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•• Fourth Edition

Nursing Theories
and Nursing Practice
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Nursing Theories & Nursing Practice


Fourth Edition
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Nursing Theories & Nursing Practice


Fourth Edition
Marlaine C. Smith, PhD, RN, AHN-BC, FAAN

Marilyn E. Parker, PhD, RN, FAAN


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Nursing theories and nursing practice.


Nursing theories & nursing practice / [edited by] Marlaine C. Smith, Marilyn E. Parker. — Fourth edition.
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Preface to the Fourth Edition

This book offers the perspective that nursing is theory and Paterson & Zderad’s humanistic
a professional discipline with a body of knowl- nursing have been moved to supplementary on-
edge that guides its practice. Nursing theories line resources at http://davisplus.fadavis.com.
are an important part of this body of knowl- This book is intended to help nursing stu-
edge, and regardless of complexity or abstrac- dents in undergraduate, masters, and doctoral
tion, they reflect phenomena central to the nursing programs explore and appreciate nurs-
discipline, and should be used by nurses to ing theories and their use in nursing practice
frame their thinking, action, and being in the and scholarship. In addition, and in response
world. As guides, nursing theories are practical to calls from practicing nurses, this book is in-
in nature and facilitate communication with tended for use by those who desire to enrich
those we serve as well as with colleagues, stu- their practice by the study of nursing theories
dents, and others practicing in health-related and related illustrations of nursing practice.
services. We hope this book illuminates for the The contributing authors describe theory de-
readers the interrelationship between nursing velopment processes and perspectives on the
theories and nursing practice, and that this un- theories, giving us a variety of views for the
derstanding will transform practice to improve twenty-first century and beyond. Each chapter
the health and quality of life of people who are of the book includes descriptions of a theory,
recipients of nursing care. its applications in both research and practice,
This very special book is intended to honor and an example that reflects how the theory
the work of nursing theorists and nurses who can guide practice. We anticipate that this
use these theories in their day-to-day practice. overview of the theory and its applications will
Our foremost nursing theorists have written lead to deeper exploration of the theory, lead-
for this book, or their theories have been de- ing students to consult published works by the
scribed by nurses who have comprehensive theorists and those working closely with the
knowledge of the theorists’ ideas and who have theory in practice or research.
a deep respect for the theorists as people, There are six sections in the book. The first
nurses, and scholars. To the extent possible, provides an overview of nursing theory and a
contributing authors have been selected by focus for thinking about evaluating and choos-
theorists to write about their work. Three ing a nursing theory for use in practice. For
middle-range theories have been added to this this edition, the evolution of nursing theory
edition of the book, bringing the total number was added to Chapter 1. Section II introduces
of middle-range theories to twelve. Obviously, the work of early nursing scholars whose ideas
it was not possible to include all existing provided a foundation for more formal theory
middle-range theories in this volume; how- development. The nursing conceptual models
ever, the expansion of this section illustrates and grand theories are clustered into three
the recent growth in middle-range theory de- parts in Sections III, IV, and V. Section III
velopment in nursing. Two chapters from the contains those theories classified within the
third edition, including Levine’s conservation interactive-integrative paradigm, and those in

v
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vi Preface to the Fourth Edition

the unitary-transformative paradigm are in- editors we’ve found that continuing to learn
cluded in Section IV. Grand theories that are about and share what we love nurtures our
focused on the phenomena of care or caring growth as scholars, reignites our passion and
appear in Section V. The final section contains commitment, and offers both fun and frustra-
a selection of middle-range theories. tion along the way. We continue to be grateful
An outline at the beginning of each chapter for the enthusiasm for this book shared by
provides a map for the contents. Major points many nursing theorists and contributing
are highlighted in each chapter. Since this authors and by scholars in practice and
book focuses on the relationship of nursing research who bring theories to life. For us, it
theory to nursing practice, we invited the has been a joy to renew friendships with col-
authors to share a practice exemplar. You will leagues who have contributed to past editions
notice that some practice exemplars were writ- and to find new friends and colleagues whose
ten by someone other than the chapter author. theories enriched this edition.
In this edition the authors also provided Nursing Theories and Nursing Practice, now
content about research based on the theory. in the fourth edition, has roots in a series of
Because of page limitations you can find nursing theory conferences held in South
additional chapter content online at http:// Florida, beginning in 1989 and ending when
davisplus.fadavis.com. While every attempt efforts to cope with the aftermath of Hurricane
was made to follow a standard format for each Andrew interrupted the energy and resources
of the chapters throughout the book, some of needed for planning and offering the Fifth
the chapters vary from this format; for exam- South Florida Nursing Theory Conference.
ple, some authors chose not to include practice Many of the theorists in this book addressed
exemplars. audiences of mostly practicing nurses at these
The book’s website features materials that conferences. Two books stimulated by those
will enrich the teaching and learning of these conferences and published by the National
nursing theories. Materials that will be helpful League for Nursing are Nursing Theories in
for teaching and learning about nursing theo- Practice (1990) and Patterns of Nursing Theories
ries are included as online resources. For exam- in Practice (1993).
ple, there are case studies, learning activities, For me (Marilyn), even deeper roots of this
and PowerPoint presentations included on book are found early in my nursing career,
both the instructor and student websites. Other when I seriously considered leaving nursing for
online resources include additional content, the study of pharmacy. In my fatigue and frus-
more extensive bibliographies and longer biog- tration, mixed with youthful hope and desire
raphies of the theorists. Dr. Shirley Gordon for more education, I could not answer the
and a group of doctoral students from Florida question “What is nursing?” and could not dis-
Atlantic University developed these ancillary tinguish the work of nursing from other tasks
materials for the third edition. For this edition, I did every day. Why should I continue this
the ancillary materials for students and faculty work? Why should I seek degrees in a field
were updated by Diane Gullett, a PhD candi- that I could not define? After reflecting on
date at Florida Atlantic University. She devel- these questions and using them to examine my
oped all materials for the new chapters as well nursing, I could find no one who would con-
as updating ancillary materials for chapters that sider the questions with me. I remember being
appeared in the third edition. We are so grate- asked, “Why would you ask that question? You
ful to Diane and Shirley for their creativity and are a nurse; you must surely know what nurs-
leadership and to the other doctoral students for ing is.” Such responses, along with a drive for
their thoughtful contributions to this project . serious consideration of my questions, led me
We hope that this book provides a useful to the library. I clearly remember reading se-
overview of the latest theoretical advances of veral descriptions of nursing that, I thought,
many of nursing’s finest scholars. We are could just as well have been about social work
grateful for their contributions to this book. As or physical therapy. I then found nursing
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Preface to the Fourth Edition vii

defined and explained in a book about educa- enough! It led to my decision to pursue my
tion of nurses written by Dorothea Orem. PhD in Nursing at New York University
During the weeks that followed, as I did my where I studied with Martha Rogers. During
work of nursing in the hospital, I explored this same time I taught at Duquesne University
Orem’s ideas about why people need nursing, with Rosemarie Parse and learned more about
nursing’s purposes, and what nurses do. I Man-Living-Health, which is now humanbe-
found a fit between her ideas, as I understood coming. I conducted several studies based on
them, with my practice, and I learned that I Rogers’ conceptual system and Parse’s theory.
could go even further to explain and design At theory conferences I was fortunate to
nursing according to these ways of thinking dialogue with Virginia Henderson, Hildegard
about nursing. I discovered that nursing shared Peplau, Imogene King, and Madeleine
some knowledge and practices with other serv- Leininger. In 1988 I accepted a faculty posi-
ices, such as pharmacy and medicine, and I tion at the University of Colorado when Jean
began to distinguish nursing from these related Watson was Dean. The School of Nursing was
fields of practice. I decided to stay in nursing guided by a caring philosophy and framework
and made plans to study and work with and I embraced caring as a central focus of the
Dorothea Orem. In addition to learning about discipline of nursing. As a unitary scholar, I
nursing theory and its meaning in all we do, I studied Newman’s theory of health as expand-
learned from Dorothea that nursing is a unique ing consciousness and was intrigued by it, so
discipline of knowledge and professional prac- for my sabbatical I decided to study it further
tice. In many ways, my earliest questions about as well as learn more about the unitary appre-
nursing have guided my subsequent study and ciative inquiry process that Richard Cowling
work. Most of what I have done in nursing has was developing.
been a continuation of my initial experience of We both have been fortunate to hold faculty
the interrelations of all aspects of nursing appointments in universities where nursing the-
scholarship, including the scholarship that is ory has been valued, and we are fortunate today
nursing practice. Over the years, I have been to hold positions at the Christine E. Lynn Col-
privileged to work with many nursing scholars, lege of Nursing at Florida Atlantic University,
some of whom are featured in this book. where faculty and students ground their teach-
My love for nursing and my respect for our ing scholarship and practice on caring theories,
discipline and practice have deepened, and including nursing as caring, developed by Dean
knowing now that these values are so often Anne Boykin and a previous faculty member at
shared is a singular joy. the College, Savina Schoenhofer. Many faculty
Marlaine’s interest in nursing theory had colleagues and students continue to help us
similar origins to Marilyn’s. As a nurse pursu- study nursing and have contributed to this book
ing an interdisciplinary master’s degree in pub- in ways we would never have adequate words to
lic health, I (Marlaine) recognized that while acknowledge. We are grateful to our knowl-
all the other public health disciplines had some edgeable colleagues who reviewed and offered
unique perspective to share, public health helpful suggestions for chapters of this book,
nursing seemed to lack a clear identity. In and we sincerely thank those who contributed
search of the identity of nursing I pursued a to the book as chapter authors. It is also our
second master’s in nursing. At that time nurs- good fortune that many nursing theorists and
ing theory was beginning to garner attention, other nursing scholars live in or visit our lovely
and I learned about it from my teachers and state of Florida. Since the first edition of this
mentors Sr. Rosemary Donley, Rosemarie book was published, we have lost many nursing
Parse, and Mary Jane Smith. This discovery was theorists. Their work continues through those
the answer I was seeking, and it both expanded refining, modifying, testing, and expanding the
and focused my thinking about nursing. The theories. The discipline of nursing is expanding
question of “What is nursing?” was answered as research and practice advances existing theories
for me by these theories and I couldn’t get and as new theories emerge. This is especially
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viii Preface to the Fourth Edition

important at a time when nursing theory can and her niece, Cherie Parker, who represents
provide what is missing and needed most in many nurses who love nursing practice and
health care today. scholarship and thus inspire the work of this
All four editions of this book have been nur- book. Marlaine acknowledges her husband
tured by Joanne DaCunha, an expert nurse and Brian and her children, Kirsten, Alicia, and
editor for F. A. Davis Company, who has shep- Brady, and their spouses, Jonathan Vankin and
herded this project and others because of her Tori Rutherford, for their love and understand-
love of nursing. Near the end of this project ing. She honors her parents, Deno and Rose
Joanne retired, and Susan Rhyner, our new ed- Cappelli, for instilling in her the love of learning,
itor, led us to the finish line. We are both grate- the value of hard work, and the importance of
ful for their wisdom, kindness, patience and caring for others, and dedicates this book to her
understanding of nursing. We give special granddaughter Iyla and the new little one who
thanks to Echo Gerhart, who served as our con- is scheduled to arrive as this book is released.
tact and coordinator for this project. Marilyn
thanks her husband, Terry Worden, for his Marilyn E. Parker, Marlaine C. Smith,
abiding love and for always being willing to help, Olathe, Kansas Boca Raton, Florida
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Nursing Theorists

Elizabeth Ann Manhart Barrett, PhD, RN, FAAN Imogene King†


Professor Emerita
Katharine Kolcaba, PhD, RN
Hunter College
Associate Professor Emeritus Adjunct
City University of New York
The University of Akron
New York, New York
Akron, Ohio
Charlotte D. Barry, PhD, RN, NCSN, FAAN
Madeleine M. Leininger†
Professor of Nursing
Christine E. Lynn College of Nursing Patricia Liehr, PhD, RN
Florida Atlantic University Professor
Boca Raton, Florida Christine E. Lynn College of Nursing
Florida Atlantic University
Anne Boykin, PhD, RN*
Boca Raton, Florida
Dean and Professor Emerita
Christine E. Lynn College of Nursing Rozzano C. Locsin, PhD, RN
Florida Atlantic University Professor Emeritus
Boca Raton, Florida Christine E. Lynn College of Nursing
Florida Atlantic University
Barbara Montgomery Dossey, PhD, RN, AHN-BC, FAAN,
Boca Raton, Florida
HWNC-BC
Co-Director, International Nurse Coach Afaf I. Meleis, PhD, DrPS(hon), FAAN
Association Professor of Nursing and Sociology
Core Faculty, Integrative Nurse Coach University of Pennsylvania
Certificate Program Philadelphia, Pennsylvania
Miami, Florida
Betty Neuman, PhD, RN, PLC, FAAN
Joanne R. Duffy, PhD, RN, FAAN Beverly, Ohio
Endowed Professor of Research and
Margaret Newman, RN, PhD, FAAN
Evidence-based Practice and Director
Professor Emerita
of the PhD Program
University of Minnesota College of Nursing
West Virginia University
Saint Paul, Minnesota
Morgantown, West Virginia
Dorothea E. Orem†
Helen L. Erickson*
Professor Emerita Ida Jean Orlando (Pelletier)†
University of Texas at Austin
Marilyn E. Parker, PhD, RN, FAAN
Austin, Texas
Professor Emerita
Lydia Hall† Christine E. Lynn College of Nursing
Florida Atlantic University
Virginia Henderson†
Boca Raton, Florida
Dorothy Johnson†
ix
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x Nursing Theorists

Rosemarie Rizzo Parse, PhD, FAAN Mary Jane Smith, PhD, RN


Distinguished Professor Emeritus Professor
Marcella Niehoff School of Nursing West Virginia University
Loyola University Chicago Morgantown, West Virginia
Chicago, Illinois
Mary Ann Swain, PhD
Hildegard Peplau† Professor and Director, Doctoral Program
Decker School of Nursing
Marilyn Anne Ray, PhD, RN, CTN
Binghamton University
Professor Emerita
Binghamton, New York
Christine E. Lynn College of Nursing
Florida Atlantic University Kristen M. Swanson, PhD, RN, FAAN
Boca Raton, Florida Dean
Seattle University
Pamela G. Reed, PhD, RN, FAAN
Seattle, Washington
Professor
University of Arizona Evelyn Tomlin*
Tucson, Arizona
Joyce Travelbee†
Martha E. Rogers†
Meredith Troutman-Jordan, PhD, RN
Sister Callista Roy, PhD, RN, FAAN Associate Professor
Professor and Nurse Theorist University of North Carolina
William F. Connell School of Nursing Chapel Hill, North Carolina
Boston College
Jean Watson, PhD, RN, AHN-BC, FAAN
Chestnut Hill, Massachusetts
Distinguished Professor Emeritus
Savina O. Schoenhofer, PhD, RN University of Colorado at Denver—Anschutz
Professor of Nursing Campus
University of Mississippi Aurora, Colorado
Oxford, Mississippi
Ernestine Wiedenbach†
Marlaine C. Smith, PhD, RN, AHN-BC, FAAN
Dean and Helen K. Persson Eminent Scholar
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida

*Retired
†Deceased
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Contributors

Patricia Deal Aylward, MSN, RN, CNS Laureen M. Fleck, PhD, FNP-BC, FAANP
Assistant Professor Associate Faculty
Santa Fe Community College Christine E. Lynn College of Nursing
Gainesville, Florida Florida Atlantic University
Boca Raton, Florida

Howard Karl Butcher, PhD, RN, PMHCNS-BC


Associate Professor Maureen A. Frey, PhD, RN*
University of Iowa
Iowa City, Iowa

Shirley C. Gordon, PhD, RN


Professor and Assistant Dean Graduate Practice
Lynne M. Hektor Dunphy, PhD, APRN-BC Programs
Associate Dean for Practice and Community Christine E. Lynn College of Nursing
Engagement Florida Atlantic University
Christine E. Lynn College of Nursing Boca Raton, Florida
Florida Atlantic University
Boca Raton, Florida

*Retired.

xi
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xii Contributors

Diane Lee Gullett, RN, MSN, MPH Beth M. King, PhD, RN, PMHCNS-BC
Doctoral Candidate Assistant Professor and RN-BSN Coordinator
Christine E. Lynn College of NursingFlorida Christine E. Lynn College of Nursing
Atlantic University Florida Atlantic University
Boca Raton, Florida Boca Raton, Florida

Donna L. Hartweg, PhD, RN Lois White Lowry, DNSc, RN*


Professor Emerita and Former Director Professor Emerita
Illinois Wesleyan University East Tennessee State University
Bloomington, Illinois Johnson City, Tennessee

Bonnie Holaday, PhD, RN, FAAN Violet M. Malinski, PhD, MA, RN


Professor Associate Professor
Clemson University College of New Rochelle
Clemson, South Carolina New Rochelle, New York

Mary B. Killeen, PhD, RN, NEA-BC Ann R. Peden, RN, CNS, DSN
Consultant Professor and Chair
Evidence Based Practice Nurse Consultants, Capital University
LLC Columbus, Ohio
Howell, Michigan
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Contributors xiii

Margaret Dexheimer Pharris, PhD, RN, CNE, FAAN Jacqueline Staal, MSN, ARNP, FNP-BC
Associate Dean for Nursing PhD Candidate
St. Catherine University Christine E. Lynn College of Nursing
St. Paul, Minnesota Florida Atlantic University
Boca Raton, Florida

Maude Rittman, PhD, RN


Associate Chief of Nursing Service for Research Marian C. Turkel, PhD, RN, NEA-BC, FAAN
Gainesville Veteran’s Administration Director of Professional Nursing Practice
Medical Center Holy Cross Medical Center
Gainesville, Florida Fort Lauderdale, Florida

Pamela Senesac, PhD, SM, RN Hiba Wehbe-Alamah, PhD, RN, FNP-BC, CTN-A
Assistant Professor Associate Professor
University of Massachusetts University of Michigan-Flint
Shrewsbury, Massachusetts Flint, Michigan

Christina L. Sieloff, PhD, RN


Associate Professor
Montana State University
Billings, Montana
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xiv Contributors

Kelly White, RN, PhD, FNP-BC Terri Kaye Woodward, MSN, RN, CNS, AHN-BC, HTCP
Assistant Professor Founder
South University Cocreative Wellness
West Palm Beach, Florida Denver, Colorado
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Reviewers

Ferrona Beason, PhD, ARNP Carol L. Moore, PhD, APRN, CNS


Assistant Professor in Nursing Assistant Professor of Nursing, Coordinator,
Barry University – Division of Nursing Graduate Nursing Studies
Miami Shores, Florida Fort Hays State University
Hays, Kansas
Abimbola Farinde, PharmD, MS
Clinical Pharmacist Specialist Kathleen Spadaro, PhD, PMHCNS, RN
Clear Lake Regional Medical Center MSN Program Co-coordinator & Assistant
Webster, Texas Professor of Nursing
Chatham University
Lori S. Lauver, PhD, RN, CPN, CNE
Pittsburgh, Pennsylvania
Associate Professor
Jefferson School of Nursing
Thomas Jefferson University
Philadelphia, Pennsylvania
Elisheva Lightstone, BScN, MSc
Professor
Department of Nursing
Seneca College
King City, Ontario, Canada

xv
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Contents

Section I An Introduction to Nursing Theory, 1


Chapter 1 Nursing Theory and the Discipline of Nursing, 3
Marlaine C. Smith and Marilyn E. Parker

Chapter 2 A Guide for the Study of Nursing Theories for Practice, 19


Marilyn E. Parker and Marlaine C. Smith

Chapter 3 Choosing, Evaluating, and Implementing Nursing Theories


for Practice, 23
Marilyn E. Parker and Marlaine C. Smith

Section II Conceptual Influences on the Evolution of Nursing


Theory, 35
Chapter 4 Florence Nightingale’s Legacy of Caring and Its Applications, 37
Lynne M. Hektor Dunphy

Chapter 5 Early Conceptualizations About Nursing, 55


Shirley C. Gordon

Chapter 6 Nurse-Patient Relationship Theories, 67


Ann R. Peden, Jacqueline Staal, Maude Rittman, and Diane Lee Gullett

Section III Conceptual Models/Grand Theories in the Integrative-


Interactive Paradigm, 87
Chapter 7 Dorothy Johnson’s Behavioral System Model and Its
Applications, 89
Bonnie Holaday

Chapter 8 Dorothea Orem’s Self-Care Deficit Nursing Theory, 105


Donna L. Hartweg

xvii
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xviii Contents

Chapter 9 Imogene King’s Theory of Goal Attainment, 133


Christina L. Sieloff and Maureen A. Frey

Chapter 10 Sister Callista Roy’s Adaptation Model, 153


Pamela Sensac and Sister Callista Roy

Chapter 11 Betty Neuman’s Systems Model, 165


Lois White Lowry and Patricia Deal Aylward

Chapter 12 Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s


Theory of Modeling and Role Modeling, 185
Helen L. Erickson

Chapter 13 Barbara Dossey’s Theory of Integral Nursing, 207


Barbara Montgomery Dossey

Section IV Conceptual Models and Grand Theories in the


Unitary–Transformative Paradigm, 235
Chapter 14 Martha E. Rogers Science of Unitary Human Beings, 237
Howard Karl Butcher and Violet M. Malinski

Chapter 15 Rosemarie Rizzo Parse’s Humanbecoming Paradigm, 263


Rosemarie Rizzo Parse

Chapter 16 Margaret Newman’s Theory of Health as Expanding


Consciousness, 279
Margaret Dexheimer Pharris

Section V Grand Theories about Care or Caring, 301


Chapter 17 Madeleine Leininger’s Theory of Culture Care Diversity
and Universality, 303
Hiba Wehbe-Alamah

Chapter 18 Jean Watson’s Theory of Human Caring, 321


Jean Watson

Chapter 19 Theory of Nursing as Caring, 341


Anne Boykin and Savina O. Schoenhofer

Section VI Middle-Range Theories, 357


Chapter 20 Transitions Theory, 361
Afaf I. Meleis
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Contents xix

Chapter 21 Katharine Kolcaba’s Comfort Theory, 381


Katharine Kolcaba

Chapter 22 Joanne Duffy’s Quality-Caring Model©, 393


Joanne R. Duffy

Chapter 23 Pamela Reed’s Theory of Self-Transcendence, 411


Pamela G. Reed

Chapter 24 Patricia Liehr and Mary Jane Smith’s Story Theory, 421
Patricia Liehr and Mary Jane Smith

Chapter 25 The Community Nursing Practice Model, 435


Marilyn E. Parker, Charlotte D. Barry. and Beth M. King

Chapter 26 Rozzano Locsin’s Technological Competency as Caring


in Nursing, 449
Rozzano C. Locsin

Chapter 27 Marilyn Anne Ray’s Theory of Bureaucratic Caring, 461


Marilyn Anne Ray and Marian C. Turkel

Chapter 28 Troutman-Jordan’s Theory of Successful Aging, 483


Meredith Troutman-Jordan

Chapter 29 Barrett’s Theory of Power as Knowing Participation


in Change, 495
Elizabeth Ann Manhart Barrett

Chapter 30 Marlaine Smith’s Theory of Unitary Caring, 509


Marlaine C. Smith

Chapter 31 Kristen Swanson’s Theory of Caring, 521


Kristen M. Swanson

Index, 533
3312_FM_i-xx 26/12/14 5:51 PM Page xx
3312_Ch01_001-018 26/12/14 9:35 AM Page 1

Section
I
An Introduction to Nursing Theory

1
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Section

I An Introduction to Nursing Theory


In this first section of the book, you will be introduced to the purpose of nursing
theory and shown how to study, analyze, and evaluate it for use in nursing
practice. If you are new to the idea of theory in nursing, the chapters in this section
will orient you to what theory is, how it fits into the evolution and context of nursing
as a professional discipline, and how to approach its study and evaluation. If
you have studied nursing theory in the past, these chapters will provide you with
additional knowledge and insight as you continue your study.
Nursing is a professional discipline focused on the study of human health and
healing through caring. Nursing practice is based on the knowledge of nursing,
which consists of its philosophies, theories, concepts, principles, research findings,
and practice wisdom. Nursing theories are patterns that guide the thinking about
nursing. All nurses are guided by some implicit or explicit theory or pattern of
thinking as they care for their patients. Too often, this pattern of thinking is implicit
and is colored by the lens of diseases, diagnoses, and treatments. This does not
reflect practice from the disciplinary perspective of nursing. The major reason for
the development and study of nursing theory is to improve nursing practice and,
therefore, the health and quality of life of those we serve.
The first chapter in this section focuses on nursing theory within the context of
nursing as an evolving professional discipline. We examine the relationship of
nursing theory to the characteristics of a discipline. You’ll learn new words that
describe parts of the knowledge structure of the discipline of nursing, and we’ll
speculate about the future of nursing theory as nursing, health care, and our global
society change. Chapter 2 is a guide to help you study the theories in this book.
Use this guide as you read and think about how nursing theory fits in your prac-
tice. Nurses embrace theories that fit with their values and ways of thinking. They
choose theories to guide their practice and to create a practice that is meaningful
to them. Chapter 3 focuses on the selection, evaluation, and implementation of
theory for practice. Students often get the assignment of evaluating or critiquing
a nursing theory. Evaluation is coming to some judgment about value or worth
based on criteria. Various sets of criteria exist for you to use in theory evaluation.
We introduce some that you can explore further. Finally, we offer reflections on
the process of implementing theory-guided practice models.

2
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Nursing Theory and the


Discipline of Nursing
Chapter
1
M ARLAINE C. S MITH AND
M ARILYN E. P ARKER

The Discipline of Nursing What is nursing? At first glance, the question


Definitions of Nursing Theory may appear to be one with an obvious an-
The Purpose of Theory in a Professional swer, but when it is posed to nurses, many
Discipline define nursing by providing a litany of func-
The Evolution of Nursing Science tions and activities. Some answer with the
The Structure of Knowledge in the elements of the nursing process: assessing,
Discipline of Nursing planning, implementing, and evaluating. Oth-
Nursing Theory and the Future ers might answer that nurses coordinate a
Summary patient’s care.
References Defining nursing in terms of the nursing
process or by functions or activities nurses per-
form is problematic. The phases of the nursing
process are the same steps we might use to
solve any problem we encounter, from a bro-
ken computer to a failing vegetable garden.
We assess the situation to determine what is
going on and then identify the problem; we
plan what to do about it, implement our plan,
and then evaluate whether it works. The nurs-
Marlaine C. Smith Marilyn E. Parker ing process does nothing to define nursing.
Defining ourselves by tasks presents other
problems. What nurses do—that is, the func-
tions associated with practice—differs based
on the setting. For example, a nurse might
start IVs, administer medications, and per-
form treatments in an acute care setting. In a
community-based clinic, a nurse might teach
a young mother the principles of infant feeding
or place phone calls to arrange community
resources for a child with special needs. Mul-
tiple professionals and nonprofessionals may
perform the same tasks as nurses, and persons
with the ability and authority to perform cer-
tain tasks change based on time and setting.
For example, both physicians and nurses may
listen to breath sounds and recognize the pres-
ence of rales. Both nurses and social workers
might do discharge planning. Both nurses

3
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4 SECTION I • An Introduction to Nursing Theory

and family members might change dressings, nurses in all nursing venues, who share a
monitor vital signs, and administer medications, commitment to values, knowledge, and
so defining nursing based solely on functions or processes to guide the thought and work of
activities performed is not useful. the discipline.
To answer the question “What is nursing?” The classic work of King and Brownell
we must formulate nursing’s unique identity (1976) is consistent with the thinking of nurs-
as a field of study or discipline. Florence ing scholars (Donaldson & Crowley, 1978;
Nightingale is credited as the founder of mod- Meleis, 1977) about the discipline of nursing.
ern nursing, the one who articulated its dis- These authors have elaborated attributes that
tinctive focus. In her book Notes on Nursing: characterize all disciplines. As you will see in
What It Is and What It Is Not (Nightingale, the discussion that follows, the attributes of
1859/1992), she differentiated nursing from King and Brownell provide a framework that
medicine, stating that the two were distinct contextualizes nursing theory within the dis-
practices. She defined nursing as putting the cipline of nursing.
person in the best condition for nature to act,
insisting that the focus of nursing was on Expression of Human Imagination
health and the natural healing process, not on Members of any discipline imagine and create
disease and reparation. For her, creating an structures that offer descriptions and explana-
environment that provided the conditions for tions of the phenomena that are of concern to
natural healing to occur was the focus of nurs- that discipline. These structures are the theories
ing. Her beginning conceptualizations were of that discipline. Nursing theory is dependent
the seeds for the theoretical development of on the imagination of nurses in practice, ad-
nursing as a professional discipline. ministration, research, and teaching, as they
In this chapter, we situate the understand- create and apply theories to improve nursing
ing of nursing theory within the context of practice and ultimately the lives of those they
the discipline of nursing. We define the dis- serve. To remain dynamic and useful, the dis-
cipline of nursing, describe the purpose of cipline requires openness to new ideas and in-
theory for the discipline of nursing, review novative approaches that grow out of members’
the evolution of nursing science, identify the reflections and insights.
structure of the discipline of nursing, and
speculate on the future place of nursing the- Domain
ory in the discipline. A professional discipline must be clearly
defined by a statement of its domain—the
The Discipline of Nursing boundaries or focus of that discipline. The do-
main of nursing includes the phenomena of in-
Every discipline has a unique focus that directs
terest, problems to be addressed, main content
the inquiry within it and distinguishes it from
and methods used, and roles required of the
other fields of study (Smith, 2008, p. 1). Nurs-
discipline’s members (Kim, 1997; Meleis,
ing knowledge guides its professional practice;
2012). The processes and practices claimed by
therefore, it is classified as a professional disci-
members of the disciplinary community grow
pline. Donaldson and Crowley (1978) stated
out of these domain statements. Nightingale
that a discipline “offers a unique perspective, a
provided some direction for the domain of the
distinct way of viewing . . . phenomena, which
discipline of nursing. Although the discipli-
ultimately defines the limits and nature of its
nary focus has been debated, there is some
inquiry” (p. 113). Any discipline includes net-
degree of consensus. Donaldson and Crowley
works of philosophies, theories, concepts, ap-
(1978, p. 113) identified the following as the
proaches to inquiry, research findings, and
domain of the discipline of nursing:
practices that both reflect and illuminate its dis-
tinct perspective. The discipline of nursing is 1. Concern with principles and laws that
formed by a community of scholars, including govern the life processes, well-being, and
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CHAPTER 1 • Nursing Theory and the Discipline of Nursing 5

optimal functioning of human beings, sick statement of philosophical unity in the disci-
or well pline was published by Roy and Jones (2007).
2. Concern with the patterning of human Statements include the following:
behavior in interactions with the environ-
• The human being is characterized by
ment in critical life situations
wholeness, complexity, and consciousness.
3. Concern with the processes through
• The essence of nursing involves the nurse’s
which positive changes in health status
true presence in the process of human-
are affected
to-human engagement.
Fawcett (1984) described the metapara- • Nursing theory expresses the values and be-
digm as a way to distinguish nursing from liefs of the discipline, creating a structure to
other disciplines. The metaparadigm is very organize knowledge and illuminate nursing
general and intended to reflect agreement practice.
among members of the discipline about the • The essence of nursing practice is the nurse–
field of nursing. This is the most abstract level patient relationship.
of nursing knowledge and closely mirrors be-
In 2008, Newman, Smith, Dexheimer-
liefs held about nursing. By virtue of being
Pharris, and Jones revisited the disciplinary
nurses, all nurses have some awareness of
focus asserting that relationship was central
nursing’s metaparadigm. However, because
to the discipline, and the convergence of
the term may not be familiar, it offers no di-
seven concepts—health, consciousness, car-
rect guidance for research and practice (Kim,
ing, mutual process, presence, patterning, and
1997; Walker & Avant, 1995). The metapara-
meaning—specified relationship in the pro-
digm consists of four concepts: persons, envi-
fessional discipline of nursing. Willis, Grace,
ronment, health, and nursing. According to
and Roy (2008) posited that the central uni-
Fawcett, nursing is the study of the interrela-
fying focus for the discipline is facilitating
tionship among these four concepts.
humanization, meaning, choice, quality of
Modifications and alternative concepts for
life, and healing in living and dying (p. E28).
this framework have been explored throughout
Finally, Litchfield and Jondorsdottir (2008)
the discipline (Fawcett, 2000). For example,
defined the discipline as the study of human-
some nursing scholars have suggested that
ness in the health circumstance. Smith (1994)
“caring” replace “nursing” in the metaparadigm
defined the domain of the discipline of nurs-
(Stevenson & Tripp-Reimer, 1989). Kim
ing as “the study of human health and healing
(1987, 1997) set forth four domains: client,
through caring” (p. 50). For Smith (2008),
client–nurse encounters, practice, and environ-
“nursing knowledge focuses on the wholeness
ment. In recent years, increasing attention has
of human life and experience and the
been directed to the nature of nursing’s rela-
processes that support relationship, integra-
tionship with the environment (Kleffel, 1996;
tion, and transformation” (p. 3). Nursing
Schuster & Brown, 1994).
conceptual models, grand theories, middle-
Others have defined nursing as the study
range theories, and practice theories explicate
of “the health or wholeness of human beings
the phenomena within the domain of nurs-
as they interact with their environment”
ing. In addition, the focus of the nursing dis-
(Donaldson & Crowley, 1978, p. 113), the life
cipline is a clear statement of social mandate
process of unitary human beings (Rogers,
and service used to direct the study and prac-
1970), care or caring (Leininger, 1978; Watson,
tice of nursing (Newman et al., 1991).
1985), and human–universe–health interrela-
tionships (Parse, 1998). A widely accepted focus
statement for the discipline was published Syntactical and Conceptual Structures
by Newman, Sime, and Corcoran-Perry Syntactical and conceptual structures are
(1991): “Nursing is the study of caring in the essential to any discipline and are inherent
human health experience” (p. 3). A consensus in nursing theories. The conceptual structure
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6 SECTION I • An Introduction to Nursing Theory

delineates the proper concerns of nursing, at conferences, societies, and other communi-
guides what is to be studied, and clarifies ac- cation networks of the nursing discipline.
cepted ways of knowing and using content of
the discipline. This structuṙe is grounded in the Tradition
focus of the discipline. The conceptual struc- The tradition and history of the discipline is ev-
ture relates concepts within nursing theories. ident in the study of nursing over time. There
The syntactical structures help nurses and is recognition that theories most useful today
other professionals to understand the talents, often have threads of connection with ideas
skills, and abilities that must be developed originating in the past. For example, many the-
within the community. This structure directs orists have acknowledged the influence of
descriptions of data needed from research, as Florence Nightingale and have acclaimed her
well as evidence required to demonstrate the leadership in influencing nursing theories of
effect on nursing practice. In addition, these today. In addition, nursing has a rich heritage
structures guide nursing’s use of knowledge in of practice. Nursing’s practical experience and
research and practice approaches developed by knowledge have been shared and transformed
related disciplines. It is only by being thor- as the content of the discipline and are evident
oughly grounded in the discipline’s concepts, in many nursing theories (Gray & Pratt, 1991).
substance, and modes of inquiry that the bound-
aries of the discipline can be understood and Values and Beliefs
possibilities for creativity across disciplinary Nursing has distinctive views of persons and
borders can be created and explored. strong commitments to compassionate and
knowledgeable care of persons through nurs-
Specialized Language and Symbols ing. Fundamental nursing values and beliefs
As nursing theory has evolved, so has the need include a holistic view of person, the dignity
for concepts, language, and forms of data that and uniqueness of persons, and the call to care.
reflect new ways of thinking and knowing spe- There are both shared and differing values and
cific to nursing. The complex concepts used in beliefs within the discipline. The metapara-
nursing scholarship and practice require lan- digm reflects the shared beliefs, and the para-
guage that can be specific and understood. The digms reflect the differences.
language of nursing theory facilitates commu-
Systems of Education
nication among members of the discipline.
Expert knowledge of the discipline is often A distinguishing mark of any discipline is the
required for full understanding of the meaning education of future and current members of
of these theoretical terms. the community. Nursing is recognized as a
professional discipline within institutions of
higher education because it has an identifiable
Heritage of Literature and
body of knowledge that is studied, advanced,
Networks of Communication and used to underpin its practice. Students of
This attribute calls attention to the array any professional discipline study its theories
of books, periodicals, artifacts, and aesthetic and learn its methods of inquiry and practice.
expressions, as well as audio, visual, and elec- Nursing theories, by setting directions for the
tronic media that have developed over cen- substance and methods of inquiry for the dis-
turies to communicate the nature of nursing cipline, should provide the basis for nursing
knowledge and practice. Conferences and fo- education and the framework for organizing
rums on every aspect of nursing held through- nursing curricula.
out the world are part of this network. Nursing
organizations and societies also provide critical
communication links. Nursing theories are Definitions of Nursing Theory
part of this heritage of literature, and those A theory is a notion or an idea that explains
working with these theories present their work experience, interprets observation, describes
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CHAPTER 1 • Nursing Theory and the Discipline of Nursing 7

relationships, and projects outcomes. Parsons in nursing practice, education, administration,


(1949), often quoted by nursing theorists, or research:
wrote that theories help us know what we
• Theory is a set of concepts, definitions, and
know and decide what we need to know. The-
propositions that project a systematic view
ories are mental patterns or frameworks cre-
of phenomena by designating specific inter-
ated to help understand and create meaning
relationships among concepts for purposes
from our experience, organize and articulate
of describing, explaining, predicting, and/or
our knowing, and ask questions leading to new
controlling phenomena (Chinn & Jacobs,
insights. As such, theories are not discovered
1987, p. 71).
in nature but are human inventions.
• Theory is a creative and rigorous structuring
Theories are organizing structures of our re-
of ideas that projects a tentative, purposeful,
flections, observations, projections, and infer-
and systematic view of phenomena (Chinn
ences. Many describe theories as lenses because
& Kramer, 2004, p. 268).
they color and shape what is seen. The same
• Nursing theory is a conceptualization
phenomena will be seen differently depending
of some aspect of reality (invented or
on the theoretical perspective assumed. For
discovered) that pertains to nursing. The
these reasons, “theory” and related terms have
conceptualization is articulated for the
been defined and described in a number of
purpose of describing, explaining, predict-
ways according to individual experience and
ing, or prescribing nursing care (Meleis,
what is useful at the time. Theories, as reflec-
1997, p. 12).
tions of understanding, guide our actions, help
• Nursing theory is an inductively and/or de-
us set forth desired outcomes, and give evi-
ductively derived collage of coherent, cre-
dence of what has been achieved. A theory, by
ative, and focused nursing phenomena that
traditional definition, is an organized, coherent
frame, give meaning to, and help explain
set of concepts and their relationships to each
specific and selective aspects of nursing re-
other that offers descriptions, explanations,
search and practice (Silva, 1997, p. 55).
and predictions about phenomena.
• A theory is an imaginative grouping of
Early writers on nursing theory brought
knowledge, ideas, and experience that are rep-
definitions of theory from other disciplines to
resented symbolically and seek to illuminate
direct future work within nursing. Dickoff and
a given phenomenon.” (Watson, 1985, p. 1).
James (1968, p. 198) defined theory as a “con-
ceptual system or framework invented for
some purpose.” Ellis (1968, p. 217) defined The Purpose of Theory in
theory as “a coherent set of hypothetical, con-
ceptual, and pragmatic principles forming a a Professional Discipline
general frame of reference for a field of in- All professional disciplines have a body of
quiry.” McKay (1969, p. 394) asserted that knowledge consisting of theories, research, and
theories are the capstone of scientific work and methods of inquiry and practice. They organize
that the term refers to “logically interconnected knowledge, guide inquiry to advance science,
sets of confirmed hypotheses.” Barnum (1998, guide practice and enhance the care of patients.
p. 1) later offered a more open definition of Nursing theories address the phenomena of in-
theory as a “construct that accounts for or or- terest to nursing, human beings, health, and
ganizes some phenomenon” and simply stated caring in the context of the nurse–person rela-
that a nursing theory describes or explains tionship1. On the basis of strongly held values
nursing. and beliefs about nursing, and within con-
Definitions of theory emphasize its various texts of various worldviews, theories are pat-
aspects. Those developed in recent years are terns that guide the thinking about, being,
more open and conform to a broader concep- and doing of nursing.
tion of science. The following definitions of the-
ory are consistent with general ideas of theory 1Person refers to individual, family, group, or community.
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8 SECTION I • An Introduction to Nursing Theory

Theories provide structures for making 2003). Engagement in practice generates the
sense of the complexities of reality for both ideas that lead to the development of nursing
practice and research. Research based in nurs- theories.
ing theory is needed to explain and predict At the empirical level of theory, abstract
nursing outcomes essential to the delivery of concepts are operationalized, or made concrete,
nursing care that is both humane and cost- for practice and research (Fawcett, 2000; Smith
effective (Gioiella, 1996). Some conceptual & Liehr, 2013). Empirical indicators provide
structure either implicitly or explicitly directs specific examples of how the theory is experi-
all avenues of nursing, including nursing edu- enced in reality; they are important for bringing
cation and administration. Nursing theories theoretical knowledge to the practice level.
provide concepts and designs that define the These indicators include procedures, tools, and
place of nursing in health care. Through instruments to determine the effects of nursing
theories, nurses are offered perspectives for practice and are essential to research and man-
relating with professionals from other disci- agement of outcomes of practice (Jennings &
plines, who join with nurses to provide Staggers, 1998). The resulting data form the
human services. Nursing has great expecta- basis for improving the quality of nursing care
tions of its theories. At the same time, the- and influencing health-care policy. Empirical
ories must provide structure and substance indicators, grounded carefully in nursing con-
to ground the practice and scholarship of cepts, provide clear demonstration of the utility
nursing and must also be flexible and dynamic of nursing theory in practice, research, admin-
to keep pace with the growth and changes in istration, and other nursing endeavors (Allison
the discipline and practice of nursing. & McLaughlin-Renpenning, 1999; Hart &
The major reason for structuring and Foster, 1998).
advancing nursing knowledge is for the sake Meeting the challenges of systems of care
of nursing practice. The primary purpose delivery and interprofessional work demands
of nursing theories is to further the develop- practice from a theoretical perspective. Nurs-
ment and understanding of nursing practice. ing’s disciplinary focus is important within
Because nursing theory exists to improve prac- the interprofessional health-care environment
tice, the test of nursing theory is a test of its (Allison & McLaughlin-Renpenning, 1999);
usefulness in professional practice (Colley, otherwise, its unique contribution to the in-
2003; Fitzpatrick, 1997). The work of nursing terprofessional team is unclear. Nursing ac-
theory is moving from academia into the tions reflect nursing concepts from a nursing
realm of nursing practice. Chapters in the re- perspective. Careful, reflective, and critical
maining sections of this book highlight the thinking are the hallmarks of expert nursing,
use of nursing theories in nursing practice. and nursing theories should undergird these
Nursing practice is both the source and the processes. Appreciation and use of nursing
goal of nursing theory. From the viewpoint of theory offer opportunities for successful col-
practice, Gray and Forsstrom (1991) suggested laboration with colleagues from other disci-
that theory provides nurses with different ways plines and provide definition for nursing’s
of looking at and assessing phenomena, ratio- overall contribution to health care. Nurses
nales for their practice, and criteria for evalu- must know what they are doing, why they are
ating outcomes. Many of the theories in this doing it, and what the range of outcomes of
book have been used to guide nursing practice, nursing may be, as well as indicators for doc-
stimulate creative thinking, facilitate commu- umenting nursing’s effects. These theoretical
nication, and clarify purposes and processes in frameworks serve as powerful guides for ar-
practice. The practicing nurse has an ethical re- ticulating, reporting, and recording nursing
sponsibility to use the discipline’s theoretical thought and action.
knowledge base, just as it is the nurse scholar’s One of the assertions referred to most often
ethical responsibility to develop the knowledge in the nursing-theory literature is that theory is
base specific to nursing practice (Cody, 1997, born of nursing practice and, after examination
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CHAPTER 1 • Nursing Theory and the Discipline of Nursing 9

and refinement through research, must be re- Although there were healers from other
turned to practice (Dickoff, James, & Wieden- countries who can be acknowledged for their
bach, 1968). Nursing theory is stimulated by importance to the history of nursing, Florence
questions and curiosities arising from nursing Nightingale holds the title of the “mother of
practice. Development of nursing knowledge modern nursing” and the person responsible
is a result of theory-based nursing inquiry. The for setting Western nursing on a path toward
circle continues as data, conclusions, and rec- scientific advancement. She not only defined
ommendations of nursing research are evalu- nursing as “putting the person in the best con-
ated and developed for use in practice. Nursing dition for nature to act,” she also established a
theory must be seen as practical and useful to phenomenological focus of nursing as caring
practice, and the insights of practice must in for and about the human–environment rela-
turn continue to enrich nursing theory. tionship to health. While nursing soldiers dur-
ing the Crimean War, Nightingale began to
study the distribution of disease by gathering
The Evolution of data, so she was arguably the first nurse-scientist
Nursing Science in that she established a rudimentary theory
Disciplines can be classified as belonging to and tested that theory through her practice and
the sciences or humanities. In any science, research.
there is a search for an understanding about Nightingale schools were established in the
specified phenomena through creating some West at the turn of the 20th century, but
organizing frameworks (theories) about the Nightingale’s influence on the nursing profes-
nature of those phenomena. These organizing sion waned as student nurses in hospital-based
frameworks (theories) are evaluated for their training schools were taught nursing primarily
empirical accuracy through research. So sci- by physicians. Nursing became strongly influ-
ence is composed of theories developed and enced by the “medical model” and for some
tested through research (Smith, 1994). time lost its identity as a distinct profession.
The evolution of nursing as a science has Slowly, nursing education moved into in-
occurred within the past 70 years; however, stitutions of higher learning where students
before nursing became a discipline or field were taught by nurses with higher degrees. By
of study, it was a healing art. Throughout 1936, 66 colleges and universities had bac-
the world, nursing emerged as a healing min- calaureate programs (Peplau, 1987). Graduate
istry to those who were ill or in need of sup- programs began in the 1940s and grew signifi-
port. Knowledge about caring for the sick, cantly from the 50s through the 1970s.
injured, and those birthing, dying, or expe- The publication of the journal Nursing Re-
riencing normal developmental transitions search in 1952 was a milestone, signifying the
was handed down, frequently in oral tradi- birth of nursing as a fledgling science (Peplau,
tions, and comprised folk remedies and prac- 1987). But well into the 1940s, “many text-
tices that were found to be effective through books for nurses, often written by physicians,
a process of trial and error. In most societies, clergy or psychologists, reminded nurses that
the responsibility for nursing fell to women, theory was too much for them, that nurses did
members of religious orders, or those with not need to think but rather merely to follow
spiritual authority in the community. With rules, be obedient, be compassionate, do their
the ascendency of science, those who were ‘duty’ and carry out medical orders” (Peplau,
engaged in the vocations of healing lost their 1987, p. 18). We’ve come a long way in a mere
authority over healing to medicine. Tradi- 70 years.
tional approaches to healing were marginal- The development of nursing curricula stim-
ized, as the germ theory and the development ulated discussion about the nature of nursing
of pharmaceuticals and surgical procedures as distinct from medicine. In the 1950s, early
were legitimized because of their grounding nursing scholars such as Hildegard Peplau,
in science. Virginia Henderson, Dorothy Johnson, and
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10 SECTION I • An Introduction to Nursing Theory

