Professional Documents
Culture Documents
INTRODUCTION TO NURSING
THEORIES
INTRODUCTION
Nursing has made phenomenal achievement in the last century that has lead to
the recognition of nursing as an academic discipline and a profession. A move
towards theory-based practice has made contemporary nursing more meaningful
and significant by shifting nursing’s focus from vocation to an organised
profession. The need for knowledge-base to guide professional nursing practice
had been realised in the first half of the twentieth century and many theoretical
works have been contributed by nurses ever since, first with the goal of making
nursing a recognised profession and later with the goal of delivering care to
patients as professionals.
A theory is a group of related concepts that propose action that guide practice. A
nursing theory is a set of concepts, definitions, relationships, and assumptions
or propositions derived from nursing models or from other disciplines and project
a purposive, systematic view of phenomena by designing specific inter-
relationships among concepts for the purposes of describing, explaining,
predicting, and /or prescribing..
Based on the knowledge structure levels the theoretical works in nursing can be
studied under the following headings:
• Metaparadigm (Person, Environment, Health & Nursing) – (Most abstract)
• Nursing philosophies.
• Conceptual models and Grand theories.
• Nursing theories and Middle range theories (Least abstract)
NURSING PHILOSOPHIES
Lydia E. Hall :Care, Cure, Nursing care is person directed towards self
Core model love.
CONCLUSION
The conceptual and theoretical nursing models help to provide knowledge to
improve practice, guide research and curriculum and identify the goals of nursing
practice. The state of art and science of nursing theory is one of continuing
growth. Using the internet the nurses of the world can share ideas and
knowledge, carrying on the work begun by nursing theorists and continue the
growth and development of new nursing knowledge. It is important the nursing
knowledge is learnt, used, and applied in the theory based practice for the
profession and the continued development of nursing and academic discipline
REFERENCES
• George B. Julia , Nursing Theories- The base for professional Nursing
Practice, 3rd ed. Norwalk, Appleton & Lange.
• Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing
Philadelphia. Lippincott Williams& wilkins.
• Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress
3rd ed. Philadelphia, Lippincott.
• Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed.
Philadelphia, Lippincott.
• Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts
Process & Practice 3rd ed. London Mosby Year Book.
• Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.).
Mosby, Philadelphia, 2002
• Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd
Ed. Mosby, Philadelphia, 2002.
DEVELOPMENT OF NURSING
THEORIES
Introduction
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
Theories are
Nursing theories are often based on & influenced by broadly applicable processes &
theories. Following theories are basic to many nursing concepts.
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
Developmental Theory
Four concepts common in nursing theory that influence & determine nursing practice
are:
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.
■ “Interaction” theories.
■ “Outcome “theories.
■ Humanistic theories.
“Needs” theories
• These theories are based around helping individuals to fulfill their physical and
mental needs. The basis of these theories is well-illustrated in Roper, Logan
and Tierney’s Model of Nursing (1980).
• Needs theories have been criticized for relying too much on the medical model
of health and placing the patient in an overtly dependent position.
“Interaction” theories
“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
Models of nursing
• Until fairly recently, nursing science was derived principally from social,
biologic, and medical science theories.
• However, from the 1950s to the present, an increasing number of nursing
theorists have developed models of nursing that provide bases for the
development of nursing theories and nursing knowledge.
• A model, as an abstraction of reality, provides a way to visualize reality to
simplify thinking.
• A conceptual model shows how various concepts are interrelated and applies
theories to predict or evaluate consequences of alternative actions.
• According to Fawcett (2000),
• A conceptual model “gives direction to the search for relevant questions about
the phenomena of central interest to a discipline and suggests solutions to
practical problems”
• Four concepts are generally considered central to the discipline of nursing: the
person who receives nursing care (the patient or client); the environment
(society); nursing (goals, roles, functions); and health. These four concepts
form a metaparadigm of nursing.
• The term metaparadigm comes from the Greek prefix “meta,” which means
more comprehensive or transcending, and the word Greek word “paradigm,”
which means a philosophical or theoretical framework of a discipline upon
which all theories, laws, and generalizations are formulated (Merriam-
Webster’s Collegiate Dictionary, 1994).
• There are two major differences in philosophical beliefs, or world views, about
the nature of change.
• “The world view of change uses the growth metaphor, and the persistence
view focuses
on stability” (Fawcett, 1989,).
• Within the change world view, change and growth are continual and desirable,
“progress is valued, and realization of one’s potential is emphasized”
(Fawcett).
• Persistence is endurance in time
• Persistence world view emphasizes equilibrium and balance.
• The drive for a unique body of knowledge is based on the assumption that
‘borrowed’ knowledge is less worthy.
• However, nurse education is based on theory borrowed from other disciplines,
such as sociology and psychology.
• It has been argued that applying knowledge from different disciplines only
serves to dilute nursing practice.
• Nevertheless, as the occupation is focused on humans, perhaps it is inevitable
that nursing uses knowledge from other social sciences.
• It has been argued that no knowledge is exclusive, and because of nursing’s
diverse nature it is impossible for it to have a unique body of knowledge and
one unified body of theory (Castledine 1994, Levine 1995).
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.
Summarization
1. Definition
2. Importance of Nursing Theories
3. The characteristics of theories:
4. Basic Processes in the Development Of Nursing Theories:
5. Nursing theories are often based on & influenced
6. ANA definition of Nursing Practice
7. Common concepts in Nursing Theories:
8. Historical Perspectives & Key Concepts
9. Clasification of Nursing Theories
10. Models Of Nursing
11. Growth and Stability Models of Change
12. Betty Neuman’s Health Care Systems Model
13. Stress/Adaptation Theory as a Framework
14. A unique body of knowledge
15. Criticisms of nursing theories
Conclusion
Littlejohn (2002) comments that, irrespective of nursing theories nurses will continue
to exhibit a caring response to the ‘sick and troubled’. If this is true, perhaps nurses
are ‘nursing’ without the knowledge of theories and theory is irrelevant. However,
theory and practice are related, and if nursing is to continue to develop, the concept
of theory must be addressed. If nursing theory does not drive the development of
nursing, it will continue to develop in the footsteps of other disciplines such as
medicine
Reference
• George B. Julia , Nursing Theories- The base for professional Nursing Practice
, 3rd ed. Norwalk, Appleton & Lange.
• Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing
Philadelphia. Lippincott Williams& wilkins.
• Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd
ed. Philadelphia, Lippincott.
• Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed.
Philadelphia, Lippincott.
• Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts
Process & Practice 3rd ed. London Mosby Year Book.
• Vandemark L.M. Awareness of self & expanding consciousness: using Nursing
theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul; 27(6) :
605-15
• Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006
Jul;19(3):225
Nursing Theorists
Definitions
Theory- a set of related statements that describes or explains phenomena in a
systematic way
Concept-a mental idea of a phenomenon
Construct- a phenomena that cannot be observed and must be inferred
Proposition- a statement of relationship between concepts
Conceptual model- made up of concepts and propositions
Nursing Theorists
• Florence Nightingale,
• Hildegard Peplau
• Virginia Henderson
• Fay Abdella
• Ida Jean Orlando
• Dorothy Johnson
• Martha Rogers
• Dorothea Orem
• Imogene King
• Betty Neuman
• Sister Calista Roy,
• Jean Watson
• Rosemary Rizzo Parse
• Madeleine Leininger
•
Patricia Benner
Concepts in the nursing
Metaparadigm
• Person
• Recipient of care, including physical, spiritual, psychological, and
sociocultural components
• Individual, family, or community
• Environment
• All internal and external conditions, circumstances, and influences affecting
the person
• Health
• Degree of wellness or illness experienced by the person
• Nursing
• Actions, characteristics and attributes of person giving care
Florence Nightingale- Environmental Theory
• First nursing theorist
• Unsanitary conditions posed health hazard (Notes on Nursing, 1859)
• 5 components of environment
• ventilation, light, warmth, effluvia, noise
• External influences can prevent, suppress or contribute to disease or death
Nightingale’s Concepts
• Person
o Patient who is acted on by nurse
o Affected by environment
o Has reparative powers
• Environment
o Foundation of theory. Included everything, physical, psychological,
and social
• Health
o Maintaining well-being by using a person’s powers
o Maintained by control of environment
• Nursing
o Provided fresh air, warmth, cleanliness, good diet, quiet to facilitate
person’s reparative process
Hildegard Peplau -Interpersonal Relations Model
• Based on psychodynamic nursing
• using an understanding of one’s own behavior to help others identify their
difficulties
• Applies principles of human relations
• Patient has a felt need
Peplau’s Concepts
• Person
o An individual; a developing organism who tries to reduce anxiety
caused by needs
o Lives in instable equilibrium
• Environment- Not defined
• Health
o Implies forward movement of the personality and human processes
toward creative, constructive, productive, personal, and community
living
• Nursing
o A significant, therapeutic, interpersonal process that functions
cooperatively with others to make health possible
o Involves problem-solving
Virginia Henderson -The Nature of Nursing
"The unique function of the nurse is to assist the individual, sick or well, in
the performance of those activities contributing to health or its recovery
(or to peaceful death) that he would perform unaided if he had the
necessary strength, will, or knowledge. And to do this in such a way as to
help him gain independence as rapidly as possible. She must in a sense,
get inside the skin of each of her patients in order to know what he needs".
Fay Abdella- Topology of 21 Nursing Problems
• A list of 21 nursing problems
• Condition presented or faced by the patient or family.
• Problems are in 3 categories
• physical, social and emotional
• The nurse must be a good problem solver
Abdella’s Concepts
• Nursing
o A helping profession
o A comprehensive service to meet patient’s needs
o Increases or restores self-help ability
o Uses 21 problems to guide nursing care
• Health
o Excludes illness
o No unmet needs and no actual or anticipated impairments
• Person
o One who has physical, emotional, or social needs
o The recipient of nursing care.
• Environment
o Did not discuss much
o Includes room, home, and community
Ida Jean Orlando- Deliberative Nursing Process
• The deliberative nursing process is set in motion by the patient’s behavior
• All behavior may represent a cry for help. Patient’s behavior can be verbal
or non-verbal.
• The nurse reacts to patient’s behavior and forms basis for determining
nurse’s acts.
• Perception, thought, feeling
• Nurses’ actions should be deliberative, rather than automatic
• Deliberative actions explore the meaning and relevance of an action.
Dorothy Johnson-Behavioral Systems Model
• The person is a behavioral system comprised of a set of organized,
interactive, interdependent, and integrated subsystems
• Constancy is maintained through biological, psychological, and sociological
factors.
• A steady state is maintained through adjusting and adapting to internal
and external forces.
Johnson’s 7 Subsystems
• Affiliative subsystem
o social bonds
• Dependency
o helping or nuturing
• Ingestive
o food intake
• Eliminative
o excretion
• Sexual
o procreation and gratification
• Aggressive
o self-protection and preservation
• Achievement
o efforts to gain mastery and control
Johnson’s Concepts
• Person
o A behavioral system comprised of subsystems constantly trying to
maintain a steady state
• Environment
o Not specifically defined but does say there is an internal and
external environment
• Health
o Balance and stability.
• Nursing
o External regulatory force that is indicated only when there is
instability.
Martha Rogers -Unitary Human Beings
• Energy fields
o Fundamental unity of things that are unique, dynamic, open, and
infinite
o Unitary man and environmental field
• Universe of open systems
o Energy fields are open, infinite, and interactive
• Pattern
o Characteristic of energy field
o A wave that changes, becomes complex and diverse
• Pandimensionality
o A nonlinear domain with out time or space
Roger’s Definitions
• Integrality
o Continuous and mutual interaction between man and environment
• Resonancy
o Continuous change longer to shorter wave patterns in human and
environmental fields
• Helicy
o Continuous, probabilistic, increasing diversity of the human and
envrionmental fields.
o Characterized by nonrepeating rhymicities
o Change
Dorothea Orem- Self-Care Model
• Self-care comprises those activities performed independently by an
individual to promote and maintain person well-being
• Self care agency is the individual’s ability to perform self care activities
• Self- care deficit occurs when the person cannot carry out self-care
• The nurse then meets the self-care needs by acting or doing for; guiding,
teaching, supporting or providing the environment to promote patient’s
ability
• Wholly compensatory nursing system-Patient dependent
• Partially compensatory- Patient can meet some needs but needs nursing
assistance
• Supportive educative-Patient can meet self care requisites, but needs
assistance with decision making or knowledge
Imogene King-Goal Attainment Theory
• Open systems framework
• Human beings are open systems in constant interaction with the
environment
• Personal System
o individual; perception, self, growth, development, time space, body
image
o Interpersonal
o Society
• Personal System
o Individual; perception, self, growth, development, time space, body
image
• Interpersonal
o Socialization; interaction, communication and transaction
• Society
o Family, religious groups, schools, work, peers
• The nurse and patient mutually communicate, establish goals and take
action to attain goals
• Each individual brings a different set of values, ideas, attitudes,
perceptions to exchange
Betty Neuman - Health Care Systems Model
• The person is a complete system, with interrelated parts
• maintains balance and harmony between internal and external
environment by adjusting to stress and defending against tension-
producing stimuli
• Focuses on stress and stress reduction
• Primarily concerned with effects of stress on health
• Stressors are any forces that alter the system’s stability
• Flexible lines of resistance
Surround basic core
Internal factors that help defend against stressors
• Normal line of resistance
Normal adaptation state
• Flexible line of defense
Protective barrier, changing, affected by variables
• Wellness is equilibrium
• Nursing interventions are activates to:
strengthen flexible lines of defense
strengthen resistance to stressors
maintain adaptation
Sister Calista Roy - Adaptation Model
• Five Interrelated Essential Elements
Patiency- The person receiving care
Goal of nursing- Adapting to change
Health-Being and becoming a whole person
Environment
Direction of nursing activities- Facilitating adaptation
• The person is an open adaptive system with input (stimuli), who adapts by
processes or control mechanisms (throughput)
• The output can be either adaptive responses or ineffective responses
Jean Watson - Philosophy and Science of Caring
• Caring can be demonstrated and practiced
• Caring consists of carative factors
• Caring promotes growth
• A caring environment accepts a person as he is and looks to what the
person may become
• A caring environment offers development of potential
• Caring promotes health better than curing
• Caring is central to nursing
Watson’s 10 Carative Factors
• Forming humanistic-altruistic value system
• Instilling faith-hope
• Cultivating sensitivity to self and others
• Developing helping-trust relationship
• Promoting expression of feelings
• Using problem-solving for decision making
• Promoting teaching-learning
• Promoting supportive environment
• Assisting with gratification of human needs
• Allowing for existential-phenomenological forces
Watson’s Concepts
• Person
o Human being to be valued, cared for, respected, nurtured,
understood and assisted
• Environment
o Society
• Health
o Complete physical, mental and social well-being and functioning
• Nursing
o Concerned with promoting and restoring health, preventing illness
Rosemary Parse - Human Becoming Theory
• Human Becoming Theory includes Totality Paradigm
o Man is a combination of biological, psychological, sociological and
spiritual factors
•
Simultaneity Paradigm
o Man is a unitary being in continuous, mutual interaction with
environment
• Originally Man-Living-Health Theory
Parse’s Three Principles
• Meaning
o Man’s reality is given meaning through lived experiences
o Man and environment cocreate
• Rhythmicity
o Man and environment cocreate ( imaging, valuing, languaging) in
rhythmical patterns
• Cotranscendence
o Refers to reaching out and beyond the limits that a person sets
o One constantly transforms
• Person
o Open being who is more than and different from the sum of the
parts
• Environment
o Everything in the person and his experiences
o Inseparable, complimentary to and evolving with
• Health
o Open process of being and becoming. Involves synthesis of values
• Nursing
o A human science and art that uses an abstract body of knowledge
to serve people
Madeleine Leininger - Culture Care Diversity and Universality
• Based on transcultural nursing, whose goal is to provide care congruent
with cultural values, beliefs, and practices
• Sunrise model consists of 4 levels that provide a base of knowledge for
delivering cultural congruent care
• Modes of nursing action
• Cultural care preservation
o help maintain or preserve health, recover from illness, or face death
• Cultural care accommodation
o help adapt to or negotiate for a beneficial health status, or face
death
• Cultural care re-patterning
o help restructure or change lifestyles that are culturally meaningful
Patricia Benner - From Novice to Expert
• Described 5 levels of nursing experience and developed exemplars and
paradigm cases to illustrate each level
• Levels reflect:
o movement from reliance on past abstract principles to the use of
past concrete experience as paradigms
o change in perception of situation as a complete whole in which
certain parts are relevant
Novice
Advanced beginner
Competent
Proficient
Expert
Importance of Theoretical Frameworks
1. Foundation of any profession is the development of a specialized body of
knowledge. Theories should be developed in nursing, not borrow theories
form other disciplines
2. Responsibility of nurses to know and understand theorists
3. Critically analyze theoretical frameworks
Reference
• 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.).
