THEORETICAL FOUNDATION SUMMARY

Virginia Henderson: Nursing Need Theory

Biography of Virginia Henderson

Virginia Avenel Henderson (November 30, 1897 – March 19, 1996) was a nurse, theorist, and author known
for her Need Theory and defining nursing as: “The unique function of the nurse is to assist the individual, sick
or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he
would perform unaided if he had the necessary strength, will or knowledge.” Henderson is also known as “The
First Lady of Nursing,” “The Nightingale of Modern Nursing,” “Modern-Day Mother of Nursing,” and “The
20th Century Florence Nightingale.”

Early Life
Virginia Henderson was born in Kansas City, Missouri, in 1897, the fifth of the eight children of Lucy Minor
Abbot and Daniel B. Henderson. She was named after the State her mother longed for. At age four, she returned
to Virginia and began her schooling at Bellevue, a preparatory school owned by her grandfather William
Richardson Abbot.
Her father was a former teacher at Bellevue and was an attorney representing the Native American Indians in
disputes with the U.S. Government, winning a major case for the Klamath tribe in 1937.

Education
Virginia Henderson received her early education at home in Virginia with her aunts, and uncle Charles Abbot,
at his school for boys in the community Army School of Nursing at Walter Reed Hospital in Washington D.C.
In 1921, she received her Diploma in Nursing from the Army School of Nursing at Walter Reed Hospital,
Washington D.C. In 1923, Henderson started teaching nursing at the Norfolk Protestant Hospital in Virginia. In
1929, she entered Teachers College at Columbia University for her Bachelor’s Degree in 1932 and took her
Master’s Degree in 1934.

Career
In 1921 after receiving her Diploma, Virginia Henderson worked at the Henry Street Visiting Nurse Service for
two years after graduation. After two years, she initially planned to switch professions, but her strong desire to
help the profession averted her plan. She helped remedy nurses’ views throughout the years through exhaustive
research that helped establish her professions’ intellectual underpinnings.

From 1924 to 1929, she worked as an instructor and educational director in Norfolk Protestant Hospital,
Norfolk, Virginia. The following year, in 1930, she was a nurse supervisor and clinical instructor at the
outpatient department of Strong Memorial Hospital, Rochester, New York.

From 1934 to 1948, 14 years of her career, she worked as an instructor and associate professor at Teachers
College, Columbia University in New York. Since 1953, Henderson was a research associate at Yale University
School of Nursing and a research associate emeritus (1971 -1996).

Throughout her career, she traveled the world at the invitation of professional societies, universities, and
governments to share and inspire nurses and other healthcare professionals.

She consistently stressed a nurse’s duty to the patient rather than the doctor. Her efforts provided a basis to the
science of nursing, including a universally used system of recording patient observations, and have helped make
nurses far more valuable to doctors.

Need Theory
Henderson’s widely known contributions to nursing are the Need Theory, among her other works. The Need
Theory emphasizes the importance of increasing the patient’s independence and focusing on the basic human
needs so that progress after hospitalization would not be delayed. The Need Theory is discussed further below.

Works of Virginia Henderson

In 1939, she was the author of three editions of “Principles and Practices of Nursing,” a widely used text. Her
“Basic Principles of Nursing,” published in 1966 and revised in 1972, has been published in 27 languages by
the International Council of Nurses.
Her most formidable achievement was a research project in which she gathered, reviewed, cataloged, classified,
annotated, and cross-referenced every known piece of research on nursing published in English, resulting in the
four-volume “Nursing Research: Survey and Assessment,” written with Leo Simmons and published in 1964,
and her four-volume “Nursing Studies Index,” completed in 1972.

Principles and Practice of Nursing

Henderson co-authored the fifth (1955) and sixth (1978) editions of Textbook of Principles and Practice of
Nursing when the original author, Bertha Harmer, died. Until 1975, the book’s fifth edition was the most widely
adopted nursing textbook in English and Spanish by various nursing schools.