Lydia Hall established the distinct character- published theories in research and practice
istics of nursing as a profession and field formalized networks into organizations and
of study. Faye Abdellah, Ida Jean Orlando, held conferences. For example the Society for
Joyce Travelbee, Ernestine Wiedenbach, Myra Rogerian Scholars held the first Rogerian
Levine, and Imogene King followed during Conference; the Transcultural Nursing Society
the 1960s, elaborating their conceptualizations was formed, and the International Association
of nursing. During the early 1960s, the federally- for Human Caring was formed. Some of these
funded Nurse Scientist Program was initiated organizations developed journals publishing
to educate nurses in pursuit of doctoral degrees the work of scholars advancing these concep-
in the basic sciences. Through this program tual models and grand theories. Metatheorists
nurses received doctorates in education, soci- such as Jacqueline Fawcett, Peggy Chinn, and
ology, physiology, and psychology. These grad- Joyce Fitzpatrick and Ann Whall published
uates brought the scientific traditions of these books on nursing theory, making nursing
disciplines into nursing as they assumed faculty theories more accessible to students. Theory
positions in schools of nursing. courses were established in graduate programs
By the 1970s, nursing theory development in nursing. The Fuld Foundation supported a
became a priority for the profession and the series of videotaped interviews of many theo-
discipline of nursing was becoming estab- rists, and the National League for Nursing dis-
lished. Martha Rogers, Callista Roy, Dorothea seminated videos promoting theory within
Orem, Betty Newman, and Josephine Pater- nursing. Nursing Science Quarterly, a journal
son and Loraine Zderad published their theo- focused exclusively on advancing extant nurs-
ries and graduate students began studying and ing theories, published its first issue in 1988.
advancing these theories through research. During the 1990s, the expansion of con-
During this time, the National League for ceptual models and grand theories in nursing
Nursing required a theory-based curriculum as continued to deepen, and forces within nurs-
a standard for accreditation, so schools of nurs- ing both promoted and inhibited this expan-
ing were expected to select, develop, and im- sion. The theorists and their students began
plement a conceptual framework for their conducting research and developing practice
curricula. This propelled the advancement of models that made the theories more visible.
theoretical thinking in nursing. (Meleis, 1992). Regulatory bodies in Canada required that
A national conference on nursing theory and every hospital be guided by some nursing the-
the Nursing Theory Think Tanks were formed ory. This accelerated the development of nurs-
to engage nursing leaders in dialogue about the ing theory–guided practice within Canada and
place of theory in the evolution of nursing sci- the United States. The accrediting bodies of
ence. The linkages between theory, research, nursing programs pulled back on their require-
and philosophy were debated in the literature, ment of a specified conceptual framework
and Advances in Nursing Science, the premiere guiding nursing curricula. Because of this,
journal for publishing theoretical articles, was there were fewer programs guided by specific
launched. conceptualizations of nursing, and possibly
In the 1980s additional grand theories such fewer students had a strong grounding in the
as Parse’s man-living-health (later changed theoretical foundations of nursing. Fewer
to human becoming); Newman’s health as grand theories emerged; only Boykin and
expanding consciousness; Leininger’s tran- Schoenhofer’s nursing as caring grand theory
scultural nursing; Erickson, Tomlinson, and was published during this time. Middle-range
Swain’s modeling and role modeling; and theories emerged to provide more descriptive,
Watson’s transpersonal caring were dissemi- explanatory, and predictive models around
nated. Nursing theory conferences were con- circumscribed phenomena of interest to nurs-
vened, frequently attracting large numbers of ing. For example, Meleis’s transition theory,
participants. Those scholars working with the Mishel’s uncertainty theory, Barrett’s power
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CHAPTER 1 • Nursing Theory and the Discipline of Nursing 11

theory, and Pender’s health promotion model distinguishing features of nursing science over
were generating interest. others.
From 2000 to the present, there has been If nursing is to advance as a science in its
accelerated development of middle-range the- own right, future generations of nurses must re-
ories with less interest in conceptual models spect and advance the theoretical legacy of our
and grand theories. There seems to be a de- discipline. Scientific growth happens through
valuing of nursing theory; many graduate pro- cumulative knowledge development with cur-
grams have eliminated their required nursing rent research building on previous findings. To
theory courses, and baccalaureate programs survive and thrive, nursing theories must be
may not include the development of concep- used in nursing practice and research.
tualizations of nursing into their curricula. This
has the potential for creating generations of
nurses who have no comprehension of the im- The Structure of Knowledge
portance of theory for understanding the focus
of the discipline and the diverse, rich legacy
in the Discipline of Nursing
of nursing knowledge from these theoretical Theories are part of the knowledge structure
perspectives. of any discipline. The domain of inquiry (also
On the other hand, health-care organiza- called the metaparadigm or focus of the disci-
tions have been more active in promoting at- pline) is the foundation of the structure. The
tention to theoretical applications in nursing knowledge of the discipline is related to its
practice. For example, those hospitals on the general domain or focus. For example, knowl-
magnet journey are required to select a guiding edge of biology relates to the study of living
nursing framework for practice. Watson’s the- things; psychology is the study of the mind;
ory of caring is guiding nursing practice in a sociology is the study of social structures and
group of acute care hospitals. These hospitals behaviors. Nursing’s domain was discussed
have formed a consortium so that best prac- earlier and relates to the disciplinary focus
tices can be shared across settings. statement or metaparadigm. Other levels of
Although nursing research is advancing and the knowledge structure include paradigms,
making a difference in people’s lives, the re- conceptual models or grand theories, middle-
search may not be linked explicitly to theory, range theories, practice theories, and research
and probably not linked to nursing theory. This and practice traditions. These levels of nursing
compromises the advancement of nursing sci- knowledge are interrelated; each level of devel-
ence. All other disciplines teach their founda- opment is influenced by work at other levels.
tional theories to their students, and their Theoretical work in nursing must be dynamic;
scientists test or develop their theories through that is, it must be continually in process and
research. useful for the purposes and work of the disci-
There is a trend toward valuing theories pline. It must be open to adapting and extend-
from other disciplines over nursing theories. ing to guide nursing endeavors and to reflect
For example, motivational interviewing is a development within nursing. Although there
practice theory out of psychology that nurse re- is diversity of opinion among nurses about the
searchers and practitioners are gravitating to in terms used to describe the levels of theory, the
large numbers. Arguably, there are several sim- following discussion of theoretical develop-
ilar nursing theoretical approaches to engaging ment in nursing is offered as a context for
others in health promotion behaviors that pre- further understanding nursing theory.
ceded motivational interviewing, yet these
have not been explored. Interprofessional prac- Paradigm
tice and interdisciplinary research are essential Paradigm is the next level of the disciplinary
for the future of health care, but we do not do structure of nursing. The notion of paradigm can
justice to this concept by abandoning the rich, be useful as a basis for understanding nursing
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12 SECTION I • An Introduction to Nursing Theory

knowledge. A paradigm is a global, general from the historical conception of nursing as


framework made up of assumptions about a part of biomedical science, developments
aspects of the discipline held by members to in the nursing discipline are directed by at
be essential in development of the discipline. least two paradigms, or worldviews, outside
Paradigms are particular perspectives on the the medical model. These are now described.
metaparadigm or disciplinary domain. The Several nursing scholars have named the ex-
concept of paradigm comes from the work of isting paradigms in the discipline of nursing
Kuhn (1970, 1977), who used the term to (Fawcett, 1995; Newman et al., 1991; Parse,
describe models that guide scientific activity 1987). Parse (1987) described two paradigms:
and knowledge development in disciplines. the totality and the simultaneity. The totality
Because paradigms are broad, shared perspec- paradigm reflects a worldview that humans are
tives held by members of the discipline, they integrated beings with biological, psychological,
are often called “worldviews.” Kuhn set forth sociocultural, and spiritual dimensions. Humans
the view that science does not always evolve as adapt to their environments, and health and ill-
a smooth, regular, continuing path of knowl- ness are states on a continuum. In the simultane-
edge development over time, but that period- ity paradigm, humans are unitary, irreducible,
ically there are times of revolution when and in continuous mutual process with the
traditional thought is challenged by new ideas, environment (Rogers, 1970, 1992). Health is
and “paradigm shifts” occur. subjectively defined and reflects a process of
Kuhn’s ideas provide a way for us to think becoming or evolving. In contrast to Parse,
about the development of science. Before any Newman and her colleagues (1991) identi-
discipline engages in the development of theory fied three paradigms in nursing: particulate–
and research to advance its knowledge, it is deterministic, integrative–interactive, and unitary–
in a preparadigmatic period of development. transformative. From the perspective of the
Typically, this is followed by a period of time particulate–deterministic paradigm, humans are
when a single paradigm emerges to guide known through parts; health is the absence
knowledge development. Research activities of disease; and predictability and control
initiated around this paradigm advance its the- are essential for health management. In the
ories. This is a time during which knowledge integrative–interactive paradigm, humans are
advances at a regular pace. At times, a new par- viewed as systems with interrelated dimensions
adigm can emerge to challenge the worldview interacting with the environment, and change
of the existing paradigm. It can be revolution- is probabilistic. The worldview of the unitary–
ary, overthrowing the previous paradigm, or transformative paradigm describes humans as
multiple paradigms can coexist in a discipline, patterned, self-organizing fields within larger
providing different worldviews that guide the patterned, self-organizing fields. Change
scientific development of the discipline. is characterized by fluctuating rhythms of
Kuhn’s work has meaning for nursing and organization–disorganization toward more
other scientific disciplines because of his recog- complex organization. Health is a reflection of
nition that science is the work of a community this continuous change. Fawcett (1995, 2000)
of scholars in the context of society. Paradigms provided yet another model of nursing para-
and worldviews of nursing are subtle and pow- digms: reaction, reciprocal interaction, and si-
erful, reflecting different values and beliefs multaneous action. In the reaction paradigm,
about the nature of human beings, human–en- humans are the sum of their parts, reaction is
vironment relationships, health, and caring. causal, and stability is valued. In the reciprocal
Kuhn’s (1970, 1977) description of scientific interaction worldview, the parts are seen within
development is particularly relevant to nursing the context of a larger whole, there is a reciprocal
today as new perspectives are being articulated, nature to the relationship with the environment,
some traditional views are being strengthened, and change is based on multiple factors. Finally,
and some views are taking their places as part the simultaneous-action worldview includes a
of our history. As we continue to move away belief that humans are known by pattern and are
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CHAPTER 1 • Nursing Theory and the Discipline of Nursing 13

in an open ever-changing process with the (1968) described this level of theory in the field
environment. Change is unpredictable and of sociology, stating that they are theories
evolving toward greater complexity (Smith, broad enough to be useful in complex situa-
2008, pp. 4–5). tions and appropriate for empirical testing.
It may help you to think of theories being Nursing scholars proposed using this level of
clustered within these nursing paradigms. theory because of the difficulty in testing grand
Many theories share the worldview established theory (Jacox, 1974). Middle-range theories
by a particular paradigm. At present, multiple are narrower in scope than grand theories and
paradigms coexist within nursing. offer an effective bridge between grand theo-
ries and the description and explanation of
Grand Theories and specific nursing phenomena. They present con-
Conceptual Models cepts and propositions at a lower level of ab-
Grand theories and conceptual models are at straction and hold great promise for increasing
the next level in the structure of the discipline. theory-based research and nursing practice
They are less abstract than the focus of the dis- strategies (Smith & Liehr, 2008). Several
cipline and paradigms but more abstract than middle-range theories are included in this
middle-range theories. Conceptual models and book. Middle-range theories may have their
grand theories focus on the phenomena of con- foundations in a particular paradigmatic per-
cern to the discipline such as persons as adaptive spective or may be derived from a grand theory
systems, self-care deficits, unitary human be- or conceptual model. The literature presents a
ings, human becoming, or health as expanding growing number of middle-range theories.
consciousness. The grand theories, or concep- This level of theory is expanding most rapidly
tual models, are composed of concepts and re- in the discipline and represents some of the
lational statements. Relational statements on most exciting work published in nursing today.
which the theories are built are called assump- Some of these new theories are synthesized
tions and often reflect the foundational philoso- from knowledge from related disciplines and
phies of the conceptual model or grand theory. transformed through a nursing lens (Eakes,
These philosophies are statements of enduring Burke, & Hainsworth, 1998; Lenz, Suppe,
values and beliefs; they may be practical guides Gift, Pugh, & Milligan, 1995; Polk, 1997).
for the conduct of nurses applying the theory The literature also offers middle-range nursing
and can be used to determine the compatibility theories that are directly related to grand the-
of the model or theory with personal, profes- ories of nursing (Ducharme, Ricard, Duquette,
sional, organizational, and societal beliefs and Levesque, & Lachance, 1998; Dunn, 2004;
values. Fawcett (2000) differentiated conceptual Olson & Hanchett, 1997). Reports of nursing
models and grand theories. For her, conceptual theory developed at this level include implica-
models, also called conceptual frameworks or tions for instrument development, theory test-
conceptual systems, are sets of general concepts ing through research, and nursing practice
and propositions that provide perspectives on strategies.
the major concepts of the metaparadigm: per-
son, environment, health, and nursing. Fawcett Practice-Level Theories
(1993, 2000) pointed out that direction for re- Practice-level theories have the most limited
search must be described as part of the concep- scope and level of abstraction and are developed
tual model to guide development and testing of for use within a specific range of nursing situa-
nursing theories. We do not differentiate be- tions. Theories developed at this level have a
tween conceptual models and grand theories more direct effect on nursing practice than do
and use the terms interchangeably. more abstract theories. Nursing practice theories
provide frameworks for nursing interventions/
Middle-Range Theories activities and suggest outcomes and/or the effect
Middle-range theories comprise the next level of nursing practice. Nursing actions may be
in the structure of the discipline. Robert Merton described or developed as nursing practice
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14 SECTION I • An Introduction to Nursing Theory

theories. Ideally, nursing practice theories are Nursing Theory and the Future
interrelated with concepts from middle-range
Nursing theory is essential to the continuing
theories or developed under the framework of
evolution of the discipline of nursing. Several
grand theories. A theory developed at this level
trends are evident in the development and use
has been called a prescriptive theory (Crowley,
of nursing theory. First, there seems to be
1968; Dickoff, James, & Wiedenbach, 1968), a
more agreement on the focus of the discipline
situation-specific theory (Meleis, 1997), and a
of nursing that provides a meaningful direction
micro-theory (Chinn & Kramer, 2011). The
for our study and inquiry. This disciplinary di-
day-to-day experience of nurses is a major
alogue has extended beyond the confines of
source of nursing practice theory.
Fawcett’s metaparadigm and explicates the im-
The depth and complexity of nursing
portance of caring and relationship as central
practice may be fully appreciated as nursing
to the discipline of nursing (Newman et al.,
phenomena and relations among aspects of
2008; Roy & Jones, 2007; Willis et al., 2008).
particular nursing situations are described and
The development of new grand theories and
explained. Dialogue with expert nurses in
conceptual models has decreased. Dossey’s
practice can be fruitful for discovery and de-
(2008) theory of integral nursing, included in
velopment of practice theory. Research find-
this book, is the only new theory at this level
ings on various nursing problems offer data
that has been developed in nearly 20 years. In-
to develop nursing practice theories. Nursing
stead, the growth in theory development is at
practice theory has been articulated using
the middle-range and practice levels. There has
multiple ways of knowing through reflective
been a significant increase in middle-range
practice (Johns & Freshwater, 1998). The
theories, and many practice scholars are work-
process includes quiet reflection on practice,
ing on developing and implementing practice
remembering and noting features of nursing
models based on grand theories or conceptual
situations, attending to one’s own feelings,
models.
reevaluating the experience, and integrating
Several changes in the teaching and learning
new knowing with other experience (Gray
of nursing theory are troubling. Many bac-
& Forsstrom, 1991). The LIGHT model
calaureate programs include little nursing the-
(Andersen & Smereck, 1989) and the atten-
ory in their curricula. Similarly, some graduate
dant nurse caring model (Watson & Foster,
programs are eliminating or decreasing their
2003) are examples of the development of
emphasis on nursing theory. This alarming
practice level theories.
trend deserves our attention. If nursing is to
continue to thrive and to make a difference
Associated Research and in the lives of people, our practitioners and
Practice Traditions researchers need to practice and expand knowl-
Research traditions are the associated meth- edge within the structure of the discipline.
ods, procedures, and empirical indicators that As health care becomes more interprofessional,
guide inquiry related to the theory. For exam- the focus of nursing becomes even more im-
ple, the theories of health as expanding con- portant. If nurses do not learn and practice
sciousness, human becoming, and cultural care based on the knowledge of their discipline, they
diversity and universality have specific associ- may be co-opted into the practice of another
ated research methods. Other theories have discipline. Even worse, another discipline could
specific tools that have been developed to emerge that will assume practices associated
measure constructs related to the theories. The with the discipline of nursing. For example,
practice tradition of the theory consists of the health coaching is emerging as an area of prac-
activities, protocols, processes, tools, and prac- tice focused on providing people with help
tice wisdom emerging from the theory. Several as they make health-related changes in their
conceptual models and grand theories have lives. However, this is the practice of nursing,
specific associated practice methods. as articulated by many nursing theories.
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CHAPTER 1 • Nursing Theory and the Discipline of Nursing 15

On a positive note, nursing theories are open and inclusive ways to theorize about nurs-
being embraced by health-care organizations ing will be developed. These new ways will ac-
to structure nursing practice. For example, knowledge the history and traditions of nursing
organizations embarking on the journey to- but will move nursing forward into new realms
ward magnet status (www.nursecredentialing of thinking and being. Reed (1995) noted
.org/magnet) are required to identify a theo- the “ground shifting” with the reforming of
retical perspective that guides nursing practice, philosophies of nursing science and called for
and many are choosing existing nursing mod- a more open philosophy, grounded in nursing’s
els. This work has great potential to refine and values, which connects science, philosophy, and
extend nursing theories. practice. Gray and Pratt (1991, p. 454) pro-
The use of nursing theory in research is in- jected that nursing scholars will continue to de-
consistent at best. Often, outcomes research velop theories at all levels of abstraction and
is not contextualized within any theoretical that theories will be increasingly interdepend-
perspective; however, reviewers of proposals ent with other disciplines such as politics, eco-
for most funding agencies request theoretical nomics, and ethics. These authors expect a
frameworks, and scoring criteria give points for continuing emphasis on unifying theory and
having one. This encourages theoretical think- practice that will contribute to the validation of
ing and organizing findings within a broader the nursing discipline. Theorists will work in
perspective. Nurses often use theories from groups to develop knowledge in an area of con-
other disciplines instead of their own and this cern to nursing, and these phenomena of inter-
expands the knowledge of another discipline. est, rather than the name of the author, will
We are hopeful about the growth, continu- define the theory (Meleis, 1992). Newman
ing development, and expanded use of nursing (2003) called for a future in which we transcend
theory. We hope that there will be continued competition and boundaries that have been
growth in the development of all levels of nurs- constructed between nursing theories and in-
ing theory. The students of all professional dis- stead appreciate the links among theories, thus
ciplines study the theories of their disciplines moving toward a fuller, more inclusive, and
in their courses of study. We must continue to richer understanding of nursing knowledge.
include the study of nursing theories within our Nursing’s philosophies and theories must
baccalaureate, master’s, and doctoral programs. increasingly reflect nursing’s values for under-
Baccalaureate students need to understand the standing, respect, and commitment to health
foundations for the discipline, our historical de- beliefs and practices of cultures throughout
velopment, and the place of nursing theory in the world. It is important to question to what
its history and future. They should learn about extent theories developed and used in one
conceptual models and grand theories. Didactic major culture are appropriate for use in other
and practice courses should reflect theoretical cultures. To what extent must nursing theory
values and concepts so that students learn to be relevant in multicultural contexts? Despite
practice nursing from a theoretical perspective. efforts of many international scholarly soci-
Middle-range theories should be included in eties, how relevant are American nursing the-
the study of particular phenomena such as self- ories for the global community? Can nursing
transcendence, sorrow, and uncertainty. As they theories inform us about how to stand with
prepare to become practice leaders of the disci- and learn from peoples of the world? Can we
pline, doctor of nursing practice students should learn from nursing theory how to come to
learn to develop and test nursing theory-guided know those we nurse, how to be with them, to
models. PhD students will learn to develop and truly listen and hear? Can these questions be
extend nursing theories in their research. New recognized as appropriate for scholarly work
and expanded nursing specialties, such as nurs- and practice for graduate students in nursing?
ing informatics, call for development and use Will these issues offer direction for studies
of nursing theory (Effken, 2003). New, more of doctoral students? If so, nursing theory
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16 SECTION I • An Introduction to Nursing Theory

will prepare nurses for humane leadership in “think tank” for nurses around the globe to di-
national and global health policy. Perspec- alogue about nursing theory. Such opportuni-
tives of various times and worlds in relation to ties could lead nurses to truly listen, learn, and
present nursing concerns were described by adapt theoretical perspectives to accommodate
Schoenhofer (1994). Abdellah (McAuliffe, cultural variations.
1998) proposed an international electronic

■ Summary
This chapter focused on the place of nursing time, it is useful for the purposes and work of
theory within the discipline of nursing. The re- the discipline. This paradox may be seen as
lationship and importance of nursing theory ambiguous or as full of possibilities. Continu-
to the characteristics of a professional disci- ing students of the discipline are required to
pline were reviewed. A variety of definitions of study and know the basis for their contribu-
theory were offered, and the evolution and tions to nursing and to those we serve; at the
structure of knowledge in the discipline was same time, they must be open to new ways
outlined. Finally, we reviewed trends and spec- of thinking, knowing, and being in nursing.
ulated about the future of nursing theory de- Exploring structures of nursing knowledge and
velopment and application. One challenge of understanding the nature of nursing as a pro-
nursing theory is that theory is always in the fessional discipline provide a frame of refer-
process of developing and that, at the same ence to clarify nursing theory.

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A Guide for the Study of


Nursing Theories for Practice
Chapter
2
M ARILYN E. P ARKER AND
M ARLAINE C. S MITH

Study of Theory for Nursing Practice Nursing is a professional discipline, a field of


A Guide for Study of Nursing Theory for study focused on human health and healing
Use in Practice through caring (Smith, 1994). The knowledge
Summary of the discipline includes nursing science, art,
References philosophy, and ethics. Nursing science in-
cludes the conceptual models, theories, and re-
search specific to the discipline. As in other
sciences such as biology, psychology, or soci-
ology, the study of nursing science requires a
disciplined approach. This chapter offers a
guide to this disciplined approach in the form
of a set of questions that facilitate reflection,
exploration, and a deeper study of the selected
nursing theories.
As you read the chapters in this book, use
Marilyn E. Parker Marlaine C. Smith
the questions in the guide to facilitate your
study. These chapters offer you an introduction
to a variety of nursing theories, which we hope
will ignite interest in deeper exploration of
some of the theories through reading the
books written by the theorists and other pub-
lished articles related to the use of the theories
in practice and research. This book’s online re-
sources can provide additional materials as you
continue your exploration.1 The questions in
this guide can lead you toward this deeper
study of the selected nursing theories.
Rapid and dramatic changes are affecting
nurses everywhere. Health-care delivery
systems are in crisis and in need of real
change. Hospitals continue to be the largest
employers of nurses, and some hospitals
are recognizing the need to develop nursing
theory–guided practice models. A criterion for
hospitals seeking magnet hospital designation

1For additional information please go to bonus chapter

content available at FA Davis http://davisplus.fadavis.com

19
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20 SECTION I • An Introduction to Nursing Theory

by the American Nurses Credentialing Cen- Groups of nurses working together as col-
ter (www.nursecredentialing.org/magnet) in- leagues to provide care often realize that they
cludes the selection of a theoretical model for share the same values and beliefs about nurs-
practice. The list of questions in this chapter ing. The study of nursing theories can clarify
can be useful to nurses as they select theories the purposes of nursing and facilitate build-
to guide practice. ing a cohesive practice to meet them. Re-
Increasingly, nurses are practicing in diverse gardless of the setting of nursing practice,
settings and often develop organized nursing nurses may choose to study nursing theories
practices through which accessible health care together to design and articulate theory-
to communities can be provided. Community guided practice.
members may be active participants in select- The study of nursing theory precedes the
ing, designing, and evaluating the nursing activities of analysis and evaluation. The eval-
they receive. In these situations, it is important uation of a theory involves preparation, judg-
for nurses and the communities they serve to ment, and justification (Smith, 2013). In the
identify the approach to nursing that is most preparation phase, the student of the theory
consistent with the community’s values. The spends time coming to know it by reading and
questions in this chapter can be helpful in the reflecting on it. The best approach involves
mutual exploration of theoretical approaches intellectual empathy, curiosity, honesty, and
to practice. responsibility (Smith, 2013). Through reading
In the current health-care environment, in- and dwelling with the theory, the student tries
terprofessional practice is the desired standard. to understand it from the point of view of the
This does not mean that practicing from a theorist. Curiosity leads to raising questions in
nursing-theoretical base is any less important. the quest for greater understanding. It involves
Interprofessional practice means that each dis- imagining ways the theory might work in prac-
cipline brings its own lens or perspective to the tice, as well as the challenges it might present.
patient care situation. Nursing’s lens is essen- Honesty involves knowing oneself and being
tial for a complete picture of the person’s true to one’s own values and beliefs in the
health and for the goals of caring and healing. process of understanding. Some theories may
The nursing theory selected will provide this resonate with deeply held values; others may
lens, and the questions in this chapter can as- conflict with them. It is important to listen to
sist nurses in selecting the theory or theories these inner messages of comfort or discomfort,
that will guide their unique contribution to the for they will be important in the selection of
interprofessional team. theories for practice.
Theories and practices from a variety of dis- Each member of a professional discipline
ciplines inform the practice of nursing. The has a responsibility to take the time and put in
scope of nursing practice is continually being the effort to understand the theories of that dis-
expanded to include additional knowledge cipline. In nursing, there is an even greater re-
and skills from related disciplines, such as sponsibility to understand and be true to those
medicine and psychology. Again, this does that are selected to guide nursing practice.
not diminish the need for practice based on a Responses to questions offered and points
nursing theory, and these guiding questions summarized in the guides may be found in
help to differentiate the knowledge and prac- nursing literature, as well as in audiovisual
tice of nursing from those of other disciplines. and electronic resources. Primary source ma-
For example, nurse practitioners may draw on terial, including the work of nurses who are
their knowledge of pathophysiology, pharma- recognized authorities in specific nursing the-
cology, and psychology as they provide primary ories and the use of nursing theory, should
care. Nursing theories will guide the way of be used.
viewing the person,2 inform the way of relating
with the person, and direct the goals of prac- 2“Person” refers to individual, family, groups and com-
tice with the person. munities throughout the chapter.
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CHAPTER 2 • A Guide for the Study of Nursing Theories for Practice 21

Study of Theory for Nursing • What is the place of nursing in interpro-


fessional practice?
Practice • What is the range of nursing situations
Four main questions (described in the next in which the theory is useful?
section) have been developed and refined to How can nursing situations be described?
facilitate the study of nursing theories for use • What are the attributes of the recipient
in nursing practice (Parker, 1993). They focus of nursing care?
on concepts within the theories, as well as on • What are characteristics of the nurse?
points of interest and general information • How can interactions between the
about each theory. This guide was developed nurse and the recipient of nursing be
for use by practicing nurses and students in un- described?
dergraduate and graduate nursing education • Are there environmental requirements
programs. Many nurses and students have used for the practice of nursing? If so, what
these questions and contributed to their con- are they?
tinuing development. As you study each the- 2. What is the context of the theory development?
ory, answer the questions and address the Who is the nursing theorist as person and as nurse?
points in the following guide. You will find the • Why did the theorist develop the
information you need in the chapters of this theory?
book; other literature, such as books and jour- • What is the background of the theorist
nal articles authored by the theorists and other as a nursing scholar?
scholars working with the theories; and audio- • What central values and beliefs does the
visual and electronic resources. theorist set forth?
What are major theoretical influences on this theory?
A Guide for Study of Nursing • What previous knowledge influenced
the development of this theory?
Theory for Use in Practice • What are the relationships between this
1. How is nursing conceptualized in the theory and other theories?
theory? • What nursing-related theories and
Is the focus of nursing stated? philosophies influenced this theory?
• What does the nurse attend to when What were major external influences on development of the
practicing nursing? theory?
• What guides nursing observations, • What were the social, economic, and
reflections, decisions, and actions? political influences that informed the
• What illustrations or examples show theory?
how the theory is used to guide • What images of nurses and nursing
practice? influenced the development of the
What is the purpose of nursing? theory?
• What do nurses do when they are • What was the status of nursing as a dis-
practicing nursing based on the theory? cipline and profession at the time of the
• What are exemplars of nursing assess- theory’s development?
ments, designs, plans, and evaluations? 3. Who are authoritative sources for information about
• What indicators give evidence of the development, evaluation, and use of this theory?
quality of nursing practice? Which nursing authorities speak about, write about, and use
• Is the richness and complexity of nursing the theory?
practice evident? • What are the professional attributes of
What are the boundaries or limits for nursing? these persons?
• How is nursing distinguished from other • What are the attributes of authorities,
health-related professions? and how does one become one?
• How is nursing related to other disci- • Which others can be considered
plines and services? authorities?
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22 SECTION I • An Introduction to Nursing Theory

What major resources are authoritative sources on the theory? What is the experience of nurses who report consistent use of
• What books, articles, and audiovisual the theory?
and electronic media exist to elucidate • What is the range of reports from
the theory? practice?
• What nursing organizations share and • Has nursing research led to further
support work related to the theory? theoretical formulations?
• What service and academic programs are • Has the theory been used to develop
authoritative sources for practicing and new nursing practices?
teaching the theory? • Has the theory influenced the design of
4. How can the overall significance of the nursing theory methods of nursing inquiry?
be described? • What has been the influence of the
What is the importance of the nursing theory over time? theory on nursing and health policy?
• What are exemplars of the theory’s use What are projected influences of the theory on nursing’s
that structure and guide individual future?
practice? • How has the theory influenced the com-
• How has the theory been used to guide munity of scholars?
programs of nursing education? • In what ways has nursing as a professional
• How has the theory been used to practice been strengthened by the theory?
guide nursing administration and • What future possibilities for nursing
organizations? have been opened because of this theory?
• How does published nursing scholarship • What will be the continuing social value
reflect the significance of the theory? of the theory?

■ Summary
This chapter contains a guide designed for the journey from a beginning to a deeper under-
study of nursing theory for use in practice. As standing of nursing theory. The study of nursing
members of the professional discipline of nurs- theory precedes its analysis and evaluation. Stu-
ing, nurses must engage in the serious study of dents should approach the study of nursing the-
the theories of nursing. The implementation of ory with intellectual empathy, curiosity, honesty,
theory-guided practice models is important for and responsibility. This guide is composed of
nursing practice in all settings. The guide pre- four main questions to foster reflection and fa-
sented in this chapter can lead students on a cilitate the study of nursing theory for practice.

References

Parker, M. (1993). Patterns of nursing theories in practice. Smith, M. C. (2013). Evaluation of middle range theo-
New York: National League for Nursing. ries for the discipline of nursing. In M. J. Smith
Smith, M. C. (1994). Arriving at a philosophy of nursing: & P. Liehr (Eds.), Middle range theory for nursing
Discovering? Constructing? Evolving? In J. Kikuchi & (3rd ed., pp. 3–14). New York: Springer.
H. Simmons (Eds.), Developing a philosophy of nursing
(pp. 43–60). Thousand Oaks, CA: Sage.
3312_Ch03_023-034 26/12/14 10:08 AM Page 23

Choosing, Evaluating, and


Implementing Nursing
Chapter
3
Theories for Practice
M ARILYN E. P ARKER AND
M ARLAINE C. S MITH

Significance of Nursing Theory The primary purpose of nursing theory is


for Practice to improve nursing practice and, therefore,
Responses to Questions from Practicing the health and quality of life of the persons, fam-
Nurses About Using Nursing Theory ilies, and communities served. Nursing theories
Choosing a Nursing Theory to Study provide coherent ways of viewing and approach-
A Reflective Exercise for Choosing ing the care of persons in their environment.
a Nursing Theory for Practice
When a theoretical model is used to organize
Evaluation of Nursing Theory
care in any setting, it strengthens the nursing
Implementing Theory-Guided Practice
focus of care and provides consistency to the
Summary
communication and activities related to nursing
References
care. The development of nursing theories and
theory-guided practice models advances the dis-
cipline and professional practice of nursing.
One of the most important issues facing
the discipline of nursing is the artificial sepa-
ration of nursing theory and practice. Nursing
can no longer afford to see these dimensions as
disconnected territories, belonging to either
scholars or practitioners. The examination and
use of nursing theories are essential for closing
Marilyn E. Parker Marlaine C. Smith the gap between nursing theory and nursing
practice. Nurses in practice have a responsibility
to study and value nursing theories, just as
nursing theory scholars must understand and
appreciate the day-to-day practice of nurses.
Nursing theory informs and guides the practice
of nursing, and nursing practice informs and
guides the process of developing theory.
The theories of any professional discipline
are useless if they have no effect on practice.
Just as psychotherapists, educators, and econ-
omists base their approaches and decisions on
particular theories, so should nurses be guided
by selected nursing theories.
When practicing nurses and nurse scholars
work together, both the discipline and practice

23
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24 SECTION I • An Introduction to Nursing Theory

of nursing benefit, and nursing service to our gain from nursing theory? Then, methods of
clients is enhanced. There are many examples analysis and evaluation of nursing theory set
throughout this book of how nursing theories forth in the literature are presented. Finally,
have been, or can be, used to guide nursing steps in implementing nursing theory in prac-
practice. Many of the nursing theorists in this tice are described.
book developed or refined their theories based
on dialogue with nurses who shared descrip- Significance of Nursing
tions of their practice. This kind of work must
continue for nursing theories to be relevant Theory for Practice
and meaningful to the discipline. Nursing practice is essential for developing,
The need to bridge the gap between nurs- testing, and refining nursing theory. The devel-
ing theory and practice is highlighted by con- opment of many nursing theories has been en-
sidering the following brief encounter during hanced by reflection and dialogue about actual
a question-and-answer period at a conference. nursing situations. The everyday practice of
A nurse in practice, reflecting her experience, nursing enriches nursing theories. When nurses
asked a nurse theorist, “What is the meaning think about nursing, they consider the content
of this theory to my practice? I’m in the real and structure of the discipline of nursing. Even
world! I want to connect—but how can con- if nurses do not conceptualize these elements
nections be made between your ideas and my theoretically, their values and perspectives are
reality?” The nurse theorist responded by de- often consistent with particular nursing theo-
scribing the essential values and assumptions ries. Making these values and perspectives ex-
of her theory. The nurse said, “Yes, I know plicit through the use of a nursing theory results
what you are talking about. I just didn’t know in a more scholarly, professional practice.
I knew it, and I need help to use it in my prac- Creative nursing practice is the direct
tice” (Parker, 1993, p. 4). To remain current result of ongoing theory-based thinking,
in the discipline, all nurses must join in com- decision-making, and action. Nursing prac-
munity to advance nursing knowledge in prac- tice must continue to contribute to thinking
tice and must accept their obligations to and theorizing in nursing, just as nursing theory
engage in the continuing study of nursing the- must be used to advance practice.
ories. Today, many health-care organizations Nursing practice and nursing theory often
that employ nurses adopt a nursing theory as reflect the same abiding values and beliefs.
a guiding framework for nursing practice. This Nurses in practice are guided by their values
decision provides an excellent opportunity for and beliefs, as well as by knowledge. These val-
nurses in practice and in administration to ues, beliefs, and knowledge often are reflected
study, implement, and evaluate nursing theo- in the literature about nursing’s metaparadigm,
ries for use in practice. Communicating the philosophies, and theories. In addition, nurs-
outcomes of this process with the community ing theorists and nurses in practice think about
of scholars advancing the theories is a useful and work with the same phenomena, including
way to initiate dialogue among nurses and to the person, the actions and relationships in the
form new bridges between the theory and nurse–person (family/community) relation-
practice of nursing. ship, and the context of nursing. It is no won-
The purpose of this chapter is to describe der that nurses often sense a connection and
the processes leading to implementation of familiarity with many of the concepts in nurs-
nursing theory-guided practice models. These ing theories. They often say, “I knew this, but
processes include choosing possible theories I didn’t have the words for it.” This is another
for use in practice, analyzing and evaluating value of nursing theory. It provides a vehicle
these theories, and implementing theory- for us to share and communicate the important
guided practice models. The chapter begins concepts within nursing practice.
with responses to the questions: Why study It is not possible to practice without some
nursing theory? What do practicing nurses theoretical frame of reference. The question is
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CHAPTER 3 • Choosing, Evaluating, and Implementing Nursing Theories for Practice 25

what frame of reference is being used in prac- delivery systems; they can integrate other
tice. As stated in Chapter 1, theories are ways health sciences and technologies as the back-
to organize our thinking about the complexi- ground or context and not the essence of their
ties of any situation. Theories are lenses we se- practice. Nurses who study nursing theory
lect that will color the way that we view reality. realize that although no group actually owns
In the case of nursing, the theories we choose ideas, professional disciplines do claim a unique
to use will frame the way we think about a par- perspective that defines their practice. In the
ticular person and his or her health situation. same way, no group actually owns the tech-
It will inform the ways that we approach the nologies of practice, although disciplines do
person, how we relate, and what we do. Many claim them for their practice. For example, be-
nurses practice according to ideas and direc- fore World War II, nurses rarely took blood
tions from other disciplines, such as medicine, pressure readings and did not give intramus-
psychology, and public health. If your approach cular injections. This was not because nurses
to a person is framed by his or her medical di- lacked the skill, but because they did not claim
agnosis, you are influenced by the medical the use of these techniques within nursing
model that focuses your attention on diagnosis, practice. Such a realization can also lead to un-
treatment, and cure. If you are thinking about derstanding that the things nurses do that are
disease prevention as you work with a commu- often called nursing are not nursing at all. The
nity group, you are influenced by public health skills and technologies used by nurses, such as
theory and approaches. Although we use this taking blood pressure readings, giving injec-
knowledge in practice, nursing theory focuses tions, and auscultating heart sounds, are actu-
us on the distinctive perspective of the disci- ally activities that are part of the context, but
pline, which is more than, and different from, not the essence, of nursing practice. Nursing
these approaches. theories provide an organizing framework that
Historically, nursing practice has been directs nurses to the essence of their purpose
deeply rooted in the medical model, and this and places the use of knowledge from other
model continues today. The depth and scope disciplines in their proper perspective.
of the practice of nurses who follow notions If nursing theory is to be useful—or
about nursing held by other disciplines are lim- practical—it must be brought into practice. At
ited to practices understood and accepted by the same time, nurses can be guided by nursing
those disciplines. Nurses who learn to practice theory in a full range of nursing situations.
from nursing perspectives are awakened to the Nursing theory can change nursing practice: It
challenges and opportunities of practicing provides direction for new ways of being pres-
nursing more fully and with a greater sense of ent with clients, helps nurses realize ways of
autonomy, respect, and satisfaction for them- expressing caring, and provides approaches to
selves. Hopefully, they also provide different understanding needs for nursing and designing
and more expansive opportunities for health care to address these needs. The chapters of
and healing for those they serve. Nurses who this book affirm the use of nursing theory in
practice from a nursing perspective approach practice and the study and assessment of the-
clients and families in ways unique to nursing. ory to ultimately use in practice.
They ask questions, receive and process infor-
mation about needs for nursing differently, and
create nursing responses that are more holistic Responses to Questions from
and client-focused. These nurses learn to re-
frame their thinking about nursing knowledge
Practicing Nurses about Using
and practice and are then able to bring knowl- Nursing Theory
edge from other disciplines within the context Study of nursing theory may either precede or
of their practice—not to direct, their practice. follow selection of a nursing theory for use in
Nurses who practice from a nursing theo- nursing practice. Analysis and evaluation of
retical base see beyond immediate facts and nursing theory follow the study of a nursing
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26 SECTION I • An Introduction to Nursing Theory

theory. These activities are demanding and thinking differently through naming new con-
deserve the full commitment of nurses who cepts or ideas. Members of disciplines do share
undertake the work. Because it is understood specific language that may be less familiar to
that the study of nursing theory is not a simple, members outside the discipline. In interprofes-
short-term endeavor, nurses often question sional communication, new terms should be
doing such work. The following questions about defined and explained to facilitate communica-
studying and using nursing theory have been tion as needed. Nursing’s unique perspective
collected from many conversations with nurses needs to be represented clearly within the in-
about nursing theory. These queries also identify terprofessional team. The diversity of each dis-
specific issues that are important to nurses who cipline’s perspective is important to provide the
consider the study of nursing theory. best care possible for patients. People deserve
and expect high-quality care. Nursing theory
My Nursing Practice has the potential to bring to bear the impor-
• Does this theory reflect nursing practice as tance of relationship and caring in the process
I know it? Can it be understood in relation of health and healing; the interrelationship of
to my nursing practice? Will it support what the environment and health; an understanding
I believe to be excellent nursing practice? of the wholeness of persons in their life situa-
tions; and an appreciation of the person’s expe-
Conceptual models and grand theories can riences, values, and choices in care. These are
guide practice in any setting and situation. essential contributions to a multidisciplinary
Middle-range theories address circumscribed perspective.
phenomena in nursing that are directly related
to practice. These levels of theory can enrich My Personal Interests, Abilities,
perspectives on practice and should foster an and Experiences
excellent professional level of practice.
• Is the study of nursing theories consistent
• Is the theory specific to my area of nursing? with my talents, interests, and goals? Is this
Can the language of the theory help me ex- something I want to do?
plain, plan, and evaluate my nursing? Will I • Will I be stimulated by thinking about and
be able to use the terms to communicate trying to use this theory? Will my study of
with others? nursing be enhanced by use of this theory?
• Can this theory be considered in relation to • What will it be like to think about nursing
a wide range of nursing situations? How theory in nursing practice?
does it relate to more general views of • Will my work with nursing theory be worth
nursing people in other settings? the effort?
• Will my study and use of this theory support
The study of nursing theory does take an in-
nursing in my interprofessional setting?
vestment in time and attention. It is a respon-
• Will those from other disciplines be able
sibility of a professional nurse who engages in
to understand, facilitating cooperation?
a scholarly level of practice. Learning about
• Will my work meet the expectations of
nursing theory is a conceptual activity that can
those I serve? Will other nurses find my
be challenging and intellectually stimulating.
work helpful and challenging?
We need nurses who will invest in these activ-
Conceptual models and grand theories are ities so that knowledgeable theory-guided prac-
not specific to any nursing specialty. Theories tice is the standard in all health-care settings.
in any discipline introduce new terminology
that is not part of general language. For exam- Resources and Support
ple, the id, ego, and superego are familiar terms • Will this be useful to me outside the
in a particular psychological theory but were classroom?
unknown at the time of the theory’s introduc- • What resources will I need to understand
tion. The language of the theory facilitates fully the terms of the theory?
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CHAPTER 3 • Choosing, Evaluating, and Implementing Nursing Theories for Practice 27

• Will I be able to find the support I need to will find examples of how a theory has been
study and use the theory in my practice? used in research and in practice. In some cases,
especially with newly formed theories, this ev-
The purpose of nursing theory goes beyond
idence may be unavailable. In these situations,
its study within courses. Nursing theory be-
you will need to imagine how the theory might
comes alive when the ideas are brought to prac-
work in practice. Theories have heuristic, or
tice. The usefulness of theory in practice is one
problem-solving, value in that they can lead to
way that we judge its value and worth. It is
new ways of thinking about situations. Con-
helpful to read about the theory from primary
sider the heuristic value of the theory as you
sources or the most notable scholars and prac-
read it. The theory should ignite your passion
titioners who have studied the theory. Nurses
about nursing.
interested in particular theories can join online
discussion groups where issues related to the
theory are discussed. Many of the theory groups Choosing a Nursing Theory
have formed professional societies and hold to Study
conferences that support lifelong learning and
It is important to give adequate attention to
growing with those applying the theory in prac-
the selection of theories. Results of this deci-
tice, administration, research, and education.
sion will have lasting influences on your nurs-
The Theorist, Evidence, and Opinion ing practice. It is not unusual for nurses who
begin to work with nursing theory to realize
• Who is the author of this theory? What
that their practice is changing and that their
background of nursing education and experi-
future efforts in the discipline and practice of
ence does the theorist bring to this work? Is
nursing are markedly altered.
the author an authoritative nursing scholar?
There is always some measure of hope mixed
• How is the theorist’s background of nursing
with anxiety as nurses seriously explore nursing
education and experience brought to this
theory for the first time. Individual nurses who
work?
practice with a group of colleagues often won-
• What is the evidence that use of the theory
der how to select and study nursing theories.
may lead to improved nursing care? Has the
Nurses in practice and nursing students in the-
theory been useful to guide nursing organi-
ory courses have similar questions. Nurses in
zations and administrations? What about
new practice settings designed and developed
influencing nursing and health-care policy?
by nurses have the same concerns about getting
• What is the evidence that this nursing the-
started as do nurses in hospital organizations
ory has led to nursing research, including
who want more from their practice.
questions and methods of inquiry? Did
The following exercise is grounded in the
the theory grow out of research findings
belief that the study and use of nursing theory
or out of practice issues and concerns?
in nursing practice must have roots in the
• Does the theory reflect the latest thinking
practice of the nurses involved. Moreover, the
in nursing? Has the theory kept pace with
nursing theory used by particular nurses must
the times in nursing? Is this a nursing
reflect elements of practice that are essential
theory for the future?
to those nurses, while at the same time bring-
Approaching the study of nursing theory ing focus and freshness to that practice. This
with openness, curiosity, imagination, and exercise calls on the nurse to think about the
skepticism is important. Evaluation of any the- major components of nursing and bring forth
ory should include evidence that practicing the values and beliefs most important to
based on the theory makes a difference in the nurses. In these ways, the exercise begins to
lives of people. Theories must have pragmatic parallel knowledge development reflected in
value; that is, they need to generate research the nursing metaparadigm (focus of the disci-
questions and provide models that can be ap- pline) and nursing philosophies described in
plied in practice. In the nursing literature, you Chapter 1. Throughout the rest of this book,
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28 SECTION I • An Introduction to Nursing Theory

the reader is guided to connect nursing theory • What was the relationship between
and nursing practice in the context of nursing the person, family, or community and
situations. myself?
• What nursing actions emerged in the
context of the relationship?
A Reflective Exercise for • What other nursing actions might have
been possible?
Choosing a Nursing Theory • What was the environment of the nursing
for Practice situation?
Select a comfortable, private, and quiet place • What about the environment was impor-
to reflect and write. Relax by taking some tant to the person, family or community’s
deep, slow breaths. Think about the reasons hopes and dreams for health and healing
you went into nursing in the first place. Bring and my nursing actions?
your nursing practice into focus. Consider your
Nursing can change when we consciously
practice today. Continue to reflect and, while
connect values and beliefs to nursing situa-
avoiding distractions, make notes to record
tions. Consider that values and beliefs are the
your thoughts and feelings. When you have
basis for our nursing. Briefly describe the con-
been thinking for a time and have taken the
nections of your values and beliefs with your
opportunity to reflect on your practice, pro-
chosen nursing situation.
ceed with the following questions. Continue
to reflect and to make notes as you consider Connecting Values and the
each one.
Nursing Situation
Enduring Values • How are my values and beliefs reflected in
any nursing situation?
• What are the enduring values and beliefs
• Are my values and beliefs in conflict or
that brought me to nursing?
frustrated in this situation?
• What beliefs and values keep me in nursing
• Do my values come to life in the nursing
today?
situation?
• What are the personal values that I hold
most dear? Cultivating Awareness
• How do my personal and nursing values
and Appreciation
connect with what is important to society?
In reflecting and writing about values and
Reflect on an instance of nursing in which nursing situations that are important to us,
you interacted with a person, family, or com- we often come to a fuller awareness and ap-
munity for nursing purposes. This can be a sit- preciation of our practice. Make notes about
uation from your current practice or may be your insights. You might consider these ini-
from your nursing in years past. Consider the tial notes the beginning of a journal in which
purpose or hoped-for outcome. you record your study of nursing theories and
their use in nursing practice. This is a valu-
Nursing Situations able way to follow your progress and is a
• Who was this person, family, or commu- source of nursing questions for future study.
nity? How did I come to know him, her, You may want to share this process and ex-
or them as unique? perience with your colleagues. Sharing is a
• What were the person’s, family’s, or com- way to explore and clarify views about nursing
munity’s hopes and dreams for their own and to seek and offer support for nursing val-
health and healing? ues and situations that are critical to your
• Who was I as a person in the nursing practice. If you are doing this exercise in a
situation? group, share your essential values and beliefs
• Who was I as a nurse in the situation? with your colleagues.
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CHAPTER 3 • Choosing, Evaluating, and Implementing Nursing Theories for Practice 29

Multiple Ways of Knowing and nursing theory. Knowing the self is essential in
Reflecting on Nursing Theory selecting a nursing theory to guide practice.
Ultimately, the choice of theoretical perspec-
Multiple ways of knowing are used in theory-
tive reflects personal values and beliefs.
guided nursing practice. Carper (1978) studied
Ethical knowing is increasingly important to
the nursing literature and described four essen-
the study and practice of nursing today. Ac-
tial patterns of knowing in nursing. Using the
cording to Carper (1978), ethics in nursing is
Phenix (1964) model of realms of meaning,
the moral component guiding choices within
Carper described personal, empirical, ethical,
the complexity of health care. Ethical knowing
and aesthetic ways of knowing in nursing.
informs us of what is right, what is obligatory,
Chinn and Kramer (2011) use Carper’s pat-
and what is desirable in any nursing situation.
terns of knowing and a fifth pattern, called
Ethical knowing is essential in every action of
emancipatory knowing, to develop an inte-
the nurse in day-to-day practice.
grated framework for nursing knowledge de-
Aesthetic knowing is described by Carper
velopment. Additional patterns of knowing in
(1978) as the art of nursing; it is the creative
nursing have been explored and described, and
and imaginative use of nursing knowledge in
the initial four patterns have been the focus
practice (Rogers, 1988). Although nursing is
of much consideration in nursing (Boykin,
often referred to as art, this aspect of nursing
Parker, & Schoenhofer, 1994; Leight, 2002;
may not be as highly valued as the science and
Munhall, 1993; Parker, 2002; Pierson, 1999;
ethics of nursing. Each nurse is an artist, ex-
Ruth-Sahd, 2003; Thompson, 1999; White,
pressing and interpreting the guiding theory
1995). Each of the patterns of knowing and
uniquely in his or her practice. Reflecting on
its relationship to theory-guided practice are
the experience of nursing is primary in under-
articulated in the following paragraphs.
standing aesthetic knowing. Through such re-
Empirical knowing is the most familiar of
flection, the nurse understands that nursing
the ways of knowing in nursing. Empirical
practice has in fact been created, that each in-
knowing is how we come to know the science
stance of nursing is unique, and that outcomes
of nursing and other disciplines that are used
of nursing cannot be precisely predicted. Be-
in nursing practice. This includes knowing the
sides the art of nursing, knowing through artis-
actual theories, concepts, principles, and re-
tic forms is part of aesthetic knowing. Often
search findings from nursing, pathophysiology,
human experiences and relationships can best
pharmacology, psychology, sociology, epidemi-
be appreciated and understood through art
ology, and other fields. Nursing theory is within
forms such as stories, paintings, music, or po-
the pattern of empirical knowing. The theoret-
etry. Some assert that aesthetic knowing allows
ical framework for practice integrates the con-
for understanding the wholeness of experience.
cepts, principles, laws, and facts essential for
Examples of this most complete knowing are
practice.
frequent in nursing situations in which even
Personal knowing is about striving to know
momentary connection and genuine presence
the self and to actualize authentic relationships
between the nurse and the person, family, or
between the nurse and person. Using this pat-
community is realized.
tern of knowing in nursing, the client is not
Emancipatory knowing as described by
seen as an object but as a person moving to-
Chinn and Kramer (2011 ) is realized in praxis,
ward fulfillment of potential (Carper, 1978).
the integration of knowing, doing and being.
The nurse is recognized as continuously learn-
Paulo Freire’s (1970) definition of praxis is si-
ing and growing as a person and practitioner.
multaneous reflection and action intended to
Reflecting on a person as a client and a person
transform the world. In this pattern knowing
as a nurse in the nursing situation can enhance
is inseparable from action and is integral to the
understanding of nursing practice and the cen-
being of the nurse. The transformative action
trality of relationships in nursing. These in-
alters the power dynamics that maintain dis-
sights are useful for choosing and studying
advantage for some and privilege for others,
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30 SECTION I • An Introduction to Nursing Theory

and is directed toward goals for social justice The whole theory must be studied. Parts of
(Kagan, Smith, & Chinn, 2014). The nurse the theory without the whole will not be fully
using this pattern cultivates awareness of how meaningful and may lead to misunderstanding.
social, political and economic forces shape Before selecting a guide for theory evalua-
assumptions and opinions about knowledge tion, consider the level and scope of the theory.
and truth. Unveiling the dynamics that sustain Is the theory a conceptual model or grand nurs-
inequity creates freedom to see and act in a ing theory? A middle-range nursing theory? A
way that improves the health of all. Emanci- practice theory? Not all aspects of theory de-
patory knowing reminds us of the contextual scribed in an evaluation guide will be evident
nature of knowing, and that through praxis in all levels of theory. Whall (2004) recognized
(reflection and action) all patterns of knowing this in offering particular guides for analysis
are integrated. and evaluation that vary according to three
types of nursing theory: models, middle-range
Using Insights to Choose Theory theories, and practice theories. Fawcett’s (2004;
The notes describing your experience will help Fawcett & DeSanto-Madeya, 2012) criteria for
in selecting a nursing theory to study and con- analysis and evaluation pertain to conceptual
sider for guiding practice. You will want to models and grand theories. Smith’s (2013)
answer these questions: criteria specifically address the evaluation of
middle-range theories.
• What nursing theory seems consistent Theory analysis and evaluation may be
with the values and beliefs that guide my thought of as one process or as a two-step
practice? sequence. It may be helpful to think of analy-
• What theories are consistent with my sis of theory as necessary for in-depth study
personal values and beliefs? of a nursing theory and evaluation of theory
• What do I hope to achieve from the use of as the assessment of a theory’s significance,
nursing theory? structure, and utility. Guides for theory eval-
• Given my reflection on a nursing situation, uation are intended as tools to inform us
how can I use theory to support this descrip- about theories and to encourage further
tion of my practice? development, refinement, and use of theory.
• How can I use nursing theory to improve No guide for theory analysis and evaluation
my practice for myself and for my patients? is adequate and appropriate for every nursing
theory.
Johnson (1974) wrote about three basic cri-
Evaluation of Nursing Theory teria to guide evaluation of nursing theory.
Evaluation of nursing theory follows its study These have continued in use over time and
and analysis and is the process of making a offer direction today. These criteria state that
determination about its value, worth, and sig- the theory should:
nificance (Smith, 2013). There are many sets
• Define the congruence of nursing practice
of criteria for evaluating conceptual models
with societal expectations of nursing
and grand theories (Chinn & Kramer, 2007;
decisions and actions
Fawcett, 2004; Fitzpatrick & Whall, 2004;
• Clarify the social significance of nursing,
Parse, 1987; Stevens, 1998). Smith (2013)
or the effect of nursing on persons receiving
has published criteria for evaluating middle-
nursing
range theories. After reading and studying
• Describe social utility, or usefulness, of the
the primary sources of the theory, the re-
theory in practice, research, and education
search and practice applications of the theory,
and other critiques and evaluations of the the- Following are summaries of the most fre-
ory, it is important for the evaluator to come quently used guides for theory evaluation.
to his or her own judgments supported by These guides are components of the entire
logical analysis and examples from the theory. work about nursing theory of the individual
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CHAPTER 3 • Choosing, Evaluating, and Implementing Nursing Theories for Practice 31

nursing scholar and offer various interesting The questions for evaluation of grand and
approaches to theory evaluation. Each guide middle-range theories address:
should be studied in more detail than is offered
• Significance
in this introduction and should be examined
• Internal consistency
in context of the whole work of the individual
• Parsimony
nurse scholar.
• Testability
The approach to theory evaluation set forth
• Empirical adequacy
by Chinn and Kramer (2011) is to use guide-
• Pragmatic adequacy
lines for describing nursing theory that are
based on their definition of theory as “a cre- Meleis (2011) stated that the structural
ative and rigorous structuring of ideas that and functional components of a theory should
projects a tentative, purposeful, and systematic be studied before evaluation. The structural
view of phenomena” (p. 58). The guidelines components are assumptions, concepts, and
set forth questions that clarify the facts about propositions of the theory. Functional com-
aspects of theory: purpose, concepts, defini- ponents include descriptions of the following:
tions, relationships and structure, and as- focus, client, nursing, health, nurse–client
sumptions. These authors suggest that the interactions, environment, nursing problems,
next step in the evaluation process is critical and interventions. After studying these dimen-
reflection about whether and how the nursing sions of the theory, critical examination of
theory works. Questions are posed to guide these elements may take place, summarized
this reflection: as follows:
• How clear is this theory? • Relations between structure and function
• How simple is this theory? of the theory, including clarity, consistency,
• How general is this theory? and simplicity
• How accessible is this theory? • Diagram of theory to elucidate the theory
• How important is this theory? by creating a visual representation
Fawcett (2004; Fawcett & DeSanto- • Contagiousness, or adoption of the theory by
Madeya, 2012) developed two frameworks for a wide variety of students, researchers, and
the analysis and evaluation of conceptual mod- practitioners, as reflected in the literature
els and theories. The questions for analysis of • Usefulness in practice, education, research,
conceptual models address: and administration
• External components of personal, profes-
• Origins of the nursing model sional, social values, and significance
• Unique focus of the nursing model
• Content of the nursing model Smith (2013) developed a framework for
the evaluation of middle-range theories that
The questions for evaluation of conceptual includes the following criteria:
models address:
Substantive foundation relates to meaning or
• Explication of origins how the theory corresponds to existing
• Comprehensiveness of content knowledge in the discipline. The questions
• Logical congruence for evaluation ask about its fit with the
• Generation of theory disciplinary focus of nursing; its specifica-
• Credibility of nursing model tion of assumptions; its substantive mean-
ing of a phenomenon; and its origins in
The framework for analysis of grand and
practice and/or research.
middle-range theories includes:
Structural integrity relates to the structure or
• Theory scope internal organization of the theory. Ques-
• Theory context tions for evaluation ask about the clarity of
• Theory content definitions of concepts, the consistency of
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32 SECTION I • An Introduction to Nursing Theory

level of abstraction, the simplicity of the involved and invested in the process of decid-
theory, and the logical representation of ing on the theoretical model that will guide
relationships among concepts. practice. This can be done is several ways. An
Functional adequacy refers to the ability of the organization’s governance structure can be
theory to be used in practice and research. used to develop the most appropriate selection
Questions are related to its applicability to process. As stated previously, the selection of
practice and client groups, the identifica- a nursing theory or model is based on values.
tion of empirical indicators, the presence Some nursing organizations have used their
of published examples of practice and re- mission, values, and vision statements as a
search using the theory and the evolution blueprint that helps them select nursing theo-
of the theory through inquiry (p. 41 x). ries that are most consistent with these values.
Another approach is to survey all nurses about
the practice models they would like to see im-
Implementing Theory-Guided plemented. The nursing staff can then study the
Practice top three or four in greater detail so that an in-
formed decision can be made. Staff develop-
Every nurse should develop a practice that is ment can be involved in planning educational
guided by nursing theory. Most conceptual offerings related to the models. A process of
models or grand theories have actual practice voting or gaining consensus can be used for the
methods or processes that can be adopted. The final selection.
scope and generality of middle-range theories Launching the initiative. Once the model
makes them less appropriate to guide nursing has been selected, the leaders (formal and in-
practice within a unit or hospital. Instead, they formal) begin to plan for its implementation.
can be used to understand and respond to phe- This involves creating a timeline, planning the
nomena that are encountered in nursing situa- phases and stages of implementation including
tions. For example, Boykin and Schoenhofer’s activities, and using all methods of communi-
Nursing as Caring theory has been adopted as cation to be sure that all are informed of these
a practice model by several hospitals (Boykin, plans. Unit champions, informal leaders who
Schoenhofer & Valentine, 2013). Reed’s middle- are enthusiastic and positive about the initia-
range theory of self-transcendence can be used tive, can be key to the building excitement for
to guide a nurse who is leading a support group the initiative. A structure to lead and manage
for women with breast cancer. Hospital units the implementation is essential. Consultants
or entire nursing departments may adopt a who are experts in the theory itself or who
model that guides nursing practice within their have experience in implementing the theory-
unit or organization. The following are sugges- guided practice model can be very helpful.
tions that can facilitate this process of adoption For example, Watson’s International Caritas
and implementation of theory-guided practice Consortium1 consists of hospitals that have
within units or organizations: experience implementing the theory in prac-
Gaining administrative support. Organiza- tice. New hospitals can join the consortium for
tional leaders need to support the initiative to consultation and support as they launch initia-
begin the process of implementing nursing tives. A kickoff event, such as an inspirational
theory-guided practice. Although the impetus presentation, can build excitement and visibility
to begin this initiative might not originate in for the initiative.
formal leadership, the organizational leaders Creating a plan for evaluation. It is impor-
and managers need to be on board. If it is to tant to build in a systematic plan for evaluation
succeed, the implementation of a model for of the new model from the beginning. An
practice requires the support of administration evaluation study should be designed to track
at the highest levels.
Selecting the theory or model to be used in prac- For additional information, visit http://watsoncaring-
tice. The entire nursing staff should be fully science.org.
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CHAPTER 3 • Choosing, Evaluating, and Implementing Nursing Theories for Practice 33

process and outcome indicators. Consultation to dialogue about their experiences: what is
from an evaluation researcher is essential. working and what is not. They need the free-
For example, outcomes of nurse satisfaction, dom to develop new ways of implementing
patient satisfaction, nurse retention, and core the model so that their scholarship and cre-
measures might be considered as outcomes to ativity flourish.
be measured before and after the implementa- Periodic feedback on outcomes and oppor-
tion of the model. Focus groups might be held tunities for reenergizing is essential. Planned
at intervals to identify nurses’ experiences and change involves anticipating the ebb and flow
attitudes related to implementation of the of enthusiasm. In the stressful health-care
model. environment, it is important to find opportu-
Consistent and constant support and educa- nities to provide feedback on how the project
tion. As the model is implemented, a process is going, to reward and celebrate the successes,
to support continuing learning and growth and to fan any dying embers of enthusiasm for
with the theory needs to be in place. The the project. This can be accomplished by invit-
nurses implementing the model will have ing study champions to attend regional or
questions and suggestions, so resident experts national conferences, bringing in speakers, or
should be available for this education and sup- holding recognition events.
port. Those working with the model will grow Revisioning of the theory-guided practice
in their expertise, and their experiences need model based on feedback. Any theory-guided
to be recorded and shared with the commu- practice model will become richer through its
nity of scholars advancing the theory in prac- testing in practice. The nurses working with
tice. Ways to foster staying on track must be the model will help to modify and revise the
developed. Some hospitals have created unit model based on evaluation data. This revision-
bulletin boards, newsletters, or signage to pre- ing should be done in partnership with theo-
vent reverting to old behaviors and to cement rists and other practice scholars working with
new ones. Staff members need opportunities the model.