Mosby, Philadelphia, 2002.
• George B. Julia , Nursing Theories- The base for professional Nursing
Practice , 3rd ed. Norwalk, Appleton and Lange.
• Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing
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.
Philadelphia, Lippincott.
• Potter A Patricia, Perry G Anne (1992)Fundamentals Of Nursing –Concepts
Process and Practice 3rd ed. London Mosby Year Book.
NURSING THEORIES: AN OVERVIEW
Theory
Kerlinger ---views theories as a set of interrelated concepts that give a systematic
view of a phenomenon ( an observable fact or event ) that is explanatory and
predictive in nature. Theories are composed of concepts, definitions, models ,
propositions and are based on assumptions. They are derived through two principal
methods: 1) Deductive reasoning 2) Inductive reasoning. Nursing theorists use both
of these methods. Nursing Theory: Barnum(1998)---- " attempts to describe or
explain the phenomenon (process, occurrence and event) called nursing"
Theories for Professional Nursing
• Theory is "a creative and rigorous structuring of ideas that projects a
tentative, purposeful, and systematic view of phenomena"
• A theory makes it possible to "organize the relationship among the concepts
to describe, explain, predict, and control practice"
Definition
• Concepts--- are basically vehicles of thought that involve images. Concepts
are words that describe objects , properties, or events and are basic
components of theory .
Types : Empirical concepts
Inferential concepts
Abstract concepts.
• Models ----- are representations of the interaction among and between the
concepts showing patterns.
• Propositions---- are statements that explain the relationship between the
concepts.
• Process ---- it is a series of actions , changes or functions intended to bring
about a desired result . During a process one takes systemic and continuous
steps to meet a goal and uses both assessments and feedback to direct
actions to the goal.
• A particular theory or conceptual frame work directs how these actions are
carried out . The delivery of nursing care within the nursing process is
directed by the way specific conceptual frameworks and theories define the
person (patient), the environment , health and nursing.
• The terms ‘model’ and ‘theory’ are often wrongly used interchangeably, which
further confounds matters.
• In nursing, models are often designed by theory authors to depict the beliefs
in their theory (Lancaster and Lancaster 1981).
• They provide an overview of the thinking behind the theory and may
demonstrate how theory can be introduced into practice, for example,
through specific methods of assessment.
• Models are useful as they allow the concepts in nursing theory to be
successfully applied to nursing practice (Lancaster and Lancaster 1981).
• Their main limitation is that they are only as accurate or useful as the
underlying theory.
Importance of Nursing Theories
• Nursing theory aims to describe, predict and explain the phenomenon of
nursing (Chinn and Jacobs1978).
• It should provide the foundations of nursing practice, help to generate further
knowledge and indicate in which direction nursing should develop in the
future (Brown 1964).
• Theory is important because it helps us to decide what we know and what we
need to know (Parsons1949).
• It helps to distinguish what should form the basis of practice by explicitly
describing nursing.
• The benefits of having a defined body of theory in nursing include better
patient care, enhanced professional status for nurses, improved
communication between nurses, and guidance for research and education
(Nolan 1996). In addition, because the main exponent of nursing – caring –
cannot be measured, it is vital to have the theory to analyze and explain what
nurses do.
• As medicine tries to make a move towards adopting a more multidisciplinary
approach to health care, nursing continues to strive to establish a unique
body of knowledge.
• This can be seen as an attempt by the nursing profession to maintain its
professional boundaries.
The characteristics of theories
Theories:
• interrelate concepts in such a way as to create a different way of looking at a
particular phenomenon.
• are logical in nature.
• are generalizable.
• are the bases for hypotheses that can be tested.
• increase the general body of knowledge within the discipline through the
research implemented to validate them.
• are used by the practitioners to guide and improve their practice.
• are consistent with other validated theories, laws, and principles but will leave
open unanswered questions that need to be investigated
Basic Processes in the Development Of Nursing Theories:
Nursing theories are often based on and influenced by broadly applicable
processes and theories. Following theories are basic to many nursing
concepts.
General System Theory:
It describes how to break whole things into parts and then to learn how the
parts work together in " systems". These concepts may be applied to different
kinds of systems, e.g.. Molecules in chemistry , cultures in sociology, organs
in Anatomy and health in Nursing.
Adaptation Theory
It defines adaptation as the adjustment of living matter to other living things
and to environmental conditions. Adaptation is a continuously occurring
process that effects change and involves interaction and response . Human
adaptation occurs on three levels:
--- the internal ( self )
--- the social (others)
--- and the physical ( biochemical reactions )
Developmental Theory
It outlines the process of growth and development of humans as orderly and
predictable , beginning with conception and ending with death.
The progress and behaviors of an individual within each stage are unique.
The growth and development of an individual are influenced by heredity ,
temperament , emotional, and physical environment , life experiences and
health status.
Common concepts in Nursing Theories:
Four concepts common in nursing theory that influence and determine nursing
practice are
-- The person( patient) .
--- The environment
-- Health
--- Nursing (goals, roles, functions)
• Each of these concepts is usually defined and described by a nursing theorist ,
Often uniquely; although these concepts are common to all nursing theories.
• Of the four concepts , the most important is that of the person. The focus of
nursing , regardless of definition or theory , is the person.
Historical Perspectives and Key Concepts
Nightingale (1860): To facilitate "the body’s reparative processes" by
manipulating client’s environment
Paplau 1952: Nursing is; therapeutic interpersonal process.
Henderson 1955: The needs often called Henderson’s 14 basic needs
Abdellah 1960: The nursing theory developed by Faye Abdellah et al
(1960) emphasizes delivering nursing care for the whole person to meet the
physical, emotional, intellectual, social, and spiritual needs of the client and
family.
Orlando 1962: To Ida Orlando (1960), the client is an individual; with a
need; that, when met, diminishes distress, increases adequacy, or enhances
well-being.
Johnson’s Theory 1968: Dorothy Johnson’s theory of nursing 1968
focuses on how the client adapts to illness and how actual or potential stress
can affect the ability to adapt. The goal of nursing to reduce stress so that;
the client can move more easily through recovery.
Rogers 1970: to maintain and promote health, prevent illness, and care
for and rehabilitate ill and disabled client through "humanistic science of
nursing" Orem1971: This is self-care deficit theory. Nursing care becomes
necessary when client is unable to fulfill biological, psychological,
developmental, or social needs.
King 1971: To use communication to help client reestablish positive
adaptation to environment.
Neuman 1972: Stress reduction is goal of system model of nursing
practice.
Roy 1979: This adaptation model is based on the physiological,
psychological, sociological and dependence-independence adaptive modes.
Watson’s Theory 1979: Watson’s philosophy of caring 1979 attempts
to define the outcome of nursing activity in regard to the; humanistic aspects
of life.
Classification of Nursing Theories
Depending On The Generalisability Of Their Principles
• Metatheory: the theory of theory. Identifies
• specific phenomena through abstract concepts.
• Grand theory: provides a conceptual framework under which the key concepts
and
• principles of the discipline can be identified.
• Middle range theory: is more precise and only analyses a particular situation
with a limited number of variables.
• Practice theory: explores one particular situation found in nursing. It identifies
explicit goals and details how these goals will be achieved.
Theories can also be categorised as:
• "Needs "theories.
• "Interaction" theories.
• "Outcome "theories.
• "Humanistic theories"
• These categories indicate the basic philosophical underpinnings of the theories
"Needs" theories
• These theories are based around helping individuals to fulfill their physical and
mental needs. The basis of these theories is well-illustrated in Roper, Logan
and Tierney’s Model of Nursing (1980).
• Needs theories have been criticized for relying too much on the medical model
of health and placing the patient in an overtly dependent position.
"Interaction" theories
• As described by Peplau (1988), these theories revolve around the
relationships nurses form with patients.
• Such theories have been criticized for largely ignoring the medical model of
health and not attending to basic physical needs.
"Outcome" theories
• These portray the nurse as the changing force, who enables individuals to
adapt to or cope with ill health (Roy 1980).
• Outcome theories have been criticized as too abstract and difficult to
implement in practice (Aggleton and Chalmers 1988).
"Humanistic" Theories:
• Humanistic theories developed in response to the psychoanalytic thought that
a person’s destiny was determined early in life.
• Humanistic theories emphasize a person’s capacity for self actualization .
• Humanists believes that the person contains within himself the potential for
healthy and creative growth.
• Carl Rogers developed a person –centered model of psychotherapy that
emphasizes the uniqueness of the individual.
• The major contribution that Rogers added to nursing practice is the
understanding that each client is a unique individual, so person-centered
approach now practice in Nursing.
MODELS OF NURSING
• Until fairly recently, nursing science was derived principally from social,
biologic, and medical science theories.
• However, from the 1950s to the present, an increasing number of nursing
theorists have developed models of nursing that provide bases for the
development of nursing theories and nursing knowledge.
• A model, as an abstraction of reality, provides a way to visualize reality to
simplify thinking.
• A conceptual model shows how various concepts are interrelated and applies
theories to predict or evaluate consequences of alternative actions.
• According to Fawcett (2000),
• A conceptual model "gives direction to the search for relevant questions about
the phenomena of central interest to a discipline and suggests solutions to
practical problems"
• . Four concepts are generally considered central to the discipline of nursing:
the person who receives nursing care (the patient or client); the environment
(society); nursing (goals, roles, functions); and health.
• These four concepts form a metaparadigm of nursing.
• The term metaparadigm comes from the Greek prefix
• "meta," which means more comprehensive or transcending,
• and the word Greek word "paradigm," which means a philosophical or
theoretical framework of a discipline
• upon which all theories, laws, and generalizations are formulated (Merriam-
Webster’s Collegiate Dictionary, 1994).
Growth and Stability Models of Change
• There are two major differences in philosophical beliefs, or world views, about
the nature of change.
• "The world view of change uses the growth metaphor, and the persistence
view focuses
on stability" (Fawcett, 1989,).
• Within the change world view, change and growth are continual and desirable,
"progress is valued, and realization of one’s potential is emphasized"
(Fawcett).
• Persistence is endurance in time
• persistence world view emphasizes equilibrium and balance.
Categories of Conceptual Models
• Ten conceptual models of nursing have been classified according to two
criteria:
• the world view of change reflected by the model (growth or stability); and
• the major theoretical conceptual classification with which the model seems
most consistent (systems, stress/adaptation, caring, or growth/development).
Systems Theory as a Framework
• Systems theory is concerned with changes caused by interactions among all
the factors (variables)
• General systems theory is emphasized
• A system is defined as "a whole with interrelated parts, in which the parts
have a function and the system as a totality has a function" (Auger, 1976)
• A general systems approach allows for consideration of the subsystems levels
of the human being, as a total human being, and as a social creature who
networks himself with others in hierarchically arranged human systems of
increasing complexity. Thus the human being, from the level of the individual
to the level of society, can be conceptualized as the client and becomes the
target system for nursing intervention. (Sills and Hall, 1977).
An example of systems interaction
1. Input (Diet teaching)
• Throughput (Assimilation of information)
• Output (Food intake)
• Feedback (Weight record ,Hb estimation etc.)
Two nursing models based on systems theory:
2. Imogene King’s systems interaction model, and
3. Betty Neuman’s health care systems model.
Imogene King’s Systems Interaction Model
• interaction model, the purpose of nursing is to help people attain, maintain,
or restore health
• King’s model conceptualizes three levels of dynamic interacting systems.
• 1. Individuals are called "personal systems."
• 2. Groups (two or more persons) form "interpersonal systems."
• 3. Society is composed of "social systems."
• As the person interacts with the environment, he or she must continuously
adjust to stressors in the internal and external environment (King, 1981).
• Health assumes achievement of maximum potential for daily living and an
ability to function
• in social roles. It is the "dynamic life experiences of a human being, which
implies continuous
• adjustment to stressors in the internal and external environment through
optimum use of one’s resources to achieve maximum potential for daily living"
(King, 1981,).
• "Illness is a deviation from normal, that is, an imbalance in a person’s
biological structure or in his psychological makeup, or a conflict in a person’s
social relationships" (King, 1989).
• "The goal of nursing is to help individuals and groups attain, maintain, and
restore health"
• Stress: "a dynamic state whereby a human being interacts with the
environment to maintain balance for growth, development, and performance"
Betty Neuman’s Health Care Systems Model
• Betty Neuman specifies that the purpose of nursing is to facilitate optimal
client system stability.
• Normal line of defense: an adaptational level of health considered normal for
an individual
• Lines of resistance: protection factors activated when stressors have
penetrated the normalline of defense
• Neuman’s model, organized around stress reduction, is concerned primarily
with how stress and the reactions to stress affect the development and
maintenance of health.
• The person is a composite of physiologic, psychological, sociocultural,
developmental, and spiritual variables considered simultaneously.
• "Ideally the five variables function harmoniously or are stable in relation to
internal and external environmental stressor influences" (Neuman, 2002).
• A person is constantly affected by stressors from the internal, external, or
created environment.
• Stressors are tension-producing stimuli that have the potential to disturb a
person’s equilibrium or normal line of defense.
• This normal line of defense is the person’s "usual steady state."
• It is the way in which an individual usually deals with stressors.
• Stressors may be of three types:
• Intrapersonal: forces arising from within the person
• Interpersonal: forces arising between persons
• Extrapersonal: forces arising from outside the person
• Resistance to stressors is provided by a flexible line of defense, a dynamic
protective buffer made up of all variables affecting a person at any given
moment the person’s resistance to any given stressor or stressors.
• If the flexible line of defense is no longer able to protect the person against a
stressor, the stressor
• breaks through, disturbs the person’s equilibrium, and triggers a reaction. The
reaction may lead
• toward restoration of balance or toward death.
