Hildegard E.

Peplau
was an American nurse and the first published nursing
theorist since Florence Nightingale.
“Psychiatric Nurse of the Century”

 Hildegard Peplau described the nurse- patient

relationship as a four-phase phenomenon
 One can view them as separate entities, but they
could overlap with each other over the
course of the nurse-patient interaction
 Each phase is unique and has distinguished
contributions on the outcome of the nurse-patient
interaction
 In Psychiatric Nursing, the concepts were so
important in the practice of this discipline that
nursing leaders formulated a therapy out of it

Nursing Roles
 In the course of the nurse-patient relationship, the
nurse assumes several roles which empower and
equip her in meeting the needs of the patient
 These roles are appropriately being used by the
nurse in different nursing situations and phases of
Interpersonal Relationship
 These roles could overlap one the other and could
be observed as soon as the situation comes up
Role of the Stranger
 In their initial contact, the nurse and the patient
are strangers to one another
 As the nurse attempts to know the patient better,
she must treat him with outmost courtesy, which
includes acceptance of the patient as a person and
due respect over his individuality (this role coincides
with the Identification Phase)
Role of the Resource Person
 As the patient assumes a dependent role, the
nurse provides specific answers to his queries which
include health information, advices, and a simple
explanation of the healthcare team’s course of care
 It is the responsibility of the nurse to appropriately
change her responses to the patient’s level of
understanding
Teaching Role
 As the interaction progresses, the nurse assumes a
teaching role as she gives much importance for self-
care and in helping him understand the therapeutic
plan
 In assuming this role, the nurse must determine
how the patient understands the subject at hand
 She must develop her discussion around the
interest of the patient and his ability of using the
information provided
Leadership Role
 Although dependent to the healthcare team over
his care, the patient is still considered vital in
deciding as to what course his plan of care would
take
 The nurse as a leader must act in behalf of the
patient’s best interest and at the same time enable
him to make decisions over his own care
 This is achieved through cooperation and active
participation
Surrogate Role
 The patient’s dependency for his care gives the
nurse a surrogate (temporary care giver) role
 This creates an atmosphere wherein feelings
previously felt, such as feelings towards her mother
 Some other relationships are reactivated and
nurtured
 Although the patient recognizes that the nurse has
similarities with the person whom he recalls in
previous relationships, the nurse must assist the
patient to make sure that her surrogate role is
different and only temporary
Counseling Role
 Peplau believes that the counseling role has the
greatest importance and emphasis in nursing
 This role strengthens the nurse-patient
relationship as the nurse becomes a listening friend,
an understanding family member, and someone
who gives sound and emphatic advises
 The very core of the interpersonal technique is for
the patient to remember and to understand the
experience and how could it be integrated into his
daily life
PHASES OF NURSE-PATIENT RELATIONSHIP
1. Orientation
 the initial interaction between the nurse and the
patient wherein the latter has a felt need and
expresses the desire for professional assistance
 the nurse assists the patient in recognizing and
understanding the “patient” experience
2. Identification
 the patient and the nurse explore the experience
and the needs of the patient which leads to a
feeling of relatedness
 it is very important in the relationship that the
nurse assist the patient in reorienting his feelings
and sustaining a constant positive environment
3. Exploitation
 in this phase, the patient derives the full value of
the relationship as he moves on from a dependent
role to an independent one
 new goals are projected by the nurse, but the
power is shifted to the patient as these goals would
be achieved through personal or self-effort
4. Resolution
 in its final stage stages, the patient earns
independence over his care as he gradually puts
aside old goals and formulates new ones
 even though the patient and the nurse end the
relationship, it is very apparent that the experience
leaves a lasting impression on the patient since
illness and assuming a dependent role is a unique
human experience

 The Interpersonal Therapeutic Process is based on

the theory proposed by Peplau and particularly
useful in helping psychiatric patients become
receptive for therapy
 Often referred by Peplau as “Psychological
Mothering,” it includes the following steps:
o the patient is accepted unconditionally as a
participant in a relationship that satisfies his
needs
o there is recognition of and response to the
patient’s readiness for growth, as his initiative
 o power in the relationships shifts to the patient,
as the patient is able to delay gratification and
to invest in goal achievement
ACCEPTANCE BY THE NURSING COMMUNITY
 Some of Peplau’s ideas were not widely accepted
at the time they were introduced
 However, as the concepts that form her
Interpersonal Relations Model were applied and
tested many nursing experts now recall Peplau as
the one who brought a new perspective, a new
approach and a theoretical foundation for nursing
practice
 Her ideas paved way for integrating other
scientific disciplines into nursing especially in
formulating the paradigm of psychiatric nursing in
early days
 As it became apparent that nursing practice in its
true value could only be accomplished through
starting and strengthening the nurse-patient
relationship, many clinicians now believe that it’s in
the interest of the profession and of the patient to
utilize he Interpersonal Model extensively
 Some researchers also used her model in their
studies
 They found out those nurses who promote trust by
remaining available at all times and being constant
in their approach, facilitates the movement of
influence from the nurse to the patient
EDUCATION
 Peplau’s book Interpersonal Relations in Nursing
(1951), is being used as a manual of instruction to
help graduate nurses and nursing students like in
creating a significant nurse-patient relationship in
any setting they are into
 Her theoretical ideas, particularly her views of
nursing and nursing process, the psycho-dynamic
theory, and her prescribed methods, have been an
essential part of the collective culture of the nursing
profession
RESEARCH
 At the arrival of the Interpersonal Model, nursing
researchers follow the major assumption that
patient problems were within the person
phenomena and were dealt inside the nurse-patient
interaction studies
 When her model was slowly integrated, research
has shifted to perspectives within the social system
as newer studies indicate that broader sets of
relationships could also affect a person in many
ways
 Peplau influenced upcoming nursing leaders
especially those in the graduate school in the field
of Psychiatric Nursing
 The role of the nurse as a stranger changed one’s
view on anxiety as an important definition of stress
and its real effect on learning
 Uncertainty about the nurse-patient relationship
was later on ended as Peplau
 Also pulled together missing pieces of this very  She functionally categorizes the four phases of the
important nursing aspect and placed them together interpersonal process with the nurse’s role taken
into systematic, scientific terms that could be into consideration together with the patient’s level
tested, proved, applied and integrated into the daily of dependence
practice of the nursing profession  Peplau’s theory may be considered to be précised
ANALYSIS but with continued research and development, the
degree of precision could be more increased
 The major focus of Peplau’s theory, inter-personal
DERIVABLE CONSEQUENCE
relations, is easily understood
 Peplau’s works are highly regarded as pioneering,
 The theory’s basic assumptions and key concepts
and more so, widening the perception of nursing as
were clearly given, explained, broken down and
a noble profession
outlined
 Her works, thoughts, and ideas have greatly
 She also demonstrated how this model could be
touched the lives of many patients and nurses, from
used as a process when she introduced the Four
students to practitioners
Phases of Nurse-Patient Relationship
 Although her work has been published five
 The different roles of the nurse added further
decades ago, it never ceases in providing the
understanding on how nurses could effectively use
direction for nursing practice, education and
the Interpersonal Model by identifying which role is
research
appropriate at a given phase or situation in perfect
 Peplau’s work has provided a significant
harmony with the nursing process
contribution to the profession
 Peplau’s logic was taken from specific observations
and applies them in general also called as Inductive
Reasoning
 Peplau closely observed relationships of the
interpersonal process, nurse, patient and
psychological experiences she was able to discover
patterns that enabled the nurse and the patient to
achieve the full measure of their relationship
 Peplau’s theory could be described as the meeting
of quality with simplicity
GENERALITY
 Believed that all nurses, regardless of their
area or clinical setting, could effectively utilize
her model
 However, the theory can be used only to
situations that communication can occur
between the nurse and the patient
 For the nurse to function as an educative,
therapeutic and maturing force, understanding
the meaning of the experience to the patient is
very important (this evaluative standard is not
met)
EMPIRICAL PRECISION
 Peplau provides a theory based on reality

 Her theory could be tested and observed using

pure observation
 The relationship between the theoretical area and
empirical data could be validated and verified
14 BASIC HUMAN NEEDS
Virginia Henderson

 Her writing, presentation, research, and

contacts with nurses have profoundly affected
nursing and gave an impression on the
recipients of care by nurses throughout the
world
 She was the first full-time instructor in nursing
in Virginia
 She was an early advocate for the introduction
of psychiatric nursing in the curriculum and
served on a committee to develop such course
at Eastern State Hospital in Williamsburg,
Virginia in 1929
 During her years at Teachers College, Columbia
University Henderson was an outstanding
teacher and students came from many
countries to study with her
 At the age of 75, Henderson directed her
career to international teaching and speaking
 This enabled another generation to harvest the
benefits of contact with this outstanding nurse
of the twentieth century

METAPARADIGM IN NURSING
As a patient
She stated that the person is an individual who requires
assistance to achieve health and independence or in
some cases, a peaceful death
She introduced the concept of the mind and body of a
person as inseparable
For a person to function to the utmost, he must be able
to maintain physiological and emotional balance
HEALTH
Henderson viewed health as a quality of life and is very
basic for a person to function fully
Since health is a multifactor phenomenon, it is
influenced by both internal and external factors which
play independent and interdependent roles in achieving
health
She also gave emphasis in prioritizing health promotion
as more important than care of the sick
ENVIRONMENT
It is important for a healthy individual to control the
environment, but as illness occurs, this ability is
diminished or affected
In caring for the sick, it is the responsibility of the nurse
to help the patient manage his surroundings to protect
him from harm or any mechanical injury
In assuming this role, the nurse must be educated about
safety and must be aware of different social customs
and religious practices to assess dangers
Nurses must provide physicians data about the safety
needs of the patient, the nurse’s observations and
judgment regarding these needs as the latter uses this
as the basis in prescribing protective devices
It is also the responsibility of the nurse to recommend
changes regarding construction of buildings, purchase
equipment, and maintenance in order for him or her to
minimize chances of injury
NURSING
Henderson asserted that nurses function independently
from the physician, but they must promote the
treatment plan prescribed by the physician
Although part of the health care team, the nurse must
act independently but in coordination with the
therapeutic plan developed by the team
Another special role of the nurses is to help both the
sick and well individual
Care must include people from all walks of life, from the
well to the sick, and from the newborn to the dying
The care given by the nurse, as Henderson stressed,
must empower the patient to gain independence as
rapidly as possible
In the role of the nurse as a health care provider, the
nurse must be knowledgeable in both biological and
social sciences and must have the ability to assess basic
human needs
Henderson’s definition of nursing was considered as the
signature of the profession
14 FUNDAMENTAL NEEDS OF HUMANS
- Virginia Henderson broke down nursing
activities into 14 components or basic needs
- These components are based off of human
needs
1. Breathing normally
2. Eating and drinking adequately
3. Eliminating body wastes
4. Moving and maintaining a desirable position
5. Sleeping and resting
6. Selecting suitable clothes
7. Maintaining normal body temperature by
adjusting clothing and modifying the
environment
8. Keeping the body clean and well groomed to
promote integument (skin)
9. Avoid dangers in the environment and
avoiding injuring others
10. Communicating with others in expressing
emotions, needs, fears, or opinions
11. Worshipping according to one’s faith
12. Working such a way that one feels a sense
of accomplishment
13. Playing or participating in various forms of
recreation
14. Learning, discovering or satisfying the
curiosity that leads to normal development and
health, and using available health facilities

THE NURSE-PATIENT RELATIONSHIP

Henderson stated that there are three levels
compromising the nurse-patient relationship