At age 75, she began the sixth edition of the Principles and Practice of Nursing text. Over the next five years of
her life, she led Gladys Nite and seventeen other contributors to synthesize the professional literature she
completed indexing. During her 50-year career in nursing and the opportunity to review all principal authors
who wrote in English, she fashioned a work that thoroughly criticized health care and offered nurses an
opportunity to correct the shortcomings. The book, operating on two levels, argued that health care would be
reformed by the individual nurses who will enable their patients to be independent in health care matters when
patients are both educated and encouraged to care for themselves. She took this philosophy to new heights by
eliminating medical jargon from the text and declaring it a reference for those who want to guard their own or
their family’s health or take care of a sick relative or a friend.

Basic Principles of Nursing Care

In 1953, she was completely rewriting the Harmer and Henderson Textbook on the Principles and Practice of
Nursing when she utilized her nursing description. After the textbook was published, Henderson was asked by
the International Council of Nurses to write an essay on nursing considered applicable in any part of the world
and relevant to both nurses and their patients, sick or well. The Basic Principles of Nursing (ICN, 1960)
resulted from this and became one of the landmark books in nursing and is considered the 20th century
equivalent of Nightingale’s Notes on Nursing.  The ICN publication is available in 29 languages and is currently
used throughout the world.

Nursing Studies Index

The Nursing Studies Index (ICN, 1963) is one of Henderson’s famous works. In 1953, she accepted a Yale
University School of Nursing position as a research associate for a research project designed to survey and
nursing research in the United States. After completing the survey, it was noted that there is an absence of
organized literature upon which to base clinical studies about nursing. Henderson was funded to direct the
Nursing Studies Index Project from 1959 to 1971. The outcome was the publication of the four-volume Nursing
Studies Index, the first annotated nursing research index published between 1900 and 1960.

Awards and Honors of Virginia Henderson

There are numerous honors and awards bestowed upon Virginia Henderson.
She received honorary doctorate degrees from the Catholic University of America, Pace University, University
of Rochester, University of Western Ontario, Yale University, Rush University, Old Dominion University,
Boston College, Thomas Jefferson University, Emory University, and many others.
In 1977 she created an Honorary Fellow of the American Academy of Nursing. In the subsequent year, she has
created an Honorary Fellow of the Royal College of Nursing of the United Kingdom for her unique contribution
to nursing’s art and science.
In 1985, Henderson was honored at the Nursing and Allied Health Section of the Medical Library Association.
In the same year, she received the first Christiane Reimann prize from the International Nursing Council (ICN),
the highest and most prestigious nursing award due to her work’s international scope.

In 1988, she was honored by the Virginia Nurses Association when the Virginia Historical Nurse Leadership
Award was presented to her.

The Virginia Henderson Global Nursing e-Repository or The Virginia Henderson International Nursing Library
was named in her honor by Sigma Theta Tau International for the global impact on nursing research. The
library in Indianapolis has been available in electronic form through the Internet since 1994.
In 2000, the Virginia Nurses Association recognized Henderson as one of the 51 Pioneer Nurses in Virginia.
She is also a member of the American Nurses Association Hall of Fame.
Death
On March 19, 1996, Henderson died at a hospice in Branford, Connecticut. She was 98. Her remains were
interred in her family’s plot of the churchyard of St. Stephen’s Church, Forest, Bedford County, Virginia.

Virginia Henderson’s Need Theory

Virginia Henderson developed the Nursing Need Theory to define the unique focus of nursing practice. The
theory focuses on the importance of increasing the patient’s independence to hasten their progress in the
hospital. Henderson’s theory emphasizes the basic human needs and how nurses can meet those needs.
“I believe that the function the nurse performs is primarily an independent one – that of acting for the patient
when he lacks knowledge, physical strength, or the will to act for himself as he would ordinarily act in health or
in carrying out prescribed therapy. This function is seen as complex and creative, as offering unlimited
opportunity to apply the physical, biological, and social sciences and the development of skills based on them.”
(Henderson, 1960).

