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Carative Nursing
Jean Watson


Theorist was born in West Virginia, US

Educated: BSN, University of Colorado, 1964, MS, University of
Colorado, 1966, PhD, University of Colorado, 1973
Distinguished Professor of Nursing and endowed Chair in Caring
Science at the University of Colorado Health Sciences Center.
Fellow of the American Academy of Nursing.
Previously, Dean of Nursing at the University Health Sciences Center
and President of the National League for Nursing
Undergraduate and graduate degrees in nursing and psychiatricmental health nursing and PhD in educational psychology and
counseling. She has six (6) Honorary Doctoral Degrees.
Her research has been in the area of human caring and loss.
In 1988, her theory was published in nursing: human science and
human care.

The seven assumptions

Caring can be effectively
demonstrated and practiced only
Caring consists of carative factors that result in the satisfaction of
certain human needs.
Effective caring promotes health and individual or family growth.
Caring responses accept person not only as he or she is now but as
what he or she may become.
A caring environment is one that offers the development of potential
while allowing the person to choose the best action for himself or
herself at a given point in time.
Caring is more healthogenic than is curing. A science of caring is
complementary to the science of curing.
The practice of caring is central to nursing.
The ten primary carative factors
1. The formation of a humanistic- altruistic system of values.
2. The installation of faith-hope.
3. The cultivation of sensitivity to ones self and to others.
4. The development of a helping-trust relationship
5. The promotion and acceptance of the expression of positive and
negative feelings.
6. The systematic use of the scientific problem-solving method for
decision making
7. The promotion of interpersonal teaching-learning.
8. The provision for a supportive, protective and /or corrective mental,
physical, socio-cultural and spiritual environment.
9. Assistance with the gratification of human needs.
The allowance for existential-phenomenological forces.
The first three carative factors form the philosophical foundation for the
science of caring. The remaining seven carative factors spring from the
foundation laid by these first three.

1. The formation of a humanistic- altruistic system of values

Begins developmentally at an early age with values shared with the
Mediated through ones own life experiences, the learning one gains
and exposure to the humanities.
Is perceived as necessary to the nurses own maturation which then
promotes altruistic behavior towards others.
2. Faith-hope
Is essential to both the carative and the curative processes.
When modern science has nothing further to offer the person, the
nurse can continue to use faith-hope to provide a sense of well-being
through beliefs which are meaningful to the individual.

3. Cultivation of sensitivity to ones self and to others

Explores the need of the nurse to begin to feel an emotion as it
presents itself.
Development of ones own feeling is needed to interact genuinely and
sensitively with others.
Striving to become sensitive, makes the nurse more authentic, which
encourages self-growth and self-actualization, in both the nurse and
those with whom the nurse interacts.
The nurses promote health and higher level functioning only when they
form person to person relationship.
4. Establishing a helping-trust relationship
Strongest tool is the mode of communication, which establishes
rapport and caring.
Characteristics needed to in the helping-trust relationship are:
o Congruence
o Empathy
o Warmth
Communication includes verbal, nonverbal and listening in a manner
which connotes empathetic understanding.
5. The expression of feelings, both positive and negative
Feelings alter thoughts and behavior, and they need to be considered
and allowed for in a caring relationship.
Awareness of the feelings helps to understand the behavior it
6. The systematic use of the scientific problem-solving method for
decision making
The scientific problem- solving method is the only method that allows
for control and prediction, and that permits self-correction.
The science of caring should not be always neutral and objective.
7. Promotion of interpersonal teaching-learning
The caring nurse must focus on the learning process as much as the
teaching process.
Understanding the persons perception of the situation assist the nurse
to prepare a cognitive plan.
8. Provision for a supportive, protective and /or corrective mental,
physical, socio-cultural and spiritual environment
Watson divides these into eternal and internal variables, which the
nurse manipulates in order to provide support and protection for the
persons mental and physical well-being.
The external and internal environments are interdependent.
Nurse must provide comfort, privacy and safety as a part of this
carative factor.
9. Assistance with the gratification of human needs
It is based on a hierarchy of need similar to that of the Maslows.
Each need is equally important for quality nursing care and the
promotion of optimal health.
All the needs deserve to be attended to and valued.
Watsons ordering of needs
Lower order needs (biophysical needs)
o The need for food and fluid

The need for elimination

The need for ventilation
Lower order needs (psychophysical needs)
o The need for activity-inactivity
o The need for sexuality
Higher order needs (psychosocial needs)
o The need for achievement
o The need for affiliation
o Higher order need (intrapersonal-interpersonal need)
o The need for self-actualization
10. Allowance for existential-phenomenological forces
Phenomenology is a way of understanding people from the way things
appear to them, from their frame of reference.
Existential psychology is the study of human existence using
phenomenological analysis.
This factor helps the nurse to reconcile and mediate the incongruity of
viewing the person holistically while at the same time attending to the
hierarchical ordering of needs.
Thus the nurse assists the person to find the strength or courage to
confront life or death.
Watsons theory and the four major concepts
Human being
Human being refers to .. a valued person in and of him or herself to
be cared for, respected, nurtured, understood and assisted; in general
a philosophical view of a person as a fully functional integrated self.
He, human is viewed as greater than and different from, the sum of his
or her parts.
Watson adds the following three elements to WHO definition of health:
o A high level of overall physical, mental and social functioning
o A general adaptive-maintenance level of daily functioning
o The absence of illness (or the presence of efforts that leads its



According to Watson, caring (and nursing) has existed in every society.
A caring attitude is not transmitted from generation to generation.
It is transmitted by the culture of the profession as a unique way of
coping with its environment.
Nursing is concerned with promoting health, preventing illness, caring
for the sick and restoring health.
It focuses on health promotion and treatment of disease. She believes
that holistic health care is central to the practice of caring in nursing.
a human science of persons and human health-illness experiences
that are mediated by professional, personal, scientific, esthetic and
ethical human transactions.

