P1 Nur Exam Notes 1 11 PDF

LESSON ONE
History of Nursing Theory
• This was dated way back when Florence Nightingale began to assume the great significance of providing a clean
and healthy environment to achieve recovery of patients and continues up to present.
➢ She also envisioned nurses as a body of educated women who organized service and caring for
wounded in wartime (Crimean War) and establishment of Nursing school in London (St. Thomas
Hospital) pioneering activities in nursing practice and education.
• Nursing evolved through different eras. Profession did not start as what it seemed to be. It started as a
vocational
course offering only skills during their time.
Nursing as a Science:
Apprenticeship Model
• Nursing practice was based on principles and traditions that were handed down through practice seen by
Florence during her time.
• Other references note that this is a practice era dated before the curriculum era where to be a nurse can have a
diploma for only 2 years under vocational.
Fawcett classified nursing models as paradigms with in a more organized / specialized meta- paradigm of:
▪ Person ▪ Environment
▪ Health ▪ Nursing Concepts
Significance of Nursing Theory:
At the beginning of the 20th century, nursing was not recognized as an academic discipline or a profession. The
accomplishments of the past century led to the recognition of nursing in both areas. The terms discipline and profession
are interrelated and some may even use them interchangeably; however, they are not the same. It is important to note
their differences and specific meaning.
Criteria for the Development of the Professional status of Nursing:
1. Utilizes in its practice a well-defined and well-organized body of specialized knowledge.
2. Constantly enlarges the knowledge it uses and improves its techniques of education and service thru scientific
method.
3. Entrusts the education of its practitioners to universities/ colleges.
4. Applies knowledge in practical services important to community welfare.
5. Functions autonomously in developing professional policy.
6. Attracts individuals with intellectual and personal qualities of intensifying service.
7. Strives to compensate nurses by providing freedom of action, opportunity for continuous professional growth and
economic security.
Historical Views of the Nature of Science
Epistemology (episteme – knowledge; logos – study of)
● meaning knowledge, understanding
● concerned with the theory of knowledge in philosophical inquiry or how knowledge came to be.
● What is real is also considered knowledge.
● Branch of philosophy concerned with the nature & scope of knowledge.
● It is the study of knowledge & justifies beliefs.
● It questions what knowledge is & how it can be acquired.
● This aims to discover the meaning of knowledge, & called it the true beginning of philosophy.
10 Phases of Concept Building Process:
1. Write a meaningful practice story.
2. Name the central phenomenon in the practice story.
3. Identify a theoretical lens for viewing the phenomenon.
4. Link the phenomenon to existing literature.
5. Gather a story from someone who has lived the phenomenon.
6. Reconstruct the shared story and create mini-saga that captures its message
7. Identify the core qualities of the phenomenon.
8. Use the core qualities to create a definition.
9. Create a model of the phenomenon

10. Write a mini synthesis that integrates the phenomenon with a population to suggest research direction.
Contemporary Issues in Nursing Theory Development:
▪ Theoretical Boundaries and Levels to Advance Nursing Science
o Proposed framework now used without reference to the author for the development of nursing science
▪ Nursing Theory, Practice and Research
o Theory-testing research may lead one nursing theory to fall aside as a new theory is developed that
explains nursing phenomena more adequately; must continue to advance the discipline.
LESSON TWO
Nursing Philosophies – sets for the meaning of nursing phenomena through analysis, reasoning and logical argument.
Are works that provide broad understanding that advances the discipline and its professional application.
The history of nursing theory was dated way back when Florence Nightingale began to assume the great significance of
providing a clean and healthy environment to achieve faster recovery of patients and continues up to present.
FLORENCE NIGHTINGALE
• Nightingale’s (1859-1992) Notes on Nursing presents the nursing theory that focuses on the manipulation of the
environment for the benefits of the patient.
• Although Nightingale did not present her work as a nursing theory, it has directed nursing practice for over 140
years. She is known as the Mother of Modern Nursing.
• Daughter of William Nightingale of Embley Park, Hampshire and was born in Italy, on the 12th day of May,
1820.
The Crimean War
▪ In March 1853, the Crimean War broke out between Russia and Turkey. It was during this war where Florence
Nightingale volunteered her services and was eventually given permission to take a group of 38 nurses to Turkey.
▪ She found the conditions as:
o soldiers lay in filth straw pallets in crowded hallways
o rats and insects crawled the floors and walls
o hospitals lack basic supplies, such as cots, mattresses, bandages, washbasins, soap, and towels
o water was rationed, and available in totally inadequate amounts
o wounded armies were wearing unwashed uniforms that were stiff with dirt and gore
o diseases such as typhus, cholera, and dysentery were the primary reasons why the death rate was high
▪ She recognized that overcrowding, filth, and poor ventilation all contributed to the illness of the soldiers.
▪ At night, she carried a lamp through the corridors, stopping to help the suffering of the wounded soldiers, for this, she
was nicknamed, “The Lady with the Lamp”
Post-War Contributions
▪ Nightingale returned to England as a national heroine in 1856
▪ She published two books: Notes on Hospital (1859) and Notes on Nursing (1859)
▪ She raised enough funds and used this to establish the Nightingale School and Home for Nurses at St. Thomas Hospital.
▪ Nightingale’s work greatly influenced John Stuart Mill’s book on women’s rights.
ENVIRONMENTAL THEORY
“Nursing is the art of utilizing the patient’s environment for his or her recovery.”
Environment – defined as the external conditions and influences affecting the life and development of an organism and
capable of preventing, suppressing, or contributing to disease, accidents, or deaths.
Components of Environment:
▪ Proper Ventilation. Nightingale believed that nurses have the responsibility to keep the air that the patient breathes
pure as the external air without necessarily chilling him. She recognized the possibility that inadequate ventilation may
be the source of disease.
▪ Adequate Light. Direct sunlight has quite as real and tangible effects on the human body who has not observed the
purifying effect of light, and especially of direct sunlight.
▪ Cleanliness. She advocated taking a bath daily and that nurses should also bathe daily while keeping their duty
uniforms clean and their hands washed clean.
▪ Warmth. Nightingale outlined a procedure for measuring the body’s temperature through palpation of, or feeling for
the extremities in order to assess for heat loss. One of the nurse’s roles is to manipulate the environment. Positioning
the patient, opening the windows, and regulating the room temperature are ways of maintaining this
balance.
▪ Quiet. Nightingale described unnecessary noise can actually be harmful to the patient who is ill.
▪ Diet. Nightingale maintained that one of the nurse’s roles is to assess both the meal schedule and its effect on the
patient, in addition to assessing the patient’s dietary intake.
▪ Management. The nurse is actually in control of the environment, physically, and administratively. The nurse is
responsible for controlling the environment so that the patient is protected from physical and psychological harm.
→ Nightingale believed that the nurse continuously controlled the environment even if she is physically absent from
caring
for the patient because she is still responsible for supervising the other members of the health team who worked on her
patient during her absence.

Application to Nursing:
▪ Nursing Practice: Ventilation, warmth, quiet, diet, and cleanliness are still important aspects of nursing care. We,
nurses, thus need to maintain adequate ventilation, promote adequate and appropriate nutrition, maintain normal
homeostatic body temperature, and observe basic hygiene and comfort measures, including environmental sanitations.
▪ Nursing Education: Nightingale had established the St. Thomas Hospital and King’s College Hospital in London, which
was able to provide a framework for the establishment of nursing training schools through a universal template that
contains principles of nursing training. She also advocated the separation of nursing training from the hospital to a more
appropriate learning environment in the school or university setting.
▪ Nursing Research: Nightingale is considered the mother of nursing research because of her interest in the scientific
methods of inquiry and statistics. She was able to gather and analyze data efficiently and resourcefully. She was the first
to use polar diagrams in presenting study data. The concepts of Nightingale’s theory still serve as a basis for current
research. In the 1990s, research studies that tested and expanded nursing theory were numerous.
WATSON'S PHILOSOPHY & THEORY OF TRANSPERSONAL CARING
“Nursing is the human science of persons and human health – illness experiences that are mediated by professional,
personal, scientific, aesthetic, and ethical human care transactions.”
JEAN WATSON
• born and grew up in a small town of Welch West Virginia; youngest of the eight children
• began developing her theory while she was assistant dean of the undergraduate program at University of
Colorado
• in 1978-1981, she served as coordinator and director of the PhD program
• worked from 11 curative factors to formulate her 10 carative factors
• modified 10 factors slightly over time and developed the caritas processes, which have a spiritual dimension and
use a more fluid and evolutionary language
• authorized 11 books which reflect the evolution of her theory of caring
o 1st book – Nursing: The Philosophy and Science of Caring (1979), use 10 carative factors but evolved to
include “caritas” (connection between caring and love)
o 2nd book – Nursing: Human Science and Human Care – A Theory of Nursing (1985), addressed her
conceptual and philosophical problem in nursing.
Transpersonal Caring Relationship
▪ foundational of her theory; it is a special kind of human care relationship
▪ a union with another person-high regard for the whole person and their being in the world
▪ “Caritas” originates from the Greek vocabulary, meaning to cherish and to give special loving attention
▪ Watson uses the term “carative” instead of curative

10 Elements of Carative Factors:
Watson introduced the concept of clinical caritas process, which have replaced her carative factors. The following are
the translation of the carative factors into clinical caritas processes.
Transpersonal caring relationship characterizes a special kind of human care relationship that depends on:
▪ the nurse’s moral commitment in protecting and enhancing human dignity as well as the deeper/higher self
▪ the nurse’s caring consciousness communicated to preserve and honor the embodied spirit, therefore, not
reducing the person to the moral status of an object
▪ the nurse’s caring consciousness and connection having the potential to heal since experience, perception,
and intentional connection are taking place
The term “transpersonal” means to go beyond one’s own ego and the here and now, as it allows one to reach deeper
spiritual connections in promoting the patient’s comfort and healing. Finally, the goal of a transpersonal relationship
corresponds to protecting, enhancing, and preserving the person’s dignity, humanity, wholeness, and inner harmony.
A caring occasion is the moment (focal point in space and time) when the nurse and another person come together in
such a way that an occasion for human caring is created. Assistance with the gratification of human needs describes the
role of the nurse in promoting wellness and health through the achievement of basic human needs according to
Maslow’s hierarchy of needs.
Theory Assertions
• The theory acknowledges the unity of the person’s mind-body-spirit.

• The mind is the point of access to the body and the spirit.
• The spirit relates to a person’s soul, the inner self, the essence of the person, the spiritual self.
• It is the spirit that allows the person to transcend the “here and now” coexisting with past, present, and future,
all at once through creative imagination and visualization.
• Watson ascertains that the care of the soul remains the most powerful aspect of the art of caring in nursing.
Major Assumptions
▪ Nurse’s ability to connect with another at this transpersonal spirit to spirit level is translated via means of
communication, into nursing human art and acts or intentional caring- healing modalities.
▪ Caring-healing modalities within the context of transpersonal caring/ caritas consciousness potentiate
harmony, wholeness and unity of being by releasing some of the disharmony.
▪ Ongoing personal & professional development and spiritual growth.
▪ Nurse’s own life history, previous experiences etc. Are valuable teachers for this work.
▪ Other facilitators are personal growth experiences such as psychotherapy and other models for spiritual
awakening.
▪ Continuous growth for developing and maturing within a transpersonal caring model is ongoing.
▪ Nursing Practice (Administration & Leadership): It calls for administrative practices and embrace caring, even in a
health care environment of increased acuity levels of hospitalized individuals, short hospital stays, increasing complexity
of technology, and rising expectations in the task of nursing.
▪ Nursing Education: Watson’s writings focus on educating graduate nursing students and providing them with
ontological, ethical, and epistemological bases for their practice, along with research directions. Watson’s caring
framework has been taught in numerous baccalaureate nursing curricula.
▪ Nursing Research: Watson’s theory to reduce distress experienced by infertile women. Her theory and the application
of theory of clinical practice hospital organizations have been their major weakness of research. Nelson and Watson
report on studies carried out in seven countries.
Implications of the Theory:

▪ One major implication of the theory is in the realm of bedside nursing where nurses of today have particularly begun
to neglect. The essence of nursing is in the caring aspect and caring is taking the wholeness, the totality, of the patient in
consideration.
▪ More importantly, nurses of today should try to care for a patient for who he is. After all, all of us were created equal
and in His likeness.
LESSON THREE
PATRICIA BENNER: CARING, CLINICAL WISDOM AND ETHICS IN NURSING PRACTICE
• born in Hampton, Virginia