■ Summary
This chapter focused on the important con- need to be present in a chosen theory. Eval-
nection between nursing theory and nursing uation of nursing theory is a judgment of its
practice and the processes of choosing, eval- value or worth. Several models of theory eval-
uating, and implementing theory for prac- uation are available for use. Implementing a
tice. The selection of a nursing theory for theory-based practice model in a health-care
practice is based on values and beliefs, and a setting can be challenging and rewarding.
reflective process can help to identify the Suggestions for successful implementation
most important qualities of practice that were offered.

References

Boykin, A., Parker, M., & Schoenhofer, S. (1994). Aes- Chinn, P., & Jacobs, M. (2007). Integrated theory and
thetic knowing grounded in an explicit conception of knowledge development in nursing. (7th edition).
nursing. Nursing Science Quarterly, 7(4), 158–161. St. Louis, MO: Mosby.
Boykin, A., Schoenhofer, S. & Valentine, K. (2013. Chinn, P., & Kramer, M. (2007). Integrated knowledge
Transformation for Nursing and Healthcare Leaders: development in nursing (7th ed.). St. Louis,
Implementing a Culture of Caring. New York, NY: MO: Mosby.
Springer. Chinn, P., & Kramer, M. (2011). Integrated theory
Carper, B. A. (1978). Fundamental patterns of knowing and knowledge development in nursing (8th ed.).
in nursing. Advances in Nursing Science, 1(1), 13–23. St. Louirs, MO: Mosby.
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Fawcett, J. (2004). Analysis and evaluation of contempo- Parse, R. R. (1987). Nursing science: Major paradigms,
rary nursing knowledge. Philadelphia: F.A. Davis. theories and critiques. Philadelphia: W. B. Saunders.
Fawcett, J. & DeSanto-Madeya . (2012). Analysis Phenix, P. H. (1964). Realms of meaning. New York:
and evaluation of contemporary nursing knowledge McGraw-Hill.
(3rd ed.). Philadelphia, PA: F.A. Davis. Pierson, W. (1999). Considering the nature of intersub-
Fitzpatrick, J., & Whall, A. (2004). Conceptual models jectivity within professional nursing. Journal of
of nursing. Stamford, CT: Appleton & Lange. Advanced Nursing, 30(2), 294–302.
Friere, Paulo. (1970). Pedagogy of the oppressed. New York, Rogers, M. E. (1988). Nursing science and art: A
NY: Herder and Herder. prospective. Nursing Science Quarterly, 1(3), 99–102.
Johnson, D. (1974). Development of theory: A requisite Ruth-Sahd, L. A. (2003). Intuition: A critical way of
for nursing as a primary health profession. Nursing knowing in a multicultural nursing curriculum.
Research, 23(5), 372–377. Nursing Education Perspectives, 24(3), 129–134.
Kagan, P., Smith, M., & Chinn, P. (Eds). (2014). Smith, M. C. (2013). Evaluation of middle range theo-
Philosophies and practices of emancipatory nursing: ries for the discipline of nursing. In M. J. Smith &
Social justice as praxis. New York, NY: Routledge. P. R. Liehr (Eds.), Middle range theory for nursing
Leight, S. B. (2002). Starry night: Using story to inform (pp. 35–50). New York, NY: Springer.
aesthetic knowing in women’s health nursing. Stevens, B. (1998). Nursing theory: Analysis, application,
Journal of Advanced Nursing, 37(1), 108–114. evaluation. Boston: Little, Brown.
Meleis, A. (2011). Theoretical nursing: Development and Thompson, C. (1999). A conceptual treadmill: The need
progress (5th ed.). Philadelphia: Lippincott. for “middle ground” in clinical decision making
Meleis, A. (2004). Theoretical nursing: Development and theory in nursing. Journal of Advanced Nursing, 30(5),
progress (3rd ed.). Philadelphia: Lippincott. 1222–1229.
Munhall, P. (1993). Unknowing: Toward another Whall, A. (2004). The structure of nursing knowledge:
pattern of knowing in nursing. Nursing Outlook, 41, Analysis and evaluation of practice, middle-range,
125–128. and grand theory. In J. Fitzpatrick & A. Whall
Parker, M. (1993). Patterns of nursing theories in practice. (Eds.), Conceptual models of nursing: Analysis and
New York: National League for Nursing. application (4th ed., pp. 5–20). Stamford, CT:
Parker, M. E. (2002). Aesthetic ways in day-to-day Appleton & Lange.
nursing. In D. Freshwater (Ed.), Therapeutic nursing: White, J. (1995). Patterns of knowing: Review, critique
Improving patient care through self-awareness and and update. Advances in Nursing Science, 17(4), 73–86.
reflection (pp. 100–120). Thousand Oaks, CA: Sage.
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Section
II
Conceptual Influences on
the Evolution of Nursing Theory

35
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Section

II Conceptual Influences on the Evolution of Nursing Theory


The second section of the book has three chapters that describe conceptual in-
fluences on the development of nursing theory. Thomas Kuhn calls the stage of
scientific development before formal theories are structured the “preparadigm
stage.” These scholars were working in this stage of our development, planting
the seeds that grew into nursing theories. Nursing theorists today have stood on
the shoulders of these “giants,” building on their brilliant conceptualizations of
the nature of nursing and the nurse–patient relationship. In Chapter 4, Dr. Lynne
Dunphy, a noted historian and Nightingale scholar, illuminates the core ideas
from Nightingale’s work that have been essential foundations for the development
of nursing theories. Although Nightingale did not develop a theory of nursing,
she did provide a direction for the development of the profession and discipline.
She believed in the natural or inherent healing ability of human beings and that
the goal of nursing was to facilitate the emergence of health and healing by at-
tending to the person–environment relationship. She said that the goal of nursing
was to put the patient in the best condition for nature to act, and she identified
five environmental components essential to health. Nightingale saw nursing and
medicine as separate fields and emphasized the importance of systematic inquiry.
Her spiritual nature and vision of nursing as an art continue to influence practice
today. The emphasis on optimal healing environments in today’s health-care sys-
tems can be related to Nightingale’s ideas. The quality of the human–environment
relationship is related to health and healing.
In Chapter 5, Dr. Shirley Gordon summarized the work of Ernestine
Wiedenbach, Virginia Henderson, and Lydia Hall. Wiedenbach emphasized
the importance of reverence for life, respect for dignity, autonomy, worth, and
uniqueness of each person, and a commitment to act on these values as the
essence of a personal philosophy of nursing. Henderson described nursing as
“getting into the skin” of the patient so that nurses would be able to provide
the strength, will, or knowledge the patient needed to heal or maintain health.
Lydia Hall is an inspiration to all who envision nursing as an autonomous dis-
cipline and practice. She created a model of nursing consisting of “the core,
the cure, and the care” and implemented that model in the Loeb Center for
Nursing and Rehabilitation. Physicians referred their patients to the Center,
and nurses admitted the patients for nursing care. Nurses worked independ-
ently with patients to foster learning, growth, and healing.
Chapter 6, written by a group of authors, focused on three nursing leaders who
described the nurse–patient relationship: Hildegard Peplau, Ida Jean Orlando, and
Joyce Travelbee. A psychiatric nurse, Peplau viewed the purpose of nursing as help-
ing the patient gain the intellectual and interpersonal competencies necessary to
heal. She articulated stages of the nurse–patient relationship, a framework for anxiety
and nursing interventions to decrease anxiety. Travelbee emphasized the human-
to-human relationship between nurse and person and spoke of the purpose of nursing
as assisting the person(s) to prevent or cope with the experience of illness and suf-
fering. Orlando described attributes of the nurse–patient relationship. She valued re-
lationship as central to the practice of nursing and was the first to describe nursing
process as identifying and responding to needs.

36
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Florence Nightingale’s Legacy


of Caring and Its Applications
Chapter
4
L YNNE M. H EKTOR D UNPHY

Introducing the Theorist Introducing the Theorist


Early Life and Education
Florence Nightingale, the acknowledged founder
Spirituality
of modern nursing, remains a compelling and
War
transformative figure. Not a year goes by in
Introducing the Theory
which new scholarship on Nightingale does
The Medical Milieu
not emerge. Florence Nightingale and the Health
The Feminist Context of Nightingale’s
Caring of the Raj was published in 2003 documenting
Ideas About Nursing Nightingale’s 40-year-long interest and in-
Nightingale’s Legacy for 21st Century volvement in Indian affairs, a previously not
Nursing Practice well explored area of scholarship (Gourley,
Summary 2003). In 2004, a new biography of Nightingale,
References Nightingales: The Extraordinary Upbringing and
Curious Life of Miss Florence Nightingale by
Gillian Gill, was published. In 2008, another
new biography, Florence Nightingale: The Mak-
ing of an Icon by Mark Bostridge, was pub-
lished. 2013 saw yet another biography, very
finely written and presented, Florence Nightingale,
Feminist by Judith Lissauer Cromwell. Squarely
in the camp of viewing Nightingale as a
“feminist”—a term that was non-existent dur-
ing the years that Nightingale was alive—it is
Florence Nightingale a fine work, told from a post-feminist perspec-
tive. Lynn McDonald’s prodigious, ambitious,
and long overdue Collected Works of Florence
Nightingale consists of 16 volumes. In 2005,
the American Nurses Association published
Florence Nightingale Today: Healing, Leader-
ship, Global Action, an ambitious casting of
Nightingale as 21st century nursing’s inspira-
tion and savior. At the time you are perusing
this chapter, it will be more than a century
since the death of Florence Nightingale in
1910 and almost 200 hundred years since her
birth on May 12 in 1820.
Nightingale transformed a “calling from
God” and an intense spirituality into a new so-
cial role for women: that of nurse. Her caring

37
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38 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

was a public one. “Work your true work,” she Nightingale was born in 1820 in Florence,
wrote, “and you will find God within you” Italy—the city she was named for. The
(Woodham-Smith, 1983, p. 74). A reflection Nightingales were on an extended European
on this statement appears in a well-known tour, begun in 1818 shortly after their mar-
quote from Notes on Nursing (Nightingale, riage. This was a common journey for those of
1859/1992): “Nature [i.e., the manifestation of their class and wealth. Their first daughter,
God] alone cures . . . what nursing has to Parthenope, had been born in the city of that
do . . . is put the patient in the best condition name in the previous year.
for nature to act upon him” (Macrae, 1995, A legacy of humanism, liberal thinking, and
p. 10). Although Nightingale never defined love of speculative thought was bequeathed
human care or caring in Notes on Nursing, there to Nightingale by her father. His views on the
is no doubt that her life in nursing exemplified education of women were far ahead of his time.
and personified an ethos of caring. Jean Watson W. E. N., as her father, William, was called,
(1992, p. 83), in the 1992 commemorative edi- undertook the education of both his daughters.
tion of Notes on Nursing, observed, “Although Florence and her sister studied music; gram-
Nightingale’s feminine-based caring-healing mar; composition; modern languages; classical
model has transcended time and is prophetic for Greek and Latin; constitutional history and
this century’s health reform, the model is yet to Roman, Italian, German, and Turkish history;
truly come of age in nursing or the health and mathematics (Barritt, 1973).
care system.” In a reflective essay, Boykin and From an early age, Florence exhibited in-
Dunphy (2002) extended this thinking and dependence of thought and action. The sketch
related Nightingale’s life, rooted in compassion (Fig. 4-1) of W. E. N. and his daughters was
and caring, as an exemplar of justice making
(p. 14). Justice making is understood as a mani-
festation of compassion and caring, “for it is our
actions that bring about justice” (p. 16).
This chapter reiterates Nightingale’s life
from the years 1820 to 1860, delineating the
formative influences on her thinking and pro-
viding historical context for her ideas about
nursing as we recall them today. Part of what
follows is a well-known tale, yet it remains one
that is irresistible, casting an age-old spell on
the reader, like the flickering shadow of
Nightingale and her famous lamp in the dark
and dreary halls of the Barrack Hospital, Scu-
tari, on the outskirts of Constantinople, circa
1854 to 1856. It is a tale that carries even more
relevance for nursing practice today.

Early Life and Education


A profession, a trade, a necessary occupation,
something to fill and employ all my faculties, I
have always felt essential to me, I have always
longed for, consciously or not. . . . The first thought
Fig 4 • 1 A sketch of W. E. N. and his daughters
I can remember, and the last, was nursing work. by one of his wife Fanny’s sisters, Julia Smith.
—FLORENCE NIGHTINGALE, CITED IN COOK Source: Woodham-Smith (1983), p. 9, with permission of
(1913, p. 106) Sir Henry Verney, Bart.
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CHAPTER 4 • Florence Nightingale’s Legacy of Caring and Its Applications 39

done by Nightingale’s beloved aunt, Julia during Illness,” located at 1 Harley Street,
Smith. It is Parthenope, the older sister, who London. After 6 months at Harley Street,
clutches her father’s hand and Florence who, Nightingale wrote in a letter to her father: “I
as described by her aunt, “independently am in the hey-day of my power” (Nightingale,
stumps along by herself” (Woodham-Smith, cited in Woodham-Smith, 1983, p. 77).
1983, p. 7). By October 1854, larger horizons beckoned.
Travel also played a part in Nightingale’s
education. Eighteen years after Florence’s
birth, the Nightingales and both daughters Spirituality
made an extended tour of France, Italy, and
Today I am 30—the age Christ began his Mis-
Switzerland between the years of 1837 and
sion. Now no more childish things, no more vain
1838 and later Egypt and Greece (Sattin,
things, no more love, no more marriage. Now,
1987). From there, Nightingale visited
Lord let me think only of Thy will, what Thou
Germany, making her first acquaintance with
willest me to do. O, Lord, Thy will, Thy will.
Kaiserswerth, a Protestant religious commu-
—FLORENCE NIGHTINGALE, PRIVATE NOTE,
nity that contained the Institution for the
1850, CITED IN WOODHAM-SMITH (1983, p. 130)
Training of Deaconesses, with a hospital
school, penitentiary, and orphanage. A Protes- By all accounts, Nightingale was an intense
tant pastor, Theodore Fleidner, and his young and serious child, always concerned with the
wife had established this community in 1836, poor and the ill, mature far beyond her years.
in part to provide training for women dea- A few months before her 17th birthday,
conesses (Protestant “nuns”) who wished to Nightingale recorded in a personal note dated
nurse. Nightingale was to return there in 1851 February 7, 1837, that she had been called to
against much family opposition to stay from God’s service. What that service was to be was
July through October, participating in a period unknown at that point in time. This was to be the
of “nurse’s training” (Cook, Vol. I, 1913; first of four such experiences that Nightingale
Woodham-Smith, 1983). documented.
Life at Kaiserswerth was spartan. The The fundamental nature of her religious
trainees were up at 5 A.M., ate bread and convictions made her service to God, through
gruel, and then worked on the hospital wards service to humankind, a driving force in her
until noon. Then they had a 10-minute break life. She wrote: “The kingdom of Heaven is
for broth with vegetables. Three P.M. saw an- within; but we must make it without”
other 10-minute break for tea and bread. (Nightingale, private note, cited in Woodham-
They worked until 7 P.M., had some broth, Smith, 1983).
and then Bible lessons until bed. What the It would take 16 long and torturous years,
Kaiserswerth training lacked in expertise it from 1837 to 1853, for Nightingale to actualize
made up for in a spirit of reverence and dedi- her calling to the role of nurse. This was a revo-
cation. Florence wrote, “The world here fills lutionary choice for a woman of her social stand-
my life with interest and strengthens me in ing and position, and her desire to nurse met
body and mind” (Huxley, 1975, p. 24). with vigorous family opposition for many years.
In 1852, Nightingale visited Ireland, touring Along the way, she turned down proposals of
hospitals and keeping notes on various institu- marriage, potentially, in her mother’s view, “bril-
tions along the way. Nightingale took two trips liant matches,” such as that of Richard Monckton
to Paris in 1853; hospital training again was the Milnes. However, her need to serve God and to
goal, this time with the sisters of St. Vincent de demonstrate her caring through meaningful ac-
Paul, an order of nursing nuns. In August 1853, tivity proved stronger. She did not think that she
she accepted her first “official” nursing post could be married and also do God’s will.
as superintendent of an “Establishment for Calabria and Macrae (1994) noted that for
Gentlewomen in Distressed Circumstances Nightingale, there was no conflict between
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40 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

science and spirituality; actually, in her view, Crimea, she was drawn closer to those suffer-
science is necessary for the development of a ing injustice. It was in the Barracks Hospital
mature concept of God. The development of of Scutari that Nightingale acted justly and re-
science allows for the concept of one perfect sponded to a call for nursing from the pro-
God Who regulates the universe through uni- longed cries of the British soldiers (Boykin &
versal laws as opposed to random happenings. Dunphy, 2002, p. 17).
Nightingale referred to these laws, or the or-
ganizing principles of the universe, as
“Thoughts of God” (Macrae, 1995, p. 9). As War
part of God’s plan of evolution, it was the re-
I stand at the altar of those murdered men and
sponsibility of human beings to discover the
while I live I fight their cause.
laws inherent in the universe and apply them
—NIGHTINGALE, CITED IN WOODHAM-SMITH
to achieve well-being. In Notes on Nursing
(1951, P. 182)
(1860/1969, p. 25), she wrote:
Nightingale had powerful friends and had
gained prominence through her study of hos-
God lays down certain physical laws. Upon his car-
pitals and health matters during her travels.
rying out such laws depends our responsibility (that
When Great Britain became involved in the
much abused word). . . . Yet we seem to be contin-
Crimean War in 1854, Nightingale was en-
ually expecting that He will work a miracle—i.e.
sconced in her first official nursing post at 1
break his own laws expressly to relieve us of respon-
Harley Street. Britain had joined France and
sibility.
Turkey to ward off an aggressive Russian ad-
Influenced by the Unitarian ideas of her vance in the Crimea (Fig. 4-2). A successful
father and her extended family, as well as by advance of Russia through Turkey could
the more traditional Anglican Church she at- threaten the peace and stability of the Euro-
tended, Nightingale remained for her entire pean continent.
life a searcher of religious truth, studying a The first actual battle of the war, the Battle
variety of religions and reading widely. She of Alma, was fought in September 1854. It
was a devout believer in God. Nightingale was written of that battle that it was a “glorious
wrote: “I believe that there is a Perfect Being, and bloody victory.” The best communication
of whose thought the universe in eternity is technology of the times, the telegraph, was to
the incarnation” (Calabria & Macrae, 1994, have an effect on what was to follow. In previ-
p. 20). Dossey (1998) recast Nightingale in ous wars, news from the battlefields trickled
the mode of “religious mystic.” However, to home slowly. However, the telegraph enabled
Nightingale, mystical union with God was war correspondents to transmit reports home
not an end in itself but was the source of with rapid speed. The horror of the battlefields
strength and guidance for doing one’s work was relayed to a concerned citizenry. Descrip-
in life. For Nightingale, service to God was tions of wounded men, disease, and illness
service to humanity (Calabria & Macrae, abounded. Who was to care for these men?
1994, p. xviii). The French had the Sisters of Charity to care
In Nightingale’s view, nursing should be a for their sick and wounded. What were the
search for the truth; it should be a discovery of British to do (Goldie, 1987; Woodham-
God’s laws of healing and their proper appli- Smith, 1951)?
cation. This is what she was referring to in The minister of war was Sidney Herbert,
Notes on Nursing when she wrote about the Lord Herbert of Lea, who was the husband of
Laws of Health, as yet unidentified. It was the Liz Herbert; both were close friends of
Crimean War that provided the stage for her Nightingale. Herbert had an innovative solu-
to actualize these foundational beliefs, rooting tion: appoint Miss Nightingale and charge her
forever in her mind certain “truths.” In the to head a contingent of nurses to the Crimea
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CHAPTER 4 • Florence Nightingale’s Legacy of Caring and Its Applications 41

Fig 4 • 2 The Crimea and the Black Sea, 1854 to 1856. Source: Huxley, E. (1975). Designed by Manuel
Lopez Parras.

to provide help and organization to the dete-


riorating battlefield situation. It was a brave Your own personal qualities, your knowledge and
move on the part of Herbert. Medicine and your power of administration, and among greater
war were exclusively male domains. To send a things, your rank and position in society, give you
woman into these hitherto uncharted waters advantages in such a work that no other person pos-
was risky at best. But, as is well known, sesses. (Dolan, 1971, p. 2)
Nightingale was no ordinary woman, and she
more than rose to the occasion. In a passionate At the same time, such that their letters actu-
letter to Nightingale, requesting her to accept ally crossed, Nightingale wrote to Herbert, offer-
this post, Herbert wrote: ing her services. Accompanied by 38 handpicked
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42 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

“nurses” who had no formal training, she (with the laundry farmed out to the soldiers’
arrived on November 4, 1854 to “take wives), it was accomplished under Nightingale’s
charge” and did not return to England until eagle eye: “She insisted on the huge wooden
August 1856. tubs in the wards being emptied, standing
Biographer Woodham-Smith and Nightin- [obstinately] by the side of each one, sometimes
gale’s own correspondence, as cited in a num- for an hour at a time, never scolding, never rais-
ber of sources (Cook, 1913; Goldie, 1987; ing her voice, until the orderlies gave way
Huxley, 1975; Summers, 1988; Vicinus & and the tub was emptied” (Woodham-Smith,
Nergaard, 1990), paint the most vivid picture 1951, p. 116).
of the experiences that Nightingale sustained Nightingale set up her own extra “diet
there, experiences that cemented her views on kitchen.” Small portions, helpings of such
disease and contagion, as well as her commit- things as arrowroot, port wine, lemonade, rice
ment to an environmental approach to health pudding, jelly, and beef tea, whose purpose was
and illness: to tempt and revive the appetite, were provided
to the men. It was therefore a logical sequence
from cooking to feeding, from administering
The filth became indescribable. The men in the cor- food to administering medicines. Because no
ridors lay on unwashed floors crawling with vermin. antidote to infection existed at this time, the
As the Rev. Sidney Osborne knelt to take down provision—by Nightingale and her nurses—of
dying messages, his paper became thickly covered cleanliness, order, encouragement to eat, feed-
with lice. There were no pillows, no blankets; the ing, clean bed linen, clean bodies, and clean
men lay, with their heads on their boots, wrapped wards was essential to recovery (Summers,
in the blanket or greatcoat stiff with blood and filth 1988).
which had been their sole covering for more than a
Mortality rates at the Barrack Hospital in
week . . . [S]he [Miss Nightingale] estimated . . . .
Scutari fell. In February, at Nightingale’s in-
there were more than 1000 men suffering from
sistence, the prime minister had sent to the
acute diarrhea and only 20 chamber pots. . . .
Crimea a sanitary commission to investigate
[T]here was liquid filth which floated over the floor
the high mortality rates. Beginning their work
an inch deep. Huge wooden tubs stood in the halls
in March, they described the conditions at the
and corridors for the men to use. In this filth lay the
Barrack Hospital as “murderous.” Setting to
men’s food—Miss Nightingale saw the skinned car-
work immediately, they opened the channel
cass of a sheep lie in a ward all night . . . the stench
through which the water supplying the hospi-
from the hospital could be smelled outside the walls.
tal flowed, where a dead horse was found. The
(Woodham-Smith, 1983)
commission cleared “556 handcarts and large
On her arrival in the Crimea, the immedi- baskets full of rubbish . . . 24 dead animals and
ate priority of Nightingale and her small band 2 dead horses buried.” In addition, they
of nurses was not in the sphere of medical or flushed and cleansed sewers, lime-washed
surgical nursing as currently known; rather, walls, tore out shelves that harbored rats, and
their order of business was domestic manage- got rid of vermin. The commission, Nightin-
ment. This is evidenced in the following ex- gale said, “saved the British Army.” Miss
change between Nightingale and one of her Nightingale’s anti-contagionism was sealed as
party as they approached Constantinople: “Oh, the mortality rates began showing dramatic
Miss Nightingale, when we land don’t let there declines (Rosenberg, 1979).
be any red-tape delays, let us get straight to Figure 4-3 illustrates Nightingale’s own
nursing the poor fellows!” Nightingale’s reply: hand-drawn “coxcombs” (as they were referred
“The strongest will be wanted at the wash tub” to), as Nightingale, always aware of the neces-
(Cook, 1913; Dolan, 1971). sity of documenting outcomes of care, kept
Although the bulk of this work continued to copious records of all sorts (Cook, 1913;
be done by orderlies after Nightingale’s arrival Rosenberg, 1979; Woodham-Smith, 1951).
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CHAPTER 4 • Florence Nightingale’s Legacy of Caring and Its Applications 43

Diagram Representing the Mortality in the Hospitals


at Scutari and Kulali from Oct. 1st 1854 to Sept. 30th 1855

May 20 to June 9
June 10 to June 30
Apr. 29 to May 19 48 per
100 22
52 per per
100 100 July 1 to Sept. 30, 1855
Apr. 8 to Apr. 28 107 per 100 22 per 100
1854
Mar. 18 to Apr.7 144 per 100 22 per 100
Oct. 1 to Oct.10
Commencement of Sanitary Improvements 85 per 100

315 per 100


Oct. 15 to Nov. 11
155 per 100
Feb. 25 to Mar. 17

427 per 100 179 per 100


321 per 100 Nov. 12 to Dec. 9

Dec. 10 to Jan. 6, 1855 Fig 4 • 3 Diagram by Florence Nightingale


Feb. 1 to Feb. 28
showing declining mortality rates. Source:
Jan. 7 to Jan. 31 Cohen (1981).

Florence Nightingale possessed moral author- In April 1855, after having been in Scutari
ity, so firm because it was grounded in caring for 6 months, Florence wrote to her mother,
and was in a larger mission that came from her “[A]m in sympathy with God, fulfilling the
spirituality. For Miss Nightingale, spirituality purpose I came into the world for” (Woodham-
was a much broader, more unifying concept than Smith, 1983, p. 97). Henry Wadsworth
that of religion. Her spirituality involved the Longfellow authored “Santa Filomena” to
sense of a presence higher than humanity, the commemorate Miss Nightingale.
divine intelligence that creates, sustains, and or-
ganizes the universe, and an awareness of our
inner connection to this higher reality. Through Lo! In That House of Misery
this inner connection flows creative endeavors A lady with a lamp I see
and insight, a sense of purpose and direction. Pass through the glimmering gloom
For Miss Nightingale, spirituality was intrinsic And flit from room to room
to human nature and was the deepest, most po- And slow as if in a dream of bliss
tent resource for healing. In Suggestions for The speechless sufferer turns to kiss
Thought (Calabria & Macrae, 1994, p. 58), Her shadow as it falls
Nightingale wrote that “human consciousness is Upon the darkening walls
tending to become what God’s consciousness As if a door in heaven should be
is—to become One with the consciousness of Opened and then closed suddenly
God.” This progression of consciousness to unity The vision came and went
with the divine was an evolutionary view and not The light shone and was spent.
typical of either the Anglican or Unitarian views A lady with a lamp shall stand
of the time (Calabria & Macrae, 1994; Macrae, In the great history of the land
1995; Rosenberg, 1979; Slater, 1994; Welch, A noble type of good
1986; Widerquist, 1992). Heroic womanhood (Longfellow, cited in Dolan,
There were 4 miles of beds in the Barrack 1971, p. 5)
Hospital at Scutari, a suburb of Constantino- Miss Nightingale slipped home quietly, ar-
ple. A letter to the London Times dated riving at Lea Hurst in Derbyshire on August
February 24, 1855, reported the following: 7, 1856, after 22 months in the Crimea and
“When all the medical officers have retired for after sustained illness from which she was
the night and silence and darkness have settled never to recover, after ceaseless work and after
upon those miles of prostrate sick, she may be witnessing suffering, death, and despair that
observed, alone with a little lamp in her hand, would haunt her for the remainder of her life.
making her solitary rounds” (Kalisch & Her hair was shorn; she was pale and drawn
Kalisch, 1987, p. 46). (Fig. 4-4). She took her family by surprise. The
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44 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

next morning, a peal of the village church bells of something quite different—of the want of
and a prayer of Thanksgiving were, her sister fresh air, or light, or of warmth, or of quiet, or
wrote, “‘all the innocent greeting’ except for of cleanliness, or of punctuality and care in the
those provided by the spoils of war that had administration of diet, of each or of all of these.
proceeded her—a one-legged sailor boy, a —FLORENCE NIGHTINGALE, NOTES ON
small Russian orphan, and a large puppy found NURSING (1860/1969, p. 8)
in some rocks near Balaclava. All England was
ringing with her name, but she had left her heart
on the battlefields of the Crimea and in the The Medical Milieu
graveyards of Scutari” (Huxley, 1975, p. 147). To gain a better understanding of Nightin-
gale’s ideas on nursing, one must enter the par-
Introducing the Theory ticular world of 19th-century medicine and its
views on health and disease. Considerable new
In watching disease, both in private homes and medical knowledge had been gained by 1800.
public hospitals, the thing which strikes the ex- Gross anatomy was well known; chemistry
perienced observer most forcefully is this, that the promised to shed light on various body
symptoms or the sufferings generally considered processes. Vaccination against smallpox ex-
to be inevitable and incident to the disease are isted. There were some established drugs in the
very often not symptoms of the disease at all, but pharmacopoeia: cinchona bark, digitalis, and
mercury. Certain major diseases, such as lep-
rosy and the bubonic plague, had almost dis-
appeared. The crude death rate in western
Europe was falling, largely related to decreas-
ing infant mortality as a result of improvement
in hygiene and standard of living (Ackernecht,
1982; Shyrock, 1959).
Yet, in 1800, physicians still had only the
vaguest notion of diagnosis. Speculative
philosophies continued to dominate medical
thought, although inroads continued to be
made that eventually gave way to a new out-
look on the nature of disease: from belief in
general states common to all illnesses to an
understanding of disease-specificity symp-
toms. It was this shift in thought—a para-
digm shift of the first order—that gave us the
triumph of 20th-century medicine, with all
its attendant glories and concurrent sterility.
The 18th century was host to two major tra-
ditions or paradigms in the healing arts: one
based on “empirics” or “experience,” trial and
error, with an emphasis on curative remedies;
the other based on Hippocratic notions and
learning. Evidence of both these trends per-
sisted into the 19th century and can be found
Fig 4 • 4 A rare photograph of Florence taken on in Nightingale’s philosophy.
her return from the Crimea. Although greatly Consistent with the philosophical nature
weakened by her illness, she refused to accept her
friends’ advice to rest, and pressed on relentlessly of her superior education (Barritt, 1973),
with her plans to reform the army medical serv- Nightingale, like many of the physicians of her
ices. Source: Huxley (1975), p. 139. time, continued to emphatically disavow the
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CHAPTER 4 • Florence Nightingale’s Legacy of Caring and Its Applications 45

reality of specific states of disease. She insisted how a minute amount of some contaminating
on a view of sickness as an “adjective,” not a substance could in turn “pollute” the entire at-
substantive noun. Sickness was not an “entity” mosphere, the very air that was breathed. What
somehow separable from the body. Consistent was at issue was the specificity of the contami-
with her more holistic view, sickness was an nating substance. Nightingale, and the anti-
aspect or quality of the body as a whole. Some contagionists, endorsed the position that a
physicians, as she phrased it, taught that dis- “sufficiently intense level of atmospheric con-
eases were like cats and dogs, distinct species tamination could induce both endemic and
necessarily descended from other cats and epidemic ills in the crowded hospital wards
dogs. She found such views misleading [with particular configurations of environ-
(Nightingale, 1860/1969). mental circumstances determining which]”
At this point in time, in the mid-19th cen- (Rosenberg, 1979).
tury, there were two competing theories re- Anti-contagionism reached its peak be-
garding the nature and origin of disease. One fore the political revolutions of 1848; the re-
view was known as “contagionism,” postulating sulting wave of conservatism and reaction
that some diseases were communicable, spread brought contagionism back into dominance,
via commerce and population migration. A where it remained until its reformulation into
strategic consequence of this explanatory model the germ theory in the 1870s. Leaders of the
was quarantine, and its attendant bureaucracy contagionists were primarily high-ranking
aimed at shutting down commerce and trade military physicians, politically united. These
to keep disease away from noninfected areas. divergent worldviews accounted in some
To the new and rapidly emerging merchant part for Nightingale’s clashes with the mili-
classes, quarantine represented government tary physicians she encountered during the
interference and control (Ackernecht, 1982; Crimean War.
Arnstein, 1988). Given the intellectual and social milieu in
The second school of thought on the nature which Nightingale was raised and educated, her
and origin of disease, of which Nightingale stance on contagionism seems preordained and
was an ardent champion, was known as “anti- logically consistent (Rosenberg, 1979). Likewise,
contagionism.” It postulated that disease re- the eclectic religious philosophy she evolved
sulted from local environmental sources and contained attributes of the philosophy of Uni-
arose out of “miasmas”—clouds of rotting filth tarianism with the fervor of Evangelicalism, all
and matter, activated by a variety of things based on an organic view of humans as part of
such as meteorological conditions (note the nature. The treatment of disease and dysfunction
similarity to elements of water, fire, air, and was inseparable from the nature of man as a
earth on humors); the filth must be eliminated whole, and likewise, the environment. And all
from local areas to prevent the spread of dis- were linked to God.
ease. Commerce and “infected” individuals The emphasis on “atmosphere” (or “environ-
were left alone (Rosenberg, 1979). ment”) in the Nightingale model is consistent
William Farr, another Nightingale associate with the views of the “anti-contagionists” of her
and avid anti-contagionist, was Britain’s statis- time. This worldview was reinforced by
tical superintendent of the General Register Nightingale’s Crimean experiences, as well as
Office. Farr categorized epidemic and infec- her liberal and progressive political thought. In
tious diseases as zygomatic, meaning pertaining addition, she viewed all ideas as being distilled
to or caused by the process of fermentation. through a distinctly moral lens (Rosenberg,
The debate as to whether fermentation was a 1979). As such, Nightingale was typical of a
chemical process or a “vitalistic” one had been number of her generation’s intellectuals. These
raging for some time (Swazey & Reed, 1978). thinkers struggled to come to grips with an in-
The familiarity of the process of fermentation creasingly complex and changing world order
helps to explain its appeal. Anyone who and frequently combined a language of two dis-
had seen bread rise could immediately grasp parate realms of authority: the moral realm and
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46 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

the emerging scientific paradigm that has as- plight in the 19th century. However, in other
sumed dominance in the 20th century. Tradi- ways, her views on women and the question of
tional religious and moral assumptions were women’s rights were quite mixed.
garbed in a mantle of “scientific objectivity,” Notes on Nursing: What It Is and What It Is
often spurious at best, but more in keeping with Not (1859/1969) was written not as a manual
the increasingly rationalized and bureaucratic to teach nurses to nurse but rather to help all
society accompanying the growth of science. women to learn how to nurse.
Nightingale believed all women required
this knowledge to take proper care of their
The Feminist Context of families during times of sickness and to pro-
Nightingale’s Caring mote health—specifically what Nightingale re-
ferred to as “the health of houses,” that is, the
I have an intellectual nature which requires sat-
“health” of the environment, which she es-
isfaction and that would find it in him. I have a
poused. Nursing, to her, was clearly situated
passionate nature which requires satisfaction and
within the context of female duty.
that would find it in him. I have a moral, an ac-
In Ordered to Care: The Dilemma of American
tive nature which requires satisfaction and that
Nursing, historian Susan Reverby (1987) traces
would not find it in his life.
contemporary conflicts within the nursing pro-
—FLORENCE NIGHTINGALE, PRIVATE NOTE,
fession back to Nightingale herself. She asserts
1849, CITED IN WOODHAM-SMITH (1983, p. 51)
that Nightingale’s ideas about female duty and
Florence Nightingale wrote the following authority, along with her views on disease
tortured note upon her final refusal of Richard causality, brought about an independent
Monckton Milnes’s proposal of marriage: “I field—that of nursing—that was separate, and
know I could not bear his life,” she wrote, in the view of Nightingale, equal, if not supe-
“that to be nailed to a continuation, an exag- rior, to that of medicine. But this field was
geration of my present life without hope of dominated by a female hierarchy and insisted
another would be intolerable to me—that vol- on both deference and loyalty to the physi-
untarily to put it out of my power ever to be cian’s authority. Reverby (1987) sums it up as
able to seize the chance of forming for myself follows: “Although Nightingale sought to free
a true and rich life would seem to be like sui- women from the bonds of familial demand, in
cide” (Nightingale, personal note cited in her nursing model she rebound them in a new
Woodham-Smith, 1983, p. 52). For Miss context.” (p. 43)
Nightingale there was no compromise. Mar- Does the record support this evidence? Was
riage and pursuit of her “mission” were not Nightingale a champion for women’s rights or
compatible. She chose the mission, a clear re- a regressive force? As noted earlier, the answer
pudiation of the mores of her time, which is far from clear.
were rooted in the time-honored role of fam- The shelter for all moral and spiritual values,
ily and “female duty.” threatened by the crass commercialism that was
The census of 1851 revealed that there were flourishing in the land, as well as the spirit of
365,159 “excess women” in England, meaning critical inquiry that accompanied this age of ex-
women who were not married. These women panding scientific progress, was agreed upon:
were viewed as redundant, as described in an the home. All considered this to be a “sacred
essay about the census titled “Why Are Women place, a Temple” (Houghton, 1957, p. 343).
Redundant?” (Widerquist, 1992, p. 52). Many And who was the head of this home? Woman.
of these women had no acceptable means of Although the Victorian family was patriarchal
support, and Nightingale’s development of a in nature in that women had virtually no eco-
suitable occupation for women, that of nursing, nomic and/or legal rights, they nonetheless
was a significant historical development and a yielded a major moral authority (Arnstein,
major contribution by Nightingale to women’s 1988; Houghton, 1957; Perkins, 1987).
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CHAPTER 4 • Florence Nightingale’s Legacy of Caring and Its Applications 47

There was hostility on the part of men as viewed with hostility and as inappropriate
well as some women toward women’s emanci- for women. Why should these women not
pation. Many intelligent women—for exam- be nurses or nurse midwives, a far superior
ple, Beatrice Webb, George Eliot, and, at calling in Nightingale’s view than that of a
times, Nightingale herself—viewed their gen- medicine “man” (Monteiro, 1984)?
der’s emancipation with apprehension. In Welch (1990) termed Nightingale a
Nightingale’s case, the best word might be “Christian feminist” on the eve of her depar-
“ambivalence.” There was a fear of weakening ture to the Crimea. She returned even more
women’s moral influence, coarsening the fem- skeptical of women. Writing to her close
inine nature itself. friend Mary Clarke Mohl, she described
This stance is best equated with cultural women whom she worked with in the Crimea
feminism, defined as a belief in inherent gen- as being incompetent and incapable of inde-
der differences. Women, in contrast to men, pendent thought (Welch, 1990; Woodham-
are viewed as morally superior, the holders of Smith, 1983). According to Palmer (1977), by
family values and continuity; they are refined, this time in her life, the concerns of the British
delicate, and in need of protection. This people and the demands of service to God took
school of thought, important in the 19th cen- precedence over any concern she had ever had
tury, used arguments for women’s suffrage about women’s rights.
such as the following: “[W]omen must make In other words, Nightingale, despite the
themselves felt in the public sphere because clear freedom in which she lived her own life,
their moral perspective would improve cor- nonetheless genderized the nursing role, leaving
rupt masculine politics.” In the case of it rooted in 19th-century morality. Nightingale
Nightingale, these cultural feminist attitudes is seen constantly trying to improve the exist-
“made her impatient with the idea of women ing order and to work within that order; she
seeking rights and activities just because men was above all a reformer, seeking to improve
valued these entities” (Bunting & Campbell, the existing order, not to change the terrain
1990, p. 21). radically.
Nightingale had chafed at the limitations In Nightingale’s mind, the specific “scien-
and restrictions placed on women, especially tific” activity of nursing—hygiene—was the
“wealthy” women with nothing to do: “What central element in health care, without which
these [women] suffer—even physically— medicine and surgery would be ineffective:
from the want of such work no one can tell.
The accumulation of nervous energy, which
The Life and Death, recovery or invaliding of patients
has had nothing to do during the day, makes
generally depends not on any great and isolated
them feel every night, when they go to bed,
act, but on the unremitting and thorough perform-
as if they were going mad.” Despite these
ance of every minute’s practical duty. (Nightingale,
vivid words, authored by Nightingale
1860/1969)
(1852/1979) in the fiery polemic “Cassan-
dra,” which was used as a rallying cry in This “practical duty” was the work of
many feminist circles, her view of the solu- women, and the conception of the proper di-
tion was measured. Her own resolution, vision of labor resting on work demands inter-
painfully arrived at, was to break from her nal to each respective “science,” nursing and
family and actualize her caring mission, that medicine, obscured the professional inequality.
of nurse. One of the many results of this was The later successes of medical science height-
that a useful occupation for other women to ened this inequity. The scientific grounding
pursue was founded. Although Nightingale espoused by Nightingale for nursing was
approved of this occupation outside of the ephemeral at best, as later 19th-century dis-
home for other women, certain other occu- coveries proved much of her analysis wrong,
pations—that of doctor, for example—she although nonetheless powerful. Much of her
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48 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

strength was in her rhetoric; if not always log- woman alone and in command (Auerbach,
ically consistent, it certainly was morally reso- 1982, pp. 120–121).
nant (Rosenberg, 1979). Nightingale’s clearly chosen spinsterhood
Despite exceptional anomalies, such as repudiated the Victorian family. Her unmar-
women physicians, what Nightingale effec- ried life provides a vision of a powerful life
tively accomplished was a genderization of lived on her own terms. This is not the spin-
the division of labor in health care: male sterhood of convention—one to be pitied, one
physicians and female nurses. This appears to of broken hearts—but a radically new image.
be a division that Nightingale supported. Be- She is freed from the trivia of family com-
cause this “natural” division of labor was plaints and scorns the feminist collectivity; yet
rooted in the family, women’s work outside in this seemingly solitary life, she finds union
the home ought to resemble domestic tasks not with one man but with all men, personified
and complement the “male principle” with by the British soldier.
the “female.” Thus, nursing was left on the Lytton Strachey’s well-known evocation of
shifting sands of a soon-outmoded “science”; Nightingale, iconoclastic and bold, is perhaps
the main focus of its authority grounded in closest to the decidedly masculine imagery she
an equally shaky moral sphere, also subject to selected to describe herself, as evidenced in
change and devaluation in an increasingly this imaginary speech to her mother written
secularized, rationalized, and technological in 1852:
20th century.
Nightingale failed to provide institution-
alized nursing with an autonomous future, on Well, my dear, you don’t imagine with my “talents,”
an equal parity with medicine. She did, how- and my “European reputation” and my “beautiful let-
ever, succeed in providing women’s work in ters” and all that, I’m going to stay dangling around
the public sphere, establishing for numerous my mother’s drawing room all my life! . . . [Y]ou must
women an identity and source of employ- look upon me as your vagabond son . . . I shan’t
ment. Although that public identity grew out cost you nearly as much as a son would have done,
of women’s domestic and nurturing roles in or had I married. You must consider me married or
the family, the conditions of a modern society a son. (Woodham-Smith, 1983, p. 66)
required public as well as private forms of
care. It is questionable whether more could
have been achieved at that point in time Ideas About Nursing
(King, 1988). Every day sanitary knowledge, or the knowledge
A woman, Queen Victoria, presided over of nursing, or in other words, of how to put the
the age: “Ironically, Queen Victoria, that constitution in such a state as that it will have
panoply of family happiness and stubborn ad- no disease, or that it can recover from disease,
versary of female independence, could not help takes a higher place.
but shed her aura upon single women.” The —FLORENCE NIGHTINGALE, NOTES ON
queen’s early and lengthy widowhood, her “re- NURSING (1860/1969), PREFACE
lentlessly spreading figure and commensurately
increasing empire, her obstinate longevity Evelyn R. Barritt, professor of nursing and
which engorged generations of men and the Nightingale scholar, suggested that nursing
collective shocks of history, lent an epic quality became a science when Nightingale identified
to the lives of solitary women” (Auerbach, the laws of nursing, also referred to as the laws
1982, pp. 120–121). Both Nightingale and the of health, or nature (Barritt, 1973; Nightin-
queen saw themselves as working through gale, 1860/1969). The remainder of all nursing
men, yet their lives added new, unexpected, theory may be viewed as mere branches and
and powerful dimensions to the myth of “acorns,” all fruit of the roots of Nightingale’s
Victorian womanhood, particularly that of a ideas. Early writings of Nightingale, compiled
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CHAPTER 4 • Florence Nightingale’s Legacy of Caring and Its Applications 49

in Notes on Nursing: What It Is and What It Is (McDonald, 1994). McDonald notes that
Not (1860/1969), provided the earliest system- Nightingale was firmly committed to “a deter-
atic perspective for defining nursing. Accord- mined, probabilistic social science” and goes
ing to Nightingale, analysis and application of on to state that “Indeed, she [Nightingale] de-
universal “laws” would promote well-being and scribed the laws of social science as God’s laws
relieve the suffering of humanity. This was the for the right operation of the world” (p. 186).
goal of nursing. Nightingale was convinced of the necessity for
As noted by the caring theorist Madeline evaluative statistics to underpin rational ap-
Leininger, Nightingale never defined human proaches to public administrations. Consis-
care or caring in Nightingale’s Notes on Nursing tently she used the presentation of statistical
(1859/1992, p. 31), and she goes on to wonder data to prove her case that the costs of disease,
if Nightingale considered “components of care crime, and excess mortality was greater than the
such as comfort, support, nurturance, and cost of sanitary improvements. In later life,
many other care constructs and characteristics Nightingale endeavored to establish a chair
and how they would influence the reparative or readership at Oxford University to teach
process.” Although Nightingale’s conceptual- Quetelet’s statistical approaches and probability
izations of nursing, hygiene, the laws of health, theory. In today’s world, this would translate to
and the environment never explicitly identify a commitment to evidence-based practice as
the construct of caring, an underlying ethos of justification for nursing’s value.
care and commitment to others echoes in her Karen Dennis and Patricia Prescott (1985)
words and, most importantly, resides in her ac- noted that including Nightingale among the
tions and the drama of her life. nurse theorists has been a recent development.
Nightingale did not theorize in the way to They make the case that nurses today continue
which we are accustomed today. Patricia to incorporate in their practice the insight,
Winstead-Fry (1993), in a review of the 1992 foresight, and, most important, the clinical
commemorative edition of Nightingale’s acumen of Nightingale’s more than century
Notes on Nursing (1859/1992, p. 161), states: and a half vision of nursing. As part of a larger
“Given that theory is the interrelationship of study, they collected a large base of descrip-
concepts which form a system of propositions tions from both nurses and physicians describ-
that can be tested and used for predicting ing “good” nursing practice. More than 300
practice, Nightingale was not a theorist. individual interviews were subjected to content
None of her major biographers present her as analysis; categories were named inductively
a theorist. She was a consummate politician and validated separately by four members of
and health care reformer.” And our emerging the project staff.
21st century has never been more in need of Noting no marked differences in the de-
nurses who are consummate politicians and scriptions obtained from either the nurses or
health-care reformers. Her words and ideas, physicians, the authors report that despite
contextualized in the earlier portion of this their independent derivation, the categories
chapter, ring differently than those of the that emerged during the study bore a striking
other nursing theorists you will study in this resemblance to nursing practice as described
book. However, her underlying ideas con- by Nightingale: prevention of illness and pro-
tinue to be relevant and, some would argue, motion of health, observation of the sick, and
prescient. attention to the physical environment. Also
Lynn McDonald, Canadian professor of referred to by Nightingale as the “health of
sociology and editor of the Collected Works of houses,” this physical environment included
Florence Nightingale, a 16-volume collection, ventilation of both the patient’s rooms and the
places Nightingale among the most promi- larger environment of the “house”: light,
nent “Women Methodologists” identified in cleanliness, and the taking of food; attention
The Women Founders of the Social Sciences to the interpersonal milieu, which included
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50 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

variety; and not indulging in superficialities with Nightingale’s Assumptions


the sick or giving them false encouragement. 1. Nursing is separate from medicine.
The authors noted that “the words change 2. Nurses should be trained.
but the concepts do not” (Dennis & Prescott, 3. The environment is important to the
1985, p. 80). In keeping with the tradition health of the patient.
established by Nightingale, they noted that 4. The disease process is not important to
nurses continue to foster an interpersonal nursing.
milieu that focuses on the person while ma- 5. Nursing should support the environment
nipulating and mediating the environment to assist the patient in healing.
to “put the patient in the best condition for 6. Research should be used through observa-
nature to act upon him” (Nightingale, 1860/ tion and empirics to define the nursing
1969, p. 133). discipline.
Afaf I. Meleis (1997), nurse scholar, does 7. Nursing is both an empirical science and
not compare Nightingale to contemporary an art.
nurse theorists; nonetheless, she refers to her fre- 8. Nursing’s concern is with the person in
quently. Meleis stated that it was Nightingale’s the environment.
conceptualization of environment as the 9. The person is interacting with the
focus of nursing activity and her de-emphasis environment.
of pathology, emphasizing instead the “laws 10. Sickness and wellness are governed by the
of health” (which she said were yet to be same laws of health.
identified), that were the earliest differenti- 11. The nurse should be observant and
ation of nursing and medicine. Meleis (1997, confidential.
pp. 114–116) described Nightingale’s con-
cept of nursing as including “the proper use The goal of nursing as described by
of fresh air, light, warmth, cleanliness, quiet, Nightingale is assisting the patient in his or her
and the proper selection and administration retention of “vital powers” by meeting his or
of diet, all with the least expense of vital her needs, and thus, putting the patient in the
power to the patient.” These ideas clearly had best condition for nature to act upon
evolved from Nightingale’s observations and (Nightingale, 1860/1969). This must not be in-
experiences. The art of observation was iden- terpreted as a “passive state” but rather one that
tified as an important nursing function in the reflects the patient’s capacity for self-healing
Nightingale model. And this observation was facilitated by nurses’ ability to create an envi-
what should form the basis for nursing ideas. ronment conducive to health. The focus of this
Meleis speculates on how differently the the- nursing activity was the proper use of fresh air,
oretical base of nursing might have evolved light, warmth, cleanliness, quiet, proper selec-
if we had continued to consider extant nurs- tion and administration of diet, monitoring the
ing practice as a source of ideas. patient’s expenditure of energy, and observing.
Pamela Reed and Tamara Zurakowski This activity was directed toward the environ-
(1983/1989, p. 33) called the Nightingale ment and the patient (see Nightingale’s
model “visionary.” They stated: “At the core of Assumptions).
all theory development activities in nursing Health was viewed as an additive process—
today is the tradition of Florence Nightingale.” the result of environmental, physical, and psy-
They also suggest four major factors that influ- chological factors, not just the absence of
enced her model of nursing: religion, science, disease. Disease was the reparative process of
war, and feminism, all of which are discussed the body to correct a problem and could pro-
in this chapter. vide an opportunity for spiritual growth. The
The following assumptions were identified laws of health, as defined by Nightingale, were
by Victoria Fondriest and Joan Osborne those to do with keeping the person, and the
(1994). population, healthy. They were dependent on
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CHAPTER 4 • Florence Nightingale’s Legacy of Caring and Its Applications 51

proper environmental control, for example, surface, these might appear to be odd bedfel-
sanitation. The environment was what the lows; however, this marriage flows directly
nurse manipulated; it included the physical from Nightingale’s underlying religious and
elements external to the patient. philosophic views, which were operational-
Nightingale isolated five environmental ized in her nursing practice. Nightingale was
components essential to an individual’s health: an empiricist, valuing the “science” of obser-
clean air, pure water, efficient drainage, clean- vation with the intent of using that knowl-
liness, and light. edge to better the life of humankind. The
The patient is at the center of the application of that knowledge required an
Nightingale model, which incorporates a ho- artist’s skill, far greater than that of the
listic view of the person as someone with painter or sculptor:
psychological, intellectual, and spiritual com-
ponents. This is evidenced in her acknowl-
Nursing is an art; and if it is to be made an art, it re-
edgment of the importance of “variety.” For
quires as exclusive a devotion, as hard a prepara-
example, she wrote of “the degree . . . to
tion, as any painter’s or sculptor’s work; for what is
which the nerves of the sick suffer from see-
the having to do with dead canvas or cold marble,
ing the same walls, the same ceiling, the same
compared with having to do with the living body—
surroundings” (Nightingale, 1860/1969). Like-
the Temple of God’s spirit? It is one of the Fine Arts;
wise, her chapter on “chattering hopes and
I had almost said, the finest of the Fine Arts. (Florence
advice” illustrates an astute grasp of human
Nightingale, cited in Donahue, 1985, p. 469)
nature and of interpersonal relationships. She
remarked on the spiritual component of dis- Nightingale’s ideas about nursing health,
ease and illness, and she felt they could pres- the environment, and the person were
ent an opportunity for spiritual growth. In grounded in experience; she regarded one’s
this, all persons were viewed as equal. sense observations as the only reliable means
A nurse was defined as any woman who of obtaining and verifying knowledge. The-
had “charge of the personal health of some- ory must be reformulated if inconsistent with
body,” whether well, as in caring for babies empirical evidence. This experiential knowl-
and children, or sick, as an “invalid” edge was then to be transformed into empir-
(Nightingale, 1860/1969). It was assumed ically based generalizations, an inductive
that all women, at one time or another in process, to arrive at, for example, the laws
their lives, would nurse. Thus, all women of health. Regardless of Nightingale’s com-
needed to know the laws of health. Nursing mitment to empiricism and experiential
proper, or “sick” nursing, was both an art and knowledge, her early education and religious
a science and required organized, formal ed- experience also shaped this emerging knowl-
ucation to care for those suffering from dis- edge (Hektor, 1992).
ease. Above all, nursing was “service to God According to Nightingale’s model, nursing
in relief of man”; it was a “calling” and contributes to the ability of persons to maintain
“God’s work” (Barritt, 1973). Nursing activ- and restore health directly or indirectly through
ities served as an “art form” through which managing the environment. The person has a
spiritual development might occur (Reed & key role in his or her own health, and this
Zurakowski, 1983/1989). All nursing actions health is a function of the interaction among
were guided by the nurses’ caring, which was person, nurse, and environment. However, nei-
guided by underlying ideas about God. ther the person nor the environment is dis-
Consistent with this caring base is cussed as influencing the nurse (Fig. 4-5).
Nightingale’s views on nursing as an art and a Although it is difficult to describe the inter-
science. Again, this was a reflection of the mar- relationship of the concepts in the Nightingale
riage, essential to Nightingale’s underlying model, Figure 4-6 is a schema that attempts
worldview, of science and spirituality. On the to delineate this. Note the prominence of
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52 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