• Neuman intends for the nurse to "assist clients to retain, attain, or maintain
optimal system stability" (Neuman, 1996).
• Thus, health (wellness) seems to be related to dynamic equilibrium of the
normal line of defense, where stressors are successfully overcome or avoided
by the flexible line of defense.
• Neuman defines illness as "a state of insufficiency with disrupting needs
unsatisfied" (Neuman, 2002).
• Illness appears to be a separate state when a stressor breaks through the
normal line of defense and causes a reaction with the person’s lines of
resistance.
Stress/Adaptation Theory as a Framework
• In contrast to systems theory, stress and adaptation theories view change
caused by person–environment interaction in terms of cause and effect.
• The person must adjust to environmental changes to avoid disturbing a
balanced existence. Adaptation theory provides a way to understand
• both how the balance is maintained and the possible effects of disturbed
equilibrium.
• This theory has been widely applied to explain, predict, and control biologic
(physiologic and psychological)
A unique body of knowledge
• The drive for a unique body of knowledge is based
• on the assumption that ‘borrowed’ knowledge is
• less worthy.
• However, nurse education is based on theory borrowed from other disciplines,
such as sociology and psychology.
• It has been argued that applying knowledge from different disciplines only
serves to dilute nursing practice.
• Nevertheless, as the occupation is focused on
• humans, perhaps it is inevitable that nursing uses
• knowledge from other social sciences.
• It has been argued that no knowledge is exclusive, and because of nursing’s
diverse nature it is impossible for it to have a unique body of knowledge and
one unified body of theory (Castledine 1994, Levine 1995).
Criticisms of nursing theories
• To understand why nursing theory is generally neglected on the wards it is
necessary to take a closer look at the main criticisms of nursing theory and
the role that nurses play in contributing to its lack of prevalence in practice.
• Use of language Scott (1994) states that the crucial ingredients of nursing
theory should be accessibility and clarity. However, one of the main criticisms
of nursing theory is its use of overtly complex language (Kenny 1993).
• It is important that the language used in the
• development of nursing theory be used consistently.
• Not part of everyday practice Despite theory and practice being viewed as
inseparable concepts, a theory-practice gap still exists in nursing (Upton
1999).
• Yet despite the availability of a vast amount of literature on the subject,
nursing theory still means very little to most practicing nurses. Perhaps this is
because the majority of nursing theory is developed by and for nursing
academics (Lathlean 1994).
• It has been recognised that traditionally nurses are used to ‘speaking with
their hands’ (Levine 1995).
• Therefore, many nurses have not had the training or experience to deal with
the abstract concepts presented by nursing theory.
• This makes it difficult for the majority of nurses to understand and apply
theory to practice (Miller 1985).
Summary
• Definition
• Importance of Nursing Theories
• The characteristics of theories:
• Basic Processes in the Development Of Nursing Theories:
• Nursing theories are often based on and influenced
• ANA definition of Nursing Practice
• Common concepts in Nursing Theories:
• Historical Perspectives and Key Concepts
• Classification of Nursing Theories
• Models Of Nursing
• Growth and Stability Models of Change
• Betty Neuman’s Health Care Systems Model
• Stress/Adaptation Theory as a Framework
• A unique body of knowledge
• Criticisms of nursing theories
Conclusion:
Littlejohn (2002) comments that irrespective of nursing theories, nurses will
continue to exhibit a caring response to the ‘sick and troubled’. If this is true,
perhaps nurses are ‘nursing’ without the knowledge of theories and theory is
irrelevant. However, theory and practice are related, and if nursing is to
continue to develop, the concept of theory must be addressed. If nursing
theory does not drive the development of nursing, it will continue to develop
in the footsteps of other disciplines such as medicine
Reference:
1. George B. Julia , Nursing Theories- The base for professional Nursing Practice
, 3rd ed. Norwalk, Appleton and Lange.
2. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing
Philadelphia. Lippincott Williamsand wilkins.
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.
Philadelphia, Lippincott.
5. Potter A Patricia, Perry G Anne (1992)Fundamentals Of Nursing –Concepts
Process and Practice 3rd ed. London Mosby Year Book.
Theories of Nursing
• Theory is "an internally consistent group of relational statements
(concepts, definitions and propositions) that present a systematic view
about a phenomenon and which is useful for description, explanation,
prediction and control".
• Theories are road maps that provide a framework for selecting and
organizing information:
o What to ask
o What to observe
o What to focus on
o What to think about
• Nursing theory is an organized and systematic articulation of a set of
statements related to questions in the discipline of nursing.
Uses of Theory
Theory is used to:
• Describe
• Explain
• Predict
• Prescribe
Uses of Nursing Theory
• Define relationships among the variables of a given field of inquiry
• Guide research, practice and communication
• Allow the prediction of the consequences of care
• Allow the prediction of a range of patient responses
Levels of Theory
There are four levels of theory
• Metatheory
• Grand Theory
• Middle Range Theory
• Practice Theory
Types of Theory
In Nursing there are four types of theories:
• Needs
• Interaction
• Outcome
• Humanistic
Practice value of theory
• Enhances understanding and explanation for events
• Influence our behavior.
• Makes to think differently about a problem or a situation
• Helps to try new approaches or altering behavior.
• We can gain a new perspective of events
• Basis for challenge of its speculative tenets or propositions
• Challenges subsequent discovery of new ideas or knowledge that might
explain and predict events not yet understood
In practice
• Assist nurses to describe, explain, and predict everyday experiences.
• Serve to guide assessment, intervention, and evaluation of nursing care.
• Provide a rationale for collecting reliable and valid data about the health
status of clients, which are essential for effective decision making and
implementation.
• Help to establish criteria to measure the quality of nursing care
• Help build a common nursing terminology to use in communicating with
other health professionals. Ideas are developed and words defined.
• Enhance autonomy (independence and self-governance) of nursing by
defining its own independent functions.
In education
• Provide a general focus for curriculum design.
• Guide curricular decision making
In research
• Offer a framework for generating knowledge and new ideas.
• Assist in discovering knowledge gaps in specific field of study.
• Offer a systematic approach to identify questions for study, select
variables, interpret findings, and validate nursing interventions.
An illustration……
The germ theory
• Explains the phenomenon of disease transmission
• Means of speculative explanation and prediction of certain observable
events
• Allows us to effectively function to prevent transmission of communicable
disease.
• Viable basis upon which to make decisions about how to prevent certain
illnesses.
• There are phenomena we do not understand that are related to germ
transmission,
• Example-the communicability of cancer.
"Nursing Practice."
All experiences and events a practicing nurse encounters in the process of
providing nursing care.
Events…..
• Some may be experienced by the client,
• Others by the nurse
• Some may be observed in the environment
• May be observed in the nurse-client interaction.
• In situations of daily work or living,
…………..but as long as they are observable during the process of providing direct
nursing care, they are considered part of nursing practice.
Approaches to inter relationships between practice and theory
• How nursing practice contributes to the process of theory development..
• How theory contributes to nursing practice…
Contribution of practice to theory development
• Theory development within nursing occurs in the context of practice.
• Two activities contribute significantly to the overall process of developing
theory in nursing.
• Concept analysis and
• Practical validation of theory.
Concept analysis
• Identify and verify abstract concepts
• "what events in practice can be linked with abstract concept x"
• Application of theory in practice
• Nursing process operation of analysis of assessment data.
• Used as scientific rationale supporting judgments in nursing care plans.
Concepts
• Concepts may be (a) readily observable, or concrete, ideas such as
thermometer, rash, and lesion; (b) indirectly observable, or inferential,
ideas such as pain and temperature; or c) non-observable, or abstract,
ideas such as equilibrium, adaptation, stress, and powerlessness
• nursing theories address and specify relationships among four major
abstract concepts referred to as the metaparadigm of nursing.
• Four concepts are considered to be central to nursing :
• Person or client, the recipient of nursing care (includes individuals,
families, groups, and communities).
• Environment, the internal and external surroundings that affect the client.
This includes people in the physical environment, such as families, friends,
and significant others.
• Health, the degree of wellness or well-being that the client experiences.
• Nursing, the attributes, characteristics, and actions of the nurse providing
care on behalf of, or in conjunction with, the client
Nightingale’s environmental theory
• "the act of utilizing the environment of the patient to assist him in his
recovery"
• She linked health with five environmental factors :
• Pure or fresh air
• Pure water
• Efficient drainage
• Cleanliness
• Light, especially direct sunlight
• Deficiencies in these five factors produced lack
• Of health or illness.
Peplau’s interpersonal relations model
• Nurses enter into a personal relationship with an individual when a felt
need is present
Henderson’s definition of nursing
• Henderson conceptualized the nurse’s role as assisting sick or well
individuals to gain independence in meeting 14 fundamental needs
(Henderson)
• Breathing normally
• Eating and drinking adequately
• Eliminating body wastes
• Moving and maintaining a desirable position
• Sleeping and resting
• Selecting suitable clothes
• Maintaining body temperature within normal range by adjusting clothing
and modifying the environment.
• Keeping the body clean and well groomed to protect the integument.
• Avoiding dangers in the environment and avoiding injuring others
• Communicating with others in expressing emotions, needs, fears, or
opinions
• Worshipping according to one’s faith
• Working in such a way that one feels a sense of accomplishment
• Playing or participating in various forms of recreation.
• Learning, discovering, or satisfying the curiosity that leads to normal
development and health, and using available health facilities
Roger’s science of unitary human beings
• She states that humans are dynamic energy fields in continuous exchange
with environmental fields, both of which are infinite.
• Nurses applying Roger's theory in practice (a) focus on the person’s
wholeness, (b) seek to promote symphonic interaction between the two
energy fields (human and environment) to strengthen the coherence and
integrity of the person, c) coordinate the human field with the
rhythmicities of the environmental field, and (d) direct and redirect
patterns of interaction between the two energy fields to promote maximum
health potential
Orem’s general theory of nursing
• Orem’s self-care deficit theory explains not only when nursing is needed
but also how people can be assisted through five methods of helping:
acting or doing for, guiding, teaching, supporting, and providing an
environment that promotes the individual’s abilities to meet current and
future demands.
King’s goal attainment theory
• King’s theory offers insight into nurses’ interactions with individuals and
groups within the environment. It highlights the importance of client’s
participation in decision that influence care and focuses on both the
process of nurse-client interaction and the outcomes of care.
Neuman’s systems model
• The model is based on the individual’s relationship to stress, the reaction
to it, and reconstitution factors that are dynamic in nature.
• Betty Neuman's model of nursing is applicable to a variety of nursing
practice settings involving individuals, families, groups, and communities.
Roy’s adaptation model
• Roy focuses on the individual as a biopsychosocial adaptive system that
employs a feedback cycle of input (stimuli), throughput (control
processes), and output (behaviors or adaptive responses).
Watson’s human caring theory
• Jean Watson (1979) believes the practice of caring is central to nursing; it
is the unifying focus for practice.
• Nursing interventions related to human care are referred to as carative
factors.
• Watson’s theory of human caring has receiving worldwide recognition and
is a major force in redefining nursing as a caring-healing health model.
Parse’s human becoming theory
• Parse’s model of human becoming emphasizes how individuals choose and
bear responsibility for patterns of personal health.
Leininger’s cultural care diversity and universality theory
• She emphasizes that human caring, although a universal phenomenon,
varies among cultures in its expressions, processes, and patterns; it is
largely culturally derived.
Orem’s general theory of nursing
Assessing
• Involves collecting data about the client’s capacities (knowledge, skills, and
motivation) to perform universal, developmental, and health-deviation self-
care requisites. Determine self-care deficits.
Diagnosing
• Stated in terms of the client’s limitations for maintaining self care (a deficit
in self-care agency)
Planning
• Involves considering and designing, with the client’s participation, an
appropriate nursing system (wholly compensatory, partially compensatory,
supportive-educative, or a mix) that will help the client achieve an optimal
level of self care
Implementing
• Assisting the client
Evaluating
1. Determining the client’s level of achievement
References
1. Phipps J Wilma, Sands K Judith. Medical Surgical Nursing: concepts &
clinical practice.6th edition. Philadelphia. Mosby publications. 1996.
2. Black M. Joice, Hawks hokanson Jane. Medical Surgical Nursing: Clinical
Management for positive outcomes. St Lois, Missouri. 2005.
3. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.).
Mosby, Philadelphia, 2002
4. Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd
Ed. Mosby, Philadelphia, 2002.
THEORIES & NURSING RESEARCH
Introduction
• 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.
• 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.
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
Conclusion
Reference
• George B. Julia , Nursing Theories- The base for professional Nursing Practice
, 3rd ed. Norwalk, Appleton and Lange.
• 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.
Focus Problems
MASLOW'S HENDERSON
Self actualization
needs
Reference
• Timber BK. Fundamental skills and concepts in Patient Care, 7th edition,
LWW, N
• George B. Julia , Nursing Theories- The base for professional Nursing
Practice , 3rd ed. Norwalk, Appleton & Lange.
• Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing
Philadelphia. Lippincott Williams& wilkins.
• Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress
3rd ed. Philadelphia, Lippincott.
• Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed.
Philadelphia, Lippincott.
• Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts
Process & Practice 3rd ed. London Mosby Year Book.
• Vandemark L.M. Awareness of self & expanding consciousness: using
Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul;
27(6) : 605-15
• Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006
Jul;19(3):225
• Delaune SC,. Ladner PK, Fundamental of nursing, standard and practice,
2nd edition, Thomson, NY, 2002
Psychodynamic nursing
Definitions
• Stranger: receives the client in the same way one meets a stranger in other
life situations provides an accepting climate that builds trust.
• Teacher: who imparts knowledge in reference to a need or interest
• Resource Person : one who provides a specific needed information that aids in
the understanding of a problem or new situation
• Counselors : helps to understand and integrate the meaning of current life
circumstances ,provides guidance and encouragement to make changes
• Surrogate: helps to clarify domains of dependence interdependence and
independence and acts on clients behalf as an advocate.
• Leader : helps client assume maximum responsibility for meeting treatment
goals in a mutually satisfying way
Additional Roles include:
1. Technical expert
2. Consultant
3. Health teacher
4. Tutor
5. Socializing agent
6. Safety agent
7. Manager of environment
8. Mediator
9. Administrator
10. Recorder observer
11. Researcher
Orientation phase
Identification phase
Exploitation phase
Resolution phase
Assessment Orientation
Data collection and Non continuous data
analysis [continuous] collection
May not be a felt need Felt need
Define needs
Nursing diagnosis Identification
Planning Interdependent goal setting
Mutually set goals
Implementation Exploitation
Plans initiated towards Patient actively seeking and
achievement of mutually drawing help
set goals Patient initiated
May be accomplished by
patient , nurse or family
Evaluation Resolution
Based on mutually Occurs after other phases are
expected behaviors completed successfully
May led to termination and Leads to termination
initiation of new plans
Limitations
References
• Timber BK. Fundamental skills and concepts in Patient Care, 7th edition,
LWW, N
• George B. Julia , Nursing Theories- The base for professional Nursing
Practice , 3rd ed. Norwalk, Appleton & Lange.
• Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing
Philadelphia. Lippincott Williams& wilkins.
• Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress
3rd ed. Philadelphia, Lippincott.
• Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed.
Philadelphia, Lippincott.
• Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts
Process & Practice 3rd ed. London Mosby Year Book.
• Vandemark L.M. Awareness of self & expanding consciousness: using
Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul;
27(6) : 605-15
• Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006
Jul;19(3):225
• Delaune SC,. Ladner PK, Fundamental of nursing, standard and practice,
2nd edition, Thomson, NY, 2002
FAYE GLENN ABDELLAH'S THEORY
TWENTY ONE NURSING PROBLEMS
INTRODUCTION
• Faye Glenn Abdellah, pioneer nursing researcher, helped transform nursing
theory, nursing care and nursing education
• Birth:1919
• Dr Abdellah worked as Deputy Surgeon General
• Former Chief Nurse Officer for the U.S Public Health Service ,
Department of Health and human services, Washington, D.C .
• She has been a leader in nursing research and has over one hundred
publications related to nursing care, education for advanced practice in
nursing and nursing research.
• In 1960, influenced by the desire to promote client-centred comprehensive
nursing care, Abdellah described nursing as a service to individuals, to
families, and, therefore to, to society.
• According to her, nursing is based on an art and science that mould the
attitudes, intellectual competencies, and technical skills of the individual
nurse into the desire and ability to help people , sick or well, cope with
their health needs.
• As a comprehensive service ,nursing includes;
• Recognizing the nursing problems of the patient
• Deciding the appropriate course of action to take in terms of
relevant nursing principles
• Providing continuous care of the individuals total needs
• Providing continuous care to relieve pain and discomfort and
provide immediate security for the individual
• Adjusting the total nursing care plan to meet the patient’s individual
needs
• Helping the individual to become more self directing in attaining or
maintaining a healthy state of mind & body
• Instructing nursing personnel and family to help the individual do
for himself that which he can within his limitations
• 8)Helping the individual to adjust to his limitations and emotional
problems
• 9) Working with allied health professions in planning for optimum
health on local, state, national and international levels
• 10) Carrying out continuous evaluation and research to improve
nursing techniques and to develop new techniques to meet the
health needs of people
• These original premises have undergone an evolutionary process.
As result, in 1973, the item 3, - “providing continuous care of the
individual’s total health needs” was eliminated.
• From these premises, Abdellah’s theory was derived.
PHILOSOPHICAL UNDERPINNINGS OF THE THEORY
• Abdellah’s patient-centred approach to nursing was developed inductively
from her practice and is considered a human needs theory.
• The theory was created to assist with nursing education and is most
applicable to the education of nurses.
• Although it was intended to guide care of those in the hospital, it also has
relevance for nursing care in community settings.
MAJOR ASSUMPTIONS, CONCEPTS & RELATIONSHIPS
1. The language of Abdellah’s framework is readable and clear.
2. Consistent with the decade in which she was writing, she uses the term
‘she’ for nurses, ‘he’ for doctors and patients, and refers to the object of
nursing as ‘patient’ rather than client or consumer.
3. She referred to Nursing diagnosis during a time when nurses were taught
that diagnosis was not a nurses’ prerogative.
4. Assumptions were related to
1. change and anticipated changes that affect nursing;
2. The need to appreciate the interconnectedness of social enterprises
and social problems;
3. the impact of problems such as poverty, racism, pollution,
education, and so forth on health care delivery;
4. changing nursing education
5. continuing education for professional nurses
6. development of nursing leaders from under reserved groups
5. Abdellah and colleagues developed a list of 21 nursing problems.
6. They also identified 10 steps to identify the client’s problems
7. 11 nursing skills to be used in developing a treatment typology
10 steps to identify the client’s problems
1. Learn to know the patient
2. Sort out relevant and significant data
3. Make generalizations about available data in relation to similar nursing
problems presented by other patients
4. Identify the therapeutic plan
5. Test generalizations with the patient and make additional generalizations
6. Validate the patient’s conclusions about his nursing problems
7. Continue to observe and evaluate the patient over a period of time to
identify any attitudes and clues affecting his behavior
8. Explore the patient’s and family’s reaction to the therapeutic plan and
involve them in the plan
9. Identify how the nurses feels about the patient’s nursing problems
10. Discuss and develop a comprehensive nursing care plan
11 nursing skills
1. Observation of health status
2. Skills of communication
3. Application of knowledge
4. Teaching of patients and families
5. Planning and organization of work
6. Use of resource materials
7. Use of personnel resources
8. Problem-solving
9. Direction of work of others
10. Therapeutic use of the self
11. Nursing procedures
The twenty one nursing problems
Three major categories
• Physical, sociological, and emotional needs of clients
• Types of interpersonal relationships between the nurse and patient
• Common elements of client care
21 NURSING PROBLEMS
BASIC TO ALL PATIENTS
• To maintain good hygiene and physical comfort
• To promote optimal activity: exercise, rest and sleep
• To promote safety through the prevention of accidents, injury, or other
trauma and through the prevention of the spread of infection
• To maintain good body mechanics and prevent and correct deformities
SUSTENAL CARE NEEDS
• To facilitate the maintenance of a supply of oxygen to all body cells
• To facilitate the maintenance of nutrition of all body cells
• To facilitate the maintenance of elimination
• To facilitate the maintenance of fluid and electrolyte balance
• To recognize the physiological responses of the body to disease conditions
• To facilitate the maintenance of regulatory mechanisms and functions
• To facilitate the maintenance of sensory function
REMEDIAL CARE NEEDS
• To identify and accept positive and negative expressions, feelings, and
reactions
• To identify and accept the interrelatedness of emotions and organic illness
• To facilitate the maintenance of effective verbal and non verbal
communication
• To promote the development of productive interpersonal relationships
• To facilitate progress toward achievement of personal spiritual goals
• To create and / or maintain a therapeutic environment
• To facilitate awareness of self as an individual with varying physical ,
emotional, and developmental needs
RESTORATIVE CARE NEEDS
• To accept the optimum possible goals in the light of limitations, physical
and emotional
• To use community resources as an aid in resolving problems arising from
illness
• To understand the role of social problems as influencing factors in the case
of illness
Abdellah's 21 problems are actually a model describing the "arenas" or concerns
of nursing, rather than a theory describing relationships among phenomena. In
this way, the theory distinguished the practice of nursing, with a focus on the 21
nursing problems, from the practice of medicine, with a focus on disease and
cure.
ABDELLAH’S THEORY AND NURSING
• Although Abdellah’s writings are not specific as to a theoretical statement,
such a statement can be derived by using her three major concepts of
health, nursing problems, and problem solving. Abdellah’s theory would
state that nursing is the use of the problem solving approach with key
nursing problems related to health needs of people. Such a statement
maintains problem solving as the vehicle for the nursing problems as the
client is moved toward health – the outcome
NURSING
• Acc to her, nursing is based on an art and science that mould the attitudes,
intellectual competencies, and technical skills of the individual nurse into
the desire and ability to help people, sick or well, cope with their health
needs.
HEALTH
• Health is a dynamic pattern of functioning whereby there is a continued
interaction with internal and external forces that results in the optimum
use of necessary resources that serve to minimize vulnerabilities
NURSING PROBLEMS
• Nursing problem presented by a client is a condition faced by the client or
client’s family that the nurse through the performance of professional
functions can assist them to meet . The problem can be either an overt or
covert nursing problem.
• An overt nursing problem is an apparent condition faced by the patient or
family, which the nurse can assist him or them to meet through the
performance of her professional functions.
• The covert nursing problem is a concealed or hidden condition faced, by
the patient or family, which the nurse can assist him or them to meet
through the performance of her professional functions
• In her attempt to bring nursing practice into its proper relationship with
restorative and preventive measures for meeting total client needs, she
seems to swing the pendulum to the opposite pole, from the disease
orientation to nursing orientation, while leaving the client somewhere in
the middle.
PROBLEM SOLVING
• The problem solving process involves identifying the problem, selecting
pertinent data, formulating hypothesis, testing hypothesis through the
collection of data, and revising hypothesis where necessary on the basis of
conclusions obtained from the data.
COMPARISON WITH OTHER THEORIES
Self
actualization
needs
Reference
• George B. Julia , Nursing Theories- The base for professional Nursing Practice
, 3rd ed. Norwalk, Appleton and Lange.
• 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.
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
· regulation includes:
The senses
Temperature
Endocrine regulation
Self – concept mode:
· composite of belief and feeling
· formed from perceptions
· directs one’s behaviour
· components are :
· the physical self
· the personal self
Role performance mode:
* performance of duties
* based on given positions in society
Interdependence mode:
* one’s relation with significant others
* support system
* maintains psychic integrity
* meets needs for nurturance and affection
MAJOR ASSUMPTIONS
• from system theory
• from Helson’s theory
• from humanism
ASSUMPTIONS FROM SYSTEMS THEORY
• a system is a set of units so related or connected as to form a unit or whole
• a system is a whole that functions as a whole by virtue of the
interdependence of its parts
• systems have inputs, outputs and control and feedback processes
• input, in the form of a standard or feedback (information)
• living systems are more complex than mechanical systems and have
standards and feedback to direct their functioning as a whole.
ASSUMPTIONS FROM HELSON’S THEORY
• human behaviour represents adaptation to environmental and organismic
forces
• adaptive behaviour is a function of the stimulus and adaptation level, that is,
the pooled effect of the focal, contextual and residual stimuli
• adaptation is a process of responding positively to environmental changes
• responses reflect the state of the organism as well as the properties of
stimuli and hence are regarded as active processes.
ASSUMPTIONS FROM HUMANISM
• Persons have their own creative power
• A persons behaviour is purposeful and not merely a chain of cause and
effect
• Person is holistic
• A person’s opinions and view points are of value
• The interpersonal relationship is significant.
ELEMENTS
Nursing
• A science and practice discipline
• A theoretical system of knowledge
• Prescribes a process of analysis and action
• Related to the care of the ill or potentially ill person
Person
• A biopsychosocial being
• A living, complex, adaptive system
• With internal processes (the cognator and regulator)
• Acting to maintain adaptation to the four modes
Health
• A state and a process of being and becoming an integrated and whole
person
Environment
1. All the conditions, circumstances and influences surrounding and affecting
the development and behaviour of persons or groups
References
• Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed.
Mosby, Philadelphia, 2002.
• Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby,
Philadelphia, 2002.
• George B. Julia , Nursing Theories- The base for professional Nursing Practice
, 3rd ed. Norwalk, Appleton and Lange.
• Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing
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.
Philadelphia, Lippincott.
Orem’s Theory
Introduction
One of America’s foremost nursing theorists.
Dorothea Orem earned her Bachelor of science in nursing education in
1939 and Master of science in nursing in 1945
During her professional career ,she worked as a staff nurse ,private duty
nurse ,nurse educator and administrator and nurse consultant
Received honorary Doctor of Science degree in 1976
Dorothea Orem as a member of a curriculum subcommittee at Catholic
University, recognized the need to continue in developing a conceptualization
of nursing.
Published first formal articulation of her ideas in Nursing: Concepts of
Practice in 1971.second in 1980,and finally in 1995
Development of Theory
1949-1957 Orem worked for the Division of Hospital and Institutional
Services of the Indiana State Board of Health. Her goal was to upgrade the
quality of nursing in general hospitals throughout the state. During this time
she developed her definition of nursing practice.
1958-1960 US Department of Health, Education and Welfare where she
help publish "Guidelines for Developing Curricula for the Education of
Practical Nurses" in 1959.
1959 Orem subsequently served as acting dean of the school of Nursing
and as an assistant professor of nursing education at CUA. She continued to
develop her concept of nursing and self care during this time.
Orem’s Nursing: Concept of Practice was first published in 1971 and
subsequently in 1980,1985, 1991, 1995, and 2001.
Continues to develop her theory after her retirement in 1984
Definitions of domain concepts
Nursing – is art, a helping service, and a technology
Actions deliberately selected and performed by nurses to help individuals
or groups under their care to maintain or change conditions in themselves or
their environments
Encompasses the patient’s perspective of health condition ,the physician’s
perspective , and the nursing perspective
Goal of nursing – to render the patient or members of his family capable
of meeting the patient’s self care needs
To maintain a state of health
To regain normal or near normal state of health in the event of
disease or injury
To stabilize ,control ,or minimize the effects of chronic poor health or
disability
Health – health and healthy are terms used to describe living things … it
is when they are structurally and functionally whole or sound … wholeness or
integrity. .includes that which makes a person human,…operating in
conjunction with physiological and psychophysiological mechanisms and a
material structure and in relation to and interacting with other human beings
Environment – environment components are environmental factors
,environmental elements, conditions ,and developmental environment
Human being – has the capacity to reflect ,symbolize and use symbols
Conceptualized as a total being with universal ,developmental needs
and capable of continuous self care
A unity that can function biologically, symbolically and socially
Nursing client- a human being who has "health related /health derived
limitations that render him incapable of continuous self care or dependent
care or limitations that result in ineffective / incomplete care.
A human being is the focus of nursing only when a self –care
requisites exceeds self care capabilities
Nursing problem – deficits in universal, developmental, and health
derived or health related conditions
Nursing process- a system to determine (1)why a person is under care
(2)a plan for care ,(3)the implementation of care
Nursing therapeutics– deliberate ,systematic and purposeful action
Orem’s General Theory of Nursing
Orem’s general theory of nursing in three related parts:-
Theory of self care
Theory of self care deficit
Theory of nursing systems
Theory of Self Care
Includes :--
Self care – practice of activities that individual initiates and perform on
their own behalf in maintaining life ,health and well being
Self care agency – is a human ability which is "the ability for engaging in
self care"
-- Conditioned by age developmental state, life experience
sociocultural orientation health and available resources
Therapeutic self care demand – "totality of self care actions to
be performed for some duration in order to meet self care requisites
by using valid methods and related sets of operations and actions"
Self care requisites-action directed towards provision of self care
3 categories of self care requisites are:--
Universal
Developmental
Health deviation
Universal self care requisites
Associated with life processes and the maintenance of the integrity of
human structure and functioning
Common to all , ADL
Identifies these requisites as:
Maintenance of sufficient intake of air ,water, food
Provision of care assoc with elimination process
Balance between activity and rest, between solitude and social
interaction
Prevention of hazards to human life well being and
Promotion of human functioning
Developmental self care requisites
Associated with developmental processes/ derived from a condition…. Or
associated with an event
E.g. adjusting to a new job
adjusting to body changes
Health deviation self care
Required in conditions of illness ,injury, or disease .these include:--
o Seeking and securing appropriate medical assistance
o Being aware of and attending to the effects and results of pathologic
conditions
o Effectively carrying out medically prescribed measures
o Modifying self concepts in accepting oneself as being in a particular
state of health and in specific forms of health care
o Learning to live with effects of pathologic conditions
Theory of self care deficit
Specifies when nursing is needed
Nursing is required when an adult (or in the case of a dependent ,the
parent) is incapable or limited in the provision of continuous effective self
care
Orem identifies 5 methods of helping:--
Acting for and doing for others
Guiding others
Supporting another
Providing an environment promoting personal development in relation to
meet future demands
Teaching another
Theory of Nursing Systems
Describes how the patient’s self care needs will be met by the nurse , the
patient, or both
Identifies 3 classifications of nursing system to meet the self care
requisites of the patient:-
Wholly compensatory system
Partly compensatory system
Supportive – educative system
Design and elements of nursing system define
Scope of nursing responsibility in health care situations
General and specific roles of nurses and patients
Reasons for nurses’ relationship with patients and
The kinds of actions to be performed and the performance patterns and
nurses’ and patients’ actions in regulating patients’ self care agency and in
meeting their self care demand
Orem recognized that specialized technologies are usually developed by
members of the health profession
A technology is systematized information about a process or a method for
affecting some desired result through deliberate practical endeavor ,with or
without use of materials or instruments
Categories of technologies
Social or interpersonal
Communication adjusted to age, health status
Maintaining interpersonal ,intragroup or intergroup relations for
coordination of efforts
Maintaining therapeutic relationship in light of psychosocial modes of
functioning in health and disease
Giving human assistance adapted to human needs ,action abilities and
limitations
Regulatory technologies
Maintaining and promoting life processes
Regulating psycho physiological modes of functioning in health and
disease
Promoting human growth and development
Regulating position and movement in space
Orem’s Theory and Nursing Process
Orem’s approach to the nursing process presents a method to determine
the self care deficits and then to define the roles of person or nurse to meet
the self care demands.
