Nursing Theories

Nursing Theories
INTRODUCTION TO NURSING
THEORIES
INTRODUCTION
Nursing has made phenomenal achievement in the last century that has lead to
the recognition of nursing as an academic discipline and a profession. A move
towards theory-based practice has made contemporary nursing more meaningful
and significant by shifting nursings focus from vocation to an organised
profession. The need for knowledge-base to guide professional nursing practice
had been realised in the first half of the twentieth century and many theoretical
works have been contributed by nurses ever since, first with the goal of making
nursing a recognised profession and later with the goal of delivering care to
patients as professionals.
A theory is a group of related concepts that propose action that guide practice. A
nursing theory is a set of concepts, definitions, relationships, and assumptions
or propositions derived from nursing models or from other disciplines and project
a purposive, systematic view of phenomena by designing specific interrelationships among concepts for the purposes of describing, explaining,
predicting, and /or prescribing..
Based on the knowledge structure levels the theoretical works in nursing can be
studied under the following headings:
Metaparadigm (Person, Environment, Health & Nursing) (Most abstract)
Nursing philosophies.
Conceptual models and Grand theories.
Nursing theories and Middle range theories (Least abstract)

NURSING PHILOSOPHIES
Theory
Key emphasis
Florence Nightingales
Legacy of caring
Focuses on nursing and the patient

environment relationship.
Helping process meets needs through the art
of individualizing care.
Ernestine Wiedenbach:
The helping art of clinical
nursing
Nurses should identify patients need-for help

by:
Observation
Understanding client behaviour
Identifying cause of discomfort
Determining if clients can resolve problems or
have a need for help
Virginia Hendersons
Definition of Nursing
Patients require help towards achieving

independence.
Derived a definition of nursing
Identified 14 basic human needs on which
nursing care is based.
Faye
G.Abedellahs Typology of
twenty one Nursing
problems
Patients problems determine nursing care
Lydia E. Hall :Care, Cure,

Core model
Nursing care is person directed towards self

love.
Jean Watsons Philosophy

and Science of caring
Caring is moral ideal: mind -body soul

engagement with one and other.
Caring is a universal, social phenomenon that
is only effective when practiced interpersonally
considering humanistic aspects and caring.
Patricia Benners Primacy

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

sets up what matters, enabling connection and
concern. It creates possibility for mutual
helpfulness.
Caring creates - possibilities of coping
possibilities for connecting with and concern
for others, possibilities for giving and receiving
help
Described systematically five stages of skill
acquisition in nursing practice novice,
advanced beginner, competent, proficient and
expert.
CONCEPTUAL MODELS AND GRAND THEORIES

Dorothea E. Orems Self
care deficit theory in
nursing
Selfcare maintains wholeness.

Three Theories:
Theory of Self-Care
Theory of Self-Care Deficit
Theory of Nursing Systems
Wholly compensatory (doing for the patient)
Partly compensatory (helping the patient do
for himself or herself)
Supportive- educative (Helping patient to learn
self care and emphasizing on the importance
of nurses role
Myra Estrin Levines: The

conservation model
Holism is maintained by conserving integrity

Proposed that the nurses use the principles of
conservation of:
Client Energy
Personal integrity
Structural integrity
Social integrity
A conceptual model with three nursing theories
Conservation
Redundancy
Therapeutic intention
Martha E.Rogers:
Science of unitary
human beings
Person environment are energy fields that

evolve negentropically
Martha proposed that nursing was a basic
scientific discipline
Nursing is using knowledge for human
betterment.
The unique focus of nursing is on the unitary
or irreducible human being and the
environment (both are energy fields) rather
than health and illness
Dorothy E.Johnsons
Behavioural system
model
Individuals maintain stability and balance

through adjustments and adaptation to the
forces that impinges them.
Individual as a behavioural system is
composed of seven subsystems.
Attachment, or the affiliative subsystems is
the corner stone of social
organisations.
Behavioural system also includes the
subsystems of dependency, achievement,
aggressive, ingestive-eliminative and
sexual.
Disturbances in these causes nursing
problems.
Sister Callista: Roys

Adaptation model
Stimuli disrupt an adaptive system

The individual is a biopsychosocial adaptive
system within an environment.
The individual and the environment provide
three classes of stimuli-the focal, residual and
contextual.
Through two adaptive mechanisms, regulator
and cognator, an individual demonstrates
adaptive responses or ineffective responses
requiring nursing interventions
Betty Neumans : Health

care systems model
Reconstitution is a status of adaptation to

stressors
A conceptual model with two theories Optimal
patient stability and prevention as
intervention
Neumans model includes intrapersonal,
interpersonal and extrapersonal stressors.
Nursing is concerned with the whole person.
Nursing actions (Primary, Secondary, and
Tertiary levels of prevention) focuses on the
variables affecting the clients response to
stressors.
Imogene Kings Goal

attainment theory
Transactions provide a frame of reference

toward goal setting.
A conceptual model of nursing from which
theory of goal attainment is derived.
From her major concepts (interaction,
perception, communication, transaction, role,
stress, growth and development) derived goal
attainment theory.
Perceptions, Judgments and actions of the

patient and the nurse lead to reaction,
interaction, and transaction (Process of
nursing).
Nancy Roper, WW.Logan

and A.J.Tierney A
model for nursing based
on a model of living
Individuality in living.
A conceptual model of nursing from which
theory of goal attainment is derived.
Living is an amalgam of activities of living
(ALs).
Most individuals experience significant life
events which can affect ALs causing actual and
potential problems.
This affects dependence independence
continuum which is bi-directional.
Nursing helps to maintain the individuality of
person by preventing potential problems,
solving actual problems and helping to cope.
Hildegard E. Peplau:
Psychodynamic Nursing
Theory
Interpersonal process is maturing force for

personality.
Stressed the importance of nurses ability to
understand own behaviour to help others
identify perceived difficulties.
The four phases of nurse-patient relationships
are:
1. Orientation
2. Identification
3. Exploitations
4. Resolution
The six nursing roles are:
1. Stranger
2. Resource person
3. Teacher
4. Leader
5. Surrogate
6. Counselor
Ida Jean Orlandos

Nursing Process Theory
Interpersonal process alleviates distress.

Nurses must stay connected to patients and
assure that patients get what they need,
focused on patients verbal and non verbal
expressions of need and nurses reactions to
patients behaviour to alleviate distress.
Elements of nursing situation:
1. Patient
2. Nurse reactions
3. Nursing actions
Joyce Travelbees Human

To Human Relationship
Model
Therapeutic human relationships.

Nursing is accomplished through human to
human relationships that began with: The
original encounter and then progressed
through stages of
Emerging identities
Developing feelings of empathy and sympathy,
until the nurse and patient attained rapport in
the final stage.
Kathryn E. Barnards
Parent Child Interaction
Model
Growth and development of children and

motherinfant relationships
Ramona T.Mercers
:Maternal Role
Attainment
Parenting and maternal role attainment in

diverse populations
Katharine Kolcabas
Theory of comfort
Comfort is desirable holistic outcome of care.
Individual characteristics of each member

influence the parentinfant system and
adaptive behaviour modifies those
characteristics to meet the needs of the
system.
A complex theory to explain the factors

impacting the development of maternal role
over time.
Health care needs are needs for comfort,

arising from stressful health care situations
that cannot be met by recipients traditional
support system.
These needs include physical, psycho spiritual,
social and environmental
needs.
Comfort measures include those nursing
interventions designed to address the specific
comfort needs.
Madeleine Leiningers
Caring is universal and varies transculturally.
Transcultural nursing,
culture-care theory
Major concepts include care, caring, culture,

cultural values and cultural variations
Caring serves to ameliorate or improve human
conditions and life base.
Care is the essence and the dominant,
distinctive and unifying feature of nursing
Rosemarie Rizzo
Parses :Theory of human
becoming
Indivisible beings and environment co-create

health.
A theory of nursing derived from Rogers
conceptual model.
Clients are open, mutual and in constant
interaction with environment.
The nurse assists the client in interaction with
the environment and co creating health
Nola J.Penders :The

Health promotion; model
Promoting optimum health supersedes disease

prevention.
Identifies cognitive, perceptual factors in
clients which are modified by demographical
and biological characteristics, interpersonal
influences, situational and behavioural factors
that help predict in health promoting behaviour
CONCLUSION
The conceptual and theoretical nursing models help to provide knowledge to
improve practice, guide research and curriculum and identify the goals of nursing
practice. The state of art and science of nursing theory is one of continuing
growth. Using the internet the nurses of the world can share ideas and
knowledge, carrying on the work begun by nursing theorists and continue the
growth and development of new nursing knowledge. It is important the nursing
knowledge is learnt, used, and applied in the theory based practice for the
profession and the continued development of nursing and academic discipline
DEVELOPMENT OF NURSING
THEORIES
Introduction
Theories are a set of interrelated concepts that give a systematic view of a
phenomenon (an observable fact or event) that is explanatory & predictive in nature.
Theories are composed of concepts, definitions, models, propositions & are based on
assumptions. They are derived through two principal methods; deductive reasoning
and inductive reasoning. Nursing theorists use both of these methods. Theory is a
creative and rigorous structuring of ideas that projects a tentative, purposeful, and
systematic view of phenomena. A theory makes it possible to organize the
relationship among the concepts to describe, explain, predict, and control practice
Definition
Concepts are basically vehicles of thought that involve images. Concepts are
words that describe objects, properties, or events & are basic components of
theory.
Types: Empirical concepts
Inferential concepts
Abstract concepts
Models are representations of the interaction among and between the

concepts showing patterns.
Propositions are statements that explain the relationship between the
concepts.
Process it is a series of actions, changes or functions intended to bring about
a desired result. During a process one takes systemic & continuous steps to
meet a goal & uses both assessments & feedback to direct actions to the goal.
A particular theory or conceptual frame work directs how these actions are
carried out. The delivery of nursing care within the nursing process is directed
by the way specific conceptual frameworks & theories define the person
(patient), the environment, health & nursing.
The terms model and theory are often wrongly used interchangeably, which
further confounds matters.
In nursing, models are often designed by theory authors to depict the beliefs
in their theory (Lancaster and Lancaster 1981).
They provide an overview of the thinking behind the theory and may
demonstrate how theory can be introduced into practice, for example,
through specific methods of assessment.
Models are useful as they allow the concepts in nursing theory to be
successfully applied to nursing practice (Lancaster and Lancaster 1981).
Their main limitation is that they are only as accurate or useful as the
underlying theory.
Importance of nursing theories

1. Nursing theory aims to describe, predict and explain the phenomenon of
nursing (Chinn and Jacobs1978).
2. It should provide the foundations of nursing practice, help to generate further
knowledge and indicate in which direction nursing should develop in the
future (Brown 1964).
3. Theory is important because it helps us to decide what we know and what we
need to know (Parsons1949).
4. It helps to distinguish what should form the basis of practice by explicitly
describing nursing.
5. The benefits of having a defined body of theory in nursing include better
patient care, enhanced professional status for nurses, improved
communication between nurses, and guidance for research and education
(Nolan 1996). In addition, because
6. The main exponent of nursing caring cannot be measured, it is vital to
have the theory to analyze and explain what nurses do.
7. As medicine tries to make a move towards adopting a more multidisciplinary
approach to health care, nursing continues to strive to establish a unique
body of knowledge.
8. This can be seen as an attempt by the nursing profession to maintain its
professional boundaries.
The characteristics of theories
Theories are
interrelating concepts in such a way as to create a different way of looking at

a particular phenomenon.
logical in nature.
generalizable.
bases for hypotheses that can be tested.
increasing the general body of knowledge within the discipline through the
research implemented to validate them.
used by the practitioners to guide and improve their practice.
consistent with other validated theories, laws, and principles but will leave
open unanswered questions that need to be investigated.
Basic processes in the development of nursing theories

Nursing theories are often based on & influenced by broadly applicable processes &
theories. Following theories are basic to many nursing concepts.
General System Theory
It describes how to break whole things into parts & then to learn how the parts work
together in systems. These concepts may be applied to different kinds of systems,
e.g. Molecules in chemistry, cultures in sociology, and organs in Anatomy & Health in
Nursing.
Adaptation Theory
It defines adaptation as the adjustment of living matter to other living

things & to environmental conditions.
Adaptation is a continuously occurring process that effects change &
involves interaction & response.
Human adaptation occurs on three levels :
The internal (self)
The social (others) &
the physical (biochemical reactions)
1.
2.
3.
Developmental Theory
1. It outlines the process of growth & development of humans as orderly &
predictable, beginning with conception & ending with death.
2. The progress & behaviors of an individual within each stage are unique.
3. The growth & development of an individual are influenced by heredity,
temperament, emotional, & physical environment, life experiences & health
status.
Common concepts in nursing theories
Four concepts common in nursing theory that influence & determine nursing practice
are:
The person (patient).

The environment
Health
Nursing (goals, roles, functions)
Each of these concepts is usually defined & described by a nursing theorist, often
uniquely; although these concepts are common to all nursing theories. Of the four
concepts, the most important is that of the person. The focus of nursing, regardless
of definition or theory, is the person.
Historical perspectives and key concepts
Nightingale (1860): To facilitate the bodys reparative processes by

manipulating clients environment
Peplau 1952: Nursing is; therapeutic interpersonal process.
Henderson 1955: The needs often called Hendersons 14 basic needs
Abdellah 1960: The nursing theory developed by Faye Abdellah et al (1960)
emphasizes delivering nursing care for the whole person to meet the physical,
emotional, intellectual, social, and spiritual needs of the client and family.
Orlando 1962: To Ida Orlando (1960), the client is an individual; with a need;
that, when met, diminishes distress, increases adequacy, or enhances wellbeing.
Johnsons Theory 1968: Dorothy Johnsons theory of nursing 1968 focuses on
how the client adapts to illness and how actual or potential stress can affect
the ability to adapt. The goal of nursing to reduce stress so that; the client
can move more easily through recovery.
Rogers 1970: to maintain and promote health, prevent illness, and care for
and rehabilitate ill and disabled client through humanistic science of nursing
Orem1971: This is self-care deficit theory. Nursing care becomes necessary
when client is unable to fulfill biological, psychological, developmental, or
social needs.
King 1971: To use communication to help client reestablish positive
adaptation to environment.
Neuman 1972: Stress reduction is goal of system model of nursing practice.
Roy 1979: This adaptation model is based on the physiological, psychological,
sociological and dependence-independence adaptive modes.
Watsons Theory 1979: Watsons philosophy of caring 1979 attempts to define
the outcome of nursing activity in regard to the; humanistic aspects of life.
Classification of nursing theories
Depending On Function (Polit et al 2001)

Descriptive
To identify the properties and
workings of a discipline
Explanatory
To examine how properties relate and
thus affect the discipline
Predictive
To calculate relationships between

properties and how they occur
Prescriptive
To identify under which conditions

relationships occur
Depending on the Generalisability of their principles

Metatheory: the theory of theory. Identifies specific
phenomena through abstract concepts.
Grand theory: provides a conceptual framework under
which the key concepts and
Principles of the discipline can be identified.
Middle range theory: is more precise and only analyses
a particular situation with a limited number of variables.
Practice theory: explores one particular situation found

in nursing. It identifies explicit goals and details how
these goals will be achieved.
Based on the philosophical underpinnings of the theories

Needs theories.
Interaction theories.
Outcome theories.
Humanistic theories.
Needs theories
These theories are based around helping individuals to fulfill their physical and
mental needs. The basis of these theories is well-illustrated in Roper, Logan
and Tierneys Model of Nursing (1980).
Needs theories have been criticized for relying too much on the medical model
of health and placing the patient in an overtly dependent position.
Interaction theories
As described by Peplau (1988), these theories revolve around the

relationships nurses form with patients.
Such theories have been criticized for largely ignoring the medical model of
health and not attending to basic physical needs.
Outcome theories
These portray the nurse as the changing force, who enables individuals to
adapt to or cope with ill health (Roy 1980).
Outcome theories have been criticized as too abstract and difficult to
implement in practice (Aggleton and Chalmers 1988).
Humanistic Theories
Humanistic theories developed in response to the psychoanalytic thought that

a persons destiny was determined early in life.
Humanistic theories emphasize a persons capacity for self-actualization.
Humanists believe that the person contains within himself the potential for
healthy & creative growth.
Carl Rogers developed a person centered model of psychotherapy that
emphasizes the uniqueness of the individual.
The major contribution that Rogers added to nursing practice is the
understandings that each client is a unique individual, so, person-centered
approach now practice in nursing.
Models of nursing
Until fairly recently, nursing science was derived principally from social,
biologic, and medical science theories.
However, from the 1950s to the present, an increasing number of nursing
theorists have developed models of nursing that provide bases for the
development of nursing theories and nursing knowledge.
A model, as an abstraction of reality, provides a way to visualize reality to
simplify thinking.
A conceptual model shows how various concepts are interrelated and applies
theories to predict or evaluate consequences of alternative actions.
According to Fawcett (2000),
A conceptual model gives direction to the search for relevant questions about
the phenomena of central interest to a discipline and suggests solutions to
practical problems
Four concepts are generally considered central to the discipline of nursing: the
person who receives nursing care (the patient or client); the environment
(society); nursing (goals, roles, functions); and health. These four concepts
form a metaparadigm of nursing.
The term metaparadigm comes from the Greek prefix meta, which means
more comprehensive or transcending, and the word Greek word paradigm,
which means a philosophical or theoretical framework of a discipline upon
which all theories, laws, and generalizations are formulated (MerriamWebsters Collegiate Dictionary, 1994).
Growth and Stability Models of Change
There are two major differences in philosophical beliefs, or world views, about
the nature of change.
The world view of change uses the growth metaphor, and the persistence
view focuses
on stability (Fawcett, 1989,).
Within the change world view, change and growth are continual and desirable,
progress is valued, and realization of ones potential is emphasized
(Fawcett).
Persistence is endurance in time
Persistence world view emphasizes equilibrium and balance.
Categories of Conceptual Models
Ten conceptual models of nursing have been classified according to two

criteria:
the world view of change reflected by the model (growth or stability);
and
the major theoretical conceptual classification with which the model
seems most consistent (systems, stress/adaptation, caring, or
growth/development).
Systems Theory as a Framework
Systems theory is concerned with changes caused by interactions among all

the factors (variables)
General systems theory is emphasized
A system is defined as a whole with interrelated parts, in which the parts
have a function and the system as a totality has a function (Auger, 1976,
A general systems approach allows for consideration of the subsystems levels
of the human being, as a total human being, and as a social creature who
networks himself with others in hierarchically arranged human systems of
increasing complexity. Thus the human being, from the level of the individual
to the level of society, can be conceptualized as the client and becomes the
target system for nursing intervention (Sills & Hall, 1977).
An example of systems interaction
Input (Diet teaching)

Throughput (Assimilation of information)
Output (Food intake)
Feedback (Weight record, Hb estimation etc.)
Two nursing models based on systems theory:
Imogene Kings systems interaction model, and
Betty Neumans health care systems model.
Major Concepts as Defined in Kings Model

Person (human being)
A personal system that interacts with
interpersonal and social systems
Environment
A context within which human beings
grow, develop, and perform daily
activities
Health
dynamic life experiences of a human
being, which implies continuous
adjustment to stressors in the internal and
external environment through optimum
use of ones resources to achieve
maximum potential for daily living
Nursing
A process of human interaction
Imogene Kings Systems Interaction Model
In interaction model, the purpose of nursing is to help people attain,

maintain, or restore health. Kings model conceptualizes three levels of
dynamic interacting systems.
1.
Individuals are called personal systems.
2.
Groups (two or more persons) form interpersonal systems.
3.
Society is composed of social systems.
As the person interacts with the environment, he or she must continuously
adjust to stressors in the internal and external environment (King, 1981).
Health assumes achievement of maximum potential for daily living and an
ability to function in social roles. It is the dynamic life experiences of a
human being, which implies continuous adjustment to stressors in the internal
and external environment through optimum use of ones resources to achieve
maximum potential for daily living (King, 1981,).
Illness is a deviation from normal, that is, an imbalance in a persons
biological structure or in his psychological makeup, or a conflict in a persons
social relationships (King, 1989).
The goal of nursing is to help individuals and groups attain, maintain, and
restore health
Stress: a dynamic state whereby a human being interacts with the
environment to maintain balance for growth, development, and performance
Betty Neumans Health Care Systems Model
Betty Neuman specifies that the purpose of nursing is to facilitate optimal

client system stability.
Normal line of defense: an adaptational level of health considered normal for
an individual
Lines of resistance: protection factors activated when stressors have
penetrated the normal line of defense
Neumans model, organized around stress reduction, is concerned primarily
with how stress and the reactions to stress affect the development and
maintenance of health.
The person is a composite of physiologic, psychological, sociocultural,
developmental, and spiritual variables considered simultaneously.
Ideally the five variables function harmoniously or are stable in relation to
internal and external environmental stressor influences (Neuman, 2002).
A person is constantly affected by stressors from the internal, external, or
created environment.
Stressors are tension-producing stimuli that have the potential to disturb a
persons equilibrium or normal line of defense.
This normal line of defense is the persons usual steady state.
It is the way in which an individual usually deals with stressors.
Stressors may be of three types:
Intrapersonal: forces arising from within the person

Interpersonal: forces arising between persons
Extrapersonal: forces arising from outside the person
Resistance to stressors is provided by a flexible line of defense, a dynamic
protective buffer made up of all variables affecting a person at any given
moment the persons resistance to any given stressor or stressors.
If the flexible line of defense is no longer able to protect the person against a
stressor, the stressor breaks through, disturbs the persons equilibrium, and
triggers a reaction. The reaction may lead toward restoration of balance or
toward death.
Neuman intends for the nurse to assist clients to retain, attain, or maintain
optimal system stability (Neuman, 1996).
Thus, health (wellness) seems to be related to dynamic equilibrium of the
normal line of defense, where stressors are successfully overcome or avoided
by the flexible line of defense.
Neuman defines illness as a state of insufficiency with disrupting needs
unsatisfied (Neuman, 2002).
Illness appears to be a separate state when a stressor breaks through the
normal line of defense and causes a reaction with the persons lines of
resistance.
Stress/Adaptation Theory as a Framework
In contrast to systems theory, stress and adaptation theories view change

caused by personenvironment interaction in terms of cause and effect.
The person must adjust to environmental changes to avoid disturbing a
balanced existence. Adaptation theory provides a way to understand both how
the balance is maintained and the possible effects of disturbed equilibrium.
This theory has been widely applied to explain, predict, and control biologic
(physiologic and psychological) phenomenon.
A unique body of knowledge
The drive for a unique body of knowledge is based on the assumption that
borrowed knowledge is less worthy.
However, nurse education is based on theory borrowed from other disciplines,
such as sociology and psychology.
It has been argued that applying knowledge from different disciplines only
serves to dilute nursing practice.
Nevertheless, as the occupation is focused on humans, perhaps it is inevitable
that nursing uses knowledge from other social sciences.
It has been argued that no knowledge is exclusive, and because of nursings
diverse nature it is impossible for it to have a unique body of knowledge and
one unified body of theory (Castledine 1994, Levine 1995).
Criticisms of nursing theories

To understand why nursing theory is generally neglected on the wards it is necessary
to take a closer look at the main criticisms of nursing theory and the role that nurses
play in contributing to its lack of prevalence in practice.
Use of language
Scott (1994) states that the crucial ingredients of nursing theory should be
accessibility and clarity. However, one of the main criticisms of nursing theory
is its use of overtly complex language (Kenny 1993). It is important that the
language used in the development of nursing theory be used consistently.
Not part of everyday practice
Despite theory and practice being viewed as inseparable concepts, a theorypractice gap still exists in nursing (Upton 1999). Yet despite the availability of
a vast amount of literature on the subject, nursing theory still means very
little to most practicing nurses. Perhaps this is because the majority of
nursing theory is developed by and for nursing academics (Lathlean 1994). It
has been recognised that traditionally nurses are used to speaking with their
hands (Levine 1995). Therefore, many nurses have not had the training or
experience to deal with the abstract concepts presented by nursing theory.
This makes it difficult for the majority of nurses to understand and apply
theory to practice (Miller 1985).
Summarization
1. Definition
2. Importance of Nursing Theories
3. The characteristics of theories:
4. Basic Processes in the Development Of Nursing Theories:
5. Nursing theories are often based on & influenced
6. ANA definition of Nursing Practice
7. Common concepts in Nursing Theories:
8. Historical Perspectives & Key Concepts
9. Clasification of Nursing Theories
10. Models Of Nursing
11. Growth and Stability Models of Change
12. Betty Neumans Health Care Systems Model
13. Stress/Adaptation Theory as a Framework
14. A unique body of knowledge
15. Criticisms of nursing theories
Conclusion
Littlejohn (2002) comments that, irrespective of nursing theories nurses will continue
to exhibit a caring response to the sick and troubled. If this is true, perhaps nurses
are nursing without the knowledge of theories and theory is irrelevant. However,
theory and practice are related, and if nursing is to continue to develop, the concept
of theory must be addressed. If nursing theory does not drive the development of
nursing, it will continue to develop in the footsteps of other disciplines such as
medicine
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Nursing Theorists
Definitions
Theory- a set of related statements that describes or explains phenomena in a
systematic way
Concept-a mental idea of a phenomenon
Construct- a phenomena that cannot be observed and must be inferred
Proposition- a statement of relationship between concepts
Conceptual model- made up of concepts and propositions
Nursing Theorists
Florence Nightingale,
Hildegard Peplau
Virginia Henderson
Fay Abdella
Ida Jean Orlando
Dorothy Johnson
Martha Rogers
Dorothea Orem
Imogene King
Betty Neuman
Sister Calista Roy,
Jean Watson
Rosemary Rizzo Parse
Madeleine Leininger
Patricia Benner
Concepts in the nursing
Metaparadigm
Person
Recipient of care, including physical, spiritual, psychological, and
sociocultural components
Individual, family, or community
Environment
All internal and external conditions, circumstances, and influences affecting
the person
Health
Degree of wellness or illness experienced by the person
Nursing
Actions, characteristics and attributes of person giving care
Florence Nightingale- Environmental Theory
First nursing theorist
Unsanitary conditions posed health hazard (Notes on Nursing, 1859)
5 components of environment
ventilation, light, warmth, effluvia, noise
External influences can prevent, suppress or contribute to disease or death
Nightingales Concepts
Person
o Patient who is acted on by nurse
o Affected by environment
o Has reparative powers
Environment
o Foundation of theory. Included everything, physical, psychological,
and social
Health
o Maintaining well-being by using a persons powers
o Maintained by control of environment

Nursing
o Provided fresh air, warmth, cleanliness, good diet, quiet to facilitate
persons reparative process
Hildegard Peplau -Interpersonal Relations Model
Based on psychodynamic nursing
using an understanding of ones own behavior to help others identify their
difficulties
Applies principles of human relations
Patient has a felt need
Peplaus Concepts
Person
o An individual; a developing organism who tries to reduce anxiety
caused by needs
o Lives in instable equilibrium
Environment- Not defined
Health
o Implies forward movement of the personality and human processes
toward creative, constructive, productive, personal, and community
living
Nursing
o A significant, therapeutic, interpersonal process that functions
cooperatively with others to make health possible
o Involves problem-solving
Virginia Henderson -The Nature of Nursing
"The unique function of the nurse is to assist the individual, sick or well, in
the performance of those activities contributing to health or its recovery
(or to peaceful death) that he would perform unaided if he had the
necessary strength, will, or knowledge. And to do this in such a way as to
help him gain independence as rapidly as possible. She must in a sense,
get inside the skin of each of her patients in order to know what he needs".
Fay Abdella- Topology of 21 Nursing Problems
A list of 21 nursing problems
Condition presented or faced by the patient or family.
Problems are in 3 categories
physical, social and emotional
The nurse must be a good problem solver
Abdellas Concepts
Nursing
o A helping profession
o A comprehensive service to meet patients needs

o Increases or restores self-help ability
o Uses 21 problems to guide nursing care
Health
o Excludes illness
o No unmet needs and no actual or anticipated impairments
Person
o One who has physical, emotional, or social needs
o The recipient of nursing care.
Environment
o Did not discuss much
o Includes room, home, and community
Ida Jean Orlando- Deliberative Nursing Process
The deliberative nursing process is set in motion by the patients behavior
All behavior may represent a cry for help. Patients behavior can be verbal or
non-verbal.
The nurse reacts to patients behavior and forms basis for determining
nurses acts.
Perception, thought, feeling
Nurses actions should be deliberative, rather than automatic
Deliberative actions explore the meaning and relevance of an action.
Dorothy Johnson-Behavioral Systems Model
The person is a behavioral system comprised of a set of organized,
interactive, interdependent, and integrated subsystems
Constancy is maintained through biological, psychological, and sociological
factors.
A steady state is maintained through adjusting and adapting to internal and
external forces.
Johnsons 7 Subsystems
Affiliative subsystem
o social bonds
Dependency
o helping or nuturing
Ingestive
o food intake
Eliminative
o excretion
Sexual
o procreation and gratification

Aggressive
o self-protection and preservation
Achievement
o efforts to gain mastery and control
Johnsons Concepts
Person
o A behavioral system comprised of subsystems constantly trying to
maintain a steady state
Environment
o Not specifically defined but does say there is an internal and external
environment
Health
o Balance and stability.
Nursing
o External regulatory force that is indicated only when there is
instability.
Martha Rogers -Unitary Human Beings
Energy fields
o Fundamental unity of things that are unique, dynamic, open, and
infinite
o Unitary man and environmental field
Universe of open systems
o Energy fields are open, infinite, and interactive
Pattern
o Characteristic of energy field
o A wave that changes, becomes complex and diverse
Pandimensionality
o A nonlinear domain with out time or space
Rogers Definitions
Integrality
o Continuous and mutual interaction between man and environment
Resonancy
o Continuous change longer to shorter wave patterns in human and
environmental fields
Helicy
o Continuous, probabilistic, increasing diversity of the human and
envrionmental fields.
o Characterized by nonrepeating rhymicities
o Change
Dorothea Orem- Self-Care Model
Self-care comprises those activities performed independently by an
individual to promote and maintain person well-being
Self care agency is the individuals ability to perform self care activities
Self- care deficit occurs when the person cannot carry out self-care
The nurse then meets the self-care needs by acting or doing for; guiding,
teaching, supporting or providing the environment to promote patients
ability
Wholly compensatory nursing system-Patient dependent
Partially compensatory- Patient can meet some needs but needs nursing
assistance
Supportive educative-Patient can meet self care requisites, but needs
assistance with decision making or knowledge
Imogene King-Goal Attainment Theory
Open systems framework
Human beings are open systems in constant interaction with the
environment
Personal System
o individual; perception, self, growth, development, time space, body
image
o Interpersonal
o Society
Personal System
o Individual; perception, self, growth, development, time space, body
image
Interpersonal
o Socialization; interaction, communication and transaction
Society
o Family, religious groups, schools, work, peers
The nurse and patient mutually communicate, establish goals and take
action to attain goals
Each individual brings a different set of values, ideas, attitudes, perceptions
to exchange
Betty Neuman - Health Care Systems Model
The person is a complete system, with interrelated parts
maintains balance and harmony between internal and external environment
by adjusting to stress and defending against tension-producing stimuli
Focuses on stress and stress reduction
Primarily concerned with effects of stress on health
Stressors are any forces that alter the systems stability

Flexible lines of resistance
Surround basic core
Internal factors that help defend against stressors
Normal line of resistance
Normal adaptation state
Flexible line of defense
Protective barrier, changing, affected by variables
Wellness is equilibrium
Nursing interventions are activates to:
strengthen flexible lines of defense
strengthen resistance to stressors
maintain adaptation
Sister Calista Roy - Adaptation Model
Five Interrelated Essential Elements
Patiency- The person receiving care
Goal of nursing- Adapting to change
Health-Being and becoming a whole person
Environment
Direction of nursing activities- Facilitating adaptation
The person is an open adaptive system with input (stimuli), who adapts by
processes or control mechanisms (throughput)
The output can be either adaptive responses or ineffective responses
Jean Watson - Philosophy and Science of Caring
Caring can be demonstrated and practiced
Caring consists of carative factors
Caring promotes growth
A caring environment accepts a person as he is and looks to what the
person may become
A caring environment offers development of potential
Caring promotes health better than curing
Caring is central to nursing
Watsons 10 Carative Factors
Forming humanistic-altruistic value system
Instilling faith-hope
Cultivating sensitivity to self and others
Developing helping-trust relationship
Promoting expression of feelings
Using problem-solving for decision making

Promoting teaching-learning
Promoting supportive environment
Assisting with gratification of human needs
Allowing for existential-phenomenological forces
Watsons Concepts
Person
o Human being to be valued, cared for, respected, nurtured,
understood and assisted
Environment
o Society
Health
o Complete physical, mental and social well-being and functioning
Nursing
o Concerned with promoting and restoring health, preventing illness
Rosemary Parse - Human Becoming Theory
Human Becoming Theory includes Totality Paradigm
o Man is a combination of biological, psychological, sociological and
spiritual factors
Simultaneity Paradigm
o Man is a unitary being in continuous, mutual interaction with
environment
Originally Man-Living-Health Theory
Parses Three Principles
Meaning
o Mans reality is given meaning through lived experiences
o Man and environment cocreate
Rhythmicity
o Man and environment cocreate ( imaging, valuing, languaging) in
rhythmical patterns
Cotranscendence
o Refers to reaching out and beyond the limits that a person sets
o One constantly transforms
Person
o Open being who is more than and different from the sum of the parts
Environment
o Everything in the person and his experiences
o Inseparable, complimentary to and evolving with

Health
o Open process of being and becoming. Involves synthesis of values
Nursing
o A human science and art that uses an abstract body of knowledge to
serve people
Madeleine Leininger - Culture Care Diversity and Universality
Based on transcultural nursing, whose goal is to provide care congruent with
cultural values, beliefs, and practices
Sunrise model consists of 4 levels that provide a base of knowledge for
delivering cultural congruent care
Modes of nursing action
Cultural care preservation
o help maintain or preserve health, recover from illness, or face death
Cultural care accommodation
o help adapt to or negotiate for a beneficial health status, or face death
Cultural care re-patterning
o help restructure or change lifestyles that are culturally meaningful
Patricia Benner - From Novice to Expert
Described 5 levels of nursing experience and developed exemplars and
paradigm cases to illustrate each level
Levels reflect:
o movement from reliance on past abstract principles to the use of past
concrete experience as paradigms
o change in perception of situation as a complete whole in which
certain parts are relevant
Novice
Advanced beginner
Competent
Proficient
Expert
Importance of Theoretical Frameworks
1.Foundation of any profession is the development of a specialized body of
knowledge. Theories should be developed in nursing, not borrow theories
form other disciplines
2.Responsibility of nurses to know and understand theorists
3.Critically analyze theoretical frameworks
Reference
Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed.
Mosby, Philadelphia, 2002.
Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.).
Practice , 3rd ed. Norwalk, Appleton and Lange.
Philadelphia. Lippincott Williamsand wilkins.
Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development and
Progress 3rd ed. Philadelphia, Lippincott.
Taylor Carol,Lillis Carol (2001)The Art and Science Of Nursing Care 4th ed.
Potter A Patricia, Perry G Anne (1992)Fundamentals Of Nursing Concepts
Process and Practice 3rd ed. London Mosby Year Book.
NURSING THEORIES: AN OVERVIEW