Observation
“observation” on the outer circle (important to
all nursing functions) and the interrelationship
Personal cleanliness of the specifics of the interventions, such as
Petty management “bed and bedding” and “cleanliness of rooms
and walls,” that go into making up the “health
Light
of houses” (Fondriest & Osborne, 1994).
Health of houses

Cleanliness of rooms Nightingale’s Legacy for 21st


Ventilation and warming Century Nursing Practice
Bed and bedding Philip Kalisch and Beatrice Kalisch (1987,
p. 26) described the popular and glorified im-
Taking food
ages that arose out of the portrayals of Florence
What food? Nightingale during and after the Crimean
War—that of nurse as self-sacrificing, refined,
Noise
Order virginal, and an “angel of mercy,” a far less
of Chattering hopes
significance and advices threatening image than one of educated and
skilled professional nurses. They attribute
Variety
nurses’ low pay to the perception of nursing as
Fig 4 • 5 Perspective on Nightingale’s 13 canons. a “calling,” a way of life for devoted women
Illustration developed by V. Fondriest, RN, BSN, and with private means, such as Florence Nightingale
J. Osborne, RN, C BSN in October 1994. (Kalisch & Kalisch, 1987, p. 20). Well over

“Nursing”
Observation

Management

Ventilation & warming


“Environment”

Health of houses (pure air, water & light)

Bed &
bedding Taking food
Light,
noise & Cleanliness
variety of rooms &
walls

What food ?
Chattering
Personal
hopes &
cleanliness
advices

Fig 4 • 6 Nightingale’s model of nursing and the environment. Illustration developed by V. Fondriest, RN, BSN,
and J. Osborne, RN, C BSN.
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CHAPTER 4 • Florence Nightingale’s Legacy of Caring and Its Applications 53

100 years later, the amount of scholarship on British Army and, indeed, the entire British
Nightingale provides a more realistic portrait Commonwealth.
of a complex and brilliant woman. To quote Themes in contemporary nursing practice
Auerbach (1982) and Strachey (1918), she was focusing on evidence-based practice and cur-
“a demon, a rebel.” ricula championing cultures of safety and qual-
Florence Nightingale’s legacy of caring and ity are all found in the life and works of
the activism it implies is carried on in nursing Florence Nightingale. I would venture to say
today. There is a resurgence and inclusion of that almost all contemporary nursing practice
concepts of spirituality in current nursing settings echo some aspect of the ideas—and
practice and a delineation of nursing’s caring ideals—of Nightingale. Themes of Nightin-
base that in essence began with the nursing gale, the environmentalist, are critical to nurs-
life of Florence Nightingale. Nightingale’s ing practice for the individual, the community,
caring, as demonstrated in this chapter, ex- and global health. An exemplar of practice
tended beyond the individual patient, beyond personifying Nightingale’s approach and prac-
the individual person. She herself said that the tice would be a larger-than-life nurse hero or
specific business of nursing was the least im- heroine championing current health-care re-
portant of the functions into which she had form by designing health-care systems that are
been forced in the Crimea. Her caring encom- truly responsive to the needs of the populace
passed a broadened sphere—that of the and that extend cross-culturally and globally.

■ Summary
The unique aspects of Florence Nightingale’s integral values of caring in an unjust health-care
personality and social position, combined with system that does not value caring. Let us look
historical circumstances, laid the groundwork again to Florence Nightingale for inspiration,
for the evolution of the modern discipline of for she remains a role model par excellence on
nursing. Are the challenges and obstacles that the transformation of values of caring into an
we face today any more daunting than what activism that could potentially transform our
confronted Nightingale when she arrived in current health-care system into a more human-
the Crimea in 1854? Nursing for Florence istic and just one. Her activism situates her in
Nightingale was what we might call today her the context of justice making. Justice making is
“centering force.” It allowed her to express her understood as a manifestation of compassion
spiritual values as well as enabled her to fulfill and caring, for it is actions that bring about jus-
her needs for leadership and authority. As his- tice (Boykin & Dunphy, 2002, p. 16). Florence
torian Susan Reverby noted, today we are chal- Nightingale’s legacy of connecting caring with
lenged with the dilemma of how to practice our activism can then truly be said to continue.

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Barritt, E. R. (1973). Florence Nightingale’s values and Cohen, I. B. (1981). Florence Nightingale: The passion-
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Cromwell, Judith Lissauer (2013). Florence Nightingale, Nightingale, F. (1860/1969). Notes on nursing: What it is
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Early Conceptualizations
About Nursing
Chapter
5
Ernestine Wiedenbach, Virginia
Henderson, and Lydia Hall

S HIRLEY C. G ORDON

Introducing the Theorists Introducing the Theorists


Overview of Wiedenbach, Henderson,
and Hall’s Conceptualizations of Nursing Ernestine Wiedenbach, Virginia Henderson,
Practice Applications and Lydia Hall are three of the most important
Practice Exemplars influences on nursing theory development of
Summary the 20th century. Indeed, their work continues
References to ground nursing thought in the new century.
The work of each of these nurse scholars was
based on nursing practice, and today some of
this work might be referred to as practice theo-
ries. Concepts and terms they first used are
heard today around the globe.
This chapter provides a brief introduction to
Wiedenbach, Henderson, and Hall; an overview
of their nursing conceptualizations; and sections
on practice applications and practice exemplars
based on their published works. The content of
Ernestine Wiedenbach Virginia Henderson this chapter is partially based on work from
scholars who have studied or worked with these
theorists and who wrote chapters for the first,
second and/or third editions of Nursing Theories
and Nursing Practice (Gesse, Dombro, Gordon,
& Rittman, 2006, 2010; Gordon, 2001; Touhy
& Birnbach, 2006, 2010).1

Ernestine Wiedenbach
Wiedenbach was born in 1900 in Germany to
an American mother and a German father,
Lydia Hall who immigrated to the United States when
Ernestine was a child. She received a bachelor
of arts degree from Wellesley College in 1922
and graduated from Johns Hopkins School of
Nursing in 1925 (Nickel, Gesse, & MacLaren,
1For additional information please see the bonus chapter
content available at http://davisplus.fadavis.com.

55
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56 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

1992). After completing a master of arts at College at Columbia University, earning her
Columbia University in 1934, she became a baccalaureate degree in 1932 and her master’s
professional writer for the American Journal of degree in 1934. She continued at Teachers Col-
Nursing and played a critical role in the recruit- lege as an instructor and associate professor of
ment of nursing students and military nurses nursing for the next 20 years.
during World War II. At age 45, she began Virginia Henderson presented her definition
her studies in nurse-midwifery. Wiedenbach’s of the nature of nursing in an era when few
roles as practitioner, teacher, author, and the- nurses had ventured into describing the complex
orist were consolidated as a member of the phenomena of modern nursing. Henderson
Yale University School of Nursing, where Yale wrote about nursing the way she lived it: focus-
colleagues William Dickoff and Patricia James ing on what nurses do, how nurses function, and
encouraged her development of prescriptive nursing’s unique role in health care. Henderson
theory (Dickoff, James, & Wiedenbach, 1968). has been heralded as the greatest advocate for
Even after her retirement in 1966, she and her nursing libraries worldwide. Of all her contribu-
lifelong friend Caroline Falls offered informal tions to nursing, Virginia Henderson’s work
seminars in Miami, always reminding students on the identification and control of nursing
and faculty of the need for clarity of purpose, literature is perhaps her greatest. In the 1950s,
based on reality. She even continued to use her there was an increasing interest on the part of
gift for writing to transcribe books for the the profession to establish a research basis for
blind, including a Lamaze childbirth manual, the nursing practice. After the completion of
which she prepared on her Braille typewriter. her revised text in 1955, Henderson moved to
Ernestine Wiedenbach died in April 1998 at Yale University and began what would become
age 98. a distinguished career in library science research.
In 1990, the Sigma Theta Tau International
Virginia Henderson Library was named in her honor.
Born in Kansas City, Missouri, in 1897, Virginia
Avenel Henderson was the fifth of eight chil- Lydia Hall
dren. With two of her brothers serving in the Lydia Hall, born in 1906, was a visionary, risk
armed forces during World War I and in antic- taker, and consummate professional. She in-
ipation of a critical shortage of nurses, Virginia spired commitment and dedication through
Henderson entered the Army School of Nursing her unique conceptual framework.
at Walter Reed Army Hospital. It was there A 1927 graduate of the York Hospital
that she began to question the regimentation School of Nursing in Pennsylvania, Hall held
of patient care and the concept of nursing as various nursing positions during the early years
ancillary to medicine (Henderson, 1991). of her career. In the mid-1930s, she enrolled at
As a member of society during a war, Hen- Teachers College, Columbia University, where
derson considered it a privilege to care for sick she earned a Bachelor of Science degree in
and wounded soldiers (Henderson, 1960). 1937, and a Master of Arts degree in 1942. She
This wartime experience forever influenced worked with the Visiting Nurse Service of New
her ethical understanding of nursing and her York from 1941 to 1947 and was a member of
appreciation of the importance and complexity the nursing faculty at Fordham Hospital
of the nurse–patient relationship. School of Nursing from 1947 to 1950. Hall was
After a summer spent with the Henry Street subsequently appointed to a faculty position at
Visiting Nurse Agency in New York City, Teachers College, where she developed and
Henderson began to appreciate the importance implemented a program in nursing consulta-
of getting to know the patients and their envi- tion and joined a community of nurse leaders.
ronments. She enjoyed the less formal visiting At the same time, she was involved in research
nurse approach to patient care and became skep- activities for the U.S. Public Health Service
tical of the ability of hospital regimes to alter (Birnbach, 1988).
patients’ unhealthy ways of living upon returning Hall’s most significant contribution to
home (Henderson, 1991). She entered Teachers nursing practice was the practice model she
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CHAPTER 5 • Early Conceptualizations About Nursing 57

designed and put into place in the Loeb Center when task-oriented team nursing was the
for Nursing and Rehabilitation at Montefiore preferred practice model in most institutions.
Medical Center in Bronx, New York. The Loeb
Center, which opened in 1963, was the culmi-
nation of 5 years of planning and construction Overview of Wiedenbach,
under Hall’s direction in collaboration with Henderson, and Hall’s
Dr. Martin Cherkasky.
As a visiting nurse, Hall had frequent Conceptualizations of Nursing
contact through the Montefiore home care Virginia Henderson, sometimes known as the
program. Hall and Cherkasky discovered modern-day Florence Nightingale, developed
they shared similar philosophies regarding the definition of nursing that is most well
health care and the delivery of quality service known internationally. Ernestine Wiedenbach
(Birnbach, 1988). In 1950, Cherkasky was gave us new ways to think about nursing prac-
appointed director of the Montefiore Medical tice and nursing scholarship, introducing us to
Center. Convalescent treatment was undergo- the ideas of (1) nursing as a professional prac-
ing rapid change owing largely to medical tice discipline and (2) nursing practice theory.
advances, new pharmaceuticals, and techno- Lydia Hall challenged us to think conceptually
logical developments. The emerging trends led about the key role of professional nursing.
to the closing of the Solomon and Betty Loeb Each of these nurse scholars helped us focus
Memorial Home in Westchester County, New on the patient, instead of on the tasks to be
York, and Cherkasky and Hall convinced the done, and to plan care to meet needs of the
board to join with Montefiore in founding person. Each emphasized caring based on the
the Loeb Center for Nursing and Rehabilita- perspective of the individual being cared for—
tion. A unique feature of the center was a through observing, communicating, designing,
separate board of trustees that interrelated and reporting. Each was concerned with the
with the Montefiore board. As a result, Hall unique aspects of nursing practice and schol-
had considerable autonomy in developing the arship and with the essential question of
center’s policies and procedures. “What is nursing?”
Hall increased the role of nurses in decision
making. For example, nurses selected patients Wiedenbach’s Conceptualizations of
for the Loeb Center based on a nursing assess- Nursing
ment of an individual patient’s potential for
Initial work on Wiedenbach’s prescriptive theory
rehabilitation. In addition, qualified profes-
is presented in her article in the American Journal
sional nurses provided direct care to patients
of Nursing (1963) and her book Meeting the
and coordinated needed services. Hall fre-
Realities in Clinical Teaching (1969).
quently described the center as “a halfway house
Her explanation of prescriptive theory is
on the road home” (Hall, 1963, p. 2), where
that “Account must be taken of the motivating
the nurse worked with the patients as active par-
factors that influence the nurse not only in
ticipants in achieving desired outcomes that
doing what she [sic] does, but also in doing
were meaningful to the patients. Over time, the
it the way she [sic] does it with the realities
effectiveness of Hall’s practice model was vali-
that exist in the situation in which she [sic] is
dated by the significant decline in the number
functioning” (Wiedenbach, 1970, p. 2). Three
of readmissions among former Loeb patients
ingredients essential to the prescriptive theory
compared with those who received other types
are as follows:
of posthospital care (“Montefiore cuts,” 1966).
Hall died in 1969, and in 1984 she was 1. The nurse’s central purpose in nursing is
posthumously inducted into the American the nurse’s professional commitment. For
Nurses’ Association Hall of Fame. Hall is Wiedenbach, the central purpose in nursing is
remembered by her colleagues as a force for to motivate the individual and/or facilitate
change; she successfully implemented a pro- efforts to overcome the obstacles that may
fessional patient-centered framework at a time interfere with the ability to respond capably
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58 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

to the demands made by the realities within • The goal, or the end to be attained through
the situation (Wiedenbach, 1970, p. 4). She nursing activity on behalf of the patient
emphasized that the nurse’s goals are grounded • The means, the actions and devices
in the nurse’s philosophy, “those beliefs and through which the nurse is enabled to
values that shape her [sic] attitude toward reach the goal
life, toward fellow human beings and toward
herself [sic].” The three concepts that epitomize Henderson’s Definition of Nursing and
the essence of such a philosophy are (1) rever- Components of Basic Nursing Care
ence for the gift of life; (2) respect for the dig-
While working on the 1955 revision of the
nity, autonomy, worth, and individuality of
Textbook of the Principles and Practice of Nursing,
each human being; and (3) resolution to act
Henderson focused on the need to be clear
dynamically in relation to one’s beliefs
about the function of nurses. She opened the
(Wiedenbach, 1970, p. 4).
first chapter with the following questions:
She recognized that nurses have different
What is nursing and what is the function of
values and various commitments to nurs-
the nurse? (Harmer & Henderson, 1955, p. 1).
ing and that to formulate one’s purpose in
Henderson believed these questions were fun-
nursing is a “soul-searching experience.”
damental to anyone choosing to pursue the
She encouraged each nurse to undergo
study and practice of nursing.
this experience and be “willing and ready
to present your central purpose in nursing
Definition of Nursing
for examination and discussion when ap-
propriate” (Wiedenbach, 1970, p. 5). Henderson’s often-quoted definition of nurs-
2. The prescription indicates the broad ing first appeared in the fifth edition of Text-
general action that the nurse deems book of the Principles and Practice of Nursing
appropriate to fulfillment of his or her (Harmer & Henderson, 1955, p. 4):
central purpose. The nurse will have thought
through the kind of results to be sought and
Nursing is primarily assisting the individual (sick or
will take action to obtain these results, accept-
well) in the performance of those activities contributing
ing accountability for what he/she does and for
to health or its recovery (or to a peaceful death), that
the outcomes of any action. Nursing action,
he [sic] would perform unaided if he [sic] had the nec-
then, is deliberate action that is mutually
essary strength, will, or knowledge. It is likewise the
understood and agreed on and that is both
unique contribution of nursing to help people be in-
patient-directed and nurse-directed
dependent of such assistance as soon as possible.
(Wiedenbach, 1970, p. 5).
3. The realities are the aspects of the immediate In presenting her definition of nursing,
nursing situation that influence the results Henderson hoped to encourage others to de-
the nurse achieves through what he or she velop their own working concept of nursing and
does (Wiedenbach, 1970, p. 3). These include nursing’s unique function in society. She be-
the physical, psychological, emotional, and lieved the definitions of the day were too general
spiritual factors in which nursing action occurs. and failed to differentiate nurses from other
Within the situation are these components: members of the health team, which led to the
• The agent, who is the nurse supplying the following questions: “What is nursing that is not
nursing action also medicine, physical therapy, social work,
• The recipient, or the patient receiving etc.?” and “What is the unique function of the
this action or on whose behalf the action nurse?” (Harmer & Henderson, 1955, p. 4).
is taken Based on her definition and after coining
• The framework, comprising situational the term basic nursing care, Henderson identi-
factors that affect the nurse’s ability to fied 14 components of basic nursing care that
achieve nursing results reflect needs pertaining to personal hygiene
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CHAPTER 5 • Early Conceptualizations About Nursing 59

and healthful living, including helping the pa- as the area of the body. Hall clearly stated that
tient carry out the physician’s therapeutic plan the focus of nursing is the provision of intimate
(Henderson, 1960; 1966, pp. 16–17): bodily care. She reflected that the public has
long recognized this as belonging exclusively to
1. Breathe normally.
nursing (Hall, 1958, 1964, 1965). In Hall’s
2. Eat and drink adequately.
opinion, to be expert, the nurse must know how
3. Eliminate bodily wastes.
to modify the care depending on the pathology
4. Move and maintain desirable postures.
and treatment while considering the patient’s
5. Sleep and rest.
unique needs and personality.
6. Select suitable clothes—dress and undress.
Based on her view of the person as patient,
7. Maintain body temperature within normal
Hall conceptualized nursing as having three
range by adjusting clothing and modifying
aspects, and she delineated the area that is the
the environment.
specific domain of nursing and those areas that
8. Keep the body clean and well groomed
are shared with other professions (Hall, 1955,
and protect the integument.
1958, 1964, 1965; Fig. 5-1). Hall believed that
9. Avoid dangers in the environment and
this model reflected the nature of nursing as a
avoid injuring others.
professional interpersonal process. She visual-
10. Communicate with others in expressing
ized each of the three overlapping circles as an
emotions, needs, fears, or opinions.
“aspect of the nursing process related to the
11. Worship according to one’s faith.
patient, to the supporting sciences and to the
12. Work in such a way that there is a sense
underlying philosophical dynamics” (Hall,
of accomplishment.
1958, p. 1). The circles overlap and change in
13. Play or participate in various forms of
size as the patient progresses through a med-
recreation.
ical crisis to the rehabilitative phase of the ill-
14. Learn, discover, or satisfy the curiosity that
ness. In the acute care phase, the cure circle is
leads to normal development and health
the largest. During the evaluation and follow-
and use the available health facilities.
up phase, the care circle is predominant. Hall’s
framework for nursing has been described as
Hall’s Care, Cure, and Core Model the Care, Core, and Cure Model.
Hall enumerated three aspects of the person as
patient: the person, the body, and the disease
(Hall, 1965). She envisioned these aspects as
overlapping circles of care, core, and cure that
influence each other. It was her belief that The Person
Social sciences
Therapeutic use of self—
aspects of nursing
[e]veryone in the health professions either neglects "The Core"
or takes into consideration any or all of these, but
each profession, to be a profession, must have an
exclusive area of expertness with which it practices, The Disease
The Body Pathological and
creates new practices, new theories, and introduces Natural and biological therapeutic sciences
newcomers to its practice. (Hall, 1965, p. 4) sciences Seeing the patient and
Intimate bodily care— family through the
aspects of nursing medical care—
Hall believed that medicine’s exclusive area aspects of nursing
"The Care"
of expertness was disease, which includes pathol- "The Cure"
ogy and treatment. The area of person, which,
according to Hall, had been sadly neglected,
Fig 5 • 1 Care, core, and cure model. (From Hall, L.
belongs to a number of professions, including [1964, February]. Nursing: What is it? The Canadian
psychiatry, social work, and the ministry, among Nurse, 60[2], 151. Reproduced with permission from
others. In contrast, she saw nursing’s expertise The Canadian Nurse.)
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60 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

Care may be viewed as the nurse assisting the doctor


Hall suggested that the part of nursing that is by assuming medical tasks/functions or as the
concerned with intimate bodily care (e.g., nurse helping the patient through his or her
bathing, feeding, toileting, positioning, moving, medical, surgical, and rehabilitative care in
dressing, undressing, and maintaining a health- the role of comforter and nurturer. Hall was
ful environment) belongs exclusively to nursing. concerned that the nursing profession was
From her perspective, nursing is required when assuming more and more of the medical
people are not able to undertake bodily care aspects of care while at the same time relin-
activities for themselves. Care provided the quishing the nurturing process of nursing to
opportunity for closeness and required seeing the less well-prepared persons. She expressed this
nursing process as an interpersonal relationship concern by stating:
(Hall, 1958). For Hall, the intent of bodily care
was to comfort the patient. Through comforting,
Interestingly enough, physicians do not have practical
the patient as a person, as well as his or her body,
doctors. They don’t need them . . . they have nurses.
responds to the physical care. Hall cautioned
Interesting, too, is the fact that most nurses show by
against viewing intimate bodily care as a task
their delegation of nurturing to others, that they prefer
that can be performed by anyone:
being second class doctors to being first class nurses.
This is the prerogative of any nurse. If she [sic] feels
To make the distinction between a trade and a pro- better in this role, why not? One good reason why
fession, let me say that the laying on of hands to wash not for more and more nurses is that with this increas-
around a body is an activity, it is a trade; but if you ing trend, patients receive from professional nurses
look behind the activity for the rationale and intent, second class doctoring; and from practical nurses,
look beyond it for the opportunities that the activity second class nursing. Some nurses would like the
opens up for something more enriching in growth, public to get first class nursing. Seeing the patient
learning and healing production on the part of the pa- through [his or her] medical care without giving up
tient—you have got a profession. Our intent when we the nurturing will keep the unique opportunity that per-
lay hands on the patient in bodily care is to comfort. sonal closeness provides to further [the] patient’s
While the patient is being comforted, he [sic] feels growth and rehabilitation. (Hall, 1958, p. 3)
close to the comforting one. At this time, his [sic] per-
son talks out and acts out those things that concern
Core
him [sic]—good, bad, and indifferent. If nothing more The third area, which Hall believed nursing
is done with these, what the patient gets is ventilation shared with all of the helping professions, was
or catharsis, if you will. This may bring relief of anxiety the core. Hall defined the core as using rela-
and tension but not necessarily learning. If the individ- tionships for therapeutic effect. This area em-
ual who is in the comforting role has in her [sic] prepa- phasized the social, emotional, spiritual, and
ration all of the sciences whose principles she [sic] intellectual needs of the patient in relation to
can offer a teaching-learning experience around his family, institution, community, and the world
[sic] concerns, the ones that are most effective in (Hall, 1955, 1958, 1965). Knowledge that is
teaching and learning, then the comforter proceeds foundational to the core is based on the social
to something beyond—to what I call “nurturer”— sciences and on therapeutic use of self.
someone who fosters learning, someone who fosters Through the closeness offered by the provision
growing up emotionally, someone who even fosters of intimate bodily care, the patient will feel
healing. (Hall, 1969, p. 86) comfortable enough to explore with the nurse
“who he [sic] is, where he [sic] is, where he [sic]
wants to go, and will take or refuse help in get-
Cure ting there—the patient will make amazingly
Hall (1958) viewed cure as being shared with more rapid progress toward recovery and reha-
medicine and asserted that this aspect of nursing bilitation” (Hall, 1958, p. 3). Hall believed that
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CHAPTER 5 • Early Conceptualizations About Nursing 61

through this process, the patient would emerge Practice Applications


as a whole person.
The practice of clinical nursing is goal directed,
Knowledge and skills the nurse needs to use
deliberately carried out, and patient centered.
self therapeutically include knowing self and
—WIEDENBACH (1964, P. 23)
learning interpersonal skills. The goals of the
interpersonal process are to help patients to
understand themselves as they participate in Wiedenbach
problem focusing and problem-solving. Hall Figure 5-2 represents a spherical model that
discussed the importance of nursing with the depicts the “experiencing individual” as the
patient as opposed to nursing at, to, or for the central focus (Wiedenbach, 1964). This model
patient. Hall reflected on the value of the ther- and detailed charts were later edited and pub-
apeutic use of self by the professional nurse lished in Clinical Nursing: A Helping Art
when she stated: (Wiedenbach, 1964).
In a paper titled “A Concept of Dynamic
Nursing,” Wiedenbach (1962, p. 7), described
The nurse who knows self by the same token can the model as follows:
love and trust the patient enough to work with him
[sic] professionally, rather than for him technically,
or at him vocationally. In its broadest sense, Practice of Dynamic Nursing
may be envisioned as a set of concentric circles,
with the experiencing individual in the circle at its
core. Direct service, with its three components,
Her [sic] goals cease being tied up with “where can identification of the individual’s experienced need
I throw my nursing stuff around,” or “how can I explain for help, ministration of help needed, and valida-
my nursing stuff to get the patient to do what we want tion that the help provided fulfilled its purpose, fills
him to do,” or “how can I understand my patient so the circle adjacent to the core. The next circle holds
that I can handle him better.” Instead her goals are
linked up with “what is the problem?” and “how can
I help the patient understand himself?” as he partici-
pates in problem facing and solving. In this way, the
nurse recognizes that the power to heal lies in the
Research
patient and not in the nurse, unless she is healing
herself. She takes satisfaction and pride in her ability Nu
rs
to help the patient tap this source of power in his in
on llaboration g
Co
continuous growth and development. She becomes
ti

Ad

Ad
ca

n
tio m
edu

mi

comfortable working cooperatively and consistently


a

in

nist
fic

with members of other professions, as she meshes her


Nursing

ist
Identi

ration

ration

contributions with theirs in a concerted program of Experiencing


tion

Co-o

care and rehabilitation. (Hall, 1958, p. 5) individual


Adv
ruc

Hall believed that the role of professional


din r
on

anc
n st

Val
nursing was enacted through the provision of idation
ati

tio
e

C
d

n
ic

care that facilitates the interpersonal process


bl

st

ns Nu
u

io
and invites the patient to learn to reach the core P ng Organizat
rsi dy

of his difficulties while seeing him through the


cure that is possible. Through the professional
nursing process, the patient has the opportu-
Fig 5 • 2 Professional nursing practice focus and
nity to see the illness as a learning experience components. (Reprinted with permission from the
from which he or she may emerge even health- Wiedenbach Reading Room [1962], Yale University
ier than before the illness (Hall, 1965). School of Nursing.)
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62 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

the essential concomitants of direct service: coordi- defined nonnursing functions as those that are
nation, i.e., charting, recording, reporting, and not a service to the person (mind and body)
conferring; consultation, i.e., conferencing, and (Harmer & Henderson, 1955). For Henderson,
seeking help or advice; and collaboration, i.e., giv- examples of nonnursing functions included
ing assistance or cooperation with members of ordering supplies, cleaning and sterilizing equip-
other professional or nonprofessional groups con- ment, and serving food (Harmer & Henderson,
cerned with the individual’s welfare. The content of 1955).
the fourth circle represents activities which are es- At the same time, Henderson was not in
sential to the ultimate well-being of the experiencing favor of the practice of assigning patients to
individual, but only indirectly related to him [sic]: lesser trained workers on the basis of complexity
nursing education, nursing administration, and nurs- level. For Henderson, “all ‘nursing care’ is essen-
ing organizations. The outermost circle comprises tially complex because it involves constant adap-
research in nursing, publication, and advanced tation of procedures to the needs of the
study, the key ways to progress in every area of individual” (Harmer & Henderson, 1955, p. 9).
practice. As the authority on basic nursing care,
Henderson believed that the nurse has the
Application of Wiedenbach’s prescriptive
responsibility to assess the needs of the indi-
theory was evident in her practice examples and
vidual patient, help individuals meet their
often related to general basic nursing procedures
health needs, and/or provide an environment
and to maternity nursing practice. The most
in which the individual can perform activities
recent application of Wiedenbach’s theory in the
unaided. It is the nurse’s role, according to
literature is a description by VandeVusse (1997)
Henderson, “to ‘get inside the patient’s skin’
of an educational project designed to guide
and supplement his [sic] strength, will or
the nurse midwife in articulating a professional
knowledge according to his needs” (Harmer
philosophy of nursing.
& Henderson, 1955, p. 5). Conceptualizing
Henderson the nurse as a substitute for the patient’s lack
of necessary will, strength, or knowledge to
Based on the assumption that nursing has a attain good health and to complete or make
unique function, Henderson believed that the patient whole, highlights the complexity
nursing independently initiates and controls and uniqueness of nursing.
activities related to basic nursing care. Relating Based on the success of Textbook of the Prin-
the conceptualization of basic care components ciples and Practice of Nursing (fifth edition),
with the unique functions of nursing provided Henderson was asked by the International
the initial groundwork for introducing the Council of Nurses to prepare a short essay
concept of independent nursing practice. In that could be used as a guide for nursing in any
her 1966 publication The Nature of Nursing, part of the world. Despite Henderson’s belief
Henderson stated: that it was difficult to promote a universal defi-
nition of nursing, Basic Principles of Nursing
Care (Henderson, 1960) became an interna-
It is my contention that the nurse is, and should be
tional sensation. To date, it has been published
legally, an independent practitioner and able to
in 29 languages and is referred to as the 20th-
make independent judgments as long as he, or she,
century equivalent of Florence Nightingale’s
is not diagnosing, prescribing treatment for disease,
Notes on Nursing. After visiting countries
or making a prognosis, for these are the physician’s
worldwide, Henderson concluded that nursing
functions. (Henderson, 1966, p. 22)
varied from country to country and that rigor-
Furthermore, Henderson believed that func- ous attempts to define it have been unsuccess-
tions pertaining to patient care could be catego- ful, leaving the “nature of nursing” largely an
rized as nursing and nonnursing. She believed unanswered question (Henderson, 1991).
that limiting nursing activities to “nursing care” Henderson’s definition of nursing has had a
was a useful method of conserving professional lasting influence on the way nursing is practiced
nurse power (Harmer & Henderson, 1955). She around the globe. She was one of the first nurses
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CHAPTER 5 • Early Conceptualizations About Nursing 63

to articulate that nursing had a unique function accomplished by the special and unique way
yielding a valuable contribution to the health nurses work with patients in a close interpersonal
care of individuals. In writing reflections on the process with the goal of fostering learning,
nature of nursing, Henderson (1966) stated that growth, and healing.
her concept of nursing anticipates universally
available health care and a partnership among
doctors, nurses, and other health-care workers. PRACTICE EXEMPLARS
The sixth edition of Principles and Practice Wiedenbach
of Nursing (Henderson & Nite, 1978) is
considered “the most important single profes- The focus of practice is the individual for whom
sional document written in the 20th century” the nurse is caring and the way this person per-
(Halloran, 1996, p. 17). In this book, the syn- ceives his or her condition or situation. Mrs. A
thesis of nursing practice, education, theory, and was experiencing a red vaginal discharge on her
research clearly demonstrated the functions of first postpartum day. The doctor recognized it as
professional nursing practice. lochia, a normal concomitant of the phenome-
Henderson was a lifelong supporter of non of involution, and had left an order for her
nursing research. In 1964, she published an to be up and move about. Instead of trying to get
influential review of nursing research that high- up, Mrs. A remained immobile in her bed. The
lighted the need to increase research studies nurse, who wanted to help her out of bed, ex-
focusing on the effect of nursing practice on pressed surprise at Mrs. A’s unwillingness to get
patients (Simmons & Henderson, 1964). This up. Mrs. A explained to the nurse that her sister
publication resulted in a renewed interest in had had a red discharge the day after giving birth
research studies that focused on the effects of 2 years ago and had almost died of hemorrhage.
nursing on patient outcomes and the need for Therefore, to Mrs. A, a red discharge was evi-
research guided by nursing theory (Halloran, dence of the onset of a potentially lethal hemor-
1996). Most recently, Henderson’s theory has rhage. The nurse expressed her understanding of
been applied to the management of the care of the mother’s fear and encouraged her to compare
patients who donate organs after brain death and her current experience with that of her sister.
their families (Nicely & Delario, 2011). When the mother did this, she recognized gross
differences between her experience and that of
Hall her sister and accepted the nurse’s explanation
In 1963, Lydia Hall was able to actualize her that the discharge was normal. The mother
vision of nursing through the creation of the voiced her relief and validated it by getting
Loeb Center for Nursing and Rehabilitation out of bed without further encouragement
at Montefiore Medical Center. The center’s (Wiedenbach, 1962, pp. 6–7). Wiedenbach
major orientation was rehabilitation and subse- considered nursing a “practical phenomenon”
quent discharge to home or to a long-term care that involved action. She believed that this
institution if further care was needed. Doctors was necessary to understand the theory that
referred patients to the center, and a professional underlies the “nurse’s way of nursing.” This
nurse made admission decisions. Criteria for involved “knowing what the nurse wanted to ac-
admission were based on the patient’s need for complish, how she [sic] went about accomplish-
rehabilitation nursing. What made the Loeb ing it, and in what context she did what she did”
Center unique was the model of professional (Wiedenbach, 1970, p. 1058).
nursing that was implemented under Lydia
Hall’s guidance. The center’s guiding philosophy
was Hall’s belief that during the rehabilitation
Henderson
phase of an illness experience, professional Henderson’s definition of nursing and the
nurses were the best prepared to foster the reha- 14 components of basic nursing care can be use-
bilitation process, decrease complications and ful in guiding the assessment and care of patients
recurrences, and promote health and prevent preparing for surgical procedures. For example,
new illnesses. Hall saw these outcomes being in assessing Mr. G’s preoperative vital signs,
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64 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

the nurse noticed he seemed anxious. The nurse each nurse was responsible for eight patients and
encouraged Mr. G to express his concerns their families. Senior staff nurses were available
about the surgery. Mr. G told the nurse that he on each ward as resources and mentors for staff
had a fear of not being able to control his body nurses. For every two professional nurses, there
and that he felt general anesthesia represented was one nonprofessional worker called a “mes-
the extreme limit of loss of bodily control. The senger-attendant.” The messenger-attendants
nurse recognized this concern as being directly did not provide hands-on care to the patients.
related to Henderson’s fourth component of Instead, they performed such tasks as getting
basic nursing care: Move and maintain desirable linen and supplies, thus freeing the nurse to
postures. The nurse explained to Mr. G that her nurse the patient (Hall, 1964). In addition, there
role was to “perform those acts he would do for were four ward secretaries. Morning and evening
himself if he was not under the influence of shifts were staffed at the same ratio. Night-shift
anesthesia” (Gillette, 1996, p. 267) and that she staffing was less; however, Hall (1965) noted
would be responsible for maintaining his body that there were “enough nurses at night to make
in a comfortable and dignified position. She ex- rounds every hour and to nurse those patients
plained how he would need to be positioned dur- who are awake around the concerns that may be
ing the surgical procedure, what part of his body keeping them awake” (p. 2). In most institutions
would be exposed, and how long the procedure of that time, the number of nurses was decreased
was expected to take. Mr. G also told the nurse during the evening and night shifts because it
about an experience he had after an earlier surgical was felt that larger numbers of nurses were
procedure in which he experienced pain in his needed during the day to get the work done.
right shoulder. Mr. G expressed concern that Hall took exception to the idea that nursing
being in one position too long during the surgery service was organized around work to be done
would damage his shoulder and result in waking rather than the needs of the patients.
up with shoulder pain again. Together they dis- The patient was the center of care at Loeb
cussed positions that would be most comfortable and actively participated in all care decisions.
for his shoulder during the upcoming procedure, Families were free to visit at any hour of the day
and she assured Mr. G that she would be assess- or night. Rather than strict adherence to insti-
ing his position throughout the procedure. tutional routines and schedules, patients at the
Loeb Center were encouraged to maintain their
own usual patterns of daily activities, thus
Hall promoting independence and an easier transi-
Hall envisioned that outcomes were accom- tion to home. There was no chart section labeled
plished by the special and unique way nurses “Doctor’s Orders.” Hall believed that to order a
work with patients in a close interpersonal patient to do something violated the right of
process with the goal of fostering learning, the patient to participate in his or her treatment
growth, and healing. Her work at the Loeb plan. Instead, nurses shared the treatment plan
Center serves as an administrative exemplar with the patient and helped him or her to discuss
of the application of her theory. At the Loeb his or her concerns and become an active learner
Center, nursing was the chief therapy, with in the rehabilitation process. In addition, there
medicine and the other disciplines ancillary to were no doctor’s progress notes or nursing notes.
nursing. In this new model of organization of Instead, all charting was done on a form titled
nursing services, nursing was in charge of the “Patient’s Progress Notes.” These notes included
total health program for the patient and was patients’ reaction to care, their concerns and
responsible for integrating all aspects of care. feelings, their understanding of the problems,
Only registered professional nurses were hired. the goals they have identified, and how they see
The 80-bed unit was staffed with 44 professional their progress toward those goals. Patients were
nurses employed around the clock. Professional also encouraged to keep their own notes to share
nurses gave direct patient care and teaching, and with their caregivers.
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CHAPTER 5 • Early Conceptualizations About Nursing 65

Staff conferences were held at least twice who worked at Loeb describe nursing situa-
weekly as forums to discuss concerns, problems, tions that demonstrate the effect of professional
or questions. A collaborative practice model nursing on patient outcomes. In addition,
between physicians and nurses evolved, and they reflect the satisfaction derived from
the shared knowledge of the two professions practicing in a truly professional role (Alfano,
led to more effective team planning (Isler, 1971; Bowar, 1971; Bowar-Ferres, 1975;
1964). The nursing stories published by nurses Englert, 1971).

■ Summary
Among other theorists featured in Section II of this book, Wiedenbach, Henderson, and Hall
introduced nursing theory to us in the mid-20th century. Each of the nurse theorists presented
in this chapter began by reflecting on her personal practice experience to explore the definition of
nursing and the importance of nurse–patient interactions. These nurse scholars challenged us to
think about nursing in new ways. Their contributions significantly influenced the way nursing was
practiced and researched, both in the United States and in other countries around the world. Perhaps
most important, each of these scholars stated and responded to the question, “What is nursing?”
Their responses helped all who followed to understand that the individual being nursed is a person,
not an object, and that the relationship of nurse and patient is valuable to all.

References

Alfano, G. (1971). Healing or caretaking—which will it Gordon, S. C. (2001). Virginia Avenel Henderson
be? Nursing Clinics of North America, 6, 273–280. definition of nursing. In: M. Parker (Ed.), Nursing
Birnbach, N. (1988). Lydia Eloise Hall, 1906–1969. In: theories and nursing practice (pp. 143–149). Philadel-
V. L. Bullough, O. M. Church, & A. P. Stein phia: F. A. Davis.
(Eds.), American nursing: A biographical dictionary Hall, L. E. (1955). Quality of nursing care. Manuscript
(pp. 161–163). New York: Garland. of an address before a meeting of the Department
Bowar, S. (1971). Enabling professional practice of Baccalaureate and Higher Degree Programs of the
through leadership skills. Nursing Clinics of North New Jersey League for Nursing, February 7, 1955,
America, 6, 293–301. at Seton Hall University, Newark, New Jersey.
Bowar-Ferres, S. (1975). Loeb Center and its philosophy Montefiore Medical Center Archives, Bronx,
of nursing. American Journal of Nursing, 75, 810–815. New York.
Chinn, P. L., & Jacobs, M. K. (1987). Theory and nursing. Hall, L. E. (1958). Nursing: What is it? Manuscript. Mon-
St. Louis, MO: C. V. Mosby. tefiore Medical Center Archives, Bronx, New York.
Dickoff, J., James, P., & Wiedenbach, E. (1968). Theory Hall, L. E. (1963, March). Summary of project report:
in a practice discipline. Nursing Research, 14(5), Loeb Center for Nursing and Rehabilitation. Unpub-
415–437. lished report. Montefiore Medical Center Archives,
Englert, B. (1971). How a staff nurse perceives her role Bronx, New York.
at Loeb Center. Nursing Clinics of North America, Hall, L. E. (1964). Nursing—what is it? Canadian
6(2), 281–292. Nurse, 60, 150–154.
Gesse, T., Dombro, M., Gordon, S. C. & Rittman, M. Hall, L. E. (1965). Another view of nursing care and quality.
R. (2006). Twentieth-Century nursing: Wieden- Address delivered at Catholic University, Washington,
bach, Henderson, and Orlando’s theories and their DC. Unpublished report. Montefiore Medical Center
applications. In: M. Parker (Ed.), Nursing theories Archives, Bronx, New York.
and nursing practice (2nd ed., pp. 70–78). Philadel- Halloran, E. J. (1996). Virgina Hendeson and her timeless
phia: F. A. Davis. writings. Journal of Advanced Nursing, 23, 17–23.
Gillette, V. A. (1996). Applying nursing theory to peri- Harmer, B., & Henderson, V. A. (1955). Textbook of the
operative nursing practice. AORN, 64(2), 261–270. principles and practice of nursing. New York: Macmillan.
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Henderson, V. A. (1960). Basic principles of nursing care. Touhy, T., & Birnbach, N. (2006). Lydia Hall: The
Geneva: International Council of Nurses. care, core, and cure model and its applications. In:
Henderson, V. A. (1966). The nature of nursing. New M. Parker (Ed.), Nursing theories and nursing practice
York: The National League for Nursing Press. (2nd ed., pp. 113–124). Philadelphia: F. A. Davis.
Henderson, V. A. (1991). The nature of nursing: Reflec- VandeVusse, L. (1997). Education exchange. Sculpting
tions after 25 years. New York: The National League a nurse-midwifery philosophy: Ernestine Wieden-
for Nursing Press. back’s Influence. Journal of Nurse-Midwifery, 42(1),
Henderson, V. A., & Nite, G. (1978). Principles and prac- 43–48.
tice of nursing (6th ed.). New York, NY: Macmillan. Wiedenbach, E. (1962). A concept of dynamic nursing:
Isler, C. (June, 1964). New concept in nursing therapy: Philosophy, purpose, practice and process. Paper pre-
Care as the patient improves. RN, 58–70. sented at the Conference on Maternal and Child
Montefiore cuts readmissions 80%. (1966, February 23). Nursing, Pittsburgh, PA. Archives, Yale University
The New York Times. School of Nursing, New Haven, CT.
Nicely, B. & Delario, G. (2011). Virginia Henderson’s Wiedenbach, E. (1963). The helping art of nursing.
principles and practice of nursing applied to organ American Journal of Nursing, 63(11), 54–57.
donation after brain death. Progress in Transplantation, Wiedenbach, E. (1964). Clinical nursing: A helping art.
21, 72–77 New York: Springer.
Nickel, S., Gesse, T., & MacLaren, A. (1992). Her pro- Wiedenbach, E. (1969). Meeting the realities in clinical
fessional legacy. Journal of Nurse Midwifery, 3, 161. teaching. New York: Springer.
Simmons, L., & Henderson, V. (1964). Nursing research: A Wiedenbach, E. (1970). A systematic inquiry: Application
survey and assessment. New York: Appleton-Century- of theory to nursing practice. Paper presented at Duke
Crofts. University, Durham, NC (author’s personal files).
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Nurse–Patient Relationship
Theories
Chapter
6
Hildegard Peplau, Joyce Travelbee, and
Ida Jean Orlando

A NN R. P EDEN , J ACQUELINE S TAAL ,


M AUDE R ITTMAN , AND D IANE
L EE G ULLETT

Hildegard Peplau’s
Part One Joyce Travelbee’s
Part Two

Nurse–Patient Relationship Human-to-Human Relationship


and Its Applications Model and Its Applications
Introducing the Theorist Introducing the Theorist
Overview of Peplau’s Nurse–Patient Overview of Travelbee’s Human-to-
Relationship Theory Human Relationship Model Theory
Practice Applications Practice Applications
Practice Exemplar Practice Exemplar
References References

Ida Jean Orlando’s


Part Three

Dynamic Nurse–Patient
Relationship
Introducing the Theorist
Overview of Orlando’s Theory of the
Dynamic Nurse–Patient Relationship
Hildegard Peplau Joyce Travelbee Practice Applications
Practice Exemplar
References

Ida Jean Orlando

67
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68 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