The steps within the approach are considered to be the technical
component of the nursing process.
Orem emphasizes that the technological component "must be coordinated
with interpersonal and social processes within nursing situations
Comparison of Orem’s Nursing Process and the Nursing Process
Nursing Process
Assessment
Nursing diagnosis
Plans with scientific rationale
Implementation
evaluation
Orem’s Nursing. Process
Diagnosis and prescription ;determine why nursing is needed. analyze and
interpret –make judgment regarding care
Design of a nursing system and plan for delivery of care
Production and management of nursing systems
Step 1-collect data in six areas:-
The person’s health status
The physician’s perspective of the person’s health status
The person’s perspective of his or her health
The health goals within the context of life history ,life style, and health
status
The person’s requirements for self care
The person’s capacity to perform self care
Step 2
Nurse designs a system that is wholly or partly compensatory or
supportive-educative.
The 2 actions are:-
Bringing out a good organization of the components of patients’
therapeutic self care demands
Selection of combination of ways of helping that will be effective and
efficient in compensating for/ overcoming patient’s self care deficits
Step 3
Nurse assists the patient or family in self care matters to achieve
identified and described health and health related results ..collecting
evidence in evaluating results achieved against results specified in the
nursing system design
Actions are directed by etiology component of nursing diagnosis
evaluation
Application of Orem’s theory to nursing process
Personal development
• Orem, D.E. (1991). Nursing: Concepts of practice (4th ed.). St. Louis, MO:
Mosby-Year Book Inc.
• Taylor, S.G. (2006). Dorthea E. Orem: Self-care deficit theory of nursing. In
A.M.
• Tomey, A. & Alligood, M. (2002). Significance of theory for nursing as a
discipline and profession. Nursing Theorists and their work. Mosby, St. Louis,
Missouri, United States of America.
• Whelan, E. G. (1984). Analysis and application of Dorothea Orem’s Self-care
Practuce Model. Retrieved October 31, 2006.
• George B. Julia , Nursing Theories- The base for professional Nursing Practice
, 3rd ed. Norwalk, Appleton & Lange.
• Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing
Philadelphia. Lippincott Williams& wilkins.
• Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress
3rd ed. Philadelphia, Lippincott.
• Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed.
Philadelphia, Lippincott.
• Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts
Process & Practice 3rd ed. London Mosby Year Book.
THE ROY'S ADAPTATION
MODEL
Introduction
Sr.Callista Roy, a prominent nurse theorist, writer, lecturer, researcher
and teacher
Professor and Nurse Theorist at the Boston College of Nursing in
Chestnut Hill
Born at Los Angeles on October 14, 1939 as the 2nd child of Mr. and Mrs.
Fabien Roy
she earned a Bachelor of Arts with a major in nursing from Mount St.
Mary's College, Los Angeles in 1963.
a master's degree program in pediatric nursing at the University of
California ,Los Angeles in 1966.
She also earned a master’s and PhD in Sociology in 1973 and 1977
,respectively.
Sr. Callista had the significant opportunity of working with Dorothy E.
Johnson
Johnson's work with focusing knowledge for the discipline of nursing
convinced Sr. Callista of the importance of describing the nature of nursing as
a service to society and prompted her to begin developing her model with the
goal of nursing being to promote adaptation.
She joined the faculty of Mount St. Mary's College in 1966, teaching
both pediatric and maternity nursing.
She organized course content according to a view of person and family
as adaptive systems.
She introduced her ideas about ‘Adaptation Nursing’ as the basis for an
integrated nursing curriculum.
Goal of nursing to direct nursing education, practice and research
Model as a basis of curriculum impetus for growth--Mount St. Mary’s
College
1970-The model was implemented in Mount St. Mary’s school
1971- she was made chair of the nursing department at the college.
Influencing Factors
• Family
• Education
• Religious Background
• Mentors
• Clinical Experience
Theory description
• The central questions of Roy’s theory are:
o Who is the focus of nursing care?
o What is the target of nursing care?
o When is nursing care indicated?
• Roy’s first ideas appeared in a graduate paper written at UCLA in 1964.
• Published these ideas in "Nursing outlook" in 1970
• Subsequently different components of her framework crystallized during
1970s, ’80s, and ’90s
• Over the years she identified assumptions on which her theory is based.
Explicit assumptions (Roy 1989; Roy and Andrews 1991)
• The person is a bio-psycho-social being.
• The person is in constant interaction with a changing environment.
• To cope with a changing world, person uses both innate and acquired
mechanisms which are biological, psychological and social in origin.
• Health and illness are inevitable dimensions of the person’s life.
• To respond positively to environmental changes ,the person must adapt.
• The person’s adaptation is a function of the stimulus he is exposed to and his
adaptation level
• The person’s adaptation level is such that it comprises a zone indicating the
range of stimulation that will lead to a positive response.
• The person has 4 modes of adaptation: physiologic needs, self- concept, role
function and inter-dependence.
• "Nursing accepts the humanistic approach of valuing other persons’ opinions,
and view points" Interpersonal relations are an integral part of nursing
• There is a dynamic objective for existence with ultimate goal of achieving
dignity and integrity
Implicit assumptions
• A person can be reduced to parts for study and care.
• Nursing is based on causality.
• Patient’s values and opinions are to be considered and respected.
• A state of adaptation frees an individual’s energy to respond to other stimuli.
Roy Adaptation Model Concepts: Early and Revised
• Adaptation -- goal of nursing
• Person -- adaptive system
• Environment -- stimuli
• Health -- outcome of adaptation
• Nursing -- promoting adaptation and health
Concepts-Adaptation
• Responding positively to environmental changes
• The process and outcome of individuals and groups who use conscious
awareness, self reflection and choice to create human and environmental
integration
Concepts-Person
• Bio-psycho-social being in constant interaction with a changing environment
• Uses innate and acquired mechanisms to adapt
• An adaptive system described as a whole comprised of parts
• Functions as a unity for some purpose
• Includes people as individuals or in groups-families, organizations,
communities, and society as a whole
Concepts-Environment
• Focal - internal or external and immediately confronting the person
• Contextual- all stimuli present in the situation that contribute to effect of focal
stimulus
• Residual-a factor whose effects in the current situation are unclear
• All conditions, circumstances, and influences surrounding and affecting the
development and behavior of persons and groups with particular
consideration of mutuality of person and earth resources, including focal,
contextual and residual stimuli
Concepts-Health
• Inevitable dimension of person's life
• Represented by a health-illness continuum
• A state and a process of being and becoming integrated and whole
Concepts-Nursing
• To promote adaptation in the four adaptive modes
• To promote adaptation for individuals and groups in the four adaptive modes,
thus contributing to health, quality of life, and dying with dignity by assessing
behaviors and factors that influence adaptive abilities and by intervening to
enhance environmental interactions
Concepts-Subsystems
• Cognator subsystem — A major coping process involving 4 cognitive-emotive
channels: perceptual and information processing, learning, judgment and
emotion.
• Regulator subsystem — a basic type of adaptive process that responds
automatically through neural, chemical, and endocrine coping channels
Relationships
• Derived Four Adaptive Modes
• 500 Samples of Patient Behavior
• What was the patient doing?
• What did the patient look like when needing nursing care?
Four Adaptive Modes
• Physiologic Needs
• Self Concept
• Role Function
• Interdependence
Four Adaptive Mode Categories
• Tested in practice for 10 years
• Criteria of significance, usefulness, and completeness were met
Sample Proposition and Hypothesis for Practice
• Self Concept Mode: Increased quality of social experience leads to increased
feelings of adequacy
• Providing support for new mothers can lead to positive parenting
Theory Development
Derived Theory
• 91 Propositions
• Described relationships between and among regulator and cognator and four
adaptive modes
• 12 Generic propositions
Questions Raised by 21st Century Changes
• How can ethics and public policy keep pace with developments in science?
• How can nurses focus on human needs not machines?
• How can nurses contribute to creating meaning and purpose in a global
society?
Scientific Assumptions for the 21st Century
• Systems of matter and energy progress to higher levels of complex self
organization
• Consciousness and meaning are constitutive of person and environment
integration
• Awareness of self and environment is rooted in thinking and feeling
• Human decisions are accountable for the integration of creative processes.
• Thinking and feeling mediate human action
• System relationships include acceptance, protection, and fostering of
interdependence
• Persons and the earth have common patterns and integral relations
• Person and environment transformations are created in human consciousness
• Integration of human and environment meanings results in adaptation
Philosophical Assumptions
• Persons have mutual relationships with the world and God
• Human meaning is rooted in an omega point convergence of the universe
• God is intimately revealed in the diversity of creation and is the common
destiny of creation
• Persons use human creative abilities of awareness, enlightenment, and faith
• Persons are accountable for the processes of deriving, sustaining, and
transforming the universe
Adaptation and Groups
• Includes relating persons, partners, families, organizations, communities,
nations, and society as a whole
Adaptive Modes
Persons
• Physiologic
• Self Concept
• Role Function
• Interdependence
Groups
• Physical
• Group Identity
• Role Function
• Interdependence
Role Function Mode
• Underlying Need of Social integrity
• The need to know who one is in relation to others so that one can act
• The need for role clarity of all participants in group
Adaptation Level
• A zone within which stimulation will lead to a positive or adaptive response
• Adaptive mode processes described on three levels:
• Integrated
• Compensatory
• Compromised
Integrated Life Processes
• Adaptation level where the structures and functions of the life processes work
to meet needs
• Examples of Integrated Adaptation
• Stable process of breathing and ventilation
• Effective processes for moral-ethical-spiritual growth
Compensatory Processes
• Adaptation level where the cognator and regulator are activated by a
challenge to the life processes
• Compensatory Adaptation Examples:
• Grieving as a growth process, higher levels of adaptation and transcendence
• Role transition, growth in a new role
Compromised Processes
• Adaptation level resulting from inadequate integrated and compensatory life
processes
• Adaptation problem
• Compromised Adaptation Examples
• Hypoxia
• Unresolved Loss
• Stigma
• Abusive Relationships
The nursing process
• RAM offers guidelines to nurse in developing the nursing process.
• The elements :
• First level assessment
• Second level assessment
• Diagnosis
• Goal setting
• Intervention
• evaluation
Usefulness of Adaptation Model
• Scientific knowledge for practice
• Clinical assessment and intervention
• Research variables
• To guide nursing practice
• To organize nursing education
• Curricular frame work for various nursing colleges
Characteristics of the theory
• Theories can interrelates concepts in such a way as to present a new view of
looking at a particular phenomenon.
• Theories must be logical in nature
• Theories should be relatively simple yet generalizable
• Theories can be the basis for the hypotheses that can be tested
• Theories contribute to and assist in increasing the general body of knowledge
of a discipline through the research implemented to validate them
• Theories can be utilized by the practitioners to guide and improve their
practice
• Theories must be consistent with other validated theories, laws and principles
but will leave open unanswered questions that need to be investigated
Testability
• RAM is testable
• BBARNS (1999) reported that 163 studies have been conducted using this
model.
• RAM is complete and comprehensive
• It explains the reality of client, so nursing interventions can be specifically
targeted.
Research studies using RAM
• Middle range theories have been derived from RAM
• 1998-Ducharme et al described a longitudinal model of psychosocial
determinants of adaptation
• 1998-Levesque et al presented a MRT of psychological adaptation
• 1999-A MRNT , the urine control theory by Jirovec et al
• Dunn, H.C. and Dunn, D. G. (1997). The Roy Adaptation Model and its
application to clinical nursing practice. Journal of Ophthalmic Nursing and
Technology. 6(2), 74-78.
• Samarel, N., Fawcett, J., Krippendorf, K., Piacentino, J.C., Eliasof, B., Hughes,
P., Kowitski, C., and Ziegler, E. (1998). Women's perception of group support
and adaptation to breast cancer. Journal of Advanced Nursing. 28(6), 1259-
1268.
• Chiou, C. (2000). A meta-analysis of the interrelationships between the
modes in Roy's adaptation model. Nursing Science Quarterly. 13(3), 252-258
• Yeh, C. H. (2001). Adaptation in children with cancer: research with Roy's
model. Nursing Science Quarterly. 14, 141-148.
• Zhan, L. (2000). Cognitive adaptation and self-consistency in hearing-
impaired older persons: testing Roy's adaptation model. Nursing Science
Quarterly. 13(2), 158-165.
Summary
1. 5 elements -person, goal of nursing, nursing activities, health and
environment
• Persons are viewed as living adaptive systems whose behaviours may be
classified as adaptive responses or ineffective responses.
• These behaviors are derived from regulator and cognator mechanisms.
• These mechanisms work with in 4 adaptive modes.
• The goal of nursing is to promote adaptive responses in relation to 4 adaptive
modes, using information about person’s adaptation level, and various stimuli.
• Nursing activities involve manipulation of these stimuli to promote adaptive
responses.
• Health is a process of becoming integrated and able to meet goals of survival,
growth, reproduction, and mastery.
• The environment consists of person’s internal and external stimuli.
References
• George B. Julia , Nursing Theories- The base for professional Nursing
Practice , 3rd ed. Norwalk, Appleton & Lange.
• Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing
Philadelphia. Lippincott Williams& wilkins.
• Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress
3rd ed. Philadelphia, Lippincott.
• Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed.
Philadelphia, Lippincott.
• Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts
Process & Practice 3rd ed. London Mosby Year Book.
• Vandemark L.M. Awareness of self & expanding consciousness: using
Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul;
27(6) : 605-15
• Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006
Jul;19(3):225
Age 56 year
Gender Female
a. Air
b. Water
c. Food
d. Elimination
e. Activity/ Rest
f. Solitude/ Interaction
g. Prevention of hazards
h. Promotion of normalcy
i. Maintain a developmental environment.
j. Prevent or manage the developmental threats
k. Maintenance of health status
l. Awareness and management of the disease process.
m. Adherence to the medical regimen
n. Awareness of potential problem.
o. modify self image
p. Adjust life style to accommodate health status changes and MR
Nursing care plan according to Orem’s theory of self care deficit
1. Perceived Susceptibility
2. Perceived severity
3. Perceived benefits
4. Perceived costs
5. Motivation
3. Perceived benefits: refers to the patient’s belief that a given treatment will
cure the illness or help to prevent it.