Assumptions of the Need Theory

Virginia Henderson’s Need Theory assumptions are: (1) Nurses care for patients until they can care for
themselves once again. Although not precisely explained, (2) patients desire to return to health. (3) Nurses are
willing to serve, and “nurses will devote themselves to the patient day and night.” (4) Henderson also believes
that the “mind and body are inseparable and are interrelated.”

Major Concepts of the Nursing Need Theory

The following are the major concepts (nursing metaparadigm) and definitions of the Need Theory of Virginia
Henderson.

Individual
Henderson states that individuals have basic health needs and require assistance to achieve health and
independence or a peaceful death. According to her, an individual achieves wholeness by maintaining
physiological and emotional balance.
She defined the patient as someone who needs nursing care but did not limit nursing to illness care. Her theory
presented the patient as a sum of parts with biopsychosocial needs, and the mind and body are inseparable and
interrelated.

Environment
Although the Need Theory did not explicitly define the environment, Henderson stated that maintaining a
supportive environment conducive to health is one of her 14 activities for client assistance.
Henderson’s theory supports the private and public health sector’s tasks or agencies to keep people healthy. She
believes that society wants and expects the nurse’s act for individuals who cannot function independently.

Health
Although not explicitly defined in Henderson’s theory, health was taken to mean balance in all realms of human
life. It is equated with the independence or ability to perform activities without aid in the 14 components or
basic human needs.
On the other hand, nurses are key persons in promoting health, preventing illness, and curing. According to
Henderson, good health is a challenge because it is affected by numerous factors such as age, cultural
background, emotional balance, and others.

Nursing
Virginia Henderson wrote her definition of nursing before the development of theoretical nursing. She defined
nursing as “the unique function of the nurse is to assist the individual, sick or well, in the performance of those
activities contributing to health or its recovery that he would perform unaided if he had the necessary strength,
will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.” The
nurse’s goal is to make the patient complete, whole, or independent. In turn, the nurse collaborates with the
physician’s therapeutic plan.

Nurses temporarily assist an individual who lacks the necessary strength, will, and knowledge to satisfy one or
more of the 14 basic needs. She states: “The nurse is temporarily the consciousness of the unconscious, the love
life for the suicidal, the leg of the amputee, the eyes of the newly blind, a means of locomotion for the infant,
knowledge, and confidence of the young mother, the mouthpiece for those too weak or withdrawn to speak.”

Additionally, she stated that “…the nurse does for others what they would do for themselves if they had the
strength, the will, and the knowledge. But I go on to say that the nurse makes the patient independent of them as
soon as possible.”
Her definition of nursing distinguished a nurse’s role in health care: The nurse is expected to carry out a
physician’s therapeutic plan, but individualized care results from the nurse’s creativity in planning for care.

The nurse should be an independent practitioner able to make an independent judgment. In her work Nature of
Nursing, she states the nurse’s role is “to get inside the patient’s skin and supplement his strength, will or
knowledge according to his needs.” The nurse is responsible for assessing the patient’s needs, helping them
meet health needs, and providing an environment in which the patient can perform activity unaided.

14 Components of the Need Theory

The 14 components of Virginia Henderson’s Need Theory show a holistic nursing approach covering
physiological, psychological, spiritual, and social needs.

Physiological Components
 1. Breathe normally
 2. Eat and drink adequately
 3. Eliminate body wastes
 4. Move and maintain desirable postures
 5. Sleep and rest
 6. Select suitable clothes – dress and undress
 7. Maintain body temperature within normal range by adjusting clothing and modifying environment
 8. Keep the body clean and well-groomed and protect the integument
 9. Avoid dangers in the environment and avoid injuring others

Psychological Aspects of Communicating and Learning

 10. Communicate with others in expressing emotions, needs, fears, or opinions.
 14. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the
available health facilities.

Spiritual and Moral

 11. Worship according to one’s faith

Sociologically Oriented to Occupation and Recreation

 12. Work in such a way that there is a sense of accomplishment
 13. Play or participate in various forms of recreation

Analysis of the Need Theory

One cannot say that every individual with similar needs indicated in the 14 activities by Virginia Henderson is
the only thing that human beings need in attaining health and survival. With today’s time, there may be added
needs that humans are entitled to be provided with by nurses.

