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ADVANCED THEORETICAL FOUNDATIONS IN NURSINGPage 1

FLORENCE NIGHTINGALE
ENVIRONMENTAL THEORY
Introduction
Florence Nightingale is considered the founder of educated and
scientific nursing and widely known as The Lady with a Lamp, wrote
the first nursing notes that became the basis of nursing practice and
research. The notes, entitled Notes on Nursing: What it is, What is not
(1860), listed some of her theories that have served as foundations of
nursing practice in various settings, including the succeeding
conceptual frameworks and theories in the field of nursing.
Nightingale is considered the first nursing theorist. One of her
theories was the Environmental Theory, which incorporated the
restoration of the usual health status of the nurses clients into the
delivery of health care- it is still practiced today.
Environmental Theory
Meaning
The environmental theory by Florence Nightingale defined
Nursing as the act of utilizing the environment of the patient to assist
him in his recovery. It involves the nurses initiative to configure
environmental settings appropriate for the gradual restoration of the
patients health, and that external factors associated with the patients
surroundings affect life or biologic and physiologic processes, and his
development.
Major Concepts
Nursing
What nursing has to do is to put the patient in the best
condition for nature to act upon him. (Nightingale, 1859/1992)
Nightingale stated that nursing ought to signify the proper use
of fresh air, light, warmth, cleanliness, quiet, and the proper selection
and administration of diet- all at the least expense of vital power to the
patient.
Human Beings
Human beings are not defined by Nightingale specifically. They
are defined in relationship to their environment and the impact of the
environment upon them.

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Environment
The physical environment is stressed by Nightingale in her
writing. Nightingales writings reflect a community health model in
which all that human beings is considered in relation to their state of
health.
Health
Nightingale did not define health specifically. She stated we
know nothing of health, the positive of which pathology is the negative,
except from observation and experience. Given her definition that of
the art of nursing is to unmake what God had made disease, then the
goal of all nursing activities should be client health.
She believed that nursing should provide care to the healthy as
well as the ill and discussed health promotion as an activity in which
nurses should engage.
Sub concepts
Health of Houses
Badly constructed houses do for the healthy what badly
hospitals do for the sick. One insures that the air is stagnant and
sickness is certain to follow.
Ventilation and Warming
Keep the air he breathes as pure as the external air, without
chilling him.
Nightingale believed that the person who repeatedly breathed
his or his own air would become sick or remain sick. She was very
concerned about noxious air or effluvia and foul odors that came
from excrement. She also criticized fumigations, for she believed that
the offensive source, not the smell must be removed.
The importance of room temperature was also stressed by
Nightingale. The patient should not be too warm or too cold the
temperature could be controlled by appropriate balance between
burning fires and ventilation from windows.
Light
Nightingale believed that second to fresh air, the sick needed the
light. She noted that direct sunlight was what patients wanted

ADVANCED THEORETICAL FOUNDATIONS IN NURSINGPage 3

Noise
She stated that patients should never be waked intentionally or
accidentally during the first part of the sleep. She asserted that
whispered or long conversations about patients are thoughtless and
cruel. She viewed unnecessary noise, including noise from female
dress, as cruel and irritating to the patient.
Variety
She discussed the need for changes in color and for, including
bringing the patient brightly colored flowers or plants. She also
advocated rotating 10 or 12 paintings and engravings each day, week,
or month to provide variety for the patient. Nightingale also advocated
reading, needlework, writing, and cleaning as activities to relive the
sick of boredom.
Bed and Bedding
Nightingale noted that an adult in health exhales about three
pints of moisture through the lungs and skin in a 24- hour period. This
organic matter enters the sheets and stays there unless the bedding is
changed and aired frequently.
She believed that the bed should be placed in the lightest part of
the room and placed so the patient could see out of the window. She
also reminded the caregiver never to lean against, sit upon, or
unnecessarily shake the bed of the patient.
Personal Cleanliness
Just as it is necessary to renew the air round a sick person
frequently to carry off morbid effluvia from the lungs and the skin, by
maintaining free ventilation, so it is necessary to keep pores of the skin
free from obstructing excretions.
Every nurse ought to wash her hands very frequently during the
day.
Nutrition and Taking Food
Nightingale noted that individuals desire different foods at
different times of the day and that frequent small servings may be
more beneficial than a large breakfast or dinner. She urged that no
business be done with patient while they are eating because this was
distraction.
Chattering Hopes and Advices

