NCM 200 - SEPT 2021
THEORETCAL FOUNDATION OF NURSING
INTRODUCTION TO NURSING THEORY: IT’S HISTORY AND
SIGNIFICANCE
History of Nursing Theory
 History of Professional nursing began w/ Florence
Nightingale
 Development of nursing knowledge apart from medical
knowledge to guide nursing practice
 Develop a body of specialized knowledge on w/c to base
nursing practice
 Strong emphasis on practice and worked throughout the
century toward the development of nursing as a
profession
Curriculum Era
 Address the question of what contents a nurse should
study to learn how to be a nurse
 Emphasis was on what course nursing students should
take, w/ the goal of arriving at a standardized curriculum
 The idea of moving nursing education from hospital-
based diploma programs into colleges and universities
began to emerge during this era
 Emphasized course selection and content for nursing
programs and gave way to the research era
Research Emphasis Era
 Focused on the research process and the long-range
goal of acquiring substantive knowledge to guide
nursing practice
 The need to do research in order to seek higher
education began in this era
 Research courses were included in nursing curricula
 Awareness for the need of concept and theory
development coincided w/ two other milestones in the
evolution of nursing theory:
1. The standardized curricula for nursing
master’s education by the National League for
Nursing accreditation criteria for
baccalaureate and high-degree programs
2. The decision that doctoral education for
nurses should be in nursing
Graduate Education Era
 Developed in tandem w/ the research era
 Master’s degree programs in nursing emerged to meet
the public need for specialized clinical nursing practice
 Included concepts in:
1. Concept development
2. Nursing models
3. Early nursing theorist
4. Knowledge development process
 Baccalaureate degree began to gain wider acceptance
as:
A. Educational level for professional nursing
B. Academic discipline in higher education
 Nurse researchers worked to develop and clarify a
specialized body of nursing knowledge w/ the ff. goals:
A. Improving the quality of patient care
B. Providing a professional style of practice
C. Achieving recognition as a profession
 Transition from vocation to profession
 Meleis (2007) noted, “theory is not a luxury in the
discipline of nursing…but an integral part of the nursing
lexicon in education, administration and practice
 Important precursor was the acceptance of nursing as a
profession and an academic discipline in its own right
Theory Era
 A natural outgrowth of the research and graduate
education eras
 Emphasis on theory development and testing
 Accelerated as early works develop as frameworks
for curricula and advanced practice guides began to
be recognized as theory
 Transition from pre-paradigm to paradigm period in
nursing
 Fawcett’s seminal proposal of four global nursing
concepts as a nursing metaparadigm served as an
organizing structure for existing nursing
frameworks and introduced a way of organizing
individual theoretical works in meaningful structure
 Classification of nursing models as paradigms w/in
metaparadigm concepts are the ff:
A. Person
B. Environment
C. Health
D. Nursing
 The said classification united nursing theoretical works
for the discipline
 Emphasis shifted from learning about the theorist to use
of the theoretical works to generate
A. Research questions
B. Guide practice
C. Organize curricula
 Theory development emerged as a process and product
of professional scholarship and growth and sought
higher education among:
A. Nurse leaders
B. Administrators
C. Educators
D. Practitioners
 The use of theory to convey an organizing structure and
meaning for these processes to the convergence of
ideas
 Fitzpatrick and Whall (1983) had said, “Nursing is on the
brink of an exciting new era”
Theory Utilization Era
 Emphasis shifted to theory application in nursing
practice, research, education and administration
 Restored balance between research and practice for
knowledge development in the discipline of nursing
 Emphasis to produce evidence for quality professional
practice
 Types of nursing theoretical works:
1. Nursing philosophy
o Sets forth the meaning of nursing phenomena
through analysis, reasoning and logical
presentation
o Basis for subsequent development
2. Nursing conceptual methods
 o Comprises nursing works by the theorist who
also are referred to as pioneers in nursing
3. Nursing Theory
o Derived from nursing philosophies, conceptual
models or more abstract nursing theories, or
from works of other disciplines
o Developed from some conceptual framework
and is more specific than the framework
o Theories may be specific to a particular aspect
or setting of nursing practice
4. Middle Range Theory
o More specific focus and is more concrete than
nursing theory in its level of abstraction
o More precise, with a focus on answering
specific nursing practice questions
o Address the specifics of nursing situations
within the perspective of the model or theory
from which they are derived
o They specify each factor as:
A. The age group of the patient
B. The family situation
C. The health condition
D. The location of the patient
E. The action of the nurse
Historical Eras Of Nursing’s Search For Specialized Knowledge
Significance of Nursing Theory
 DISCIPLINE- refers to a branch of education, a
department of learning, or domain of knowledge
 PROFESSION - refers to a specialized field of practice,
founded upon the theoretical structure of the science or
knowledge of the discipline and accompanying practice
abilities
Significance for the Discipline
 This emphasis led into theory development era that
moved nursing toward the goal developing nursing
knowledge to guide nursing practice
 The discipline and the profession are inextricably linked
and failure to recognize and separate them from each
other anchors nursing in a vocational rather than a
professional view
 The significance of theory for the discipline of nursing -
the discipline is dependent on theory for its continued
existence
 Nurses moved from the functional focus, with an
emphasis on what nurses do, to patient focus,
emphasizing what nurse know for thought, decision
making and action
 Forms of basis in recognizing nursing as discipline:
A. Knowledge of person
B. Health
C. Environment
 Every discipline or field of knowledge includes
theoretical knowledge
 Nursing as academic discipline depends on the
existence of nursing knowledge
Significance for the Profession
 Theory is essential for the existence of nursing as an
academic discipline
 Theory is also vital to the practice of professional
nursing
 Higher degree nursing is recognized as a profession
today
 Nursing was the subject of numerous studies by
sociologist who used the criteria for a profession
 Criteria for development of the professional status of
nursing:
1. Utilizes in its practice a well-defined and well-
organized body of specialized knowledge (that) is
on the intellectual level of higher learning
2. Constantly enlarges the body of knowledge it uses
and improves its techniques of education and
service through use of the scientific method
3. Entrust the education of its practitioners to
institutions of higher education…
4. Applies its body of knowledge in practical services
vital to human and social welfare
5. Functions autonomously in the formulation of
professional policy and thereby in the control of
professional activity
6. Attracts individuals with intellectual and personal
qualities of exalting service above personal gain
who recognize their chosen occupation as a life
work
7. Strives to compensate its practitioners by providing
freedom of action, opportunity for continuous
professional growth and economic security
 Nursing is recognized as a profession and emphasis is
placed on the relationship between nursing theoretical
works and achievement of status as a profession
 The use of substantive knowledge for the theory-based
evidence for nursing is a quality that is characteristic of
their practice
  The commitment to the theory-based evidence for
practice is beneficial to patients in that it guides
systematic, knowledgeable ca
 EX. all patients who are not able to take good care of
themselves need nurses
Phenomenon
 A fact or occurrence that can be observed
 Something notable; excites people’s interest and
curiosity

Philosophy
 A statement of beliefs and values about human beings
TERMINOLOGIES and their world
 Is concerned with the purpose of human life, the nature
Science of being and reality, the theory and limits of knowledge
 From the latin “scientia” meaning knowledge
 A systematically organized body of knowledge about a
particular subject
 Is performing the process of observation, description,
experimental, investigation and theoretical explanation
of natural phenomenon
Knowledge
 general awareness, understanding or possession of
information, facts, ideas, truths or principles
 Information, skills and expertise acquired by a person
through various experiences or through formal/informal
learning
Sources of Knowledge
1. Tradition - nursing practice which is passed down from
generation to generation
2. Authoritative - is an idea by a person of authority which
is perceived as true because of his or her expertise
3. Scientific - knowledge came from a scientific method
through research
Theory
 Knowledge came from a scientific method through
research
 A group of related concepts that propose actions that
guide practice
 A system of ideas that is proposed to explain a given
phenomena
Concept
 Idea, belief, view, notion, thought, perception,
impression
 Are building blocks of theories
 Enhances one’s capacity to understand phenomena as it
helps define the meaning
Abstract Concept
 Are indirectly observed
 It is independent on time and place
 EX. love, care, and freedom
Concrete Concept
 Are directly observed
 Specific to time and place
 EX. Nurse, mother, and chair
Proposition
 Statements that explain the relationships of different
concepts
 EX. Children don’t want to stay in the hospital because
of their fear of injections
Definition
 Is composed of various descriptions which convey a
general meaning and reduces the vagueness in
understanding a set of concepts
Assumption
 A statement that specifies the relationship or
connection of factual concepts or phenomena
 THEORY
Characteristics of a Theory
1. Theory can correlate concepts in such a way as to
generate a different way of looking at a certain fact or
phenomenon
o EX. the relationship between self-care deficit and
nursing
2. Theories must be logical in nature
o Logic – an orderly reasoning
o Interrelationships of concepts must be sequential
and consistently used within the theory
3. Theories should be simple but generally broad in nature
o Parsimonious – simple terms that describes,
explains, or predicts a wide range of phenomena
4. Theory can be the source of hypotheses that can be
tested for it to be elaborated
5. Theories contribute in enriching the general body of
knowledge through the studies implemented to validate
them
6. Theories can be used by practitioners to direct or
enhance their practice
7. Theories must be consistent with other validated
theories, laws, and principles but will leave open
unanswered questions that need to be tested
Types of Theories
1. Descriptive or factor isolating theories
o To know the properties and workings of a discipline
o Do not explain the relationship of concepts
o EX. Filipino nursing practices like using herbal
medicines and other alternative treatment
2. Explanatory or factor relating theories
o To examine how properties relate and thus affect
the discipline
o EX. research study about the factors affecting
newborns in failing to thrive
3. Predictive or situation relating theories
o To calculate relationships between properties and
how they occur
o EX. effects of unsanitary environment on the
recovery of post operative patients
4. Prescriptive or situation producing theories
o To identify under which conditions relationships
occur
o EX. explaining the difference in nsg. management in
the ER in relieving anxiety
Components of a Theory
1. Context - resembles environment to which nursing act
takes place
2. Content - subject of the theory
3. Process - method by which nurse acts in using nursing
theory
Nursing Theory
 The term given to the body of knowledge used to
support nursing practice
 A group of related concepts that derive from the nursing
models
Examples of Nursing Theories:
1. Environmental Theory
2. Theory of Human Caring
3. “Nurses have to provide care when patients cannot take
care of themselves.”
Nursing Theories and Models
 Provide information on:
o Definitions of nursing and nursing practice
o Principles that form the basis of practice
o Goals and functions of nursing
 Derived from concepts
 Based on the nursing metaparadigm
Nursing Paradigm
 Patterns or models used to show a clear relationship
among the existing theoretical works in nursing
Metaparadigm
 Greek “Meta”- with; “Paradeigma”- pattern
 Main concepts encompassing the subject matter and the
scope of discipline
 Organizing conceptual or philosophical framework of a
discipline or profession
 It defines and describes relationships among major ideas
and values
Metaparadigm of Nursing
 Person
o Refers to the recipient of nursing care, including
physical, spiritual, psychological, socio-cultural
components
 Environment
o Refers to all internal and external conditions and
circumstances, and influences affecting the person
 Health
o Refers to the degree of wellness or illness
experienced by the person
 Nursing
o Refers to the actions, characteristics, and attributes
of the individual providing the nursing care
Importance of nursing theory
 Helps to decide what nurses know and what nurses
need to know
 Theory analyzes and explains what nurses do
 Better patient care, enhanced professional status for
nurses and improved communication between nurses
 Guides nursing research and nursing education
Purposes of nursing theory
1. Education
o Provide a general focus for curriculum design
o Guide curricular decision-making process
2. Research
o Offers framework for generating knowledge and
new ideas
o Assist in the discovery of knowledge in a specific
field of study
o Offer a systematic approach to identify questions
for scaling, selection of variables and interpretation
of findings
 3. Clinical practice
o Assist nurses to describe, explain, and predict
everyday experiences
o Serve to guide assessment, implementation and
evaluation of nursing care
o Provide rationale for collecting reliable and valid
data about the health status of clients which are
important for effective decision making and
implementation Helps establish criteria to measure
the quality of nursing care
o Helps build common nursing terms in
communicating with other health programs
o Assist in clarifying beliefs, values and goals
o Help define the unique contributions of nursing
care to clients
o Enhance autonomy in nursing