THE NURSE AS A SUBSTITUTE FOR THE PATIENT

In times of illness, when the patient cannot function
fully, the nurse serves as the substitute as to what the
patient lacks such as knowledge, will and strength in
order to make him complete, whole and independent
once again
THE NURSE AS A HELPER TO THE PATIENT
In situations where the patient cannot meet his basic
needs, the nurse serves as a helper to accomplish them
Since these needs are needed to achieve health, the
nurse focuses he attention in assisting the patient meet
these needs so as to regain independence as quickly as
possible
ACCEPTANCE BY THE NURSING COMMUNITY
ASSESSMENT PHASE
 The nurse would assess the 14 fundamental needs
of the patients and check which one is lacking or
fully met
 She gathers data by observing, smelling, feeling,
and hearing
 To complete this phase, the nurse uses critical
thinking and analyzes every data collected to come
up with a clear picture of the condition of the
patient
PLANNING PHASE
 Involves giving the plan of care to meet the needs
and personality of the patient
 It must serve as a record and at the same time
must fit in the prescribed plan made by the
physician
 To make the plan same with the goals of the
healthcare team, the roles and responsibilities of
each professional member must be included and
integrated to the care plan
IMPLEMENTATION PHASE
 The nurse uses the 14 basic needs in answering the
factors that are contributing to the illness state of
the patient
 These interventions are focused on maintaining
health, to recover from illness, or to aid in peaceful
death
 She performs these activities that are directed in
helping the patient attain his independence as fast
as possible
EVALUATION PHASE
 The nurse and the patient reviews the relationship
and decides whether the goals are met or not
 The nurse also assess if the patient attained
independence and if health is achieved
ANALYSIS
Virginia Henderson had no intention on formulating a
theory; but her definitions of nursing, person, health
and environment could still be considered as a grand
theory or philosophy in the early days where nursing
has not yet fully developed the theories we are using
today
SIMPLICITY
 Henderson’s concept of nursing is complex rather
than simplistic
 Many variables and several descriptive
interpretations could be derived and other
explanatory relationships could be seen
 The 14 basic needs had undergone several
revisions clear, simple and concise
GENERALITY
 The definitions provided by Henderson are
broad in scope
 They work in such a way that they cover all
areas of nursing practice and could be applied in
every setting
DERIVABLE CONSEQUENCES
 The perspective related to Henderson’s theory
opened doors for development by the upcoming
nursing theorists
 In most of her published works, she emphasized
the importance of Nursing’s independence from
and interdependence on the different healthcare
professions
 She advocated curriculum development and at the
same time viewed research as an important tool in
improving the clinical practice of nursing
 Henderson’s definition of the unique function of a
nurse has been widely read and accepted
 This became a first huge step in developing nursing
into a professional scientific discipline
 Until today, Henderson’s works are still given
credit and are often mentioned in nursing literature
and researches in all areas of the professions
HUMAN-TO-HUMAN RELATIONSHIP MODEL OF
NURSING( interactive theories 3)
Joyce Travelbee
 She was a psychiatric nurse, educator and writer
 Born in 1926 and died in 1973 at the age of 47 after
a brief sickness
METAPARADIGM IN NURSING
 Defined as human being
 Both the nurse and the patient are human beings
 A human being is a unique, irreplaceable individual
who is in the continuous process of becoming,
evolving and changing
HEALTH
 She stated that health is measured by subjective
and objective health
 “a person’s subjective health status is an
individually defined state of well being in accord
with self-appraisal of physical-emotional-spiritual
status”
 Objective health is “an absence of discernible
disease, disability, or defect as measured by
physical examination, laboratory tests, assessment
by a spiritual director or psychological counselor ”
ENVIRONMENT
 Was not clearly defined in Travelbee’s theory
 She defined human conditions and life experiences
encountered by all men as sufferings, hope, pain
and illness
 These conditions are associated to the environment
NURSING
 “is an interpersonal process whereby the
professional nurse practitioner assists an individual,
family, or community to prevent or cope with the
experience of illness and suffering and, if necessary,
to find meaning in these experiences”
 She explained that nursing is an interpersonal
process because it is an experience that occurs
between the nurse and an individual or group of
individuals
HUMAN-TO-HUMAN RELATIONSHIP MODEL
 Travelbee’s formulation of her theory was greatly
influenced by her experiences in nursing education
and practice in Catholic charity institutions
 She concluded that the nursing care rendered to
patients in these institutions lacked compassion
 She thought that nursing care needed a “humanistic
revolution” – a return to focus on the caring
function towards the ill person
 Ida Jean Orlando-her mentor- is one of her
influences in her theory ; Orlando’s model has
similarities to the model that Travelbee proposes
 Travelbee stated that the purpose of nursing is to
“assist an individual, family, or community to
 prevent or cope with the experience of illness and
suffering, and, if necessary, to find meaning in these
experiences”
 In her human-to-human relationship model, the
nurse and the patient undergoes the following
series of interactional phases
 (note that the interactional phases are in
consecutive order with one another goes deeper
and more therapeutic)
ORIGINAL ENCOUNTER
 This described as the first impression by the nurse
of the sick person and vice-versa
 The nurse and patient see each other in
stereotyped or traditional roles
EMERGING IDENTITIES
 This phase is described by the nurse and patient
perceiving each other as unique individuals
 At this time, the link of relationship begins to form
EMPATHY
 Travelbee proposed that two qualities that enhance
the empathy process are similarities of experience
and the desire to understand another person
 This phase is described as the ability to share in the
person’s experience
 The result of the empathic process is the ability to
expect the behavior of the individual with whom
he/she empathized
SYMPATHY
 Happens when the nurse wants to lessen the cause
of the patient’s suffering
 It goes beyond empathy
 “When one sympathizes, one is involved but not
incapacitated by the involvement.”
 The nurse should use a disciplined intellectual
approach together with therapeutic use of self to
make helpful nursing actions
RAPPORT
 Is described as nursing interventions that lessens
the patient’s suffering
 The nurse and the sick person are relating as human
being to human being
 The sick person shows trust and confidence in the
nurse
 “A nurse is able to establish rapport because she
possesses the necessary knowledge and skills
required to assist ill persons and because she is able
to perceive, respond to, and appreciate the
uniqueness of the ill human being ”
ACCEPTANCE OF THE NURSING COMMUNITY
PRACTICE
 The hospice is one good example in which
Travelbee’s theory is applied
 The hospice nurse attempts to build rapport or a
working relationship with the patient, as well as
with his significant others
 She stated that understanding illness and suffering
enables the patient not only to accept the sickness,
but also to use it as a self-actualizing life experience
 A sick person’s insight of worthlessness in his or her
sickness leads to non-acceptance of his condition
and the great possibility to lose hope
 A hospice nurse believes that the dying person must
find meaning in his/her death before he/she can
ever begin to accept the actuality of death, just as
his/her loved ones must find meaning in death
before they can complete the grieving process
EDUCATION
 Travelbee’s concepts served as a better assistance
for nurses who help individuals understand the
meaning of illness and suffering
 Intervention in Psychiatric Nursing Process in the
One-to-One Relationship, has been used in different
nursing programs
 According to Travelbee’s model, courses in
philosophy and religion would also be helpful in
preparing nursing students to fulfill the purpose of
nursing sufficiently
RESEARCH
 Numerous sources in research studies have cited
some aspects of the one-to-one relationship
projected by Travelbee
 One study by O’Connor, Wicker and Germino,
which is nearly related to some of Travelbee’s ideas,
discovers how individuals who were recently
diagnosed with cancer described their personal
search for meaning
 The result of this study make known that the
search for meaning seems to be both a spiritual and
psychosocial process
 The researchers acknowledge nursing interventions
that would support this process
 No other theory of Travelbee that would create
further development is available
ANALYSIS
CLARITY
 The definition of Travelbee’s theory are not
consistent in clarity and origin
 Some of the definitions are Travelbee’s own and
some are adopted from standard sources; she also
used different terms for same definition
 She had more focus on adult individuals who are
sick and the nurse’s role I helping them find
meaning in their sickness and suffering
 She dealt with families and their needs minimally
but they do not include communities
SIMPLICITY
 The theory contains different variables, for that
reason simplicity is not that evident
 It is intended to assist nurses appreciate and
understand not only the patient’s humanness, but
also her own, thus her theory was not able to meet
this criteria
 To be human is not unique, so the variables present
in each phase of the human-to-human relationship
are numerous
GENERALITY
 The theory has a wide scope of application
 She mainly developed this from her experiences
with psychiatric patients
 However, it is not limited to use in this setting
 It is applicable whenever the nurse encounters
patients in distress and life changing events
 It seems to be most useful when working with those
who are chronically ill, those who are undergoing
long term rehabilitation, and the dying or terminally
ill
EMPIRICAL PRECISION
 Appears to have a low measure of empirical
soundness, as the result of lack of simplicity in the
theory
 Defines concepts theoretically, but does not define
them operationally, or in the practical setting
 This model has not been tested; thus it has no
empirical support
DERIVABLE CONSEQUENCES
 The theory is useful for the reason that it has the
ability to describe, explain, predict and control
phenomena
 The theory explains some variables that may affect
the establishment of a therapeutic relationship
between the nurse and the patient
 However, the lack of empirical precision also
creates lack of usefulness
 The theory focuses on the development of the
quality of caring; thus, the theory can be useful
since caring is a major characteristic that a nurse
should possess
SYSTEMS THEORIES 1
SYSTEM MODEL IN NURSING PRACTICE
Betty Neuman
 She was born in 1924 on a farm near Lowell, Ohio
 Her father was a farmer and her mother was a
homemaker
 Her initial nursing education was completed with
double honors at People's Hospital School of
Nursing (now General Hospital) Akron, Ohio in 1947
 She moved to California and worked as hospital
staff and head nurse, school nurse, industrial nurse
 She was also involved in clinical teaching in what is
now the University of Southern California medical
Center, Los Angeles in the areas of medical-surgical,
communicable disease and critical care
 She has been involved in a whole variety of
professional international activities since developing
the Neuman Systems Model including numerous
publications, paper presentations, consultation ,
lectures and conferences
 She serves as a consultant internationally for
nursing schools theory-based practice
METAPARADIGM IN NURSING
 Her theory incorporated the concept of a whole
person and an open system approach
 The concept is aimed towards the development of
a person in a state of wellness having the capacity
to function optimally
 The main role of the nurse in her theory is to help a
person to adopt with environmental stimuli causing
illnesses back to a state of wellness
NURSING
• Nursing requires a holistic approach, an approach
that considers all factors afflicting a client’s health
• The model sets a structure that depicts the part and
subparts of a client as a complete system
• The concept provides the nurse to consider that a
client’s physical , physiological, psychological,
mental , social, cultural, developmental and spiritual
well-being is dynamic
• A nurse must be able to adjust to meet the
individual and unique needs of every client
PERSON
 The concept of a person an individual, family,
community or the society
 She uses a person as an open system that works
together with other parts of its body as it interact
with the environment
 An open system is characterized presence of an
exchange of information and reaction with other
factors surrounding a person
HEALTH
 Considers health as dynamic in nature
 A person’s health depends upon which state of the
health continuum they are in line with the person
maybe in line with the state of wellness or illness
 The state of wellness exists when all the part or
system of a person works harmoniously
 Disharmonious system reflects illness as a result of
unmet needs of a person
 The state of health varies according to the degree of
reaction a person has to environmental forces
 If a person successfully copes with the
environmental influences and is able to maintain
adequate level of health, the person can preserve
the integrity of all the parts of its system
ENVIRONMENT
 Can be an internal, external and created force that
interacts with a person’s state of health
 It can alter or improve the systems in which a
person exists
 These forces are termed as the stressors
 Stressors are tensions that produce alterations in
the normal flow of the environment
 These stressors can be:
 Intrapersonal - occurs within the self and
comprises of man as psychospiritual being
 Interpersonal – occurs between one or more
individual and consists of man as a social being
SYSTEM MODEL IN NURSING PRACTICE
CLIENT VARIABLES
 The clients variables can be one or combination of
the following physiological, sociocultural,
developmental and spiritual
 These variables function to achieve stability in
relation to the environmental stressors experienced
by the client
LINES OF RESISTANCE
 Lines of Resistance act when the Normal Line of
Defense is invaded by too much stressor,
producing alterations in the client’s health
 It acts to facilitate coping to overcome the
stressors that are present within the individual
NORMAL LINE OF DEFENSE
 To achieve the stability of the system the Normal
Line of Defense must act in coordination with the
normal wellness state
 It must reflect the actual range of responses that is
normally acted by clients in response to any
stressors
 It is the baseline in determining the level of wellness
of client within the continuum of health
FLEXIBLE LINE OF DEFENSE
 Serves as a boundary for the Normal Line of
Defense to adjust to situations that threaten the
imbalance within the client’s stability
 It expanded the range of normal defense from
becoming invaded by the stressors thus increasing
protection
STRESSORS
 Are forces that produce tensions, alterations or
potential problems causing instability within the
client’s system
 The importance of identifying the stressors helps
nurses to appropriately use actions to address and
help solve the produced problem
REACTION
 Are the outcomes or produced results of a certain
stressors and actions of the lines of resistance of a
client (it can be positive or negative depending on
the degree of reaction the client produces to adjust
and adapt with the situation)
 Neuman specified these reactions as:
- NEGENTROPHY – is set towards stability or wellness
- EGENTROPHY – is set towards disorganization of the
system producing illness
PREVENTION
 Is used to attain balance within the continuum of
health
 These are actions that generate good results or
aimed towards hindering negative outcomes
 There are three LEVELS OF PREVENTION according
to this theory
PRIMARY PREVENTION – focuses on foreseeing the
result of an act or
situation and preventing its unnecessary effects as
possible
-it also aims to strengthen the capacity of a person to
maintain an optimum level of functioning while being
interactive with the
environment like promotion and disease prevention
SECONDARY PREVENTION – focuses on helping
alleviate the actual
existing effects of an action that altered that balance of
health of a person
-it aims to reduce environmental influences that lead to
the decline of the level of functioning of a person and
strengthening or restoring a person’s resistance after
the illness exposure, early detection of disease
and prompt treatment for example