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Nightingale wrote that to falsely cheer the sick by making light of


their illness and its danger is not helpful. She encouraged the nurse to
heed what is being said by visitors, believing that sick persons should
hear good news that would assist them in becoming healthier.
Social Considerations
Nightingale supported the importance of looking beyond the
individual to the social environment in which he or she lived.
Environmental Factors
She identified five (5) environmental factors: fresh air, pure
water, efficient drainage, cleanliness or sanitation and light or direct
sunlight.
1. Pure fresh air- to keep the air he breathes as pure as the
external air without chilling him.
2. Pure water- well water of a very impure kind is used for
domestic purposes. And when epidemic disease shows itself,
persons using such water are almost sure to suffer.
3. Effective drainage- all the while the sewer maybe nothing
but a laboratory from which epidemic disease and ill health is
being installed into the house.
4. Cleanliness- the greater part of nursing consists in preserving
cleanliness.
5. Light (especially direct sunlight)- the usefulness of light in
treating disease is very important.
Any deficiency in one or more of these factors could lead to
impaired functioning of life processes or diminished health
status
Provision of Care by Environment
The factors posed great significance during Nightingales time,
when health institutions had poor sanitation, and health workers had
little education and training and were frequently incompetent and
unreliable in attending to the needs of the patients.
Nightingales theory was shown to be applicable during the
Crimean war when she, along with other nurses she had trained, took
care of injured soldiers by attending to their immediate needs, when
communicable diseases and rapid spread of infections were rampant in
this early period in the development of disease- capable medicines.
Assumptions of Nightingales Theory

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Natural laws
Mankind can achieve perfection
Nursing is a calling
Nursing is an art and science
Nursing is achieved though environmental alteration
Nursing requires a specific educational base
Nursing is distinct and separate from medicine

Origin
Theoretical Sources of the Environmental Theory
Education
Nightingale is a very good mathematician (a nurse statistician)
and a philosopher
Literature
Dickens novel The Adventures of Martin Chuzzlewit, a novel
portrays a Victorian drunken, untrained and inexpert nurse causes a
stigma and bad impressions about nurses. The novel greatly affects
her beliefs about being a nurse and pursues the battle to change the
negative stigma about nurses.
Intellectuals
Political leaders greatly affected and influenced her beliefs of
changing things as she viewed as unacceptable to society.
Religious Beliefs
For Nightingale, an action for the benefit of others is called
Gods Calling.
Use of Empirical Evidence
She uses the polar diagram in her reports, books, and letters.
She highlighted the use of observation and the performance of
tasks in the nursing education.
Usefulness

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Importance of Environmental Theory


Practice
1. Disease control
2. Sanitation and water treatment
3. Utilized modern architecture in the prevention of sick
building syndrome applying the principles of ventilation and
good lighting
4. Waste disposal
5. Control of room temperature
6. Noise management
Education
1. Principles of nursing training. Better practice result from
better education
2. Skills measurement through licensing by the use of testing
methods, the case studies
Testability
Nightingale wrote articles and books on hospitals, nursing and
community health in the 19th and in the 20th century. Per Small
(1998), Nightingale's work served as the basis for nursing education for
over a long time (cited in McEwen and Wills, 2011, p. 125).
Concepts that Nightingale identified have served as the basis
for current research, which adds to modern nursing science and
practice. Most notable is her focus on the surroundings and its
importance to nursing." (Alligood and Tomey, ed.7,p .81).
Nightingale's environmental theory was applied and tested
several times. Few of the case studies related to this theory are as
follows:
1. Environmental Theory Applied to the Home Environment of
children exposed to HIV at birth: A Descriptive Research
Crisitna Vieira, I ., &Gimeniz (2011) did a descriptive study on
few children exposed to HIV at birth to analyse their vulnerability to
diseases due to unhealthy living conditions.The researchers observed
that factors like unhygienic practices, lack of pure drinking water,
sanitation and unhealthy housing conditions were placing these
children at a higher risk in getting infected with respiratory,
gastrointestinal and other opportunistic diseases . This study proved
once again that the five elements of environment - pure air, water,
sanitation, diet and cleanliness really have a great impact on the

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health of an individual. This reality indicated the significant need for a


holistic approach by nurses towards their patients and their families
keeping in consideration the social and environmental context from
where they come.
2. Nightingales theory and intentional comfort touch
management of tineapedis in vulnerable populations."

in

Howett, Maeve ; Connor, Ann ; Downes, Elizabeth , did a study on


farm workers who were basically homeless and had a very low
socioeconomic status for an increased risk for foot infections. Frequent
exposure to wet environment, limited access to health care , lack of
clean and dry socks and "daily routines that requires them to be on
their feet for long periods of time" made these subjects prone to
severe fungal infection on their feet. Thus, this study revealed the
importance of Nightingale's environmental major concepts (sunlight,
fresh air and cleanliness) on health.
Overall Evaluation
Nightingales theory is simple. The beauty of her model is its
generalizability including its continued applicability today.
Strengths
This theory seems to have more relevance to practitioners today
than ever before
Her theory relies on observation and data collection, which has
transformed into evidence-based practice
Environmental Theory gives nurses an active role while also
encouraging patients to take a key role in their health with the
need for self-healing.
Weaknesses
She focused more on physical factors than on psychological
needs of the patient