The prioritization of the 14 Activities was not clearly explained whether the first one is a prerequisite to the
other. But still, it is remarkable that Henderson was able to specify and characterize some of the needs of
individuals based on Abraham Maslow’s hierarchy of needs.

Some of the activities listed in Henderson’s concepts can only be applied to fully functional individuals
indicating that there would always be patients who always require aided care which is contrary to the goal of
nursing indicated in the definition of nursing by Henderson.
Because of the absence of a conceptual diagram, interconnections between Henderson’s principles’ concepts
and subconcepts are not delineated.

Strengths
Virginia Henderson’s concept of nursing is widely accepted in nursing practice today. Her theory and 14
components are relatively simple, logical, and applied to individuals of all ages.

Weaknesses
There is an absence of a conceptual diagram that interconnects Henderson’s theory’s 14 concepts and
subconcepts. On assisting the individual in the dying process, there is little explanation of what the nurse does
to provide “peaceful death.”

Application of the Need Theory

Henderson’s Needs Theory can be applied to nursing practice as a way for nurses to set goals based on
Henderson’s 14 components. Meeting the goal of achieving the 14 needs of the client can be a great basis to
further improve one’s performance towards nursing care. In nursing research, each of her 14 fundamental
concepts can serve as a basis for research, although the statements were not written in testable terms.
Jean Watson: Theory of Human Caring
Dr. Jean Watson is a nurse theorist who developed “Philosophy and Theory of Transpersonal Caring” or
“Caring Science” and founder of Watson Caring Science Institute. Get to know about Dr. Watson’s nursing
theory, its major concepts, assumptions, and application to nursing in this study guide.

Biography of Jean Watson

Jean Watson (June 10, 1940 – present) is an American nurse theorist and nursing professor known for
her “Philosophy and Theory of Transpersonal Caring.” She has also written numerous texts, including
Nursing: The Philosophy and Science of Caring. Watson’s study on caring has been integrated into education
and patient care to various nursing schools and healthcare facilities worldwide.

Early Life
Jean Watson was born Margaret Jean Harmon and grew up in Welch, West Virginia, in the Appalachian
Mountains. She was the youngest of eight children and was surrounded by an extended family–community
environment. Watson attended high school in West Virginia and then the Lewis Gale School of Nursing in
Roanoke, Virginia, where she graduated in 1961.

Personal Life
After her graduation in 1961, Jean Watson married her husband, Douglas, and moved west to his native state of
Colorado. In 1997, she experienced an accidental injury that resulted in the loss of her left eye, and soon after,
in 1998, her husband, whom she considers as her physical and spiritual partner, and her best friend passed away
and left Watson and their two grown daughters, Jennifer and Julie, and five grandchildren.

Watson states that she is “attempting to integrate these wounds into my life and work. One of the gifts through
the suffering was the privilege of experiencing and receiving my own theory through the care from my husband
and loving nurse friends and colleagues.” These two personal life-altering events contributed to writing her third
book, Postmodern Nursing and Beyond.

Education
Jean Watson ardently and quickly progressed through her nursing education, earning her bachelor’s degree in
nursing in 1964, a master of science in psychiatric and mental health nursing in 1966, and a Ph.D. in
educational psychology and counseling in 1973, all from the University of Colorado at Boulder.

Career and Appointments

After Jean Watson concluded her doctoral degree, she has served in both faculty and administrative positions in
the School of Nursing faculty, University of Colorado Health Sciences Center in Denver. In 1981 and 1982, she
pursued international sabbatical studies in New Zealand, Australia, India, Thailand, and Taiwan.