Relationships between…
1. Theory & Research
o Research validates & modifies theory
o Theory stimulates exploration
2. Theory & Practice
o Theory guides practice
o Theory provides insights about nursing practice
situations
o Practice shapes theory
3. Research & Practice
o Research develops practice
 MARTHA ROGER: SCIENCE OF UNITARY HUMAN BEING
Martha Roger’s theory science of unitary human beings
 Mainly focusing on the 4 concepts and 3 principles of
homeodynamics that are energy fields, openness,
pattern, pandimensional, integrality, resonancy, and
helicy respectively
Assumptions
 Human being is considered as a whole w/c cannot be
viewed as subparts
 The life process of human is irreparable and one way i.e.
from birth to death
 Health and illness are the continuous expression of the
life process
 The energy flows freely between the individual and
environment
 Human being possesses the ability to think, imagine,
sense, feel, and use language for expression
 Human being has the ability to adapt according to the
new changes in the environment
Concepts
 All human beings are viewed as an integral part of
universe
 Human beings and the environment have energy field,
nursing action is directed towards patterning and
maintaining these energy fields
Energy Fields
 It is the inevitable part of life
 Human and environment both have energy fields w/c
are open i.e. energy can freely flow between human and
environment
Openness
 There is no boundary or barrier that can inhibit the flow
of energy between human and environment w/c leads
to the continuous movement or matter of energy
Pattern
 The distinguishing character of the energy field
Pandimensional
 Undeviating field w/c is not constricted by space or
time, it is an infinite domain w/out boundary
Principles of homeodynamics
 Refers to the balance between the dynamic life process
and environment
 These principles help to view human unitary human
being
 The 3 separate principles are integrality, resonancy, and
heliecy
Principles of Integrality
 Energy fields are dynamic and constantly interact w/ the
human and environment, w/c affects our environment
and vice versa
 This is the principle on w/c meditation and humor works
to produce a positive environment
Principles of Resonancy
 An ordered arrangement of rhythm characterizing both
human field and environmental field
 Constant change in the way or pattern of the energy
field from a lower to higher frequency
 This movement of energy can be made by human touch,
guided imagery activities, drawing, storytelling and
other active use of imagination
Principles of Heliecy
 Any minute change in the environment w/c leads to
ripple effect i.e. results in a larger changes in other field
 This change is constant, unpredictable and there many
factors w/c mutually interact and interact and cause the
change
Metaparadigm of Nursing
 Person
o Unitary human being is open systems w/c
continuously interact w/ environment
o A person cannot be viewed as parts it should be
considered as a whole
 Environment
o It includes the entire energy field other than a
person
o These energy fields are irreducible, not limited by
space and time, identified by its pattern and
organization
 Health
o Not clearly defined by Roger
o It is determined by the interaction between energy
fields i.e. human environment
o Bad interaction or misplacing of the energy leads to
illness
 Person
o It is both science and art
o It constantly maintains the energy field w/c is
conducive for the px
o Nursing action – directs the interaction of person
and environment to maximize health potential
Application of SUBH
Clinical Practice
 Nursing action is always focused on unitary human being
and change the energy field between human and
environment
 Nursing interventions include all noninvasive actions
such as guided imaginary, humor, therapeutic touch,
 music, etc. w/c are used to increase the potential of
human being
 More importance should be on the management of
pain, supportive psychotheraphy and rehabilitation of
the human being

Nursing Education
 Emphasis should be given on the understanding of the
px and self, energy field, and environment
 Training should lay more focus on teaching non-invasive
modalities such as therapeutic touch, meditation,
humor, regular in-service education programme etc.
Nursing Research
 Rogerian theory has been used in many research works
and has always been found testable and applicable in
research
Nursing Process According to SUBH

Pattern appraisal
 It is an inclusive assessment of human and environment
energy fields, its organization of energy field, and
identification of areas of dissonance
 Nurses validate the entire appraisal along w/ the client