5. Motivation: includes the desire to comply with a treatment and the belief that
people should do what
6. Modifying factors: include personality variables, patient satisfaction, and
socio-demographic factors.
REFERENCES
1. Marriner TA, Raile AM. Nursing theorists and their work. 5th ed. Sakraida
T.Nola J. Pender. The Health Promotion Model. St Louis: Mosby; 2005
2. Polit DF, Beck CT. Nursing research:Principles and methods. 7th ed.
Philadelphia: Lippincott Williams & Wilkins; 2007
3. Black JM, Hawks JH, Keene AM. Medical surgical nursing. 6th ed.
Philadelphia: Elsevier Mosby; 2006.
4. Potter PA, Perry AG. Fundamentals of nursing. 6th ed. St.Louis: Elsevier
Mosby; 2006.
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
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.
Nancy Milio a nurse and leader in public health policy and public health education
developed a framework for prevention that includes concepts of community-oriented,
population focused care.(1976,1981).The basic treatise is that behavioral patterns of
populations and individuals who make up populations are a result of habitual
selection from limited choices. She challenged the common notion that a main
determinant for unhealthful behavioral choice is lack of knowledge. Governmental
and institutional policies, she said set the range of options for personal choice
making. It neglected the role of community health nursing, examining the
determinants of community health and attempting to influence those determinants
through public policy.
Salmon White’s construct for public health nursing
Mark Salmon White (1982) describes a public health as an organized societal effort
to protect, promote and restore the health of people and public health nursing as
focused on achieving and maintaining public health.
He gave 3 practice priorities i.e.; prevention of disease and poor health, protection
against disease and external agents and promotion of health. For these 3 general
categories of nursing intervention have also been put forward, they are:
11. education directed toward voluntary change in the attitude and behaviour of
the subjects
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
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.
The community health nurse works with individuals, families, groups, communities,
populations, systems and/or society, but at all times the health of the person or
community is the focus and motivation from which nursing actions flow. The
standards of practice are applied to practice in all settings where people live, work,
learn, worship and play.
The philosophical base and foundational values and beliefs that characterize
community health nursing - caring, the principles of primary health care, multiple
ways of knowing, individual/community partnerships and empowerment - are
embedded in the standards and are reflected in the development and application of
the community health nursing process.
The community health nursing process involves the traditional nursing process
components of assessment, planning, intervention and evaluation but is enhanced by
community health nurses in three dimensions: 1) individual/community participation
in each component, 2) multiple ways of knowing, each of which is necessary to
understand the complexity and diversity of nursing in the
community; knowledge and utilization of all these ways of knowing forms evidence-
based practice consistent with these standards, and 3) the inherent influence of the
broader environment on the individual/community that is the focus of care (e.g. the
community will be affected by provincial/territorial policies, its own economic status
and by the actions of its individual citizens). The standards of practice are founded
on the values and beliefs of community health nurses, and utilization of the
community health nursing process.
The model illustrates the dynamic nature of community health nursing practice,
embracing the present and projecting into the future. The values and beliefs (green
or shaded) ground practice in the present yet guide the evolution of community
health nursing practice over time. The community health nursing process provides
the vehicle through which community health nurses work with people, and supports
practice that exemplifies the standards of community health nursing. The standards
of practice revolve around both the values and beliefs and the nursing process with
the energies of community health nursing always being focused on improving the
health of people in the community and facilitating change in systems or society in
support of health. Community health nursing practice does not occur in isolation but
rather within an environmental context, such as policies within their workplace and
the legislative framework applicable to their work.
References
1. Allender J.N; Spradely B.W. Community Health Nursing Concepts and practice.
(8th edn) 2001.Lippincott,342-45.
· He sleeps during
daytime
Conclusion
Mr. AS has been suffering form Prostate cancer for the last 1 year. But his
symptoms started about 4 years back. For about 3 years he tried folk remedies
based on the advice of other people. He approached medical advice when his
symptoms aggravated. He is currently undergoing radiotherapy for prostate
cancer and medications for diabetes and other symptoms. This case study
helps to understand the psychosocial aspects of illness development and
application illness behaviour model in nursing practice.
Reference
• Guptha MC, Mahajan B. Text book of Social Medicine, 3rd Edn. JayPee,
ND,2003
• Coe RM. Sociology of Medicine. McGraw-Hill Inc. New York, 1978.
APPLICATION OF BETTY NEUMAN'S
SYSTEMS MODEL
OBJECTIVES:
• to assess the patient condition by the various methods explained by the
nursing theory
• to identify the needs of the patient
• to demonstrate an effective communication and interaction with the
patient.
• to select a theory for the application according to the need of the patient
• to apply the theory to solve the identified problems of the patient
• to evaluate the extent to which the process was fruitful.
INTRODUCTION
SYSTEM MODEL- BETTY NEUMAN
A theory is a group of related concepts that propose action that guide practice. A
nursing theory is a set of concepts, definitions, relationships, and assumptions or
propositions derived from nursing models or from other disciplines and project a
purposive, systematic view of phenomena by designing specific inter-relationships
among concepts for the purposes of describing, explaining, predicting, and /or
prescribing.
The Neuman’s system model has two major components i.e. stress and reaction
to stress. The client in the Neuman’s system model is viewed as an open system
in which repeated cycles of input, process, out put and feed back constitute a
dynamic organizational pattern. The client may be an individual, a group, a family,
a community or an aggregate. In the development towards growth and
development open system continuously become more differentiated and elaborate
or complex. As they become more complex, the internal conditions of regulation
become more complex. Exchange with the environment are reciprocal, both the
client and the environment may be affected either positively or negatively by the
other.
The system may adjust to the environment to itself. The ideal is to achieve
optimal stability. As an open system the client, the client system has propensity to
seek or maintain a balance among the various factors, both with in and out side
the system, that seek to disrupt it. Neuman seeks these forces as stressors and
views them as capable of having either positive or negative effects. Reaction to
the stressors may be possible or actual with identifiable responses and symptom.
MAJOR CONCEPTS
I. PERSON VARIABLES-
Each layer, or concentric circle, of the Neuman model is made up of the five
person variables. Ideally, each of the person variables should be considered
simultaneously and comprehensively.
1. Physiological - refers of the physicochemical structure and function of the body.
2. Psychological - refers to mental processes and emotions.
3. Sociocultural - refers to relationships; and social/cultural expectations and
activities.
4. Spiritual - refers to the influence of spiritual beliefs.
5. Developmental - refers to those processes related to development over the
lifespan.
II. CENTRAL CORE-
The basic structure, or central core, is made up of the basic survival factors that
are common to the species (Neuman, 1995, in George, 1996). These factors
include: system variables, genetic features, and the strengths and weaknesses of
the system parts. Examples of these may include: hair color, body temperature
regulation ability, functioning of body systems homeostatically, cognitive ability,
physical strength, and value systems. The person's system is an open system and
therefore is dynamic and constantly changing and evolving. Stability, or
homeostasis, occurs when the amount of energy that is available exceeds that
being used by the system. A homeostatic body system is constantly in a dynamic
process of input, output, feedback, and compensation, which leads to a state of
balance.
III. FLEXIBLE LINES OF DEFENSE-
The flexible line of defense is the outer barrier or cushion to the normal line of
defense, the line of resistance, and the core structure. If the flexible line of
defense fails to provide adequate protection to the normal line of defense, the
lines of resistance become activated. The flexible line of defense acts as a cushion
and is described as accordion-like as it expands away from or contracts closer to
the normal line of defense. The flexible line of defense is dynamic and can be
changed/altered in a relatively short period of time.
IV. NORMAL LINE OF DEFENSE-
The normal line of defense represents system stability over time. It is considered
to be the usual level of stability in the system. The normal line of defense can
change over time in response to coping or responding to the environment. An
example is skin, which is stable and fairly constant, but can thicken into a callus
over time.
V. LINES OF RESISTANCE-
The lines of resistance protect the basic structure and become activated when
environmental stressors invade the normal line of defense. Example: activation of
the immune response after invasion of microorganisms. If the lines of resistance
are effective, the system can reconstitute and if the lines of resistance are not
effective, the resulting energy loss can result in death.
VI. RECONSTITUTION-
Reconstitution is the increase in energy that occurs in relation to the degree of
reaction to the stressor. Reconstitution begins at any point following initiation of
treatment for invasion of stressors. Reconstitution may expand the normal line of
defense beyond its previous level, stabilize the system at a lower level, or return
it to the level that existed before the illness.
VII. STRESSORS--
The Neuman Systems Model looks at the impact of stressors on health and
addresses stress and the reduction of stress (in the form of stressors). Stressors
are capable of having either a positive or negative effect on the client system. A
stressor is any environmental force which can potentially affect the stability of the
system: they may be:
• Intrapersonal - occur within person, e.g. emotions and feelings
• Interpersonal - occur between individuals, e.g. role expectations
• Extra personal - occur outside the individual, e.g. job or finance
pressures
The person has a certain degree of reaction to any given stressor at any given
time. The nature of the reaction depends in part on the strength of the lines of
resistance and defense. By means of primary, secondary and tertiary
interventions, the person (or the nurse) attempts to restore or maintain the
stability of the system.
VII. PREVENTION-
As defined by Neuman's model, prevention is the primary nursing intervention.
Prevention focuses on keeping stressors and the stress response from having a
detrimental effect on the body.
• Primary -Primary prevention occurs before the system reacts to a stressor.
On the one hand, it strengthens the person (primarily the flexible line of
defense) to enable him to better deal with stressors, and on the other
hand manipulates the environment to reduce or weaken stressors. Primary
prevention includes health promotion and maintenance of wellness.
• Secondary-Secondary prevention occurs after the system reacts to a
stressor and is provided in terms of existing systems. Secondary
prevention focuses on preventing damage to the central core by
strengthening the internal lines of resistance and/or removing the stressor.
• Tertiary -Tertiary prevention occurs after the system has been treated
through secondary prevention strategies. Tertiary prevention offers support
to the client and attempts to add energy to the system or reduce energy
needed in order to facilitate reconstitution.
NURSING METAPARADIGM
A. PERSON-
The person is a layered multidimensional being. Each layer consists of five person
variables or subsystems:
• Physical/Physiological
• Psychological
• Socio-cultural
• Developmental
• Spiritual
The layers, usually represented by concentric circle, consist of the central core,
lines of resistance, lines of normal defense, and lines of flexible defense. The basic
core structure is comprised of survival mechanisms including: organ function,
temperature control, genetic structure, response patterns, ego, and what Neuman
terms 'knowns and commonalities'. Lines of resistance and two lines of defense
protect this core. The person may in fact be an individual, a family, a group, or a
community in Neuman's model. The person, with a core of basic structures, is
seen as being in constant, dynamic interaction with the environment. Around the
basic core structures are lines of defense and resistance (shown diagrammatically
as concentric circles, with the lines of resistance nearer to the core. The person is
seen as being in a state of constant change and-as an open system-in reciprocal
interaction with the environment (i.e. affecting, and being affected by it).
B. THE ENVIRONMENT-
The environment is seen to be the totality of the internal and external forces
which surround a person and with which they interact at any given time. These
forces include the intrapersonal, interpersonal and extra personal stressors which
can affect the person's normal line of defense and so can affect the stability of the
system.
• The internal environment exists within the client system.
• The external environment exists outside the client system.
• Neuman also identified a created environment which is an environment
that is created and developed unconsciously by the client and is symbolic
of system wholeness.
C. HEALTH-
Neuman sees health as being equated with wellness. She defines health/wellness
as "the condition in which all parts and subparts (variables) are in harmony with
the whole of the client (Neuman, 1995)". As the person is in a constant
interaction with the environment, the state of wellness (and by implication any
other state) is in dynamic equilibrium, rather than in any kind of steady state.
Neuman proposes a wellness-illness continuum, with the person's position on that
continuum being influenced by their interaction with the variables and the
stressors they encounter. The client system moves toward illness and death when
more energy is needed than is available. The client system moves toward wellness
when more energyis available than is needed.
D. NURSING-
Neuman sees nursing as a unique profession that is concerned with all of the
variables which influence the response a person might have to a stressor. The
person is seen as a whole, and it is the task of nursing to address the whole
person. Neuman defines nursing as actions which assist individuals, families and
groups to maintain a maximum level of wellness, and the primary aim is stability
of the patient/client system, through nursing interventions to reduce stressors.
Neuman states that, because the nurse's perception will influence the care given,
then not only must the patient/client's perceptions be assessed, but so must
those of the caregiver (nurse). The role of the nurse is seen in terms of degrees of
reaction to stressors, and the use of primary, secondary and tertiary
interventions.
Neuman envisions a 3-stage nursing process:
1. Nursing Diagnosis - based of necessity in a thorough assessment, and with
consideration given to five variables in three stressor areas.
2. Nursing Goals - these must be negotiated with the patient, and take account of
patient's and nurse's perceptions of variance from wellness
3. Nursing Outcomes - considered in relation to five variables, and achieved
through primary, secondary and tertiary interventions.
NURSING PROCESS BASED ON SYSTEM MODEL
Assessment: Neuman’s first step of nursing process parallels the assessment and
nursing diagnosis of the six phase nursing process. Using system model in the
assessment phase of nursing process the nurse focuses on obtaining a
comprehensive client data base to determine the existing state of wellness and
actual or potential reaction to environmental stressors.
Nursing diagnosis- the synthesis of data with theory also provides the basis for
nursing diagnosis. The nursing diagnostic statement should reflect the entire
client condition.
Outcome identification and planning- it involves negotiation between the care
giver and the client or recipient of care. The overall goal of the care giver is to
guide the client to conserve energy and to use energy as a force to move beyond
the present.
Implementation – nursing action are based on the synthesis of a comprehensive
data base about the client and the theory that are appropriate to the client’s and
caregiver’s perception and possibilities for functional competence in the
environment. According to this step the evaluation confirms that the anticipated
or prescribed change has occurred. Immediate and long range goals are
structured in relation to the short term goals.
Evaluation – evaluation is the anticipated or prescribed change has occurred. If
it is not met the goals are reformed.
-------------------------------------------------------------------
ASSESSMENT
PATIENT PROFILE
1. Name- Mr. AM
2. Age- 66 years
3. Sex-Male
4. Marital status-married
5. Referral source- Referred from ------- Medical College, -------
STRESSORS AS PERCEIVED BY CLIENT
(Information collected from the patient and his wife)
Investigations Values
Hemoglobin(13- 6.9
19g/dl)
Basophil (0-2%) .2
ESR (0-10mm/hr) 86
Pus C/S _
Urea (8-35mg/dl) 28
Potassium (3.5-5 4
mEq/L)
PT (patient)(11.4- 12.3
15.6 sec)
Blood group A+
HIV Negative
HCV Negative
HBsAg Negative
THERAPEUTIC MANAGEMENT
• 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
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
Nursing action
Evaluation – patient’s physical activity improved and he is able to move from bed
with support. Patient started doing the active and passive exercises and he
verbalized improvement.
-----------------------------------------------------------
Conclusion
The Neuman’s system model when applied in nursing practice helped in identifying
the interpersonal, intrapersonal and extra personal stressors of Mr. AM from various
aspects. This was helpful to provide care in a comprehensive manner. The application
of this theory revealed how well the primary, secondary and tertiary prevention
interventions could be used for solving the problems in the client.