• obtained a baccalaureate of arts degree from Pasadena College in 1964
• earned Master’s degree in Nursing with major emphasis in medical-surgical nursing from University of California,
San Francisco, School of Nursing
• has a wide range of clinical experience, including acute medical-surgical, critical care and home health care
• noted that experience-based skill acquisition is safer and quicker when it is founded on a sound educational
base
“Nursing is a caring relationship and practice that cares for and studies the lived experiences of patients on health,
illness, and disease, and the relationships among these three elements.”
"The Nurse - Patient Relationship is not a uniform, professionalized blueprint but rather a Kaleidoscope of intimacy and
distance in some of the most dramatic, poignant, and mundane moments of life".
The Dreyfus Model is situational that describes the five levels of skill acquisition and development:
▪ Novice (0 to 1 year)
▪ Advanced Beginner (1 to 2 years)
▪ Competent (2 to 3 years)
▪ Proficient (3 to 5 years) – intuitive
▪ Expert (>5 years) – clinical eye
The model proposes that, as a person improves in skill level, there is a corresponding change in the performance of a
given skill. These are:
• Movement from reliance on abstract principles and rules to use of past, concrete experience.
• Shift from reliance on analytical, rule-based thinking to intuition.
• Change in the learner’s perception of the situation from viewing it as a compilation of equally relevant pieces to
viewing it as an increasingly complex whole in which some parts stand out as more or less relevant.
Passage from a detached observer, standing outside the situation, to one of a position of involvement, fully engaged in
the situation. Skill refers to nursing interventions and clinical judgment skills in actual clinical situations. Expertise is
developed when the clinician tests and modifies principle-based expectations in the actual setting.
Novice Stage
▪ characterized by a person who lacks background experience of the situation he or she is involved in
▪ in order to guide the performance, simple rules and objectives, attributes should be given because the novice
will usually have difficulty differentiating relevant and irrelevant aspects of a situation
▪ examples are nursing students and professional nurses who have been assigned to an area totally different
from the one they are accustomed to
▪ when the novice has already started coping with enough real situations and has allowed him/her to
demonstrate minimally acceptable performance within a given situation, his/her skill level also advances to that
of an advanced beginner
Advanced Beginner
▪ has enough experience to grasp aspects of a situation but not within the context of the situation
▪ should be guided by rules and are oriented by the completion of tasks
▪ feels highly responsible for managing patient care but will still need the help of other nurses who are more
experienced than her
▪ examples are newly registered professional nurses
▪ progresses into a competent level of skill acquisition by learning from actual practice situations and by
following the actions of others.
Competent Nurse
▪ considerable conscious and deliberate planning which determines the important aspects of present and future
situations.
▪ exhibits a sense of mastery, increased level of efficiency, consistency, predictability, and time management.
Proficient Nurse
▪ already has a holistic view of a particular situation
▪ the nurse’s performance is guided by maxims by this stage
▪ can already show an intuitive grasp of the situation based on background understanding
▪ can see changing relevance in a given situation including recognition and implementation of skilled responses
to the situation as it evolves
Expert Nurse
▪ does not rely anymore on the analytical principles of rules, guidelines, and maxims to connect her
understanding of the situation to an appropriate action
▪ characterized by the following vital traits:
o demonstrate a clinical grasp and resource-based practice
o possess embodied know-how
o see the big picture
o see the unexpected

Competency – defined as an interpretively defined area of skilled performance identified and described by its intent,
functions, and meanings.
Experience – the active process of refining and changing preconceived theories, notions, and ideas when confronted
with actual situations; it reflects that there is communication between what is found in practice and what is expected.
Maxim – a mysterious description of skilled performance.
• It requires a certain level of experience to recognize the implications of the instructions.

• Paradigm case is a clinical experience that stands out.
• It alters the way the nurse will perceive and understand and open new clinical viewpoints and alternatives.
Hermeneutics – interpretive; it describes meaningful human activities or phenomena in a careful and detailed manner.
• The description is free from analytical assumptions. It is based purely on practical understanding of the
phenomena.
Application of the Theory:
▪ Benner’s contribution to the nursing profession is the use of phenomenal approaches to nursing practice.
▪ Phenomenal approaches have resulted in the development of clinical promotion ladders, new graduate orientation
programs, and clinical knowledge development seminars.
▪ Her model is instrumental in differentiating knowledge development and career progression in nursing. This allowed
nursing educators to realize that learning needs at the early stages of clinical knowledge development are different from
those required at later or higher stages.
▪ It is important to understand that different employees will have different levels of skills.
▪ It is important to emphasize the importance of learning the skill of involvement and caring through practical
experience, articulation of knowledge with practice, and the use of narratives in undergraduate education.
▪ It is important for nursing students and professional nurses alike to learn through experience or by experiential
learning.
▪ Learning by experience will allow you to gain mastery of a given skill.
MARILYN ANN RAY
• 1958 – went to LA, CA work at OB-Gyn, ER, CCU

• 1960 – US Citizen, US Air Force- flight nurse, clinician, administrator, educator, researcher with a rank of
Colonel. The first nurse to go to the Soviet Union with the Aerospace Medical association.
• 1965 – BSN-MSN in MCN at the University of Colorado; Dr. Madeleine Leininger, a nurse anthropologist,
influenced Ray's life.
• 1973 – went back to Canada to be with her family, faculty in McMaster University
• 1989 – appointed as an Eminent Scholar at Florida Atlantic University and continues as Professor Emeritus
• Her research interests continue to focus on nurses, nurse administrators and patients in critical care and
intermediate care, and in nursing administration in complex hospital organizational cultures
Theoretical Sources:
▪ Dr. Leininger – transcultural nursing and ethnographic-ethnonursing research methods.
▪ Hegel – posited the interrelationship among thesis, antithesis, and synthesis.
▪ Chaos Theory – describes simultaneous order and disorder, and order within disorder. Ray compares change in
complex organizations with this creative process and challenges nurses to step back and renew their perceptions of
everyday events, to discover the embedded meanings.
Major Concepts & Definitions:
▪ Holography – everything is a whole in one context and a part in another, with each part being in the whole and the
whole being in the part
▪ Caring – a complex transcultural, relational process grounded in an ethical, spiritual context (charity and right action,
love as compassion in response to suffering and need and justice or fairness of what to be done)
▪ Spirituality – involves creativity and choice and is revealed in attachment, love, and community
o Spiritual- Ethical caring for nursing focuses on the facilitation of choices for the good of others
▪ Educational – formal and informal educational programs, use of audiovisual media to convey information and other
forms of teaching and sharing information
▪ Physical – related to the physical state of being, including biological and mental patterns (mind and body)
▪ Social-Cultural – ethnicity & family structures, intimacy with friends and family, communication; social interaction and
support.
▪ Legal – meaning of caring include responsibility and accountability; rules and principles to guide behaviors such as
policies, procedures informed consent; right to privacy
▪ Technological – nonhuman resources, like machinery to maintain the physiological well-being of the patient,
diagnostic tests, knowledge and skills needed to utilize these resources
▪ Economic – includes money, budget, insurance systems, limitations and guidelines imposed by managed care
organizations, allocation of human and material resources to maintain services
▪ Political – power structure within health care administration, pattern of decision making in the organization; role and
gender stratification among health care providers; competition for scarce human and material resources
Major Assumptions:
▪ The meaning of caring is highly differential, depending on its structures (social-cultural, educational, political,
economic, physical, technological, legal)
▪ Caring is bureaucratic as well as spiritual/ ethical, given the extent to which meaning can be understood in relation to
the organizational structure
▪ Caring is the primordial construct and consciousness of nursing.
▪ Nursing Practice (Administration & Leadership): The theory of Bureaucratic Caring has direct application for nursing.
We are challenged to integrate knowledge, skills and caring. This synthesis of behaviors and knowledge reflects the
holistic nature of the theory. This shows that nurses, patients, and administrators value the caring intentionality that is
co-created in the nurse-patient or administrator-nurse relationship. This can transform the working environment,
fostering ethical choices, respect, and trust, resulting to successful organizations
▪ Nursing Education: Useful in nursing education in terms of its broad focus on caring in nursing and its
conceptualization of the health care system. Interconnectedness of all things
▪ Nursing Research: Particularly significant because it is grounded in the philosophy of humanism and caring, and it
encourages nurses to utilize phenomenological-hermeneutics through the lens of caring.
LESSON FOUR
KARI MARTINSEN’S PHILOSOPHY OF CARING
“Nursing is founded on caring for life, on neighborly love, ... At the same time, it is necessary that the nurse is
professionally educated...”
Summary of Credentials and Background:
• From 1972 to 1974, she attended the Department of Philosophy at the University of Bergen
• In her work for the graduate degree in philosophy (Magister Artium), she grappled philosophically with
questions that had disturbed her as a citizen, a professional, and a healthcare worker
• The dissertation Philosophy and Nursing: A Marxist and Phenomenological Contribution created an instant
debate and received much critical attention.
• Period from 1976 to 1986 can be described as a historical phase in her work & published several historical
articles Published a “lit torch” of a book with the provocative title, Caring Without Care? In this book, they raised
important questions about whether nurses were “moving away” from the sickbed, whether caring for the ill and
infirm was disappearing with the advent of increasingly technical care and treatment, and whether nurses were
becoming administrators and researchers who increasingly relinquished the concrete execution of care to other
occupational groups.
• Based on this work, she attained the doctor of philosophy degree from the University of Bergen in 1984.
In analysis of profession of nursing in the early 1970s, she looked to three philosophers in particular:
▪ Karl Marx, the German philosopher, politician, and social theorist
▪ Edmund Husserl, the German philosopher and founder of phenomenology
▪ Maurice Merleau-Ponty, the French philosopher and phenomenologist of the body
▪ Care
→ This “forms not only the value base of nursing, but is a fundamental precondition for our lives. Care is
the positive development of the person through the Good”.
→ Care is a trinity: relational, practical, and moral simultaneously. Caring is directed outward toward
the situation of the other. In professional contexts, caring requires education and training.
→ “Without professional knowledge, concern for the patient becomes mere sentimentality”. She is clear
that guardianship negligence or sentimentality are not expressions of care.
▪ Professional judgment and discernment
→ It is through the exercise of professional judgment in practical, living contexts that we learn clinical
observation. It is “training not only to see, listen and touch clinically, but to see, listen and touch clinically in a
good way”.
→ “Because perception has an analogue character, it evokes variation and context in the situation”.
→ Discretion expresses professional knowledge through the natural senses and everyday language.
▪ Moral practice is founded on care
→ “Moral practice is when empathy and reflection work together in such a way that caring can be
expressed in nursing”. Morality is present in concrete situations and must be accounted for. Our actions need to
be accounted for; they are learned and justified through the objectivity of empathy.
→ This means in concrete terms to discover how the other will best be helped. Sincerity and judgment
enter into moral practice.
▪ Person-oriented professionalism
→ This is “to demand professional knowledge which affords the view of the patient as a suffering
person, and which protects his integrity. It challenges professional competence and humanity in a benevolent
reciprocation, gathered in a communal basic experience of the protection and care for life... It demands an
engagement in what we do, it is about having an understanding of one’s position within a life context that
demands something from us, and about placing the other at the centre, about the caring encounter’s
orientation toward the other”.
▪ Sovereign life utterances
→ These are phenomena that accompany the Creation itself. They exist as pre-cultural phenomena in all
societies; they are present as potentials.
→ They are beyond human control and influence. Sovereign life utterances are openness, mercy, trust,
hope, and love.
→ Sovereign life utterances are preconditions for care, simultaneously as caring actions are necessary
conditions for the realization of sovereign life utterances in the concrete life.
▪ The untouchable zone
→ This refers to a zone that we must not interfere with in encounters with the other and encounters
with nature. It refers to boundaries for which we must have respect.
→ The untouchable zone creates a certain protective distance in the relation; it ensures impartiality and
demands argumentation, theory, and professionalism. In caring, the untouchable zone is united with its
opposite, which is openness, in which closeness, vulnerability, and motive have their correct place.
→ Openness and the untouchable zone constitute a unifying contradiction in caring
Vocation
→ a demand life makes to us in a completely human way, is given as a law of life concerning neighborly love which is
foundationally human
→ an ethical demand to take care of neighbor, so nursing requires a personal refinement in addition to professional
knowledge
The Eye of the Heart
→ the concept stems from the parable of good Samaritan