The theory's emphasis on environmental measures -- clean air


and water, drainage, light and warmth -- may be effective to an
extent but is inherently limited. Healthy environmental
conditions can only go so far in treating disease and illness. It
says little about the application of medical technology, which
was rudimentary but nonetheless existent in Nightingale's time.

Conclusion

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The Environmental Theory of Nursing is a patient- care theory. It


focuses in the alteration of the patients environment in order to affect
change in his or her health. Caring of the patient is of more importance
rather than the nursing process, the relationship between patient and
nurse, or the individual nurse.
In this way, the model must be adapted to fit the needs of
individual patients, the environmental factors affect different patients
unique to their situations and illnesses, and the nurse must address
these factors on a case-by-case basis in order to make sure the factors
are altered in a way that best cares for an individual patient and his or
her needs.

HILDEGARD E. PEPLAU
INTERPERSONAL RELATIONS THEORY
Meaning
According to Peplau (1952/1988), nursing is therapeutic because
it is a healing art, assisting an individual who is sick or in need of
health care. Nursing can be viewed as an interpersonal process
because it involves interaction between two or more individuals with a
common goal.
In nursing, this common goal provides the incentive for the
therapeutic process in which the nurse and patient respect each other
as individuals, both of them learning and growing as a result of the
interaction. An individual learns when she or he selects stimuli in the
environment and then reacts to these stimuli.
Assumptions
The kind of nurse each person becomes makes a
substantial difference in what each client will learn as she or
he is nursed throughout his or her experience with illness.
Fostering personality development in the direction of maturity is
a function of nursing and educations; it requires the use of principles

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and methods that permit and guide the process of grappling with
everyday interpersonal problems or difficulties.
Nurse and patient can interact.
Peplau stresses that both the patient and nurse mature as the
result of the therapeutic interaction.
Communication
and
interviewing
skills
remain
fundamental nursing tools.
Peplau believed that nurses must clearly understand themselves
to promote their clients growth and to avoid limiting clients choices to
those that nurses value.
Major concepts
Peplau (1952/1988) defines man as an organism that strives in
its own way to reduce tension generated by needs. The client is an
individual with a felt need.
Health is defined as 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.
Although Peplau does not directly address society/environment,
she does encourage the nurse to consider the patients culture and
mores when the patient adjusts to hospital routine.
Hildegard Peplau considers nursing to be
therapeutic, interpersonal process. She define it
relationship between an individual who is sick, or in
services, and a nurse specially educated to recognize
to the need for help.

a significant,
as a human
need of health
and to respond

The theory explains the purpose of nursing is to help others


identify their self-difficulties. Nurses should apply principles of human
relations to the problems that arise at all levels of experience. Nursing
is an interpersonal process because it involves interaction between two
or more individuals with a common goal.
Therapeutic Nurse-client relationship
A professional and planned relationship between client and nurse
that focuses on the clients needs, feelings, problems, and ideas.
Four phases of the therapeutic nurse-patient relationship:

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Orientation phase is directed by the nurse and involves


engaging the client in treatment, providing explanations and
information, and answering questions.
Identification phase begins when the client works
interdependently with the nurse, expresses feelings, and begins to feel
stronger.
Exploitation phase, the client makes full use of the services
offered.
Resolution phase, the client no longer needs professional
services and gives up dependent behavior. The relationship ends.
Sub-concepts
Roles of the nurse in therapeutic relationship
Stranger: offering the client the same acceptance and courtesy
that the nurse would to any stranger.
Resource person: providing specific answers to questions
within a larger context.
Teacher: helping the client to learn formally or informally
Leader: offering direction to the client or group
Surrogate: servicing as a substitute for another such as a
parent or a sibling.
Counselor: promoting experiences leading to health for the
client such as expression of feelings.
Technical expert:
explaining clinical skills.

the nurse provides physical care by

Peplau also believed that the nurse could take on many other
roles,
including
consultant,
tutor,
safety
agent,
mediator,
administrator, observer, and researcher. These were not defined in
detail but were left to the intelligence and imagination of the
readers, (Peplau, 1952).
Origin of the Theory