TERTIARY PREVENTION - focuses on actual treatments
or adjustments to facilitate the strengthening of a
person after being exposed to a certain disease or
illness
-It aims to prevent the regression or reoccurrence of the
illness in the manner of rehabilitation, as in the case of
disability avoidance and physical therapy
RECONSTITUTION
• Is the adjustment state from the degree of reaction
• It is a state of going back to the actual state of
health before the illness occurred
ACCEPTANCE BY THE NURSING COMMUNITY
PRACTICE
 With Neuman’s system model, nursing practice
became unified and holistic in approach
 The concept is not only applicable to nursing but
also multidisciplinary as nurses use the nursing
process format and prevention as an intervention
to collaborate with the health care team
 The model can be applicable in addressing the
problem of an individual, family, community or the
society in different practice settings
 The model can be applicable in hospitals, health
care clinics, nursing homes, rehabilitation centers
and even birthing centers
 The model’s holistic approach can be specifically
applicable to clients’ health condition facing
complex stressors
 This model can help nurses to formulate an
approach that can prevent and alleviate the client’s
condition
 It is also applicable in organizing a framework to
plan care at primary, secondary and tertiary levels
of prevention of health care facilities
EDUCATION
• Has been applicable in the academe because of its
holistic approach, as it has been widely used both
by nursing students and educators
• As a model demonstrated effectiveness in
conceptual transition among levels of nursing
education
• It has formed a basis for continuing study after
graduation thus facilitating growth of nursing
knowledge and practice as it is integrated in nursing
curriculum
• Education through Neuman’s model provides a
direction to validate nursing roles and activities
setting its applicability beyond nursing practice
RESEARCH
 Research incorporated the use of testing efficacy
and usefulness of the model in different areas and
scope of the nursing practice
 It’s been noted that Neuman’s model has been one
of the widely used framework used in nursing
research as it guide the enhancement of nursing
care
 Nursing research expanded the used of the model in
the hospital, health clinics, homes, community and
schoolsS
ANALYSIS
 Viewed to have contradicting reactions
 Others say that her model was not simple enough,
but others believe that it can be easily understood
and used
 Its simplicity for others can be used to understand
the health of a person within the health continuum
 Identifying the related stressors and possible
reactions it can produce to a person helps to simply
understand a client’s well-being
 Using her model, nurses and other health care
professionals can also have prevention and
restoration activities for a person if used correctly
 GENERALITY
 Can be used in different health care settings in
which the nurse is one of the facilitators
 Her theory was comprehensive and adaptable for
the nurse to use in the different practice settings
 Its applicability is congruent with the social,
physical, physiological, psychological. Spiritual
aspects of a person which is very holistic
EMPIRICAL PRECISION
 Some critiques believe that the use of Neuman’s
theory increases the collection of empiricism within
the scope of the nursing practice
 It is predicted that the enhancement of the theory
has an increasing chance
 This prediction will improve nursing practice as it is
being widely used in different practice settings
DERIVABLE CONSEQUENCES
 Provides guidelines for a professional nurse to have
an accurate assessment, planning, implementation
and evaluation of the planned care for their clients
 Its characteristics are applicable to the 21 st century,
therefore, it can be useful for basis for research,
thus producing new nursing knowledge that can
significantly utilized within the scope of the nursing
practice
SYSTEMS THEORIES 2
BEHAVIORAL SYSTEM MODEL
Dorothy Johnson
 She was born in Savannah, Georgia in 1919 and the
youngest in family of seven
 She obtained her Bachelor of science in Nursing
degree from Vanderbilt University, Nashville,
Tennessee and her Master in Public Health from
Harvard University in Boston, Massachusetts (she
began publishing her ideas about nursing soon after
graduation from Vanderbilt)
 Most of her education career was in Pediatric
Nursing at the University of California, Los Angeles
 Johnson has influenced nursing through her
publications since the 1950’s
 Through her career, Johnson has made her cause on
the importance of Research-Base Knowledge about
the effect of nursing care on clients
 She was an early advocate of Nursing as a Science as
well as an Art; she assumed that nursing had a body
of knowledge reflecting both the science and the art
 In 1961, Johnson proposed that nursing care
facilitated the client’s maintenance of a state of
equilibrium (she projected that clients were
“stressed” by a stimulus of either an internal or
external nature and these stressful stimulus shaped
such conflict or “tensions” in the patient a state of
disequilibrium occurred); Johnson recognized two
areas of focus for nursing care that are based in
giving back to the client to a state of equilibrium or
a balance:
first – nursing care should lessen stimuli that are
stressors
second - nursing care should offer support of
the client’s
 In 1968, Johnson first proposed her model of
nursing care as the nurturing of the competent and
helpful behavioral, functioning in the patient to
avoid illness; consequently the patient is seen as a
behavioral system subsystems (at this point,
Johnson began to join concepts related to system
models into her work)
 In 1980, Johnson made in print her
conceptualization of the Behavioral System Model
for Nursing (this is the work published by Johnson
that defines her definitions of the Behavioral
System Model )
 In 1992, Johnson uttered that much of her thinking
was influenced by Florence Nightingale (while
reading Nightingale’s Notes on Nursing, she found
that ) Nightingale placed importance on the primary
needs of people rather than the disease process and
she also noted that Nightingale gave little bit of
importance on the connection of the person to the
environment rather than the disease to the person
METAPARADIGM IN NURSING
PERSON
 Views a person as having two major systems: the
biological system and the behavioral system
 It is the role of medicine to focus on the biological
system, whereas nursing focus is on the behavioral
system
 There is recognition of the reciprocal actions that
occur between the biological and behavioral
systems when some type of dysfunction occurs in
one or the other of the systems
HEALTH
 Is an elusive state that is affected by social,
physiological, biological, and physiological factors
 Johnson’s behavioral model supports the idea that
the individual is striving to retain some balance or
equilibrium
 The individual’s goal is to sustain the entire
behavioral system efficiently and effectively but
with an adequate amount of flexibility to return to
an acceptable if malfunction disrupts the original
balance
ENVIRONMENT
 An individual’s behavior is influenced by all the
events in the environment
 Cultural influences on the individual’s behavior are
viewed as profound (however, it is evident that
there are many factors that influence specific
behaviors in a group )
 These factors are believed to vary from culture to
culture although the outcomes for all the groups or
individuals are the same
NURSING
 The primary goal is to cultivate equilibrium within
the individual which allows for the practice of
nursing with individuals at any point in the health-
illness continuum
 Nursing implementations may focus on correction
of a behavior that is not concerned to maintaining
equilibrium for the individual in earlier works
 Johnson focused nursing on impaired individuals
 By 1980, she stated that nursing is concerned with
the organized and integrated whole or holistic
growth of the individual, but that the chief focus is
on maintaining a balance in the behavioral system
when illness occurs in the individual
SEVEN BEHAVIORAL SUBSYSTEMS
 THE ATTACHMENT OR AFFILIATIVE SUBSYSTEMS –
is well-known as the earliest response system to
expand in the individual. The most favorable
functioning of the affiliative subsystems allows
social inclusion, closeness, and the pattern and
continuance of a strong public bond. Attachment to
a note worthy caregiver has been found to be
important for the survival of an infant
 THE DEPENDENCY SUBSYSTEM – is distinguished
from the attachment or affiliative subsystem.
Dependency behaviors are actions that trigger
nurturing behaviors from other individuals in the
environment. The product of dependency behavior
is consent, interest or appreciation, and physical
support
 THE INGESTIVE SUBSYSTEMS – relates to the
behaviors surrounding the ingestion of food. It is
associated to the biological system. The perspective
is in the significance and arrangement of the social
events surrounding the occasions when food is
eaten. Behaviors related to the ingestion of food
may relate more to what is socially satisfactory in a
specified culture than to the biological necessities of
the human being
 THE ELIMINATIVE SUBSYSTEMS – relate to
behaviors surrounding the secretion of waste
products from the body. Johnson concludes this
may be tricky to separate fro a biological system
perspective. However, as with behaviors
surrounding the ingestion of food there are socially
adequate behaviors for the time and place for
humans to excrete waste. Human cultures have
defined different socially acceptable behaviors for
excretion of waste, but the continuation of such an
outline remains from culture to culture
 THE SEXUAL SUBSYSTEM – imitates behaviors
related to procreation or reproduction. Both
biological and social factors are involved behaviors
in the sexual subsystem. Again, the behaviors
from culture to culture. Behaviors also vary
according to the gender of the individual. The key is
that the goal in all societies has the same outcome-
behaviors suitable to the society at large
 THE AGGRESSIVE SUBSYSTEMS - relates to
behaviors concerned with defense and self-
preservation. Johnson sees the aggressive
subsystems as one that creates defensive responses
from the individual when life or territory is
threatened. The aggressive subsystems does not
include those behaviors with a primary purpose of
injuring other individuals, but rather those whose
purpose is to protect and conserve self and society
 THE ACHIEVEMENT SUBSYSTEM – contains
behaviors that attempt to control the environment.
Intellectual, physical, imaginative, mechanical and
communal skills are some of the areas that Johnson
distinguishes. Other areas of personal
accomplishment or success may also be integrated
in this subsystem
ACCEPTANCE BY THE NURSING COMMUNITY
PRACTICE
 The Johnson Behavioral System Model was used to
develop a self-support and observational
instrument to be carried out with the nursing
process
 The implementation of the instrument provided a
more comprehensive and organized step to
assessment and intervention, thereby increasing
patient and nurse satisfaction with care
 Moreover, this theory was used as a model to
develop as assessment tool when caring for children
(this tool allowed the nurse to objectively describe
the child’s behavior and to guide nursing action)
EDUCATION
 A core curriculum based on a person as a behavioral
system would have definite goals and clear course
of planning
 The study would center on the patient as a
behavioral system and its dysfunction, which would
necessitate the use of the nursing process
In addition to an understanding of systems theory , the
student would need knowledge from the social and
behavioral disciplines and the physical and biological
sciences
 RESEARCH
 Nursing research, according to Johnson is vital to
explain and identify the behavioral system disorders
which arise in relation with illness and develop good
reasoning for the means of management
 The theory resulting from the Behavioral Model
influences to the researcher to choose between two
options
(One researcher might examine the functioning of the
system and subsystemby focusing on the Basic Sciences
and another researcher might focus on investigating
methods of gathering diagnostic data or problem-
solving activities as these influences the behavioral
system
ANALYSIS
SIMPLICITY
 This theory is somewhat straightforward in relation
to the number of concepts
 A person is described as a behavioral system
composed of seven subsystems; Nursing is an
external regulatory force
 However, the theory is potentially complex since
there is a number of a possible interrelationship
between and among the behavioral systems, its
subsystems, and the forces drawing on them
GENERALITY
 This theory is relatively limitless when applied to
sick individual or groups
 Johnson perceives a person as a behavioral system
comprised of seven subsystems, the sum of
interactive behavioral systems; she did not clearly
address non-illness situation or preventive nursing
(In later publications, Johnson emphasized the
role of nurses in preventive healthcare of individuals
and for the society; she stated that Nursing needs to
focus on developing preventive nursing to fulfill its
social obligations)
EMPIRICAL PRECISION
Is achieved byidentifying empirical indicators for the
theory because models contain abstract concepts
It improves when the subconcepts and the
relationships between and among the sunconcepts become
better defined and empirical indicators are introduced to the
science
So far, a moderate degree of empirical precision has
been demonstrated in research using Johnson’s model
(However, throughout Johnsons’s writings, terms
such as balance stability and equilibrium, adjustments
and adaptations, disturbances disequilibrium and
behavioral disorders are use interchangeably, which
confuse their meanings; the clarity of definitions in the
subsystems improves the model’s empirical precision)
DERIVABLE CONSEQUENCES
 Johnson’s model guides nursing practice, education
and research generates new ideas about nursing
and differentiates nursing from other professions
 By focusing on behavior rather than biology, the
theory clearly differentiates Nursing from Medicine,
although the concepts overlap with the
psychosocial professions
 The theory has directed questions for nursing
research
 It has been analyzed and judged to be appropriate
as a basis for the development of nursing
curriculum
 Practitioners and patients have judged the resulting
nursing actions to be satisfactory
 The theory has a good potential for continued use in
nursing to achieve valued nursing goals
GOAL ATTAINMENT THEORY
Imogene King
 Imogene King was born on January 30, 1923 in West
Point, Iowa
 She received her nursing diploma from St. John’s
Hospital School of Nursing in St. Louis, Missouri, in
1945
 In 1948, she earned her Bachelor of Science in
Nursing from St. Louis University, and went on to
complete her Master’s of Science in Nursing, also
from St. Louis University in 1957
 She also earned her doctoral degree from Teachers
College, Columbia University in 1961. She died on
December 24, 2007
 Between 1966 and 1968, King worked as Assistant
Chief of the Research Grants Branch of the Division
of Nursing in Washington, D.C. under Dr. Jessie
Scott
 She was the director of the Ohio State University
School of Nursing from 1968 until 1972. She was an
Associate Professor from 1961 until 1966 and a
Professor from 1971 until 1980 at Loyola University
in Chicago. After serving as a professor at the
University of South Florida’s College of Nursing in
Tampa, Florida from 1980 until 1990, King retired
with the title Professor Emeritus.
METAPARADIGM IN NURSING
 King’s model is composed of three interacting
systems: these are Personal, Interpersonal and
Social Communication
 These are used to establish a nurse-client
relationship and utilized by the nurse to form a
strong foundation for a dynamic and interactive
environment. King discussed the three health
needs of human beings:
1. Need for information
2. Need for care for illness prevention and
3. Need for total care when a person doesn’t have
the capacity to help themselves
 The theory focuses on creating a positive behavior
that can be adapted both by the nurse and client to
achieve goals established by the client with the help
of a nurse
PERSON
Viewed a person existing in an open system as a
spiritual being and rational thinker who makes choices,
selects alternative courses of action, and has the ability
to record their history through their own language and
symbols, unique , holistic and have different needs,
wants and goals
HEALTH
Viewed Health as the ability of a person to adjust to the
stressors that the internal and external environment
exposes to the client . It is the maximal use of the
potentials that a person can perform to achieve balance
in one’s health. Adjusting to the environment bring the
client back to their usual roles before the reaction
occurred
ENVIRONMENT
Defined environment as the process of balance