→ the heart says something about the existence of the whole person, about being touched or moved by the suffering of
the other and the situation the other experiences
The Registering Eye
→ objectifying, the perspective is that of the observer; concerned with finding connections, systematizing, ranking,
classifying and placing in a system
→ represents alliance between modern natural science, technology and industrialization
Theoretical Assertions:
• People are created dependent and relational. The person is fundamentally dependent upon community and the
creation.
• To the created belong the sovereign life utterances.
• These are phenomena present in the service of life.
• They create life, they release life's possibilities.
▪ Nursing Practice: Caring is practically relevant as an overarching/general philosophy of nursing. It is clearly articulated
and encompasses a precise formulation of how to understand and approach patients and nursing. The ability to promote
reflection upon nursing practice in different contexts.
▪ Nursing Education: Most nursing colleges make good use of her texts, and works form part of the curriculum at a
variety of educational levels.
▪ Nursing Research: Countless dissertations based on practical, concrete, and more theoretical issues discuss the
relationship between empirical experience in light of her terminology and philosophy.
KATIE ERIKSSON’S CARITATIVE CARING THEORY
“Caritative caring means that we take “caritas” into use when caring for the human being in health and
suffering...Caritative caring is a manifestation of the love that ‘just exists’... Caring communion, true caring, occurs when
the one caring in a spirit of caritas alleviates the suffering of the patient.”
Summary of Credentials and Background:
• From 1972 to 1974, she attended the Department of Philosophy at the University of Bergen.
• She is one of the pioneers of caring science in the Nordic countries. She has the ability from the beginning to
design caring science as a discipline, while bringing to life the abstract substance of caring.
• She was born on November 18, 1943, in Jakobstad, Finland.
Her leading thoughts have been not only to develop the substance of caring, but also to develop caring science as an
independent discipline.
• She wanted to go back to the Greek classics by Plato, Socrates, and Aristotle, from whom she found her
inspiration for the development of both the substance and the discipline of caring science.
• From her basic idea of caring science as a humanistic science, she developed a meta-theory that she refers to as
“the theory of science for caring science”.
▪ Caritas
→ Caritas means love & charity. In caritas, eros and agapé are united, and caritas is by nature unconditional
love.
→ Caritas, which is the fundamental motive of caring science, also constitutes the motive for all caring.
→ It means that caring is an endeavor to mediate faith, hope, and love through tending, playing, and learning.
▪ Caring communion
→ It is a form of intimate connection that characterizes caring. Caring communion requires meeting in time and
space, an absolute, lasting presence.
→ This is characterized by intensity and vitality, and by warmth, closeness, rest, respect, honesty, and tolerance.
It cannot be taken for granted but pre-supposes a conscious effort to be with the other.
→ Caring communion is seen as the source of strength and meaning in caring.
▪ The act of caring
→ This contains the caring elements (faith, hope, love, tending, playing, and learning), involves the categories of
infinity and eternity, and invites deep communion.
→ The act of caring is the art of making something very special out of something less special.
▪ Dignity
→ This constitutes one of the basic concepts of caritative caring ethics. Human dignity is partly absolute dignity,
partly relative dignity.
→ Absolute dignity is granted the human being through creation, while relative dignity is influenced and formed
through culture and external contexts.
→ A human being’s absolute dignity involves the right to be confirmed as a unique human being.
▪ Invitation
→ This refers to the act that occurs when the carer welcomes the patient to the caring communion.
→ The concept of invitation finds room for a place where the human being is allowed to rest, a place that
breathes genuine hospitality, and where the patient’s appeal for charity meets with a response.
▪ Suffering
→ This is an ontological concept described as a human being’s struggle between good and evil in a state of
becoming.
→ Suffering implies in some sense dying away from something, and through reconciliation, the wholeness of
body, soul, and spirit is re-created, when the human being’s holiness and dignity appear.
→ Suffering is a unique, isolated total experience and is not synonymous with pain.
▪ Suffering related to illness, to care, and to life
→ This is related to illness and is experienced in connection with illness and treatment. When the patient is
exposed to suffering caused by care or absence of caring, the patient experiences suffering related to care,
which is always a violation of the patient’s dignity.
→ Not to be taken seriously, not to be welcome, being blamed, and being subjected to the exercise of power
are various forms of suffering related to care. In the situation of being a patient, the entire life of a human being
may be experienced as suffering related to life.
▪ The suffering human being
→ This is the concept that Eriksson uses to describe the patient. The patient refers to the concept of patiens
(Latin), which means “suffering”.
→ The patient is a suffering human being, or a human being who suffers and patiently endures.
▪ Reconciliation
→ It refers to the drama of suffering. Reconciliation implies a change through which a new wholeness is formed
of the life the human being has lost in suffering.
→ In reconciliation, the importance of sacrifice emerges. Having achieved reconciliation implies living with an
imperfection with regard to oneself and others but seeing a way forward and a meaning in one’s suffering.
→ Reconciliation is a prerequisite of caritas.
▪ Caring culture
→ Concept that Eriksson uses instead of environment. It characterizes the total caring reality and is based on
cultural elements such as traditions, rituals, and basic values.
→ It transmits an inner order of value preferences or ethos.
→ Respect for the human being, dignity and holiness, forms the goal of communion and participation in a caring
culture.
→ The origin of the concept of culture is to be found in such dimensions as reverence, tending, cultivating, and
caring; these dimensions are central to the basic motive of preserving and developing a caring culture.
▪ Use of empirical evidence
→ Established it in empiricism by systematically employing a hermeneutical and hypothetical deductive

approach. In conformity with a human science and hermeneutical way of thinking, Eriksson developed a caring
science concept of evidence.
→ Her main argument for this is that the concept of evidence in natural science is too narrow to capture and
reach the depth of the complex caring reality.
→ Her concept of evidence is derived from Gadamer’s Concept of Truth, which encompasses the true, the
beautiful, and the good.
Major Assumptions:
Eriksson distinguishes between two kinds of major assumptions:
1. Axioms as fundamental truths in relation to the conception of the world. These are as follow:
• The human being is fundamentally an entity of body, soul, and spirit.

• The human being is fundamentally a religious being.
• The human being is fundamentally holy. Human dignity means accepting the human obligation of serving with
love, of existing for the sake of others.
• Communion is the basis for all humanity. Human beings are fundamentally interrelated to an abstract and/or
concrete other in a communion.
• Caring is something human by nature, a call to serve in love.
• Suffering is an inseparable part of life. Suffering and health are each other’s prerequisites.
• Health is more than the absence of illness. Health implies wholeness and holiness.
• The human being lives in a reality that is characterized by mystery, infinity, and eternity.
2. Theses are fundamental statements concerning the general nature of caring science. These are as follow:
• Ethos confers ultimate meaning on the caring context.

• The basic motive of caring is the caritas motive.
• The basic category of caring is suffering. Caring communion forms the context of meaning of caring and derives
its origin from the ethos of love, responsibility, and sacrifice, namely, caritative ethics.
• Health means a movement in becoming, being, and doing while striving for wholeness and holiness, which is
compatible with endurable suffering.
Caring implies alleviation of suffering in charity, love, faith, and hope. Natural basic caring is expressed
through tending, playing, and learning in a sustained caring relationship, which is asymmetrical by nature.
→ These kinds of major assumptions had their validity tested through basic research.
→ Axioms and theses jointly constitute the ontology of caring science and therefore also are the foundation of its
epistemology.
▪ Nursing Practice: Eriksson’s thinking and process model of caring are general, the nursing care process model has
proved to be applicable in all contexts of caring, from acute clinical caring and psychiatric care to health-promoting and
preventive care.
o It has been influential in nursing leadership and nursing administration, where the caritative theory of nursing
forms the core of the development of nursing leadership at various levels of the nursing organization.
o Her ideas about caring and her nursing care process model work in practice has been verified by everything
from a multiplicity of essays and tests of learning in clinical practice to master’s theses, licentiates’ theses, and
doctoral dissertations produced all over the Nordic countries.
▪ Nursing Education: Eriksson’s theory has been integrated into the education of nurses at various levels, and her books
have been included continuously in the examination requirements in various forms of nursing education has been based
entirely on Eriksson’s ideas, and her caritative caring theory forms the core of the development of substance in
education and research.
o Development of the caring science–centered curriculum and caring didactics continued in the educational and
research program in caring science didactics offered as part of continuing education for those who work in
clinical practice.
o Sees caring science not as profession oriented but as a “pure” academic discipline, it has aroused interest
among students in other disciplines, that genuine interdisciplinary cooperation is needed between caring
science and medicine.
o Most nursing colleges make good use of her texts, and works form part of the curriculum at a variety of
educational levels.
▪ Nursing Research: Countless dissertations based on practical, concrete, and more theoretical issues discuss the
relationship between empirical experience in light of her terminology and philosophy.
Summary:
▪ She has been a guide and visionary who has gone before and “ploughed new furrows” in theory development.
Eriksson’s caritas-based theory and her whole caring science thinking have developed over years. Characteristic of her
thinking is that while she is working at an abstract level developing concepts and theory, rooted in clinical reality and
teaching.
▪ The whole caritative theory and the caring that are built up around the theoretical core get their distinctive character
and deeper meaning. The ultimate goal of caring is to alleviate suffering and serve life and health.
▪ Knowledge formation, which Eriksson sees as a hermeneutic spiral, starts from the thought that ethics precedes
ontology. In a concrete sense, this implies that the thought of human holiness and dignity is always kept alive in all
phases of the search for knowledge. Ethics precedes ontology in theory as well as in practice.
▪ Eriksson’s caring science tradition and discipline of caring science form a basis for the activity at the Department of
Caring Science. Eriksson’s caritative caring theory and the discipline of caring science have inspired many, and they are
used as the basis for research, education, and clinical practice.
LESSON FIVE
MYRA E. LEVINE'S CONSERVATION MODEL
“Nursing is a human interaction that promotes adaptation and maintains wholeness either by acting in the therapeutic
sense or by providing supportive care in order to influence adaptation favorably, or toward renewed social wellbeing.”
• This is focused on the preservation of the individual’s wholeness or totality.

• She believed that nursing activities were conservation activities, a keeping-together function that promotes
wholeness in the patient.
Four Principles:
1. Conservation of Energy – all physiologic and psychological processes that sustain life depend on the body’s energy
balance
• adjusting to life in the nursing home

• improving nutritional status, balancing resident activity
• controlling resident anxiety and pain
2. Conservation of Structural Integrity – all body systems decline with aging; chronic illness also produces bodily
structural changes
• maintaining or promoting mobility

• preventing injury
• preventing infection
• maintaining skin integrity
3. Conservation of Personal Integrity – self-identity is intrinsically bound to wholeness and all individuals cherish the
sense of self; it includes recognition of the holiness of each person
• respecting one’s privacy and property

• enhancing self-esteem through good personal hygiene, grooming and dressing
• fostering independence through choice and rehabilitation
• promoting self-identity for those who are cognitively impaired
• obtaining advance directives for treatment
4. Conservation of Social Integrity – individual life has meaning only in the context of social life
• providing meaningful social activities for residents and staff, considering the family and resident as a unit
▪ Conservation
→ describes the way complex systems are able to continue to function even when severely challenged
→ it is through conservation that man is able to confront obstacles, adapt accordingly, and maintain their
uniqueness and individuality, from Latin word conservation which means “to keep together”
▪ Wholeness
→ emphasizes a sound, organic, progressive, mutuality between diversified functions and parts within an
entirety, the boundaries of which are open and fluent
→ it connotes integrity – the oneness of persons, highlighting their capacity to respond in an integrated and
singular fashion to environmental challenges
▪ Adaptation
→ the process of change wherein the person is able to keep his integrity within situations and circumstances of
his environment, both internal and external
→ it is the bridge; the process by which individuals fit the environments in which they live
→ health and disease are patterns of adaptive change
→ the goal of adaptive change is the conservation of wholeness (health) and integrity
→ the result of adaptation is conservation which has 3 characteristics:
➢ Historicity – patterned responses passed on through genetics

➢ Specificity – unique adaptive responses to specific environmental challenges
➢ Redundancy – availability of multiple adaptive responses
→ Levine suggests “the possibility exists that aging itself is a consequence of failed redundancy of physiological
and psychological processes”
▪ Environment
→ Internal environment – composed of the physiologic and pathophysiologic domains of the person
→ External environment has three levels:
1. Perceptual level – includes all aspects of the world wherein the person is able to intercept and
interpret with his sense organs.
2. Operational level – refers to things that physically affect the individual but may not be perceived by
the individual himself. An example of these are microorganisms. We can get an infection because of a
microorganism but we cannot really perceive what a microorganism really is.
3. Conceptual level – the environment is the product of cultural patterns, characterized by spirituality,
and moderated by language, history, and thought.
▪ Organismic response
→ refers to the person’s ability to adapt to his or her environment and is made up of four levels of integration
➢ Fight or flight – the most primitive response; the person either “fights” or “flies away” from a
perceived stressor in order to ensure his own safety and well-being
➢ Inflammatory response – body defense mechanism that protects the body tissue from insults in
an unfriendly environment
➢ Response to stress – refers to the wear and tear of body tissues that reflect the body’s
continued response and adaptation to stressful situations; it is characterized by irreversibility
and influences the way the patients respond to nursing care
➢ Perceptual awareness / Sensory response – it occurs as the person experiences life and the
world around him; individuals are constantly immersed in an environmental background of
sensory input that never cases, even during sleep, prompts to maintain safety and seek
wholeness
▪ Trophicognosis
→ a scientific method of reaching a nursing care judgment; an alternative recommendation of Levine to Nursing
Diagnosis
• "A holistic approach to care of all people, well or sick."