References
1. Alligood M R, Tomey A M. Nursing Theory: Utilization &Application .3rd ed.
Missouri: Elsevier Mosby Publications; 2002.
2. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby,
Philadelphia, 2002
3. George JB .Nursing Theories: The Base for Professional Nursing Practice,5th ed.
New Jersey :Prentice Hall;2002.
APPLICATION OF ROY’S ADAPTATION
MODEL IN NURSING PRACTICE
Outline
• Introduction
• Assumptions of Roy's Adaptation Model
• Roy's Adaptation Model (RAM) –Terms
• Nursing Process
• First Level Assessment
• Second Level Assessment
• Nursing Care Plan
• Conclusion
• Reference
INTRODUCTION
Born at Los Angeles on October 14, 1939 as the 2nd child of Mr. and Mrs.
Fabien Roy
At age 14 she began working at a large general hospital, first as a pantry girl,
then as a maid, and finally as a nurse's aid.
She entered the Sisters of Saint Joseph of Carondelet.
she earned a Bachelor of Arts with a major in nursing from Mount St. Mary's
College, Los Angeles in 1963.
a master's degree program in pediatric nursing at the University of California
,Los Angeles in 1966.
She also earned a master’s & PhD in Sociology in 1973 & 1977 ,respectively
Sr. Callista had the significant opportunity of working with Dorothy E.
Johnson
Johnson's work with focusing knowledge for the discipline of nursing
convinced Sr. Callista of the importance of describing the nature of nursing as
a service to society and prompted her to begin developing her model with the
goal of nursing being to promote adaptation.
Sister Callista Roy (1984), Introduction to Nursing: An Adaptation Model (2nd ed)
Scientific
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
ENVIRONMENT
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
Physiologic-Physical 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)
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
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
DEMOGRAPHIC DATA
• Name • Mr. NR
• Age
• 53 years
• Sex
• Male
• IP number
• -----
• Education
• Degree
• Occupation
• Bank clerk
• Marital status
• Married
• Religion
• Informants • Hindu
PHYSIOLOGIC-PHYSICAL MODE
Oxygenation:
Stable process of ventilation and stable process of gas exchange. RR= 18Bpm.
Chest normal in shape. Chest expansion normal on either side. Apex beat felt on left
5th inter-costal space mid-clavicular line. Air entry equal bilaterally. No ronchi or
crepitus. NVBS. S1& S2 heard. No abnormal heart sounds. Delayed capillary refill+.
JVP0. Apex beat felt- normal rhythm, depth and rate. Dorsalis pedis pulsation of
affected limp is not palpable. All other pulsations are normal in rate, depth, tension
with regular rhythm. Cardiac dull ness heard over 3rd ICS near to sternum to left 5ht
ICS mid clavicular line. S1& S2 heard. No abnormal heart sounds. BP- Normotensive.
. Peripheral pulses felt-Normal rate and rhythm, no clubbing or cyanosis.
Nutrition
Elimination:
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.
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:
Endocrine function
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:
He was the earning member in the family. His role shift is not compensated. His son
doesn’t have any work. His role clarity is not achieved.
INTERDEPENDENCE MODE:
He has good relationship with the neighbours. Good interaction with the friends
relatives. But he believes, no one is capable of helping him at this moment. He
says ”all are under financial constrains”. He was moderately active in local social
activities
FOCAL STIMULUS:
Non-healing wound after amputation of great and second toe of left leg- 4 week. A
wound first found on the junction between first and second toe-4 month back. The
wound was non-healing and gradually increased in size with pus collected over the
area.
He first showed in a local (---) hospital. From there, they referred to ---- medical
college; where he was admitted for 1 month and 4 days. During hospital stay great
and second toe amputated. But surgical wound turned to non- healing with pus and
black colour. So the physician suggested for below knee amputation. That made
them to come to ---Hospital, ---. He underwent a plastic surgery 3 week before.
CONTEXTUAL STIMULI:
Known case DM for past 10 years. Was on oral hypoglycemic agent for initial 2
years, but switched to insulin and using it for 8 years now. Not wearing foot wear in
house and premises.
RESIDUAL STIMULI:
He had TB attack 10 year back, and took complete course of treatment. Previously,
he admitted in ---Hospital for leg pain about 4 year back. . Mother’s brother had DM.
Mother had history of PTB. He is a graduate in humanities, no special knowledge on
health matters.
CONCLUSION
Mr.NR who was suffering with diabetes mellitus for past 10 years. Diabetic foot ulcer
and recent amputation made his life more stressful. Nursing care of this patient
based on Roy's adaptation model provided had a dramatic change in his condition.
Wound started healing and he planned to discharge on 25th april. He studied how to
use crutches and mobilized at least twice in a day. Patient’s anxiety reduced to a
great extends by proper explanation and reassurance. He gained good knowledge
on various aspect of diabetic foot ulcer for the future self care activities.
NURSING CARE PLAN
ASSESS.
ASSESSMEN
OF NURSING INTERVENTIO EVALUATIO
T OF GOAL
BEHAVIO DIAGNOSIS N N
STIMULI
UR
REFERENCE
1) Marriner TA, Raile AM. Nursing theorists and their work. 5th ed. St Louis: Mosby;
2005
2) George BJ, Nursing Theories- The Base for Nursing Practice.3rd ed. Chapter 8. Lobo
ML. Behavioral System Model. St Louis: Mosby; 2005
3) Alligood MR “Nursing Theory Utilization and Application” 5th ed. St Louis: Mosby;
2005
4) Black JM, Hawks JH, Keene AM. Medical surgical nursing. 6th ed. Philadelphia:
Elsevier Mosby; 2006.
5) Brunner LS, Suddharth DS. Text book of Medical Surgical Nursing. 6 th ed. London:
Mosby; 2002
6) Boon NA, Colledge NR, Walker BR, Hunter JAA. Davidson’s principle and practices of
medicine. 20th ed. London: Churchill Livingstone Elsevier; 2006.
APPLICATION OF INTERPERSONAL
THEORY IN NURSING PRACTICE
Outline
• Introduction
• The four phases of nurse-patient relationships are
• Overlapping phases in nurse- patient relationship
• Peplau’s theory and nursing process
• Peplau’s theory application nursing process
• Summary
• Evaluation of the theory of application
• References:
Introduction
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.
Peplau defines Nursing Process as a deliberate intellectual activity that guides the
professional practice of nursing in providing care in an orderly, systematic manner.
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.
Provide active
and passive
exercises to all
Made the patient
the extremities
to perform
to improve the
breathing
muscle tone
exercises
and strength.
Make the
patient to
perform the
breathing
exercises which Massaged the
will strengthen upper and lower
the respiratory extremities
muscle.
Provided article
Massage the within the reach
upper and of the patient
lower
extremities
which help to
improve the
circulation. Provided positive
reinforcement to
Provide articles the patient
near to the
patient and
encourage
doing activities
within limits.
Provide positive
reinforcement
for even a small
improvement to
increase the
frequency of
the desired
activity.
Provide non-
Regarding pharmacological
Provided non Expressed that she
pain, measures for
pharmacological got slight relief from
discussion pain relief such
measures like pain.
was made as diversional
diversion,
to assess activity which
massaging, and
the severity diverts the
pelvic traction.
and the patients mind.
type and
duration of Give the client a
pain. Also neutral position
Provided supine
the
position to the
measures Always use back
client
to reduce support while
pain were turning the
discussed. patient that Supported the
reduces the strainback during
on the back. position change
Given pelvic
traction and
Provide pelvic explained the
traction to the need for traction
patient
Assessment Nursing Planning Implementation Evaluation
(Orientatio diagnosis (Identification (Exploitation (Resolution phase)
n phase) phase) phase)
Mrs. JL Self care Goal setting Carried out plans Mrs. JL was free to
expresses deficit was done along mutually agreed express problems of
that she related to with patient upon. self care.
need the
assistance presence
to get down of pelvic
from bed. traction. Client will She used to call for
achieve and the needs and all her
maintain self needs were met
care activities appropriately
Regarding with assistance
self care of caregiver or
discussion within her
was done limits. She achieved and
and maintained self care
discussed activities within her
regarding limits
the Kept the articles
Keep all the
measures within t he reach
articles within
to solve the of the client
the reach of the
problems. patient.
Provide a call
bell to the
patient to call
in any
emergency
Frequently visited
the patient and
enquired for any
Frequently visitneeds
the patient and
enquire for any
needs.
Assisted the
client in doing her
self care activities
Assist the
patient in doing
her self care
activities. Removed the
weight as and
when needed.
Remove the
weight of the
traction as
needed by the
patient.
Explain in simple
understandable
language of the
client.
Allowed the client
and family
Allow and members to ask
encourage the questions
client and family
to ask questions.
She and her
Allow the client
husband
and family to
expressed their
verbalize anxiety.
anxiety
Stress that
frequent
assessment are
routine and do
not necessarily
imply a
deteriorating
condition.
Explained
regarding the
Explain to the signs of
client the signs aggravation of
of aggravation of disease
illness
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
2. Identification
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.
With the help of the theory of interpersonal relations, the client's needs could be
assessed. It helped her to achieve them within her limits. This theory application
helped in providing comprehensive care to the client.
References:
1. Chinn P L, and Kramer M K. Theory and nursing- a systemic approach.
3rd edition. Philadelphia: Mosby year book;1991
2. George J B. Nursing theories. 5th edition. New Jersey: Prentice hall;
2002
3. Alligood M R, Tomey A M. Nursing theory- utilization and application. 3rd
edition. Missouri: Mosby Elsevier; 2006
4. Craven R F, Hirnle C J. Fundamentals of nursing – human health and
function. 5th edition. Philadelphia: Lippincott Williams and Wilkins;
2007
5. McQuiston C M and Webb A A. Foundations of nursing theory-
Contributions of 12 key theorists. New Delhi: Sage Publications; 1995
APPLICATION OF THEORY IN
NURSING PROCESS
Introduction
Objectives
Definition:
Theories are
TRANSCULTURAL NURSING
Outline
• INTRODUCTION
• TRADITIONAL CONCEPTS OF HEALTH AND DISEASE
• CONCEPT OF CULTURE
• PURPOSES OF KNOWING THE PATIENTS CULTURE AND RELIGION FOR
HEALTH CARE PERSONNEL
• USE OF SUBSTANCES
• ILLNESS CAUSE AND PREVENTION RELATED TO FOOD
• ECONOMIC BARRIERS
• SOCIOCULTURAL FACTORS AND THE NURSING PROCESS
• ROLE OF NURSE
• CONCLUSION
• REFERENCES
INTRODUCTION
The central purpose of the theory is to discover and explain diverse and universal
culturally based care factors influencing the health, well-being, illness, or death of
individuals or groups.
The purpose and goal of the theory is to use research findings to provide
culturally congruent, safe, and meaningful care to clients of diverse or similar
cultures.
Status of Traditional Practices
Many traditional practices are used to prevent and a redemptive practice used to
prevent illness and harm treat illness, including objects and substances and
religious practices. (Morgenstern, 1966)
USE OF PROTECTIVE OBJECTS
Protective objects can be worn or carried or hung in the home. Amulets are
objects with magical powers, for all walks of life and cultural and ethnic
backgrounds is example, charms worn on a string or chain around the neck, wrist,
or waist to protect the wearer from the evil eye or evil spirits. Amulets exist in
societies all over the world and are associated with protection from trouble
(Budge, 1978)
USE OF SUBSTANCES
Substances are ingested in certain ways or amounts regimen, an effort must be
made to determine if they are worn or hung in the home. This practice uses diet
and consists of many different observances. It is believed that the body is kept in
balance or harmony by the type of food eaten so many food taboos and
combinations exist in traditional belief systems. For example, it is believed that
some food substances can be ingested to prevent illness. People from many ethnic
backgrounds eat raw garlic or onion In an effort to prevent illness or wear them
on' the body or hang them in the home.
Jews also believe that milk and meat must never be mixed or eaten at the same
meal (Steinberg, 1947) mind, and spirit, or the restoration of holistic health
RELIGIOUS PRACTICES Another traditional approach to illness prevention
female centers around religion and includes practices such as from a divine source
the burning of candles, rituals of redemption, and In many instances a heritage
consistent person may prayer. Religion strongly affects the way people attempt to
prevent illness, and it plays a strong role in rituals associated with health
protection. Religion dictates social, moral, and dietary practices designed to keep
a traditional healer (Kaptchuk and Croucherl987)
Traditional Remedies The admitted use of folk or traditional medicine
increasing, and the practice is seen among people from all walks of life and
cultural ethnic back ground Use of folk medicine is not a new practice among
heritage consistent people, so many of the remedies have been used and passed
on for generations. The pharmaceutical, must be made to determine properties of
vegetation-plants, roots, tested stems, flowers, seeds, and herbs-have been
studied tested, cataloged, and used for countless centuries. Many of these plants
are used by specific communities. Others cross ethnic and community lines and
are used in certain Geographic areas in the person's country of origin.
When patients -do not adhere to a pharmacological regimen an effort must be
made to determine the remedy if they are taking traditional remedies. Frequently,
the active ingredients of traditional remedies are unknown. If a client is believed
to be, taking them an effort must be made to determine the remedy as well as its
active in gradients Often, these ingredients can be antagonistic or synergistic to
prescribed medications. Over dose may occur.
Healer's
In the traditional context, healing is the restoration of the person to a state of
harmony between the body, Within a given community, specific people are known
to have the power to heal. The healer may be male or and is thought to have
received the gift of healing In many instances a heritage consistent person may
consult a traditional healer before, instead of, or in conjunction with a modern
health care provider. Many differences exist between the Western physician and
the Eastern A broad range of health and illness beliefs exist many of these beliefs
have roots in the culture, ethnic, religious, or social back ground .of a person
family, or community. 'When people anticipate fear or experience an illness or
crisis, they may use a modern or traditional approach toward prevention and
healing.
These approach may originate in culture, ethnicity or religion. These beliefs and
practices may be internal or personal and person may be able to define or
describe them. However, they may be due to external social forces not within the
person's control Examples of external social forces include communication
barriers, such as language differences, or economic barriers causing limited
access or lack of access to modem, health care facilities.
IMMIGRATION
Every immigrant group has its own cultural attitudes ranging beliefs and practices
regarding these areas Health and illness can be interpreted in terms of personal
experience and expectations. There are countless ways to explain health and
illness, and people base their responses on cultural, religious, and ethnic back
ground. The responses are culture specific, based on a client's experience and
perception.
Gender Roles
In many cultures, the male is dominant figure. In cultures where this is time,
males make decisions for other family members well as for themselves. For
example, no matter which family member is involved cultures where the male
dominate. The female usually is passive. In African -American families, however
as well as in many Caucasian families, the female often is dominant Knowledge of
the dominant member of the family is important consideration in planning Nursing
care folk illnesses, which are perceived to arise from a variety of causes, often
require the services of a folk healer who may be a local curandero, shaman,
native healer, spiritualist, root doctor, or other specialized healer. Recognize that
the use of traditional or alternate models of health care deliveries widely varied
and may come into conflict with Western models of health care practice.