The nurse–patient relationship was a signif- After graduating, Peplau remained at


icant focus of early conceptualizations Columbia to teach in their master’s program.
of nursing. Hildegard Peplau, Joyce Travel- At that time, there was no direction for what
bee, and Ida Jean Orlando were three early to include in graduate nursing programs.
nursing scholars who explicated the nature of Taking educational experiences from psychi-
this relationship. Their work shifted the atry and psychology, she adapted them to
focus of nursing from performance of tasks her conceptualization of nursing. Peplau
to engagement in a therapeutic relationship described this as a time of “innovation or
designed to facilitate health and healing. nothing.”
Each of these conceptualizations will be de- Peplau arranged clinical experiences at
scribed in Parts One, Two, and Three of the Brooklyn State Hospital so that her students
chapter. met twice weekly with the same patient for a
session lasting 1 hour. Using carbon paper, the
students took verbatim notes during the session.
Part One Peplau’s Nurse–Patient Relationship Students then met individually with Peplau to
ANN R. PEDEN1 review the interaction in detail. Through this
process, both Peplau and her students began to
Introducing the Theorist learn what was helpful and what was harmful in
the interaction.
Hildegard Peplau (1909–1999) was an out-
In 1955, Peplau left Columbia for Rutgers,
standing leader and pioneer in psychiatric
where she began the clinical nurse specialist
nursing whose career spanned 7 decades. A
program in psychiatric–mental health nursing.
review of the events in her life also serves as
Students were prepared as nurse psychothera-
an introduction to the history of modern psy-
pists, developing expertise in individual, group,
chiatric nursing. With the publication of In-
and family therapies. Peplau required her
terpersonal Relations in Nursing in 1952,
students to examine their own verbal and non-
Peplau provided a framework for the practice
verbal communication and its effects on the
of psychiatric nursing that would result in a
nurse–patient relationship.
paradigm shift in this specialty. Before this,
In addition to being an educator, re-
patients were viewed as objects to be ob-
searcher, and clinician, Peplau is the only per-
served. Peplau taught that psychiatric nurses
son to serve as both executive director and
must participate with the patients, engaging
president of the American Nurses Association.
in the nurse–patient relationship. Although
Holding 11 honorary degrees, in 1994, she
Interpersonal Relations in Nursing was not
was inducted into the American Academy of
well received when first published, the book’s
influence later became widespread. It was Nursing’s (ANA) Living Legends Hall of
Fame. She was named one of the 50 great
reprinted in 1988 and has been translated
Americans by Marquis Who’s Who in 1995. In
into at least six languages.
1997, Peplau received the Christiane Reiman
During World War II, Peplau serving in the
Prize. In 1998, she was inducted into the
Army Nurse Corps, was assigned to the School
ANA Hall of Fame. Hildegard Peplau died
of Military Neuropsychiatry in England. This
in March 1999 at her home in Sherman
experience introduced her to the psychiatric
Oaks, California.
problems of soldiers at war. After the war,
Peplau attended Columbia University on the
GI Bill, earning her master’s degree in psychi- Overview of Peplau’s Nurse–
atric–mental health nursing. Patient Relationship Theory
Peplau (1952) defined nursing as a “signifi-
1The author would like to acknowledge the contributions cant, therapeutic, interpersonal process” that
of Kennetha Curtis who assisted in updating the literature. is an “educative instrument, a maturing
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CHAPTER 6 • Nurse–Patient Relationship Theories 69

force, that aims to promote forward move- interactions. She advised strongly against the
ment of personality in the direction of cre- use of “social chit-chat.” In fact, she would
ative, constructive, productive, personal, and view this as wasting valuable time with your
community living” (p. 16). Peplau was the patient. Every interaction must focus on
first nursing theorist to identify the nurse– being therapeutic. Even something as simple
patient relationship as being central to all as sharing a meal with psychiatric patients
nursing care. In fact, nursing cannot occur can be a therapeutic encounter.
if there is no relationship, or connection, The nurse–patient relationship, viewed as
between the patient and the nurse. Her growth-promoting with forward movement,
work, although written for all nursing spe- is enhanced when nurses are aware of how
cialties, provides specific guidelines for the their own behavior affects the patient. The
psychiatric nurse. “behavior of the nurse-as-a-person interact-
The nurse brings to the relationship pro- ing with the patient-as-a person has signifi-
fessional expertise, which includes clinical cant effect on the patient’s well-being and the
knowledge. Peplau valued knowledge, believ- quality and outcome of nursing care” (Peplau,
ing that the psychiatric nurse must possess 1992, p. 14). An essential component of this
extensive knowledge about the potential relationship is the continuing process of the
problems that emerge during a nurse–patient nurse becoming more self-aware. This occurs
interaction. The nurse must understand via supervision.
psychiatric illnesses and their treatments Peplau (1989) recommended that nurses
(Peplau, 1987). The nurse interacts with the participate in weekly supervision meetings with
patients as both a resource person and a an expert nurse clinician. The focus of the
teacher (Peplau, 1952). Through education supervisory meetings is on the nurses’ interac-
and supervision, the nurse develops the tions with patients. The primary purpose is to
knowledge base required to select the most review observations and interpersonal patterns
appropriate nursing intervention. To engage that the nurse has made or used. The goal
fully in the nurse–patient relationship, the is always to develop the nurse’s skills as an ex-
nurse must possess intellectual, interpersonal, pert in interpersonal relations. Peplau (1989)
and social skills. These are the same skills emphasized “the slow but sure growth of
often diminished or lacking in psychiatric nurses” (p. 166) as they developed their com-
patients. For nurses to promote growth in petencies in working with patients. Not only
patients, they must themselves use these are patient problems reviewed but treatment
skills competently (Peplau, 1987). options and the nurses’ own pattern of re-
There are four components of the nurse– sponding to the patient are explored. If an in-
patient relationship: two individuals (nurse teraction between a nurse and a patient has not
and patient), professional expertise, and pa- gone well, the nurse’s response is to examine
tient need (Peplau, 1992). The goal of the his or her own behaviors first. Asking questions
nurse–patient relationship is to further the such as, “Did my own anxiety interfere with
personal development of the patient (Peplau, this interaction?” or “Is there something in my
1960). Nurse and patient meet as “strangers” experiences that influenced how I interacted
who interact differently than friends would. with this patient?” leads to continual growth
The role of stranger implies respect and pos- and development as a skilled clinician. This
itive interest in the patient as an individual. process also ensures the delivery of quality care
The nurse “accepts the patients as they are in psychiatric settings. Supervision continues to
and interacts with them as emotionally be an important aspect in advanced practice
able strangers and relating on this basis until psychiatric nursing and is a requirement for
evidence shows otherwise” (Peplau, 1992, certification as a psychiatric clinical specialist or
p. 44). Peplau valued therapeutic communi- nurse practitioner. Supervision is essential as
cation as a key component of nurse–patient the nurse assumes the role of counselor. In this
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70 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

role, the nurse assists the patient in integrating to “they,” using the phrase “you know,” and
the thoughts and feelings associated with the overgeneralizing responses to situations. The
illness into the patient’s own life experiences nurse clarifies who “they” are, responds that
(Lakeman, 1999). she or he does not know and needs further in-
The nurse–patient relationship is objec- formation, and assists patients to be more spe-
tive, and its focus is on the needs of the cific as they describe their experiences
patient. To focus on the patient’s needs, the (Forchuk, 1993).
nurse must be a skilled listener and able to
respond in ways that foster the patient’s Phases of the Nurse–Patient
growth and return to health. Active listening Relationship
facilitates the nurse–patient relationship. As Peplau (1952) introduced the phases of the
Peplau wrote in 1960, nursing is an “oppor- nurse–patient relationship in her interpersonal
tunity to further the patient’s learning about relations theory. This time-limited relationship
himself [sic], the focus in the nurse–patient is interpersonal in nature and has a starting
relationship will be upon the patient —his point, proceeds through identifiable phases,
[sic] needs, difficulties, lack in interpersonal and ends. Initially, Peplau (1952) included
competence, interest in living” (p. 966). four phases in the relationship: orientation,
Within the nurse–patient relationship, the identification, exploitation, and resolution.
nurse works “to create a mood that encour- In 1991, Forchuk, a Canadian researcher who
ages clients to reflect, to restructure percep- has tested and refined some of Peplau’s work,
tions and views of situations as needed, to get proposed three phases: orientation, working,
in touch with their feelings, and to connect and resolution (Peplau, 1992). Forchuk’s rec-
interpersonally with other people” (Peplau, ommendation of a three-phase nurse–patient
1988, p. 10). Although the nurse–patient re- relationship resolves the lack of easy differen-
lationship is “time-limited in both duration tiation between the identification and exploita-
and frequency, the aim is to create an inter- tion stages. These two phases were collapsed
personally intimate encounter, however brief, into the working phase. By renaming these
as if two whole persons are involved in a pur- two phases the working phase, a more accurate
posive, enduring relationship; this requires reflection of what actually occurs in this im-
discipline and skill on the part of the nurse” portant aspect of the nurse–patient relation-
(p. 11). Peplau continued to emphasize that ship is provided. Although the nurse–patient
nurses must possess “well-developed intellec- relationship is time limited in nature, much of
tual competencies, and disciplined attention this relationship is spent “working.”
to the work at hand” (p. 13).
Communication, both verbal and nonver- Orientation Phase
bal, is an essential component of the nurse– The relationship begins with the orientation
patient relationship. However, in Peplau’s phase (Peplau, 1952). This phase is particularly
view, verbal communication is required for the important because it sets the stage for the de-
nurse–patient relationship to develop. She velopment of the relationship. During the
wrote, “[A]nything clients act out with nurses orientation period, the nurse and patient’s re-
will most probably not be talked about, and lationship is still new and unfamiliar. Nurse
that which is not discussed cannot be under- and patient get to know each other as people;
stood” (Peplau, 1989, p. 197). One objective their expectations and roles are understood.
of the nurse–patient relationship is to talk During this first phase, the patient expresses a
about the problem or need that has resulted in “felt need” and seeks professional assistance
the patient interacting with the nurse. Peplau from the nurse. In reaction to this need, the
provided descriptions of phrases commonly nurse helps the individual by recognizing and
used by patients that require clarification on assessing his or her situation. It is during the as-
the part of the nurse. These included referring sessment that the patient’s needs are evaluated
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CHAPTER 6 • Nurse–Patient Relationship Theories 71

by the patient and nurse working together as take place only when the patient has gained
a team. Through this process, trust develops the ability to be free from nursing assistance
between the patient and the nurse. Also, the and act independently (Lloyd, Hancock, &
parameters for the relationship are clarified. Campbell, 2007). At this point, old needs
Nursing diagnoses, goals, and outcomes for are abandoned, and new goals are adopted
the patient are created based on the assessment (Lakeman, 1999). The completion of the res-
information. Nursing interventions are imple- olution phase results in the mutual termination
mented, and the evaluations of the patient’s of the nurse–patient relationship and involves
goals are also incorporated (Peplau, 1992). planning for future sources of support (Peplau,
1952). Completion of this final phase “is one
Working Phase measure of the success of . . . all the other
The working phase incorporates identification phases” (Lloyd et al., 2007, p. 50).
and exploitation. The focus of the working
phase is twofold: first is the patient, who “ex-
ploits” resources to improve health; second is Applications of the Theory
the nurse, who enacts the roles of “resource Almost all of the research that has tested
person, counselor, surrogate, and teacher in fa- Peplau’s nurse–patient relationship has been
cilitating . . . development toward well-being” conducted by Forchuk (1994, 1995) and col-
(Fitzpatrick & Wallace, 2005, p. 460). This leagues (Forchuk & Brown, 1989; Forchuk
phase of the relationship is meant to be flexible et al., 1998; Forchuk et al., 1998). Much of
so that the patient is able to function “depen- Forchuk’s work has focused on the orientation
dently, independently, or interdependently phase. Forchuk and Brown (1989) emphasized
with the nurse, based on . . . developmental the importance of being able to identify the
capacity, level of anxiety, self-awareness, and orientation phase and not rush movement
needs” (Fitzpatrick & Wallace, 2005, p. 460). into the working phase. To assist in this, they
A balance between independence and depend- developed a one-page instrument, the Rela-
ence must exist here, and it is the nurse tionship Form, which they have used to deter-
who must aid the patient in its development mine the current phase of the relationship and
(Lakeman, 1999). overall progression from phase to phase.2
During the exploitation phase of the working Peplau first wrote about the nurse–patient
phase, the client assumes an active role on the relationship in 1952. She hoped that through
health team by taking advantage of available this work, nurses would change how they inter-
services and determining the degree to which acted with their patients. She wanted nurses to
they are used (Erci, 2008). Within this phase, “do with” clients rather than “do to” (Forschuk,
the client begins to develop responsibility and 1993). The majority of the work that has tested
independence, becoming better able to face new Peplau’s nurse–patient relationship has been
challenges in the future (Erci, 2008). Peplau conducted with individuals with severe mental
(1992) wrote that “[e]xploiting what a situation illness, many of them in psychiatric hospitals.
offers gives rise to new differentiations of the In these studies, patients did move through the
problem and the development and improvement phases of the nurse–patient relationship.
of skill in interpersonal relations” (pp. 41–42). As psychiatric nurses have changed the
location of their practice from hospital to com-
Resolution Phase munity, they have carried Peplau’s work to this
The resolution phase is the last phase and in- new arena. Unfortunately, there has been lim-
volves the patient’s continual movement from ited testing of the nurse–patient relationship
dependence to independence, based on both a in community settings. Parrish, Peden, and
distancing from the nurse and a strengthening
of individual’s ability to manage care (Peplau, 2For additional information, please visit DavisPlus at
1952). According to Peplau, resolution can http://davisplus.fadavis.com.
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72 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

Staten (2008) explored strategies used by ad- raised the question: Isn’t relationship-based care
vanced practice psychiatric nurses treating in- what Peplau described as early as the 1950s?
dividuals with depression. All the participants One such institution, St. Mary’s located in
in this study practiced in community settings. Evansville, Indiana, has developed a model of
When describing the strategies used, the relationship-based care. It is defined as “health-
nurse–patient relationship was the primary ve- care achieved through collaborative relation-
hicle by which strategies were delivered. These ships. Relationship-Based Care takes place in
strategies included active listening, partnering a caring, competent and healing environment
with the client, and a holistic view of the client. organized around the needs and priorities of the
This work supports the integration of Peplau’s patients and their families who are at the center
nurse–patient relationship into the work of the of the care team” (www.stmarys.org/relation-
psychiatric nurse. shipbasedcare; retrieved February 5, 2013).
Moving beyond application of Peplau’s Some of the principles of this type of care
theory in psychiatric settings with psychiatric include developing a therapeutic relationship,
patients, Merritt and Proctor (2010) used being knowledgeable of self, experiencing
Peplau’s four phases of the nurse–patient rela- change that occurs over time, and believing that
tionship to guide their practice as mental everyone has a valuable contribution to make.
health consultation liaison nurses. Working As literature describing relationship-based care
with patients experiencing psychiatric symp- is reviewed (Campbell, 2009; Small & Small,
toms but who did not have a psychiatric dis- 2011), citations of Peplau’s work are notably
order, these practitioners were guided by lacking. Their absence may be attributed to how
Peplau’s four phases of the nurse–patient thoroughly Peplau’s writings have become in-
relationship. This clinical application led to tegral to nursing practice—as if they belong to
better engagement with patients, provided nursing, are a part of nursing’s language and
patients with the tools needed to address life culture, and are no longer recognizable as being
changes that precipitated their illness, and fi- separate from what is nursing.
nally resulted in movement toward health that Not only is nursing practice enhanced when
included meaningful, productive living. They Peplau’s work is reviewed and applied, it also
concluded that Peplau’s work provided a may provide guidance in maintaining profes-
model to ensure successful engagement with sional roles. In a more informal society with its
patients requiring consultation liaison nursing consequent easing of professional behaviors in
interventions. registered nurses, boundary violations reported
Peplau’s theoretical work on the nurse– to boards of nursing are increasing (Jones,
patient relationship continues to be essential Fitzpatrick, & Drake, 2008). A return to the
to nursing practice. To increase patient satis- structure of the nurse–patient relationship and
faction with care received in health-care set- revisiting the roles as defined by Peplau may
tings, relationship-based care has become an be needed (Jones, 2012). Peplau clearly artic-
important component in the delivery of nursing ulated the roles of the nurse. At the time when
care. Large institutions are educating their she was writing about this, nursing was moving
workforce on the importance of having a rela- from hospital-based educational systems into
tionship, a connection with those with whom university settings. The focus of nursing was on
the nurse interacts and to whom he or she pro- becoming a profession. With this movement,
vides care. The premise is that by putting the more autonomy in nursing practice was needed.
patient and his or her family at the center of To provide a framework for this, Peplau devel-
care, patient satisfaction and outcomes will im- oped, primarily for psychiatric-mental health
prove. In response to this and other changes in nurses, six roles that were integral in the nurse–
health care, Jones (2012) wrote a thoughtful patient relationship. These were described
editorial encouraging nurse leaders and educa- earlier in this chapter.
tors to reclaim the structure of the nurse– The stranger role has particular relevance
patient relationship as defined by Peplau. He to establishing professional boundaries. All
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CHAPTER 6 • Nurse–Patient Relationship Theories 73

nurse–patient relationships begin with meet- interaction is therapeutic, as described by


ing the patient. The nurse enters into this Peplau, then in the nurse–patient relationship
relationship as a nurse, not as a friend. The there is no time for social chit-chat or devel-
nurse is respectful of the patient and values his oping friendships. The work of nursing is to
or her privacy. When a nurse moves from pro- engage the patient in therapeutic relationships
fessional to friend, boundary issues have been that move them toward greater health. This
violated. If this is not recognized or even raised was as vital to nursing in the 1950s as it
as a concern, nursing care deteriorates. If every is today.

Practice Exemplar
Karen Thomas is a 49-year-old married woman responses are guarded as she alludes to marital
who has a scheduled appointment with an ad- infidelity on the part of her husband. Inter-
vanced practice psychiatric nurse (APPN). She spersed throughout the conversation are state-
appears anxious and uncomfortable in the en- ments about her dislike of medications. The
counter with the APPN. In an effort to help APPN then begins to ask more pointed assess-
Ms. Thomas feel more comfortable, the APPN ment questions related to depressive symptoms.
offers her a glass of water or cup of coffee. Ms. Thomas shares that she has very poor sleep,
Ms. Thomas announces that she has not eaten cannot concentrate, is isolating herself, has dif-
all day and would like something to drink. The ficulties making decisions, and feels hopeless
APPN provides a cup of water and several about her future. At this point, Ms. Thomas
crackers for Ms. Thomas to eat. Once they are also shares that she had never taken the antide-
both seated, the APPN asks Ms. Thomas about pressant prescribed for her. By sharing this,
the reason for the appointment (what brought Ms. Thomas indicates the beginning of a trust-
her here today). Ms. Thomas replies that she ing relationship with the APPN. Once the
does not know; her husband made the appoint- initial assessment is complete, a preliminary di-
ment for her. To more fully understand the rea- agnosis is determined, and client and nurse are
son for her husband making the appointment, ready to move into the working phase.
the APPN asks Ms. Thomas to tell her what The working phase is initiated with problem
aspects of her behavior were viewed by her identification. For Ms. Thomas, the primary
husband as calling for attention. Once again, problem is major depression with a secondary
Ms. Thomas shares that she does not know. problem, partner-relational issues. The APPN,
Continuing to focus on getting acquainted and acting as a resource person, provides education
enhancing Ms. Thomas’s comfort in this begin- about the illness, major depression. Included is
ning relationship, the APPN asks Ms. Thomas information about the biological causes of the
to tell her about herself. Ms. Thomas shares illness, genetic predisposition, and explanations
that she has been depressed in the past and was about the symptoms. A partnership is formed as
treated by a psychiatric nurse practitioner, who the APPN and Ms. Thomas discuss treatment
prescribed an antidepressant medication. Be- options. Although Ms. Thomas shares that she
coming tearful, she also shares that she left her does not like to take medications, she agrees to
husband several days ago and has moved in an appointment with a psychiatric nurse practi-
with her oldest son, stating that she “just needs tioner, who will conduct a medication evalua-
some time to think.” For the next 15 minutes, tion. That appointment is scheduled later in the
Ms. Thomas talks about her marriage, her love week. Ms. Thomas also shares that she really
for her husband, and her lack of trust in him. wants to talk about her relationship with her
She also shares symptoms of depression that are husband and come to some decision about the
present. Ms. Thomas speaks tangentially and future of their marriage. Marital counseling is
is a poor historian when recalling events in mentioned as a possible treatment option, but
the marriage that have caused her pain. Her the APPN suggests that this be delayed until
Continued
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74 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

Practice Exemplar cont.


Ms. Thomas’s depressive symptoms have At the next session, Ms. Thomas is notice-
decreased. The first session ends with both ably improved. She states that she is sleeping,
client and nurse committed to working to de- not crying as much, concentrating better, and
crease Ms. Thomas’s depressive symptoms. feeling more hopeful about her marriage. She
Ms. Thomas is reminded about her appoint- also shares that she and her husband have met
ment for a medication evaluation, and a second for dinner several times and that he is willing to
therapy appointment is made with the APPN. come with her for marital counseling. However,
At the second visit, Ms. Thomas reports that she shares that she is not yet ready for this,
she has started taking an antidepressant but as preferring to spend time focusing on her own
of yet has not seen any relief of her symptoms. mental health. Over the course of several
The APPN provides information about the months, Ms. Thomas and the APPN meet. In
usual length of time required for results to these sessions, Ms. Thomas explores her child-
occur. Although Ms. Thomas does not see no- hood, talks about the recent death of her
ticeable results from the medication, the APPN mother, decides to begin a new exercise pro-
shares that Ms. Thomas looks more relaxed gram, and reconnects with childhood friends.
and seems less anxious. Ms. Thomas states that Through this work, Ms. Thomas grows more
she would like to spend this session talking secure in who she is and in how she wants to
about her relationship with her husband. She live. During this same time period, she contin-
describes what was once a very happy mar- ues to meet her husband regularly for dinner and
riage. The APPN listens, asks for clarification sometimes a movie.
when needed, and encourages Ms. Thomas to At their final session, Ms. Thomas shares
share her perceptions of her marriage. The that she is ready to go with her husband to
APPN asks Ms. Thomas again to talk about marital counseling. As a result of antidepres-
what might have caused her husband to call sant medication and therapy, the problem of
and make the therapy appointment for her. major depression has been resolved. However,
Ms. Thomas shares that her husband does not the focus of this last session returns to depres-
want their marriage to end; however, she is not sion. This is done to help Ms. Thomas recog-
sure yet about their future. Her perception is nize the early symptoms of depression to
that her husband thinks she is the one with the prevent a relapse. Ms. Thomas shares that her
problem and once she is “fixed” that their mar- first symptoms were not sleeping well and
riage will return to its former state of happi- withdrawing from friends and family. The
ness. The session ends with the APPN asking APPN emphasizes the importance of monitor-
Ms. Thomas to focus on her own physical and ing this and calling for an appointment if these
mental health. Possible interventions include early symptoms occur. The focus now is on
beginning an exercise program, practicing stress the secondary problem of partner-relationship
reduction strategies, and reconnecting with in- issues. With this, the APPN makes a referral
dividuals who have been supportive in the past. to a marital and family therapist.

■ Summary
Peplau is considered the first modern-day the nursing profession forward. She also be-
nurse theorist. Her clinical work provided di- lieved that nursing research should be
rection for the practice of psychiatric-mental grounded in clinical problems. She worked
health nursing. This occurred at a time when tirelessly to advance the profession of nursing,
there were few innovations in the care of the as both an educator and a leader at the national
mentally ill. She valued education, believing and international levels. Her contributions
that attaining advanced degrees would move continue to have an influence today.
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CHAPTER 6 • Nurse–Patient Relationship Theories 75

References

Campbell, M. P. (2009). Relationship based Care is education. Archives of Psychiatric Nursing, 22,
here! The Journal of Lancaster General Hospital, 4 (3), 356–363.
87–89. Lakeman, R. (1999). Remembering Hildegard Peplau.
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Forchuk, C. (1991). Peplau’s theory: Concepts and their Strategies used by advanced practice psychiatric
relations. Nursing Science Quarterly, 4(2), 64–80. doi: nurses in treating adults with depression. Perspectives
10.1177/089431849100400205 in Psychiatric Care, 44, 232–240.
Forchuk, C. (1993). Hildegard E. Peplau: Interpersonal Peplau, H. E. (1952). Interpersonal relations in nursing.
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27(2), 30–34. Peplau, H. E. (1988). The art and science of nursing:
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Valledor, T. (1998). From hospital to community: Science Quarterly, 1, 8–15.
Bridging therapeutic relationships. Journal of Psychi- Peplau, H. E. (1989). Clinical supervision of staff
atric and Mental Health Nursing, 5, 197–202. nurses. In A. O’Toole, & S. R. Welt (Eds.),
Forchuk, C., Westwell, J., Martin, A., Azzapardi, W. Interpersonal theory in nursing practice: Selected works
B., Kosterewa-Tolman, D., & Hux, M. (1998). Fac- of Hildegard Peplau (pp. 164–167). New York:
tors influencing movement of chronic psychiatric pa- Springer.
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the nurse-client relationship on an inpatient unit. ical framework for application in nursing practice.
Perspectives in Psychiatric Care, 34, 36–44. Nursing Science Quarterly, 5(1), 13–18.
Jones, J. (2012). Has anybody seen my old friend Pe- Peplau, H. E. (1998). Life of an angel: Interview with
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76 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

Part Two Joyce Travelbee’s Human-to-Human was enrolled in doctoral study at the time of her
Relationship Model and Its Applications death at age 47. Travelbee was Director of
JACQUELINE STAAL Graduate Education at the Louisiana State
University School of Nursing when she died.
Travelbee’s first book, Interpersonal Aspects
Introducing the Theorist of Nursing (1966), identified the purpose of
Joyce Travelbee (1926–1973) practiced psychi- nursing and the roles of the nurse in achieving
atric/mental health nursing for more than this purpose. The delicate balance between
30 years in both the clinical setting and as a scientific knowledge and the ability to apply
nurse educator. She is best known for her evidence-based interventions with the thera-
human-to-human relationship model, a mid- peutic use of self in effecting change was de-
dle-range theory that guides the nurse–patient scribed and the ultimate goal of helping the
interaction with emphasis on helping the patient find hope and meaning in the illness
patient find hope and meaning in the illness experience was identified. In Travelbee’s sec-
experience (Travelbee, 1971). The human-to- ond book, Intervention in Psychiatric Nursing:
human relationship model provided an early Process in the One-to-One Relationship (1969),
framework for delivering patient-centered the role of the psychiatric nurse in patient care
care, as promoted today by the Agency for is described, the concept of communication
Healthcare Research and Quality with the in the human-to-human relationship is exam-
U.S. Department of Health and Human Serv- ined, and the process of establishing, maintain-
ices and as noted in the Institute of Medicine’s ing, and terminating a relationship is described.
(2001) report, “Crossing the Quality Chasm:
A New Health System for the 21st Century.”
Travelbee graduated from the diploma nurs-
Overview of Travelbee’s
ing program at Charity Hospital School of Conceptualization
Nursing in New Orleans, Louisiana, in 1943. Travelbee’s human-to-human relationship
Her early clinical practice at Charity Hospital, model was based on the work of nurse theorists
combined with her faith, spirituality, and reli- Hildegard Peplau and Ida Jean Orlando
gious background, influenced her view on nurs- (Tomey & Alligood, 2006). Viktor E. Frankl’s
ing and later the development of her theoretical logotherapy guided Travelbee’s (1971) concept
model. She received her bachelor of science de- of nursing intervention and the role of the
gree in nursing from Louisiana State University nurse in helping patients and their families
in 1956 and later her master of science degree in find meaning in the illness experience.
nursing with a focus on psychiatric/mental Caring, in the human-to-human relation-
health nursing in 1959 from Yale University. ship model, involves the dynamic, reciprocal,
Travelbee taught psychiatric and mental interpersonal connection between the nurse
health nursing at Louisiana State University, and patient, developed through communica-
New Orleans; the Department of Nursing Ed- tion and the mutual commitment to perceive
ucation at New York University; the University self and other as unique and valued. Through
of Mississippi School of Nursing in Jackson; and the therapeutic use of self and the integration
at the Hotel Dieu School of Nursing in New of evidence-based knowledge, the nurse pro-
Orleans, Louisiana (Meleis, 1997; Travelbee, vides quality patient care that can foster the
1971). As a clinical instructor and later a profes- patient’s trust and confidence in the nurse
sor of nursing, Travelbee (1972) incorporated (Travelbee, 1971). The meaning of the illness
her philosophy of caring into her teaching meth- experience becomes self-actualizing for the
ods, challenging students to learn not only from patient as the nurse helps the patient find
their textbooks and nursing colleagues but rather meaning in the experience. The purpose of the
from the patients and their relatives themselves. nurse is to “enable (the individual) to help
She later served as a nursing consultant for the themselves . . . in prevention of illness and
Veteran’s Administration Hospital in MS and promotion of health, and in assisting those
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CHAPTER 6 • Nurse–Patient Relationship Theories 77

who are incapable, or unable, to help them- and despair. Hope and motivation are impor-
selves” (Travelbee, 1969, p. 7). tant nursing tasks in caring for an ill person in
The human-to-human relationship “refers despair. However, the nurse “cannot ‘give’
to an experience or series of experiences be- hope to another person; she can, however,
tween the human being who is nurse and an ill strive to provide some ways and means for an
person,” culminating in the nurse meeting the ill person to experience hope” (Travelbee,
ill person’s unique needs (Travelbee, 1971, 1971, p. 83).
pp. 16–17). The term patient is not used All human beings endure suffering, al-
in Travelbee’s model, because patient refers to though the experience of suffering differs from
a label or category of people, rather than a one individual to another (Travelbee, 1971).
unique individual in need of nursing care. The Suffering may be inevitable, but one’s attitude
purpose of nursing, according to Travelbee toward it affects how an individual copes with
(1971), is “to assist an individual, family or any illness. If the patient’s needs are not met
community to prevent or cope with the expe- in his suffering, he may develop “despairful
rience of illness and suffering and, if necessary, not-caring,” in which he does not care if he
to find meaning in these experiences” (p. 16). dies or recovers, or “apathetic indifference,” in
Simply caring about an individual is not suffi- which he has “lost the will to live” (Travelbee,
cient for providing quality care but rather the 1971, pp. 180–181). Hope helps the suffer-
integration of a broad knowledge base with the ing person to cope, and it is an assumption
therapeutic use of self is needed. To effect of Travelbee’s (1971) that “the role of the
change in the human relationship, the nurse nurse . . . [is] to assist the ill person [to] ex-
must transcend her sense of self to focus on the perience hope in order to cope with the stress
recipient of care (Travelbee, 1969). of illness and suffering” (p. 77).
Transcendence of the traditional titles of To relieve the patient’s suffering and to
nurse and patient is necessary to prevent dehu- foster hope, the nurse provides care based on
manization of the ill person. With the rapid the individual’s unique needs. Nursing care,
expansion of health technology, combined with according to Travelbee (1971), is delivered
financial constraints leading to restructuring of through five stages: observation, interpreta-
nurse–patient ratios, competing demands are tion, decision making, action (or nursing
placed on the nurse’s time and attention. An intervention), and appraisal (or evaluation).
emotional detachment between the nurse and The nursing intervention is designed to achieve
ill person is created when the nurse views the the purpose of nursing and is communicated
ill person as simply “patient,” rather than as a to the patient. The goals of communication in
unique individual with his own understanding the nursing process are “to know (the) person,
of the illness experience. By performing nurs- (to) ascertain and meet the nursing needs of ill
ing tasks without an emotional investment in persons, and (to) fulfill the purpose of nursing”
the nurse–patient relationship, the ill person’s (Travelbee, 1971, p. 96).
physical needs are met. However, the ill person In the observation stage of nursing care, the
recognizes the lack of caring in the transaction nurse “does not observe signs of illness” but
and is left alone to suffer with the symptoms of rather collects sensory data to identify a prob-
illness. Dehumanization occurs when the ill lem or need (Travelbee, 1971, p. 99). The
person is left alone to find meaning in his nurse validates her interpretation of the prob-
illness experience. lem or need with the ill person and decides
Many ill persons and their family members whether or not to act upon her interpretation.
may ask questions such as “why me?” or “why A nursing intervention is developed in align-
my loved one?” By inquiring into the individ- ment with the purpose of nursing, and requires
ual’s perception of his illness and how he has the nurse to “assist ill persons to find meaning
derived meaning from his illness experience, in the experience of illness, suffering, and pain”
the nurse can assess his coping ability and pro- (Travelbee, 1971, p. 158). However, the nurse
vide nursing interventions to prevent suffering may not assume she understands the meaning
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78 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

of the illness experience to the ill person with- the “intellectual and . . . emotional comprehen-
out first inquiring into this meaning. To do so sion of another person” (Travelbee, 1964).
would communicate to the ill person that his Empathy is the precursor to sympathy, or the
or her experience is not of value to the nurse, “desire, almost an urge, to help or aid an individ-
resulting in dehumanization. The nurse evalu- ual in order to relieve his distress” (Travelbee,
ates the outcomes of her nursing intervention 1964). Sympathy is not pity, but rather a demon-
based on objectives developed before the phase stration to the person that he is not carrying the
of appraisal. burden of illness alone. Trust develops between
In meeting the ill person’s needs through the nurse and person in the phase of sympathy,
the human-to-human relationship, the nurse and the person’s distress is diminished.
employs a disciplined intellectual approach Rapport is essential in the nurse–patient
or a logical approach consistent with nursing relationship. Travelbee (1971) defined rapport
standards and clinical practice guidelines to as “a process, a happening, and experience, or
identify, manage, and evaluate the ill person’s series of experiences, undergone simultane-
problem (Travelbee, 1971). Each stage in the ously by nurse and the recipient of her care”
nursing process may be employed without (p. 150). Rapport “is composed of a cluster of
the establishment of a human-to-human interrelated thoughts and feelings: interest in
relationship. An acute medical need may be and concern for, others; empathy, compassion,
met, but the patient’s deeper spiritual and and sympathy; a non-judgmental attitude, and
emotional needs are neglected. These spiri- respect for each individual as a unique human
tual and emotional needs are addressed in the being” (Travelbee, 1963). Through the estab-
human-to-human relationship in the pro- lishment of rapport, the nurse is able to foster
gression through five phases: the original a meaningful relationship with the ill person
encounter, emerging identities, empathy, during multiple points of contact in the care
sympathy, and rapport. setting. Rapport is not established in every
In the phase of the original encounter, the nurse–person encounter; however, emotional
nurse and ill person form judgments about involvement is required from the nurse. To
each other that will guide and shape future establish this emotional bond with one’s pa-
nurse–person interactions. Past experiences, tient, the nurse must first ensure her own emo-
the media, and stereotypes may influence one’s tional needs are met.
perception of another, blocking the develop- In Travelbee’s second book, Intervention in
ment of a human-to-human relationship. In Psychiatric Nursing, implementation of the
the phase of emerging identities, a bond begins human-to-human relationship model is ex-
to form between nurse and person as each plained through the stages of selecting and es-
individual begins to “appreciate the uniqueness tablishing a patient relationship, the process of
of the other” (Travelbee, 1971, p. 132). The maintaining the relationship, and ultimate ter-
bond is created and shaped through each mination of the relationship. Patients in the
nurse–person interaction and is facilitated by acute care facility are typically assigned to a
the therapeutic use of self, combined with nurse based on acuity, skill level and experience
nursing knowledge. The nurse must recognize of the nurse. However, nurses can select a pa-
how she perceives the person to create a foun- tient to develop a one-on-one relationship
dation of empathy. with based on availability and willingness of
In the phase of empathy, the nurse begins the nurse and patient.
to see the individual “beyond outward behavior During the preinteraction phase, the nurse
and sense accurately another’s inner experience and patient relationship is chosen or assigned.
at a given point in time” (Travelbee, 1971, The nurse may have preconceived thoughts and
p. 136). Empathy enables the nurse to pre- feelings toward the patient she is entering the
dict what the person is experiencing and re- relationship with and must identify these preju-
quires acceptance because empathy involves dices before the next phase of their relationship.
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CHAPTER 6 • Nurse–Patient Relationship Theories 79

Goals and objectives for the interaction are es- Practice Applications
tablished before the first meeting and may
Cook (1989) used Travelbee’s nursing con-
evolve over time (Travelbee, 1969, p. 143).
cepts to design a support group for nurses
Once the nurse and patient are acquainted,
facing organizational restructuring at a
both the nurse and patient begin to assess each
New York hospital. The purpose of the sup-
other and make an assumption about the
port group was to help nurses develop more
other. The nurse should clarify to the patient
meaningful perceptions of their roles during
that she is not there simply to collect data but
a nursing shortage created during a financial
rather to get to “know” the patient (p. 151).
crisis that resulted in a restructuring of
Data should be collected in a manner that is
patient care delivery and nurse/patient ratios.
sensitive to the patient’s privacy and comfort
Group morale was low in the beginning, and
level. The nurse’s own thoughts and feelings of
nurses were frustrated with higher nurse/
the interaction must be considered following a
patient ratios. The support group met over
one-on-one interaction to determine whether
2 weeks, and the group intervention was
her own behavior may have affected the patient
designed by incorporating Hoff’s theory on
interaction (Travelbee, 1969, p. 132). Like-
crisis intervention with Travelbee’s phases of
wise, the nurse must evaluate whether the in-
observation and communication. Travelbee’s
teraction met previously established objectives
human-to-human relationship was used to
and set goals for future interactions. The nurse
guide supportive discussions and problem-
and patient affect each other’s thoughts and
solving as nurses struggled to regain a sense
feelings during each encounter, based on “the
of meaning and purpose related to their pro-
nurse’s knowledge and her ability to use it, the
fessional identity.
ill person’s willingness or capacity to respond
Participants shared their perceptions of their
to the nurse’s effort, and the kind of problem
work environment during the initial encounter.
experienced by the ill person” (Travelbee,
Support group members discussed the similar-
1969, p. 139).
ities and differences in their work perceptions
The phase of emerging identities occurs
during the phase of emerging identities. Empa-
when the nurse and the patient have overcome
thy and trust developed as nurses became more
their own anxieties about the interaction,
accepting and nonjudgmental of each other’s
stereotypes, and past experiences. The nurse
perceptions, culminating in the establishment
and patient come to see each other as unique,
of rapport as group members were able to “re-
and the nurse works to transcend her view of
capture” the meaning of nursing (Cook, 1989).
the situation. The nurse helps the patient to
Cook (1989) found that nurses who had
identify problems and helps the patient change
threatened to quit earlier had remained in the
his own behaviors. During this stage of devel-
system by the end of the support group. Nurse
opment, the nurse helps the patient find
productivity had increased over time, and the
meaning in the illness experience “whether this
number of sick days taken by the nurses had
suffering be predominately mental, physical, or
diminished over the 6-month period after pro-
spiritual in origin” (Travelbee, 1969, p 157).
gram cessation. Nurses regained a sense of
Eventually, the relationship is terminated, and
meaning of their work and reported increased
preparation for termination of the relationship
job satisfaction after completion of the pro-
should begin early in the Phase of Emerging
gram. Travelbee’s ideas hold potential as an ef-
Identities. Patients may feel abandoned or
fective nursing intervention for improving
angry regarding the termination if remaining
nurse retention rates. However, further re-
in the facility. In some cases, the nurse may be
search is necessary because the exact number
able to elicit their thoughts and feelings. Those
of nurses recruited into the support group and
to be discharged from the facility should be en-
the actual number of nurses who completed
couraged to express their fears and be assisted
the program are unknown.
in problem-solving solutions.
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80 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

Practice Exemplar
Luciana came into nurse practitioner Janice’s her physical examination, taking care to doc-
office for her annual well-woman examina- ument the extent of her swelling and the size,
tion. A 53-year-old mother of three without shape, smoothness, mobility, and location of
insurance, Luciana had delayed her visit for any lumps palpated during the clinical breast
several months due to lack of money. Despite examination.
a nagging feeling that the pain in her breasts Once the examination was finished, Janice
might be serious, Luciana waited until she excused herself and sought out the office man-
could no longer tolerate the pain and the red- ager. She pulled Sophia aside in private and ex-
ness and swelling of the breasts that had since plained the situation. They contacted their local
developed. representative from the health department in
When Janice explained to Luciana that she charge of a grant that allocated money for
was a nurse practitioner and would be per- diagnostic mammography and arranged for the
forming her examination today and address- patient to obtain the mammography through
ing any concerns she may have. Luciana sat the program. Janice returned to the examina-
silently, looking slightly below Janice’s eyes as tion room with the referral form, prescription
she spoke. She avoided eye contact until asked for the diagnostic imaging, and contact infor-
if something was wrong. Unable to wait for mation for the program representative. The
Janice to complete the history, Luciana lifted patient began to cry softly as she expressed
her shirt and showed the nurse practitioner concern for her three children and wondered
her erythematous, swollen breasts. The most who would take care of them? Janice hugged
significant swelling noted was located in the Luciana as she cried and shared her story of
upper left quadrant, where Janice’s own working as a stay-at-home mom while her
mother-in-law had experienced her most sig- husband worked for low wages. She felt lonely
nificant swelling and lesions from her breast and missed her family who lived abroad. She
cancer 5 years earlier—a cancer she hid from had not shared her breast pain with any one,
her family until it was too late to intervene. wanting to protect her family from worrying
“What do you think this means?” Luciana about her. Tears began to fall from Janice’s
asked. Stunned by her bluntness, Janice took own eyes, as she remembered her mother-
a closer look at the swelling and warm, red in-law lying in a hospice bed when she finally
skin across Luciana’s chest. Dread filled shared the gaping wounds where her own
quickly inside Janice. “Do you think this is breast cancer had eaten away at her skin. Dread
cancer?” she asked. Trying to think back to had filled inside Janice then, too, as she knew
what she had been taught to say in her nursing she was powerless to help her. As Janice
education, her mind drew a blank and honesty hugged Luciana, a shimmer of hope radiated
was the only thought to come to mind. “Yes,” from somewhere in that examination room as
Janice replied softly. “I do.” Tears began to fall she realized she could actually do something to
from Luciana’s calm face, as though she knew help Luciana. Even though she did not have a
she had breast cancer all along. Janice gave her background in oncology, Janice knew how to
a big hug and whispered softly into her left ear, connect her with providers that could further
“It will be alright. I am going to help you.” Lu- evaluate and manage her breast cancer. Janice
ciana explained that she did not work showed Luciana the documents that she had
and did not have either health insurance or carried into the examination room and ex-
Medicaid. Janice explained that programs plained how she could obtain the mammogram
were available to help provide financial assis- at no charge. Janice described the program
tance and that she would help her contact a being offered through the health department
representative from a state-run breast cancer and gave her the name of the woman who
program. Janice carefully finished performing would now help facilitate the care she needed.
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CHAPTER 6 • Nurse–Patient Relationship Theories 81

Practice Exemplar cont.


Luciana looked her in the eyes, hopefully em- cues and body language led her to the purpose
powered by the information Janice had given of Luciana’s visit and to identify Luciana’s
her, and said “thank you.” fear related to the breast cancer. By identi-
Several days later, Janice received the radi- fying barriers to care and existing sources of
ologist’s report from Luciana’s diagnostic support for the patient (Concept of Decision-
mammography. The report confirmed that Making), Janice developed a care plan that in-
Luciana did indeed have breast cancer. Fortu- volved a referral to the health department for
nately, Sophia, the assistant office manager, access to a state grant available to fund Lu-
had spoken with Jan at the health department ciana’s mammogram and to a representative
and learned Luciana had received Medicaid with the state Medicaid program for financial
and was now under the care of an oncologist assistance with breast cancer treatment (Con-
with experience in treating breast cancer. Lu- cept of Action, or Nursing Intervention). By
ciana returned to the clinic a couple weeks caring for her as a person, Luciana was able to
later and expressed her gratitude for their help express her story freely and let go of her feel-
in getting her the health care she needed. She ings of powerlessness and fear that had built
had started chemotherapy treatment and her up inside her since she first noticed her breast
mother had come to stay with her to help take pain. The barrier between Janice-as-clinician
care of her children. and Luciana-as-patient blurred as they con-
Travelbee’s concepts are evident in this nected in that examination room, their stories
exemplar. Janice, the nurse practitioner, col- intertwining as they came together as woman-
lected the preliminary patient history and ex- to-woman each affected by breast cancer dif-
amination findings needed to formulate a ferently and yet somehow the same (concept
diagnosis during the Stage of Observation. of appraisal).
However, Janice’s interpretation of nonspoken

■ Summary
Travelbee’s conceptualizations of the human- concept of therapeutic use of self to effect
to-human relationship guide the nurse–patient change in patient-centered care. Patients are
interaction with an emphasis on helping the viewed as unique, and nursing care is delivered
patient find hope and meaning in the illness over five stages: observation, interpretation,
experience. Scientific knowledge and clinical decision making, action (or nursing interven-
competence are incorporated into Travelbee’s tion), and appraisal (or evaluation).

References

Cook, L. (1989). Nurses in crisis: A support group based Travelbee, J. (1963). What do we mean by rapport?
on Travelbee’s nursing theory. Nursing and Health American Journal of Nursing, 63(2), 70–72.
Care, 10(4), 203–205. Travelbee, J. (1964). What’s wrong with sympathy?
Institute of Medicine. (2001). Crossing the quality American Journal of Nursing, 64(1), 68–71.
chasm: A new health system for the 21st Century. Travelbee, J. (1966). Interpersonal aspects of nursing.
Available at: www.iom.edu/Reports/2001/Crossing- Philadelphia, PA: F. A. Davis.
the-Quality-Chasm-A-New-Health-System-for- Travelbee, J. (1969). Intervention in psychiatric nursing:
the-21st-Century.aspx Process in the one-to-one relationship. Philadelphia:
Meleis, A. I. (1997). Theoretical nursing: Development & F.A. Davis.
progress (3rd ed.). New York: Lippincott. Travelbee, J. (1971). Interpersonal aspects of nursing
Tomey, A. M., & Alligood, M. R. (2006). Nursing theo- (2nd ed.). Philadelphia: F. A. Davis.
rists and their work (6th ed.). St. Louis, MO: Mosby Travelbee, J. (1972). Speaking out: To find meaning in
Elsevier. illness. Nursing, 2(12), 6–8.
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82 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

Part Three Ida Jean Orlando’s Dynamic Nurse– direct assistance to individuals in whatever set-
Patient Relationship ting they are found for the purpose of avoid-
MAUDE RITTMAN AND DIANE GULLETT ing, relieving, diminishing or curing the
individual’s sense of helplessness (Orlando,
1972).
Introducing the Theorist The essence of Orlando’s theory, the dy-
Ida Jean Orlando was born in 1926 in namic nurse–patient relationship, reflects her
New York. Her nursing education began at beliefs that practice should be based on needs
New York Medical College School of Nursing of the patient and that communication with
where she received a diploma in nursing. In the patient is essential to understanding needs
1951, she received a bachelor of science degree and providing effective nursing care. Following
in public health nursing from St. John’s is an overview of the major components of
University in Brooklyn, New York, and in Orlando’s work:
1954, she completed a master’s degree in nurs-
ing from Columbia University. Orlando’s early 1. The nursing process includes identifying the
nursing practice experience included obstetrics, needs of patients, responses of the nurse,
medicine, and emergency room nursing. and nursing action. The nursing process,
Her first book, The Dynamic Nurse–Patient as envisioned and practiced by Orlando, is
Relationship: Function, Process and Principles not the linear model often taught today
(1961/1990), was based on her research and but is more reflexive and circular and
blended nursing practice, psychiatric–mental occurs during encounters with patients.
health nursing, and nursing education. It was 2. Understanding the meaning of patient be-
published when she was director of the gradu- havior is influenced by the nurse’s percep-
ate program in mental health and psychiatric tions, thoughts, and feelings. It may be
nursing at Yale University School of Nursing. validated through communication between
Ida Jean Orlando passed away November 28, the nurse and the patient. Patients experi-
2007. ence distress when they cannot cope with
Orlando’s theoretical work is both practice unmet needs. Nurses use direct and indi-
and research based. She received funding from rect observations of patient behavior to
the National Institute of Mental Health to discover distress and meaning.
improve education of nurses about interper- 3. Nurse–patient interactions are unique, com-
sonal relationships. As a consultant at McLean plex, and dynamic processes. Nurses help
Hospital in Belmont, Massachusetts, Orlando patients express and understand the mean-
continued to study nursing practice and devel- ing of behavior. The basis for nursing
oped an educational program and nursing serv- action is the distress experienced and
ice department based on her theory. From expressed by the patient.
evaluation of this program, she published her 4. Professional nurses function in an independ-
second book, The Discipline and Teaching of ent role from physicians and other health-
Nursing Process (Orlando, 1972; Rittman, care providers.
1991).
Practice Applications
Overview of Orlando’s Theory Orlando’s theoretical work was based on
analysis of thousands of nurse–patient interac-
of the Dynamic Nurse–Patient tions to describe major attributes of the rela-
Relationship tionship. Based on this work, her later book
Nursing is responsive to individuals who suffer provided direction for understanding and
or anticipate a sense of helplessness; it is fo- using the nursing process (Orlando, 1972).
cused on the process of care in an immediate This has been known as the first theory of
experience; it is concerned with providing nursing process and has been widely used in
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CHAPTER 6 • Nurse–Patient Relationship Theories 83

nursing education and practice in the United theoretical framework was used to describe the
States and across the globe. Orlando consid- communication among the nursing students,
ered her overall work to be a theoretical frame- homecare nurses, and city residents (Aponte,
work for the practice of professional nursing, 2009, p. 326). Dufault et al. (2010) developed
emphasizing the essentiality of the nurse– a cost-effective, easy-to-use, best practice
patient relationship. Orlando’s theoretical protocol for nurse-to-nurse shift handoffs at
work reveals and bears witness to the essence Newport Hospital, using specific components
of nursing as a practice discipline. of Orlando’s theory of deliberative nursing
Orlando’s work has been used as a founda- process. Abraham (2011) proposed addressing
tion for master’s theses (Grove, 2008; Hendren, fall risk in hospitals using Orlando’s concep-
2012). Reinforcing Orlando’s theory as a prac- tualizations. The author asserts that three
tice and conceptual framework continues to be elements (patient’s behavior, nurse’s reaction,
relevant and applicable to nursing situations in and anything the nurse does to alleviate the
today’s healthcare environment. distress) can effectively act as a roadmap for
Laurent (2000) proposed a dynamic leader– decreasing fall risk.
follower relationship model using Orlando’s The New Hampshire Hospital, a university-
dynamic nurse–patient relationship. The dy- affiliated psychiatric facility, adopted Orlando’s
namic leader-follower relationship model re- framework for nursing practice (Potter, Vitale-
focuses the nature of “control” through shared Nolen, & Dawson, 2005; Potter, Williams, &
responsibility and meaning making, thereby Constanzo, 2004). Two nursing interventions
granting the employee or patient the ability stemmed directly from the adoption of Or-
to actively engage in resolving the issue or lando’s ideas. Potter, Williams, and Constanzo
problem at hand. The emphasis is on recog- (2004) developed a structured group curriculum
nizing in both patient care and management for nurse-led psychoeducational groups in an
that the person who knows most about the inpatient setting. Both nurses and patients
situation is the person himself or herself. To demonstrated improved comfort, active involve-
be truly effective in resolving a problem or ment and learning from combining Orlando’s
situation involves engaging in a dynamic re- dynamic nurse–patient relationship and a psy-
lationship of shared responsibility and active choeducational curriculum with training in
participation on the part of both parties group leadership.
(i.e., nurse–patient/nurse manager–employee) Potter, Vitale-Nolen, and Dawson (2005)
without which the true nature of the issue at conducted a quasi-experimental study to
hand may go unresolved. Laurant (2000) sug- determine the effectiveness of implementing
gested that engaging in a dynamic relation- a safety agreement tool among patients who
ship with the other provides a means by threaten self-harm. Orlando’s concepts were
which management of care and/or employees used to guide the creation of the safety agree-
becomes a process of providing direction ment. Results demonstrated that RNs per-
rather than control, thereby generating nurs- ceived the safety agreements as promoting
ing leaders in roles of authority rather than a more positive and effective nurse–patient
just nurse managers of care. relationship related to the risk of self-harm
Aponte (2009) employed Orlando’s and believed the safety agreements increased
Dynamic Nurse–Patient Relationship as a their comfort in helping patients at risk for
conceptual framework for the Influenza Initia- self-harm. The nurses were divided, however,
tive in New York City to address the linguistic about whether the safety agreements en-
disparities within communities. A needs survey hanced their relationships with patients, and
identified unmet linguistic needs and gaps ex- the majority did not feel the safety agreements
isting within the city; nursing students, many decreased self-harming incidents. The rate of
of whom were bilingual, served as translators self-harm incidents was not statistically sig-
for non-English speaking Spanish, Chinese, nificant but the authors report the findings as
Russian, and Ukraine residents. Orlando’s clinically significant citing no increase in
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84 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

self-harming rates despite higher acuity levels nursing process. The authors used cognitive in-
and shorter hospital stays during post imple- terviews with a convenience sample of five ex-
mentation stages. perienced nurses to gain insight into the process
Sheldon and Ellington (2008) conducted a of nurse communication with patients and the
pilot study to expand Orlando’s process into se- strategies nurses use when responding to patient
quential steps that further define the deliberative concerns.

Practice Exemplar
Krystal, a 23-year-old woman with a history hypotheses about the patient. The nurse may
of asthma, presents to the emergency depart- hypothesize that Krystal needs financial assis-
ment with her boyfriend. She states, “I just tance in obtaining her medications and addi-
can’t seem to catch my breath, I just can’t seem tional education about asthma and the role of
to relax”; appearing extremely agitated. Avoid- medications in managing the disease. A nurse
ing eye contact, Krystal fearfully explains to not using Orlando’s theory might administer
the nurse that she has not been able to obtain the necessary asthma medications; provide
any of her regular medications for approxi- asthma education and resources for obtaining
mately 4 months. The nurse obtains vital signs free or low cost medications. A nurse using
including a blood pressure of 113/68; pulse of Orlando’s theoretical framework, however,
98; respiratory rate of 22; an oral temperature understands that no nursing action should be
of 37.0 degrees Celsius; and an oxygen satu- taken without first validating each hypothesis
ration of 95% on room air. Assessment reveals with the patient as a means of determining the
no increased work of breathing with slight, bi- patient’s immediate needs. The nurse in this
lateral, expiratory wheezing. The nurse, em- situation validates with the patient the source
ploying standing orders, places the patient on of her anxiety and inability to catch her breath.
2L of oxygen per nasal cannula and initiates a In doing so, the nurse learns that the patient’s
respiratory treatment. concern now is not with her wheezing or ob-
Seeking privacy with the patient, the nurse taining her asthma medication but rather with
kindly asks the boyfriend to wait in the patient her boyfriend.
lounge. He becomes argumentative and reluc- The nurse hypothesizes that Krystal is a vic-
tant to leave, the nurse calmly states that she tim of intimate partner violence. Again, the
simply needs to complete her assessment with nurse seeks to validate this with the patient,
the patient and again asks again for him to asking Krystal if her boyfriend is physically or
wait in the lounge; this time he complies. Fur- emotionally harming her. Krystal continues to
ther investigation by the nurse reveals that look fearfully at the door and states, “He is
Krystal normally uses albuterol and Advair to going to kill me if I tell you anything.” The
control her asthma, but she has been unable to nurse assures Krystal that she is in a safe place
obtain her medications over the past 4 months right now, that she is not alone and that there
because of “personal problems.” are safety measures that can be taken to re-
In this example, the nurse formulates an move the boyfriend from the premises if that
immediate hypothesis based on direct and in- would make Krystal feel safer. Krystal requests
direct observations and attempts to validate the nurse to do this and begins crying, telling
this hypothesis by collecting additional data the nurse she had a fight with her boyfriend
(questioning the patient about her normal today and he hit her. “He always makes sure
medications, observing the boyfriend’s reluc- to hit me where people can’t see, and he is al-
tance to leave the room, assessing the patient’s ways sorry.” The nurse asks if Krystal is injured
agitated state and refusal to make eye contact, in any way right now. Krystal pulls up her shirt
and obtaining vital signs). From the patient to reveal extensive bruising at various stages of
data, the nurse formulates several additional healing to her torso and what looks like several
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CHAPTER 6 • Nurse–Patient Relationship Theories 85

Practice Exemplar cont.


fresh cigarette burns to both her breasts. The charted (documentation follows the guidelines
nurse asks Krystal if it would be okay to per- needed to be admissible in a court of law if
form some additional assessmentsto ensure no necessary). The nurse also provides Krystal
further internal injury has occurred. Krystal with the number for the National Resource
nods her head yes, and the nurse asks if this Center on Domestic Violence, and with two
has happened before. Krystal tells the nurse websites one for Violence Against Women
that these days it happens almost daily but that Network (www.vawnet.org) and the Florida
she deserves it because she doesn’t have a job Coalition Against Domestic Violence
and he is the only one who loves her. “I want (www.fcadv.org). The nurse calls the shelter a
to leave. I really do, but I am afraid he will kill few days later to check that Krystal is safe and
me, and I don’t have anywhere else to go.” The learns that Krystal will be remaining at the
nurse acknowledges Krystal’s distress, clarify- shelter and has not had any further correspon-
ing that Krystal does not deserve this type of dence with her boyfriend.
treatment and that she fears for her safety, Through mutual engagement, the patient
emphasizing abuse is a crime and only worsens and nurse were able to create a dynamic envi-
over time. ronment that fostered effective communica-
At this point, the nurse discusses how the tion and the ability to address the immediate
patient wishes to address this concern ensuring needs of the patient. Providing asthma educa-
there is a dynamic interaction occurring be- tion and financial resources would not have
tween the patient and the nurse. Offering the addressed Krystal’s need for physical safety re-
patient the resources and opportunity to ex- lated to domestic abuse because the plan
press and understand the meaning of her own would have been based on an invalid hypoth-
behavior inspires Krystal to find meaning in esis. The nurse in this situation used her
the experience and ownership in the choices perception and knowledge of the nursing
needed to address these concerns. Using her situation to explore the meaning of Krystal’s
nursing knowledge of domestic abuse, the behavior. Through communication and vali-
nurse engages Krystal in a conversation about dation with the patient of the nurses’ hypothe-
the cycle of violence and empowers Krystal by ses, perceptions and supporting data, the nurse
providing her with choices and resources to was able to elicit the nature of the patient’s
address her current situation. After the nurse– problem and mutually engage the patient in
patient interaction, Krystal decides to go to a identifying what help was needed. After mutual
local domestic abuse shelter for women (the decision making, the nurse took deliberative
nurse makes arrangements by calling the shel- nursing actions to meet Krystal’s immediate
ter and providing transportation), to file a po- needs including initiating safety protocols, pro-
lice report (the nurse arranges for an officer to viding resources, gathering additional data, and
come to the hospital), and allow for photos creating a supportive and encouraging environ-
and documentation of her injuries to be ment for the patient.