Theory
Kerlinger ---views theories as a set of interrelated concepts that give a systematic
view of a phenomenon ( an observable fact or event ) that is explanatory and
predictive in nature. Theories are composed of concepts, definitions, models ,
propositions and are based on assumptions. They are derived through two principal
methods: 1) Deductive reasoning 2) Inductive reasoning. Nursing theorists use both
of these methods. Nursing Theory: Barnum(1998)---- " attempts to describe or
explain the phenomenon (process, occurrence and event) called nursing"
Theories for Professional Nursing
Theory is "a creative and rigorous structuring of ideas that projects a

tentative, purposeful, and systematic view of phenomena"
A theory makes it possible to "organize the relationship among the concepts

to describe, explain, predict, and control practice"
Definition
Concepts--- are basically vehicles of thought that involve images. Concepts

are words that describe objects , properties, or events and are basic
components of theory .
Types : Empirical concepts
Inferential concepts
Abstract concepts.
Models ----- are representations of the interaction among and between the
concepts showing patterns.
Propositions---- are statements that explain the relationship between the

concepts.
Process ---- it is a series of actions , changes or functions intended to bring

about a desired result . During a process one takes systemic and continuous
steps to meet a goal and uses both assessments and feedback to direct
actions to the goal.
A particular theory or conceptual frame work directs how these actions are
carried out . The delivery of nursing care within the nursing process is
directed by the way specific conceptual frameworks and theories define the
person (patient), the environment , health and nursing.
The terms model and theory are often wrongly used interchangeably, which
further confounds matters.
In nursing, models are often designed by theory authors to depict the beliefs
in their theory (Lancaster and Lancaster 1981).
They provide an overview of the thinking behind the theory and may
demonstrate how theory can be introduced into practice, for example,
through specific methods of assessment.
Models are useful as they allow the concepts in nursing theory to be

successfully applied to nursing practice (Lancaster and Lancaster 1981).
Their main limitation is that they are only as accurate or useful as the
underlying theory.
Importance of Nursing Theories
Nursing theory aims to describe, predict and explain the phenomenon of

nursing (Chinn and Jacobs1978).
It should provide the foundations of nursing practice, help to generate further

knowledge and indicate in which direction nursing should develop in the
future (Brown 1964).
Theory is important because it helps us to decide what we know and what we

need to know (Parsons1949).
It helps to distinguish what should form the basis of practice by explicitly

describing nursing.
The benefits of having a defined body of theory in nursing include better

patient care, enhanced professional status for nurses, improved
communication between nurses, and guidance for research and education
(Nolan 1996). In addition, because the main exponent of nursing caring
cannot be measured, it is vital to have the theory to analyze and explain what
nurses do.
As medicine tries to make a move towards adopting a more multidisciplinary

approach to health care, nursing continues to strive to establish a unique
body of knowledge.
This can be seen as an attempt by the nursing profession to maintain its

professional boundaries.
The characteristics of theories

Theories:
interrelate concepts in such a way as to create a different way of looking at a

particular phenomenon.
are logical in nature.
are generalizable.
are the bases for hypotheses that can be tested.
increase the general body of knowledge within the discipline through the
research implemented to validate them.
are used by the practitioners to guide and improve their practice.
are consistent with other validated theories, laws, and principles but will leave
open unanswered questions that need to be investigated
Basic Processes in the Development Of Nursing Theories:

Nursing theories are often based on and influenced by broadly applicable
processes and theories. Following theories are basic to many nursing
concepts.
General System Theory:
It describes how to break whole things into parts and then to learn how the
parts work together in " systems". These concepts may be applied to different
kinds of systems, e.g.. Molecules in chemistry , cultures in sociology, organs
in Anatomy and health in Nursing.
Adaptation Theory
It defines adaptation as the adjustment of living matter to other living things
and to environmental conditions. Adaptation is a continuously occurring
process that effects change and involves interaction and response . Human
adaptation occurs on three levels:
--- the internal ( self )
--- the social (others)
--- and the physical ( biochemical reactions )
Developmental Theory
It outlines the process of growth and development of humans as orderly and
predictable , beginning with conception and ending with death.
The progress and behaviors of an individual within each stage are unique.
The growth and development of an individual are influenced by heredity ,
temperament , emotional, and physical environment , life experiences and
health status.
Common concepts in Nursing Theories:
Four concepts common in nursing theory that influence and determine nursing
practice are
-- The person( patient) .
--- The environment
-- Health
--- Nursing (goals, roles, functions)
Each of these concepts is usually defined and described by a nursing theorist ,

Often uniquely; although these concepts are common to all nursing theories.
Of the four concepts , the most important is that of the person. The focus of
nursing , regardless of definition or theory , is the person.
Historical Perspectives and Key Concepts
Nightingale (1860): To facilitate "the bodys reparative processes" by

manipulating clients environment
Paplau 1952: Nursing is; therapeutic interpersonal process.
Henderson 1955: The needs often called Hendersons 14 basic needs
Abdellah 1960: The nursing theory developed by Faye Abdellah et al

(1960) emphasizes delivering nursing care for the whole person to meet the
physical, emotional, intellectual, social, and spiritual needs of the client and
family.
Orlando 1962: To Ida Orlando (1960), the client is an individual; with a

need; that, when met, diminishes distress, increases adequacy, or enhances
well-being.
Johnsons Theory 1968: Dorothy Johnsons theory of nursing 1968

focuses on how the client adapts to illness and how actual or potential stress
can affect the ability to adapt. The goal of nursing to reduce stress so that;
the client can move more easily through recovery.
Rogers 1970: to maintain and promote health, prevent illness, and care
for and rehabilitate ill and disabled client through "humanistic science of
nursing" Orem1971: This is self-care deficit theory. Nursing care becomes
necessary when client is unable to fulfill biological, psychological,
developmental, or social needs.
King 1971: To use communication to help client reestablish positive

adaptation to environment.
Neuman 1972: Stress reduction is goal of system model of nursing

practice.
Roy 1979: This adaptation model is based on the physiological,

psychological, sociological and dependence-independence adaptive modes.
Watsons Theory 1979: Watsons philosophy of caring 1979 attempts

to define the outcome of nursing activity in regard to the; humanistic aspects
of life.
Classification of Nursing Theories

Depending On The Generalisability Of Their Principles
Metatheory: the theory of theory. Identifies
specific phenomena through abstract concepts.
Grand theory: provides a conceptual framework under which the key concepts
and
principles of the discipline can be identified.
Middle range theory: is more precise and only analyses a particular situation
with a limited number of variables.
Practice theory: explores one particular situation found in nursing. It identifies

explicit goals and details how these goals will be achieved.
Theories can also be categorised as:
"Needs "theories.
"Interaction" theories.
"Outcome "theories.
"Humanistic theories"
These categories indicate the basic philosophical underpinnings of the theories
"Needs" theories
These theories are based around helping individuals to fulfill their physical and
mental needs. The basis of these theories is well-illustrated in Roper, Logan
and Tierneys Model of Nursing (1980).
Needs theories have been criticized for relying too much on the medical model
of health and placing the patient in an overtly dependent position.
"Interaction" theories
As described by Peplau (1988), these theories revolve around the

relationships nurses form with patients.
Such theories have been criticized for largely ignoring the medical model of
health and not attending to basic physical needs.
"Outcome" theories
These portray the nurse as the changing force, who enables individuals to
adapt to or cope with ill health (Roy 1980).
Outcome theories have been criticized as too abstract and difficult to

implement in practice (Aggleton and Chalmers 1988).
"Humanistic" Theories:
Humanistic theories developed in response to the psychoanalytic thought that

a persons destiny was determined early in life.
Humanistic theories emphasize a persons capacity for self actualization .
Humanists believes that the person contains within himself the potential for
healthy and creative growth.
Carl Rogers developed a person centered model of psychotherapy that

emphasizes the uniqueness of the individual.
The major contribution that Rogers added to nursing practice is the

understanding that each client is a unique individual, so person-centered
approach now practice in Nursing.
MODELS OF NURSING
Until fairly recently, nursing science was derived principally from social,
biologic, and medical science theories.
However, from the 1950s to the present, an increasing number of nursing

theorists have developed models of nursing that provide bases for the
development of nursing theories and nursing knowledge.
A model, as an abstraction of reality, provides a way to visualize reality to

simplify thinking.
A conceptual model shows how various concepts are interrelated and applies
theories to predict or evaluate consequences of alternative actions.
According to Fawcett (2000),
A conceptual model "gives direction to the search for relevant questions about
the phenomena of central interest to a discipline and suggests solutions to
practical problems"
. Four concepts are generally considered central to the discipline of nursing:

the person who receives nursing care (the patient or client); the environment
(society); nursing (goals, roles, functions); and health.
These four concepts form a metaparadigm of nursing.
The term metaparadigm comes from the Greek prefix
"meta," which means more comprehensive or transcending,
and the word Greek word "paradigm," which means a philosophical or

theoretical framework of a discipline
upon which all theories, laws, and generalizations are formulated (MerriamWebsters Collegiate Dictionary, 1994).
There are two major differences in philosophical beliefs, or world views, about
the nature of change.
"The world view of change uses the growth metaphor, and the persistence
view focuses
on stability" (Fawcett, 1989,).
Within the change world view, change and growth are continual and desirable,
"progress is valued, and realization of ones potential is emphasized"
(Fawcett).
Persistence is endurance in time
persistence world view emphasizes equilibrium and balance.
Categories of Conceptual Models
Ten conceptual models of nursing have been classified according to two

criteria:
the world view of change reflected by the model (growth or stability); and
the major theoretical conceptual classification with which the model seems
most consistent (systems, stress/adaptation, caring, or growth/development).
Systems Theory as a Framework
Systems theory is concerned with changes caused by interactions among all

the factors (variables)
General systems theory is emphasized
A system is defined as "a whole with interrelated parts, in which the parts
have a function and the system as a totality has a function" (Auger, 1976)
A general systems approach allows for consideration of the subsystems levels

of the human being, as a total human being, and as a social creature who
networks himself with others in hierarchically arranged human systems of
increasing complexity. Thus the human being, from the level of the individual
to the level of society, can be conceptualized as the client and becomes the
target system for nursing intervention. (Sills and Hall, 1977).
An example of systems interaction

1. Input (Diet teaching)
Throughput (Assimilation of information)
Output (Food intake)
Feedback (Weight record ,Hb estimation etc.)
Two nursing models based on systems theory:

2. Imogene Kings systems interaction model, and
3. Betty Neumans health care systems model.
Imogene Kings Systems Interaction Model
interaction model, the purpose of nursing is to help people attain, maintain, or

restore health
Kings model conceptualizes three levels of dynamic interacting systems.
1. Individuals are called "personal systems."
2. Groups (two or more persons) form "interpersonal systems."
3. Society is composed of "social systems."
As the person interacts with the environment, he or she must continuously

adjust to stressors in the internal and external environment (King, 1981).
Health assumes achievement of maximum potential for daily living and an

ability to function
in social roles. It is the "dynamic life experiences of a human being, which

implies continuous
adjustment to stressors in the internal and external environment through

optimum use of ones resources to achieve maximum potential for daily living"
(King, 1981,).
"Illness is a deviation from normal, that is, an imbalance in a persons

biological structure or in his psychological makeup, or a conflict in a persons
social relationships" (King, 1989).
"The goal of nursing is to help individuals and groups attain, maintain, and
restore health"
Stress: "a dynamic state whereby a human being interacts with the
environment to maintain balance for growth, development, and performance"
Betty Neuman specifies that the purpose of nursing is to facilitate optimal

client system stability.
Normal line of defense: an adaptational level of health considered normal for

an individual
Lines of resistance: protection factors activated when stressors have

penetrated the normalline of defense
Neumans model, organized around stress reduction, is concerned primarily

with how stress and the reactions to stress affect the development and
maintenance of health.
The person is a composite of physiologic, psychological, sociocultural,

developmental, and spiritual variables considered simultaneously.
"Ideally the five variables function harmoniously or are stable in relation to

internal and external environmental stressor influences" (Neuman, 2002).
A person is constantly affected by stressors from the internal, external, or

created environment.
Stressors are tension-producing stimuli that have the potential to disturb a

persons equilibrium or normal line of defense.
This normal line of defense is the persons "usual steady state."
It is the way in which an individual usually deals with stressors.
Stressors may be of three types:
Intrapersonal: forces arising from within the person
Interpersonal: forces arising between persons
Extrapersonal: forces arising from outside the person
Resistance to stressors is provided by a flexible line of defense, a dynamic

protective buffer made up of all variables affecting a person at any given
moment the persons resistance to any given stressor or stressors.
If the flexible line of defense is no longer able to protect the person against a
stressor, the stressor
breaks through, disturbs the persons equilibrium, and triggers a reaction. The
reaction may lead
toward restoration of balance or toward death.
Neuman intends for the nurse to "assist clients to retain, attain, or maintain
optimal system stability" (Neuman, 1996).
Thus, health (wellness) seems to be related to dynamic equilibrium of the

normal line of defense, where stressors are successfully overcome or avoided
by the flexible line of defense.
Neuman defines illness as "a state of insufficiency with disrupting needs

unsatisfied" (Neuman, 2002).
Illness appears to be a separate state when a stressor breaks through the

normal line of defense and causes a reaction with the persons lines of
resistance.
In contrast to systems theory, stress and adaptation theories view change

caused by personenvironment interaction in terms of cause and effect.
The person must adjust to environmental changes to avoid disturbing a

balanced existence. Adaptation theory provides a way to understand
both how the balance is maintained and the possible effects of disturbed
equilibrium.
This theory has been widely applied to explain, predict, and control biologic
(physiologic and psychological)
The drive for a unique body of knowledge is based
on the assumption that borrowed knowledge is
less worthy.
However, nurse education is based on theory borrowed from other disciplines,

such as sociology and psychology.
It has been argued that applying knowledge from different disciplines only
serves to dilute nursing practice.
Nevertheless, as the occupation is focused on
humans, perhaps it is inevitable that nursing uses
knowledge from other social sciences.
It has been argued that no knowledge is exclusive, and because of nursings

diverse nature it is impossible for it to have a unique body of knowledge and
one unified body of theory (Castledine 1994, Levine 1995).
To understand why nursing theory is generally neglected on the wards it is

necessary to take a closer look at the main criticisms of nursing theory and
the role that nurses play in contributing to its lack of prevalence in practice.
Use of language Scott (1994) states that the crucial ingredients of nursing
theory should be accessibility and clarity. However, one of the main criticisms
of nursing theory is its use of overtly complex language (Kenny 1993).
It is important that the language used in the
development of nursing theory be used consistently.
Not part of everyday practice Despite theory and practice being viewed as
inseparable concepts, a theory-practice gap still exists in nursing (Upton
1999).
Yet despite the availability of a vast amount of literature on the subject,

nursing theory still means very little to most practicing nurses. Perhaps this is
because the majority of nursing theory is developed by and for nursing
academics (Lathlean 1994).
It has been recognised that traditionally nurses are used to speaking with
their hands (Levine 1995).
Therefore, many nurses have not had the training or experience to deal with
the abstract concepts presented by nursing theory.
This makes it difficult for the majority of nurses to understand and apply
theory to practice (Miller 1985).
Summary
Definition
Importance of Nursing Theories
The characteristics of theories:
Basic Processes in the Development Of Nursing Theories:
Nursing theories are often based on and influenced
ANA definition of Nursing Practice
Common concepts in Nursing Theories:
Historical Perspectives and Key Concepts
Classification of Nursing Theories
Models Of Nursing
Conclusion:
Littlejohn (2002) comments that irrespective of nursing theories, nurses will
continue to exhibit a caring response to the sick and troubled. If this is true,
perhaps nurses are nursing without the knowledge of theories and theory is
irrelevant. However, theory and practice are related, and if nursing is to
continue to develop, the concept of theory must be addressed. If nursing
theory does not drive the development of nursing, it will continue to develop
in the footsteps of other disciplines such as medicine
Reference:
1. George B. Julia , Nursing Theories- The base for professional Nursing

2. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing

3. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development and Progress

3rd ed. Philadelphia, Lippincott.
4. Taylor Carol,Lillis Carol (2001)The Art and Science Of Nursing Care 4th ed.
5. Potter A Patricia, Perry G Anne (1992)Fundamentals Of Nursing Concepts

UNDERSTANDING THE WORK OF

NURSE THEORISTS
Creative Beginning
Theories of Nursing
Theory is "an internally consistent group of relational statements (concepts,
definitions and propositions) that present a systematic view about a
phenomenon and which is useful for description, explanation, prediction
and control".
Theories are road maps that provide a framework for selecting and
organizing information:
o What to ask
o What to observe
o What to focus on
o What to think about
Nursing theory is an organized and systematic articulation of a set of
statements related to questions in the discipline of nursing.
Uses of Theory
Theory is used to:
Describe
Explain
Predict
Prescribe
Uses of Nursing Theory
Define relationships among the variables of
a given field of inquiry
Guide research, practice and communication

Allow the prediction of the consequences of care
Allow the prediction of a range of patient responses
Levels of Theory
There are four levels of theory
Metatheory
Grand Theory
Middle Range Theory
Practice Theory
Types of Theory
In Nursing there are four types of theories:
Needs
Interaction
Outcome
Humanistic
Practice value of theory
Enhances understanding and explanation for events
Influence our behavior.
Makes to think differently about a problem or a situation
Helps to try new approaches or altering behavior.
We can gain a new perspective of events
Basis for challenge of its speculative tenets or propositions
Challenges subsequent discovery of new ideas or knowledge that might
explain and predict events not yet understood
In practice
Assist nurses to describe, explain, and predict everyday experiences.
Serve to guide assessment, intervention, and evaluation of nursing care.
Provide a rationale for collecting reliable and valid data about the health
status of clients, which are essential for effective decision making and
implementation.
Help to establish criteria to measure the quality of nursing care

Help build a common nursing terminology to use in communicating with
other health professionals. Ideas are developed and words defined.
Enhance autonomy (independence and self-governance) of nursing by
defining its own independent functions.
In education
Provide a general focus for curriculum design.
Guide curricular decision making
In research
Offer a framework for generating knowledge and new ideas.
Assist in discovering knowledge gaps in specific field of study.
Offer a systematic approach to identify questions for study, select variables,
interpret findings, and validate nursing interventions.
An illustration
The germ theory
Explains the phenomenon of disease transmission
Means of speculative explanation and prediction of certain observable events
Allows us to effectively function to prevent transmission of communicable
disease.
Viable basis upon which to make decisions about how to prevent certain
illnesses.
There are phenomena we do not understand that are related to germ
transmission,
Example-the communicability of cancer.
"Nursing Practice."
All experiences and events a practicing nurse encounters in the process of
providing nursing care.
Events..
Some may be experienced by the client,
Others by the nurse
Some may be observed in the environment
May be observed in the nurse-client interaction.
In situations of daily work or living,
..but as long as they are observable during the process of providing direct
nursing care, they are considered part of nursing practice.
Approaches to inter relationships between practice and theory
How nursing practice contributes to the process of theory development..
How theory contributes to nursing practice
Contribution of practice to theory development
Theory development within nursing occurs in the context of practice.
Two activities contribute significantly to the overall process of developing
theory in nursing.
Concept analysis and
Practical validation of theory.
Concept analysis
Identify and verify abstract concepts

"what events in practice can be linked with abstract concept x"
Application of theory in practice
Nursing process operation of analysis of assessment data.
Used as scientific rationale supporting judgments in nursing care plans.
Concepts
Concepts may be (a) readily observable, or concrete, ideas such as
thermometer, rash, and lesion; (b) indirectly observable, or inferential,
ideas such as pain and temperature; or c) non-observable, or abstract,
ideas such as equilibrium, adaptation, stress, and powerlessness
nursing theories address and specify relationships among four major
abstract concepts referred to as the metaparadigm of nursing.
Four concepts are considered to be central to nursing :
Person or client, the recipient of nursing care (includes individuals, families,
groups, and communities).
Environment, the internal and external surroundings that affect the client.
This includes people in the physical environment, such as families, friends,
and significant others.
Health, the degree of wellness or well-being that the client experiences.
Nursing, the attributes, characteristics, and actions of the nurse providing
care on behalf of, or in conjunction with, the client
Nightingales environmental theory
"the act of utilizing the environment of the patient to assist him in his
recovery"
She linked health with five environmental factors :
Pure or fresh air
Pure water
Efficient drainage
Cleanliness
Light, especially direct sunlight
Deficiencies in these five factors produced lack
Of health or illness.
Peplaus interpersonal relations model
Nurses enter into a personal relationship with an individual when a felt need
is present
Hendersons definition of nursing
Henderson conceptualized the nurses role as assisting sick or well
individuals to gain independence in meeting 14 fundamental needs
(Henderson)
Breathing normally
Eating and drinking adequately
Eliminating body wastes
Moving and maintaining a desirable position
Sleeping and resting
Selecting suitable clothes
Maintaining body temperature within normal range by adjusting clothing and
modifying the environment.
Keeping the body clean and well groomed to protect the integument.
Avoiding dangers in the environment and avoiding injuring others
Communicating with others in expressing emotions, needs, fears, or
opinions
Worshipping according to ones faith
Working in such a way that one feels a sense of accomplishment
Playing or participating in various forms of recreation.
Learning, discovering, or satisfying the curiosity that leads to normal
development and health, and using available health facilities
Rogers science of unitary human beings
She states that humans are dynamic energy fields in continuous exchange
with environmental fields, both of which are infinite.
Nurses applying Roger's theory in practice (a) focus on the persons
wholeness, (b) seek to promote symphonic interaction between the two
energy fields (human and environment) to strengthen the coherence and
integrity of the person, c) coordinate the human field with the
rhythmicities of the environmental field, and (d) direct and redirect
patterns of interaction between the two energy fields to promote maximum
health potential
Orems general theory of nursing
Orems self-care deficit theory explains not only when nursing is needed but
also how people can be assisted through five methods of helping: acting or
doing for, guiding, teaching, supporting, and providing an environment that
promotes the individuals abilities to meet current and future demands.
Kings goal attainment theory
Kings theory offers insight into nurses interactions with individuals and
groups within the environment. It highlights the importance of clients
participation in decision that influence care and focuses on both the
process of nurse-client interaction and the outcomes of care.
Neumans systems model
The model is based on the individuals relationship to stress, the reaction to

it, and reconstitution factors that are dynamic in nature.
Betty Neuman's model of nursing is applicable to a variety of nursing
practice settings involving individuals, families, groups, and communities.
Roys adaptation model
Roy focuses on the individual as a biopsychosocial adaptive system that
employs a feedback cycle of input (stimuli), throughput (control
processes), and output (behaviors or adaptive responses).
Watsons human caring theory
Jean Watson (1979) believes the practice of caring is central to nursing; it is
the unifying focus for practice.
Nursing interventions related to human care are referred to as carative
factors.
Watsons theory of human caring has receiving worldwide recognition and is
a major force in redefining nursing as a caring-healing health model.
Parses human becoming theory
Parses model of human becoming emphasizes how individuals choose and
bear responsibility for patterns of personal health.
Leiningers cultural care diversity and universality theory
She emphasizes that human caring, although a universal phenomenon,
varies among cultures in its expressions, processes, and patterns; it is
largely culturally derived.
Orems general theory of nursing
Assessing
Involves collecting data about the clients capacities (knowledge, skills, and
motivation) to perform universal, developmental, and health-deviation selfcare requisites. Determine self-care deficits.
Diagnosing
Stated in terms of the clients limitations for maintaining self care (a deficit
in self-care agency)
Planning
Involves considering and designing, with the clients participation, an
appropriate nursing system (wholly compensatory, partially compensatory,
supportive-educative, or a mix) that will help the client achieve an optimal
level of self care
Implementing
Assisting the client
Evaluating
1.Determining the clients level of achievement
References
1.Phipps J Wilma, Sands K Judith. Medical Surgical Nursing: concepts & clinical
practice.6th edition. Philadelphia. Mosby publications. 1996.
2.Black M. Joice, Hawks hokanson Jane. Medical Surgical Nursing: Clinical
Management for positive outcomes. St Lois, Missouri. 2005.
3.Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.).
Mosby, Philadelphia, 2002
4.Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed.
THEORIES & NURSING RESEARCH

Introduction
RESEARCH Process of inquiry

THEORY Product of knowledge
SCIENCE Result of the relationship between research & theory
To effectively build knowledge to research process should be developed within

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

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

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

To propose plausible approaches to health problems.
To develop or refine theories
Define the concepts and proposed relationships between concepts.
To interpret research findings
To develop clinical practice protocols.
Generate nursing diagnosis.
Types of theory and corresponding research
Type of theory
Type of research
Descriptive or
explanatory
Co relational
Experimental
Descriptive
Explanatory
Predictive
How Theory is used in Research
Causal theory of planned behaviour
Theory Generating Research
It is designed to develop and describe relationships between and among

phenomena without imposing preconceived notations.
It is inductive and includes field observations and phenomenology.
During the theory generating process, the researcher moves by logical

thought from fact to theory by means of a proposition stated as an empirical
generalization.
Grounded Theory Research
Inductive research technique developed by Glazer and Strauss (1967)
Grounded theory provides a way to describe what is happening and

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

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

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

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

In the studys problem statement
1.
2.
3.
4.
Introduce the framework

Briefly explain why it is a good fit for the research problem area
At the end of the literature review
Thoroughly describe the framework and explain its application to the
present study.
5. Describe how the framework has been used in studies about similar
problems
6. In the studys methodology section
7. Explain how the framework is being operationalized in the studys
design.
8. Explain how data collection methods (such as questionnaire items)
reflect the concepts in the framework.
9. In the studys discussion section
10. Describe how study findings are consistent (or inconsistent) with the
framework.
11. Offer suggestions for practice and further research that are congruent
with the frameworks concepts and propositions.
Conclusion
The relationship between research and theory is undeniable, and it is
important to recognize the impact of this relationships on the development of
nursing knowledge. So interface theory and research by generating theories,
testing the theories and by using it as a conceptual framework that drives the
study.
Reference

Polit DF, Hungler BP. Nursing Research: Principles and Methods. Philadelphia:
JB Lippincott Company; 1998.
Burns N, Grove SK. The practice of Nursing Research. 4th Ed. Philadelphia:
WB Saunders Publications; 2001.
Treece JW, Treece EW. Elements of Research in Nursing (3rded.). St. Louis:
Mosby; 1982.
VIRGINIA HENDERSONS NEED

THEORY
Nursing theories mirror different realities, throughout their development; they
reflected the interests of nurses of that time.
Introduction
The Nightingale of Modern Nursing
Modern-Day Mother of Nursing.
"The 20th century Florence Nightingale."
"little Miss 3x5"
Born in Kansas City, Missouri, in 1897 and is the 5th child of a family of 8th
children but spent her formative years in Virginia
Received a Diploma in Nursing from the Army School of Nursing at Walter

Reed Hospital, Washington, D.C. in 1921.
Worked at the Henry Street Visiting Nurse Service for 2 years after
graduation.
In 1923, she accepted a position teaching nursing at the Norfolk Protestant
Hospital in Virginia, where she remained for several years
In 1929, Henderson determined that she needed more education and
entered Teachers College at Columbia University where she earned her;
Bachelors Degree in 1932, Masters Degree in 1934.
Subsequently, she joined Columbia as a member of the faculty, where she
remained until 1948(Herrmann,1998)
Since 1953, she has been a research associate at Yale University School of
Nursing.
Died: March 19, 1996.
Achievements
Is the recipient of numerous recognitions for her outstanding contributions
to nursing?
VH was a well known nursing educator and a prolific author.
She has received honorary doctoral degrees from the
o Catholic University of America
o Pace University,
o University of Rochester,
o University of Western Ontario,
o Yale University
Her stature as a nurse, teacher, author, researcher, and consumer health
advocate warranted an obituary in the New York Times, Friday March 22.
1996.
In 1985, Miss Henderson was honored at the Annual Meeting of the Nursing
and Allied Health Section of the Medical Library Association.
Contribution
In 1937 Henderson and others created a basic nursing curriculum for the
National League for Nursing in which education was patient centered and
organized around nursing problems rather than medical diagnoses
(Henderson,1991)
In 1939, she revised: Harmers classic textbook of nursing for its 4th
edition, and later wrote the 5th; edition, incorporating her personal
definition of nursing (Henderson,1991)
Although she was retired, she was a frequent visitor to nursing schools well
into her nineties.
OMalley (1996) states that Henderson is known as the modern-day mother
of nursing. Her work influenced the nursing profession in America and
throughout the world
The founding members of ICIRN (Interagency Council on Information

Resources for Nursing) and a passionate advocate for the use and sharing
of health information resources.
In 1978 the fundamental concept of nursing was revisited by Virginia
Henderson from Yale University School of Nursing ( USA ). She argued that
nurses needed to be prepared for their role by receiving the broadest
understanding of humanity and the world in which they lived.
Publications
1956 (with B. Harmer)-Textbook for the principles and practices of Nursing.
1966-The Nature of Nursing. A definition and its implication for practice,
Research and Education
1991- The Nature of Nursing Reflections after 20 years
Analysis of Nursing Theory
Images of Nursing, 1950-1970
The First School of Thought: Needs
This school of thought includes theories that reflect an image of nursing as
meeting the needs of clients and were developed in response to such
questions as
What do nurses do?
What are their functions?
What roles do nurses play?
Answers to these questions focused on a number of theorist describing
functions and roles of nurses.
Conceptualizing functions led theorists to consider nursing client in terms of
a Hierarchy of needs. When any of these needs are unmet and when a
person is unable to fulfill his own needs, the care provided by nurses is
required.
Nurses then provide the necessary functions and play those roles that could
help patients meet their needs.
School of thought in Nursing Theories-1950-1970
Need theorists
Interaction
theorists
Outcome theorists
Abdellah
King
Johnson
Henderson
Orlando
Levine
Orem
Peterson and Zderad
Rogers
Paplau
Roy
Travelbee
Wiedenbach
Analysis of nursing theories according to 1st School
Focus
Problems
Human being
A set of needs or problems.

A developmental being.
Patient
Need Deficit
Orientation
Illness, disease
Role of nurse
Dependent on medical practice.

Beginnings of independent functions
Fulfill needs requisites
Decision making
Primarily health care professional
Hendersons Theory Background
Hendersons concept of nursing was derived form her practice and

education therefore, her work is inductive.
She called her definition of nursing her concept (Henderson1991)
Although her major clinical experiences were in medical-surgical

hospitals, she worked as a visiting nurse in New York City. This experience
enlarges Hendersons view to recognize the importance of increasing the
patients independence so that progress after hospitalization would not be
delayed (Henderson,1991)
Virginia Henderson defined nursing as "assisting individuals to gain

independence in relation to the performance of activities contributing to
health or its recovery" (Henderson, 1966, p. 15).
She was one of the first nurses to point out that nursing does not
consist of merely following physician's orders.
She categorized nursing activities into 14 components, based on

human needs.
She described the nurse's role as substitutive (doing for the person),
supplementary (helping the person), complementary (working with the
person), with the goal of helping the person become as independent as
possible.
Her famous definition of nursing was one of the first statements

clearly delineating nursing from medicine:
"The unique function of the nurse is to assist the individual, sick or well, in
the performance of those activities contributing to health or its recovery
(or to peaceful death) that he would perform unaided if he had the
necessary strength, will or knowledge. And to do this in such a way as to
help him gain independence as rapidly as possible" (Henderson, 1966, p.
15).
The development of Hendersons definition of nursing
Two events are the basis for Hendersons development of a definition of
nursing.
First, she participated in the revision of a nursing textbook.
Second, she was concerned that many states had no provision for nursing
licensure to ensure safe and competent care for the consumer.
In the revision she recognized the need to be clear about the functions of
the nurse and she believed that this textbook serves as a main learning
source for nursing practice should present a sound and definitive
description of nursing.
Furthermore, the principles and practice or nursing must be built

upon and derived from the definition of the profession.
Although official statements on the nursing function were published

by the ANA in 1932 and 1937, Henderson viewed these statements as
nonspecific and unsatisfactory definitions of nursing practice.
Then in 1955, the earlier ANA definition was modified.
Henderson's focus on individual care is evident in that she stressed

assisting individuals with essential activities to maintain health, to recover,
or to achieve peaceful death.
She proposed 14 components of basic nursing care to augment her

definition.
In 1955, Hendersons first definition of nursing was published in

Bertha Harmers revised nursing textbook.
The 14 components
Breathe normally.
Eat and drink adequately.
Eliminate body wastes.
Move and maintain desirable postures.
Sleep and rest.
Select suitable clothes-dress and undress.
Maintain body temperature within normal range by adjusting clothing
and modifying environment
Keep the body clean and well groomed and protect the integument
Avoid dangers in the environment and avoid injuring others.
Communicate with others in expressing emotions, needs, fears, or
opinions.
Worship according to ones faith.
Work in such a way that there is a sense of accomplishment.
Play or participate in various forms of recreation.
Learn, discover, or satisfy the curiosity that leads to normal development
and health and use the available health facilities.
The first 9 components are physiological.
The tenth and fourteenth are psychological aspects of communicating

and learning
The eleventh component is spiritual and moral
The twelfth and thirteenth components are sociologically oriented to

occupation and recreation
Assumption
The major assumption of the theory is that:
Nurses care for patients until patient can care for themselves once again.