• Decisions for nursing interventions must be based on the unique behavior of the individual patient. Patient
centered nursing care means individualized nursing care and requires a unique constellation of skills,
techniques, and ideas designed specifically for the patient.
Application to Nursing Community:
▪ Conservation principles have been used as a framework for numerous practice settings by identifying the activities it
encompasses and giving the scientific principles behind them.
MARTHA E. ROGER’S SCIENCE OF UNITARY HUMAN BEING CONCEPTUAL MODELS OF NURSING
“Nursing is an art and science that seeks to promote symphonic interaction between the environment and man, to
strengthen the coherence and integrity of the human beings, and to direct and redirect patterns of interaction between
man and his environment for the realization of maximum health potential.”
• This theory provides a radical vision of nursing reality.

• It provides a framework for nursing practice, education, and research that promises a move away from the
previous predominant medical model approach to the delivery of nursing care.
• Rogers formulated five basic assumptions that describe man and the life process in man.
• These assumptions or “building blocks” underlay the conceptual framework and consist of the concepts of
wholeness, openness, unidirectionality, pattern and organization, and sentience and thought.
• According to Rogers, a person is an irreducible whole, the whole being greater than the sum of its parts.
• Man is a dynamic energy field in constant exchange with environmental energy fields.
• Four “critical elements” that are basic in the theory:
o Energy fields
o Open system
o Pattern
o Pan-dimensionality – was previously known as multidimensionality, and prior to that, four-

dimensionality
▪ Wholeness
→ refers to the state in which the human being is regarded as a unified whole which is more than and different
from the sum of the parts
▪ Openness
→ where the individual and the environment are continuously exchanging matter and energy with each other
▪ Open systems (openness)
→ describe the open nature of the fields, the preferred terminology being that there is a “continuous process”
without the mention of energy or matter
▪ Unidirectionality
→ refers to where the life process exists along an irreversible space time continuum
→ pattern and organization identify individuals and reflect their innovative wholeness
▪ Energy fields
→ are the “fundamental unit of the living and the non-living”
→ they consist of the human energy field and the environment energy field
▪ The human field
→ an “irreducible, indivisible, pan-dimensional energy field identified by pattern and manifesting characteristics
that are specific to the whole and which cannot be predicted form knowledge of the parts”
▪ The environmental field
→ is integral with the human field; each environmental field is specific to its given human field
▪ Universe of open system
→ holds that energy fields are infinite, open, and integral with one another
▪ Pattern
→ is the “distinguishing characteristic of the energy field perceived as a single wave”, which gives identity to the
field
→ human behavior can be regarded as manifestations of changing pattern
→ the pattern is constantly changing and might be regarded as an indication of pain, illness or disease
→ sentience and thought states that all of life, human beings are the only ones capable of abstraction and
imagery, language and thought, sensation and emotion
▪ Pan-dimensionality
→ is a nonlinear domain without spatial or temporal attitudes; it describes an infinite domain without limits
→ it short, it is a unitary whole
Theory Assertions:
• Rogers viewed the person as an open system in constant process with the open system of the environment.
• She added that man is a unified whole possessing his own integrity and manifesting characteristics more than
and different from the sum of his parts.
• In continuously exchanging matter and energy with the environment, identified by pattern and organization
and reflects his innovative wholeness.
• This is characterized by the capacity for abstraction and imagery, language and thought, sensation, and
emotion.
8 Concepts in Roget’s Nursing Theory:

▪ energy field ▪ openness
▪ pattern ▪ pan-dimensionality
▪ hemodynamic principles ▪ resonance
▪ helicy ▪ integrality
LESSON SIX
DOROTHEA OREM’S SELF-CARE DEFICIT MODEL
“Nursing is a helping profession of assisting patients overcome or compensate for their health-associated limitations and
engaging in actions to regulate their own functioning and development or that of their dependents.”
• The model is a collection of three interrelated theories.

• These are nursing systems, self-care, and self-care deficit.
• The focus of Orem’s model is to enhance the person’s ability for self-care and this also extends to the care of
dependents.
• A person’s self-care deficits are the result of environmental situations.
• Theoretical sources – philosophical system of moderate realism.
There are three systems that exist within this professional nursing practice model:
1. Wholly Compensatory System – nurse provides total care
2. Partially Compensatory System – nurse & patient share responsibility for care
3. Supportive-Educative System – client has primary responsibility for personal health, with nurse acting as a consultant
▪ The basic premise of the model is that individuals can take responsibility for their health and the health of others.
▪ In a general sense, individuals have the capacity to care for themselves or their dependents.
▪ It is based upon the philosophy that all “patients wish to care for themselves”.
▪ When an individual is unable to meet his own self-care requisites, a self-care deficit occurs.
▪ It is the duty and obligation of the professional nurse to recognize and identify these deficits in order to define a
support modality or intervention.

▪ Self-care
→ It is composed of the practice of activities that maturing and mature individuals initiate and perform, within
time periods, on their behalf. This is to ensure maintaining life, healthful functioning, continuing personal
development, and well-being.
→ Self-care requisites are formulated and expressed insights about actions to be performed which are known to
be relevant and vital to human functioning.
1. Universal self-care requisites – those needs that all people have; include air, water, food, elimination,
activity and rest, solitude and social interaction, hazard prevention, and promotion of normal functioning
2. Developmental self-care requisites – those needs that relate to the development of the individual;
include conditions that promote development, engagement in self-development, and prevention of or
overcoming effects of human conditions and life situations that can adversely affect human development
3. Health deviation requisites – those needs that arise as a result of a patient’s condition; include all
pathologic conditions or disorders which include defects, deformities, and disabilities. These require medical
intervention and management.
▪ Therapeutic self-care demand
→ This is composed of the totality of nursing care measures important at certain times or over a period of time
for meeting all of the individual’s known self-care requisites.
→ It uses methods appropriate for managing the factors identified in the requisites and fulfilling the activity
element of the requisite.
▪ Nursing agency
→ It refers to the developed capabilities of nurses that empower them to meet the therapeutic self-care
demands of the patient.
▪ Self-care agency
→ This is a complex acquired ability of mature & maturing individuals to know & meet their continuing
requirements for deliberate & purposive action to regulate their own human functioning and development.
▪ Dependent-care agent
→ This is a maturing adolescent who accepts and fulfills the responsibility to know and meet the therapeutic
self-care demand of significant others who are socially dependent on them.
▪ Nursing systems
→ These are series and sequences of deliberate practical actions of nurses performed at times.
• Nursing systems are action systems formed by nurses through the exercise of their nursing agency for persons
with health-derived or health-associated limitations in self-care or dependent care.
• It includes deliberate action, intentionality, diagnosis, prescription, and regulation.
• “Self-care is a regulatory function by man. It is deliberate and is performed by the person himself or have them
performed by another person or them in order to maintain life, health, development, and well-being.”
Application to Nursing Community:
▪ What is clear in the model of Orem is the emphasis on education and supportive measures. It becomes clear that
nurses today should not move away from this very important aspect of clinical nursing – health teachings.
IMOGENE KING’S INTERACTING SYSTEMS FRAMEWORK AND GOAL ATTAINMENTTHEORY
“Nursing is an observable behavior found in the health care systems in society that aims to help individuals maintain their
health so they can function in their roles.”
Interacting System Framework
• This theory emphasizes the importance of the interaction between the nurse andpatients.
• It views this interaction as an open system which is in constant interaction with a variety of environmental
factors.
• There are three interrelated systems that represent the domain of nursing:
1. Personal systems – composed of body image, growth and development, perception, self, space, and
time.
▪ When two or more persons interact, they form an interpersonal system.
2. Interpersonal system – composed of the concepts of communication, interaction, role, stress, and
transaction.
▪ A comprehensive interacting system is composed of groups that make up a society. This

results in the social system.
3. Social system – composed of the concepts of authority, decision-making, organization power, and
status.
Goal Attainment Theory
• This is a middle-range theory that is the product of developments from her first Interacting Systems Framework.
• The theory stated that mutual goal-setting between a nurse and a client is based on:
o nurse’s assessment of a client’s concerns, problems, and disturbances in health

o nurse’s & client’s perceptions of the interference
o nurse’s & client’s sharing of information wherein each functions to help the client attain the goals
identified
• The theory also maintained that nurses interact with family members when clients cannot verbally participate
in the goal-setting.
• As such, this theory is focused on the interpersonal system and the interactions that take place between
individuals, more specifically in the nurse-client relationship.
• The system is an open one in that it allows feedback because each phase of the nurse-patient activity has the
potential to influence perception.
8 propositions related to the Goal Attainment Theory:
1. If perceptual accuracy is present in the nurse-client interactions, then transactions will occur.
2. If a nurse and client make transactions, then goals will be attained.
3. If goals are attained, then satisfaction will occur.
4. If goals are attained, then effective nursing care will occur.
5. If transactions are made in nurse-client interactions, then growth and development will be enhanced.
6. If role expectations and role performance as perceived by nurse and client are congruent, then transactions will
result.
7. If role conflict is experienced by nurse and client or both, then stress in nurse-relationship interactions will occur.
8. If nurses with special knowledge and skills communicate appropriate information to clients, then mutual goal setting
and goal attainment will occur.
▪ Perception
→ a process in which data obtained through the senses and from memory are organized, interpreted, and
transformed
▪ Stress
→ an ever changing condition in which an individual, through environmental interaction, seeks to keep
equilibrium to support growth and development and activity
→ an organization is made up of individuals who have prescribed roles and positions and who make use of
resources to meet goals-both personal and organizational.
▪ The self
→ made up of thoughts and feelings related to one’s awareness of being a person separate from others and
influencing one’s view of who and what he or she is
▪ Growth and development
→ processes in people’s lives through which they move from potential for achievement to actualization of self
▪ Body image
→ includes both the way one perceives one’s body and others’ reactions to one’s appearance
▪ Space
→ the physical area known as territory and by the behaviors of those who occupy it
▪ Interactions
→ observable behaviors of two or more persons in mutual presence
▪ Communication
→ verbal and non-verbal situational, perceptual, transactional, irreversible, or moving forward in time, personal,
and dynamic
→ Transactions are a series of exchanges between human beings and the environment that include observable
behaviors that seek to reach goals of worth to the participants
▪ Role
→ characterized by reciprocity in that a person may be a giver at one time and a taker at another time, with the
relationship between two or more individuals who are functioning in two or more roles that are learned social,
complex, and situational
▪ Authority
→ refers to the active, reciprocal process of transaction in which the actors’ experience, understanding, and
values influence the meaning, legitimacy and acceptance of those in organizational positions associated with
authority
▪ Status
→ the relationship of one’s place in a group to others in the group or of a group to other groups
▪ Decision-making
→ a changing and orderly process through which choices related to goals are made among toward the goal
▪ Time
→ an interval between the two events that is experienced differently by each person
Theory Assumptions:
• The focus of nursing is the care of the human being (patient).