Mutual patterning
 It is the proper patterning of energy fields between the
human and environment
 It is the mutual interaction between the client and nurse
 Patterning can be done by suggesting the various
alternatives, educating, empowering, encouraging etc.
depending on the client’s condition and needs
 Pattern appraisal include appraisal of nutrition, rest and
sleep, exercises, discomfort, and relation w/ other
 Pattering activities can be therapeutic, touch,
meditation, humor, imaginary etc.
Evaluation
 Done by repeating the pattern appraisal after the
mutual patterning to determine the extents of
dissonance and harmony
 MARGARET JEAN WATSON: PHILOSOPHY AND SCIENCE OF
CARING
Background
 Born in Southern West Virginia
 1964 – BSN in Colorado
 1966 – MS in Psychiatric – Mental Health Nsg
 1973 – PhD in Educational Psychology
Metaparadigm of Nursing
 Person
o Human being to be valued, cared for, respected,
nurtured, understood and assisted
o Must be viewed according to the client’s
development & the conflicts arising in this
development
 Environment
o Defined as society with all its influences
o It provides the values that determine how one
should behave and what goals one should strive
toward
o Encompasses social, cultural & spiritual aspect
 Health
o Refers to unity & harmony with in the mind, body &
soul
o Watson, in addition to WHO’s definition, include
these three elements:
1. A higher level of over-all physical, mental &
social functioning
2. A general adaptive- maintenance level of daily
functioning; and
3. The absence of illness (or the presence of
efforts that lead to its absence)
 Nursing
o Providing holistic health care
o A human science of people & human health-illness
experiences that are mediated by professional,
personal, scientific, aesthetic & ethical human care
transactions
Major Assumption
 Caring can be demonstrated and practiced only
interpersonally
 Caring consists of carative factors that result in the
satisfaction of certain human needs
 Effective caring promotes health & individual or family
growth
 A caring environment accepts a person as he is and
looks to what the person may become
 A caring environment offers development of potential
while allowing the person to choose the best action for
himself/herself at a given time
 Caring is more “healthogenic” than is curing
 The practice of caring integrates biophysical knowledge
with knowledge of human behavior to generate or
promote health & to provide ministrations of those who
are ill
 A science of caring is therefore complementary to the
science of curing
 Caring is central to nursing
Watson’s 10 Carative Factors
1. Forming humanistic-altruistic value system
o Occurs early in life but can be greatly influenced by
nursing educators
o Can be accomplished by examining one’s views,
beliefs, and interactions with various cultures as
well as personal growth experiences
o Provides satisfaction through giving & extending
oneself
o Begins developmentally at an early age with values
shared with the parents
o Mediated through one’s own life experiences, the
learning one gains, and exposure to the humanities
o Perceived as necessary to the nurse’s own
maturation which then promotes altruistic behavior
towards others
2. Instillation of faith-hope
o Describes the nurse’s role in developing effective
nurse-patient interrelationships& in promoting
wellness
o Is accomplished by helping a client adopt health
seeking behaviors, by positively using the powers of
suggestion & positively supporting the client
o This is essential to both the carative and curative
processes
o When modern science has nothing further too offer
the person, the nurse can continue to use faith-
hope to provide a sense of well-being through
beliefs which are meaningful to the individual
3. Cultivating sensitivity to self and others
o The recognition of feelings leads to self-
actualization through self-acceptance for both the
nurse & the patient
o As Nurses acknowledge their sensitivity and
feelings, they become more genuine, authentic,
and sensitive to others
o Striving to become sensitive, makes the nurse more
authentic, which encourages self-growth and self-
actualization in both the nurse and those with
whom the nurse interacts
o The nurse promote health and higher level
functioning only when they form person to person
relationship
4. Development of a helping-trust relationship
o Establishes rapport & caring
o Helps promote expression of positive and negative
feelings
o Is accomplished through congruence, empathy,
nonpossesive warmth, and effective
communication
 o Strongest tool is the mode of communication,
which establishes rapport and caring
o She has defined the characteristics needed to
develop the helping –trust relationship
5. Promotion & acceptance of the expression of positive
& negative feelings
o Involves sharing of feelings
o Includes being prepared for negative as well as
positive feelings
o Feelings alter the thoughts and behavior, they need
to be considered and allowed for in a caring
relationship
o Awareness of feelings helps to understand the
behavior
6. Systematic use of the scientific problem-solving
method for decision making
o Is important for research, defining the discipline &
developing a scientific knowledge base for nursing
o Brings scientific, problem-solving approach to
nursing care
7. Promotion of interpersonal teaching-learning
o Gives a client maximum health control because it
provides information & alternatives
o Distinguishes caring from curing by assigning
responsibility for health to the client
o Enables a client to provide self-care, determine
personal needs & provide opportunities for their
personal growth
8. Provision for supportive, protective & corrective
mental, physical, sociocultural & spiritual environment
o Involves assessing & facilitating a client’s coping
abilities to support & protect mental & physical
well-being
o Requires understanding that a person’s
environment includes internal & external
independent variables
o Includes providing comfort, privacy, safety & a
clean, aesthetic surroundings
9. Assisting with gratification of human needs
o Addresses the needs of both the nurse & the client
o Requires meeting lower-order needs before
attaining higher-order needs
10. Allowance for existential-phenomenological forces
o Permits one to understand people from the way
things appear to them; their experiences shape
their individual perceptions
o Leads to better understanding of oneself & of
others
 FLORENCE NIGHTINGALE: ENVIRONMENTAL THEORY
Background
 1851 – trained in nursing (Kaiserwerth, Germany)
 Pioneered the concept of formal education
Crimean War
 October 21, 1854
 Florence was invited to take a group of 34 female nurses
to work in hospitals in the Crimea
 Served during the Crimean war treating sick and injured
soldiers – influenced her philosophy
November 1854
 Nightingale reorganized patient care
 Discovered the condition of the hospital
 Insufficient medicines
 Poor hygiene
 Infections are rampant
 4077 soldiers died on her first winter in Scutari
 More deaths due to infections than from battlefield
wounds
 “dirt, damp, drains, drink, and diet”
 Scutari, the British base hospital in Constantinople
The Lady with the Lamp
 In the evenings she moved through the dark hallways
carrying a lamp while making her rounds, ministering to
patient after patient
 The soldiers, who were both moved and comforted by
her endless supply of compassion, took to calling her
“the Lady with the Lamp”
 Others simply called her “the Angel of the Crimea” Her
work reduced the hospital’s death rate by two-thirds
March 1855
 Britain sends Sanitary Commision to Scutari
 Sewers were flushed; ventilation was improved
 Death rates were reduced
 Created a kitchen – supply of appealing food and foods
specific to those with certain dietary constrictions
 Laundry – which provided clean linens for the hospital
beds
 Also instituted a classroom and a library for patients’
intellectual stimulation and entertainment
War Finished in 1856
 Florence wanted to improve hospitals in this country
 Conditions in hospitals began to improve
1860
 Nightingale decided to use the money to further her
cause
 She funded the establishment of St. Thomas’ Hospital,
and within it, the Nightingale Training School for Nurses
 Nightingale published Notes on Nursing
 Considered the first “nursing theorist”
 Information on her theory has been obtained through
interpretation of her writings
1883
 Royal Red Cross
1907
 Order of Merit
Bedridden 1896
 Chronic Fatigue Syndrome
 Pioneered in the field of Hospital Planning
 Died in August 13, 1910
 While at Scutari, Nightingale had contracted “Crimean
fever” and would never fully recover
 By the time she was 38 years old, she was homebound
and bedridden, and would be so for the remainder of
her life
 Fiercely determined and dedicated as ever to improving
health care and alleviating patients’ suffering,
Nightingale continued her work from her bed
Florence Nightingale’s Grave
 St Margaret’s Church, East Wellow, Great Britain
Florence Nightingale
 Florence is remembered today as the person
responsible for improving conditions in hospitals and
making nursing an acceptable job
 Strongest influence: education, observation and hands-
on experience
Nightingale’s Nursing Theory
 Theory basis: the inter-relationship of a healthful
environment with nursing
o External influences and conditions can
prevent, suppress, or contribute to disease or
death
 Theory goal: Nurses help patients retain their own
vitality by meeting their basic needs through control of
the environment
 Nursing’s Focus: control of the environment for
individuals, families & the community
Three Types of Environments
1. Physical
2. Psychological
3. Social
Physical Environment
 Consists of physical elements where the patient is being
treated
 Affects all other aspects of the environment
 Cleanliness of environment relates directly to disease
prevention and patient mortality
 Ventilation, warmth, cleanliness, light, noise, and
drainage
Psychological Environment
 Providing a positive stress-free surrounding
 Can be affected by a negative physical environment
which then causes STRESS
 Requires various activities to keep the mind active (i.e,
manual work, appealing food, a pleasing environment)
 Involves communication with the person, about the
person, and about other people
Social
 Involves collecting data about illness and disease
prevention
 Consists of a person’s home or hospital room, as well as
the total community that affects the patient’s specific
environment
 Stress free surroundings
5 Major Components of a Healthful Environment
1. Proper ventilation
2. Adequate light
3. Sufficient warmth
4. Control of noise
5. Control of effluvia
(noxious odors)
Nightingale’s 13 Canons:
1. Ventilation and warming
 o Keeping the air that the patients breathe as pure as
the external air, without chilling them
2. Health of houses
o Pure air, pure water, efficient drainage, cleanliness,
light; without these, no house can be healthy, and
it will be unhealthy jus int proportion as they are
deficient
3. Petty Management
o All the results of good nursing may be negated by
one defect: not knowing how to manage what you
do when you are there and what shall be done
when you are not there
4. Observation of the sick
o What to observe, how to observe, which symptoms
indicate improvement, which indicate the reverse,
which are important, which are not, and which are
evidence of neglect and what kind of neglect
5. Personal Cleanliness
o Nurses should always remember that if they allow
patients to remain unwashed or to remain in
clothing saturated with perspiration or other
excretion, they are interfering injuriously with the
natural processes of health just as much as if they
were to give their patients a dose of slow poison
6. Light
o Essentially direct sunlight, has a purifying effect
upon the air of a room
7. Cleanliness of room and walls
o Preserving the cleanliness; the inside air can be
kept clean only by excessive care to aid rooms and
their furnishings of the organic matter and dust
with which they become saturated
o Without cleanliness, you cannot have all the effects
of ventilation; without ventilation, you can have no
thorough cleanliness
8. Bed and Bedding
o Patients’ bed should have a clean bed every 12
hours
o The bed should be narrow, so that the patient does
not feel “out of humanity’s reach”
o The bed should not be so high so that the patient
cannot easily get in or out of it
o The bed should be in the lightest spot in the room,
preferably near the window
o Pillows should be used to support the back below
the breathing apparatus, to allow shoulders room
to fall back, and to support the head without
throwing it forward
9. Taking food
o The nurse should be conscious of patients’ diets
and remember how much food each patient has
had and ought to have each day
10. What food
o Watch for the opinions the patients’ stomach gives,
rather than to read “analyses of foods,” is the
business of all those who have to decide what the
patient should eat
11. Noise
o unnecessary noise, or noise that creates as
expectation in the mind, is that which hurts
patients
o Anything that wakes patients suddenly will
invariably put them into a state of greater
excitement and do them more serious and lasting
mischief than any continuous noise
12. Chattering hopes and advices
o All friends, visitors, and attendants of the sick
should avoid the practice of attempting to cheer
the sick by making light of their danger and by
exaggerating their probabilities of recovery
13. Variety
o The nerves of the sick suffer from seeing the same
walls, the same ceiling, the same surroundings
during a long confinement to one or two rooms
o The majority of cheerful cases are of those patients
who are not confined to one room
o Most depressed cases will be subjected to a long
monotony of objects around them
Metaparadigm of Nursing
 Person
o The patient, a human being acted upon by a nurse
or affected by the environment who has reparative
powers
o Recovery is within the patient’s power as long as
safe environment for recuperation exists
 Environment
o Comprises the external conditions and forces that
affect one’s life and development
o Everything from person’s food to a nurse’s verbal
and nonverbal interactions with the person
 Health
o Maintaining well-being by using a person’s powers
to the fullest extent; disease is viewed as a
reparative process instituted by nature
o Maintained by controlling environmental factors to
prevent disease; nurse helps the person through
the healing process
 Nursing
o Aims to provide fresh air, light, warmth,
