nursing, :LEI+
E components of environment
ventilation, light, warmth, effluvia, noise
(ternal influences can prevent, suppress or contribute to disease or death
Nightinga(e5s Con$epts
'erson
o 'atient who is acted on by nurse
o Affected by environment
o )as reparative powers
(nvironment
o 0oundation of theory. 6ncluded everything, physical, psychological,
and social
)ealth
o %aintaining well-being by using a persons powers
o %aintained by control of environment
Nursing
o 'rovided fresh air, warmth, cleanliness, good diet, 9uiet to facilitate
persons reparative process
)ildegard 'eplau -6nterpersonal >elations %odel
"ased on psychodynamic nursing
using an understanding of ones own behavior to help others identify their
difficulties
Applies principles of human relations
'atient has a felt need
Pep(au5s Con$epts
'erson
o An individualG a developing organism who tries to reduce aniety
caused by needs
o /ives in instable e9uilibrium
(nvironment- Not defined
)ealth
o 6mplies forward movement of the personality and human processes
toward creative, constructive, productive, personal, and community
living
Nursing
o A significant, therapeutic, interpersonal process that functions
cooperatively with others to make health possible
o 6nvolves problem-solving
8irginia )enderson -The Nature of Nursing
NThe uni9ue function of the nurse is to assist the individual, sick or well, in
the performance of those activities contributing to health or its recovery
&or to peaceful death+ that he would perform unaided if he had the
necessary strength, will, or knowledge. And to do this in such a way as to
help him gain independence as rapidly as possible. =he must in a sense,
get inside the skin of each of her patients in order to know what he needsN.
0ay Abdella- Topology of C: Nursing 'roblems
A list of C: nursing problems
-ondition presented or faced by the patient or family.
'roblems are in D categories
physical, social and emotional
The nurse must be a good problem solver
A/#e((a5s Con$epts
Nursing
o A helping profession
o A comprehensive service to meet patients needs
o 6ncreases or restores self-help ability
o 5ses C: problems to guide nursing care
)ealth
o (cludes illness
o No unmet needs and no actual or anticipated impairments
'erson
o 4ne who has physical, emotional, or social needs
o The recipient of nursing care.
(nvironment
o 7id not discuss much
o 6ncludes room, home, and community
6da <ean 4rlando- 7eliberative Nursing 'rocess
The deliberative nursing process is set in motion by the patients behavior
All behavior may represent a cry for help. 'atients behavior can be verbal
or non-verbal.
The nurse reacts to patients behavior and forms basis for determining
nurses acts.
'erception, thought, feeling
Nurses actions should be deliberative, rather than automatic
7eliberative actions eplore the meaning and relevance of an action.
7orothy <ohnson-"ehavioral =ystems %odel
The person is a behavioral system comprised of a set of organi2ed,
interactive, interdependent, and integrated subsystems
-onstancy is maintained through biological, psychological, and sociological
factors.
A steady state is maintained through adjusting and adapting to internal and
eternal forces.
9ohnson5s : Su/systems
Affiliative subsystem
o social bonds
7ependency
o helping or nuturing
6ngestive
o food intake
(liminative
o ecretion
=eual
o procreation and gratification
Aggressive
o self-protection and preservation
Achievement
o efforts to gain mastery and control
9ohnson5s Con$epts
'erson
o A behavioral system comprised of subsystems constantly trying to
maintain a steady state
(nvironment
o Not specifically defined but does say there is an internal and eternal
environment
)ealth
o "alance and stability.
Nursing
o (ternal regulatory force that is indicated only when there is
instability.
%artha >ogers -5nitary )uman "eings
(nergy fields
o 0undamental unity of things that are uni9ue, dynamic, open, and
infinite
o 5nitary man and environmental field
5niverse of open systems
o (nergy fields are open, infinite, and interactive
'attern
o -haracteristic of energy field
o A wave that changes, becomes comple and diverse
'andimensionality
o A nonlinear domain with out time or space
Roger5s De%initions
6ntegrality
o -ontinuous and mutual interaction between man and environment
>esonancy
o -ontinuous change longer to shorter wave patterns in human and
environmental fields
)elicy
o -ontinuous, probabilistic, increasing diversity of the human and
envrionmental fields.
o -haracteri2ed by nonrepeating rhymicities
o -hange
7orothea 4rem- =elf--are %odel
=elf-care comprises those activities performed independently by an
individual to promote and maintain person well-being
=elf care agency is the individuals ability to perform self care activities
=elf- care deficit occurs when the person cannot carry out self-care
The nurse then meets the self-care needs by acting or doing forG guiding,
teaching, supporting or providing the environment to promote patients
ability
1holly compensatory nursing system-'atient dependent
'artially compensatory- 'atient can meet some needs but needs nursing
assistance
=upportive educative-'atient can meet self care re9uisites, but needs
assistance with decision making or knowledge
6mogene Aing-.oal Attainment Theory
4pen systems framework
)uman beings are open systems in constant interaction with the
environment
'ersonal =ystem
o individualG perception, self, growth, development, time space, body
image
o 6nterpersonal
o =ociety
'ersonal =ystem
o 6ndividualG perception, self, growth, development, time space, body
image
6nterpersonal
o =ociali2ationG interaction, communication and transaction
=ociety
o 0amily, religious groups, schools, work, peers
The nurse and patient mutually communicate, establish goals and take
action to attain goals
(ach individual brings a different set of values, ideas, attitudes, perceptions
to echange
"etty Neuman - )ealth -are =ystems %odel
The person is a complete system, with interrelated parts
maintains balance and harmony between internal and eternal environment
by adjusting to stress and defending against tension-producing stimuli
0ocuses on stress and stress reduction
'rimarily concerned with effects of stress on health
=tressors are any forces that alter the systems stability
0leible lines of resistance
=urround basic core
6nternal factors that help defend against stressors
Normal line of resistance
Normal adaptation state
0leible line of defense
'rotective barrier, changing, affected by variables
1ellness is e9uilibrium
Nursing interventions are activates to#
strengthen fleible lines of defense
strengthen resistance to stressors
maintain adaptation
=ister -alista >oy - Adaptation %odel
0ive 6nterrelated (ssential (lements
'atiency- The person receiving care
.oal of nursing- Adapting to change
)ealth-"eing and becoming a whole person
(nvironment
7irection of nursing activities- 0acilitating 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
<ean 1atson - 'hilosophy and =cience of -aring
-aring can be demonstrated and practiced
-aring consists of carative factors
-aring 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
-aring promotes health better than curing
-aring is central to nursing
;atson5s -, Carati'e !a$tors
0orming humanistic-altruistic value system
6nstilling faith-hope
-ultivating sensitivity to self and others
7eveloping helping-trust relationship
'romoting epression of feelings
5sing problem-solving for decision making
'romoting teaching-learning
'romoting supportive environment
Assisting with gratification of human needs
Allowing for eistential-phenomenological forces
;atson5s Con$epts
'erson
o )uman being to be valued, cared for, respected, nurtured,
understood and assisted
(nvironment
o =ociety
)ealth
o -omplete physical, mental and social well-being and functioning
Nursing
o -oncerned with promoting and restoring health, preventing illness
>osemary 'arse - )uman "ecoming Theory
)uman "ecoming Theory includes Totality 'aradigm
o %an is a combination of biological, psychological, sociological and
spiritual factors
=imultaneity 'aradigm
o %an is a unitary being in continuous, mutual interaction with
environment
4riginally %an-/iving-)ealth Theory
Parse5s Three Prin$ip(es
%eaning
o %ans reality is given meaning through lived eperiences
o %an and environment cocreate
>hythmicity
o %an and environment cocreate & imaging, valuing, languaging+ in
rhythmical patterns
-otranscendence
o >efers to reaching out and beyond the limits that a person sets
o 4ne constantly transforms
'erson
o 4pen being who is more than and different from the sum of the parts
(nvironment
o (verything in the person and his eperiences
o 6nseparable, complimentary to and evolving with
)ealth
o 4pen process of being and becoming. 6nvolves synthesis of values
Nursing
o A human science and art that uses an abstract body of knowledge to
serve people
%adeleine /eininger - -ulture -are 7iversity and 5niversality
"ased on transcultural nursing, whose goal is to provide care congruent with
cultural values, beliefs, and practices
=unrise model consists of ; levels that provide a base of knowledge for
delivering cultural congruent care
%odes of nursing action
-ultural care preservation
o help maintain or preserve health, recover from illness, or face death
-ultural care accommodation
o help adapt to or negotiate for a beneficial health status, or face death
-ultural care re-patterning
o help restructure or change lifestyles that are culturally meaningful
'atricia "enner - 0rom Novice to (pert
7escribed E levels of nursing eperience and developed eemplars and
paradigm cases to illustrate each level
/evels reflect#
o movement from reliance on past abstract principles to the use of past
concrete eperience as paradigms
o change in perception of situation as a complete whole in which
certain parts are relevant
Novice
Advanced beginner
-ompetent
'roficient
(pert
6mportance of Theoretical 0rameworks
:.0oundation of any profession is the development of a speciali2ed body of
knowledge. Theories should be developed in nursing, not borrow theories
form other disciplines
C.>esponsibility of nurses to know and understand theorists
D.-ritically analy2e theoretical frameworks
Re%eren$e
%osby, 'hiladelphia, CHHC.
'ractice , D
rd
ed. Norwalk, Appleton and /ange.
'hiladelphia. /ippincott 1illiamsand wilkins.
%eleis 6brahim Afaf &:IIJ+ , Theoretical Nursing # 7evelopment and
'rogress D
rd
Taylor -arol,/illis -arol &CHH:+The Art and =cience 4f Nursing -are ;
th
ed.
'otter A 'atricia, 'erry . Anne &:IIC+0undamentals 4f Nursing ,-oncepts
'rocess and 'ractice Drd ed. /ondon %osby Kear "ook.
NURSING THEORIES< AN O"ER"IE;
Theory
Aerlinger ---views theories as a set of interrelated concepts that give a systematic
view of a phenomenon & an observable fact or event + that is eplanatory and
predictive in nature. Theories are composed of concepts, definitions, models ,
propositions and are based on assumptions. They are derived through two principal
methods# :+ 7eductive reasoning C+ 6nductive reasoning. Nursing theorists use both
of these methods. Nursing Theory# "arnum&:IIL+---- N attempts to describe or
eplain the phenomenon &process, occurrence and event+ called nursingN
Theories %or Pro%essiona( Nursing
Theory is Na creative and rigorous structuring of ideas that projects a
tentative, purposeful, and systematic view of phenomenaN
A theory makes it possible to Norgani2e the relationship among the concepts
to describe, eplain, predict, and control practiceN
De%inition
-oncepts--- are basically vehicles of thought that involve images. -oncepts
are words that describe objects , properties, or events and are basic
components of theory .
O Types # (mpirical concepts
O 6nferential concepts
O Abstract concepts.
%odels ----- are representations of the interaction among and between the
concepts showing patterns.
'ropositions---- are statements that eplain the relationship between the
concepts.
'rocess ---- it is a series of actions , changes or functions intended to bring
about a desired result . 7uring 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 3model and 3theory are often wrongly used interchangeably, which
further confounds matters.
6n nursing, models are often designed by theory authors to depict the beliefs
in their theory &/ancaster and /ancaster :IL:+.
They provide an overview of the thinking behind the theory and may
demonstrate how theory can be introduced into practice, for eample,
through specific methods of assessment.
%odels are useful as they allow the concepts in nursing theory to be
successfully applied to nursing practice &/ancaster and /ancaster :IL:+.
Their main limitation is that they are only as accurate or useful as the
underlying theory.
Importan$e o% Nursing Theories
Nursing theory aims to describe, predict and eplain the phenomenon of
nursing &-hinn and <acobs:IJL+.
6t should provide the foundations of nursing practice, help to generate further
knowledge and indicate in which direction nursing should develop in the
future &"rown :IF;+.
Theory is important because it helps us to decide what we know and what we
need to know &'arsons:I;I+.
6t helps to distinguish what should form the basis of practice by eplicitly
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 :IIF+. 6n addition, because the main eponent of nursing , caring ,
cannot be measured, it is vital to have the theory to analy2e and eplain 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 uni9ue
body of knowledge.
This can be seen as an attempt by the nursing profession to maintain its
professional boundaries.
The $hara$teristi$s o% theories
Theories#
interrelate concepts in such a way as to create a different way of looking at a
particular phenomenon.
are logical in nature.
are generali2able.
are the bases for hypotheses that can be tested.
increase the general body of knowledge within the discipline through the
research implemented to validate them.
are used by the practitioners to guide and improve their practice.
are consistent with other validated theories, laws, and principles but will leave
open unanswered 9uestions that need to be investigated
&asi$ Pro$esses in the De'e(opment O% Nursing Theories<
Nursing theories are often based on and influenced by broadly applicable
processes and theories. 0ollowing theories are basic to many nursing
concepts.
Genera( System Theory#
6t describes how to break whole things into parts and then to learn how the
parts work together in N systemsN. These concepts may be applied to different
kinds of systems, e.g.. %olecules in chemistry , cultures in sociology, organs
in Anatomy and health in Nursing.
A#aptation Theory
6t 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 . )uman
adaptation occurs on three levels#
--- the internal & self +
--- the social &others+
--- and the physical & biochemical reactions +
De'e(opmenta( Theory
6t 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 uni9ue.
The growth and development of an individual are influenced by heredity ,
temperament , emotional, and physical environment , life eperiences and
health status.
Common $on$epts in Nursing Theories<
0our concepts common in nursing theory that influence and determine
nursing practice are
-- The person& patient+ .
--- The environment
-- )ealth
--- Nursing &goals, roles, functions+
(ach of these concepts is usually defined and described by a nursing theorist ,
4ften uni9uelyG although these concepts are common to all nursing theories.
4f the four concepts , the most important is that of the person. The focus of
nursing , regardless of definition or theory , is the person.
Histori$a( Perspe$ti'es an# Key Con$epts
O Nightinga(e *-=>,.< To facilitate Nthe bodys reparative processesN by
manipulating clients environment
O Pap(au -?@+< Nursing isG therapeutic interpersonal process.
O Hen#erson -?@@< The needs often called )endersons :; basic needs
O A/#e((ah -?>,# The nursing theory developed by 0aye Abdellah et al
&:IFH+ emphasi2es delivering nursing care for the whole person to meet the
physical, emotional, intellectual, social, and spiritual needs of the client and
family.
O Or(an#o -?>+< To 6da 4rlando &:IFH+, the client is an individualG with a
needG that, when met, diminishes distress, increases ade9uacy, or enhances
well-being.
O 9ohnson5s Theory -?>=< 7orothy <ohnsons theory of nursing :IFL
focuses on how the client adapts to illness and how actual or potential stress
can affect the ability to adapt. The goal of nursing to reduce stress so thatG
the client can move more easily through recovery.
O Rogers -?:,< to maintain and promote health, prevent illness, and care
for and rehabilitate ill and disabled client through Nhumanistic science of
nursingN Orem-?:-# This is self-care deficit theory. Nursing care becomes
necessary when client is unable to fulfill biological, psychological,
developmental, or social needs.
O King -?:-< To use communication to help client reestablish positive
adaptation to environment.
O Neuman -?:+< =tress reduction is goal of system model of nursing
practice.
O Roy -?:?< This adaptation model is based on the physiological,
psychological, sociological and dependence-independence adaptive modes.
O ;atson5s Theory -?:?# 1atsons philosophy of caring :IJI attempts
to define the outcome of nursing activity in regard to theG humanistic aspects
of life.
C(assi%i$ation o% Nursing Theories
Depen#ing On The Genera(isa/i(ity O% Their Prin$ip(es
%etatheory# the theory of theory. 6dentifies
specific phenomena through abstract concepts.
.rand theory# provides a conceptual framework under which the key concepts
and
principles of the discipline can be identified.
%iddle range theory# is more precise and only analyses a particular situation
with a limited number of variables.
'ractice theory# eplores one particular situation found in nursing. 6t identifies
eplicit goals and details how these goals will be achieved.
Theories $an a(so /e $ategorise# as<
NNeeds Ntheories.
N6nteractionN theories.
N4utcome Ntheories.
N)umanistic theoriesN
These categories indicate the basic philosophical underpinnings of the theories
ANee#sA theories
These theories are based around helping individuals to fulfill their physical and
mental needs. The basis of these theories is well-illustrated in >oper, /ogan
and Tierneys %odel of Nursing &:ILH+.
Needs theories have been critici2ed for relying too much on the medical model
of health and placing the patient in an overtly dependent position.
AIntera$tionA theories
As described by 'eplau &:ILL+, these theories revolve around the
relationships nurses form with patients.
=uch theories have been critici2ed for largely ignoring the medical model of
health and not attending to basic physical needs.
AOut$omeA theories
These portray the nurse as the changing force, who enables individuals to
adapt to or cope with ill health &>oy :ILH+.
4utcome theories have been critici2ed as too abstract and difficult to
implement in practice &Aggleton and -halmers :ILL+.
AHumanisti$A Theories<
)umanistic theories developed in response to the psychoanalytic thought that
a persons destiny was determined early in life.
)umanistic theories emphasi2e a persons capacity for self actuali2ation .
)umanists believes that the person contains within himself the potential for
healthy and creative growth.
-arl >ogers developed a person ,centered model of psychotherapy that
emphasi2es the uni9ueness of the individual.
The major contribution that >ogers added to nursing practice is the
understanding that each client is a uni9ue individual, so person-centered
approach now practice in Nursing.
ODELS O! NURSING
5ntil fairly recently, nursing science was derived principally from social,
biologic, and medical science theories.
)owever, from the :IEHs 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 visuali2e reality to
simplify thinking.
A conceptual model shows how various concepts are interrelated and applies
theories to predict or evaluate conse9uences of alternative actions.
According to 0awcett &CHHH+,
A conceptual model Ngives direction to the search for relevant 9uestions about
the phenomena of central interest to a discipline and suggests solutions to
practical problemsN
. 0our concepts are generally considered central to the discipline of nursing#
the person who receives nursing care &the patient or client+G the environment
&society+G nursing &goals, roles, functions+G and health.
These four concepts form a metaparadigm of nursing.
The term metaparadigm comes from the .reek prefi
Nmeta,N which means more comprehensive or transcending,
and the word .reek word Nparadigm,N which means a philosophical or
theoretical framework of a discipline
upon which all theories, laws, and generali2ations are formulated &Merriam-
Websters Collegiate Dictionary, :II;+.
Gro2th an# Sta/i(ity o#e(s o% Change
There are two major differences in philosophical beliefs, or world views, about
the nature of change.
NThe world view of change uses the growth metaphor, and the persistence
view focuses
on stabilityN &0awcett, :ILI,+.
1ithin the change world view, change and growth are continual and desirable,
Nprogress is valued, and reali2ation of ones potential is emphasi2edN
&0awcett+.
'ersistence is endurance in time
persistence world view emphasi2es e9uilibrium and balance.
Categories o% Con$eptua( o#e(s
Ten conceptual models of nursing have been classified according to two
criteria#
the world view of change reflected by the model &growth or stability+G and
the major theoretical conceptual classification with which the model seems
most consistent &systems, stress!adaptation, caring, or growth!development+.
Systems Theory as a !rame2or)
=ystems theory is concerned with changes caused by interactions among all
the factors &variables+
.eneral systems theory is emphasi2ed
A system is defined as Na whole with interrelated parts, in which the parts
have a function and the system as a totality has a functionN &Auger, :IJF+
A general systems approach allows for consideration of the subsystems levels
of the human being, as a total human being, and as a social creature who
networks himself with others in hierarchically arranged human systems of
increasing compleity. Thus the human being, from the level of the individual
to the level of society, can be conceptuali2ed as the client and becomes the
target system for nursing intervention. &=ills and )all, :IJJ+.
An eample of systems interaction
:. 6nput &7iet teaching+
Throughput &Assimilation of information+
4utput &0ood intake+
0eedback &1eight record ,)b estimation etc.+
T2o nursing mo#e(s /ase# on systems theory<
C. 6mogene Aings systems interaction model, and
D. "etty Neumans health care systems model.
Imogene King5s Systems Intera$tion o#e(
interaction model, the purpose of nursing is to help people attain, maintain,
or restore health
Aings model conceptuali2es three levels of dynamic interacting systems.
:. 6ndividuals are called Npersonal systems.N
C. .roups &two or more persons+ form Ninterpersonal systems.N
D. =ociety is composed of Nsocial systems.N
As the person interacts with the environment, he or she must continuously
adjust to stressors in the internal and eternal environment &Aing, :IL:+.
)ealth assumes achievement of maimum potential for daily living and an
ability to function
in social roles. 6t is the Ndynamic life eperiences of a human being, which
implies continuous
adjustment to stressors in the internal and eternal environment through
optimum use of ones resources to achieve maimum potential for daily
livingN &Aing, :IL:,+.
N6llness is a deviation from normal, that is, an imbalance in a persons
biological structure or in his psychological makeup, or a conflict in a persons
social relationshipsN &Aing, :ILI+.
NThe goal of nursing is to help individuals and groups attain, maintain, and
restore healthN
=tress# Na dynamic state whereby a human being interacts with the
environment to maintain balance for growth, development, and performanceN
&etty Neuman5s Hea(th Care Systems o#e(
"etty 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
/ines of resistance# protection factors activated when stressors have
penetrated the normalline of defense
Neumans model, organi2ed 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.
N6deally the five variables function harmoniously or are stable in relation to
internal and eternal environmental stressor influencesN &Neuman, CHHC+.
A person is constantly affected by stressors from the internal, eternal, or
created environment.
=tressors are tension-producing stimuli that have the potential to disturb a
persons e9uilibrium or normal line of defense.
This normal line of defense is the persons Nusual steady state.N
6t is the way in which an individual usually deals with stressors.
=tressors may be of three types#
6ntrapersonal# forces arising from within the person
6nterpersonal# forces arising between persons
(trapersonal# forces arising from outside the person
>esistance to stressors is provided by a fleible line of defense, a dynamic
protective buffer made up of all variables affecting a person at any given
moment the persons resistance to any given stressor or stressors.
6f the fleible line of defense is no longer able to protect the person against a
stressor, the stressor
breaks through, disturbs the persons e9uilibrium, and triggers a reaction. The
reaction may lead
toward restoration of balance or toward death.
Neuman intends for the nurse to Nassist clients to retain, attain, or maintain
optimal system stabilityN &Neuman, :IIF+.
Thus, health &wellness+ seems to be related to dynamic e9uilibrium of the
normal line of defense, where stressors are successfully overcome or avoided
by the fleible line of defense.
Neuman defines illness as Na state of insufficiency with disrupting needs
unsatisfiedN &Neuman, CHHC+.
6llness appears to be a separate state when a stressor breaks through the
normal line of defense and causes a reaction with the persons lines of
resistance.
Stress6A#aptation Theory as a !rame2or)
6n 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 eistence. Adaptation theory provides a way to understand
both how the balance is maintained and the possible effects of disturbed
e9uilibrium.
This theory has been widely applied to eplain, predict, and control biologic
&physiologic and psychological+
A uni7ue /o#y o% )no2(e#ge
The drive for a uni9ue body of knowledge is based
on the assumption that 3borrowed knowledge is
less worthy.
)owever, nurse education is based on theory borrowed from other disciplines,
such as sociology and psychology.
6t 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.
6t has been argued that no knowledge is eclusive, and because of nursings
diverse nature it is impossible for it to have a uni9ue body of knowledge and
one unified body of theory &-astledine :II;, /evine :IIE+.
Criti$isms o% nursing theories
To understand why nursing theory is generally neglected on the wards it is
necessary to take a closer look at the main criticisms of nursing theory and
the role that nurses play in contributing to its lack of prevalence in practice.
5se of language =cott &:II;+ states that the crucial ingredients of nursing
theory should be accessibility and clarity. )owever, one of the main criticisms
of nursing theory is its use of overtly comple language &Aenny :IID+.
6t is important that the language used in the
development of nursing theory be used consistently.
Not part of everyday practice 7espite theory and practice being viewed as
inseparable concepts, a theory-practice gap still eists in nursing &5pton
:III+.
Ket despite the availability of a vast amount of literature on the subject,
nursing theory still means very little to most practicing nurses. 'erhaps this is
because the majority of nursing theory is developed by and for nursing
academics &/athlean :II;+.
6t has been recognised that traditionally nurses are used to 3speaking with
their hands &/evine :IIE+.
Therefore, many nurses have not had the training or eperience to deal with
the abstract concepts presented by nursing theory.
This makes it difficult for the majority of nurses to understand and apply
theory to practice &%iller :ILE+.
Summary
7efinition
6mportance of Nursing Theories
The characteristics of theories#
"asic 'rocesses in the 7evelopment 4f Nursing Theories#
Nursing theories are often based on and influenced
ANA definition of Nursing 'ractice
-ommon concepts in Nursing Theories#
)istorical 'erspectives and Aey -oncepts
-lassification of Nursing Theories
%odels 4f Nursing
.rowth and =tability %odels of -hange
"etty Neumans )ealth -are =ystems %odel
=tress!Adaptation Theory as a 0ramework
A uni9ue body of knowledge
-riticisms of nursing theories
Con$(usion<
/ittlejohn &CHHC+ comments that irrespective of nursing theories, nurses will
continue to ehibit a caring response to the 3sick and troubled. 6f this is true,
perhaps nurses are 3nursing without the knowledge of theories and theory is
irrelevant. )owever, theory and practice are related, and if nursing is to
continue to develop, the concept of theory must be addressed. 6f nursing
theory does not drive the development of nursing, it will continue to develop
in the footsteps of other disciplines such as medicine
Re%eren$e<
:. .eorge ". <ulia , Nursing Theories- The base for professional Nursing
'ractice , D
rd
C. 1ills %.(velyn, %c(wen %elanie &CHHC+. Theoretical "asis for Nursing
D. %eleis 6brahim Afaf &:IIJ+ , Theoretical Nursing # 7evelopment and 'rogress
D
rd
;. Taylor -arol,/illis -arol &CHH:+The Art and =cience 4f Nursing -are ;
th
ed.
E. 'otter A 'atricia, 'erry . Anne &:IIC+0undamentals 4f Nursing ,-oncepts
'rocess and 'ractice D
rd
UNDERSTANDING THE ;ORK O!
NURSE THEORISTS
BBB Creati'e &eginning
Theories o% Nursing
Theory is Nan internally consistent group of relational statements &concepts,
definitions and propositions+ that present a systematic view about a
phenomenon and which is useful for description, eplanation, prediction
and controlN.
Theories are road maps that provide a framework for selecting and
organi2ing information#
o 1hat to ask
o 1hat to observe
o 1hat to focus on
o 1hat to think about
Nursing theory is an organi2ed and systematic articulation of a set of
statements related to 9uestions in the discipline of nursing.
Uses o% Theory
Theory is used to#
7escribe
(plain
'redict
'rescribe
Uses o% Nursing Theory
7efine relationships among the variables of a given field of in9uiry
.uide research, practice and communication
Allow the prediction of the conse9uences of care
Allow the prediction of a range of patient responses
Le'e(s o% Theory
There are four levels of theory
%etatheory
.rand Theory
%iddle >ange Theory
'ractice Theory
Types o% Theory
6n Nursing there are four types of theories#
Needs
6nteraction
4utcome
)umanistic
Pra$ti$e 'a(ue o% theory
(nhances understanding and eplanation for events
6nfluence our behavior.
%akes to think differently about a problem or a situation
)elps to try new approaches or altering behavior.
1e can gain a new perspective of events
"asis for challenge of its speculative tenets or propositions
-hallenges subse9uent discovery of new ideas or knowledge that might
eplain and predict events not yet understood
In pra$ti$e
Assist nurses to describe, eplain, and predict everyday eperiences.
=erve to guide assessment, intervention, and evaluation of nursing care.
'rovide a rationale for collecting reliable and valid data about the health
status of clients, which are essential for effective decision making and
implementation.
)elp to establish criteria to measure the 9uality of nursing care
)elp build a common nursing terminology to use in communicating with
other health professionals. 6deas are developed and words defined.
(nhance autonomy &independence and self-governance+ of nursing by
defining its own independent functions.
In e#u$ation
'rovide a general focus for curriculum design.
.uide curricular decision making
In resear$h
4ffer a framework for generating knowledge and new ideas.
Assist in discovering knowledge gaps in specific field of study.
4ffer a systematic approach to identify 9uestions for study, select variables,
interpret findings, and validate nursing interventions.
An i((ustrationBB
The germ theory
(plains the phenomenon of disease transmission
%eans of speculative eplanation and prediction of certain observable events
Allows us to effectively function to prevent transmission of communicable
disease.
8iable basis upon which to make decisions about how to prevent certain
illnesses.
There are phenomena we do not understand that are related to germ
transmission,
(ample-the communicability of cancer.
ANursing Pra$ti$eCA
All eperiences and events a practicing nurse encounters in the process of
providing nursing care.
E'entsBCC
=ome may be eperienced by the client,
4thers by the nurse
=ome may be observed in the environment
%ay be observed in the nurse-client interaction.
6n situations of daily work or living,
PPPP..but as long as they are observable during the process of providing direct
nursing care, they are considered part of nursing practice.
Approa$hes to inter re(ationships /et2een pra$ti$e an# theory
)ow nursing practice contributes to the process of theory development..
)ow theory contributes to nursing practiceP
Contri/ution o% pra$ti$e to theory #e'e(opment
Theory development within nursing occurs in the contet of practice.
Two activities contribute significantly to the overall process of developing
theory in nursing.
-oncept analysis and
'ractical validation of theory.
Con$ept ana(ysis
6dentify and verify abstract concepts
Nwhat events in practice can be linked with abstract concept N
Application of theory in practice
Nursing process operation of analysis of assessment data.
5sed as scientific rationale supporting judgments in nursing care plans.
Con$epts
-oncepts may be &a+ readily observable, or concrete, ideas such as
thermometer, rash, and lesionG &b+ indirectly observable, or inferential,
ideas such as pain and temperatureG or c+ non-observable, or abstract,
ideas such as e9uilibrium, adaptation, stress, and powerlessness
nursing theories address and specify relationships among four major
abstract concepts referred to as the metaparadigm of nursing.
0our concepts are considered to be central to nursing #
'erson or client, the recipient of nursing care &includes individuals, families,
groups, and communities+.
(nvironment, the internal and eternal surroundings that affect the client.
This includes people in the physical environment, such as families, friends,
and significant others.
)ealth, the degree of wellness or well-being that the client eperiences.
Nursing, the attributes, characteristics, and actions of the nurse providing
care on behalf of, or in conjunction with, the client
Nightinga(e5s en'ironmenta( theory
Nthe act of utili2ing the environment of the patient to assist him in his
recoveryN
=he linked health with five environmental factors #
'ure or fresh air
'ure water
(fficient drainage
-leanliness
/ight, especially direct sunlight
7eficiencies in these five factors produced lack
4f health or illness.
Pep(au5s interpersona( re(ations mo#e(
Nurses enter into a personal relationship with an individual when a felt need
is present
Hen#erson5s #e%inition o% nursing
)enderson conceptuali2ed the nurses role as assisting sick or well
individuals to gain independence in meeting :; fundamental needs
&)enderson+
"reathing normally
(ating and drinking ade9uately
(liminating body wastes
%oving and maintaining a desirable position
=leeping and resting
=electing suitable clothes
%aintaining body temperature within normal range by adjusting clothing and
modifying the environment.
Aeeping the body clean and well groomed to protect the integument.
Avoiding dangers in the environment and avoiding injuring others
-ommunicating with others in epressing emotions, needs, fears, or
opinions
1orshipping according to ones faith
1orking in such a way that one feels a sense of accomplishment
'laying or participating in various forms of recreation.
/earning, discovering, or satisfying the curiosity that leads to normal
development and health, and using available health facilities
Roger5s s$ien$e o% unitary human /eings
=he states that humans are dynamic energy fields in continuous echange
with environmental fields, both of which are infinite.
Nurses applying >ogerQs theory in practice &a+ focus on the persons
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 maimum
health potential
Orem5s genera( theory o% nursing
4rems self-care deficit theory eplains 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 individuals abilities to meet current and future
demands.
King5s goa( attainment theory
Aings theory offers insight into nurses interactions with individuals and
groups within the environment. 6t highlights the importance of clients
participation in decision that influence care and focuses on both the
process of nurse-client interaction and the outcomes of care.
Neuman5s systems mo#e(
The model is based on the individuals relationship to stress, the reaction to
it, and reconstitution factors that are dynamic in nature.
"etty NeumanQs model of nursing is applicable to a variety of nursing
practice settings involving individuals, families, groups, and communities.
Roy5s a#aptation mo#e(
>oy 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+.
;atson5s human $aring theory
<ean 1atson &:IJI+ believes the practice of caring is central to nursingG it is
the unifying focus for practice.
Nursing interventions related to human care are referred to as carative
factors.
1atsons theory of human caring has receiving worldwide recognition and is
a major force in redefining nursing as a caring-healing health model.
Parse5s human /e$oming theory
'arses model of human becoming emphasi2es how individuals choose and
bear responsibility for patterns of personal health.
Leininger5s $u(tura( $are #i'ersity an# uni'ersa(ity theory
=he emphasi2es that human caring, although a universal phenomenon,
varies among cultures in its epressions, processes, and patternsG it is
largely culturally derived.
Orem5s genera( theory o% nursing
Assessing
6nvolves collecting data about the clients capacities &knowledge, skills, and
motivation+ to perform universal, developmental, and health-deviation
self-care re9uisites. 7etermine self-care deficits.
Diagnosing
=tated in terms of the clients limitations for maintaining self care &a deficit
in self-care agency+
P(anning
6nvolves considering and designing, with the clients participation, an
appropriate nursing system &wholly compensatory, partially compensatory,
supportive-educative, or a mi+ that will help the client achieve an optimal
level of self care
Imp(ementing
Assisting the client
E'a(uating
:.7etermining the clients level of achievement
Re%eren$es
:.'hipps < 1ilma, =ands A <udith. %edical =urgical Nursing# concepts * clinical
practice.Fth edition. 'hiladelphia. %osby publications. :IIF.
C."lack %. <oice, )awks hokanson <ane. %edical =urgical Nursing# -linical
%anagement for positive outcomes. =t /ois, %issouri. CHHE.
D.Tomey A%, Alligood. %>. Nursing theorists and their work. &Eth ed.+.
;.Alligood %.>, Tomey. A.%. Nursing theory utili2ation and application. Cnd
THEORIES D NURSING RESEARCH
Intro#u$tion
>(=(A>-) , 'rocess of in9uiry
T)(4>K , 'roduct of knowledge
=-6(N-( , >esult of the relationship between research * theory
To effectively build knowledge to research process should be developed within
some theoretical structure that facilities analysis and interpretation of
findings.
>elationship between theory and research in nursing is not well understood. 6t
may be give to the relative youth of the discipline and debates over
philosophical world views. &(mpiricism, constructivism, etcP+
Nee# to Lin) Theory an# Resear$h
>esearch 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 9uestions, aids in
design, analysis and interpretation.
6t enables the scientist to weave the facts together.
Theories %rom Nursing or Other Dis$ip(inesE
Nursing science is blend of knowledge that is uni9ue to nursing and
knowledge that is borrowed from other disciplines.
7ebate is whether the use of borrowed theory has hindered the development
of the discipline.
6t has contributed to problems connecting research and theory in nursing.
Histori$a( O'er'ie2 o% Resear$h an# Theory in Nursing
0lorence Nightingale supported her theoretical propositions through research,
as statistical data and prepared graphs were used to depict the impact of
nursing care on the health of "ritish soldiers.
Afterwards, for almost century reports of nursing research were rare.
>esearch and theory developed separately in nursing.
"etween :ICL and :IEI only C out of :EC studies reported a theoretical basis
for the research design.
6n :IJHs growing number of nurse theorists were seeking researchers to test
their models in research and clinical application
.rand nursing theories are still not widely used. 6n :IIHs borrowed theories
were used more.
Now the focus of research and theory have moved more towards middle
range theories
Purpose o% Theory in Resear$h
To identify meaningful and relevant areas for study.
To propose plausible approaches to health problems.
To develop or refine theories
7efine the concepts and proposed relationships between concepts.
To interpret research findings
To develop clinical practice protocols.
.enerate nursing diagnosis.
Types o% theory an# $orrespon#ing resear$h
Type o% theory Type o% resear$h
7escriptive
(planatory
'redictive
7escriptive or
eplanatory
-o relational
(perimental
Ho2 Theory is use# in Resear$h
Causa( theory o% p(anne# /eha'iour
Theory Generating Resear$h
6t is designed to develop and describe relationships between and among
phenomena without imposing preconceived notations.
6t is inductive and includes field observations and phenomenology.
7uring the theory generating process, the researcher moves by logical
thought from fact to theory by means of a proposition stated as an empirical
generali2ation.
Groun#e# Theory Resear$h
6nductive research techni9ue developed by .la2er and =trauss &:IFJ+
.rounded theory provides a way to describe what is happening and
understanding the process of why it happens.
%ethodology , The researcher observes, collects data, organi2es data and
forms theory from the data at the same time.
7ata may be collected by interview, observation, records or a combination of
these techni9ues.
7ata are coded in preparation for analysis.
-ategory development , -ategories are identified and named
-ategory saturation , -omparison of similar characteristics in each of the
categories
-oncept development , 7efines the categories
=earch for additional categories , -ontinues to eamine the data for
additional categories
-ategory reduction , )igher order categories are selected
/inking of categories , The researcher seeks to understand relationships
among categories
=elective sampling of the literature
(mergence of the core variable , -entral theme are focus of the theory
-oncept modification and integration , (plaining the phenomenal
Theory testing resear$h
6n theory testing research, theoretical statements are translated into
9uestions and hypothesis. 6t re9uires a deductive reasoning process.
The interpretation determines whether the study supports are contradicts the
propositional statement.
6f a conceptual model is used as a theoretical framework for research it is not
theory testing.
Theory testing re9uires detailed eamination of theoretical relationships.
Theory as a $on$eptua( %rame2or)
'roblem being investigated is fit into an eisting 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.
0indings are interpreted in light of eplanations provided by the framework.
6mplications are based on the eplanatory power of a framework.
A Typo(ogy o% Resear$h
Testing
Analy2ing
(perimentation
7educting
7eductive research
Muantitative research
The scientific method
Theory ! hypothesis testing
Assaying
>efining
6nterpreting
>eflecting
6nducing
6nductive research
Mualitative research
'henomenological research
Theory generation
37iviningG 3heuristic research
Gui#e(ines %or 2riting a/out a resear$h stu#y5s theoreti$a( %rame2or)
6n the studys problem statement
:. 6ntroduce the framework
C. "riefly eplain why it is a good fit for the research problem area
D. At the end of the literature review
;. Thoroughly describe the framework and eplain its application to the
present study.
E. 7escribe how the framework has been used in studies about similar
problems
F. 6n the studys methodology section
J. (plain how the framework is being operationali2ed in the studys
design.
L. (plain how data collection methods &such as 9uestionnaire items+
reflect the concepts in the framework.
I. 6n the studys discussion section
:H. 7escribe how study findings are consistent &or inconsistent+ with the
framework.
::. 4ffer suggestions for practice and further research that are congruent
with the frameworks concepts and propositions.
Con$(usion
The relationship between research and theory is undeniable, and it is
important to recogni2e the impact of this relationships on the development of
nursing knowledge. =o interface theory and research by generating theories,
testing the theories and by using it as a conceptual framework that drives the
study.
Re%eren$e
'ractice , Drd ed. Norwalk, Appleton and /ange.
'olit 70, )ungler "'. Nursing >esearch# 'rinciples and %ethods. 'hiladelphia#
<" /ippincott -ompanyG :IIL.
"urns N, .rove =A. The practice of Nursing >esearch. ;th (d. 'hiladelphia#
1" =aunders 'ublicationsG CHH:.
Treece <1, Treece (1. (lements of >esearch in Nursing &Drded.+. =t. /ouis#
%osbyG :ILC.