Self-Care Theory
Dorothea Orem (1914-2007)


One of foremost nursing theorists.

Born 1914 in Baltimore.
Earned her diploma at Providence Hospital Washington, DC
1939 BSN Ed., Catholic University of America
1945 MSN Ed., Catholic University of America
Involved in nursing practice, nursing service, and nursing education
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
Published first formal articulation of her ideas in Nursing: Concepts of
Practice in 197, second in 1980, and 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.
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
Orems Nursing: Concept of Practice was first published in 1971 and
subsequently in 1980, 1985, 1991, 1995, and 2001.

Major Assumptions

People should be self-reliant and responsible for their own care and
others in their family needing care
People are distinct individuals
Nursing is a form of action interaction between two or more persons
Successfully meeting universal and development self-care requisites is
an important component of primary care prevention and ill health
A persons knowledge of potential health problems is necessary for
promoting self-care behaviors
Self-care and dependent care are behaviors learned within a sociocultural context

Definition of Domain Concept

1. Nursing is art, a helping service, and a technology

Actions deliberately selected and performed by nurses to help

individuals or groups under their care to maintain or change
conditions in themselves or their environments
Encompasses the patients perspective of health condition ,the
physicians perspective , and the nursing perspective
Goal of nursing to render the patient or members of his family
capable of meeting the patients self-care needs
To maintain a state of health
To regain normal or near normal state of health in the event of
disease or injury
To stabilize ,control ,or minimize the effects of chronic poor health
or disability

2. 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.

3. Environment

enthronement elements, conditions, and developed environment

4. 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

A human being is the focus of nursing only when a self care

requisites exceeds self-care capabilities


Orems general theory of nursing in three related parts:

Theory of self-care
Theory of self-care deficit
Theory of nursing system

A. Theory of Self Care

This theory 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:

1. Universal

Health deviation

2. 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 associated with elimination process
Balance between activity and rest, between solitude and social
Prevention of hazards to human life well-being and
Promotion of human functioning

3. Developmental self-care requisites

Associated with developmental processes/ derived from a condition or

associated with an event
o E.g. adjusting to a new job
o adjusting to body changes
Health deviation self-care
o 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

B. 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:
o Acting for and doing for others
o Guiding others
o Supporting another
o Providing an environment promoting personal development in
relation to meet future demands
o Teaching another

C. Theory of Nursing Systems

Describes how the patients self-care needs will be met by the nurse ,
the patient, or both
Identifies 3 classifications of nursing system to meet the self-care
requisites of the patient:Wholly compensatory system
Partly compensatory system
Supportive educative system
Design and elements of nursing system define
Scope of nursing responsibility in health care situations
General and specific roles of nurses and patients
Reasons for nurses relationship with patients and
The kinds of actions to be performed and the performance patterns
and nurses and patients actions in regulating patients self-care
agency and in meeting their self-care demand
Orem recognized that specialized technologies are usually developed
by members of the health profession
A technology is systematized information about a process or a method
for affecting some desired result through deliberate practical
endeavor ,with or without use of materials or instruments

Self care deficit
Nursing system

Self care

Four Conservation Principles

Myra Estrine Levine


Born in Chicago

Very fond of her father who was often ill and frequently hospitalized
with GI problem. This was the reason of choosing nursing as a career

Also called as renaissance women-highly principled, remarkable and

committed to patients quality of care

Died in 1996

Educational Achievement

Diploma in nursing:-Cook county SON, Chicago, 1944

BSN:-University of Chicago,1949
MSN:-Wayne state University, Detroit, 1962
Publication:-An Introduction to Clinical Nursing, 1969,1973 & 1989
Received honorary doctorate from Loyola University in 1992


Clinical experience in OT technique and oncology nursing

Civilian nurse at the Gardiner general hospital

Director of nursing at Drexel home in Chicago

Clinical instructor at Bryan memorial hospital in Lincoln, Nebraska
Administrative supervisor at university of Chicago
Chairperson of clinical nursing at cook country SON
Visiting professor at Tel Aviv university in Israel

Conservational model

Goal: To promote adaptation and maintain wholeness using the

principles of conservation
Model guides the nurse to focus on the influences and responses at the
organismic level

Nurse accomplishes the goal of model through the conservation of

energy, structure and personal and social integrity


Every individual has a unique range of adaptive responses

The responses will vary by heredity, age, gender or challenges of
illness experiences
Example: The response to weakness of cardiac muscle is an increased
heart rate, dilation of ventricle and thickening of myocardial muscle
While the responses are same, the timing and manifestation of
organismic responses will be unique for each individual pulse rate)
An ongoing process of change in which patient maintains his integrity
within the realities of environment
Achieved through the "frugal, economic, contained and controlled use
of environmental resources by individual in his or her best interest"