• The goal of nursing is the health care of both individuals and groups.
• Human beings are open systems interacting with their environments constantly.
• The nurse and patient communicate information, set goals mutually, and then act to achieve those goals. This is
also the basic assumption of the nursing process.
• Patients perceive the world as a complete person making transactions with individuals and things in the
environment.
• The transaction represents a life situation in which the perceiver and the thing being perceived are
encountered. It also represents a life situation in which a person enters the situation as an active participant.
Each is changed in the process of these experiences.
LESSON SEVEN
BETTY NEUMAN’S SYSTEMS MODEL
“Nursing is a unique profession that is concerned with all of the variables affecting an individual’s response to stress.”
• A unique, systems-based perspective that provides a unifying focus for approaching a wide range of nursing
concerns.
• A comprehensive guide for nursing practice, research, education, and administration that is open to creative
implementation.
• It has the potential for unifying various health-related theories, clarifying the relationships of variables in
nursing care and role definitions at various levels of nursing practice.
• Based on the person’s relationship to stress, his reaction to it, and reconstitution factors that are dynamic in
nature.
• considers the person as an open system which is composed of a basic structure of energy resources.
• These resources include physiologic, psychologic, sociocultural, developmental, and spiritual.
• The basic structure, or central core, is surrounded by two concentric boundaries or rings called the lines of
resistance.
• These lines represent the internal factors that aid the person defend against a stressor.
• The line of resistance is further surrounded by two lines of defense.
o First line of defense is the person’s state of equilibrium or the state of adaptation developed and
maintained over time and which is considered normal for the person.
o Second line of defense is flexible, dynamic, and can be readily and rapidly changed over a short period
of time.
• She classified stressors as intrapersonal, interpersonal, and extrapersonal stressors.

• Man’s reaction to stress is dependent on the integrity of the lines of resistance and defense.
• When the line of defense fails, man’s reaction will now depend on the lines of resistance.
• Because of the reaction, man can adapt to a stressor This is called reconstitution.
• Therefore, nursing interventions focus on keeping or maintaining the stability of the open system. These
interventions can be carried out on the three levels of prevention: primary, secondary, and tertiary.
In holistic approach, the client as a whole, whose parts are in dynamic interaction with itself and the environment. It
strongly advises the consideration of all variables that simultaneously affect the client system.
▪ Open system
→ characterized by elements that are in continuous exchange within a complex organization
→ these exchanges may be in the form of information or energy
→ basic to this is stress and stress reaction
▪ Created environment
→ developed unconsciously by the client in order to express the wholeness of the system by using symbols
▪ Client system
→ composed of the five system variables interacting with the environment.
1. Physiologic variables are body structure and function
2. Psychological variables include mental processes in interaction with the environment
3. Sociocultural variables are the effects and influences of social and cultural conditions
4. Developmental variables are age-related processes and activities throughout life
5. Spiritual variables are beliefs and influences related to spirituality
▪ Basic client structure
→ composed of a central core surrounded by concentric rings
→ the core reflects basic survival factors or energy resources of the client
▪ Lines of resistance
→ represents resources that help the client defend against a stressor
→ normal line of defense reflects the client’s stability which serves as the guide to assess deviations from the
client’s usual wellness
▪ Flexible line of defense
→ a protective layer for preventing stressors from breaking through the usual wellness state
1. Intrapersonal factors occur within the individual
2. Interpersonal factors occur between one or more individuals
3. Extrapersonal factors occur outside the individual
▪ Preventive interventions
→ purposeful actions to help the client retain, attain, or maintain the stability of the client system and carried
out when a stressor is either suspected or identified
▪ Reconstitution
→ occurs following the treatment of stressor reactions; marks the return of the client system to stability
▪ Level of stability
→ after reconstitution, may be higher or lower than the previous level before the invasion of the stressor
• Each client system is unique, a composite of factors and characteristics within a given range of responses.
• Many known, unknown, and universal stressors exist. Each differs in its potential for disturbing a client’s usual
stability level or normal line of defense. The particular interrelationships of client variables at any point in time
can affect the degree to which a client is protected by the flexible line of defense against possible reaction to
stressors.
• Each client/client system has evolved a normal range of responses to the environment referred to as a normal
line of defense. The normal line of defense can be used as a standard from which to measure health deviation.
• When the flexible line of defense is no longer capable of protecting the client/client system against an
environmental stressor, the stressor breaks through the normal line of defense.
• Whether in a state of wellness or illness, the client is a dynamic composite of the variables’ interrelationships.
Wellness is on a continuum of available energy to support the system in an optimal system stability state.
• Implicit within each client system are internal resistance factors known as lines of resistance, which function to
stabilize and realign the client to the usual wellness state.
SISTER CALLISTA ROY’S ADAPTATION MODEL OF NURSING
• The model assumes that systems of matter and energy progress to higher levels of complex self-organization.
• Consciousness and meaning comprise person and environment integration while awareness of self and
environment is rooted in thinking and feeling.
• System relationships include acceptance, protection and fostering of independence
• Man and his environment have common patterns and integral relationships and transformations are created in
human consciousness.
• Integration of man and environment meanings result in adaptation.
• Roy’s model of nursing is best exemplified in the nursing process.
The nursing process is 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 evaluating the outcome of care provided.
It includes the following steps:
Four Adaptive Modes:
These are how the regulator and cognator mechanisms are manifested; in other words, they are the external
expressions of the above and internal processes.
1. Physiological-Physical Mode
▪ Physical and chemical processes are involved in the function and activities of living organisms. These are the
actual processes put in motion by the regulator subsystem.
▪ This mode’s basic need is composed of the needs associated with oxygenation, nutrition, elimination, activity
and rest, and protection.
▪ This model’s complex processes are associated with the senses, fluid and electrolytes, neurologic function, and
endocrine function.
2. Self-Concept Group Identity Mode
▪ The goal of coping is to have a sense of unity, meaning the purposefulness in the universe, and a sense of
identity integrity. This includes body image and self-ideals.
3. Role Function Mode
▪ This focuses on the primary, secondary, and tertiary roles that a person occupies in society and knowing where
they stand as a member of society.
4. Interdependence Mode
▪ This mode focuses on attaining relational integrity through the giving and receiving of love, respect and value.
This is achieved with effective communication and relations.
▪ Health
→ a state and process of being and becoming integrated and whole that reflects person and environmental
mutuality
▪ Adaptation
→ the process and outcome whereby thinking and feeling persons, as individuals and in groups, use conscious
awareness and choice to create human and environmental integration
▪ Adaptive responses
→ responses that promote integrity in terms of the goals of the human system, that is, survival, growth,
reproduction, mastery, and personal and environmental transformation
▪ Ineffective responses
→ responses that do not contribute to integrity in terms of the goals of the human system
▪ Adaptation levels
→ represent the condition of the life processes described on three different levels: integrated, compensatory,
and compromised.
Theory Assertions:
• Roy’s model views the person as an adaptive system with coping processes.
• She described the person as a whole comprising parts and which functions as a unity for some purpose.
• It includes people as individuals or in groups (families, organizations, communities, nations, and society as
whole).
• The person is an adaptive system with cognator and regulator subsystems acting to maintain adaptation in the
four adaptive modes.
• The environment is viewed as all conditions, circumstances, and influences surrounding and affecting the
development and behavior of persons and groups with particular consideration of mutuality of person and
earth resources.
• Nursing is the science and practice that expands adaptive abilities and enhances person and environment
transformation.
• The goals of nursing are to promote adaptation for individuals and groups in the four adaptive modes, thus
contributing to health, quality of life, and dying with dignity.
• This is done by assessing behavior and factors that influence adaptive abilities and by intervening to expand
those abilities and to enhance environmental interactions.
• Nursing process is cyclical in nature – beginning with assessment, diagnosis, planning, implementation, and
evaluation – the evaluation may also serve as the assessment findings for another set of nursing problems.
• It means that the assessment component of the nursing process is the stimuli or the input and the planning and
implementation are the throughput processes.
• The output is the evaluation which then provides the necessary feedback to the goal of care.
• The nurse then decides what necessary actions should be taken next, in the light of the patient’s response to
the nursing interventions. This action by the nurse is adaptation in its simplest terms.
• Patients adapt, too. The nursing interventions we perform ultimately elicits a response from our patients, our
patients may or may not actually adapt according to our expectations.
DOROTHY JOHNSON’S BEHAVIORAL SYSTEMS MODEL
“Nursing is an external force that acts 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.”
Credentials and Background of Johnson:
• Born August 21, 1919 in Savannah, Georgia.

• Graduated BSN from Vanderbilt University in Nashville, Tennessee and her M.P.H. from Harvard University in
Boston.
• She was a staff nurse at the Chatham-Savannah Health Council (1943-1944).
• She is proud to receive the 1975 Faculty Award from graduate students.
• She was an early proponent of nursing as a science as well as an art; also believed nursing had a body of
knowledge reflecting both the science and the art.
• Johnson (1959) proposed that the science of nursing necessary for effective nursing care included a synthesis of
key concepts drawn from basic and applied sciences.
• In 1961, she proposed that nursing care facilitated the client’s maintenance of a state of equilibrium.
• She also proposed that clients were “stressed” by a stimulus of either an internal or external nature.
o These stressful stimuli created such disturbance, or “tensions”, in the patient that a state of
disequilibrium occurred.
• She identified 2 areas that nursing care should be based in order to return the client to a state of equilibrium:
o Reduce stressful stimuli
o Support natural and adaptive processes
• Johnson’s behavioral system theory springs from Nightingale’s belief that nursing’s goal is to help individuals
prevent or recover from disease or injury.
• The “science and art” of nursing should focus on the patient as an individual and not on the specific disease
entity. The model is patterned after a systems model; a system is defined as consisting of interrelated parts
functioning together to form a whole.
• She stated that a nurse should use the behavioral system as their knowledge base. The reason Johnson chose
the behavioral system model is the idea that “all the patterned, repetitive, purposeful ways of behaving that
characterize each person’s life make up an organized and integrated whole, or a system”.
7 Subsystems of Human Behavior:
The ultimate goal for each subsystem is expected to be the same for all individuals.
1. Attachment – probably the most critical, because it forms the basis for all social organization
• provides survival & security; its consequences are social inclusion, intimacy, & formation and
maintenance of a strong social bond
2. Achievement – attempts to manipulate the environment with its function is control or mastery of an aspect of
self or environment to some standard of excellence
• areas of achievement behavior include intellectual, physical, creative, mechanical, & social skills
3. Aggressive – function is protection & preservation which holds that aggressive behavior is not only learned,
but has a primary intent to harm others
• however, society has placed limits when dealing with self-protection and that people & their
properly be respected and protected
4. Dependence – promotes helping behavior that calls for a nurturing response
• its consequences are approval, attention, or recognition, and physical assistance