VIRGINIA HENDERSONS NEED
THEORY
?Nursing theories mirror different realities, throughout their developmentG they
reflected the interests of nurses of that time.@
Intro#u$tion
?The Nightingale of %odern Nursing@
?%odern-7ay %other of Nursing.@
NThe CHth century 0lorence Nightingale.N
Nlittle %iss DEN
"orn in Aansas -ity, %issouri, in :LIJ and is the E
th
child of a family of L
th

children but spent her formative years in 8irginia
>eceived a 7iploma in Nursing from the Army =chool of Nursing at 1alter
>eed )ospital, 1ashington, 7.-. in :IC:.
1orked at the )enry =treet 8isiting Nurse =ervice for C years after
graduation.
6n :ICD, she accepted a position teaching nursing at the Norfolk 'rotestant
)ospital in 8irginia, where she remained for several years
6n :ICI, )enderson determined that she needed more education and
entered Teachers -ollege at -olumbia 5niversity where she earned herG
"achelors 7egree in :IDC, %asters 7egree in :ID;.
=ubse9uently, she joined -olumbia as a member of the faculty, where she
remained until :I;L&)errmann,:IIL+
=ince :IED, she has been a research associate at Kale 5niversity =chool of
Nursing.
7ied# %arch :I, :IIF.
A$hie'ements
6s the recipient of numerous recognitions for her outstanding contributions
to nursingR
8) was a well known nursing educator and a prolific author.
=he has received honorary doctoral degrees from the
o -atholic 5niversity of America
o 'ace 5niversity,
o 5niversity of >ochester,
o 5niversity of 1estern 4ntario,
o Kale 5niversity
)er stature as a nurse, teacher, author, researcher, and consumer health
advocate warranted an obituary in the New Kork Times, 0riday %arch CC.
:IIF.
6n :ILE, %iss )enderson was honored at the Annual %eeting of the Nursing
and Allied )ealth =ection of the %edical /ibrary Association.
Contri/ution
6n :IDJ )enderson and others created a basic nursing curriculum for the
National /eague for Nursing in which education was ?patient centered and
organi2ed around nursing problems rather than medical diagnoses@
&)enderson,:II:+
6n :IDI, she revised# )armers classic tetbook of nursing for its ;th
edition, and later wrote the EthG edition, incorporating her personal
definition of nursing &)enderson,:II:+
Although she was retired, she was a fre9uent visitor to nursing schools well
into her nineties.
4%alley &:IIF+ states that )enderson is known as the modern-day mother
of nursing. )er work influenced the nursing profession in America and
throughout the world
The founding members of 6-6>N &6nteragency -ouncil on 6nformation
>esources for Nursing+ and a passionate advocate for the use and sharing
of health information resources.
6n :IJL the fundamental concept of nursing was revisited by 8irginia
)enderson from Kale 5niversity =chool of Nursing & 5=A +. =he argued that
nurses needed to be prepared for their role by receiving the broadest
understanding of humanity and the world in which they lived.
Pu/(i$ations
:IEF &with ". )armer+-Tetbook for the principles and practices of Nursing.
:IFF-The Nature of Nursing. A definition and its implication for practice,
>esearch and (ducation
:II:- The Nature of Nursing >eflections after CH years
Ana(ysis o% Nursing Theory
6mages of Nursing, :IEH-:IJH
The 0irst =chool 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
9uestions as
1hat do nurses doR
1hat are their functionsR
1hat roles do nurses playR
Answers to these 9uestions focused on a number of theorist describing
functions and roles of nurses.
-onceptuali2ing functions led theorists to consider nursing client in terms of
a )ierarchy of needs. 1hen any of these needs are unmet and when a
person is unable to fulfill his own needs, the care provided by nurses is
re9uired.
Nurses then provide the necessary functions and play those roles that could
help patients meet their needs.
S$hoo( o% thought in Nursing TheoriesF-?@,F-?:,
Nee# theorists Intera$tion
theorists
Out$ome theorists
Abdellah
)enderson
4rem
Aing
4rlando
'eterson and Sderad
'aplau
Travelbee
1iedenbach
<ohnson
/evine
>ogers
>oy
Ana(ysis o% nursing theories a$$or#ing to -st S$hoo(
!o$us Pro/(ems
)uman being A set of needs or problems.
A developmental being.
'atient Need 7eficit
4rientation 6llness, disease
>ole of nurse 7ependent on medical practice.
"eginnings of independent functions
0ulfill needs re9uisites
7ecision making 'rimarily health care professional
Hen#erson5s Theory &a$)groun#
)endersons concept of nursing was derived form her practice and
education therefore, her work is inductive.
=he called her definition of nursing her ?concept@ &)enderson:II:+
Although her major clinical eperiences were in medical-surgical
hospitals, she worked as a visiting nurse in New Kork -ity. This eperience
enlarges )endersons view to recogni2e the importance of increasing the
patients independence so that progress after hospitali2ation would not be
delayed &)enderson,:II:+
8irginia )enderson defined nursing as Nassisting individuals to gain
independence in relation to the performance of activities contributing to
health or its recoveryN &)enderson, :IFF, p. :E+.
=he was one of the first nurses to point out that nursing does not
consist of merely following physicianQs orders.
=he categori2ed nursing activities into :; components, based on
human needs.
=he described the nurseQs 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.
)er famous definition of nursing was one of the first statements
clearly delineating nursing from medicine#
NThe uni9ue 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 possibleN &)enderson, :IFF, p.
:E+.
The #e'e(opment o% Hen#erson5s #e%inition o% nursing
Two events are the basis for )endersons development of a definition of
nursing.
0irst, she participated in the revision of a nursing tetbook.
=econd, she was concerned that many states had no provision for nursing
licensure to ensure safe and competent care for the consumer.
6n the revision she recogni2ed the need to be clear about the functions of
the nurse and she believed that this tetbook serves as a main learning
source for nursing practice should present a sound and definitive
description of nursing.
0urthermore, 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 :IDC and :IDJ, )enderson viewed these statements as
nonspecific and unsatisfactory definitions of nursing practice.
Then in :IEE, the earlier ANA definition was modified.
)endersonQs 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.
=he proposed :; components of basic nursing care to augment her
definition.
6n :IEE, )endersons first definition of nursing was published in
"ertha )armers revised nursing tetbook.
The -G $omponents
"reathe normally.
(at and drink ade9uately.
(liminate body wastes.
%ove and maintain desirable postures.
=leep and rest.
=elect suitable clothes-dress and undress.
%aintain body temperature within normal range by adjusting clothing
and modifying environment
Aeep the body clean and well groomed and protect the integument
Avoid dangers in the environment and avoid injuring others.
-ommunicate with others in epressing emotions, needs, fears, or
opinions.
1orship according to ones faith.
1ork in such a way that there is a sense of accomplishment.
'lay or participate in various forms of recreation.
/earn, discover, or satisfy the curiosity that leads to normal development
and health and use the available health facilities.
The first I 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.
'atients desire to return to health, but this assumption is not
eplicitly 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.
Hen#erson5s theory an# the %our ma4or $on$epts
In#i'i#ua(
)ave basic needs that are component of health.
>e9uiring assistance to achieve health and independence or a
peaceful death.
%ind and body are inseparable and interrelated.
-onsiders 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.
En'ironment
=ettings in which an individual learns uni9ue pattern for living.
All eternal conditions and influences that affect life and
development.
6ndividuals in relation to families
%inimally discusses the impact of the community on the individual
and family.
=upports tasks of private and public agencies
=ociety wants and epects nurses to act for individuals who are
unable to function independently.
6n return she epects society to contribute to nursing education.
"asic nursing care involves providing conditions under which the
patient can perform the :; activities unaided
Hea(th
7efinition based on individuals ability to function independently as
outlined in the :; components.
Nurses need to stress promotion of health and prevention and cure of
disease.
.ood health is a challenge.
Affected by age, cultural background, physical, and intellectual
capacities, and emotional balance
6s the individuals ability to meet these needs independentlyR
Nursing
Temporarily assisting an individual who lacks the necessary strength,
will and knowledge to satisfy : or more of :; basic needs.
Assists and supports the individual in life activities and the
attainment of independence.
Nurse serves to make patient ?complete@ ?wholeN, or Nindependent.N
)endersonQs 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 nowledge! "ut I go on to say that
the nurse maes the patient independent of him or her as soon as
possible!"
The nurse is epected to carry out physicians therapeutic plan
6ndividuali2ed care is the result of the nurses creativity in planning
for care.
5se nursing research
-ategori2ed
o Nursing # nursing care
o Non nursing# ordering supplies, cleanliness and serving food.
6n 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 individuali2ed and human
care and should be a scientific problem solver.@
6n the Nature of Nursing
o Nurse role is,@ to get inside the patients 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.
Hen#ersonHs $(assi$ #e%inition o% nursing
"I say that the nurse does for others what they would do for themselves if they
had the strength, the will, and the nowledge! "ut I go on to say that the nurse
maes the patient independent of him or her as soon as possible!"
Hen#erson5s an# Nursing Pro$ess
)enderson views the nursing process as ?really the application of the
logical approach to the solution of a problem. The steps are those of the
scientific method.@
?Nursing process stresses the science of nursing rather than the
miture of science and art on which it seems effective health care service
of any kind is based.@
Summari8ation o% the stages o% the nursing pro$ess as app(ie# to
Hen#erson5s #e%inition o% nursing an# to the -G $omponents o% /asi$
nursing $areC
Nursing 'rocess )endersons :; components and definition of
nursing
Nursing Assessment )endersons :; components
Analysis# -ompare data to knowledge base
of health and disease.
Nursing 7iagnosis 6dentify individuals ability to meet own
needs with or without assistance, taking into
consideration strength, will or knowledge.
Nursing plan 7ocument how the nurse can assist the
individual, sick or well.
Nursing implementation Assist the sick or well individual in to
performance of activities in meeting human
needs to maintain health, recover from
illness, or to aid in peaceful death.
Nursing implementation 6mplementation based on the physiological
principles, age, cultural background,
emotional balance,
and physical and intellectual capacities.
-arry out treatment prescribed by the
physician.
Nursing process )endersons :; components and definition of
nursing
Nursing evaluation 5se the acceptable definition of Gnursing and
appropriate laws related to the practice of
nursing.
The 9uality of care is drastically affected by
the preparation and native ability of the
nursing personnel rather that the amount of
hours of care.
=uccessful outcomes of nursing care are
based on the speed with which or degree to
which the patient performs independently
the activities of daily living.
Comparison 2ith as(o2Hs Hierar$hy o% Nee#
ASLO;HS HENDERSON
'hysiological
needs
"reathe normally
(at and drink ade9uately
(liminate by all avenues of elimination
%ove and maintain desirable posture
=leep and rest
=elect suitable clothing
%aintain body temperature
Aeep body clean and well groomed and protect the
integument
=afety needs Avoid environmental dangers and avoid injuring
others
"elongingness
and love needs
-ommunicate with others
1orship according to faith
(steem needs 1ork at something providing a sense of
accomplishment
'lay or participate in various forms of recreation
/earn, discover, or satisfy curiosity
=elf actuali2ation
needs

Chara$teristi$ o% Hen#erson5s theory
Theories can interrelate concepts in such a way as to create a
different way of looking at a particular phenomenon.
-oncepts of fundamental human needs, biophysiology, culture, and
interaction, communication and is borrowed from other discipline.(.g..
%aslows )ierarchy of human needsG concept of interaction-communication
i.e. nurse-patient relationship
Theories must be logical in nature.
)er definition and components are logical and the :; components are
a guide for the individual and nurse in reaching the chosen goal.
Theories should be relatively simple yet generali2able.
)er work can be applied to the health of individuals of all ages.
Theories can be the bases for hypotheses that can be tested.
)er definition of nursing cannot be viewed as theoryG therefore, it is
impossible to generate testable hypotheses.
)owever some 9uestions to investigate the definition of nursing and
the :; components may be useful.
6s the se9uence of the :; components followed by nurses in the 5=A
and the other countriesR
1hat priorities are evident in the use of the basic nursing functionsR
Theories contribute to and assist in increasing the general body of
knowledge within the discipline through the research implemented to
validate them.
)er ideas of nursing practice are well accepted throughout the world
as a basis for nursing care.
)owever, the impact of the definition and components has not been
established through research.
Theories can be utili2ed by practitioners to guide and improve their
practice.
6deally the nurse would improve nursing practice by using her
definition and :; 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 9uestions that need to be
investigated.
Phi(osophi$a( $(aims
The philosophy reflected in )endersonQs theory is an integrated approach to
scientific study that would capitali2e on nursingQs richness and compleity, and not
to separate the art from the science, the NdoingN of nursing from the NknowingN,
the psychological from the physical and the theory from clinical care.
"a(ues an# &e(ie%s
)enderson believed nursing as primarily complementing the patient
by supplying what he needs in knowledge, will or strength to perform his
daily activities and to carry out the treatment prescribed for him by the
physician.
=he strongly believed in "getting inside the sin" of her patients in
order to know what he or she needs. The nurse should be the substitute
for the patient, helper to the patient and partner with the patient. /ike she
said...
"#he nurse is temporarily the consciousness of the unconscious, the love of
life for the suicidal, the leg of the amputee, the eyes of the newly blind, a
means of locomotion for the infant and the nowledge and confidence for
the young mother!!!"
)enderson stated that ?Thorndikes fundamental needs of man@
&)enderson, :II:, p.:F+ had an influence on her beliefs.
"a(ue in e3ten#ing nursing s$ien$e
0rom an historical standpoint, her concept of nursing enhanced
nursing science this has been particularly important in the area of nursing
education.
)er contributions to nursing literature etended from the :IDHs
through the :IIHs 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.
Use%u(ness
Nursing education has been deeply affected by )endersons clear
vision of the functions of nurses.
The principles of )endersons theory were published in the major
nursing tetbooks used from the :IDHs through the :IFHs, and the
principles embodied by the :; activities are still important in evaluating
nursing care in theeC:st centaury.
4thers concepts that )enderson &:IFF+ proposed have been used in
nursing education from the :IDHs until the present 4Q%alley, :IIF+
Testa/i(ity
)enderson supported nursing research, but believed that it should be
clinical research &4%alley, :IIF+. %uch of the research before her time
had been on educational processes and on the profession of nursing itself,
rather than onG the practice and outcomes of nursing , and she worked to
change that.
(ach of the :; activities can be the basis for research. Although the
statements are not.
1ritten in testable terms, they may be reformulated into
researchable 9uestions. 0urther, the theory can guide research in any
aspect of the individuals care needs.
Limitations
/ack of conceptual linkage between physiological and other human
characteristics.
No concept of the holistic nature of human being.
6f the assumption is made that the :; components prioriti2ed, the
relationship among the components is unclear.
/acks 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 eplanation of what the nurse does.
?'eaceful death@ is curious and significant nursing role.
Purposes o% nursing theories
In Pra$ti$e<
=erve to guide assessment, interventions, and evaluation of nursing
care.
'rovide a rationale for collecting reliable and valid data about the
health status of clients, which are essential for effective decision making
and implementation.
)elp to describe criteria to measure the 9uality of nursing care.
)elp build a common nursing terminology to use in communicating
with other health professionals.
6deas are developed and words are defined.
(nhance autonomy &independence and self-governance+ of nursing
through defining its own independent functions.
In E#u$ation<
'rovide a general focus for curriculum design
.uide curricular decision making.
In Resear$h<
4ffer a framework for generating knowledge and new ideas.
Assist in discovering knowledge gaps in the specific field of study.
4ffer a systematic approach to identify 9uestions for studyG select
variables, interpret findings, and validate nursing interventions.
Approa$hes to #e'e(oping nursing theory
"orrowing conceptual frameworks from other disciplines.
6nductively looking at nursing practice to discover theories!concepts
to eplain phenomena.
7eductively looking for the compatibility of a general nursing theory
with nursing practice.
Iuestions %rom pra$ti$ing Nurse a/out using Nursing theory
Pra$ti$e
7oes this theory reflect nursing practice as 6 know itR
1ill it support what 6 believe to be ecellent nursing practiceR
-an this theory be considered in relation to a wide range of nursing
situationR
Persona( InterestsJ A/i(ities an# E3perien$es
1hat will it be like to think about nursing theory in nursing practiceR
1ill my work with nursing theory be worth the effortR
Summary
:. "ackground
C. Achievements
D. 'ublications
;. Analysis of Nursing theories
E. 7evelopment of )endersons definition of nursing
F. :; components
J. %ajor four concepts
L. Nursing process with )endersons theory
I. -omparison with %aslowQs )ierarchy need
:H. Assumptions
::. 5sefulness
:C. Testability
:D. -haracteristics
:;. imitation
Con$(usion
6n conclusion, )enderson provides the essence of what she believes is a definition
of nursing. =he didnt intend to develop a theory of nursing but rather she
attempted to define the uni9ue focus of nursing. )er 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. )er definition of nursing and the :; components of basic
nursing care are uncomplicated and self-eplanatory.
Re%eren$e
Timber "A. 0undamental skills and concepts in 'atient -are, Jth edition,
/11, N
'ractice , D
rd
D
rd
th
ed.
rd
8andemark /.%. Awareness of self * epanding consciousness# using
Nursing theories to prepare nurse ,therapists %ent )ealth Nurs. CHHF <ulG
CJ&F+ # FHE-:E
<ulG:I&D+#CCE
7elaune =-,. /adner 'A, 0undamental of nursing, standard and practice,
Cnd edition, Thomson, NK, CHHC
Theory of interpersonal relations
Hi(#egar# CEC Pep(au
Intro#u$tion
"orn in >eading, 'ennsylvania T:IHIU
.raduated from a diploma program in 'ottstown, 'ennsylvania in :ID:.
7one "A in interpersonal psychology from "ennington -ollege in :I;D.
%A in psychiatric nursing from -olombia 5niversity New Kork in :I;J.
(d7 in curriculum development in :IED.
'rofessor emeritus from >utgers university
=tarted first post baccalaureate program in nursing
'ublished 6nterpersonal >elations in Nursing in :IEC
:IFL #interpersonal techni9ues-the cru of psychiatric nursing
1orked as eecutive director and president of ANA.
1orked with 1.).4, N6%) and nurse corps.
7ied in :III.
Psy$ho#ynami$ nursing
:. 5nderstanding of ones own behavior
C. To help others identify felt difficulties
D. To apply principles of human relations to the problems that arise at all levels
of eperience
;. 6n her book she discussed the phases of interpersonal process, roles in
nursing situations and methods for studying nursing as an interpersonal
process.
E. According to 'eplau, nursing is therapeutic in that it is a healing art, assisting
an individual who is sick or in need of health care.
F. Nursing is an interpersonal process because it involves interaction between
two or more individuals with a common goal.
J. The attainment of goal is achieved through the use of a series of steps
following a series of pattern.
L. The nurse and patient work together so both become mature and
knowledgeable in the process.
De%initions
:. 'erson #A developing organism that tries to reduce aniety caused by needs
C. (nvironment # (isting forces outside the organism and in the contet of
culture
D. )ealth # 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.
;. Nursing# A significant therapeutic interpersonal process. 6t functions
cooperatively with other human process that make health possible for
individuals in communities
Ro(es o% nurse
=tranger# 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
>esource 'erson # one who provides a specific needed information that aids in
the understanding of a problem or new situation
-ounselors # helps to understand and integrate the meaning of current life
circumstances ,provides guidance and encouragement to make changes
=urrogate# helps to clarify domains of dependence interdependence and
independence and acts on clients behalf as an advocate.
/eader # helps client assume maimum responsibility for meeting treatment
goals in a mutually satisfying way
Additional >oles include#
:. Technical epert
C. -onsultant
D. )ealth teacher
;. Tutor
E. =ociali2ing agent
F. =afety agent
J. %anager of environment
L. %ediator
I. Administrator
:H. >ecorder observer
::. >esearcher
Theory o% interpersona( re(ations
%iddle range descriptive classification theory
6nfluenced by )arry =tack =ullivanQs theory of inter personal relations &:IED+
Also influenced by 'ercival =ymonds , Abraham %aslowQs and Neal (lger
%iller
6dentified four se9uential phases in the interpersonal relationship#
:. 4rientation
C. 6dentification
D. (ploitation
;. >esolution
Orientation phase
'roblem defining phase
=tarts when client meets nurse as stranger
7efining problem and deciding type of service needed
-lient seeks assistance ,conveys needs ,asks 9uestions, shares
preconceptions and epectations of past eperiences
Nurse responds, eplains roles to client, helps to identify problems and to use
available resources and services
!a$tors in%(uen$ing orientation phase
I#enti%i$ation phase
=election of appropriate professional assistance
'atient begins to have a feeling of belonging and a capability of dealing with
the problem which decreases the feeling of helplessness and hopelessness
E3p(oitation phase
5se of professional assistance for problem solving alternatives
Advantages of services are used is based on the needs and interests of the
patients
6ndividual feels as an integral part of the helping environment
They may make minor re9uests or attention getting techni9ues
The principles of interview techni9ues must be used in order to eplore
,understand and ade9uately deal with the underlying problem
'atient may fluctuates on independence
Nurse must be aware about the various phases of communication
Nurse aids the patient in eploiting all avenues of help and progress is made
towards the final step
Reso(ution phase
Termination of professional relationship
The patients needs have already been met by the collaborative effect of
patient and nurse
Now they need to terminate their therapeutic relationship and dissolve the
links between them.
=ometimes may be difficult for both as psychological dependence persists
'atient drifts away and breaks bond with nurse and healthier emotional
balance is demonstrated and both becomes mature individuals
Interpersona( theory an# nursing pro$ess
"oth are se9uential and focus on therapeutic relationship
"oth use problem solving techni9ues for the nurse and patient to collaborate
on, with the end purpose of meeting the patients needs
"oth use observation communication and recording as basic tools utili2ed by
nursing
Assessment
7ata collection and
analysis TcontinuousU
%ay not be a felt need
4rientation
Non continuous data
collection
0elt need
7efine needs
Nursing diagnosis
'lanning
%utually set goals
6dentification
6nterdependent goal setting
6mplementation
'lans initiated towards
achievement of mutually
set goals
%ay be accomplished by
patient , nurse or family
(ploitation
'atient actively seeking and
drawing help
'atient initiated
(valuation
"ased on mutually
epected behaviors
%ay led to termination and
initiation of new plans
>esolution
4ccurs after other phases are
completed successfully
/eads to termination
Pep(au5s 2or) an# $hara$teristi$s o% a theory
Theories can interrelate concepts in such a way as to create a different way of
looking at a particular phenomenon.
0our phases interrelate the different components of each phase.
The nurse patient interaction can apply to the concepts of human
being ,health, environment and nursing.
Theories must be logical in nature
'rovides a logical systematic way of viewing nursing situations
Aey concepts such as aniety, tension, goals, and frustration are
indicated with eplicit relationships among them and progressive
phases
Theories should be relatively simple yet generali2able
6t provides simplicity in regard to the natural progression of the N'
relationship.
/eads to adaptability in any nurse patient relationship.
The basic nature of nursing still considered an interpersonal process
Theories can be the bases for hypothesis that can be tested.
)as generated testable hypotheses.
validate them.
6n :IEHs two third of the nursing research concentrated on N-'
relation ship.
Theories can be utili2ed by practitioners to guide and improve their practice.
'eplaus aniety continuum is still used in aniety patients
Theories must be consistent with other validated theories, laws, and
investigated.
-onsistent with various theories
Limitations
6ntra family dynamics, personal space considerations and community social
service resources are considered less
)ealth promotion and maintenance were less emphasi2ed
-annot be used in a patient who doesnt have a felt need eg. 1ith drawn
patients, unconscious patients
some areas are not specific enough to generate hypothesis
Resear$h &ase# on Pep(au5s Theory
:. )ays .7. &:IF:+.'hases and steps of eperimental teaching to patients of
a concept of aniety# 0indings revealed that when taught by the
eperimental method, the patients were able to apply the concept of
aniety after the group was terminated.
C. "urd .=.0. 7evelop and test a nursing intervention framework for working
with anious patients# =tudents developed competency in beginning
interpersonal relationship
Re%eren$es
/11, N
'ractice , D
rd
D
rd
th
ed.
rd
CJ&F+ # FHE-:E
<ulG:I&D+#CCE
!AKE GLENN A&DELLAHHS THEORK
T;ENTK ONE NURSING PRO&LES
INTRODUCTION
0aye .lenn Abdellah, pioneer nursing researcher, helped transform nursing
theory, nursing care and nursing education
"irth#:I:I
7r Abdellah worked as 7eputy =urgeon .eneral
0ormer -hief Nurse 4fficer for the 5.= 'ublic )ealth =ervice , 7epartment
of )ealth and human services, 1ashington, 7.- .
=he 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.
6n :IFH, 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 includesG
>ecogni2ing the nursing problems of the patient
7eciding the appropriate course of action to take in terms of relevant
nursing principles
'roviding continuous care of the individuals total needs
'roviding continuous care to relieve pain and discomfort and provide
immediate security for the individual
Adjusting the total nursing care plan to meet the patients individual
needs
)elping the individual to become more self directing in attaining or
maintaining a healthy state of mind * body
6nstructing nursing personnel and family to help the individual do for
himself that which he can within his limitations
L+)elping the individual to adjust to his limitations and emotional
problems
I+ 1orking with allied health professions in planning for optimum
health on local, state, national and international levels
:H+ -arrying out continuous evaluation and research to improve
nursing techni9ues and to develop new techni9ues to meet the
health needs of people
These original premises have undergone an evolutionary process. As
result, in :IJD, the item D, - ?providing continuous care of the
individuals total health needs@ was eliminated.
0rom these premises, Abdellahs theory was derived.
PHILOSOPHICAL UNDERPINNINGS O! THE THEORK
Abdellahs 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.
A9OR ASSUPTIONSJ CONCEPTS D RELATIONSHIPS
:.The language of Abdellahs framework is readable and clear.
C.-onsistent with the decade in which she was writing, she uses the term 3she
for nurses, 3he for doctors and patients, and refers to the object of nursing
as 3patient rather than client or consumer.
D.=he referred to Nursing diagnosis during a time when nurses were taught
that diagnosis was not a nurses prerogative.
;.Assumptions were related to
:.change and anticipated changes that affect nursingG
C.The need to appreciate the interconnectedness of social enterprises
and social problemsG
D.the impact of problems such as poverty, racism, pollution, education,
and so forth on health care deliveryG
;.changing nursing education
E.continuing education for professional nurses
F.development of nursing leaders from under reserved groups
E.Abdellah and colleagues developed a list of C: nursing problems.
F.They also identified :H steps to identify the clients problems
J.:: nursing skills to be used in developing a treatment typology
-, steps to i#enti%y the $(ient5s pro/(ems
:./earn to know the patient
C.=ort out relevant and significant data
D.%ake generali2ations about available data in relation to similar nursing
problems presented by other patients
;.6dentify the therapeutic plan
E.Test generali2ations with the patient and make additional generali2ations
F.8alidate the patients conclusions about his nursing problems
J.-ontinue to observe and evaluate the patient over a period of time to
identify any attitudes and clues affecting his behavior
L.(plore the patients and familys reaction to the therapeutic plan and
involve them in the plan
I.6dentify how the nurses feels about the patients nursing problems
:H. 7iscuss and develop a comprehensive nursing care plan
-- nursing s)i((s
:.4bservation of health status
C.=kills of communication
D.Application of knowledge
;.Teaching of patients and families
E.'lanning and organi2ation of work
F.5se of resource materials
J.5se of personnel resources
L.'roblem-solving
I.7irection of work of others
:H. Therapeutic use of the self
::. Nursing procedures
The t2enty one nursing pro/(ems
Three major categories
'hysical, sociological, and emotional needs of clients
Types of interpersonal relationships between the nurse and patient
-ommon elements of client care
+- NURSING PRO&LES
&ASIC TO ALL PATIENTS
To maintain good hygiene and physical comfort
To promote optimal activity# eercise, 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 oygen 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 recogni2e 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
REEDIAL CARE NEEDS
To identify and accept positive and negative epressions, 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
RESTORATI"E 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
AbdellahQs C: problems are actually a model describing the NarenasN or concerns
of nursing, rather than a theory describing relationships among phenomena. 6n
this way, the theory distinguished the practice of nursing, with a focus on the C:
nursing problems, from the practice of medicine, with a focus on disease and
cure.
A&DELLAH5S THEORK AND NURSING
Although Abdellahs 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. Abdellahs theory would
state that nursing is the use of the problem solving approach with key
nursing problems related to health needs of people. =uch 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
)ealth is a dynamic pattern of functioning whereby there is a continued
interaction with internal and eternal forces that results in the optimum
use of necessary resources that serve to minimi2e vulnerabilities
NURSING PRO&LES
Nursing problem presented by a client is a condition faced by the client or
clients 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
6n 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.
PRO&LE SOL"ING
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.
COPARISON ;ITH OTHER THEORIES
ASLO; HENDERSON A&DELLAH

'hysiological
needs
:. "reathe normally

C. (at and drink
ade9uately
D. (liminate by all
avenues of
elimination
;. %ove * maintain
desirable posture
E. =leep * rest
F. =elect suitable
clothing
J. %aintain body
temperature
L. Aeep body clean and
well groomed *
protect the
integument

:. To facilitate the maintenance
of a supply of oygen to all
body cells
C. To facilitate the maintenance
of nutrition of all body cells
D. To facilitate the maintenance
of fluid and electrolyte
balance
;. To facilitate the maintenance
of elimination
E. To maintain good body
mechanics and prevent and
correct deformities
F. To promote optimal activity#
eercise , rest and sleep
J. To facilitate the maintenance
of regulatory mechanisms
and functions
L. To maintain good hygiene
and physical comfort

=afety needs
I. Avoid
environmental
dangers * avoid
injuring others
I. To promote safety through
the prevention of accidents,
injury, or other trauma and
through the prevention of
the spread of infection
:H. To facilitate the
maintenance of sensory
function
"elongingness
* love needs
:H. -ommunicate with
others
::. 1orship according
to faith
::.To facilitate the maintenance
of effective verbal and non
verbal communication
:C. To promote the
development of productive
interpersonal relationships
:D. To facilitate progress toward
achievement of personal
spiritual goals
(steem needs

:C. 1ork at something
providing a sense of
accomplishment
:D. 'lay or participate
in various forms of
recreation
:;. /earn, discover, or
satisfy curiosity

:;. To accept the optimum
possible goals in the light of
limitations, physical and
emotional
:E. To recogni2e the
physiological responses of
the body to disease
conditions
:F. To identify and accept
positive and negative
epressions, feelings, and
reactions
:J. To identify and accept the
interrelatedness of emotions
and organic illness
:L. To create and ! or maintain
a therapeutic environment
:I. To facilitate awareness of
self as an individual with
varying physical, emotional,
and developmental needs
CH. To use community
resources as an aid in
resolving problems arising
from illness
C:. To understand the role of
social problems as
influencing factors in the
case of illness
=elf
actuali2ation
needs

A&DELLAH5S THEORK AND THE !OUR A9OR CONCEPTS
Nursing
Nursing is a helping profession. 6n Abdellahs 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 C: problem areas to guide care and
promote use of nursing judgment.
=he 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.
'atient is described as the only justification for the eistence of nursing.
6ndividuals &and families+ are the recipients of nursing
)ealth, or achieving of it, is the purpose of nursing services.
Hea(th
6n 'atient ,-entered Approaches to Nursing, Abdellah describes health as a
state mutually eclusive 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.
So$iety6En'ironment
=ociety is included in ?planning for optimum health on local, state, national,
and international levels@. )owever, as she further delineated her ideas, the
focus of nursing service is clearly the individual.
The environment is the home or community from which patient comes.
A&DELLAH5S ;ORK AND CHARACTERISTICS O! A THEORK
Chara$teristi$-
Abdellahs theory has interrelated the concepts of health, nursing problems,
and problem solving as she attempts to create a different way of viewing
nursing phenomenon
The result was the statement that nursing is the use of problem solving
approach with key nursing problems related to health needs of people.
Chara$teristi$+
'roblem solving is an activity that is inherently logical in nature
Chara$teristi$ L
0ramework seems to focus 9uite heavily on nursing practice and individuals.
This somewhat limit the ability to generali2e although the problem solving
approach is readily generali2able to clients with specific health needs and
specific nursing problems
Chara$teristi$G
4ne of the most important 9uestions that arise when considering her work is
the role of client within the framework. This 9uestion could generate
hypothesis for testing and thus demonstrates the ability of Abdellahs work
to generate hypothesis for testing
Chara$teristi$@
The results of testing such hypothesis would contribute to the general body
of nursing knowledge
Chara$teristi$>
Abdellahs 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
Chara$teristi$:
Although consistency with other theories eist, many 9uestions remain
unanswered
USE O! +- PRO&LES IN THE NURSING PROCESS
ASSESSENT 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 clients 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.
.iven that these problems are called nursing problems, then it becomes
reasonable to conclude that these goals are basically nursing goals.
IPLEENTATION
5sing the goals as the framework, a plan is developed and appropriate
nursing interventions are determined.
E"ALUATION
According to the American Nurses Association =tandards of Nursing
'ractice, the plan is evaluated in terms of the clients progress or lack of
progress toward the achievement of the stated goals.
This would be etremely difficult if not impossible to do for Abdellahs
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 i((ustration o% the imp(ementation o% A/#e((ah5s %rame2or) in Ryan5s
$are
-onsider a case of >yan who eperienced severe crushing chest pain 3shortness of
breath, tachycardia and profuse diaphoresis
=tage of illness is basic to care
=elected Abdellah nursing problem
To maintain good hygiene and personal comfort
-lassification and approach
4vert problem of painG 7irect and indirect method
=elected Nursing 6nterventions
administer oygen
elevate headrest
reposition client
administer prescribed analgesic
remain with client
-riterion measure- Amount of pain
CONCEPT O! PROGRESSI"E PATIENT CARE
:.''- is defined as better patient care through the organi2ation of hospital
facilities, services and staff around the changing medical and nursing
needs of the patient
C.''- is tailoring of hospital services to meet patients needs
D.''- is caring for the right patient in the right bed with the right services at
the right time
;.''- is systematic classification of patients based on their medical needs
E(ements o% PPC
6ntensive care
o -ritically and seriously ill patients re9uiring highly skilled nursing
care, close and fre9uent if not constant, nursing observation are
assigned to the 6-5. 4ne patient in an 6-5 re9uires at least three
nurses to observe him in C; hrs
6ntermediate care
o 'atients assigned to this unit are both the moderately ill and those
for whom the treatment can only be palliative
=elf care
o Ambulatory patients who are convalescencing or re9uire diagnosis or
therapy may be cared for in this unit
/ong 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
maimum potential
)ome care
o This programme makes it possible to etend needed services to the
patient after he leaves the hospital and returns to his home in the
community
&ene%its o% PPC
PATIENT
better attention
better adjustment
minimi2ed problems
life saving care
constant medical and nursing care
PHKSICIAN
assuring best nursing care
drugs and e9uipments 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
COUNITK
continuity with hospital services
minimi2e the need of hospitali2ation
Imp(i$ations o% PPC %or nursing e#u$ation
%any nurse educators feel that the ''- hospital where all five phases of
care are available can provide clinical eperience 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.
Organi8ation o% hospita( an# $ommunity ser'i$es /ase# on patients nee#s
6n 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 techni9ues and e9uipment immediately available
6n the intermediate care unit are concentrated patients re9uiring 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
re9uire diagnostic and convalescent care in hotel-type accommodations.
This unit serves as a link between the hospital and the home.
6n the long-term care unit are concentrated patients re9uiring prolonged
care. The grouping of such patients will permit staffing patterns that are
less costly
)ome care, the fifth element of progressive patient care, etends hospital
services into the home to assist the physician in the care of his patients
USE!ULNESS
The patient centered approach was constructed to be useful to nursing
practice, with impetus for it being nursing education.
Abdellahs publications on nursing education began with her dissertationG
her interest in education for nurses continues into the present.
-ontP
Abdellah has also published on nursing, nursing research, and public policy
related to nursing in several international publications. =he has been a
strong advocate for improving nursing practice through nursing research
"ALUE IN EMTENDING NURSING SCIENCE
6t helped to bring structure and organi2ation to what was often a
disorgani2ed collection of lectures and eperiences.
=he categori2ed nursing problems based on the individuals needs and
developed developed a typology of nursing treatment and nursing skills..
NURSING RESEARCH
=he 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.
LIITATIONS
8ery strong nursing centered orientation
/ittle emphasis on what the client is to achieve
)er framework is inconsistent with the concept of holism
'otential problems might be overlooked
SUARK
5sing Abdellahs 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.
0rom this framework, C: nursing problems were developed
CONCLUSIONS
Abdellahs theory provides a basis for determining and organi2ing nursing
care. The problems also provide a basis for organi2ing appropriate nursing
strategies.
6t is anticipated that by solving the nursing problems, the client would be
moved toward health. The nurses philosophical frame of reference would
determine whether this theory and the C: nursing problems could be
implemented in practice.
RE!ERENCES
:. .eorge <ulia ". Nursing theories# The base of professional nursing practice D
rd