cleanliness, quiet and proper diet; facilitates a
person’s reparative by ensuring the best possible
environment; influences the environment to affect
health
Nightingale’s Assumption
1. Nursing is separate from medicine
2. Nurses should be trained
3. The environment is important in nursing
4. The disease process is not important to nursing
5. Nursing should support the environment to assist the
patient in healing
6. Research should be utilized through observation and
empirics to define the nursing discipline
7. Nursing is both an empirical science and an art
8. Nursing’s concern is with the person in the environment
9. The person is interacting with the environment
10. Sick and well are governed by the same laws of health
11. The nurse should be observant and confidential
DOROTHEA E. OREM: SELF-CARE DEFICIT THEORY
Credentials and Background
 Born on 1914 in Baltimore, Maryland
 Began her nursing education at Providence Hospital
School of Nursing in Washington, DC
 1939 – she earned her BSN education at the Catholic
University of America
 1946 – earned her M.S.N. from Catholic University of
America.
  Her nursing experiences included
a. operating room nursing,
b. private duty nursing (home & hospital),
c. hospital staff nursing on pediatric and adult
medical and surgical units, evening supervisor in
the E.R.
d. biological science teacher
 1958-1960 curriculum consultant
 1959 – “Guides for developing the curricula for the
Education of Practical Nurses” was published
 1971 – “Nursing Concepts of Practice” which is Orem’s
first book was published.
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 & health development
 The theory is aimed towards making the clients perform
self-care activities in order to live independently
Metaparadigm of Nursing
 Person
o Defined as the patient- a being who functions
biologically, symbolically & socially & who has the
potential for learning & development
o Is an individual subject to the forces of nature, with
a capacity for self-knowledge, who can engage in
deliberate action, interpret experiences & perform
beneficial actions
o Is an individual who can learn to meet self-care
requisites; if for some reason, the person cannot
learn self-care measures, others must provide the
care
 Environment
o Consists of environmental factors, environmental
elements, environmental conditions (external
physical & psychosocial surroundings) &
developmental environment (promotion of
personal development through motivation to
establish appropriate goals & to adjust behavior to
meet these goals; includes formation of or change
in attitudes & values, creativity, self-concept &
physical development)
 Health
o Orem supports the WHO’s definition of health as
“the state of physical, mental, and social well-being
and not merely the absence of disease or infirmity”
o Consists of physical, psychological, interpersonal &
social aspects; according to Orem, these aspects
are inseparable
o Includes promotion & maintenance of health,
treatment of illness & prevention of complications
 Nursing
o Helping clients to establish or identify ways to
perform self-care activities
o Nursing actions are geared towards the
independence of the client
o Nursing is a human service-its focus is on persons
with inabilities to maintain continuous provision of
healthcare
o Nursing is based on values
Major Concepts & Definitions
 Self – Care
 Self – Care Requisites
 Universal Self-Care Requisites
 Developmental Self – Care Requisites
 Health Deviation Self – Care Requisites
 Therapeutic Self – Care Demand
 Self-Care Agency
 Agent
 Dependent-Care Agent
 Self-Care Deficit
 Nursing Agency
 Nursing Design
 Nursing System
 Helping Methods
Self-care Deficit Theory as a General Theory is Composed of 3
Related Theories:
1. The theory of self-care
o Describes why & how people care for themselves
o Self- Care: refers to those activities an individual
performs independently throughout life to
promote & maintain personal well-being
o Self- Care agency: the complex acquired ability of
mature & maturing persons to know & meet their
continuing requirements for deliberate, purposive
action to regulate their own functioning &
development
Consists of two agents: An agent (individual
who is engage in meeting the need of a
person; like bridges that facilitate what has
been done and what needs to be done)
a. Self-care agent – person who provides
the self-care
b. Dependent care agent – person other
than the individual who provides cares
o Self-care requisites or Self-care needs: are insights of
actions or requirements that a person must be able to
meet and perform in order to achieve well-being
Categories of Self-care requisites:
a. Universal Self-care requisites
 these are universally set goals that
must be undertaken in order for an
individual to function in scope of
healthy living
1. Maintenance of sufficient intake of
air
2. Maintenance of sufficient intake of
food
 3. Maintenance of 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
b. Developmental Self-care requisites
 Result from maturation or
associated with conditions or events
such as adjusting to a change in body
image or loss of a spouse
 They promote processes for life &
maturation & prevent conditions
deleterious to maturation or those
that lessens those effects
c. Health deviation self-care requisites
 Requisites that result from illness,
injury or disease or its treatment;
they include such actions as seeking
medical assistance, carrying out a
prescribed treatment or learning to
live with the effects of illness or
treatment
 These health care deviations set
standards to which the degree of
self-care demand is needed
o Therapeutic Self-Care Demand
 Refers to all self-care activities required to
meet existing self-care requisites
 Involves the use of actions to maintain health
& well-being, each patient’s therapeutic self-
care demands varies throughout life
2. The theory of self-care deficit
o Which describes & explains why people can be
helped through nursing
o Self-care deficit: arises when the self-care agency
cannot meet self-care requisites
o Helping Methods:
a. Acting or doing for another
b. Guiding and directing
c. Providing physical or psychological support
d. Teaching
e. Providing and maintaining an environment
that supports personal development
3. Theory of nursing systems
o Describes and explains relationships that must be
brought about & maintained for nursing to be
produced
o Refers to the series of actions a nurse takes to meet
a patient’s self-care requisites
o Nursing Agency: set of established capabilities of a
nurse who can legitimately perform activities of
care for a client
o Helps a person achieve their health care demand
o Nursing Design: these are professional functions
that must be performed by the nurse in order to
meet client needs, it serves as a guideline of
needed & foreseen results in the production of
nursing toward the achievement of nursing goals
3 Types of Nursing Systems
 Each system describes nursing responsibilities, roles of
the nurse & patient, rationales for the nurse-patient
relationship & types of actions needed to meet the
patient’s self-care agency & therapeutic self-care
demand
1. A wholly compensatory nursing system
o is used when a patient’s self-care agency is so
limited that the patient depends on others for
well-being
2. A partly compensatory nursing system
o Is used when a patient can meet some self-
care requisites but needs a nurse to help meet
others
o The nurse & the patient play major roles in
performing self-care
3. Supportive – Educative Nursing System
o Is used when a patient can meet self-care
requisites but needs assistance with decision
making, behavior control or knowledge
acquisition skills
Major Assumptions
1. Human beings require continuous, deliberate inputs to
themselves and their environments to remain alive and
function in accordance with natural human
endowments.
2. Human agency, the power to act deliberately, is
exercised in the form of care for self and others in
identifying needs and making needed inputs
3. Mature human beings experience privations in the form
of limitations for action in care for self and others
involving and making of life sustaining and function-
regulating inputs
4. Human agency is exercised in discovering, developing,
and transmitting ways and means to identify needs and
make inputs to self and others
5. Groups of human beings with structured relationship
cluster tasks and allocate responsibilities for providing
care to group members who experience privations for
making required, deliberate input to self and others
Basic Nursing Systems
Acceptance by the Nursing Community
 Practice - the first documented use of Orem’s theory as
the basis for structuring practice is found in descriptions
of nurse-managed clinics at John Hopkins Hospital in
1973.
Research articles on the use of SCDNT or components in
clinical practice include:
a. Teaching self-care to individuals with DM, ESRD,
hemodialysis, peritoneal dialysis, renal transplant
b. Pain assessment
c. Cardiac research
d. Oncology – focus cancer prevention, self-care after
being diagnosed with malignancies
e. e. Psychiatry etc.
 Education
“Guides for Developing Curriculum for the Education of
Practical Nurses”
a. Orem worked on a book, “Foundations of Nursing
Practice” (Morris Harvey College)
 Research
a. First instrument to measure the exercise of Self-
care agency (ESCA) was published in 1979
Further Development
 Orem is presently working with a group of scholars,
known as Orem study Group
 International Orem Society for Nursing scholarships (IOS
est. 1993)
 The Sixth International Self-Care deficit theory
Conference which was held in Bangkok, Thailand in
February 2000
 IMOGENE KING: GOAL ATTAINMENT THEORY
Background
 Youngest of 3 children, born in 1923
 St. John's Hospital School of Nursing in St. Louis,
Missouri (1946)
 St. Louis University - BS in Nursing Education (1948) &
MS in Nursing (1957)
 Teachers College, Columbia University, New York: - EdD
(1961) - Postdoctoral study in research design, statistics,
and computers
 Expertise: adult medical-surgical nursing
 Experiences: an administrator, educator, and
practitioner
Nursing Metaparadigm
 Person
o Individuals are spiritual being
o have the capacity to think, know, make
choices & select alternative courses of action
o Have the ability through their language &
other symbols to record their history &
preserve their culture
o Open system in transaction with the
environment
o Unique & holistic, are of intrinsic worth & are
capable of rational thinking & decision making
in most situations
o Individuals differ in their needs, wants & goals
o 3 fundamental health needs of human beings:
1. Need for information
2. Need for care for illness prevention
3. Need for total care when a person
doesn’t have the capacity to help
themselves
 Environment
o The process of balance involving internal &
external interactions inside the social system
o Interpreted from the general systems theory
as an open system with permeable boundaries
that allow the exchange of matter, energy, and
information
 Health
o Is a dynamic state in the life cycle; illness is an
interference in the life cycle
o Implies continuous adjustment to stress in the
internal and external environments, using
personal resources to achieve optimal daily
living
 Nursing
o Is an act wherein the nurse interacts &
communicates with the client
o The nurse helps the client identify the existing
health condition, exploring & agreeing on
activities that promote health
o The goal of the nurse in King’s theory is to help
the client maintain health through health
promotion & maintenance, restoration &
caring for the sick & dying
Goal Attainment Theory
 Involves the nurse and the patient mutually
communicating information, establishing goals, and
taking action to obtain goals
 Two people who are usually strangers come together in
a health care organization to help or to be helped to a
mutual state of health
Central Focus of the Theory
 Man
o As a dynamic human being whose perceptions
of objects, persons, and events influence his
behavior, social interaction, and health
o Man is an important focus of King's framework
o She proposes three basic premises; man is:
1. A reactive being
2. A time oriented being
3. A social being
o Man as a reactive being is aware of other
things; persons and events in the environment
o Man as a time-oriented being is influenced by
time orientation, each person is influenced by
his past actions
o Man as a social being has a continuous
exchange with persons in the environment,
language is a social link and facilitates
interpersonal communication
3 Interacting Systems of the Theory
1. Personal system
o Individuals
o How the nurse views & integrates self-based
from personal goals & beliefs
o The personal interacting system consists of:
a. The Individual's Perception - the person's
representation of reality and it is unique
to each individual
b. Self - the person's subjective
environment, values, ideas, attitudes, and
commitment
c. Growth and Development - involves all
the changes that occur (cellular,
molecular, and behavioral). These
changes are usually orderly and
predictable, but may vary with individuals
d. Body Image -the way a person perceives
their body and the reaction of others to
their body. Body image is subjective and
changes as the person changes physically
or emotionally
e. Space -is the immediate physical territory
occupied by the person and person's
behavior
f. Time -is the order of events and their
relationship to each other
2. Interpersonal System
o Two or more interacting individuals
 o How the nurse interrelates with a co-worker 6. The ability to select means of accomplishing goals
or patient, particularly in a nurse-patient Propositions of King’s Goal Attainment Theory
relationship 1. If perceptual accuracy is present in nurse-client
o Concepts of interpersonal system: interactions, transactions will occur
a. Interaction – any situation wherein the 2. If nurse & client make transactions, goals will be
nurse relates & deals with a patient attained
b. Communication – refers to the 3. If goals are attained, satisfactions will occur
transmission of information from one 4. If goals are attained, effective nursing care will occur
person to another; either directly or 5. If transactions are made in nurse-client interactions,
indirectly growth & development will be enhanced
c. Transaction – refers to the interaction 6. If role expectations & role performance as perceived by
between a person & the environment for nurse & client are congruent, transactions will occur
the purpose of goal attainment 7. If role conflict is experienced by the nurse & client or