Understanding these differences may help you to be more sensitive to the special
beliefs and practices of multicultural target groups when planning a program.
Helping skills
The responsive and initiative factors of helping dominate the helping process
facilitating E+ U+A
That culminate in the physical, emotional and intellectual helpee outcomes. As a
result of attempts to teach they are further refined into concrete helping skills
(A+R+P+I). The attending skills are transitional between responding and
initiating.
Attending : “Being attentive to to the helpee” is made up of attending physically,
observing and listening to the helpee. The function of attending is to give them
the feelings of security that make their involvement in the helping process. By
attending physically the helper communicates interest in the helpee’s welfare, by
observing and listening, helper learns from and about the helpee. By
communicating interest in the helpee, helper establishes the conditions for the
helpee’s involvement in the helping process.
Responding: Responding to the helpee’ s expression of her experience, involves
responding to content, feeling and feeling and content together. The function of he
responding to the helpee’s experience is to facilitate self exploration. T thus she
signals her readiness for the next goal of helping- understanding, which signals
the helper to begin personalizing. They serve to stimulate the helpee’s exploration
of where he or she is in his or her experiences of the world and that the helper is
fully in tune with the helpee’s experience.
Personalizing: “To enable the helpee to understand where she is in relation to
where she wants or needs to be”, involves building a base of interchangeable
responses before personalizing the meaning, the problem, the feelings and the
goal. The purpose is to facilitate helpee self understanding in the areas of concern
to her, thus she signals readiness for using initiating. They are used to provide a
transition from responding to initiating and from exploring to acting. Personalizing
skills culminate in the helpee’s personal experience of the problem as the inability
to handle difficult situations.
Initiating: ”Finding direction in life or acting in following the direction, bringing
direction to culmination – giving life meaning in productivity and creativity”. It
involves operationalizing goals and initiating steps, schedules and reinforcements
to achieve these goals. These goals resolve helpee’s problems. Fosters the
development and implementation of the mechanical steps required to achieve the
personally meaningful goals that the helpee has developed. Initiating skills
conclude the first cycle of helping process in which helper facilitate helpee’s acting
to get to where he or she wants to be in the world.
If you have attended to to the helpee’s needs and responded to her experience,
you have facilitated her exploration of where she is. If you have personalized your
understanding of the helpee, you have facilitated her understanding of where she
is in relation to where wants to be. If you have initiated to help the helpee achieve
her goals have facilitated her acting to get from where she is to where she wants
to be. Thus you have helped her solve her problems and achieve her goals. You
have seen her grow and develop. But growth is not static, is life long learning.
Life long Learning is recycling exploring, understanding and acting. A growing
person is constantly involved in the learning person.
Growing is more than learning and helping. It is helping others to learn, which
means to explore, understand and act plus recycle. E.g. All people can do with
each other in their daily contacts, first and foremost by attending and making an
effective response to the other.
Having begun by attending and responding, over an extended period of time each
person can learn to personalize and initiate with the people with whom they are
involved
At the highest level people communicate with immediacy, which means
understanding and interpreting in the moment what is going on between you and
the helpee (highest levels of responsive and initiative behaviour). It means being
simultaneously aware of both the helpee’s and one’s own experience.
A less than whole person is never actually talking about what she seems to be
talking about, may talk in comparison or relation to other people. A whole person
is always talking about what she seems to be talking about, communicates fully.
As helpers our tasks is to become whole people. Thus helping is a process of
teaching people who do not communicate fully to communicate fully with
themselves and others. Whatever the effective helper or the whole person is
doing, she is always checking back with the helpee accuracy of the responses. She
makes this by making responses that are interchangeable with the feeling and
content expressed by the helpee, no matter how advanced is the stage of the
helping relationship. The helper is fully alive, concerned and capable of
communicating thierliving energy, concern and capability to those who are most in
need.
In fully alive communication each person may be helper to the other. But one
must initiate the helping process by communicating her openness to
understanding the other. In doing so she establishes the model for the other to
imitate, Mutual problems are resolved. There is no edge in helping. The helpee
informs us that she is ready to function as a helper by her behaviour. One clear
demonstration of the helpee’s readiness to terminate the helping process, to go
out on her own is her ability to respond to the experience of the helper. THE
CLEAR DEMONSTRATION OF THE ABILITY TO FUNCTION AS A HELPER WILL BE
ONE’S ABILITY TO RESPOND AND INITIATE EFFECTIVELY.
The Assumption
The only assumption made in developing the helping skill programs involves one’s
motivation. Other assumption is that one wants to grow, want to be like the
facilitative helpers and teachers one has experienced, one wants to become
involved in a life long learning process.- CARKHUFF
Brammer and Macdonald-
• The basic interpersonal communication processes implied by the
specialized helping relationships are similar
• People know their needs
• Basically it is a process of enabling the person to grow in the directions
that person chooses, to solve problems and to face crises.
• Voluntary quality of the helping process is a crucial point since many
persons wanting to help others have their own helping agenda and seek to
meet their own unrecognised needs.
• The act of helping people with the presumed goal of doing something for
them or changing them in some way has an arrogant quality too.
• The aim of all help is self help and self sufficiency.
• Each individual behaves in a competent and trustworthy manner if given
the freedom and encouragement to do so.
• Helper must assume some responsibility for creating conditions of trust
whereby helpeescan respond in a trusting manner and help themselves.
• Helper must be alert to the impact on the helpee of other people and of
the physical environment.
• Helping takes place over the lifespan. Each developmental period and the
transitions between usually require some form of outside help to make life
more effective and satisfying. .
• The nature of the informal agreement implies a growth contract, that
helpees will try to change under their own initiative, with minimal helper
assistance.
Basic Helping scale
I + E + U + A = New learning (behaviour)
5.0 Initiating steps
4.5 Initiating goal operationalization
4.0 Personalizing problem, feelings and goal
3.5 Personalizing meaning
3.0 Responding to feeling and content
2.5 Responding to feeling
2.0 Responding to content
1.5 Attending
1.0 Non attending
Non attending covers all behaviours, both verbal and non verbal that are
unrelated or irrelevant to the helpee’s situation or expressions.
Attending: includes the verbal and non verbal behaviours that are directly
related to involving the helpee, but do not respond to what the helpee has shared
about where she is.
Responding to content: involves summarising what the helpee has shared
concerning her situation.
Responding to feeling: involves accurately identifying a feeling word that is
interchangeable with the helpee’s experience of the situation.
Responding to feeling and content: involves the clear communication of helper
understanding of both the content and feelings expressed by the helpee.
Personalizing meaning: involves responding to identify the personal
significance or implications of the expressed situation for the helpee.
Personalizing problem, feelings and goal: involves responding to identify the
personal deficits (assets) of the helpee that are contributing to the problem or
situation, the feelings that the helpee is experiencing about her deficits (assets)
and the goal that the helpee wants to achieve.
Initiating goal operationalization: covers responses that express a clear
understanding of the helpee’s personalized problem, feelings and goal in
behavioural terms.
Initiating steps: involves responses that identify specific steps toward
accomplishing the operationalised goal.
Ingredients to secret of success
a. Skills of helping: Apply the skills then only you recognise the need for more
skills. The most of basic of all skills is learning how to learn. N ext is the
basic skill of teaching.
b. Discipline: Employ skills with discipline. The accuracy of the discriminations and
communications is the effective ingredient.
c. Work: Our real learning in life comes from working very hard, applying skills with
disciplines in a variety of human experiences. While working hard they must
protect themselves by receiving the maximum return for the minimum
investment. e.g. Once you understand the response deficits of the helpees they
will tend to employ teaching in groups as the preferred mode of treatment.
Evaluation of theory
i. 1960’s: (Eysenk, 1960, 1965; Levitt 1963; Lewis 1965) stated that
psychotherapy and counseling did not make a difference. They discovered that
both adults and children who were in control groups that were not assigned to
professional practitioners, gained as much on the average as people assigned to
professional counselors and therapists. About two thirds of the patients improved
and remained out of the hospital a year after treatment whether they were
treated or not. This research was updated in longitudinal studies in more than 50
treatment setting by Anthony(1979) who studied lasting effects of counseling,
rehabilitation and psychotherapeutic techniques. Within 3-5 years after treatment
65-75% of the patients were once again patients. The gainful employment of
patients was below 20%. Conclusion was that psychotherapy has lasting positive
effects in 17-22% of the cases.
ii. Naturalistic studies: (Rogers et al 1967, Traux and Carkhuff 1967) The clients
and patients of professional helpers demonstrated a greater range of effects than
those in professionally untreated groups. But study revealed a very distressing
conclusion that counseling and psychotherapy have a two edged effect- they may
be harmful or helpful. The effects could be determined by the levels of functioning
of the helpers on certain interpersonal dimensions such as empathy/empathetic
understanding. One who offered high level of core interpersonal dimensions
facilitated the process movement.
iii. Predictive studies: involved manipulating the levels of helpers functioning on
interpersonal dimensions such as empathy and its effects both within the helping
process and upon the helping outcomes. (Carkhuff and Alexik 1967, Holder et al
1967; Piaget et al 1968; Traux and Carkhuff 1967). Helpees of helpers
functioning at high levels of these interpersonal dimensions moved towards higher
levels of functioning (explored their problems in meaningful ways)
iv. Generalization Studies: To study the effects of teacher’s levels of interpersonal
functioning upon learner’s development. The students of teachers offering high
levels of these interpersonal dimensions demonstrated significant constructive
gains in areas of emotional, interpersonal and intellectual functioning (Aspy and
Roebuck, 1977) These effects have been generalised in all areas of helping and
human relationships where the more knowing person influences the less knowing
person, parent child relations (Carkhuff 1971, 1976); Student teacher relations
(Carkhuff 1969); counselor –client relation and therapist patient relations
v. Extension studies: Michelson and Stevic(1971) found that career information
seeking behaviour was dependent upon the helper’s levels of interpersonal
functioning in interaction with their reinforcement program Helping dimensions
were validated in predictive studies of both helping process and outcome. The
acceptance of the fundamental ingredients of helping has been widely
demonstrated in the professional literature.
The applications:
i. With credentialed counselors and therapists: Trained counselors were able to
demonstrate success rates between 74-91%. Aspy and Roebuck(1977)
demonstrated positive effects of helping skills upon student physical, emotional
and intellectual functioning.
ii. Functional Professionals: Staff personnel, such as nurses, hospital attendants,
policeman, prison guards, dormitory counselors, community volunteers were
trained and their effects in treatment studied. Lay helpers were able to elicit
significant changes in work behaviours, discharge rates, recidivism rates and a
variety of other areas including self reports, significant other reports and expert
reports.
iii. Indigenous personnel: They can work effectively with the populations from
which they are drawn. For example, new career teachers, drawn from the ranks of
unemployed have systematically helped others to learn the skills they needed in
order to get and hold meaningful jobs.
iv. Helpee population: in the kinds of skills which they need to service themselves.
Thus parents of emotionally disturbed children were systematically trained in the
skills which they needed to function effectively with themselves and their children.
Patients were trained to offer each other rewarding human relationships. The
results were significantly more positive than all other forms of treatment. The
concept of training as treatment led to the development of programs to train
entire communities to create a therapeutic milieu.
v. Science and art of helping: On implication of the research into helping is to
select persons as helpers who already possess the artful qualities and then quickly
and systematically give them basic helping skills and behaviour concepts.
vi. Self Help Groups: Hurvitz (1970) studied many groups as participant observer
and concluded saying much of their effectiveness was due to peer relationships,
inspirational methods, explicit goals, fellow ship and a variety of helping
procedures. They use many sources of help that are outside conventional helping
methods.
Helping Relationship (Brammer)
The third component of the helping relationship is described as the working
alliance, which is the agreement of helper and helpee on the goals and tasks and
the experience of an emotional bond in this mutual act. The working alliance is
considered equal in importance to helper attitudes (Gelso & Carter, 1994). Helping
relationship is dynamic at verbal and nonverbal levels, the relationship is the
principal process vehicle for both helper and helpee to express and fulfill their
needs as well as to mesh helpee problems with helper expertise. All authorities on
the helping process agree that the quality of the helping relationship is important
to effective helping(Sexton and Whiston 1994.)All agree that good working
relationship established early, yield a helping relationship. Its dimensions are
(Brammer, Abrego and Shostrom 1993) uniqueness-commonality and intellectual
– emotional content. However helping relationship is different from friendship, is
not a reciprocal relationship. The focus is on the helpee’s emotional and
intellectual issues, the helper must resist the urge to move the focus to his or her
experience.
Helping affiliations
Helping affiliations can be classified into formal and structured (professional,
paraprofessionals and volunteer helper) to informal and unstructured (friendships,
family, community& general human).
Stages in helping process
There are eight stages contained in the two basic phases of the helping process.
Phase 1: Building relationships:
• Entry: preparing the helpee and opening relationship
• Clarification: state the problem or concern and reasons for seeking help
• Structure: formulating the contract and the structure
• Relationship: building the helping relationship
Phase 2: Facilitating Positive Action
• Exploration: exploring problems, formulating goals, planning strategies,
gathering facts, expressing deeper feelings, learning new skills.
• Consolidation: exploring alternatives, working through feelings, practicing
new skills
• Planning: developing a plan of action using strategies to resolve conflicts,
reducing painful feelings, and consolidating and generalizing new skills or
behaviours to continue self-directed activities.
• Termination: evaluating outcomes and terminating the relationship.
Helping skills for understanding: of self and others
i. Listening skills
• Attending – noting verbal and nonverbal behaviours
• Paraphrasing – responding to basic messages
• Clarifying – self disclosing and focusing discussion
• Perception checking – determining accuracy of learning
ii. Leading Skills
• Indirect leading – getting started
• Direct leading – encouraging and elaborating discussion
• Focusing – controlling confusion, diffusion and vagueness
• Questioning – conducting open and closed inquiries
iii. Reflecting skills
• Reflecting feeling – responding to feelings
• Reflecting experience – responding to toal experience
• Reflecting content – repeating ideas in fresh words or for emphasis
iv. Confronting skills:
• Recognising feelings in oneself – being aware of helper experience
• Describing and sharing feelings – modeling feeling expression
• Feeding back opinions – reacting honestly to helpee expressions
• Self-confrontation
v. Interpreting skills
• INTERPRETIVE QUESTIONS – FACILITATING AWARENESS
• FANTASY AND METAPHOR- SYMBOLIZING IDEAS AND FEELINGS
vi. Informing skills
• Advising – giving suggestions and opinions based on experience
• Informing- giving valid information based on expertise
vii. Summarising Skills
• Pulling themes together.
Ethical issues in helping relationships: Informed consent
Worker self care- recognise own weak spots and work on prevention
Dual relationships- recognise them and manage them Ask following questions.
Is there a a power difference between us?
What other role obligations do I have in this situation?
How will my knowledge about you change our relationship?
Physical contact with helpees: Sexual relationships of any kind are unethical
Touching clients for support, out of compassion or to express care is controversial.
Conclusion
Our task in life is to improve the quantity and quality of human experience, our
own as well as others which is growth. Life is process, is growth and growth is
learning skills. When we use the helping skills effectively, we can be healthy and
we can help each other to actualize our human potential. The only meaning to life
is to grow for growing is life.
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2. Brammer L M, Macdonald G. Helping relationship process and skills. 6th ed.
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