edition. Norwalk, -N# Appleton and /angeG :IIH.
C. Abdellah, 0... The federal role in nursing education. Nursing outlook. :ILJ,
DE&E+,CC;-CCE.
D. Abdellah, 0... 'ublic policy impacting on nursing care of older adults .6n (.%.
"aines &(d.+, perspectives on gerontological nursing. Newbury, -A# =age
publications. :II:.
;. Abdellah, 0..., * /evine, (. 'reparing nursing research for the C:
st
century. New
Kork# =pringer. :II;.
E. Abdellah, 0..., "eland, 6./., %artin, A., * %atheney, >.8. 'atient-centered
approaches to nursing &C
nd
ed.+. New Kork# %ac %illan. :IFL.
F. Abdellah, 0... (volution of nursing as a profession# perspective on manpower
development. 6nternational Nursing >eview, :IJC+G :I, D..
J. Abdellah, 0...+. The nature of nursing science. 6n /.). Nicholl &(d.+, perspectives
on nursing theory. "oston# /ittle, "rown, :ILF.
9EAN ;ATSONHS PHILOSOPHK O!
NURSING
Intro#u$tion
"orn# 1est 8irginia
(ducated# "=N, 5niversity of -olorado, :IF;, %=, 5niversity of -olorado,
:IFF, 'h7, 5niversity of -olorado, :IJD
7r. <ean 1atson is 7istinguished 'rofessor of Nursing and holds an endowed
-hair in -aring =cience at the 5niversity of -olorado )ealth =ciences -enter.
=he is founder of the original -enter for )uman -aring in -olorado and is a
0ellow of the American Academy of Nursing. =he previously served as 7ean of
Nursing at the 5niversity )ealth =ciences -enter and is a 'ast 'resident of
the National /eague for Nursing
7r. 1atson has earned undergraduate and graduate degrees in nursing and
psychiatric-mental health nursing and holds her 'h7 in educational
psychology and counseling.
=he is a widely published author and recipient of several awards and honors,
including an international Aellogg 0ellowship in Australia, a 0ulbright >esearch
Award in =weden and si &F+ )onorary 7octoral 7egrees, including D
6nternational )onorary 7octorates &=weden, 5nited Aingdom, Muebec,
-anada+.
)er research has been in the area of human caring and loss.
The foundation of <ean 1atsons theory of nursing was published in :IJI in
nursing# ?The philosophy and science of caring@
6n :ILL, her theory was published in ?nursing# human science and human
care@.
1atson believes that the main focus in nursing is on carative factors. =he
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.
=he asserts that the caring stance that nursing has always held is being
threatened by the tasks and technology demands of the curative factors.
The se'en assumptions
1atson proposes even assumptions about the science of caring. The basic
assumptions are#
:. -aring can be effectively demonstrated and practiced only interpersonally.
C. -aring consists of carative factors that result in the satisfaction of certain
human needs.
D. (ffective caring promotes health and individual or family growth.
;. -aring responses accept person not only as he or she is now but as what he
or she may become.
E. 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.
F. -aring is more ? healthogenic@ than is curing. A science of caring is
complementary to the science of curing.
J. The practice of caring is central to nursing.
The ten primary $arati'e %a$tors
The stru$ture %or the s$ien$e o% $aring is /ui(t upon ten $arati'e %a$torsC
These are<
The formation of a humanistic- altruistic system of values.
The installation of faith-hope.
The cultivation of sensitivity to ones self and to others.
The development of a helping-trust relationship
The promotion and acceptance of the epression 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 eistential-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.
-C The %ormation o% a humanisti$F a(truisti$ system o% 'a(ues
"egins developmentally at an early age with values shared with the parents.
%ediated through ones own life eperiences, the learning one gains and
eposure to the humanities.
6s perceived as necessary to the nurses own maturation which then promotes
altruistic behavior towards othersC
+C !aithFhope
6s essential to both the carative and the curative processes.
1hen 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.
LC Cu(ti'ation o% sensiti'ity to one5s se(% an# to others
(plores the need of the nurse to begin to feel an emotion as it presents
itself.
7evelopment of ones own feeling is needed to interact genuinely and
sensitively with others.
=triving to become sensitive, makes the nurse more authentic, which
encourages self-growth and self-actuali2ation, 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.
GC Esta/(ishing a he(pingFtrust re(ationship
=trongest tool is the mode of communication, which establishes rapport and
caring.
=he has defined the characteristics needed to in the helping-trust relationship.
These are#
Congruence
$mpathy
Warmth
-ommunication includes verbal, nonverbal and listening in a manner which
connotes empathetic understanding.
@C The e3pression o% %ee(ingsJ /oth positi'e an# negati'e
According to 1atson, 0%ee(ings a(ter thoughts an# /eha'iorJ an# they
nee# to /e $onsi#ere# an# a((o2e# %or in a $aring re(ationship1C
According to her such epression improves ones level of awareness.
Awareness of the feelings helps to understand the behavior it engenders.
>C The systemati$ use o% the s$ienti%i$ pro/(emFso('ing metho# %or #e$ision
ma)ing
According to 1atson, the scientific problem- solving method is the only
method that allows for control and prediction, and that permits self-
correction.
=he also values the relative nature of nursing and supports the need to
eamine and develop the other methods of knowing to provide an holistic
perspective.
The science of caring should not be always neutral and objective.
:C Promotion o% interpersona( tea$hingF(earning
The caring nurse must focus on the learning process as much as the teaching
process.
5nderstanding the persons perception of the situation assist the nurse to
prepare a cognitive planC
=C Pro'ision %or a supporti'eJ prote$ti'e an# 6or $orre$ti'e menta(J physi$a(J
so$ioF$u(tura( an# spiritua( en'ironment
1atson divides these into eternal and internal variables, which the nurse
manipulates in order to provide support and protection for the persons
mental and physical well-being.
The eternal and internal environments are interdependent.
1atson suggests that the nurse also must provide comfort, privacy and safety
as a part of this carative factor.
?C Assistan$e 2ith the grati%i$ation o% human nee#s
6t is grounded in a hierarchy of need similar to that of the %aslows.
=he has created a hierarchy which she believes is relevant to the science of
caring in nursing.
According to her each need is e9ually important for 9uality nursing care and
the promotion of optimal health. All the needs deserve to be attended to and
valuedC
;atson5s or#ering o% nee#s
/ower order needs &biophysical needs+
o #he need for food and fluid
o #he need for elimination
o #he need for ventilation
/ower order needs &psychophysical needs+
o #he need for activity-inactivity
o #he need for se%uality
1atsons ordering of needs
o &igher order needs 'psychosocial needs(
o #he need for achievement
o #he need for affiliation
o &igher order need 'intrapersonal-interpersonal need(
o #he need for self-actuali)ation
>esearch findings have established a correlation between emotional distress
and illness. According to 1atson, the current thinking of holistic care
emphasi2es that#
o *actors of the etiological component interact and produce change
through comple% neuro-physiological and neuro-chemical pathways
o $ach psychological function has a physiological correlate
o $ach physiological component has a psychological correlate
E3amp(e<
"ulemia, anoreia and gastro-intestinal ulcers are a just few of the disorders that
indicate a comple interaction between the physiological and psychological.
-,C A((o2an$e %or e3istentia(Fphenomeno(ogi$a( %or$es
'henomenology is a way of understanding people from the way things appear
to them, from their frame of reference.
(istential psychology is the study of human eistence 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.
;atson5s theory an# the %our ma4or $on$epts
-C Human /eing
=he adopts a view of the human being as# ?P.. a valued person in and of him
or herself to be cared for, respected, nurtured, understood and assistedG in
general a philosophical view of a person as a fully functional integrated self.
)e, human is viewed as greater than and different from, the sum of his or her
parts@.
+C Hea(th
1atson believes that there are other factors that are needed to be included in
the 1)4 definition of health. =he 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.
LC En'ironment6so$iety
According to 1atson caring &and nursing+ has eisted in every society. A
caring attitude is not transmitted from generation to generation. 6t is
transmitted by the culture of the profession as a uni9ue way of coping with
its environmentC
GC Nursing
According to 1atson 0 nursing is concerned with promoting health, preventing
illness, caring for the sick and restoring health@.
6t focuses on health promotion and treatment of disease. =he believes that
holistic health care is central to the practice of caring in nursing.
=he defines nursing asP..
0A human science of persons and human health-illness eperiences that are
mediated by professional, personal, scientific, esthetic and ethical human
transactions@.
;atson5s theory an# nursing pro$ess
1atson points out that nursing process contains the same steps as the
scientific research process. They both try to solve a problem. "oth provide a
framework for decision making. 1atson elaborates the two processes as#
-C Assessment
6nvolves observation, identification and review of the problemG use of
applicable knowledge in literature.
Also includes conceptual knowledge for the formulation and conceptuali2ation
of framework.
6ncludes the formulation of hypothesisG defining variables that will be
eamined in solving the problem.
+C P(an
6t helps to determine how variables would be eamined or measuredG includes
a conceptual approach or design for problem solving. 6t determines what data
would be collected and how on whom.
LC Inter'ention
6t is the direct action and implementation of the plan.
6t includes the collection of the data.
GC E'a(uation
Analysis of the data as well as the eamination of the effects of interventions
based on the data. 6ncludes the interpretation of the results, the degree to
which positive outcome has occurred and whether the result can be
generali2ed.
6t may also generate additional hypothesis or may even lead to the
generation of a nursing theory.
;atson5s 2or) an# the $hara$teristi$ o% a theory
According to 1atsonJ 0a theory is an imaginative grouping of knowledge,
ideas and eperiences that are represented symbolically and seek to
illuminate a given phenomenon@
=he views nursing as,
?P.both a human science and an art and as such it cannot be considered
9ualitatively continuous with traditional, reductionistic, scientific
methodology@.
=he 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 uni9ue in 1atsons
theory.
=he describes caring in both philosophical and scientific terms.
1atson also indicates that needs are interrelated.
The science of caring suggests that the nurse recogni2e and assist with each
of the interrelated needs in order to reach the highest order need of self-
actuali2ation.
Theories must /e (ogi$a( in nature
1atsons work is logical in that the factors are based on broad assumptions
which provide a supportive framework.
1ith these carative factors she delineates nursing from other professions
These carative factors are logically derived from the assumptions and related
to he hierarchy of needs.
Theories shou(# /e re(ati'e(y simp(e yet genera(i8a/(e
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-emphasi2es the
pathophysiological for the psychosocial diminishes its ability to be
generali2able.
=he discusses this in the preface of her book when she speaks of the ?trim@
and the ?core@ of nursing.
=he defines trim as the clinical focus, the procedure and the techni9ues.
The core of the nursing is that which is intrinsic to the nurse-client interaction
that produces a therapeutic result. -ore mechanisms are the carative factors.
Theories $an /e the /asis %or hypotheses that $an /e teste#
1atsons theory is based on phenomenological studies that generally ask
9uestions rather than state hypotheses. 6ts purpose is to describe the
phenomena, to analy2e 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 1atson the best method to test this theory is through field
study.
An eample is her work in the area of loss and caring that took place in
-undeelee, 1estern Australia and involved a tribe of aborigines.
Theories $an /e uti(i8e# /y pra$titioners to gui#e an# impro'e their pra$ti$e
1atsons work can be used to guide and improve practice.
6t 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 9uestions that need to be investigated
1atsons work is supported by the theoretical work of numerous humanists,
philosophers, developmentalists and psychologists.
=he clearly designates the theories of stress, development, communication,
teaching-learning, humanistic psychology and eistential phenomenology
which provide the foundation for the science of caring.
Strengths
"esides assisting in providing the 9uality 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 clients
struggle towards self-actuali2ation.
The client is placed in the contet of the family, the community and the
culture.
6t places the client as the focus of practice rather than the technology.
Limitations
.iven the acuity of illness that leads to hospitali2ation, the short length stay ,
and the increasing comple technology, such 9uality of care may be deemed
impossible to give in the hospital.
1hile 1atson 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.
1hile the carative factors have a sound foundation based on other disciplines,
they need further research in nursing to demonstrate their application to
practice.
Summary
1atsons theory
6ts seven assumptions
The ten carative factors
1atsons theory and the four major concepts
1atsons theory and the nursing process
1atsons work and the characteristics of the theory
=trengths
/imitations
Resear$h re(ate# to ;atson5s theory
=aint <oseph )ospital in 4range, -alifornia has selected <ean 1atsons theory
of human caring as the framework base for nursing practice.
The effectiveness of 1atsonQs -aring %odel on the 9uality of life and blood
pressure of patients with hypertension. < Adv Nurs. CHHD <anG;:&C+#:DH-I.
This study demonstrated a relationship between care given according to
1atsonQs -aring model and increased 9uality of life of the patients with
hypertension. 0urther, in those patients for whom the caring model was
practised, there was a relationship between the -aring model and a decrease
in patientQs blood pressure. The 1atson -aring %odel is recommended as a
guide to nursing patients with hypertension, as one means of decreasing
blood pressure and increase in 9uality of life.
%artin, /. =. &:II:+. 5sing 1atsons theory to eplore the dimensions of adult
polycystic kidney disease . ANNA <ournal, :L, ;HD-;HF .
%ullaney, <. A. ". &CHHH+. The lived eperience of using 1atsons actual
caring occasions to treat depressed women . <ournal of )olistic Nursing,
:L&C+, :CI-:;C
%artin, /. =. &:II:+. 5sing 1atsons theory to eplore the dimensions of adult
polycystic kidney disease . ANNA <ournal, :L, ;HD-;HF
Con$(usion
:. 1atson provides many useful concepts for the practice of nursing.
C. =he 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.
D. The detailed descriptions of the carative factors can give guidance to those
who wish to employ them in practice or research.
;. 5sing her theory can add a dimension to practice that is both satisfying and
challenging.
Re%eren$e
/11, N
'ractice , D
rd
%eleis 6brahim Afaf &:IIJ+ , Theoretical Nursing # 7evelopment * 'rogress D
rd
th
ed.
rd
8andemark /.%. Awareness of self * epanding consciousness# using Nursing
theories to prepare nurse ,therapists %ent )ealth Nurs. CHHF <ulG CJ&F+ #
FHE-:E
<ulG:I&D+#CCE
-heng %K. 5sing AingQs .oal Attainment Theory to facilitate drug compliance
in a psychiatric patient. )u /i Sa Shi. CHHF <unGED&D+#IH-J.
7elaune =-,. /adner 'A, 0undamental of nursing, standard and practice, Cnd
edition, Thomson, NK, CHHC.
9OHNSON5S &EHA"IOUR SKSTE
ODEL
Intro#u$tion
7orothy (. <ohnson was born August C:, :I:I, in =avannah, .eorgia.
". =. N. from 8anderbilt 5niversity in Nashville, Tennessee, in :I;CG and her
%.'.). from )arvard 5niversity in "oston in :I;L.
0rom :I;I until her retirement in :IJL she was an assistant professor of
pediatric nursing, an associate professor of nursing, and a professor of
nursing at the 5niversity of -alifornia in /os Angeles.
7orothy <ohnson has had an influence on nursing through her publications
since the :IEHs. Throughout her career, <ohnson has stressed the
importance of research-based knowledge about the effect of nursing care
on clients.
9ohnson5s /eha'ior system mo#e(
6n :IFL 7orothy first proposed her model of nursing care as fostering of
?the efficient and effective behavioral functioning in the patient to prevent
illnessN.
=he also stated that nursing was ?concerned with man as an integrated
whole and this is the specific knowledge of order we re9uire@.
6n :ILH <ohnson published her conceptuali2ation of ?behavioral system of
model for nursing@ this is the first work of 7orothy that eplicates her
definitions of the behavioral system model.
De%inition o% nursing
=he defined nursing as ?an eternal regulatory force which acts to preserve the
organi2ation 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@
"ased on this definition there are four goals of nursing are to assist the patient#
1hose behavior commensurate with social demands.
1ho is able to modify his behavior in ways that it supports biological
imperatives
1ho is able to benefit to the fullest etent during illness from the physicians
knowledge and skill.
1hose behavior does not give evidence of unnecessary trauma as a
conse9uence of illness
Assumptions o% /eha'iora( system mo#e(
There are several layers of assumptions that <ohnson makes in the development
of conceptuali2ation of the behavioral system model &<ohnson was influenced by
"uckley ,-hin and >apport+ there are ; assumptions of system#
:. 0irst assumption states that there is ?organi2ation, interaction, interdependency
and integration of the parts and elements of behaviors that go to make up The
system @
C. A system ?tends to achieve a balance among the various forces operating within
and upon itQ, 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.@
D. A behavioral system, which both re9uires 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.
;. The final assumption states ?system balance reflects adjustments and
adaptations that are successful in some way and to some degree.@
:.The integration o% these assumptions pro'i#es the behavioral system
with the pattern of action to form ?an organi2ed 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.
C.The integration o% these assumptions pro'i#es the behavioral system
with the pattern of action to form ?an organi2ed 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 a/out stru$ture an# %un$tion o% ea$h su/system
C.?from the form the behavior takes and the conse9uences it achieves can be
inferred what ?drive@ has been stimulated or what ?goal@ is being sought@
D.(ach individual has a ?predisposition to act with reference to the goal, in
certain ways rather than the other ways@. This predisposition is called as
?set@.
;.(ach subsystem has a repertoire of choices or ?scope of action@
:.The fourth assumption is that it produce ?observable outcome@ that is the
individuals behavior.
(ach subsystem has three functional re9uirements
C.=ystem must be ?protectedN from noious influences with which system
cannot cope@.
D.(ach subsystem must be ?nurtured@ through the input of appropriate
supplies from the environment.
:.(ach subsystem must be ?stimulated@ for use to enhance growth and
prevent stagnation
<ohnson believes each individual has patterned, purposeful, repetitive ways of
acting that comprise a behavioral system specific to that individual. These actions
and behaviors form an organi2ed and integrated functional unit that determines
and limits the interaction between the person and his environment and
establishes the relationship of the person to the objects event situations in the
environment. These behaviors are ?orderly, purposeful and predictable and
sufficiently stable and recurrent to be amenable to description and eplanation@
9ohnson5s &eha'iora( Su/system
C.Atta$hment or a%%i(iati'e su/system# ?social inclusion intimacy and the
formation and attachment of a strong social bond.@
D.Depen#en$y su/system# ?approval, attention or recognition and physical
assistance@
;.Ingesti'e su/system# ?the emphasis is on the meaning and structures of
the social events surrounding the occasion when the food is eaten@
E.E(iminati'e su/system# ?human cultures have defined different socially
acceptable behaviors for ecretion of waste ,but the eistence of such a
pattern remains different from culture to -ulture.@
F.Se3ua( su/system<A both biological and social factor affect the behavior in
the seual subsystem@
J.Aggressi'e su/system#N it relates to the behaviors concerned with
protection and self preservation <ohnson views aggressive subsystem as
one that generates defensive response from the individual when life or
territory is being threatened@
:.A$hie'ement su/system#1 provokes behavior that attempt to control the
environment intellectual, physical, creative, mechanical and social skills
achievement are some of the areas that <ohnson recogni2esA.
Representation o% 9ohnsonHs o#e(
.oal ----- =et --- -hoice of "ehavior --- "ehavior
Affiliation
7ependency
=euality
Aggression
(limination
6ngestion
Achievement
The %our ma4or $on$epts
C.<ohnson views ?human being+ as having two major systems, the biological
system and the behavioral system. 6t is role of the medicine to focus on
biological system where as NurslingQs focus is the behavioral system.
D.,-ociety+ relates to the environment on which the individual eists.
According to <ohnson an individuals behavior is influenced by the events in
the environment
;.,&ealth+ is a purposeful adaptive response, physically mentally, emotionally,
and socially to internal and eternal stimuli in order to maintain stability
and comfort.
:.,.ursing+ has a primary goal that is to foster e9uilibrium within the
individual .she stated that nursing is concerned with the organi2ed and
integrated whole, but that the major focus is on maintaining a balance in
the "ehavior system when illness occurs in an individual.
Nursing pro$ess
Assessment
.rubbs developed an assessment tool based on <ohnsons seven subsystems plus
a subsystem she labeled as restorative which focused on activities of daily
living .An assessment based on behavioral model does not easily permit the nurse
to gather detailed information about the biological systems#
:.Affiliation
C.7ependency
D.=euality
;.Aggression
E.(limination
F.6ngestion
J.Achievement
L.>estorative
Diagnosis
7iagnosis tends to be general to the system than specific to the problem. .rubb
has proposed ; categories of nursing diagnosis derived from <ohnsonQs behavioral
system model#
:.6nsufficiency
C.7iscrepancy
D.6ncompatibility
;.7ominance
P(anning an# imp(ementation
6mplementation 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.
E'a(uation
(valuation is based on the attainment of a goal of balance in the identified
subsystems. 6f the baseline data are available for an individual, the nurse may
have goal for the individual to return to the baseline behavior. 6f the alterations in
the behavior that are planned do occur, the nurse should be able to observe the
return to the previous behavior patterns. <ohnsonQs 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
<ohn =mith, F weeks brought into the clinic for a routine check-up. )e presents
with no weight gain since his check up at the age of C weeks .)is mother stated
she feeds him but he does not seem to eat much. )e sleeps ;to E hour between
the feedings. )is mother holds him in her arms without trunk to trunk contact. As
the assessment is made the nurse notes that %rs. =mith never looks at <ohnny
and never speaks to him. =he stated he was a planned baby but that she never
reali2ed how much work a baby could be. =he says, her mother told her she was
not a good mother because <ohn is not gaining weight like he should. =he states
she had not called the nurse when she knew <ohn 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
:.Affiliative subsystem between mother and <ohn.
C.7ependency subsystem between mother and <ohn
D.Affiliative subsystem between %rs.=mith and her mother.
;.6nsufficiency ingesion subsystem.
Diagnosis
:.6nsufficient development of the affiliative subsystem.
C.6nsufficient development of the dependency subsystem
P(anning an# imp(ementation
:.6ncreasing mothers awareness of the babys clues.
C.Assisting her to talk with the baby.
D.Teach her to bring a bond between her and the baby by touch, pat and
cuddles etc.
E'a(uation
:.<ohnnyQs weight gain or weight loss will be carefully assessed.
C.The ,infant interaction could be reassessed, using the nursing child
assessment feeding scale.
D.The interaction of %rs. =mith with her mother.
9ohnson5s an# Chara$teristi$s o% a theory
:.6nterrelate concepts to create a different way of viewing a phenomenon.
C.Theories must be logical in nature.
D.Theories must be simple yet generali2able
;.Theories can be bases of hypothesis that can be tested.
E.Theories contribute to and assist in increasing the body of knowledge within
the discipline through the research implemented to validate them
F.Theories can be utili2ed by practitioners to guide and improve their practice.
J.Theories must be consistent with other validated theories, laws and
principles but will leave unanswered 9uestions that need to be
investigated.
Limitation
<ohnson 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.
6t is difficult to test <ohnsonQs 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.
<ohnson does not define the epected outcomes when one of the system is
affected by the nursing implementation an implicit epectation is made
that all human in all cultures will attain same outcome ,homeostasis.
<ohnsons behavioral system model is not fleible.
Summary
<ohnsons "ehavioral 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 J behavioral
subsystems. (ach subsystem composed of four structural characteristics i.e.
drives, set, choices and observable behavior. Three functional re9uirement of
each subsystem includes &:+ 'rotection from noious influences, &C+ 'rovision for
the nurturing environment, and &D+ stimulation for growth. Any imbalance in each
system results in dise9uilibrium .it is nursing role to assist the client to return to
the state of e9uilibrium.
Re%eren$e
'ractice , Drd ed. Norwalk, Appleton and /ange.
'olit 70, )ungler "'. Nursing >esearch# 'rinciples and %ethods. 'hiladelphia#
<" /ippincott -ompanyG :IIL.
"urns N, .rove =A. The practice of Nursing >esearch. ;th (d. 'hiladelphia#
1" =aunders 'ublicationsG CHH:.
Treece <1, Treece (1. (lements of >esearch in Nursing &Drded.+. =t. /ouis#
%osbyG :ILC.
IOGENE KING< THEORK O! GOAL
ATTAINENT
Intro#u$tion o% Theorist
"orn in :ICD
-ompleted her "achelor in science of nursing from =t. /ouis 5niversity in
:I;L
-ompleted her %aster of science in nursing from =t. /ouis 5niversity in :IEJ
-ompleted her 7octorate from Teachers college, -olumbia 5niversity
King5s Con$eptua( !rame2or)
6t includes#
=everal basic assumptions
Three interacting systems
=everal concepts relevant for each system
&asi$ assumptions
Nursing focus is the care of human being
Nursing goal is the health care of individuals * groups
)uman beings# are open systems interacting constantly with their
environment
6nteracting systems#
personal system
6nterpersonal system
=ocial system
-oncepts are given for each system
Con$epts %or Persona( System
'erception
=elf
.rowth * development
"ody image
=pace
Time
Con$epts %or Interpersona( System
6nteraction
-ommunication
Transaction
>ole
=tress
Con$epts %or So$ia( System
4rgani2ation
Authority
'ower
=tatus
7ecision making
a4or Theses o% King5s $on$eptua( %rame2or)
?(ach 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 eperiences@
King5s Theory o% Goa( Attainment
Theory of goal attainment was first introduced by 6mogene Aing in the early
:IFHs.
Theory describes a dynamic, interpersonal relationship in which a person
grows and develops to attain certain life goals.
0actors which affects the attainment of goal are# roles, stress, space * time
Propositions o% King5s Theory
0rom the theory of goal attainment king developed predictive propositions, which
includes#
6f perceptual interaction accuracy is present in nurse-client interactions,
transaction will occur
6f nurse and client make transaction, goal will be attained
6f goal are attained, satisfaction will occur
'roposition contP
6f transactions are made in nurse-client interactions, growth * development
will be enhanced
6f role epectations and role performance as perceived by nurse * client are
congruent, transaction will occur
6f role conflict is eperienced by nurse or client or both, stress in nurse-client
interaction will occur
6f nurse with special knowledge skill communicate appropriate information to
client, mutual goal setting and goal attainment will occur.
a4or $on$epts o% )ing5s theory
-C Human /eing 6person# is social being who are rational and sentient. 'erson has
ability to #
-perceive
-think
-feel
-choose
-set goals
-select means to achieve goals
-and to make decision
According to Aing, 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.
+C Hea(th<
According to Aing, health involves dynamic life eperiences of a human being, which
implies continuous adjustment to stressors in the internal and eternal environment
through optimum use of ones resources to achieve maimum potential for daily
living
LC En'ironment
(nvironment is the background for human interactions. 6t involves#
&a+ 6nternal environment# transforms energy to enable person to
adjust to continuous eternal environmental changes.
&b+ (ternal environment# involves formal and informal
organi2ations. Nurse is a part of the patients environment.
GC 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, eplore means,
and agree on means to achieve goals.@
:. A$tion< is defined as a se9uence of behaviors involving mental and
physical action.
C. Rea$tion< not specified, but might be considered as included in the
se9uence of behaviors described in action.
D. 6n addition king discussed#
&a+ goal
&b+ domain and
&c+ functions of professional nurse
;. Goa( o% nurse< ?To help individuals to maintain their health so they can
function in their roles.@
E. Domain o% nurse< ?includes promoting, maintaining, and restoring
health, and caring for the sick, injured and dying.
F. !un$tion o% pro%essiona( nurse# ?To interpret information in nursing
process to plan, implement and evaluate nursing care.
Aing said in her theory, ?A professional nurse, with special knowledge and skills, and
a client in need of nursing, with knowledge of self and perception of personal
problems, meet as strangers in natural environment. They interact mutually, identify
problems, establish and achieve goals.
Theory o% Goa( Attainment an# Nursing Pro$ess
Assumptions
"asic 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
Aing 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.
7uring assessment nurse collects data regarding client &his!her growth *
development, perception of self and current health status, roles etc.+
'erception is the base for collection and interpretation of data.
-ommunication is re9uired to verify accuracy of perception, for interaction
and transaction.
Nursing #iagnosis
The data collected by assessment are used to make nursing diagnosis in
nursing process. Acc. to king in process of attaining goa6 the nurse identifies
the problems, concerns and disturbances about which person seek help.
P(anning
After diagnosis, planning for interventions to solve those problems is done.
6n 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 clients participation is encouraged in making
decision on the means to achieve the goals.
Imp(ementations
6n nursing process implementation involves the actual activities to achieve the
goals.
6n goal attainment it is the continuation of transaction.
E'a(uation
:. 6t involves to finding out weather goals are achieved or not.
C. 6n king description evaluation speaks about attainment of goal and
effectiveness of nursing care.
Nursing Pro$ess an# Theory o% Goa( Attainment
Nursing pro$ess metho# Nursing pro$ess theory
A system of oriented actions A system of oriented concepts
Assessment
'erception, communication and
interaction of nurse and client
'lanning 7ecision making about the goals
"e agree on the means to attain
the goals
6mplementation Transaction made
(valuation .oal attained
Re%eren$es
Alligood %.>, Tomey. A.%. Nursing theory utili2ation and application. Cnd (d.
'ractice , Drd ed. Norwalk, Appleton * /ange.
&ETTK NEUANN5S SKSTE ODEL
INTRODUCTION
"etty Neumanns system model provides a comprehensive fleible holistic
and system based perspective for nursing.
6t 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.
HISTORK AND &ACKGROUND O! THE THEORIST
"etty Neumann was born in :IC;, in /owel, 4hio.
=he completed "= in nursing in :IEJ and %= in %ental )ealth 'ublic health
consultation, from 5-/A in :IFF. =he holds a 'h.7. in clinical psychology
=he was a pioneer in the community mental health movement in the late
:IFHs.
"etty Neumann began developing her health system model while a lecturer
in community health nursing at 5niversity of -alifornia, /os Angeles.
The models was initially developed in response to graduate nursing students
epression of a need for course content that would epose them to breadth
of nursing problems prior to focusing on specific nursing problem areas.
The model was published in :IJC as ?A %odel for Teaching Total 'erson
Approach to 'atient 'roblems@ in Nursing >esearch.
6t was refined and subse9uently published in the first edition of -onceptual
%odels for Nursing 'ractice, :IJ;, and in the second edition in :ILH.
DE"ELOPENT O! THE ODEL
Neumanns model was influenced by a variety of sources.
The philosophy writers de-hardin and cornu &on wholeness in system+.
8on "ertalanfy, and /a2lo on general system theory.
=elye on stress theory.
/ararus on stress and coping.
&ASIC ASSUPTIONS
(ach client system is uni9ue, a composite of factors and characteristics
within a given range of responses contained within a basic structure.
%any known, unknown, and universal stressors eist. (ach differ in its
potential for disturbing a clients usual stability level or normal /47
The particular inter-relationships of client variables at any point in time can
affect the degree to which a client is protected by the fleible /47 against
possible reaction to stressors.
(ach client! client system has evolved a normal range of responses to the
environment that is referred to as a normal /47. The normal /47 can be
used as a standard from which to measure health deviation.
1hen the fleible /47 is no longer capable of protecting the client! client
system against an environmental stressor, the stressor breaks through the
normal /47
The client whether in a state of wellness or illness, is a dynamic composite
of the inter-relationships of the variables. 1ellness is on a continuum of
available energy to support the system in an optimal state of system
stability.
6mplicit within each client system are internal resistance factors known as
/4>, which function to stabili2e and realign the client to the usual wellness
state.
'rimary prevention relates to ..A. that is applied in client assessment and
intervention, in identification and reduction of possible or actual risk
factors.
=econdary prevention relates to symptomatology following a reaction to
stressor, appropriate ranking of intervention priorities and treatment to
reduce their noious 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 echange with the
environment.
CONCEPTS
Content< F the variables of the person in interaction with the internal and
eternal environment comprise the whole client system
&asi$ stru$ture6Centra( $ore< F common client survival factors in uni9ue
individual characteristics representing basic system energy resources.
The basis structure, or central core, is made up of the basic survival factors
that are common to the species &Neumann,CHHC+.
These factors include#- - Normal temp. range, .enetic structure.- >esponse
pattern. 4rgan strength or weakness, (go structure
=tability, or homeostasis, occurs when the amount of energy that is
available eceeds that being used by the system.
A homeostatic body system is constantly in a dynamic process of input,
output, feedback, and compensation, which leads to a state of balance.
Degree to rea$tion< - the amount of system instability resulting from
stressor invasion of the normal /47.
Entropy< - a process of energy depletion and disorgani2ation moving the
system toward illness or possible death.
!(e3i/(e LOD< - a protective, accordion like mechanism that surrounds and
protects the normal /47 from invasion by stressors.
Norma( LOD< F 6t represents what the client has become over time, or the
usual state of wellness. 6t is considered dynamic because it can epand or
contract over time.
LOR< F The series of concentric circles that surrounds the basic structure.
'rotection factors activated when stressors have penetrated the normal
/47, causing a reaction symptomatology. (.g. mobili2ation of 1"- and
activation of immune system mechanism
InputF output# - The matter, energy, and information echanged between
client and environment that is entering or leaving the system at any point
in time.
Negentropy< F A process of energy conservation that increase organi2ation
and compleity, moving the system toward stability or a higher degree of
wellness.
Open system<F A system in which there is continuous flow of input and
process, output and feedback. 6t is a system of organi2ed compleity
where all elements are in interaction.
Pre'ention as inter'ention< F 6nterventions modes for nursing action and
determinants for entry of both client and nurse in to health care system.
Re$onstitution< F The return and maintenance of system stability, following
treatment for stressor reaction, which may result in a higher or lower level
of wellness.
Sta/i(ity< F A state of balance of harmony re9uiring energy echanges as
the client ade9uately copes with stressors to retain, attain, or maintain an
optimal level of health thus preserving system integrity.
Stressors< F environmental factors, intra &emotion, feeling+, inter &role
epectation+, and etra personal &job or finance pressure+ in nature, that
have potential for disrupting system stability.
A stressor is any phenomenon that might penetrate both the 0 and N /47,
resulting either a positive or negative outcome.
;e((ness6I((ness< - 1ellness is the condition in which all system parts and
subparts are in harmony with the whole system of the client.
o 6llness is a state of insufficiency with disrupting needs unsatisfied
&Neuman, CHHC+.
o 6llness is an ecessive ependiture of energyP when more energy is
used by the system in its state of disorgani2ation than is built and
storedG the outcome may be death &Neuman, CHHC+.
PRE"ENTION
According to Neumanns model, prevention is the primary nursing
intervention. 'revention focuses on keeping stressors and the stress
response from having a detrimental effect on the body.
PRIARK PRE"ENTION
'rimary prevention occurs before the system reacts to a stressor. 4n the
one hand, it strengthens the person &primary the fleible /47+ to enable
him to better deal with stressors
4n the other hand manipulates the environment to reduce or weaken
stressors.
'rimary prevention includes health promotion and maintenance of wellness.
SECONDARK PRE"ENTION
=econdary prevention occurs after the system reacts to a stressor and is
provided in terms of eisting system.
=econdary prevention focuses on preventing damage to the central core by
strengthening the internal lines of resistance and!or removing the stressor.
TERTIARK PRE"ENTION
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.
!OUR A9OR 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.
(ach layer consists of five person variable or subsystems#
o Physio(ogi$a(- >efer of the physicochemical structure and function
of the body.
o Psy$ho(ogi$a(F >efers to mental processes and emotions.
o So$ioF$u(tura(- >efers to relationshipsG and social!cultural
epectations and activities.
o Spiritua(F >efers to the influence of spiritual beliefs.
o De'e(opmenta(F >efers to those processes related to development
over the lifespan.
EN"IRONENT
The environment is seen to be the totality of the internal and eternal forces
which surround a person and with which they interact at any given time.
These forces include the intrapersonal, interpersonal and etra-personal
stressors which can affect the persons normal line of defense and so can
affect the stability of the system.
The internal environment eists within the client system.
The external environment eists outside the client system.
Neumann also identified a reate! 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 e9uated with wellness. =he defines
health!wellness as ?the condition in which all parts and subparts
&variables+ are in harmony with the whole of the client &Neumann, :IIE+@.
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 uni9ue 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 maimum 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 nurses perception will influence the care
given, then not only must the patient!clients 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 O! NURSING PROCESS *&K NEUAN.
NURSING DIAGNOSIS
6t depends on ac9uisition of appropriate databaseG the diagnosis identifies,
assesses, classifies, and evaluates the dynamic interaction of the five
variables.
8ariances from wellness &needs and problems+ are determined by
correlations and constraints through synthesis of theory and data base.
"road hypothetical interventions are determined, i.e. maintain fleible line of
defense.
NURSING GOALS
These must be negotiated with the patient, and take account of patients
and nurses perceptions of variance from wellness.
NURSING OUTCOES
Nursing intervention using one or more preventive modes.
-onfirmation of prescriptive change or reformulation of nursing goals.
=hort term goal outcomes influence determination of intermediate and long
, term goals.
A client outcome validates nursing process.
NEUANN5S SKSTE ODEL !ORAT
Neumanns nursing process format designates the following categories of data
about the client system as the major areas of assessment.
ASSESSENT
'otential and actual stressors.
-ondition and strength of basic structure factors and energy sources.
-haracteristics of fleible and normal line of defenses, lines of resistance,
degree of reaction and potential for reconstitution.
6nteraction between client and environment.
/ife process and coping factors &past, present and future+ actual and
potential stressors &internal and eternal+ for optimal wellness eternal.
'erceptual difference between care giver and the client.
NURSING DIAGNOSIS
The data collected are then interpreted to condition and formulate the
Nursing diagnosis.
)ealth seeking behaviors.
Activity intolerance.
6neffective coping.
6neffective thermoregulation.
GOAL
6n Neumanns systems model the goal is to keep the client system stable.
PLANNING
'lanning is focused on strengthening the lines of defense and resistance.
IPLEENTATION
The goal of stabili2ing the client system is achieved through three modes of
prevention
'rimary prevention # actions taken to retain stability
=econdary prevention # actions taken to attain stability
Tertiary prevention # actions taken to maintain stability
E"ALUATION
The nursing process is evaluated to determine whether e9uilibrium is
restored and a steady state maintained.
ACCEPTANCE &K THE NURSING COUNITK
Neumanns model has been described as a grand nursing theory by walker
and Avant.
.rand theories can provide a comprehensive perspective for nursing
practice, education, and research and Neumans 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. 4ne of the models strengths is that it can be used in a
variety of settings
5sing this conceptual model permits comparison of a nurses 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.
"ecause this model re9uires 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.
6t 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.
6n the associate degree program at 6ndiana 5niversity.
4ne 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 =tate 5niversity in =hreveport, /ouisiana, the faculty
determined that a systems model approach was preferred for their
masters program because of the universality framework.
Acceptance by the nursing community for education therefore is evident.
RESEARCH
A study was published by >iehl and >oy 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 analy2ing data for identifying client
problems.
o To test the assessment tool for its usefulness in the identification of
congruence between the clients perception of stressors and the
care givers perception of client stressors.
>esults indicated that the model can help categori2e data for assessing and
planning care and for guiding decision making.
Neumanns model can easily generate nursing research.
6t 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.
NEUANN5S AND THE CHARACTERISTICS O! A THEORK
Theories $onne$ts the interre(ate# $on$epts in su$h a 2ay as to
$reate a #i%%erent 2ay o% (oo)ing at a parti$u(ar phenomenonC
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
ade9uate according to the criteria.
Theories must /e (ogi$a( in nature
o Neumanns model in general presents itself as logically consistent.
o There is a logical se9uence in the process of nursing wherein
emphasis on the importance of accurate data assessment is basic to
the se9uential steps of the nursing process.
Theories shou(# /e re(ati'e(y simp(e yet genera(i8a/(eC
o Neumanns 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 generali2ability for use ion practice.
o 4ne drawback in relation to simplicity is the diagrammed model since
it presents over DE variables and tends to be awesome to the
viewer.
Theories $an /e the /ases %or hypotheses that $an /e teste#C
o Neumanns model, due to its high level and breadth of abstraction,
lends itself to theory development.
o 4ne are for future consideration as a beginning testable theory might
be the concept of prevention as intervention, subse9uent to basis
concept refinement in the Neuman model.
Theories $ontri/ute to an# assist in in$reasing the genera( /o#y o%
)no2(e#ge 2ithin the #is$ip(ine through the resear$h imp(emente#
to 'a(i#ate themC
o The model has provided clear, comprehensive guidelines for nursing
education and practice in a variety of settingsG this is its primary
contribution to nursing knowledge.
o The concept within the guidelines is clearly eplicated and many
applications of the theory have been published, little research
eplicitly derived from this model has been published to date.
Theories $an /e uti(i8e# /y the pra$titioner to gui#e an# impro'e
their pra$ti$eC
o 4ne 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 etensively in a variety of setting
in nursing practice, education and administration.
Theories must /e $onsistent 2ith other 'a(i#ate# theoriesJ (a2s an#
prin$ip(es /ut 2i(( (ea'e open unans2ere# 7uestions that nee# to
/e in'estigate#C
o 6n 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.
Resear$h Arti$(es
:.0Using the Neuman Systems o#e( %or &est Pra$ti$es55FFSharon AC
De;anJ Pear( NC UmeFN2ag/oJ Nursing S$ien$e Iuarter(yJ "o(C -?J
NoC -J L-FL@ *+,,>.C
:.The purpose of this study was to present two case studies based
upon Neuman systems modelG one case is directed toward family
care, and the other demonstrates care with an individual. Theory-
based eemplars serve as teaching tools for students and practicing
nurses.
C.These case studies illustrate how nursesQ actions, directed by
NeumanQs wholistic principles, integrate evidence-based practice
and generate high 9uality care
C.e(ton L, Se$rest 9, Chien A, An#ersen &. 0A $ommunity nee#s
assessment %or a SANE program using NeumanHs mo#e(1 < Am Acad
Nurse 'ract. CHH: AprG:D&;+#:JL-LF.
:.The purpose of the study was to present guidelines for a community
needs assessment for a =eual Assault Nurse (aminer &=AN(+
program using NeumanQs =ystems %odel.
C.=eual assault is a problem faced by almost every community. A
thorough community assessment is an important first step in
establishing programs that ade9uately meet a communityQs needs.
D..uidelines for conducting such an assessment related to
implementation of a =AN( program are rare, and guidelines using a
nursing model were not found in the literature
Re%eren$e
/11, N
'ractice , D
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D
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CJ&F+ # FHE-:E
<ulG:I&D+#CCE
LE"INE5S !OUR CONSER"ATION
PRINCIPLES
%yra (strine /evine
Intro#u$tion
"orn in -hicago, raised with a sister and a brother with whom she shared a
close loving relationship
Also very fond of her father who was often ill and fre9uently hospitali2ed
with .6 problem. This was the reason of choosing nursing as a career
Also called as renaissance women-highly principled, remarkable and
committed to patients 9uality of care
7ied in :IIF
E#u$ationa( A$hie'ement
7iploma in nursing#--ook county =4N, -hicago, :I;;
"=N#-5niversity of -hicago,:I;I
%=N#-1ayne state 5niversity, 7etroit, :IFC
'ublication#-An 6ntroduction to -linical Nursing, :IFI,:IJD * :ILI
>eceived honorary doctorate from /oyola 5niversity in :IIC
A$hie'ements
-linical eperience in 4T techni9ue and oncology nursing
-ivilian nurse at the .ardiner general hospital
7irector of nursing at 7reel home in -hicago
-linical instructor at "ryan memorial hospital in /incoln, Nebraska
Administrative supervisor at university of -hicago
-hairperson of clinical nursing at cook country =4N
8isiting professor at Tel Aviv university in 6srael
Conser'ationa( mo#e(
Goa(< To promote adaptation and maintain wholeness using the principles of
conservation
%odel 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
A#aptation
(very individual has a uni9ue range of adaptive responses
The responses will vary by heredity, age, gender or challenges of illness
eperiences
(ample# The response to weakness of cardiac muscle is an increased heart
rate, dilation of ventricle and thickening of myocardial muscle
1hile the responses are same, the timing and manifestation of organismic
responses will be uni9ue for each individual pulse rate+
An ongoing process of change in which patient maintains his integrity within
the realities of environment
Achieved through the Nfrugal, economic, contained and controlled use of
environmental resources by individual in his or her best interestN
;ho(eness
(ist when the interaction or constant adaptations to the environment
permits the assurance of integrity
'romoted by use of conservation principle
Conser'ation
The product of adaptation
NAeeping together Nof the life systems or the wholeness of the individual
Achieving a balance of energy supply and demand that is with in the uni9ue
biological realities of the individual
Nursing5s para#igm
Person
A holistic being who constantly strives to preserve wholeness and integrity
A uni9ue individual in unity and integrity, feeling, believing, thinking and
whole system of system
En'ironment
-ompetes the wholeness of person
6nternal
)omeostasis
)omeorrhesis
(ternal
'reconceptual
4perational
-onceptual
Interna( En'ironment
Homeostasis # A state of energy sparing that also provide the necessary
baselines for a multitude of synchroni2ed physiological and psychological
factors
A state of conservation
)omeorrhesis# A stabili2ed flow rather than a static state
(mphasis the fluidity of change within a space-time continuum
7escribe the pattern of adaptation, which permit the individuals body to
sustain its well being with the vast changes which encroach upon it from
the environment
E3terna( En'ironment
'reconceptual# Aspect of the world that individual are able to intercept
4perational# (lements that may physically affects individuals but not
perceived by hem# radiation, micro-organism and pollution
-onceptual# 'art of personQs environment including cultural patterns
characteri2ed by spiritual eistence, ideas, values, beliefs and tradition
Person an# en'ironment
Adaptation
4rganismic response
-onservation
A#aptation
-haracteristics
Histori$ity< Adaptations are grounded in history and await the challenges
to which they respond
Spe$i%i$ity< 6ndividual responses and their adaptive pattern varies on the
base of specific genetic structure
Re#un#an$y< =afe and fail options available to the individual to ensure
continued adaptation
Organismi$ response
A change in behavior of an individual during an attempt to adapt to the
environment
)elp individual to protect and maintain their integrity
They co-eist
They are four types
-C !(ight or %ight< An instantaneous response to real or imagined threat,
most primitive response
+C In%(ammatory< response intended to provide for structural integrity
and the promotion of healing
LC Stress< >esponse developed over time and influenced by each stressful
eperience encountered by person
G. Per$eptua(< 6nvolves gathering information from the environment and
converting it in to a meaning eperience
Nine mo#e(s o% gui#e# assessment
8itals signs
"ody movement and positioning
%inistration of personal hygiene needs
'ressure gradient system in nursing interventions
Nursing determination in provision of nutritional needs
'ressure gradient system in nursing
/ocal application of heat and cold
Administration of medicine
(stablishing an aseptic environment
Assumption
The nurse creates an environment in which healing could occur
A human being is more than the sum of the part
)uman being respond in a predictable way
)uman being are uni9ue in their responses
)uman being know and appraise objects ,condition and situation
)uman being sense ,reflects, reason and understand
human being action are self determined even when emotional
)uman being are capable of prolonging reflection through such strategists
raising 9uestions
)uman being make decision through prioriti2ing course of action
)uman being must be aware and able to contemplate objects, condition and
situation
)uman being are agents who act deliberately to attain goal
Adaptive changes involve the whole individual
A human being has unity in his response to the environment
(very person possesses a uni9ue adaptive ability based on ones life
eperience which creates a uni9ue message
There is an order and continuity to life change is not random
A human being respond organismically in an ever changing manner
A theory of nursing must recogni2ed the importance of detail of care for a
single patient with in an empiric framework that successfully describe the
re9uirement of the all patient
A human being is a social animal
A human being is an constant interaction with an ever changing society
-hange is inevitable in life
Nursing needs eisting and emerging demands of self care and dependant
care
Nursing is associated with condition of regulation of eercise or development
of capabilities of providing care
Le'ine5s 2or) D Chara$teristi$s o% theory
Theories can interrelate concepts in such a way as to create a different way
of looking at a particular phenomenon
The concept of illness adaptation, using interventions, and the evaluation of
nursing interventions are interrelated .they are combined to look at
nursing care in a different way &more comprehensive view incorporating
total patient care+ form previous time.
Theories must be logical in nature.
/evines idea about nursing care are organi2ed in such a way as to b
se9uential and logical. they can be used to eplain the conse9uences of
nursing action
Theories should be relatively simple yet generali2able.
/evines theory is easy to use .
6ts major elements are easily comprehensible and the relation ship have the
potential for being comple but are easily manageable
-ertain isolated aspect of the theory are the generali2able i.e. those related
to the conservational principles
Theories can be the bases for hypotheses that can be tested.
/evines idea can be tested
)ypothesis can be derived from them .
The principle of conservation are specific enough to be testable
/evines work * -haracteristics of theory
validate them.
=ince /evines idea have not yet been widely researched ,it is hard o
determine the contribution to the general body of knowledge with in the
discipline
Theories can be utili2ed by the practitioner to guide and improve their
practice.
'aula (.-rawford-gamble #-successfully applied /evines theory to the
female patient undergoing surgery for the traumatic amputation of the
fingers
These ideas lend themselves to use in practice particularly in acute care
setting
Theories must be consistent with other validated theories, laws and
investigated .
/evines ideas seem to be consistent with other theories, laws and principles
particularly those from the humanities and sciences
Conser'ationa( Prin$ip(e
-onservation of energy
-onservation of structural integrity
-onservation of personal integrity
-onservation of social integrity
-C Conser'ation o% energy
>efers to balancing energy input and output to avoid ecessive fatigue
includes ade9uate rest, nutrition and eercise
(ample#
availability of ade9uate rest
%aintenance of ade9uate nutrition
+C Conser'ation o% stru$tura( integrity
>efers to maintaining or restoring the structure of body preventing physical
breakdown And promoting healing
(ample#
Assist patient in >4% eercise
%aintenance of patients personal hygiene
LC Conser'ation o% persona( integrity
>ecogni2es the individual as one who strives for recognition, respect, self
awareness, selfhood and self determination
(ample#
>ecogni2e and protect patients space needs
GC Conser'ation o% so$ia( integrity
An individual is recogni2ed as some one who resides with in a family, a
community ,a religious group, an ethnic group, a political system and a
nation
(ample#
'osition patient in bed to foster social interaction with other patients
Avoid sensory deprivation
'romote patients use of news paper, maga2ines, radio. T8
'rovide support and assistance to family
Hea(th
)ealth is a wholeness and successful adaptation
6t 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
7isease# 6t is unregulated and undisciplined change and must be stopped or
death will ensue
Nursing
Nnursing 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 sciencesN
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 Nhuman interactionsN
Goa( o% Nursing
To promote wholeness, reali2ing that every individual re9uires a uni9ue and
separate cluster of activities
The individual integrity is his abiding concern and it is the nurses
responsibility to assist him to defend and to seek its reali2ation
Nursing Pro$ess
Assessment
Trophicognosis
)ypothesis
6nterventions
(valuation
Nursing Pro$ess
Assessment
-ollection of provocative facts through observation and interview of
challenges to the internal and eternal 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
Trophi$ognosis
Nursing diagnosis-gives provocative facts meaning
A nursing care judgment arrived at through the use of the scientific process
<udgment is made about patients needs for assistance
Hypothesis
'lanning
Nurse proposes hypothesis about the problems and the solutions which
becomes the plan of care
.oal is to maintain wholeness and promoting adaptation
Inter'entions
Testing the hypothesis
6nterventions are designed based on the conservation principles
%utually acceptable
.oal is to maintain wholeness and promoting adaptation
E'a(uation
4bservation of organismic response to interventions
6t is assesses whether hypothesis is supported or not supported
6f not supported, plan is revised, new hypothesis is proposed
Conser'ationa( mo#e(s
-onservational model provides the basis for development of two theories
o Theory of redundancy
o Theory of therapeutic intention
Theory o% re#un#an$y
5ntested ,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 o% therapeuti$ intention
.oal# To seek a way of organi2ing nursing interventions out of the biological
realities which the nurse has to confront
Therapeutic regimens should support the following goals#
0acilitate healing through natural response to disease
'rovide support for a failing auto regulatory portion of the integrated system
>estore individual integrity and well being
Theory o% therapeuti$ intention
'rovide supportive measure to ensures comfort
"alance a toic risk against the threat of disease
%anipulate diet and activity to correct metabolic imbalance and stimulate
physiological process
>einforce usual response to create a therapeutic changes
Uses
-ritical, acute or long term care unit
Neonates, infant and young children, pregnant young adult and elderly care
unit
'rimary health care
4T
-ommunity setting
Uti(ity o% Theory
Nursing research
Nursing education
Nursing administration
Nursing practice
Nursing resear$h
'rinciples of conservation have been used for data collection in various
researches
-onservational model was used by )anson et al.in their study of incidence
and prevalence of pressure ulcers in hospice patient
Newport used principle of conservation of energy and social integrity for
comparing the body temperature of infants who had been placed on
mothers chest immediately after birth with those who were placed in
warmer
Nursing e#u$ation
-onservational model was used as guidelines for curriculum development
6t was used to develop nursing undergraduate program at Allentown college
of =t.0rancis de sales, 'ennsylvania
5sed in nursing education program sponsored by Aapat )olim in 6srael
Nursing a#ministration
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
%c-all developed an assessment tool for data collection on the basis of four
conservational principles to identify nursing care needs of epileptic patients
0amily assessment tool was designed by /ynn-%chale and =mith for families
of patient in critical care setting
Nursing pra$ti$e
-onservational model has been used for nursing practice in different settings
"ayley discussed the care of a severely burned teenagers on the basis of
four conservational principles and discussed patients perceptual,
operational and conceptual environment
'ond used conservation model for guiding the nursing care of homeless at a
clinic, shelters or streets
Nursing pro$ess a$$or#ing to Le'ine5s mo#e(
%rs. %ona, a wife of an abusive husband, underwent a radical
hysterectomy. 'ost operatively has pain ,weight loss, nausea and inability
to empty bladder .'atient has history of smoking and stays in house which
is less than sanitary
Assessment
-hallenges to the internal env#-weight loss, nausea, loss of reproductive
ability
-hallenges to the eternal env#-abusive husband, insanitary condition in
home
(nergy conservation#-weight loss, nausea ,pain
=tructural integrity#-threatened by surgical procedure, inability to pass urine
'ersonal integrity#-not able to give birth to more children
=ocial integrity#-=trained relationship with husband
Trophi$ognosis
6nade9uate nutritional status
'ain
'otential for wound and bladder infection
Need to learn self catheteri2ation
7ecreased self worth
'otential for abuse
Hypothesis
Nutritional consultation
Teaching and return demonstration of urinary self catheteri2ation
-are of surgical wound
(ploring concern regarding hysterectomy
Inter'entions
Energy $onser'ation
'rovide medication for pain and nausea
Allowing rest period
Stru$tura( integrity
Administrating antibiotic for wound,
Teaching self catheteri2ation
Persona( integrity
(ploring her feeling about uterus removal while respecting her privacy
So$ia( integrity
Assess potential abuse form husband
=upport to the family
Organismi$ response
-ontrolled pain
Abdominal wound healing
6mproved appetite ,weight gain
-lean urinary self catheteri2ation
Assistance from husband
Criti7uing the theory
=he values the holistic approach to all individual, well or sick
8alues patients participation in nursing care
-omprehensive content in depth
'rovides direction of nursing research , education, administration and
practice
/ogically congruent
=hows high regard to adjunctive disciplines to develop theoretical basis for
nursing
Limitation
/imited 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 dont 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.
Resear$h High(ights
A theory of health promotion for preterm infants based on conservational
model of nursing. Nursing science 9uarterly,CHH; <ul,:J &D+
The article describes a new middle range theory of health promotion for
preterm infants based on /evines conservational model that can be used
to guide neonatal nursing practice.
Summary
6ntroduction to the theorist
-onservational model
-oncept of the model
Adaptation
1holeness
-onservation
:.-onservation principles
C.Nursing process
:.Assessment
C.Trophicogosis
D.)ypothesis
;.6nterventions
E.(valuation
D.Theory of redundancy
;.Theory of therapeutic intention
E.5tility of theory
:.Nursing research
C.Nursing education
D.Nursing administration
;.Nursing practices
Re%eren$es
/11.
CJ&F+ # FHE-:E
<ulG:I&D+#CCE
Cnd edition, Thomson, NK, CHHC.
ARTHA ROGER5S SCIENCE O!
UNITARK HUAN &EINGS
Intro#u$tion
"orn #%ay :C, :I:;, 7allas, Teas
7iploma #Anoville .eneral )ospital =chool of Nursing&:IDF+
.raduation in 'ublic )ealth Nursing, .eorge 'eabody -ollege, TN, :IDJ
%A #Teachers college, -olumbia university, New Kork, :I;E
%') #<ohns )opkins 5niversity, "altimore, %7, :IEC
7octorate in nursing #<ohns )opkins 5niversity, "altimore, :IE;
0ellowship# American academy of nursing
'osition# 'rofessor (merita, 7ivision of Nursing, New Kork 5niversity,
-onsultant, =peaker
7ied # %arch :D , :II;
Pu/(i$ations o% artha Rogers
O Theoretical basis of nursing &>ogers :IJH+
O Nursing science and art #a prospective &>ogers :ILL+
O Nursing #science of unitary, irreducible, human beings update &>ogers
:IIH+
O 8ision of space based nursing &>ogers :IIH+
Rogers nursing theory
O Nursing is both a science and art. the uni9ueness of nursing, like that of
any other science, lies in the phenomenon central to its focus.
O Nurses long established concern with the people and the world they live is
in a natural forerunner of an organi2ed abstract system encompassing people
and the environments.
O The irreducible nature of individuals is different from the sum of the parts.
O 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.
O The purpose of nurses is to promote health and well-being for all persons
wherever they are.
Evol"tion of a#strat system
O 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
O The science of unitary human beings originated as a synthesis of facts and
ideas from multiple sources of knowledge
O The uni9ueness is in the central phenomena # people and environment
O The >ogerian view of a causality emerges from an infinite universe of open
system
Overvie$ of Ro%erian mo!el
>ogers model provides the way of viewing the unitary human being
)umans 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
-hange of pattern and organi2ation 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 eperience
"asic characteristics which describes the life process of human #energy field,
openness, pattern, and pan dimensionality
"asic concepts include unitary human being ,environment, and
homeodynamic principles
&onepts of Ro%ers mo!el
Energy %ie(#
The energy field is the fundamental unit of both the living and nonliving
This energy field Nprovide a way to perceive people and environment as
irreducible wholesN
The energy fields continuously varies in intensity, density, and etent
Openness
The human field and the environmental field are constantly echanging their
energy
There are no boundaries or barrier that inhibit energy flow between fields
Pattern
'attern is defined as the distinguishing characteristic of an energy field
perceived as a single waves
Npattern is an abstraction and it gives identity to the fieldN
Pan #imensiona(ity
'an dimensionality is defined as Nnon linear domain without spatial or
temporal attributesN
The parameters that human use in language to describe events are arbitrary.
The present is relative Gthere is no temporal ordering of lives.
Unitary Human &eing *person.
A unitary human being is an Nirreducible, 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 partsN and Na unified whole having its own distinctive characteristics
which cannot be perceived by looking at , describing, or summari2ing the
partsN
The people has the capacity to participate knowingly and probabilistically in
the process of change
En'ironment
The environment is an Nirreducible ,pan dimensional energy field identified by
pattern and integral with the human fieldN
The field coeist and are integral. %anifestation emerge from this field and
are perceived.
Hea(th
>ogers defined health as an epression of the life processG they are the
Ncharacteristics and behavior emerging out of the mutual, simultaneous
interaction of the human and environmental fieldsN
)ealth and illness are the part of the sane continuum.
The multiple events taking place along lifeQs ais denote the etent to which
man is achieving his maimum health potential and very in their epressions
from greatest health to those conditions which are incompatible with the
maintaining life process
Nursing
The concept Nursing encompasses two dimensions
6ndependent science of nursing
An organi2ed 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
Ass"mptions a#o"t people an! n"rsin%
Nursing eists to serve peoplePPP..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 practicePP.the imaginative,
intellectual judgment with which such knowledge is made in service to the
man kind
'eople needs knowledgeable nursing
Homeo!ynami priniples
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
>esonancy
)elicy
integrality
Resonane
>esonance is an ordered arrangement of rhythm
characteri2ing both human field and environmental
field that undergoes continuous dynamic
metamorphosis in the human environmental process
Heliy
)elicy describes the unpredictable, but continuous, nonlinear evolution of
energy fields as evidenced by non repeating rhythmicties
The principle of )elicy postulates an ordering of the humans evolutionary
emergence
Inte%rality
6ntegrality cover the mutual, continuous relationship of the human energy
field and the environmental field .
-hanges occur by by the continuous repatterning of the human and
environmental fields by resonance waves
The fields are one and integrated but uni9ue to each other
Ro%erian theories
Ro%erian theories'Gran! theories
The theory of accelerating evolution
The theory of paranormal phenomena
The theory of rhythmicities
Theory of paranormal phenomena
This theory focus on the eplanations for precognition, dVjWvu, clairvoyance,
telepathy, and therapeutic touch
-lairvoyance is rational in a four dimensional human field in continuous
mutual, simultaneous interaction with a four dimensional worldG there is no
linear time nor any separation of human and the environmental fields
The theory of aeleratin% evol"tion
Theory postulates that evolutionary change is speeding up and that the range
of diversity of life process is widening. >ogers eplained that higher wave
fre9uencies are associated with accelerating human development
Theory of Rhythmiity
0ocus 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 !erive! from the siene of "nitary h"man #ein%s
The perspective rhythm model &'atrick :ILD+
Theory of health as epanding consciousness &Neumann, :ILF+
Theory of creativity, actuali2ation and empathy &Alligood :II:+
Theory of self transcendence &>eed:IIJ+
'ower as knowing participation in change &"arrett :IIL+
Ro%ers onepts of n"rsin%
Nursing is a learned profession-it is a science and art
Nursing is the study of unitary. 6rreducible, 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
>ogers challenges nurses to consider nursing needs of all people ,including
future generation of space kind Gas life continuous to evolve from earth to
space and beyond.
)er 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
>ogers 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.
'rofessional 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 reali2ation of maimum 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 maimum potential.
Nursing practice should be emphasi2ed on pain management, supportive
psychotherapy motivation for rehabilitation.
%aintenance and promotion of health, prevention of disease, nursing
diagnosis, intervention, and rehabilitation encompasses the scope of nursing
Ro%ers ontri#"tion to n"rsin% (no$le!%e
>ogers was one of the first nurse scholars to eplicitly identify the person
&unitary man+ as the central phenomena of nursing concern
Nursing abstract system is a matri of concepts relevant to the life process in
man
>ogers conceptual system provides a body of knowledge in nursing that will
have relevance for all workers concerned with people, but with special
relevance for nursesG because it matters to human beingsG conse9uently to
nurses
6n the evolution it is properly subjected to reformulation and change as the
knowledge grows, the the conceptual data will be more clearer and it will take
new dimensions
The utili2ation of >ogerian model is used as a guide for theory development,
research, nursing education, and in the direct patient care practice
R"les for n"rsin% researh %"i!e! #y the Ro%erian theory
Ru(es %or resear$h
The >ogerian research re9uire both basic and applied research
The phenomena to be studied are unitary human beings and their
environmental interaction
=tudy participants may be any person or group, with the provision that both
person and environment are taken into account
Resear$h metho#o(ogy
Mualitative and 9uantitative methods can be applied
(perimental researches are 9uestionable because she rejects the notion of
causality
-ase study and longitudinal research are better than cross sectional study
>esearch instruments that are directly derived from science of unitary human
beings should be used
7ata analysis , multivariate analysis &canonical correlation studies+
Resear$h too(s #eri'e# %rom s$ien$e o% unitary human /eings
'erceived field motion scale
)uman field rhythm scale
Temporal eperience scale
Assessment of dream eperience scale
'erson environment participation scale
/eddy healthiness scale
%utual eploration of the healing human-environment field scale
.aron assessment of pain scale
0amily assessment tool
-ommunity health assessment tool
R"les for n"rsin% e!"ation %"i!e! #y Ro%erian theory
!o$us o% the $urri$u(um
Nursing education can be for professional nursing , technical
nursing
The focus is the transmission of the body of knowledge
Teaching and practicing therapeutic touch
-onducting regular in-service education
Nursing programs
"accalaureate degree program
%asters program
7octoral program
The major concepts are , principal of >esonancy, )elicy,
6ntegrality
The faculty in the nursing education must be prepared at
doctoral level
Tea$hingF (earning strategies
(mphasis should be on developing self awareness as an aspect
of the clients environmental energy field and the dynamic role
of nurse pattern manifestation on the client
(mphasis on laboratory study- the lab setting include homes,
schools, industry, clinics, hospitals, other places where people
lives
6mportance of use of media in education
R"les for n"rsin% a!ministration %"i!e! #y Ro%erian theory
Purpose o% nursing ser'i$es
Nursing services is the center of any health care system
The purpose of nursing services is health promotion
Chara$teristi$s o% nursing personne(
The administrators should hold higher degrees in nursing and
licensed
/eaders must be visionary and willing to embrace innovative
and creative change
/eaders should be able to identify the patterning to ensure the
integrated behaviors for client and employees
anagement strategies an# a#ministrati'e po(i$ies
Administrative policies foster an open and supportive
administrative climate that enhances staff members self esteem
, actuali2ation, and freedom of choice and provide opportunity
for staff development and continuing education
The ultimate goal is the clients well-being
R"les for in!epen!ent pratitioner %"i!e! #y Ro%erian mo!el
Nursing is an independent science
Nurse assumes the role of potentiater of care
=he proposes the independent role in various setting like school, industry,
community, space &by CHEHA7+
6ndependent practitioner is an advanced practice registered registered nurse
who focus on well-being or mutual patterning of individual, family, community
across the life span ,at risk for developing dissonance!illness
R"les for n"rsin% pratie %"i!e! #y Ro%erian theory
Areas of Ro%erian mo!el appliation
=(TT6N.=
All spheres of life
=chool
6ndustry
0amily
-ommunity
=pace
='(-6A/6T6(=
'ediatrics
'sychiatry
4ncology
"urns
.eriatrics
Neurology
-ardiology
>ehabilitative medicine
='(-6A/6S(7 A>(A= 40 '>A-T6-(
o Neonatal 6-5
o 'ediatric 6-5
o 'ost operative unit
o 're operative unit
o 'alliative care unit
o >ehabilitation center
o "urns unit
o Adult 6-5s
o 4ld age homes
o Neuropsychiatric units
o A>(A 1)(>( >4.(>6AN %47(/ 6= N4T A''/6-A"/(
o 4peration theaters
Purpose o% nursing pra$ti$e
To promote well-being for all persons, wherever they are
To assist both the client and nurse to increase their awareness
of their own rhythm
Setting %or pra$ti$e
0rom community to hospital to outer space
Legitimate parti$ipants
'eople of all ages both as individual human energy fields and
group energy fields
N"rsin% proess' Health patternin% pratie metho!
Assessment
8oluntary mutual patterning
(valuation
!or the nurse
'attern appraisal
%utual patterning of human and environmental fields
(valuation
!or the patient
=elf reflection
'atterning activities
'ersonal appraisal
Nursing pro$ess
Assessment
Areas of assessment
=imultaneous states of the individual and the environment
Total pattern of events at any given point in space ,time
>hythms of life process
=upplementary data
-ategorical disease entities
=ubsystem pathology
'attern appraisal
6t is a comprehensive assessment of#
)uman field patterns of communication, echange, rhythms,
dissonance
(nvironmental fields pattern of communication, rhythms,
dissonance, harmony
6ntuitive reflection of self
8alidation of the appraisal
8alidate with self
8alidate with the client
%utual patterning of human and environmental field
o =haring knowledge
o 4ffering choices
o (mpowering the client
o 0ostering patterning
o (valuation
>epeat pattern appraisal
6dentify dissonance and harmony
8alidate appraisal with the client
=elf reflection for the client
'attern appraisal include appraisal of multiple lifestyle rhythms such as#
Nutrition
1ork!leisure activities
(ercise
=leep ! wake cycles
>elationships
7iscomfort or pain
0ear !hopes
'atterning activities for the client
O %editation
O 6magery
O <ournaling
O %odifying the surroundings
&linial ase st"!y of Ra!ha "sin% Ro%erian onept"al )o!el
>adha is a CCyears old female admitted in a psychiatry unit with
severe depression secondary to diagnosis of ovarian malignancy
=he becomes tearful during history taking
>adha is accompanied with her husband and :year old child
)er husband appeared anious but supportive and attentive PPPPhe
is working as an accountant in their native place
>adha was diagnosed with ovarian cancer C months back and
underwent bilateral salphingio oopherectomy and hysterectomyPPP
DHdays ago
=he is undergoing chemotherapy due to its %etastatic patternPP.
0rom past D weeks >adha started sitting lonely, decreased A7/,
repeated crying spells, decreased talks, neglects hygiene, muttering to
self, decreased sleep , appetite, neglecting her child care, complaints
of severe pain in the body,PPPP.D days back attempted suicide by
consuming rat poison.
-urrent assessment findings PP.her general appearance is a teary
eyed young woman ,ill-kempt, clinging to her husband ,looking
perpleed, not talkingP..poor nutritional intake, when asked about her
illnessP.cries inconsolably Pon repeated asking epressed sadness of
mood
Nursing $are o% Ra#ha 2ith Rogers mo#e(
1ith rogerian model, the process of caring >adha begins with pattern
appraisal
Nursing care involve pattern appraisal, mutual patterning, and evaluation
Pattern appraisa(
This visible rhythmical pattern is a manifestation of evolution towards
dissonance
>adha has pattern manifestation of dissonancePP..depression with suicidal
ideation, ovarian malignancy, pain
>adha has a low educational background
A pattern activity of healing is noted through reports of a positive operative
course
'atterning has to be directed towards reduction in perceived dissonance with
her personal and environmental field
'ain is a manifestation of perceived dissonance
7ecreased environmental energy transfer is visible by decreased talking and
crying
>adha has manifestation of fearPP.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 echanging patterns, communication patterns,
and relating patterns
Time between nurse and >adha is needed to foster her healing
7uring the process nurse must rely on personal intuition and insight regarding
the emerging pattern
All this pattern forms the unitary pattern of >adha
utua( patterning
The process is mutual between the nurse and >adha
The surgery performed, medication she is receiving are patterning modalities
'atterning activities planned by the nurse for >adha PP..therapeutic touch,
humor , meditation, imagery
>adha needs to be assessed fully regarding her ability to understand and
agree with different patterning modalities
Therapeutic touch can be introduced to >adha
Touch is introduced and incorporated into the management of pain, helps in
energy transmission for healing and PP.helps in developing trust in the nurse
Teach her how to center the energy and channel her energy to the area of
pain
5se humor for increasing sociali2ation and developing self confidence and
developing worthiness
)uman environmental patterning needs to involve the other individual who
share her environment including husband and son
4ptions are introduced relating to increase communication and hygiene
patterns
The entire family is involved in power as knowing participation in change
E'a(uation
The evaluation process centers on the perceptions of dissonance that eist
after the mutual pattern activities
The appraisal process is repeated
%anifestation 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 >adha, and mutual patterning is modified or instituted ad
indicated based on the evaluation
S"mmary
"iographical sketch of %artha >ogers
4verview of >ogerian concepts
>ogerian terminologies
>ogerian theories
Nursing concepts, nursing process
'erspectives of nursing education, administration, nursing practice
-ontribution to nursing knowledge
-linical eample
Referenes
:. .eorge ". <ulia , Nursing Theories- The base for professional Nursing
C. 1ills %.(velyn, %c(wen %elanie &CHHC+. Theoretical "asis for Nursing
D. %eleis 6brahim Afaf &:IIJ+ , Theoretical Nursing # 7evelopment * 'rogress
;. Taylor -arol,/illis -arol &CHH:+The Art * =cience 4f Nursing -are ;th ed.
E. 'otter A 'atricia, 'erry . Anne &:IIC+ 0undamentals 4f Nursing ,-oncepts
THEORIES &ASED ON INTERACTI"E
PROCESS
IOGENE KING< THEORK O! GOAL ATTAINENT
a4or Con$epts an# De%initions
Intera$tion
B A process of perception and communication
B "etween person and environment
B "etween person and person
B >epresented by verbal and nonverbal behaviors
B .oal-directed
B (ach individual brings different knowledge , needs, goals, past eperiences
and perceptions, which influence interaction
Communi$ation
B 6nformation from person to person
B 7irectly or indirectly
B 6nformation component of interaction
Per$eption
B (ach persons representation of reality
Transa$tion
B 'urposeful interaction leading to goal attainment
Ro(e
B A set of behaviours epected of persons occupying a position in a social
system
B >ules that define rights and obligations in a position
Stress
B 7ynamic state
B )uman being interacts with the environment
Gro2th an# #e'e(opment
B -ontinuous changes in individuals
B At cellular, molecular and behavioural levels of activities
B )elps individuals move towards maturity
Time
B =e9uence of events
B %oving onwards to the future
Spa$e
B (isting in all directions
B =ame everywhere
B 6mmediate environment &nurse and client interaction+
A9OR ASSUPTIONS
Nursing
B 4bservable behaviour
B 6n health care system in society
B .oal , to help individuals maintain health
B 6nterpersonal process of actionG reaction, interaction and transaction
Person
B =ocial beings
B =entient beings
B >ational beings
B 'erceiving beings
B -ontrolling beings
B 'urposeful beings
B Action , oriented beings
B Time , oriented beings
Hea(th
B 7ynamic state in the life cycle
B -ontinuous adaptation to stress
B To achieve maimum potential for daily living
B 0unction of nurse, patient, physicians, family and other interactions
En'ironment
B 4pen system
B -onstantly changing
B 6nfluences adjustment to life and health
Persona( system
Con$epts
'erception
=elf
"ody image
.rowth and development
Time
=pace
Interpersona( system
Con$epts
6nteraction
Transaction
-ommunication
>ole
=tress
So$ia( system
Con$epts
4rgani2ation
Authority
'ower
=tatus
7ecision making
ASSUPTIONS
'erceptions, goals, needs and values of the nurses and client influence
interaction process
6ndividuals have the right to knowledge about themselves and to participate
in decisions that influence their life, health and community services
)ealth professionals have the responsibility that helps individuals to make
informed decisions about their health care
6ndividuals have the right to accept or reject health care
.oals of health professionals and recipients of health care may not be
congruent