involving internal and external interactions inside the
social system. Reactions from the interaction between
the internal and external environment can be
biological, psychological, physical, social or spiritual.
External environment is the factor that exists outside
the boundary of the open system while the internal
environment is the exact opposite as adapted by the
Neuman’s Systems Model. The environment has a
direct exchange of information between the internal
and external environment
NURSING
Nursing is an act wherein the nurse interacts and
communicates with the client. The nurse helps the
client identify the existing health condition, exploring
and agreeing on activities to promote health. The goal
of the nurse in King’s theory is to help the client
maintain health through health promotion and
maintenance restoration and caring for the sick and
dying
INTERACTING SYSTEMS FRAMEWORK
 King proposed that the nurse interacts in the system
simultaneously at three different levels, namely:
Personal, Interpersonal, and Social Frameworks.
These three levels are independent and at the same
time co-exist to influence over-all nursing practice
 PERSONAL – how the nurse views and integrates
self based from personal goals and beliefs
 INTERPERSONAL – how the nurse interrelates with
a co-worker or patient , particularly in a nurse-
patient relationship
 SOCIAL – how the nurse interacts with co-workers,
superiors, subordinates and the client environment
GOAL ATTAINMENT THEORY
 ACTION – is means of behavior or activities that are
towards the accomplishment of certain act. It is
both physical and mental. The accomplishment of a
task begins with mental action whereby a person
seeks or formulate plan of activities and proceeded
by physical action. Actions are aimed towards
setting goals through communication between the
nurse and the client then exploring and agreeing
means to perform them thereby achieving the set
goal
 REACTION – (in King’s theory is not specified but
somehow relates reaction as part of action) is a
form of reacting or a response to a certain stimuli
 INTERACTION – (as defined by King) is any situation
wherein the nurse relates and deals with a clientele
 OPEN SYSTEM – is the absence of boundary
existence, where a dynamic interaction between
the internal and external environment can
exchange information without barriers or
hindrances
PROPOSITION OF KING’S GOAL ATTAINMENT
THEORY
 King gave a proposal wherein goal attainment is
possible if the nurse will fulfill several conditions
 If a continuous accuracy is currently is a nurse-
patient interaction, a transaction will happen
 If nurse and patient will build a transaction, goals
will be achieved
 If goals are achieved, satisfaction will happen
 If goals are met, efficient nursing care will happen
 If transactions re done in a nurse-client interaction,
growth and development will increase
 If role anticipation and performance in the nurse
and patient are the same , transactions will happen
 If role disagreement happens in both nurse and
patient, stress would be the result
 If nurse with exceptional skill and knowledge
correspond adequate information to patient, the
same goals and accomplishment will happen
ACCEPTANCE BY THE NURSING COMMUNITY
PRACTICE
 Professionals have used King’s theory in different
specialized area with the use of dynamic interactive
communication between the nurse and the client as
proof
 Professionals need communication to successfully
and correctly make decisions for their plan of care
 The significance of King’s Goal Attainment Theory
have been applied to different professional practice
setting such as in nursing administration, theory-
based practice in the emergency department, in
tertiary hospitals and in the community
 King also developed the Goal Oriented Nursing
Record (GONR) from her theory GONR have been
useful in documenting the outcome of care that
was performed by nurses
 It helps nurses to easily facilitate the present
problem from careful assessment of the client
gathered through the interactive communication
process between the nurse and the client
 Her record management facilitates proper and
correct range for the use of evaluation system
EDUCATION
 King’s interacting system has been used to design
the nursing curriculum in different schools and
universities and framework for nursing education
 It provides a systematic means of viewing the
nursing profession, organizing nursing knowledge
and clarifying the nursing discipline
RESEARCH
 King’s theory has bee one of theoretical basis of
some researchers that helped in formulating a
system view of the application of the nursing
practice
 Some researchers have formulated a middle range
theory out of King’s theory such as patient’s
satisfaction from nursing care, client’s with chronic
illness and family health
 The theory can also help set a framework for
nursing studies which can further prove the use and
advantages of the nursing practice
ANALYSIS
SIMPLICITY
 King’s theory was a result of a careful research
study
 Her research literature was based on the existing
evidence during her study.
 She maintains the simplicity of her theory even if
she presented different complex concepts
 GENERALITY
 King’s theory has been said to have limited
application for the nursing practice
 It was stated that the interaction between the
nurse and the client also comprises non-verbal
communication that cannot be clearly defined and
evaluated
 This has been the issue of the communication
barriers that exist between the nurse-relationships
 King addresses this critique through concepts of
other theorist that cannot also be tested completely
EMPIRICAL PRECISION
 King’s formulated theory was based on empirical
data that are observed within the boundaries of the
nurse-patient relationship
 Her observation consists of the different
characteristics of transactions among different
patients
 As her theory has been used by different nursing
students and other allied nursing practitioner, it is
noted that hr theory can be used to measure the
effectiveness of nursing care provided to clients
DERIVABLE CONSEQUENCES
 King’s theory can be applied to nursing process:
Assessment , Planning, Implementation and
Evaluation
 She believes that nurses must carefully assess
clients to set mutual goals and achieve those goals
appropriately and effectively
 Her theory provided clients to think choices and be
able to participate in the desired outcome of the
care plan
SYSTEMS THEORIES 4
SELF-CARE DEFICIT THEORY
Dorothea Orem
 Born in Baltimore, Maryland in 1914
 Providence Hospital School of Nursing in
Washington, D.C. (where she received a diploma of
nursing in the early 1930’s)
 1939 – BS in Nursing Education and in 1946 she
received an MS in Nursing Education – Catholic
University in America
 Her early nursing experiences included operating
room nursing private duty nursing (home and
hospital), hospital staff nursing on pediatric and
adult medical-surgical units, evening supervisor in
the emergency room, and biological science
teaching
 Retired in 1984 and resides in Savannah, Georgia
 She continues working alone and with colleagues on
the development of Self-Care Deficit Nursing Theory
METAPARADIGM IN NURSING
 Orem’s theory addresses client’s self-care needs
 It is defined as goal-oriented activities that are
set towards generating interest in the part of
the client to maintain life and health
development
 The theory aimed towards making the clients
perform self-care activities in order to live
independently
PERSON
 Human beings are very much different from other
living things in terms of their capacity
 Humans can reflect upon events, themselves, and
their environment
 They can symbolize experiences that they have
been through by using words or ideas (such symbols
could be used creatively in guiding and
communicating in their efforts towards the
attainment of something beneficial to them)
 human functioning is an integral system comprised
of physical, psychological, interpersonal, and social
aspects
 Orem believes that individuals have the potential
to be developed and learned
HEALTH
 Orem supports the WHO’s definition of health
 “a state of physical, mental, and social well-being
and not merely the absence of disease or infirmity”
 Health should be perceived this way since she
believes that these integrated aspects of health are
inseparable
 Presents health based on preventive healthcare
 This model of health care includes the promotion
and maintenance of health, the treatment of
disease or injury, and the prevention of
complications
ENVIRONMENT
 A phenomenon affected by inseparable entities
shows her view of the surrounding environment as
an external source of influence in the internal
interaction of a person’s different aspects
NURSING
 Is helping clients to establish or identify ways to
perform self-care activities
 Nursing actions are geared towards the
independence of the client (if the client is highly
dependent, there is a need for the nurse to assist
and address the needs of the client)
 A human service (it is a distinguished human service
since its focus is on persons with inabilities to
maintain continuous provision of healthcare)
 Nursing is based on values
SELF-CARE DEFICIT THEORY OF NURSING
SELF-CARE
- is an activity that promotes a person’s well-being
- it is performed by persons who are aware of the
time frames on behalf of maintaining life,
continuing personal development and a healthy
functional living
SELF-CARE REQUISITES
- are insights of actions or requirements that a
person must be able to meet and perform in
order to achieve well-being (these are reasons
for any actions of self-care that must be
undertaken)
 The two elements of self-care requisites are:
1. The factor to be controlled or managed to keep as
aspect(s) of human functioning and development
within the norms compatible with life, health and
personal well-being
2. The nature of the required action
UNIVERSAL SELF-CARE REQUISITES
-These are universally set goals that must be
undertaken in order for an individual to function in
scope of a healthy living
-The eight self-care requisites common in men, women
and children are as follows:
1. Maintenance of a sufficient intake of air
2. Maintenance of a sufficient intake of food
3. Maintenance of a sufficient intake of water
4. Provision of care associated with elimination
5. Maintenance of balance between activity and
rest
6. Maintenance of balance between solitude and
social interaction
 7. Prevention of hazards to human life, human
functioning and human well-being
8. Promotion of human functioning and
development
DEVELOPMENTAL SELF-CARE REQUISITES
- the following are actions to be undertaken
that will provide developmental growth:
a. Provision of conditions that promote
development
b. Engagement in self-development
c. Prevention of the effects of human conditions
that threatens life
THERAPEUTIC SELF-CARE DEMAND
- these are the summation of all activities needed
to alleviate the existing diseases or illness
- controlling or managing the factors will result to
appropriate care of plan
SELF-CARE AGENCY
- these are complex set of activities required to
purposively regulate the actions needed for
planning a care plan for a client
AGENT
- is the individual who engage in meeting the needs
of a person
- they are like bridges that facilitate what has been
done and what needs to be done
DEPENDENT CARE AGENT
- these individuals who takes full responsibility of
taking care of a person who are incapable of
providing for themselves or those who are living
dependently with others aid
NURSING AGENCY
- is a set of established capabilities of a nurse who
can legitimately perform activities of care for a
client
- it serves as a guideline of needed and foreseen
results
NURSING DESIGN
- these are professional functions that must be
performed by the nurse in order to meet clients
need
- it serves as a guideline of needed and foreseen
results
ACCEPTANCE OF THE NURSING COMMUNITY
PRACTICE
 had been used in studies in patients having heart
problems, cancer and mental illness
 had been widely use in dealing with geriatric cases,
especially those having chronic-illnesses
 The use of her theory gave way for further studies
in health promotion, self-care, and family caregiver
stress
 In the communities, several government health
agencies used her theory to practice as well
 In other areas of nursing such as occupational
health, Orem’s concepts are used to design nursing
activities that deals with job-related hazards
 The ability to identify health problems, interpret
data, and come up with conclusion is very
important in occupational health nursing
 Was being used in defining the roles of the nurse in
multiple settings
 There are also several reports that the Self-Care
Deficit Theory is used in the development of clinical
measurement approaches
EDUCATION
 The use of Orem’s theory in curriculum
development was reported in the late 1970’s
 The theory is used at all levels of curriculum and
continuing education
 Gradually, focus on preventive health care is being
introduced also in nursing process
RESEARCH
 A number of researchers derived from Orem’s
theory can be classified relating to the development
of research instruments for scientific measurements
of the components of her theory and studies that
test these components
 One of the instruments developed is the Exercise of
Self-Care Agency (ESCA) which was published in
1979
 Another instrument developed is the Appraisal of
Self-Care Agency or ASA; this scale was utilized
developed to measure the core concept of Orem’s
Self Care Deficit Theory
 Both of these instrument tools are used to assess
basic conditioning factors and self-care abilities to
the care of well and the ill
ANALYSIS
SIMPLICITY
 Orem’s theory is expressed in limited number of
terms; these terms are defined and used
consistently in her theories
 The Self- Care Deficit Theory of Nursing is a
systematic synthesis of knowledge about the
theoretical entities such as self-care, self-care
agency, therapeutic self-care –demand, the
relational entity self-care deficit and nursing agency
 In terms of simplicity, the theory could be well
understood as the theory is presented in a
straightforward manner
GENERALITY
 As Orem described her theory, Self-Care Deficit
Theory assists nurses in different areas in any
clinical setting; this is true as the theory operates
upon the combination of several conceptualized
properties or feature common to all instances of
nursing knowledge, and in teaching and learning the
nursing profession
EMPIRICAL PRECISION
 Orem’s theory is used in both qualitative and
quantitative methodologies
 Although widely used by researchers, several
components of the theory still need instrument
development in order for them to be measured
accurately
 The significant value of Orem’s theory is in its scope,
complexity , and clinical usefulness
 It could be effectively used in generating
hypotheses and adding to the body of knowledge of
nursing
DERIVABLE CONSEQUENCES
 Orem’s theory differentiates nursing from other
disciplines in terms of focus
 Although other disciplines use the instruments
developed from Orem’s theory, the theory of
nursing systems in terms of focus and emphasis sets
the nursing profession apart
 Orem’s theory gives direction to nursing-specific
outcomes related to identifying and meeting the
therapeutic self-care demands and self-
management systems
SYSTEMS THEORIES 5
21 NURSING PROBLEMS THEORY
Faye Abdellah
 Born in New York City in March 13, 1919
 She finished her basic nursing education, magna
cum laude in 1942 from Fitkin Memorial Hospital
School of Nursing
 She obtained her Bachelor of Science in Nursing in
1945, her Master of Arts in 1947 and her Doctor of
Education in 1955 from the Teachers College at
Columbia University
 She became the first nurse and first woman to serve
as Deputy Surgeon General of the United States (the
Surgeon General is basically the leader of United
States Public Health Service Commissioned Corps
and thus the main spokesperson on issues of Public
Health)
 Due to her contributions in the field of Education
and Nursing Research, she was inducted into the US
National Women’s Hall of Fame in 2000
 It was in 1960 that she was profoundly influenced
by the desire to promote client-centered all-
inclusive nursing care, thus making the idea of
Nursing as a true humanitarian service to
individuals, to families and therefore to society
 According to her, Nursing is grounded as an art and
science that molds the attitudes, intellectual
capabilities, and technical know-how of the
individual nurse into the desire and capacity to
assist people, sick or well, and to deal with their
health needs
 Nursing may be implemented out under general or
specific medical direction
 As a complete humanitarian service, Nursing
includes the following:
- be acquainted with the nursing problems of
the patient
- choose the definite courses of action to make
in the scope of relevant nursing principles
- make available continuous care of the
individual’s entire health needs
give continuous care to relieve pain and discomfort and
provide immediate security for the individual
- regulate the total nursing care plan to meet
the patient’s tailored needs