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The autonomous, nursing controlled Nightingale era schools


came to an end- schools controlled by hospitals now and formal book
learning was discouraged.
Hospitals and physicians saw women in nursing as a source of
free or inexpensive labor.
Exploitation was not uncommon or nurses employers, physicians
and educational providers.
Nursing practice was controlled by medicine.
Foundation of Peplaus framework
Hilda witnessed injustices in life, being determined to push past
them for social justice
First exposure to Interpersonal Theory at Bennington:
Attended lectures by Harold Sullivan on Interpersonal Relations
Studied with Frieda Fromm-Reichman and Eric Fromm
She had a vision to bring the Sullivan theory to interactions with
her patients- they need:

Humane treatment
Dignity and respect
Healing discussion

Teachers College: Director of Advanced Program in Psychiatric


Nursing

She created nursing curriculum


She included study of nurse-patient interactions through Process
Recordings

Peplauanalyzed interactions of students with patients, taking her


own experience into account, (Forchuk, 1993; Gastmans, 1998).
Her book, or conceptual framework, was completed by 1948,
entitled Interpesonal Relations in Nursing. (Forchuk, 1993).
Her theory was derived from theorists: Maslow, Sullivan, Miller,
Symonds and reflected psychoanalytic theory as well as different
facets of personality development (Comlev, 1994).
As a young teenager, she made the decision to do what very few
women did in her day: she decided to pursue an education and a

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career. She made this decision out of a passion to be her own mistress,
to determine her own future, to live her life differently than anyone
around her. Within her lifetime, she earned not only the celebrity of
being recognized by the American Academy of Nursing as a Living
Legend but also the unofficial designation, bestowed by the College of
Nursing of the University of California at Los Angeles, as Psychiatric
Nurse of the Century.
Peplau was an imaginative innovator who left an indelible stamp
on the theory and practice of psychiatric nursing. Known as The
Mother of Psychiatric Nursing, she devoted herself to the redefinition,
clarification, and expansion of nursing services for psychiatric patients
and left an enduring mark on graduate education for clinical
specialization in nursing. Although her contributions continue to
stimulate debate and discussion, there is no doubt that Hildegard
Peplau almost single-handedly led psychiatric nurses from the
confinement of providing custodial care in public mental hospitals to
theory-driven professional practice.
Her work always involved great risks, both personal and professional. It
took a woman of uncommon courage and resilience to continually push
forward the boundaries in nursing education, to test radically new
approaches in nursing theory and practice, and in the process to
challenge and ultimately revolutionize entrenched practices in
psychiatric care.
American nursing was greatly influenced by the ideas of Florence
Nightingale and the theories of sanitary nursing and care of the injured
she introduced to the world during the mid-19 th century Crimean War.
Nightingales work and the principles she introduced in the nursing
school she founded became a model for American nursing education in
the late 19th and early 20th centuries.
The whole notion of the trained nurse, with her stress on sanitary
methods, as well as orderly and efficient administration of the hospital
wards, originated with Florence Nightingale. Her ideas and example led
nurse-training schools to stress the connection of good health to good
care and a clean environment. Nightingale saw the world in terms of
polarities: purity as opposed to filth, orders versus disorder, health
versus disease. In her own training, the focus on cleanliness was
something Hilda Peplau could relate to.
Usefulness
Peplau conceptualized clear sets of nurses roles that can be
used by each and every nurse with their practice. It implies that a

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nurses duty is not just to care but the profession encompasses every
activity that may affect the care of the patient.
The idea of a nurse-client interaction is limited with those
individuals incapable of conversing, specifically those who are
unconscious.
The concepts are highly applicable with the care of psychiatric
patients considering Peplaus background. But it is not limited in those
set of individuals. It can be applied to any person capable and has the
will to communicate.
Nurse gains competencies of higher understanding of self,
concepts, roles and processes to help patient toward growth and
healing.
Peplau warns: danger of social talk with patients. Nurse
shouldnt speak the same way to patient as to family or friends. It
should lead to therapeutic effects-promoting long-term well-being.
Nurses own emotional needs should not get in the way of
tending to the needs of the patient.
Interpersonal relations theory assists the nurse to:
Observe more intelligently

Intervene more sensitively

Testability
Research based on Peplaus theory
Hays D. (1961) phases and steps of experimental teaching to
patients of a concept of anxiety: findings revealed that when taught by
the experimental method, the patients were able to apply the concept
of anxiety after the group was terminated.
Burd S.F. develop and test a nursing intervention framework for
working with anxious patients: students developed competency in
beginning interpersonal relationship.
Power to gain knowledge (Bradbury-Jones, 2012). Studied
nursing students 2007-2009 which gives an effect of interpersonal
relationships on education. Students felt empowered and increase their
clinical ability which also increase the ability to empower patients.