IIC SISTER CALLISTA ROK< ADAPTATION ODEL
Intro#u$tion
B "egins with man
B %an as a biopsychosocial being
B 6n constant interaction with his environment
!o$us o% nursing
B %ans position on the health , illness continuum
B 6nfluenced by ability to adapt to confronted stimuli
A9OR CONCEPTS AND DE!INITIONS
=ystem
B a set of units so related or connected as to form a unit
B characterised by inputs, out puts, control and feedback process.

Adaptational level
B a constantly changing point, made up of focal, contetual and residual stimuli
B represent the persons own standard of the range of stimuli, to which one can
respond with the ordinary adaptive response
Adaptation problems#
B the occurrence of situations of inade9uate responses to need deficits or
ecesses
0ocal stimulus#
B stimulus most immediately confronting the person
B must make an adaptive response
B factor that precipitates behaviour
-ontetual stimuli

B all other stimuli present
B contribute to behaviour caused by the focal stimuli
>esidual stimuli

B factors that may be affecting behaviour
B effect not validated
>egulator
B subsystem coping mechanism
B responds automatically through neural-chemical-endocrine processes
-ognator
B subsystem coping mechanism
B cognitive , emotive process
B responds through
B perception, information
B processing, learning
B judgment and emotion
Adaptive &effector+ modes
B classification of ways of coping
B manifests regulator and cognator activity
B physiologic, self concept, role function and interdependence
Adaptive responses
B 'romote integrity of the person in terms of the goals of survival, growth,
reproduction and mastery.
6neffective responses#
B 7oes not contribute to adaptive goals
'hysiological mode
B involves bodys basic needs and ways of dealing with adaptation in relation to

0luid and electrolytes
(ercise and rest
(limination
Nutrition
-irculation
4ygen

B regulation includes#
The senses
Temperature
(ndocrine regulation
=elf , concept mode#
B composite of belief and feeling
B formed from perceptions
B directs ones behaviour
B components are #
B the physical self
B the personal self
Ro(e per%orman$e mo#e<
X performance of duties
X based on given positions in society
Inter#epen#en$e mo#e<
X ones relation with significant others
X support system
X maintains psychic integrity
X meets needs for nurturance and affection
A9OR ASSUPTIONS
from system theory
from )elsons theory
from humanism
ASSUPTIONS !RO SKSTES THEORK
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 comple than mechanical systems and have
standards and feedback to direct their functioning as a whole.
ASSUPTIONS !RO HELSON5S THEORK
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, contetual 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.
ASSUPTIONS !RO HUANIS
'ersons have their own creative power
A persons behaviour is purposeful and not merely a chain of cause and effect
'erson is holistic
A persons opinions and view points are of value
The interpersonal relationship is significant.
ELEENTS
Nursing
A science and practice discipline
A theoretical system of knowledge
'rescribes a process of analysis and action
>elated to the care of the ill or potentially ill person
Person
A biopsychosocial being
A living, comple, adaptive system
1ith internal processes &the cognator and regulator+
Acting to maintain adaptation to the four modes
Hea(th
A state and a process of being and becoming an integrated and whole person
En'ironment
:. All the conditions, circumstances and influences surrounding and affecting
the development and behaviour of persons or groups
Re%eren$es
Alligood %.>, Tomey. A.%. Nursing theory utili2ation and application. Cnd (d.
Tomey A%, Alligood. %>. Nursing theorists and their work. &Eth ed.+. %osby,
'hiladelphia, CHHC.
'ractice , D
rd
%eleis 6brahim Afaf &:IIJ+ , Theoretical Nursing # 7evelopment and 'rogress
D
rd
Taylor -arol,/illis -arol &CHH:+The Art and =cience 4f Nursing -are ;
th
ed.
'otter A 'atricia, 'erry . Anne &:IIC+0undamentals 4f Nursing ,-oncepts
'rocess and 'ractice Drd ed. /ondon %osby Kear "ook.
Orem5s Theory
Intro#u$tion
O 4ne of Americas foremost nursing theorists.
O 7orothea 4rem earned her "achelor of science in nursing education in
:IDI and %aster of science in nursing in :I;E
O 7uring her professional career ,she worked as a staff nurse ,private duty
nurse ,nurse educator and administrator and nurse consultant
O >eceived honorary 7octor of =cience degree in :IJF
O 7orothea 4rem as a member of a curriculum subcommittee at -atholic
5niversity, recogni2ed the need to continue in developing a conceptuali2ation
of nursing.
O 'ublished first formal articulation of her ideas in N"rsin%* &onepts of
+ratie in :IJ:.second in :ILH,and finally in :IIE
De'e(opment o% Theory
O :I;I-:IEJ 4rem worked for the 7ivision of )ospital and 6nstitutional
=ervices of the 6ndiana =tate "oard of )ealth. )er goal was to upgrade the
9uality of nursing in general hospitals throughout the state. 7uring this time
she developed her definition of nursing practice.
O :IEL-:IFH 5= 7epartment of )ealth, (ducation and 1elfare where she
help publish N.uidelines for 7eveloping -urricula for the (ducation of
'ractical NursesN in :IEI.
O :IEI 4rem subse9uently served as acting dean of the school of Nursing
and as an assistant professor of nursing education at -5A. =he continued to
develop her concept of nursing and self care during this time.
O 4rems Nursing# -oncept of 'ractice was first published in :IJ: and
subse9uently in :ILH,:ILE, :II:, :IIE, and CHH:.
O -ontinues to develop her theory after her retirement in :IL;
De%initions o% #omain $on$epts
O Nursing , is art, a helping service, and a technology
O 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
O (ncompasses the patients perspective of health condition ,the physicians
perspective , and the nursing perspective
O .oal of nursing , to render the patient or members of his family capable
of meeting the patients 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 stabili2e ,control ,or minimi2e the effects of chronic poor health or
disability
O Hea(th , health and healthy are terms used to describe living things P it
is when they are structurally and functionally whole or sound P wholeness or
integrity. .includes that which makes a person human,Poperating in
conjunction with physiological and psychophysiological mechanisms and a
material structure and in relation to and interacting with other human beings
O En'ironment , environment components are environmental factors
,environmental elements, conditions ,and developmental environment
O Human /eing , has the capacity to reflect ,symboli2e and use symbols
-onceptuali2ed as a total being with universal ,developmental needs
and capable of continuous self care
A unity that can function biologically, symbolically and socially
O Nursing $(ient- a human being who has Nhealth related !health derived
limitations that render him incapable of continuous self care or dependent
care or limitations that result in ineffective ! incomplete care.
A human being is the focus of nursing only when a self ,care
re9uisites eceeds self care capabilities
O Nursing pro/(em , deficits in universal, developmental, and health
derived or health related conditions
O Nursing pro$essF a system to determine &:+why a person is under care
&C+a plan for care ,&D+the implementation of care
O Nursing therapeuti$s, deliberate ,systematic and purposeful action
Orem5s Genera( Theory o% Nursing
O 4rems general theory of nursing in three related parts#-
O Theory of self care
O Theory of self care deficit
O Theory of nursing systems
Theory o% Se(% Care
O 6ncludes #--
O Se(% $are , practice of activities that individual initiates and perform on
their own behalf in maintaining life ,health and well being
O Se(% $are agen$y , is a human ability which is Nthe ability for engaging in
self careN
-- -onditioned by age developmental state, life eperience
sociocultural orientation health and available resources
O Therapeuti$ se(% $are #eman# , Ntotality of self care actions to
be performed for some duration in order to meet self care re9uisites
by using valid methods and related sets of operations and actionsN
=elf care re9uisites-action directed towards provision of self care
D categories of self care re9uisites are#--
O 5niversal
O 7evelopmental
O )ealth deviation
Uni'ersa( se(% $are re7uisites
O Associated with life processes and the maintenance of the integrity of
human structure and functioning
O -ommon to all , A7/
O 6dentifies these re9uisites as#
O %aintenance of sufficient intake of air ,water, food
O 'rovision of care assoc with elimination process
O "alance between activity and rest, between solitude and social
interaction
O 'revention of ha2ards to human life well being and
O 'romotion of human functioning
De'e(opmenta( se(% $are re7uisites
O Associated with developmental processes! derived from a conditionP. 4r
associated with an event
O (.g. adjusting to a new job
O adjusting to body changes
Hea(th #e'iation se(% $are
O >e9uired in conditions of illness ,injury, or disease .these include#--
o =eeking and securing appropriate medical assistance
o "eing aware of and attending to the effects and results of pathologic
conditions
o (ffectively carrying out medically prescribed measures
o %odifying self concepts in accepting oneself as being in a particular
state of health and in specific forms of health care
o /earning to live with effects of pathologic conditions
Theory o% se(% $are #e%i$it
O =pecifies when nursing is needed
O Nursing is re9uired 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 i#enti%ies @ metho#s o% he(ping<FF
O Acting for and doing for others
O .uiding others
O =upporting another
O 'roviding an environment promoting personal development in relation to
meet future demands
O Teaching another
Theory o% Nursing Systems
O 7escribes how the patients self care needs will be met by the nurse , the
patient, or both
O 6dentifies D classifications of nursing system to meet the self care
re9uisites of the patient#-
O 1holly compensatory system
O 'artly compensatory system
O =upportive , educative system
O 7esign and elements of nursing system define
O =cope of nursing responsibility in health care situations
O .eneral and specific roles of nurses and patients
O >easons for nurses relationship with patients and
O 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
O 4rem recogni2ed that speciali2ed technologies are usually developed by
members of the health profession
O A technology is systemati2ed 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 o% te$hno(ogies
O So$ia( or interpersona(
O -ommunication adjusted to age, health status
O %aintaining interpersonal ,intragroup or intergroup relations for
coordination of efforts
O %aintaining therapeutic relationship in light of psychosocial modes of
functioning in health and disease
O .iving human assistance adapted to human needs ,action abilities and
limitations
O >egulatory technologies
O %aintaining and promoting life processes
O >egulating psycho physiological modes of functioning in health and
disease
O 'romoting human growth and development
O >egulating position and movement in space
Orem5s Theory an# Nursing Pro$ess
O 4rems approach to the nursing process presents a method to determine
the self care deficits and then to define the roles of person or nurse to meet
the self care demands.
O The steps within the approach are considered to be the technical
component of the nursing process.
O 4rem emphasi2es that the technological component Nmust be coordinated
with interpersonal and social processes within nursing situations
Comparison o% Orem5s Nursing Pro$ess an# the Nursing Pro$ess
Nursing Pro$ess
O Assessment
O Nursing diagnosis
O 'lans with scientific rationale
O 6mplementation
O evaluation
Orem5s NursingC Pro$ess
O 7iagnosis and prescription Gdetermine why nursing is needed. analy2e and
interpret ,make judgment regarding care
O 7esign of a nursing system and plan for delivery of care
O 'roduction and management of nursing systems
Step -F$o((e$t #ata in si3 areas<F
O The persons health status
O The physicians perspective of the persons health status
O The persons perspective of his or her health
O The health goals within the contet of life history ,life style, and health
status
O The persons re9uirements for self care
O The persons capacity to perform self care
Step +
O Nurse designs a system that is wholly or partly compensatory or
supportive-educative.
O The C actions are#-
O "ringing out a good organi2ation of the components of patients
therapeutic self care demands
O =election of combination of ways of helping that will be effective and
efficient in compensating for! overcoming patients self care deficits
Step L
O Nurse assists the patient or family in self care matters to achieve
identified and described health and health related results ..collecting
evidence in evaluating results achieved against results specified in the
nursing system design
O Actions are directed by etiology component of nursing diagnosis
O evaluation
App(i$ation o% Orem5s theory to nursing pro$ess

Persona(
%a$tors
Uni'ersa(
se(% $are
De'e(opmenta
( se(% $are
Hea(th
#e'iation
e#i$a(
pro/(em D
p(an
Se(% $are
#e%i$its
CI yr.
0emale
(arly
adulthood
transition
DCpack !yr
1ater-no
restrictions
0ood ,nil
1tLIlb
1t loss-:IY
nauseated
Teenage
pregnancy-C
4--:H yrs
)usband
emotionally
away
=eeks
medical
attention
for overt
s!s
Aware of
disease
No
evidence

Lth grade
Teenage
pregnancy
No work
%arried
-hild-C
5rinary
retention
6ntermittent
self
catheteri2atio
n
'ain

No "=(
6nfre9uent
physical
eamination
No )>T
'oor health
ability to
manage
effects
=urgery on
reproductive
organs
7ifference
between
knowledge
base *
lifestyle
/ives at
mothers
home.
Tearful
)usband
(75 deprivation
4ppressive
1ill receive >T
,perform
intermittent

(nvironment
unclean
/imited
resources
abusive
7issatisfied
with home
>T
living conditions catheteri2atio
n

Therapeuti$
se(% $are
#eman#
A#e7ua$y
o% se(%
$are
agen$y
Nursing
#iagnosis
etho#s o% he(ping
Air
%aintain
effective
respiration
1ater
No problem
0ood maintain
sufficient intake
6nade9uate

Ade9uate

6nade9uate
'otential for
impaired
respiratory status
' 0 fluid imbalance
Actual nutritional
deficit r!t ausea
.uiding * directing

Teaching

'roviding physical
support

)a2ards
'revent spouse
abuse
'romotion of
normalcy

6nade9uate

6nade9uate

'!0 injury

A!d in
environment
=hared housing
'ersonal development

.uiding * directing

.uiding * directing

%aintain
developmental
environment
=upport ed
normalcy in
environment
'revent
!manage dev
threat
6nade9uate

6nade9uate
Actual delay in
normaldev. >!T
early parenthood
/evel of education

7ev deficit r!t loss
of reproductive
organs
.uiding * directing
'roviding psy support

'roviding physical,
psy support
%aintenance of
health status
%anagement of
disease process
6nade9uate

6nade9uate
'!0 contd.
alterations in
health status
'!0 5T6
.uiding *
directing, teaching
.uiding * directing,
teaching
Adherence to
med regimen

Awareness of
potential
problems
6nade9uate

6nade9uate
'!0 Z adherence
in self
catheteri2ation *
4'7 >T
Actual deficit in
awareness of
advisability of
)>T * >T effects
teaching

teaching
Adjust to loss of
reproductive
ability * dev
healthy view of
illness
Adjust life style
to cope with
change
6nade9uate