- serving the individual to become more self-
determining in achieving maintaining a healthy state of
mind and body
- informing nursing personnel, family and
support-system to provide the individual act for oneself
within perceived limitations
- facilitate the individual to adapt to limits and
emotional problems
- team up with different allied health
professions in working with diagram for optimum health
on local, state, national and international levels
- engaging in non-stop evaluation and research
to develop nursing techniques and to create new
techniques to serve the health needs of different people
METAPARADIGM IN NURSING
PERSON
 Abdellah classifies the beneficiary of care as
individuals; however, she does not set standard
limits on the nature and essence of human beings
 The twenty-one nursing problems relate with
biological, psychological and social aspects of
individuals and can be said correspond to concepts
of
HEALTH
 In this theory, the concept of health is defined as
the center and purpose of nursing services
(although Abdellah does not give a definition of
health )
TWENTY-ONE NURSING PROBLEMS
 A theoretical statement from Abdellah’s work can
be created by utilizing her three chief concepts of
health, nursing problems and problem solving
 Abdellah’s theory proposes that nursing is the
utilization of the problem-solving techniques with
chief nursing problems related to the health
requirements of clients
 It gives much importance to problem solving as
medium for the nursing problems as the medium
for the nursing problems as the client is geared in
the direction of health, which is the outcome
 It is such a simple statement, and as such, it can be
applied as a foundation for practice, education and
research in the area of Nursing
NURSING PROBLEMS
 Health Needs are seen as problems, which may
be:
- overt which is obvious or can be seen
condition
- covert which is an unseen or masked one
 Since covert problems relationships in nature, they
are often seen incorrectly (yet, in many instances
solving the covert problems may solve the overt
problems as well)
 Such analysis points to a client-centered orientation
 Abdellah’s usage of the term Nursing Problems is
more in tune with “nursing goals” and “nursing
functions” than client-centered problems
 Therefore, the focus of the theory is more nursing-
centered than client-centered
 According to Abdellah, the practice of competent
nursing care in the future is for the nursing student
to realize that identifying and answering overt and
covert nursing problems is the core of Nursing
 Therefore, the focus of the theory is more nursing-
centered than client-centered
 According to Abdellah, the practice of competent
nursing care in the future is for the nursing student
to realize that identifying and answering overt and
covert nursing problems is the core of Nursing
 These conditions can be satisfied by the Problem-
Solving Approach
 The Problem –Solving Process includes:
1. identifying the problem
2. selecting relevant data
3. devising hypotheses
4. testing hypotheses through the assortment
of data
5. revising hypotheses when necessary on the
basis of conclusions obtained from the data
 these steps resemble the pace of the Nursing
Process of Assessment, Diagnosis, Planning,
Implementation, and Evaluation; the problem-
solving approach was chosen because of the belief
that the best recognition of nursing problems will
greatly persuade the nurse’s judgment in selecting
the next steps in solving the client’s nursing
problems
TYPOLOGY OF TWENTY-ONE NURSING PROBLEMS
1. To maintain good hygiene and physical comfort
2. To maintain optimal activity: exercise, rest,
sleep
3. To promote safety through prevention of
accident, injury, or other trauma and through
the prevention of the spread of infection
4. To maintain good body mechanics and prevent
and correct deformity
5. To facilitate the maintenance of supply of
oxygen to all body cells
6. To facilitate the maintenance of nutrition of all
body cells
7. To facilitate the maintenance of elimination
8. To facilitate the maintenance of fluid and
electrolyte balance
9. To recognize the physiological responses of the
body to disease conditions-pathological,
physiological and compensatory
10. To facilitate the maintenance of the regulatory
mechanism and functions
11. To facilitate the maintenance of sensory
function
12. To identify and accept positive and negative
expressions, feelings and reactions
13. To identify and accept interrelatedness of
emotions and organic illness
14. To facilitate the maintenance of effective verbal
and non-verbal communications
 15. To promote the development of productive
interpersonal relationship
16. To facilitate progress toward achievement and
personal spiritual goals
17. To create or maintain a therapeutic
environment
18. To facilitate awareness of self as an individual
with varying physical, emotional and
developmental needs
19. To accept the optimum possible goals in the
light of limitations, physical and emotional
20. To use community resources as an aid in
resolving problems arising from illness
21. To understand the role of social problems as
influencing factors in the cause of illness
 The Twenty-one Nursing Problem’s focal point is on
the holistic (biopsychospiritual) requirements of the
client and the challenge to provide a more
meaningful starting point for association than the
category system of the body
 It is anticipated that the Twenty-one Nursing
problems as an extensive collection, would give
confidence to the simplification of principles and as
result, would guide care and promote the
development of the nurse’s judgmental ability
 It is expected that the constant relating of the broad
basic nursing problems to the specific problems of
the individual client and vice-versa would
encourage the development of increased ability to
use theory in clinical practice
 Thus, a greater understanding of the relationship
between theory and practice would strengthen the
usefulness of the nursing problems
 From this, it can be said that Abdellah’s Twenty-one
Typology of Nursing Problems is one of the
forerunners of the Nursing Diagnoses
ACCEPTANCE BY THE NURSING COMMUNITY
PRACTICE
 Abdellah's Typology of Twenty-one Nursing
Problems and nursing students perform in a
scientific, systematic way
 Using this scientific foundation will empower the
nurse to give meaning to each and every nursing
action that he/she will perform
 Using this Twenty-one Nursing Problems technique,
the clinical practitioner could assess the patient,
make a nursing diagnosis and plan interventions
 With the Problem-Solving process, the nurse and
nursing student will now attempt to make the
welfare of the patient as the essential goal or
objective rather than his/her medical condition
 Using this typology in the clinical setting, nurses will
now give their work an empirical basis
EDUCATION
 Abdellah's Typology of Twenty-one Nursing
Problems had the most potent effect on the
educational system
 Educators came to the realization that revisions are
of prime importance if nurses were to become self-
governing; they saw that the biggest flaw in the
profession was the absence or limited base of a
scientific body of knowledge unique to nursing
 The typology satisfied this void and gave the most
crucial and timely opportunity to move away from
the medical replica of cultivating nurses
RESEARCH
 The Typology of Twenty-one Nursing Problems
was produced through research therefore it is
expected that more research followed after its
introduction to the academic world
 Intensive research scrutinized the quantity of
time the nurse spent with the patient
 Typology utilized by Abdellah and Strachan
became the root for cultivating the nursing care
model and was then employed for setting up
the staffing outline in clinical settings
 The staffing patterns were found on the patient’s
identified needs and, as Abdellah foresaw, they
comprise of:
- intensive care
- intermediate care
- long-term care
- self care
- home-care units
 Arranging patients by similar needs than diagnoses,
the nursing service could give the optimum staffing
patterns to acknowledge patient’s needs
 1965 Abdellah and Levine released the first major
text book in nursing research entitled Better Patient
Care through Nursing Research
ANALYSIS
SIMPLICITY
 The typology is straightforward and it is practical to
use among patients
 The notion of nursing problems and problem-
solving-process are distinctly explicit
 The Metaparadigm of Nursing are understood and
implied
 Nursing and nursing problems were connotatively
given meaning whereas the problem solving process
is given denotatively
 These styles of definitions do not seem to move
away from the simplicity of the definitions
GENERALITY
 The Typology of Twenty-one Nursing Problems are
collective and associated to neither time nor
environment
 Abdellah admits that her list is neither broad nor
listed in using priorities; she also agreed that more
emphasis should be focused towards environment
 The aim of this model differs in generalization
 The more general goal is to affect nursing education
optimistically, whereas sub-goals are present
scientific basis for practice and to present a method
of qualitative appraisal of educational familiarity of
the students (therefore, its goals are suitable for
nursing)
EMPIRICAL PRECISION
 The concepts are very exact with empirical referents
that are easily recognizable
 The concepts are inclusive of the field of nursing
 The faculty of 40 collegiate schools of nursing
performed a rigorous analysis and study then
confirmed and validated the typology
DERIVABLE CONSEQUENCES
 The importance on problem solving is not restricted
by time or space and gives a way for continual
growth and change in the service of nursing care
 The problem solving process and the typology of
twenty-one nursing problems can be deemed the
forerunner of the nursing care process, classification
of nursing diagnoses and outcome calculation in
evidence in the present time
 Abdellah has made a significant contribution to
education, research and client care in nursing and
the healthcare profession in this country and
throughout the world
DEVELOPMENTAL THEORIES 1
ADAPTATION MODEL
Sister Callista Roy
 Sister Callista Roy, CSJ (born October 14, 1939) is an
American nun, nursing theorist, professor and
author. She is known for creating the adaptation
model of nursing. She was a nursing professor
at Boston College before retiring in 2017. Roy was
designated as a 2007 Living Legend by the American
Academy of Nursing.
 Roy earned an undergraduate degree in nursing
from Mount St. Mary's College in 1963, followed by
a master's degree in nursing from University of
California, Los Angeles (UCLA) in 1966. She then
earned master's and doctoral degrees in sociology
from UCLA. She served as a postdoctoral fellow in
neuroscience nursing at the University of California,
San Francisco. She has been awarded four honorary
doctorates.
 Roy was Professor and Nursing Theorist at Boston
College's Connell School of Nursing. In 1991, she
founded the Boston Based Adaptation Research in
Nursing Society (BBARNS), which would later be
renamed the Roy Adaptation Association. She has
lectured across the United States and in more than
thirty other countries. Late in her career, she
studied the role of lay study partners in recovery
from mild head injury. She retired from Boston
College in 2017 and moved back to California.
 She belonged to the Sisters of St. Joseph of
Carondelet.
METAPARADIGM IN NURSING
PERSON
 Roy’s models view the person as a biopsychosocial
being in constant interaction with a changing
environment. The person is an open, adaptive
system who uses coping skills to deal with stressors.
It includes people as individuals or in groups
(families, organizations, communities nations, and
society as a whole)
 An adaptive system has cognator and regulator
subsystems which act to maintain adaptation in the
four adaptive modes: physiologic, physical, self-
concept-group identity, role function, and
interdependence
ENVIRONMENT
 Roy viewed environment as conditions,
circumstances and influences that surround and
affect the development and behavior of the person.
She described stressors as stimuli and uses the term
“residual stimuli” to describe those stressors whose
influence on the person are not clear. Three kinds
of stimuli are the focal, contextual and residual.
Significant stimuli in all human adaptation include
stages of development, family and culture
HEALTH
 Originally, Roy wrote that health and illness are on a Focal
continuum with many different states or degree Those most immediately confronting the person, it
possible. More recently , she states that health is attracts the most attention
the process of being and becoming an integrated Contextual
and whole person. Adaptation is defined as the All other stimuli that strengthens the effect of the focal
process and outcome whereby thinking and feeling stimulus
as individuals and in groups, use conscious Residual
awareness and choice to create human and Those stimuli that can affect the focal stimulus bit the
environmental integration effects are unclear
 The three types of stimuli act together and
NURSING
influence the adaptation level which is defined as
 Nursing is the science and practice that expands
the ability to respond positively in a situation. A
adaptive abilities and enhances person and
person’s adaptation level may be described as
environment transformation. Roy’s goal of nursing
integrated compensatory or compromised (Roy and
is the promotion of adaptation in each of the four
Andrew, 1999)
modes, thereby contributing to the person’s health,
 The Adaptation Level is modulated by a person’s
quality of life and dying with dignity. Nursing is
coping mechanism and control processes. Thus, a
about the decrease, enhancement, modification
person does not respond passively to
and alteration of the stimulus to achieve
environmental stimuli. There are two categories of
adaptation
coping mechanisms according to Roy namely the
ROY ADAPTATION MODEL
regulator and the cognator subsystems
 Roy, a sister of Saint Joseph of Carondetet,
 Regulator subsystems transpires through neutral,
developed by Roy Adaptation Model (RAM) in
chemical and endocrine processes like the increase
1964 in response to a challenges by her professor,
in vital signs – sympathetic response to stress
Dorothy E. Johnson. Since then, the Ram has been
 Cognator subsystems on the other hand occurs
reconceptualized to be used in the 21 st century.
through cognitve-emotive processes. For instance
The expansion of the model has been a vibrant
are the effects of prolonged hospitalization for a
process.
four-year-old child
 The key ideas of this conceptual framework were
 Furthermore, Roy identified two control stabilizer
first published in an article entitled, Adaptation: A
subsystems and the innovator subsystem. These
Conceptual Framework for Nursing (Roy, 1970).
two coincides with the regulator and cognator
The RAM greatly influences the nursing community
subsystems when a person responds to a stimulus
and has inspired nursing scholars to publish books
 The innovator subsystems on the other hand,
related to the model, and it has been put into
allows the person to change to higher levels of
action in various healthcare settings and applied to
potential through cognitive and emotional
various populations
strategies
 The Roy Adaptation Model contains the following
 Roy suggests that although direct observation
key concepts
of the processes of the regulator and cognator
 The person is adapting in a stable interaction with
subsystems is not possible, the behavioral
the environment, either internal or external
responses of these two subsystems can be
 The environment serves as the source of a range of
observed in any of the four adaptive modes,
stimuli that will either threaten or promote the
namely:
person’s unique wholeness
 physiological
 The person’s major task is to maintain integrity in
 self-concept
face of these
 role function
environmental stimuli
 interdependence adaptive modes
 Roy and Andrews (1991) defined integrity as the
 Roy’s theory of the Person as an Adaptive System
degree of wholeness achieved by adapting to
claims that the four adaptive modes are
changes in needs
interrelated through perception. An adaptive or
Types of Stimuli (Helson, 1964)
 ineffective response in one mode can influence  According to Roy and Andrews (1999), health is
adaptation in the other modes a state and a process of being and becoming
an integrated and whole person. It is an
indication of how well an individual has adapted
to environmental stimuli. Therefore the goal of
nursing is to help the person attain adaptation
by helping the person to survive grow,
reproduce and master
NURSING PROCESS
 The Nursing Process, as utilized by Roy in her
theory, is a goal-oriented, problem-solving
approach to guide the provision of comprehensive,
competent nursing care to a person or group of
persons. It relates directly to the view of the person
as an adaptive system (Andrew and Roy, 1991).
The goal of nursing in the RAM is to promote
adaptation in each of the four adaptive modes
 Roy employs Six Steps in the Nursing Process:

 Adaptive or ineffective responses result fro these

coping mechanisms. Adaptive responses support
the integrity of the person and the goals of
adaptation. The major task of the person is to
become accustomed with environmental stimuli in
order to achieve survival, growth, development and
ACCEPTANCE BY THE COMMUNITY
mastery ineffective responses neither promote
PRACTICE
integrity nor contribute to the goals of adaptation
 Roy’s Model is useful for nursing practice because it
(Andrew and Roy, 1999)
outline the features of the discipline and provides
 Adaptation is done through two main coping
direction for practice, education and research. The
subsystems namely the regulator and cognator.
model considers goals, values, patient and
Roy did not explain further the mechanism
practitioner interventions. They view Roy’s nursing
o f regulator and cognator because its
process as well developed. The two-level
mechanism cannot be directly observed and unknown.
assessment assisted in identification of nursing
However, its behaviors are manifested in the four
goals and diagnosis. They also note the need for
adaptive modes
 continued work on a typology of nursing and in
organizing categories of nursing interventions
 It is a valuable theory for nursing practice because it
includes a goal that is specified as the aim for
activity and prescription of activities to attain the
goal. The goal of the model is the person’s
adaptation in four adaptive models n situations of
health and illness. The prescriptions or
interventions are the management of stimuli by
removing increasing, decreasing or altering. This
prescription can be obtained by listing practice
related hypothesis
 The nursing process is well suited for use in a
practice setting. The two-level assessment is unique
to this model and leads to identification of
adaptation problems of nursing diagnosis
EDUCATION
 Roy’s Adaptation model can serve as basis for
student nurses who render care for clients to
promote adaptation with regard to their adaptive
modes. The model also delineates nursing science
from medical science. According to Roy, the goal of
a nurse is to help a patient put his energy to achieve
recovery. On the other hand, the medical student
focuses on the health illness continuum. She also
added that through this model, clarification of
objective, identification techniques and
specification of patterns for teaching and learning
can be achieved
RESEARCH
 Roy’s theory culminated a number of propositions
in which in return generated hypothesis that can be
developed and tested. Roy’s model was used
extensively to guide knowledge development
through nursing research. Roy together with her
colleagues outlined a typology of adaptation
problems or nursing diagnosis in which research
and testing is considered necessary
ANALYSIS
SIMPLICITY
 Roy’s model is considered complex in terms of
structure because it is composed of several major
concepts (nursing, person, health-illness,
environment, adaptation and nursing
interventions), sub-concepts (regulator, and
cognator) and four effector modes (physiological,
self-concept, role function and interdependence)
GENERALITY
 The Roy’s Adaptation Model is described as broad in
scope, which is considered an advantage because it
can be used for theory building and testing. It can
also be applied in all settings of nursing practice.
However, it is limited because it only focuses on the
patient and his adaptation in the environment
EMPIRICAL PRECISION
 The RAM’s broad scope branched from different
fields such as, Physiological, Psychology, Sociology
and Nursing. The empirical data indicates that this
theory has substance. It also offers a guide to
researchers who wants to integrate physiological
phenomena in their study. In order for its empirical
precision to increase researchers should continue to
utilize the model as a basis for their study. The
holistic approach of the model makes it helpful for
researchers who are interested to study adaptive
processes
DERIVABLE CONSEQUENCES
 The Ram has clearly identified the nursing process
which is an important tool in nursing practice. It
provides direction in providing holistic care for a
client. In the process of hypothesis testing, new
information can be derived from Roy’s model.
Truly, it served as a valuable contribution to nursing
science
DEVELOPMENTAL THEORIES 2
TRANSCULTURAL THEORY IN NURSING
Madeleine Leininger
 Leininger was born on 13 July 1925. She earned
a nursing diploma from St. Anthony's Hospital
School of Nursing, followed by undergraduate
degrees at Benedictine College and Creighton
University. She received a Master of Science in
Nursing at Catholic University of America. She later
studied cultural and social anthropology at
the University of Washington, earning a PhD in
1966.[3] Leininger held at least three honorary
doctoral degrees.[3]
 Dr. Leininger held faculty positions at the University
of Cincinnati and the University of Colorado,
[3]
 followed by service as a nursing school dean at
both the University of Washington and
the University of Utah. She was Professor
Emeritus of Nursing at Wayne State University and
an adjunct faculty member at the University of
Nebraska Medical Center in Omaha.[3] Leininger died
at her home in Omaha, Nebraska on 10 August
2012.[