• dependency behavior develops from the complete reliance on others for certain resources
essential for survival
• an imbalance produces tension, which results in disequilibrium
5. Sexual – has dual functions of procreation & gratification that begins with the development of gender role
identity & includes the broad range of sex role behaviors
6. Ingestive – have to do with when, how, what, how much, and under what conditions we eat
7. Eliminative – have to do with when, how, what, how much, and under what conditions we eliminate
• These responses are a set of behavioral responses or tendencies that share a common goal developed
through experience and learning and are determined by numerous physical, biological, psychological,
and social factors.
• Each subsystem has three functional requirements:
o Each subsystem must be “protected from noxious influences with which the system cannot cope”.
o Each subsystem must be “nurtured through the input of appropriate supplies from the environment”.
o Each subsystem must be “stimulated for use to enhance growth and prevent stagnation”.
• As long as the subsystems are meeting these functional requirements, the system and the subsystems
are viewed as self-maintaining and self-perpetuating.
▪ Behavior
→ the output of intra-organismic structures and processes as they are coordinated and articulated by &
responsive to changes in sensory stimulation
▪ System
→ a whole that functions as a whole by virtue of the interdependence of its parts characterized by organization,
interaction, interdependency, & integration of the parts & elements
▪ Behavioral system
→ encompasses the patterned, repetitive, & purposeful ways of behaving
→ the system is flexible enough to allow influence that affect it
▪ Subsystems
→ mini-systems with its own particular goal & function that can be maintained as long as its relationship to the
other subsystems or the environment is not changed or disturbed
▪ Equilibrium
→ a stabilized but more or less transitory, resting state where the person is in harmony with himself & with his
environment
▪ Tension
→ the state of being stretched or strained can be viewed as an end-product of a disturbance in equilibrium
▪ Stressor
→ a stimulus, either internal or external, that produce tension and result in a degree of instability
Theory Assumptions:
These are in three categories: assumptions about system, assumptions about structure, and assumptions about
functions.
• Assumptions about system
1. There is “organization, interaction, interdependency and integration of the parts and elements of
behaviors that go to make up the system.”
2. A system “tends to achieve a balance among the various forces operating within and upon it, and that
man strives continually to maintain a behavioral system balance and steady-state by more or less automatic
adjustments and adaptations to the natural forces occurring on him.”
3. A behavioral system, which requires and results in regularity and constancy in behavior, is essential to
man. It is functionally significant because it serves a useful purpose in social life and the individual.
4. “System balance reflects adjustments and adaptations that are successful in some way and to some
degree.”
• Assumptions about structure
1. “From the form the behavior takes and the consequences it achieves can be inferred what ‘drive’ has
been stimulated or what ‘goal’ is being sought.”
2. Each person has a “predisposition to act concerning the goal, in certain ways rather than the other
ways.” This predisposition is called a “set.”
3. Each subsystem has a repertoire of choices called a “scope of action.”
4. The individual patient’s behavior produces an outcome that can be observed.
• Assumptions about functions
1. The system must be protected from toxic influences with which the system cannot cope.
2. Each system has to be nurtured through the input of appropriate supplies from the environment.
3. The system must be stimulated for use to enhance growth and prevent stagnation.
• The subsystems are interactive and interdependent, restoration in one subsystem could bring about
restoration of behavior in another or others. This means that healthcare practitioners must direct all
efforts, interventions, or actions to all the subsystems.
• As nurses, we should provide the highest level of quality care to our patients by taking into
consideration the whole person and trying to understand the interrelatedness of its individual
component parts.
LESSON EIGHT
HILDEGARD PEPLAU’S THEORY OF INTERPERSONAL RELATIONSHIP
“Nursing is the interpersonal therapeutic process of functioning cooperatively with other human processes that make
health possible for individuals in communities through education that aims to promote forward movement of
personality.”
Credentials & Background of the Theorist:
• She is considered as the “Mother of Psychiatric Mental Health Nursing” and “Nurse of the Century”.
• She served as Executive Director and President of the American Nurses Association (ANA).
• Peplau taught the first classes for graduate psychiatric nursing students at Teachers College, Columbia
University.
• Contributed to the advancement of the nursing profession was more than what she gave for this special area of
clinical nursing.
• Her seminal book is recognized as the first nursing theory textbook since Nightingale’s work in the 1850s.
Peplau is credited for the following in nursing profession:
o promotion of professional standards and regulation through credentialing
o introduced the concept of advanced nursing practice
o stressed the importance of psychodynamics in nursing practice
o proponent of the nurse’s unique ability to understand his or her own behavior in order to help others
identify their perceived difficulties
• She discussed four psychobiological experiences that compel destructive or constructive patient responses, as
follows: needs, frustrations, conflicts, and anxieties.
4 Phases of the Nurse-Patient Relationship (which Peplau identified):
▪ Orientation – the phase in the nurse-patient interaction where the client seeks help and the nurse assists the client to
understand the problem and the extent of the help
▪ Identification – characterized by the client who assumes a posture of dependence, interdependence, or independence
in relation to the nurse; the nurse’s focus is to assure the person that the nurse understands the interpersonal meaning
of the client’s situation
▪ Exploitation – the client derives full value from what the nurse offers through the relationship; client uses available
services based on self- interest and needs; power shifts from the nurse to the client
▪ Resolution – old needs and goals are set aside and new ones are adopted; once older needs are resolved, newer and
more mature one become evident.
6 Proposed Nursing Roles:
1. Stranger Role – is exemplified by the nurse receiving the client in the same way one meets a stranger in other life
situations. The nurse provides an accepting climate that builds trust.
2. Resource Role – the nurse answers questions, interprets clinical treatment data, and gives information.
3. Teaching Role – the nurse gives instructions and provides training. She also involves analysis and synthesis of the
learner’s experience.
4. Counseling Role – the nurse helps clients understand and integrate the meaning of current life circumstances and
provides guidance and encouragement to make changes.
5. Surrogate Role – the nurse helps clients clarify domains of dependence, interdependence, and independence and acts
on client’s behalf as advocate.
6. Active Leadership Role – the nurse helps the client assume maximum responsibility for meeting treatment goals in a
mutually satisfying way.
• Nurse and the patient can interact.

• Peplau emphasized that both the patient and nurse mature as the result of the therapeutic interaction.
• Communication and interviewing skills remain fundamental nursing tools.
• Peplau believed that nurses must clearly understand themselves to promote their client’s growth and avoid
limiting their choices to those that nurses value.
IDA JEAN ORLANDO’S THEORY OF DELIBERATIVE NURSING PROCESS
“Nursing is a profession that seeks to find out and meet the patient’s immediate need forhelp.”
Credentials & Background of the Theorist:
• Developed her theory from a study conducted at the Yale University School of Nursing, integrating mental
health concepts into basic nursing curriculum.
• She was one of the first nursing leaders to identify and emphasize the elements of the nursing process and the
critical importance of the patient’s participation in the nursing process.
• Orlando’s theory focuses on how to produce improvement in the patient’s behavior. Evidence of relieving the
patient’s distress is seen as positive changes in the patient’s observable behavior.
• Orlando analyzed the content of 2000 nurse-patient contacts and created her theory based on analysis of these
data.
• She was one of the early thinkers in nursing who proposed that patients have their own meanings and
interpretations of situations and therefore nurses must validate their inferences and analyses with patients
before drawing conclusions.
Theory Description:
• Ida Jean Orlando’s theory developed observations she recorded between a nurse and patient. Orlando’s nursing
theory stresses the reciprocal relationship between patient and nurse. What the nurse and the patient say and
do affects them both.
• According to Orlando (1961), persons become patients who require nursing care when they have needs for help
that cannot be met independently because they have physical limitations, have negative reactions to an
environment, or have an experience that prevents them from communicating their needs.
• Patients experience distress or feelings of helplessness as the result of unmet needs for help (Orlando, 1961).
• Orlando proposed a positive correlation between the length of time the patient experiences unmet needs and
the degree of distress. Therefore, immediacy is emphasized throughout her theory.
• In Orlando’s view, when individuals are able to meet their own needs, they do not feel distress and do not
require care from a professional nurse.
• Orlando emphasizes that it is crucial for nurses to share their perceptions, thoughts, and feelings so they can
determine whether their inferences are congruent with the patient’s need (Schmieding, 2006).
• Abraham (2011) used Orlando’s theory to help nurses achieve more successful patient outcomes such as fall
reduction. Orlando’s theory remains a most effective practice theory that is especially helpful to new nurses as
they begin their practice.
Nursing Process Theory: the nursing process is an interaction of three basic elements.
1. The behavior of the patient
2. The reaction of the nurse
3. The nursing actions which are designed for the patient’s benefit.
▪ The role of the nurse is to find out and meet the patient’s immediate need for help.
▪ Nursing process helps the nurse find out the nature of the distress and what helps the patient.
▪ The use of this theory keeps the nurse’s focus on the patient.
▪ The strength of the theory is that it is clear, concise and easy to use.
Nurse’s responsibility is composed of whatever help the patient may require for his needs to be met. The nurse may
either
give this need for help directly herself or indirectly employing the aid of other members of the healthcare team.
▪ Need
→ is a situationally defined requirement of the patient which relieves or diminishes his immediate distress if this
is supplied
▪ Presenting behavior of patient
→ any observable verbal and nonverbal behavior of the patient
▪ Immediate reactions
→ the nurse’s and patient’s individual perceptions, thoughts, and feelings
▪ Nursing process discipline
→ includes the nurse communicating to the patient his or her own immediate reaction
→ made in order to ask for validation, clarification, or correction from the patient
→ once referred to as the “deliberative nursing process”
▪ Automatic nursing actions
→ nursing activities that are decided upon for reasons other than the patient’s immediate need
▪ Deliberative nursing actions
→ those decided upon after ascertaining a need and then meeting this need
Theory Assumptions:
• When patients cannot 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, the environment, and health.
• Patients need help communicating their needs; they are uncomfortable and ambivalent about their
dependency needs.
• People can 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 cannot state the nature and meaning of his or her distress without the nurse’s help or 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.
• Since the premise of Orlando’s theory is in the immediacy of help needed by patients, this framework will be
important for nurses who are assigned in special clinical areas that require quick decision making and critical
thinking skills. Such areas are the OR, ER, and ICU/Critical Care Unit.
• Orlando's theory stresses the reciprocal relationship between patient and nurse remains a most effective
practice theory that is especially helpful to new nurses as they begin their practice.
LESSON NINE
JOYCE TRAVELBEE’S HUMAN-TO-HUMAN RELATIONSHIP MODEL OF NURSING
“...human-to-human relationship is the means through which the purpose of nursing is fulfilled.”
Life Story:
• A psychiatric nurse, educator and writer born in 1926.

• 1956, she completed her BSN degree at Louisiana State University
• 1959, she completed her Master of Science Degree in Nursing at Yale University
• She started a Doctoral program in Florida in 1973. Unfortunately, she was not able to finish it because she died
later that year. She passed away at the prime age of 47 after a brief sickness.
Working Experience:
• 1952, Psychiatric Nursing Instructor at DePaul Hospital Affiliate School, New Orleans.
• Also, she taught at Charity Hospital School of Nursing in Louisiana State University, New York University and
University of Mississippi.
• 1970, the Project Director of Graduate Education at Louisiana State University School of Nursing until her death.
Publications:
• 1963, started to publish articles and journals in nursing.

• 1966 and 1971, publication of her first book entitled Interpersonal Aspects of Nursing.
• 1969, when she published her 2nd book Intervention in Psychiatric Nursing: Process in the One-to-One
Relationship.
Theory Concepts:
• Travelbee believed the spiritual values a person holds will determine to a great extent, his perception of illness.
The spiritual values of the nurse or her philosophical beliefs about illness and suffering will determine the
degree to which he or she will be able to help ill persons find meaning, or no meaning, in these situations.
• Travelbee extended the interpersonal relationship theories of Peplau and Orlando, but greatly emphasized on
the therapeutic human relationship between the nurse and the patient.
• Her model emphasizes: empathy, sympathy, rapport, and emotional aspects of nursing. Sympathy and empathy
are both acts of feeling.
• The establishment of a nurse-patient relationship and the experience that rapport is the end of all nursing
endeavors.
• Travelbee’s other contributions to the nursing profession included her works on illness, suffering, pain, hope,
communication, interaction, empathy, sympathy, rapport, and therapeutic use of self.
• Catholic charity institutions

• Ida Jean Orlando, her instructor— “The nurse is responsible for helping the patient avoid and alleviate the
distress of unmet needs.” The nurse and patient interrelate with each other.
• Viktor Frankl, a survivor of Auschwitz and other Nazi concentration camps—proposed the theory of logotherapy
in which a patient is actually confronted with and reoriented toward the meaning of his life.
▪ Rapport
→ is experienced when nurse and patient has progresses through the four interlocking phases preceding
rapport (4 phases of experience):
1. Original encounter – first impressions
2. Emerging identities – perceiving each other’s uniqueness
3. Empathy – ability to share in the person’s experience; to emphasize is to gain an intellectual

understanding of the mental world & psychological state of another
4. Sympathy – when the nurse wants to lessen the cause of patient’s suffering; “When one sympathizes,
one is involved but not incapacitated by the involvement.”
→ “A nurse is able to establish rapport because she possesses the necessary knowledge and skills required to
assist ill persons and because she is able to perceive, respond to and appreciate the uniqueness of the ill human
being.” | “A nurse does not only seek to alleviate physical pain or render physical care – she ministers to the
whole person. The existence of the suffering whether physical, mental or spiritual is the proper concern of the
nurse.”
▪ Therapeutic use of self
→ ability to use one’s personality consciously and in full awareness in an attempt to establish relatedness and to
structure nursing intervention
▪ Communication
→ the vehicle through which nurse-patient relationships are established
▪ Nurse-patient interaction
→ refers to any contact between a nurse and an ill person
→ an experience or series of experiences between nurse and patient
→ means thru which the purpose of nursing is accomplished
▪ Logical form
→ an inductive theory that uses specific nursing situations to create general ideas
▪ Nursing Practice: Hospice – self-actualizing life experience. Assumption of the sick role. Meaning of life and sickness
and death.
▪ Nursing Education: Teaches nurses to understand the meaning of illness and suffering.
▪ Nursing Research: Applied in the theory of caring for cancer patients.