6nade9uate
Actual threat to
self image

Actual self deficit
in planning for
future needs
'roviding psy
support

.uiding * directing
Orem5s 2or) an# the $hara$teristi$s o% a theory
O Theories can interrelate concepts in such a way as to create a different
way of looking at a particular phenomenon
O Theories must be logical in nature
O Theories must be relatively simple yet generali2able
O Theories are the basis for hypothesis that can be tested
O Theories contribute to and assist in increasing the general body of
validate them
O Theories can be used by the practitioners to guide and improve their
practice
O Theories must be consistent with other validated theories ,laws and
principles
Theory Testing
O 4rems theory has been used as the basis for the development of research
instruments to assist researchers in using the theory
O A self care 9uestionnaire was developed and tested by %oore&:IIE+ for
the special purpose of measuring the self care practice of children and
adolescents
O The theory has been used as a conceptual framework in assoc. degree
programs &0enner :IJI+ also in many nursing schools
Strengths
O 'rovides a comprehensive base to nursing practice
O 6t has utility for professional nursing in the areas of nursing practice
nursing curricula ,nursing education administration ,and nursing research
O =pecifies when nursing is needed
O Also includes continuing education as part of the professional component
of nursing education
O )er self care approach is contemporary with the concepts of health
promotion and health maintenance
O (panded her focus of individual self care to include multiperson units
Limitations
O 6n general system theory a system is viewed as a single whole thing while
4rem defines a system as a single whole ,thing
O )ealth is often viewed as dynamic and ever changing .4rems visual
presentation of the boed nursing systems implies three static conditions of
health
O Appears that the theory is illness oriented rather with no indication of its
use in wellness settings
Summary
O 4rems 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 D steps of nursing process
O 6t has a broad scope in clinical practice and to lesser etent in research
,education and administration
Re%eren$es
4rem, 7.(. &:II:+. Nursing# -oncepts of practice &;th ed.+. =t. /ouis, %4#
%osby-Kear "ook 6nc.
Taylor, =... &CHHF+. 7orthea (. 4rem# =elf-care deficit theory of nursing. 6n
A.%.
Tomey, A. * Alligood, %. &CHHC+. =ignificance of theory for nursing as a
discipline and profession. Nursing Theorists and their work. %osby, =t. /ouis,
%issouri, 5nited =tates of America.
1helan, (. .. &:IL;+. Analysis and application of 7orothea 4rems =elf-care
'ractuce %odel. >etrieved 4ctober D:, CHHF.
THE ROKHS ADAPTATION
ODEL
Intro#u$tion
O =r.-allista >oy, a prominent nurse theorist, writer, lecturer, researcher
and teacher
O 'rofessor and Nurse Theorist at the "oston -ollege of Nursing in -hestnut
)ill
O "orn at /os Angeles on 4ctober :;, :IDI as the C
nd
child of %r. and %rs.
0abien >oy
O she earned a "achelor of Arts with a major in nursing from %ount =t.
%aryQs -ollege, /os Angeles in :IFD.
O a masterQs degree program in pediatric nursing at the 5niversity of
-alifornia ,/os Angeles in :IFF.
O =he also earned a masters and 'h7 in =ociology in :IJD and :IJJ
,respectively.
O =r. -allista had the significant opportunity of working with 7orothy (.
<ohnson
O <ohnsonQs work with focusing knowledge for the discipline of nursing
convinced =r. -allista of the importance of describing the nature of nursing as
a service to society and prompted her to begin developing her model with the
goal of nursing being to promote adaptation.
O =he joined the faculty of %ount =t. %aryQs -ollege in :IFF, teaching both
pediatric and maternity nursing.
O =he organi2ed course content according to a view of person and family as
adaptive systems.
O =he introduced her ideas about 3Adaptation Nursing as the basis for an
integrated nursing curriculum.
O .oal of nursing to direct nursing education, practice and research
O %odel as a basis of curriculum impetus for growth--%ount =t. %arys
-ollege
O :IJH-The model was implemented in %ount =t. %arys school
O :IJ:- she was made chair of the nursing department at the college.
In%(uen$ing !a$tors
0amily
(ducation
>eligious "ackground
%entors
-linical (perience
Theory #es$ription
The central 9uestions of >oys theory are#
o 1ho is the focus of nursing careR
o 1hat is the target of nursing careR
o 1hen is nursing care indicatedR
>oys first ideas appeared in a graduate paper written at 5-/A in :IF;.
'ublished these ideas in N.ursing outlooN in :IJH
=ubse9uently different components of her framework crystalli2ed during
:IJHs, LHs, and IHs
4ver the years she identified assumptions on which her theory is based.
E3p(i$it assumptions *Roy -?=?N Roy an# An#re2s -??-.
The person is a bio-psycho-social being.
The person is in constant interaction with a changing environment.
To cope with a changing world, person uses both innate and ac9uired
mechanisms which are biological, psychological and social in origin.
)ealth and illness are inevitable dimensions of the persons life.
To respond positively to environmental changes ,the person must adapt.
The persons adaptation is a function of the stimulus he is eposed to and his
adaptation level
The persons adaptation level is such that it comprises a 2one indicating the
range of stimulation that will lead to a positive response.
The person has ; modes of adaptation# physiologic needs, self- concept, role
function and inter-dependence.
NNursing accepts the humanistic approach of valuing other persons opinions,
and view pointsN 6nterpersonal relations are an integral part of nursing
There is a dynamic objective for eistence with ultimate goal of achieving
dignity and integrity
Imp(i$it assumptions
A person can be reduced to parts for study and care.
Nursing is based on causality.
'atients values and opinions are to be considered and respected.
A state of adaptation frees an individuals energy to respond to other stimuli.
Roy A#aptation o#e( Con$epts< Ear(y an# Re'ise#
Adaptation -- goal of nursing
'erson -- adaptive system
(nvironment -- stimuli
)ealth -- outcome of adaptation
Nursing -- promoting adaptation and health
Con$eptsFA#aptation
>esponding 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
Con$eptsFPerson
"io-psycho-social being in constant interaction with a changing environment
5ses innate and ac9uired mechanisms to adapt
An adaptive system described as a whole comprised of parts
0unctions as a unity for some purpose
6ncludes people as individuals or in groups-families, organi2ations,
communities, and society as a whole
Con$eptsFEn'ironment
0ocal - internal or eternal and immediately confronting the person
-ontetual- all stimuli present in the situation that contribute to effect of focal
stimulus
>esidual-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,
contetual and residual stimuli
Con$eptsFHea(th
6nevitable dimension of personQs life
>epresented by a health-illness continuum
A state and a process of being and becoming integrated and whole
Con$eptsFNursing
To promote adaptation in the four adaptive modes
To promote adaptation for individuals and groups in the four adaptive modes,
thus contributing to health, 9uality of life, and dying with dignity by assessing
behaviors and factors that influence adaptive abilities and by intervening to
enhance environmental interactions
Con$eptsFSu/systems
-ognator subsystem [ A major coping process involving ; cognitive-emotive
channels# perceptual and information processing, learning, judgment and
emotion.
>egulator subsystem [ a basic type of adaptive process that responds
automatically through neural, chemical, and endocrine coping channels
Re(ationships
7erived 0our Adaptive %odes
EHH =amples of 'atient "ehavior
1hat was the patient doingR
1hat did the patient look like when needing nursing careR
!our A#apti'e o#es
'hysiologic Needs
=elf -oncept
>ole 0unction
6nterdependence
!our A#apti'e o#e Categories
Tested in practice for :H years
-riteria of significance, usefulness, and completeness were met
Samp(e Proposition an# Hypothesis %or Pra$ti$e
=elf -oncept %ode# 6ncreased 9uality of social eperience leads to increased
feelings of ade9uacy
'roviding support for new mothers can lead to positive parenting
Theory De'e(opment
Deri'e# Theory
I: 'ropositions
7escribed relationships between and among regulator and cognator and four
adaptive modes
:C .eneric propositions
Iuestions Raise# /y +-st Century Changes
)ow can ethics and public policy keep pace with developments in scienceR
)ow can nurses focus on human needs not machinesR
)ow can nurses contribute to creating meaning and purpose in a global
societyR
S$ienti%i$ Assumptions %or the +-st Century
=ystems of matter and energy progress to higher levels of comple self
organi2ation
-onsciousness and meaning are constitutive of person and environment
integration
Awareness of self and environment is rooted in thinking and feeling
)uman decisions are accountable for the integration of creative processes.
Thinking and feeling mediate human action
=ystem relationships include acceptance, protection, and fostering of
interdependence
'ersons and the earth have common patterns and integral relations
'erson and environment transformations are created in human consciousness
6ntegration of human and environment meanings results in adaptation
Phi(osophi$a( Assumptions
'ersons have mutual relationships with the world and .od
)uman meaning is rooted in an omega point convergence of the universe
.od is intimately revealed in the diversity of creation and is the common
destiny of creation
'ersons use human creative abilities of awareness, enlightenment, and faith
'ersons are accountable for the processes of deriving, sustaining, and
transforming the universe
A#aptation an# Groups
6ncludes relating persons, partners, families, organi2ations, communities,
nations, and society as a whole
A#apti'e o#es
'ersons
'hysiologic
=elf -oncept
>ole 0unction
6nterdependence
.roups
'hysical
.roup 6dentity
>ole 0unction
6nterdependence
Ro(e !un$tion o#e
5nderlying Need of =ocial 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
A#aptation Le'e(
A 2one within which stimulation will lead to a positive or adaptive response
Adaptive mode processes described on three levels#
6ntegrated
-ompensatory
-ompromised
Integrate# Li%e Pro$esses
Adaptation level where the structures and functions of the life processes work
to meet needs
(amples of 6ntegrated Adaptation
=table process of breathing and ventilation
(ffective processes for moral-ethical-spiritual growth
Compensatory Pro$esses
Adaptation level where the cognator and regulator are activated by a
challenge to the life processes
-ompensatory Adaptation (amples#
.rieving as a growth process, higher levels of adaptation and transcendence
>ole transition, growth in a new role
Compromise# Pro$esses
Adaptation level resulting from inade9uate integrated and compensatory life
processes
Adaptation problem
-ompromised Adaptation (amples
)ypoia
5nresolved /oss
=tigma
Abusive >elationships
The nursing pro$ess
>A% offers guidelines to nurse in developing the nursing process.
The elements #
0irst level assessment
=econd level assessment
7iagnosis
.oal setting
6ntervention
evaluation
Use%u(ness o% A#aptation o#e(
=cientific knowledge for practice
-linical assessment and intervention
>esearch variables
To guide nursing practice
To organi2e nursing education
-urricular frame work for various nursing colleges
Chara$teristi$s o% 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 generali2able
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 utili2ed 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 9uestions that need to be investigated
Testa/i(ity
>A% is testable
""A>N= &:III+ reported that :FD studies have been conducted using this
model.
>A% is complete and comprehensive
6t eplains the reality of client, so nursing interventions can be specifically
targeted.
Resear$h stu#ies using RA
%iddle range theories have been derived from >A%
:IIL-7ucharme et al described a longitudinal model of psychosocial
determinants of adaptation
:IIL-/eves9ue et al presented a %>T of psychological adaptation
:III-A %>NT , the urine control theory by <irovec et al
7unn, ).-. and 7unn, 7. .. &:IIJ+. The >oy Adaptation %odel and its
application to clinical nursing practice. <ournal of 4phthalmic Nursing and
Technology. F&C+, J;-JL.
=amarel, N., 0awcett, <., Arippendorf, A., 'iacentino, <.-., (liasof, "., )ughes,
'., Aowitski, -., and Siegler, (. &:IIL+. 1omenQs perception of group support
and adaptation to breast cancer. <ournal of Advanced Nursing. CL&F+, :CEI-
:CFL.
-hiou, -. &CHHH+. A meta-analysis of the interrelationships between the
modes in >oyQs adaptation model. Nursing =cience Muarterly. :D&D+, CEC-CEL
Keh, -. ). &CHH:+. Adaptation in children with cancer# research with >oyQs
model. Nursing =cience Muarterly. :;, :;:-:;L.
Shan, /. &CHHH+. -ognitive adaptation and self-consistency in hearing-
impaired older persons# testing >oyQs adaptation model. Nursing =cience
Muarterly. :D&C+, :EL-:FE.
Summary
:. E elements -person, goal of nursing, nursing activities, health and
environment
'ersons are viewed as living adaptive systems whose behaviours may be
classified as adaptive responses or ineffective responses.
These behaviors are derived from regulator and cognator mechanisms.
These mechanisms work with in ; adaptive modes.
The goal of nursing is to promote adaptive responses in relation to ; adaptive
modes, using information about persons adaptation level, and various stimuli.
Nursing activities involve manipulation of these stimuli to promote adaptive
responses.
)ealth is a process of becoming integrated and able to meet goals of survival,
growth, reproduction, and mastery.
The environment consists of persons internal and eternal stimuli.
Re%eren$es
CJ&F+ # FHE-:E
<ulG:I&D+#CCE
ORLANDOHS NURSING PROCESS
THEORK
INTRODUCTION
O 6da <ean 4rlando, a first-generation American of 6talian descent was
born in :ICF.
O =he received her nursing diploma from New Kork %edical -ollege, her
"= in public health nursing from =t. <ohnQs 5niversity, NK, and her %A in
mental health nursing from -olumbia 5niversity, New Kork.
O 4rlando was an Associate 'rofessor at Kale =chool of Nursing where
she was 7irector of the .raduate 'rogram in %ental )ealth 'sychiatric
Nursing.
O 1hile at Kale she was project investigator of a National 6nstitute of
%ental )ealth grant entitled# 6ntegration of %ental )ealth -oncepts in a
"asic Nursing -urriculum.
O 6t was from this research that she developed her theory which was
published in her :IF: book, The 7ynamic Nurse-'atient >elationship.
O =he furthered the development of her theory when at %c/ean )ospital
in "elmont, %A as 7irector of a >esearch 'roject# Two =ystems of Nursing
in a 'sychiatric )ospital.
O The results of this research are contained in her :IJC book titled# The
7iscipline and Teaching of Nursing 'rocesses
O 4rlando held various positions in the "oston area, was a board member
of )arvard -ommunity )ealth 'lan, and served as both a national and
international consultant.
O =he is a fre9uent lecturer and conducted numerous seminars on
nursing process.
O 4rlandoQs theory was developed in the late :IEHs from observations
she recorded between a nurse and patient.
O 7espite her efforts, she was only able to categori2e the records as
NgoodN or NbadN nursing.
O 6t then dawned on her that both the formulations for NgoodN and NbadN
nursing were contained in the records.
O 0rom these observations she formulated the deliberative nursing
process
Muestions
O 1hat prompts nursing actionsR
O 1hat are the properties of dynamic nurse patient relationships that
may lead to effective careR
Answer
O Nurses were prompted in their actions for reasons other than the
patients immediate eperiences and needs
INTRODUCTION TO THEORK
O The role of the nurse is to find out and meet the patientQs immediate
need for help.
O The patientQs presenting behavior may be a plea for help, however, the
help needed may not be what it appears to be.
O Therefore, nurses need to use their perception, thoughts about the
perception, or the feeling engendered from their thoughts to eplore with
patients the meaning of their behavior.
O This process helps nurse find out the nature of the distress and what
help the patient needs.
A9OR DIENSIONS O! THE THEORK
O 0unction of professional nursing - organi2ing principle
O 'resenting behavior - problematic situation
O 6mmediate reaction - internal response
O Nursing process discipline , investigation
O 6mprovement - resolution
!UNCTIONS O! PRO!ESSIONAL NURSING
O ORGANIPING PRINCIPLE
O 0inding out and meeting the patients immediate needs for help
O NursingP.is responsive to individuals who suffer or anticipate a sense of
helplessness, it is focused on the process of care in an immediate
eperience, 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
O The purpose of nursing is to supply the help a patient re9uires for his
needs to be met
O Nursing thought - 7oes the patient have an immediate need for help or
notR
O 6f 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 &EHA"IOR O PRO&LEATIC SITUATION
O To find out the immediate need for help the nurse must first recogni2e
the situation as problematic
O The presenting behavior of the patient, regardless of the form in which
it appears, may represent a plea for help
O 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
IEDIATE REACTION OINTERNAL RESPONSE
O 'erson perceives with any one of his five sense organs an object or
objects
O The perceptions stimulate automatic thought
O (ach thought stimulates an automatic feeling
O Then the person acts
O The first three items taken together are defined as the persons
immediate reaction
O >eflects how the nurse eperiences her or his participation in the nurse
patient situation
NURSING PROCESS DISCIPLINE F IN"ESTIGATION
O Any observation shared and eplored with the patient is immediately
useful in ascertaining and meeting his need or finding out that he is not in
need at that time
O 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
eploration with the patient
O The nurse initiates a process of eploration to ascertain how the patient
is affected by what she says or does
O 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
O 1hen the nurse does not eplore with the patient her reaction it seems
reasonably certain that clear communication between them stops
IPRO"EENT F RESOLUTION
O 6t 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
O 6n each contact the nurse repeats a process of learning how to help the
individual patient.
O )er own individuality and that of the patient re9uires that she go
through this each time she is called upon to render service to those who
need her
ASSUPTIONS
O 1hen patients cannot cope with their needs without help, they become
distressed with feelings of helplessness
O Nursing , in its professional character , does add to the distress of the
patient
O 'atients are uni9ue and individual in their responses
O Nursing offers mothering and nursing analogous to an adult mothering
and nurturing of a child
O Nursing deals with people, environment and health
O 'atient need help in communicating needs, they are uncomfortable and
ambivalent about dependency needs
O )uman beings are able to be secretive or eplicit about their needs,
perceptions, thoughts and feelings
O The nurse , patient situation is dynamic, actions and reactions are
influenced by both nurse and patient
O )uman beings attach meanings to situations and actions that are not
apparent to others
O 'atients entry into nursing care is through medicine
O 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
O 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
O Nurses are concerned with needs that patients cannot meet on their
own
DOAIN CONCEPTS
O Nursing , is responsive to individuals who suffer or anticipate a sense
of helplessness
O 'rocess of care in an immediate eperienceP.. for avoiding, relieving,
diminishing or curing the individuals sense of helplessness
O 0inding out meeting the patients immediate need for help
O .oal of nursing , increased sense of well being, increase in ability,
ade9uacy in better care of self and improvement in patients behavior
O )ealth , sense of ade9uacy or well being . 0ulfilled needs. =ense of
comfort
O (nvironment , not defined directly but implicitly in the immediate
contet for a patient
O )uman being , developmental beings with needs, individuals have their
own subjective perceptions and feelings that may not be observable
directly
O Nursing client , patients who are under medical care and who cannot
deal with their needs or who cannot carry out medical treatment alone
O Nursing problem , distress due to unmet needs due to physical
limitations, adverse reactions to the setting or eperiences which prevent
the patient from communicating his needs
O Nursing process , the interaction of :+the behavior of the patient, C+
the reaction of the nurse and D+the nursing actions which are assigned for
the patients benefit
O Nurse , patient relations , central in theory and not differentiated from
nursing therapeutics or nursing process
O Nursing therapeutics , 7irect function # initiates a process of helping
the patient epress the specific meaning of his behavior in order to
ascertain his distress and helps the patient eplore the distress in order to
ascertain the help he re9uires so that his distress may be relieved.
O 6ndirect function , calling for help of others , whatever help the patient
may re9uire for his need to be met
O Nursing therapeutics - 7isciplined and professional activities ,
automatic activities plus matching of verbal and nonverbal responses,
validation of perceptions, matching of thoughts and feelings with action
O Automatic activities , perception by five senses, automatic thoughts,
automatic feeling, action
THEORK ANALKSIS
PARADIGATIC ORIGINS
O 'aplaus focus of interpersonal relationships in nursing
O 'aplau acknowledged the influence of )arry =tack =ullivan on the
development of her ideas
O =ymbolic interactionism , -hicago school
O 5se of field methodology
O <ohn 7eweys theory of in9uiry
ORLANDOHS ;ORK AND CHARACTERISTICS O! A THEORK
O Theories can interrelate concepts in such a way in such a way as to
create a different way of looking at a particular phenomenon
O Theories must be logical in nature
O Theories should be relatively simple yet generali2able
O Theories can be the bases for hypotheses that can be tested
O Theories contribute to and assist in increasing the general body of
validate them
O Theories can be utilili2ed by practitioners to guide and improve their
practice
O Theories must be consistent with other validated theories, laws, and
investigated
INTERNAL DIENSIONS
Analy2ed CHHH nurse , patient interactions to identify the properties,
dimensions and goals of interactions
5se of field approach
0ocus on describing psychosocial aspects of nurse - patient interaction
5sed a miture of operational and problematic methods of theory
development
0ocus on how to deliver care not on what care to be given
Nursing process theory of low to medium level abstraction
STRENGTHS
5se of her theory assures that patient will be treated as individuals and that
they will have active and constant input into their own care
'revents inaccurate diagnosis or ineffective plans because the nurse has to
constantly eplore her reactions with the patient
Assertion of nursings independence as a profession and her belief that this
independence must be based on a sound theoretical frame work
.uides the nurse to evaluate her care in terms of objectively observable
patient outcomes
%ake evaluation a less time consuming and more deliberate function, the
results of which would be documented in patients charts
Nursing can pursue 4rlandoQs work for retesting and further developing her
work
THEORK CRITIIUE
/ack 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
0ocus on short term care, particularly aware and conscious individuals and
on the virtual absence of reference group or family members
LIITATIONS
)ighly interactive nature 4rlandoQs theory makes it hard to include the
highly technical and physical care that nurses give in certain settings
)er theory struggles with the authority derived from the function of
profession and that of the employing institutions commitment to the public
EMTERNAL COPONENTS
8alue of nursing shifted from task oriented to patient oriented nursing
process
Theory is culturally bound
%isinterpretation of continuous validation as lack of knowledge and epertise
The uni9ueness of individuals assumed by the theory could counteract
automatic responses of nurses
COPARISON ;ITH NURSING PROCESS
THEORK TESTING
8alidation of perceptions, thoughts and feelings is essential for enhancing
the congruence between patients needs and the care given
>esults indicate uni9ue nursing process is more effective than other
approaches in dealing with pain, in reducing stress, in understanding
patients needs, in relieving distress to eperienced by patients during the
process of admission to a hospital
5sed in describing the responsibilities of nursing students to distressed
patients
A number of studies focused on eplicating the properties and components
of nurse , patient interactions
'erceptions was used as a frame work to describe needs of grieving spouses
.illis supported 4rlandos differentiation between presenting problems as
perceived by the nurse and those as perceived and validated by patients
5sed as a framework to research nursing administration
USES O! THEORK
Use in E#u$ation
%idwestern =tate 5niversity in 1ichita 0alls, Teas, is using
4rlandoQs theory for teaching entering nursing students.
=outh 7akota =tate 5niversity in "rookings, =7 has been using
)aggertys &:ILE+ description of the communication based on
4rlandos theory for entering nursing students as well as re-
enforcing it in their junior year
Uses in A#ministration
o =chmieding successfully used 4rlandoQs theory in two major hospitals
for both practice and administration &/incoln .eneral )ospital,
/incoln, N( and "oston -ity )ospital, "oston, %A+.. 6mplementation
of 4rlandos theory produced substantial benefits. 6ts use increased
effectiveness in meeting patient needsG improved decision-making
skills among staff nurses, including determining what constituted
nursing versus non-nursing functionsG negotiated more effectively
in resolving conflict among staff nurses and between staff and
physiciansG and influenced a more positive nursing identity and
unity among staff.
Use in Resear$h
o 6n an 8eterans Administration &8A+ ambulatory psychiatric practice in
'rovidence, >6 =hea, %c"ride, .avin, and "auer &:ILJ+ used
4rlandos theoretical model with patients &N \ JF+ having a bipolar
disorder. Their research results indicate that there were# higher
patient retention, reduction of emergency services, decreased
hospital stay, and increased satisfaction.
6n a pilot study, 'otter and "ockenhauer &CHHH+ found positive
results after implementing 4rlandos theory. These included#
positive, patient-centered outcomes, a model for staff to use to
approach patients, and a decrease in patients immediate distress.
Use in C(ini$a( Pra$ti$e
o Nursing care plan
o -ase studies
o 'rogressive patient care settings
Nursing pro$ess
Assessment
7iagnosis
'lanning
6mplementation
(valuation
SUARK
Theorist , 67A <(AN 4>/AN74
7evelopment of theory
7imensions of theory
Assumptions
-oncepts
Theory analysis
-haracteristics of a theory
'aradigmatic origins
=trengths and limitations
6nternal and eternal components
-omparison with nursing process
Theory testing and uses of theory
CONCLUSION TO THEORK
:.4rlandoQs theory remains one the of the most effective practice theories
available.
C.The use of her theory keeps the nurseQs focus on the patient.
D.The strength of the theory is that it is clear, concise, and easy to use.
;.1hile providing the overall framework for nursing, the use of her theory
does not eclude nurses from using other theories while caring for the
patient.
RE!ERENCES
CJ&F+ # FHE-:E
<ulG:I&D+#CCE
APPLICATION O! IOGENE
KING5S THEORK O! GOAL
ATTAINENT
O/4e$ti'es
:.to assess the patient condition by the various methods eplained by the
nursing theory
C.to identify the needs of the patient
D.to demonstrate an effective communication and interaction with the patient.
;.to select a theory for the application according to the need of the patient
E.to apply the theory to solve the identified problems of the patient
F.to evaluate the etent to which the process was fruitful.
Intro#u$tion
Aings theory offers insight into nurses interactions with individuals and groups
within the environment. 6t highlights the importance of clients participation in
decision that influences care and focuses on both the process of nurse-client
interaction and the outcomes of care. %r.=y &J; years+ was admitted in /D ward
of ...)ospital, for a herniorrhaphy on ... for his left indirect inguinal hernia and
was epecting discharge from hospital... the theory of goal attainment was used
in his nursing process.
a4or Con$epts an# De%initions
-C Intera$tion
O A process of perception and communication
O "etween person and environment
O "etween person and person
O >epresented by verbal and nonverbal behaviours
O .oal-directed
O (ach individual brings different knowledge , needs, goals, past eperiences
and perceptions, which influence interaction
+C Communi$ation
O 6nformation from person to person
O 7irectly or indirectly
O 6nformation component of interaction
LC Per$eption
O (ach persons representation of reality
GC Transa$tion
O 'urposeful interaction leading to goal attainment
@C Ro(e
O A set of behaviours epected of persons occupying a position in a social
system
O >ules that define rights and obligations in a position
>C Stress
O 7ynamic state
O )uman being interacts with the environment
:C Gro2th an# #e'e(opment
O -ontinuous changes in individuals
O At cellular, molecular and behavioural levels of activities
O )elps individuals move towards maturity
=C Time
O =e9uence of events
O %oving onwards to the future
?C Spa$e
O (isting in all directions
O =ame everywhere
O 6mmediate environment &nurse and client interaction+
A9OR ASSUPTIONS
Nursing
O 4bservable behaviour
O 6n health care system in society
O .oal , to help individuals maintain health
O 6nterpersonal process of actionG reaction, interaction and transaction
Person
:. =ocial beings
C. =entient beings
D. >ational beings
;. 'erceiving beings
E. -ontrolling beings
F. 'urposeful beings
J. Action , oriented beings
L. Time , oriented beings
Hea(th
O 7ynamic state in the life cycle
O -ontinuous adaptation to stress
O To achieve maimum potential for daily living
O 0unction of nurse, patient, physicians, family and other interactions
En'ironment
O 4pen system
O -onstantly changing
O 6nfluences adjustment to life and health
Dynami$ Intera$ting Systems
Persona( system
Con$epts
O 'erception
O =elf
O "ody image
O .rowth and development
O Time
O =pace
Interpersona( system
Con$epts
:. 6nteraction, C. Transaction D. -ommunication ;. >ole E. =tress
So$ia( system
Con$epts
:. 4rgani2ation C. Authority D. 'ower ;. =tatus, E. 7ecision making
ASSUPTIONS
O 'erceptions, goals, needs and values of the nurses and client influence
interaction process
O 6ndividuals have the right to knowledge about themselves and to
participate in decisions that influence their life, health and community services
O )ealth professionals have the responsibility that helps individuals to make
informed decisions about their health care
O 6ndividuals have the right to accept or reject health care
O .oals of health professionals and recipients of health care may not be
congruent
Propositions o% King5s Theory
0rom the theory of goal attainment king developed predictive propositions, which
includes#
O 6f perceptual interaction accuracy is present in nurse-client interactions,
transaction will occur
O 6f nurse and client make transaction, goal will be attained
O 6f goal are attained, satisfaction will occur
O 'roposition contP
O 6f transactions are made in nurse-client interactions, growth *
development will be enhanced
O 6f role epectations and role performance as perceived by nurse * client
are congruent, transaction will occur
O 6f role conflict is eperienced by nurse or client or both, stress in nurse-
client interaction will occur
O 6f nurse with special knowledge skill communicate appropriate information
to client, mutual goal setting and goal attainment will occur.
Theory o% Goa( Attainment an# Nursing Pro$ess
Assumptions
"asic 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
O Aing 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.
O7uring assessment nurse collects data regarding client &his!her growth *
development, perception of self and current health status, roles etc.+
O'erception is the base for collection and interpretation of data.
O-ommunication is re9uired to verify accuracy of perception, for interaction and
transaction.
The %irst pro$ess in nursing pro$ess is nurse meets the patient an#
$ommuni$ates an# intera$ts 2ith himC Assessment is $on#u$te# /y
gathering #ata a/out the patient /ase# on re(e'ant $on$epts.
%r. =y is J;yrs married, got admitted in /D ward of ...)ospital on CJ!HD!HL with a
diagnosis of indirect inguinal hernia underwent herniorraphy with prolene mesh
done on DH!HD!HL. The following areas were addressed to for gathering data.
1hat is the patients
perception of the situationR
'atient says
@ 6 have undergone surgery for hernia@. ? The
wound is getting healed, 6 have no other problem@
?6 have pain in the area of surgery when moving@
?6m taking medicines for hypertension for the last
J years from here@
?6 have vision problem to my left eye. 6 had
undergone a surgery for my right eye about :H
years back@.
1hat are my perceptions of
the situationR
'atient underwent herniorahaphy operation on
DHth %arch for indirect inguinal hernia which he
kept untreated for DE years.
'atient has health maintenance related problems.
'atient is at risk of developing infection.
'atient has pain related to surgical incision.
'atient may develop hypertension related
complications in future.
1hat other information do 6
need to assist this patient
to achieve healthR
History
I#enti%i$ation #etai(s
%r. =y is J;yrs married, male, studied up to Jth
=td is doing "usiness, a practicing %uslim, got
admitted in /D ward of ...)ospital on CJ!HD!HL with
a diagnosis of indirect inguinal hernia underwent
herniorraphy with prolene mesh done on DH!HD!HL.
Present History o% I((ness
Abdominal swelling for DE years with difficulty in
activities and occasional abdominal pain. )e has
hypertension for seven years.
The swelling remained stable with uncomplicated
progress, getting increasing si2e when standing for
long and reducible on applying pressure
No h!o severe pain but increasing si2e for the last
few years
>elived after pressing the swelling back to position
and on taking rest and applying pressure
Past hea(th history
'atient underwent cataract surgery about :H years
back
4n treatment for hypertension
No other significant illness
!ami(y History
'atients net elder brother and net younger
brother had inguinal hernia and were operated
(lder brother underwent D surgeries for hernia
So$ioe$onomi$ Status
)igh economic status ]>s.CHHHH!- per month
Li%e Sty(e
Non vegetarian
No habit of smoking or alcoholism.
Aware about health care facilities
Physi$a( e3amination
Alert, conscious and oriented
%oderately built, ade9uate nourishment, with "%6
of CC
8ital signs , normal ecept "' :;H!IH mm)g
.eneral head-to-foot eamination reveals normal
finding ecept for the vision difficulty of the right
eye and healing surgical wound on th left inguinal
region.
=ubjective problems
'ain at the surgical wound site
/ack of bowel movement for C days
>eview of relevant systems
GI system
Inspe$tion<
)ealing wound, No infection, No redness, No
swelling
Aus$u(tation<
Normal bowel sounds
Pa(pation
No pain at the site, Normal abdominal organs
Per$ussion<
No dull sound suggesting fluid collection or ascitis
GenitoFUrinary system
Inspe$tion<
Testicles in position, No infection, No swelling or
enlargement
Pa(pation
No c!o pain,No prostate enlargement
Per$ussion
No fluid collection in scrotum
Aus$u(tation
Normal "owel sounds
La/oratory In'estigations
0"= - I: mg!dl
Na&:DH-:;Dm(9!dl+ - :D; m(9 ! dl
A^ &D.E-E mg!dl+ - D.E m(9 ! dl
5rea&L-DEmg!dl+-CI mg ! dl
-r &H.F-:.F mg! dl+- _: mg! dl
Other in'estigations
(lectro cardio gram
Ant. 0ascicular block
/eft atrial enlargement
Normal ais
1hat does this information
means to this situationR
O 'atient neglected a health problem for DE
years
O 'atient has acute pain at the site of surgical
wound
O 'atient has family history of inguinal hernia
and risk for recurrence
O 'atient has a risk for recurrence due to
constipation.
O 'atient has risk for infection due to
inade9uate knowledge and age.
O 'atient is at risk of developing complications
of hypertension
O 'atient re9uires education regarding health
maintenance
1hat conclusion
&judgement+ does this
patient makeR
O 'atient re9uires management for his pain
O 'atient understands the need taking care of
health risks and agrees to work on these aspects
1hat conclusions
&judgement+ do 6 makeR
Nursing #iagnosis
O The data collected
by assessment are used to
make nursing diagnosis in
nursing process. Acc. to
Aing in process of attaining
goal, the nurse identifies
the problems, concerns and
disturbances about which
person seek help.
"ased on the assessment following nursing
diagnoses were formulated, i.e. the clinical
judgement about the patients actual and potential
problems.
Acute pain related to surgical incision
>isk for infection related to surgical incision
>isk for constipation related to bed rest, pain
medication and N'4 or soft diet
7eficient knowledge regarding the treatment
and home care
6neffective health maintenance
P(anning
After diagnosis, planning for interventions to solve those problems is done.
6n 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 clients participation is encouraged in making decision
on the means to achieve the goals.
I#enti%ying the goa(s an# p(anning to a$hie'e these goa(s&this step is
congruent with planning in the traditional nursing process+
1hat goals do 6 think will
serve the patients best
interestR
:. The client will eperience improved comfort, as
evidenced by#
O a decrease in the rating of the pain,
O the ability to rest and sleep comfortably
C. The client will be free of infection as evidenced
by normal temperature, normal vital signs.
D. The client will have improved bowel
elimination, as evidenced by#
O (limination of stool without straining
;. -lient will ac9uire ade9uate knowledge
regarding the treatment and home care.
E. -lient will attend to health problems promptly
1hat are the patients
goalsR
'atients goals are#
O 0reedom from pain
O >apid healing
O Ade9uate bowel movement
O Ac9uiring ade9uate knowledge regarding his
health problems
Are the patients goals
and professional goals
are congruentR
Kes
1hat are the priority
goalsR
>elief of pain
0reedom from infection
Ade9uate bowel movement
6mprovement knowledge aspect of health conditions
'rompt attendance to health problems
1hat does the patient
perceives as the best way
to achieve goalsR
O 1orking with the health professionals
O .aining knowledge
O 7isclosing ade9uate information regarding
health problems
6s the patient willing to
work towards the goalsR
Kes
1hat do 6 perceive to be
the best way to achieve
the goalsR
Goa( -<
Assess the characteristics of pain
Administration of prescribed medicine
%onitor the responses to drug therapy
'rovide calm, efficient manner that reassures the
client and minimi2es aniety
'rovide a comfortable position as per clients
re9uests.
Goa( +<
%onitor vital signs
Administer antibiotics as advised
5se aseptic techni9ues while changing dressing
Aept the surgical wound site clean
>eport surgeon regarding early signs of infection
Goa( L<
(nsure that the client has ade9uate bulk in diet and
ade9uate fluid intake
6nstruct the client on prevention of straining and
avoiding valsalva manoeuvre
-onsult treating physician regarding medications.
Goa( G<
(plain the treatment measures to the patient and
their benefits in a simple understandable language.
(plain demonstrate about the home care.
-larify the doubts of the patient as the patient may
present with some matters of importance.
>epeat the information whenever necessary to
reinforce learning.
Goa( @<
)ealth education given about the following.
- >estriction of heavy weight lifting &more than
CHkg+ for F months
- 0urther management which may be
necessary
- 7iet control for his hypertension
- >ehabilitation measures to promote better
living
0or regular eamination of the site for recurrence
of hernia
Are the goals short-term
or long termR
.oals are both short-term and long term
1hat modifications
re9uired based on
mutualityR
'ain is tolerable to the patient and re9uires no
=4= medication
-onstipation is not that severe enough to take
medication
4ther interventions are mutually acceptable.
Imp(ementations
:.6n nursing process implementation involves the actual activities to achieve
the goals.
C.This step results in transactions being made.
D.Transactions occur as a result of perceiving the other person and the
situation, making judgments about those perceptions, and taking some
actions in response.
;.>eactions to action lead to transactions that reflect a shared view and
commitment
E.This step reflects implementation in the traditional nursing process.
Am 6 doing what the patient and 6
have agreed uponR
Kes
)ow am 6 carrying out the
actionsR
4n a mutually acceptable manner in
accordance with the goals set.
1hen do 6 carry out the actionR According to priority, a few interventions
re9uire immediate attention.
4ther interventions are carried out during
the period of hospitali2ation till E
th
April.
1hy am 6 carrying out the actionR 'atients condition demands nursing car.
6s it reasonable to think that the
identified goals will be reached by
carrying out the actionR
Kes
E'a(uation
6t involves to finding out weather goals are achieved or not.
6n Aings description evaluation speaks about attainment of goal and effectiveness
of nursing care.
Are my actions helping the patient
achieve mutually defined goalsR
Kes
)ow well are goals being metR =hort-term goals are met before
discharge from hospital
/ong-term goals are epected to be met,
because the patient is motivated to
continue home care.
1hat actions are not workingR
1hat is patients response to my
actionsR
'atient is satisfied with my actions
Are other factors hindering goal
achievementR
'atients age is a hindering factor in goal
achievement regarding health
maintenance.
)ow should the plan be changed to
achieve goalsR
)ealth teaching can be modified
according to developmental stage.
6nvolvement of family member in care of
the patient.
Re%eren$es
'hipps < 1ilma, =ands A <udith. %edical =urgical Nursing# concepts * clinical
practice.Fth edition. 'hiladelphia. %osby publications. :IIF.
"lack %. <oice, )awks )okanson <ane. %edical =urgical Nursing# -linical
%anagement for positive outcomes. =t /ois, %issouri. CHHE.
APPLICATION O! OREHS SEL!FCARE
DE!ICIT THEORK IN NURSING
PRACTICE
INTRODUCTION
The history of professional nursing begins with 0lorence nightingale.
/ater in last century nursing began with a strong emphasis on practice.
0ollowing that came the curriculum era which addressed the 9uestions
about what the nursing students should study in order to achieve the re9uired
standard of nursing.
As more and more nurses began to pursue higher degrees in nursing,
there emerged the research era.
/ater graduate education and masters education was given much
importance.
The development of the theory era was a natural outgrowth of the
research era.
1ith an increased number of researches it became obvious that the
research without theory produced isolated informationG however research and
theory produced the nursing sciences.
1ithin the contemporary phase there is an emphasis on theory use
and theory based nursing practice and lead to the continued development of
the theories.
O&9ECTI"ES
to assess the patient condition by the various methods eplained 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 etent to which the process was fruitful.
Areas Patient #etai(s
Name
Age
=e
(ducation
4ccupation
%arital status
>eligion
7iagnosis
Theory
applied
%rs. `
EF years
0emale
No formal
education
)ouse hold
%arried
)indu
>heumatoid
arthritis
4rems theory of
self care deficit.
ORE5S THEORK O! SEL! CARE DE!ICIT
The self care deficit theory proposed by 4rem is a combination of three
theories, i.e. theory of self care, theory of self care deficit and the theory of
nursing systems.
6n the theory of self care, she eplains self care as the activities
carried out by the individual to maintain their own health.
The se(% $are agen$y is the ac9uired ability to perform the self care
and this will be affected by the /asi$ $on#itioning %a$tors such as age,
gender, health care system, family system etc.
Therapeutic self-care demand is the totality of the self care measures
re9uired.
The self care is carried out to fulfill the se(%F$are re7uisites.
There are mainly D types of self care re9uisites such as universal,
developmental and health deviation self care re9uisites.
1henever there is an inade9uacy of any of these self care re9uisite, the
person will be in need of self care or will have a #e%i$it in se(% $are.
The deficit is identified by the nurse through the thorough assessment
of the patient.
4nce the need is identified, the nurse has to select re9uired 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.
4nce 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.
!or rsC MBC
:. =he came to the hospital with complaints of pain over all the joints,
stiffness which is more in the morning and reduces by the activities.
C. =he has these complaints since E years and has taken treatment from
local hospital.
D. The symptoms were not reducing and came to --%-, )ospital for
further management.
;. 'atient was able to do the A7/ by herself but the way she performed
and the posture she used was making her prone to develop the complications
of the disease.
E. =he also was malnourished and was not having awareness about the
deficiencies and effects.
DATA COLLECTION ACCORDING TO ORE5S THEORK O! SEL! CARE DE!ICIT
-C &ASIC CONDITIONING !ACTORS
Age EF year
.ender 0emale
)ealth state 7isability due to health condition, therapeutic
self care demand
7evelopment state (go integrity vs despair
=ociocultural
orientation
No formal education, 6ndian, )indu
)ealth care system 6nstitutional health care
0amily system %arried, husband working
'atterns of living At home with partner
(nvironment >ural area, items for A7/ not in easy reach, no
special precautions to prevent injuries
resources )usband, daughter, sisters son
+C UNI"ERSAL SEL!FCARE REIUISITES<
Air "reaths without difficulty, no pallor cyanosis
1ater 0luid intake is sufficient. (dema present over
ankles.
Turgor normal for the age
0ood )b , I.FgmY, "%6 \ :;.0ood intake is not
ade9uate or the diet is not nutritious.
(limination 8oids and eliminates bowel without difficulty.
Activity! rest 0re9uent rest is re9uired due to pain.
'ain not completely relieved,
Activity level ha s come down.
7eformity of the joint secondary to the disease
process and use of the joints.
=ocial interaction -ommunicates well with neighbors and calls the
daughter by phone Need for medical care is
communicated to the daughter.
'revention of
ha2ards
Need instruction on care of joints and prevention of
falls. Need instruction on improvement of
nutritional status. 'refer to walk bare foot.
'romotion of
normalcy
)as good relation with daughter
LC DE"ELOPENTAL SEL!FCARE REIUISITES<
%aintenance of
developmental environment
Able to feed self , 7ifficult to perform
the dressing, toileting etc
'revention!management of the
conditions threatening the
normal development
0eels that the problems are due to her
own behaviours and discusses the
problems with husband and daughter.
GC HEALTH DE"IATION SEL! CARE REIUISITES
Adherence to medical
regimen
>eports the problems to the physician when
in the hospital. -ooperates with the
medication, Not much aware about the use
and side effects of medicines
Awareness of potential
problem associated
with the regimen
Not aware about the actual disease process.
Not compliant with the diet and prevention of
ha2ards. Not aware about the side effects of
the medications
%odification of self
image to incorporates
changes in health
status
)as adapted to limitation in mobility.