In the 1980s, Watson and colleagues established the Center for Human Caring at the University of Colorado,
the nation’s first interdisciplinary center committed to using human caring knowledge for clinical practice,
scholarship, administration, and leadership. At the center, Watson and others sponsor clinical, educational, and
community scholarship activities and human caring projects. These activities involve national and international
scholars in residence and international connections with colleagues around the world, such as Australia, Brazil,
Canada, Korea, Japan, New Zealand, the United Kingdom, Scandinavia, Thailand, and Venezuela, among
others. Activities such as these continue at the University of Colorado’s International Certificate Program in
Caring Healing, where Watson offers her theory courses for doctoral students.

Watson served as chairperson and assistant dean of the undergraduate program at the University of Colorado
School of Nursing. She was involved in the planning and implementing of the nursing Ph.D. program and
served as coordinator and director of the Ph.D. program between 1978 and 1981. From 1983 to 1990, she was
Dean of University of Colorado School of Nursing and Associate Director of Nursing Practice at University
Hospital. During her deanship, she was instrumental in developing a post-baccalaureate nursing curriculum in
human caring, health, and healing that led to a Nursing Doctorate (ND), a professional clinical doctoral degree
that in 2005 became the Doctor of Nursing Practice (DNP) degree.

Between 1993 and 1996, Watson served as a member of the Executive Committee and the Governing Board and
as an officer for the NLN, and she was elected president from 1995 to 1996.

In 2005, she took a sabbatical for a walking pilgrimage in the Spanish El Camino. And in 2008, Watson created
a non-profit foundation: Watson Caring Science Institute, to further the work of Caring Science in the world.
Philosophy and Theory of Transpersonal Caring
Watson’s Philosophy and Science of Caring is concerned with how nurses express care to their patients. Her
theory stresses the humanistic aspects of nursing as they intertwine with scientific knowledge and nursing
practice.

The nursing model states that “nursing is concerned with promoting health, preventing illness, caring for the
sick, and restoring health.” It focuses on health promotion, as well as the treatment of diseases. According to
Watson, caring is central to nursing practice and promotes health better than a simple medical cure. She
believes that a holistic approach to health care is central to the practice of caring in nursing.
According to her theory, caring can be demonstrated and practiced by nurses. Caring for patients promotes
growth; a caring environment accepts a person as they are and looks to what they may become.

Watson also defined three of the four metaparadigm concepts in nursing, including the person or human being,
health, and nursing. She referred to the human beings as a valued person in and of themselves to be cared for,
respected, nurtured, understood, and assisted; in general, a person’s philosophical view as a fully functional
integrated self. A human is viewed as greater than and different from the sum of his or her parts. Meanwhile,
health is defined as a high level of overall physical, mental, and social functioning, a general adaptive-
maintenance level of daily functioning, the absence of illness, or the presence of efforts leading to the absence
of illness. And nursing is a science of persons and health-illness experience mediated by professional, personal,
scientific, and ethical care interactions.

She does not define the fourth metaparadigm concept of the environment but instead devised 10 caring needs
specific carative factors critical to the caring human experience that need to be addressed by nurses with their
patients when in a caring role.

10 Carative Factors
Watson’s 10 carative factors are: (1) forming humanistic-altruistic value systems, (2) instilling faith-hope, (3)
cultivating a sensitivity to self and others, (4) developing a helping-trust relationship, (5) promoting an
expression of feelings, (6) using problem-solving for decision-making, (7) promoting teaching-learning, (8)
promoting a supportive environment, (9) assisting with the gratification of human needs, and (10) allowing for
existential-phenomenological forces. The first three factors form the “philosophical foundation” for the science
of caring, and the remaining seven come from that foundation.

In assisting with the gratification of human needs, Watson’s hierarchy of needs begins with lower-order

biophysical needs or survival needs, including the need for food and fluid, elimination, and ventilation. Next
are the lower-order psychophysical needs or functional needs, including the need for activity, inactivity, and
sexuality. The higher-order psychosocial needs or integrative needs include the need for achievement and
affiliation. And finally, the higher-order intrapersonal-interpersonal need or growth-seeking need, which is
self-actualization.
The nursing process outlined in Watson’s model contains the same steps as the scientific research
process: assessment, plan, intervention, and evaluation. The assessment includes observation, identification,
and review of the problem and the formation of a hypothesis. Creating a care plan helps the nurse determine
how variables would be examined or measured and what data would be collected. Intervention is the
implementation of the care plan and data collection. Finally, the evaluation analyzes the data, interprets the
results, and may lead to an additional hypothesis.