Patients desire to return to health, but this assumption is not
explicitly stated.
Nurses are willing to serve and that nurses will devote themselves to
the patient day and night
A final assumption is that nurses should be educated at the university

level in both arts and sciences.
Hendersons theory and the four major concepts
Individual
Have basic needs that are component of health.
Requiring assistance to achieve health and independence or a

peaceful death.
Mind and body are inseparable and interrelated.
Considers the biological, psychological, sociological, and spiritual

components.
The theory presents the patient as a sum of parts with

biopsychosocial needs, and the patient is neither client nor consumer.
Environment
Settings in which an individual learns unique pattern for living.
All external conditions and influences that affect life and

development.
Individuals in relation to families
Minimally discusses the impact of the community on the individual

and family.
Supports tasks of private and public agencies
Society wants and expects nurses to act for individuals who are
unable to function independently.
In return she expects society to contribute to nursing education.
Basic nursing care involves providing conditions under which the

patient can perform the 14 activities unaided
Health
Definition based on individuals ability to function independently as

outlined in the 14 components.
Nurses need to stress promotion of health and prevention and cure of

disease.
Good health is a challenge.
Affected by age, cultural background, physical, and intellectual

capacities, and emotional balance
Is the individuals ability to meet these needs independently?
Nursing
Temporarily assisting an individual who lacks the necessary strength,

will and knowledge to satisfy 1 or more of 14 basic needs.

Assists and supports the individual in life activities and the
attainment of independence.
Nurse serves to make patient complete whole", or "independent."
Henderson's classic definition of nursing:

"I say that the nurse does for others what they would do for themselves if
they had the strength, the will, and the knowledge. But I go on to say that
the nurse makes the patient independent of him or her as soon as
possible."
The nurse is expected to carry out physicians therapeutic plan
Individualized care is the result of the nurses creativity in planning

for care.
Use nursing research
Categorized
o
Nursing : nursing care
Non nursing: ordering supplies, cleanliness and serving food.
In the Nature of Nursing that the nurse is and should be legally, an

independent practitioner and able to make independent judgments as long
as s/he is not diagnosing, prescribing treatment for disease, or making a
prognosis, for these are the physicians function.
Nurse should have knowledge to practice individualized and human

care and should be a scientific problem solver.
In the Nature of Nursing

o Nurse role is, to get inside the patients skin and supplement his
strength will or knowledge according to his needs.
o
And nurse has responsibility to assess the needs of the
individual patient, help individual meet their health need, and or
provide an environment in which the individual can perform activity
unaided.
Henderson's classic definition of nursing

"I say that the nurse does for others what they would do for themselves if they
had the strength, the will, and the knowledge. But I go on to say that the nurse
makes the patient independent of him or her as soon as possible."
Hendersons and Nursing Process
Henderson views the nursing process as really the application of the

logical approach to the solution of a problem. The steps are those of the
scientific method.
Nursing process stresses the science of nursing rather than the

mixture of science and art on which it seems effective health care service
of any kind is based.
Summarization of the stages of the nursing process as applied to
Hendersons definition of nursing and to the 14 components of basic
nursing care.
Nursing Process
Hendersons 14 components and definition of

nursing
Nursing Assessment
Hendersons 14 components
Analysis: Compare data to knowledge base
of health and disease.
Nursing Diagnosis
Identify individuals ability to meet own

needs with or without assistance, taking into
consideration strength, will or knowledge.
Nursing plan
Document how the nurse can assist the

individual, sick or well.
Nursing implementation
Assist the sick or well individual in to

performance of activities in meeting human
needs to maintain health, recover from
illness, or to aid in peaceful death.
Nursing implementation
Implementation based on the physiological

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

nursing
Nursing evaluation
Use the acceptable definition of ;nursing and

appropriate laws related to the practice of
nursing.
The quality of care is drastically affected by
the preparation and native ability of the
nursing personnel rather that the amount of
hours of care.
Successful outcomes of nursing care are
based on the speed with which or degree to
which the patient performs independently
the activities of daily living.
Comparison with Maslow's Hierarchy of Need

MASLOW'S
HENDERSON
Physiological
needs
Breathe normally
Eat and drink adequately
Eliminate by all avenues of elimination
Move and maintain desirable posture
Sleep and rest
Select suitable clothing
Maintain body temperature
Keep body clean and well groomed and protect the
integument
Safety needs
Avoid environmental dangers and avoid injuring

others
Belongingness
and love needs
Communicate with others
Esteem needs
Work at something providing a sense of

accomplishment
Worship according to faith
Play or participate in various forms of recreation

Learn, discover, or satisfy curiosity
Self actualization
needs
Characteristic of Hendersons theory
Theories can interrelate concepts in such a way as to create a

different way of looking at a particular phenomenon.
Concepts of fundamental human needs, biophysiology, culture, and

interaction, communication and is borrowed from other discipline.E.g..
Maslows Hierarchy of human needs; concept of interaction-communication
i.e. nurse-patient relationship
Theories must be logical in nature.
Her definition and components are logical and the 14 components are
a guide for the individual and nurse in reaching the chosen goal.
Theories should be relatively simple yet generalizable.
Her work can be applied to the health of individuals of all ages.
Theories can be the bases for hypotheses that can be tested.
Her definition of nursing cannot be viewed as theory; therefore, it is

impossible to generate testable hypotheses.
However some questions to investigate the definition of nursing and

the 14 components may be useful.
Is the sequence of the 14 components followed by nurses in the USA

and the other countries?
What priorities are evident in the use of the basic nursing functions?

Theories contribute to and assist in increasing the general body of
knowledge within the discipline through the research implemented to
validate them.
Her ideas of nursing practice are well accepted throughout the world
as a basis for nursing care.
However, the impact of the definition and components has not been
established through research.
Theories can be utilized by practitioners to guide and improve their

practice.
Ideally the nurse would improve nursing practice by using her

definition and 14 components to improve the health of individuals and thus
reduce illness.
Theories must be consistent with other validated theories, laws, and

principles but will leave open unanswered questions that need to be
investigated.
Philosophical claims
The philosophy reflected in Henderson's theory is an integrated approach to
scientific study that would capitalize on nursing's richness and complexity, and not
to separate the art from the science, the "doing" of nursing from the "knowing",
the psychological from the physical and the theory from clinical care.
Values and Beliefs
Henderson believed nursing as primarily complementing the patient

by supplying what he needs in knowledge, will or strength to perform his
daily activities and to carry out the treatment prescribed for him by the
physician.
She strongly believed in "getting inside the skin" of her patients in

order to know what he or she needs. The nurse should be the substitute
for the patient, helper to the patient and partner with the patient. Like she
said...
"The nurse is temporarily the consciousness of the unconscious, the love of
life for the suicidal, the leg of the amputee, the eyes of the newly blind, a
means of locomotion for the infant and the knowledge and confidence for
the young mother..."
Henderson stated that Thorndikes fundamental needs of man

(Henderson, 1991, p.16) had an influence on her beliefs.
Value in extending nursing science
From an historical standpoint, her concept of nursing enhanced

nursing science this has been particularly important in the area of nursing
education.
Her contributions to nursing literature extended from the 1930s

through the 1990s and has had an impact on nursing research by
strengthening the focus on nursing practice and confirming the value of
tested interventions in assisting individuals to regain health.
Usefulness
Nursing education has been deeply affected by Hendersons clear

vision of the functions of nurses.

The principles of Hendersons theory were published in the major
nursing textbooks used from the 1930s through the 1960s, and the
principles embodied by the 14 activities are still important in evaluating
nursing care in thee21st centaury.
Others concepts that Henderson (1966) proposed have been used in

nursing education from the 1930s until the present O'Malley, 1996)
Testability
Henderson supported nursing research, but believed that it should be

clinical research (OMalley, 1996). Much of the research before her time
had been on educational processes and on the profession of nursing itself,
rather than on; the practice and outcomes of nursing , and she worked to
change that.
Each of the 14 activities can be the basis for research. Although the
statements are not.
Written in testable terms, they may be reformulated into

researchable questions. Further, the theory can guide research in any
aspect of the individuals care needs.
Limitations
Lack of conceptual linkage between physiological and other human

characteristics.
No concept of the holistic nature of human being.
If the assumption is made that the 14 components prioritized, the

relationship among the components is unclear.
Lacks inter-relate of factors and the influence of nursing care.
Assisting the individual in the dying process she contends that the
nurse helps, but there is little explanation of what the nurse does.
Peaceful death is curious and significant nursing role.
Purposes of nursing theories

In Practice:
Serve to guide assessment, interventions, and evaluation of nursing

care.
Provide a rationale for collecting reliable and valid data about the
health status of clients, which are essential for effective decision making
and implementation.
Help to describe criteria to measure the quality of nursing care.
Help build a common nursing terminology to use in communicating

with other health professionals.
Ideas are developed and words are defined.
Enhance autonomy (independence and self-governance) of nursing

through defining its own independent functions.
In Education:
Provide a general focus for curriculum design
Guide curricular decision making.
In Research:
Offer a framework for generating knowledge and new ideas.
Assist in discovering knowledge gaps in the specific field of study.
Offer a systematic approach to identify questions for study; select

variables, interpret findings, and validate nursing interventions.
Approaches to developing nursing theory
Borrowing conceptual frameworks from other disciplines.
Inductively looking at nursing practice to discover theories/concepts

to explain phenomena.
Deductively looking for the compatibility of a general nursing theory

with nursing practice.
Questions from practicing Nurse about using Nursing theory
Practice
Does this theory reflect nursing practice as I know it?
Will it support what I believe to be excellent nursing practice?
Can this theory be considered in relation to a wide range of nursing

situation?
Personal Interests, Abilities and Experiences
What will it be like to think about nursing theory in nursing practice?
Will my work with nursing theory be worth the effort?
Summary
1.
Background
2.
Achievements
3.
Publications
4.
Analysis of Nursing theories
5.
Development of Hendersons definition of nursing
6.
14 components
7.
Major four concepts
8.
Nursing process with Hendersons theory
9.
Comparison with Maslow's Hierarchy need
10.
Assumptions
11.
Usefulness
12.
Testability
13.
Characteristics
14.
imitation
Conclusion
In conclusion, Henderson provides the essence of what she believes is a definition
of nursing. She didnt intend to develop a theory of nursing but rather she
attempted to define the unique focus of nursing. Her emphasis on basic human
needs as the central focus of nursing practice has led to further theory
development regarding the needs of the person and how nursing can assist in
meeting those needs. Her definition of nursing and the 14 components of basic
nursing care are uncomplicated and self-explanatory.
JEAN WATSON'S PHILOSOPHY OF

NURSING
Introduction
Born: West Virginia
Educated: BSN, University of Colorado, 1964, MS, University of Colorado,

1966, PhD, University of Colorado, 1973
Dr. Jean Watson is Distinguished Professor of Nursing and holds an endowed

Chair in Caring Science at the University of Colorado Health Sciences Center.
She is founder of the original Center for Human Caring in Colorado and is a
Fellow of the American Academy of Nursing. She previously served as Dean of
Nursing at the University Health Sciences Center and is a Past President of the
National League for Nursing
Dr. Watson has earned undergraduate and graduate degrees in nursing and
psychiatric-mental health nursing and holds her PhD in educational
psychology and counseling.
She is a widely published author and recipient of several awards and honors,
including an international Kellogg Fellowship in Australia, a Fulbright Research
Award in Sweden and six (6) Honorary Doctoral Degrees, including 3
International Honorary Doctorates (Sweden, United Kingdom, Quebec,
Canada).
Her research has been in the area of human caring and loss.
The foundation of Jean Watsons theory of nursing was published in 1979 in

nursing: The philosophy and science of caring
In 1988, her theory was published in nursing: human science and human
care.
Watson believes that the main focus in nursing is on carative factors. She
believes that for nurses to develop humanistic philosophies and value system,
a strong liberal arts background is necessary.
This philosophy and value system provide a solid foundation for the science of
caring. A humanistic value system thus under grids her construction of the
science of caring.
She asserts that the caring stance that nursing has always held is being
threatened by the tasks and technology demands of the curative factors.
The seven assumptions
Watson proposes even assumptions about the science of caring. The basic
assumptions are:
1. Caring can be effectively demonstrated and practiced only interpersonally.
2. Caring consists of carative factors that result in the satisfaction of certain
human needs.
3. Effective caring promotes health and individual or family growth.
4. Caring responses accept person not only as he or she is now but as what he
or she may become.
5. A caring environment is one that offers the development of potential while
allowing the person to choose the best action for himself or herself at a given
point in time.
6. Caring is more healthogenic than is curing. A science of caring is
complementary to the science of curing.
7. The practice of caring is central to nursing.
The ten primary carative factors
The structure for the science of caring is built upon ten carative factors.
These are:
The formation of a humanistic- altruistic system of values.
The installation of faith-hope.
The cultivation of sensitivity to ones self and to others.
The development of a helping-trust relationship
The promotion and acceptance of the expression of positive and negative

feelings.
The systematic use of the scientific problem-solving method for decision

making
The promotion of interpersonal teaching-learning.
The provision for a supportive, protective and /or corrective mental, physical,
socio-cultural and spiritual environment.
Assistance with the gratification of human needs.
The allowance for existential-phenomenological forces.
The first three carative factors form the philosophical foundation for the science of
caring. The remaining seven carative factors spring from the foundation laid by these
first three.
1. The formation of a humanistic- altruistic system of values
Begins developmentally at an early age with values shared with the parents.
Mediated through ones own life experiences, the learning one gains and
exposure to the humanities.
Is perceived as necessary to the nurses own maturation which then promotes

altruistic behavior towards others.
2. Faith-hope
Is essential to both the carative and the curative processes.
When modern science has nothing further to offer the person, the nurse can
continue to use faith-hope to provide a sense of well-being through beliefs
which are meaningful to the individual.
3. Cultivation of sensitivity to ones self and to others
Explores the need of the nurse to begin to feel an emotion as it presents

itself.
Development of ones own feeling is needed to interact genuinely and

sensitively with others.
Striving to become sensitive, makes the nurse more authentic, which

encourages self-growth and self-actualization, in both the nurse and those
with whom the nurse interacts.
The nurses promote health and higher level functioning only when they form
person to person relationship.
4. Establishing a helping-trust relationship
Strongest tool is the mode of communication, which establishes rapport and

caring.
She has defined the characteristics needed to in the helping-trust relationship.

These are:
Congruence
Empathy
Warmth
Communication includes verbal, nonverbal and listening in a manner which

connotes empathetic understanding.
5. The expression of feelings, both positive and negative
According to Watson, feelings alter thoughts and behavior, and they

need to be considered and allowed for in a caring relationship.
According to her such expression improves ones level of awareness.
Awareness of the feelings helps to understand the behavior it engenders.
6. The systematic use of the scientific problem-solving method for decision

making
According to Watson, the scientific problem- solving method is the only

method that allows for control and prediction, and that permits selfcorrection.
She also values the relative nature of nursing and supports the need to
examine and develop the other methods of knowing to provide an holistic
perspective.
The science of caring should not be always neutral and objective.
7. Promotion of interpersonal teaching-learning
The caring nurse must focus on the learning process as much as the teaching
process.
Understanding the persons perception of the situation assist the nurse to

prepare a cognitive plan.
8. Provision for a supportive, protective and /or corrective mental, physical,

socio-cultural and spiritual environment
Watson divides these into eternal and internal variables, which the nurse
manipulates in order to provide support and protection for the persons
mental and physical well-being.
The external and internal environments are interdependent.
Watson suggests that the nurse also must provide comfort, privacy and safety
as a part of this carative factor.
9. Assistance with the gratification of human needs
It is grounded in a hierarchy of need similar to that of the Maslows.
She has created a hierarchy which she believes is relevant to the science of
caring in nursing.
According to her each need is equally important for quality nursing care and
the promotion of optimal health. All the needs deserve to be attended to and
valued.
Watsons ordering of needs
Lower order needs (biophysical needs)

o
The need for food and fluid
The need for elimination
The need for ventilation
Lower order needs (psychophysical needs)

o
The need for activity-inactivity
The need for sexuality
Watsons ordering of needs

o
Higher order needs (psychosocial needs)
The need for achievement
The need for affiliation
Higher order need (intrapersonal-interpersonal need)
The need for self-actualization
Research findings have established a correlation between emotional distress

and illness. According to Watson, the current thinking of holistic care
emphasizes that:
o Factors of the etiological component interact and produce change
through complex neuro-physiological and neuro-chemical pathways
o Each psychological function has a physiological correlate
o
Each physiological component has a psychological correlate
Example:
Bulemia, anorexia and gastro-intestinal ulcers are a just few of the disorders that
indicate a complex interaction between the physiological and psychological.
10. Allowance for existential-phenomenological forces
Phenomenology is a way of understanding people from the way things appear
to them, from their frame of reference.
Existential psychology is the study of human existence using
phenomenological analysis.
This factor helps the nurse to reconcile and mediate the incongruity of viewing
the person holistically while at the same time attending to the hierarchical
ordering of needs.
Thus the nurse assists the person to find the strength or courage to confront
life or death.
Watsons theory and the four major concepts
1.
Human being
She adopts a view of the human being as: .. a valued person in and of him
or herself to be cared for, respected, nurtured, understood and assisted; in
general a philosophical view of a person as a fully functional integrated self.
He, human is viewed as greater than and different from, the sum of his or her
parts.
2.
Health
Watson believes that there are other factors that are needed to be included in
the WHO definition of health. She adds the following three elements:
A high level of overall physical, mental and social functioning
3.
A general adaptive-maintenance level of daily functioning
The absence of illness (or the presence of efforts that leads its absence)
Environment/society
According to Watson caring (and nursing) has existed in every society. A
caring attitude is not transmitted from generation to generation. It is
transmitted by the culture of the profession as a unique way of coping with
its environment.
4.
Nursing
According to Watson nursing is concerned with promoting health, preventing
illness, caring for the sick and restoring health.
It focuses on health promotion and treatment of disease. She believes that
holistic health care is central to the practice of caring in nursing.
She defines nursing as..
A human science of persons and human health-illness experiences that are
mediated by professional, personal, scientific, esthetic and ethical human
transactions.
Watsons theory and nursing process
Watson points out that nursing process contains the same steps as the
scientific research process. They both try to solve a problem. Both provide a
framework for decision making. Watson elaborates the two processes as:
1.
Assessment
Involves observation, identification and review of the problem; use of
applicable knowledge in literature.
Also includes conceptual knowledge for the formulation and conceptualization
of framework.
Includes the formulation of hypothesis; defining variables that will be
examined in solving the problem.
2.
Plan
It helps to determine how variables would be examined or measured; includes
a conceptual approach or design for problem solving. It determines what data
would be collected and how on whom.
3.
Intervention
It is the direct action and implementation of the plan.
It includes the collection of the data.
4.
Evaluation
Analysis of the data as well as the examination of the effects of interventions
based on the data. Includes the interpretation of the results, the degree to
which positive outcome has occurred and whether the result can be
generalized.
It may also generate additional hypothesis or may even lead to the generation
of a nursing theory.
Watsons work and the characteristic of a theory
According to Watson, a theory is an imaginative grouping of knowledge,
ideas and experiences that are represented symbolically and seek to
illuminate a given phenomenon
She views nursing as,
.both a human science and an art and as such it cannot be considered
qualitatively continuous with traditional, reductionistic, scientific
methodology.
She suggests that nursing might want to develop its own science that would
not be related to the traditional sciences but rather would develop its own
concepts, relationships and methodology.
Theories can interrelate concepts in such a way as to create a different way of
looking at a particular phenomenon
The basic assumptions for the science of caring in nursing and the ten
carative factors that form the structure for that concept is unique in Watsons
theory.
She describes caring in both philosophical and scientific terms.
Watson also indicates that needs are interrelated.
The science of caring suggests that the nurse recognize and assist with each
of the interrelated needs in order to reach the highest order need of selfactualization.
Theories must be logical in nature
Watsons work is logical in that the factors are based on broad assumptions
which provide a supportive framework.
With these carative factors she delineates nursing from other professions
These carative factors are logically derived from the assumptions and related
to he hierarchy of needs.
Theories should be relatively simple yet generalizable
The theory is relatively simple as it does not use theories from other
disciplines that are familiar to nursing.
The theory is simple relatively but the fact that it de-emphasizes the
pathophysiological for the psychosocial diminishes its ability to be
generalizable.
She discusses this in the preface of her book when she speaks of the trim
and the core of nursing.
She defines trim as the clinical focus, the procedure and the techniques.
The core of the nursing is that which is intrinsic to the nurse-client interaction
that produces a therapeutic result. Core mechanisms are the carative factors.
Theories can be the basis for hypotheses that can be tested
Watsons theory is based on phenomenological studies that generally ask
questions rather than state hypotheses. Its purpose is to describe the
phenomena, to analyze and to gain an understanding.
Theories contribute to and assist in increasing the general body within the
discipline through research implemented to validate them
According to Watson the best method to test this theory is through field
study.
An example is her work in the area of loss and caring that took place in
Cundeelee, Western Australia and involved a tribe of aborigines.
Theories can be utilized by practitioners to guide and improve their practice
Watsons work can be used to guide and improve practice.
It can provide the nurse with the most satisfying aspects of practice and can
provide the client with the holistic care so necessary for human growth and
development.
Theories must be consistent with other validated theories, laws and principles
but will leave open unanswered questions that need to be investigated
Watsons work is supported by the theoretical work of numerous humanists,
philosophers, developmentalists and psychologists.
She clearly designates the theories of stress, development, communication,
teaching-learning, humanistic psychology and existential phenomenology
which provide the foundation for the science of caring.
Strengths
Besides assisting in providing the quality of care that client ought to receive,
it also provides the soul satisfying care for which many nurses enter the
profession.
As the science of caring ranges from the biophysical through the
intrapersonal, each nurse becomes an active coparticipant in the clients
struggle towards self-actualization.
The client is placed in the context of the family, the community and the
culture.
It places the client as the focus of practice rather than the technology.
Limitations
Given the acuity of illness that leads to hospitalization, the short length stay ,
and the increasing complex technology, such quality of care may be deemed
impossible to give in the hospital.
While Watson acknowledges the need for biophysical base to nursing, this
area receives little attention in her writings.
The ten caratiive factors primarily delineate the psychosocial needs of the
person.
While the carative factors have a sound foundation based on other disciplines,
they need further research in nursing to demonstrate their application to
practice.
Summary
Watsons theory
Its seven assumptions
The ten carative factors
Watsons theory and the four major concepts
Watsons theory and the nursing process
Watsons work and the characteristics of the theory
Strengths
Limitations
Research related to Watsons theory

Saint Joseph Hospital in Orange, California has selected Jean Watsons theory
of human caring as the framework base for nursing practice.
The effectiveness of Watson's Caring Model on the quality of life and blood
pressure of patients with hypertension. J Adv Nurs. 2003 Jan;41(2):130-9.
This study demonstrated a relationship between care given according to
Watson's Caring model and increased quality of life of the patients with
hypertension. Further, in those patients for whom the caring model was
practised, there was a relationship between the Caring model and a decrease
in patient's blood pressure. The Watson Caring Model is recommended as a
guide to nursing patients with hypertension, as one means of decreasing
blood pressure and increase in quality of life.
Martin, L. S. (1991). Using Watsons theory to explore the dimensions of adult
polycystic kidney disease . ANNA Journal, 18, 403-406 .
Mullaney, J. A. B. (2000). The lived experience of using Watsons actual

caring occasions to treat depressed women . Journal of Holistic Nursing,
18(2), 129-142
Martin, L. S. (1991). Using Watsons theory to explore the dimensions of adult
polycystic kidney disease . ANNA Journal, 18, 403-406
Conclusion
1. Watson provides many useful concepts for the practice of nursing.
2. She ties together many theories commonly used in nursing education and
does so in a manner helpful to practioners of the art and science of nursing.
3. The detailed descriptions of the carative factors can give guidance to those
who wish to employ them in practice or research.
4. Using her theory can add a dimension to practice that is both satisfying and
challenging.
Reference
Timber BK. Fundamental skills and concepts in Patient Care, 7th edition, LWW,
N
Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd
ed. Philadelphia, Lippincott.
Vandemark L.M. Awareness of self & expanding consciousness: using Nursing

theories to prepare nurse therapists Ment Health Nurs. 2006 Jul; 27(6) :
605-15
Jul;19(3):225
Cheng MY. Using King's Goal Attainment Theory to facilitate drug compliance
in a psychiatric patient. Hu Li Za Zhi. 2006 Jun;53(3):90-7.
Delaune SC,. Ladner PK, Fundamental of nursing, standard and practice, 2nd
edition, Thomson, NY, 2002.
JOHNSONS BEHAVIOUR SYSTEM

MODEL
Introduction
Dorothy E. Johnson was born August 21, 1919, in Savannah, Georgia.
B. S. N. from Vanderbilt University in Nashville, Tennessee, in 1942; and her
M.P.H. from Harvard University in Boston in 1948.
From 1949 until her retirement in 1978 she was an assistant professor of
pediatric nursing, an associate professor of nursing, and a professor of
nursing at the University of California in Los Angeles.
Dorothy Johnson has had an influence on nursing through her publications
since the 1950s. Throughout her career, Johnson has stressed the
importance of research-based knowledge about the effect of nursing care
on clients.
Johnsons behavior system model
In 1968 Dorothy first proposed her model of nursing care as fostering of
the efficient and effective behavioral functioning in the patient to prevent
illness".
She also stated that nursing was concerned with man as an integrated
whole and this is the specific knowledge of order we require.
In 1980 Johnson published her conceptualization of behavioral system of
model for nursing this is the first work of Dorothy that explicates her
definitions of the behavioral system model.
Definition of nursing
She defined nursing as an external regulatory force which acts to preserve the
organization and integration of the patients behaviors at an optimum level under
those conditions in which the behaviors constitutes a threat to the physical or
social health, or in which illness is found
Based on this definition there are four goals of nursing are to assist the patient:
Whose behavior commensurate with social demands.
1.
2.
3.
4.
Who is able to modify his behavior in ways that it supports biological

imperatives
Who is able to benefit to the fullest extent during illness from the physicians
knowledge and skill.
Whose behavior does not give evidence of unnecessary trauma as a
consequence of illness
Assumptions of behavioral system model
There are several layers of assumptions that Johnson makes in the development
of conceptualization of the behavioral system model (Johnson was influenced by
Buckley ,Chin and Rapport) there are 4 assumptions of system:
First assumption states that there is organization, interaction, interdependency
and integration of the parts and elements of behaviors that go to make up The
system
A system tends to achieve a balance among the various forces operating within
and upon it', and that man strive continually to maintain a behavioral system
balance and steady state by more or less automatic adjustments and adaptations
to the natural forces impinging upon him.
A behavioral system, which both requires and results in some degree of
regularity and constancy in behavior, is essential to man that is to say, it is
functionally significant in that it serves a useful purpose, both in social life and for
the individual.
The final assumption states system balance reflects adjustments and
adaptations that are successful in some way and to some degree.
1. The integration of these assumptions provides the behavioral system

with the pattern of action to form an organized and integrated functional
unit that determines and limits the interaction between the person and his
environment and establishes the relation of the person to the objects,
events and situations in his environment.
2. The integration of these assumptions provides the behavioral system
with the pattern of action to form an organized and integrated functional

unit that determines and limits the interaction between the person and his
environment and establishes the relation of the person to the objects,
events and situations in his environment.
Assumptions about structure and function of each subsystem
2.from the form the behavior takes and the consequences it achieves can be
inferred what drive has been stimulated or what goal is being sought
3.Each individual has a predisposition to act with reference to the goal, in
certain ways rather than the other ways. This predisposition is called as
set.
4.Each subsystem has a repertoire of choices or scope of action
1.The fourth assumption is that it produce observable outcome that is the
individuals behavior.
Each subsystem has three functional requirements
2.System must be protected" from noxious influences with which system
cannot cope.
3.Each subsystem must be nurtured through the input of appropriate
supplies from the environment.
1.Each subsystem must be stimulated for use to enhance growth and
prevent stagnation
Johnson believes each individual has patterned, purposeful, repetitive ways of

acting that comprise a behavioral system specific to that individual. These actions
and behaviors form an organized and integrated functional unit that determines
and limits the interaction between the person and his environment and establishes
the relationship of the person to the objects event situations in the environment.
These behaviors are orderly, purposeful and predictable and sufficiently stable
and recurrent to be amenable to description and explanation
Johnsons Behavioral Subsystem
2. Attachment or affiliative subsystem: social inclusion intimacy and the

formation and attachment of a strong social bond.
3. Dependency subsystem: approval, attention or recognition and physical

assistance
4. Ingestive subsystem: the emphasis is on the meaning and structures of

the social events surrounding the occasion when the food is eaten
5. Eliminative subsystem: human cultures have defined different socially

acceptable behaviors for excretion of waste ,but the existence of such a
pattern remains different from culture to Culture.
6. Sexual subsystem:" both biological and social factor affect the behavior in
the sexual subsystem
7. Aggressive subsystem:" it relates to the behaviors concerned with
protection and self preservation Johnson views aggressive subsystem as

one that generates defensive response from the individual when life or
territory is being threatened
1. Achievement subsystem: provokes behavior that attempt to control the
environment intellectual, physical, creative, mechanical and social skills

achievement are some of the areas that Johnson recognizes".
Representation of Johnson's Model
Goal ----Set
--Choice of Behavior --Behavior
Affiliation
Dependency
Sexuality
Aggression
Elimination
Ingestion
Achievement
The four major concepts
2. Johnson views human being as having two major systems, the biological
system and the behavioral system. It is role of the medicine to focus on
biological system where as Nursling's focus is the behavioral system.
3. Society relates to the environment on which the individual exists.
According to Johnson an individuals behavior is influenced by the events in

the environment
4. Health is a purposeful adaptive response, physically mentally, emotionally,

and socially to internal and external stimuli in order to maintain stability
and comfort.
1. Nursing has a primary goal that is to foster equilibrium within the
individual .she stated that nursing is concerned with the organized and
integrated whole, but that the major focus is on maintaining a balance in

the Behavior system when illness occurs in an individual.
Nursing process
Assessment
Grubbs developed an assessment tool based on Johnsons seven subsystems plus
a subsystem she labeled as restorative which focused on activities of daily
living .An assessment based on behavioral model does not easily permit the nurse
to gather detailed information about the biological systems:
1.Affiliation
2.Dependency
3.Sexuality
4.Aggression
5.Elimination
6.Ingestion
7.Achievement
8.Restorative
Diagnosis
Diagnosis tends to be general to the system than specific to the problem. Grubb
has proposed 4 categories of nursing diagnosis derived from Johnson's behavioral
system model:
1.Insufficiency
2.Discrepancy
3.Incompatibility
4.Dominance
Planning and implementation
Implementation of the nursing care related to the diagnosis may be difficult
because of lack of clients input in to the plan. the plan will focus on nurses actions
to modify clients behavior, these plan than have a goal ,to bring about
homeostasis in a subsystem, based on nursing assessment of the individuals
drive, set behavior, repertoire, and observable behavior. The plan may include
protection, nurturance or stimulation of the identified subsystem.
Evaluation
Evaluation is based on the attainment of a goal of balance in the identified
subsystems. If the baseline data are available for an individual, the nurse may
have goal for the individual to return to the baseline behavior. If the alterations in
the behavior that are planned do occur, the nurse should be able to observe the
return to the previous behavior patterns. Johnson's behavioral model with the
nursing process is a nurse centered activity, with the nurse determining the clients
needs and state behavior appropriate for that need.
Situation
John Smith, 6 weeks brought into the clinic for a routine check-up. He presents
with no weight gain since his check up at the age of 2 weeks .His mother stated
she feeds him but he does not seem to eat much. He sleeps 4to 5 hour between
the feedings. His mother holds him in her arms without trunk to trunk contact. As
the assessment is made the nurse notes that Mrs. Smith never looks at Johnny
and never speaks to him. She stated he was a planned baby but that she never
realized how much work a baby could be. She says, her mother told her she was
not a good mother because John is not gaining weight like he should. She states
she had not called the nurse when she knew John was not gaining weight because
she thought nurse would think she was a bad mother just like her own mother
thought she was a bad mother.
Assessment
1.Affiliative subsystem between mother and John.
2.Dependency subsystem between mother and John
3.Affiliative subsystem between Mrs.Smith and her mother.
4.Insufficiency ingesion subsystem.
Diagnosis
1.Insufficient development of the affiliative subsystem.
2.Insufficient development of the dependency subsystem
Planning and implementation
1.Increasing mothers awareness of the babys clues.
2.Assisting her to talk with the baby.
3.Teach her to bring a bond between her and the baby by touch, pat and
cuddles etc.
Evaluation
1.Johnny's weight gain or weight loss will be carefully assessed.
2.The infant interaction could be reassessed, using the nursing child
assessment feeding scale.
3.The interaction of Mrs. Smith with her mother.
Johnsons and Characteristics of a theory
1.Interrelate concepts to create a different way of viewing a phenomenon.
2.Theories must be logical in nature.
3.Theories must be simple yet generalizable
4.Theories can be bases of hypothesis that can be tested.
5.Theories contribute to and assist in increasing the body of knowledge within
the discipline through the research implemented to validate them
6.Theories can be utilized by practitioners to guide and improve their practice.
7.Theories must be consistent with other validated theories, laws and
principles but will leave unanswered questions that need to be
investigated.
Limitation
Johnson does not clearly interrelate her concepts of subsystems comprising
the behavioral system model.
The definition of concept is so abstract that they are difficult to use.
It is difficult to test Johnson's model by development of hypothesis.
The focus on the behavioral system makes it difficult for nurses to work with
physically impaired individual to use this theory.
The model is very individual oriented so the nurses working with the group
have difficulty in its implementation.
The model is very individual oriented so the family of the client is only
considered as an environment.
Johnson does not define the expected outcomes when one of the system is
affected by the nursing implementation an implicit expectation is made
that all human in all cultures will attain same outcome homeostasis.
Johnsons behavioral system model is not flexible.
Summary
Johnsons Behavioral system model is a model of nursing care that advocates the
fostering of efficient and effective behavioral functioning in the patient to prevent
illness. The patient is defined as behavioral system composed of 7 behavioral
subsystems. Each subsystem composed of four structural characteristics i.e.
drives, set, choices and observable behavior. Three functional requirement of each
subsystem includes (1) Protection from noxious influences, (2) Provision for the
nurturing environment, and (3) stimulation for growth. Any imbalance in each
system results in disequilibrium .it is nursing role to assist the client to return to
the state of equilibrium.
Reference

Polit DF, Hungler BP. Nursing Research: Principles and Methods. Philadelphia:
JB Lippincott Company; 1998.
Burns N, Grove SK. The practice of Nursing Research. 4th Ed. Philadelphia:
WB Saunders Publications; 2001.
Treece JW, Treece EW. Elements of Research in Nursing (3rded.). St. Louis:
Mosby; 1982.
IMOGENE KING: THEORY OF GOAL