METAPARADIGM IN NURSING
PERSON
 Human beings are best explained n he
assumptions. Humans are thus believed to be
caring and capable of being concerned about the
desires, welfare and continued existence of others.
Human care is collective, that is seen in all cultures
 Humans have endured within cultures and through
place and time because they have been able to care
for infants, children and the elderly in a variety of
ways and in many different environments. Thus,
humans are universally caring beings who survive in
a diversity of cultures through their ability to
provide the universality of care in a variety of ways
according to differing cultures, needs and settings.
Leininger (1991) also indicates that nursing as a
caring science should focus ahead of traditional
nurse-patient interactions to include “families,
groups, communities, total cultures, institutions” as
well as worldwide health institutions and ways to
expand international nursing care policies and
practices
ENVIRONMENT
 In terms of Environment, Leininger speaks
about worldview , social structures and
environmental context. However, environment,
if viewed as being signified in culture, is a major
principle of Leininger’s theory Environment
framework is defined as being the totality of an
event, situation, or experience. Her description
of culture centers on a particular group (society)
and the patterning of actions, thoughts and
decisions that occurs as the result of “learned,
shared and transmitted values, beliefs, norms,
and lifeways. This leading, sharing, transmitting
and patterning take place within a group of
people who function in an identifiable setting
or environment. Therefore, although Leininger
does not use the specific terms of society or
environment, the concept of culture is closely
related to society/environment, and is a center
matter of her theory
HEALTH
 She discussed about components of health,
specifically:
 health systems
 health care practices
 changing health patterns
 health promotion
 health maintenance
 Health is a key concept in transcultural nursing.
Because of the weight on the need for nurses to
have knowledge that is specific to the culture in
which nursing is being practiced, it is acknowledged
that health is seen as being universal across cultures
but distinct within each culture in a way that
represents the beliefs, values and practices of the
particular culture. Thus, health is both universal
and diverse
NURSING
 Leininger showed her concern to nurses who do not
have sufficient preparation for a transcultural
perspective
 For that reason, they will not be able to value nor
practice such viewpoint to the fullest extent
possible
 She gave three types of nursing actions that are
culturally-based and thus consistent with the needs
and values of the clients. These are:
• Cultural care preservation/maintenance
• Cultural care accommodation/negotiation
• Cultural care repatterning/restructuring
 These three modes of action can lead to the
deliverance of nursing care that best fits with
the client’s culture and thus reduce cultural
stress and chance for conflict between client
and caregiver
TRANSCULTURAL THEORY IN NURSING
 The concept of culture in Leininger,s theory
borrows its meaning from anthropology. Cultute is
the “learned, shared and transmitted values, beliefs,
norms and actions in patterend ways.” (Leininger,
1985). Culture can be seen in the actions, words,
rules and standards, symbols and behavior patterns
of people and is learned and then handed down
from generation to generation
 A key component of Leininger’s theory is that of
cultural diversity. This refers to the differences or
variation that can be found both between and
among different cultures. By recognizing the
variations
the nurse can avoid the problem of stereotyping
(using general standards) and assuming that all people
will react to the same nursing care. A similar concept is
that of cultural universality, the opposite of diversity,
which refers to the commonalities or similarities that
exist in different cultures. These ideas have led to an
important achievement of the theory – that is, “to
discover similarities and differences about care and its
impact on the health and well-being of groups.”
(Leininger, 1995)
MAJOR IDEAS OF CULTURAL CARE
ACCEPTANCE BY THE NURSING COMMUNITY
PRACTICE
 As our world becomes more culturally varied,
nurses will find the pressing need to be prepared to
present culturally competent care. Some nurses
understand culture shock, conflict and clashes as
they move from one place to another like from rural
to urban communities without Transcultural
Nursing preparation
 As cultural difference arises, families are less
satisfied with nursing and medical services. Nurses
who travel and seek employment in foreign lands
are experiencing immigrant status. Transcultural
nursing education has become crucial for all nurses
nationwide
EDUCATION
 The addition of culture and relative care in nursing
curricula began in 1966 at the University of
Colorado, where Leininger was a professor of
Nursing and Anthropology. Nowadays, with the
sensitive public awareness of healthcare costs,
different cultures and human rights, there is a much
superior demand for transcultural people who are
trained to safeguard quality-based care and to
prevent legal suits related to improper client care
RESEARCH
 A lot of nurses are using Leininger’s Culture Theory
worldwide. The theory is the only one in nursing
focused purposely on culture care and with a
research techniques (ethnonursing) to examine the
theory. Finances to sustain transcultural nursing
are not enough. Transcultural nurses and other
nurses interested in transcultural nursing in
research are enduring their research despite
inadequate funds. Through continual efforts and
tough competencies of Transcultural Nurse
Specialists, progress has been forthcoming.
Transcultural nurses have inspired many nurses to
pursue research and to learn some entirely new
knowledge in nursing. This understanding will
greatly reshape and transform nursing in the future
ANALYSIS
SIMPLICITY
 Transcultural Nursing Theory is really a wide and
holistic standpoint of human population. It is
beyond doubt transcultural and universal in scope.
Consequently, it requires Transcultural Nursing
knowledge and fitting research methods to explain
the phenomena. Leininger’s Culture Care Theory is
applicable worldwide to help direct nurse
researchers in conceptualizing the theory and
research advances and to conduct practice. It is
holistic and comprehensive in nature: therefore
several concepts and constructs related t social
 structure, environment, and language are extremely
important to discover and obtain culturally-based
knowledge
GENERALITY
 The Transcultural Theory does not demonstrate the
criterion of generality because it is a qualitively-
oriented theory that is broad, comprehensive, and
worldwide in scope. In fact, Transcultural Nursing
theory addresses nursing care from a multicultural
and worldwide perspective. It is useful and
applicable to both groups and individuals with the
goal of rendering culture-specific nursing care. The
broad and generic concepts are well-organized and
defined for study in specific cultures. The theory is
most helpful as a guide for the study of any cultures
and for the comparative study of several cultures.
Findings from the theory are being used presently in
client care in a variety of health and community
settings worldwide to transform nursing education
and service
EMPIRICAL PRECISION
 The Transcultural Nursing Theory is researchable
and qualitative research has been primary
paradigm to discover largely unknown
phenomena of care and health in diverse
cultures. This qualitative approach differs from the
traditional quantitative research method which
renders measurement of goals of research. However,
the ethnoscience and ethonursing research methods
are extremely rigorous and linguistically exacting in
nature and outcomes. The important attribute is that
accuracy of grounded data derived with the use of
ethnomethods or from the people’s viewpoint is leading
to high credibility, conformability and wealth of
empirical data. The qualitative criteria of credibility and
conformability from in-depth studies of informants and
their contexts are becoming clearly evident. Clearly, a
body of Trancultural Nursing knowledge has been
established over the past decade that has a great
impact on nursing and many healthcare systems
DERIVABLE CONSEQUENCES
 Transcultural Nursing Theory has important
outcomes for nursing. Rendering culture-specific
care is an essential goal in nursing because it
places the Transcultural Nursing Theory central to
the domain of nursing knowledge acquisition and
use. The theory is highly useful, applicable, and
essential to nursing practice, education and
research. The concept of care as the primary focus
of nursing and the base of nursing knowledge and
practice is long overdue and essential to advanced
nursing knowledge and practices. Leininger notes
that although nursing has always made claims to
the concept of care, rigorous research on car has
been limited until the last three decades. This
theory could be the means to establish a sound and
defensible and profession, guiding practice to meet
a multicultural world because it has a broad and
multicultural focus
DEVELOPMENTAL THEORIES 3
PHILOSOPHY AND SCIENCE OF CARING
Margaret Jean Watson
METAPARADIGM IN NURSING
PERSON
 Human being is a valued person in and of him to
be cared for, respected, nurtured, understood,
and assisted. In general, it is a philosophical
view of a person as a fully functional integrated
self. She viewed human as greater than and
different from the sum of his parts
ENVIRONMENT
 Environment provides the values that
determine how one should behave and what
goals one should strive toward. These values
are affected by change in the social, cultural,
and spiritual arenas, which in turn affects the
perception of the person and can lead to stress.
Thus Watson states, “Caring (and nursing) has
existed in every society. Every society has had
some people who have cared for others. A
caring attitude is not transmitted from
generation to generation by genes. It is
transmitted by the culture of the profession as
a unique way of coping with environment.”
HEALTH
 Health is refer to unity and harmony within the
mind, body and soul. It is also associated with
the degree of congruence between self as
perceived and as experienced . Watson, in
addition to WHO’s definition, include these
three elements :
1. A high level of over-all physical, mental and social
functioning
2. The general adaptive-maintenance level of daily
functioning; and
3. The absence of illness (or the presence of efforts that
lead to its absence)
 NURSING
 Watson sees Nursing as having to move
educationally in the two areas of stress and
developmental conflicts to promote holistic health
care, which she believes is central to the practice of
caring in Nursing. She asserts that nursing’s social,
moral and scientific contributions to humankind
and society lie in its commitment to human care
ideas in theory, practice, and research
 In further writings, she defines nursing as “a human
science of people and human health-illness
experiences that are mediated by professional,
personal, scientific, aesthetic and ethical human
care transactions.”
PHILOSOPHY AND SCIENCE OF CARING
 Watson’s philosophy and theory of human science
can be traced through the last 25 years from its
earliest beginnings as a textbook that was originally
planned to present an integrated curriculum for
undergraduate nursing programs but evolved
instead into an original structure for basic nursing
process. Beginning with the question of the
relationship between human caring and nursing,
this initial work laid the foundation for what was to
become the Theory of Human Caring (1977) and
Nursing: Human Science and Human Care
 Watson proposes seven assumptions about the
science of caring and ten primary carative factors
to form the framework of her theory. The basic
assumptions are the following:
 Caring can be effectively demonstrated and
practiced only
interpersonally:
 Effective caring promotes health and individual or
family
growth:
 Caring responses accept a 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 curing. The
practice of caring integrates biophysical knowledge
with knowledge of human behavior to generate or
promote health and to provide care to those who
are ill. A science of caring is therefore
complementary to the science of curing
 The practice of caring is central to nursing
 Furthermore, she stressed that the focus of nursing
is on carative factors that are derived from a
humanistic perspective combined with scientific
knowledge base. Her work in 1979 is organized
around ten carative factors as a framework for
providing a formal and focus for nursing
phenomena
TEN CARATIVE FACTORS
1. Formation of a Humanistic-altruistic system of
values
2. Instillation of faith-hope
3. Cultivation of sensitivity to one’s self and to
others
4. Development of a helping-trusting human
caring relationship
5. Promotion and acceptance of the expression of
positive and negative feelings
6. Systematic use of a creative problem-solving
caring process
7. Promotion of transpersonal teaching-learning
8. Provision for a supportive, protective and
corrective mental, physical, societal and
spiritual environment
9. Assistance with gratification of human needs
10. Allowance for existential-phenomenological-
spiritual forces
ACCEPTANCE IN THE NURSING COMMUNITY
PRACTICE