Works
Watson has authored 11 books, shared in the authorship of six books, and has written countless nursing journal
articles. The following publications reflect her theory of caring from her ideas about the philosophy and science
of caring.

Theory of Human Caring of Jean Watson

Nowadays, a lot of people choose nursing as a profession. There are many reasons to consider becoming a
professional nurse, but compassion is often a trait required of nurses. This is for the reason that taking care of
the patients’ needs is its primary purpose. Jean Watson’s “Philosophy and Theory of Transpersonal
Caring” mainly concerns how nurses care for their patients and how that caring progresses into better plans to
promote health and wellness, prevent illness and restore health.
In today’s world, nursing seems to be responding to the various demands of the machinery with less
consideration of the needs of the person attached to the machine. In Watson’s view, the disease might be cured,
but illness would remain because, without caring, health is not attained. Caring is the essence of nursing and
connotes responsiveness between the nurse and the person; the nurse co-participates with the person. Watson
contends that caring can help the person gain control, become knowledgeable, and promote healthy changes.
What is Watson’s Theory of Transpersonal Caring?
According to Watson’s theory, “Nursing is concerned with promoting health, preventing illness, caring for the
sick, and restoring health.” It focuses on health promotion, as well as the treatment of diseases. According to
Watson, caring is central to nursing practice and promotes health better than a simple medical cure.
The nursing model also states that caring can be demonstrated and practiced by nurses. Caring for patients
promotes growth; a caring environment accepts a person as they are and looks to what they may become.

Assumptions
Watson’s model makes seven assumptions: (1) Caring can be effectively demonstrated and practiced only
interpersonally. (2) Caring consists of carative factors that result in the satisfaction of certain human needs. (3)
Effective caring promotes health and individual or family growth. (4) Caring responses accept the patient as he
or she is now, as well as what he or she may become. (5) A caring environment offers the development of
potential while allowing the patient to choose the best action for themselves at a given point in time. (6) The
science of caring is complementary to the science of curing. (7) The practice of caring is central to nursing.

Major Concepts
The Philosophy and Science of Caring have four major concepts: human being, health, environment or society,
and nursing.

Society
The society provides the values that determine how one should behave and what goals one should strive toward.
Watson states:
“Caring (and nursing) has existed in every society. Every society has had some people who have cared for
others. A caring attitude is not transmitted from generation to generation by genes. The culture of the
profession transmits it as a unique way of coping with its environment.”

Human being
Human being is a valued person to be cared for, respected, nurtured, understood, and assisted; in general, a
philosophical view of a person as a fully functional integrated self. A human is viewed as greater than and
different from the sum of his or her parts.

Health
Health is the unity and harmony within the mind, body, and soul; health is associated with the degree of
congruence between the self and the self as experienced. It is defined as a high level of overall physical, mental,
and social functioning; a general adaptive-maintenance level of daily functioning; and the absence of illness, or
the presence of efforts leading to the absence of illness.

Nursing
Nursing is a human science of persons and human health-illness experiences mediated by professional,
personal, scientific, esthetic, and ethical human care transactions.

Actual Caring Occasion

The actual caring occasion involves actions and choices by the nurse and the individual. The moment of coming
together on a caring occasion presents the two persons with the opportunity to decide how to be in the
relationship – what to do with the moment.

Transpersonal
The transpersonal concept is an intersubjective human-to-human relationship in which the nurse affects and is
affected by the other person. Both are fully present in the moment and feel a union with the other; they share a
phenomenal field that becomes part of both’s a life story.