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Overall Evaluation
Strengths:
The phases provide simplicity regarding the natural
progression of the nurse-patient relationship.
The simplicity leads to adaptability in any nurse-patient
interaction, thus providing generalizability.
Promotes interactive care
Harmonious relationships enhances healing
Weaknesses:
Health promotion and maintenance were less emphasized
The theory cannot be used in a patient who doesnt have a
felt need such as with withdrawn patients.
Cannot use with non-participative patient: unable to
participate and unwilling to participate
Application of Interpersonal theory in nursing practice
Urology nursing used the theory to educate newly diagnosed
bladder cancer patients with the need for a urinary diversion, and
ensure understanding.
Outcome shows that the scope of a patients needs requires a
competent nurse to assume the changing roles in the four phases of
the theory, expressing the importance of involving the patient in
establishing goals and reviewing the goals frequently.
British Journal of Nursing had an article researching the
credibility of Peplaus theory, in mental health care, due to the
expansion of nursing knowledge and the dynamics of a
multidisciplinary team currently used in todays practice.
Public Health Nursing did a study, in homecare visits, (testing the
use of Peplaus theory) to work with the multi problem families, to
identify interventions, individualized for the members, to see if
relationship progression was increased within the family system
resulting in optimized care of the patient.
Application of theory in MY nursing practice.
The theory will be useful with our newly diagnosed cancer
patients and their family. Resistance is met when trying to educate
them about the treatment, encouraging enrolment in studies, and
education about how to care for the patient in their home setting.

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Orientation- patient gets admitted to the unit, nurse helps the


patient to recognize and understand that they have cancer and the
importance of treatment.
Identification- patient takes the time to internalize the diagnosis,
the nurse participated in helping the patient to do so.
Exploitation the nurse works to have the patient explore what
help is needed to meet goals. Incorporating other disciplines to
problem solve (oncologist, therapists, alternative medicine, etc.)
Patient test the limits of the nurses availability, and the nurse
encourages patient to evaluate ways to meet their final goals.
Resolution when in-patient treatment is complete, the nurse has
to evaluate feelings and remove themselves from the bond that is
made, allowing the patient and family to move on and regain balance
in their own lives.
Conclusion
Peplaus theory has proved of great use to later nurse theorist
and clinicians in developing more sophisticated and therapeutic
nursing interventions which show the dynamic character roles typical
in clinical nursing. It entails that a nurses duty is not just a care but
the profession also incorporates every activity that may affect the
clients health.
However, the idea of a nurse-client cooperation is found narrow
with those individuals who are unfit and powerless in conversing
specifically those who are unconscious and paralyze.
Studying Peplaus interpersonal relations theory of nursing can
very substantial especially to those who are aspiring to be a part of the
profession. Having the knowledge of the seven roles of nursing, future
nurses can apply different roles in different situations which will
guarantee of patients to acquire the best care possible and will
ultimately speed along treatment and recovery.

VIRGINIA HENDERSON
14 BASIC HUMAN NEEDS
Meaning
The nurse is temporarily the consciousness of the unconscious,
the love of life for the suicidal, the leg of the amputee, the eyes of the

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newly blind, a means of locomotion for the infant, knowledge and


confidence for the mother, the mouthpiece for those too weak or
withdrawn to speak and so on.
Henderson's theory stresses the priority of patient selfdetermination so the patient will continue doing well after being
released from the hospital. Henderson characterized the nurse's role as
substitutive, which the nurse does for the patient; supplementary,
which is helping the patient; or complementary, which is engaging with
the patient to do something. The role of the nurse helps the patient
become an individual again. She arranged nursing tasks into 14
different components based on personal needs. Not only are nurses
responsible for the patient, but also to help the patient be themselves
when they leave their care. This assures that the patient has fewer
obstacles during recovery from being sick or injured, and helping
getting back into self-care is easier when a nurse is there to motivate
until the patient goes home.
Assumptions
1. Nurses care for patients until they can care for themselves
once again.
2. Patients desire to return to health
3. Nurses are willing to serve and that nurses will devote
themselves to the patient day and night.
4. The mind and body are inseparable and are interrelated
Main Concepts
Person
Henderson referred to a person as a patient. She stated that the
person is an individual who requires assistance to achieve health and
independence or in some cases, a peaceful death. She introduced the
concept of the mind and body of a person as inseparable. For a person
to function optimally, he must be able to maintain psychological and
emotional balance.
Health
Henderson viewed health as a quality of life and is very basic for
person to function fully. As a vital need, health requires independence
and interdependence which are influenced by internal and external
factors. She gave emphasis in prioritizing health promotion as more
important than care of the sick.
Environment