The adoption of new ways for activities leads
to deformities and progression of the disease.
Adjustment of lifestyle
to accommodate
changes in the health
status and medical
regimen.
Adjusted with the deformities.
'ain tolerance not achieved
@C EDICAL PRO&LE AND PLAN<
Physi$ian5s perspe$ti'e o% the $on#ition#
7iagnosed with rheumatoid arthritis and is on the following medications#
T. 8alus => 47
T. 'an ;H mg 47
T. Trama2ac EH mg 47
T. >ecofi 0orte "7
T. =helcal "7
=yp. )eamup Ctsp T67
e#i$a( Diagnosis# >heumatoid arthritis
e#i$a( Treatment# %edication and physical therapy.
AREAS AND PRIORITK ACCORDING TO ORE5S THEORK O! SEL!FCARE
DE!ICIT< IPORTANT !OR PRIORITIPING THE NURSING DIAGNOSISC
a. Air
b. 1ater
c. 0ood
d. (limination
e. Activity! >est
f. =olitude! 6nteraction
g. 'revention of ha2ards
h. 'romotion of normalcy
i. %aintain a developmental environment.
j. 'revent or manage the developmental threats
k. %aintenance 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 %>
Nursing $are p(an a$$or#ing to Orem5s theory o% se(% $are #e%i$it
Nursing
#iagnosis
* #iagnosti$
operations .
Out$ome an# p(an
*Pres$ripti'e
operations.
Imp(ementation
*$ontro(
operations.
E'a(uation
*regu(atory
operations .
"ased on self care
deficits
:. 4utcome
C. Nursing goal
and objectives
D. 7esign of
nursing system
;. Appropriate
method of
helping
Nurse- patient
actions to
- 'romote
patient as
self care
agent
- %eet self
care needs
- 7ecrease the
self care
deficit.
:. (ffectiveness of
the nurse patient
action to
-'romote patient
as self care agent
- %eet self
care needs
- 7ecrease
the self
care deficit.
C. (ffectiveness of
the selected
nursing system to
meet the needs.
Thus in the patient rsC M the areas that nee# assistan$e 2ereB
Air
1ater
0ood
(limination
Activity! >est&C+
=olitude! 6nteraction
'revention of ha2ards&C+
'romotion of normalcy
%aintain a developmental environment.
'revent or manage the developmental threats
%aintenance 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
APPLKING THE ORE5S THEORK O! SEL!FCARE DE!ICITJ A NURSING CARE
PLAN !OR RSC M COULD &E PREPARED AS !OLLO;S B
Therapeuti$ se(% $are #eman#< deficient area# food
A#e7ua$y o% se(% $are agen$y< 6nade9uate
NURSING DIAGNOSIS
6nability to maintain the ideal nutrition related to inade9uate intake and knowledge
deficit
OUTCOES AND PLAN
aC Out$ome#
improved nutrition
%aintenance of a balanced diet with ade9uate iron supplementation.
/C Nursing Goa(s an# o/4e$ti'es
Goa(# to achieve optimal levels of nutrition.
O/4e$ti'es# %rs. ` will#
- state the importance of maintaining a balanced diet.
- /ist the food items rich in iron , that are available in the locality.
$C Design o% the nursing system<
supportive educative
#C etho# o% he(ping#
guidance
support
Teaching
'roviding developmental environment
IPLEENTATION
%utually planned and identified the objectives and the patient were made to
understand about the re9uired changes in the behaviour to have the re9uisites met.
E"ALUATION
%rs. ` understood the importance of maintaining an optimum nutrition.
=he told that she will select the iron rich diet for her food.
=he listed the foods that are rich in iron and that are locally available.
The self care deficit in terms of food will be decreased with the initiation of the
nutritional intake.
The supportive educative system was useful for %rs. `
--------------------------------------------------------------------------
Therapeuti$ se(% $are #eman## deficient area# Activity
NURSING DIAGNOSIS
=elf-care deficit# dressing, toileting related to restricted joint movement, secondary
to the inflammatory process in the joints.
OUTCOES AND PLAN
aC Out$ome#
- improved self-care
- maintain the ability to perform the toileting and dressing with modification as
re9uired.
Goa(< to achieve optimal levels of ability for self care.
O/4e$ti'es< %rs. ` will#
-perform the dressing activities within limitations
-utili2e the alternative measures available for improving the toileting
-perform the other activities of daily living with minimal assistance.
$C Design o% the nursing system< 'artly compensatory
#C etho# o% he(ping#
Gui#an$e #
Assess the various hindering factors for self care and how to tackle them.
Support<
'rovide all the articles needed for self care, near to the patient and ask the family
members also to give the articles near to her.
'rovide passive eercises and make to perform active eercises so as to promote the
mobility of the joint.
%ake the patient use commodes or stools to perform toileting and insist on
avoidance of s9uatting position
'rovide assistance whenever needed for the self care activities
'rovide encouragement and positive reinforcement for minor improvement in the
activity level.
6nitiate the pain relieving measures always before the patient go for any of the
activities of daily living
%ake the patient to use loose fitting clothes which will be easy to wear and remove.
Tea$hing<
Teach the family members the limitation in the activity level the patient has and the
cooperation re9uired
Promoting a #e'e(opmenta( en'ironment<
Teach the family and help them to practice how to help the patient according to her
needs
IPLEENTATION
%utually planned and identified the objectives and the patient was made to
understand about the re9uired changes in the behaviour to have the re9uisites met.
E"ALUATION
'atient was performing some of the activities and she practiced toileting using a
commode in the hospital.
=he verbali2ed an improved comfort and self care ability.
=he performed the dressing activities with minimal assistance
'atient verbali2ed that she will perform the activities as instructed to get her A7/
done.
The partly compensatory system was useful for %rs. `
----------------------------------------------------------------------
Therapeuti$ se(% $are #eman## deficient area# 'ain control
NURSING DIAGNOSIS
6neffective pain control related to lack of utili2ation of pain relief measures
OUTCOES AND PLAN
aC Out$ome#
- improved pain self control
- achieve and maintain a reduction in the pain.
Goa(< to achieve reduction in the pain.
describe the total plan of pharmacological and non pharmacological pain
relief
demonstrate a reduction in the pain behaviours
verbali2e a reduction in the pain scale score from J , ;
$C Design o% the nursing system< supportive educative
#C metho# o% he(ping<
Gui#an$e<
(plore the past eperience of pain and methods used to manage them.
Ask the client to report the intensity, location, severity, associated and
aggravating factors.
Support<
'rovide rest to the joints and avoid ecessive manipulations
provide hot and cold application to have better mobility.
(ncourage eercises to the joints by immersing in the warm water.
Administer T. 5ltracet and Tab 7iclofecac as prescribed.
'rovide diversion and psychological support to the patient
Tea$hing<
Teach the non , pharmacological method to the patient once the pain is a
little reduced.
Pro'i#ing the #e'e(opmenta( en'ironment<
7iscuss with the patient the necessity to maintain a pain diary with all
information regarding episodes of pain and refer to that periodically
(n9uire from the health team, the need for opioid analgesics or other
analgesics and get a prescription for the patient.
IPLEENTATION
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
E"ALUATION
'atient still has pain over the joints and she agreed that she will use the
measures for pain relief that is told to her.
The pain scale score was F after the measures were provided to the patient.
=he demonstrated slight reduction in the pain behaviours.
--------------------------------------------------------------
Therapeuti$ se(% $are #eman#< deficient area# prevention of ha2ards.
A#e7ua$y o% se(% $are agen$y# 6nade9uate
NURSING DIAGNOSIS
'otential for fall and fractures related to rheumatoid arthritis.
OUTCOES AND PLAN
aC Out$ome<
Absence of falls and injury to the patient
Goa(# prevent the falls and injury and to maintain a good body mechanics.
o/4e$ti'es< %rs. ` will#
-remain free from injury as evidenced by#
-absence of signs and symptoms of fall or injury
- eplaining 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
(ncourage the patient to use supportive devices as re9uired.
'rovide a safe environment in the hospital by avoiding sharp objects or
wooden objects on the way and slippery floor.
6nvolve the family members in providing and maintaining a safe environment
in the home
6nvolve the family members to provide support to the patient whenever
necessary
'lan a balanced diet for the patient with a mutual interaction
IPLEENTATION
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
E"ALUATION
'atient remained free from injury as evidenced by absence of signs and
symptoms.
'atient eplained the various measures that they will take to prevent the
injury.
------------------------------------------------------------------
Therapeuti$ se(% $are #eman#< deficient area# prevention of ha2ards.
NURSING DIAGNOSIS<
'otential for impaired skin integrity related to edema secondary to renal cysts.
OUTCOES AND PLAN<
aC Out$ome#
%aintenance of normal skin integrity.
/C nursing Goa(s an# o/4e$ti'es
Goa(< %aintain the skin integrity and take measures to prevent skin impairment.
:. maintain a normal skin integrity
C. list the measures to prevent the loss of skin integrity
D. identify the measures to relieve edema.
Support<
Assess the skin regularly for any ecoriation or loss of integrity or colour changes.
Aeep the skin clean always
Avoid stress or pressure over the area of edema by providing etra cushions or
padding
%onitor the lab values as well as the patient for any signs and symptoms of renal
failure.
(ncourage the patient to use slippers while walking and that should not be tight
fitting.
Assess the edema for its degree, pitting or non pitting and continue the assessment
daily.
'rovide a leg end elevated position or elevation of the leg on a pillow if no cardiac
abnormalities are identified.
(plain the patient the need for taking care of the edematous parts
(plain the patient to report the symptoms like decreased urine output, palpitations,
increased edema etc. to the health team
IPLEENTATION
----------------------------------
----------------------------------
E"ALUATION
'atient remained free from impaired skin integrity
=he listed the measures to prevent the loss of skin integrity
=he identified the measures to relieve edema.
The supportive educative system was useful for %rs.
-----------------------------------------------------------------
Therapeuti$ se(% $are #eman#< deficient area# awareness of the disease process
and management
NURSING DIAGNOSIS
'otential for complications related to rheumatoid arthritis secondary to knowledge
deficit.
OUTCOES AND PLAN
aC Out$ome#
Absence of complications and improved awareness about the disease process.
/C nursing Goa(s an# o/4e$ti'es
Goa(< 6mprove the knowledge of the patient about the disease process and the
complications.
O/4e$ti'es< rsC M 2i((<
-verbali2e the various complication and their preventions
-verbali2e 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 o% the nursing system<
supportive educative
#C etho#s o% he(ping<
.uidance
Teaching
'romoting a developmental environment
IPLEENTATION
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
E"ALUATION
'atient got ade9uate information regarding the disease
=he verbali2ed what she understood about the disease and its management.
'atient has cleared her doubts regarding the medication actions and the side
effect
E"ALUATION O! THE APPLICATION O! SEL! CARE DE!ICIT THEORK
The theory of self-care deficit when applied could identify the self care re9uisites of
%rs. ` from various aspects. This was helpful to provide care in a comprehensive
manner. 'atient 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.
RE!ERENCES
:. Alligood % >, Tomey A %. Nursing Theory# 5tili2ation *Application .Drd ed. %issouri#
(lsevier %osby 'ublicationsG CHHC.
C. Tomey A%, Alligood. %>. Nursing theorists and their work. &Eth ed.+. %osby,
'hiladelphia, CHHC
D. .eorge <" .Nursing Theories# The "ase for 'rofessional Nursing 'ractice .Eth ed.
New <ersey #'rentice )allGCHHC.
HEALTH PROOTION ODEL
INTRODUCTION
The health promotion model &)'%+ proposed by Nola < 'ender &:ILCG revised, :IIF+
was designed to be a ?complementary counterpart to models of health protection.@ 6t
defines health as a positive dynamic state not merely the absence of disease. )ealth
promotion is directed at increasing a clients 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#
O 6ndividual characteristics and eperiences
O "ehavior-specific cognitions and affect
O "ehavioral outcomes
The health promotion model notes that each person has uni9ue personal
characteristics and eperiences that affect subse9uent actions. The set of variables
for behavioral specific knowledge and affect have important motivational
significance. These variables can be modified through nursing actions. )ealth
promoting behavior is the desired behavioral outcome and is the end point in the
)'%. )ealth promoting behaviors should result in improved health, enhanced
functional ability and better 9uality 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.
ASSUPTIONS O! THE HEALTH PROOTION ODEL
The )'% is based on the following assumptions, which reflect both nursing and
behavioral science perspectives#
:. 'ersons seek to create conditions of living through which they can epress
their uni9ue human health potential.
C. 'ersons have the capacity for reflective self-awareness, including
assessment of their own competencies.
D. 'ersons value growth in directions viewed as positive and attempts to
achieve a personally acceptable balance between change and stability.
;. 6ndividuals seek to actively regulate their own behavior.
E. 6ndividuals in all their biopsychosocial compleity interact with the
environment, progressively transforming the environment and being
transformed over time.
F. )ealth professionals constitute a part of the interpersonal environment,
which eerts influence on persons throughout their lifespan.
J. =elf-initiated reconfiguration of person-environment interactive patterns is
essential to behavior change.
THEORETICAL PROPOSITIONS O! THE HEALTH PROOTION ODEL
Theoretical statements derived from the model provide a basis for investigative work
on health behaviors. The )'% is based on the following theoretical propositions#
:. 'rior behavior and inherited and ac9uired characteristics influence beliefs,
affect, and enactment of health-promoting behavior.
C. 'ersons commit to engaging in behaviors from which they anticipate
deriving personally valued benefits.
D. 'erceived barriers can constrain commitment to action, a mediator of
behavior as well as actual behavior.
;. 'erceived competence or self-efficacy to eecute a given behavior
increases the likelihood of commitment to action and actual performance of
the behavior.
E. .reater perceived self-efficacy results in fewer perceived barriers to a
specific health behavior.
F. 'ositive affect toward a behavior results in greater perceived self-efficacy,
which can in turn, result in increased positive affect.
J. 1hen positive emotions or affect are associated with a behavior, the
probability of commitment and action is increased.
L. 'ersons are more likely to commit to and engage in health-promoting
behaviors when significant others model the behavior, epect the behavior to
occur, and provide assistance and support to enable the behavior.
I. 0amilies, peers, and health care providers are important sources of
interpersonal influence that can increase or decrease commitment to and
engagement in health-promoting behavior.
:H. =ituational influences in the eternal environment can increase or decrease
commitment to or participation in health-promoting behavior.
::. The greater the commitments to a specific plan of action, the more likely
health-promoting behaviors are to be maintained over time.
:C. -ommitment to a plan of action is less likely to result in the desired behavior
when competing demands over which persons have little control re9uire
immediate attention. :D. -ommitment 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.
:D. 'ersons can modify cognitions, affect, and the interpersonal and physical
environment to create incentives for health actions.
THE A9OR CONCEPTS AND DE!INITIONS O! THE HEALTH PROOTION
ODEL
In#i'i#ua( Chara$teristi$s an# E3perien$e
' PRIOR RELATED &EHA"IOR
0re9uency of the similar behaviour in the past. 7irect and indirect effects on the
likelihood of engaging in health promoting behaviors.
' PERSONAL !ACTORS
'ersonal factors categori2ed 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.
Persona( /io(ogi$a( %a$tors
6nclude variable such as age gender body mass inde pubertal status, aerobic
capacity, strength, agility, or balance.
Persona( psy$ho(ogi$a( %a$tors
6nclude variables such as self esteem self motivation personal competence perceived
health status and definition of health.
Persona( so$ioF$u(tura( %a$tors
6nclude variables such as race ethnicity, accuculturation, education and
socioeconomic status.
&eha'ioura( Spe$i%i$ Cognition an# A%%e$t
' PERCEI"ED &ENE!ITS O! ACTION
Anticipated positive out comes that will occur from health behaviour.
' PERCEI"ED &ARRIERS TO ACTION
Anticipated, imagined or real blocks and personal costs of understanding a given
behaviour
' PERCEI"ED SEL! E!!ICACK
<udgment of personal capability to organise and eecute a health-promoting
behaviour. 'erceived self efficacy influences perceived barriers to action so higher
efficacy result in lowered perceptions of barriers to the performance of the behavior.
' ACTI"ITK RELATED A!!ECT
=ubjective positive or negative feeling that occur before, during and following
behavior based on the stimulus properties of the behaviour itself. Activity-related
affect influences perceived self-efficacy, which means the more positive the
subjective feeling, the greater the feeling of efficacy. 6n turn, increased feelings of
efficacy can generate further positive affect.
' INTERPERSONAL IN!LUENCES
-ognition concerning behaviours, beliefs, or attitudes of the others. 6nterpersonal
influences include# norms &epectations of significant others+, social support
&instrumental and emotional encouragement+ and modelling &vicarious learning
through observing others engaged in a particular behaviour+. 'rimary sources of
interpersonal influences are families, peers, and healthcare providers.
' SITUATIONAL IN!LUENCES
'ersonal perceptions and cognitions of any given situation or contet that can
facilitate or impede behaviour. 6nclude perceptions of options available, demand
characteristics and aesthetic features of the environment in which given health
promoting is proposed to take place. =ituational influences may have direct or
indirect influences on health behaviour.
&eha'ioura( Out$ome
' COITENT TO PLAN O! ACTION
The concept of intention and identification of a planned strategy leads to
implementation of health behaviour.
' IEDIATE COPETING DEANDS AND PRE!ERENCES
-ompeting demands are those alternative behaviour over which individuals have low
control because there are environmental contingencies such as work or family care
responsibilities. -ompeting preferences are alternative behaviour over which
individuals eert relatively high control, such as choice of ice cream or apple for a
snack
' HEALTH PROOTING &EHA"IOUR
(ndpoint or action outcome directed toward attaining positive health outcome such
as optimal well-being, personal fulfillment, and productive living.
RE!ERENCES
:. %arriner TA, >aile A%. Nursing theorists and their work. Eth ed. =akraida
T.Nola <. 'ender. The )ealth 'romotion %odel. =t /ouis# %osbyG CHHE
C. 'olit 70, "eck -T. Nursing research#'rinciples and methods. Jth ed.
'hiladelphia# /ippincott 1illiams * 1ilkinsG CHHJ
D. "lack <%, )awks <), Aeene A%. %edical surgical nursing. Fth ed. 'hiladelphia#
(lsevier %osbyG CHHF.
;. 'otter 'A, 'erry A.. 0undamentals of nursing. Fth ed. =t./ouis# (lsevier
%osbyG CHHF.
HEALTH &ELIE! ODEL *H&.
INTRODUCTION
)"% 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 persons perception of a threat posed
by a health problem and the value associated with actions aimed at reducing the
threat. )"% addresses the relationship between a persons beliefs and behaviors.
6t 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 A9OR CONCEPTS AND DE!INITIONS O! THE HEALTH PROOTION
ODEL
There are si major concepts in )"%#
:. 'erceived =usceptibility
C. 'erceived severity
D. 'erceived benefits
;. 'erceived costs
E. %otivation
F. (nabling or modifying factors
:. Per$ei'e# Sus$epti/i(ity< refers to a persons perception that a health
problem is personally relevant or that a diagnosis of illness is accurate.
C. Per$ei'e# se'erity< even when one recogni2es personal susceptibility, action
will not occur unless the individual perceives the severity to be high enough to
have serious organic or social complications.
D. Per$ei'e# /ene%its# refers to the patients belief that a given treatment will
cure the illness or help to prevent it.
;. Per$ei'e# Costs< refers to the compleity, duration, and accessibility and
accessibility of the treatment
E. oti'ation< includes the desire to comply with a treatment and the belief that
people should do what
F. o#i%ying %a$tors< include personality variables, patient satisfaction, and
socio-demographic factors.

RE!ERENCES
:. %arriner TA, >aile A%. Nursing theorists and their work. Eth ed. =akraida
T.Nola <. 'ender. The )ealth 'romotion %odel. =t /ouis# %osbyG CHHE
C. 'olit 70, "eck -T. Nursing research#'rinciples and methods. Jth ed.
'hiladelphia# /ippincott 1illiams * 1ilkinsG CHHJ
D. "lack <%, )awks <), Aeene A%. %edical surgical nursing. Fth ed.
'hiladelphia# (lsevier %osbyG CHHF.
;. 'otter 'A, 'erry A.. 0undamentals of nursing. Fth ed. =t./ouis# (lsevier
%osbyG CHHF.
E. >osenstoch 6. )istorical origin of )ealth "elief model. )ealth (duc %onogr
C#DD;, :IJ;.
THEORIES USED IN COUNITK
HEALTH NURSING
Intro#u$tion
The concept of community is defined as Na group of people who share some
important feature of their lives and use some common agencies and institutions.N
The concept of health is defined as Na balanced state of well-being resulting from
harmonious interactions of body, mind, and spirit.N The term community health is
defined by meeting the needs of a community by identifying problems and managing
interactions within the community
&asi$ E(ements
The si basic elements of nursing practice incorporated in community health
programs and services are &:+ promotion of healthful living &C+ prevention of health
problems &D+ treatment of disorders &;+ rehabilitation &E+ evaluation and &F+
research.
a4or Ro(es
The focus of nursing includes not only the individual, but also the family and the
community, meeting these multiple needs re9uires multiple roles. The seven major
roles of a community health nurse are &:+ care provider, &C+ educator, &D+ advocate,
&;+ manager, &E+ collaborator, &F+ leader, and &J+ researcher.
a4or Settings
=ettings for community health nursing can be grouped into si categories# &:+
homes, &C+ ambulatory care settings, &D+ schools, &;+ occupational health settings,
&E+ residential institutions, and &F+ the community at large. -ommunity health
nursing practice is not limited to a specific area, but can be practiced anywhere.
Theories an# o#e(s %or $ommunity hea(th nursing
The commonly used theories are#
:. Nightingales theory of environment
C. 4rems =elf care model
D. Neumanns health care system model
;. >ogers model of the science and unitary man
E. 'enders health promotion model
F. >oys adaptation model
J. %ilios 0ramework of prevention
L. =almon 1hites -onstruct for 'ublic health nursing
I. "lock and <ostens (thical Theory of population focused nursing
:H. -anadian %odel
i(io5s !rame2or) o% pre'ention
Nancy %ilio 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.&:IJF,:IL:+.The basic treatise is that behavioral patterns of
populations and individuals who make up populations are a result of habitual
selection from limited choices. =he challenged the common notion that a main
determinant for unhealthful behavioral choice is lack of knowledge. .overnmental
and institutional policies, she said set the range of options for personal choice
making. 6t neglected the role of community health nursing, eamining the
determinants of community health and attempting to influence those determinants
through public policy.
Sa(mon ;hite5s $onstru$t %or pu/(i$ hea(th nursing
%ark =almon 1hite &:ILC+ describes a public health as an organi2ed societal effort
to protect, promote and restore the health of people and public health nursing as
focused on achieving and maintaining public health.
)e gave D practice priorities i.e.G prevention of disease and poor health, protection
against disease and eternal agents and promotion of health. 0or these D general
categories of nursing intervention have also been put forward, they are#
::. education directed toward voluntary change in the attitude and behaviour of
the subjects
:C. engineering directed at managing risk-related variables
:D. enforcement directed at mandatory regulation to achieve better health.
=cope of prevention spans individual, family, community and global care.
6ntervention target is in ; categories :.)uman!"iological C. (nvironmental D.
%edical!technological!organi2ational ;. =ocial
&(o$) an# 9osten5s Ethi$a( Theory o% popu(ation %o$use# nursing
7erryl "lock and /avohn <osten, public health educators proposed this based on
intersecting fields of public health and nursing. They have given D essential elements
of population focused nursing that stem from these C fields#
:. an obligation to population
C. the primacy of prevention
D. centrality of relationship- based care
the first two are from public health and the third element from nursing. )ence it
implies to nursing that relation-based care is very important in population focused
care.
Cana#ian o#e( %or $ommunity
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 characteri2e
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# :+ individual!community participation
in each component, C+ multiple ways of knowing, each of which is necessary to
understand the compleity and diversity of nursing in the
communityG knowledge and utili2ation of all these ways of knowing forms evidence-
based practice consistent with these standards, and D+ 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 citi2ens+. The standards of practice are founded
on the values and beliefs of community health nurses, and utili2ation 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 eemplifies 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. -ommunity health nursing practice does not occur in isolation but
rather within an environmental contet, such as policies within their workplace and
the legislative framework applicable to their work.
Re%eren$es
:. Allender <.NG =pradely ".1. -ommunity )ealth Nursing -oncepts and
practice. &L
th
edn+ CHH:./ippincott,D;C-;E.
:. =tanhope %G /ancaster <. -ommunity )ealth Nursing 'romoting health of
Aggregates, 0amilies and individuals.&;
th
edn+ CHH:.%osby,CFE-LH.
App(i$ation o% Su$hman5s Stages o%
i((ness o#e(
Intro#u$tion
%an is a social being. =ocial factors play important role in health. =ocial
conditions and not only promote the possibility of illness and disability, they
also enhance prospect for disease prevention and health maintenance. )ealth
life style and the avoidance of high-risk behaviour, advance the individuals
potential for a longer and healthier life. The recognition of the fact that the
health of an individual is more than biological phenomena has brought in to the
forefront the significance of behavioural dimension of health.
%r. A=, a JD years old, %uslim, male patient admitted in ---ward of ---)ospital
with a diagnosis of prostate cancer. 7ata regarding psychosocial aspects of his
life and illness were collected through interview. )e was cooperative and
interactive with me for most part. "ut later he was found to be reluctant to talk
...as he was fre9uently epressing his financial troubles which could not be
helped by anyone related to him.
Can$er Prostate
'rostate cancer is the fifth most common type of cancer in men and its
incidence rises with advancing years. 6t occurs in : in :H in the men living to
the age of JH years. (arly clinical features are indistinguishable from those of
"') and the gland may feel normal on digital eamination. The '=A may be
elevated &]; ng!ml+. As the tumour grows locally it may produce bladder neck
obstruction, obstruct the ureters and rapidly lead to renal impairment. 6n late
disease rectal eamination shows the prostate to be large, hard and irregular.
>ectal ultrasound may show the spread of the cancer and this should also be
used for directing needle or aspiration biopsy. 'rostatic biopsy is important in
giving prognostic information- prognosis being poorer with poorly differentiated
tumours.
Therapy depends on staging. (arly disease is treated with local radiotherapy
and more advanced disease by orchidectomy and hormone therapy with
oestrogen. 6t has been suggested that all men over the age of EH years should
be screened by rectal eamination, transrectal ultrasound and '=A
measurement.
Genera( in%ormation
Name # %r. A=
Age # JD years
.ender # %ale
%arital status # %arried
'lace # ---! ----
)osp. No. # ------
7ate of admission # :-;-HL
1ard!5nit # --------
(ducation # No formal education
Cu(ture D (i%eFsty(e
>eligion # 6slam, %uslim, believes in Q7urgasQ, and has gone
too.
0ood habits # four time in a day
# Non-vegetarian once in a day
So$ioe$onomi$ $on#ition
B /ower socioeconomic status
B 4ccupation
B 0isher man for :C years
B )e was a beedi worker for :H years
B went to gulf and worked there for ; years
B -ook for DE years
B )is son is in .ulf country, but earns only >s.EHHH!month
B )is residence is about LH km away from ----,
to and fro journey costs rs.EH! person
Ro(e in the %ami(y
B )ead of the family, earning member, and father
B These role are affected due the illness ? everything is disturbed at home@
So$ia( Support Net2or)
B 'atient has poor social support network
B There is no one to support him financially for treatment of his illness
B )is daughter visited him twice in the hospital, no other person visited him
or en9uired him about his illness after coming in the hospital
Patient $omp(aints *on the %irst meeting.
B 'ain at the genital area &on catheteri2ation+
B 5rine tube needs to be removed
B No taste for anything he eats
B No money in hand to pay the hospital bill
B No sleep at night
I#enti%i$ation
o% patient
nee#s
Co((e$tionJ
o/ser'ing6
per%orming
a$ti'ities re(ating to
$aring
Interpretation an#
ana(ysis
Nee#s arising
%rom present
i((ness an# the
$onse7uent
response to
$ope 2ith
B ?6 have pain at
genital region@
B ?6 have problem of
passing urine without
control, that is why
tube is inserted@
B 'atients main
complaints are pain,
irritation at the site of
urinary catheter, and
sleep disturbance
B ?6 want to get this
urine tube removed@
B ?1ho will pay my
hospital bill of
>s.EH,HHHR@
B 'atient complains
that he is not getting
ade9uate sleep during
night
B )e sleeps during
daytime

B )e was a cook,
working most of his life
in night time for
marriage parties
B -urrently, he is
hospitalised for cancer,
prostate and is
receiving radiotherapy
for the last one month
&asi$ physi$a(
nee#s
B )e is advised not
to take bath till the
end of radiotherapy to
avoid skin ecoriation
at the site
B )e maintains
ade9uate cleanliness
B )e visits toilet with
assistance from his
wife
B )e is catheteri2ed
for the last C months
B )e says is a
practicing %uslim
B )e is taking bath
means it interferes with
his religious practices
B )e is advised not to
take bath because he
may wet the irradiation
area, but the cultural
issues are not
addressed.
Nee#s re(ate#
to (i%e sty(e
B )e is a non-
vegetarian
B "ut he not getting
any non-veg food in
the hospital
B )is life style
related needs hindered
in this hospital
environment
Nee#s re(ate#
to ha/its
B )e does not take
tea or coffee
B )e does not smoke
or take drinks
B As he has any
regular habits of taking
tea or coffee or drinking
alcohol
In#i'i#ua(5s
)no2(e#ge an#
e3perien$e o%
i((ness
Patient5s Kno2(e#ge
o% Present i((ness
'atient eplains his
illness#
B ?6 have pain and
urine block for the last
F months@
B ?%y illness is
serious@
B ?6 have diabetes
for the last one year@
B ?6 underwent a

B 'atient has
understanding of the
illness as his illness is
serious.
B 'atient underwent
orchidectomy and T5>'
in -------- ; months
back and later referred
to %anipal for further
surgery for urinary
block and pain in -----
; months back@
;hat the patient
2ants to )no2
a/out the i((nessE
?will this illness get
cured@
?6 have come here
because, doctors in
---- told me my illness
can be cured only in
%anipal@
management
B 'atient wants to
know whether his illness
will get cured.
B )e says he has no
money to spend her.
B "ut his epenses are
met by his daughter
and one brother
E3perien$e o%
i((ness
;hat has /een his
past e3perien$e
2ith i((nessE
Past I((ness History
B ?(arlier 6 went to
many local folk
doctors, they only
made all these illness@
B ?6 have sugar
illness for the last one
year@
B ? The doctor in
Aundapura told me to
check sugar, so 6
know 6 have sugar
problem@
B ?6 have not had
any major illness in
my life other than
this@
!ami(y History
B No major illness
in his knowledge
;hether patient has
a$$epte# his i((ness
B ?6 dont have any
habits, drinking,
smoking or taking
even coffee since
childhood. 6 dont
know why 6 got this
illness@

B 'atient has
consulted many folk
doctors for minor illness
and never satisfied with
them.
B )e had minor
troubles with urinary
fre9uency for about ;
years
B =o he consulted
some folk people for
some remedies
B "ut never satisfied

B 'atient has
accepted the illness as
some thing which he
does not deserve.
B )e puts it on fate
Kno2(e#ge o% B )e has ade9uate )e had tried alternative
%orma( an#
a(ternati'e
therapies
information about
formal and folk
medicines
B ?6 have gone to
them, but no benefits@
medicines and found to
have no benefit in his
illness
Kno2(e#ge at
present an#
%uture $ourse
o% a$tionC
;hat is the
treatment p(an
Does the
person )no2s
a/out it
B 'atient says he has
one month duration of
-ray treatment
B ?nobody tells me
what is my illness@
B ?6m taking
medicines regularly@

B 'atient has only
partial knowledge of his
illness and treatment
plans
B )e is illiterate, but
nobody has eplained
him about his treatment
plans
Coping 2ith the
i((ness an# its
out$ome
*Patient an#
%ami(y.
B ?1hat will we doR@
B ?1e have to suffer
everything@
B )e looks depressed
and tries to avoid
visitors
B ?6 dont have
money pay here, 6
dont know what to
do@
B 'atient is not
showing adaptive
responses
B )e has depressive
cognitions
B )e has financial
problems
Ana(yse the
in#i'i#ua(s an#
%ami(y5s 'ie2s
on
Q hea(th team
Q #o$tors
Q nurses
B ?7octor 'eople
come and asks how
you areR &he eplains
sarcastically+, nothing
else@
B ?They do not want
to know about my
pain@
B ?sometimes,
nurses come asks
about me@
?7octor has told
something to my
daughter@
)e is not satisfied with
the psychological
attention given to him
by nurse or doctor
)is wife too has the
same opinion
7octor has eplained
about the illness to his
daughter about the
diagnosis and prognosis
Distinguish
/et2een the
meanings o%
the patientJ
#o$torJ nurse
'atient# ?they are not
asking me anything@
7octor# ?he will not
understand anything,
it is eplained to his
daughter@
Nurse# ?doctor has
'atient wants to know
about his illness, and
course of treatment, but
doctor is preoccupied
with the patients
educational status.

eplained everything
to him, we cannot tell
anything to the
patient@
Nursing staff is
bothered whether they
may convey wrong
message to the patient.
There is a
communication gap
eists among these
people.
O/ser'e the
patientJ #o$tor
an# nurse
intera$tion
1hat patient says has
reason.
B 7octor has advised
him >T for : month,
so he feels there is
nothing more to talk
to the patient than
en9uiring any
problems
B Nurse is largely
functionally oriented
and interact with
patient only in such
occasions
The mutual interaction
among the treating
team and patient is
missing in this situation
Su$hman5s Stages o% i((ness o#e(
App(i$ation o% Su$hmanHs o#e(
Con$(usion
%r. A= has been suffering form 'rostate cancer for the last : year. "ut his
symptoms started about ; years back. 0or about D years he tried folk remedies
based on the advice of other people. )e approached medical advice when his
symptoms aggravated. )e 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.
Re%eren$e
.uptha %-, %ahajan ". Tet book of =ocial %edicine, Drd (dn. <ay'ee,
N7,CHHD
-oe >%. =ociology of %edicine. %c.raw-)ill 6nc. New Kork, :IJL.
APPLICATION OF BETTY NEUMAN'S
SYSTEMS MODEL
OBJECTIVES:
to assess the patient condition by the various methods eplained by the
nursing theory
to demonstrate an effective communication and interaction with the patient.
to select a theory for the application according to the need of the patient
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, eplaining, predicting, and !or
prescribing.
The Neumans system model has two major components i.e. stress and reaction
to stress. The client in the Neumans system model is viewed as an open system
in which repeated cycles of input, process, out put and feed back constitute a
dynamic organi2ational pattern. The client may be an individual, a group, a
family, a community or an aggregate. 6n the development towards growth and
development open system continuously become more differentiated and elaborate
or comple. As they become more comple, the internal conditions of regulation
become more comple. (change 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. >eaction
to the stressors may be possible or actual with identifiable responses and
symptom.
MAJOR CONCEPTS
I. PERSON VARIABLES-
(ach layer, or concentric circle, of the Neuman model is made up of the five
person variables. 6deally, each of the person variables should be considered
simultaneously and comprehensively.
:. 'hysiological - refers of the physicochemical structure and function of the body.
C. 'sychological - refers to mental processes and emotions.
D. =ociocultural - refers to relationshipsG and social!cultural epectations and
activities.
;. =piritual - refers to the influence of spiritual beliefs.
E. 7evelopmental - 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, :IIE, in .eorge, :IIF+. These factors
include# system variables, genetic features, and the strengths and weaknesses of
the system parts. (amples of these may include# hair color, body temperature
regulation ability, functioning of body systems homeostatically, cognitive ability,
physical strength, and value systems. The personQs system is an open system and
therefore is dynamic and constantly changing and evolving. =tability, or
homeostasis, occurs when the amount of energy that is available eceeds 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 fleible line of defense is the outer barrier or cushion to the normal line of
defense, the line of resistance, and the core structure. 6f the fleible line of
defense fails to provide ade9uate protection to the normal line of defense, the
lines of resistance become activated. The fleible line of defense acts as a cushion
and is described as accordion-like as it epands away from or contracts closer to
the normal line of defense. The fleible 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. 6t 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
eample 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. (ample# activation of
the immune response after invasion of microorganisms. 6f 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-
>econstitution is the increase in energy that occurs in relation to the degree of
reaction to the stressor. >econstitution begins at any point following initiation of
treatment for invasion of stressors. >econstitution may epand the normal line of
defense beyond its previous level, stabili2e the system at a lower level, or return
it to the level that eisted before the illness.
VII. STRESSORS--
The Neuman =ystems %odel looks at the impact of stressors on health and
addresses stress and the reduction of stress &in the form of stressors+. =tressors
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#
Intrapersona( - occur within person, e.g. emotions and feelings
Interpersona( - occur between individuals, e.g. role epectations
E3tra persona( - 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. "y 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 NeumanQs model, prevention is the primary nursing intervention.
'revention focuses on keeping stressors and the stress response from having a
detrimental effect on the body.
'rimary -'rimary prevention occurs before the system reacts to a stressor.
4n the one hand, it strengthens the person &primarily the fleible line of
defense+ to enable him to better deal with stressors, and on the other
hand manipulates the environment to reduce or weaken stressors. 'rimary
prevention includes health promotion and maintenance of wellness.
=econdary-=econdary prevention occurs after the system reacts to a
stressor and is provided in terms of eisting systems. =econdary
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. (ach layer consists of five person
variables or subsystems#
'hysical!'hysiological
'sychological
=ocio-cultural
7evelopmental
=piritual
The layers, usually represented by concentric circle, consist of the central core,
lines of resistance, lines of normal defense, and lines of fleible defense. The basic
core structure is comprised of survival mechanisms including# organ function,
temperature control, genetic structure, response patterns, ego, and what Neuman
terms Qknowns and commonalitiesQ. /ines 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 NeumanQs 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 eternal forces
which surround a person and with which they interact at any given time. These
forces include the intrapersonal, interpersonal and etra personal stressors which
can affect the personQs normal line of defense and so can affect the stability of the
system.
The internal environment eists within the client system.
The external environment eists outside the client system.
Neuman also identified a reate! 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 e9uated with wellness. =he defines health!wellness
as Nthe condition in which all parts and subparts &variables+ are in harmony with
the whole of the client &Neuman, :IIE+N. As the person is in a constant
interaction with the environment, the state of wellness &and by implication any
other state+ is in dynamic e9uilibrium, rather than in any kind of steady state.
Neuman proposes a wellness-illness continuum, with the personQs 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 uni9ue 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 maimum 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 nurseQs perception will influence the care given,
then not only must the patient!clientQs 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 D-stage nursing process#
:. Nursing Diagnosis - based of necessity in a thorough assessment, and with
consideration given to five variables in three stressor areas.
C. Nursing Goa(s - these must be negotiated with the patient, and take account of
patientQs and nurseQs perceptions of variance from wellness
D. Nursing Out$omes - considered in relation to five variables, and achieved
through primary, secondary and tertiary interventions.
NURSING PROCESS BASED ON SYSTEM MODEL
Assessment< Neumans first step of nursing process parallels the assessment
and nursing diagnosis of the si phase nursing process. 5sing system model in the
assessment phase of nursing process the nurse focuses on obtaining a
comprehensive client data base to determine the eisting state of wellness and
actual or potential reaction to environmental stressors.
Nursing #iagnosisF the synthesis of data with theory also provides the basis for
nursing diagnosis. The nursing diagnostic statement should reflect the entire
client condition.
Out$ome i#enti%i$ation an# p(anning- 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.
Imp(ementation , nursing action are based on the synthesis of a comprehensive
data base about the client and the theory that are appropriate to the clients and
caregivers perception and possibilities for functional competence in the
environment. According to this step the evaluation confirms that the anticipated
or prescribed change has occurred. 6mmediate and long range goals are
structured in relation to the short term goals.
E'a(uation O evaluation is the anticipated or prescribed change has occurred. 6f
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
!"#formatio# collected from t$e %atie#t a#d $is &ife'
1. Major stress area, or areas o !ea"t! #o$#er$
'atient was suffering from severe abdominal pain , nausea, vomiting,
yellowish discolorations of eye, palm, and urine, reduced appetite and
gross weight loss&Lkg with in ; months+
'atient is been diagnosed to have 'eriampullary carcinoma one week back.
(atie#t u#der&e#t o%erati)e %rocedure i.e. *+"((,-.S (R/C-01R--
(a#creato duode#ectomy o# 2233345.
(syc$ologically distur6ed a6out $is disease co#ditio#- a#tici%ati#g it as a life
t$reate#i#g co#ditio#. (atie#t is i# de%ressi)e mood a#d does #ot i#teracti#g.
(atie#t is distur6ed 6y t$e t$oug$ts t$at $e 6ecame a 6urde# to $is c$ildre# &it$
so ma#y serious ill#esses &$ic$ made t$em to stay &it$ $im at $os%ital.
(atie#t $as %itti#g ty%e of edema o)er t$e a#7le regio# a#d it is more duri#g t$e
e)e#i#g a#d &ill #ot 6e relie)ed 6y ele)atio# of t$e affected extremities.
+e $ad de)elo%ed 8(+ fe& mo#t$s 6ac7 !2445 9a#uary' a#d u#der&e#t surgery
:1R( o# 9a#uary 12. Still $e $as mild difficulty i# i#itiati#g t$e stream of
uri#e.
(atie#t is a 7#o&# case of 0ia6etes si#ce last 25 years a#d for t$e last 4 years $e
is o# "#;. +."#suli# !41-4-4'. "t is addi#g u% $is distress regardi#g $is $ealt$.
2. L%e st&"e 'atter$s
patient is a retired school teacher
cares for wife and other family members
living with his son and his family
acti)e i# c$urc$
%artici%ates i# commu#ity grou% meeti#g i.e. local %olitics
$as a su%%orti)e s%ouse a#d family
ta7i#g mixed diet
#o $a6its of smo7i#g or dri#7i#g
s%e#ds leisure time 6y readi#g #e&s %a%er &atc$i#g :< s%e#di#g time &it$
family mem6ers a#d relati)es
3. (a)e &o* e+'er%e$#e, a s%-%"ar 'ro."e-/
:$e fatigue is similar to t$at of %re)ious $os%itali=atio# !after t$e surgery of t$e
8(+'
Se)erity of %ai# &as some &$at similar i# t$e %re)ious time of surgery i.e.
:1R(.
*as %syc$ologically distur6ed duri#g t$e %re)ious surgery i.e. :1R(.
*$at $el%ed t$e#- family mem6ers %syc$ological su%%ort $el%ed $im to o)er
come t$e crisis situatio#
4. A$t%#%'at%o$ o t!e *t*re
Co#cer#s a6out t$e $ealt$y a#d s%eedy reco)ery.
A#tici%atio# of c$a#ges i# t$e lifestyle a#d food $a6its
A#tici%ati#g a6out t$e dema#ds of modified life style
A#tici%ati#g t$e #eeds of future follo& u%
5. 0!at ,o%$1 to !e"' !%-se"/
:al7i#g to $is frie#ds a#d relati)es
Readi#g t$e religious materials i.e. readi#g t$e 8i6le
"#stillatio# of %ositi)e t$oug$ts i.e. %la##i#g a6out t$e acti)ities to 6e resume
after disc$arge s%e#di#g time &it$ gra#d c$ildre# goi#g to t$e c$urc$ retur#
6ac7 to t$e social i#teractio#s etc
A)oidi#g t$e #egati)e t$oug$ts i.e. di)erts t$e atte#tio#s from t$e %ai# or
difficulties try to elimi#ate t$e distur6i#g t$oug$ts a6out t$e disease a#d
surgery etc
:ryi#g to acce%t t$e reality etc..
6. 0!at %s e+'e#te, o ot!ers/
>amily mem6ers )isiti#g t$e %atie#t a#d s%e#di#g some time &it$ $im &ill $el%
to a great exte#t to relie)e $is te#sio#.
Co#)ey a &arm a#d acce%ti#g 6e$a)iour to&ards $im.
>amily mem6ers &ill $el% $im to meet $is o&# %erso#al #eeds as muc$ as
%ossi6le.
"#)ol)e t$e %atie#t also i# ta7i#g decisio#s a6out $is o&# care treatme#t follo&
u% etc
STRESSORS AS PERCEIVED BY T(E CARE 2IVER3
1. Major stress areas
(ersiste#t fatigue
Massi)e &eig$t loss i.e.! 5 7g of 6ody &eig$t &it$ i# 4 mo#t$s'
+istory of 8(+ a#d its surgery
(ersiste#ce of uri#ary sym%toms !difficulty i# i#itiati#g t$e stream of uri#e' a#d
edema of t$e lo&er extremities
(ersiste#t disease- c$ro#ic $y%erte#si)e si#ce last 25 years
0e%ressi)e ideatio#s a#d #egati)e t$oug$ts
2. Prese$t #%r#*-sta$#es ,%er%$1 ro- t!e *s*a" 'atter$ o "%)%$1
+os%itali=atio#
acute %ai# ! 6efore t$e surgery %atie#t $ad %ai# 6ecause of t$e u#derlyi#g
%at$ology a#d after t$e surgery %ai# is %rese#t at t$e surgical site'
#ausea a#d )omiti#g &$ic$ &as %rese#t 6efore t$e surgery a#d is still %ersisti#g
after t$e surgery also
a#tici%atory a#xiety co#cer#s t$e reco)ery a#d %rog#osis of t$e disease
#egati)e t$oug$ts t$at $e $as 6ecome a 6urde# to $is c$ildre#
A#tici%atory a#xiety co#cer#i#g t$e restrictio#s after t$e surgery a#d t$e life
style modificatio#s &$ic$ are to 6e follo&ed.
3. C"%e$ts 'ast e+'er%e$#e 4%t! t!e s%-%"ar s%t*at%o$s
(atie#t )er6ali=ed t$at t$e se)erity of %ai# #ausea fatigue etc &as similar to
t$at of %atie#t.s %re)ious surgery. Cou#ter c$ec7ed &it$ t$e family mem6ers
t$at &$at t$ey o6ser)ed.
(syc$ologically distur6ed %re)iously also 6efore t$e surgery. !collected from t$e
%atie#t a#d cou#ter c$ec7ed &it$ t$e relati)es'
Clie#t %ercei)ed t$at t$e %rese#t disease co#ditio# is muc$ more se)ere t$a# t$e
%re)ious co#ditio#. +e t$i#7s it is a serious form of ca#cer a#d t$e reco)ery is
)ery %oor. So %atie#t is %syc$ologically de%ressed.
53 F*t*re a$t%#%'at%o$s
Clie#t is ca%a6le of $a#dli#g t$e situatio#- &ill #eed su%%ort a#d e#courageme#t
to do so.
+e $as t$e %la#s to go 6ac7 $ome a#d to resume t$e acti)ities &$ic$ $e &as
doi#g %rior to t$e $os%itali=atio#.
+e also %la##ed i# $is mi#d a6out t$e future follo& u% ie co#ti#uatio# of
c$emot$era%y
5. 0!at #"%e$t #a$ ,o to !e"' !%-se"/
(atie#t is usi#g $is o&# co%i#g strategies to ad;ust to t$e situatio#s.
+e is s%e#di#g time to read religious 6oo7s a#d also s%e#ds time i# tal7i#g &it$
ot$ers
+e is tryi#g to clarify $is o&# dou6ts i# a# attem%t to elimi#ate dou6ts a#d to
i#still $o%e.
+e sets $is ma;or goal i.e. a $ealt$y a#d s%eedy reco)ery.
6. C"%e$t's e+'e#tat%o$s o a-%"&, r%e$,s a$, #are1%)ers
$e sees t$e $ealt$ care %ro)iders as a source %f i#formatio#.
+e tries to co#sider t$em as a sig#ifica#t mem6ers &$o ca# $el% to o)er come
t$e stress
+e see7s 6ot$ %syc$ological a#d %$ysical su%%ort from t$e care gi)ers frie#ds
a#d family mem6ers
)e sees the family members as helping hands and feels relaed
when they are with him.
E)a"*at%o$6 s*--ar& o %-'ress%o$s-
There is no apparent discrepancies identified between patients perception and the
care givers perceptions.
INTRAPERSONAL FACTORS
73 P!&s%#a" e+a-%$at%o$ a$, %$)est%1at%o$s
HeightF :FC cm
;eight , ;C kg
TPRF DJo -, J; b!m, :; breaths per min
&P- :DH!JL mm of )g
Eye- vision is normal, on eamination the appearance of eye is normal.
-onjunctiva is pale in appearance. 'upils reacting to the light.
Ear- appearance of ears normal. No wa deposition. 'inna is normal in
appearance and hearing ability is also normal.
Respiratory system- respiratory rate is normal, no abnormal sounds on
auscultation. >espiratory rate is :F breaths per min.
Car#io'as$u(ar system- heart rate is JF per min. on auscultation no
abnormalities detected. (dema is present over the left ankle which is non
pitting in nature.
GIT- patient has the complaints of reduced appetite, nauseaG vomiting etc.
food intake is very less. %outh- on eamination is normal. "owel sounds
are reduced. Abdomen could not be palpated because of the presence of
the surgical incision. "owel habits are not regular after the hospitali2ation
E3tremities- range of motion of the etremities are normal. (dema is
present over the left ankle which is non pitting in nature. "ecause of
weakness and fatigue he is not able to walk with out support
Integumentary system- etremities are mild yellowish in color. No
cyanosis. -apillary refill is normal.
Genitor urinary system- %atie#t $as difficulty i# i#itiati#g t$e uri#e stream. No
com%lai#ts of %ai#ful micturatio# or difficulty i# %assi#g uri#e.
Self acre activities- %erform some of $is acti)ities for getti#g u% from t$e 6ed
$e #eeds some ot$er %erso#.s su%%ort. :o &al7 also $e #eeds a su%%ort. +e do
$is %erso#al care acti)ities &it$ t$e su%%ort from t$e ot$ers
Immunizations- it is 6ee# told t$at $e $as ta7e# t$e immu#i=atio#s at t$e
s%ecific %eriods itself a#d $e also $ad ta7e# $e%atitis immu#i=atio# arou#d 5
years 6ac7
Sleep ?. +e told t$at slee% is reduced 6ecause of t$e %ai# a#d ot$er difficulties.
Slee% is reduced after t$e $os%itali=atio# 6ecause of t$e #oisy e#)iro#me#t.
iet an! nutrition- %atie#t is ta7i#g mixed diet 6ut t$e food i#ta7e is less &$e#
com%ared to %re)ious food i#ta7e 6ecause of t$e #ausea a#d )omiti#g. 1sually
$e ta7es food t$ree times a day.
"a#its- %atie#t does #ot $a)e t$e $a6it of dri#7i#g or smo7i#g.
Ot$er complaints- %atie#t $as t$e com%lai#ts of %ai# fatigue loss of a%%etite
di==i#ess difficulty i# uri#atio# etc...
83 Ps&#!o- so#%o #*"t*ra"
Anious about his condition
7epressive mood
(atie#t is a retired teac$er a#d $e is C$ristia# 6y religio#.
Studied u% to 8A
Married a#d $as 4 c$ildre#!2so#s a#d 2 daug$ters'
Co#ge#ial $ome e#)iro#me#t a#d good relatio#s$i% &it$ &ife a#d c$ildre#
"s acti)e i# t$e social acti)ities at $is #ati)e %lace a#d also acti)ely i#)ol)es i#
t$e religious acti)ities too.
@ood a#d co#ge#ial relatio#s$i% &it$ t$e #eig$6ours
+as some good a#d close frie#d at $is %lace a#d $e acti)ely i#teract &it$ t$em.
:$ey also )ery su%%orti)e to $im
.ood social support system is present from the family as well
as from the neighborhood
93 De)e"o'-e$ta" a#tors
'atient confidently says that he had been worked for DC years as a teacher
and he was a very good teacher for students and was a good coworker for
the friends.
+e told t$at $e could ma#age t$e official a#d $ouse $old acti)ities )ery &ell
)e was very active after the retirement and once he go back
also he will resume the activities
53 S'%r%t*a" .e"%e s&ste-
'atient is -hristian by religion
+e 6elie)es i# got a#d used to go to c$urc$ a#d also a# acti)e mem6er i# t$e
religious acti)ities.
+e $as a %erso#al 8i6le a#d $e used to read it mi# of 2 times a day a#d also
&$e#e)er $e is &orried or te#sed $e used to %ray or read 8i6le.
)e has a good social support system present which helps him
to keep his mind active.
INTERPERSONAL FACTORS
has supportive family and friends
good social i#teractio# &it$ ot$ers
good social su%%ort system is %rese#t
acti)e i# t$e agricultural &or7s at $ome after t$e retireme#t
acti)e i# t$e religious acti)ities.
@ood i#ter%erso#al relatio#s$i% &it$ &ife a#d t$e c$ildre#
.ood social adjustment present
E:TRAPERSONAL FACTORS
All the health care facilities are present at his place
All commu#icatio# facilities tra)el a#d tra#s%ort facilities etc are %rese#t at $is
o&# %lace.
+is $ouse at a )illage &$ic$ is #ot muc$ far from t$e city a#d t$e facilities are
a)aila6le at t$e %lace.
0inancially they are stable and are able to meet the treatment
epenses.
S*--ar&
'hysiological- thin body built pallor of etremities, yellowish discoloration of
the mucus membrane and sclera of eye. Nausea, vomiting, reduced
appetite, reduced urinary out put. 7iagnosed to have periampullary
carcinoma.
'sycho socio cultural factors- patient is anious abut his condition.
7epressive mood. Not interacting much with others. .ood support system
is present.
7evelopmental ,no developmental abnormalities. Appropriate to the age.
=piritual- patients belief system has a positive contribution to his recovery
and adjustment.
CLINICAL FEATURES
pain abdomen since ; days
7iscoloration of urine
-omplaints of vomiting
0atigue
>educed appetite
on and off fever
Kellowish discoloration of eye, palms and nails
-omplaints of weight loss
(dema over the left leg
INVESTI2ATIONS
I$)est%1at%o$s
Va"*es
)emoglobin&:D-
:Ig!dl+
F.I
)-T &;H-EHY+ C:.I
1"- &;HHH-::HHH
cells!cumm+
:CCHH
Neutrophil &;H-
JEY+
JJ.C
/ymphocyte &CE-
;EY+
:H.E
%onocyte &C-:HY+ ;.E
(osinophil &H-
:HY+
C.F
"asophil &H-CY+ .C
'latelet &:EHHHH- D;EHHH
;HHHHH
cells!cumm+
(=> &H-:Hmm!hr+ LF
>"= &FH-:EH
mg!dl+
:;L
'us -!= a
5=. 5=. shows mild
diffuse cell
growth at the
Ampulla of 8ater
which suggests
peri ampullary
carcinoma of
.rade 6 with out
metastasis and
gross spread.
5rea &L-DEmg!dl+ CL
-reatinine &H.F-:.F
mg!dl+
:.L
=odium &:DH-:;D
m(9!/+
:DF
'otassium &D.E-E
m(9!/+
;
'T &patient+&::.;-
:E.F sec+
:C.D
A'TT- patient &C;-
DC.; sec+
CF.;
"lood group A^
)68 Negative
)-8 Negative
)"sAg Negative
5rine 'rotein
&negative+
Negative
5rine 1"- &H-E
cells!hpf+
Nil
>"- &nil + Nil
(pithelial cell&H-E+ ;-E
-ast , granular cast
&absent+
Nil
T(ERAPEUTIC MANA2EMENT
I$%t%a" Treat-e$t:
'atient got admitted to ----
%edical college for D days
and the symptoms not
relieved. =o they asked for
discharge and came to
---this hospital
There treated with
6nj Trama2ac 68
=4=
68 fluids , 7N=
Treat-e$t at t!%s !os'%ta"333
Pre operati'e perio#
Tab -lovipas JE
mg H-:-H
Tab %onotrate :-
H-:
Tab %etalor `/ :-
H-H
6nj ) 6nsulin =!-
F-H-F5
6nj Trama2ac EH
mg 68 ML)
6nj (mset ; mg
ML)
Tab 'antodac ;H
mg :-H-H
-ap beneficiale H-
:-H
=yp Aristo2yme :-
Post o'erat%)e 'er%o,
;%--e,%ate 'ost o'<
6nj 'ethedine
:mg =4=
6nj 'henargan
=4=
6nj 'antodac ;H
mg 68 47
6nj -leane H.D
ml =!- 47
6nj 8orth ' ;H
mg 6% M:C)
6nj calcium
.luconate :H
ml over :H min
68 fluids , 7N=
Late post op perio#
a%ter L #ays o%
surgery +
6nj ) 6nsulin =!-
F-H-F5
Tab 'antodac ;H
mg :-H-H
-ap beneficiale
H-:-H
Tab -lovipas JE
mg H-:-H
Tab %onotrate :-
H-:
Tab %etalor `/ :-
:-:
A bind 6 sachet
T67
Surgi$a( management
'atient underwent 1hipples
procedure &pancreato
duodenectomy+
H-H
Other instru$tions
6ncentive
spirometry
=team inhalation
(arly ambulation
7iabetic diet
NURSIN2 PROCESS
I3 NURSIN2 DIA2NOSIS
A#*te 'a%$ re"ate, to t!e 'rese$#e o s*r1%#a" 4o*$, o$ a.,o-e$ se#o$,ar& to
'er%a-'*""ar& #ar#%$o-a
Des%re, O*t#o-e61oa" : 'atient will get relief from pain as evidenced by a reduction
in the pain scale score and verbali2ation
N*rs%$1 a#t%o$
Pr%-ar&
're)e$t%o$
Se#o$,ar& 're)e$t%o$ Tert%ar& 're)e$t%o$
Assess
severity
of pain
by using
a pain
scale
-heck the
surgical
site for any
signs of
infection or
complicatio
ns
=upport
the areas
with etra
pillow to
allow the
normal
alignment
and to
prevent
strain
)andle the
area
gently.
Avoid
unnecessar
y handling
as this will
affect the
healing
process
-lean the
area
around the
incision
and do
surgical
Teach the patient
about the
relaation
techni9ues and
make him to do it
(ncourage the
patient to divert
his mind from pain
and to engage in
pleasurable
activities like
taking with others
7o not allow the
patient to do
strainous
activities. And
eplain to the
patient why those
activities are
contraindicated.
6nvolve the
patient in making
decisions about
his own care and
provide a positive
psychological
support
'rovide the
primary
preventive care
when ever
necessary.
(ducate the
client about
the
importance
of
cleanliness
and
encourage
him to
maintain
good
personal
hygiene.
6nvolve the
family
members in
the care of
patient
(ncourage
relatives to
be with the
client in
order
provide a
psychologic
al well
being to
patient .
(ducate the
family
members
about the
pain
managemen
dressing at
the site of
incision to
prevent
any form of
infections
'rovide
non-
pharmacolo
gical
measures
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.
Aeep the
patients
body clean
in order to
avoid
infection.
t measures.
'rovide the
primary and
secondary
preventive
measures to
the client
whenever
necessary.