Exist when the interaction or constant adaptations to the environment

permits the assurance of integrity
Promoted by use of conservation principle


The product of adaptation

"Keeping together "of the life systems or the wholeness of the
Achieving a balance of energy supply and demand that is with in the
unique biological realities of the individual

Nursings paradigm
1. Person

A holistic being who constantly strives to preserve wholeness and

A unique individual in unity and integrity, feeling, believing, thinking
and whole system of system

2. Environment

Competes the wholeness of person


Internal Environment

Homeostasis: A state of energy sparing that also provide the

necessary baselines for a multitude of synchronized physiological and
psychological factors
A state of conservation
Homeorrhesis: A stabilized flow rather than a static state
Emphasis the fluidity of change within a space-time continuum
Describe the pattern of adaptation, which permit the individuals body
to sustain its well-being with the vast changes which encroach upon it
from the environment

External Environment

Preconceptual: Aspect of the world that individual are able to intercept

Operational: Elements that may physically affects individuals but not
perceived by hem: radiation, micro-organism and pollution
Conceptual: Part of person's environment including cultural patterns
characterized by spiritual existence, ideas, values, beliefs and tradition

Person and environment

Organismic response


Historicity: Adaptations are grounded in history and await the

challenges to which they respond
Specificity: Individual responses and their adaptive pattern varies on
the base of specific genetic structure
Redundancy: Safe and fail options available to the individual to
ensure continued adaptation

Organismic response

A change in behavior of an individual during an attempt to adapt to the

Help individual to protect and maintain their integrity
They co-exist

They are four types:

1. Flight or fight: An instantaneous response to real or imagined

threat, most primitive response

2. Inflammatory: response intended to provide for structural integrity

and the promotion of healing
3. Stress: Response developed over time and influenced by each
stressful experience encountered by person
4. Perceptual: Involves gathering information from the environment
and converting it in to a meaning experience

Nine models of guided assessment

Vital signs
Body movement and positioning
Ministration of personal hygiene needs
Pressure gradient system in nursing interventions
Nursing determination in provision of nutritional needs
Pressure gradient system in nursing
Local application of heat and cold
Administration of medicine

Establishing an aseptic environment


The nurse creates an environment in which healing could occur

A human being is more than the sum of the part
Human being respond in a predictable way
Human being are unique in their responses
Human being know and appraise objects ,condition and situation
Human being sense ,reflects, reason and understand
human being action are self-determined even when emotional
Human being are capable of prolonging reflection through such
strategists raising questions

Levines work & Characteristics of theory

Theories can interrelate concepts in such a way as to create a different

way of looking at a particular phenomenon
The concept of illness adaptation, using interventions, and the
evaluation of nursing interventions are interrelated .they are combined
to look at nursing care in a different way (more comprehensive view
incorporating total patient care) form previous time.
Theories must be logical in nature.
Levines ideas about nursing care are organized in such a way as to b
sequential and logical. they can be used to explain the consequences
of nursing action
Theories should be relatively simple yet generalizable.
Levines theory is easy to use.
Its major elements are easily comprehensible and the relationship
have the potential for being complex but are easily manageable
Certain isolated aspect of the theory are the generalizable i.e. those
related to the conservational principles
Theories can be the bases for hypotheses that can be tested.

Levines idea can be tested

Hypothesis can be derived from them.
The principle of conservation are specific enough to be testable
Levines work & Characteristics of theory
Theories contribute to and assist in increasing the general body of
knowledge within the discipline through the research implemented to
validate them.
Since Levines idea have not yet been widely researched ,it is hard to
determine the contribution to the general body of knowledge with in
the discipline
Theories can be utilized by the practitioner to guide and improve their
Paula E.Crawford-gamble-successfully applied Levines theory to the
female patient undergoing surgery for the traumatic amputation of the
These ideas lend themselves to use in practice particularly in acute
care setting
Theories must be consistent with other validated theories, laws and
principles but will leave open unanswered questions that need to be
Levines ideas seem to be consistent with other theories, laws and
principles particularly those from the humanities and sciences

Conservational Principle



structural integrity
personal integrity
social integrity

1. Conservation of energy

Refers to balancing energy input and output to avoid excessive fatigue

includes adequate rest, nutrition and exercise

Availability of adequate rest
Maintenance of adequate nutrition

2. Conservation of structural integrity

Refers to maintaining or restoring the structure of body preventing

physical breakdown And promoting healing

Assist patient in ROM exercise
Maintenance of patients personal hygiene

3. Conservation of personal integrity

Recognizes the individual as one who strives for recognition, respect,

self-awareness, selfhood and self determination

Recognize and protect patients space needs

4. Conservation of social integrity

An individual is recognized as someone who resides with in a family, a

community ,a religious group, an ethnic group, a political system and a


Position patient in bed to foster social interaction with other patients

Avoid sensory deprivation
Promote patients use of newspaper, magazines, radio. TV
Provide support and assistance to family

3. Health

Health is a wholeness and successful adaptation

It is not merely healing of an afflicted part ,it is return to daily
activities, selfhood and the ability of the individual to pursue once
more his or her own interest without constraints
Disease: It is unregulated and undisciplined change and must be
stopped or death will ensue