ATTAINMENT
Introduction of Theorist
Born in 1923
Completed her Bachelor in science of nursing from St. Louis University in

1948
Completed her Master of science in nursing from St. Louis University in 1957
Completed her Doctorate from Teachers college, Columbia University
Kings Conceptual Framework

It includes:
Several basic assumptions
Three interacting systems
Several concepts relevant for each system
Basic assumptions
Nursing focus is the care of human being
Nursing goal is the health care of individuals & groups
Human beings: are open systems interacting constantly with their

environment
Interacting systems:
personal system
Interpersonal system
Social system
Concepts are given for each system
Concepts for Personal System
Perception
Self
Growth & development
Body image
Space
Time
Concepts for Interpersonal System
Interaction
Communication
Transaction
Role
Stress
Concepts for Social System
Organization
Authority
Power
Status
Decision making
Major Theses of Kings conceptual framework
Each human being perceives the world as a total person in making

transactions with individuals and things in environment
Transaction represents a life situation in which perceiver & thing perceived

are encountered and in which person enters the situation as an active
participant and each is changed in the process of these experiences
Kings Theory of Goal Attainment
Theory of goal attainment was first introduced by Imogene King in the early
1960s.
Theory describes a dynamic, interpersonal relationship in which a person

grows and develops to attain certain life goals.
Factors which affects the attainment of goal are: roles, stress, space & time
Propositions of Kings Theory

From the theory of goal attainment king developed predictive propositions, which
includes:
If perceptual interaction accuracy is present in nurse-client interactions,

transaction will occur
If nurse and client make transaction, goal will be attained
If goal are attained, satisfaction will occur
Proposition cont
If transactions are made in nurse-client interactions, growth & development

will be enhanced
If role expectations and role performance as perceived by nurse & client are
congruent, transaction will occur
If role conflict is experienced by nurse or client or both, stress in nurse-client

interaction will occur
If nurse with special knowledge skill communicate appropriate information to

client, mutual goal setting and goal attainment will occur.
Major concepts of kings theory

1. Human being /person: is social being who are rational and sentient. Person has
ability to :
-perceive
-think
-feel
-choose
-set goals
-select means to achieve goals
-and to make decision
According to King, human being has three fundamental needs:
(a) The need for the health information that is unable at the time
when it is needed and can be used
(b) The need for care that seek to prevent illness, and
(c) The need for care when human beings are unable to help
themselves.
2.
Health:
According to King, health involves dynamic life experiences of a human being, which
implies continuous adjustment to stressors in the internal and external environment
through optimum use of ones resources to achieve maximum potential for daily
living
3.
Environment
Environment is the background for human interactions. It involves:

(a) Internal environment: transforms energy to enable person to
adjust to continuous external environmental changes.
(b) External environment: involves formal and informal
organizations. Nurse is a part of the patients environment.
4.
Nursing
Nursing: is defined as A process of action, reaction and interaction by which nurse

and client share information about their perception in nursing situation. and a
process of human interactions between nurse and client whereby each perceives the
other and the situation, and through communication, they set goals, explore means,
and agree on means to achieve goals.
1.
Action: is defined as a sequence of behaviors involving mental and

physical action.
2.
Reaction: not specified, but might be considered as included in the

sequence of behaviors described in action.
3.
In addition king discussed:

(a)
goal
(b)
domain and
(c)
functions of professional nurse
4.
Goal of nurse: To help individuals to maintain their health so they can

function in their roles.
5.
Domain of nurse: includes promoting, maintaining, and restoring

health, and caring for the sick, injured and dying.
6.
Function of professional nurse: To interpret information in nursing

process to plan, implement and evaluate nursing care.
King said in her theory, A professional nurse, with special knowledge and skills, and
a client in need of nursing, with knowledge of self and perception of personal
problems, meet as strangers in natural environment. They interact mutually, identify

problems, establish and achieve goals.
Theory of Goal Attainment and Nursing Process
Assumptions
Basic assumption of goal attainment theory is that nurse and client communicate
information, set goal mutually and then act to attain those goals, is also the basic
assumption of nursing process.
Assessment
King indicates that assessment occur during interaction. The nurse brings
special knowledge and skills whereas client brings knowledge of self and
perception of problems of concern, to this interaction.
During assessment nurse collects data regarding client (his/her growth &
development, perception of self and current health status, roles etc.)
Perception is the base for collection and interpretation of data.
Communication is required to verify accuracy of perception, for interaction

and transaction.
Nursing diagnosis
The data collected by assessment are used to make nursing diagnosis in

nursing process. Acc. to king in process of attaining goaI the nurse identifies
the problems, concerns and disturbances about which person seek help.
Planning
After diagnosis, planning for interventions to solve those problems is done.
In goal attainment planning is represented by setting goals and making

decisions about and being agreed on the means to achieve goals.
This part of transaction and clients participation is encouraged in making

decision on the means to achieve the goals.
Implementations
In nursing process implementation involves the actual activities to achieve the

goals.
In goal attainment it is the continuation of transaction.
Evaluation
1. It involves to finding out weather goals are achieved or not.
2. In king description evaluation speaks about attainment of goal and
effectiveness of nursing care.
Nursing Process and Theory of Goal Attainment
Nursing process method
Nursing process theory
A system of oriented actions A system of oriented concepts

Assessment
Perception, communication and

interaction of nurse and client
Planning
Decision making about the goals

Be agree on the means to attain
the goals
Implementation
Transaction made
Evaluation
Goal attained
References


Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress


Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby,
Philadelphia, 2002
BETTY NEUMANNS SYSTEM MODEL

INTRODUCTION
Betty Neumanns system model provides a comprehensive flexible holistic
and system based perspective for nursing.
It focuses attention on the response of the client system to actual or
potential environmental stressors.
And the use of primary, secondary and tertiary nursing prevention
intervention for retention, attainment, and maintenance of optimal client
system wellness.
HISTORY AND BACKGROUND OF THE THEORIST
Betty Neumann was born in 1924, in Lowel, Ohio.
She completed BS in nursing in 1957 and MS in Mental Health Public health
consultation, from UCLA in 1966. She holds a Ph.D. in clinical psychology
She was a pioneer in the community mental health movement in the late
1960s.
Betty Neumann began developing her health system model while a lecturer
in community health nursing at University of California, Los Angeles.
The models was initially developed in response to graduate nursing students
expression of a need for course content that would expose them to breadth
of nursing problems prior to focusing on specific nursing problem areas.
The model was published in 1972 as A Model for Teaching Total Person
Approach to Patient Problems in Nursing Research.
It was refined and subsequently published in the first edition of Conceptual
Models for Nursing Practice, 1974, and in the second edition in 1980.
DEVELOPMENT OF THE MODEL
Neumanns model was influenced by a variety of sources.
The philosophy writers deChardin and cornu (on wholeness in system).
Von Bertalanfy, and Lazlo on general system theory.
Selye on stress theory.
Lararus on stress and coping.
BASIC ASSUMPTIONS
Each client system is unique, a composite of factors and characteristics

within a given range of responses contained within a basic structure.
Many known, unknown, and universal stressors exist. Each differ in its
potential for disturbing a clients usual stability level or normal LOD
The particular inter-relationships of client variables at any point in time can
affect the degree to which a client is protected by the flexible LOD against
possible reaction to stressors.
Each client/ client system has evolved a normal range of responses to the
environment that is referred to as a normal LOD. The normal LOD can be
used as a standard from which to measure health deviation.
When the flexible LOD is no longer capable of protecting the client/ client
system against an environmental stressor, the stressor breaks through the
normal LOD
The client whether in a state of wellness or illness, is a dynamic composite
of the inter-relationships of the variables. Wellness is on a continuum of
available energy to support the system in an optimal state of system
stability.
Implicit within each client system are internal resistance factors known as
LOR, which function to stabilize and realign the client to the usual wellness
state.
Primary prevention relates to G.K. that is applied in client assessment and
intervention, in identification and reduction of possible or actual risk
factors.
Secondary prevention relates to symptomatology following a reaction to
stressor, appropriate ranking of intervention priorities and treatment to
reduce their noxious effects.
Tertiary prevention relates to adjustive processes taking place as
reconstitution begins and maintenance factors move the back in circular
manner toward primary prevention.
The client as a system is in dynamic, constant energy exchange with the
environment.
CONCEPTS
Content: - the variables of the person in interaction with the internal and
external environment comprise the whole client system
Basic structure/Central core: - common client survival factors in unique
individual characteristics representing basic system energy resources.
The basis structure, or central core, is made up of the basic survival factors
that are common to the species (Neumann,2002).
These factors include:- - Normal temp. range, Genetic structure.- Response
pattern. Organ strength or weakness, Ego structure
Stability, or homeostasis, occurs when the amount of energy that is
available exceeds that being used by the system.
A homeostatic body system is constantly in a dynamic process of input,
output, feedback, and compensation, which leads to a state of balance.
Degree to reaction: - the amount of system instability resulting from

stressor invasion of the normal LOD.
Entropy: - a process of energy depletion and disorganization moving the
system toward illness or possible death.
Flexible LOD: - a protective, accordion like mechanism that surrounds and
protects the normal LOD from invasion by stressors.
Normal LOD: - It represents what the client has become over time, or the
usual state of wellness. It is considered dynamic because it can expand or
contract over time.
LOR: - The series of concentric circles that surrounds the basic structure.
Protection factors activated when stressors have penetrated the normal
LOD, causing a reaction symptomatology. E.g. mobilization of WBC and
activation of immune system mechanism
Input- output: - The matter, energy, and information exchanged between
client and environment that is entering or leaving the system at any point
in time.
Negentropy: - A process of energy conservation that increase organization
and complexity, moving the system toward stability or a higher degree of
wellness.
Open system:- A system in which there is continuous flow of input and
process, output and feedback. It is a system of organized complexity
where all elements are in interaction.
Prevention as intervention: - Interventions modes for nursing action and
determinants for entry of both client and nurse in to health care system.
Reconstitution: - The return and maintenance of system stability, following
treatment for stressor reaction, which may result in a higher or lower level
of wellness.
Stability: - A state of balance of harmony requiring energy exchanges as
the client adequately copes with stressors to retain, attain, or maintain an
optimal level of health thus preserving system integrity.
Stressors: - environmental factors, intra (emotion, feeling), inter (role
expectation), and extra personal (job or finance pressure) in nature, that
have potential for disrupting system stability.
A stressor is any phenomenon that might penetrate both the F and N LOD,
resulting either a positive or negative outcome.
Wellness/Illness: - Wellness is the condition in which all system parts and
subparts are in harmony with the whole system of the client.
o Illness is a state of insufficiency with disrupting needs unsatisfied
(Neuman, 2002).
o Illness is an excessive expenditure of energy when more energy is
used by the system in its state of disorganization than is built and
stored; the outcome may be death (Neuman, 2002).
PREVENTION
According to Neumanns model, prevention is the primary nursing

intervention. Prevention focuses on keeping stressors and the stress
response from having a detrimental effect on the body.
PRIMARY PREVENTION
Primary prevention occurs before the system reacts to a stressor. On the
one hand, it strengthens the person (primary the flexible LOD) to enable
him to better deal with stressors
On the other hand manipulates the environment to reduce or weaken
stressors.
Primary prevention includes health promotion and maintenance of wellness.
SECONDARY PREVENTION
Secondary prevention occurs after the system reacts to a stressor and is
provided in terms of existing system.
Secondary prevention focuses on preventing damage to the central core by
strengthening the internal lines of resistance and/or removing the stressor.
TERTIARY PREVENTION
Tertiary prevention occurs after the system has been treated through
secondary prevention strategies.
Tertiary prevention offers support to the client and attempts to add energy
to the system or reduce energy needed in order to facilitate reconstitution.
FOUR MAJOR CONCEPTS
PERSON
The focus of the Neumann model is based on the philosophy that each
human being is a total person as a client system and the person is a
layered multidimensional being.
Each layer consists of five person variable or subsystems:
o Physiological- Refer of the physicochemical structure and function
of the body.
o Psychological- Refers to mental processes and emotions.
o Socio-cultural- Refers to relationships; and social/cultural
expectations and activities.
o Spiritual- Refers to the influence of spiritual beliefs.
o Developmental- Refers to those processes related to development
over the lifespan.
ENVIRONMENT
The environment is seen to be the totality of the internal and external forces
which surround a person and with which they interact at any given time.
These forces include the intrapersonal, interpersonal and extra-personal
stressors which can affect the persons normal line of defense and so can
affect the stability of the system.
The internal environment exists within the client system.
The external environment exists outside the client system.
Neumann also identified a created environment which is an

environment that is created and developed unconsciously by the
client and is symbolic of system wholeness.
HEALTH
Neumann sees health as being equated with wellness. She defines
health/wellness as the condition in which all parts and subparts
(variables) are in harmony with the whole of the client (Neumann, 1995).
The client system moves toward illness and death when more energy is
needed than is available. The client system moved toward wellness when
more energy is available than is needed
NURSING
Neumann sees nursing as a unique profession that is concerned with all of
the variables which influence the response a person might have to a
stressor.
The person is seen as a whole, and it is the task of nursing to address the
whole person.
Neuman defines nursing as action which assist individuals, families and
groups to maintain a maximum level of wellness, and the primary aim is
stability of the patient/client system, through nursing interventions to
reduce stressors.
Neuman states that, because the nurses perception will influence the care
given, then not only must the patient/clients perception be assessed, but
so must those of the caregiver (nurse).
The role of the nurse is seen in terms of degree of reaction to stressors, and
the use of primary, secondary and tertiary interventions
STAGES OF NURSING PROCESS (BY NEUMAN)
NURSING DIAGNOSIS
It depends on acquisition of appropriate database; the diagnosis identifies,
assesses, classifies, and evaluates the dynamic interaction of the five
variables.
Variances from wellness (needs and problems) are determined by
correlations and constraints through synthesis of theory and data base.
Broad hypothetical interventions are determined, i.e. maintain flexible line of
defense.
NURSING GOALS
These must be negotiated with the patient, and take account of patients
and nurses perceptions of variance from wellness.
NURSING OUTCOMES
Nursing intervention using one or more preventive modes.
Confirmation of prescriptive change or reformulation of nursing goals.
Short term goal outcomes influence determination of intermediate and long
term goals.
A client outcome validates nursing process.
NEUMANNS SYSTEM MODEL FORMAT
Neumanns nursing process format designates the following categories of data

about the client system as the major areas of assessment.
ASSESSMENT
Potential and actual stressors.
Condition and strength of basic structure factors and energy sources.
Characteristics of flexible and normal line of defenses, lines of resistance,
degree of reaction and potential for reconstitution.
Interaction between client and environment.
Life process and coping factors (past, present and future) actual and
potential stressors (internal and external) for optimal wellness external.
Perceptual difference between care giver and the client.
NURSING DIAGNOSIS
The data collected are then interpreted to condition and formulate the
Nursing diagnosis.
Health seeking behaviors.
Activity intolerance.
Ineffective coping.
Ineffective thermoregulation.
GOAL
In Neumanns systems model the goal is to keep the client system stable.
PLANNING
Planning is focused on strengthening the lines of defense and resistance.
IMPLEMENTATION
The goal of stabilizing the client system is achieved through three modes of
prevention
Primary prevention : actions taken to retain stability
Secondary prevention : actions taken to attain stability
Tertiary prevention : actions taken to maintain stability
EVALUATION
The nursing process is evaluated to determine whether equilibrium is
restored and a steady state maintained.
ACCEPTANCE BY THE NURSING COMMUNITY
Neumanns model has been described as a grand nursing theory by walker
and Avant.
Grand theories can provide a comprehensive perspective for nursing
practice, education, and research and Neumans model does.
PRACTICE
The Neumann systems model has been applied and adapted to various
specialties include family therapy, public health, rehabilitation, and hospital
nursing.
The sub specialties include pulmonary, renal, critical care, and hospital
medical units. One of the models strengths is that it can be used in a
variety of settings
Using this conceptual model permits comparison of a nurses interpretation
of a problem with that of the patient, so the patient and nurse do not work
on two separate problems.
The role of the nurse in the model is to work with the patient to move him
as far as possible along a continuum toward wellness.
Because this model requires individual interaction with the total health care
system, it is indicative of the futuristic direction the nursing profession is
taking.
The patient is being relabeled as a consumer with individual needs and
wants.
EDUCATION
The model has also been widely accepted in academic circles.
It has often been selected as a curriculum guide for a conceptual framework
oriented more toward wellness than toward a medical model and has been
used at various levels of nursing education.
In the associate degree program at Indiana University.
One of the objectives for nursing graduate is to demonstrate ability to use
the Neumann health care system in nursing practice. This helps prepare
the students for developing a frame of reference centered on holistic care.
At northwestern State University in Shreveport, Louisiana, the faculty
determined that a systems model approach was preferred for their
masters program because of the universality framework.
Acceptance by the nursing community for education therefore is evident.
RESEARCH
A study was published by Riehl and Roy to test the usefulness of the
Neumann model in nursing practice.
There were two major objectives of the study.
o To test the model/assessment tool for its usefulness as a unifying
method of collecting and analyzing data for identifying client
problems.
o To test the assessment tool for its usefulness in the identification of
congruence between the clients perception of stressors and the
care givers perception of client stressors.
Results indicated that the model can help categorize data for assessing and
planning care and for guiding decision making.
Neumanns model can easily generate nursing research.
It does this by providing a framework to develop goals for desired outcomes.
Acceptance by the nursing community for research applying this model is
in the beginning stages and positive.
NEUMANNS AND THE CHARACTERISTICS OF A THEORY
Theories connects the interrelated concepts in such a way as to

create a different way of looking at a particular phenomenon.
o The Neumann model represents a focus on nursing interest in the
total person approach to the interaction of environment and health.
o The interrelationships between the concepts of person, health,
nursing and society/environment are repeatedly mentioned
throughout the Neumann model and are considered to be basically
adequate according to the criteria.
o Neumanns model in general presents itself as logically consistent.
o There is a logical sequence in the process of nursing wherein
emphasis on the importance of accurate data assessment is basic to
the sequential steps of the nursing process.
o Neumanns model is fairly simple and straightforward in approach.
o The terms used are easily identifiable and for the most part have
definitions that are broadly accepted.
o The multiple use of the model in varied nursing situations (practice,
curriculum, and administration) is testimony in itself to its broad
applicability.
o The potential use of this model by other health care disciplines also
attests to its generalizability for use ion practice.
o One drawback in relation to simplicity is the diagrammed model since
it presents over 35 variables and tends to be awesome to the
viewer.
o Neumanns model, due to its high level and breadth of abstraction,
lends itself to theory development.
o One are for future consideration as a beginning testable theory might
be the concept of prevention as intervention, subsequent to basis
concept refinement in the Neuman model.
knowledge within the discipline through the research implemented
to validate them.
o The model has provided clear, comprehensive guidelines for nursing
education and practice in a variety of settings; this is its primary
contribution to nursing knowledge.
o The concept within the guidelines is clearly explicated and many
applications of the theory have been published, little research
explicitly derived from this model has been published to date.
Theories can be utilized by the practitioner to guide and improve
their practice.
o One of the most significant attributes of the Neumann model is the

assessment/intervention instrument together with comprehensive
guidelines for its use with the nursing process.
o These guidelines have provided a practical resource for many nursing
practitioners and have been used extensively in a variety of setting
in nursing practice, education and administration.
Theories must be consistent with other validated theories, laws and
principles but will leave open unanswered questions that need to
be investigated.
o In general, there is no direct conflict with other theories. There is,
however, a lack of specificity in systems concepts such as
boundaries which are indirectly addressed throughout the model.
Research Articles
1.Using the Neuman Systems Model for Best Practices--Sharon A.
DeWan, Pearl N. Ume-Nwagbo, Nursing Science Quarterly, Vol. 19,
No. 1, 31-35 (2006).
1.The purpose of this study was to present two case studies based
upon Neuman systems model; one case is directed toward family
care, and the other demonstrates care with an individual. Theorybased exemplars serve as teaching tools for students and practicing
nurses.
2.These case studies illustrate how nurses' actions, directed by
Neuman's wholistic principles, integrate evidence-based practice
and generate high quality care
2.Melton L, Secrest J, Chien A, Andersen B. A community needs
assessment for a SANE program using Neuman's model J Am Acad
Nurse Pract. 2001 Apr;13(4):178-86.
1.The purpose of the study was to present guidelines for a community
needs assessment for a Sexual Assault Nurse Examiner (SANE)
program using Neuman's Systems Model.
2.Sexual assault is a problem faced by almost every community. A
thorough community assessment is an important first step in
establishing programs that adequately meet a community's needs.
3.Guidelines for conducting such an assessment related to
implementation of a SANE program are rare, and guidelines using a
nursing model were not found in the literature
Reference
Timber BK. Fundamental skills and concepts in Patient Care, 7th edition,
LWW, N
Vandemark L.M. Awareness of self & expanding consciousness: using
Nursing theories to prepare nurse therapists Ment Health Nurs. 2006 Jul;
27(6) : 605-15
Jul;19(3):225
Cheng MY. Using King's Goal Attainment Theory to facilitate drug compliance
in a psychiatric patient. Hu Li Za Zhi. 2006 Jun;53(3):90-7.
Delaune SC,. Ladner PK, Fundamental of nursing, standard and practice,
2nd edition, Thomson, NY, 2002
LEVINES FOUR CONSERVATION

PRINCIPLES
Myra Estrine Levine
Introduction
Born in Chicago, raised with a sister and a brother with whom she shared a
close loving relationship
Also very fond of her father who was often ill and frequently hospitalized
with GI problem. This was the reason of choosing nursing as a career
Also called as renaissance women-highly principled, remarkable and
committed to patients quality of care
Died in 1996
Educational Achievement
Diploma in nursing:-Cook county SON, Chicago, 1944
BSN:-University of Chicago,1949
MSN:-Wayne state University, Detroit, 1962
Publication:-An Introduction to Clinical Nursing, 1969,1973 & 1989
Received honorary doctorate from Loyola University in 1992
Achievements
Clinical experience in OT technique and oncology nursing
Civilian nurse at the Gardiner general hospital
Director of nursing at Drexel home in Chicago
Clinical instructor at Bryan memorial hospital in Lincoln, Nebraska
Administrative supervisor at university of Chicago
Chairperson of clinical nursing at cook country SON

Visiting professor at Tel Aviv university in Israel
Conservational model
Goal: To promote adaptation and maintain wholeness using the principles of
conservation
Model guides the nurse to focus on the influences and responses at the
organismic level
Nurse accomplishes the goal of model through the conservation of energy,
structure and personal and social integrity
Adaptation
Every individual has a unique range of adaptive responses
The responses will vary by heredity, age, gender or challenges of illness
experiences
Example: The response to weakness of cardiac muscle is an increased heart
rate, dilation of ventricle and thickening of myocardial muscle
While the responses are same, the timing and manifestation of organismic
responses will be unique for each individual pulse rate)
An ongoing process of change in which patient maintains his integrity within
the realities of environment
Achieved through the "frugal, economic, contained and controlled use of
environmental resources by individual in his or her best interest"
Wholeness
Exist when the interaction or constant adaptations to the environment
permits the assurance of integrity
Promoted by use of conservation principle
Conservation
The product of adaptation
"Keeping together "of the life systems or the wholeness of the individual
Achieving a balance of energy supply and demand that is with in the unique
biological realities of the individual
Nursings paradigm
Person
A holistic being who constantly strives to preserve wholeness and integrity
A unique individual in unity and integrity, feeling, believing, thinking and
whole system of system
Environment
Competes the wholeness of person
Internal
Homeostasis
Homeorrhesis
External
Preconceptual
Operational
Conceptual
Internal Environment
Homeostasis: A state of energy sparing that also provide the necessary
baselines for a multitude of synchronized physiological and psychological
factors
A state of conservation
Homeorrhesis: A stabilized flow rather than a static state
Emphasis the fluidity of change within a space-time continuum
Describe the pattern of adaptation, which permit the individuals body to
sustain its well being with the vast changes which encroach upon it from
the environment
External Environment
Preconceptual: Aspect of the world that individual are able to intercept
Operational: Elements that may physically affects individuals but not
perceived by hem: radiation, micro-organism and pollution
Conceptual: Part of person's environment including cultural patterns
characterized by spiritual existence, ideas, values, beliefs and tradition
Person and environment
Adaptation
Organismic response
Conservation
Adaptation
Characteristics
Historicity: Adaptations are grounded in history and await the challenges
to which they respond
Specificity: Individual responses and their adaptive pattern varies on the
base of specific genetic structure
Redundancy: Safe and fail options available to the individual to ensure
continued adaptation
Organismic response
A change in behavior of an individual during an attempt to adapt to the
environment
Help individual to protect and maintain their integrity
They co-exist
They are four types
1. Flight or fight: An instantaneous response to real or imagined threat,
most primitive response
2. Inflammatory: response intended to provide for structural integrity

and the promotion of healing
3. Stress: Response developed over time and influenced by each stressful
experience encountered by person
4. Perceptual: Involves gathering information from the environment and
converting it in to a meaning experience
Nine models of guided assessment
Vitals signs
Body movement and positioning
Ministration of personal hygiene needs
Pressure gradient system in nursing interventions
Nursing determination in provision of nutritional needs
Pressure gradient system in nursing
Local application of heat and cold
Administration of medicine
Establishing an aseptic environment
Assumption
The nurse creates an environment in which healing could occur
A human being is more than the sum of the part
Human being respond in a predictable way
Human being are unique in their responses
Human being know and appraise objects ,condition and situation
Human being sense ,reflects, reason and understand
human being action are self determined even when emotional
Human being are capable of prolonging reflection through such strategists
raising questions
Human being make decision through prioritizing course of action
Human being must be aware and able to contemplate objects, condition and
situation
Human being are agents who act deliberately to attain goal
Adaptive changes involve the whole individual
A human being has unity in his response to the environment
Every person possesses a unique adaptive ability based on ones life
experience which creates a unique message
There is an order and continuity to life change is not random
A human being respond organismically in an ever changing manner
A theory of nursing must recognized the importance of detail of care for a
single patient with in an empiric framework that successfully describe the
requirement of the all patient
A human being is a social animal

A human being is an constant interaction with an ever changing society
Change is inevitable in life
Nursing needs existing and emerging demands of self care and dependant
care
Nursing is associated with condition of regulation of exercise or development
of capabilities of providing care
Levines work & Characteristics of theory
Theories can interrelate concepts in such a way as to create a different way
of looking at a particular phenomenon
The concept of illness adaptation, using interventions, and the evaluation of
nursing interventions are interrelated .they are combined to look at
nursing care in a different way (more comprehensive view incorporating
total patient care) form previous time.
Theories must be logical in nature.
Levines idea about nursing care are organized in such a way as to b
sequential and logical. they can be used to explain the consequences of
nursing action
Levines theory is easy to use .
Its major elements are easily comprehensible and the relation ship have the
potential for being complex but are easily manageable
Certain isolated aspect of the theory are the generalizable i.e. those related
to the conservational principles
Levines idea can be tested
Hypothesis can be derived from them .
The principle of conservation are specific enough to be testable
Levines work & Characteristics of theory
validate them.
Since Levines idea have not yet been widely researched ,it is hard o
determine the contribution to the general body of knowledge with in the
discipline
Theories can be utilized by the practitioner to guide and improve their
practice.
Paula E.Crawford-gamble :-successfully applied Levines theory to the
female patient undergoing surgery for the traumatic amputation of the
fingers
These ideas lend themselves to use in practice particularly in acute care
setting
Theories must be consistent with other validated theories, laws and

principles but will leave open unanswered questions that need to be
investigated .
Levines ideas seem to be consistent with other theories, laws and principles
particularly those from the humanities and sciences
Conservational Principle
Conservation of energy
Conservation of structural integrity
Conservation of personal integrity
Conservation of social integrity
1. Conservation of energy
Refers to balancing energy input and output to avoid excessive fatigue
includes adequate rest, nutrition and exercise
Example:
availability of adequate rest
Maintenance of adequate nutrition
2. Conservation of structural integrity
Refers to maintaining or restoring the structure of body preventing physical
breakdown And promoting healing
Example:
Assist patient in ROM exercise
Maintenance of patients personal hygiene
3. Conservation of personal integrity
Recognizes the individual as one who strives for recognition, respect, self
awareness, selfhood and self determination
Example:
Recognize and protect patients space needs
4. Conservation of social integrity
An individual is recognized as some one who resides with in a family, a
community ,a religious group, an ethnic group, a political system and a
nation
Example:
Position patient in bed to foster social interaction with other patients
Avoid sensory deprivation
Promote patients use of news paper, magazines, radio. TV
Provide support and assistance to family
Health
Health is a wholeness and successful adaptation
It is not merely healing of an afflicted part ,it is return to daily activities,

selfhood and the ability of the individual to pursue once more his or her
own interest without constraints
Disease: It is unregulated and undisciplined change and must be stopped or
death will ensue
Nursing
"nursing is a profession as well as an academic discipline, always practiced
and studied in concert with all of the disciplines that together from the
health sciences"
The human interaction relying on communication ,rooted in the organic
dependency of the individual human being in his relationships with other
human beings
Nursing involves engaging in "human interactions"
Goal of Nursing
To promote wholeness, realizing that every individual requires a unique and
separate cluster of activities
The individual integrity is his abiding concern and it is the nurses
responsibility to assist him to defend and to seek its realization
Nursing Process
Assessment
Trophicognosis
Hypothesis
Interventions
Evaluation
Nursing Process
Assessment
Collection of provocative facts through observation and interview of
challenges to the internal and external environment using four
conservation principles
Nurses observes patient for organismic responses to illness, reads medical
reports. talks to patient and family
Assesses factors which challenges the individual
Trophicognosis
Nursing diagnosis-gives provocative facts meaning
A nursing care judgment arrived at through the use of the scientific process
Judgment is made about patients needs for assistance
Hypothesis
Planning
Nurse proposes hypothesis about the problems and the solutions which
becomes the plan of care
Goal is to maintain wholeness and promoting adaptation
Interventions
Testing the hypothesis
Interventions are designed based on the conservation principles
Mutually acceptable
Goal is to maintain wholeness and promoting adaptation
Evaluation
Observation of organismic response to interventions
It is assesses whether hypothesis is supported or not supported
If not supported, plan is revised, new hypothesis is proposed
Conservational models
Conservational model provides the basis for development of two theories
o Theory of redundancy
o Theory of therapeutic intention
Theory of redundancy
Untested ,speculative theory that redefined aging and everything else that
has to do with human life
Aging is diminished availability of redundant system necessary for effective
maintenance of physical and social well being
Theory of therapeutic intention
Goal: To seek a way of organizing nursing interventions out of the biological
realities which the nurse has to confront
Therapeutic regimens should support the following goals:
Facilitate healing through natural response to disease
Provide support for a failing auto regulatory portion of the integrated system
Restore individual integrity and well being
Theory of therapeutic intention
Provide supportive measure to ensures comfort
Balance a toxic risk against the threat of disease
Manipulate diet and activity to correct metabolic imbalance and stimulate
physiological process
Reinforce usual response to create a therapeutic changes
Uses
Critical, acute or long term care unit
Neonates, infant and young children, pregnant young adult and elderly care
unit
Primary health care
OT
Community setting
Utility of Theory
Nursing research
Nursing education
Nursing administration
Nursing practice
Nursing research
Principles of conservation have been used for data collection in various
researches
Conservational model was used by Hanson et al.in their study of incidence
and prevalence of pressure ulcers in hospice patient
Newport used principle of conservation of energy and social integrity for
comparing the body temperature of infants who had been placed on
mothers chest immediately after birth with those who were placed in
warmer
Nursing education
Conservational model was used as guidelines for curriculum development
It was used to develop nursing undergraduate program at Allentown college
of St.Francis de sales, Pennsylvania
Used in nursing education program sponsored by Kapat Holim in Israel
Nursing administration
Taylor described an assessment guide for data collection of neurological
patients which forms basis for development of comprehensive nursing care
plan and thus evaluate nursing care
McCall developed an assessment tool for data collection on the basis of four
conservational principles to identify nursing care needs of epileptic patients
Family assessment tool was designed by Lynn-Mchale and Smith for families
of patient in critical care setting
Nursing practice
Conservational model has been used for nursing practice in different settings
Bayley discussed the care of a severely burned teenagers on the basis of
four conservational principles and discussed patients perceptual,
operational and conceptual environment
Pond used conservation model for guiding the nursing care of homeless at a
clinic, shelters or streets
Nursing process according to Levines model
Mrs. Mona, a wife of an abusive husband, underwent a radical
hysterectomy. Post operatively has pain ,weight loss, nausea and inability
to empty bladder .Patient has history of smoking and stays in house which
is less than sanitary
Assessment
Challenges to the internal env:-weight loss, nausea, loss of reproductive
ability
Challenges to the external env:-abusive husband, insanitary condition in
home
Energy conservation:-weight loss, nausea ,pain

Structural integrity:-threatened by surgical procedure, inability to pass urine
Personal integrity:-not able to give birth to more children
Social integrity:-Strained relationship with husband
Trophicognosis
Inadequate nutritional status
Pain
Potential for wound and bladder infection
Need to learn self catheterization
Decreased self worth
Potential for abuse
Hypothesis
Nutritional consultation
Teaching and return demonstration of urinary self catheterization
Care of surgical wound
Exploring concern regarding hysterectomy
Interventions
Energy conservation
Provide medication for pain and nausea
Allowing rest period
Structural integrity
Administrating antibiotic for wound,
Teaching self catheterization
Personal integrity
Exploring her feeling about uterus removal while respecting her privacy
Social integrity
Assess potential abuse form husband
Support to the family
Organismic response
Controlled pain
Abdominal wound healing
Improved appetite ,weight gain
Clean urinary self catheterization
Assistance from husband
Critiquing the theory
She values the holistic approach to all individual, well or sick
Values patients participation in nursing care
Comprehensive content in depth

Provides direction of nursing research , education, administration and
practice
Logically congruent
Shows high regard to adjunctive disciplines to develop theoretical basis for
nursing
Limitation
Limited attention can be focused on health promotion and illness prevention.
Nurse has the responsibility for determining the patient ability to participate
in the care ,and if the perception of nurse and patient about the patient
ability to participate in care dont match, this mismatch will be an area of
conflict.
The major limitation is the focus on individual in an illness state and on the
dependency of patient.
Research Highlights
A theory of health promotion for preterm infants based on conservational
model of nursing. Nursing science quarterly,2004 Jul,17 (3)
The article describes a new middle range theory of health promotion for
preterm infants based on Levines conservational model that can be used
to guide neonatal nursing practice.
Summary
Introduction to the theorist
Conservational model
Concept of the model
Adaptation
Wholeness
Conservation
1. Conservation principles
2.Nursing process
1.Assessment
2.Trophicogosis
3.Hypothesis
4.Interventions
5.Evaluation
3. Theory of redundancy
4. Theory of therapeutic intention
5.Utility of theory
1.Nursing research
2.Nursing education
3.Nursing administration
4.Nursing practices
MARTHA ROGERS SCIENCE OF

UNITARY HUMAN BEINGS
Introduction
Born :May 12, 1914, Dallas, Texas
Diploma :Knoxville General Hospital School of Nursing(1936)
Graduation in Public Health Nursing, George Peabody College, TN, 1937
MA :Teachers college, Columbia university, New York, 1945
MPH :Johns Hopkins University, Baltimore, MD, 1952
Doctorate in nursing :Johns Hopkins University, Baltimore, 1954
Fellowship: American academy of nursing
Position: Professor Emerita, Division of Nursing, New York University,

Consultant, Speaker
Died : March 13 , 1994
Publications of Martha Rogers

Theoretical basis of nursing (Rogers 1970)
Nursing science and art :a prospective (Rogers 1988)
Nursing :science of unitary, irreducible, human beings update (Rogers
1990)
Vision of space based nursing (Rogers 1990)
Rogers nursing theory
Nursing is both a science and art. the uniqueness of nursing, like that of
any other science, lies in the phenomenon central to its focus.
Nurses long established concern with the people and the world they live is
in a natural forerunner of an organized abstract system encompassing people
and the environments.
The irreducible nature of individuals is different from the sum of the parts.
The integral ness of people and the environment that coordinate with a
multidimensional universe of open systems points to a new paradigm :the
identity of nursing as a science.
The purpose of nurses is to promote health and well-being for all persons
wherever they are.
Evolution of abstract system
The development of the abstract system was strongly influenced by an

early grounding in arts and background of science and her keen interest in
space
The science of unitary human beings originated as a synthesis of facts and
ideas from multiple sources of knowledge
The uniqueness is in the central phenomena : people and environment
The Rogerian view of a causality emerges from an infinite universe of open
system
Overview of Rogerian model
Rogers model provides the way of viewing the unitary human being
Humans are viewed as integral with the universe
The unitary human being and the environment are one ,not dichotomous
Nursing focus on people and the manifestations that emerge from the mutual
human /environmental field process
Change of pattern and organization of the human field and the environmental
field is propagated by waves
The manifestations of the field patterning that emerge are observable events
The identification of the pattern provide knowledge and understanding of

human experience
Basic characteristics which describes the life process of human :energy field,
openness, pattern, and pan dimensionality
Basic concepts include unitary human being ,environment, and

homeodynamic principles
Concepts of Rogers model

Energy field
The energy field is the fundamental unit of both the living and nonliving
This energy field "provide a way to perceive people and environment as

irreducible wholes"
The energy fields continuously varies in intensity, density, and extent

Openness
The human field and the environmental field are constantly exchanging their
energy
There are no boundaries or barrier that inhibit energy flow between fields
Pattern
Pattern is defined as the distinguishing characteristic of an energy field

perceived as a single waves
"pattern is an abstraction and it gives identity to the field"

Pan dimensionality
Pan dimensionality is defined as "non linear domain without spatial or

temporal attributes"
The parameters that human use in language to describe events are arbitrary.
The present is relative ;there is no temporal ordering of lives.