d. Role – refers to the expected behaviors both, stress in nurse-client interactions will occur
of a person in a specific position & to the 8. If nurses with special knowledge & skills communicate
rules that govern the position & affect appropriate information to clients, mutual goal setting &
interaction between two or more persons goal attainment will occur
e. Stress – refers to an exchange of energy,
either positive or negative between a
person & the environment; objects,
persons & events can serve as stressors
3. Social System
o Composed of larger group of individuals with
common interests or goals
o How the nurse interacts with co-workers,
superiors, subordinates & the client
environment in general
o EX. families, religious groups, schools,
workplaces, and peer groups
o  A social system comprises the:
a. Social roles
b. Behaviors
c. Practices
o Concepts of social system:
a. Organization – refers to a group of
people with similar interest who have
prescribed roles & positions & who use
resources to achieve personal &
organizational goals
b. Authority – refers to the observable
behavior of providing guidance & order &
being responsible for actions
c. Power – is characterized by the ability to
use resources for goal achievement; also
a means by which one or more persons
can influence others
d. Status – refers to the position occupied
by a person in a group or the position
occupied by a group in relation to other
groups in an organization; it is
accomplished by certain duties, privileges
& obligations
e. Decision Making – results from
developing & acting on perceived choices
for goal attainment
6 Characteristics of Man
1. The ability to perceive – perceptions will influence
behavior and thus life and health
2. The ability to think – thinking is based upon the
inquiring mind of man
3. The ability to feel - have emotions
4. The ability to choose between alternative course of
action
5. The ability to set goals
PATRICIA BENNER: From Novice to Expert
Excellence and Power in Clinical Nursing Practice
Credentials and background of the theorist
 Patricia Benner, R.N., Ph.D., F.A.A.N.
Professor, University of California-San Francisco
 Obtained a Bachelor of Arts degree from Pasadena
College in 1964
 Aug 31, 1942
 Hampton, Virginia
 Fellow of the American Academy of Nursing.
 Earned a master’s degree in nursing from the University
of California, San Francisco School of Nursing in 1970
 She published From Novice to Expert in 1984 and
became a Fellow in the American Academy of Nursing in
1985
 Authored 9 books
 American Journal of Nursing Boook of the year for
nursing education and nursing research
 1990- Book of the year – The Primacy of Caring – co-
authored with Judith Wrubel
Nursing Metaparadigm
 Person
o “a self-interpreting being, that is, the person does
not come into the world predefined but gets
defined in the course of living a life.”
o The person is viewed as participant in
common meanings.
o The major aspects of understanding that the
person must deal with:
1. The role of the situation
2. The role of the body
3. The role of personal concerns
4. The role of temporality
o Benner believed that there are significant aspects
that make up a person. She had conceptualized the
major aspects of understanding that the person
must deal as:
 Environment
o She used the word situation because it suggests a
social environment with social definition and
meaning.
o Situation – defined by the person’s engaged
interaction, interpretation and understanding of
the situation.
o Persons enter into situations with their own sets of
meaning, habits & perspectives.
o Instead of using the term “environment”, Benner
used the term “Situation”
 Health
o Health – what can be assessed
o Well-being – human experience of health or
wholeness.
o Illness – the human experience of loss or
dysfunction.
o Disease – is what can be assessed at the physical
level
o Patricia Benner focused “on the lived experience of
being healthy and ill.
o Health is described as not just the absence of
disease and illness.
o Also, a person may have 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.
 Nursing
o She described nursing as a caring relationship, an
“enabling condition of connection and concern.
o Viewed nursing practice as the care and study of
the lived experience of health, illness, and disease
and the relationships among these three elements
Stages of Clinical Competence
Benner's Stages of Clinical Competence (1984; 2004)
 Novice
o No experience of the situations in which they are
expected to perform
o Learn context-free rules to guide action (stimulus-
response thinking)
o Rule-governed behavior is typical, tends to be
inflexible
o Has difficulty discriminating between relevant &
irrelevant aspects of a situation
o Noun. a person who is new to the circumstances,
work, etc., in which he or she is placed; 
o This would be a nursing student in his or her first
year of clinical education; behavior in the clinical
setting is very limited and inflexible. Novices have a
very limited ability to predict what might happen in
a particular patient situation. Signs and symptoms,
such as change in mental status, can only be
recognized after a novice nurse has had experience
with patients with similar symptoms.
 Advance Beginner
o Can demonstrate marginally acceptable
performance
o Have begun to identify recurring meaningful
situational aspects and apply these in new
situations
o Unable to see the entirety of a new situation (may
miss some critical details)
o They feel more responsible for managing patient
care, yet they still rely on the help of those who
have more experiences
o Nurses have had more experiences that enable
them to recognize recurrent, meaningful
components of a situation. They have the
 knowledge and the know-how but not enough in-
depth experience.
o Those are the new grads in their first jobs
 Competent
o Considers consistency, predictability & time
management as essential components & gaining a
sense of mastery
o There is an increased level of efficiency but the
focus is on time management & the nurses
organization of the task are more important rather
than on timing in relation to the patient’s needs
o This stage is critical because the nurse must know
how to recognize the patterns & identify which
element of the situation needs attention & which
ones to ignore
o These nurses lack the speed and flexibility of
proficient nurses, but they have some mastery and
can rely on advance planning and organizational
skills.
o Competent nurses recognize patterns and nature of
clinical situations more quickly and accurately than
advanced beginners.
 Proficient
o Perceives situations as whole rather than in terms
of aspects
o Performance is guided by maxims (cryptic
instructions that make sense only if there is already
a deep understanding of the situation)
o Perception is a key word
o Possesses a web of perspectives on a situation
o Demonstrate an increased confidence in their
knowledge & abilities
o At this level, nurses are capable to see situations as
“wholes” rather than parts. Proficient nurses learn
from experience what events typically occur and
are able to modify plans in response to different
events.
 Expert
o No longer relies on an analytic principle (rule,
guideline, maxim) to connect understanding of a
situation to appropriate action
o Operates from a deep understanding of the total
situation
o Possessing an intuitive grasp of the problem
o There is a qualitative change as the expert
performer “knows the patient”, which means that
knowing typical patterns of responses & knowing
the patient as a person
o Focus is on the most relevant problems and not
irrelevant ones.
o Analytical tools are used only when they have no
experience with an event, or when events don’t
occur as expected
o Key aspects of the expert nurse practice:
 Demonstrating a clinical grasp and resource-
based practice
 Possessing embodied knowledge
o Beginner nurses focus on tasks and follow a “to do”
list.
o Expert nurses focus on the whole picture even
when performing tasks.
o They are able to notice subtle signs of a situation
such as a patient that is a little harder to arouse
than in previous encounters.
SEVEN DOMAINS OF NURSING PRACTICE
1. Helping role
o This includes competencies related to establishing
a healing relationship, providing comfort measures,
and inviting active patient participation and control
in care
2. Teaching or coaching function
o This includes timing, readying patients for learning,
motivating, change, assisting with lifestyle
alterations, and negotiating agreement on goals
3. Diagnostic client-monitoring function
o This refers to competencies in ongoing assessment
and anticipation of outcomes
4. Effective management of rapidly changing situations
o This includes the ability to contingently match
demands with resources and to assess and manage
care during crisis situations
5. Administering & monitoring therapeutic interventions &
regimens
o This includes competencies related to preventing
complications during drug therapy, wound
management and hospitalization
6. Monitoring & ensuring quality health care practices
o This includes competencies with regard to
maintenance of safety, continuous quality
improvement, collaboration and consultations with
physicians, self-evaluation, and management of
technology
7. Organizational & work-role performance
o This includes competencies in priority setting, team
building, coordinating, and providing for continuity
Theoretical knowledge
 Can be acquired in an abstract fashion through reading,
observing, or discussing
Practical knowledge
 The development of practical knowledge requires actual
experience in a situation because it is contextual and
transactional
According to Benner Clinical nursing requires theoretical
knowledge and practical knowledge
The significance of this theory is that these levels reflect a
movement from past, abstract concepts to past, concrete
experiences. Each step builds from the previous one as these
abstract principles are expanded by experience, and the nurse
gains clinical experience.
This theory has changed the perception of what it means to be an
expert nurse.
The expert is no longer the nurse with the highest paying job, but
the nurse who provides the most exquisite nursing care.
VIRGINIA HENDERSON: 14 Basic Human Needs
Virginia Avenel Henderson
 VH views her work as a philosophical statement rather
than a theory
 In her definition, she emphasizes the care of both sick &
well individuals, and she was one of the 1st theorist to
include spiritual aspects of nursing care
 According to VH, the nurse assist the patient with
essential activities to maintain health, recover from
illness or achieves a peaceful death
 Patient’s independence is an important criterion for
health
 Henderson identifies 14 basic needs that forms the
components of nursing care; the nurse helps the patient
meet these needs
14 Basic Human Needs
1. Physiological
o Breathe normally
o Eat and drink adequately
o Eliminate body wastes
o Move and maintain desirable postures
o Sleep and rest
o Select suitable clothes - dress and undress
o Maintain body temperature within normal range by
adjusting clothing and modifying the environment
o Keep the body clean and well groomed and protect
the integument.
o Avoid dangers in the environment and avoid
injuring others
o Communicate with others in expressing emotions,
needs, fears, or opinions.
2. Spiritual
o Worship according to one’s faith
3. Sociological
o Work in such a way that there is a sense of
accomplishment.
o Play or participate in various forms of recreation
4. Psychological
o Learn, discover, or satisfy the curiosity that leads to
normal development and health and use the
available health facilities
Henderson also emphasized the need to view the patient and his
family as a single unit
For the patient to achieve health, he must be able to meet his
need for support system – provided by the family
Nursing Metaparadigm
 Person
o Referred as a patient
o An individual requiring assistance to achieve health
& independence or a peaceful death, the person &
family are viewed as a unit
o The mind &body are inseparable
o Must be able to maintain physiological & emotional
balance
 Environment
o Not specifically defined
o Involves the relationship one shares with one
family\also involves the community & its
responsibility for providing health care.
o VH believes that society wants & expects nurses to
provide a service for individuals incapable of
functioning independently
 Health
o Is a quality of life that is basic to human functioning
o Health requires independence & interdependence
o Promotion of health is more important than care
for the sick
o Individuals will achieve or maintain health if they
have the necessary strength, will or knowledge
 Nursing
o Henderson stated “the unique function of the
nurse is to assist the individual, sick or well in the
performance of those activities contributing to
health or its recovery (or to peaceful death) that he
would perform unaided if he had the necessary
strength, will or knowledge. And to do this in such a
way as to help him gain independence as rapidly as
possible.”
o Requires working interdependently with other
members of the health care team; the nurse
functions independently of the physician but uses
the physician’s plan of care to provide holistic care
to the patient
The Nurse functions in relation with the patient, physician, and
other members of the health team
The Nurse – Patient Relationship
 The nurse as a substitute for the patient
o Making up for what the patient lacks to be whole &
independent again
 The nurse as a helper to the patient
o Instituting medical interventions to assist the
patient meet his basic needs
 The nurse as a partner with the patient
o Fostering a therapeutic relationship with the
patient & functioning as a member of the health
care team
The Nurse – Physician Relationship
 Henderson asserted that nurses function independently
from physicians
 The plan of care must be implemented in such a way
that will promote the physician’s prescribed therapeutic
plan
The Nurse as Member of the Healthcare Team
 For a team to work together in harmony, every member
must work interdependently
 The nurse, as a member of the healthcare, works &
contributes in carrying out the total program of care
 “She is temporarily the consciousness of the unconscious, the
love of life for the suicidal, the leg of the amputee, the eyes
of the newly blind, a means of locomotion for the infant,
knowledge and confidence for the young mother, the
mouthpiece for those too weak or withdrawn to speak, and
so on.”