4. Nursing

"Nursing is a profession as well as an academic discipline, always

practiced and studied in concert with all of the disciplines that together
from the health sciences"
The human interaction relying on communication ,rooted in the organic
dependency of the individual human being in his relationships with
other human beings
Nursing involves engaging in "human interactions"


Science of Unitary Human Beings

Martha Roger

Born :May 12, 1914, Dallas, Texas
Diploma : Knoxville General Hospital School of Nursing(1936)
Graduation in Public Health Nursing : George Peabody College, TN,
MA :Teachers college, Columbia university, New York, 1945
MPH :Johns Hopkins University, Baltimore, MD, 1952
Doctorate in nursing :Johns Hopkins University, Baltimore, 1954
Fellowship: American academy of nursing
Position: Professor Emerita, Division of Nursing, New York University,
Consultant, Speaker
Died : March 13 , 1994
Publications of Martha Rogers
Theoretical basis of nursing (Rogers 1970)
Nursing science and art :a prospective (Rogers 1988)
Nursing :science of unitary, irreducible, human beings update (Rogers
Vision of space based nursing (Rogers 1990)
Rogers nursing theory
Nursing is both a science and art. the uniqueness of nursing, like that
of any other science, lies in the phenomenon central to its focus.

Nurses long established concern with the people and the world they
live is in a natural forerunner of an organized abstract system
encompassing people and the environments.

The irreducible nature of individuals is different from the sum of the

The integral ness of people and the environment that coordinate with a
multidimensional universe of open systems points to a new paradigm
the identity of nursing as a science.
The purpose of nurses is to promote health and well-being for all
persons wherever they are.
Evolution of abstract system
The development of the abstract system was strongly influenced by an
early grounding in arts and background of science and her keen
interest in space
The science of unitary human beings originated as a synthesis of facts
and ideas from multiple sources of knowledge
The uniqueness is in the central phenomena : people and environment
The Rogerian view of causality emerges from an infinite universe of
open system.
Overview of Rogerian model
Rogers model provides the way of viewing the unitary human being
Humans are viewed as integral with the universe
The unitary human being and the environment are one ,not
Nursing focus on people and the manifestations that emerge from the
mutual human /environmental field process
Change of pattern and organization of the human field and the
environmental field is propagated by waves
The manifestations of the field patterning that emerge are observable
The identification of the pattern provide knowledge and understanding
of human experience
Basic characteristics which describes the life process of human: energy
field, openness, pattern, and pan dimensionality
Basic concepts include unitary human being, environment, and
homeodynamic principles
Concepts of Rogers model

Energy field

The energy field is the fundamental unit of both the living and
This energy field "provide a way to perceive people and environment
as irreducible wholes"
The energy fields continuously varies in intensity, density, and extent


The human field and the environmental field are constantly exchanging
their energy
There are no boundaries or barrier that inhibit energy flow between


Pattern is defined as the distinguishing characteristic of an energy field

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

Pan dimensionality

Pan dimensionality is defined as "nonlinear domain without spatial or

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

Homeodynamic principles

The principles of homeodynamic postulates the way of perceiving

unitary human beings

The fundamental unit of the living system is an energy field

Three principle of homeodynamics
o Resonancy
o Helicy
o integrality


Resonance is an ordered arrangement of rhythm characterizing both

human field and environmental field that undergoes continuous
dynamic metamorphosis in the human
environmental process

Helicy describes the unpredictable, but continuous, nonlinear evolution
of energy fields as evidenced by non-repeating rhythmic ties
The principle of Helicy postulates an ordering of the humans
evolutionary emergence
Integrality covers the mutual, continuous relationship of the human
energy field and the environmental field.
Changes occur by
the continuous patterning of the human and
environmental fields by resonance waves
The fields are one and integrated but unique to each other
Nursing Paradigms
1. Unitary Human Being (person)

A unitary human being is an "irreducible, indivisible, pan dimensional

(four-dimensional) energy field identified by pattern and manifesting
characteristics that are specific to the whole and which cannot be
predicted from knowledge of the parts" and "a unified whole having its
own distinctive characteristics which cannot be perceived by looking
at, describing, or summarizing the parts"
The people has the capacity to participate knowingly and
probabilistically in the process of change

2. Environment

The environment is an "irreducible ,pan dimensional energy field

identified by pattern and integral with the human field"
The fields coexist and are integral. Manifestations emerge from this
field and are perceived.

3. Health

Rogers defined health as an expression of the life process; they are the
"characteristics and behavior emerging out of the mutual,
simultaneous interaction of the human and environmental fields"
Health and illness are the part of the sane continuum.
The multiple events taking place along life's axis denote the extent to
which man is achieving his maximum health potential and very in their
expressions from greatest health to those conditions which are
incompatible with the maintaining life process

4. Nursing

The concept Nursing encompasses two dimensions Independent

science of nursing
An organized body of knowledge which is specific to nursing is arrived
at by scientific research and logical analysis
Art of nursing practice:
o The creative use of science for the betterment of the human
o The creative use of its knowledge is the art of its practice
Nursing exists to serve people. it is the direct and overriding
responsibility to the society
The safe practice of nursing depends on the nature and amount of
scientific nursing knowledge the individual brings to practice. the
imaginative, intellectual judgment with which such knowledge is made
in service to the man kind
People need knowledgeable nursing.