ERNESTINE WIEDENBACH’S HELPING ART OF CLINICAL NURSING THEORY
“Nursing is the art of nurturing or caring for someone in a motherly fashion.”
• Her contributions to the nursing profession reiterated the helping role of the nurse in terms of providing direct
care to patients needing help.
• Her definition of nursing is rooted in her experience in the field of maternity nursing.
4 Elements in the Art of Nursing:
1. Philosophy – is what motivates the nurse to act in a certain way.
o includes major concepts of her philosophy:
▪ patient – need for help
▪ nurse – purpose, philosophy, practice (knowledge, judgment, skills), administration, validation,

coordination (reporting, consulting, conferring), art (stimulus, preconception, interpretation, actions, rational,
reactionary, deliberative)
o the nurse’s philosophy is their attitude and belief about life and how that affected reality for them
o 3 essential components associated with nursing philosophy:
▪ Reverence for life
▪ Respect for the dignity, worth, autonomy and individuality of each human being.
▪ Resolution to act on personally and professionally held beliefs
2. Purpose – is that which the nurse wants to accomplish through what she does.
o It is all of the activities directed towards the overall good of the patient.
3. Practice – are those observable nursing actions that are affected by beliefs and feelings about meeting the patient’s
need for help.
4. Art – this includes:
o Understanding patient’s needs and concerns
o Developing goals and actions intended to enhance patients’ ability
o Directing activities related to the medical plan to improve patient’s condition
Ways to Identify Patients’ Need for Help:
▪ Observing behavior consistent or inconsistent with their comfort
▪ Exploring the meaning of their behavior
▪ Determining the cause of their discomfort or incapacity
▪ Determining whether they can resolve their problems or have a need-for-help
▪ The patient
→ is any person who has entered the healthcare system and is receiving help of some kind, such as care,
teaching, or advice.
→ The patient need not be ill since someone receiving health-related education would qualify as a patient.
▪ Need-for-help
→ is defined as any measure desired by the patient that has the potential to restore or extend the ability to
cope with various life situations that affect health and wellness.
▪ Clinical judgment
→ represents the nurse’s likeliness to make sound decisions.
▪ Sound decisions
→ are based on differentiating fact from assumption and relating them to cause and effect. It is the result of
disciplined functioning of mind and emotions, and improves with expanded knowledge and increased clarity of
professional purpose.
▪ Nursing skills
→ are carried out to achieve a specific patient-centered purpose rather than completion of the skill itself being
the end goal.
▪ Skills
→ are made up of a variety of actions, and characterized by harmony of movement, precision, and effective use
of self.
LESSON TEN
NANCY ROPER-WINIFRED LOGAN-ALISON TIERNEY'S MODEL OF NURSING BASED ON ACTIVITIES OF LIVING
“Nursing is the practice of assisting patients live through life.”
• This model incorporates a life span approach wherein the characteristics of the person are considered with
respect to prior development, current level of development, and likely future development.
• In conjunction with the life span approach an independence/dependence continuum is used.
• The model then incorporates a set of 12 activities of living which represent those activities engaged in by
individuals whether sick or well.
12 Activities of Living: together these elements are referred to as a “model of living”
1. Maintaining a safe environment 7. Personal cleansing and dressing
2. Breathing 8. Maintaining body temperature
3. Communication 9. Working and playing
4. Mobilizing 10. Sleeping
5. Eating and Drinking 11. Expressing sexuality
6. Eliminating 12. Dying
5 Main Factors that Influenced the ADLs:
▪ Biological ▪ Sociocultural
▪ Psychological ▪ Environmental
▪ Politico-economic
▪ The model has been a significant guide towards advancing nursing practice, research, and education in that it places
great emphasis on the nurse’s ability to perform continuous patient assessment, provide assistance in the performance
of activities of living and individualizing patient care.
▪ Health is viewed as a reflection of the person’s ability to perform the activities of living in the light of the five factors
that influence its degree of performance and within the context of the person’s developmental age.
▪ Individuality of living
→ the way in which the person attends to his activities of living with respect to his developmental
age or his place in the life span, on the dependence-independence continuum, and as influenced by biological,
psychological, environmental, and politico-economic factors
▪ The activities of living
→ describe the person in the complex process of living from the perspective of an amalgam of
activities
▪ Life span
→ refers to the concept of continuous change from birth until death and may refer to
developmental age
▪ The dependence-independence continuum
→ relates to the factors and activities of the person
→ the continuum ranges from full incapacitation to having the ability to achieve activities of living
→ both concepts occur at anticipated points across the lifespan and at unexpected times
throughout life
▪ The Theory of the Elements of Nursing: A Model Based on a Model of Living emphasizes the importance of
developmental assessment and of individualizing patient care.
▪ No two patients can have similar reactions to a particular disease condition or illness state because of the concept of
individuality of living.
▪ The first vital step towards high quality patient care is for the nurse to individualize patient care and to make a
thorough nursing and health assessment.
LYDIA HALL’S CARE, CURE, CORE THEORY OF NURSING
“Nursing is a distinct body of knowledge that provides nursing care to patients who are in need of nursing care in support
of medical interventions, in collaboration with other members of the health team, or exclusively and independently by
the nurse herself.”
Life Story:
• Born in New York City September 21, 1906

• Graduated from York Hospital School of Nursing in Pennsylvania
• Bachelor of Science & Master of Arts from Teachers College, Columbia University
• Died February 27, 1969 of heart disease in Queens Hospital of New York
Interests & Research Focus:
• Research in the field of rehabilitation of chronically ill patient’s brought her to develop the Care, Cure, Core
Theory
• Interested in rehabilitative nursing and the role that the professional nurse played and the patient’s recovery
and welfare (Alligood & Tomey 2010)
• She became the founder and first director of the Loeb Center for Nursing and Rehabilitation at the Montefiore
Medical Center in Bronx, New York
Theory Description:
• This theory defines Nursing as the “participation in care, core and cure aspects of patient care, where CARE is
the sole function of nurses, whereas the CORE and CURE are shared with other members of the health team.”
• The major purpose of care is to achieve an interpersonal relationship with the individual that will facilitate the
development of the core.
• As Hall says; “To look at and listen to self is often too difficult without the help of a significant figure (nurturer)
who has learned how to hold up a mirror and sounding board to invite the behavior to look and listen to
himself. If he accepts the invitation, he will explore the concerns in his acts and as he listens to his exploration
through the reflection of the nurse, he may uncover in sequence his difficulties, the problem area, his problem,
and eventually the threat which is dictating his out-of-control behavior.”
Theory Assumptions:
▪ The motivation and energy necessary for healing exist

within the patient, rather than in the healthcare team.
▪ The three aspects of nursing should not be viewed as

functioning independently but as interrelated.
▪ The three aspects interact, and the circles

representing them change size, depending on the
patient’s total course of progress.
▪ Nursing theory in line with Lydia Hall is nothing short

of revolutionary.
▪ In the 1960s, she put down in her own simple words,

her thoughts about nursing.
▪ She did not consider herself a nurse theorist but

instead talked about her transparent thoughts and
remarkable ideas of nursing care as she learned it over
the years.
▪ These lead to the development of her “Care, Cure, Core Theory” also known as the “Three Cs of Lydia Hall”.
▪ She believed that patients should receive care only from professional nurses.
▪ Nursing involves interacting with a patient in a complex process of teaching and learning.
▪ She was not pleased with the concept of team nursing.
Subconcepts:
▪ Lydia Hall’s theory has three components which are represented by three independent but interconnected circles. The
three circles are: the care, the cure, and the core.
▪ The size of each circle constantly varies and depends on the state of the patient.
Strengths:
• This model appears to be completely and simply logical. Her work may be viewed as the philosophy of nursing.
• The three C’s in this theory were unique. In all the circles of the model, the nurse is present, although focus of
the nurse’s role is on the care circle.
Weaknesses:
• This model is considered to be plain and simple in its presentation. However, the receptiveness and resilience
necessary for its utilization and function may not be so simple for nurses whose personality, educational
preparation, and experience have not prepared them to function with minimal structure. This and the self-
imposed age and illness requirements limit the generalizability.
• The age requirement for the application of her theory which is 16 years of age and above limits the theory since
it cannot be disregarded that nurses are faced with pediatric clients every now and then.
• The concept of a patient aggregate such as having families and communities as the focus of nursing practice
was not tackled. It is purely on the individual himself. Although, the role of the family or the community within
the patient’s environment was modestly discussed.
How Do Nurses Relate?
▪ She proposed many ideas of professional practice, such as the nursing process
▪ Improvement of nurses to meet the needs of the patient with better professional nursing care
▪ Management of nursing care
▪ Establishment of nurse-patient relationship
▪ Collaboration with other health professionals
▪ Deliverance of care to ill patients
Theory Assertions:
▪ Nursing is viewed as a distinct body of knowledge that provides nursing care to patients who are in need of nursing
care.
▪ Care of patients can be performed in support of medical interventions, in collaboration with other members of the
health team, or exclusively and independently by the nurse herself. Nursing is described as interacting with a patient in a
complex process of teaching and learning.
▪ The patient or person, in this case, is the recipient of care which may come from three different domains.
▪ Nurses are able to carry out nursing interventions independently, dependently, or interdependently.
▪ The core aspect of the theory maintains that it is our responsibility to make sure that the patient receives the highest
level of care possible from all concerned health professions.
▪ The role of the nurse is in the collaboration, coordination, and cooperation with other members of the health care
team on matters that pertain to the patient’s welfare.
▪ The cure aspect of the theory clearly delineates nursing functions that are dependent on the members of the medical
profession.
▪ Examples of these include medication administration, performance of diagnostic procedures, and some other
interventions that need a written order from the doctor.
▪ The care domain of the theory refers to the independent roles and functions of the nurse insofar as her knowledge
and skills about the patient’s condition will allow her to carry on with her responsibilities.
Conclusion:
▪ Hall believed patients should only receive care from professional nurses.
▪ Hall defined her philosophy on the basis of the patient.
▪ Hall believed that patients come to the hospital in a biological crisis (acute episode of a disease) and that medicine
does a great job at treating this crisis, but fails to treat the chronic underlying disease. This is where she felt nursing
could make a significant difference.
▪ Hall felt that taking over this sub-acute phase was the way for nursing to legitimize itself into a true profession.
L E S S O N E L E V EN
FAYE GLENN ABDELLAH’S 21 NURSING PROBLEMS THEORY
“Nursing is based on an art and science that molds the attitudes, intellectual competencies, and technical skills of the
individual nurse into the desire and ability to help people, sick or well, cope with their health needs.”
Life Story: (March 13, 1919 – present)
• She was born on March 13, 1919 in New York to a father of Algerian heritage and Scottish mother. Her family
subsequently moved to New Jersey where she attended high school.
• She is a pioneer in nursing research who developed the Twenty-One Nursing Problems. Her model of nursing
was progressive for the time in that it refers to a nursing diagnosis during a time in which nurses were taught
that diagnoses were not part of their role in health care.
• She was the first nurse officer to earn the ranking of a two-star rear admiral and the first nurse and the first
woman to serve as a Deputy Surgeon General.
• She is well known for her development of her theory that has interrelated the concepts of health, nursing
problems, and problem-solving.
• She views nursing as an art and a science that mold the attitude, intellectual competencies, and technical skills
of the individual nurse into the desire and ability to help individuals cope with their health needs, whether they
are ill or well.
• She used Henderson’s 14 basic human needs and nursing research to establish the classification of nursing
problems.
Education:
• Faye Abdellah earned a nursing diploma from Fitkin Memorial Hospital’s School of Nursing, now known as Ann
May School of Nursing.
• It was sufficient to practice nursing during her time in the 1940s, but she believed that nursing care should be
based on research, not hours of care.
• Abdellah went on to earn three degrees from Columbia University: a bachelor of science degree in nursing in
1945, a master of arts degree in physiology in 1947 and a doctor of education degree in 1955.
• With her advanced education, Abdellah could have chosen to become a doctor. However, as she explained in
one of her interviews that she wanted to be an M.D. because she could do all she wanted to do in nursing,
which is a caring profession.
As an Education:
• In her early twenties, she worked as a health nurse at a private school and her first administrative position was
on the faculty of Yale University from 1945-1949.
• At that time, she was required to teach a class called “120 Principles of Nursing Practice” using a standard
nursing textbook published by the National League for Nursing. The book included guidelines that had no
scientific basis which challenged her to explain everything to what she called the “brilliant” students.
As a Researcher:
• In 1949, she met Lucile Petry Leone who was the first Nurse Officer and decided to join the Public Health
Service. Her first assignment was with the division of nursing that focused on research and studies. They
performed studies with numerous hospitals to improve nursing practice.
• She was an advocate of degree programs for nursing. Diploma programs, she believes, were never meant to
prepare nurses at the professional level. Nursing education, she argued, should be based on research; she
herself became among the first in her role as an educator to focus on theory and research. Her first studies were
qualitative; they simply described situations. As her career progressed, her research evolved to include
physiology, chemistry, and behavioral sciences.
Theory Description:
• The patient-centered approach to nursing was developed from her practice, and the theory is considered a
human needs theory. It was formulated to be an instrument for nursing education, so it is most suitable &
useful in that field.
• The nursing model is intended to guide care in hospital institutions, but can also be applied to community
health nursing, as well.
Theory Assumption:
▪ This relates to change and anticipated changes that affect nursing; the need to appreciate the
interconnectedness of social enterprises and social problems; the impact of problems such as poverty, racism, pollution,
education, and so forth on health and health care delivery; changing nursing education; continuing education for
professional nurses; and development of nursing leaders from underserved groups.
▪ Individual
→ She describes nursing recipients as individuals (and families), although she does not delineate her beliefs or
assumptions about the nature of human beings.
▪ Health
→ The achieving of it, is the purpose of nursing services. Although Abdellah does not define health, she speaks
to “total health needs” and “a healthy state of mind and body.”
→ Health may be defined as the dynamic pattern of functioning whereby there is a continued interaction with
internal and external forces that results in the optimal use of necessary resources to minimize vulnerabilities.
▪ Society
→ It is included in “planning for optimum health on local, state, and international levels.” However, as Abdellah
further delineates her ideas, the focus of nursing service is clearly the individual.
▪ Nursing Problems
→ The client’s health needs can be viewed as problems, overt as an apparent condition, or covert as a hidden or
concealed one.
→ Because covert problems can be emotional, sociological, and interpersonal in nature, they are often missed
or misunderstood. Yet, in many instances, solving the covert problems may solve the overt problems as well.
▪ Problem Solving
→ Quality professional nursing care requires that nurses be able to identify and solve overt and covert nursing
problems.
→ The problem-solving process can meet these requirements by identifying the problem, selecting pertinent
data, formulating hypotheses, testing hypotheses through collecting data, and revising hypotheses when
necessary based on conclusions obtained from the data.
Abdellah’s Typology of 21 Nursing Problems: these fall into three categories: (1) physical, sociological, and emotional
needs of patients; (2) types of interpersonal relationships between the patient and nurse; and (3) common elements of
patient care.
1. To maintain good hygiene and physical comfort.
2. To promote optimal activity: exercise, rest, sleep
3. To promote safety by preventing accidents, injuries, or other trauma and preventing the spread of infection.
4. To maintain good body mechanics and prevent and correct the deformity.
5. To facilitate the maintenance of a supply of oxygen to all body cells.
6. To facilitate the maintenance of nutrition for all body cells.
7. To facilitate the maintenance of elimination.
8. To facilitate the maintenance of fluid and electrolyte balance.
9. To recognize the physiologic responses of the body to disease conditions—pathologic, physiologic, and compensatory.
10. To facilitate the maintenance of regulatory mechanisms and functions.
11. To facilitate the maintenance of sensory function.
12. To identify and accept positive and negative expressions, feelings, and reactions.
13. To identify and accept interrelatedness of emotions and organic illness.