Unitary Human Being (person)
A unitary human being is an "irreducible, indivisible, pan dimensional (fourdimensional) energy field identified by pattern and manifesting characteristics
that are specific to the whole and which cannot be predicted from knowledge
of the parts" and "a unified whole having its own distinctive characteristics
which cannot be perceived by looking at , describing, or summarizing the
parts"
The people has the capacity to participate knowingly and probabilistically in

the process of change
Environment
The environment is an "irreducible ,pan dimensional energy field identified by

pattern and integral with the human field"
The field coexist and are integral. Manifestation emerge from this field and
are perceived.
Health
Rogers defined health as an expression of the life process; they are the
"characteristics and behavior emerging out of the mutual, simultaneous
interaction of the human and environmental fields"
Health and illness are the part of the sane continuum.
The multiple events taking place along life's axis denote the extent to which
man is achieving his maximum health potential and very in their expressions
from greatest health to those conditions which are incompatible with the
maintaining life process
Nursing
The concept Nursing encompasses two dimensions
Independent science of nursing

An organized body of knowledge which is specific to nursing is arrived
at by scientific research and logical analysis
Art of nursing practice

The creative use of science for the betterment of the human
The creative use of its knowledge is the art of its practice
Assumptions about people and nursing
Nursing exists to serve people..it is the direct and overriding

responsibility to the society
The safe practice of nursing depends on the nature and amount of scientific
nursing knowledge the individual brings to practice.the imaginative,
intellectual judgment with which such knowledge is made in service to the
man kind
People needs knowledgeable nursing
Homeodynamic principles
The principles of homeodynamic postulates the way of perceiving unitary

human beings
The fundamental unit of the living system is an energy field
Three principle of homeodynamic
Resonancy
Helicy
integrality
Resonance
Resonance is an ordered arrangement of rhythm
characterizing both human field and environmental
field that undergoes continuous dynamic
metamorphosis in the human environmental process
Helicy
Helicy describes the unpredictable, but continuous, nonlinear evolution of

energy fields as evidenced by non repeating rhythmicties
The principle of Helicy postulates an ordering of the humans evolutionary

emergence
Integrality
Integrality cover the mutual, continuous relationship of the human energy

field and the environmental field .
Changes occur by by the continuous repatterning of the human and

environmental fields by resonance waves
The fields are one and integrated but unique to each other
Rogerian theories
Rogerian theories-Grand theories
The theory of accelerating evolution
The theory of paranormal phenomena
The theory of rhythmicities
Theory of paranormal phenomena
This theory focus on the explanations for precognition, djvu, clairvoyance,

telepathy, and therapeutic touch
Clairvoyance is rational in a four dimensional human field in continuous

mutual, simultaneous interaction with a four dimensional world; there is no
linear time nor any separation of human and the environmental fields
The theory of accelerating evolution
Theory postulates that evolutionary change is speeding up and that the range
of diversity of life process is widening. Rogers explained that higher wave
frequencies are associated with accelerating human development
Theory of Rhythmicity
Focus on the human field rhythms
(these rhythms are different from the biological ,psychological rhythm)
Theory deals with the manifestations of the whole unitary man as changes in
human sleep wake patterns, indices of human field motion, perception of time
passing, and other rhythmic development
Theories derived from the science of unitary human beings
The perspective rhythm model (Patrick 1983)
Theory of health as expanding consciousness (Neumann, 1986)
Theory of creativity, actualization and empathy (Alligood 1991)
Theory of self transcendence (Reed1997)
Power as knowing participation in change (Barrett 1998)
Rogers concepts of nursing
Nursing is a learned profession-it is a science and art
Nursing is the study of unitary. Irreducible, indivisible human and

environmental energy fields
The art of nursing involves the imaginative and creative use of nursing
knowledge
The purpose of nurses is to promote health and well-being for all person and
groups wherever they are using the art and science of nursing
The health services should be community based
Rogers challenges nurses to consider nursing needs of all people ,including

future generation of space kind ;as life continuous to evolve from earth to
space and beyond.
Her view provides a different world view that encompasses a practice of

nursing for the present time and for the imagined and for the yet to be
imagined future
Rogers envisions a nursing practice of noninvasive modalities, such as

therapeutic touch, humor, guided imagery, use of color, light, music,
meditation focusing on health potential of the person.
Professional practice in nursing seeks to promote symphonic interaction

between man and environment, to strengthen the coherence and integrity of
the human field, and to direct and redirect patterning of the human and
environmental fields for realization of maximum health potential
Nursing intervention seeks to coordinate environmental field and human field

rhythmicities, participates in the process of change , to help people move
toward better health
Nursing aims to assist people in achieving their maximum potential.
Nursing practice should be emphasized on pain management, supportive

psychotherapy motivation for rehabilitation.
Maintenance and promotion of health, prevention of disease, nursing

diagnosis, intervention, and rehabilitation encompasses the scope of nursing
Rogers contribution to nursing knowledge
Rogers was one of the first nurse scholars to explicitly identify the person
(unitary man) as the central phenomena of nursing concern
Nursing abstract system is a matrix of concepts relevant to the life process in

man
Rogers conceptual system provides a body of knowledge in nursing that will

have relevance for all workers concerned with people, but with special
relevance for nurses; because it matters to human beings; consequently to
nurses
In the evolution it is properly subjected to reformulation and change as the

knowledge grows, the the conceptual data will be more clearer and it will take
new dimensions
The utilization of Rogerian model is used as a guide for theory development,

research, nursing education, and in the direct patient care practice
Rules for nursing research guided by the Rogerian theory

Rules for research
The Rogerian research require both basic and applied research
The phenomena to be studied are unitary human beings and their

environmental interaction
Study participants may be any person or group, with the provision that both
person and environment are taken into account
Research methodology
Qualitative and quantitative methods can be applied
Experimental researches are questionable because she rejects the notion of

causality
Case study and longitudinal research are better than cross sectional study
Research instruments that are directly derived from science of unitary human
beings should be used
Data analysis multivariate analysis (canonical correlation studies)
Research tools derived from science of unitary human beings
Perceived field motion scale
Human field rhythm scale
Temporal experience scale
Assessment of dream experience scale
Person environment participation scale
Leddy healthiness scale
Mutual exploration of the healing human-environment field scale
Garon assessment of pain scale
Family assessment tool
Community health assessment tool
Rules for nursing education guided by Rogerian theory

Focus of the curriculum
Nursing education can be for professional nursing , technical

nursing
The focus is the transmission of the body of knowledge
Teaching and practicing therapeutic touch
Conducting regular in-service education
Nursing programs
Baccalaureate degree program
Masters program
Doctoral program
The major concepts are principal of Resonancy, Helicy,

Integrality
The faculty in the nursing education must be prepared at

doctoral level
Teaching- learning strategies
Emphasis should be on developing self awareness as an aspect

of the clients environmental energy field and the dynamic role
of nurse pattern manifestation on the client
Emphasis on laboratory study- the lab setting include homes,

schools, industry, clinics, hospitals, other places where people
lives
Importance of use of media in education
Rules for nursing administration guided by Rogerian theory

Purpose of nursing services
Nursing services is the center of any health care system
The purpose of nursing services is health promotion
Characteristics of nursing personnel
The administrators should hold higher degrees in nursing and

licensed
Leaders must be visionary and willing to embrace innovative

and creative change
Leaders should be able to identify the patterning to ensure the

integrated behaviors for client and employees
Management strategies and administrative policies
Administrative policies foster an open and supportive

administrative climate that enhances staff members self esteem
, actualization, and freedom of choice and provide opportunity
for staff development and continuing education
The ultimate goal is the clients well-being
Rules for independent practitioner guided by Rogerian model
Nursing is an independent science
Nurse assumes the role of potentiater of care
She proposes the independent role in various setting like school, industry,
community, space (by 2050AD)
Independent practitioner is an advanced practice registered registered nurse

who focus on well-being or mutual patterning of individual, family, community
across the life span ,at risk for developing dissonance/illness
Rules for nursing practice guided by Rogerian theory

Areas of Rogerian model application
SETTINGS
All spheres of life
School
Industry
Family
Community
Space
SPECIALITIES
Pediatrics
Psychiatry
Oncology
Burns
Geriatrics
Neurology
Cardiology
Rehabilitative medicine
SPECIALIZED AREAS OF PRACTICE

o
Neonatal ICU
Pediatric ICU
Post operative unit
Pre operative unit
Palliative care unit
Rehabilitation center
Burns unit
Adult ICUs
Old age homes
Neuropsychiatric units
AREA WHERE ROGERIAN MODEL IS NOT APPLICABLE
Operation theaters
Purpose of nursing practice
To promote well-being for all persons, wherever they are
To assist both the client and nurse to increase their awareness

of their own rhythm
Setting for practice
From community to hospital to outer space
Legitimate participants
People of all ages both as individual human energy fields and

group energy fields
Nursing process- Health patterning practice method
Assessment
Voluntary mutual patterning
Evaluation
For the nurse
Pattern appraisal
Mutual patterning of human and environmental fields
Evaluation
For the patient
Self reflection
Patterning activities
Personal appraisal
Nursing process
Assessment
Areas of assessment
Simultaneous states of the individual and the environment
Total pattern of events at any given point in space time
Rhythms of life process
Supplementary data
Categorical disease entities
Subsystem pathology
Pattern appraisal
It is a comprehensive assessment of:
Human field patterns of communication, exchange, rhythms,

dissonance
Environmental fields pattern of communication, rhythms,

dissonance, harmony
Intuitive reflection of self

Validation of the appraisal
Validate with self
Validate with the client
Mutual patterning of human and environmental field

o
Sharing knowledge
Offering choices
Empowering the client
Fostering patterning
Evaluation
Repeat pattern appraisal
Identify dissonance and harmony
Validate appraisal with the client
Self reflection for the client
Pattern appraisal include appraisal of multiple lifestyle rhythms such as:
Nutrition
Work/leisure activities
Exercise
Sleep / wake cycles
Relationships
Discomfort or pain
Fear /hopes
Patterning activities for the client

Meditation
Imagery
Journaling
Modifying the surroundings
Clinical case study of Radha using Rogerian conceptual Model
Radha is a 22years old female admitted in a psychiatry unit with
severe depression secondary to diagnosis of ovarian malignancy
She becomes tearful during history taking
Radha is accompanied with her husband and 1year old child
Her husband appeared anxious but supportive and attentive he
is working as an accountant in their native place
Radha was diagnosed with ovarian cancer 2 months back and
underwent bilateral salphingio oopherectomy and hysterectomy
30days ago
She is undergoing chemotherapy due to its Metastatic pattern.
From past 3 weeks Radha started sitting lonely, decreased ADL,
repeated crying spells, decreased talks, neglects hygiene, muttering to
self, decreased sleep , appetite, neglecting her child care, complaints
of severe pain in the body,.3 days back attempted suicide by
consuming rat poison.
Current assessment findings .her general appearance is a teary
eyed young woman ,ill-kempt, clinging to her husband ,looking
perplexed, not talking..poor nutritional intake, when asked about her
illness.cries inconsolably on repeated asking expressed sadness of

mood
Nursing care of Radha with Rogers model
With rogerian model, the process of caring Radha begins with pattern
appraisal
Nursing care involve pattern appraisal, mutual patterning, and evaluation

Pattern appraisal
This visible rhythmical pattern is a manifestation of evolution towards

dissonance
Radha has pattern manifestation of dissonance..depression with suicidal

ideation, ovarian malignancy, pain
Radha has a low educational background
A pattern activity of healing is noted through reports of a positive operative

course
Patterning has to be directed towards reduction in perceived dissonance with

her personal and environmental field
Pain is a manifestation of perceived dissonance
Decreased environmental energy transfer is visible by decreased talking and

crying
Radha has manifestation of fear.her self knowledge links her illness to her
personal belief of being punished for her past sins
Appraisal is needed in her sleep patterns, nutrition and her perception of self
Appraisal can be grouped into exchanging patterns, communication patterns,

and relating patterns
Time between nurse and Radha is needed to foster her healing
During the process nurse must rely on personal intuition and insight regarding
the emerging pattern
All this pattern forms the unitary pattern of Radha

Mutual patterning
The process is mutual between the nurse and Radha
The surgery performed, medication she is receiving are patterning modalities
Patterning activities planned by the nurse for Radha ..therapeutic touch,

humor , meditation, imagery
Radha needs to be assessed fully regarding her ability to understand and

agree with different patterning modalities
Therapeutic touch can be introduced to Radha
Touch is introduced and incorporated into the management of pain, helps in

energy transmission for healing and .helps in developing trust in the nurse
Teach her how to center the energy and channel her energy to the area of
pain
Use humor for increasing socialization and developing self confidence and
developing worthiness
Human environmental patterning needs to involve the other individual who

share her environment including husband and son
Options are introduced relating to increase communication and hygiene

patterns
The entire family is involved in power as knowing participation in change

Evaluation
The evaluation process centers on the perceptions of dissonance that exist

after the mutual pattern activities
The appraisal process is repeated
Manifestation of worry, pain, fear, sadness of moos has to be appraised with

family members
A summary of the dissonance and/or harmony that is perceived is then

shared with Radha, and mutual patterning is modified or instituted ad
indicated based on the evaluation
Summary
Biographical sketch of Martha Rogers
Overview of Rogerian concepts
Rogerian terminologies
Rogerian theories
Nursing concepts, nursing process
Perspectives of nursing education, administration, nursing practice
Contribution to nursing knowledge
Clinical example
References
1. George B. Julia , Nursing Theories- The base for professional Nursing
2. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing
3. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress
4. Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed.
5. Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing Concepts
THEORIES BASED ON INTERACTIVE

PROCESS
IMOGENE KING: THEORY OF GOAL ATTAINMENT
Major Concepts and Definitions
Interaction
A process of perception and communication
Between person and environment
Between person and person
Represented by verbal and nonverbal behaviors
Goal-directed
Each individual brings different knowledge , needs, goals, past experiences

and perceptions, which influence interaction
Communication
Information from person to person
Directly or indirectly
Information component of interaction

Perception
Each persons representation of reality

Transaction
Purposeful interaction leading to goal attainment

Role
A set of behaviours expected of persons occupying a position in a social

system
Rules that define rights and obligations in a position

Stress
Dynamic state
Human being interacts with the environment

Growth and development
Continuous changes in individuals
At cellular, molecular and behavioural levels of activities
Helps individuals move towards maturity
Time
Sequence of events
Moving onwards to the future

Space
Existing in all directions
Same everywhere
Immediate environment (nurse and client interaction)

MAJOR ASSUMPTIONS
Nursing
Observable behaviour
In health care system in society
Goal to help individuals maintain health
Interpersonal process of action; reaction, interaction and transaction

Person
Social beings
Sentient beings
Rational beings
Perceiving beings
Controlling beings
Purposeful beings
Action oriented beings
Time oriented beings

Health
Dynamic state in the life cycle
Continuous adaptation to stress
To achieve maximum potential for daily living
Function of nurse, patient, physicians, family and other interactions

Environment
Open system
Constantly changing
Influences adjustment to life and health

Personal system
Concepts
Perception
Self
Body image
Time
Space
Concepts
Interaction
Transaction
Communication
Role
Stress
Social system
Concepts
Organization
Authority
Power
Status
Decision making
ASSUMPTIONS
Perceptions, goals, needs and values of the nurses and client influence
interaction process
Individuals have the right to knowledge about themselves and to participate
in decisions that influence their life, health and community services
Health professionals have the responsibility that helps individuals to make
informed decisions about their health care
Individuals have the right to accept or reject health care
Goals of health professionals and recipients of health care may not be
congruent
II.
SISTER CALLISTA ROY: ADAPTATION MODEL
Introduction
Begins with man
Man as a biopsychosocial being
In constant interaction with his environment

Focus of nursing
Mans position on the health illness continuum
Influenced by ability to adapt to confronted stimuli

MAJOR CONCEPTS AND DEFINITIONS
System
a set of units so related or connected as to form a unit
characterised by inputs, out puts, control and feedback process.

Adaptational level
a constantly changing point, made up of focal, contextual and residual stimuli
represent the persons own standard of the range of stimuli, to which one can
respond with the ordinary adaptive response
Adaptation problems:
the occurrence of situations of inadequate responses to need deficits or

excesses
Focal stimulus:
stimulus most immediately confronting the person
must make an adaptive response
factor that precipitates behaviour

Contextual stimuli

all other stimuli present
contribute to behaviour caused by the focal stimuli

Residual stimuli
factors that may be affecting behaviour
effect not validated

Regulator
subsystem coping mechanism
responds automatically through neural-chemical-endocrine processes

Cognator
subsystem coping mechanism
cognitive emotive process
responds through
perception, information
processing, learning
judgment and emotion

Adaptive (effector) modes
classification of ways of coping
manifests regulator and cognator activity
physiologic, self concept, role function and interdependence

Adaptive responses
Promote integrity of the person in terms of the goals of survival, growth,

reproduction and mastery.
Ineffective responses:
Does not contribute to adaptive goals

Physiological mode
involves bodys basic needs and ways of dealing with adaptation in relation to
Fluid and electrolytes
Exercise and rest
Elimination
Nutrition
Circulation
Oxygen
regulation includes:
The senses
Temperature
Endocrine regulation
Self concept mode:
composite of belief and feeling
formed from perceptions
directs ones behaviour
components are :

the physical self
the personal self

Role performance mode:
* performance of duties
* based on given positions in society
Interdependence mode:
* ones relation with significant others
* support system
* maintains psychic integrity
* meets needs for nurturance and affection
MAJOR ASSUMPTIONS
from system theory
from Helsons theory
from humanism
ASSUMPTIONS FROM SYSTEMS THEORY
a system is a set of units so related or connected as to form a unit or whole
a system is a whole that functions as a whole by virtue of the
interdependence of its parts
systems have inputs, outputs and control and feedback processes
input, in the form of a standard or feedback (information)
living systems are more complex than mechanical systems and have
standards and feedback to direct their functioning as a whole.
ASSUMPTIONS FROM HELSONS THEORY
human behaviour represents adaptation to environmental and organismic
forces
adaptive behaviour is a function of the stimulus and adaptation level, that is,
the pooled effect of the focal, contextual and residual stimuli
adaptation is a process of responding positively to environmental changes
responses reflect the state of the organism as well as the properties of
stimuli and hence are regarded as active processes.
ASSUMPTIONS FROM HUMANISM
Persons have their own creative power
A persons behaviour is purposeful and not merely a chain of cause and effect
Person is holistic
A persons opinions and view points are of value
The interpersonal relationship is significant.
ELEMENTS
Nursing
A science and practice discipline
A theoretical system of knowledge
Prescribes a process of analysis and action
Related to the care of the ill or potentially ill person
Person
A biopsychosocial being
A living, complex, adaptive system

With internal processes (the cognator and regulator)
Acting to maintain adaptation to the four modes
Health
A state and a process of being and becoming an integrated and whole person
Environment
1. All the conditions, circumstances and influences surrounding and affecting
the development and behaviour of persons or groups
References
Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby,
Philadelphia, 2002.
Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development and Progress
Taylor Carol,Lillis Carol (2001)The Art and Science Of Nursing Care 4th ed.
Potter A Patricia, Perry G Anne (1992)Fundamentals Of Nursing Concepts
Orems Theory
Introduction
One of Americas foremost nursing theorists.
Dorothea Orem earned her Bachelor of science in nursing education in

1939 and Master of science in nursing in 1945
During her professional career ,she worked as a staff nurse ,private duty
nurse ,nurse educator and administrator and nurse consultant
Received honorary Doctor of Science degree in 1976
Dorothea Orem as a member of a curriculum subcommittee at Catholic

University, recognized the need to continue in developing a conceptualization
of nursing.
Published first formal articulation of her ideas in Nursing: Concepts of

Practice in 1971.second in 1980,and finally in 1995
Development of Theory
1949-1957 Orem worked for the Division of Hospital and Institutional

Services of the Indiana State Board of Health. Her goal was to upgrade the
quality of nursing in general hospitals throughout the state. During this time
she developed her definition of nursing practice.
1958-1960 US Department of Health, Education and Welfare where she

help publish "Guidelines for Developing Curricula for the Education of
Practical Nurses" in 1959.
1959 Orem subsequently served as acting dean of the school of Nursing

and as an assistant professor of nursing education at CUA. She continued to
develop her concept of nursing and self care during this time.
Orems Nursing: Concept of Practice was first published in 1971 and

subsequently in 1980,1985, 1991, 1995, and 2001.
Continues to develop her theory after her retirement in 1984
Definitions of domain concepts
Nursing is art, a helping service, and a technology
Actions deliberately selected and performed by nurses to help individuals

or groups under their care to maintain or change conditions in themselves or
their environments
Encompasses the patients perspective of health condition ,the physicians

perspective , and the nursing perspective
Goal of nursing to render the patient or members of his family capable

of meeting the patients self care needs
To maintain a state of health
To regain normal or near normal state of health in the event of
disease or injury
To stabilize ,control ,or minimize the effects of chronic poor health or
disability
Health health and healthy are terms used to describe living things it
is when they are structurally and functionally whole or sound wholeness or
integrity. .includes that which makes a person human,operating in
conjunction with physiological and psychophysiological mechanisms and a
material structure and in relation to and interacting with other human beings
Environment environment components are environmental factors

,environmental elements, conditions ,and developmental environment
Human being has the capacity to reflect ,symbolize and use symbols
Conceptualized as a total being with universal ,developmental needs
and capable of continuous self care
A unity that can function biologically, symbolically and socially
Nursing client- a human being who has "health related /health derived
limitations that render him incapable of continuous self care or dependent
care or limitations that result in ineffective / incomplete care.
A human being is the focus of nursing only when a self care
requisites exceeds self care capabilities
Nursing problem deficits in universal, developmental, and health

derived or health related conditions
Nursing process- a system to determine (1)why a person is under care

(2)a plan for care ,(3)the implementation of care
Nursing therapeutics deliberate ,systematic and purposeful action
Orems General Theory of Nursing
Orems general theory of nursing in three related parts:
Theory of self care
Theory of self care deficit
Theory of nursing systems
Theory of Self Care
Includes :--
Self care practice of activities that individual initiates and perform on

their own behalf in maintaining life ,health and well being
Self care agency is a human ability which is "the ability for engaging in
self care"
-- Conditioned by age developmental state, life experience
sociocultural orientation health and available resources
Therapeutic self care demand "totality of self care actions to

be performed for some duration in order to meet self care requisites
by using valid methods and related sets of operations and actions"
Self care requisites-action directed towards provision of self care
3 categories of self care requisites are:--
Universal
Developmental
Health deviation
Universal self care requisites
Associated with life processes and the maintenance of the integrity of

human structure and functioning
Common to all , ADL
Identifies these requisites as:
Maintenance of sufficient intake of air ,water, food
Provision of care assoc with elimination process
Balance between activity and rest, between solitude and social

interaction
Prevention of hazards to human life well being and
Promotion of human functioning
Developmental self care requisites
Associated with developmental processes/ derived from a condition. Or

associated with an event
E.g. adjusting to a new job
adjusting to body changes

Health deviation self care
Required in conditions of illness ,injury, or disease .these include:-o

o
o
o
o
Seeking and securing appropriate medical assistance

Being aware of and attending to the effects and results of pathologic
conditions
Effectively carrying out medically prescribed measures
Modifying self concepts in accepting oneself as being in a particular
state of health and in specific forms of health care
Learning to live with effects of pathologic conditions
Theory of self care deficit
Specifies when nursing is needed

Nursing is required when an adult (or in the case of a dependent ,the
parent) is incapable or limited in the provision of continuous effective self
care
Orem identifies 5 methods of helping:-
Acting for and doing for others
Guiding others
Supporting another
Providing an environment promoting personal development in relation to

meet future demands
Teaching another
Theory of Nursing Systems
Describes how the patients self care needs will be met by the nurse , the
patient, or both
Identifies 3 classifications of nursing system to meet the self care

requisites of the patient:-
Wholly compensatory system
Partly compensatory system
Supportive educative system
Design and elements of nursing system define
Scope of nursing responsibility in health care situations
General and specific roles of nurses and patients
Reasons for nurses relationship with patients and
The kinds of actions to be performed and the performance patterns and

nurses and patients actions in regulating patients self care agency and in
meeting their self care demand
Orem recognized that specialized technologies are usually developed by

members of the health profession
A technology is systematized information about a process or a method for

affecting some desired result through deliberate practical endeavor ,with or
without use of materials or instruments
Categories of technologies
Social or interpersonal
Communication adjusted to age, health status
Maintaining interpersonal ,intragroup or intergroup relations for

coordination of efforts
Maintaining therapeutic relationship in light of psychosocial modes of

functioning in health and disease
Giving human assistance adapted to human needs ,action abilities and

limitations
Regulatory technologies
Maintaining and promoting life processes
Regulating psycho physiological modes of functioning in health and

disease
Promoting human growth and development
Regulating position and movement in space
Orems Theory and Nursing Process
Orems approach to the nursing process presents a method to determine

the self care deficits and then to define the roles of person or nurse to meet
the self care demands.
The steps within the approach are considered to be the technical

component of the nursing process.
Orem emphasizes that the technological component "must be coordinated

with interpersonal and social processes within nursing situations
Comparison of Orems Nursing Process and the Nursing Process
Nursing Process
Assessment
Nursing diagnosis
Plans with scientific rationale
Implementation
evaluation
Orems Nursing. Process
Diagnosis and prescription ;determine why nursing is needed. analyze and

interpret make judgment regarding care
Design of a nursing system and plan for delivery of care
Production and management of nursing systems
Step 1-collect data in six areas:
The persons health status
The physicians perspective of the persons health status
The persons perspective of his or her health
The health goals within the context of life history ,life style, and health
status
The persons requirements for self care
The persons capacity to perform self care
Step 2
Nurse designs a system that is wholly or partly compensatory or

supportive-educative.
The 2 actions are:-
Bringing out a good organization of the components of patients

therapeutic self care demands
Selection of combination of ways of helping that will be effective and

efficient in compensating for/ overcoming patients self care deficits
Step 3
Nurse assists the patient or family in self care matters to achieve

identified and described health and health related results ..collecting
evidence in evaluating results achieved against results specified in the

nursing system design
Actions are directed by etiology component of nursing diagnosis
evaluation
Application of Orems theory to nursing process
Personal
factors
Universal
self care
29 yr.
32pack /yr
Female
Water-no
restrictions
Early
adulthood
transition
Food nil
Wt89lb
Wt loss-19%
Developmenta Health
l self care
deviation
Teenage
pregnancy-2
OC-10 yrs
Husband
emotionally
away
nauseated
8th grade
Teenage
pregnancy
No work
Married
Child-2
Lives at
mothers
home.
Environment
unclean
Limited
resources
Urinary
retention
Intermittent
self
catheterizatio
n
Pain
Medical
problem &
plan
Self care
deficits
Surgery on
reproductive
organs
Difference
between
knowledge
base &
lifestyle
Seeks
medical
attention
for overt
s/s
Aware of
disease
No
evidence
No BSE
Infrequent
physical
examination
ability to
manage
effects
No HRT
Poor health
Tearful
EDU deprivation
Husband
abusive
Oppressive
living conditions
Dissatisfied
with home
Will receive RT
,perform
intermittent
catheterizatio
n
RT
Therapeutic
self care
demand
Adequacy
of self
care
agency
Nursing
diagnosis
Methods of helping
Air
Maintain
effective
respiration
Water
No problem
Food maintain
sufficient intake
Inadequate Potential for

impaired
respiratory status
P F fluid imbalance
Adequate
Actual nutritional
deficit r/t ausea
Inadequate
Guiding & directing
Teaching
Providing physical
support
Personal development
Hazards
Inadequate P/F injury
Prevent spouse
abuse
Promotion of
normalcy
Guiding & directing

Guiding & directing
Inadequate A/d in
environment
Shared housing
Maintain
developmental
environment
Support ed
normalcy in
environment
Prevent
/manage dev
threat
Inadequate Actual delay in

normaldev. R/T
early parenthood
Inadequate
Guiding & directing

Providing psy support
Level of education Providing physical,

psy support
Dev deficit r/t loss
of reproductive
organs
Maintenance of
health status
Inadequate
Management of
disease process
Inadequate
Adherence to
med regimen
Inadequate
Awareness of
potential
problems
Inadequate
Adjust to loss of Inadequate

reproductive
ability & dev
healthy view of
Inadequate
illness
Adjust life style
to cope with
change
P/F contd.
alterations in
health status
P/F UTI
Guiding &
directing, teaching
Guiding & directing,
teaching
P/F adherence teaching

in self
catheterization &
OPD RT
teaching
Actual deficit in
awareness of
advisability of
HRT & RT effects
Actual threat to
self image
Providing psy
support
Actual self deficit Guiding & directing

in planning for
future needs
Orems work and the characteristics of a theory
Theories can interrelate concepts in such a way as to create a different

way of looking at a particular phenomenon
Theories must be relatively simple yet generalizable
Theories are the basis for hypothesis that can be tested

validate them
Theories can be used by the practitioners to guide and improve their

practice
Theories must be consistent with other validated theories ,laws and

principles
Theory Testing
Orems theory has been used as the basis for the development of research
instruments to assist researchers in using the theory
A self care questionnaire was developed and tested by Moore(1995) for

the special purpose of measuring the self care practice of children and
adolescents
The theory has been used as a conceptual framework in assoc. degree

programs (Fenner 1979) also in many nursing schools
Strengths
Provides a comprehensive base to nursing practice

It has utility for professional nursing in the areas of nursing practice
nursing curricula ,nursing education administration ,and nursing research
Specifies when nursing is needed
Also includes continuing education as part of the professional component

of nursing education
Her self care approach is contemporary with the concepts of health

promotion and health maintenance
Expanded her focus of individual self care to include multiperson units
Limitations
In general system theory a system is viewed as a single whole thing while

Orem defines a system as a single whole ,thing
Health is often viewed as dynamic and ever changing .Orems visual

presentation of the boxed nursing systems implies three static conditions of
health
Appears that the theory is illness oriented rather with no indication of its
use in wellness settings
Summary
Orems general theory of nursing is composed of three constructs

.Throughout her work ,she interprets the concepts of human beings, health,
nursing and society .and has defined 3 steps of nursing process
It has a broad scope in clinical practice and to lesser extent in research

,education and administration
References
Orem, D.E. (1991). Nursing: Concepts of practice (4th ed.). St. Louis, MO:
Mosby-Year Book Inc.
Taylor, S.G. (2006). Dorthea E. Orem: Self-care deficit theory of nursing. In
A.M.
Tomey, A. & Alligood, M. (2002). Significance of theory for nursing as a
discipline and profession. Nursing Theorists and their work. Mosby, St. Louis,
Missouri, United States of America.
Whelan, E. G. (1984). Analysis and application of Dorothea Orems Self-care
Practuce Model. Retrieved October 31, 2006.