Behaviour System Model

Dorothy E. Johnson
Dorothy E. Johnson was born August 21, 1919, in
Savannah, Georgia.
B. S. N. from Vanderbilt University in Nashville, Tennessee, in 1942; and
her M.P.H. from Harvard University in Boston in 1948.
From 1949 till retirement in 1978 she was an assistant professor of
pediatric nursing, an associate professor of nursing, and a professor of
nursing at the University of California in Los Angeles.
Johnson stressed the importance of research-based knowledge about
the effect of nursing care on clients.
Behavior system model
Dorothy first proposed her model of nursing care in 1968 as fostering
of the efficient and effective behavioral functioning in the patient to
prevent illness".
She also stated that nursing was concerned with man as an
integrated whole and this is the specific knowledge of order we
In 1980 Johnson published her conceptualization of behavioral system
of model for nursingwhere she explains her definitions of the
behavioral system model.
Definition of nursing
She defined nursing as an external regulatory force which acts to preserve
the organization and integration of the patients behaviors at an optimum
level under those conditions in which the behaviors constitutes a threat to
the physical or social health, or in which illness is found
Four goals of nursing are to assist the patient:
1. Whose behavior commensurate with social demands.
2. Who is able to modify his behavior in ways that it supports biological
3. Who is able to benefit to the fullest extent during illness from the
physicians knowledge and skill.
4. Whose behavior does not give evidence of unnecessary trauma as a
consequence of illness
There are several layers of assumptions that Johnson makes in the
development of conceptualization of the behavioral system model viz.
Assumptions about system

Assumptions about structure

Assumptions about functions

Assumptions about system

There are 4 assumptions of system:

1. First, there is organization, interaction, interdependency and
integration of the parts and elements of behaviors that go to make up
the system
2. A system tends to achieve a balance among the various forces
operating within and upon it', and that man strive continually to
maintain a behavioral system balance and steady state by more or less
automatic adjustments and adaptations to the natural forces impinging
upon him.
3. A behavioral system, which both requires and results in some degree of
regularity and constancy in behavior, is essential to man that is to say,
it is functionally significant in that it serves a useful purpose, both in
social life and for the individual.
4. Last, system balance reflects adjustments and adaptations that are
successful in some way and to some degree.
Assumptions about structure and function of each subsystem
from the form the behavior takes and the consequences it achieves
can be inferred what drive has been stimulated or what goal is
being sought
Each individual has a predisposition to act with reference to the goal,
in certain ways rather than the other ways. This predisposition is
called as set.
Each subsystem has a repertoire of choices or scope of action
The fourth assumption is that it produce observable outcome that is
the individuals behavior.
Each subsystem has three functional requirements
1. System must be protected" from noxious influences with which
system cannot cope.
2. Each subsystem must be nurtured through the input of appropriate
supplies from the environment.
3. Each subsystem must be stimulated for use to enhance growth and
prevent stagnation.
These behaviors are orderly, purposeful and predictable and
sufficiently stable and recurrent to be amenable to description and
Johnsons Behavioral Subsystem
Attachment or affiliative subsystem: social inclusion intimacy and
the formation and attachment of a strong social bond.
Dependency subsystem: approval, attention or recognition and
physical assistance
Ingestive subsystem: the emphasis is on the meaning and
structures of the social events surrounding the occasion when the food
is eaten
Eliminative subsystem: human cultures have defined different
socially acceptable behaviors for excretion of waste, but the existence
of such a pattern remains different from culture to Culture.
Sexual subsystem:" both biological and social factor affect the
behavior in the sexual subsystem
Aggressive subsystem: " it relates to the behaviors concerned with
protection and self-preservation Johnson views aggressive subsystem

as one that generates defensive response from the individual when life
or territory is being threatened

Achievement subsystem: provokes behavior that attempt to

control the environment intellectual, physical, creative, mechanical and
social skills achievement are some of the areas that Johnson

Representation of Johnson's Model

Goal ----- Set --- Choice of Behavior --- Behavior


Adaptation Model
Sister Callista Roy

Sr.Callista Roy, a prominent nurse theorist, writer, lecturer, researcher

and teacher
Professor and Nurse Theorist at the Boston College of Nursing in
Chestnut Hill
Born at Los Angeles on October 14, 1939 as the 2nd child of Mr. and
Mrs. Fabien Roy
she earned a Bachelor of Arts with a major in nursing from Mount St.
Mary's College, Los Angeles in 1963.
a master's degree program in pediatric nursing at the University of
California ,Los Angeles in 1966.
She also earned a masters and PhD in Sociology in 1973 and 1977,
Sr. Callista had the significant opportunity of working with Dorothy E.
Johnson's work with focusing knowledge for the discipline of nursing
convinced Sr. Callista of the importance of describing the nature of
nursing as a service to society and prompted her to begin developing
her model with the goal of nursing being to promote adaptation.
She joined the faculty of Mount St. Mary's College in 1966, teaching
both pediatric and maternity nursing.

She organized course content according to a view of person and family

as adaptive systems.
She introduced her ideas about Adaptation Nursing as the basis for an
integrated nursing curriculum.
Goal of nursing to direct nursing education, practice and research
Model as a basis of curriculum impetus for growth--Mount St. Marys
1970-The model was implemented in Mount St. Marys school

1971- She was made chair of the nursing department at the college.