■ Summary
The most important contribution of Orlando’s states what nursing is or should be today.
theoretical work is the primacy of the nurse– Regardless of the changes in the health-care
client relationship. Inherent in this theory is a system, the human transaction between the
strong statement: What transpires between the nurse and the patient in any setting holds the
patient and the nurse is of the highest value. greatest value —not only for nursing, but also
The true worth of her ideas is that it clearly for society at large. Orlando’s writings can
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86 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

serve as a philosophy as well as a theory, health care today? The answer to that question
because it is the foundation on which our pro- may lead to reconsideration of the value of
fession has been built. With all of the benefits Orlando’s theory as perhaps the critical link for
that modern technology and modern health enhancing relationships between nursing and
care bring—and there are many—we need to patient today (Rittman, 1991).
pause and ask the question, What is at risk in

References

Abraham, S. (2011). Fall prevention conceptual frame- Orlando, I. J. (1972). The discipline and teaching of nurs-
work. The Health Care Manager, 30(2), 179–184. doi: ing process: An evaluative study. New York: G. P.
10.1097/HCM.0b013e31826fb74 Putnam’s Sons.
Aponte, J. (2009). Meeting the linguistic needs of urban Potter, M. L., Vitale-Nolen, R., & Dawson, A. M.
communities. Home Health Nurse, 27(5), 324–329. (2005). Implementation of safety agreements in an
Dufault, M., Duquette, C. E., Ehmann, J., Hehl, R., acute psychiatric facility. Journal of the American
Lavin, M., Martin, V., Moore, M. A., Sargent, S., Psychiatric Nurses Association, 11(3), 144–155. doi:
Stout, P., Willey, C. (2010). Translating an evi- 10.1177/1078390305277443
dence-based protocol for nurse-to-nurse shift hand- Potter, M. L., Williams, R. B. & Costanzo, R. (2004).
offs. Worldviews on Evidence-Based Nursing, 7(2), Using nursing theory and structured psychoeduca-
59–75. tional curriculum with inpatient groups. Journal of
Grove, C. (2008). Staff intervention to improve patient the American Psychiatric Nurses Association, 10(3),
satisfaction (master’s thesis). Retrieved from Pro- 122–128. doi: 10.1177/1078390304265212
Quest Dissertations and Theses database. (UMI Rittman, M. R. (1991). Ida Jean Orlando (Pelletier)—
1454183) the dynamic nurse–patient relationship. In: M.
Hendren, D. W. (2012). Emergency departments and Parker (Ed.), Nursing theories and nursing practice
STEMI care, are the guidelines being followed? (mas- (pp. 125–130). Philadelphia: F. A. Davis.
ter’s thesis). Retrieved from ProQuest Dissertations Sheldon, L. K., & Ellington, L. (2008). Application
and Theses database. (UMI 1520156) of a model of social information processing to nurs-
Laurent, C. L. (2000). A nursing theory of nursing lead- ing theory: How nurses respond to patients. Journal
ership. Journal of Nursing Management, 8, 83–87. of Advanced Nursing 64(4), 388–398. doi:
Orlando, I. J. (1990). The dynamic nurse–patient relation- 10.111/j.1365-2648.2008.04795.x
ship: Function, process and principles. New York: Na-
tional League for Nursing New York: G. P.
Putnam’s Sons. (Original work published 1961)
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Section
III
Conceptual Models/Grand
Theories in the Integrative-
Interactive Paradigm

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Section

III
Section III includes seven chapters on the conceptual models or grand theories
situated in the integrative-interactive nursing paradigm. These chapters are
written by either the theorist or an author designated as an authority on the
theory by the theorist or the community of scholars advancing that theory. The-
ories in the integrative-interactive paradigm view persons1 as integrated
wholes or integrated systems interacting with the larger environmental system.
The integrated dimensions of the person are influenced by environmental fac-
tors leading to some change that impacts health or well-being. The subjectivity
of the person and the multidimensional nature of any outcome are considered.
Most of the theories are based explicitly on a systems perspective.
In Chapter 7, Johnson’s behavioral systems model is described. It includes
principles of wholeness and order, stabilization, reorganization, hierarchic in-
teraction, and dialectic contradiction. The person is viewed as a compilation
of subsystems. According to Johnson, the goal of nursing is to restore, maintain,
or attain behavioral system balance and stability at the highest possible level.
Chapter 8 features Orem’s self-care deficit nursing theory, a conceptual model
with four interrelated theories associated with it: theory of nursing systems, theory of
self-care deficit, and the theory of self-care and theory of dependent care. According
to Orem, when requirements for self-care exceed capacity for self-care, self-care
deficits occur. Nursing systems are designed to address these self-care deficits.
King’s theory of goal attainment presented in Chapter 9 offers a view that the
goal of nursing is to help persons maintain health or regain health. This is accom-
plished through a transaction,setting a mutually agreed-upon goal with the patient.
In Chapter 10, Pamela Senesac and Sr. Callista Roy describe the Roy adap-
tation model and its applications. In this model, the person is viewed as a holistic
adaptive system with coping processes to maintain adaptation and promote
person–environment transformations. The adaptive system can be integrated,
compensatory, or compromised depending on the level of adaptation. Nurses
promote coping and adaptation within health and illness.
Lois White Lowry and Patricia Deal Aylward authored Chapter 12 on Neuman’s
systems model. The model includes the client–client system with a basic structure
protected from stressors by lines of defense and resistance. The concern of nursing
is to keep the client stable by assessing the actual or potential effects of stressors
and assisting client adjustments for optimal wellness.
In Chapter 13, Erickson, Tomlin, and Swain’s modeling and role modeling
theory is presented by Helen Erickson. Modeling and role modeling theory pro-
vides a guide for the practice or process of nursing. The theory integrates a holistic
philosophy with concepts from a variety of theoretical perspectives such as adap-
tation, need status, and developmental task resolution.
The final chapter in this section is Dossey’s theory of integral nursing, a relatively
new grand theory that posits an integral worldview and body–mind–spirit connect-
edness. The theory is informed by a variety of ideas including Nightingale’s tenets,
holism, multidimensionality, spiral dynamics, chaos theory, and complexity. It includes
the major concepts of healing, the metaparadigm of nursing, patterns of knowing,
and Wilber’s integral theory and Wilber’s all quadrants, all levels, all lines.

1 Person refers to individuals, families, groups or communities.

88
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Dorothy Johnson’s Behavioral


System Model and Its
Chapter
7
Applications
B ONNIE H OLADAY

Introducing the Theorist Introducing the Theorist


Overview of Johnson’s Behavioral
System Model Dorothy Johnson’s earliest publications per-
Applications of the Model tained to the knowledge base nurses needed for
Practice Exemplar by Kelly White nursing care (Johnson, 1959, 1961). Through-
Summary out her career, Johnson (1919–1999) stressed
References that nursing had a unique, independent con-
tribution to health care that was distinct from
“delegated medical care.” Johnson was one of
the first “grand theorists” to present her views
as a conceptual model. Her model was the first
to provide a guide to both understanding and
action. These two ideas—understanding seen
first as a holistic, behavioral system process me-
diated by a complex framework and second as
an active process of encounter and response—
are central to the work of other theorists who
Dorothy Johnson followed her lead and developed conceptual
models for nursing practice.
Dorothy Johnson received her associate of
arts degree from Armstrong Junior College in
Savannah, Georgia, in 1938 and her bachelor
of science in nursing degree from Vanderbilt
University in 1942. She practiced briefly as a
staff nurse at the Chatham-Savannah Health
Council before attending Harvard University,
where she received her master of public health
in 1948. She began her academic career at
Vanderbilt University School of Nursing. A
call from Lulu Hassenplug, Dean of the
School of Nursing, enticed her to the Univer-
sity of California at Los Angeles in 1949. She
served there as an assistant, associate, and pro-
fessor of pediatric nursing until her retirement
in 1978. Johnson is recognized as one of the
founders of modern systems-based nursing
theory (Glennister, 2011; Meleis, 2011).

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90 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

During her academic career, Dorothy Johnson Five Core Principles


addressed issues related to nursing practice, ed- Johnson’s model incorporates five core principles
ucation, and science. While she was a pediatric of system thinking: wholeness and order, stabi-
nursing advisor at the Christian Medical College lization, reorganization, hierarchic interaction,
School of Nursing in Vellare, South India, she and dialectical contradiction. Each of these gen-
wrote a series of clinical articles for the Nursing eral systems principles has analogs in develop-
Journal of India (Johnson, 1956, 1957). She mental theories that Johnson used to verify the
worked with the California Nurses’ Association, validity of her model (Johnson, 1980, 1990).
the National League for Nursing, and the Wholeness and order provide the basis for con-
American Nurses’ Association to examine the tinuity and identity, stabilization for develop-
role of the clinical nurse specialist, the scope of ment, reorganization for growth and/or change,
nursing practice, and the need for nursing re- hierarchic interaction for discontinuity, and di-
search. She also completed a Public Health alectical contradiction for motivation. Johnson
Service–funded research project (“Crying as a conceptualized a person as an open system with
Physiologic State in the Newborn Infant”) in organized, interrelated, and interdependent sub-
1963 (Johnson & Smith, 1963). The founda- systems. By virtue of subsystem interaction and
tions of her model and her beliefs about nursing independence, the whole of the human organism
are clearly evident in these early publications. (system) is greater than the sum of its parts (sub-
systems). Wholes and their parts create a system
Overview of Johnson’s with dual constraints: Neither has continuity and
identity without the other.
Behavioral System Model The overall representation of the model can
Johnson noted that her theory, the Johnson be- also be viewed as a behavioral system within an
havioral system model (JBSM), evolved from environment. The behavioral system and the
philosophical ideas, theory, and research; her environment are linked by interactions and
clinical background; and many years of thought, transactions. We define the person (behavioral
discussions, and writing (Johnson, 1968). She system) as comprising subsystems and the en-
cited a number of sources for her theory. From vironment as comprising physical, interpersonal
Florence Nightingale came the belief that nurs- (e.g., father, friend, mother, sibling), and soci-
ing’s concern is a focus on the person rather than ocultural (e.g., rules and mores of home, school,
the disease. Systems theorists (Buckley, 1968; country, and other cultural contexts) compo-
Chin, 1961; Parsons & Shils, 1951; Rapoport, nents that supply the sustenal imperatives
1968; Von Bertalanffy, 1968) were all sources for (Grubbs, 1980; Holaday, 1997; Johnson, 1990;
her model. Johnson’s background as a pediatric Meleis, 2011). Sustenal imperatives are the nec-
nurse is also evident in the development of her essary prerequisites for the optimal functioning
model. In her papers, Johnson cited developmen- of the behavioral system. The environment must
tal literature to support the validity of a behavioral supply the sustenal imperatives of protection,
system model (Ainsworth, 1964; Crandal, 1963; nurturance, and stimulation to all subsystems to
Gerwitz, 1972; Kagan, 1964; Sears, Maccoby, & allow them to develop and to maintain stability.
Levin, 1954). Johnson also noted that a number Some examples of conditions that protect, stim-
of her subsystems had biological underpinnings. ulate, and nurture related to achievement would
Johnson’s theory and her related writings include encouragement from parents and peers;
reflect her knowledge about both development enriched, stimulating environments, awards
and general systems theories. The combination and recognition; and increased autonomy and
of nursing, development, and general systems responsibility.
introduces some of the specifics into the rhet-
oric about nursing theory development that Wholeness and Order
make it possible to test hypotheses and con- The developmental analogy of wholeness and
duct critical experiments. order is continuity and identity. Given the
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CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 91

behavioral system’s potential for plasticity, a than a set point. A toddler placed in a body
basic feature of the system is that both conti- cast may show motor lags when the cast is re-
nuity and change can exist across the life span. moved but soon show age-appropriate motor
The presence of or potentiality for at least some skills. An adult newly diagnosed with asthma
plasticity means that the key way of casting the who does not receive proper education until a
issue of continuity is not a matter of deciding year after diagnosis can successfully incorpo-
what exists for a given process or function of a rate the material into her daily activities. These
subsystem. Instead, the issue should be cast in are examples of homeorhetic processes or self-
terms of determining patterns of interactions righting tendencies that can occur over time.
among levels of the behavioral system that may What nurses observe as development or
promote continuity for a particular subsystem adaptation of the behavioral system is a product
at a given point in time. Johnson’s work im- of stabilization. When a person is ill or threat-
plies that continuity is in the relationship of ened with illness, he or she is subject to biopsy-
the parts rather than in their individuality. chosocial perturbations. The nurse, according
Johnson (1990) noted that at the psychological to Johnson (1980, 1990), acts as the external
level, attachment (affiliation) and dependency regulator and monitors patient response, look-
are examples of important specific behaviors ing for successful adaptation to occur. If behav-
that change over time, although the represen- ioral system balance returns, there is no need
tation (meaning) may remain the same. Johnson for intervention. If not, the nurse intervenes to
stated: “[D]evelopmentally, dependence be- help the patient restore behavioral system bal-
havior in the socially optimum case evolves ance. It is hoped that the patient matures and
from almost total dependence on others to a with additional hospitalizations, the previous
greater degree of dependence on self, with a patterns of response have been assimilated, and
certain amount of interdependence essential to there are few disturbances.
the survival of social groups” (1990, p. 28). In
terms of behavioral system balance, this pat- Reorganization
tern of dependence to independence may be Adaptive reorganization occurs when the behav-
repeated as the behavioral system engages in ioral system encounters new experiences in the
new situations during the course of a lifetime. environment that cannot be balanced by existing
system mechanisms. Adaptation is defined as
Stabilization change that permits the behavioral system to
Stabilization or behavioral system balance is maintain its set points best in new situations. To
another core principle of the JBSM. Dynamic the extent that the behavioral system cannot as-
systems respond to contextual changes by ei- similate the new conditions with existing regu-
ther a homeostatic or homeorhetic process. latory mechanisms, accommodation must occur
Systems have a set point (like a thermostat) either as a new relationship between subsystems
that they try to maintain by altering internal or by the establishment of a higher order or dif-
conditions to compensate for changes in exter- ferent cognitive schema (set, choice). The nurse
nal conditions. Human thermoregulation is an acts to provide conditions or resources essential
example of a homeostatic process that is pri- to help the accommodation process, may impose
marily biological but is also behavioral (turning regulatory or control mechanisms to stimulate
on the heater). The use of attribution of ability or reinforce certain behaviors, or may attempt to
or effort is a behavioral homeostatic process we repair structural components (Johnson, 1980). If
use to interpret activities so that they are con- the focus is on a structural part of the subsystem,
sistent with our mental organization. then the nurse will focus on the goal, set, choice,
From a behavioral system perspective, or action of a specific subsystem. The nurse
homeorrhesis is a more important stabilizing might provide an educational intervention to
process than is homeostasis. In homeorrhesis, alter the client’s set and broaden the range of
the system stabilizes around a trajectory rather choices available.
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92 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

The difference between stabilization and re- physical setting. The person needs to resolve
organization is that the latter involves change (maintain behavioral system balance of) a cas-
or evolution. A behavioral system is embedded cade of contradictions between goals related to
in an environment, but it is capable of oper- physical status, social roles, and cognitive status
ating independently of environmental con- when faced with illness or the threat of illness.
straints through the process of adaptation. The Nurses’ interventions during these periods can
diagnosis of a chronic illness, the birth of a make a significant difference in the lives of the
child, or the development of a healthy lifestyle persons involved because the nurse can help
regimen to prevent problems in later years are clients compare opposing propositions and
all examples in which accommodation not only make decisions. Dealing with these contradic-
promotes behavioral system balance but also tions can be viewed as the “driving force” of de-
involves a developmental process that results velopment as resolution brings about a higher
in the establishment of a higher order or more level of understanding of the issue at hand. This
complex behavioral system. may also alter the persons set, choice and ac-
tion. Behavioral system balance is restored and
Hierarchic Interaction a new level of development is attained.
Each behavioral system exists in a context of Johnson’s model is unique in part because it
hierarchical relationships and environmental takes from both general systems and develop-
relationships. From the perspective of general mental theories. One may analyze the patient’s
systems theory, a behavioral system that has response in terms of behavioral system balance
the properties of wholeness and order, stabi- and, from a developmental perspective, ask,
lization, and reorganization will also demon- “Where did this come from, and where is it
strate a hierarchic structure (Buckley, 1968). going?” The developmental component neces-
Hierarchies, or a pattern of relying on particular sitates that we identify and understand the
subsystems, lead to a degree of stability. A dis- processes of stabilization and sources of distur-
ruption or failure will not destroy the whole bances that lead to reorganization. These need
system but instead will lead to decomposition to be evaluated by age, gender, and culture. The
to the next level of stability. combination of systems theory and develop-
The judgment that a discontinuity has oc- ment identifies “nursing’s unique social mission
curred is typically based on a lack of correlation and our special realm of original responsibility
between assessments at two points of time. For in patient care” (Johnson, 1990, p. 32).
example, one’s lifestyle before surgery is not a
good fit postoperatively. These discontinuities Major Concepts of the Model
can provide opportunities for reorganization Next, we review the model as a behavioral sys-
and development. tem within an environment.

Dialectical Contradiction Person


The last core principle is the motivational force Johnson conceptualized a nursing client as a
for behavioral change. Johnson (1980) de- behavioral system. The behavioral system is or-
scribed these as drives and noted that these re- derly, repetitive, and organized with interre-
sponses are developed and modified over time lated and interdependent biological and
through maturation, experience, and learning. behavioral subsystems. The client is seen as a
A person’s activities in the environment lead to collection of behavioral subsystems that inter-
knowledge and development. However, by act- relate to form the behavioral system. The sys-
ing on the world, each person is constantly tem may be defined as “those complex, overt
changing it and his or her goals, and therefore actions or responses to a variety of stimuli pres-
changing what he or she needs to know. The ent in the surrounding environment that are
number of environmental domains that the purposeful and functional” (Auger, 1976, p. 22).
person is responding to includes the biological, These ways of behaving form an organized
psychological, cultural, familial, social, and and integrated functional unit that determines
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CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 93

Table 7 • 1 The Subsystems of Behavior


Achievement Subsystem
Goal Mastery or control of self or the environment
Function To set appropriate goals
To direct behaviors toward achieving a desired goal
To perceive recognition from others
To differentiate between immediate goals and long-term goals
To interpret feedback (input received) to evaluate the achievement of goals
Affiliative Subsystem
Goal To relate or belong to someone or something other than oneself; to
achieve intimacy and inclusion
Function To form cooperative and interdependent role relationships within human
social systems
To develop and use interpersonal skills to achieve intimacy and inclusion
To share
To be related to another in a definite way
To use narcissistic feelings in an appropriate way
Aggressive/Protective Subsystem
Goal To protect self or others from real or imagined threatening objects, per-
sons, or ideas; to achieve self-protection and self-assertion
Function To recognize biological, environmental, or health systems that are po-
tential threats to self or others
To mobilize resources to respond to challenges identified as threats
To use resources or feedback mechanisms to alter biological, environ-
mental, or health input or human responses in order to diminish threats
to self or others
To protect one’s achievement goals
To protect one’s beliefs
To protect one’s identity or self-concept
Dependency Subsystem
Goal To obtain focused attention, approval, nurturance, and physical assis-
tance; to maintain the environmental resources needed for assistance; to
gain trust and reliance
Function To obtain approval, reassurance about self
To make others aware of self
To induce others to care for physical needs
To evolve from a state of total dependence on others to a state of in-
creased dependence on the self
To recognize and accept situations requiring reversal of self-dependence
(dependence on others)
To focus on another or oneself in relation to social, psychological, and
cultural needs and desires
Eliminative Subsystem
Goal To expel biological wastes; to externalize the internal biological
environment
Function To recognize and interpret input from the biological system that signals
readiness for waste excretion
To maintain physiological homeostasis through excretion
To adjust to alterations in biological capabilities related to waste excre-
tion while maintaining a sense of control over waste excretion
To relieve feelings of tension in the self
To express one’s feelings, emotions, and ideas verbally or nonverbally
Continued
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94 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Table 7 • 1 The Subsystems of Behavior—cont’d


Ingestive Subsystem
Goal To take in needed resources from the environment to maintain the in-
tegrity of the organism or to achieve a state of pleasure; to internalize
the external environment
Function To sustain life through nutritive intake
To alter ineffective patterns of nutritive intake
To relieve pain or other psychophysiological subsystems
To obtain knowledge or information useful to the self
To obtain physical and/or emotional pleasure from intake of nutritive or
nonnutritive substances
Restorative Subsystem
Goal To relieve fatigue and/or achieve a state of equilibrium by reestablish-
ing or replenishing the energy distribution among the other subsystems;
to redistribute energy
Function To maintain and/or return to physiological homeostasis
To produce relaxation of the self system
Sexual Subsystem
Goal To procreate, to gratify or attract; to fulfill expectations associated with
one’s gender; to care for others and to be cared about by them
Function To develop a self-concept or self-identity based on gender
To project an image of oneself as a sexual being
To recognize and interpret biological system input related to sexual grat-
ification and/or procreation
To establish meaningful relationships in which sexual gratification
and/or procreation may be obtained
Sources: Based on J. Grubbs (1980). An interpretation of the Johnson behavioral system model. In J. P. Riehl & C. Roy
(Eds.), Conceptual models for nursing practice (2nd ed., pp. 217–254). New York: Appleton-Century-Crofts; D. E. Johnson
(1980). The behavioral system model for nursing. In J. P. Riehl & C. Roy (Eds.), Conceptual models for nursing practice
(2nd ed., pp. 207–216). New York: Appleton-Century-Crofts; D. Wilkie (1987). Operationalization of the JBSM. Unpub-
lished paper, University of California, San Francisco; and B. Holaday (1972). Operationalization of the JBSM. Unpub-
lished paper, University of California, Los Angeles.

and limits the interaction between the person Johnson identified seven subsystems. How-
and environment and establishes the relation- ever, in this author’s operationalization of the
ship of the person to the objects, events, and model, as in Grubbs (1980), I have included
situations in the environment. Johnson (1980, eight subsystems. These eight subsystems and their
p. 209) considered such “behavior to be or- goals and functions are described in Table 7-1.
derly, purposeful and predictable; that is, it is Johnson noted that these subsystems are found
functionally efficient and effective most of the cross-culturally and across a broad range of the
time, and is sufficiently stable and recurrent to phylogenetic scale. She also noted the signifi-
be amenable to description and exploration.” cance of social and cultural factors involved in
the development of the subsystems. She did
Subsystems not consider the seven subsystems as complete,
The parts of the behavioral system are called because “the ultimate group of response systems
subsystems. They carry out specialized tasks or to be identified in the behavioral system will
functions needed to maintain the integrity of undoubtedly change as research reveals new
the whole behavioral system and manage its re- subsystems or indicated changes in the struc-
lationship to the environment. Each of these ture, functions, or behavioral groupings in the
subsystems has a set of behavioral responses that original set” (Johnson, 1980, p. 214).
is developed and modified through motivation, Each subsystem has functions that serve to
experience, and learning. meet the conceptual goal. Functional behaviors
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CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 95

are the activities carried out to meet these behaviors in a situation that will best meet the
goals. These behaviors may vary with each in- goal and attain the desired outcome. The larger
dividual, depending on the person’s age, sex, the behavioral repertoire of alternative behav-
motives, cultural values, social norms, and iors in a situation, the more adaptable is the
self-concepts. For the subsystem goals to be individual. The fourth structural component of
accomplished, behavioral system structural each subsystem is the observable action of the
components must meet functional require- individual. The concern is with the efficiency
ments of the behavioral system. and effectiveness of the behavior in goal attain-
Each subsystem is composed of at least four ment. Actions are any observable responses
structural components that interact in a spe- to stimuli.
cific pattern: goal, set, choice, and action. The For the eight subsystems to develop and
goal of a subsystem is defined as the desired maintain stability, each must have a constant
result or consequence of the behavior. The supply of functional requirements (sustenal
basis for the goal is a universal drive that can imperatives). The concept of functional re-
be shown to exist through scientific research. quirements tends to be confined to conditions
In general, the drive of each subsystem is the of the system’s survival, and it includes biolog-
same for all people, but there are variations ical as well as psychosocial needs. The prob-
among individuals (and within individuals over lems are related to establishing the types of
time) in the specific objects or events that are functional requirements (universal vs. highly
drive-fulfilling, in the value placed on goal at- specific) and finding procedures for validating
tainment, and in drive strength. With drives the assumptions of these requirements. It also
as the impetus for the behavior, goals can be suggests a classification of the various states or
identified and are considered universal. processes on the basis of some principle and
The behavioral set is a predisposition to act perhaps the establishment of a hierarchy
in a certain way in a given situation. The be- among them. The Johnson model proposes
havioral set represents a relatively stable and that for the behavior to be maintained, it must
habitual behavioral pattern of responses to par- be protected, nurtured, and stimulated: It re-
ticular drives or stimuli. It is learned behavior quires protection from noxious stimuli that
and is influenced by knowledge, attitudes, and threaten the survival of the behavioral system;
beliefs. The set contains two components: per- nurturance, which provides adequate input to
severation and preparation. The perseveratory sustain behavior; and stimulation, which con-
set refers to a consistent tendency to react to tributes to continued growth of the behavior
certain stimuli with the same pattern of behav- and counteracts stagnation. A deficiency in any
ior. The preparatory set is contingent on the or all of these functional requirements threat-
function of the perseveratory set. The prepara- ens the behavioral system as a whole, or the ef-
tory set functions to establish priorities for fective functioning of the particular subsystem
attending or not attending to various stimuli. with which it is directly involved.
The conceptual set is an additional com-
ponent to the model (Holaday, 1982). It is a Environment
process of ordering that serves as the mediat- In systems theory, the term environment is de-
ing link between stimuli from the preparatory fined as the set of all objects for which a change
and perseveratory sets. Here attitudes, beliefs, in attributes will affect the system as well as
information, and knowledge are examined those objects whose attributes are changed by
before a choice is made. There are three levels the behavior of the system (von Bertalanffy,
of processing—an inadequate conceptual set, 1968). Johnson referred to the internal and
a developing conceptual set, and a sophisti- external environment of the system. She also
cated conceptual set. referred to the interaction between the person
The third and fourth components of each and the environment and to the objects, events,
subsystem are choice and action. Choice refers and situations in the environment. She further
to the individual’s repertoire of alternative noted that there are forces in the environment
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96 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

that impinge on the person and to which the system balance and stability. Behavioral system
person adjusts. Thus, the JBSM environment balance and stability are demonstrated by ob-
consists of all elements that are not a part of the served behavior that is purposeful, orderly, and
individual’s behavioral system but that influ- predictable. Such behavior is maintained when
ence the system and can also serve as a source it is efficient and effective in managing the
of sustenal imperatives. Some of these elements person’s relationship to the environment.
can be manipulated by the nurse to achieve Behavior changes when efficiency and ef-
health (behavioral system balance or stability) fectiveness are no longer evident or when a
for the patient. Johnson provided no other spe- more optimal level of functioning is per-
cific definition of the environment, nor did she ceived. Individuals are said to achieve effi-
identify what she considered internal versus ex- cient and effective behavioral functioning
ternal environment. But much can be inferred when their behavior is commensurate with
from her writings, and system theory also pro- social demands, when they are able to modify
vides additional insights into the environment their behavior in ways that support biological
component of the model. imperatives, when they are able to benefit to
The external environment may include peo- the fullest extent during illness from the
ple, objects, and phenomena that can poten- physician’s knowledge and skill, and when
tially permeate the boundary of the behavioral their behavior does not reveal unnecessary
system. This external stimulus forms an organ- trauma as a consequence of illness (Johnson,
ized or meaningful pattern that elicits a re- 1980, p. 207).
sponse from the individual. The behavioral Behavior system imbalance and instability
system attempts to maintain equilibrium in re- are not described explicitly but can be inferred
sponse to environmental factors by assimilating from the following statement to be a malfunc-
and accommodating to the forces that impinge tion of the behavioral system:
on it. Areas of external environment of interest
The subsystems and the system as a
to nurses include the physical settings, people,
whole tend to be self-maintaining and
objects, phenomena, and psychosocial–cultural
self-perpetuating so long as conditions
attributes of an environment.
in the internal and external environment
Johnson provided detailed information
of the system remain orderly and pre-
about the internal structure and how it func-
dictable, the conditions and resources nec-
tions. She also noted that “[i]llness or other
essary to their functional requirements are
sudden internal or external environmental
met, and the interrelationships among the
change is most frequently responsible for sys-
subsystems are harmonious. If these con-
tem malfunction” (Johnson, 1980, p. 212).
ditions are not met, malfunction becomes
Such factors as physiology; temperament; ego;
apparent in behavior that is in part disor-
age; and related developmental capacities, at-
ganized, erratic, and dysfunctional. Illness
titudes, and self-concept are general regulators
or other sudden internal or external envi-
that may be viewed as a class of internalized
ronmental change is most frequently re-
intervening variables that influence set, choice,
sponsible for such malfunctions. (Johnson,
and action. They are key areas for nursing as-
1980, p. 212)
sessment. For example, a nurse attempting to
respond to the needs of an acutely ill hospital- Thus, Johnson equated behavioral system
ized 6-year-old would need to know some- imbalance and instability with illness. How-
thing about the developmental capacities of a ever, as Meleis (2011) has pointed out, we
6-year-old and about self-concept and ego de- must consider that illness may be separate
velopment to understand the child’s behavior. from behavioral system functioning. Johnson
also referred to physical and social health but
Health did not specifically define wellness. Just as the
Johnson viewed health as efficient and effective inference about illness may be made, it may
functioning of the system and as behavioral be inferred that wellness is behavioral system
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CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 97

balance and stability, as well as efficient and The source of difficulty arises from structural
effective behavioral functioning. and functional stresses. Structural and func-
tional problems develop when the system is un-
Nursing and Nursing Therapeutics able to meet its own functional requirements.
As a result of the inability to meet functional
Nursing is viewed as “a service that is com-
requirements, structural impairments may take
plementary to that of medicine and other
place. In addition, functional stress may be
health professions, but which makes its own
found as a result of structural damage or from
distinctive contribution to the health and
the dysfunctional consequences of the behavior.
well-being of people” (Johnson, 1980, p. 207).
Other problems develop when the system’s
She distinguished nursing from medicine by
control and regulatory mechanisms fail to
noting that nursing views the patient as a
develop or become defective.
behavioral system, and medicine views the
Four diagnostic classifications to delineate
patient as a biological system. In her view,
these disturbances are differentiated in the
the specific goal of nursing action is “to re-
model. A disorder originating within any one
store, maintain, or attain behavioral system
subsystem is classified as either an insuffi-
balance and stability at the highest possible
ciency, which exists when a subsystem is not
level for the individual” (Johnson, 1980,
functioning or developed to its fullest capacity
p. 214). This goal may be expanded to in-
due to inadequacy of functional requirements,
clude helping the person achieve an optimal
or as a discrepancy, which exists when a be-
level of balance and functioning when this is
havior does not meet the intended conceptual
possible and desired.
goal. Disorders found between more than one
The goal of the system’s action is behavioral
subsystem are classified either as an incompat-
system balance. For the nurse, the area of con-
ibility, which exists when the behaviors of two
cern is a behavioral system threatened by the
or more subsystems in the same situation con-
loss of order and predictability through illness
flict with each other to the detriment of the in-
or the threat of illness. The goal of a nurse’s ac-
dividual, or as dominance, which exists when
tion is to maintain or restore the individual’s
the behavior of one subsystem is used more
behavioral system balance and stability or to
than any other, regardless of the situation or
help the individual achieve a more optimal
to the detriment of the other subsystems. This
level of balance and functioning.
is also an area where Johnson believed addi-
Johnson did not specify the steps of the
tional diagnostic classifications would be de-
nursing process but clearly identified the role
veloped. Nursing therapeutics address these
of the nurse as an external regulatory force. She
three areas.
also identified questions to be asked when an-
The next critical element is the nature of the
alyzing system functioning, and she provided
interventions the nurse would use to respond
diagnostic classifications to delineate distur-
to the behavioral system imbalance. The first
bances and guidelines for interventions.
step is a thorough assessment to find the source
Johnson (1980) expected the nurse to base
of the difficulty or the origin of the problem.
judgments about behavioral system balance
There are at least three types of interventions
and stability on knowledge and an explicit
that the nurse can use to bring about change.
value system. One important point she made
The nurse may attempt to repair damaged
about the value system is that
structural units by altering the individual’s set
given that the person has been provided with and choice. The second would be for the nurse
an adequate understanding of the potential to impose regulatory and control measures. The
for and means to obtain a more optimal level nurse acts outside the patient environment to
of behavioral functioning than is evident at provide the conditions, resources, and controls
the present time, the final judgment of the necessary to restore behavioral system balance.
desired level of functioning is the right of the The nurse also acts within and upon the exter-
individual. (Johnson, 1980, p. 215) nal environment and the internal interactions
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98 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

of the subsystem to create change and restore clinical practice in a variety of ways. The ma-
stability. The third, and most common, treat- jority of the research focuses on clients’ func-
ment modality is to supply or to help the client tioning in terms of maintaining or restoring
find his or her own supplies of essential func- behavioral system balance, understanding the
tional requirements. The nurse may provide system and/or subsystems by focusing on the
nurturance (resources and conditions necessary basic sciences, or focusing on the nurse as an
for survival and growth; the nurse may train the agent of action who uses the JBSM to gather
client to cope with new stimuli and encourage diagnostic data or to provide care that influ-
effective behaviors), stimulation (provision of ences behavioral system balance.
stimuli that brings forth new behaviors or in- Derdiarian (1990, 1991) examined the
creases behaviors, provides motivation for a nurse as an action agent within the practice
particular behavior, and provides opportunities domain. She focused on the nurses’ assess-
for appropriate behaviors), and protection ment of the patient using the JBSM and the
(safeguarding from noxious stimuli, defending effect of using this instrument on the quality
from unnecessary threats, and coping with a of care (Derdiarian, 1990, 1991). This ap-
threat on the individual’s behalf). The nurse proach expanded the view of nursing knowl-
and the client negotiate the treatment plan. edge from exclusively client-based to knowledge
about the context and practice of nursing that
is model-based. The results of these studies
Applications of the Model found a significant increase in patient and
Fundamental to any professional discipline is nurse satisfaction when the JBSM was used.
the development of a scientific body of knowl- Derdiarian (1983, 1988; Derdiarian & Forsythe,
edge that can be used to guide its practice. 1983) also found that a model-based, valid,
JBSM has served as a means for identifying, and reliable instrument could improve the
labeling, and classifying phenomena important comprehensiveness and the quality of assess-
to the nursing discipline. Nurses have used the ment data; the method of assessment; and the
JBSM model since the early 1970s, and the quality of nursing diagnosis, interventions,
model has demonstrated its ability to provide and outcome. Derdiarian’s body of work re-
a medium for theoretical growth; organization flects the complexity of nursing’s knowledge
for nurses’ thinking, observations, and inter- as well as the strategic problem-solving capa-
pretations of what was observed; a systematic bilities of the JBSM. Her 1991 article in Nurs-
structure and rationale for activities; direction ing Administration Quarterly demonstrated the
to the search for relevant research questions; clear relationship between Johnson’s theory
solutions for patient care problems; and, fi- and nursing practice.
nally, criteria to determine whether a problem Others have demonstrated the utility of
has been solved. Johnson’s model for clinical practice. Tamilarasi
and Kanimozhi (2009) used the JBSM to de-
Practice-Focused Research velop interventions to improve the quality of
Stevenson and Woods (1986) stated: “Nursing life of breast cancer survivors. Oyedele (2010)
science is the domain of knowledge concerned used the JBSM to develop and test nursing in-
with the adaptation of individuals and groups terventions to prevent teen pregnancy in South
to actual or potential health problems, the en- African teens. Box 7-1 highlights other JBSM
vironments that influence health in humans research. Talerico (1999) found that the JBSM
and the therapeutic interventions that promote demonstrated utility in accounting for differ-
health and affect the consequences of illness” ences in the expression of aggressive behavioral
(1986, p. 6). This position focuses efforts in actions in elders with dementia in a way that
nursing science on the expansion of knowledge the biomedical model has proved unable.
about clients’ health problems and nursing Wang and Palmer (2010) used the JBSM to
therapeutics. Nurse researchers have demon- gain a better understanding of women’s toilet-
strated the usefulness of Johnson’s model in a ing behavior, and Colling, Owen, McCreedy,
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CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 99

about the links between nursing input and


Bonnie Holaday’s Research
Box 7-1 health outcomes for clients. The model has
Highlighted
been useful in practice because it identifies an
My program of research has examined nor- end product (behavioral system balance),
mal and atypical patterns of behavior of chil- which is nursing’s goal. Nursing’s specific ob-
dren with a chronic illness and the behavior
of their parents and the interrelationship be-
jective is to maintain or restore the person’s
tween the children and the environment. My behavioral system balance and stability, or to
goal was to determine the causes of instability help the person achieve a more optimum level
within and between subsystems (e.g., break- of functioning. The model provides a means
down in internal regulatory or control mecha- for identifying the source of the problem in
nisms) and to identify the source of problems
the system. Nursing is seen as the external
in behavioral system balance.
regulatory force that acts to restore balance
(Johnson, 1980).
One of the best examples of the model’s
and Newman (2003) used it to study the effec- use in practice has been at the University of
tiveness of a continence program for frail eld- California, Los Angeles, Neuropsychiatric
ers. Poster, Dee, and Randell (1997) found the Institute. Auger and Dee (1983) designed a
JBSM was an effective framework to evaluate patient classification system using the JBSM.
patient outcomes. Each subsystem of behavior was operational-
ized in terms of critical adaptive and maladap-
Education tive behaviors. The behavioral statements were
Johnson’s model was used as the basis for un- designed to be measurable, relevant to the
dergraduate education at the UCLA School of clinical setting, observable, and specific to the
Nursing. The curriculum was developed by the subsystem. The use of the model has had a
faculty; however, no published material is major effect on all phases of the nursing
available that describes this process. Texts by Wu process, including a more systematic assess-
(1973) and Auger (1976) extended Johnson’s ment process, identification of patient strengths
model and provided some idea of the content and problem areas, and an objective means for
of that curriculum. Later, in the 1980s, Harris evaluating the quality of nursing care (Dee &
(1986) described the use of Johnson’s theory Auger, 1983).
as a framework for UCLA’s curriculum. The The early works of Dee and Auger led to
Universities of Hawaii, Alaska, and Colorado further refinement in the patient classification
also used the JBSM as a basis for their under- system. Behavioral indices for each subsystem
graduate curricula. have been further operationalized in terms of
Loveland-Cherry and Wilkerson (1983) critical adaptive and maladaptive behaviors.
analyzed Johnson’s model and concluded that Behavioral data is gathered to determine the
the model could be used to develop a curricu- effectiveness of each subsystem (Dee, 1990;
lum. The primary focus of the program would Dee & Randell, 1989).
be the study of the person as a behavioral sys- The scores serve as an acuity rating system
tem. The student would need a background in and provide a basis for allocating resources.
systems theory and in the biological, psycho- These resources are allocated based on the as-
logical, sociological sciences, and genetics. The signed levels of nursing intervention, and re-
mapping of the human genome and clinical source needs are calculated based on the total
exome and genome sequencing has provided number of patients assigned according to levels
evidence that genes serve as general regulators of nursing interventions and the hours of nurs-
of behavioral system activity. ing care associated with each of the levels (Dee
& Randell, 1989). The development of this
Nursing Practice and Administration system has provided nursing administration
Johnson has influenced nursing practice be- with the ability to identify the levels of staff
cause she enabled nurses to make statements needed to provide care (licensed vocational
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100 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

nurse vs. registered nurse), bill patients for ac- of the JBSM as a basis for clinical practice
tual nursing care services, and identify nursing within a health care setting. From the findings
services that are absolutely necessary in times of their work, it is clear that the JBSM estab-
of budgetary restraint. Recent research has lished a systematic framework for patient as-
demonstrated the importance of a model- sessment and nursing interventions, provided
based nursing database in medical records a common frame of reference for all practition-
(Poster et al., 1997) and the effectiveness of ers in the clinical setting, provided a frame-
using a model to identify the characteristics of work for the integration of staff knowledge
a large hospital’s managed behavioral health about the clients, and promoted continuity in
population in relation to observed nursing care the delivery of care. These findings should be
needs, level of patient functioning on admis- generalizable to a variety of clinical settings.
sion and discharge, and length of stay (Dee,
Van Servellen, & Brecht, 1998).1
The work of Vivien Dee and her colleagues 1 For additional information please see the bonus chap-
has demonstrated the validity and usefulness ter content available at http://davisplus.fadavis.com

Practice Exemplar
Provided by Kelly White of smoking three packs per day of cigarettes
for 30 years. He states he quit when he began
During the change-of-shift report that morn-
his chemotherapy.
ing, I was told that a new patient had just been
Jim, a high school graduate, is married to
wheeled onto the floor at 7:00 a.m. As a result,
his high school sweetheart, Ellen. He lives
it was my responsibility to complete the ad-
with his wife and three children in their
mission paperwork and organize the patient’s
home. He and his wife are currently unem-
day. He was a 49-year-old man who was ad-
ployed secondary to recent layoffs at the fac-
mitted through the emergency department to
tory where they both worked. He explained
our oncology floor for fever and neutropenia
that Ellen has been emotionally pushing him
secondary to recent chemotherapy for lung
away and occasionally disappears from the
cancer.
home for hours at a time without explaining
Immediately after my initial rounds, to en-
her whereabouts. He informs me that before
sure all my patients were stable and comfort-
his diagnosis, they were the best of friends
able, I rolled the computer on wheels into his
and inseparable.
room to begin the nursing admission process.
He has tolerated his treatments well until
Jim explained to me that he was diagnosed
now, except for having frequent, burning, un-
with small cell lung carcinoma 2 months ear-
controlled diarrhea for days at a time after
lier after he was admitted to another hospital
his chemotherapy treatments. These episodes
for coughing, chest pain, and shortness of
have caused raw, tender patches of skin
breath. He went on to explain that a recent
around his rectal area that become increas-
magnetic resonance imaging scan showed
ingly more painful and irritated with each
metastasis to the liver and brain.
bowel movement.
His past health history revealed that he ir-
Jim is exceptionally tearful this morning as
regularly visited his primary health care
he expresses concerns about his own future
provider. He is 6 feet 3 inches tall and weighs
and the future of his family. He informs me
168 pounds (76.4 kg). He states that he has
that Ellen’s mother is flying in from out
lost 67 pounds in the past 6 months. His ap-
of state to care for the children while he is
petite has significantly diminished because
hospitalized.
“everything tastes like metal.” He has a history
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CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 101

Practice Exemplar cont.


Assessment Jim’s wife, Ellen, is distant these days,
which would have an effect on the
Johnson’s behavioral systems model guided
couple’s intimacy.
the assessment process. The significant behav-
The environmental assessment is as follows:
ioral data are as follows:
Internal/external
Achievement subsystem
After the admission process was completed, I
Jim is losing control of his life and of the re-
had several concerns for my new patient. I
lationships that matter most to him as a
recognized that Jim was a middle-aged man
person—his family.
whose developmental stage was compro-
He is a high school graduate.
mised regarding his productivity with fam-
Affiliative protective subsystem
ily and career due to his illness. Mental and
Jim is married but states that his wife is dis-
physical abilities could be impaired as this
tancing herself from him. He feels he is
disease process advances. In addition, this
losing his “best friend” at a time when he
may create further strain on his relationship
really needs this support.
with his wife, as she attempts to deal with
Aggressive protective subsystem
her own feelings about his diagnosis. Fam-
Jim is protective of his health now (he quit
ily support would be essential as Jim’s jour-
smoking when he began chemotherapy)
ney continued. Lastly, Jim needed to be
but has a long history of neglecting it
educated on the expectations of his diagno-
(smoking for 30 years, unexplained weight
sis, participate in a plan for treatment dur-
loss for 4 months, irregular visits to his
ing his hospital stay, and assist in the
primary health-care provider).
development of goals for his future.
Dependency subsystem
Jim is realizing his ability to care for self and Diagnostic Analysis
family is diminishing and will continue to
diminish as his health deteriorates. He Jim is likely uncertain about his future as a hus-
questions who he can depend on because band, father, employee, and friend. Realizing
his wife is not emotionally available to him. this, I encouraged Jim to verbalize his concerns
Eliminative subsystem regarding these four areas of his life while I
Jim is experiencing frequent, burning, un- completed my physical assessment and assisted
controlled diarrhea for days at a time him in settling into his new environment. At
after his chemotherapy treatments. These first he was hesitant to speak about his family
episodes have caused raw, tender patches concerns but soon opened up to me after I sat
of skin around his rectal area that become down in a chair at his bedside and simply made
increasingly more painful and irritated him my complete focus for 5 minutes. As a re-
with each bowel movement. sult of this brief interaction, together we were
Ingestive subsystem able to develop short-term goals related to his
Jim has lost 67 pounds in 6 months and hospitalization and home life throughout the
has decreased appetite secondary to the rest of my shift with him that day. In addition,
chemotherapy side effects. he acquiesced and allowed me to order a social
Restorative subsystem work consult, recognizing that he would no
Jim currently experiences shortness of breath, longer be able to adequately meet his family’s
pain, and fatigue. needs independently at this time.
Sexual subsystem We also addressed the skin impairment is-
Jim has shortness of breath and possible pain sues in his rectal area. I was able to offer him
on exertion, which may be leading to con- ideas on how to keep the area from experiencing
cerns about his sexual abilities. further breakdown. Lastly, the wound care nurse
was consulted.
Continued
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102 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Practice Exemplar cont.


Evaluation been in months. He stated that they were talk-
ing about the future and that Ellen had ac-
During his 10-day hospitalization, Jim and
knowledged her fears to him the previous
his wife agreed to speak to a counselor regard-
evening. Jim was wheeled out of the hospital
ing their thoughts on Jim’s diagnosis and
because he continued to have shortness of
prognosis upon his discharge. Jim’s rectal
breath on extended exertion. As his wife drove
area healed because he did not receive any
away from the hospital, Jim waved to me with
chemotherapy/radiation during his stay. He
a genuine smile and a sparkle in his eye.
received tips on how to prevent breakdown in
that area from the wound care nurse who took Epilogue
care of him on a daily basis. Jim gained 3
pounds during his stay and maintained that he Jim passed away peacefully 3 months later at
would continue drinking nutrition supple- home, with his wife and children at his side.
ments daily, regardless of his appetite changes His wife contacted me soon afterward to let
during his cancer treatment. Jim’s stamina and me know that the nursing care Jim received
thirst for life grew stronger as his body grew during his first stay on our unit opened the
physically stronger. As he was being dis- doors to allow them both to recognize that
charged, he whispered to me that he was they needed to modify their approach to the
thankful for the care he had received while on course of his disease. In the end, they flour-
our floor, and he believed that the nurses had ished as a couple and a family, creating a sup-
brought him and his wife closer than they had portive transition for Jim and the entire family.