BETTY NEUMAN: System Model in Nursing Practice

 Environment
“Health is a condition in which all parts and subparts are in
o Defined as being all the internal & external factors
harmony with the whole of the client.”
that surround or interact with person & client
Background of the theorist
*internal environment exists within the client
8. Born in 1924 on a farm near Lowell, Ohio.
system.
9. 1947 - Received RN Diploma from Peoples Hospital
*external environment exists outside the client
School of Nursing, Akron, Ohio
system.
10. Moved to California and gained experience as a hospital,
o Includes stressor, described as environmental
staff, and head nurse; school nurse and industrial nurse;
forces that interact with & potentially alter system
and as a clinical instructor in medical-surgical, critical
stability
care and communicable disease nursing
 Health
11. 1972   Her model was first published in Nursing
o Neuman sees health as being equated with
Research as a “Model for teaching total person
wellness.
approach to patient problems”
o She defines health/wellness as "the condition in
12. The model is based on philosphical views, Gestalt
which all parts and subparts (variables) are in
theory, Han’s Selye’s stress theory & General System’s
harmony with the whole of the client (Neuman,
theory
1995)".
General Information o Views health as a continuum of wellness to illness
 Systems Model “Neuman’s model focuses on the person that is dynamic in nature & constantly subject to
as a complete system, the subparts of which are change
interrelated physiological, psychological, sociocultural, o “optimal wellness or stability indicates that total
spiritual, and developmental factors.” system needs are being met”
 Neuman’s model deals with stress & stress reduction & o The client is in a dynamic state of either wellness or
is primarily concerned with the effects of stress on illness in varying degrees at any given point of time.
health

Nursing Metaparadigm
 Person
o Is viewed by Neuman as a whole multidimensional,
dynamic system
o Can be an individual, family or group or community
o She sees a person as an open system that works
together with other parts of its body as it interact
with the environment
* open system – characterized by presence of
an exchange of information & reaction with
other factors surrounding a person
o Is composed of basic core (genetic features, and
 Nursing
the strengths and weaknesses of the system parts)
o Neuman believes nursing is concerned with whole
as well as physiological, sociocultural,
person (holistic approach), an approach that
developmental & spiritual variables
considers all factors affecting a client’s health
status.
o Views nursing as a unique profession that is
concerned with all of the variables affecting an
individual’s response to stress.
o the primary aim is stability of the patient/client
system, through nursing interventions to reduce
stressors.