Influencing Factors
Religious Background
Clinical Experience
The central questions of Roys theory are:
o Who is the focus of nursing care?
o What is the target of nursing care?
o When is nursing care indicated?
Roys first ideas appeared in a graduate paper written at UCLA in 1964.
Published these ideas in "Nursing outlook" in 1970
Subsequently different components of her framework crystallized
during 1970s, 80s, and 90s
Over the years she identified assumptions on which her theory is
Explicit assumptions (Roy 1989; Roy and Andrews 1991)
The person is a bio-psycho-social being.
The person is in constant interaction with a changing environment.
To cope with a changing world, person uses both innate and acquired
mechanisms which are biological, psychological and social in origin.
Health and illness are inevitable dimensions of the persons life.
To respond positively to environmental changes, the person must
The persons adaptation is a function of the stimulus he is exposed to
and his adaptation level
The persons adaptation level is such that it comprises a zone
indicating the range of stimulation that will lead to a positive response.
The person has 4 modes of adaptation: physiologic needs, selfconcept, role function and inter-dependence.
"Nursing accepts the humanistic approach of valuing other persons
opinions, and viewpoints" Interpersonal relations are an integral part of
There is a dynamic objective for existence with ultimate goal of
achieving dignity and integrity.
Implicit assumptions
A person can be reduced to parts for study and care.
Nursing is based on causality.
Patients values and opinions are to be considered and respected.

A state of adaptation frees an individuals energy to respond to other

Adaptation -- goal of nursing
Person -- adaptive system
Environment -- stimuli
Health -- outcome of adaptation
Nursing -- promoting adaptation and health
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

Bio-psycho-social being in constant interaction with a changing
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.
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
Inevitable dimension of person's life
Represented by a health-illness continuum
A state and a process of being and becoming integrated and whole
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
Cognator subsystem A major coping process involving 4 cognitiveemotive 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
Derived Four Adaptive Modes


500 Samples of Patient Behavior

What was the patient doing?
What did the patient look like when needing nursing care?
Adaptive Modes
Physiologic Needs
Role Function


Betty Neuman's System Model


Betty Neumans system model provides a comprehensive flexible

holistic and system based perspective for nursing.

It focuses on the response of the client system to actual or potential

environmental stressors and the use of primary, secondary and tertiary
nursing prevention intervention for retention, attainment, and
maintenance of optimal client system wellness.


Betty Neuman was born in 1924, in Lowel, Ohio.

BS in nursing in 1957

MS in Mental Health Public health consultation, from UCLA in 1966.

Ph.D. in clinical psychology

A pioneer in the community mental health movement in the late


Developed the model while working as a lecturer in community health

nursing at University of California, Los Angeles.

The model was published in 1972 as A Model for Teaching Total Person
Approach to Patient Problems in Nursing Research.

It was refined and subsequently published in the first edition of

Conceptual Models for Nursing Practice, 1974, and in the second
edition in 1980.


Neumans model was influenced by a variety of sources:

The philosophy writers deChardin and Cornu (on wholeness in system).

Von Bertalanfy, and Lazlo on general system theory.

Selye on stress theory.

Lararus on stress and coping.


Each client system is unique, a composite of factors and characteristics

within a given range of responses contained within a basic structure.

Many known, unknown, and universal stressors exist. Each differ in its
potential for disturbing a clients usual stability level or normal LOD
(Line of Defence).

The particular inter-relationships of client variables at any point in time

can affect the degree to which a client is protected by the flexible LOD
against possible reaction to stressors.

Each client/ client system has evolved a normal range of responses to

the environment that is referred to as a normal LOD. The normal LOD
can be used as a standard from which to measure health deviation.

When the flexible LOD is no longer capable of protecting the client/

client system against an environmental stressor, the stressor breaks
through the normal LOD

The client whether in a state of wellness or illness, is a dynamic

composite of the inter-relationships of the variables. Wellness is on a
continuum of available energy to support the system in an optimal
state of system stability.

Implicit within each client system are internal resistance factors known
as LOR, which function to stabilize and realign the client to the usual
wellness state.

Primary prevention relates to G.K. that is applied in client assessment

and intervention, in identification and reduction of possible or actual
risk factors.

Secondary prevention relates to symptomatology following a reaction

to stressor, appropriate ranking of intervention priorities and treatment
to reduce their noxious effects.

Tertiary prevention relates to adjustive processes taking place as

reconstitution begins and maintenance factors move the back in
circular manner toward primary prevention.

The client as a system is in dynamic, constant energy exchange with

the environment.


the variables of the person in interaction with the internal and external
environment comprise the whole client system

Basic structure/Central core

The common client survival factors in unique individual characteristics

representing basic system energy resources.

The basic structure, or central core, is made up of the basic survival

factors that are common to the species (Neuman,2002).

These factors include:- - Normal temp. range, Genetic structure.Response pattern. Organ strength or weakness, Ego structure

Stability, or homeostasis, occurs when the amount of energy that is

available exceeds that being used by the system.

A homeostatic body system is constantly in a dynamic process of input,

output, feedback, and compensation, which leads to a state of balance.

Degree to reaction

The amount of system instability resulting from stressor invasion of the

normal LOD.


A process of energy depletion and disorganization moving the system

toward illness or possible death.

Flexible LOD

It is a protective, accordion like mechanism that surrounds and

protects the normal LOD from invasion by stressors.

Normal LOD

It represents what the client has become over time, or the usual state
of wellness. It is considered dynamic because it can expand or contract
over time.