■ Summary
The Johnson Behavioral System Model cap- subsystems. For example, a study could examine
tures the richness and complexity of nursing. the way a person deals with the transition from
It also addresses the interdependent functional health to illness with the onset of asthma. There
biological, psychological, and sociological is concern with the relations between one’s bi-
components within the behavioral system and ological system (e.g., unstable, problems breath-
locates this within a larger social system. The ing), one’s psychological self (e.g., achievement
JBSM focuses on the person as a whole, as well goals, need for assistance, self-concept), self in
as on the complex interrelationships among its relation to the physical environment (e.g., aller-
constituent parts. Once the diagnosis has been gens, being away from home), and transactions
made, the nurse can proceed inward to the related to the sociocultural context (e.g., attitudes
subsystem and outward to the environment. It and values about the sick). The study of transi-
also asks nurses to be systems thinkers as they tions (e.g., the onset of puberty, menopause,
formulate their assessment plan, make their di- death of a spouse, onset of acute illness) also rep-
agnosis of the problem, and plan interventions. resents a treasury of open problems for research
The JBSM provides nurses with a clear con- with the JBSM. Findings obtained from these
ception of their goal and of their mission as an studies will provide not only an opportunity to
integral part of the health-care team. revise and advance the theoretical conceptual-
Johnson expected the theory’s further devel- ization of the JBSM, but also information about
opment in the future and that it would uncover nursing interventions. The JBSM approach
and shape significant research problems that leads us to seek common organizational param-
have both theoretical and practical value to the eters in every scientific explanation and does
discipline. Some examples include examining so using a shared language about nursing and
the levels of integration (biological, psycholog- nursing care.
ical, and sociocultural) within and between the
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CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 103

References

Ainsworth, M. (1964). Patterns of attachment behavior Gerwitz, J. (Ed.). (1972). Attachment and dependency.
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Auger, J. (1976). Behavioral systems and nursing. Engle- of nursing: A literature review. Proceedings of the
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Auger, J., & Dee, V. (1983). A patient classification sys- ety for Systems Sciences). Retrieved February 20, 2013,
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Buckley, W. (Ed.). (1968). Modern systems research for the havioral system model. In J. P. Riehl & C. Roy (Eds.),
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frail community-dwelling elderly persons. Urologic Angeles.
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Crandal, V. (1963). Achievement. In H. W. Stevenson cally ill infants’ attachment behavior of crying.
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18–23. nursing practice. In M. Alligood & A. Marriner-
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Dee, V., Van Servellen, G., & Brecht, M. (1998). activities of chronically ill children. In P. Hinton-
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Johnson, D. E., & Smith, M. M. (1963). Crying as a Sears, R., Maccoby, E., & Levin, H. (1954). Patterns of
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Johnson’s behavioral system model. In J. Fitzpatrick tion, School of Nursing, University of Pennsylvania.
& A. Whall (Eds.), Conceptual models of nursing: Tamilarasi, B., & Kanimozhi, M. (2009). Improving
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Oyedele, O.A. (2010). Guidelines to prevent teenage preg- dations, development, application. New York: George
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Dorothea Orem’s Self-Care


Deficit Nursing Theory
Chapter
8
D ONNA L. H ARTWEG

Introducing the Theorist Introducing the Theorist


Overview of the Theory
Dorothea E. Orem (1914–2007) dedicated her
Applications of the Theory
life to creating and developing a theoretical
Practice Applications
structure to improve nursing practice. As a
Practice Exemplar by Laureen Fleck
voracious reader and extraordinary thinker, she
Summary
framed her ideas in both theoretical and the
References
practical terms. She viewed nursing knowledge
as theoretical, with conceptual structure and
elements as exemplified in her self-care deficit
nursing theory (SCDNT), and as “practically
practical,” with knowledge, rules, and defined
roles for practice situations (Orem, 2001).
Orem’s personal life experiences, formal
education, employment, and her reading of
philosophers such as Aristotle, Aquinas, Harre
(1970), and Wallace (1983) directed her think-
Dorothea E. Orem
ing (Orem, 2006). She sought to understand
the phenomena she observed, creating concep-
tualizations of nursing education, disciplinary
knowledge, and finally, a general theory of
nursing or SCDNT.
Orem worked independently and then col-
laboratively until her death at age 93. For a
lifetime of contributions to nursing science and
practice, Orem received honors from organiza-
tions such as Sigma Theta Tau, the American
Academy of Nursing, the National League for
Nursing, and Catholic University of America
as well as four honorary doctorates.
Orem received her initial nursing education
at Providence Hospital School of Nursing
in Washington, DC. After her 1934 gradua-
tion, Orem quickly moved into hospital staff/
supervisory positions in operating and emer-
gency areas. Her BSN Ed from Catholic
University of America (1939) led to a faculty
position there. After completing her MSN Ed
at Catholic University (1946), Orem became

105
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106 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Director of Nursing Service and Education conferences encouraged international collabo-


at Provident Hospital School of Nursing in ration among institutions.
Detroit (Taylor, 2007). In 1991, the International Orem Society
Orem’s early formulations on the nature of (IOS) for Nursing Science and Scholarship was
nursing occurred while she was working for founded by a group of international scholars.
the Indiana State Board of Health between The IOS’s mission is “To disseminate informa-
1949 and 1957 (Hartweg, 1991). She became tion related to development of nursing science
aware of nurses’ ability to “do nursing,” but and its articulation with the science of self-care”
their inability to “describe nursing.” Without (www.scdnt.com). This mission has been real-
this understanding, Orem believed nurses ized through the publication of newsletters
could not improve practice. She made an ini- (1993–2001) and a peer-reviewed journal,
tial effort to define nursing in a report titled Self-Care, Dependent Care & Nursing begun in
“The Art of Nursing in Hospital Service: An 2002 (www.scdnt.com/ja/jarchive.html). Twelve
Analysis” (Orem, 1956). The language of the biennial Orem congresses have been held
patient doing-for-self or the nurse helping to- throughout the world (Berbiglia, Hohmann, &
do-for-self appears in the report as antecedent Bekel, 2012; www.ioscongress2012.lu).
language for the concept of self-care. In 1995, Orem convened the Orem Study
During her tenure at the Office of Educa- Group. This international group of scholars met
tion, Vocational Section in Washington, DC, regularly at her home in Savannah, GA, for im-
Orem generated a simple yet important ques- mersion in areas of SCDNT needing further
tion: Why do people need nursing? In Guides development. Several publications resulted from
for Developing Curriculum for the Education of this group work (Denyes, Orem, & Bekel,
Practical Nurses (Orem, 1959), she expanded 2001; Taylor, Renpenning, Geden, Neuman, &
the question to what she termed “the proper Hart, 2001). Work groups continue today to re-
object of nursing”: “What condition exists in a fine or develop concepts such as the universal
person when judgments are made that a requisite of normalcy (personal communication,
nurse(s) should be brought into the situation?” Taylor & Renpenning, January, 20, 2014).
(Orem, 2001, p. 20). Her answer was the in- Many of Orem’s original papers are pub-
ability of persons to provide continuously for them- lished in Self-Care Theory in Nursing: Selected
selves the amount and quality of required self-care Papers of Dorothea Orem (Renpenning &
because of situations of personal health. Taylor, 2003) and are also available in the
Although Orem worked independently, Mason Chesney Archives of the Johns
two groups contributed to the theory’s early Hopkins Medical Institutions for the Orem
development (Taylor, 2007). The first group Collection (www.medicalarchives.jhmi.edu/
was the Nursing Model Committee at papers/orem.html) and in the archives of the
Catholic University of America. In 1968, the IOS website. Audios and videos of the theo-
Nursing Development Conference Group rist’s lectures are available through the Helene
(NDCG) was formed and continued the work Fuld Health Trust (1988) and the National
of the Nursing Model committee. The collab- League for Nursing (1987). Self-Care Science,
orative process and outcomes were published Nursing Theory, and Evidence-based Practice
in Concept Formalization: Process and Product (Taylor & Renpenning, 2011) is the most
(NDCG, 1973, 1979), edited by Orem. Con- recent theory development and practice publi-
current with group work, Orem published the cation. Orem’s 50-year influence on nursing
first of six editions of Nursing: Concepts of science and practice is also summarized in
Practice (1971), which has been translated into recent works by Clarke, Allison, Berbiglia, and
many languages. Taylor (2009) and by Taylor (2011).1
By 1989, the global impact of Orem’s work
was evident when the First International self-
care deficit nursing theory Conference was 1For additional information please see the bonus chapter
held in Kansas City (Hartweg, 1991). These content available at http://davisplus.fadavis.com
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CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 107

Overview of the Theory presents the general focus of the theory, the
presuppositions are assumptions specific to this
As noted earlier, Orem’s general theory of
theory, and the propositions are statements
nursing is correctly referred to as self-care
about the concepts and their interrelationships.
deficit nursing theory. Orem believed a general
The propositions have changed over time with
model or theory created for a practical science
SCDNT refinement. These occurred in part
such as nursing encompasses not only the
through theory testing that validated or inval-
What and Why, but also the Who and How
idated hypotheses generated from the relation-
(Orem, 2006). This action theory therefore in-
ships. As Orem used terminology at various
cludes clear specifications for nurse and patient
levels of abstraction within constituent theo-
roles. The grand theory originally comprised
ries, the reader is advised to thoroughly study
three interrelated theories: the theory of self-
SCDNT concepts, including the synonyms.
care, the theory of self-care deficit, and the
For example, agency is also called capability,
theory of nursing systems. A fourth, the theory
ability and/or power.
of dependent care, emerged over time to ad-
dress the complexity not only of the individual 1. Theory of Self-Care (TSC)
in need of care but also of the caregivers whose
The central idea describes self-care in contrast
requisites and capabilities influence the design
to other forms of care. Self-care, or care for
of the nursing system (Taylor & Renpenning,
oneself, must be learned and be deliberately
2011). The building blocks of these theories
performed for life, human functioning, and
are six major concepts, with parallel concepts
well-being. Six presuppositions articulate
from the theory of dependent care, and one
Orem’s notions about necessary resources, ca-
peripheral concept. The following is a brief
pabilities for learning, and motivation for self-
overview of each theory and concept. Readers
care. However, there are situational variations
are encouraged to study relevant sections in
that affect self-care such as culture.
Orem’s Concepts of Practice (2001) or other
Orem (2001) expanded two sets of propo-
citations to enhance understanding.
sitions from previous writings. She introduced
Foundational to learning any theory is explo-
requirements necessary for life, health, and
ration of its underlying assumptions, the key to
well-being and explained the complexity of a
conceptual understanding. Many principles
self-care system. A person performing self-care
emerged from Orem’s independent work as well
must first estimate or investigate what can and
as from discussions within the Nursing Develop-
should be done. This is a complex action of
ment Conference Group and the Nursing Study
knowing and seeking information on specific
Group. Five general assumptions/principles
care measures. The self-care sequence contin-
about humans provided guidance to Orem’s
ues by deciding what can be done and finally pro-
conceptualizations (Orem, 2001, p. 140). When
ducing the care (see Orem, 2001, pp. 143–145).
thinking about humans within the context of the
theory, Orem viewed two types: those who need 2. Theory of Dependent Care
nursing care and those who produce it (Orem,
Taylor and others (2001) formalized the the-
2006). In the simplest terms, this is the patient
ory of dependent care as a corollary theory to
and the nurse, respectively. These assumptions
the theory of self-care. Concepts within the
also reveal human powers and properties neces-
theory of dependent care (TDC) parallel those
sary for self-care. Consistent with most Orem
in the theory of self-care. Assumptions relate
writings, the term patient is used to refer to the
to the nature of interpersonal action systems
recipient of care.
and social dependency. Within a particular so-
cial unit such as a family, the self-care agent
Four Constituent Theories Within (the patient) is in a socially dependent rela-
Self-Care Deficit Nursing Theory tionship with the person or persons providing
Each theory includes a central idea, presuppo- care, such as a parent (the dependent-care
sitions, and propositions. The central idea agent). The presence of a self-care deficit of
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108 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

the dependent also gives rise to the need for (Orem, 2001, p. 147). Although much of the
nursing (Taylor & Renpenning, 2011; Taylor, theory relates to diagnosis, actions, and out-
Renpenning, Geden, Neuman, & Hart, 2001). comes based on a deficit relationship between
self-care capabilities and self-care demand,
3. Theory of Self-Care Deficit Orem also presents theoretical work related to
The central idea describes why people need nurs- the interpersonal relationship between nurse
ing (Orem, 2001, pp. 146–147). Requirements and person(s) receiving nursing and a social
for nursing are health-related limitations for contract between the nurse and patient(s)
knowing, deciding, and producing care to self. (Orem, 2001, pp. 314–317). These compo-
Orem presents two sets of presuppositions that nents are often overlooked when studying the
articulate this theory with the theory of self- SCDNT and are important antecedents and
care and what she calls the idea of social de- concurrent actions in the process of nursing.
pendency. To engage in self-care, persons must The theory of nursing systems includes
have values and capabilities to learn (to know), seven propositions related to most SCDNT
to decide, and to manage self (to produce and concepts but adds nursing agency (capabilities
regulate care). The second set presents the con- of the nurse) and nursing systems (complex ac-
text of nursing as a health service when people tions). Nursing agency and nursing systems are
are in a state of social dependency. linked to the concepts of the person receiving
The theory of self-care deficit (TSCD) in- care or dependent care, such as self-care capa-
cludes nine propositions called principles or bilities (agency), self-care demands (therapeu-
guides for future development and theory test- tic self-care demand), and limitations (deficits)
ing. These statements are essential ideas of the for self-care. Through this, the general theory
larger, SCDNT. Orem describes the situations or SCDNT becomes concrete to the practicing
that affect legitimate nursing. Nursing is legit- nurse. Although the language is implicit,
imate or needed when the individual’s self-care Orem proposes that nursing systems are deter-
capabilities and care demands are equal to, less mined by the person’s (or dependent-care
than, or more than at a point in time. With the agent’s) self-care limitations (capabilities in
existence of this inequity, a self-care deficit ex- relationship to health-related self-care or
ists, and nursing is needed. In a dependent- dependent-care demand). Nursing systems
care system, a self-care deficit exists in the therefore vary by the amount of care the nurse
patient as well as a dependent-care deficit in a must provide, such as a total care system, or
caregiver. The latter is an inequity between the wholly compensatory system (e.g., unconscious
dependent-care demand and agency (abilities) critical care patient); partial care, or partially
to care for the person in need of health care. compensatory system (e.g., patient in rehabil-
Legitimate nursing also occurs when a future itation); or supportive-educative system (e.g.,
deficit relationship is predicted such as an up- patient needing teaching).
coming surgery. Theoretical development by Orem scholars
and others continues as nursing practice
4. Theory of Nursing Systems evolves. The addition of the theory of depend-
The fourth theory, the theory of nursing sys- ent care is a major example and extends basic
tems (TNS), encompasses the three others. concepts, such as adding “dependent-care sys-
The central focus is the product of nursing, tem” (Taylor & Renpenning, 2011). Other
establishing both structure and content for concepts such as self-care and self-care requi-
nursing practice as well as the nursing role (see sites, their processes and core operations, con-
Orem, 2001, pp. 111, 147–149). The four pre- tinue to be explicated (Denyes, Orem & Bekel,
suppositions direct the nurse to major com- 2001). Some researchers or theorists develop
plexities of nursing practice. For example, the subconcepts of basic concepts such as self-
Orem stated that “Nursing has results-achieving care agency through exploration of congruent
operations that must be articulated with the in- theories. For example, Pickens (2012) proposed
terpersonal and societal features of nursing” exploration of motivation, a foundational
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CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 109

capability and power component of self-care another on whom the person is socially de-
agency, through examination of several theories pendent (dependent-care agent). Orem also
including self-determination theory (Ryan, addresses multiperson situations and multi-
Patrick, Deci, & Williams, 2008). Others cre- person units such as entire families, groups,
ate new concepts, such as spiritual self-care or communities.
(White, Peters, & Schim, 2011) or extend gen- Each concept is defined and presented with
eral concepts such as environment (Banfield, levels of abstraction. Varied constructs within
2011). each concept allow theoretical testing at the
level of middle-range theory or at the practice
Concepts application level whether with the individual
SCDNT is constructed from six basic con- or multiperson situations. All constructs and
cepts and a peripheral concept. Four concepts concepts build on decades of Orem’s inde-
are patient related: self-care/dependent care, pendent and collaborative work. A “kite-like”
self-care agency/dependent-care agency, ther- model provides a visual guide for the six con-
apeutic self-care demand/dependent-care de- cepts and their interrelationships (Fig. 8-1).
mand, and self-care deficit/dependent-care For a model of concepts and relationships of
deficit. Two concepts relate to the nurse: dependent care, the reader is referred to Taylor
nursing agency and nursing system. Basic and Renpenning (2011, p. 112). For a model
conditioning factors, the peripheral concept, of multiperson structure, the reader is referred
is related to both the self-care agent (person to Taylor and Renpenning (2001).
receiving care)/dependent-care agent (family
member/friend providing care) and also to Basic Conditioning Factors
the nurse (nurse agent). Orem defines agent A peripheral concept, basic conditioning factors
as the person who engages in a course of action (BCFs), is related to three major concepts. For
or has the power to do so (Orem, 2001, simplicity, only the patient component is pre-
p. 514). Hence there is a self-care agent, a sented rather than the parallel dependent-care
dependent-care agent, and a nurse agent. components. In general, basic conditioning fac-
The unit of service is a person(s), whether tors relate to the patient concepts (self-care
that is the individual (self-care agent) or agency and therapeutic self-care demand) and

Self-care
R R

Self-care R Self-care
Conditioning Conditioning
agency demands
factors factors

Deficit R
R

Conditioning Nursing
factors agency

Fig 8 • 1 Structure of SCDNT.


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110 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

one nurse concept (nursing agency). These capabilities (self-care agency; Taylor et al.,
conditioning factors are values that affect the 2001; Taylor & Renpenning, 2011).
constructs: age, gender, developmental state, Although the practice of maintaining life is
health state, sociocultural orientation, health- self-explanatory, Orem (2001) viewed outcomes
care system factors, family system factors, pat- of health and well-being as related but different.
tern of living, environmental factors, and Health is a state of physical–psychological,
resource availability and adequacy (Orem, 2001, structural–functional soundness and wholeness.
p. 245). For example, the family system factor In contrast, well-being is conceived as experi-
such as living alone or with others may affect ences of contentment, pleasure, and kinds of happi-
the person’s ability (self-care agency) to care ness; by spiritual experiences; by movement toward
for self after hospital discharge. The self-care fulfilment of one’s self-ideal; and by continuing
demand (care requirements) of a person taking personalization (Orem, 2001, p. 186). Self-care
insulin for type 2 diabetes will vary based performed deliberately for well-being versus
on availability of resources and health system structural–functional health was conceptualized
services (e.g., access to medications and care and developed as health promotion self-care by
services). These same BCFs apply to nursing Hartweg (1990, 1993) and Hartweg and
agency, such as health state. A nurse with recent Berbiglia (1996). Exploration of the relation-
back surgery may have limitations in nursing ship between self-care and well-being was later
capabilities (nurse agency) in relationship to conducted by Matchim, Armer, and Stewart
specific care demands of the patient. (2008).
These BCF categories have many subfactors Key to understanding self-care and depend-
that have not been explicitly defined and con- ent care is the concept of deliberate action, a
tinue in development. For example, sociocul- voluntary behavior to achieve a goal. Deliberate
tural orientation refers to culture with its action is preceded by investigating and deciding
various components such as values and prac- what choice to make (Orem, 2001). In practice,
tices. Sociocultural includes economic condi- the nurse’s understanding of each of these
tions as well as others. The BCFs related to phases of investigating, deciding, and produc-
nursing agency include those such as age but ing self-care is essential for positive health
expand to include nursing experience and ed- outcomes. Take two situations: A pregnant
ucation. A clinical specialist in diabetes usually woman avoids alcohol for her fetus’s health
has more capabilities in caring for the self-care and a woman with breast cancer requires
agent with type 2 diabetes than one without chemotherapy for life and health. Each woman
such credentials. All these affect the parame- must first know and understand the relation-
ters of the nurse’s capability to provide care. ship of self-care to life, health, and well-being.
Decision making follows, such as deciding to
Self-Care (Dependent Care) avoid alcohol or choosing to engage in
Orem (2001) defined self-care as the practice of chemotherapy. Finally, the individual must
activities that individuals initiate and perform on take action, such as not drinking when offered
their own behalf in maintaining life, health, and alcohol or accepting chemotherapy treatment.
well-being (p. 43). Self-care is purposeful ac- Without each phase, self-care does not occur.
tion performed in sequence and with a pattern. The pregnant woman may know the dangers to
Although engagement in purposeful self-care her fetus and decide not to drink but engage in
may not improve health or well-being, a posi- drinking when pressured to do so. The woman
tive outcome is assumed. Dependent care is with cancer may understand the health out-
performed by mature, responsible persons on come without treatment, decide to have
behalf of socially dependent individuals or self- treatment, then not follow through because
care agents such as an infant, child, or cognitively transportation to chemotherapy sessions dis-
impaired person. The purpose is to meet the rupts her husband’s employment. Because each
person’s health-related demands (dependent- phase of the action sequence has many compo-
care demand) and/or to develop their self-care nents, nurses often provide partial support to
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CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 111

patients and self-care action does not occur. If


skills related to the operation to avoid alcohol
when pressured or the operations necessary for
transportation to a cancer center are not antic-
ipated by the nurse for these patients, the self- Capabilities
for self-care
care action sequences may not be completed. operations
Then outcomes related to life, health, and well-
being are affected. Power components
(enabling capabilities
Self-Care Agency (Dependent for self-care)
Care Agency)
Orem (2001) defined self-care agency (SCA) Foundational capabilities
as complex acquired capability to meet one’s con- and disposition
tinuing requirements for care of self that regulates
Fig 8 • 2 Structure of self-care agency.
life processes, maintains or promotes integrity of
human structure and functioning [health] and
human development, and promotes well-being
(p. 254). Capability, ability, and power are all are abilities related to perception, memory,
terms used to express agency. Self-care agency and orientation. One example is the deliberate
is therefore the mature or maturing individ- act of repairing a car. One must have perception
ual’s capability for deliberate action to care for of the concept of the car and its parts, memory
self. Dependent care agency is a complex ac- of methods of repair, and orientation of self to
quired ability of mature or maturing persons to the equipment and vehicle. If these founda-
know and meet some or all of the self-care requi- tional abilities are not present, then actions
sites of persons who have health-derived or health cannot occur.
associated limitations of self-care agency, which
places them in socially dependent relationships for Power Components
care (Taylor & Renpenning, 2011, p. 108). At the midlevel of the hierarchy are the power
Viewed as the summation of all human capabil- components, or 10 powers or types of abilities
ities needed for performing self-care, these range necessary for self-care. Examples are the valu-
from a very basic ability, such as memory, to ing of health, ability to acquire knowledge
capability for a specific action in a sequence to about self-care resources, and physical energy
meet a specific self-care demand or require- for self-care. At a very general level, these ca-
ment. At this concrete level, the capabilities of pabilities relate to knowledge, motivation, and
knowing, deciding, and acting or producing skills to produce self-care. If a mature person
self-care are necessary. If these capabilities do becomes comatose, the abilities to maintain at-
not exist, then the abilities of others are nec- tention, to reason, to make decisions, to phys-
essary, such as the family member or the nurse. ically carry out the actions are not functioning.
A three-part, hierarchical model of self-care The self-care actions necessary for life, health,
agency provides a visualization of this structure and well-being must then be performed by the
(Fig. 8-2). Understanding these elements is dependent-care agent or the nurse agent.
necessary to determine the self-care agent role,
dependent-care agent role, and the nurse role. Capabilities for Estimative,
Transitional, and Productive
Foundational Capabilities Operations
and Dispositions The most concrete level of self-care agency is
Foundational capabilities and dispositions are one specific to the individual’s detailed com-
at the most basic level (Orem, 2001, pp. 262– ponents of self-care demand or requirements.
263). These are capabilities for all types of Capabilities related to estimative operations
deliberate action, not just self-care. Included are those necessary to determine what self-care
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112 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

actions are needed in a specific nursing situa- nurse agent must provide care. Similar varia-
tion at one point in time—in other words, ca- tions of development and operability occur
pabilities of investigating and estimating what with dependent-care agency and must be con-
needs to be done. This includes capabilities of sidered by the nurse when developing the self-
learning in situations related to health and care or dependent-care system.
well-being. For example, does the person
newly diagnosed with asthma have the capa- Therapeutic Self-Care Demand
bility to learn about regular exercise activities (Dependent-Care Demand)
and rescue medication? Does the person know Therapeutic self-care demand (TSCD) is a
how to obtain the necessary resources? Tran- complex theoretical concept that summarizes
sitional operations relate to abilities necessary all actions that should be performed over time
for decision making, such as reflecting on the for life, health, and well-being. When first de-
course of action and making an appropriate veloped, the concept was referred to as action
decision. The patient may have the capabilities demand or self-care demand (Orem, 2001).
to learn and obtain resources but not the ability Readers will therefore see these terms used in
to make the decision. The asthma patient has Orem’s writings and in the literature. Dependent
the capability to learn about exercise and med- care demand is the summation of all care actions
ication but not the capability to make the for meeting the dependent caregiver’s therapeutic
decision to follow through on directions. self-care demand when his or her agency is not ade-
Capabilities for productive operations are quate or operational (Taylor & Renpenning,
those necessary for preparing the self for the 2011, p. 108).
action, carrying out the action, monitoring the The word therapeutic is essential to one’s un-
effects, and evaluating the action’s effective- derstanding of the concept. Consideration is
ness. If the person decides to use the inhaler, always on a therapeutic outcome of life, health,
does the person have the ability to take time to and well-being. A Haitian mother in a remote
engage in the necessary self-care, to physically village may expect to apply horse or cow dung
push the device, to monitor the changes, and to the severed umbilical cord to facilitate dry-
determine the effectiveness of the action? Just ing, a culturally adjusted self-care measure for
as the action sequence is important in the self- a newborn. With horse/cow dung as the major
care concept, these types of capabilities reveal carrier of Clostridium tetanus, this dependent-
the complexity of human capability. care action may lead to disease and infant
At the concrete practice level, self-care death, not a therapeutic outcome.
agency also varies by development and oper- Constructing or calculating a TSCD re-
ability. For example, the nurse must determine quires extensive nursing knowledge of evi-
whether capabilities for learning are fully de- denced-based practice, communication, and
veloped at the level necessary to understand interpersonal skills. Both scientific nursing
and retain information about the required ac- knowledge and knowledge of the person and
tions. For example, a mature adult with late environment are merged to formulate what
stage Alzheimer’s disease is not able to retain needs to be done in a particular nursing situation
new information. The self-care agency is there- (NDCG, 1979). The process of calculating the
fore developed but declining, creating the possi- TSCD includes adjusting values by the basic
ble need for dependent-care agency or nursing conditioning factors. For example, a mental
agency. A second determination is the oper- health patient will have different needs based
ability of agency. Is agency not operative, par- on the type of mental health condition (health
tially operative, or fully operative? A comatose state), family system factors, and health-care
patient may have fully developed capabilities resources.
before a motor vehicle accident, but the trauma
results in inoperable cognitive functioning. Self-Care Requisites
SCA is therefore developed, but not operative at To provide the framework for determining the
that moment in time. In this situation, the TSCD, Orem developed three types of self-care
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CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 113

requisites (or requirements): universal, develop- hazards to ingestion of food such as avoiding
mental, and health deviation. These are the pur- pesticides.
poses or goals for which actions are performed for
life, health, and well-being. The individual Developmental Self-Care Requisites
sleeps once each day and engages in daily activ- Orem (2001) identified three types of devel-
ities to meet the requisite or goal of maintaining opmental self-care requisites (DSCRs). The
a balance of activity and rest. Without rest, a first refers to actions necessary for general
human cannot survive. Therefore, these are gen- human developmental processes throughout
eral statements within a three-part framework the life span. These requisites are often met by
that provide a level of abstraction similar to the dependent-care agents when caring for devel-
power components of self-care agency. Denyes oping infants and children or when disaster and
et al. (2001) explicated the self-care requisite to serious physical or mental illness affects adults.
maintain an adequate intake of water. Their work Engagement in self-development, the second
demonstrates the complexity of actions neces- DSCR, refers to demands for action by indi-
sary to meet a basic human need. Without con- viduals in positive roles and in positive mental
sideration of this complexity, analysis and health. Examples include self-reflection,
diagnosis of patient requirements is not com- goal-setting, and responsibility in one’s roles.
plete. This scholarly contribution by Denyes and The third DSCR, interferences with develop-
others (2001) can serve as a model for structur- ment, expresses goals achieved by actions that
ing information regarding all other requisites are necessary in situational crises such as loss
(personal communication, Dr. Susan G. Taylor, of friends and relatives, loss of job, or terminal
March 12, 2013). illness. Originally subsumed under USCRs,
Orem created the developmental self-care
Universal Self-Care Requisites requisite category to indicate the importance
The eight universal self-care requisites (USCR) of human development to life, health, and
are necessary for all human beings of all ages well-being.
and in all conditions, such as air, food, activity
and rest, solitude, and social interaction. The Health Deviation Self-Care Requisites
BCFs influence the quality and quantity of the Health deviation self-care requisites (HDSCR)
action necessary to achieve the purpose. Ac- are situation-specific requisites or goals when
tions to be performed over time that meet the people have disease, injuries, or are under pro-
requisite, prevention of hazards to human life, fessional medical care. These six requisites
human functioning, and human well-being (the guide actions when pathology exists or when
purpose), will vary for an infant (e.g., keeping medical interventions are prescribed. The first
crib rails up) versus an adult (e.g., ambulation HDSCR refers in part to a patient purpose: to
safety). Some requisites are very general yet seek and secure appropriate medical assistance for
provide important concepts necessary for all genetic, physiological, or psychological conditions
humans. One example is the concept of nor- known to produce or be associated with human
malcy, the eighth USCR. The goal is promotion pathology (Orem, 2001, p. 235). For a person
of human functioning and development within with history of breast cancer, seeking regular
social groups in accord with human potential, diagnostic tests is a goal to preserve life, health,
human limitations, and the human desire to be and well-being. A teenager in treatment for se-
normal (Orem, 2001, p. 225). Practice exam- vere acne takes action to meet HDSCR 5: to
ples in the literature have emerged, such as the modify the self-concept (and self-image) in ac-
importance of normalcy to individuals with cepting oneself as being in a particular state of
learning disabilities (Horan, 2004). These two health and in need of a specific form of health care
requisites, prevention of hazards and promo- (Orem, p. 235).
tion of normalcy, also relate to the other six Each TSCD, through the three types of
USCRs. For example, when maintaining a self-care requisites, is individualized and ad-
sufficient intake of food, one must consider justed by the basic conditioning factors (BCFs)
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114 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

such as age, health state, and sociocultural ori- meet the therapeutic self-care demand? If ade-
entation. Once adjusted to the specific patient quate, there is no need for nursing.
in a unique situation, the purposes are specific A dependent-care deficit is a statement of
for the patient or type of patient. These are the relationship between the dependent-care
called “particularized self-care requisites.” demand and the powers and capabilities of the
Dennis and Jesek-Hale (2003) proposed a list dependent-care agent to meet the self-care
of particularized self-care requisites for a nurs- deficit of the socially dependent person, the
ing population of newborns. Although created self-care agent (Taylor & Renpenning, 2011).
for nursery newborns, a group particularized When this deficit occurs, then a need for nurs-
by age, the individual patient adjustments are ing exists. When a parent has the capabilities
then made. For example, a newborn’s sucking to meet all health-related self-care requisites
needs may vary, necessitating variation in feed- of an ill child, then no nursing is needed.
ing methods. More recent nursing literature When an existing or potential self-care deficit
continues to expand the types of requisites var- is identified and legitimate nursing is needed, an
ied by specific diseases or illnesses that provide analysis by the nurse/patient/dependent-care
a basis for application to specific patients and agents results in identification of types of limi-
caregivers. tations in relationship to the particularized self-
care requisites. These are generally described as
Self-Care Deficit (Dependent-Care limitations of knowing, limitations or restric-
Deficit) tions of decision-making, and limitations in
As a theoretical concept, self-care deficit ex- ability to engage in result-achieving courses of
presses the value of the relationship between action. Orem classified these into sets of limi-
two other concepts: self-care agency and ther- tations (Orem, 2001, pp. 279–282).
apeutic self-care demand (Orem, 2001). When
the person’s self-care agency is not adequate to Nursing System (Dependent-Care
meet all self-care requisites (TSCD), a self- System)
care deficit exists. This qualitative and quanti- Orem describes a nursing system as an “action
tative relationship at the conceptual level of system,” an action or a sequence of actions per-
abstraction is expressed as “equal to,” “more formed for a purpose. This is a composite of all
than,” or “less than” (see Fig. 8-1). A deficit the nurse’s concrete actions completed or to be
relationship is also described as complete or completed for or with a self-care agent to pro-
partial; a complete deficit suggests no capabil- mote life, health, and well-being. The compos-
ity to engage in self-care or dependent care. ite of actions and their sequence produced by
An example of a complete deficit may exist in the dependent-care agent to meet the thera-
a premature infant in a neonatal intensive care peutic dependent self-care demand is termed
unit. A partial self-care deficit may exist in a a dependent-care system (Taylor et al., 2001).
patient recovering from a routine bowel resec- These actions relate to three types of subsys-
tion 1 day after surgery. This person is able to tems: interpersonal, social/contractual, and
provide some self-care. professional-technological.
Understanding self-care deficit is necessary The interpersonal subsystem includes all
to appreciate Orem’s concept of legitimate nurs- necessary actions or operations such as enter-
ing. If a nurse determines a patient has self-care ing into and maintaining effective relation-
agency (estimative, transitional, and productive ships with the patient and/or family or others
capabilities) to carry out a sequence of actions involved in care. The social/contractual subsys-
to meet the self-care requisites, then nursing is tem relates to all nursing actions/operations to
not necessary. A self-care deficit or anticipated reach agreements with the patient and others
self-care deficit must exist before a nursing sys- related to information necessary to determine
tem is designed and implemented. The nurse the therapeutic self-care demand and self-care
reflects with the patient: Is self-care agency agency of an individual and caregivers. Within
(and/or dependent-care agency) adequate to this subsystem, the nurse, in collaboration with
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CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 115

the patient or dependent-caregiver, determines With determination of a real or potential


roles for all care participants (Orem, 2001). self-care deficit or dependent-care deficit, the
These are based on social norms and other nurse develops one of three types of nursing
variables such as basic conditioning factors. systems: wholly compensatory, partly compen-
Although other nursing theories emphasize in- satory, or supportive-educative (developmen-
terpersonal interactions, Orem’s general theory tal). The nurse then continues the query: Who
clearly specifies details of interpersonal and can or should perform actions that require move-
contractual operations as necessary antecedents ment in space and controlled manipulation?
and concurrent components of care. This ele- (Orem, 2001, p. 350). If the answer is only the
ment of Orem’s model is often overlooked and nurse, then a wholly compensatory system is
clarifies the decision-making process and col- designed. If the patient has some capabilities
laborative relationship within the nurse– to perform operations or actions, then the
patient–family/multiperson roles. nurse and patient share responsibilities. If the
The professional–technological subsystem patient can perform all actions that control
comprises actions/operations that are diagnostic, movement in space and controlled manipula-
prescriptive, regulatory, evaluative, and case tion, but nurse actions are required for support
management. The latter involves placing all (physical or psychological), then the system is
operations within a system that uses resources supportive–educative. Note, in all systems, the
effectively and efficiently with a positive pa- self-care deficit is the necessary element that
tient outcome. Orem views the professional– leads to the design of a nursing system. Using
technological subsystem as the process of the interpersonal and social–contractual oper-
nursing, a nonlinear one that integrates all ations, the nurse first enters into an interper-
operations of this subsystem with those of the sonal relationship and an agreement to
interpersonal and the social–contractual. This determine a real or potential self-care deficit,
involves collecting data to determine existing prescribe roles, and implement productive
and projected universal, developmental, and operations of self-care and/or dependent
health-deviation self-care requisites, and meth- care. Regulation or treatment operations are
ods to meet these requisites as adjusted by the designed or planned and then produced or
basic conditioning factors. Using the interper- performed. Control operations are used to
sonal and social–contractual subsystems, the appraise and evaluate the effectiveness of
nurse incorporates modifications of her or his nursing actions and to determine whether
diagnosis and prescriptions in collaboration with adjustments should be made. These ap-
the patient and family on what is possible. The praisals emphasize validity of operations or
nurse also identifies the patient’s usual self-care actions in relationship to standards. Selecting
practices and assesses the person’s estimative, valid operations in the plan and in evaluation
transitional, and productive capabilities for incorporate evidence-based practices. These
knowledge, skills, and motivation in relationship processes, including diagnosis, prescription,
to the known self-care requisites. That is, are the designing, planning, regulating, and control-
capabilities (self-care agency/dependent-care ling, can be viewed as elements of Orem’s
agency) needed to meet the self-care requisites steps in the process of nursing (Fig. 8-3).
developed, operable, and adequate? Are there Orem’s language of the nursing process
limitations in knowing, deciding, or producing varies from the standard language of assess-
self-care? If no limitations exist, then there is no ment, diagnosis, planning, implementation,
need for nursing and no nursing system is devel- and evaluation. The interaction of the three
oped. If there is a self-care deficit or dependent- aforementioned subsystems creates a model for
care deficit, then the nurse and patient or true collaboration with the recipient of care or
caregivers reach agreement about the patient’s the caregiver.
role, the family’s role, and/or the nurse’s role. The three steps of Orem’s process of nurs-
Orem (2001) charted the progression of these ing are as follows: (1) diagnosis and prescrip-
steps by subsystems (pp. 311, 314–317). tion, (2) design and plan, and (3) produce and
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116 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Accomplishes patient’s
(capabilities)? What, if any, are limitations
therapeutic self-care for deliberate action related to the estimative
(investigative–knowing), transitional (decision
Nurse
Compensates for patient’s making), and productive (performing) phases
inability to engage in of self-care? (Orem, 2001, p. 312). The nurse
action
self-care
collects information, analyses it, and makes
Supports and protects judgments about the information within the
patient limits of nursing agency (capabilities of the
nurse, such as expertise).
Wholly compensatory system
Orem describes nursing as a specialized
Performs some self-care helping service and identifies five helping
measures for patient methods to overcome self-care limitations or
regulate functioning and development of pa-
Compensates for self-care
limitations of patient
tients or their dependents. Nurses employ one
or more of these methods throughout the
Nurse Assists patient as required process of nursing, including acting for or
action doing for another, guiding another, supporting
another, providing for a developmental envi-
Performs some self-care ronment, and teaching another (Orem, 2001,
measures
pp. 56–60). Acting for or doing for another in-
Regulated self-care Patient cludes physical assistance such as positioning
agency action the patient. Assuming self-care agency that is
developed and operable, the nurse replaces this
Accepts care and
assistance from nurse method with others that focus on cognitive de-
velopment, such as guiding and teaching.
Partly compensatory system These methods are not unique to nursing, but
are used by most health professionals. Through
Accomplishes self-care
their unique role functions, nurses perform a
Patient
action specific sequence of actions in relationship to
Regulates the exercise
Nurse
and development of the identified patient and/or dependent-care
action agent’s self-care limitations in combination
self-care agency
with other health professionals to meet the
Supportive-educative system self-care requirements.
Fig 8 • 3 Basic nursing system. Although comparisons are made between
these steps and those of the general nursing
process, Orem’s complexity is unique in ad-
control. For example, Orem considers the term dressing an integration of interpersonal, social–
“assessment” too limiting. Within Orem’s contractual, and professional–technological
process, assessments are made throughout the subsystems. The intricacy of her steps is also ev-
iterative social–contractual and professional- ident in the complexity of the diagnostic and
technological operations. During the first step prescriptive components. The practice exemplar
of diagnosis, data are collected on the basic in this chapter provides one simplified example
conditioning factors and a determination is of this process.
made about their relationship to the self-care
requisites and to self-care agency. How does Nursing Agency
health state (e.g., type 2 diabetes) affect the Nursing agency is the power or ability to nurse.
individual’s universal, developmental, and The agency or capabilities are necessary to know
health-deviation self-care requirements? How and meet patients’ therapeutic self-care demands
does the basic conditioning factor, or health and to protect and to regulate the exercise of devel-
state, affect the individual’s self-care agency opment of patient’s self-care agency (Orem, 2001,
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CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 117

p. 290). Nursing agency is analogous to self- groups, and communities, where the recipient
care agency but with capabilities performed on of nursing care is more than a single individual
behalf of “legitimate patients.” Similar to self- with a self-care deficit. They distinguished
care agency, nursing agency is affected by basic among types of multiperson units, such as
conditioning factors. The nurse’s family system, community groups and family or residential
as well as nursing education and experience, group units. These authors present categories
may affect his or her ability to nurse. of multiperson care systems, create family and
Orem categorizes nursing capabilities community as basic conditioning factors, and
(agency) as interpersonal, social–contractual, present a model of community as aggregate.
and professional-technological. That is, the This model appropriately incorporates addi-
nurse must have capabilities within each of the tional basic conditioning factors such as public
subsystems described in the nursing system. policy, health-care system changes, and com-
Capabilities that result in desirable interper- munity development. Other frameworks such
sonal nurse characteristics include effective as a community participation model have been
communication skills and ability to form rela- developed (Isaramalai, 2002).
tionships with patients and significant others. Community groups have a selected number
Social–contractual characteristics require of common self-care requisites and/or limita-
the ability to apply knowledge of variations in tions of knowledge, decision making, and pro-
patients to nursing situations and to form con- ducing care. These can be based on requirements
tracts with patients and others for clear of entire communities, groups within the com-
role boundaries. Desirable professional– munities, or to other situations when groups
technologic characteristics require the ability have common needs. For example, the focus of
to perform techniques related to the process of a student health nurse at a university may be a
nursing: diagnosis of therapeutic self-care de- group of first-year students and the self-care req-
mand of an assigned patient with considera- uisite, prevention of the hazards of alcohol poi-
tion of all self-care requisites (universal, soning. The self-care limitations of the group
developmental, and health deviation) and a may be knowledge of binge drinking outcomes
concomitant diagnosis of a patient’s self-care and the skills to resist peer pressure at parties.
agency. Other desired nurse characteristics in- This environment and situation, the college mi-
clude the ability to prescribe roles: Assuming lieu and new independence, creates the common
a self-care deficit (and therefore a legitimate set of self-care requisites. The action system de-
patient), what are the roles and related respon- signed by the college health nurse is to develop
sibilities of the nurse, the patient, the aide, and the knowledge, decision-making, and result-
the family? Nurses must also have the ability producing skills of new students collectively so
to know and apply care measures such as gen- life, health, and well-being are enhanced for the
eral helping techniques (teaching, guiding) and group, as well as the college community.
specialized interventions and technologies Family or others in a communal living
such as those identified with evidence-based arrangement are another type of multiperson
practice. These necessary nursing capabilities unit of service. Because of the interrelationship
also have implications for nursing education of the individuals in the living unit, the purpose
and nursing administration. Knowledge of all of nursing varies from that for a community
components of nursing agency will direct nurs- group. In this situation, the focus is often an
ing curricula for successful development of individual, as well as the family as a unit. The
nursing abilities. Likewise, knowledge related health-related requirements of one individual
to nursing administration is critical to oper- trigger the need for nursing but also affect the
ability of nursing agency (Banfield, 2011). unit as a whole. In one situation, an elderly par-
ent moves into the family home. Not only is
Multiperson Situations and Units the therapeutic self-care demand of the parent
Taylor and Renpenning (2001) extended ap- involved, but also the needs of family members
plication of Orem’s concepts to families, as it affects their self-care requisites. The health
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118 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

of the unit is therefore established and main- Child and Adolescent Self-Care Performance
tained by meeting the therapeutic self-care de- Questionnaire (Jaimovich, Campos, Campos
mands of all members and facilitating the & Moore, 2009); The Nutrition Self-Care
development and exercise of self-care agency Inventory (Fleck, 2012); and Self-Care
for each group member (Taylor & Renpen- Outcomes (Valente, Saunders, & Uman,
ning, 2011). 2011).
A few Orem scholars continue with devel-
opment of theoretical elements through well-
Applications of the Theory designed programs of research with specific
Nursing Education Applications populations. For example, Armer et al. (2009)
Many educational programs used Orem’s con- studied select power components (elements
ceptualizations to frame the curriculum and to of self-care agency) to describe those important
guide nursing practice (Hartweg, 2001; Ransom, in developing supportive-educative nursing
2008). Taylor and Hartweg (2002) found systems with postmastectomy breast cancer
Orem’s conceptualization was the most fre- patients. A secondary analysis of this study
quently used nursing theory in U.S. programs. contributed to identification of the types of
Examples of Orem-based schools included self-care limitations experienced by this popula-
Morris Harvey College in Charleston, West tion. The results have potential to promote effec-
Virginia, Georgetown University, the University tive nursing interventions (Armer, Brooks, &
of Missouri—Columbia, and Illinois Wesleyan Steward, 2011). Research is needed on actions
University (Taylor, 2007). Current application and methods to meet health deviation self-care
of Orem’s theory in nursing education ranges requisites in a variety of specific health situations
from application to pedagogy in a hybrid (Casida, Peters, Peters, & Magnan, 2009).
RN-BSN course in the United States (Davidson, Many studies use SCDNT as a framework
2012) to use as a general framework for nursing for research and reference select concepts but
education in Germany (Hintze, 2011). with limited application (Lundberg & Thrakul,
2011). For example, Carthron and others
Research Applications (2010) used Orem’s SCDNT to guide research
The use of SCDNT as a framework for re- related to specific concepts such as therapeutic
search continues to increase with application self-care demand and self-care agency. How-
to specific populations and conditions. Studies ever, a family system factor (the primary care
range from those with general reference to role of grand-mothering) on type 2 diabetes
Orem’s theory to more sophisticated explo- self-management was the primary emphasis
ration of concepts and their relationships. within the study. Other studies combine ele-
Early Orem studies concentrated on theory ments from SCDNT with other theories with-
development and testing, including creation of out consideration of the congruence of
theory-derived research instruments (Gast et al., underlying assumptions. For example, Single-
1989), a necessary process in theory building. ton, Bienemy, Hutchinson, Dellinger, and
Examples of widely used concept-based instru- Rami (2011) framed their study in part within
ments include those by Denyes (1981, 1988) Orem’s theory of self-care as well as in the
on self-care practices and self-care agency. The health belief model and the concept of self-
Appraisal of Self-care Agency (ASA scale) was efficacy. This combination of concepts and
an early tool used in international research (van theories in research studies is common. Fur-
Achterberg et al., 1991) and later modified for ther, Klainin and Ounnapiruk (2010) summa-
specific populations (West & Isenberg, 1997). rized research findings from 20 studies of
More recent instruments derive from structural Thai elderly guided by Orem’s SCDNT. Al-
components of SCDNT but are applicable in though their analysis revealed two of six major
more specific situations: Self-Care for Adults concepts and one peripheral concept were
on Dialysis Tool (Costantini, Beanlands, & evident in the research, many studies explored
Horsburgh, 2011); Spanish Version of the other non–SCDNT-specific concepts such as
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CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 119

self-concept, self-efficacy, and locus of control. Table 8-1 provides examples of domestic
The authors suggest that SCDNT should be and international theory development and
revisited to include additional concepts to practice-related research conducted in the past
strengthen the theory. 5 years at the time of this writing.

Table 8 • 1 Examples of Research Applications


Author (Year), Population/ SCDNT
Country Purpose Settings Concept(s) Methods Results
Armer, Brooks, & To examine Breast cancer SCA, Secondary Identified types
Steward (2011), patient per- survivors, especially analysis of of self-care limi-
USA ceptions of postsurgery estimative, qualitative tations in rela-
SC limitations (N = 14) transi- data from tionship to sets
to meet TSCD tional, and pilot study of limitations,
to reduce productive (Armer e.g., “know-
lymphedema phases of et al., ing.” Most limi-
self-care 2009) tations were not
necessary related to lack
to de- of knowledge
crease but to energy,
risk of lym- patterns of liv-
phedema; ing, etc. Em-
supportive- phasized the
educative “supportive”
nursing element in this
system nursing system.
Arvidsson, To describe Rheumatic Health- Phenome- Perspectives re-
Bergman, the meaning disease promoting nology vealed that SC
Arvidsson, of health- patients SC requires dia-
Fridlund, & Tops promoting (N = 12) logues with the
(2011), Sweden SC in pa- body and envi-
tients with ronment, power
rheumatic struggles with
diseases the disease,
and making
choices to fight
the disease. SC
was viewed as
a way of life.
Burdette (2012), To examine Rural midlife BCFs, Predictive SCA predicted
USA relationship women SCA, and correla- SC. Education,
among SCA, (N = 224) SC prac- tional employment,
SC, and tices; com- design and health sta-
obesity plemented was used. tus facilitated
with rural SC practices;
nursing smoking and
theory chronic condi-
tions were
barriers.
Carthron, To compare African BCF (fam- Nonexper- Before and
Johnson, Hubbart, diabetes self- American ily system imental, after beginning
Strickland, & management GMs with factor of compara- caregiving:
Nance (2010), activities of type 2 grand- tive design GMs were sta-
USA primary care- diabetes mother tistically differ-
giving grand- (N = 68, 34 role; ent with fewer
mothers (GM) per group) patterns of days of eating
Continued
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120 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Table 8 • 1 Examples of Research Applications—cont’d


Author (Year), Population/ SCDNT
Country Purpose Settings Concept(s) Methods Results
before and living); a healthy diet
after begin- TSCD; and fewer per-
ning caregiv- SCA, formed self-
ing activities; especially management
to compare power blood glucose
these GMs’ compo- tests. Fewer self-
self-manage- nents management
ment activi- blood glucose
ties with tests and fewer
those of GMs eye examina-
not providing tions were per-
primary care formed by GMs
providing pri-
mary care to
grandchildren.
Kim (2011), To determine Prostate can- SCA; Quasi- Significant dif-
Korea effectiveness cer patients quality experimen- ference was
of a program (N = 69) of life tal; non- found between
to develop equivalent self-care
SCA based control agency and
on SC needs group using quality of life in
specific to pre–post treatment
prostatectomy test design group vs con-
trol group at
8 weeks after
prostatectomy.
Lundberg & To explore Thai Muslim Orem’s Ethno- Four themes
Thrakul (2011), Thai Muslim women living SCDNT graphic emerged on self-
Sweden & women’s self- in Bangkok was used study using management:
Thailand management (N = 29) as frame- participant daily life prac-
of type 2 work observation tices (dietary, ex-
diabetes ercise, medicine,
doctor follow-up,
blood sugar
self-monitoring,
use of herbal
remedies), af-
fect of illness,
family support
and need for
everyday life
as before
diagnosis (e.g.,
maintaining
religious prac-
tices during
Ramadan).
Ovayolu, To explore re- Turkish pa- SCA; Cross- For patients
Ovayolu, & lationship tients with Factors re- sectional; with RA, pa-
Karadag (2011), among SCA, rheumatoid lated to descriptive– tients with
Turkey disability lev- arthritis (RA) health- correla- higher disabil-
els, and other (N = 467) care, such tional ity and pain
factors as pain had lower self-
and dis- care agency.
ability The potential for
level. development of
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CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 121

Table 8 • 1 Examples of Research Applications—cont’d


Author (Year), Population/ SCDNT
Country Purpose Settings Concept(s) Methods Results
knowledge,
skills, and re-
sources neces-
sary for SC
were identified.
Rujiwatthanakorn, To examine Thais with SC de- Quasi- Patients in treat-
Panpakdee, effectiveness essential mands, experimen- ment group
Malathum, & of a SC man- hypertension self-care tal had higher
Tanomsup (2011), agement (N = 96) ability knowledge of
Thailand program and self-care de-
blood mands and self-
pressure care ability
control regarding med-
ication, dietary,
physical activity,
self-monitoring.
Both systolic
and diastolic
readings of
treatment group
were lower
than control
group.
Surucu & Kizilci To explore Type 2 dia- TSCD, Descriptive Demonstrated
(2012), Turkey the use of betes patients HDSCR, case study improvement in
SCDNT in di- SCA health indica-
abetes self- tors after design
management of a nursing sys-
education tem directed at
deficits in SCA
related to
HDSCR.
Thi (2012), South To describe Hepatitis B in- SCA (SC Descriptive/ 51% of patients
Vietnam levels of SC patients and knowl- compara- had the re-
knowledge in outpatients edge), tive quired hepatitis
patients (N = 230) SCR, B SC knowl-
BCFs edge, espe-
cially need for
exercise, rest,
and methods of
prevention of
transmission
through sexual
activity. There
was a knowl-
edge deficit re-
lated to diet and
management/
monitoring of
disease.
Level of educa-
tion, type of
occupation,
previous health
education, and
Continued
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122 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Table 8 • 1 Examples of Research Applications—cont’d


Author (Year), Population/ SCDNT
Country Purpose Settings Concept(s) Methods Results
health-care set-
ting affected
levels of SC
knowledge.
Wilson, To determine Urban radia- SCA: SC Nonexperi- Knowledge
Mood, whether tion oncology knowledge mental, about radiation
Nordstrom reading low clinic pa- of radia- exploratory side effect man-
(2012), USA literacy pam- tients, tion side agement var-
phlets on (N = 47) effects ied by literacy
radiation level despite
side effects low literacy
affect patient level of pam-
knowledge phlets. Sup-
ported premise
that founda-
tional capaci-
ties for self-care
include skills
for reading,
writing, com-
munication per-
ception and
reasoning.
Note. BCF = basic conditioning factors; HDSCR = health deviation self-care requisites; SC = self-care or self-care practices;
SCA = self-care agency; SCDNT = self-care deficit nursing theory; SCR = self-care requisites; TSCD = therapeutic self-care demand.

Practice Applications Table 8-2 provides examples of specific prac-


Nursing practice has informed development tice applications in the past 5 years at the
of SCDNT as SCDNT has guided nursing time of this writing.
practice and research. Biggs (2008) con- One theoretical application to nursing prac-
ducted a review of nursing literature from tice exemplifies the continued scholarly work
1999 to 2007. The results revealed more necessary for practice models and addresses
than 400 articles, including those in Inter- one deficit area noted by Biggs (2008). Casida
national Orem Society Newsletters and Self- and colleagues (2009) applied Orem’s general
Care, Dependent-Care, and Nursing, the theoretical framework to formulate and de-
official journal of the International Orem velop the health-deviation self-care requisites
Society. Although Biggs noted a tremendous of patients with left ventricular assist devices.
increase in publications during that period, This article specifies not only the self-care
the author observed that SCDNT research requisites for this population but also the nec-
has not always contributed to theory progres- essary subsystems unique to practice applica-
sion and development or to nursing practice. tions. This work illustrates the complexity of
She identified deficient areas such as those SCDNT and also the utility of SCDNT for
related to concepts such as therapeutic self- patients with all types of technology assisted
care demand, self-care deficit, nursing sys- living.
tems, and the methods of helping or One change in the past few years has been
assisting. Recent publications on Orem based an emphasis on self-management rather than or
practice address areas identified by Biggs. in conjunction with self-care (Ryan, Aloe, &
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CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 123

Table 8 • 2 Examples of Practice Applications


Patient or Practice
Author (Year), Health or SCDNT Focus (Selected
Country Illness Focus Settings Concept(s) Examples) Other
Alspach Hypertension/ Critical care SC Development Editorial
(2011), USA heart failure unit of checklist demonstrating
in elderly tool to meas- use of theoreti-
ure SC at cal framework
home after to design a
critical care brief checklist
discharge
Casida, Left-ventricular Acute care HDSCR, in- Reformulation An exemplar
Peters, Peters, assist devices cluding SC of HDSCR for the six HD-
& Magnan (LVAD) systems common to SCRs specific
(2009), USA patients with health situation
LVAD using and model for
five guidelines developing
described by other condi-
Orem (2001) tions using
to validate multifaceted
form and technological
adequacy care
Green Children with School setting SCR; SCD; Demonstration An example of
(2012), USA special needs BCF; SCA; of utility of types of nurs-
DCA; SCS SCDNT ing systems
through two
case studies:
wholly com-
pensatory sys-
tem for child
with cerebral
palsy; partly
compensatory
for child with
asthma; and
supportive-
educative sys-
tem for diabetic.
Hohdorf Hospitalized Acute care SCDNT Exemplified One hospital’s
(2010), patients settings change of goal to im-
Germany focus to prove quality
theory-based care and de-
nursing crease length
practice of stay by mov-
ing to theory
based practice
Hudson & Adults with Community SCDNT as Demonstration An example of
Macdonald hemodialysis dialysis unit framework; of SCDNT as application or
(2010), arteriovenous all concepts guide to de- SCDNT to ar-
Canada fistula self- including NA velop and teriovenous
cannulation update patient- fistula SC
teaching re-
sources in
preparation for
home care; as-
sisted nurses
with role
clarification
Continued
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124 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Table 8 • 2 Examples of Practice Applications—cont’d


Patient or Practice
Author (Year), Health or SCDNT Focus (Selected
Country Illness Focus Settings Concept(s) Examples) Other
Pickens Adults with Psychiatric SCA: Explored vari- Theoretical
(2012), USA schizophrenia nursing care motivation ous theories paper incorpo-
component of motivation rating elements
to develop of other theo-
SCDNT’s ries to expand
foundational supportive-
capability developmental
and power technologies in
component of patients with
motivation serious mental
illness
Seed & Acute psychi- Recovery SCDNT con- SCDNT pro- Demonstrates
Torkelson atric care principles cepts in align- vided a com- use of SCDNT
(2012), USA ment with prehensive toward partner-
recovery can framework based relation-
be used to for delivering ships for
structure inter- interventions recovery from
ventions and that empower mental illness
research in individuals to
acute psychi- make choices
atric settings in care and
treatment
through part-
nerships and
education
Surucu & Use of University set- BCFs; SCA; Implemented This case study
Kizilci, SCDNT in ting; diabetes SCD; TSCD, steps of gen- provides an ex-
(2012), type 2 dia- education with empha- eral nursing emplar for self-
Turkey betes self- center sis on HDSCR process using management of
management Orem-specific type 2 diabetes
education concepts
Swanson & Integration Orem’s self- SCA; SCD; Demonstrates SCDNT as
Tidwell model of care deficit helping incorporation component of
(2011), USA shared gover- theory as methods of SCDNT as health system
nance using general prac- the theoreti- practice model
magnet com- tice frame- cal guide to
ponents to work professional
promote pa- practice at
tient safety one institution
and its com-
bination
shared gover-
nance to en-
hance patient
safety
Wanchai, Breast cancer Multiple SCA SC agency
Armer, & survivors settings enhancement
Stewart based on through use
(2010), USA, review of 11 of comple-
Canada, studies from mentary or
Germany 1990 alternative
through therapies to
2009 meet HDSCR,
specifically to
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CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 125

Table 8 • 2 Examples of Practice Applications—cont’d


Patient or Practice
Author (Year), Health or SCDNT Focus (Selected
Country Illness Focus Settings Concept(s) Examples) Other
maintain
physical and
emotional
well-being
and to man-
age side ef-
fects of
treatment
BCFs = basic conditioning factors; DCA = dependent-care agency; HDSCR = health deviation self-care requisites; NA =
nursing agency; SC = self-care; SCA = self-care agency; SCD = self-care deficit; SCR = self-care requisites; SCS = self-care
systems; TSCD = therapeutic self-care demand.