Systems Model in Nursing Practice

1. Client Variables
 o The client variables can be one or combination of
the following:
* physiological, sociocultural, psychological,
spiritual & developmental
o These variables function to achieve stability in
relation to the environmental stressors
experienced by the client
2. Lines of Resistance
o Represent the internal factors of a person that help
defend against a stressor (e.g. body’s immune
response system)
o It acts to facilitate coping to overcome the stressors
that are present with in the individual.
3. Normal Line of Defense
o Represents a stability state for the individual or
system
o It is maintained overtime & serves as a standard to
assess deviations from the client’s usual wellness
o It includes system variables & behaviors such as the
individual’s usual coping patterns, lifestyles, &
developmental stage
4. Flexible Line of Defense
o Acts as a protective barrier to prevent stressors
from breaking through the normal line of defense
o Is dynamic and can change rapidly over a short time
o Can be affected by variables such as loss of sleep,
that reduce a client’s ability to use a flexible line of
defense against stressors.
5. Stressors
o Are forces that produce tensions, alterations or a
potential problems causing instability with in the
client’s system
o They may be:
a. Intrapersonal stressors – are those stimuli
that occur within the individual (e.g. emotions
and feelings)
b. Interpersonal stressors – are those stimuli
that occur between individuals (e.g. pressures
related to role expectation)
c. Extrapersonal stressors – are those stimuli
that occur outside the person (e.g. job or
financial pressures)
6. Reaction
o Are the outcomes or produced results of certain
stressors & actions of the lines of resistance of a
client
o Can be positive or negative depending on the
degree of reaction the client produces to adjust &
adapt with the situation
o Neuman specified these reactions as:
*negentropy – is set towards stability or
wellness
*egentropy – is set towards disorganization of
the system producing illness
7. Degree of Reaction
o Is the amount of energy required for the client to
adjust to the stressors
8. Prevention
o interventions are purposeful actions to help the
client retain, attain & or maintain system stability
o Used to attain balance within the continuum of
health
o These are the actions that generate good results or
aimed towards hindering negative outcomes
o 3 Levels of Prevention
1. Primary Prevention
o Refers to intervention before a reaction
occurs
o Is carried out when a stressor is
suspected or identified
o It also aims to strengthen the capacity of
a person to maintain an optimum level of
functioning while being interactive with
the environment, like health promotion &
disease prevention
2. Secondary Prevention
o Refers to intervention after a reaction
occurs
o Focuses on helping alleviate the actual
existing effects of an action that altered
that balance of health of a person
o It aims to reduce environmental
influences that lead to the decline of the
level of functioning of a person &
strengthening or restoring a person’s
resistance after the illness exposure
o Examples: early detection of disease &
prompt treatment
3. Tertiary Prevention
o Refers to intervention that occurs after
the system has been treated through
secondary
o Focuses on actual treatments or
adjustments to facilitate the
strengthening of a person after being
exposed to a certain or illness
o It aims to prevent the reoccurrence of the
illness in the manner of rehabilitation, as
in the case of disability avoidance &
physical therapy
9. Reconstitution
o Is the adjustment state from the degree of reaction
 o It is a state of going back to the actual state of
health before the illness occurred

Once an individual is exposed to stress, the flexible line of

defense will be “alarmed” to protect the normal (solid) line of
defense to keep the system free from stressor reactions.
However, if this individual is continuously exposed to stress and
if the flexible line of defense is unable anymore to cope up with
the stressors, the normal line of defense will be altered. If this
happens, there will be a threat to the wall that protects the basic
structure of the individual and therefore causing instability of
the systems and illness develops.
Sample Situation:
 Mr. Yoso is a 38 year-old business executive. His
colleagues describe him as hard working, perfectionist,
and very dedicated to work. His day starts by leaving the “Health is a condition in which all parts and subparts are in
house very early from Laguna to Makati and begins harmony with the whole of the client.”
work by delegating various tasks with firm expectations
and deadlines that somewhat impossible to meet. He
usually responds with pressure and intimidating remarks
for works not perfectly done. He smokes and drinks
alcohol whenever he is stressed. Recently, the company
experienced continuous dropped in their sales and his
bosses started to put blame to him.

Mr. Yoso began exhibiting weird mannerisms and

behaviors that appear strange to his family and people
around him. He misses breakfast and lunch very often
and sleeps very late at night while doing work. He has
no time anymore for his family and focuses so hard on
meeting deadlines and his preconceived objectives.
Because of these weird changes in him, the company
decided to temporarily relieve him from his position as
executive manager. A week later, he started to have
periods of mania and depression. His family becomes
worried and called up the hospital to seek assistance
after he locked himself in the room, refusing to eat, and
most of the time quiet and staring blankly on the wall.
Later, he developed pneumonia.

Using Neuman’s System Model in the above situation,

the identified possible stressors that contributed to
Mr. Yoso’s condition were as follows: work,
personality, and attitude. Mr. Yoso is not anymore able
to handle the stressors and that had caused the
“breakdown” of his lines of defense. Without seeking
help from his family and friends, he was not able to
maintain his flexible line of defense and brought
instability to his system. (The diagram on the next page
shows the effect of the stress in his lines of defense
and the corresponding prevention that might have or
may be done to prevent illness/or complications from
occurring.)
SR. CALLISTA ROY: Adaptation model
Callista Roy
 Born on October 14, 1939 in Los Angeles California
 BSN in 1963 Mount St. Mary College, Los Angeles
 MA in Pediatric Nursing 1966/Doctorate in Sociology in
1977 University of California, L.A.
 With honorary doctorate from 4 other institutions
 She is a nurse theorist and a professor
 She is a fellow in the American Academy of Nursing, an
honorary nursing society that elects nursing leaders
annually
 Has numerous publications, including books & journal
articles on nursing theory & other professional topics
 Entered Sisters of St. Joseph Carondelet
 Her publications:
o Introduction to Nursing: An Adaptation Model
o Essentials of the Roy Adaptation Model
o Theory Construction in Nursing: An Adaptation
Model
o Essentials of the Roy Adaptation Model
o Roy Adaptation Model: The Definitive Statement
 Her works has been interpreted in several languages
worldwide
Nursing Metaparadigm
 Person
o Is the recipient of nursing care; main focus of
nursing
o A biopsychosocial being in constant interaction
with a changing environment.
o The person is an open adaptive system who uses
coping skills to deal with stressors.
o It includes people as individuals or in groups
(families, organizations, communities, nations &
society as a whole)
o An adaptive system has cognator and regulator
subsystems to maintain the 4 adaptive modes-
 physiologic-physical,
 self-concept-group identity,
 role function, and
 interdependence
 Environment
o Conditions, circumstances and influences that
surround and affect the development and behavior
of the person.
o Consists of internal & external environments, which
provide input in the form of stimuli
o Stressors are stimuli that are significant in human
adaptation: stages of development, family &
culture
 Health
o Was originally described by Roy as a health-illness
continuum; health & illness were considered an
inevitable dimension of the person’s life
o More recently, Health is the process of being and
becoming an integrated and whole person.
o Is it a reflection of adaptation that is the interaction
of the person & the environment
o Adaptation is defined as the process and outcome
whereby thinking and feeling, as individuals and
groups, use conscious awareness and choice to
create human and environmental integration
 Nursing
o Nursing is the science and practice that expands
adaptive abilities and enhances person and
environment transformation.
o Roy’s goal of nursing is the promotion of
adaptation in each of the 4 modes thus
contributing to health, quality of life and dying with
dignity
o Nursing is about the increase, enhancement,
modification and alteration of the stimulus to
achieve adaptation.
Roy Adaptation Model (RAM)
 THE KEY CONCEPTS:
o The person is adapting in a stable interaction with
the environment, either internal or external.
o The environment serves as the source of a range of
stimuli that will either threaten or promote the
person’s unique wholeness.
o The person’s major task is to maintain integrity in
face of these stimuli.
 INTEGRITY - the degree of wholeness achieved
by adapting to changes in needs.
o SYSTEM – is a set of parts connected to function as
a whole for some purpose & that does so by virtue
of the interdependence of its parts
 Roy considers the recipient of care to be an
open adaptive system
 react & interact with other systems in the
environment
 have boundaries that are flexible & open to
permit interaction with other systems
 employ a feedback cycle of input, throughput
& output
 Input – defined as stimuli which can come
from the environment or from within a
person
o Throughput – makes use of a person’s processes &
effectors
 Processes refer to the control mechanisms
that a person uses as an adaptive system
 Effectors refer to the physiologic function, self-
concept & role function involves in adaptation
o Output – is the outcome of the system, when the
system is a person, the output refers to the
person’s behaviors
Categories of Output:
 Adaptive responses – those that promote
integrity in terms of the goals of the human
system
 Ineffective responses – those that do not
contribute to integrity in terms of the goals of
the human system
Types of Stimuli (Helson, 1964)
1. FOCAL – the internal or external stimulus most
immediately confronting the person, it attracts the most
attention.
2. CONTEXTUAL – all other stimuli present in the situation
that strengthens/contribute the effect of the focal
stimulus.
3. RESIDUAL - those stimuli that can affect the focal
stimulus but the effects are unclear.
o The three types of stimuli act together and
influence the adaptation level which is defined as
the ability to respond positively in a situation
4. COPING MECHANISM – are the processes that a person
uses for self-control
o are innate or acquired ways of interacting with the
changing environment
a. innate coping mechanisms are genetically
determined or common to the species & are
genetically viewed as automatic process
b. acquired coping mechanisms are developed
through strategies such as learning
5. REGULATOR SUBSYSTEM - major coping process
involving the neural, chemical, and endocrine system
e.g. increase in vital signs- sympathetic response to
stress.
6. COGNATOR SUBSYSTEM – is a major coping process
involving four cognitive-emotive channels: perceptual &
information processing; learning; judgment & emotion
e.g. effects of prolonged hospitalization for a 4year-old
child
7. CONTROL PROCESSES – stabilizer subsystem & innovator
subsystem
o Stabilizer subsystem – analogous to regulator :
concerned with stability
o Innovator subsystem – analogous to cognator:
concerned with creativity, change & growth
Adaptation level
1. Integrated - Adaptation level at which the structures and
functions of a life process are working as a whole to
meet human needs.
o Example: Stable processes of ventilation, the
complex process of breathing that exchanges air
between lungs and atmosphere
2. Compensatory - Adaptation level at which the cognator
and regulator have been activated by a challenge to the
integrated life processes
o EXAMPLE: GRIEVING, ROLE TRANSITION
3. Compromised- Adaptation level resulting from
inadequate integrated and compensatory life processes;
adaptation problem.
o EXAMPLES:
 Hypoxia
 Ventilatory Impairment
 Unresolved loss
 Abusive Relationships
Adaptive modes
 are categories of behavior to adapt to stimuli
 can be used to determine a person’s adaptation level
 can be used to identify adaptive or ineffective responses
by observing a person’s behavior in relation to the
adaptive modes
4 Adaptive Modes
1. PHYSIOLOGICAL – the way a person responds as a
physical being to a stimuli from the environment.
o GOAL: Physiological Integrity
o Five Physiologic Needs: oxygenation, nutrition,
activity & rest , elimination & protection
o Four Complex Processes:
a. senses;
b. fluids, electrolytes & acid-base balance;
c. neurologic function;
d. endocrine function
Physiological
Self concept – group identity
Role function
Interdependence
2. SELF-CONCEPT – GROUP IDENTITY MODE - focuses
specifically on the psychological & spiritual aspects of
the human system
o Self- concept – defined as the composite of beliefs
& feelings about oneself at a given time & is
formed from internal perceptions of other’s
reaction
o Two components:
a. physical self (body sensation and body image)
b. personal self (self consistency, self ideal, and
moral ethical spiritual self)
o Group Identity – reflects how people in groups
perceive themselves based on environmental
feedback
 Comprised of interpersonal relationships,
group self-image & culture
 GOAL: Psychological Integrity
3. ROLE FUNCTION MODE – a role is a set of expectations
about how a person occupying one’s position behaves
towards a person occupying another position.
o GOAL: Social Integrity
  Roles are carried out with both instrumental including the behavior and the most relevant
behaviors (the actual physical performance of stimuli.
a behavior) and expressive behaviors ( are the 4. GOAL SETTING
feelings, attitudes, likes or dislikes that a o Establishment of clear statements of the behavioral
person has about a role or about the outcomes for nursing care which is realistic and
performance of a role) attainable. This is done together with the client
5. INTERVENTION
Persons perform primary, secondary & tertiary roles o Determination of how best to assist the person in
a. Primary – determines the majority of behavior attaining the established goals
engaged in by the person during a particular 6. EVALUATION
period of life (age, sex, developmental stage) o Judging the effectiveness of the nursing
b. Secondary – are those that a person assumes intervention in relation to the behavior after it was
to complete the task associated with a performed in comparison with the goal established
developmental stage & primary role (husband,
wife)
c. Tertiary – related primarily to secondary roles
& represent ways in which individuals meet
their role associated obligations
d. Temporary in nature, freely chosen by the
individual
4. INTERDEPENDENCE MODE– focuses on close
relationships which results to giving & receiving of love,
respect, value, nurturing, knowledge, skills,
commitments, material possessions, time & talents
o Occurs between the person and the most
significant other or between the person and the
support system.
o GOAL: Affectional Adequacy