14. To facilitate the maintenance of effective verbal and nonverbal communication.
15. To promote the development of productive interpersonal relationships.
16. To facilitate progress toward achievement and personal spiritual goals.
17. To create or maintain a therapeutic environment.
18. To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs.
19. To accept the optimum possible goals in the light of limitations, physical and emotional.
20. To use community resources as an aid in resolving problems that arise from an illness.
21. To understand the role of social problems as influencing factors in the cause of illness.
10 Steps to Identify the Patient’s Problems:
▪ Learn to know the patient.
▪ Sort out relevant and significant data.
▪ Make generalizations about available data concerning similar nursing problems presented by other patients.
▪ Identify the therapeutic plan.
▪ Test generalizations with the patient and make additional generalizations.
▪ Validate the patient’s conclusions about his nursing problems.
▪ Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting his or
her behavior.
▪ Explore the patient and their family’s reactions to the therapeutic plan and involve them in the plan.
▪ Identify how the nurses feel about the patient’s nursing problems.
▪ Discuss and develop a comprehensive nursing care plan
11 Nursing Skills to Develop a Treatment Typology:
• observation of health status

• skills of communication
• application of knowledge
• the teaching of patients and families
• planning and organization of work
• use of resource materials
• use of personnel resources
• problem-solving
• the direction of work of others
• therapeutic uses of the self
• nursing procedure
Abdellah also explained nursing as a comprehensive
service, which includes:
▪ Recognizing the nursing problems of the patient
▪ Deciding the appropriate course of action to take in

terms of relevant nursing principles
▪ Providing continuous care of the individual’s total needs
▪ Providing continuous care to relieve pain and discomfort

and provide immediate security for the individual
▪ Adjusting the total nursing care plan to meet the

patient’s individual needs
▪ Helping the individual to become more self-directing in obtaining or maintaining a healthy state of body and mind
▪ Instructing nursing personnel and family to help the individual do for himself that which he can within his limitations
▪ Helping the individual to adjust to his limitations and emotional problems
▪ Working with allied health professions in planning for optimum health on local, state, national, and international levels
▪ Carrying out continuous evaluation and research to improve nursing techniques and to develop new techniques to
meet people’s health needs
Patient-Centered Approaches to Nursing:
• Faye Abdellah’s work is a set of problems formulated in terms of nursing-centered services used to determine
the patient’s needs. The nursing-centered orientation to client care appears to be contradicting the client-
centered approach that Abdellah professes to support. This can be observed by her desire to move away from a
disease-centered orientation.
• The nursing-centered orientation to client care seems contrary to the client-centered approach that Abdellah
professes to uphold. The apparent contradiction can be explained by her desire to move away from a disease-
centered orientation.
• In her attempt to bring nursing practice to its proper relationship with restorative and preventive measures for
meeting total client needs, she seems to swing the pendulum to the opposite pole, from the disease orientation
to nursing orientation, while leaving the client somewhere in the middle.
Theory Analysis:
▪ With the aim of Faye Abdellah in formulating a clear categorization of patient’s problems as health needs, she rather
conceptualized nurses’ actions in nursing care which is contrary to her aim. Nurses roles were defined toalleviate the
problems assessed through the proposed problem-solving approach.
▪ The problem-solving approach introduced by Abdellah has the advantage of increasing the nurse’s critical and
analytical thinking skills since the care to be provided would be based on sound assessment and validation of findings.
Strengths:
• The problem-solving approach is readily generalizable to the client with specific health needs and specific
nursing problems.
• With the model’s nature, healthcare providers and practitioners can use Abdellah’s problem-solving approach
to guide various activities within the clinical setting. This is true when considering nursing practice that deals
with clients who have specific needs and specific nursing problems.
• The language of Faye Abdellah’s framework is simple and easy to comprehend.
• The theoretical statement greatly focuses on problem-solving, an activity that is inherently logical in nature.
Weaknesses:
• The major limitation to Abdellah’s theory and the 21 nursing problems is their very strong nurse-centered
orientation. She rather conceptualized nurses’ actions in nursing care which is contrary to her aim.
• Another point is the lack of emphasis on what the client is to achieve was given in terms of client care.
• Framework seems to focus quite heavily on nursing practice and individuals. This somewhat limits the ability to
generalize although the problem-solving approach is readily generalizable to clients with specific health needs
and specific nursing.
• Also, Abdellah’s framework is inconsistent with the concept of holism. The nature of the 21 nursing problems
attests to this. As a result, the client may be diagnosed as having numerous problems that would lead to
fractionalized care efforts, and potential problems might be overlooked because the client is not deemed to be
in a particular stage of illness.
Conclusion:
▪ Abdellah ‘s typology of 21 nursing problems is a conceptual model mainly concerned with patient’s needs and the role
of nurses in problem identification using a problem analysis approach.
▪ According to the model, patients are described as having physical, emotional, and sociological needs. People are also
the only justification for the existence of nursing. That is, without people, nursing would not be a professionsince they
are the recipients of nursing.
▪ However, Abdellah rather conceptualized nurses’ actions in nursing care which is contrary to her aim of formulating a
clear categorization of a patient's problems as health needs. Nurses roles were defined to alleviate the problems
assessed through the proposed problem-solving approach.
▪ As a whole, the theory is intended to guide care not just in the hospital setting, but can also be applied to community
nursing, as well. The model has interrelated concepts of health and nursing problems, as well as problem-solving, which
is an activity inherently logical in nature.
▪ Furthermore, the 21 nursing problems progressed to a second-generation development referred to as patient

problems and patient outcomes. Abdellah educated the public on AIDS, drug addiction, violence, smoking, and
alcoholism. Her work is a problem-centered approach or philosophy of nursing.

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LESSON ONE

History of Nursing Theory

course offering only skills during their time.

▪ Health ▪ Nursing Concepts

Significance of Nursing Theory:

1. Utilizes in its practice a well-defined and well-organized body of specialized knowledge.

3. Entrusts the education of its practitioners to universities/ colleges.

4. Applies knowledge in practical services important to community welfare.

5. Functions autonomously in developing professional policy.

6. Attracts individuals with intellectual and personal qualities of intensifying service.

Historical Views of the Nature of Science

Epistemology (episteme – knowledge; logos – study of)

● meaning knowledge, understanding

● What is real is also considered knowledge.

● Branch of philosophy concerned with the nature & scope of knowledge.

● It is the study of knowledge & justifies beliefs.

● It questions what knowledge is & how it can be acquired.

1. Write a meaningful practice story.

2. Name the central phenomenon in the practice story.

3. Identify a theoretical lens for viewing the phenomenon.

4. Link the phenomenon to existing literature.

5. Gather a story from someone who has lived the phenomenon.

7. Identify the core qualities of the phenomenon.

8. Use the core qualities to create a definition.

9. Create a model of the phenomenon

Contemporary Issues in Nursing Theory Development:

▪ Theoretical Boundaries and Levels to Advance Nursing Science

▪ Nursing Theory, Practice and Research

The Crimean War

▪ She found the conditions as:

o soldiers lay in filth straw pallets in crowded hallways

o rats and insects crawled the floors and walls

o water was rationed, and available in totally inadequate amounts

▪ Nightingale returned to England as a national heroine in 1856

patient during her absence.

WATSON'S PHILOSOPHY & THEORY OF TRANSPERSONAL CARING

Transpersonal Caring Relationship

▪ foundational of her theory; it is a special kind of human care relationship

▪ Watson uses the term “carative” instead of curative

• The theory acknowledges the unity of the person’s mind-body-spirit.

▪ Ongoing personal & professional development and spiritual growth.

Implications of the Theory:

PATRICIA BENNER: CARING, CLINICAL WISDOM AND ETHICS IN NURSING PRACTICE

• born in Hampton, Virginia

▪ Advanced Beginner (1 to 2 years)

▪ Proficient (3 to 5 years) – intuitive

▪ Expert (>5 years) – clinical eye

▪ should be guided by rules and are oriented by the completion of tasks

▪ examples are newly registered professional nurses

▪ already has a holistic view of a particular situation

▪ the nurse’s performance is guided by maxims by this stage

▪ characterized by the following vital traits:

o demonstrate a clinical grasp and resource-based practice

o possess embodied know-how

o see the big picture

o see the unexpected

Maxim – a mysterious description of skilled performance.

• It requires a certain level of experience to recognize the implications of the instructions.

Application of the Theory:

▪ Learning by experience will allow you to gain mastery of a given skill.

MARILYN ANN RAY

• 1958 – went to LA, CA work at OB-Gyn, ER, CCU

▪ Dr. Leininger – transcultural nursing and ethnographic-ethnonursing research methods.