Line of Resistance-LOR

The series of concentric circles that surrounds the basic structure.

Protection factors activated when stressors have penetrated the

normal LOD, causing a reaction symptomatology. E.g. mobilization of
WBC and activation of immune system mechanism

Input- output

The matter, energy, and information exchanged between client and

environment that is entering or leaving the system at any point in


A process of energy conservation that increase organization and

complexity, moving the system toward stability or a higher degree of

Open system

A system in which there is continuous flow of input and process, output

and feedback. It is a system of organized complexity where all
elements are in interaction.

Prevention as intervention

Interventions modes for nursing action and determinants for entry of

both client and nurse in to health care system.


The return and maintenance of system stability, following treatment for

stressor reaction, which may result in a higher or lower level of


A state of balance of harmony requiring energy exchanges as the client

adequately copes with stressors to retain, attain, or maintain an
optimal level of health thus preserving system integrity.


Environmental factors, intra (emotion, feeling), inter (role expectation),

and extra personal (job or finance pressure) in nature, that have
potential for disrupting system stability.

A stressor is any phenomenon that might penetrate both the F and N

LOD, resulting either a positive or negative outcome.


Wellness is the condition in which all system parts and subparts are in
harmony with the whole system of the client.

Illness is a state of insufficiency with disrupting needs unsatisfied

(Neuman, 2002).

Illness is an excessive expenditure of energy when more

energy is used by the system in its state of disorganization than
is built and stored; the outcome may be death (Neuman, 2002).


The primary nursing intervention. Prevention focuses on keeping

stressors and the stress response from having a detrimental effect on
the body.

Primary Prevention

Primary prevention occurs before the system reacts to a stressor. On

the one hand, it strengthens the person (primary the flexible LOD) to
enable him to better deal with stressors

Primary prevention includes health promotion and maintenance of


Secondary Prevention

Secondary prevention occurs after the system reacts to a stressor and

is provided in terms of existing system.

Secondary prevention focuses on preventing damage to the central

core by strengthening the internal lines of resistance and/or removing
the stressor.

Tertiary Prevention

Tertiary prevention occurs after the system has been treated through
secondary prevention strategies.

Tertiary prevention offers support to the client and attempts to add

energy to the system or reduce energy needed in order to facilitate



Human being is a total person as a client system and the person is a

layered multidimensional being.

Each layer consists of five person variable or subsystems:


Physiological - Refers of the physicochemical structure and

function of the body.

Psychological - Refers to mental processes and emotions.

Socio-cultural - Refers to relationships; and social/cultural

expectations and activities.

Spiritual - Refers to the influence of spiritual beliefs.

Developmental - Refers to
development over the lifespan.






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 extrapersonal stressors which can affect the persons normal line of defense
and so can affect the stability of the system.

The internal environment exists within the client system.

The external environment exists outside the client system.

The created environment is an environment that is created

and developed unconsciously by the client and is symbolic of
system wholeness.


Health as being equated with wellness. Health/wellness is defined as

the condition in which all parts and subparts (variables) are in
harmony with the whole of the client (Neuman, 1995).

The client system moves toward illness and death when more energy is
needed than is available. The client system moved toward wellness
when more energy is available than is needed.


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

The person is seen as a whole, and it is the task of nursing to address

the whole person.

Neuman defines nursing as action which assist individuals, families

and groups to maintain a maximum level of wellness, and the primary
aim is stability of the patient/client system, through nursing
interventions to reduce stressors.

Neuman states that, because the nurses perception will influence the
care given, then not only must the patient/clients perception be
assessed, but so must those of the caregiver (nurse).

The role of the nurse is seen in terms of degree of reaction to stressors,

and the use of primary, secondary and tertiary interventions

Person / physiologic needs



Betty Neuman's System Model


Retirement and Role Discontinuities

Sister Letty Kuan

Born on November 19, 1936 in KatipunanDipolog, Zamboanga del Norte

Sister Letty G. Kuan is a nurse with two (2) Masters Degrees, MA in

Nursing and MS in Education major in Guidance Counselling.

Holds a Doctoral Degree in Education major in Guidance Counselling.

All these postgraduate studies were obtained from the University of
the Philippines - Diliman, Quezon City

For her vast contributions to the University of the Philippines - College

of Nursing faculty and academic achievements, she was awarded the
distinctive post of Professor Emeritus, a title awarded only to a few who
met the strict criteria set by the University of the Philippines in
September 2004.

She has clinical fellowship and specialization in Neuropsychology

obtained from University of Paris, France in (Salpetriere Hospital).
Neurogerontology in Watertown, New York (Good Samaritan Hospital)
and Syracuse University, New York

Basic Assumptions and Concepts:

Physiological Age
-> is the endurance of cells and tissues to withstand the wear-and-tear
phenomenon of the human body. Some individuals are gifted with
strong genetic affinity to stay young for a long time.

-> refers to the set of shared expectations focused upon a particular
position. These may include beliefs about what goals or values the
position incumbent is to pursue and the

norms that will govern his behavior. It is also the set of shared
expectations from the retirees socialization experiences and the
values internalized while preparing for the position as well as the
adaptations to the expectations socially defined for the position itself.

For every social role, there is complementary set of roles in the social
structure among which interaction constantly occurs.