PROMOTE ADAPTATION IN EACH OF THE FOUR ADAPTIVE

MODES

Points to remember
 Adaptive or ineffective responses result from the 4
modes of coping mechanisms.
 Adaptive responses support the integrity of the person
and the goals of adaptation.
 Ineffective responses neither promote integrity nor
contribute to the goals of adaptation.
Nursing process
 A problem-solving approach for gathering data,
identifying the capacities and needs of the human
adaptive system, selecting and implementing
approaches for nursing care, and evaluation of the
outcome of care provided
6 Steps in the nursing process
1. Assessment of behavior
o Data gathering about the behavior of the person as
an adaptive system in each of the adaptive modes.
 Observable behavior: vital signs
 Non-observable behavior: feelings
experienced by the person (anxiety)
2. ASSESSMENT OF STIMULI
o A STIMULUS is defined as any change in the
internal and external environment that induces a
response in the adaptive system. It is classified as
focal, contextual or residual.
o In this level of assessment, the nurse analyzes the
subjective and objective behaviors and look more
deeply for possible causes of a particular set of
behaviors
3. NURSING DIAGNOSIS
o Formulation of statements that interpret data
about the adaptation on status of the person,
DOROTHY E. JOHNSON: Systems theory
THE BEHAVIORAL SYSTEM MODEL
Background
 Aug. 19, 1919 – Born in Savannah, Georgia
 1942 – BSN from Vanderbilt University
 1948 – MSN in Public Health from Harvard
 1949 – Faculty at UCLA
 1977 – Retired in Florida
 Johnson first proposed her model in 1968 to foster the
“efficient & effective behavioral functioning in the
patient to prevent illness”
 She based her model on Florence Nightingale’s belief
that nursing is designed to help people prevent or
recover from illness or injury
 She borrowed ideas from systems theory to explain that
nursing is concerned with the individual as an integrated
whole
Johnson, 1990
 The person experiencing a disease is more important
than the disease itself
Dorothy Johnson Behavioral Systems Model
 The person is a behavioral system comprised of a set of
organized, interactive, interdependent, and integrated
subsystems
 Constancy is maintained through actions & behaviors
that are regulated & controlled by biological,
psychological, and sociological factors.
Nursing Metaparadigm
 Nursing
o Views person as having two major systems:
biological and behavioral system
o As a behavioral system with patterned, repetitive &
purposeful ways of behaving that link the person to
the environment
o An individual composed of seven open &
interactive subsystems; a disturbance in one
usually affects the others
o Continually strives to maintain a steady state by
adapting & adjusting to environmental forces that
cause an imbalance; when an imbalance or health
problem occurs, the person’s physical, social or
psychological integrity is threatened.
 Environment
o Consists of all the factors that are not part of the
individual’s behavioral system, but influence the
system, some of which can be manipulated by the
nurse to achieve the health goal for the patient
o An individual’s behavior is influenced by all the
events in the environment. It varies from culture to
culture
 Health
o A state that is affected by social, biological,
psychological, and physiological factors.
o The individual strives to maintain stability in these
factors
 Nursing
o Is an external force acting to preserve the
organization of the patient’s behavior by means of
imposing regulatory mechanisms or by providing
resources while the patient is under stress
A steady state is maintained through adjusting and adapting to
internal and external forces
Johnson’s 7 Subsystems
 Attachment or Affiliative Subsystem
 Forms the basis for all social organization
 Promotes survival & provides a sense of security
 Results in social inclusion, intimacy & the formation of
strong bonds
Dependency Subsystem
 Promotes helping or nurturing behavior from others
 Results in approval, attention, recognition & physical
assistance
Ingestive Subsystem
 Involves food intake
 Relates to the biological need for food & the
psychological meanings & structures of social events
surrounding food consumption
 Results in appetite satisfaction
Eliminative subsystem
 Involves behavior surrounding the excretion of waste
from the body
 - Includes the psychological meanings & structures of
socially acceptable behaviors for waste elimination
Sexual Subsystem
 Involves behavior associated with procreation & sexual
gratification
 Includes psychologically & socially acceptable behaviors
such as courtship & mating
 Results in the development of sex role identity & sex
role behavior
Aggressive Subsystem
 involves behavior related to self- protection &
preservation of the self & society
 includes the belief that aggression is learned & harmful
& that people & property must be respected &
protected
 includes acknowledgment of real or imaginary dangers
to develop defenses to these threats
Achievement Subsystem
 involves behavior related to manipulation of the
environment to gain mastery & control over some
aspect of oneself or environment, this control is
measured against a standard of excellence
 includes intellectual, physical, creative, mechanical &
social skills
3 Functional Requirements of Humans
 To be protected from noxious influences with which the
person cannot cope
 To be nurtured through the input of supplies from the
environment
 To be stimulated to enhance growth and prevent
stagnation
IDA JEAN ORLANDO: Nursing Process Theory
Ida Jean Orlando
 Born in August 12, 1926
 Nursing diploma - New York Medical College
 BS in public health nursing - St. John's University, NY,
 MA in mental health nursing - Columbia University, New
York
 Associate Professor at Yale School of Nursing and
Director of the Graduate Program in Mental Health
Psychiatric Nursing.
 Project investigator of a National Institute of Mental
Health grant entitled: Integration of Mental Health
Concepts in a Basic Nursing Curriculum.
 published in her 1961 book, The Dynamic Nurse-Patient
Relationship and revised 1972 book: The Discipline and
Teaching of Nursing Processes
 A board member of Harvard Community Health Plan
Nursing Process Theory
 Allows nurses to formulate an effective nursing care
plan that can also be easily adapted when and if any
complexity comes up with the patient.
 Stresses the reciprocal relationship between patient and
nurse.
 It emphasizes the critical importance of the patient’s
participation in the nursing process
 Orlando also considered nursing as a distinct profession
and separated it from medicine where nurses as
determining nursing action rather than being prompted
by physician’s orders, organizational needs and past
personal experiences.
 She believed that the physician’s orders are for patients
and not for nurses
Major Dimensions
 The role of the nurse is to find out and meet the
patient's immediate need for help.
 The patient's presenting behavior may be a plea for
help, however, the help needed may not be what it
appears to be
 Therefore, nurses need to use their perception,
thoughts about the perception, or the feeling
engendered from their thoughts to explore with
patients the meaning of their behavior
 This process helps nurse find out the nature of the
distress and what help the patient needs
Goals
 To develop a theory of effective nursing practice
 The theory explains that the role of the nurse is to find
out and meet the patient’s immediate needs for help
 All patient behavior can be a cry for help
 The nurse’s job is to find out the nature of the patient’s
distress and provide the help he or she needs
Assumptions
 When patients are unable to cope with their needs on
their own, they become distressed by feelings of
helplessness.
 In its professional character, nursing adds to the distress
of the patient.
 Patients are unique and individual in how they respond.
 Nursing offers mothering and nursing analogous to an
adult who mothers and nurtures a child
 The practice of nursing deals with people, environment,
and health
 Patients need help communicating their needs; they are
uncomfortable and ambivalent about their dependency
needs
 People are able to be secretive or explicit about their
needs, perceptions, thoughts, and feelings
 The nurse-patient situation is dynamic; actions and
reactions are influenced by both the nurse and the
patient.
 People attach meanings to situations and actions that
aren’t apparent to others.
 Patients enter into nursing care through medicine.
 The patient is unable to state the nature and meaning of
his or her distress without the help of the nurse, or
without him or her first having established a helpful
relationship with the patient.
 Any observation shared and observed with the patient is
immediately helpful in ascertaining and meeting his or
her need, or finding out that he or she is not in need at
that time.
 Nurses are concerned with the needs the patient is
unable to meet on his or her own
Terms
 Distress is the experience of a patient whose need has
not been met.
 Nursing role is to discover and meet the patient’s
immediate need for help.
 Patient’s behavior may not represent the true need.
 The nurse validates his/her understanding of the need
with the patient.
 Nursing actions directly or indirectly provide for the
patient’s immediate need.
 An outcome is a change in the behavior of the patient
indicating either a relief from distress or an unmet need.
 Observable verbally and nonverbally.
 FEELING OF PAIN OR SUFFERING AFFECTING A BODILY
PART
 STATE OF DANGER
Nursing Metaparadigm
 Person
o Orlando uses the concept of human as she
emphasizes individuality and the dynamic nature of
the nurse-patient relationship.
o For her, humans in need are the focus of nursing
practice
o PEOPLE ARE SOMETIMES ABLE TO MEET THEIR
OWN NEEDS..SOMETIMES THEY BECOME STRESSED
IF THEY ARE UNABLE TO DO SO…
o NURSES – CONCERNED WITH PT WHO ARE UNABLE
TO MEET THEIR NEEDS…. HOWEVER NURSES
OBSERVE PT PERIODICALLY TO DETERMINE IF THEY
HAVE NEW NEEDS FOR HELP….
 Environment
o Orlando completely disregarded environment in
her theory,
o only focusing on the immediate need of the
patient,
 o chiefly the relationship and actions between the
nurse and the patient
o (only an individual in her theory; no families or
groups were mentioned).
o The effect that the environment could have on the
patient was never mentioned in Orlando’s theory.
 Health
o In Orlando’s theory, health is replaced by a sense of
helplessness as the initiator of a necessity for
nursing.
o She stated that nursing deals with individuals who
are in need of help.
o FREEDOM FROM MENTAL AND PHYSICAL
DISCOMFORT AND FEELINGS OF ADEQUACY AND
WELL BEING
 Nursing
o Orlando speaks of nursing as unique and
independent in its concerns for an individual’s need
for help in an immediate situation
o The efforts to meet the individual’s need for help
are carried out in an interactive situation and in a
disciplined manner that requires proper training.
Concepts
 Function of professional nursing - organizing principle
 Presenting behavior - problematic situation
 Immediate reaction - internal response
 Nursing process discipline – investigation
 Improvement - resolution
Function of professional nursing - organizing principle
 Finding out and meeting the patients immediate needs
for help
 "Nursing….is responsive to individuals who suffer or
anticipate a sense of helplessness, it is focused on the
process of care in an immediate experience
 it is concerned with providing direct assistance to
individuals in whatever setting they are found for the
purpose of avoiding, relieving, diminishing or curing the
individuals sense of helplessness." - Orlando
Presenting behavior - problematic situation
 To find out the immediate need for help the nurse must
first recognize the situation as problematic
 The presenting behavior of the patient, regardless of the
form in which it appears, may represent a plea for help
 The presenting behavior of the patient, the stimulus,
causes an automatic internal response in the nurse, and
the nurses behavior causes a response in the patient
Immediate reaction - internal response
1. Person perceives with any one of his five sense organs
an object or objects
2. The perceptions stimulate automatic thought
3. Each thought stimulates an automatic feeling
4. Then the person acts
 The first three items taken together are defined as the
person’s immediate reaction
Nursing process discipline – investigation
 Any observation shared and explored with the patient is
immediately useful in ascertaining and meeting his need
or finding out that he is not in need at that time
 The nurse does not assume that any aspect of her
reaction to the patient is correct, helpful or appropriate
until she checks the validity of it in exploration with the
patient
Improvement – resolution
 It is not the nurses activity that is evaluated but rather
its result: whether the activity serves to help the patient
communicate her or his need for help and how it is met
 In each contact the nurse repeats a process of learning
how to help the individual patient
NURSING PROCESS
1. Assessment
o In the assessment stage, the nurse completes a
holistic assessment of the patient’s needs
o This is done without taking the reason for the
encounter into consideration
2. Diagnosis
o The diagnosis stage uses the nurse’s clinical
judgment about health problems
o The diagnosis can then be confirmed using links to
defining characteristics, related factors, and risk
factors found in the patient’s assessment
3. Planning
o The planning stage addresses each of the problems
identified in the diagnosis
o Each problem is given a specific goal or outcome,
and each goal or outcome is given nursing
interventions to help achieve the goal
4. Implementation
o In the implementation stage, the nurse begins
using the nursing care plan
5. Evaluation
o The nurse looks at the progress of the patient
toward the goals set in the nursing care plan
o Changes can be made to the nursing care plan
based on how well (or poorly) the patient is
progressing toward the goals
Conclusion
 Focuses on the interaction between the nurse and
patient, perception validation, and the use of the
nursing process to produce positive outcomes or patient
improvement. Orlando's key focus was to define the
function of nursing.
 Orlando's theory remains one the of the most effective
practice theories available.
 The use of her theory keeps the nurse's focus on the
patient.
 The strength of the theory is that it is clear, concise, and
easy to use
 While providing the overall framework for nursing, the
use of her theory does not exclude nurses from using
other theories while caring for the patient
FAYE ABDELLAH: 21 Nursing Problems
FAYE GLENN ABDELLAH
 Dedicated her life to nursing, and as a researcher ,and
educator, helped change the profession’s focus from a
disease-centered approach to a patient centered –
approach.
 She served as a public health nurse for 40 years helping
to educate Americans about the needs of the elderly
and the dangers posed by AIDS, addiction, smoking and
violence
 Born on March 13, 1919 in New York City
 Began her nursing career in 1942 when she received her
diploma in nursing from Fitkin Memorial Hospital school
of Nursing in Neptune, New Jersey
 BSN – 1945, MA-1947, doctoral of Education -1955 from
Teacher's College, Columbia University, New York City
 Years later on May 6, 1937,german hydrogen –fueled
airship exploded in new jersey, where 18 year old
Abdellah with her family lived with her brother ran to
the scene to help .but did not know how to take care of
them , so it was then that she vowed that she would
learn Nursing.
 Became the 1st nurse & 1st woman to serve as Deputy
Surgeon General of the United States
 Was inducted into the US National Women’s Hall of
Fame in 2000 due to her contributions in the field of
Education & Nursing Research
 Surgeon general is basically the leader of US public
health service commissioned Corps, thus the
spokesperson on issues of public health
 She was motivated to develop her typology by a desire
to promote comprehensive, client-centered nursing care
– she used the problem solving approach as basis for her
typology
 Her typology of Nursing problems was 1st published in
1960 in Patient Centered Approaches in Nursing
Nursing Metaparadigm
 Person
o Is the recipient of nursing care
o One who has physical, emotional or sociological
needs, helping a person with these needs is
nursing’s only justfication
o According to Abdellah: the typology of nursing
problems evolve from the recognition of a need for
patient-centered approaches to nursing
o Includes families as well as individuals
o Is capable of learning & of self-help to varying
degrees
 Environment
o Least discussed concept in Abdellah’s model
o Includes the atmosphere of a client’s room, home
& community
o APEX (core) of nursing service is the individual
 Health
o Defined as the center & purpose of nursing services
o She speaks to a “total health needs” & a “healthy
state of mind & body”
o Viewed as a state that excludes illness
o Can also be described as a state in which the
person has no unmet needs & no anticipated or
actual impairments
 Nursing
o Is a helping profession
o Considers nursing to be an all-inclusive service that
is based on the disciplines of art & science that
serves individuals sick or well, cope with their
health needs
o Uses the nursing process, a problem-solving
approach
o Can use the 21 nursing problems as a guide from
nursing care
o In abdellah’s model nursing care is doing something
to or for the person with the goals of meeting the
needs, increasing or restoring self help ability or
alleviating impairment.
General information
 A theoretical statement from Abdellah’s works can be
created by utilizing her 3 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 client is geared in the
direction of health, which is the outcome
 It is such a simple statement that can be applied as a
foundation for practice ,education , and research in the
area of nursing
Nursing problems
 A Nursing Problem is defined as any condition presented
or faced by a client or family for which a nurse can offer
assistance
 Health needs are seen as problems, which may be:
 A.) overt – obvious or can be seen condition
 B.) covert – unseen or masked one
 An overt nursing problem is an apparent condition faced
by the patient or family which the nurse can assist him
or them to meet through the performance of her
professional function.
 Covert nursing problem is cancelled or hidden
conditioned faced by the client which the nurse can
assist to meet through the performance of her
professional function
 Covert problems can be in times with emotions and
relationships in nature they are often seen incorrectly.
but in many instances solving the covert problems may
solve the overt problems
 According to Abdellah, the practice of competent
nursing care in the future is for the nursing student to
realize that identifying & answering overt & covert
nursing problems is the core of Nursing
 The Typology of 21 Nursing Problems: the identification
& classification of problems
 Abdellah’s typology as divided into three areas:
a. physical, sociological & emotional needs of the
patient
b. types of interpersonal relationships between the
nurse & the patient
c. common elements of patient care
TYPOLOGY OF 21 NURSING PROBLEMS
1. To maintain good hygiene & physical comfort
2. To promote optimal activity: exercise, rest, sleep
3. To promote safety through prevention of accident,
injury or other trauma & through the prevention of the
spread of infection
 4. To maintain good body mechanics & prevent & correct The Problem Solving Process includes:
deformity
5. To facilitate the maintenance of a supply of oxygen to all 1. Identifying the problem
body cells. 2. Selecting relevant data
6. To facilitate the maintenance of nutrition of all body 3. Formulating hypotheses
cells 4. Testing hypotheses through the collection of data
7. To facilitate the maintenance of elimination. 5. Revising hypotheses when necessary on the basis of
8. To facilitate the maintenance of fluid & electrolyte conclusions obtained from the data
balance
9. To recognize the physiological responses of the body to
disease conditions – pathological, physiological &
compensatory
10. To facilitate the maintenance of regulatory mechanisms
& functions
11. To facilitate the maintenance of sensory function.
12. To identify & accept positive & negative expression,
feelings & reactions.
13. To identify & accept interrelatedness of emotions &
organic illness
14. To facilitate the maintenance of effective verbal &
nonverbal communication.
15. To promote the development of productive
interpersonal relationships
16. To facilitate progress toward achievement & personal
spiritual goals
17. To create or maintain a therapeutic environment
18. To facilitate awareness of self as individual with varying
physical, emotional & developmental needs
19. To accept the optimum possible goals in the light of
limitations, physical & 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

(#1-4 basic to all px, 5-11 sustenal care needs, 12-18 remedial care
needs, 19-21 restorative care needs)

One of the forerunners of the nursing diagnoses as compiled by

NANDA-North American Nursing Diagnosis Association

Helps the nurses and students perform in a scientific ,systematic

way. empower the nurse to give meaning to each and every
nursing action that she will perform with the essential goal or
objective for the welfare of the client.

Abdellah’s 21 problems are actually a model describing the

ARENAs or concerns of nursing rather than a theory describing
relationships among phenomena.

On this way, the theory distinguished the practice of nursing

with focus on 21 nursing problems from the practice of medicine
with focus on disease and cure.

Problem Solving

 The process of identifying overt & covert nursing

problems & interpeting, analyzing & selecting
appropriate actions to solve these problems
 The steps resemble the pace of the Nursing process of
Assessment, Diagnosis, Planning, Implementation &
Evaluation
 The problem-solving approach was chosen because of
the belief that the best recognition of nursing problems
will greatly persuade the nurses judgement in selecting
the next steps in solving the clients nursing problems