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It is important for a healthy individual to control the


environment, but as illness occurs, this ability is diminished or
affected. In caring for the sick, it is the responsibility of the nurse to
help manage his surroundings to protect him from harm or any
mechanical injury. Thus, the nurse must be educated about safety and
must be aware of the different social customs and religious practices to
assess dangers.
Nursing
Henderson asserted that nurses function independently from the
physician, but they must promote the treatment plan prescribed by the
physician. Although part of the health care team, the nurse must act
independently but in coordination with the therapeutic plan developed
by the team. A nurse helps both sick and well individuals. The care
given by the nurse must empower the patient to gain independence as
rapidly as possible. As a health care provider, the nurse must be
knowledgeable in both biological and social sciences and must have
the ability to assess basic human needs. Hendersons definition of
nursing was considered as the signature of the profession.
She conceptualized the 14 Fundamental Needs of Humans. These
needs are:
1.
2.
3.
4.
5.
6.
7.

Breathing normally
Eating and drinking adequately
Eliminating body wastes
Moving and maintaining a desirable position
Sleeping and resting
Selecting suitable clothes
Maintaining normal body temperature by adjusting clothing and
modifying the environment
8. Keeping the body clean and well groomed to promote
integument (skin)
9. Avoiding dangers in the environment and avoiding injuring others
10.
Communicating with others in expressing emotions, needs,
fears, or opinions
11.
Worshipping according to ones faith
12.
Working in such a way that one feels a sense of
accomplishment
13.
Playing or participating in various forms of recreation
14.
Learning, discovering or satisfying the curiosity that leads
to normal development and health, and using available health
facilities

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Henderson also emphasized the need to view the patient and his
family as a single unit. For the patient to achieve health, he must be
able to meet his need for support system (emotional needs) which in
many cases provided by the family.
Henderson postulated that nurse functions in relation with
patient, physician and other members of the health team and each
type of relationship gives nurses specific responsibilities and roles.
The Nurse-Patient Relationship
Henderson stated that there are three levels comprising the
nurse-patient relationship:
The nurse as a substitute for the patient. In times of illness, when
the patient cannot function fully, the nurse serves as the substitute as
to what the patient lacks, such as knowledge, will and strength in order
to make him complete, whole and independent once again.
The nurse as a helper to the patient. In situations where the
patient cannot meet his basic needs, the nurse serves as a helper to
accomplish them. Since these needs are needed to achieve health, the
nurse focuses her attention in assisting the patient meet these needs
so as to regain independence as quickly as possible.
The nurse as a partner with the patient. As partners, the nurse
and the patient formulate the care plan together. Both as an advocate
and as a resource-person, the nurse can empower the patient to make
effective decisions regarding his care plans. As the relationship goes
on, the patient and the nurse see each other as partners whose
interest are the same having the patient achieve health and
independence.
The Nurse-Physician Relationship
Henderson asserted that nurses functions independently from
physicians. Though the nurse and the patient, as partners, formulate
the plan of care, it must be implemented in such a way that will
promote the physicians prescribed therapeutic plan. She also insisted
that nurses do not follow doctors orders; rather they follow in a
philosophy which allows physicians to give orders to patients or other
healthcare team members. Henderson also indicated that many
nursing roles and responsibilities overlap with that those of the
physicians.
The nurse as a Member of the Healthcare Team

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For a team to work together in harmony, every member must


work interdependently. The nurse, as a member of the healthcare
team, works and contributes in carrying out the total program of care.
However, working interdependently, as Henderson indicated, does not
include taking other members roles and responsibilities.
Origins of the Theory
Virginia Henderson has been called the First Lady of Nursing
and the First Truly International Nurse. Her writing, presentations,
research and contacts with nurses have profoundly affected nursing
and gave an impression on the recipients of care by nurses throughout
the world. She began her career in public health nursing in the Henry
Street Settlement and in the visiting nurse service in Washington, D.C.
She was the first full-time instructor in nursing in Virginia when she
was at Norfolk Protestant Hospital. While in the state, she was active in
the Graduate Nurses Association of Virginia. She designed a plan to
create district organizations within the state.
Virginia Henderson was an early advocate for the introduction of
psychiatric nursing in the curriculum and served on a committee to
develop such a course at Eastern State Hospital in Williamsburg,
Virginia in 1929.
During her years at Teachers College, Columbia University,
Henderson was an outstanding teacher and students came from many
countries to study with her. Nurses through the United States studied
with her without ever leaving their home schools when her revision of
Bertha Harmers Textbook of the Principles and Practice of Nursing
became widely used. Other important publications grew out of
Hendersons years at Yale University including Nursing Research: A
Survey and Assessment. She also directed a twelve-year project
entitled Nursing Studies Index, four volumes recognized as an essential
reference for many years. In Hendersons book, Nature of Nursing, she
expressed her belief about the essence of nursing and influenced the
hearts and minds of those who read it.
At the age of 75, Henderson directed her career to international
teaching and speaking. This enabled another generation to harvest the
benefits of contact with this outstanding nurse of the twentieth
century.
The honors bestowed on Henderson are numerous. To mention
just a few, she held honorary degrees from thirteen universities; she
was selected to the American Nurses Association Hall of Fame and had