Change of Life
-> is the period between near retirement and post retirement years. In
medico-physiologic terms, this equates with the climacteric period of
adjustment and readjustment to another tempo of life.

-> is an individual who has left the position occupied for the past years
of productive life because he/she has reached the prescribed
retirement age of has completed the required years of service.

Role Discontinuity
->is the interruption in the line of status enjoyed or role performed.
The interruption may be brought about by an accident, emergency,
and change of position or retirement.

Coping Approaches
->refer to the interventions or measures applied to solve a problematic
situation or state in order to restore or maintain equilibrium and normal

Determinants of positive perceptions in retirement and positive reactions

toward role discontinuities:
1. Health Status refer to physiological and mental state of the
respondents, classified as either sickly or healthy.
2. Income (economic level) refers to the financial affluence of the
respondent which can be classified as poor, moderate or rich.
3. Work Status
4. Family Constellation means the type of family composition
described either close knit or extended family where three more
generations of family members live under one roof; or distanced
family, whose member live in separate dwelling units; or nuclear type
of family where only husband, wife and children live together.

5. Self-Preparation


The theory can be applied not only for the population undergoing
retirement process, but also for the population that is undergoing life

The theory is easy to understand, wherein most people can relate to

the effects of role change.

Weakness/ Limitations

The theory focuses too much on the positive determinants. Retirement

adjustment is clearly a multidimensional process but the theory only
used a single indicator which is the positive determinants to


The theory is useful in geriatric nursing where nurses can derive a plan
of care to help the patient to have ease of movement through a
transitional process

If individuals have a better understanding of the retirement process

and their new role, they will prepare and adjust better. (Kelly &
Swisher, 1998)

PREPARE ME Interventions & the Quality of Life

of Advance Progressive Cancer Patients
Carmencita Abaquin

Obtained her Masters Degree in Nursing from the University of the

Philippines College of Nursing.

An expert in Medical Surgical Nursing with subspecialty in Oncologic

Nursing, which made her known both here and abroad

She had served the University of the Philippines College of Nursing, as

faculty and held the position as Secretary of the College of Nursing.

Being appointed as Chairman of the Board of Nursing speaks of her

competence and integrity in the field she has chosen


PREPARE ME (Holistic Nursing Interventions) are the nursing
interventions provided to address the multi-dimensional problems of cancer
patients that can be given in any setting where patients choose to be
confined. This program emphasizes a holistic approach to nursing care.
PREPARE ME has the following components:
1. Presence being with another person during the times of need. This
includes therapeutic communication, active listening, and touch.
2. Reminisce Therapy recall of past experiences, feelings and thoughts to
facilitate adaptation to present circumstances.
3. Prayer
4. Relaxation- Breathing techniques to encourage and elicit relaxation for
the purpose

of decreasing undesirable signs and symptoms such as pain,

muscle tension, and anxiety.

5. Meditation encourages an elicit form of relaxation for the purpose of

altering patients level of awareness by focusing on an image or thought to

facilitate inner sight which helps establish connection and relationship with
God. It may be done through the use of music and other relaxation
6. Values Clarification assisting another individual to clarify his own values
about health and illness in order to facilitate effective decision making skills.
Through this, the patient develops an open mind that will facilitate
acceptance of disease state or may help deepen or enhance values. The
process of values clarification helps one become internally consistent by
achieving closer between what we do and what we feel.
Origins of the theory
the incidence of cancer has significantly increased not only in the Philippines
but also worldwide
Meaning of theory
1. Terminally-ill patients especially cancer patients require holistic approach
of nursing in different aspects of man namely the emotional, psychological,
social and spiritual. In this premise, patients with incurable disease require
multidimensional nursing care to improve quality of life.
2. PREPARE ME nursing interventions are effective in improving quality of life
in terminally-ill patients.
3. Utilization of intervention as a basic part of care given to cancer patients,
likewise, incorporation in the basic nursing curriculum in the care of these
patients. PREPARE ME must be introduced and focus during training of nurse
both in academe and practice.
4. Development of training programs for care provider as well as health care
profession where intervention is a part of treatment modalities.
5. The nurse must be honest about the feedback on his/her condition. Nurses
must do this so that they would know what the expectations of the patient
and the family so that they may render a holistic caring style for the patient
together with his family in his dying days. This would help the patient and
family address the needs of the patient in any manner possible. (Physical,
emotional and spiritual)
6. The nurse must help make a supportive environment for the patient and
his family in his dying days. An environment like this would promote dignity
in his days left thus helping the patient accept his fate and help him/her be

ready for the afterlife. The family is also guided in this rough time addressing
their grieving process by instilling in them that death is part of life.

Holistic Nursing Interventions
Prepare Me
Reminisce Therapy
Terminally ill Patients (Cancer)


Level of Independence

It provides us standardized and holistic approach in addressing the

needs of terminally ill cancer patients.

It can also be used for other terminal cases.

Weakness/ Limitations:

More time is needed to make the patient interested in PREPARE ME

interventions because they are already experiencing loss of interest in

"Understaffing in Philippine hospitals is prevalent. (Inamarga, 2009)

In the Philippine setting, due to understaffing and financial constrain,

time for bed side care is limited


This theory is useful in addressing the needs of terminally-ill cancer








relationship and self-actualization.

2. Appreciating the impact of a relative's cancer and offering guidance
and support via patient-centered counseling can enhance quality of