Mason-Johnson, 2009; Sürücu & Kizilci, In addition to creating models for specific
2012; Swanlund, Scherck, Metcalfe, & Jesek- health-care conditions, Orem’s SCDNT is
Hale, 2008; Wilson, Mood, & Nordstrom, also used as a general framework for nursing
2012). Orem (2001) introduced the term practice in health care institutions. For ex-
self-management in her final book, defining the ample, Cedars Sinai Medical Center in Los
concept as the ability to manage self in stable or Angeles, California, integrates SCDNT with
changing environments and ability to manage one’s its shared governance model to promote pa-
personal affairs (p. 111). This definition relates tient safety (Swanson & Tidwell, 2011).
to continuity of contacts and interactions one However, most practice applications use the
would expect over time with nursing, especially general theory or elements of the theory with
when caring for people with chronic conditions specific populations. Table 8-2 includes di-
such as diabetes. By nature, chronic disease vari- verse examples from English publications.
ations over time are collaboratively managed However, the reader is also directed to non-
by the self-care agent, dependent-care agent, English publications including examples
the nurse agent, and others. The dependent- from practitioners or researchers in Brazil
care theory enhances the self-management (Herculano, De Souse, Galvão, Caetano, &
component, a uniqueness of SCDNT (Casida Damasceno, 2011) and China (Su & Jueng,
et al., 2009). With increases in chronic illness 2011).
and treatment, especially in relationship to To further develop the sciences of self-
allocation of health-care dollars, countries such care related to specific self-care systems and
as Thailand now emphasize self-management to nursing systems for diverse populations
versus self-care in health policy decisions around the globe, collaboration will be nec-
(personal communication, Prof. Dr. Somchit essary between reflective practitioners and
Hanucharurnkul, January 15, 2013). Taylor and scholars (Taylor & Renpenning, 2011).
Renpenning (2011) presented diverse perspec- Orem’s wise approach to theory develop-
tives on self-management, describing it first ment, combining independent work with
as a subset of self-care with emphasis on creat- formal collaboration among practitioners,
ing a sense of order in life using all available administrators, educators, and researchers
resources, social and other. Another perspective will determine the future of self-care deficit
relates to controlling and directing actions in nursing theory. The International Orem So-
a particular situation at a particular time. This ciety for Nursing Science and Scholarship
includes incorporating standardized models for continues as an important avenue for collab-
self-management in specific health situations orative work among expert and novice
such as diabetes. SCDNT scholars around the globe.
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126 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Practice Exemplar
Provided by Laureen M. Fleck, PhD, worships in a community-based black church,
FNP-BC, CDE a source of spiritual strength and social support.
Marion has a high school education.
Marion W. presents to a primary care office
Questions about health state and health
seeking care for recent fatigue. She is assigned
system reveal Marion has type 2 diabetes that
to the nurse practitioner. The nurse explains
was diagnosed more than 5 years ago. Except
the need for information to determine what
for periodic fatigue, she believes she has man-
needs to be done and by whom to promote
aged this chronic condition by following the
Marion’s life, health, and well-being. Infor-
treatment plan, faithfully taking oral medica-
mation regarding Marion is gathered in part
tion, and checking blood sugar once per day.
using Orem’s conceptualizations as a guide.
The morning reading was 230 mg/dL. Al-
First, the nurse introduces herself and then de-
though the family has no health insurance,
scribes the information she will seek to help
Marion has access to the community health
her with the health situation. Marion agrees
care clinic and free oral medications. There is
to provide information to the best of her
a small co-pay for her blood glucose testing
knowledge. As the nurse and Marion have en-
strips, which is now a concern. The children
tered into a professional relationship and
receive health care through the State Chil-
agreed to the roles of nurse and patient, the
dren’s Health Insurance Program. The neigh-
nurse initiates the three steps of Orem’s
borhood Marion lives in has a safe, outdoor
process of nursing:
environment. The latter has been a comfort
Step 1: Diagnosis and Prescription because she works as a crossing guard and
I. Basic Conditioning Factors walks her children to school. Although she en-
As basic conditioning factors affect the value joys this exercise, her increasing fatigue dis-
of therapeutic self-care demand and self-care courages additional exercise.
agency, the nurse seeks information regarding When asked about her perception of her
the following: age, gender, developmental current condition, Marion expressed concern
state, patterns of living, family system factors, for her weight and considers this a partial ex-
sociocultural factors, health state, health-care planation for the fatigue. She desires to lose
system factors, availability and adequacy of re- weight but admits she has no willpower,
sources, and external environmental factors snacks late at night, and finds “healthy foods”
such as the physical or biological. too expensive. At 205 lbs (93 kg) and 5 feet
Marion is 42, female, in a developmental 3 inches (1.6 m), Marion is classified as obese
stage of adulthood where she carries out tasks with a body mass index of 38 kg/m2.
of family and work responsibilities as a produc- II. Calculating the Therapeutic Self-Care Demand
tive member of society. The history related to With Marion, the nurse identifies many ac-
patterns of living and family system reveals em- tions that should be performed to meet the
ployment as a school crossing guard, a role that universal, developmental, and health devia-
allows time after school with her children, ages tion self-care requisites. Her health state and
5, 7, and 9. Her husband works for “the city” health system factors (including previous
but recently had hours cut to 4 days per week. treatment modalities) are major conditioners
Therefore, money is tight. They pay bills on of two universal self-care requisites: maintain
time, but no money remains at the end of the a sufficient intake of food and maintain a
month. She has learned to stretch their money balance between activity and rest. Throughout
by shopping at the local discount store for the interview, the nurse determines that
clothes and food and cooking “one-pot meals” Marion is clear about her chronic condition
so that they have leftovers to stretch through- and has accepted herself in need of continued
out the week. As an African American, she monitoring and care, including quarterly
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CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 127

Practice Exemplar cont.


hemoglobin A1C and lipid blood tests 4. Seek assistance from health professional
(American Diabetes Association [ADA], when levels are below 60 mg/dL and not
2013) responsive to sugar intake or higher than
Two health deviation self-care requisites also 300 mg/dL with feelings of fatigue, thirst,
emerge as the primary focus for seeking helping or visual disturbances.
services: being aware and attending to effects 5. Adjust activity and meal planning/portion
and results of pathological conditions; and sizes when levels are not within parameters.
effectively carrying out medically prescribed
B. Make healthy food choices.
diagnostic and therapeutic measures. Without
additional self-care actions beyond the pre- 6. Seek knowledge of healthy food choices
scribed medication, short walks, and daily blood for family meal planning from dietitian at
glucose testing, the risks of uncontrolled dia- clinic.
betes may lead to diabetic retinopathy, 7. Review family expenses with health pro-
nephropathy, neuropathy, and cardiovascular fessional to adjust grocery budget to pur-
disease (ADA, 2013). chase affordable but healthy foods.
One particularized self-care requisite 8. Eat three balanced meals per day including
(PSCRs) is presented as an example, with midmorning, afternoon, and evening
the related actions Marion should perform to snack as desired. These meals and snacks
improve her health and well-being. Once the will have portion sizes established between
actions to be performed and concomitant meth- Marion and the nurse.
ods are identified, then the nurse determines 9. All meals will have a selection of protein,
Marion’s self-care agency: the capabilities of fats, and carbohydrates, and the snacks
knowing (estimative operations), deciding will be limited to 15 grams of carbohy-
(transitional operations), and performing these drate or less (ADA, 2013).
actions (productive operations).
C. Increase physical activity to 150 minutes/
PSCR: Reduce and maintain blood glucose
week of moderate intensity exercise (ADA,
level within normal parameters through in-
2013).
creased blood glucose monitoring, appropriate
healthy food choices, and increased activity. If 10. Gain knowledge regarding step-walking
this PSCR is achieved, Marion’s weight will be program to increase activity. Discuss
decreased, a related purpose that provides mo- community options for safe walking areas.
tivation to engage in self-care. The methods to 11. Explore budget to include properly fitting
achieve the PSCR include detailed actions: footwear. Tennis shoes with socks are to
A. Increase blood glucose monitoring to twice be worn for each walk. Obtain free pe-
per day; set goals for 100–110 mg/dL fasting dometer from clinic to measure perform-
and <140 mg/dL at 2 hours after a main meal. ance of steps and walking.
12. Review pedometer measures three times a
1. Obtain discounted glucose monitoring
week. Increase steps by 10% each week if
strips from ABC drug company.
natural increase in steps has not occurred.
2. Obtain assistance from community clinic
For example, if walking 2000 steps/walk
for monthly replacement request to ABC
increase next walk by 200 steps as a goal.
drug company.
Maintain goals until 10,000 step/day is
3. Monitor glucose level through testing two
achieved (ADA, 2013).
times per day, with one test before break-
fast and one test 2 hours after a main meal. III. Determining Self-Care Agency
Add more testing when needed for symp- The nurse and Marion then seek information
toms of high or low blood sugar (ADA, about self-care agency or the capabilities
2013). related to knowledge, decision making, and

Continued
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128 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Practice Exemplar cont.


performance necessary to meet this PSCR. performing the necessary actions is intact
This includes the ability to seek and obtain re- to meet the particularized self-care requi-
quired resources important to each action. site, maintain blood glucose level at 100–
What capabilities are necessary to increase 110 mg/dL fasting and <140 mg/dL at
blood glucose testing? Does Marion have the 2 hours after a main meal.
knowledge about access to drug company re- 2. Dietary practices: The nurse seeks infor-
sources (testing strips) available to persons mation from Marion on her knowledge of
with their income level? Does she have the effective dietary practices and healthy
communication skills to seek resources from foods, including flexibility in the family
the community center? Does she have the budget, shopping practices, and family
knowledge regarding blood glucose parame- cultural practices that may influence her
ters and methods to adjust exercise and diet to food purchases. The nurse learns Marion
maintain the levels? The nurse and Marion to- has misinformation about her selected
gether determine capabilities for each of these foods and is aware of resources, such as the
components of each action necessary to meet local health department that offers free
her particularized self-care requisite. classes by a registered dietitian. However,
After collecting and analyzing data about transportation to dietary classes is not pos-
her abilities in relationship to the required sible because her husband uses the only car
actions, the nurse determines the absence or to drive to work. Although Marion under-
existence of a self-care deficit—that is, is self- stands the relationship of her high blood
agency adequate to meet the therapeutic self- glucose levels to the resulting fatigue, she
care demand? The nurse quickly determines seems to focus on losing weight, a possible
throughout the data collection period that motivational asset. Marion maintains the
Marion’s foundational and disposition capa- ability to shop, cook, use the stove safely,
bilities (necessary for any deliberate action) and ingest all food types.
and the power components (necessary for self- 3. The nurse assesses that Marion enjoys
care) are developed and operable. The question walking and generally feels safe in the sur-
is the adequacy of self-care agency in relation- rounding environment. She also has time
ship to this PSCR. while the children are at school to take
walks. The nurse discovers that Marion is
1. Blood glucose monitoring: The nurse
not aware of proper foot care or the step
learns that Marion possesses necessary ca-
program for increasing exercise. Marion
pabilities of knowing, deciding, and per-
does not believe the family budget can
forming to obtain additional testing strips
manage both changes in food purchases as
from ABC drug company and to increase
well as the purchase of good walking shoes.
her blood glucose testing to two times per
day. After questioning, the nurse deter- IV. Self-Care Limitations
mines Marion is aware of norms and in Marion has self-care limitations in the area of
general the effect of food and exercise. In knowledge and decision making about re-
addition to verbalizing available time for quired dietary actions. The limitations of
testing, Marion also recalls that the school knowing are related to healthy dietary prac-
nurse where she works agreed to be a re- tices. This includes the use of carbohydrate
source if blood glucose readings are not counting. She lacks knowledge about purchas-
within the required range. She agreed to ing options for healthier foods and methods to
seek out this resource if adjustment in ex- incorporate these into her meal effort. Al-
ercise or food intake is needed. The nurse though interested, she is unable to enroll in di-
practitioner concludes Marion’s self-care etary classes at the health department due to
capabilities of knowing, deciding, and transportation issues. Marion has knowledge
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CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 129

Practice Exemplar cont.


and decision-making authority for managing goal is to maintain blood glucose levels at
the family budget but has no experience incor- 100–110 mg/dL fasting and <140 mg/dL at
porating healthier foods into the planning. 2 hours after a main meal, the priority actions
Marion also has self-care limitations in rela- relate to dietary changes, followed by slow,
tionship to knowledge of the step program, incremental changes in activity. The nurse
proper footwear, and related foot care. No re- expects it will take 1 month to obtain the
sources exist to purchase the necessary walking necessary footwear. Objectives will be re-
shoes. Major capabilities include Marion’s viewed at 1 month. Marion knows that
ability to learn, availability of time, and her weight loss is her objective, but she must
motivation to lose weight, and hence have less start changes in dietary practices. The goal
fatigue. If Marion decides to make healthier for weight loss will be set at the first
food choices that are affordable and also in- month’s meeting after attendance at the di-
crease her general activity, she will need mon- etary sessions and initial experience with
itoring, counseling, and support from a health changing the family’s food purchases and
professional related to the blood glucose levels, meal planning. Marion and the nurse prac-
access to resources for classes, budgeting, and titioner begin implementing their roles as
purchase of equipment. prescribed.
With analysis of self-care agency in rela- Step 3: Treatment, Regulation, Case Management,
tionship to the particularized self-care requi- Control/Evaluation
site, the nurse and patient establish the Marion and the nurse begin implementing
presence of a self-care deficit. Now that legit- their agreed-on actions as they collaborate
imate nursing has been established, a nursing within the nursing system. The nurse practi-
system is designed. tioner maintains contact via phone with Marion
Step 2: Design and Plan of Nursing System as she completes actions, such as seeking
Now that the self-care limitations of knowing resources for the dietary classes and footwear.
are identified, the nurse will use helping Marion contacts the school nurse where she
methods of guiding and supporting by de- works to see if she will be a resource for
signing a supportive-educative nursing sys- weekly reports on blood glucose levels. She
tem. The design involves planning Marion’s also seeks out additional testing strips and
activities to meet the particularized self-care calls the clinic to obtain the routine forms for
requisite with nurse guidance and monitoring monthly renewal requests. They proceed
and also to establishing the nurse’s role. through each of these actions as agreed on as
Together they agree on communication social–contractual operations. Throughout
methods to work together to monitor progress this step, the interpersonal operations are
as Marion attends classes to learn healthy essential as the nurse evaluates Marion’s
dietary practices and increase activity. Marion progress and new roles are determined and
agrees to share information related to blood agreed on. This continues over time, with
glucose testing with the school nurse and the continued review of the design, the role pre-
pharmacist at the community clinic when scriptions, until Marion’s therapeutic self-
refilling medication and supplies. care demand is decreased or self-care agency
The nurse agrees to seek out resources for is developed so no self-care deficit exists, and
transportation to the health department for nursing is no longer required.
dietary classes, purchase of footwear, assis- Throughout the process, nursing agency
tance to fill out forms, and also to meet with was evident. The capabilities related to inter-
Marion every 2 weeks to review food con- personal, social–contractual, and professional–
sumption and activity records. Although the technological operations were evident.
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130 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

■ Summary
This chapter provided an overview of Orem’s blocks of these theories are six major concepts
self-care deficit nursing theory. Orem created and one peripheral concept. Orem’s SCDNT
this general theory of nursing to address the has been applied extensively in nursing practice
proper objective of nursing through the ques- throughout the United States and internation-
tion, What condition exists in a person when ally in diverse settings and with diverse popu-
judgments are made that a nurse(s) should be lations. SCDNT continues to be used as a
brought into the situation (i.e., that a person framework for research with specific patient
should be under nursing care; Orem, 2001, populations throughout the world. Collabora-
p. 20)? The grand theory comprises four inter- tion among scholars, researchers, and practi-
related theories: the theory of self-care, theory tioners is necessary to provide the science of
of dependent care, theory of self-care deficit, self-care useful to improve nursing practice
and theory of nursing systems. The building into the future (Taylor & Renpenning, 2011).

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Imogene King’s Theory


of Goal Attainment
Chapter
9
C HRISTINA L. S IELOFF AND
M AUREEN A. F REY

Introducing the Theorist Introducing the Theorist


Overview of the Conceptual System
(King’s Conceptual System and Theory of Imogene M. King was born on January 30,
Goal Attainment) 1923, in West Point, Iowa. She received a
Applications of the Theory In Practice diploma in nursing from St. John’s Hospital
Practice Exemplar by Mary B. Killeen School of Nursing, St. Louis, Missouri (1945);
Summary a bachelor of science in nursing education
References (1948); a master of science in nursing from
St. Louis University (1957); and a doctor of
education (EdD) from Teachers College,
Columbia University, New York (1961). She
held educational, administrative, and leader-
ship positions at St. John’s Hospital School
of Nursing, the Ohio State University, Loyola
University, the Division of Nursing in the
U.S. Department of Health, Education, and
Welfare, and the University of South Florida.
King’s hallmark theory publications include:
Imogene M. King “A Conceptual Frame of Reference for Nurs-
ing” (1968), Towards a Theory for Nursing:
General Concepts of Human Behaviour (1971),
and A Theory for Nursing: Systems, Concepts,
Process (1981). Since 1981, King has clarified
and expanded her conceptual system, her
middle-range theory of goal attainment, and
the transaction process model in multiple book
chapters, articles in professional journals, and
presentations. After retiring as professor
emerita from the University of South Florida
in 1990, King remained an active contributor
to nursing’s theoretical development and
worked with individuals and groups in devel-
oping additional middle range theories, apply-
ing her theoretical formulations to various
populations and settings and implementing
the theory of goal attainment in clinical prac-
tice. King received recognition and numerous

133
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134 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

awards for her distinguished career in nursing review of nursing literature provided me with
from the American Nurses Association, the ideas to identify five comprehensive concepts
Florida Nurses Association, the American as a basis for a conceptual system for nursing.
Academy of Nursing, and Sigma Theta Tau The overall concept is a human being, com-
International. King died in December 2007. monly referred to as an “individual” or a “per-
Her theoretical formulations for nursing con- son.” Initially, I selected abstract concepts of
tinue to be taught at all levels of nursing edu- perception, communication, interpersonal re-
cation and applied and extended by national lations, health, and social institutions (King,
and international scholars.1 1968). These ideas forced me to review my
knowledge of philosophy relative to the nature
of human beings (ontology) and to the nature
Overview of the Conceptual of knowledge (epistemology).
System (King’s Conceptual
Philosophical Foundation
System and Theory of Goal In the late 1960s, while auditing a series of
Attainment) courses in systems research, I was introduced
Theoretical Evolution in King’s to a philosophy of science called general system
Own Words theory (von Bertalanffy, 1968). This philoso-
phy of science gained momentum in the
My first theory publication pronounced the
1950s, although its roots date to an earlier pe-
problems and prospect of knowledge devel-
riod. This philosophy refuted logical positivism
opment in nursing (King, 1964). More than
and reductionism and proposed the idea of iso-
30 years ago, the problems were identified as
morphism and perspectivism in knowledge
(1) lack of a professional nursing language,
development. Von Bertalanffy, credited with
(2) a theoretical nursing phenomena, and
originating the idea of general system theory,
(3) limited concept development. Today, the-
defined this philosophy of science movement
ories and conceptual frameworks have iden-
as a “general science of wholeness: systems of
tified theoretical approaches to knowledge
elements in mutual interaction” (von Bertalanffy,
development and utilization of knowledge in
1968, p. 37).
practice. Concept development is a continu-
My philosophical position is rooted in gen-
ous process in the nursing science movement
eral system theory, which guides the study of
(King, 1988).
organized complexity as whole systems. This
My rationale for developing a schematic
philosophy gave me the impetus to focus on
representation of nursing phenomena was in-
knowledge development as an information-
fluenced by the Howland systems model
(Howland, 1976) and the Howland and processing, goal-seeking, and decision-making
system. General system theory provides a ho-
McDowell conceptual framework (Howland
listic approach to study nursing phenomena as
& McDowell, 1964). The levels of interaction
an open system and frees one’s thinking from
in those works influenced my ideas relative to
the parts-versus-whole dilemma. In any dis-
organizing a conceptual frame of reference for
cussion of the nature of nursing, the central
nursing. Because concepts offer one approach
ideas revolve around the nature of human be-
to structure knowledge for nursing, a thorough
ings and their interaction with internal and ex-
ternal environments. During this journey, I
began to conceptualize a theory for nursing.
For additional information about the theorist, publica- However, because a manuscript was due in the
tions and research using King’s conceptual model and publisher’s office, I organized my ideas into a
the theory of goal attainment (Tables 9-1 to 9-15), conceptual system (formerly called a “concep-
please go to bonus chapter content available at
http://davisplus.fadavis.com. Some tables are specifically
tual framework”), and the result was the pub-
referenced throughout the text to further guide the lication of a book titled Toward a Theory of
reader. Nursing (King, 1971).
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CHAPTER 9 • Imogene King’s Theory of Goal Attainment 135

Design of a Conceptual System Process for Development of Concepts


A conceptual system provides structure for or- “Searching for scientific knowledge in nursing
ganizing multiple ideas into meaningful wholes. is an ongoing dynamic process of continuous
From my initial set of ideas in 1968 and 1971, identification, development, and validation of
my conceptual framework was refined to show relevant concepts” (King, 1975, p. 25). What
some unity and relationships among the con- is a concept? A concept is an organization of
cepts. The conceptual system consists of indi- reference points. Words are the verbal symbols
vidual systems, interpersonal systems, and social used to explain events and things in our envi-
systems and concepts that are important for un- ronment and relationships to past experiences.
derstanding the interactions within and be- Northrop (1969) noted: “[C]oncepts fall into
tween the systems (Fig. 9-1). different types according to the different
The next step in this process was to review sources of their meaning. . . . A concept is a
the research literature in the discipline in term to which meaning has been assigned.”
which the concepts had been studied. For ex- Concepts are the categories in a theory.
ample, the concept of perception has been The concept development and validation
studied in psychology for many years. The lit- process is as follows:
erature indicated that most of the early studies 1. Review, analyze, and synthesize research
dealt with sensory perception. Around the literature related to the concept.
1950s, psychologists began to study interper- 2. From the review, identify the characteris-
sonal perception, which related to my ideas tics (attributes) of the concept.
about interactions. From this research literature, 3. From the characteristics, write a concep-
I identified the characteristics of perception and tual definition.
defined the concept for my framework. I con- 4. Review literature to select an instrument
tinued searching literature for knowledge of or develop an instrument.
each of the concepts in my framework. An up- 5. Design a study to measure the character-
date on my conceptual system was published istics of the concept.
in 1995 (King, 1995). 6. Select the population to be sampled.
7. Collect data.
8. Analyze and interpret data.
9. Write results of findings and conclusions.
Social systems 10. State implications for adding to nursing
(society) knowledge.
Concepts that represent phenomena in
Interpersonal systems nursing are structured within a framework and
(group) theory to show relationships.
Multiple concepts were identified from my
Personal analysis of nursing literature (King, 1981). The
systems
(individuals)
concepts that provided substantive knowledge
about human beings (self, body image, percep-
tion, growth and development, learning, time,
and personal space) were placed within the
personal system, those related to small groups
(interaction, communication, role, transac-
tions, and stress) were placed within the inter-
personal system, and those related to large
groups that make up a society (decision mak-
ing, organization, power, status, and authority)
were placed within the social system (King,
Fig 9 • 1 King’s conceptual system. 1995). However, knowledge from all of the
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136 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

concepts is used in nurses’ interactions with in- Lo and behold, a theory of goal attainment was
dividuals and groups within social organiza- developed (King, 1981, 1992). More recently,
tions, such as the family, the educational others have derived theories from my conceptual
system, and the political system. Knowledge of system (Frey & Sieloff, 1995).
these concepts came from my synthesis of re-
search in many disciplines. Concepts, when Theory of Goal Attainment
defined from research literature, give nurses Generally speaking, nursing care’s goal is to
knowledge that can be applied in the concrete help individuals maintain health or regain
world of nursing. The concepts represent basic health (King, 1990). Concepts are essential
knowledge that nurses use in their role and elements in theories. When a theory is derived
functions either in practice, education, or ad- from a conceptual system, concepts are se-
ministration. In addition, the concepts provide lected from that system. Remember my ques-
ideas for research in nursing. tion: What is the essence of nursing? The
One of my goals was to identify what I call concepts of self, perception, communication,
the essence of nursing. That brought me back interaction, transaction, role, growth and de-
to the question: What is the nature of human velopment, stress, time, and personal space
beings? A vicious circle? Not really! Because were selected for the theory of goal attainment.
nurses are first and foremost human beings who
give nursing care to other human beings, my Transaction Process Model
philosophy of the nature of human beings A transaction model, shown in Figure 9-2, was
has been presented along with assumptions I developed that represented the process in
have made about individuals (King, 1989a). which individuals interact to set goals that re-
Recognizing that a conceptual system repre- sult in goal attainment (King, 1981, 1995).
sents structure for a discipline, the next step in The model is a human process that can be
the process of knowledge development was to observed in many situations when two or more
derive one or more theories from this structure. people interact, such as in the family and in

Feedback

PERCEPTION

JUDGMENT

ACTION
NURSE
REACTION INTERACTION TRANSACTION

ACTION

JUDGMENT
PATIENT

PERCEPTION

Feedback
Fig 9 • 2 Transaction process model. (From King, I. M. [1981]. A theory for nursing: Systems, concepts, process
[p. 145]. New York: Wiley.)
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CHAPTER 9 • Imogene King’s Theory of Goal Attainment 137

social events (King, 1996). As nurses, we bring designing critical paths, various care plans, and
knowledge and skills that influence our percep- other types of forms when, with knowledge of
tions, communications, and interactions in per- this system, the nurse documents nursing care
forming the functions of the role. In your role directly on the patient’s chart? Why do we use
as a nurse, after interacting with a patient, sit multiple forms to complicate a process that is
down and write a description of your behavior knowledge-based and also provides essential
and that of the patient. It is my belief that you data to demonstrate outcomes and to evaluate
can identify your perceptions, mental judg- quality nursing care?
ments, mental action, and reaction (negative or Federal laws have been passed that indicate
positive). Did you make a transaction? That is, that patients must be involved in decisions
did you exchange information and set a goal about their care and about dying. This trans-
with the patient? Did you explore the means action process provides a scientifically based
for the patient to use to achieve the goal? Was process to help nurses implement federal laws
the goal achieved? If not, why? It is my opinion such as the Patient Self-Determination Act
that most nurses use this process but are not (Federal Register, 1995).
aware that it is based in a nursing theory. With
knowledge of the concepts and of the process, Goal Attainment Scale
nurses have a scientific base for practice that Analysis of nursing research literature in the
can be clearly articulated and documented to 1970s revealed that few instruments were de-
show quality care. How can a nurse document signed for nursing research. In the late 1980s,
this transaction model in practice? the faculty at the University of Maryland, ex-
perts in measurement and evaluation, applied
Documentation System for and received a grant to conduct conferences
A documentation system was designed to im- to teach nurses to design reliable and valid in-
plement the transaction process that leads to struments. I had the privilege of participating
goal attainment (King, 1984). Most nurses use in this 2-year continuing education confer-
the nursing process to assess, diagnose, plan, ence, where I developed a Goal Attainment
implement, and evaluate, which I call a Scale (King, 1989b). This instrument may be
method. My transaction process provides the used to measure goal attainment. It may also
theoretical knowledge base to implement this be used as an assessment tool to provide pa-
method. For example, as one assesses the tient data to plan and implement nursing care.
patient and the environment and makes a
nursing diagnosis, the concepts of perception, Vision for the Future
communication, and interaction represent My vision for the future of nursing is that
knowledge the nurse uses to gather informa- nursing will provide access to health care for
tion and make a judgment. A transaction is all citizens. The United States’ health-care sys-
made when the nurse and patient decide mu- tem will be structured using my conceptual
tually on the goals to be attained, agree on the system. Entry into the system will be via
means to attain goals that represent the plan nurses’ assessment so that individuals are di-
of care, and then implement the plan. Evalua- rected to the right place in the system for
tion determines whether or not goals were nursing care, medical care, social services in-
attained. If not, you ask why, and the process formation, health teaching, or rehabilitation.
begins again. The documentation is recorded My transaction process will be used by every
directly in the patient’s chart. The patient’s practicing nurse so that goals can be achieved
record indicates the process used to achieve to demonstrate quality care that is cost-effective.
goals. On discharge, the summary indicates My conceptual system, theory of goal attain-
goals set and goals achieved. One does not ment, and transaction process model will con-
need multiple forms when this documentation tinue to serve a useful purpose in delivering
system is in place, and the quality of nursing professional nursing care. The relevance of
care is recorded. Why do nurses insist on evidence-based practice, using my theory, joins
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138 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

the art of nursing of the 20th century to the purpose of this part of the chapter is to provide
science of nursing in the 21st century. an updated review of the state of the art in
terms of the application of King’s conceptual
Concepts and Middle-Range Theory system (KCS) and middle-range theory in a
Development Within King’s variety of areas: practice, administration, edu-
Conceptual System or the Theory cation, and research. Publications, identified
of Goal Attainment from a review of the literature, are summarized
Concept development within a conceptual and briefly discussed. Finally, recommenda-
framework is particularly valuable, as it tions are made for future knowledge develop-
often explicates concepts more clearly than ment in relation to KCS and middle-range
a theorist may have done in his or her origi- theory, particularly in relation to the impor-
nal work. Concept development may also tance of their application within an evidence-
demonstrate how other concepts of interest based practice environment.
to nursing can be examined through a nurs- In conducting the literature review, the
ing lens. Such explication further assists authors began with the broadest category
the development of nursing knowledge by of application—application within KCS to
enabling the nurse to better understand the nursing care situations. Because a conceptual
application of the concept within specific framework is, by nature, very broad and
practice situations. Examples of concepts abstract, it can serve only to guide, rather than
developed from within King’s work include to prescriptively direct, nursing practice.
the following: collaborative alliance relation- Development of middle-range theories is a
ship (Hernandez, 2007); decision making natural extension of a conceptual framework.
(Ehrenberger, Alligood, Thomas, Wallace, & Middle-range theories, clearly developed from
Licavoli, 2007), empathy (May, 2007), holis- within a conceptual framework, accomplish two
tic nursing (Li, Li, & Xu, 2010), managerial goals: (1) Such theories can be directly applied
coaching (Batson & Yoder, 2012), patient to nursing situations, whereas a conceptual
satisfaction with nursing care (Killeen, framework is usually too abstract for such direct
2007), sibling closeness (Lehna, 2009), and application, and (2) validation of middle-range
whole person care (Joseph, Laughon, & theories, clearly developed within a particular
Bogue, 2011).2 conceptual framework, lends validation to the
conceptual framework itself. King (1981) stated
that individuals act to maintain their own
Applications of the Theory health. Although not explicitly stated, the
in Practice converse is probably true as well: Individuals
often do things that are not good for their
Since the first publication of King’s work health. Accordingly, it is not surprising that the
(1971), nursing’s interest in the application of KCS and related middle-range theory are often
her work to practice has grown. The fact that directed toward patient and group behaviors
she was one of the few theorists who generated that influence health.
both a framework and a middle range theory In addition to the middle-range theory of
further expanded her work. Today, new pub- goal attainment (King, 1981), several other mid-
lications related to King’s work are a frequent dle-range theories have been developed from
occurrence. Additional middle-range theories within King’s interacting systems framework. In
have been generated and tested, and applica- terms of the personal system, Brooks and
tions to practice have expanded. After her re- Thomas (1997) used King’s framework to derive
tirement, King continued to publish and a theory of perceptual awareness. The focus was
examine new applications of the theory. The to develop the concepts of judgment and action
as core concepts in the personal system. Other
2See Table 9-2 in the bonus chapter content available at concepts in the theory included communication,
http://davisplus.fadavis.com. perception, and decision making.
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CHAPTER 9 • Imogene King’s Theory of Goal Attainment 139

In relation to the interpersonal system, reproductive health and related quality of life
several middle-range theories have been among Indian women in mining communities”
developed regarding families. Doornbos (p. 1963).
(2007), using her family health theory, ad-
dressed family health in terms of families of Nursing Process and Nursing
adults with persistent mental illness. Thoma- Terminologies, Including
son and Lagowski (2008) used concepts from Standardized Nursing Languages
King along with other nursing theorists to Within the nursing profession, the nursing
develop a model for collaboration through process has consistently been used as the basis
reciprocation in health-care organizations. for nursing practice. King’s framework and
In relation to social systems, Sieloff and middle-range theory of goal attainment (1981)
Bularzik (2011) revised the “theory of group have been clearly linked to the process of nurs-
power within organizations” to the “theory ing. Although many published applications
of group empowerment within organiza- have broad reference to the nursing process,
tions” to assist in explaining the ability several deserve special recognition. First, King
of groups to empower themselves within herself (1981) clearly linked the theory of goal
organizations.3 attainment to nursing process as theory and to
Review of the literature identified instru- nursing process as method. Application of
ments specifically designed within King’s King’s work to nursing curricula further
framework. King (1988) developed the Health strengthened this link.
Goal Attainment instrument, designed to de- In addition, the steps of the nursing process
tail the level of attainment of health goals by have long been integrated within the KCS
individual clients. The Nurse Performance and the middle-range theory of goal attain-
Goal Attainment (NPGA) was developed by ment (Daubenmire & King, 1973; D’Souza,
Kameoka, Funashima, and Sugimori (2007). Somayaji, & Suybrahmanya, 2011; Woods,
1994). In these process applications, assess-
Applications in Nursing Practice ment, diagnosis, and goal-setting occur, fol-
There have been many applications of King’s lowed by actions based on the nurse–client
middle-range theory to nursing practice be- goals. The evaluation component of the nurs-
cause the theory focuses on concepts relevant ing process consistently refers back to the orig-
to all nursing situations—the attainment of inal goal statement(s). In related research, Frey
client goals. The application of the middle- and Norris (1997) also drew parallels between
range theory of goal attainment (King, 1981) the processes of critical thinking, nursing, and
is documented in several categories: (1) general transaction.
application of the theory, (2) exploring a par- Over time, nursing has developed nursing
ticular concept within the context of the theory terminologies that are used to assist the pro-
of goal attainment, (3) exploring a particular fession to improve communication both
concept related to the theory of goal attain- within, and external to, the profession. These
ment, and (4) application of the theory in non- terminologies include the nursing diagnoses,
clinical nursing situations. For example, King nursing interventions, and nursing outcomes.
(1997) described the use of the theory of goal With the use of these standardized nursing
attainment in nursing practice. Short-term languages (SNLs), the nursing process is fur-
group psychotherapy was the focus of theory ther refined. Standardized terms for diagnoses,
application for Laben, Sneed, and Seidel (1995). interventions, and outcomes also potentially
D’Souza, Somayaji, and Subrahmanya (2011) improve communication among nurses.
used the theory to “examine determinants of Using SNLs also enables the development
of middle-range theory by building on con-
cepts unique to nursing, such as those concepts
See Table 9-5 in the bonus chapter content available at of King that can be directly applied to the
http://davisplus.fadavis.com. nursing process: action, reaction, interaction,
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140 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

transaction, goal setting, and goal attainment. Dalri (2006), and Palmer (2006) implemented
Biegen and Tripp-Reimer (1997) suggested nursing diagnoses within the context of King’s
middle-range theories be constructed from the framework.4
concepts in the taxonomies of the nursing lan-
guages focusing on outcomes. Alternatively, Applications in Client Systems
King’s framework and theory may be used as a KCS and middle-range theory of goal attain-
theoretical basis for these phenomena and may ment have a long history of application with
assist in knowledge development in nursing in large groups or social systems (organizations,
the future. communities). The earliest applications in-
With the advent of SNLs, “outcome volved the use of the framework and theory to
identification” is identified as a step in the guide continuing education (Brown & Lee,
nursing process after assessment and diagnosis 1980) and nursing curricula (Daubenmire,
(McFarland & McFarland, 1997, p. 3). King’s 1989; Gulitz & King, 1988). More contempo-
(1981) concept of mutual goal setting is anal- rary applications address a variety of organiza-
ogous to the outcomes identification step, tional settings. For example, the framework
because King’s concept of goal attainment served as the basis for the development of a
is congruent with the evaluation of client middle-range theory relating to practice in a
outcomes. nursing home (Zurakowski, 2007). Nwinee
In addition, King’s concept of perception (2011) used King’s work, along with Peplau’s,
(1981) lends itself well to the definition of to develop the sociobehavioral self-care man-
client outcomes. Moorhead, Johnson, and agement nursing model (p. 91). In addition,
Maas (2013) define a nursing-sensitive patient the theory of goal attainment has been pro-
outcome as “an individual, family or commu- posed as the practice model for case manage-
nity state, behaviour or perception that is ment (Hampton, 1994; Tritsch, 1996). These
measured along a continuum in response to latter applications are especially important be-
nursing intervention(s)” (p. 2). This is fortu- cause they may be the first use of the frame-
itous because the development of nursing work by other disciplines.
knowledge requires the use of client outcome Applicable to administration and manage-
measurement. The use of standardized client ment in a variety of settings, a middle-range
outcomes as study variables increases the ease theory of group power within organizations
with which research findings can be compared has been developed and revised to the theory
across settings and contributes to knowledge of group empowerment within organizations
development. Therefore, King’s concept of (Sieloff, 1995, 2003, 2007; Sieloff & Dunn,
mutually set goals may be studied as “expected 2008; Sieloff & Bularzik, 2011). Educational
outcomes.” Also, by using SNLs, King’s settings, also considered as social systems,
(1981) middle-range theory of goal attainment have been the focus of application of King’s
can be conceptualized as the “attainment of ex- work (George, Roach, & Andfrade, 2011;
pected outcomes” as the evaluation step in the Greef, Strydom, Wessels, & Schutte, 2009;
application of the nursing process. Ritter, 2008).5
In summary, although these terminologies,
including SNLs, were developed after many of Multidisciplinary Applications
the original nursing theorists had completed Because of King’s emphasis on the attainment
their works, nursing frameworks such as the of goals and the relevancy of goal attainment
KCS (1981) can still find application and use to many disciplines, both within and external
within the terminologies. In addition, it is this to health care, it is reasonable to expect that
type of application that further demonstrates
the framework’s utility across time. For exam- 4See Table 9-4 in the bonus chapter content available at
ple, Chaves and Araujo (2006), Ferreira De http://davisplus.fadavis.com.
Sourza, Figueiredo De Martino, and Daena 5See Table 9-8 in the bonus chapter content available at

De Morais Lopes (2006), Goyatá, Rossi, and http://davisplus.fadavis.com.


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CHAPTER 9 • Imogene King’s Theory of Goal Attainment 141

King’s work can find application beyond Undoubtedly, the strongest evidence for the
nursing-specific situations. Two specific ex- cultural utility of King’s conceptual framework
amples of this include the application of and midrange theory of goal attainment (1981)
King’s work to case management (Hampton, is the extent of work that has been done in
1994; Sowell & Lowenstein, 1994) and to other cultures. Applications of the framework
managed care (Hampton, 1994). Both case and related theories have been documented in
management and managed care incorporate the following countries beyond the United
multiple disciplines as they work to improve States: Brazil (Firmino, Cavalcante, & Celia,
the overall quality and cost-efficiency of the 2010), Canada (Plummer & Molzahn, 2009),
health care provided. These applications also China (Li, Li, & Xu, 2010), India (D’Souza,
address the continuum of care, a priority in Somayaji, & Subrahmanya, 2011; George
today’s health-care environment. Specific re- et al., 2011), Japan (Kameoka et al., 2007),
searchers (Fewster-Thuente & Velsor- Portugal (Chaves & Araujo, 2006; Goyatá
Friedrich, 2008; Khowaja, 2006) detailed et al., 2006; Pelloso & Tavares, 2006), Slovenia
their research related to multidisciplinary ac- (Harih & Pajnkihar, 2009), Sweden (Rooke,
tivities and interdisciplinary collaborations, 1995a, 1995b), and West Africa (Nwinee,
respectively.6 2011). In Japan, a culture very different from
the United States with regard to communica-
Multicultural Applications tion style, Kameoka (1995) used the classifica-
Multicultural applications of KCS and re- tion system of nurse–patient interactions
lated theories are many. Such applications identified within the theory of goal attainment
are particularly critical because many theo- (King, 1981) to analyze nurse–patient interac-
retical formulations are limited by their tions. In addition to research and publications
culture-bound nature. Several authors specif- regarding the application of King’s work to
ically addressed the utility of King’s frame- nursing practice internationally, publications by
work and theory for transcultural nursing. and about King have been translated into other
Spratlen (1976) drew heavily from King’s languages, including Japanese (King, 1976,
framework and theory to integrate ethnic 1985; Kobayashi, 1970). Therefore, perception
cultural factors into nursing curricula and and the influence of culture on perception were
to develop a culturally oriented model for identified as strengths of King’s theory.
mental health care. Key elements derived
from King’s work were the focus on percep- Research Applications in Varied
tions and communication patterns that mo- Settings and Populations
tivate action, reaction, interaction, and KCS has been used to guide nursing practice
transaction. Rooda (1992) derived proposi- and research in multiple settings and with
tions from the midrange theory of goal multiple populations. For example, Harih and
attainment as the framework for a conceptual Pajnkihar (2009) applied King’s model in
model for multicultural nursing. treating elderly diabetes patients. Joseph et al.
Cultural relevance has also been demon- (2011) examined the implementation of
strated in reviews by Frey, Rooke, Sieloff, whole-person care.7 As stated previously, dis-
Messmer, and Kameoka (1995) and Husting eases or diagnoses are often identified as the
(1997). Although Husting identified that cul- focus for the application of nursing knowledge.
tural issues were implicit variables throughout Maloni (2007) and Nwinee (2011) conducted
King’s framework, particular attention was research with patients with diabetes, and
given to the concept of health, which, accord- women with breast cancer were the focus of
ing to King (1990), acquires meaning from the work of Funghetto, Terra, and Wolff
cultural values and social norms. (2003). In addition, clients with chronic

6See Table 9-14 in the bonus chapter content available 7See Table 9-11 in the bonus chapter content available
at http://davisplus.fadavis.com. at http://davisplus.fadavis.com.
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142 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

obstructive pulmonary disease were involved in obesity (Ongoco, 2012). Gender-specific work
research by Wicks, Rice, and Talley (2007). included Sharts-Hopko’s (2007) use of a middle-
Clients experiencing a variety of psychiatric range theory of health perception to study the
concerns have also been the focus of work, health status of women during menopause
using King’s conceptualizations (Murray & transition and Martin’s (1990) application
Baier, 1996; Schreiber, 1991). Clients’ con- of the framework toward cancer awareness
cerns ranged from psychotic symptoms among males.
(Kemppainen, 1990) to families experiencing Several of the applications with adults have
chronic mental illness (Doornbos, 2007), to targeted the mature adult, thus demonstrating
clients in short-term group psychotherapy contributions to the nursing specialty of geron-
(Laben, Sneed, & Seidel, 1995).8 The theory tology. Reed (2007) used a middle-range the-
has also been applied in nonclinical nursing ory to examine the relationship of social
situations. Secrest, Iorio, and Martz (2005) support and health in older adults. Harih and
used the theory in examining the empower- Pajnkihar (2009) applied “King’s model in the
ment of nursing assistants. Li et al. (2010) ex- treatment of elderly diabetes patients” (p. 201).
plored the “development of the concept of Clearly, these applications, and others, show
holistic nursing” (p. 33).9 how the complexity of King’s framework and
midrange theory increases its usefulness for
Research Applications with Clients Across nursing.10
the Life Span
Additional evidence of the scope and usefulness Research Applications to Client Systems
of King’s framework and theory is its use with In addition to discussing client populations
clients across the life span. Several applications across the life span, client populations can be
have targeted high-risk infants (Frey & Norris, identified by focus of care (client system)
1997; Syzmanski, 1991). Frey (1993, 1995, and/or focus of health problem (phenomenon
1996) developed and tested relationships among of concern). The focus of care, or interest, can
multiple systems with children, youth, and be an individual (personal system) or group
young adults. Lehna (2009) explicated the con- (interpersonal or social system). Thus, applica-
cept of sibling closeness in a study of siblings tion of King’s work, across client systems, can
experiencing a major burn trauma. Interestingly, be divided into the three systems identified
these studies considered personal systems (in- within the KCS (1981): personal (the individ-
fants), interpersonal systems (parents, families), ual), interpersonal (small groups), and social
and social systems (the nursing staff and hospi- (large groups/society).
tal environment). Clearly, a strength of King’s Use with personal systems has included
framework and theory is its utility in encom- both patients and nurses. LaMar (2008) exam-
passing complex settings and situations. ined nurses in a tertiary acute care organization
KCS and the midrange theory of goal at- as the personal system of interest. Nursing stu-
tainment have also been used to guide practice dents as personal systems were the focus of
with adults (young adults, adults, mature Lockhart and Goodfellow’s research (2009).
adults) with a broad range of concerns. Goyatá When the focus of interest moves from an in-
et al. (2006) used King’s work in their study of dividual to include interaction between two
adults experiencing burns. Additional exam- people, the interpersonal system is involved.
ples of applications focusing on adults include Interpersonal systems often include clients and
individuals with hypertension (Firmino et al., nurses. An example of an application to a
2010) and perceptions of students toward nurse–client dyad is Langford’s (2008) study
of the perceptions of transactions with nurse
8See
practitioners and obese adolescents. In relation
Table 9-8 and 9-11 in the bonus chapter content
available at http://davisplus.fadavis.com.
9See Table 9-3 in the bonus chapter content available at 10 See Table 9-7 in the bonus chapter content available
http://davisplus.fadavis.com. at http://davisplus.fadavis.com.
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CHAPTER 9 • Imogene King’s Theory of Goal Attainment 143

to interpersonal systems, or small groups, the outcome of concern in practice applications


many publications focus on the family. Frey by Smith (1988). Several applications used
and Norris (1997) used both KCS and the the- health-related terms. For example, DeHowitt
ory of goal attainment in planning care with (1992) studied well-being, and D’Souza et al.
families of premature infants. Alligood (2010) (2011) examined the determinants of health.
described “family health care with King’s the- Health promotion has also been an em-
ory of goal attainment” (p. 99). phasis for the application of King’s ideas.
Sexual counseling was the focus of work by
Research Applications Focusing on Villeneuve and Ozolins (1991). Health be-
Phenomena of Concern to Clients haviors were Hanna’s (1995) focus of study,
Within King’s work, it is critically important and Plummer and Molzahn (2009) explored
for the nurse to focus on, and address, the the “quality of life in contemporary nursing
phenomenon of concern to the client. With- theory” (p. 134). Frey (1996, 1997) examined
out this emphasis on the client’s perspective, both health behaviors and illness manage-
mutual goal setting cannot occur. Hence, a ment behaviors in several groups of children
client’s phenomenon of concern was selected with chronic conditions as well as risky
as neutral terminology that clearly demon- behaviors (1996). Recently, researchers have
strated the broad application of King’s work explored weight loss and obesity (Langford,
to a wide variety of practice situations. A topic 2008; Ongoco, 2012).
that frequently divides nurses is their area of
specialty. However, by using a consistent Research Applications in Varied Work
framework across specialties, nurses may be Settings
able to focus more clearly on their common- An additional potential source of division
alities, rather than highlighting their differ- within the nursing profession is the work sites
ences.11 A review of the literature clearly where nursing is practiced and care is deliv-
demonstrates that King’s framework and re- ered. As the delivery of health care moves from
lated theories have application within a variety the acute care hospital to community-based
of nursing specialties.12 This application is ev- agencies and clients’ homes, it is important to
ident whether one is reviewing a “traditional” highlight commonalities across these settings,
specialty, such as surgical nursing (Bruns, and it is important to identify that King’s
Norwood, Bosworth, & Gill, 2009; Lockhart framework and middle-range theory of goal
& Goodfellow, 2009; Sivaramalingam, 2008), attainment continue to be applicable. Al-
or the nontraditional specialties of forensic though many applications tend to be with
nursing (Laben et al., 1991) and/or nursing nurses and clients in traditional settings, suc-
administration (Gianfermi & Buchholz, 2011; cessful applications have been shown across
Joseph et al., 2011). other, including newer and nontraditional set-
Health is one area that certainly binds tings. From hospitals (Bogue, Jospeh, &
clients and nurses. Improved health is clearly Sieloff, 2009; Firmino et al., 2010; Kameoka
the desired end point, or outcome, of nursing et al., 2007) to nursing homes (Zurakowski,
care and something to which clients aspire. 2007), King’s framework and related theories
Review of the outcome of nursing care, as provide a foundation on which nurses can
addressed in published applications, tends to build their practice interventions. In addition,
support the goal of improved health directly the use of the KCS and related theories are ev-
and/or indirectly, as the result of the applica- ident within quality improvement projects
tion of King’s work. Health status is explicitly (Anderson & Mangino, 2006; Durston, 2006;
Khowaja, 2006).13 Nurses also use the theory
11See Table 9-9 in the bonus chapter content available at

http://davisplus.fadavis.com.
12See Table 9-10 in the bonus chapter content available 13See Table 9-11 in the bonus chapter content available

at http://davisplus.fadavis.com. at http://davisplus.fadavis.com.
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144 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

of goal attainment (King, 1981) to examine 2009; Gemmill et al., 2011; Mardis, 2011),
concepts related to the theory. This application nurse administrators (Sieloff & Bularzik,
was demonstrated by Smith (2003), by Jones 2011), and client-consumers (Killeen, 2007)
and Bugge (2006), by Sivaramalingam (2008) as part of evolving evidence-based nursing
in a study of patients’ perceptions of nurses’ practice.14
roles and responsibilities, and by Mardis
(2012) in a study of patients’ perceptions of Recommendations for Future
minimal lift equipment. Applications Related to King’s
Framework and Theory
Relationship to Evidence-Based Practice Obviously, new nursing knowledge has resulted
From an evidence-based practice and King from applications of King’s framework and the-
perspective, the profession must implement ory. However, nursing is evolving as a science.
three strategies to apply theory-based research Additional work continues to be needed. On
findings effectively. First, nursing as a disci- the basis of a review of the applications previ-
pline must agree on rules of evidence in evalu- ously discussed, recommendations for future
ation of quality research that reflect the unique applications continue to focus on (1) the need
contribution of nursing to health care. Second, for evidence-based nursing practice that is the-
the nursing rules of evidence must include oretically derived; (2) the integration of King’s
heavier weight for research that is derived work in evidence-based nursing practice; (3) the
from, or adds to, nursing theory. Third, the integration of King’s concepts within SNLs;
nursing rules of evidence must reflect higher (4) analysis of the future effect of managed care,
scores when nursing’s central beliefs are af- continuous quality improvement, and technol-
firmed in the choice of variables. This third ogy on King’s concepts; (5) identification, or de-
strategy, for the use of concepts central to velopment and implementation, of additional
nursing, has clear relevance for evidence-based relevant instruments; and (6) clarification of ef-
practice when using King’s (1981) concepts as fective nursing interventions, including identi-