ADVANCED THEORETICAL FOUNDATIONS IN NURSINGPage 20

the Sigma Theta Tau International Library named in her honor. She was
honoured by the Virginia Nurses Association in 1988 when the Virginia
Historical Nurse Leadership Award was presented to her. In 2000, the
Virginia Nurses Association recognized Henderson as one of the fiftyone Pioneer Nurses in Virginia.
Halloran, a nurse theorist, wrote, Henderson was to the
twentieth century as Nightingale was to the nineteenth. Both wrote
extensive works that have influenced the world.
Usefulness
Hendersons approach focuses on decision-making and is
deliberate in such a way that in every step of the Nursing Process, it
plays very important roles. Even though Henderson believed that
Nursing Process is a problem-solving process that could be used to
answer the patients needs, the steps involved are not that strange to
nursing alone.
Assessment Phase
The nurse would assess the 14 fundamental needs of the
patients and check which one is lacking or fully met. She gathers data
by observing, smelling, feeling and hearing. To complete this phase,
the nurse uses critical thinking and analysed every data collected to
come up with a clear picture of the condition of the patient.
Diagnosis Phase
The nurse identifies the patients ability to meet own needs with
or without assistance, taking into consideration strength, will or
knowledge
Planning Phase
This involves giving the plan of care to meet the needs and
personality of the patient. It must serve as a record and at the same
time must fit in the prescribed plan made by the physician. To make
the plan same with the goals of the healthcare team, the roles and
responsibilities of each professional member must be included and
integrated to the care plan.
Implementation Phase
The nurse uses the 14 basic needs in answering the factors that
are contributing to the illness state of the client. These interventions
are focused on maintaining health, to recover from illness, or to aid in
peaceful death. She performs these activities that are directed in
helping the patient attain his independence as fast as possible.

ADVANCED THEORETICAL FOUNDATIONS IN NURSINGPage 21

Evaluation Phase
The nurse and the patient reviews the relationship and decides
whether the goals are met or not. The nurse also assess if the patient
attained independence and if health is achieved.
Testability
Henderson supported nursing research, but believed that it
should be clinical research (OMalley, 1996). Much of the research
before her time had been on educational processes and on the
profession of nursing itself, rather than on; the practice and outcomes
of nursing , and she worked to change that.
Each of the 14 activities can be the basis for research. Although
the statements are not.
Written in testable terms, they may be reformulated into
researchable questions. Further, the theory can guide research in any
aspect of the individuals care needs.
Certain studies conducted using Hendersons theory are as
follows:

Nursing-Care Dependency: Development of an Assessment


Scale for Demented and Mentally Handicapped Patients by
Ate Dijkstra RN, MSc, GirbeBuist andTheo Dassen
Measurement of Health-Related Quality of Life in Chronic
Heart Failure, from a Nursing Perspectivea Review of the
Literature by Peter Johansson, MattiasAgnebrink, Ulf
Dahlstrm and Anders Brostrm
Violence content in nursing curricula: strategic issues and
implementation by Lee Ann Hoff RN PhD and Margaret Ross
RN PhD
Care dependency: testing the German version of the care
dependency scale in nursing homes and on geriatric wards
by Christa Lohrmann RN MA PhD, Ate Dijkstra RN MEd PhD
andTheo Dassen RN Dr Professor FEANS

Overall Evaluation
Henderson used the concepts of fundamental humanneeds, bio
physiology, culture and interactioncommunication,which give the
theory a dynamiccoverage regarding patients need. (Geroge, 2011).