THE ROY'S ADAPTATION

MODEL
Introduction
Sr.Callista Roy, a prominent nurse theorist, writer, lecturer, researcher and
teacher
Professor and Nurse Theorist at the Boston College of Nursing in Chestnut
Hill
Born at Los Angeles on October 14, 1939 as the 2nd child of Mr. and Mrs.
Fabien Roy
she earned a Bachelor of Arts with a major in nursing from Mount St.
Mary's College, Los Angeles in 1963.
a master's degree program in pediatric nursing at the University of
California ,Los Angeles in 1966.
She also earned a masters and PhD in Sociology in 1973 and 1977
,respectively.
Sr. Callista had the significant opportunity of working with Dorothy E.
Johnson
Johnson's work with focusing knowledge for the discipline of nursing
convinced Sr. Callista of the importance of describing the nature of nursing as
a service to society and prompted her to begin developing her model with the
goal of nursing being to promote adaptation.
She joined the faculty of Mount St. Mary's College in 1966, teaching both
pediatric and maternity nursing.
She organized course content according to a view of person and family as
adaptive systems.
She introduced her ideas about Adaptation Nursing as the basis for an
integrated nursing curriculum.
Goal of nursing to direct nursing education, practice and research
Model as a basis of curriculum impetus for growth--Mount St. Marys
College
1970-The model was implemented in Mount St. Marys school
1971- she was made chair of the nursing department at the college.
Influencing Factors
Family
Education
Religious Background
Mentors
Clinical Experience
Theory description
The central questions of Roys theory are:

o
Who is the focus of nursing care?
What is the target of nursing care?
When is nursing care indicated?
Roys first ideas appeared in a graduate paper written at UCLA in 1964.
Published these ideas in "Nursing outlook" in 1970
Subsequently different components of her framework crystallized during

1970s, 80s, and 90s
Over the years she identified assumptions on which her theory is based.
Explicit assumptions (Roy 1989; Roy and Andrews 1991)
The person is a bio-psycho-social being.
The person is in constant interaction with a changing environment.
To cope with a changing world, person uses both innate and acquired
mechanisms which are biological, psychological and social in origin.
Health and illness are inevitable dimensions of the persons life.
To respond positively to environmental changes ,the person must adapt.
The persons adaptation is a function of the stimulus he is exposed to and his

adaptation level
The persons adaptation level is such that it comprises a zone indicating the
range of stimulation that will lead to a positive response.
The person has 4 modes of adaptation: physiologic needs, selfconcept, role
function and inter-dependence.
"Nursing accepts the humanistic approach of valuing other persons opinions,

and view points" Interpersonal relations are an integral part of nursing
There is a dynamic objective for existence with ultimate goal of achieving

dignity and integrity
Implicit assumptions
A person can be reduced to parts for study and care.
Nursing is based on causality.
Patients values and opinions are to be considered and respected.
A state of adaptation frees an individuals energy to respond to other stimuli.
Roy Adaptation Model Concepts: Early and Revised
Adaptation -- goal of nursing
Person -- adaptive system
Environment -- stimuli
Health -- outcome of adaptation
Nursing -- promoting adaptation and health
Concepts-Adaptation
Responding positively to environmental changes
The process and outcome of individuals and groups who use conscious
awareness, self reflection and choice to create human and environmental
integration
Concepts-Person
Bio-psycho-social being in constant interaction with a changing environment
Uses innate and acquired mechanisms to adapt
An adaptive system described as a whole comprised of parts
Functions as a unity for some purpose
Includes people as individuals or in groups-families, organizations,

communities, and society as a whole
Concepts-Environment
Focal - internal or external and immediately confronting the person
Contextual- all stimuli present in the situation that contribute to effect of focal
stimulus
Residual-a factor whose effects in the current situation are unclear
All conditions, circumstances, and influences surrounding and affecting the

development and behavior of persons and groups with particular
consideration of mutuality of person and earth resources, including focal,
contextual and residual stimuli
Concepts-Health
Inevitable dimension of person's life
Represented by a health-illness continuum
A state and a process of being and becoming integrated and whole

Concepts-Nursing
To promote adaptation in the four adaptive modes
To promote adaptation for individuals and groups in the four adaptive modes,
thus contributing to health, quality of life, and dying with dignity by assessing
behaviors and factors that influence adaptive abilities and by intervening to
enhance environmental interactions
Concepts-Subsystems
Cognator subsystem A major coping process involving 4 cognitive-emotive

channels: perceptual and information processing, learning, judgment and
emotion.
Regulator subsystem a basic type of adaptive process that responds

automatically through neural, chemical, and endocrine coping channels
Relationships
Derived Four Adaptive Modes
500 Samples of Patient Behavior
What was the patient doing?
What did the patient look like when needing nursing care?
Four Adaptive Modes
Physiologic Needs
Self Concept
Role Function
Interdependence
Four Adaptive Mode Categories
Tested in practice for 10 years
Criteria of significance, usefulness, and completeness were met

Sample Proposition and Hypothesis for Practice
Self Concept Mode: Increased quality of social experience leads to increased

feelings of adequacy
Providing support for new mothers can lead to positive parenting
Theory Development
Derived Theory
91 Propositions
Described relationships between and among regulator and cognator and four
adaptive modes
12 Generic propositions
Questions Raised by 21st Century Changes
How can ethics and public policy keep pace with developments in science?
How can nurses focus on human needs not machines?
How can nurses contribute to creating meaning and purpose in a global

society?
Scientific Assumptions for the 21st Century
Systems of matter and energy progress to higher levels of complex self

organization
Consciousness and meaning are constitutive of person and environment

integration
Awareness of self and environment is rooted in thinking and feeling
Human decisions are accountable for the integration of creative processes.
Thinking and feeling mediate human action
System relationships include acceptance, protection, and fostering of

interdependence
Persons and the earth have common patterns and integral relations
Person and environment transformations are created in human consciousness
Integration of human and environment meanings results in adaptation
Philosophical Assumptions
Persons have mutual relationships with the world and God
Human meaning is rooted in an omega point convergence of the universe
God is intimately revealed in the diversity of creation and is the common

destiny of creation
Persons use human creative abilities of awareness, enlightenment, and faith
Persons are accountable for the processes of deriving, sustaining, and

transforming the universe
Adaptation and Groups
Includes relating persons, partners, families, organizations, communities,

nations, and society as a whole
Adaptive Modes
Persons
Physiologic
Self Concept
Role Function
Interdependence
Groups
Physical
Group Identity
Role Function
Interdependence
Role Function Mode
Underlying Need of Social integrity
The need to know who one is in relation to others so that one can act
The need for role clarity of all participants in group

Adaptation Level
A zone within which stimulation will lead to a positive or adaptive response
Adaptive mode processes described on three levels:
Integrated
Compensatory
Compromised
Integrated Life Processes
Adaptation level where the structures and functions of the life processes work
to meet needs
Examples of Integrated Adaptation
Stable process of breathing and ventilation
Effective processes for moral-ethical-spiritual growth

Compensatory Processes
Adaptation level where the cognator and regulator are activated by a

challenge to the life processes
Compensatory Adaptation Examples:
Grieving as a growth process, higher levels of adaptation and transcendence
Role transition, growth in a new role

Compromised Processes
Adaptation level resulting from inadequate integrated and compensatory life

processes
Adaptation problem
Compromised Adaptation Examples
Hypoxia
Unresolved Loss
Stigma
Abusive Relationships
The nursing process
RAM offers guidelines to nurse in developing the nursing process.
The elements :
First level assessment
Second level assessment
Diagnosis
Goal setting
Intervention
evaluation
Usefulness of Adaptation Model
Scientific knowledge for practice
Clinical assessment and intervention
Research variables
To guide nursing practice
To organize nursing education
Curricular frame work for various nursing colleges
Characteristics of the theory
Theories can interrelates concepts in such a way as to present a new view of

looking at a particular phenomenon.
Theories should be relatively simple yet generalizable
Theories can be the basis for the hypotheses that can be tested
Theories contribute to and assist in increasing the general body of knowledge

of a discipline through the research implemented to validate them
Theories can be utilized by the practitioners to guide and improve their

practice
Theories must be consistent with other validated theories, laws and principles
but will leave open unanswered questions that need to be investigated
Testability
RAM is testable
BBARNS (1999) reported that 163 studies have been conducted using this
model.
RAM is complete and comprehensive
It explains the reality of client, so nursing interventions can be specifically

targeted.
Research studies using RAM
Middle range theories have been derived from RAM
1998-Ducharme et al described a longitudinal model of psychosocial

determinants of adaptation
1998-Levesque et al presented a MRT of psychological adaptation
1999-A MRNT , the urine control theory by Jirovec et al
Dunn, H.C. and Dunn, D. G. (1997). The Roy Adaptation Model and its
application to clinical nursing practice. Journal of Ophthalmic Nursing and
Technology. 6(2), 74-78.
Samarel, N., Fawcett, J., Krippendorf, K., Piacentino, J.C., Eliasof, B., Hughes,
P., Kowitski, C., and Ziegler, E. (1998). Women's perception of group support
and adaptation to breast cancer. Journal of Advanced Nursing. 28(6), 12591268.
Chiou, C. (2000). A meta-analysis of the interrelationships between the

modes in Roy's adaptation model. Nursing Science Quarterly. 13(3), 252-258
Yeh, C. H. (2001). Adaptation in children with cancer: research with Roy's

model. Nursing Science Quarterly. 14, 141-148.
Zhan, L. (2000). Cognitive adaptation and self-consistency in hearingimpaired older persons: testing Roy's adaptation model. Nursing Science
Quarterly. 13(2), 158-165.
Summary
1. 5 elements -person, goal of nursing, nursing activities, health and
environment
Persons are viewed as living adaptive systems whose behaviours may be

classified as adaptive responses or ineffective responses.
These behaviors are derived from regulator and cognator mechanisms.
These mechanisms work with in 4 adaptive modes.
The goal of nursing is to promote adaptive responses in relation to 4 adaptive

modes, using information about persons adaptation level, and various stimuli.
Nursing activities involve manipulation of these stimuli to promote adaptive

responses.
Health is a process of becoming integrated and able to meet goals of survival,

growth, reproduction, and mastery.
The environment consists of persons internal and external stimuli.
APPLICATION OF IMOGENE
KINGS THEORY OF GOAL
ATTAINMENT
Objectives
1.to assess the patient condition by the various methods explained by the
nursing theory
2.to identify the needs of the patient
3.to demonstrate an effective communication and interaction with the patient.
4.to select a theory for the application according to the need of the patient
5.to apply the theory to solve the identified problems of the patient
6.to evaluate the extent to which the process was fruitful.
Introduction
Kings theory offers insight into nurses interactions with individuals and groups
within the environment. It highlights the importance of clients participation in
decision that influences care and focuses on both the process of nurse-client
interaction and the outcomes of care. Mr.Sy (74 years) was admitted in L3 ward of
...Hospital, for a herniorrhaphy on ... for his left indirect inguinal hernia and was
expecting discharge from hospital... the theory of goal attainment was used in his
nursing process.
Major Concepts and Definitions
1.
Interaction
A process of perception and communication
Between person and environment
Between person and person
Represented by verbal and nonverbal behaviours
Goal-directed
Each individual brings different knowledge , needs, goals, past experiences

and perceptions, which influence interaction
2.
Communication
Information from person to person
Directly or indirectly
Information component of interaction

3.
Perception
Each persons representation of reality

4.
Transaction
Purposeful interaction leading to goal attainment

5.
Role
A set of behaviours expected of persons occupying a position in a social

system
Rules that define rights and obligations in a position

6.
Stress
Dynamic state

Human being interacts with the environment
7.
Continuous changes in individuals
At cellular, molecular and behavioural levels of activities
Helps individuals move towards maturity

8.
Time
Sequence of events
Moving onwards to the future

9.
Space
Existing in all directions
Same everywhere
Immediate environment (nurse and client interaction)

MAJOR ASSUMPTIONS
Nursing
Observable behaviour
In health care system in society
Goal to help individuals maintain health
Interpersonal process of action; reaction, interaction and transaction

Person
1.
Social beings
2.
Sentient beings
3.
Rational beings
4.
Perceiving beings
5.
Controlling beings
6.
Purposeful beings
7.
Action oriented beings
8.
Time oriented beings
Health
Dynamic state in the life cycle
Continuous adaptation to stress
To achieve maximum potential for daily living
Function of nurse, patient, physicians, family and other interactions

Environment
Open system
Constantly changing
Influences adjustment to life and health

Dynamic Interacting Systems
Personal system
Concepts
Perception
Self
Body image
Time
Space
Concepts
1. Interaction, 2. Transaction 3. Communication 4. Role 5. Stress
Social system
Concepts
1.
Organization 2. Authority 3. Power 4. Status, 5. Decision making
ASSUMPTIONS
Perceptions, goals, needs and values of the nurses and client influence
interaction process
Individuals have the right to knowledge about themselves and to

participate in decisions that influence their life, health and community services
Health professionals have the responsibility that helps individuals to make

informed decisions about their health care
Individuals have the right to accept or reject health care
Goals of health professionals and recipients of health care may not be

congruent
Propositions of Kings Theory
From the theory of goal attainment king developed predictive propositions, which
includes:
If perceptual interaction accuracy is present in nurse-client interactions,

transaction will occur
If nurse and client make transaction, goal will be attained
If goal are attained, satisfaction will occur
Proposition cont
If transactions are made in nurse-client interactions, growth & development

will be enhanced
If role expectations and role performance as perceived by nurse & client

are congruent, transaction will occur
If role conflict is experienced by nurse or client or both, stress in nurseclient interaction will occur
If nurse with special knowledge skill communicate appropriate information

to client, mutual goal setting and goal attainment will occur.
Theory of Goal Attainment and Nursing Process
Assumptions
Basic assumption of goal attainment theory is that nurse and client communicate
information, set goal mutually and then act to attain those goals, is also the basic
assumption of nursing process.
Assessment
King indicates that assessment occur during interaction. The nurse brings
special knowledge and skills whereas client brings knowledge of self and
perception of problems of concern, to this interaction.
During assessment nurse collects data regarding client (his/her growth &
development, perception of self and current health status, roles etc.)
Perception is the base for collection and interpretation of data.
Communication is required to verify accuracy of perception, for interaction and
transaction.
The first process in nursing process is nurse meets the patient and
communicates and interacts with him. Assessment is conducted by
gathering data about the patient based on relevant concepts.
Mr. Sy is 74yrs married, got admitted in L3 ward of ...Hospital on 27/03/08 with a
diagnosis of indirect inguinal hernia underwent herniorraphy with prolene mesh
done on 30/03/08. The following areas were addressed to for gathering data.
What is the patients
perception of the situation?
Patient says
I have undergone surgery for hernia. The
wound is getting healed, I have no other problem
I have pain in the area of surgery when moving
Im taking medicines for hypertension for the last
7 years from here
I have vision problem to my left eye. I had
undergone a surgery for my right eye about 10
years back.
What are my perceptions of

the situation?
Patient underwent herniorahaphy operation on 30th

March for indirect inguinal hernia which he kept
untreated for 35 years.
Patient has health maintenance related problems.
Patient is at risk of developing infection.
Patient has pain related to surgical incision.
Patient
may
develop
hypertension
related
complications in future.
What other information do I

need to assist this patient
to achieve health?
History
Identification details
Mr. Sy is 74yrs married, male, studied up to 7th
Std is doing Business, a practicing Muslim, got
admitted in L3 ward of ...Hospital on 27/03/08 with
a diagnosis of indirect inguinal hernia underwent
herniorraphy with prolene mesh done on 30/03/08.
Present History of Illness
Abdominal swelling for 35 years with difficulty in
activities and occasional abdominal pain. He has
hypertension for seven years.
The swelling remained stable with uncomplicated
progress, getting increasing size when standing for
long and reducible on applying pressure
No h/o severe pain but increasing size for the last
few years
Relived after pressing the swelling back to position
and on taking rest and applying pressure
Past health history
Patient underwent cataract surgery about 10 years
back
On treatment for hypertension
No other significant illness
Family History
Patients next elder brother and next younger
brother had inguinal hernia and were operated
Elder brother underwent 3 surgeries for hernia
Socioeconomic Status
High economic status >Rs.20000/- per month
Life Style
Non vegetarian
No habit of smoking or alcoholism.
Aware about health care facilities
Physical examination
Alert, conscious and oriented
Moderately built, adequate nourishment, with BMI
of 22
Vital signs normal except BP 140/90 mmHg
General head-to-foot examination reveals normal
finding except for the vision difficulty of the right
eye and healing surgical wound on th left inguinal
region.
Subjective problems
Pain at the surgical wound site
Lack of bowel movement for 2 days
Review of relevant systems
GI system
Inspection:
Healing wound, No infection, No redness, No
swelling
Auscultation:
Normal bowel sounds
Palpation
No pain at the site, Normal abdominal organs
Percussion:
No dull sound suggesting fluid collection or ascitis
Genito-Urinary system
Inspection:
Testicles in position, No infection, No swelling or
enlargement
Palpation
No c/o pain,No prostate enlargement
Percussion
No fluid collection in scrotum
Auscultation
Normal Bowel sounds
Laboratory Investigations
FBS - 91 mg/dl
Na(130-143mEq/dl) - 134 mEq / dl

K+ (3.5-5 mg/dl) - 3.5 mEq / dl
Urea(8-35mg/dl)-29 mg / dl
Cr (0.6-1.6 mg/ dl)- <1 mg/ dl
Other investigations
Electro cardio gram
Ant. Fascicular block
Left atrial enlargement
Normal axis
What does this information
means to this situation?
Patient neglected a health problem for 35

years
Patient has acute pain at the site of surgical

wound
Patient has family history of inguinal hernia

and risk for recurrence
Patient has a risk for recurrence due to

constipation.
Patient has risk for infection due to

inadequate knowledge and age.
Patient is at risk of developing complications

of hypertension
Patient requires education regarding health

maintenance
What conclusion
(judgement) does this
patient make?
Patient requires management for his pain
Patient understands the need taking care of

health risks and agrees to work on these aspects
What conclusions
(judgement) do I make?
Nursing diagnosis
The data collected

by assessment are used to
make nursing diagnosis in
nursing process. Acc. to
King in process of attaining
goal, the nurse identifies
the problems, concerns and
disturbances about which
person seek help.
Based on the assessment following nursing

diagnoses were formulated, i.e. the clinical
judgement about the patients actual and potential
problems.
Acute pain related to surgical incision
Risk for infection related to surgical incision
Risk for constipation related to bed rest, pain
medication and NPO or soft diet
Deficient knowledge regarding the treatment
and home care
Ineffective health maintenance
Planning
After diagnosis, planning for interventions to solve those problems is done.
In goal attainment planning is represented by setting goals and making decisions
about and being agreed on the means to achieve goals.
This part of transaction and clients participation is encouraged in making decision
on the means to achieve the goals.
Identifying the goals and planning to achieve these goals(this step is
congruent with planning in the traditional nursing process)
What goals do I think will
1.
The client will experience improved comfort, as
serve the patients best

interest?
evidenced by:
a decrease in the rating of the pain,
the ability to rest and sleep comfortably

2.
The client will be free of infection as evidenced
by normal temperature, normal vital signs.
3.
The client will have improved bowel
elimination, as evidenced by:
Elimination of stool without straining

4.
Client will acquire adequate knowledge
regarding the treatment and home care.
5.
Client will attend to health problems promptly
What are the patients

goals?
Patients goals are:
Freedom from pain
Rapid healing
Adequate bowel movement
Acquiring adequate knowledge regarding his

health problems
Are the patients goals

and professional goals
are congruent?
Yes
What are the priority

goals?
Relief of pain
Freedom from infection
Adequate bowel movement
Improvement knowledge aspect of health conditions
Prompt attendance to health problems
What does the patient

perceives as the best way
to achieve goals?
health
Is the patient willing to

work towards the goals?
Yes
What do I perceive to be
the best way to achieve
the goals?
Goal 1:
Assess the characteristics of pain
Administration of prescribed medicine
Monitor the responses to drug therapy
Provide calm, efficient manner that reassures the
client and minimizes anxiety
Provide a comfortable position as per clients
requests.
Goal 2:
Monitor vital signs
Administer antibiotics as advised
Use aseptic techniques while changing dressing
Kept the surgical wound site clean
Report surgeon regarding early signs of infection
Goal 3:
Working with the health professionals

Gaining knowledge
Disclosing adequate information regarding
problems
Ensure that the client has adequate bulk in diet and

adequate fluid intake
Instruct the client on prevention of straining and
avoiding valsalva manoeuvre
Consult treating physician regarding medications.
Goal 4:
Explain the treatment measures to the patient and
their benefits in a simple understandable language.
Explain demonstrate about the home care.
Clarify the doubts of the patient as the patient may
present with some matters of importance.
Repeat the information whenever necessary to
reinforce learning.
Goal 5:
Health education given about the following.
Restriction of heavy weight lifting (more than
20kg) for 6 months
Further management which may be
necessary
Diet control for his hypertension
Rehabilitation measures to promote better
living
For regular examination of the site for recurrence
of hernia
Are the goals short-term
or long term?
Goals are both short-term and long term
What modifications
required based on
mutuality?
Pain is tolerable to the patient and requires no

SOS medication
Constipation is not that severe enough to take
medication
Other interventions are mutually acceptable.
Implementations
1.In nursing process implementation involves the actual activities to achieve
the goals.
2.This step results in transactions being made.
3.Transactions occur as a result of perceiving the other person and the
situation, making judgments about those perceptions, and taking some
actions in response.
4.Reactions to action lead to transactions that reflect a shared view and
commitment
5.This step reflects implementation in the traditional nursing process.
Am I doing what the patient and I
have agreed upon?
Yes
How am I carrying out the

actions?
On a mutually acceptable manner in

accordance with the goals set.
When do I carry out the action?
According to priority, a few interventions

require immediate attention.
Other interventions are carried out during

the period of hospitalization till 5th April.
Why am I carrying out the action?
Patients condition demands nursing car.
Is it reasonable to think that the

identified goals will be reached by
carrying out the action?
Yes
Evaluation
It involves to finding out weather goals are achieved or not.
In Kings description evaluation speaks about attainment of goal and effectiveness
of nursing care.
Are my actions helping the patient
achieve mutually defined goals?
Yes
How well are goals being met?
Short-term goals are met before

discharge from hospital
Long-term goals are expected to be met,
because the patient is motivated to
continue home care.
What actions are not working?

What is patients response to my
actions?
Patient is satisfied with my actions
Are other factors hindering goal

achievement?
Patients age is a hindering factor in goal

achievement regarding health
maintenance.
How should the plan be changed to

achieve goals?
Health teaching can be modified

according to developmental stage.
Involvement of family member in care of
the patient.
APPLICATION OF OREM'S SELF-CARE

DEFICIT THEORY IN NURSING
PRACTICE
INTRODUCTION
The history of professional nursing begins with Florence nightingale.
Later in last century nursing began with a strong emphasis on practice.
Following that came the curriculum era which addressed the questions
about what the nursing students should study in order to achieve the required
standard of nursing.
As more and more nurses began to pursue higher degrees in nursing,

there emerged the research era.

Later graduate education and masters education was given much
importance.
The development of the theory era was a natural outgrowth of the

research era.
With an increased number of researches it became obvious that the

research without theory produced isolated information; however research and
theory produced the nursing sciences.
Within the contemporary phase there is an emphasis on theory use

and theory based nursing practice and lead to the continued development of
the theories.
OBJECTIVES
to assess the patient condition by the various methods explained by

the nursing theory
to identify the needs of the patient
to demonstrate an effective communication and interaction with the

patient.
to select a theory for the application according to the need of the

patient
to apply the theory to solve the identified problems of the patient
to evaluate the extent to which the process was fruitful.

Areas
Patient details
Name
Mrs. X
Age
56 years
Sex
Female
Education
Occupation
No formal
education
Marital status
Religion
Diagnosis
Theory
applied
House hold
Married
Hindu
Rheumatoid
arthritis
Orems theory of
self care deficit.
OREMS THEORY OF SELF CARE DEFICIT
The self care deficit theory proposed by Orem is a combination of three

theories, i.e. theory of self care, theory of self care deficit and the theory of
nursing systems.
In the theory of self care, she explains self care as the activities
carried out by the individual to maintain their own health.
The self care agency is the acquired ability to perform the self care
and this will be affected by the basic conditioning factors such as age,
gender, health care system, family system etc.

Therapeutic self-care demand is the totality of the self care measures
required.
The self care is carried out to fulfill the self-care requisites.
There are mainly 3 types of self care requisites such as universal,

developmental and health deviation self care requisites.
Whenever there is an inadequacy of any of these self care requisite, the

person will be in need of self care or will have a deficit in self care.
The deficit is identified by the nurse through the thorough assessment

of the patient.
Once the need is identified, the nurse has to select required nursing
systems to provide care: wholly compensatory, partly compensatory or
supportive and educative system.
The care will be provided according to the degree of deficit the patient
is presenting with.
Once the care is provided, the nursing activities and the use of the
nursing systems are to be evaluated to get an idea about whether the
mutually planned goals are met or not.
Thus the theory could be successfully applied into the nursing practice.
For Mrs. X.
1.
She came to the hospital with complaints of pain over all the joints,
stiffness which is more in the morning and reduces by the activities.
2.
She has these complaints since 5 years and has taken treatment from
local hospital.
3.
The symptoms were not reducing and came to --MC, Hospital for
further management.
4.
Patient was able to do the ADL by herself but the way she performed
and the posture she used was making her prone to develop the complications
of the disease.
5.
She also was malnourished and was not having awareness about the
deficiencies and effects.
DATA COLLECTION ACCORDING TO OREMS THEORY OF SELF CARE DEFICIT
1. BASIC CONDITIONING FACTORS
Age
56 year
Gender
Female
Health state
Disability due to health condition, therapeutic

self care demand
Development state
Ego integrity vs despair
Sociocultural
orientation
No formal education, Indian, Hindu
Health care system
Institutional health care
Family system
Married, husband working
Patterns of living
At home with partner
Environment
Rural area, items for ADL not in easy reach, no

special precautions to prevent injuries
resources
Husband, daughter, sisters son
2. UNIVERSAL SELF-CARE REQUISITES:

Air
Breaths without difficulty, no pallor cyanosis
Water
Fluid intake is sufficient. Edema present over

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

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

Pain not completely relieved,
Activity level ha s come down.
Deformity of the joint secondary to the disease
process and use of the joints.
Social interaction Communicates well with neighbors and calls the

daughter by phone Need for medical care is
communicated to the daughter.
Prevention of
hazards
Need instruction on care of joints and prevention of

falls. Need instruction on improvement of
nutritional status. Prefer to walk bare foot.
Promotion of
normalcy
Has good relation with daughter
3. DEVELOPMENTAL SELF-CARE REQUISITES:

Maintenance of
developmental environment
Prevention/management of the
conditions threatening the
normal development
Able to feed self , Difficult to perform

the dressing, toileting etc
Feels that the problems are due to her
own behaviours and discusses the
problems with husband and daughter.
4. HEALTH DEVIATION SELF CARE REQUISITES

Adherence to medical
regimen
Reports the problems to the physician when in

the hospital. Cooperates with the medication,
Not much aware about the use and side
effects of medicines
Awareness of potential
problem associated
with the regimen
Not aware about the actual disease process.
Modification of self
image to incorporates
changes in health
status
Has adapted to limitation in mobility.
Adjustment of lifestyle
to accommodate
changes in the health
status and medical
regimen.
Adjusted with the deformities.
Not compliant with the diet and prevention of

hazards. Not aware about the side effects of
the medications
The adoption of new ways for activities leads

to deformities and progression of the disease.
Pain tolerance not achieved
5. MEDICAL PROBLEM AND PLAN:
Physicians perspective of the condition:

Diagnosed with rheumatoid arthritis and is on the following medications:
T. Valus SR OD
T. Pan 40 mg OD
T. Tramazac 50 mg OD
T. Recofix Forte BD
T. Shelcal BD
Syp. Heamup 2tsp TID
Medical Diagnosis: Rheumatoid arthritis

Medical Treatment: Medication and physical therapy.
AREAS AND PRIORITY ACCORDING TO OREMS THEORY OF SELF-CARE
DEFICIT: IMPORTANT FOR PRIORITIZING THE NURSING DIAGNOSIS.
a. Air
b. Water
c. Food
d. Elimination
e. Activity/ Rest
f.
Solitude/ Interaction
g. Prevention of hazards
h. Promotion of normalcy
i.
j.
Maintain a developmental environment.

Prevent or manage the developmental threats
k. Maintenance of health status

l.
Awareness and management of the disease process.
m. Adherence to the medical regimen
n. Awareness of potential problem.

o.
modify self image
p. Adjust life style to accommodate health status changes and MR

Nursing care plan according to Orems theory of self care deficit
Nursing
diagnosis
( diagnostic
operations )
Based on self care
deficits
Outcome and plan
Implementation
Evaluation
(Prescriptive
operations)
(control
operations)
(regulatory
operations )
Nurse- patient
actions to
1. Effectiveness of
the nurse patient
action to
1. Outcome
2. Nursing goal
and objectives
3. Design of
nursing system
4. Appropriate
method of
helping
Promote
patient as
self care
agent
Meet self
care needs
-Promote patient
as self care agent
-
Meet self
care needs
- Decrease
Decrease the
the self
self care
care deficit.
deficit.
2. Effectiveness of
the selected
nursing system to
meet the needs.
Thus in the patient Mrs. X the areas that need assistance were
Air
Water
Food
Elimination
Activity/ Rest(2)
Solitude/ Interaction
Prevention of hazards(2)
Promotion of normalcy
Maintain a developmental environment.
Prevent or manage the developmental threats
Maintenance of health status
Awareness and management of the disease process.
Adherence to the medical regimen
Awareness of potential problem.
modify self image

Adjust life style to accommodate health status changes and medical regimen
APPLYING THE OREMS THEORY OF SELF-CARE DEFICIT, A NURSING CARE

PLAN FOR MRS. X COULD BE PREPARED AS FOLLOWS
Therapeutic self care demand: deficient area: food

Adequacy of self care agency: Inadequate
NURSING DIAGNOSIS
Inability to maintain the ideal nutrition related to inadequate intake and knowledge
deficit
OUTCOMES AND PLAN
a. Outcome:
improved nutrition
Maintenance of a balanced diet with adequate iron supplementation.
b. Nursing Goals and objectives
Goal: to achieve optimal levels of nutrition.
Objectives: Mrs. X will:
- state the importance of maintaining a balanced diet.
- List the food items rich in iron , that are available in the locality.
c. Design of the nursing system:
supportive educative
d. Method of helping:
guidance
support
Teaching
Providing developmental environment
IMPLEMENTATION
Mutually planned and identified the objectives and the patient were made to
understand about the required changes in the behaviour to have the requisites met.
EVALUATION
Mrs. X understood the importance of maintaining an optimum nutrition.
She told that she will select the iron rich diet for her food.
She listed the foods that are rich in iron and that are locally available.
The self care deficit in terms of food will be decreased with the initiation of the
nutritional intake.
The supportive educative system was useful for Mrs. X
-------------------------------------------------------------------------Therapeutic self care demand: deficient area: Activity
NURSING DIAGNOSIS
Self-care deficit: dressing, toileting related to restricted joint movement, secondary
to the inflammatory process in the joints.
OUTCOMES AND PLAN
a. Outcome:
- improved self-care
- maintain the ability to perform the toileting and dressing with modification as
required.

Goal: to achieve optimal levels of ability for self care.
-perform the dressing activities within limitations
-utilize the alternative measures available for improving the toileting
-perform the other activities of daily living with minimal assistance.
c. Design of the nursing system: Partly compensatory
d. Method of helping:
Guidance:
Assess the various hindering factors for self care and how to tackle them.
Support:
Provide all the articles needed for self care, near to the patient and ask the family
members also to give the articles near to her.
Provide passive exercises and make to perform active exercises so as to promote the
mobility of the joint.
Make the patient use commodes or stools to perform toileting and insist on
avoidance of squatting position
Provide assistance whenever needed for the self care activities
Provide encouragement and positive reinforcement for minor improvement in the
activity level.
Initiate the pain relieving measures always before the patient go for any of the
activities of daily living
Make the patient to use loose fitting clothes which will be easy to wear and remove.
Teaching:
Teach the family members the limitation in the activity level the patient has and the
cooperation required
Promoting a developmental environment:
Teach the family and help them to practice how to help the patient according to her
needs
IMPLEMENTATION
Mutually planned and identified the objectives and the patient was made to
understand about the required changes in the behaviour to have the requisites met.
EVALUATION
Patient was performing some of the activities and she practiced toileting using a
commode in the hospital.
She verbalized an improved comfort and self care ability.
She performed the dressing activities with minimal assistance
Patient verbalized that she will perform the activities as instructed to get her ADL
done.
The partly compensatory system was useful for Mrs. X
---------------------------------------------------------------------Therapeutic self care demand: deficient area: Pain control
NURSING DIAGNOSIS
Ineffective pain control related to lack of utilization of pain relief measures
OUTCOMES AND PLAN

a. Outcome:
- improved pain self control
- achieve and maintain a reduction in the pain.

Goal: to achieve reduction in the pain.
describe the total plan of pharmacological and non pharmacological pain
relief
demonstrate a reduction in the pain behaviours
verbalize a reduction in the pain scale score from 7 4
c. Design of the nursing system: supportive educative
d. method of helping:
Guidance:
Explore the past experience of pain and methods used to manage them.
Ask the client to report the intensity, location, severity, associated and
aggravating factors.
Support:
Provide rest to the joints and avoid excessive manipulations
provide hot and cold application to have better mobility.
Encourage exercises to the joints by immersing in the warm water.
Administer T. Ultracet and Tab Diclofecac as prescribed.
Provide diversion and psychological support to the patient
Teaching:
Teach the non pharmacological method to the patient once the pain is a
little reduced.
Providing the developmental environment:
Discuss with the patient the necessity to maintain a pain diary with all
information regarding episodes of pain and refer to that periodically
Enquire from the health team, the need for opioid analgesics or other
analgesics and get a prescription for the patient.
IMPLEMENTATION
----------------------------------------------------------------------------EVALUATION
Patient still has pain over the joints and she agreed that she will use the
measures for pain relief that is told to her.
The pain scale score was 6 after the measures were provided to the patient.
She demonstrated slight reduction in the pain behaviours.
-------------------------------------------------------------Therapeutic self care demand: deficient area: prevention of hazards.