E)a"*at%o$ O patient verbali2ed that the pain got reduced and the pain scale score
also was 2ero. )is facial epression also reveals that he got relief from pain.
II3 NURSIN2 DIA2NOSIS
A#t%)%t& %$to"era$#e re"ate, to at%1*e se#o$,ar& to 'a%$ at t!e s*r1er& s%te, a$, ,%etar&
restr%#t%o$s
O*t#o-e6 1oa"s# -lient will develop appropriate levels of activity free from ecess
fatigue, as evidenced by normal vital signs * verbali2ed understanding of the
benefits of gradual increase in activity * eercise.
N*rs%$1 a#t%o$s
Pr%-ar&
're)e$t%o$
Se#o$,ar&
're)e$t%o$
Tert%ar& 're)e$t%o$
Ade9uately
oygenate
the client
6nstruct
the client
to avoid
the
activities
which
causes
etreme
fatigue
'rovide the
necessary
articles
near the
patients
bed side.
Assist the
patient in
early
ambulation
%onitor
clients
response
to the
activities in
order to
reduce
discomfort
s.
'rovide
nutritious
diet to the
client.
Avoid
psychologi
cal distress
to the
6nstruct the
client to
avoid the
activities
which
causes
etreme
fatigue.
Advice the
client to
perform
eercises to
strengthen
the
etremities*
promote
activities
Tell the
client to
avoid the
activities
such as
straining at
stool etc
Teach the
client about
the
importance
of early
ambulation
and assist
the patient
in early
ambulation
Teach the
mobility
eercises
appropriate
for the
patient to
(ncourage the
client to do the
mobility
eercises
Tell the family
members to
provide nutritious
diet in a fre9uent
intervals
Teach the patient
and the family
about the
importance of
psychological
well being in
recovery.
'rovide the
primary and
secondary level
care if necessary.
client. Tell
the family
members
to be with
him.
=chedule
rest
periods
because it
helps to
alleviate
fatigue
improve the
circulation
E)a"*at%o$ O patient verbali2ed that his activity level improved. )e is able to do
some of his activities with assistance. 0atigue relieved and patient looks much
more active and interactive.
NURSIN2 DIA2NOSIS-III
I-'a%re, '!&s%#a" -o.%"%t& re"ate, to 'rese$#e o ,ress%$1, 'a%$ at t!e s%te o s*r1%#a"
%$#%s%o$
O*t#o-es61oa"s: 'atient will have improved physical mobility as evidenced by
walking with minimum support and doing the activities in limit.
N*rs%$1 a#t%o$
Pr%-ar& 're)e$t%o$ Se#o$,ar& 're)e$t%o$ Tert%ar& 're)e$t%o$
'rovide active
and passive
eercises to
all the
etremities to
improve the
muscle tone
and strength.
%ake the
patient to
perform the
breathing
eercises
which will
strengthen the
respiratory
muscle.
%assage the
upper and
lower
etremities
which help to
improve the
circulation.
'rovide
articles near
to the patient
and encourage
doing
activities
within limits
which promote
a feeling of
well being.
'rovide positive
reinforcement for
even a small
improvement to
increase the
fre9uency of the
desired activity.
Teach the
mobility eercises
appropriate for
the patient to
improve the
circulation and to
prevent
contractures
%obili2e the
patient and
encourage him to
do so whenever
possible
%otivate the
client to involve
in his own care
activities
'rovide primary
preventive
measures
whenever
necessary
(ducate and
reeducate the
client and family
about the
patients care
and recovery
=upport the
patient, and
family towards
the attainment
of the goals
-oordinate the
care activities
with the family
members and
other disciplines
like
physiotherapy.
Teach the
importance of
psychological
well being which
influence
indirectly the
physical
recovery
'rovide primary
preventive
measures
whenever
necessary
E)a"*at%o$ O patients physical activity improved and he is able to move from bed
with support. 'atient started doing the active and passive eercises and he
verbali2ed improvement.
-----------------------------------------------------------
Co$#"*s%o$
The Neumans system model when applied in nursing practice helped in identifying
the interpersonal, intrapersonal and etra personal stressors of %r. A% 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.
Reere$#es
:. Alligood % >, Tomey A %. Nursing Theory# 5tili2ation *Application .D
rd
ed.
%issouri# (lsevier %osby 'ublicationsG CHHC.
'hiladelphia, CHHC
D. .eorge <" .Nursing Theories# The "ase for 'rofessional Nursing 'ractice,E
th
ed.
New <ersey #'rentice )allGCHHC.
APPLICATION O! ROK5S ADAPTATION
ODEL IN NURSING PRACTICE
Out(ine
6ntroduction
Assumptions of >oyQs Adaptation %odel
>oyQs Adaptation %odel &>A%+ ,Terms
Nursing 'rocess
0irst /evel Assessment
=econd /evel Assessment
Nursing -are 'lan
-onclusion
>eference
INTRODUCTION
"orn at /os Angeles on 4ctober :;, :IDI as the Cnd child of %r. and %rs.
0abien >oy
At age :; she began working at a large general hospital, first as a pantry girl,
then as a maid, and finally as a nurseQs aid.
=he entered the =isters of =aint <oseph of -arondelet.
she earned a "achelor of Arts with a major in nursing from %ount =t. %aryQs
-ollege, /os Angeles in :IFD.
a masterQs degree program in pediatric nursing at the 5niversity of
-alifornia ,/os Angeles in :IFF.
=he also earned a masters * 'h7 in =ociology in :IJD * :IJJ ,respectively
=r. -allista had the significant opportunity of working with 7orothy (.
<ohnson
<ohnsonQs work with focusing knowledge for the discipline of nursing
convinced =r. -allista of the importance of describing the nature of nursing
as a service to society and prompted her to begin developing her model with
the goal of nursing being to promote adaptation.
=ister -allista >oy &:IL;+, 6ntroduction to Nursing# An Adaptation %odel &C
nd
ed+
ASSUPTIONS O! ROK5S ADAPTATION ODEL
S$ienti%i$
=ystems of matter and energy progress to higher levels of comple self-
organi2ation
-onsciousness and meaning are constitutive of person and environment
integration
Awareness of self and environment is rooted in thinking and feeling
)umans by their decisions are accountable for the integration of creative
processes
Thinking and feeling mediate human action
=ystem relationships include acceptance, protection, and fostering of
interdependence
'ersons and the earth have common patterns and integral relationships
'ersons and environment transformations are crated in human consciousness
6ntegration of human and environment meanings results in adaptation
+hilosophial
'ersons have mutual relationships with the world and .od
)uman meaning is rooted in an omega point convergence of the universe
.od is intimately revealed in the diversity of creation and is the common
destiny of creation
'ersons use human creative abilities of awareness, enlightenment, and faith
'ersons are accountable for the processes of deriving, sustaining, and
transforming the universe
PERSONS AND RELATING PERSONS
An adaptive system with coping processes
7escribed as a whole comprised of parts
0unctions as a unity for some purpose
6ncludes people as individuals or in groups &families, organi2ations,
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
EN"IRONENT
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, contetual, and residual
=ignificant stimuli in all human adaptation include stage of development,
family, and culture
HEALTH AND ADAPTATION
)ealth# 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 >esponses# responses that promotes integrity in terms of the goals
of the human system, that is, survival, growth, reproduction, mastery, and
personal and environmental transformation
6neffective >esponses# 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 epands 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, 9uality of life, and dying with
dignity
This is done by assessing behavior and factors that influence adaptive
abilities and by intervening to epand those abilities and to enhance
environmental interactions
ROK ADAPTATION ODEL *RA. OTERS
SystemFa set of parts connected to function as a whole for some purpose.
Stimu(us-something that provokes a response, point of interaction for the human
system and the environment
!o$a( Stimu(i-internal or eternal stimulus immediately affecting the system
Conte3tua( Stimu(us-all other stimulus present in the situation.
Resi#ua( Stimu(us-environmental factor, that effects on the situation that
are unclear.
Regu(ator Su/system-automatic response to stimulus &neural, chemical, and
endocrine+
Cognator Su/system-responds through four cognitive responds through four
cognitive-emotive channels &perceptual and information processing, learning,
judgment, and emotion+
&eha'ior Finternal or eternal actions and reactions under specific circumstances
Physio(ogi$FPhysi$a( o#e
"ehavior pertaining to the physical aspect of the human system
'hysical and chemical processes
Nurse must be knowledgeable about normal processes
E needs &4ygenation, Nutrition, (limination, Activity * >est, and 'rotection+
Se(% Con$eptFGroup I#entity o#e
The composite of beliefs and feelings held about oneself at a given time. 0ocus on
the psychological and spiritual aspects of the human system. Need to know who one
is, so that one can eist with a state of unity, meaning, and purposefulness of C
modes &physical self, and personal self+
Ro(e %un$tion o#e
=et of epectations about how a person occupying one position behaves toward a
occupying another position. "asic need-social integrity, the need to know who one is
in relation to others
Inter#epen#en$e o#e
"ehavior pertaining to interdependent relationships of individuals and groups. 0ocus
on the close relationships of people and their purpose. (ach relationship eists for
some reason. 6nvolves the willingness and ability to give to others and accept from
others. "alance results in feelings of being valued and supported by others. "asic
need - feeling of security in relationships
A#apti'e Responses-promote the integrity of the human system.
Ine%%e$ti'e Responses-neither promote not contribute to the integrity of
the human system
Copping Pro$essFinnate or ac9uired ways innate or of interacting with the
changing of environment
NURSING PROCESS
:. 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 o% &eha'ior< 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 o% Stimu(i< the second step of the nursing process which
involves the identification of internal and eternal stimuli that are influencing
the persons adaptive behaviors. =timuli are classified as# :+ 0ocal- those
most immediately confronting the personG C+ -ontetual-all other stimuli
present that are affecting the situation and D+ >esidual- 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
Goa( Setting< the forth step of the nursing process which involves the
establishment of clear statements of the behavioral outcomes for nursing
care.
Inter'ention< the fifth step of the nursing process which involves the
determination of how best to assist the person in attaining the established
goals
E'a(uation< the sith 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.
DE)OGRA+HI& DATA
Name
Age
=e
6' number
(ducation
4ccupation
%arital status
>eligion
6nformants
7ate of admission
%r. N>
ED years
%ale
-----
7egree
"ank clerk
%arried
)indu
'atient and 1ife
C:!H:!HL
!IRST LE"EL ASSESSENT
PHKSIOLOGICFPHKSICAL ODE
O3ygenation<
=table process of ventilation and stable process of gas echange. >>\ :L"pm.
-hest normal in shape. -hest epansion normal on either side. Ape beat felt on left
E
th
inter-costal space mid-clavicular line. Air entry e9ual bilaterally. No ronchi or
crepitus. N8"=. =:* =C heard. No abnormal heart sounds. 7elayed capillary refill^.
<8'
H
. Ape beat felt- normal rhythm, depth and rate. 7orsalis pedis pulsation of
affected limp is not palpable. All other pulsations are normal in rate, depth, tension
with regular rhythm. -ardiac dull ness heard over D
rd
6-= near to sternum to left Eht
6-= mid clavicular line. =:* =C heard. No abnormal heart sounds. "'-
Normotensive. . 'eripheral pulses felt-Normal rate and rhythm, no clubbing or
cyanosis.
Nutrition
)e is on diabetic diet &:EHHkcal+. Non vegetarian. >ecently his 1eight reduced
markedly &:H kg! F month+. )e has stable digestive process. )e has complaints of
anoreia and not taking ade9uate food. No abdominal distension. =oft on palpation.
No tenderness. No visible peristaltic movements. "owel sounds heard. 'ercussion
revealed dullness over hepatic area. 4ral mucosa is normal. No difficulty to swallow
food
E(imination<
No signs of infections, no pain during micturation or defecation. Normal bladder
pattern. 5sing urinal for micturation. . =tool is hard and he complaints of
constipation.
A$ti'ity an# rest<
Taking ade9uate rest. =leep pattern disturbed at night due unfamiliar surrounding.
Not following any peculiar relaation measure. /ike movies and reading. No regular
pattern of eercise. 1alking from home to office during morning and evening. Now,
activity reduced due to amputated wound. %obility impaired. 1alking with crutches.
'ain from joints present. No paralysis. >4% is limited in the left leg due to wound.
No contractures present. No swelling over the joints. 'atient need assistance for
doing the activities.
Prote$tion<
/eft lower fore foot is amputated. "lack discoloration present over the area. No
redness, discharge or other signs of infection. Nomothermic. 1ound healing better
now. 1alking with the use of left leg is not possible. 5sing crutches. 'ain form knee
and hip joint present while walking. 7orsalis pedis pulsation, not present over the
left leg. >ight leg is normal in length and si2e. =everal 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. >elatively, reduced touch and pain sensation
in the lower peripheryG because of neuropathy. 5sing spectacle for reading.
.ustatory, olfaction, and auditory senses are normal.
!(ui#s an# e(e$tro(ytes<
7rinks approimately CHHHml of water. =table intake out put ratio. =erum
electrolyte values are with in normal limit. No signs of acidosis or alkalosis. "lood
glucose elevated
Neuro(ogi$a( %un$tion<
)e is conscious and oriented. )e is anious about the disease condition. /ike to go
home as early as possible. =howing signs of stress. Touch and pain sensation
decreased in lower etremity. Thinking and memory is intact.
En#o$rine %un$tion
)e is on insulin. No signs and symptoms of endocrine disorders, ecept elevated
blood sugar value. No enlarged glands.
SEL! CONCEPT ODE
Physi$a( se(%<
)e is anious about changes in body image, but accepting treatment and coping
with the situation. )e deprived of seual activity after amputation.
"elongs to a Nuclear family. E members. =tays along with wife and three children.
.ood relationship with the neighbours. .ood interaction with the friends. %oderately
active in local social activities
Persona( se(%<
=elf esteem disturbed because of financial burden and hospitali2ation. )e believes in
god and worshiping )indu culture.
ROLE PER!ORANCE ODE<
)e was the earning member in the family. )is role shift is not compensated. )is son
doesnt have any work. )is role clarity is not achieved.
INTERDEPENDENCE ODE<
)e has good relationship with the neighbours. .ood interaction with the friends
relatives. "ut he believes, no one is capable of helping him at this moment. )e
says @all are under financial constrains@. )e was moderately active in local social
activities
SECOND LE"EL ASSESSENT
!OCAL STIULUS<
Non-healing wound after amputation of great and second toe of left leg- ; week. A
wound first found on the junction between first and second toe-; month back. The
wound was non-healing and gradually increased in si2e with pus collected over the
area.
)e first showed in a local &---+ hospital. 0rom there, they referred to ---- medical
collegeG where he was admitted for : month and ; days. 7uring hospital stay great
and second toe amputated. "ut surgical wound turned to non- healing with pus and
black colour. =o the physician suggested for below knee amputation. That made
them to come to ---)ospital, ---. )e underwent a plastic surgery D week before.
CONTEMTUAL STIULI<
Anown case 7% for past :H years. 1as on oral hypoglycemic agent for initial C
years, but switched to insulin and using it for L years now. Not wearing foot wear in
house and premises.
RESIDUAL STIULI<
)e had T" attack :H year back, and took complete course of treatment. 'reviously,
he admitted in ---)ospital for leg pain about ; year back. . %others brother had 7%.
%other had history of 'T". )e is a graduate in humanities, no special knowledge on
health matters.
CONCLUSION
%r.N> who was suffering with diabetes mellitus for past :H years. 7iabetic foot ulcer
and recent amputation made his life more stressful. Nursing care of this patient
based on >oyQs adaptation model provided had a dramatic change in his condition.
1ound started healing and he planned to discharge on CEth april. )e studied how to
use crutches and mobili2ed at least twice in a day. 'atients aniety reduced to a
great etends by proper eplanation and reassurance. )e gained good knowledge
on various aspect of diabetic foot ulcer for the future self care activities.
NURSING CARE PLAN
ASSESSC
O!
&EHA"IO
UR
ASSESSEN
T O!
STIULI
NURSING
DIAGNOSIS
GOAL
INTER"ENTIO
N
E"ALUATIO
N

Ineffeiti
ve
protetio
n an!
sense in
physial'
physiolo%
ial mo!e

&No pain
sensation
from the
wound
site.+

!o$a(
stimu(i#
Non-healing
wound after
amputation of
great and
second toe of
left leg- ;
week

-C
Impaire#
s)in
integrity
re(ate# to
%ragi(ity o%
the s)in
se$on#ary
to 'as$u(ar
insu%%i$ien$
y

LongFterm
o/4e$ti'e<
:. amputated
area will be
completely
healed by
CH!E!HL
C.=kin will
remain
intact with no
ongoing
ulcerations.
ShortFTerm
O/4e$ti'e<
i. =i2e of
wound
decreases to
:: cm
within
C;!;!HL.
ii. No
signs of
infection over
the wound
within :-wk
iii. Normal
1"- values
within :-wk
iv. 'resence
of healthy
granular
tissues in the
wound site
within :-wk

b %aintain the
wound area
clean as
contamination
affects the
healing
process.
b 0ollow
sterile
techni9ue while
providing cares
to prevent
infection and
delay in
healing.
b 'erform
wound dressing
with betadine
which promote
healing and
growth of new
tissue.
b 7o not
move the
affected area
fre9uently as it
affects the
granulation
tissue
formation.
b %onitor for
signs and
symptoms of
infection or
delay in
healing.

=hort term
goal#
et< si2e of
wound
decreased to
less than ::
cms.
1"- values
became
normal on
C;!;!HL

/ong term
goal#
Partia((y
et< skin
partially
intact with no
ulcerations.
-ontinue plan
>eassess goal
and
interventions
Unmet< not
achieved
complete
healing of
amputated
area.
-ontinue plan
>eassess goal
and
interventions
b Administer
the antibiotics
and vitamin -
supplementatio
n which will
promote the
healing
process.

Impaire!
ativity
in
physial'
physiolo%
ial mo!e

!o$a(
stimu(i<
7uring
hospital stay
great and
second toe
amputated.
"ut surgical
wound turned
to non-
healing with
pus and black
colour.

C.
Impaire#
physi$a(
mo/i(ity
re(ate# to
amputation
o% the (e%t
%ore%oot
an#
presen$e o%
unhea(e#
2oun#

Long term
O/4e$ti'e #
'atient will
attain
maimum
possible
physical
mobility with
in F months.
Short term
o/4e$ti'e<
i.
-orrect use
of crutches
with in
CC!;!HL
ii. walking
with
minimum
support-
CC!;!HL
iii. )e will
be self
motivated in
activities-
CH!;!HL.

b Assess the
level of
restriction of
movement
b 'rovide
active and
passive
eercises to all
the etremities
to improve the
muscle tone
and strength.
b %ake the
patient to
perform the
>4% eercises
to lower
etremities
which will
strengthen the
muscle.
b %assage the
upper and
lower
etremities
which help to
improve the
circulation.
b 'rovide
articles near to
the patient and
encourage
performing
activities within
limits which
promote a
feeling of well
being.
b 'rovide
positive
reinforcement
for even a small
improvement to
increase the
fre9uency of
the desired
activity.
b %easures
for pain relief

=hort term
goal#
et< used
crutches
correctly on
CC!;!HL.
he is self
motivated in
doing minor
ecesses
Partia((y
et# walking
with
minimum
support.

/ong term
goal#
Unmet< not
attained
maimum
possible
physical
mobility-
-ontinue plan
>eassess goal
and
interventions

should be taken
before the
activities are
initiated as pain
can hinder with
the activity.

Alteration
in
+hysial
self in
Self'
onept
mo!e

&)e is
anious
about
changes in
body
image+

&han%e in
Role
performa
ne
mo!e. &)e
was the
earning
member in
the family.
)is role
shift is not
compensat
e+

Conte3tua(
stimu(i<
Anown case
7% for past
:H years and
on treatment
with insulin
for L years.

Resi#ua(
stimu(i# no
special
knowledge in
health
matters

D.
An3iety
re(ate# to
hospita(
a#mission
an#
un)no2n
Out$ome o%
the #isease
an#
%inan$ia(
$onstrainsC

Long term
O/4e$ti'e #
The client will
remain free
from aniety

Short term
o/4e$ti'e<
i.
demonstratin
g appropriate
range
effective
coping in the
treatment
ii. "eing
able to rest
and
iii. Asking
fewer
9uestions

b Allow and
encourage the
client and
family to ask
9uestions.
"ring up
common
concerns.
b Allow the
client and
family to
verbali2e
aniety.
b =tress that
fre9uent
assessment are
routine and do
not necessarily
imply a
deteriorating
condition.
b >epeat
information as
necessary
because of the
reduced
attention span
of the client
and family
b 'rovide
comfortable
9uiet
environment for
the client and
family

=hort term
goal#
et<
demonstrated
appropriate
range
effective
coping with
treatment
)e is able to
rest 9uietly.

/ong term
goal#
Unmet<
client not
completely
remained free
from aniety
due to
financial
constrains-
-ontinue plan
>eassess goal
and
interventions

------

Conte3tua(
stimu(i<
Anown case
7% for past
:H years and
on treatment
with insulin
for L years.

Resi#ua(
stimu(i< no
special
knowledge in
health
matters

GC #e%i$ient
)no2(e#ge
regar#ing
the %oot
$areJ
2oun#
$areJ
#ia/eti$
#ietJ an#
nee# o%
%o((o2 up
$areC

Long term
O/4e$ti'e #
'atient will
ac9uire
ade9uate
knowledge
regarding the
t foot care,
wound care,
diabetic diet,
and need of
follow up
care and
practice in
their day to
day life.
Short term
o/4e$ti'e<
i.
8erbali2ation
and
demonstratio
n of foot
care.
ii. =trictly
following
diabetic diet
plan
iii.
7emonstratio
n of wound
care.

b (plain the
treatment
measures to
the patient and
their benefits in
a simple
understandable
language.
b (plain
about the home
care. 6nclude
the points like
care of wounds,
nutrition,
activity etc.
b -lear the
doubts of the
patient as the
patient may
present with
some matters
of importance.
b >epeat the
information
whenever
necessary to
reinforce
learning.

=hort term
goal#
et<
8erbali2ation
and
demonstratio
n of foot
care.
=trictly
following
diabetic diet
plan

Unmet#
7emonstratio
n of wound
care.

/ong term
goal#
Unmet< not
completely
ac9uired and
practiced the
re9uired
knowledge.
-ontinue plan
>eassess goal
and
interventions

RE!ERENCE
:+ %arriner TA, >aile A%. Nursing theorists and their work. E
th
ed. =t /ouis# %osbyG
CHHE
C+ .eorge "<, Nursing Theories- The "ase for Nursing 'ractice.Drd ed. -hapter L. /obo
%/. "ehavioral =ystem %odel. =t /ouis# %osbyG CHHE
D+ Alligood %> ?Nursing Theory 5tili2ation and Application@ E
th
ed. =t /ouis# %osbyG
CHHE
;+ "lack <%, )awks <), Aeene A%. %edical surgical nursing. F
th
ed. 'hiladelphia#
(lsevier %osbyG CHHF.
E+ "runner /=, =uddharth 7=. Tet book of %edical =urgical Nursing. F
th
ed. /ondon#
%osbyG CHHC
F+ "oon NA, -olledge N>, 1alker ">, )unter <AA. 7avidsons principle and practices of
medicine. CH
th
ed. /ondon# -hurchill /ivingstone (lsevierG CHHF.
APPLICATION O! INTERPERSONAL
THEORK IN NURSING PRACTICE
Out(ine
6ntroduction
The four phases of nurse-patient relationships are
4verlapping phases in nurse- patient relationship
'eplaus theory and nursing process
'eplaus theory application nursing process
=ummary
(valuation of the theory of application
>eferences#
Intro#u$tion
'eplaus theory focuses on the interpersonal processes and therapeutic relationship
that develops between the nurse and client. The interpersonal focus of 'eplaus
theory re9uires that the nurse attend to the interpersonal processes that occur
between the nurse and client. 6nterpersonal process is maturing force for personality.
6nterpersonal processes include the nurse- client relationship, communication,
pattern integration and the roles of the nurse. 'sychodynamic nursing is being able
to understand ones own behavior to help others identify felt difficulties and to apply
principles of human relations to the problems that arise at all levels of eperience.
This theory stressed the importance of nurses ability to understand own behavior to
help others identify perceived difficulties.
The %our phases o% nurseFpatient re(ationships are<
-C Orientation<
7uring this phase, the individual has a felt need and seeks professional
assistance. The nurse helps the individual to recogni2e and understand his!
her problem and determine the need for help.
+C I#enti%i$ation
The patient identifies with those who can help him! her. The nurse permits
eploration of feelings to aid the patient in undergoing illness as an
eperience that reorients feelings and strengthens positive forces in the
personality and provides needed satisfaction.
LC E3p(oitation
7uring 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.
GC Reso(ution
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.
O'er(apping phases in nurseF patient re(ationship
Pep(au5s theory an# nursing pro$ess<
'eplau defines Nursing 'rocess as a deliberate intellectual activity that guides the
professional practice of nursing in providing care in an orderly, systematic manner.
'eplau eplains ; phases such as#
Orientation< Nurse and patient come together as strangersG meeting
initiated by patient who epresses a ?felt need@G work together to recogni2e,
clarify and define facts related to need.
I#enti%i$ation< 'atient participates in goal settingG has feeling of
belonging and selectively responds to those who can meet his or her needs.
E3p(oitation< 'atient actively seeks and draws knowledge and
epertise of those who can help.
Reso(ution< 4ccurs after other phases are completed successfully.
This leads to termination of the relationship.
6n Nursing 'rocess, the orientation phase parallels with assessment phase where
both the patient and nurse are strangersG meeting initiated by patient who epresses
a felt need. -onjointly, the nurse and patient work together, clarifies and gathers
important information. "ased 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 epected behaviours.
Pep(au5s theory app(i$ation nursing pro$ess<
The nursing process for %rs. </ based on 'eplaus theory is as follows#
%rs. </
CJ years
7iagnosis# 6nter vertebral disc prolapse
/ssessment
'0rientatio
n phase(
.ursing
diagnosis
1lanning
'Identification
phase(
Implementation
'$%ploitation
phase(
$valuation
'2esolution phase(
%rs. </ is
on pelvic
traction and
she is
restricted
to bed.

The need
for bed rest
and
restriction
was
discussed.
6mpaired
physical
mobility
related to
the
presence
of pelvic
traction.

3oal setting
was done along
with patient

'atient will
have improved
physical
mobility as
evidenced by
participating in
self care within
the limits.

'rovide active
and passive
eercises to all
the etremities
to improve the
muscle tone
and strength.
%ake the
patient to
perform the
breathing
eercises which
will strengthen
the respiratory
muscle.
%assage the
upper and
lower
etremities
which help to
improve the
-arried out plans
mutually agreed
upon.

'rovided active
and passive
eercises to all
the etremities

%ade the patient
to perform
breathing
eercises

%assaged the
upper and lower
etremities
'rovided article
within the reach
of the patient

%rs. </ was free to
epress problems
regarding difficulty in
mobili2ing.

=he epressed
satisfaction when able
to move without
difficulty.
circulation.
'rovide articles
near to the
patient and
encourage
doing activities
within limits.
'rovide positive
reinforcement
for even a small
improvement to
increase the
fre9uency of
the desired
activity.
'rovided positive
reinforcement to
the patient

/ssessmen
t
'0rientatio
n phase(
.ursing
diagnosis
1lanning
'Identification
phase(
Implementation
'$%ploitation
phase(
$valuation
'2esolution phase(
%rs. </
epresses
pain in the
low back
region.

>egarding
pain,
discussion
was made
to assess
the
severity
and the
type and
duration of
pain. Also
the
measures
to reduce
pain were
discussed.

'ain related to
the
degenerative
changes in the
lumbar region.
3oal setting was
done along with
patient
%rs. </ will have
reduction in pain
as evidenced by
her verbalisation
of reduction in
pain responses.
'rovide non-
pharmacological
measures for
pain relief such
as diversional
activity which
diverts the
patients mind.
.ive the client a
neutral position
Always use back
support while
turning the
patient that
reduces the
strain on the
back.
=upport the areas
with etra pillow
to allow the
normal alignment
and to prevent
strain.
Administer
analgesics as
prescribed by the
physician.

'rovide pelvic
traction to the
patient
-arried out plans
mutually agreed
upon.

'rovided non
pharmacological
measures like
diversion,
massaging, and
pelvic traction.

'rovided supine
position to the
client
=upported the
back during
position change

5sed pillows to
support the back.

Administered
Tab. )ifenac '
and -ap. %yoril
;mg as
prescribed.
.iven pelvic
traction and
eplained the
need for traction
%rs. </ was free to
epress problems of
pain.

(pressed that she
got slight relief from
pain.

/ssessment
'0rientatio
n phase(
.ursing
diagnosis
1lanning
'Identification
phase(
Implementation
'$%ploitation
phase(
$valuation
'2esolution phase(
%rs. </
epresses
that she
need
assistance
to get down
from bed.

>egarding
self care
discussion
was done
and
discussed
regarding
the
measures
to solve the
problems.
=elf care
deficit
related to
the
presence
of pelvic
tractionC
3oal setting
was done along
with patient

-lient will
achieve and
maintain self
care activities
with assistance
of caregiver or
within her
limits.

Aeep all the
articles within
the reach of the
patient.

'rovide a call
bell to the
patient to call
in any
emergency

0re9uently visit
the patient and
en9uire for any
needs.

Assist the
patient in doing
her self care
activities.

>emove the
weight of the
-arried out plans
mutually agreed
upon.

Aept the articles
within t he reach
of the client

0re9uently visited
the patient and
en9uired for any
needs

Assisted the
client in doing her
self care activities

>emoved the
weight as and
when needed.
%rs. </ was free to
epress problems of
self care.

=he used to call for
the needs and all her
needs were met
appropriately

=he achieved and
maintained self care
activities within her
limits
traction as
needed by the
patient.

/ssessment
'0rientatio
n phase(
.ursing
diagnosis
1lanning
'Identification
phase(
Implementation
'$%ploitation
phase(
$valuation
'2esolution phase(
%rs. </ is
en9uiring
about the
disease
condition,
its outcome
and need
for surgery

7iscussed
with the
client
regarding
the disease
process and
the findings
in the client
Aniety
related to
hospital
admission as
evidenced by
verbalisation
and client *
family
appearing
withdrawn
3oal setting was
done along with
patient

-lient will have
reduced feeling
of aniety as
evidenced by
asking fewer
9uestions

Teach the family
and client
regarding the
disease process.
(plain in simple
understandable
language of the
client.
Allow and
encourage the
client and family
to ask 9uestions.
Allow the client
and family to
verbali2e
aniety.
=tress that
fre9uent
assessment are
routine and do
not necessarily
imply a
deteriorating
condition.
Allow the family
members to visit
the client
fre9uently

-arried out plans
mutually agreed
upon.

Taught the family
regarding the
disease process
in simple
Aannada

Allowed the client
and family
members to ask
9uestions
=he and her
husband
epressed their
aniety

Allowed the
family members
to fre9uently visit
the client
%rs. </ was free to
epress problems of
self care.

=he asked her doubts
regarding the illness
and the diagnostic
procedures

=he verbali2ed that
her aniety has
reduced to some
etent.

/ssessment
'0rientatio
n phase(
.ursing
diagnosis
1lanning
'Identification
phase(
Implementation
'$%ploitation
phase(
$valuation
'2esolution phase(
%rs. </ is
en9uiring
about the
disease
condition,
its outcome
and need
for surgery

7iscussed
with the
client
regarding
the disease
process and
the need
for follow
up
7eficient
knowledge
related to
the
treatment
measures to
be
continued
even after
the
discharge.
3oal setting was
done along with
patient

'atient will
ac9uire ade9uate
knowledge
regarding the
treatment and
home care.

(plain the
treatment
measures to the
patient and their
benefits

(plain to the
client the signs
of aggravation of
illness

5se simple and
understandable
terms

-larify all the
doubts of the
patient of
importance.

>epeat the
information
whenever
-arried out plans
mutually agreed
upon.

(plained
treatment
measures and the
need for follow up

(plained
regarding the
signs of
aggravation of
disease

5sed simple and
understandable
terms for
eplaining
-larified her
doubts

>epeated the
information
%rs. </ was free to
epress problems of
self care.