ADVANCED THEORETICAL FOUNDATIONS IN NURSINGPage 22

Her division of the fourteen component well address patientneed in


different domains yet simple to apply inclinical setting. Moreover it is
more concise ascompare to other models like unitary human beings
byMartha Rogers which is difficult to address and lacksapplicability into
practice (Mackenna, 2005). It is applicable to different dimensions of
client- nurserelationship. It can effectively address patient need and
elaborate nurses role. Its design successfully wrap thecomponents of
nursing process. Hendersons needtheory is relevant to Maslows
hierarchy of human needs (George,2011).In general this theory is
wellsuited and adoptable for nursing care and practice invarious
clinical settings.
Strengths
The concept of nursing formulated by Henderson in her
definition of nursing and the 14 components of basic
nursing is uncomplicated and self-explanatory. Therefore, it
can be used without difficulty as a guide for nursing
practice by most nurses.
Hendersons concept of nursing is widely accepted in
nursing practice today.
Hendersons work is relatively simple yet generalizable
with some limitations.
Her work can be applied to the health of individuals of all
ages
Each of the 14 needs can be the basis for research
Weaknesses
A major shortcoming is the lack of a conceptual linkage
between physiological and other human characteristics
No concept of the holistic nature of human being
Lacks inter-relatedness of factors and the influence of
nursing care
Assisting the individual in the dying process she contends
that the nurse helps, but there is little explanation of what
the nurse does

ADVANCED THEORETICAL FOUNDATIONS IN NURSINGPage 23

JOYCE TRAVELBEE
HUMAN TO HUMAN RELATIONSHIP MODEL
A nurse does not only seek to alleviate physical pain or render
physical care she ministers to the whole person. The existence of the
suffering whether physical, mental or spiritual is the proper concern of
the nurse. Joyce Travelbee
Meaning
A means through which the purpose of nursing is fulfilled
Travelbee believed nursing is accomplished through
human-to-human relationships that begin with the original
encounter and then progress through stages of emerging
identities, developing feelings of empathy, and later
feelings of sympathy.
The nurse and patient attain a rapport in the final stage.
For meeting the goals of nursing it is a prerequisite to
achieving genuine human-to-human relationships which
can only be achieved by interaction process.
Five phases:
a. The inaugural meeting or original encounter
b. Visibility of personal identities/emerging identities
c. Empathy
d. Sympathy
e. Establishing mutual understanding and
contact/rapport
Origins of the Theory
Travelbee based the assumptions of her theory on the
concepts of existentialism by Soren Kierkegaard and logo
therapy by Viktor Frankl.

ADVANCED THEORETICAL FOUNDATIONS IN NURSINGPage 24

Existential theory believes that humans are constantly


faced choices and conflicts and is accountable to the
choices we make in life.
Logotherapyis meaning-centered psychotherapy based on
the assumption that meaning fulfilment in life is the best
protection against emotional instability.
Catholic charity institutions
Ida jean Orlando, her instructor The nurse is responsible
for helping the patient avoid and alleviate the distress of
unmet needs. The nurse and patient interrelate with each
other.
Usefulness
Travelbees theory has greatly influenced nursing and
healthcare
Travelbees ideas have greatly influenced the hospice
movement in the west
Practice: Hospice self-actualizing experience. Assumption
of the sick role. Meaning of life and sickness and death.
Education: teaches nurses to understand the meaning of
illness and suffering
Research: applied in the theory of caring cancer patients
According to Travelbees model, courses in philosophy and
religion would also be helpful in preparing nursing students
to fulfil the purpose of nursing sufficiently
Testability
Numerous researches in research studies have cited some
aspects of the one-to-one relationship projected by
Travelbee. One study by OConnor, Wicker and Germino,
which is nearly related to some of Travelbees ideas
discover how individuals who were recently diagnosed with
cancer described their personal search for meaning. The
results of this study make known that the search for
meaning seems to be both a spiritual and psychosocial
process. The researchers acknowledged nursing
interventions that would support this process. No other
theory of Travelbee would create further development is
available.

ADVANCED THEORETICAL FOUNDATIONS IN NURSINGPage 25

Overall Evaluation
Travelbees theory is indeed a very great contribution not
only to those who are in Psychiatric Nursing field but in the
whole nursing practice. Not only should we be able to
assist them towards wellness but also to be able to find
meaning in the situation or experiences they had been
through whether it may be good or bad. Her theory does
not only focus on the patient but as well as with the nurse
practitioner, both having a unique personality.
Her theory is interesting that it focuses more than just the
patients physical condition. It focuses on compassion and
building rapport with the patient which is extremely
important.
The ideas of her theory are applicable to a hospital, nursing
home or hospice setting. Rapport being the last stage is
very important overall. The idea of her theory is fully
functional when rapport is involved.
Her theory shows promise in providing improved patient
care in the future. It transcends the idea of the physical
and helps focus on the mental, emotional and spiritual
aspects of the patient. It will provide the unique
personalized care needed for today and the future.

ADVANCED THEORETICAL FOUNDATIONS IN NURSINGPage 26

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