NURSING DIAGNOSIS
Potential for fall and fractures related to rheumatoid arthritis.
OUTCOMES AND PLAN
a. Outcome:
Absence of falls and injury to the patient
Goal: prevent the falls and injury and to maintain a good body mechanics.
objectives: Mrs. X will:
-remain free from injury as evidenced by:
-absence of signs and symptoms of fall or injury
- explaining the methods to prevent the injury.
Support
Never leave the client alone in the unit
Assess the patients gait, activities and the mental status for any confusion or
disorientation
Encourage the patient to use supportive devices as required.
Provide a safe environment in the hospital by avoiding sharp objects or
wooden objects on the way and slippery floor.
Involve the family members in providing and maintaining a safe environment
in the home
Involve the family members to provide support to the patient whenever
necessary
Plan a balanced diet for the patient with a mutual interaction
IMPLEMENTATION
-----------------------------------------------------------------EVALUATION
Patient remained free from injury as evidenced by absence of signs and
symptoms.
Patient explained the various measures that they will take to prevent the
injury.
-----------------------------------------------------------------Therapeutic self care demand: deficient area: prevention of hazards.
NURSING DIAGNOSIS:
Potential for impaired skin integrity related to edema secondary to renal cysts.
OUTCOMES AND PLAN:

a. Outcome:
Maintenance of normal skin integrity.
b. nursing Goals and objectives
Goal: Maintain the skin integrity and take measures to prevent skin impairment.
1. maintain a normal skin integrity
2. list the measures to prevent the loss of skin integrity
3.
identify the measures to relieve edema.

Support:
Assess the skin regularly for any excoriation or loss of integrity or colour changes.
Keep the skin clean always
Avoid stress or pressure over the area of edema by providing extra cushions or
padding
Monitor the lab values as well as the patient for any signs and symptoms of renal
failure.
Encourage the patient to use slippers while walking and that should not be tight
fitting.
Assess the edema for its degree, pitting or non pitting and continue the assessment
daily.
Provide a leg end elevated position or elevation of the leg on a pillow if no cardiac
abnormalities are identified.
Explain the patient the need for taking care of the edematous parts
Explain the patient to report the symptoms like decreased urine output, palpitations,
increased edema etc. to the health team
IMPLEMENTATION
------------------------------------------------------------------EVALUATION
Patient remained free from impaired skin integrity
She listed the measures to prevent the loss of skin integrity
She identified the measures to relieve edema.
The supportive educative system was useful for Mrs. x
----------------------------------------------------------------Therapeutic self care demand: deficient area: awareness of the disease process
and management
NURSING DIAGNOSIS
Potential for complications related to rheumatoid arthritis secondary to knowledge
deficit.
OUTCOMES AND PLAN
a. Outcome:
Absence of complications and improved awareness about the disease process.
b. nursing Goals and objectives
Goal: Improve the knowledge of the patient about the disease process and the
complications.
-verbalize the various complication and their preventions
-verbalize the changes occurring with the disease process and the treatment
available
-describe the actions and side effects of the medications which she is using
c. Design of the nursing system:
supportive educative
d. Methods of helping:
Guidance
Teaching
Promoting a developmental environment
IMPLEMENTATION
------------------------------------------------------------EVALUATION
Patient got adequate information regarding the disease
She verbalized what she understood about the disease and its management.
Patient has cleared her doubts regarding the medication actions and the side
effect
EVALUATION OF THE APPLICATION OF SELF CARE DEFICIT THEORY
The theory of self-care deficit when applied could identify the self care requisites of
Mrs. X from various aspects. This was helpful to provide care in a comprehensive
manner. Patient was very cooperative. the application of this theory revealed how
well the supportive and educative and partly compensatory system could be used for
solving the problems in a patient with rheumatoid arthritis.
HEALTH PROMOTION MODEL

INTRODUCTION
The health promotion model (HPM) proposed by Nola J Pender (1982; revised, 1996)
was designed to be a complementary counterpart to models of health protection. It
defines health as a positive dynamic state not merely the absence of disease. Health
promotion is directed at increasing a clients level of wellbeing. The health promotion
model describes the multi dimensional nature of persons as they interact within their
environment to pursue health. The model focuses on following three areas:
Individual characteristics and experiences
Behavior-specific cognitions and affect
Behavioral outcomes
The health promotion model notes that each person has unique personal
characteristics and experiences that affect subsequent actions. The set of variables
for behavioral specific knowledge and affect have important motivational significance.
These variables can be modified through nursing actions. Health promoting behavior
is the desired behavioral outcome and is the end point in the HPM. Health promoting
behaviors should result in improved health, enhanced functional ability and better
quality of life at all stages of development. The final behavioral demand is also
influenced by the immediate competing demand and preferences, which can derail an
intended health promoting actions.
ASSUMPTIONS OF THE HEALTH PROMOTION MODEL
The HPM is based on the following assumptions, which reflect both nursing and
behavioral science perspectives:
1.
Persons seek to create conditions of living through which they can express
their unique human health potential.
2.
Persons have the capacity for reflective self-awareness, including

assessment of their own competencies.
3.
Persons value growth in directions viewed as positive and attempts to

achieve a personally acceptable balance between change and stability.
4.
Individuals seek to actively regulate their own behavior.
5.
Individuals in all their biopsychosocial complexity interact with the

environment, progressively transforming the environment and being
transformed over time.
6.
Health professionals constitute a part of the interpersonal environment,

which exerts influence on persons throughout their lifespan.
7.
Self-initiated reconfiguration of person-environment interactive patterns is

essential to behavior change.
THEORETICAL PROPOSITIONS OF THE HEALTH PROMOTION MODEL

Theoretical statements derived from the model provide a basis for investigative work
on health behaviors. The HPM is based on the following theoretical propositions:
1.
Prior behavior and inherited and acquired characteristics influence beliefs,

affect, and enactment of health-promoting behavior.
2.
Persons commit to engaging in behaviors from which they anticipate

deriving personally valued benefits.
3.
Perceived barriers can constrain commitment to action, a mediator of

behavior as well as actual behavior.
4.
Perceived competence or self-efficacy to execute a given behavior increases

the likelihood of commitment to action and actual performance of the
behavior.
5.
Greater perceived self-efficacy results in fewer perceived barriers to a

specific health behavior.
6.
Positive affect toward a behavior results in greater perceived self-efficacy,

which can in turn, result in increased positive affect.
7.
When positive emotions or affect are associated with a behavior, the

probability of commitment and action is increased.
8.
Persons are more likely to commit to and engage in health-promoting

behaviors when significant others model the behavior, expect the behavior to
occur, and provide assistance and support to enable the behavior.
9.
Families, peers, and health care providers are important sources of

interpersonal influence that can increase or decrease commitment to and
engagement in health-promoting behavior.
10. Situational influences in the external environment can increase or decrease

commitment to or participation in health-promoting behavior.
11. The greater the commitments to a specific plan of action, the more likely
health-promoting behaviors are to be maintained over time.
12. Commitment to a plan of action is less likely to result in the desired behavior
when competing demands over which persons have little control require
immediate attention. 13. Commitment to a plan of action is less likely to
result in the desired behavior when other actions are more attractive and thus
preferred over the target behavior.
13. Persons can modify cognitions, affect, and the interpersonal and physical
environment to create incentives for health actions.
THE MAJOR CONCEPTS AND DEFINITIONS OF THE HEALTH PROMOTION
MODEL
Individual Characteristics and Experience
v
PRIOR RELATED BEHAVIOR
Frequency of the similar behaviour in the past. Direct and indirect effects on the
likelihood of engaging in health promoting behaviors.
v
PERSONAL FACTORS
Personal factors categorized as biological, psychological and socio-cultural. These

factors are predictive of a given behavior and shaped by the nature of the target
behaviour being considered.
Personal biological factors
Include variable such as age gender body mass index pubertal status, aerobic
capacity, strength, agility, or balance.
Personal psychological factors
Include variables such as self esteem self motivation personal competence perceived
health status and definition of health.
Personal socio-cultural factors
Include variables such as race ethnicity, accuculturation, education and
socioeconomic status.
Behavioural Specific Cognition and Affect

v
PERCEIVED BENEFITS OF ACTION
Anticipated positive out comes that will occur from health behaviour.
v
PERCEIVED BARRIERS TO ACTION
Anticipated, imagined or real blocks and personal costs of understanding a given

behaviour
v
PERCEIVED SELF EFFICACY
Judgment of personal capability to organise and execute a health-promoting

behaviour. Perceived self efficacy influences perceived barriers to action so higher
efficacy result in lowered perceptions of barriers to the performance of the behavior.
v
ACTIVITY RELATED AFFECT
Subjective positive or negative feeling that occur before, during and following
behavior based on the stimulus properties of the behaviour itself. Activity-related
affect influences perceived self-efficacy, which means the more positive the
subjective feeling, the greater the feeling of efficacy. In turn, increased feelings of
efficacy can generate further positive affect.
v
INTERPERSONAL INFLUENCES
Cognition concerning behaviours, beliefs, or attitudes of the others. Interpersonal

influences include: norms (expectations of significant others), social support
(instrumental and emotional encouragement) and modelling (vicarious learning
through observing others engaged in a particular behaviour). Primary sources of
interpersonal influences are families, peers, and healthcare providers.
v
SITUATIONAL INFLUENCES
Personal perceptions and cognitions of any given situation or context that can
facilitate or impede behaviour. Include perceptions of options available, demand
characteristics and aesthetic features of the environment in which given health
promoting is proposed to take place. Situational influences may have direct or
indirect influences on health behaviour.
Behavioural Outcome
v
COMMITMENT TO PLAN OF ACTION
The concept of intention and identification of a planned strategy leads to

implementation of health behaviour.
v
IMMEDIATE COMPETING DEMANDS AND PREFERENCES
Competing demands are those alternative behaviour over which individuals have low
control because there are environmental contingencies such as work or family care
responsibilities. Competing preferences are alternative behaviour over which
individuals exert relatively high control, such as choice of ice cream or apple for a
snack
v
HEALTH PROMOTING BEHAVIOUR
Endpoint or action outcome directed toward attaining positive health outcome such
as optimal well-being, personal fulfillment, and productive living.
HEALTH BELIEF MODEL (HBM)

INTRODUCTION
HBM is a popular model in nursing, especially in issues focusing on patient
compliance and preventive health care practices. the model postulates that
health-seeking behaviour is influenced by a persons perception of a threat posed
by a health problem and the value associated with actions aimed at reducing the
threat. HBM addresses the relationship between a persons beliefs and behaviors.
It provides a way to understanding and predicting how clients will behave in
relation to their health and how they will comply with health care therapies.
THE MAJOR CONCEPTS AND DEFINITIONS OF THE HEALTH PROMOTION

MODEL
There are six major concepts in HBM:
1.
Perceived Susceptibility
2.
Perceived severity
3.
Perceived benefits
4.
Perceived costs
5.
Motivation
6.
Enabling or modifying factors
1.
Perceived Susceptibility: refers to a persons perception that a health

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

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

accessibility of the treatment
5.
Motivation: includes the desire to comply with a treatment and the belief that
people should do what
6.
Modifying factors: include personality variables, patient satisfaction, and

socio-demographic factors.
THEORIES USED IN COMMUNITY

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

Intervention target is in 4 categories 1.Human/Biological 2. Environmental 3.
Medical/technological/organizational 4. Social
Block and Jostens Ethical Theory of population focused nursing
Derryl Block and Lavohn Josten, public health educators proposed this based on
intersecting fields of public health and nursing. They have given 3 essential elements
of population focused nursing that stem from these 2 fields:
1. an obligation to population
2. the primacy of prevention
3. centrality of relationship- based care
the first two are from public health and the third element from nursing. Hence it
implies to nursing that relation-based care is very important in population focused
care.
Canadian Model for community
The community health nurse works with individuals, families, groups, communities,
populations, systems and/or society, but at all times the health of the person or
community is the focus and motivation from which nursing actions flow. The
standards of practice are applied to practice in all settings where people live, work,
learn, worship and play.
The philosophical base and foundational values and beliefs that characterize
community health nursing - caring, the principles of primary health care, multiple
ways of knowing, individual/community partnerships and empowerment - are
embedded in the standards and are reflected in the development and application of
the community health nursing process.
The community health nursing process involves the traditional nursing process
components of assessment, planning, intervention and evaluation but is enhanced by
community health nurses in three dimensions: 1) individual/community participation
in each component, 2) multiple ways of knowing, each of which is necessary to
understand the complexity and diversity of nursing in the
community; knowledge and utilization of all these ways of knowing forms evidencebased practice consistent with these standards, and 3) the inherent influence of the
broader environment on the individual/community that is the focus of care (e.g. the
community will be affected by provincial/territorial policies, its own economic status
and by the actions of its individual citizens). The standards of practice are founded
on the values and beliefs of community health nurses, and utilization of the
community health nursing process.
The model illustrates the dynamic nature of community health nursing practice,
embracing the present and projecting into the future. The values and beliefs (green
or shaded) ground practice in the present yet guide the evolution of community
health nursing practice over time. The community health nursing process provides
the vehicle through which community health nurses work with people, and supports
practice that exemplifies the standards of community health nursing. The standards
of practice revolve around both the values and beliefs and the nursing process with
the energies of community health nursing always being focused on improving the
health of people in the community and facilitating change in systems or society in

support of health. Community health nursing practice does not occur in isolation but
rather within an environmental context, such as policies within their workplace and
the legislative framework applicable to their work
APPLICATION OF BETTY NEUMAN'S

SYSTEMS MODEL
OBJECTIVES:
to assess the patient condition by the various methods explained by the
nursing theory
to demonstrate an effective communication and interaction with the patient.
to select a theory for the application according to the need of the patient
INTRODUCTION
SYSTEM MODEL- BETTY NEUMAN
A theory is a group of related concepts that propose action that guide practice. A
nursing theory is a set of concepts, definitions, relationships, and assumptions or
propositions derived from nursing models or from other disciplines and project a
purposive, systematic view of phenomena by designing specific inter-relationships
among concepts for the purposes of describing, explaining, predicting, and /or
prescribing.
The Neumans system model has two major components i.e. stress and reaction
to stress. The client in the Neumans system model is viewed as an open system
in which repeated cycles of input, process, out put and feed back constitute a
dynamic organizational pattern. The client may be an individual, a group, a family,
a community or an aggregate. In the development towards growth and
development open system continuously become more differentiated and elaborate
or complex. As they become more complex, the internal conditions of regulation
become more complex. Exchange with the environment are reciprocal, both the
client and the environment may be affected either positively or negatively by the
other.
The system may adjust to the environment to itself. The ideal is to achieve
optimal stability. As an open system the client, the client system has propensity to
seek or maintain a balance among the various factors, both with in and out side
the system, that seek to disrupt it. Neuman seeks these forces as stressors and
views them as capable of having either positive or negative effects. Reaction to
the stressors may be possible or actual with identifiable responses and symptom.
MAJOR CONCEPTS
I. PERSON VARIABLESEach layer, or concentric circle, of the Neuman model is made up of the five
person variables. Ideally, each of the person variables should be considered
simultaneously and comprehensively.
1. Physiological - refers of the physicochemical structure and function of the body.
2. Psychological - refers to mental processes and emotions.
3.
Sociocultural - refers to relationships; and social/cultural expectations and

activities.
4. Spiritual - refers to the influence of spiritual beliefs.

5.
Developmental - refers to those processes related to development over the

lifespan.
II. CENTRAL COREThe basic structure, or central core, is made up of the basic survival factors that
are common to the species (Neuman, 1995, in George, 1996). These factors
include: system variables, genetic features, and the strengths and weaknesses of
the system parts. Examples of these may include: hair color, body temperature
regulation ability, functioning of body systems homeostatically, cognitive ability,
physical strength, and value systems. The person's system is an open system and
therefore is dynamic and constantly changing and evolving. Stability, or
homeostasis, occurs when the amount of energy that is available exceeds that
being used by the system. A homeostatic body system is constantly in a dynamic
process of input, output, feedback, and compensation, which leads to a state of
balance.
III. FLEXIBLE LINES OF DEFENSEThe flexible line of defense is the outer barrier or cushion to the normal line of
defense, the line of resistance, and the core structure. If the flexible line of
defense fails to provide adequate protection to the normal line of defense, the
lines of resistance become activated. The flexible line of defense acts as a cushion
and is described as accordion-like as it expands away from or contracts closer to
the normal line of defense. The flexible line of defense is dynamic and can be
changed/altered in a relatively short period of time.
IV. NORMAL LINE OF DEFENSEThe normal line of defense represents system stability over time. It is considered
to be the usual level of stability in the system. The normal line of defense can
change over time in response to coping or responding to the environment. An
example is skin, which is stable and fairly constant, but can thicken into a callus
over time.
V. LINES OF RESISTANCEThe lines of resistance protect the basic structure and become activated when
environmental stressors invade the normal line of defense. Example: activation of
the immune response after invasion of microorganisms. If the lines of resistance
are effective, the system can reconstitute and if the lines of resistance are not
effective, the resulting energy loss can result in death.
VI. RECONSTITUTIONReconstitution is the increase in energy that occurs in relation to the degree of
reaction to the stressor. Reconstitution begins at any point following initiation of
treatment for invasion of stressors. Reconstitution may expand the normal line of
defense beyond its previous level, stabilize the system at a lower level, or return
it to the level that existed before the illness.
VII. STRESSORS-The Neuman Systems Model looks at the impact of stressors on health and
addresses stress and the reduction of stress (in the form of stressors). Stressors
are capable of having either a positive or negative effect on the client system. A
stressor is any environmental force which can potentially affect the stability of the
system: they may be:
Intrapersonal - occur within person, e.g. emotions and feelings
Interpersonal - occur between individuals, e.g. role expectations
Extra personal - occur outside the individual, e.g. job or finance pressures
The person has a certain degree of reaction to any given stressor at any given
time. The nature of the reaction depends in part on the strength of the lines of
resistance and defense. By means of primary, secondary and tertiary
interventions, the person (or the nurse) attempts to restore or maintain the
stability of the system.
VII. PREVENTIONAs defined by Neuman's model, prevention is the primary nursing intervention.
Prevention focuses on keeping stressors and the stress response from having a
detrimental effect on the body.
Primary -Primary prevention occurs before the system reacts to a stressor.
On the one hand, it strengthens the person (primarily the flexible line of
defense) to enable him to better deal with stressors, and on the other
hand manipulates the environment to reduce or weaken stressors. Primary
prevention includes health promotion and maintenance of wellness.
Secondary-Secondary prevention occurs after the system reacts to a
stressor and is provided in terms of existing systems. Secondary
prevention focuses on preventing damage to the central core by
strengthening the internal lines of resistance and/or removing the stressor.
Tertiary -Tertiary prevention occurs after the system has been treated
through secondary prevention strategies. Tertiary prevention offers support
to the client and attempts to add energy to the system or reduce energy
needed in order to facilitate reconstitution.
NURSING METAPARADIGM
A. PERSONThe person is a layered multidimensional being. Each layer consists of five person
variables or subsystems:
Physical/Physiological
Psychological
Socio-cultural
Developmental
Spiritual
The layers, usually represented by concentric circle, consist of the central core,
lines of resistance, lines of normal defense, and lines of flexible defense. The basic
core structure is comprised of survival mechanisms including: organ function,
temperature control, genetic structure, response patterns, ego, and what Neuman
terms 'knowns and commonalities'. Lines of resistance and two lines of defense
protect this core. The person may in fact be an individual, a family, a group, or a
community in Neuman's model. The person, with a core of basic structures, is
seen as being in constant, dynamic interaction with the environment. Around the
basic core structures are lines of defense and resistance (shown diagrammatically
as concentric circles, with the lines of resistance nearer to the core. The person is
seen as being in a state of constant change and-as an open system-in reciprocal
interaction with the environment (i.e. affecting, and being affected by it).
B. THE ENVIRONMENTThe environment is seen to be the totality of the internal and external forces
which surround a person and with which they interact at any given time. These
forces include the intrapersonal, interpersonal and extra personal stressors which
can affect the person's normal line of defense and so can affect the stability of the
system.
The internal environment exists within the client system.
The external environment exists outside the client system.
Neuman also identified a created environment which is an environment
that is created and developed unconsciously by the client and is symbolic
of system wholeness.
C. HEALTHNeuman sees health as being equated with wellness. She defines health/wellness
as "the condition in which all parts and subparts (variables) are in harmony with
the whole of the client (Neuman, 1995)". As the person is in a constant
interaction with the environment, the state of wellness (and by implication any
other state) is in dynamic equilibrium, rather than in any kind of steady state.
Neuman proposes a wellness-illness continuum, with the person's position on that
continuum being influenced by their interaction with the variables and the
stressors they encounter. The client system moves toward illness and death when
more energy is needed than is available. The client system moves toward wellness
when more energyis available than is needed.
D. NURSINGNeuman sees nursing as a unique profession that is concerned with all of the
variables which influence the response a person might have to a stressor. The
person is seen as a whole, and it is the task of nursing to address the whole
person. Neuman defines nursing as actions which assist individuals, families and
groups to maintain a maximum level of wellness, and the primary aim is stability
of the patient/client system, through nursing interventions to reduce stressors.
Neuman states that, because the nurse's perception will influence the care given,
then not only must the patient/client's perceptions be assessed, but so must
those of the caregiver (nurse). The role of the nurse is seen in terms of degrees of
reaction to stressors, and the use of primary, secondary and tertiary
interventions.
Neuman envisions a 3-stage nursing process:
1. Nursing Diagnosis - based of necessity in a thorough assessment, and with
consideration given to five variables in three stressor areas.
2. Nursing Goals - these must be negotiated with the patient, and take account of
patient's and nurse's perceptions of variance from wellness
3. Nursing Outcomes - considered in relation to five variables, and achieved

through primary, secondary and tertiary interventions.
NURSING PROCESS BASED ON SYSTEM MODEL
Assessment: Neumans first step of nursing process parallels the assessment and
nursing diagnosis of the six phase nursing process. Using system model in the
assessment phase of nursing process the nurse focuses on obtaining a
comprehensive client data base to determine the existing state of wellness and
actual or potential reaction to environmental stressors.
Nursing diagnosis- the synthesis of data with theory also provides the basis for
nursing diagnosis. The nursing diagnostic statement should reflect the entire
client condition.
Outcome identification and planning- it involves negotiation between the care
giver and the client or recipient of care. The overall goal of the care giver is to
guide the client to conserve energy and to use energy as a force to move beyond
the present.
Implementation nursing action are based on the synthesis of a comprehensive
data base about the client and the theory that are appropriate to the clients and
caregivers perception and possibilities for functional competence in the
environment. According to this step the evaluation confirms that the anticipated
or prescribed change has occurred. Immediate and long range goals are
structured in relation to the short term goals.
Evaluation evaluation is the anticipated or prescribed change has occurred. If
it is not met the goals are reformed.
-------------------------------------------------------------------
ASSESSMENT
PATIENT PROFILE
1. Name- Mr. AM
2. Age- 66 years
3. Sex-Male
4. Marital status-married
5. Referral source- Referred from ------- Medical College, ------STRESSORS AS PERCEIVED BY CLIENT
(Information collected from the patient and his wife)

1. Major stress area, or areas of health concern
Patient was suffering from severe abdominal pain , nausea, vomiting,
yellowish discolorations of eye, palm, and urine, reduced appetite and
gross weight loss(8kg with in 4 months)
Patient is been diagnosed to have Periampullary carcinoma one week back.
Patient underwent operative procedure i.e. WHIPPLES PROCEDUREPancreato duodenectomy on 27/3/08.
Psychologically disturbed about his disease condition- anticipating it as a life

threatening condition. Patient is in depressive mood and does not interacting.
Patient is disturbed by the thoughts that he became a burden to his children with
so many serious illnesses which made them to stay with him at hospital.
Patient has pitting type of edema over the ankle region, and it is more during the
evening and will not be relieved by elevation of the affected extremities.
He had developed BPH few months back (2008 January) and underwent surgery
TURP on January 17. Still he has mild difficulty in initiating the stream of
urine.
Patient is a known case of Diabetes since last 28 years and for the last 4 years he
is on Inj. H.Insulin (4U-0-0). It is adding up his distress regarding his health.
2.Life style patterns

patient is a retired school teacher
cares for wife and other family members
living with his son and his family
active in church
participates in community group meeting i.e. local politics
has a supportive spouse and family
taking mixed diet
no habits of smoking or drinking
spends leisure time by reading news paper, watching TV, spending time with
family members and relatives
3. Have you experienced a similar problem?
The fatigue is similar to that of previous hospitalization (after the surgery of the
BPH)
Severity of pain was some what similar in the previous time of surgery i.e.
TURP.
Was psychologically disturbed during the previous surgery i.e. TURP.
What helped then- family members psychological support helped him to over
come the crisis situation
4. Anticipation of the future
Concerns about the healthy and speedy recovery.
Anticipation of changes in the lifestyle and food habits
Anticipating about the demands of modified life style
Anticipating the needs of future follow up
5. What doing to help himself?
Talking to his friends and relatives
Reading the religious materials i.e. reading the Bible
Instillation of positive thoughts i.e. planning about the activities to be resume

after discharge, spending time with grand children, going to the church, return
back to the social interactions etc
Avoiding the negative thoughts i.e. diverts the attentions from the pain or
difficulties, try to eliminate the disturbing thoughts about the disease and
surgery etc
Trying to accept the reality etc..
6. What is expected of others?
Family members visiting the patient and spending some time with him will help
to a great extent to relieve his tension.
Convey a warm and accepting behaviour towards him.
Family members will help him to meet his own personal needs as much as
possible.
Involve the patient also in taking decisions about his own care, treatment, follow
up etc
STRESSORS AS PERCEIVED BY THE CARE GIVER.
1. Major stress areas
Persistent fatigue
Massive weight loss i.e.( 8 kg of body weight with in 4 months)
History of BPH and its surgery
Persistence of urinary symptoms (difficulty in initiating the stream of urine) and

edema of the lower extremities
Persistent disease- chronic hypertensive since last 28 years
Depressive ideations and negative thoughts
2. Present circumstances differing from the usual pattern of living
Hospitalization
acute pain ( before the surgery patient had pain because of the underlying
pathology and after the surgery pain is present at the surgical site)
nausea and vomiting which was present before the surgery and is still persisting
after the surgery also
anticipatory anxiety concerns the recovery and prognosis of the disease
negative thoughts that he has become a burden to his children
Anticipatory anxiety concerning the restrictions after the surgery and the life
style modifications which are to be followed.
3. Clients past experience with the similar situations
Patient verbalized that the severity of pain, nausea, fatigue etc was similar to
that of patients previous surgery. Counter checked with the family members
that what they observed.
Psychologically disturbed previously also before the surgery. (collected from the
patient and counter checked with the relatives)
Client perceived that the present disease condition is much more severe than the
previous condition. He thinks it is a serious form of cancer and the recovery is
very poor. So patient is psychologically depressed.
4. Future anticipations
Client is capable of handling the situation- will need support and encouragement
to do so.
He has the plans to go back home and to resume the activities which he was
doing prior to the hospitalization.
He also planned in his mind about the future follow up ie continuation of

chemotherapy
5. What client can do to help himself?
Patient is using his own coping strategies to adjust to the situations.
He is spending time to read religious books and also spends time in talking with
others
He is trying to clarify his own doubts in an attempt to eliminate doubts and to

instill hope.
He sets his major goal i.e. a healthy and speedy recovery.
6. Client's expectations of family, friends and caregivers
he sees the health care providers as a source pf information.
He tries to consider them as a significant members who can help to over come
the stress
He seeks both psychological and physical support from the care givers, friends
and family members
He sees the family members as helping hands and feels relaxed

when they are with him.
Evaluation/ summary of impressionsThere is no apparent discrepancies identified between patients perception and the
care givers perceptions.
INTRAPERSONAL FACTORS
1. Physical examination and investigations
Height- 162 cm
Weight 42 kg
TPR- 37o C, 74 b/m, 14 breaths per min
BP- 130/78 mm of Hg
Eye- vision is normal, on examination the appearance of eye is normal.
Conjunctiva is pale in appearance. Pupils reacting to the light.
Ear- appearance of ears normal. No wax deposition. Pinna is normal in
appearance and hearing ability is also normal.
Respiratory system- respiratory rate is normal, no abnormal sounds on
auscultation. Respiratory rate is 16 breaths per min.
Cardiovascular system- heart rate is 76 per min. on auscultation no
abnormalities detected. Edema is present over the left ankle which is non
pitting in nature.
GIT- patient has the complaints of reduced appetite, nausea; vomiting etc.
food intake is very less. Mouth- on examination is normal. Bowel sounds
are reduced. Abdomen could not be palpated because of the presence of
the surgical incision. Bowel habits are not regular after the hospitalization
Extremities- range of motion of the extremities are normal. Edema is
present over the left ankle which is non pitting in nature. Because of
weakness and fatigue he is not able to walk with out support
Integumentary system- extremities are mild yellowish in color. No
cyanosis. Capillary refill is normal.
2.
Genitor urinary system- patient has difficulty in initiating the urine stream. No
complaints of painful micturation or difficulty in passing urine.
Self acre activities- perform some of his activities, for getting up from the bed
he needs some other persons support. To walk also he needs a support. He do
his personal care activities with the support from the others
Immunizations- it is been told that he has taken the immunizations at the

specific periods itself and he also had taken hepatitis immunization around 8
years back
Sleep . He told that sleep is reduced because of the pain and other difficulties.
Sleep is reduced after the hospitalization because of the noisy environment.
Diet and nutrition- patient is taking mixed diet, but the food intake is less when
compared to previous food intake because of the nausea and vomiting. Usually
he takes food three times a day.
Habits- patient does not have the habit of drinking or smoking.
Other complaints- patient has the complaints of pain fatigue, loss of appetite,
dizziness, difficulty in urination, etc...
Psycho- socio cultural

Anxious about his condition
Depressive mood
Patient is a retired teacher and he is Christian by religion.
Studied up to BA
Married and has 4 children(2sons and 2 daughters)
Congenial home environment and good relationship with wife and children
Is active in the social activities at his native place and also actively involves in
the religious activities too.
Good and congenial relationship with the neighbours
Has some good and close friend at his place and he actively interact with them.
They also very supportive to him
Good social support system is present from the family as well

as from the neighborhood
3. Developmental factors
Patient confidently says that he had been worked for 32 years as a teacher
and he was a very good teacher for students and was a good coworker for
the friends.
He told that he could manage the official and house hold activities very well
He was very active after the retirement and once he go back

also he will resume the activities
4. Spiritual belief system

Patient is Christian by religion
He believes in got and used to go to church and also an active member in the
religious activities.
He has a personal Bible and he used to read it min of 2 times a day and also
whenever he is worried or tensed he used to pray or read Bible.
He has a good social support system present which helps him

to keep his mind active.
INTERPERSONAL FACTORS
has supportive family and friends
good social interaction with others
good social support system is present
active in the agricultural works at home after the retirement
active in the religious activities.
Good interpersonal relationship with wife and the children
Good social adjustment present
EXTRAPERSONAL FACTORS
All the health care facilities are present at his place
All communication facilities, travel and transport facilities etc are present at his
own place.
His house at a village which is not much far from the city and the facilities are
available at the place.
Financially they are stable and are able to meet the treatment
expenses.
Summary
Physiological- thin body built pallor of extremities, yellowish discoloration of
the mucus membrane and sclera of eye. Nausea, vomiting, reduced
appetite, reduced urinary out put. Diagnosed to have periampullary
carcinoma.
Psycho socio cultural factors- patient is anxious abut his condition.
Depressive mood. Not interacting much with others. Good support system
is present.
Developmental no developmental abnormalities. Appropriate to the age.
Spiritual- patients belief system has a positive contribution to his recovery
and adjustment.
CLINICAL FEATURES
pain abdomen since 4 days
Discoloration of urine
Complaints of vomiting
Fatigue
Reduced appetite
on and off fever
Yellowish discoloration of eye, palms and nails
Complaints of weight loss
Edema over the left leg
INVESTIGATIONS
Investigations
Values
Hemoglobin(1319g/dl)
6.9
HCT (40-50%)
21.9
WBC (4000-11000
cells/cumm)
12200
Neutrophil
75%)
(40-
77.2
Lymphocyte
45%)
(25-
10.5
Monocyte (2-10%)
4.5
Eosinophil
10%)
2.6
(0-
Basophil (0-2%)
.2
Platelet (150000400000
cells/cumm)
345000
ESR (0-10mm/hr)
86
RBS
mg/dl)
148
(60-150
Pus C/S
USG
USG shows mild

diffuse cell
growth at the
Ampulla of Vater
which suggests
peri ampullary
carcinoma of
Grade I with out
metastasis and
gross spread.
Urea (8-35mg/dl)
28
Creatinine (0.6-1.6
mg/dl)
1.8
Sodium (130-143
mEq/L)
136
Potassium (3.5-5
mEq/L)
PT (patient)(11.415.6 sec)
12.3
APTT- patient (2432.4 sec)
26.4
Blood group
A+
HIV
Negative
HCV
Negative
HBsAg
Negative
Urine Protein
(negative)
Negative
Urine WBC (0-5

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

(absent)
Nil
THERAPEUTIC MANAGEMENT
Initial Treatment:
Patient got admitted to ---Medical college for 3 days
and the symptoms not
relieved. So they asked for
discharge and came to
---this hospital
Post
operative
period
(immediate post op)
There treated with
Inj Tramazac
SOS
IV
IV fluids DNS
Treatment at this hospital...
Inj
Pethedine
1mg SOS
Inj
Phenargan
SOS
Inj Pantodac 40
mg IV OD
Inj Clexane 0.3

ml S/C OD
Inj Vorth P 40
mg IM Q12H
Pre operative period
Tab Clovipas
mg 0-1-0
75
Tab Monotrate 1-01
Inj
calcium
Gluconate 10
ml over 10 min
IV fluids DNS
Tab Metalor XL 10-0
Inj H Insulin S/C