 Watson is an eternal optimist and she writes from a
deep place about the personal as well as the sacred.
This philosophy invites to explore one’s curiosities
about the origins of his/her call to care. Her writing
encourages explorations of questions such as:
“What calls me to care?”
“What is the root of my caring response?”
“How will I respond?”
“Why do I fail to respond?”
“When is it hard to care?”
“How will I sustain and nurture my caring
consciousness?”
“Who will care for me?”
EDUCATION
 Watson defines her intent to describe the core of
nursing (those aspects of the nurse-patient
relationship resulting in a therapeutic outcome)
rather than the trim of nursing (the procedures
 tasks and techniques used by various practice
settings). With this focus , the framework is not
limited to any nursing specialty. Although , she
emphasizes that both the core and the trim are
necessary , she believes that the trim cannot be
center of a professional model of “nursing qu
nursing”
 A study of Watson’s frameworks leads the reader
through an inspiring experience by emphasizing
deep inner reflection and personal growth,
communication skills, use of self-transpersonal
growth , attention to both nurse and patient and
the human caring process that potentiates human
health and healing
RESEARCH
 Patient outcomes in caring transactions are a
potential area for studies. Research and practice
shall focus both on subjective and objective patient
outcomes to determine whether or not caring is
indeed the truest essence of nursing
ANALYSIS
SIMPLICITY
 Watson’s theory makes use of sophisticated
language to put forth subtle thoughts about caring,
and this entails “reading between the lines” to
decipher its profound meaning
GENERALITY
 The theory provides moral and philosophical basis
for nursing. The scope of the framework
encompasses all aspects of the health-illness
continuum. In addition, it addresses aspects of
preventing illness and experiencing a peaceful
death, thereby increasing its generality
EMPIRICAL PRECISION
 Watson draws heavily on widely accepted work
from other disciplines. This solid foundation
strengthens that views. She describes her
theory as descriptive and she acknowledges the
evolving nature the theory and welcomes input
by others. The methodologies that are
important in studying transpersonal caring and
developing nursing as a human Science and Art
can be classified as qualitative, naturalistic or
phenomenological
DERIVABLE CONSEQUENCES
 Theoretical concepts such as use of self,
patient-identified needs, the caring process, and
the spiritual sense of human being may help
nurses and their patients find meaning and
harmony in a period of increasing complexity
DEVELOPMENTAL THEORIES 4
SKILL ACQUISITION IN NURSING:
FROM NOVICE TO EXPERT
Patricia Benner
 Imogene King (January 30, 1923 – December 24,
2007) was a pioneer of nursing theory
development. Her interacting systems theory
of nursing and her theory of goal attainment have
been included in every major nursing theory text.
These theories are taught to thousands of nursing
students, form the basis of nursing education
programs, and are implemented in a variety of
service settings.
 King's educational achievements began with a
nursing diploma in 1945. She attended St. Louis
University, earning a Bachelor of Science in Nursing
in 1948 and a Master of Science in Nursing in 1957.
She subsequently earned a Doctor of Education
from Teachers College, Columbia University.
 King was on the faculty at Loyola University from
1961-1966 and 1972-1980. She directed the nursing
program at Ohio State University between 1968 and
1972. She taught at University of South Florida from
1980 to 1990.
METAPARADIGM IN NURSING
NURSING
 Benner described nursing as an “enabling condition
of connection and concern” (Marimer-Tomey,
1989, p.192) which shows a high level of emotional
involvement in the nurse client relationship. She
viewed nursing practice as the care and study of
the lived experience of health, illness and disease
and the relationship among these three elements
PERSON
 Benner stated that “ a self-interpreting being, that
is, the person does not come into the world
predefined but that gets defined in the course of
living a life. A person also has an effortless and
non-reflective understanding of the self in the
world. The person is viewed as a participant in
common meanings. (Tomey, 2002, pp. 173 )
 Benner believed that there are significant aspects
that makes up a person. She had conceptualized
the major aspects of understanding that the person
must deal with as:
1. The role of the situation
 2. The role of the body
3. The role of personal concerns
4. The role of temporality
HEALTH
 Benner focused “on the lived experience of being
healthy and ill.” She defined health as what can be
assessed while well-being is the human experience
of health or wholeness. Well-being and being ill
are recognized as different ways of being in the
world. Health is described as not just the absence
of disease and illness. Also a person may have a
disease and not experience illness because illness is
the human experience of loss or dysfunction,
whereas disease is what can be assessed at the
physical level
ENVIRONMENT
 Instead of using the term “environment”, Benner
used the term “situation” , because it suggests a
social environment with social definition and
meaning. She used the phenomenological terms of
being situated and situated meaning, which are
defined by the person’s engaged interaction,
interpretation and understanding of the situation
SKILL ACQUISITION IN NURSING: FROM NOVICE TO
EXPERT
 Benner noted that in application of the model to
nursing skill acquisition based on experience is safer
if it is grounded in a sound
NOVICE
 The novice stage of skills acquisition describes that
the person has no background experience of the
situation in which he or she is involved. At To guide
performance, context free rules and objective
attributes must be given. The novice also has
difficulty discriminating between relevant and
irrelevant aspects of a situation. In general, this is
the level in which nursing students belong.
However, Benner proposed that nurses at higher
levels can be classified as a novice if they are placed
in an unfamiliar situation
ADVANCE BEGINNER
 The advance beginner, as described by Benner, has
a sufficient experience to easily understand aspects
of the situation. Unlike attributes and features,
aspects cannot be objectified completely because
they require experience based on recognition in the
background of the situation
 Clinical situations are viewed by nurses as the
advanced beginner stage as a challenge of their
abilities and the demands of the situation placed on
them instead of the patient’s needs. Also, they feel
more responsible for managing patient care, yet
they still rely on the help of those have more
experienced. Benner places most newly graduated
nurses at this level
COMPETENT
 Competent performance considers consistency,
predictability, and time management as essential
components. Benner believes that a sense of
mastery is acquired through planning and
predictability
 An increase level of efficiency is evident . However,
time management and the nurse’s organization of
the task are more important rather than on timing
in relation to the patients needs. The competent
nurse may display nurse may display more
responsibility for the patient, often more than what
is realistic and may exhibit critical view of the self
 Moreover, this stage is the most essential in clinical
learning because the learner must know how to
recognize patterns and identify which element of
the situation needs attention and which ones to
ignore. This competent nurse develops new rules
and reasoning procedures to ignore plan while
applying learned rules for action on the basis of the
relevant facts of the situation. To become skillful,
the competent nurse must allow situations to guide
responses. Studies point to the significance of
active teaching and learning in the competent stage
to help nurses in shifting from competency to
proficiency
PROFICIENT
 According to Dreyfuss model, the performer in the
stage perceives the situation as a whole rather than
in terms of aspects, and performance is guided by
maxims. The proficient level is qualitative leap
beyond the competent. In this level, the performer
identifies the most significant aspects and has a
better understanding of the situation based on
background understanding, responses to the
situations as it changes. They no longer rely on
present goals for organization, and they show an
increased confidence in their knowledge and skills.
In this stage, there is much more involvement with
the patient and family. The proficient stage is the
transition into expertise
EXPERT
 The last stage of Dreyfuss model is accomplished
when the expert performer no longer relies on
analytical principle like rules, guidelines and
maxims to connect her understanding of the
situation to an appropriate action. Benner viewed
an expert nurse as possessing an intuitive grasp of
the problem without losing time considering a
range of alternative diagnosis and solutions
 There is qualitative change as the expert performer
“knows the patient” which means that knowing
typical patterns of responses and knowing the
patient as a person. Key aspects of the expert nurse
practice are as follows (Benner et al. 1996)
 Demonstrating a clinical grasp and resource-based
practice
 Possessing embodied knowledge
 Seeing the big picture
 Seeing the unexpected
 The expert nurse has these abilities to identify
patterns on the basis of deep experiential
background. For the expert nurse, meeting the
patient’s actual concerns and needs is of utmost
importance, even if it means planning and
negotiating for a change in the plan of care (Benner
et al. 1992)
SEVEN DOMAINS OF NURSING PRACTICE
1. Helping role
2. Teaching and coaching function
3. Diagnostic client-monitoring function
4. Effective management of rapidly changing situations
5. Administering and monitoring therapeutic
interventions and
regimens
6. Monitoring and ensuring quality of health care
practices
7. Organizational and work-role competencies
ACCEPTANCE BY THE NURSING COMMUNITY
PRACTICE
 In her book, FROM NOVICE TO EXPERT, Benner
describes clinical nursing practice using an
interpretive approach. The model has been used to
aid in the development of clinical ladders of
promotion, new graduate orientation programs
and clinical knowledge development seminars. This
has greatly contributed in the competency ladders
and promotions in the nursing service organization.
She has been cited extensively in nursing literature
regarding nursing practice concerns and the role of
caring in such practice. She continues to publish
nursing practice concerns, and the role of caring in
such practice
EDUCATION
 Benner’s seven domains of nursing practice have
the greatest influence and impact on nursing
education with regards to her works. Nursing
educators have realized that learning needs at the
early stages of clinical knowledge development are
different from those required at later researchers
RESEARCH
 Her researchers have been used in studying the
impact of nursing and its seven domains in every
aspect of the profession. Several researchers
tested these models and validated them in
application of the theory presented by Benner,
nurses have a clear vision of the competencies
required in order for them to climb up into the
leadership ladder
ANALYSIS
SIMPLICITY
 Benner’s model is comparatively simple about the
five stages of skill acquisition . It gives a relative
guide for classifying levels of nursing practice
___individual nurse _______ and _________in
actual nursing practice. The interpretations are
validated by _________ __ by general acceptance
 Clinical knowledge is _____ and _____ with
____specific, historical ____. Benner uses narrative
accounts of actual clinical situations and ______that
the model ______the reader to recognize similar
____ and meanings, although the objective
circumstances may be quite different
GENERALITY
 Benner’s model has universal characteristic for the
reason that it is not restricted by age, illness,
health or location of nursing practice. However,
the characteristic of theoretical universality involve
properties of functionality for prediction that is not
a part of this perspective
 The descriptive model of nursing practice has the
potential for universal application as a framework,
however the descriptions are limited by
dependence on the actual nursing situations from
which they be used. It depends on the
understanding of the five levels of competency and
the ability to identify the characteristic intentions
and meanings intrinsic at each level of practice
EMPIRICAL PRECISION
 In terms of empirical precision, Benner’s model was
tested using qualitative methodologies.
Succeeding researches suggest that the framework
is applicable and useful in providing knowledge of
the description of nursing practice. The strength of
Benner’s model is that data-based research
contributes to the science of nursing
DERIVABLE CONSEQUENCES
 The usefulness of Benner’s model gives a general
framework for identifying, defining and describing
clinical nursing practice. She uses a
phenomenological approach to express and obtain
meaning and abilities from interactions in life
situation. The implication of Benner’s research
finding lies in her conclusions that “a nurse’s
clinical knowledge is relevant to the extent to
which its manifestation in nursing skill makes a
difference in patient care and patient outcome”