=he epressed
ac9uisition of
knowledge regarding
the disease and the
signs of aggravation
of illness
necessary to
reinforce
learning.
Summary<
-C Orientation phase
-lient is initially reluctant to talk due to pain.
-lient is epressing that while standing she is having much pain.
-lient epressed without movement and supine position gave her relief
from pain.
+C I#enti%i$ation
The client participates and interdependent with the nurse
(presses the need for measure to get relief from pain
(presses need for improving the mobility
(presses need to know more about prognosis, discharge and home
care and follow up.
LC E3p(oitation
-lient eplains that she gets relief of pain when lying down supine.
-ooperates and participates actively in performing eercises.
-lient mobili2es changes position and cooperates during position
changes.
GC Reso(ution
-lient epressed that pain has reduced a lot and she is able to tolerate
it now
=he has agreed upon to continue the eercises at home
=he also epressed that she would come for regular follow up after
discharge.
E'a(uation o% the theory o% interpersona( re(ations /y Pep(au
1ith the help of the theory of interpersonal relations, the clientQs needs could be
assessed. 6t helped her to achieve them within her limits. This theory application
helped in providing comprehensive care to the client.
Re%eren$es<
:. -hinn ' /, and Aramer % A. Theory and nursing- a systemic approach.
D
rd
edition. 'hiladelphia# %osby year bookG:II:
C. .eorge < ". Nursing theories. E
th
edition. New <ersey# 'rentice hallG
CHHC
D. Alligood % >, Tomey A %. Nursing theory- utili2ation and application. D
rd
edition. %issouri# %osby (lsevierG CHHF
;. -raven > 0, )irnle - <. 0undamentals of nursing , human health and
function. E
th
edition. 'hiladelphia# /ippincott 1illiams and 1ilkinsG
CHHJ
E. %cMuiston - % and 1ebb A A. 0oundations of nursing theory-
-ontributions of :C key theorists. New 7elhi# =age 'ublicationsG :IIE
APPLICATION O! THEORK IN
NURSING PROCESS
Intro#u$tion
Theories are a set of interrelated concepts that give a systematic view of a
phenomenon &an observable fact or event+ that is eplanatory * predictive in nature.
Theories are composed of concepts, definitions, models, propositions * are based on
assumptions. They are derived through two principal methodsG deductive reasoning
and inductive reasoning.
O/4e$ti'es
to assess the patient condition by the various methods eplained by the
nursing theory
to demonstrate an effective communication and interaction with the patient.
to select a theory for the application according to the need of the patient
De%inition<
Nursing theory is an organi2ed and systematic articulation of a set of statements
related to 9uestions 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, eplaining, predicting, and !or prescribing..
Importan$e o% nursing theories<
Nursing theory aims to describe, predict and eplain the phenomenon
of nursing
6t should provide the foundations of nursing practice, help to generate
further knowledge and indicate in which direction nursing should
develop in the future
Theory is important because it helps us to decide what we know and
what we need to know
6t helps to distinguish what should form the basis of practice by
eplicitly describing nursing
The benefits of having a defined body of theory in nursing include
better patient care, enhanced professional status for nurses, improved
communication between nurses, and guidance for research and
education
The main eponent of nursing , caring , cannot be measured, it is
vital to have the theory to analy2e and eplain what nurses do
As medicine tries to make a move towards adopting a more
multidisciplinary approach to health care, nursing continues to strive to
establish a uni9ue body of knowledge
This can be seen as an attempt by the nursing profession to maintain
its professional boundaries
Chara$teristi$s o% theories<
Theories are
6nterrelating concepts in such a way as to create a different way of
/ogical in nature.
.enerali2able.
"ases for hypotheses that can be tested.
6ncreasing the general body of knowledge within the discipline through
the research implemented to validate them.
5sed by the practitioners to guide and improve their practice.
-onsistent with other validated theories, laws, and principles but will
leave open unanswered 9uestions that need to be investigated.
Purposes o% theory in pra$ti$e<
=erve to guide assessment, intervention, and evaluation of nursing
care.
'rovide a rationale for collecting reliable and valid data about the
health status of clients, which are essential for effective decision
making and implementation.
)elp to establish criteria to measure the 9uality of nursing care
)elp build a common nursing terminology to use in communicating
with other health professionals. 6deas are developed and words
defined.
(nhance autonomy &independence and self-governance+ of nursing by
defining its own independent functions.
6f theory is epected to benefit practice, it must be developed cooperatively
with people who practice nursing. 'eople 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.
'rocedural rules or principles help to standardise nursing practice and can
also be useful in achieving minimum goals of 9uality of care. Theory is ought
to improve the nursing practice. 4ne of the most common ways theory has
been organi2ed in practice is in the nursing process of analy2ing assessment
data.
Application .oal Attainment Theory
Application 4remQs =elf-care 7eficit Theory
Theories used in -ommunity )ealth Nursing
Application of =uchmans =tages of 6llness %ode
Application of "etty NeumanQs =ystems %odel in Nursing -are
RE!ERENCES
:. Alligood % >, Tomey A %. Nursing Theory# 5tili2ation *Application .Drd ed. %issouri#
(lsevier %osby 'ublicationsG CHHC.
'hiladelphia, CHHC
D. .eorge <" .Nursing Theories# The "ase for 'rofessional Nursing 'ractice .Eth ed. New
<ersey #'rentice )allGCHHC.
TRANSCULTURAL NURSING
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INTRODUCTION
Transcultural nursing with established clinical approached to clients with varying
cultures are relatively new. According to %adeleine /eininger &:ILJ+ founder of
the filed of transcultural nursing in the mid :IFHs. 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 individuali2ed clinical approaches.
>eligious and -ultural knowledge is an important ingredient in health care. 6f the
client do not respond as nurse epects the nurse may interpret it as unconcern or
resistance the nurse then can be anious and frustrated in order to incorporate
cultural knowledge in care cultural knowledge in care.
6t is important to understand some definition and cultural components that are
important in health care.
0or a nurse to successfully provide care for a client of a different cultural or ethnic
to background, effective intercultural communication must take place.
6ntercultural communication occurs when each person attempts to understand the
others point of view from his or her own cultural frame of reference. (ffective
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.
%ajor Nursing organi2ations have emphasi2ed in the last decade the importance
of considering culture factors when delivering nursing care.
According to the American Nurses s Association &:IJF+@-onsideration of
individual value systems and lifestyles should be included in the planning and
health care for each client Nursing curriculum recogni2e the contribution nursing
to the health care needs of a diverse and multi cultural society life-style may
ret:ect cultural heritage.
Cu(tureF"roadly defines set of values, beliefs and traditions, that are held
by a specific group of people and handed down from generation to
generation. -ulture is also beliefs, habits, likes, dislikes, customs and
rituals learn from ones family. &=pecter :II:+
Cu(ture 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.
Re(igion<
6s 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 universeR (thical values
and religion system of beliefs and practices, difference within the culture
and across culture are found
Ethni$< refers to a group of people who share a common and distinctive
culture and who are members of a specific group.
Ethni$ity <a consciousness of belonging to a group.
Cu(tura( I#enti%y< the sense of being part of an ethnic group or culture
Cu(tureFuni'ersa(s< commonalities of values, norms of behavior, and life
patterns that are similar among different cultures.
Cu(tureFspe$i%ies N values, beliefs, and patterns of behavior that tend to be
uni9ue to a designate culture.
ateria( $u(tureN refers to objects &dress, art, religious arti:acts+
NonFmateria( $u(tureN refers to beliefs customs, languages, social
institutions. Su/$u(ture< -composed of people who have a distinct identity
but are related to a larger cultural group.
&i$u(tura( < a person who crosses two cultures, lifestyles, and sets of
values.
Di'ersity< refers to the fact or state of being different. 7iversity can occur
between cultures and within a cultural group.
A$$u(turationN individuals who have taken on, usually observable, features
of another culture. 'eople of a minority group tend to assume the
attitudes, values, beliefs, find practices of the dominant society resulting in
a blended cultural pattern.
Cu(tura( sho$)<Fthe state of being disoriented or unable to respond to a
different cultural environment because of its sudden strangeness,
unfamiliarity, and incompatibility to the strangerQs perceptions and
epectations at is differentiated from others by symbolic markers
&cultures, biology, territory, religion+.
Ethni$ groupsN share a common social and cultural heritage that is passed
on to successive generations.,
Ethni$ i#entityNF refers to a subjective perspective of the personQs heritage
and to a sense of belonging to a group that is distinguishable from other
groups.
Ra$e< 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 O! HEALTH AND DISEASE
1hen viewed across a variety of multicultural groups, eplanations for health and
disease that characteri2ed, many traditional beliefs about disease causation,
treatment, and general health practices can be seen as highly comple, dynamic,
and interactive. These eplanations 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
NdifferencesN can have serious implications for the success of any )ealth
'romotion and 7isease 'revention &)'7'+ effort.
"e aware that the health concepts held by many cultural, groups may result
in people choosing not to seek 1estern medical treatment procedures
because they do not view the illness or disease as coming from within
themselves
"e aware that in many (astern cultures and other cultures in the developing
world, the locus of control for disease causality often is centered outside
the individual, whereas in 1estern cultures, the locus of control tends to
be more internally oriented &7im-out, :IIE+.
>emember that if the more traditional person does seek 1estern medical
treatment, then that person might not be able to provide or describe his or
her symptoms in precise terms that the 1estern medical practitioner can
readily treat &/andline * /ogoff, :IIC+.
>ecogni2e 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 eperience.
Acknowledge that many individual patients and health care practitioners
have specific notions about health and disease causality and treatment
called eplanatory models. These models are generally a conglomeration of
the respective cultural and social training, beliefs, and valuesG the personal
beliefs, values, and behaviors-, and the understanding of biomedical
concepts that each group holds &Alein man, :ILH+.
>ecogni2e that the more disparate the differences are between the
biomedical model and the lay!popular eplanatory models, the greater the
potential for, on to encounter resistance to 1estern )'7' programs.
"e aware of the need to be fleible 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.
Tra#itiona( Con$epts o% I((ness Causa(ity
"e 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.
>emember that most cases of lay illness have multiple causalities and may
re9uire several different approaches to diagnosis, treatment, and cure
including folk and 1estern medical interventions
>ecogni2e that folk illnesses, which are perceived to arise from a variety of
causes, often re9uire the services of a folk healer who may be a local
corianders, shaman, native healer, spiritualist, root doctor, or other
speciali2ed healer.
>ecogni2e that the use of traditional or alternate models of health care
delivery is widely varied and may come into conflict with 1estern models
of health care practice.
5nderstanding these differences may help us to be more sensitive to the
special beliefs and practices of multicultural target groups when planning a
program. -ulture 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 O! CULTURE
-ulture is learned by each generation through both formal and informal life
eperiences. /anguage is primary through means of transmitting culture
The practices of particular culture often arise because of the groupQs social
and physical environment
-ulture practice and beliefs are adapted over time but they mainly remain
constant as long as they satisfy needs.
Cu(tura( a2areness
6t is an in-depth self-eamination of oneQs own background, recogni2ing biases
and prejudices and assumptions about other people
PURPOSES O! KNO;ING THE PATIENTS CULTURE AND RELIGION !OR
HEALTH CARE PERSONNEL
-ultural background affect a personQs health in all dimensions, so the nurse should
consider the clientQs 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. 'rovides
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
emphasi2es care of the suffering person rather than attention simply more
to the pathophysiology of disease, and recogni2es the physician as a
dynamic component of that relationship.
To facilitate in recogni2ing the role of the hospital chaplain and the patientQs
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 (ast, such as
ayurveda and pancha karma
/eininger &:II:,CHHCa+ has defined transcultural nursing as a comparative study
of cultures to understand similarities &culture universal+ and difference &culture-
specific+ across human groups
Cu(tura((y $ongruent $areN
-are that fits the peopleQs valued life patterns and set of meanings -which is
generated from the people themselves, rather than based on predetermined
criteria. 7iscovering clientQs culture care values, meanings, beliefs and practices
as they relate to nursing and health care re9uires nurses to assumes the roles of
learners of clients culture and copartners with clientQs and families in defining the
characteristics of meaningful and beneficial care.&/eininger,CHHC
Cu(tura((y $ompetent $are 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. -ulturally competent care re9uires
specific knowledge, skills, and attitudes in the delivery of culturally congruent care
and awareness.
'ac9uiato '4556( identifies three distinct levels of cultural competence at the
practitioner, organi2ational and social levels.
Nursing De$isions
/eininger &:II:+ 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.
-C Cu(tura( preser'ation or maintenan$e< >etain and or preserve relevant care
values so that clients can maintain their well-being, recover from illness, or face
handicaps and!or death .
+CCu(tura( $are a$$ommo#ation or negotiationF Adapt or negotiate with the
others for a beneficial or satisfying health outcome
LC Cu(tura( $are repatterning or restru$turing # >ecords, change, or greatly
modify clients life ways for a new, different and beneficial health care pattern
PURPOSE AND GOAL O! THE THEORK
The central purpose of the theory is to discover and eplain 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 o% Tra#itiona( Pra$ti$es
%any 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. &%orgenstern, :IFF+
USE O! PROTECTI"E O&9ECTS
'rotective 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 eample, 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 eist in
societies all over the world and are associated with protection from trouble
&"udge, :IJL+
USE O! SU&STANCES
=ubstances 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. 6t is believed that the body is kept in
balance or harmony by the type of food eaten so many food taboos and
combinations eist in traditional belief systems. 0or eample, it is believed that
some food substances can be ingested to prevent illness. 'eople from many
ethnic backgrounds eat raw garlic or onion 6n an effort to prevent illness or wear
them onQ the body or hang them in the home.
<ews also believe that milk and meat must never be mied or eaten at the same
meal &=teinberg, :I;J+ 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 6n many instances a heritage
consistent person may prayer. >eligion strongly affects the way people attempt to
prevent illness, and it plays a strong role in rituals associated with health
protection. >eligion dictates social, moral, and dietary practices designed to keep
a traditional healer &Aaptchuk and -roucherlILJ+
Tra#itiona( Reme#ies 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 5se 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. %any of these plants
are used by specific communities. 4thers cross ethnic and community lines and
are used in certain .eographic areas in the personQs country of origin.
1hen patients -do not adhere to a pharmacological regimen an effort must be
made to determine the remedy if they are taking traditional remedies. 0re9uently,
the active ingredients of traditional remedies are unknown. 6f a client is believed
to be, taking them an effort must be made to determine the remedy as well as its
active in gradients 4ften, these ingredients can be antagonistic or synergistic to
prescribed medications. 4ver dose may occur.
Hea(erHs
6n the traditional contet, healing is the restoration of the person to a state of
harmony between the body, 1ithin 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 6n many instances a heritage consistent person may
consult a traditional healer before, instead of, or in conjunction with a modern
health care provider. %any differences eist between the 1estern physician and
the (astern A broad range of health and illness beliefs eist many of these beliefs
have roots in the culture, ethnic, religious, or social back ground .of a person
family, or community. Q1hen people anticipate fear or eperience 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. )owever, they may be due to eternal social forces not within the
personQs control (amples of eternal social forces include communication
barriers, such as language differences, or economic barriers causing limited
access or lack of access to modem, health care facilities.
IIGRATION
(very immigrant group has its own cultural attitudes ranging beliefs and practices
regarding these areas )ealth and illness can be interpreted in terms of personal
eperience and epectations. There are countless ways to eplain health and
illness, and people base their responses on cultural, religious, and ethnic back
ground. The responses are culture specific, based on a clientQs eperience and
perception.
Gen#er Ro(es
6n many cultures, the male is dominant figure. 6n cultures where this is time,
males make decisions for other family members well as for themselves. 0or
eample, no matter which family member is involved cultures where the male
dominate. The female usually is passive. 6n African -American families, however
as well as in many -aucasian families, the female often is dominant Anowledge 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
re9uire the services of a folk healer who may be a local curandero, shaman,
native healer, spiritualist, root doctor, or other speciali2ed healer. >ecogni2e that
the use of traditional or alternate models of health care deliveries widely varied
and may come into conflict with 1estern models of health care practice.
5nderstanding 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 PRE"ENTION RELATED TO !OOD
=everal factors cause illness. A hot-cold imbalance, for eample, is primarily
caused by improper diet. 0ood 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. (amples of cold food are, honey, avocados, bananas, and
lima beans. (amples of hot foods-are chocolate, coffee, com meal, garlic, kidney
beans, onions, and peas. 6llness can occur if these foods are eaten in improper
combinations or amounts. .
Tra#itiona( /e(ie%s a/out menta( hea(th 6n the traditional belief system,
mental illnesses are caused by a lack of harmony of emotions or, sometimes, by
evil spirits. %ental wellness occurs when psychological and physiologic functions
are integrated. =ome elderly Asian Americans share the "uddhist belief that
problems in this life are most likely related to transgressions committed in a past
life. 6n addition our previous life and our future life are as much a part of the life
cycle.
ECONOIC &ARRIERS
=everal economic barriers, such as unemployment, underemployment,
homelessness, lack of health insurance poverty prevent people from entering the
health care system. 'overty is by far the most critical factor. 'overty a relative
term and changes from time and place. 6n the 5nited =tates, poverty is pervasive
and found etensively among people in certain norms geographical areas, such as
rural populations, the elderly migrant workers, and illegal aliens. 'oor health,
crippling diseases, drug and alcohol abuse, poor educationG and inferior are
contributing social causes of poverty.
=everal programs, both governmental and private, aid people with short- and
long-tem problems. 6t is important for the nurse to be aware clients needs and
financial resources available in the local community.
Time orientation
6t 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 TERRITORIALITKN
'ersonal space involves a personQs set of behaviors and attitudes toward the
space around himself. =taff members and other clients fre9uently encroach on a
clientQs territory in the hospital, which includes his room, bed, closet, and
belongings. The nurse should try, to respect the clientQs territory as much as
possible, especially when performing nursing procedures. The nurse should also
welcome visiting members of the family and etended family. This can remind the
client of home, lessening the effects of isolation and shock from hospitali2ation.
SOCIOCULTURAL !ACTORS AND THE NURSING PROCESS
Re(igious /e(ie% that e%%e$t the $are NursingN
"elief about birth *death.
"elief about diet and food practices.
"elief regarding medical care
-omments &cremation is preferred+
ROLE O! NURSE
:.The nurse should begin the assessment by attempting to determine the
clientQs 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
C.Nurses should evaluate their attitudes toward ethnic nursing care. =ome
nurses may believe they should treat all clients the same and simply act
naturally, but this attitude fails to acknowledge that cultural differences do
eist and that there is no one NnaturalN human behavior The nurse cannot
act the same with all clients and still hope to deliver effective,
individuali2ed ,holistic care.
D.=ometimes, ineperienced nurses are so self-conscious about cultural
differences and so afraid of making a mistake that they impede the nursing
process by not asking 9uestions about areas of difference or by asking so
many 9uestions that they seem to try into the clientQ personal life.
;.The process of self-evaluation can help the nurse become more comfortable
when providing care to clients from diverse backgrounds
E.-ulture is the sum total of mores traditions * beliefs about how people
function encompasses others products of human works * thoughts.
=pecific to member of an intergenerational group, community or
population.
F.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.
J.A childQs self concepts evolves from ideas about his or her social roles
L.'rimary groups are characteri2ed by intimate contact mutual support and
pressure for conformity.
I.6mportant sub culture influences on children include ethnicity social class,
occupation school peers and mass culture
:H. =ocioeconomic influences play major role in ability to seek opportunity for
health promotion for wellness
::. >eligious practices greatly influences health promotion belief in families.
:C. %any ethnic and cultural groups in country retain the cultural heritage of
their original culture.
:D. )ow culture influences behaviors, attitudes, and values depends on many
factors and thus is not the same for different members of a cultural group.
:;. (thnocentrism can impede the delivery of care to ethnic minority clients
and, when pervasive, can become cultural racism.
:E. =tereotyping ethnic group members can lead to mistaken assumptions
about a client.
:F. The nurse should have an understanding of the general characteristics of
the major ethnic groups, but should always individuali2e care rather than
generali2e about all clients in these groups.
:J. "efore assessing the cultural background of a client, nurses should assess
how they are influenced by their own culture.
:L. The nursing diagnosis for clients should include potential problems in their
interaction with the health care system and problems involving the effects
of culture.
:I. The planning and implementation of nursing interventions should be
adapted as much as possible to the clientQs cultural background.
CH. (valuation should include the nurseQs self-evaluation of attitudes and
emotions toward providing nursing care to clients from diverse
sociocultural backgrounds.
C:. 1hen nurses provide care to clients from a background other than their
own, they must be aware of and sensitive to the clientsQ 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 individuali2ed care
CC. The nurse should begin the assessment by attempting to determine the
clientQs 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
CD. 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. 6n addition the nursing diagnosis should state the probable cause
.The identification of the cause of the problem further individuali2es the
nursing care plan and encourages selection of appropriate interventions-
cultural variables as they relate to the client. The etended family should
be involved in the care the -lientQs strongest support group. -ultural
beliefs and practices can be in-corporate into therapy.
C;. The clients the nursing processG educational level and language skills
should be considered when planning teaching activities.
CE. (planations of and practices into nursing therapiesG aspects of care
usually not 9uestioned by acculturated clients may be re9uired for non-
(nglish speaking or non- acculturated clients to avoid confusion,
misunderstanding, or cultural conflict.
CF. 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 eti9uette. A client who is modest and self-conscious about
the body may need psychological preparation before some procedures and
tests.
CJ. The nurse can find out what care the client considers appropriate by
involving him and his family in planning care and asking about their
epectations. This should be done in every case, even if the nursing care
cannot be modified. "ecause both the nurse and the client are likely to
take many aspects of their cultures for granted, 9uestions should be clear
and eplanations should be eplicit.
CL. 7iscussing cultural 9uestions related to care with the client and family
during the planning stage helps the nurse understand how cultural
variables are related to the clientQs health beliefs and practices, so that
interventions can be individuali2ed for the client.
CI. The nurse evaluates the results of nursing care for ethnic clients as for all
clients, determining the etent to which the goals of care have been met.
(valuation continues throughout the nursing process and should include feedback
from the client and family. 1ith an ethnic minority client, however, self-evaluation
by the nurse is crucial as he or she increases skills for interaction. The nurse
should consider 9uestions such as the following# .
Am 6 open to understanding ways in which the clientQs values differ from
mineR
)ave 6 given sufficient attention to communicating with the client with
limited language skillsR
)ave 6 have successful clientQs family in nursing processR
Am 6 incorporating the clientQs traditional beliefs and practices into nursing
therapiesR
6s my therapeutic relationship with the client grounded on respect for the
client regardless of cultural differencesR
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 epertise to implement culturally
acceptable strategies to provide nursing care, and identify and use resources
acceptable to the client &"oyle, :ILJ+.
RE!ERENCES
:. "oyle, <=# The practice of trans cultural nursing, Transcultural Nursing
%orgenstern, <# >ites of birth, marriage, death, and kindred occasions
C. .eorge <ulia ". Nursing theories# The base of professional nursing practice Drd
edition. Norwalk, -N# Appleton and /angeG :IIH.
D. Ao2ier ", (rb ., "arman A, =ynder A<. 0undamentals of nursingG concepts,
process and practice, (dn Jth, CHH:.
;. /eninger %, %c0arland %. Transcultural Nursing# -oncepts, Theory, >esearch, and
'racticeG (dn Drd, %c.raw-)ill 'rofessionalG New Kork, CHHC.
E. 'otter A, 'erry . ."asic Nursing-Theory and 'ractice, (dn Drd %osby -ompany.
HELPING AND HUAN
RELATIONSHIPS THEORK
"y
>4"(>T >. -A>A)500
Intro#u$tion
1hen 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.
He(ping
)elping 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. -hildren 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. 'ersons who are fully alive help other persons to become fully
alive. >esponsive and initiative behaviours are the basic dimensions of helping
and development.
'otentially all relationships are helping relationships. 6t depends upon the helping
skills one has, the effects of skills depend upon how we se9uence them. Thus
helping in real sense is a developmental process like child rearing. (ffective
parenting involves both responsive and initiative skills. )elpers who are fully
responsive and fully initiative teach their helpees to be fully responsive and fully
initiative.
Human Re(ationships
)uman >elationships may be facilitative or retarding effects. /ike a marriage,
the conse9uences of all human relationships may be for better or for worse.
-onse9uences may be constructive or destructive, may produce persons and non
personsG health care provider-patientG employee-employer etc. The effects may
be positive or negative or any of the degrees in between these etremes. The
effects are seen in physical, emotional and intellectual functioning. 1ith
facilitative agents the recipients may be physically energetic, emotionally
epansive and intellectually acuteG with retarding agents the recipients may be
physically listless, emotionally shallow and intellectually dull.
Po2er an# human re(ationships
The effects of human relationships depend upon the power relationship. 6f the
person is ceded the power in the relationship is functioning at a high level, then
all parties involved can benefit from the relationship. (g. 'arents. 5nfortunately
power relations are developed for reasons other than functionality like tradition,
politics etc. 6t 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.
S)i((s
%ost fundamentally, it is the powerful persons 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.
Respon#ing an# initiating s)i((s
These skills are cycled in an individuals 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.
Responsi'eness
>esponsiveness is the basic ingredient of human relations, which involves
empathy. >esponsiveness is the most profound variable in the human
condition. To know more than that person does of her own eperience, to be
able to describe and predict and influence that eperience constructively, is the
test of responsive skills. >esponsive skills thus involve eperiencing anothers
condition and communicating to her own eperience. 6t involves the other
person in a process leading to her own self-eploration and self-understanding.
Initiati'e
6nitiative is the basic ingredient of human functionality. 6t involves
operationali2ing the goal or breaking it down into its components. 6t involves
developing the steps and systems to achieve the goal, it is more than a
mechanical process. 6t begins with a vision of the possible, building upon our
own eperience to see a goal, further it stimulates the other person to take
action to achieve the goal.
1hen people share their problems, what skills do you have to truly show
that you are responding to their eperienceR
)ow do you physically show thisR (motionallyR 6ntellectuallyR
1hat do you do and say that will assure the people that you are sensitively
attuned to their eperienceR )ow do you show you heard themR 1hat
feedback do you giveR
1hen you are wrestling with their problems, how do you share your
eperience to help them to develop achievable goals that solve their
problemsR
Now that you have responded to their eperience, how do you help them to
initiate steps to get to their goals.
Ne2 &eha'iour
"efore we can ac9uire the skills of helping, we must understand the goals of
helping. New behavior is the overall goal of helping. 4ne must eplore where she
is, eplore herself in relation to herself and in relation to her world. 1e must
know the problems before we can change the behavior. 6n eploring herself, the
person seeking help is attempting to understand where she is in relation to where
she wants to be. =elf understanding is not real until the individual has acted upon
it. 6n 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.
E'o(ution o% #imensions
"efore we understand the dimensions, we must understand four things.
iC He(ping Sour$es< There are two approaches to helping -insight and action. The
insight approach was supported by many traditional therapeutic schools,
emphasi2ed the clients insight as the basis for the development of an effective
set of assumptions about his or her world. The action approach has been
promulgated by the learning theory and behaviour modification schools as well as
the trait and factor school, which matches people to jobs and vice versa, who
emphasi2ed the clients development and implementation of rational action plans
for managing his or her world. 6n order to effectively help human beings to
change behaviour the insight and action approaches must be integrated into one
effective helping process.
iiC He(ping Pro$ess< 6n 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 themG in order to
understand their goals, the helpees must eplore their world eperientially. 0inally
they must act to get from where they are to where they want to be. 1ith the
feedback they can recycle the learning process
(ploration -----------5nderstanding------------Action-----------0eedback
0eedback-------further eploration----self understanding--------real
understanding
>eal 5nderstanding-----------modification of action &effective action+.
iiiC He(per S)i((s< The historic dimension of empathy was complemented by
unconditional positive regard and genuineness, which were then operationali2ed
into accurate empathy, respect and genuineness. These were in turn
complemented by other dimensions including specificity or concreteness, self
disclosure, confrontation and immediacyG then factored into responsive and
initiative dimensions. The responsive dimensions &empathy, respect, specificity of
epression+ responded to the helpees eperience and thus facilitated the helpees
movement towards understanding. The initiative dimensions &genuineness, self
disclosure, confrontation, immediacy and concreteness+ were generated from the
helpers eperience and stimulated the helpees movement toward action. The
initiative dimensions were later etended to incorporate the problem solving skills
and program development skills needed to fully help the helpeeQs to achieve
appropriate outcomes.
i'C He(pee Out$omes< emphasi2ed the emotional changes or gains of he
helpeeQs. =ince the helping methods were insight oriented, the process
emphasi2ed helpee eploration and outcome assessments measured the changes
in the helpees level of emotional insights, which were restrictive because they
were assessing only one dimension of the helpees functioning. These were later
etended to incorporate the interpersonal functioning of the helpeeQs. The
dimension of physical functioning was added, to measure fitness and energyG
intellectual dimension to measure the intellectual achievement and capabilities.
Le'e(s an# sty(es o% %un$tioning
-arkhuff and "erenson&:IFJ+ described five levels of dimensions.
The #imensions are empathyJ respe$t or regar#J genuinenessJ
$on$retenessJ 2armth. /evels#
!irst# no empathy is taking place& no evidence of the helper characteristic+
Se$on## (mpathi2ing very little and at a level that detracts from helpee
functioning&:HY of time+
Thir## minimum level of feeling response necessary to be efective&EHY of time+
!ourth an# %i%th# )igher levels of helper empathy&;
th
, JEYG E
th
, consistently
present+
The responsi/i(ity $ontinuum#
He(ping s)i((s
The responsive and initiative factors of helping dominate the helping process
facilitating (^ 5^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^>^'^6+. The attending skills are transitional between responding and
initiating.
Atten#ing # ?"eing 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. "y
attending physically the helper communicates interest in the helpees welfare, by
observing and listening, helper learns from and about the helpee. "y
communicating interest in the helpee, helper establishes the conditions for the
helpees involvement in the helping process.
Respon#ing# >esponding to the helpee s epression of her eperience, involves
responding to content, feeling and feeling and content together. The function of
he responding to the helpees eperience is to facilitate self eploration. T thus
she signals her readiness for the net goal of helping- understanding, which
signals the helper to begin personali2ing. They serve to stimulate the helpees
eploration of where he or she is in his or her eperiences of the world and that
the helper is fully in tune with the helpees eperience.
Persona(i8ing# ?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 personali2ing 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 eploring to acting. 'ersonali2ing
skills culminate in the helpees personal eperience of the problem as the inability
to handle difficult situations.
Initiating# @0inding direction in life or acting in following the direction, bringing
direction to culmination , giving life meaning in productivity and creativity@. 6t
involves operationali2ing goals and initiating steps, schedules and reinforcements
to achieve these goals. These goals resolve helpees problems. 0osters the
development and implementation of the mechanical steps re9uired to achieve the
personally meaningful goals that the helpee has developed. 6nitiating skills
conclude the first cycle of helping process in which helper facilitate helpees acting
to get to where he or she wants to be in the world.
6f you have attended to to the helpees needs and responded to her eperience,
you have facilitated her eploration of where she is. 6f you have personali2ed your
understanding of the helpee, you have facilitated her understanding of where she
is in relation to where wants to be. 6f 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. Kou
have seen her grow and develop. "ut growth is not static, is life long learning.
/ife long /earning is recycling eploring, understanding and acting. A growing
person is constantly involved in the learning person.
.rowing is more than learning and helping. 6t is helping others to learn, which
means to eplore, understand and act plus recycle. (.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.
)aving begun by attending and responding, over an etended period of time each
person can learn to personali2e 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+. 6t means being
simultaneously aware of both the helpees and ones own eperience.
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. 1hatever the effective helper or the whole person is
doing, she is always checking back with the helpee accuracy of the responses.
=he makes this by making responses that are interchangeable with the feeling
and content epressed 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.
6n fully alive communication each person may be helper to the other. "ut one
must initiate the helping process by communicating her openness to
understanding the other. 6n doing so she establishes the model for the other to
imitate, %utual 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. 4ne clear
demonstration of the helpees readiness to terminate the helping process, to go
out on her own is her ability to respond to the eperience of the helper. #&$
C7$/2 D$M0.-#2/#I0. 0* #&$ /"I7I#8 #0 *9.C#I0. /- / &$71$2 WI77 "$
0.$- /"I7I#8 #0 2$-10.D /.D I.I#I/#$ $**$C#I:$78!
The Assumption
#he only assumption made in developing the helping sill programs involves ones
motivation. 4ther assumption is that one wants to grow, want to be like the
facilitative helpers and teachers one has eperienced, one wants to become
involved in a life long learning process.- -A>A)500
"rammer and %acdonald-
The basic interpersonal communication processes implied by the speciali2ed
helping relationships are similar
'eople know their needs
"asically it is a process of enabling the person to grow in the directions that
person chooses, to solve problems and to face crises.
8oluntary 9uality of the helping process is a crucial point since many
persons wanting to help others have their own helping agenda and seek to
meet their own unrecognised needs.
The act of helping people with the presumed goal of doing something for
them or changing them in some way has an arrogant 9uality too.
The aim of all help is self help and self sufficiency.
(ach individual behaves in a competent and trustworthy manner if given the
freedom and encouragement to do so.
)elper must assume some responsibility for creating conditions of trust
whereby helpeescan respond in a trusting manner and help themselves.
)elper must be alert to the impact on the helpee of other people and of the
physical environment.
)elping takes place over the lifespan. (ach developmental period and the
transitions between usually re9uire some form of outside help to make life
more effective and satisfying. .
The nature of the informal agreement implies a growth contract, that
helpees will try to change under their own initiative, with minimal helper
assistance.
&asi$ He(ping s$a(e
6 ^ ( ^ 5 ^ A \ New learning &behaviour+
E.H 6nitiating steps
;.E 6nitiating goal operationali2ation
;.H 'ersonali2ing problem, feelings and goal
D.E 'ersonali2ing meaning
D.H >esponding to feeling and content
C.E >esponding to feeling
C.H >esponding to content
:.E Attending
:.H Non attending
Non atten#ing covers all behaviours, both verbal and non verbal that are
unrelated or irrelevant to the helpees situation or epressions.
Atten#ing# 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.
Respon#ing to $ontent# involves summarising what the helpee has shared
concerning her situation.
Respon#ing to %ee(ing# involves accurately identifying a feeling word that is
interchangeable with the helpees eperience of the situation.
Respon#ing to %ee(ing an# $ontent# involves the clear communication of
helper understanding of both the content and feelings epressed by the helpee.
Persona(i8ing meaning# involves responding to identify the personal
significance or implications of the epressed situation for the helpee.
Persona(i8ing pro/(em, %ee(ings an# goa(# involves responding to identify the
personal deficits &assets+ of the helpee that are contributing to the problem or
situation, the feelings that the helpee is eperiencing about her deficits &assets+
and the goal that the helpee wants to achieve.
Initiating goa( operationa(i8ation# covers responses that epress a clear
understanding of the helpees personali2ed problem, feelings and goal in
behavioural terms.
Initiating steps# involves responses that identify specific steps toward
accomplishing the operationalised goal.
Ingre#ients to se$ret o% su$$ess
a. =kills of helping# Apply the skills then only you recognise the need for more
skills. The most o% /asi$ o% a(( s)i((s is (earning ho2 to (earnC N et is the
basic skill of teaching.
b. 7iscipline# (mploy skills with discipline. The accuracy of the discriminations and
communications is the effective ingredient.
c. 1ork# 4ur real learning in life comes from working very hard, applying skills with
disciplines in a variety of human eperiences. 1hile working hard they must
protect themselves by receiving the maimum return for the minimum
investment. e.g. 4nce you understand the response deficits of the helpees they
will tend to employ teaching in groups as the preferred mode of treatment.
E'a(uation o% theory
i. :IFHs# &(ysenk, :IFH, :IFEG /evitt :IFDG /ewis :IFE+ 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 EH
treatment setting by Anthony&:IJI+ who studied lasting effects of counseling,
rehabilitation and psychotherapeutic techni9ues. 1ithin D-E years after treatment
FE-JEY of the patients were once again patients. The gainful employment of
patients was below CHY. -onclusion was that psychotherapy has lasting positive
effects in :J-CCY of the cases.
ii. Naturalistic studies# &>ogers et al :IFJ, Trau and -arkhuff :IFJ+ The clients
and patients of professional helpers demonstrated a greater range of effects than
those in professionally untreated groups. "ut 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. 4ne who offered high level of core interpersonal dimensions
facilitated the process movement.
iii. 'redictive 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. &-arkhuff and Aleik :IFJ, )older et al
:IFJG 'iaget et al :IFLG Trau and -arkhuff :IFJ+. )elpees of helpers
functioning at high levels of these interpersonal dimensions moved towards higher
levels of functioning &eplored their problems in meaningful ways+
iv. .enerali2ation =tudies# To study the effects of teachers levels of interpersonal
functioning upon learners 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
>oebuck, :IJJ+ 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 &-arkhuff :IJ:, :IJF+G =tudent teacher relations
&-arkhuff :IFI+G counselor ,client relation and therapist patient relations
v. (tension studies# %ichelson and =tevic&:IJ:+ found that career information
seeking behaviour was dependent upon the helpers levels of interpersonal
functioning in interaction with their reinforcement program )elping 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 app(i$ations#
i. 1ith credentialed counselors and therapists# Trained counselors were able to
demonstrate success rates between J;-I:Y. Aspy and >oebuck&:IJJ+
demonstrated positive effects of helping skills upon student physical, emotional
and intellectual functioning.
ii. 0unctional 'rofessionals# =taff personnel, such as nurses, hospital attendants,
policeman, prison guards, dormitory counselors, community volunteers were
trained and their effects in treatment studied. /ay 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 epert
reports.
iii. 6ndigenous personnel# They can work effectively with the populations from
which they are drawn. 0or eample, 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. )elpee 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.
'atients 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. =cience and art of helping# 4n implication of the research into helping is to
select persons as helpers who already possess the artful 9ualities and then 9uickly
and systematically give them basic helping skills and behaviour concepts.
vi. =elf )elp .roups# )urvit2 &:IJH+ studied many groups as participant observer
and concluded saying much of their effectiveness was due to peer relationships,
inspirational methods, eplicit goals, fellow ship and a variety of helping
procedures. They use many sources of help that are outside conventional helping
methods.
He(ping Re(ationship *&rammer.
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 eperience of an emotional bond in this mutual act. The working alliance is
considered e9ual in importance to helper attitudes &.elso * -arter, :II;+.
)elping relationship is dynamic at verbal and nonverbal levels, the relationship is
the principal process vehicle for both helper and helpee to epress and fulfill their
needs as well as to mesh helpee problems with helper epertise. All authorities on
the helping process agree that the 9uality of the helping relationship is important
to effective helping&=eton and 1histon :II;.+All agree that good working
relationship established early, yield a helping relationship. 6ts dimensions are
&"rammer, Abrego and =hostrom :IID+ uni9ueness-commonality and intellectual
, emotional content. )owever helping relationship is different from friendship, is
not a reciprocal relationship. The focus is on the helpees emotional and
intellectual issues, the helper must resist the urge to move the focus to his or her
eperience.

He(ping a%%i(iations
)elping affiliations can be classified into formal and structured &professional,
paraprofessionals and volunteer helper+ to informal and unstructured &friendships,
family, community* general human+.
Stages in he(ping pro$ess
There are eight stages contained in the two basic phases of the helping process.
'hase :# "uilding relationships#
(ntry# preparing the helpee and opening relationship
-larification# state the problem or concern and reasons for seeking help
=tructure# formulating the contract and the structure
>elationship# building the helping relationship
'hase C# 0acilitating 'ositive Action
(ploration# eploring problems, formulating goals, planning strategies,
gathering facts, epressing deeper feelings, learning new skills.
-onsolidation# eploring alternatives, working through feelings, practicing
new skills
'lanning# developing a plan of action using strategies to resolve conflicts,
reducing painful feelings, and consolidating and generali2ing new skills or
behaviours to continue self-directed activities.
Termination# evaluating outcomes and terminating the relationship.
He(ping s)i((s %or un#erstan#ing< o% se(% an# others
i. /istening skills
Attending , noting verbal and nonverbal behaviours
'araphrasing , responding to basic messages
-larifying , self disclosing and focusing discussion
'erception checking , determining accuracy of learning
ii. /eading =kills
6ndirect leading , getting started
7irect leading , encouraging and elaborating discussion
0ocusing , controlling confusion, diffusion and vagueness
Muestioning , conducting open and closed in9uiries
iii. >eflecting skills
>eflecting feeling , responding to feelings
>eflecting eperience , responding to toal eperience
>eflecting content , repeating ideas in fresh words or for emphasis
iv. -onfronting skills#
>ecognising feelings in oneself , being aware of helper eperience
7escribing and sharing feelings , modeling feeling epression
0eeding back opinions , reacting honestly to helpee epressions
=elf-confrontation
v. 6nterpreting skills
6NT(>'>(T68( M5(=T64N= , 0A-6/6TAT6N. A1A>(N(==
0ANTA=K AN7 %(TA')4>- =K%"4/6S6N. 67(A= AN7 0((/6N.=
vi. 6nforming skills
Advising , giving suggestions and opinions based on eperience
6nforming- giving valid information based on epertise
vii. =ummarising =kills
'ulling themes together.
Ethi$a( issues in he(ping re(ationships< In%orme# $onsent
1orker self care- recognise own weak spots and work on prevention
7ual relationships- recognise them and manage them Ask following 9uestions.
6s there a a power difference between usR
1hat other role obligations do 6 have in this situationR
)ow will my knowledge about you change our relationshipR
'hysical contact with helpees# =eual relationships of any kind are unethical
Touching clients for support, out of compassion or to epress care is controversial.
Con$(usion
4ur task in life is to improve the 9uantity and 9uality of human eperience, our
own as well as others which is growthC /ife is process, is growth and growth is
learning skills. 1hen we use the helping skills effectively, we can be healthy and
we can help each other to actuali2e our human potential. The only meaning to life
is to grow for growing is life.
Re%eren$es
:. -arkhuff >. The art of helping. ;
th
ed. Amherst# )uman >esource 7evelopment
pressG :ILD
C. "rammer / %, %acdonald .. )elping relationship process and skills. F
th
ed.
"oston# Allyn and "aconG :IIF.
D. =hea - A, 'elletier / >, 'oster ( -, =tuart . 1, 8erhey % '. Advanced practice
nursing in psychiatric and mental health care. =t. /ouis# %osbyG :III
;. Topalis %, Aguilera 7 -. 'sychiatric nursing. J
th
ed. =t /ouis# - 8 %osbyG :IJL.
E. %orrison %. 0oundations of mental health nursing. =t. /ouis# %osbyG :IIJ.
F. Taylor -, /illis -, /e %one ', /ynn '. 0undamentals of nursing. F
th
ed.
'hiladelphis# /ippincott 1illiams * 1ilkinsG CHHE.
J. 7eter ., 1alsh %. 'sychiatric skills a pateint centred approach. C
nd
ed. /ondon#
-hapman * )allG :IIE.
L. =tuart . 1, /araia % T. 'rinciples and practice of psychiatric nursing. =t /ouis#
%osby )arcourt 'vt. /imitedG CHH:.
I. "oon NA, -olledge N>, 1alker ">, )unter <AA. 7avidsons principle and
practices of medicine. CH
th
ed. /ondon# -hurchill /ivingstone (lsevierG CHHF.

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