6-0-6U
Inj Tramazac
mg IV Q8H
50
Late post op period

after 3 days of
surgery)
Inj H Insulin S/C

6-0-6U
Tab Pantodac 40
mg 1-0-0
Inj Emset
Q8H
mg
Cap
beneficiale
0-1-0
Tab Pantodac
mg 1-0-0
40
Tab Clovipas 75
mg 0-1-0
Cap beneficiale 01-0
Tab Monotrate 10-1
Syp Aristozyme 11-1
Tab Metalor XL 10-0
K bind I sachet
TID
Surgical management
Patient underwent Whipples
procedure (pancreato
duodenectomy)
Other instructions
Incentive
spirometry
Steam inhalation
Early ambulation
Diabetic diet
NURSING PROCESS
I. NURSING DIAGNOSIS
Acute pain related to the presence of surgical wound on abdomen secondary to
periampullary carcinoma
Desired Outcome/goal : Patient will get relief from pain as evidenced by a reduction
in the pain scale score and verbalization
Nursing action
Primary prevention
Assess
severity of
pain by
using a pain
scale
Check the
surgical site
for any signs
of infection or
complications
Support the
areas with
extra pillow to
allow the
normal
alignment and
to prevent
strain
Handle the
area gently.
Avoid
unnecessary
handling as
this will affect
the healing
process
Clean the area

around the
incision and do
surgical
dressing at the
Secondary prevention
Teach the
patient about
the relaxation
techniques and
make him to
do it
Encourage the
patient to
divert his mind
from pain and
to engage in
pleasurable
activities like
taking with
others
Do not allow
the patient to
do strainous
activities. And
explain to the
patient why
those activities
are
contraindicate
d.
Involve the
patient in
Tertiary prevention
Educate the
client about
the importance
of cleanliness
and encourage
him to
maintain good
personal
hygiene.
Involve the
family
members in
the care of
patient
Encourage
relatives to be
with the client
in order
provide a
psychological
well being to
patient .
Educate the
family
members
about the pain
management
making
decisions
about his own
care and
provide a
positive
psychological
support
site of incision
to prevent any
form of
infections
Provide nonpharmacologic
al measures
for pain relief
such as
diversional
activity which
diverts the
patients mind.
Administer
the pain
medications as
per the
prescription by
the pain clinics
to relieve the
severity of
pain.
Keep the
patients body
clean in order
to avoid
infection.
measures.
Provide the
primary
preventive
care when
ever
necessary.
Provide the
primary and
secondary
preventive
measures to
the client
whenever
necessary.
Evaluation patient verbalized that the pain got reduced and the pain scale score
also was zero. His facial expression also reveals that he got relief from pain.
II. NURSING DIAGNOSIS
Activity intolerance related to fatigue secondary to pain at the surgery site, and dietary
restrictions
Outcome/ goals: Client will develop appropriate levels of activity free from excess
fatigue, as evidenced by normal vital signs & verbalized understanding of the
benefits of gradual increase in activity & exercise.
Nursing actions
Primary prevention
Adequately
oxygenate
the client
Instruct the
client to avoid
the activities
Secondary
prevention
Instruct the
client to
avoid the
activities
which
causes
Tertiary prevention
Encourage the
client to do the
mobility
exercises
Tell the family

members to
which causes
extreme
fatigue
Provide the
necessary
articles near
the patients
bed side.
Assist
the
patient
in
early
ambulation
Monitor
clients
response to
the activities
in order to
reduce
discomforts.
Provide
nutritious diet
to the client.
Avoid
psychological
distress to
the client. Tell
the family
members to
be with him.
Schedule rest
periods
because it
helps to
alleviate
fatigue
extreme
fatigue.
Advice the
client to
perform
exercises to
strengthen
the
extremities
& promote
activities
Tell the
client to
avoid the
activities
such as
straining at
stool etc
Teach the
client about
the
importance
of early
ambulation
and assist
the patient
in early
ambulation
Teach the
mobility
exercises
appropriate
for the
patient to
improve the
circulation
provide
nutritious diet
in a frequent
intervals
Teach the
patient and the
family about
the importance
of
psychological
well being in
recovery.
Provide the
primary and
secondary level
care if
necessary.
Evaluation patient verbalized that his activity level improved. He is able to do

some of his activities with assistance. Fatigue relieved and patient looks much
more active and interactive.
NURSING DIAGNOSIS-III
Impaired physical mobility related to presence of dressing, pain at the site of surgical
incision
Outcomes/goals: Patient will have improved physical mobility as evidenced by
walking with minimum support and doing the activities in limit.
Nursing action
Primary prevention
Secondary prevention
Tertiary prevention
Provide active
and passive
exercises to
all the
extremities to
improve the
muscle tone
and strength.
Make the
patient to
perform the
breathing
exercises
which will
strengthen the
respiratory
muscle.
Massage the
upper and
lower
extremities
which help to
improve the
circulation.
Provide
articles near
to the patient
and encourage
doing
activities
within limits
which promote
a feeling of
well being.
Provide positive
reinforcement for
even a small
improvement to
increase the
frequency of the
desired activity.
Teach the
mobility exercises
appropriate for
the patient to
improve the
circulation and to
prevent
contractures
Mobilize the
patient and
encourage him to
do so whenever
possible
Motivate the
client to involve
in his own care
activities
Provide primary
preventive
measures
whenever
necessary
Educate and
reeducate the
client and family
about the
patients care
and recovery
Support the
patient, and
family towards
the attainment
of the goals
Coordinate the
care activities
with the family
members and
other disciplines
like
physiotherapy.
Teach the
importance of
psychological
well being which
influence
indirectly the
physical
recovery
Provide primary
preventive
measures
whenever
necessary
Evaluation patients physical activity improved and he is able to move from bed
with support. Patient started doing the active and passive exercises and he
verbalized improvement.
----------------------------------------------------------Conclusion
The Neumans system model when applied in nursing practice helped in identifying
the interpersonal, intrapersonal and extra personal stressors of Mr. AM from various
aspects. This was helpful to provide care in a comprehensive manner. The application
of this theory revealed how well the primary, secondary and tertiary prevention
interventions could be used for solving the problems in the client.
References
1. Alligood M R, Tomey A M. Nursing Theory: Utilization &Application .3rd ed.
Missouri: Elsevier Mosby Publications; 2002.
2. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby,
Philadelphia, 2002
3. George JB .Nursing Theories: The Base for Professional Nursing Practice,5 th ed.
New Jersey :Prentice Hall;2002.
APPLICATION OF ROYS ADAPTATION

MODEL IN NURSING PRACTICE
Outline
Introduction
Assumptions of Roy's Adaptation Model
Roy's Adaptation Model (RAM) Terms
Nursing Process
First Level Assessment
Second Level Assessment
Nursing Care Plan
Conclusion
Reference
INTRODUCTION
Born at Los Angeles on October 14, 1939 as the 2nd child of Mr. and Mrs.
Fabien Roy
At age 14 she began working at a large general hospital, first as a pantry girl,
then as a maid, and finally as a nurse's aid.
She entered the Sisters of Saint Joseph of Carondelet.
she earned a Bachelor of Arts with a major in nursing from Mount St. Mary's
College, Los Angeles in 1963.
a master's degree program in pediatric nursing at the University of

California ,Los Angeles in 1966.
She also earned a masters & PhD in Sociology in 1973 & 1977 ,respectively
Sr. Callista had the significant opportunity of working with Dorothy E. Johnson
Johnson's work with focusing knowledge for the discipline of nursing

convinced Sr. Callista of the importance of describing the nature of nursing as
a service to society and prompted her to begin developing her model with the
goal of nursing being to promote adaptation.
Sister Callista Roy (1984), Introduction to Nursing: An Adaptation Model (2nd ed)
ASSUMPTIONS OF ROYS ADAPTATION MODEL
Scientific
Systems of matter and energy progress to higher levels of complex selforganization

Consciousness and meaning are constitutive of person and environment
integration
Awareness of self and environment is rooted in thinking and feeling
Humans by their decisions are accountable for the integration of creative

processes
Thinking and feeling mediate human action
System relationships include acceptance, protection, and fostering of

interdependence
Persons and the earth have common patterns and integral relationships
Persons and environment transformations are crated in human consciousness
Integration of human and environment meanings results in adaptation
Philosophical
Persons have mutual relationships with the world and God

Human meaning is rooted in an omega point convergence of the universe
God is intimately revealed in the diversity of creation and is the common

destiny of creation
Persons use human creative abilities of awareness, enlightenment, and faith
Persons are accountable for the processes of deriving, sustaining, and

transforming the universe
PERSONS AND RELATING PERSONS
An adaptive system with coping processes

Described as a whole comprised of parts
Functions as a unity for some purpose
Includes people as individuals or in groups (families, organizations,

communities, nations, and society as a whole)
An adaptive system with cognator and regulator subsystems acting to

maintain adaptation in the four adaptive modes: physiologic-physical, selfconcept-group identity, role function, and interdependence
ENVIRONMENT
All conditions, circumstances, and influences surrounding and affecting the

development and behavior of persons and groups with particular
consideration of mutuality of person and earth resources
Three kinds of stimuli: focal, contextual, and residual
Significant stimuli in all human adaptation include stage of development,

family, and culture
HEALTH AND ADAPTATION
Health: a state and process of being and becoming integrated and whole that
reflects person and environmental mutuality
Adaptation: the process and outcome whereby thinking and feeling persons,
as individuals and in groups, use conscious awareness and choice to create
human and environmental integration
Adaptive Responses: responses that promotes integrity in terms of the goals

of the human system, that is, survival, growth, reproduction, mastery, and
personal and environmental transformation
Ineffective Responses: responses that do not contribute to integrity in terms

of the goals of the human system
Adaptation levels represent the condition of the life processes described on

three different levels: integrated, compensatory, and compromised
NURSING
Nursing is the science and practice that expands adaptive abilities and
enhances person and environment transformation
Nursing goals are to promote adaptation for individuals and groups in the four
adaptive modes, thus contributing to health, quality of life, and dying with
dignity
This is done by assessing behavior and factors that influence adaptive abilities
and by intervening to expand those abilities and to enhance environmental
interactions
ROY ADAPTATION MODEL (RAM) TERMS

System-a set of parts connected to function as a whole for some purpose.
Stimulus-something that provokes a response, point of interaction for the human
system and the environment
Focal Stimuli-internal or external stimulus immediately affecting the system

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

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

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

Physical and chemical processes
Nurse must be knowledgeable about normal processes
5 needs (Oxygenation, Nutrition, Elimination, Activity & Rest, and Protection)
Self Concept-Group Identity Mode

The composite of beliefs and feelings held about oneself at a given time. Focus on
the psychological and spiritual aspects of the human system. Need to know who one
is, so that one can exist with a state of unity, meaning, and purposefulness of 2
modes (physical self, and personal self)
Role function Mode
Set of expectations about how a person occupying one position behaves toward a
occupying another position. Basic need-social integrity, the need to know who one is
in relation to others
Interdependence Mode
Behavior pertaining to interdependent relationships of individuals and groups. Focus
on the close relationships of people and their purpose. Each relationship exists for
some reason. Involves the willingness and ability to give to others and accept from
others. Balance results in feelings of being valued and supported by others. Basic
need - feeling of security in relationships
Adaptive Responses-promote the integrity of the human system.

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

involves gathering data about the behavior of the person as an adaptive
system in each of the adaptive modes
Assessment of Stimuli: the second step of the nursing process which

involves the identification of internal and external stimuli that are influencing
the persons adaptive behaviors. Stimuli are classified as: 1) Focal- those
most immediately confronting the person; 2) Contextual-all other stimuli
present that are affecting the situation and 3) Residual- those stimuli whose
effect on the situation are unclear.
Nursing Diagnosis: step three of the nursing process which involves the
formulation of statements that interpret data about the adaptation status of
the person, including the behavior and most relevant stimuli
Goal Setting: the forth step of the nursing process which involves the
establishment of clear statements of the behavioral outcomes for nursing
care.
Intervention: the fifth step of the nursing process which involves the
determination of how best to assist the person in attaining the established
goals
Evaluation: the sixth and final step of the nursing process which involves
judging the effectiveness of the nursing intervention in relation to the
behavior after the nursing intervention in comparison with the goal
established.
DEMOGRAPHIC DATA
Name
Age
Mr. NR
53 years
Sex
Male
IP number
-----
Education
Degree
Occupation
Bank clerk
Marital status
Married
Religion
Hindu
Informants
Patient and Wife
Date of admission
21/01/08
FIRST LEVEL ASSESSMENT

PHYSIOLOGIC-PHYSICAL MODE
Oxygenation:
Stable process of ventilation and stable process of gas exchange. RR= 18Bpm.
Chest normal in shape. Chest expansion normal on either side. Apex beat felt on left
5th inter-costal space mid-clavicular line. Air entry equal bilaterally. No ronchi or
crepitus. NVBS. S1& S2 heard. No abnormal heart sounds. Delayed capillary refill+.
JVP0. Apex beat felt- normal rhythm, depth and rate. Dorsalis pedis pulsation of
affected limp is not palpable. All other pulsations are normal in rate, depth, tension
with regular rhythm. Cardiac dull ness heard over 3rd ICS near to sternum to left 5ht
ICS mid clavicular line. S1& S2 heard. No abnormal heart sounds. BPNormotensive. . Peripheral pulses felt-Normal rate and rhythm, no clubbing or
cyanosis.
Nutrition
He is on diabetic diet (1500kcal). Non vegetarian. Recently his Weight reduced
markedly (10 kg/ 6 month). He has stable digestive process. He has complaints of
anorexia and not taking adequate food. No abdominal distension. Soft on palpation.
No tenderness. No visible peristaltic movements. Bowel sounds heard. Percussion
revealed dullness over hepatic area. Oral mucosa is normal. No difficulty to swallow
food
Elimination:
No signs of infections, no pain during micturation or defecation. Normal bladder
pattern. Using urinal for micturation. . Stool is hard and he complaints of
constipation.
Activity and rest:
Taking adequate rest. Sleep pattern disturbed at night due unfamiliar surrounding.
Not following any peculiar relaxation measure. Like movies and reading. No regular
pattern of exercise. Walking from home to office during morning and evening. Now,
activity reduced due to amputated wound. Mobility impaired. Walking with crutches.
Pain from joints present. No paralysis. ROM is limited in the left leg due to wound.
No contractures present. No swelling over the joints. Patient need assistance for
doing the activities.
Protection:
Left lower fore foot is amputated. Black discoloration present over the area. No
redness, discharge or other signs of infection. Nomothermic. Wound healing better
now. Walking with the use of left leg is not possible. Using crutches. Pain form knee
and hip joint present while walking. Dorsalis pedis pulsation, not present over the
left leg. Right leg is normal in length and size. Several papules present over the foot.
All peripheral pulses are present with normal rate, rhythm and depth over right leg.
Senses:
No pain sensation from the wound site. Relatively, reduced touch and pain sensation
in the lower periphery; because of neuropathy. Using spectacle for reading.
Gustatory, olfaction, and auditory senses are normal.
Fluids and electrolytes:
Drinks approximately 2000ml of water. Stable intake out put ratio. Serum electrolyte
values are with in normal limit. No signs of acidosis or alkalosis. Blood glucose
elevated
Neurological function:
He is conscious and oriented. He is anxious about the disease condition. Like to go
home as early as possible. Showing signs of stress. Touch and pain sensation
decreased in lower extremity. Thinking and memory is intact.
Endocrine function
He is on insulin. No signs and symptoms of endocrine disorders, except elevated
blood sugar value. No enlarged glands.
SELF CONCEPT MODE
Physical self:
He is anxious about changes in body image, but accepting treatment and coping
with the situation. He deprived of sexual activity after amputation.
Belongs to a Nuclear family. 5 members. Stays along with wife and three children.
Good relationship with the neighbours. Good interaction with the friends. Moderately
active in local social activities
Personal self:
Self esteem disturbed because of financial burden and hospitalization. He believes in
god and worshiping Hindu culture.
ROLE PERFORMANCE MODE:
He was the earning member in the family. His role shift is not compensated. His son
doesnt have any work. His role clarity is not achieved.
INTERDEPENDENCE MODE:
He has good relationship with the neighbours. Good interaction with the friends
relatives. But he believes, no one is capable of helping him at this moment. He
says all are under financial constrains. He was moderately active in local social
activities
SECOND LEVEL ASSESSMENT
FOCAL STIMULUS:
Non-healing wound after amputation of great and second toe of left leg- 4 week. A
wound first found on the junction between first and second toe-4 month back. The
wound was non-healing and gradually increased in size with pus collected over the
area.
He first showed in a local (---) hospital. From there, they referred to ---- medical
college; where he was admitted for 1 month and 4 days. During hospital stay great
and second toe amputated. But surgical wound turned to nonhealing with pus and
black colour. So the physician suggested for below knee amputation. That made
them to come to ---Hospital, ---. He underwent a plastic surgery 3 week before.
CONTEXTUAL STIMULI:
Known case DM for past 10 years. Was on oral hypoglycemic agent for initial 2
years, but switched to insulin and using it for 8 years now. Not wearing foot wear in
house and premises.
RESIDUAL STIMULI:
He had TB attack 10 year back, and took complete course of treatment. Previously,
he admitted in ---Hospital for leg pain about 4 year back. . Mothers brother had DM.
Mother had history of PTB. He is a graduate in humanities, no special knowledge on
health matters.
CONCLUSION
Mr.NR who was suffering with diabetes mellitus for past 10 years. Diabetic foot ulcer
and recent amputation made his life more stressful. Nursing care of this patient
based on Roy's adaptation model provided had a dramatic change in his condition.
Wound started healing and he planned to discharge on 25th april. He studied how to
use crutches and mobilized at least twice in a day. Patients anxiety reduced to a
great extends by proper explanation and reassurance. He gained good knowledge
on various aspect of diabetic foot ulcer for the future self care activities.
NURSING CARE PLAN

ASSESS.
OF
BEHAVIO
UR
ASSESSMEN
NURSING
T OF
DIAGNOSIS
STIMULI
GOAL
INTERVENTIO EVALUATIO
N
N
Ineffeciti
ve
protectio
n and
sense in
physicalphysiolog
ical mode
(No pain
sensation
from the
wound
site.)
Focal
stimuli:
1.
Impaired
Non-healing skin
wound after integrity
related to
amputation
of great and fragility of
second toe of the skin
secondary
left leg- 4
to vascular
week
insufficienc
y
Long-term
objective:
Maintain the
wound area
1. amputated clean as
area will be contamination
affects the
completely
healing
healed by
process.
20/5/08
Follow
2.Skin will
sterile
remain
technique while
intact with no providing cares
ongoing
to prevent
ulcerations. infection and
Short-Term delay in
healing.
Objective:
i. Size of
wound
decreases to
1x1 cm
within
24/4/08.
ii. No signs
of infection
over the
wound within
1-wk
Perform
wound dressing
with betadine
which promote
healing and
growth of new
tissue.
Short term
goal:
Met: size of
wound
decreased to
less than 1x1
cms.
WBC values
became
normal on
24/4/08
Long term
goal:
Partially
Met: skin
partially
intact with no
ulcerations.
Continue plan
Reassess goal
and
interventions
Do not
move the
affected area
Unmet: not
frequently as it
achieved
affects the
iii. Normal
complete
granulation
WBC values
healing of
tissue
within 1-wk
amputated
formation.
area.
iv. Presence
Monitor for Continue plan

of healthy
signs and
Reassess goal
granular
symptoms of
and
tissues in the
infection or
interventions
wound site
delay in
within 1-wk
healing.
Administer
the antibiotics
and vitamin C
supplementatio
n which will
promote the
healing
process.
Impaired
activity
in
physicalphysiolog
ical mode
Focal
stimuli:
2.
Impaired
physical
During
hospital stay mobility
related to
great and
amputation
second toe
amputated. of the left
But surgical forefoot
wound turned and
presence of
to nonhealing with unhealed
pus and black wound
colour.
Long term
Objective:
Patient will
attain
maximum
possible
physical
mobility with
in 6 months.
Short term
objective:
i.
Correct use
of crutches
with in
22/4/08
Assess the
level of
restriction of
movement
Provide
active and
passive
exercises to all
the extremities
to improve the
muscle tone
and strength.
Short term
goal:
Met: used
crutches
correctly on
22/4/08.
he is self
motivated in
doing minor
excesses
Partially
Met: walking
with
minimum
support.
Make the
patient to
perform the
ROM exercises
to lower
ii.
walking extremities
Long term
with
which will
goal:
minimum
strengthen the
Unmet: not
supportmuscle.
attained
22/4/08
Massage the maximum
iii.
He will upper and
possible
be self
lower
physical
motivated in extremities
mobilityactivitieswhich help to
Continue plan
20/4/08.
improve the
Reassess goal
circulation.
and
interventions
Provide
articles near to
the patient and
encourage
performing
activities within
limits which
promote a
feeling of well
being.
Provide
positive
reinforcement
for even a
small
improvement
to increase the
frequency of
the desired
activity.
Measures
for pain relief
should be taken
before the
activities are
initiated as pain
can hinder with
the activity.
Alteration
in
Physical
self in
Selfconcept
mode
(He is
anxious
about
changes in
body
image)
Change in
Role
performa
nce mode.
(He was
the earning
member in
the family.
His role
shift is not
compensat
e)
Contextual
stimuli:
3.
Anxiety
Known case related to
DM for past hospital
10 years and admission
on treatment and
unknown
with insulin
for 8 years. Outcome of
the disease
and
financial
Residual
stimuli: no constrains.
special
knowledge in
health
matters
Long term
Objective:
Allow and
encourage the
The client will client and
remain free family to ask
from anxiety questions.
Bring up
common
Short term concerns.
objective:
Allow the
i.
demonstratin
g appropriate
range
effective
coping in the
treatment
ii.
Being
able to rest
and
iii. Asking
fewer
questions
Short term
goal:
Met:
demonstrated
appropriate
range
effective
coping with
treatment
client and
family to
verbalize
anxiety.
He is able to
rest quietly.
Stress that
frequent
assessment are
routine and do
not necessarily
imply a
deteriorating
condition.
Long term
goal:
Unmet:
client not
completely
remained free
from anxiety
due to
financial
Repeat
information as constrainsContinue plan
necessary
because of the Reassess goal
and
reduced
attention span interventions
of the client
and family
Provide
comfortable
quiet
environment
for the client
and family
Contextual
stimuli:
------
4. deficient
knowledge
Known case regarding
DM for past the foot
10 years and care,
on treatment wound
care,
with insulin
for 8 years. diabetic
diet, and
need of
follow up
Residual
stimuli: no care.
special
knowledge in
health
matters
Long term
Objective:
Explain the
treatment
measures to
Patient will
the patient and
acquire
their benefits in
adequate
a simple
knowledge
regarding the understandable
language.
t foot care,
wound care, Explain
diabetic diet, about the home
and need of care. Include
follow up
the points like
care and
care of wounds,
practice in
nutrition,
their day to activity etc.
day life.
Clear the
Short term
objective:
doubts of the
patient as the
patient may
i.
Verbalization present with
some matters
and
demonstratio of importance.
n of foot
Repeat the
care.
information
ii.
Strictly whenever
necessary to
following
diabetic diet reinforce
learning.
plan
iii.
Demonstratio
n of wound
care.
Short term
goal:
Met:
Verbalization
and
demonstratio
n of foot
care.
Strictly
following
diabetic diet
plan
Unmet:
Demonstratio
n of wound
care.
Long term
goal:
Unmet: not
completely
acquired and
practiced the
required
knowledge.
Continue plan
Reassess goal
and
interventions
APPLICATION OF INTERPERSONAL
THEORY IN NURSING PRACTICE
Outline
Introduction
The four phases of nurse-patient relationships are

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

Peplau defines Nursing Process as a deliberate intellectual activity that guides the
professional practice of nursing in providing care in an orderly, systematic manner.
Peplau explains 4 phases such as:
Orientation: Nurse and patient come together as strangers; meeting

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

belonging and selectively responds to those who can meet his or her needs.
Exploitation: Patient actively seeks and draws knowledge and

expertise of those who can help.
Resolution: Occurs after other phases are completed successfully.

This leads to termination of the relationship.
In Nursing Process, the orientation phase parallels with assessment phase where
both the patient and nurse are strangers; meeting initiated by patient who expresses
a felt need. Conjointly, the nurse and patient work together, clarifies and gathers
important information. Based on this assessment the nursing diagnoses are
formulated, outcome and goal set. The interventions are planned, carried out and
evaluation done based on mutually established expected behaviours.
Peplaus theory application nursing process:
The nursing process for Mrs. JL based on Peplaus theory is as follows:
Mrs. JL
27 years
Diagnosis: Inter vertebral disc prolapse
Assessment
(Orientatio
n phase)
Mrs. JL is
on pelvic
traction and
she is
restricted
to bed.
The need
for bed rest
and
restriction
was
discussed.
Nursing
diagnosis
Impaired
physical
mobility
related to
the
presence
of pelvic
traction.
Planning
(Identification
phase)
Goal setting
was done along
with patient
Patient will
have improved
physical
mobility as
evidenced by
participating in
self care within
the limits.
Provide active
and passive
exercises to all
the extremities
to improve the
muscle tone
and strength.
Implementation Evaluation
(Exploitation
(Resolution phase)
phase)
Carried out plans Mrs. JL was free to
mutually agreed express problems
upon.
regarding difficulty in
mobilizing.
Provided active
and passive
exercises to all
the extremities
Made the patient

to perform
breathing
exercises
Make the
patient to
perform the
breathing
exercises which Massaged the
will strengthen upper and lower
the respiratory extremities
muscle.
Provided article
within the reach
Massage the
of the patient
upper and
lower
extremities
which help to
improve the
circulation.
Provided positive
Provide articles reinforcement to
near to the
the patient
patient and
encourage
She expressed
satisfaction when able
to move without
difficulty.
doing activities
within limits.
Provide positive
reinforcement
for even a small
improvement to
increase the
frequency of
the desired
activity.
Assessmen
t
(Orientatio
n phase)
Mrs. JL
expresses
pain in the
low back
region.
Regarding
Nursing
diagnosis
Planning
(Identification
phase)
Implementation
(Exploitation
phase)
Evaluation
(Resolution phase)
Pain related to Goal setting was Carried out plans Mrs. JL was free to
the
done along with mutually agreed express problems of
degenerative patient
upon.
pain.
changes in the
lumbar region. Mrs. JL will have
reduction in pain
as evidenced by
her verbalisation
of reduction in
pain responses.
Provide nonpharmacological
Provided non
Expressed that she
pain,
discussion
was made
to assess
the severity
and the
type and
duration of
pain. Also
the
measures
to reduce
pain were
discussed.
measures for
pain relief such
as diversional
activity which
diverts the
patients mind.
got slight relief from

pharmacological pain.
measures like
diversion,
massaging, and
pelvic traction.
Give the client a

neutral position Provided supine
position to the
Always use back client
support while
turning the
Supported the
patient that
back during
reduces the strainposition change
on the back.
Support the areas
with extra pillow Used pillows to
to allow the
support the back.
normal alignment
and to prevent
strain.
Administered Tab.
Administer
Hifenac P and
analgesics as
Cap. Myoril 4mg
prescribed by the
as prescribed.
physician.
Provide pelvic
traction to the
patient
Assessment
(Orientatio
n phase)
Nursing
diagnosis
Planning
(Identification
phase)
Given pelvic
traction and
explained the
need for traction
Implementation
(Exploitation
phase)
Evaluation
(Resolution phase)
Mrs. JL
expresses
that she
need
assistance
to get down
from bed.
Regarding
self care
discussion
was done
and
discussed
regarding
the
measures
to solve the
problems.
Self care
deficit
related to
the
presence
of pelvic
traction.
Goal setting
was done along mutually agreed express problems of
with patient
upon.
self care.
Client
will
achieve
and
maintain
self
care
activities
with assistance
of caregiver or
within
her
limits.
Kept the articles

Keep all the
within t he reach
articles
within
of the client
the reach of the
patient.
Provide a
bell
to
patient to
in
emergency
call
the
call
any
Frequently visited
the patient and
enquired for any
Frequently visitneeds
the patient and
enquire for any
needs.
Assisted the
client in doing her
self care activities
Assist
the
patient in doing
her self care
Removed the
activities.
weight as and
when needed.
Remove
the
weight of the
traction
as
needed by the
patient.
She used to call for

the needs and all her
needs were met
appropriately
She achieved and

maintained self care
activities within her
limits
Assessment
(Orientatio
n phase)
Mrs. JL is
enquiring
about the
disease
condition,
its outcome
and need
for surgery
Discussed
with the
client
regarding
the disease
process and
the findings
in the client
Nursing
diagnosis
Anxiety
related to
hospital
admission as
evidenced by
verbalisation
and client &
family
appearing
withdrawn
Planning
(Identification
phase)
Goal setting was
done along with
patient
(Exploitation
(Resolution phase)
phase)
mutually agreed express problems of
upon.
self care.
Client will have

reduced feeling
of anxiety as
evidenced by
She asked her doubts

regarding the illness
and the diagnostic
procedures
asking fewer
questions
She verbalized that
Taught the family her anxiety has
reduced to some
regarding the
Teach the family disease process extent.
and client
in simple
regarding the
Kannada
disease process.
Explain in simple
understandable
language of the
client.
Allowed the client

and family
members to ask
questions
Allow and
encourage the
client and family
to ask questions.
She and her
Allow the client
husband
and family to
expressed their
verbalize anxiety.
anxiety
Stress that
frequent
assessment are
routine and do
not necessarily
imply a
deteriorating
condition.
Allow the family Allowed the

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

understandable
terms
Used simple and

understandable
terms for
explaining
Clarified her
doubts
Clarify all the

doubts of the
patient of
importance.
Repeated the
information
Repeat the
information
whenever
necessary to
reinforce
learning.
Summary:
1. Orientation phase
Client is initially reluctant to talk due to pain.
Client is expressing that while standing she is having much pain.
Client expressed without movement and supine position gave her relief
from pain.
2. Identification
The client participates and interdependent with the nurse
Expresses the need for measure to get relief from pain
Expresses need for improving the mobility
Expresses need to know more about prognosis, discharge and home

care and follow up.
3. Exploitation
Client explains that she gets relief of pain when lying down supine.
Cooperates and participates actively in performing exercises.

Client mobilizes changes position and cooperates during position
changes.
4. Resolution
Client expressed that pain has reduced a lot and she is able to tolerate
it now
She has agreed upon to continue the exercises at home
She also expressed that she would come for regular follow up after
discharge.
Evaluation of the theory of interpersonal relations by Peplau
With the help of the theory of interpersonal relations, the client's needs could be
assessed. It helped her to achieve them within her limits. This theory application
helped in providing comprehensive care to the client.
APPLICATION OF THEORY IN
NURSING PROCESS
Introduction
Theories are a set of interrelated concepts that give a systematic view of a
phenomenon (an observable fact or event) that is explanatory & predictive in nature.
Theories are composed of concepts, definitions, models, propositions & are based on
assumptions. They are derived through two principal methods; deductive reasoning
and inductive reasoning.
Objectives
to assess the patient condition by the various methods explained by the

nursing theory
to demonstrate an effective communication and interaction with the patient.
to select a theory for the application according to the need of the patient
Definition:
Nursing theory is an organized and systematic articulation of a set of statements
related to questions in the discipline of nursing. A nursing theory is a set of
concepts, definitions, relationships, and assumptions or propositions derived from
nursing models or from other disciplines and project a purposive, systematic view of
phenomena by designing specific inter-relationships among concepts for the
purposes of describing, explaining, predicting, and /or prescribing..
Importance of nursing theories:
Nursing theory aims to describe, predict and explain the phenomenon

of nursing
It should provide the foundations of nursing practice, help to generate
further knowledge and indicate in which direction nursing should
develop in the future
Theory is important because it helps us to decide what we know and
what we need to know
It helps to distinguish what should form the basis of practice by
explicitly describing nursing
The benefits of having a defined body of theory in nursing include
better patient care, enhanced professional status for nurses, improved
communication between nurses, and guidance for research and
education
The main exponent of nursing caring cannot be measured, it is
vital to have the theory to analyze and explain what nurses do
As medicine tries to make a move towards adopting a more
multidisciplinary approach to health care, nursing continues to strive to
establish a unique body of knowledge
This can be seen as an attempt by the nursing profession to maintain
its professional boundaries
Characteristics of theories:
Theories are
Interrelating concepts in such a way as to create a different way of

looking at a particular phenomenon.
Logical in nature.
Generalizable.
Bases for hypotheses that can be tested.
Increasing the general body of knowledge within the discipline through
the research implemented to validate them.
Used by the practitioners to guide and improve their practice.
Consistent with other validated theories, laws, and principles but will
leave open unanswered questions that need to be investigated.
Purposes of theory in practice:

Serve to guide assessment, intervention, and evaluation of nursing
care.
Provide a rationale for collecting reliable and valid data about the
health status of clients, which are essential for effective decision
making and implementation.
Help to establish criteria to measure the quality of nursing care
Help build a common nursing terminology to use in communicating
with other health professionals. Ideas are developed and words
defined.
Enhance autonomy (independence and self-governance) of nursing by
defining its own independent functions.
If theory is expected to benefit practice, it must be developed cooperatively

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

Application Orem's Self-care Deficit Theory
Theories used in Community Health Nursing
Application of Suchmans Stages of Illness Mode
Application of Betty Neuman's Systems Model in Nursing Care

Nursing Theories

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Nursing Theories

Metaparadigm (Person, Environment, Health & Nursing) (Most abstract)

Conceptual models and Grand theories.

Nursing theories and Middle range theories (Least abstract)

Focuses on nursing and the patient

Nurses should identify patients need-for help

Patients require help towards achieving

Patients problems determine nursing care

Lydia E. Hall :Care, Cure,

Nursing care is person directed towards self

Jean Watsons Philosophy

Caring is moral ideal: mind -body soul

Patricia Benners Primacy

Caring is central to the essence of nursing. It

CONCEPTUAL MODELS AND GRAND THEORIES

Selfcare maintains wholeness.

Myra Estrin Levines: The

Holism is maintained by conserving integrity

Person environment are energy fields that

Individuals maintain stability and balance

Sister Callista: Roys

Stimuli disrupt an adaptive system

Betty Neumans : Health

Reconstitution is a status of adaptation to

Imogene Kings Goal

Transactions provide a frame of reference

Perceptions, Judgments and actions of the

Nancy Roper, WW.Logan

Interpersonal process is maturing force for

Ida Jean Orlandos

Interpersonal process alleviates distress.

Joyce Travelbees Human

Therapeutic human relationships.

Growth and development of children and

Parenting and maternal role attainment in

Comfort is desirable holistic outcome of care.

Individual characteristics of each member

A complex theory to explain the factors

Health care needs are needs for comfort,

Caring is universal and varies transculturally.

Major concepts include care, caring, culture,

Indivisible beings and environment co-create

Nola J.Penders :The

Promoting optimum health supersedes disease

Models are representations of the interaction among and between the

Importance of nursing theories

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

Basic processes in the development of nursing theories

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

The person (patient).

Nightingale (1860): To facilitate the bodys reparative processes by

Classification of nursing theories

Depending On Function (Polit et al 2001)

To calculate relationships between

To identify under which conditions

Depending on the Generalisability of their principles

Practice theory: explores one particular situation found

Based on the philosophical underpinnings of the theories

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

Humanistic theories developed in response to the psychoanalytic thought that

Growth and Stability Models of Change

Categories of Conceptual Models

Ten conceptual models of nursing have been classified according to two

Systems Theory as a Framework