Subconcepts

Phenomenal field
The totality of human experience of one’s in the world. This refers to the individual’s frame of reference that
can only be known to that person.
Self
The organized conceptual gestalt is composed of perceptions of the characteristics of the “I” or “ME” and the
perceptions of the relationship of the “I” and “ME” to others and various aspects of life.
Time
The present is more subjectively real, and the past is more objectively real. The past is before or in a different
mode of being than the present, but it is not clearly distinguishable. Past, present, and future incidents merge
and fuse.

10 Carative Factors
Watson devised 10 caring needs specific carative factors critical to the caring human experience that need to be
addressed by nurses with their patients when in a caring role. As carative factors evolved within an expanding
perspective, and as her ideas and values evolved, Watson offered a translation of the original carative factors
into clinical caritas processes that suggested open ways in which they could be considered.
The first three carative factors are the “philosophical foundation” for the science of caring, while the remaining
seven derive from that foundation. The ten primary carative factors with their corresponding translation into
clinical caritas processes are listed below.

Carative Factors Caritas Process

1. “The formation of a humanistic-altruistic system of
values.”
2. “The instillation of faith-hope.”
3. “The cultivation of sensitivity to one’s self and
others.”
4. “Development of a helping-trust relationship”
became “development of a helping-trusting, human
caring relation” (in 2004 Watson website)
5. “The promotion and acceptance of the expression
of positive and negative feelings.”
6. “The systematic use of the scientific problem-
solving method for decision making” became
“systematic use of a creative problem solving caring
process” (in 2004 Watson website)
7. “The promotion of transpersonal teaching-
learning.”
8. “The provision of the supportive, protective, and
(or) corrective mental, physical, societal, and spiritual as well as the nonphysical, subtle environment of
environment.”
9. “The assistance with the gratification of human
needs.”
10. “The allowance for existential-phenomenological “Opening and attending to spiritual-mysterious and
forces” became “allowance for existential-
phenomenological spiritual forces” (in 2004 Watson
website)
“Practice of loving-kindness and equanimity within
the context of caring consciousness.”
“Being authentically present and enabling and
sustaining the deep belief system and subjective life-
world of self and one being cared for.”
“Cultivation of one’s own spiritual practices and
transpersonal self going beyond the ego-self.”
“Developing and sustaining a helping trusting,
authentic caring relationship.”
“Being present to, and supportive of, the expression
of positive and negative feelings as a connection with
deeper spirit and self and the one-being-cared for.”
“Creative use of self and all ways of knowing as part
of the caring process; to engage in the artistry of
caring-healing practices.”
“Engaging in genuine teaching-learning experience
that attends to the unity of being and meaning,
attempting to stay within others’ frame of reference.”
“Creating healing environment at all levels (physical
energy and consciousness, whereby wholeness,
beauty, comfort, dignity, and peace are potentiated).”
“Assisting with basic needs, with an intentional
caring consciousness, administering ‘human care
essentials,’ which potentiate alignment of mind-
body-spirit, wholeness, and unity of being in all
aspects of care.”
existential dimensions of one’s own life-death; soul
care for self and the one-being-cared for”

Watson’s Hierarchy of Needs

With the gratification of human needs, Watson’s hierarchy of needs begins with lower-order biophysical needs
or survival needs, the lower-order psychophysical needs or functional needs, the higher-order psychosocial
needs or integrative needs, and finally, the higher-order intrapersonal-interpersonal need or growth-seeking
need. Watson’s Hierarchy of Needs

Lower Order Biophysical Needs or Survival Needs

Watson’s hierarchy of needs begins with lower-order biophysical needs or survival needs. These include the
need for food and fluid, elimination, and ventilation.
Lower Order Psychophysical Needs or Functional Needs
Next in line are the lower-order psychophysical needs or functional needs. These include the need for activity,
inactivity, and sexuality.

Higher-Order Psychosocial Needs or Integrative Needs

The higher-order psychosocial needs or integrative needs include the need for achievement and affiliation.

Higher-Order Intrapersonal-Interpersonal Need or Growth-seeking Need

The higher-order intrapersonal-interpersonal need or growth-seeking need is the need for self-actualization.

Watson’s Theory and The Nursing Process

The nursing process in Watson’s theory includes the same steps as the scientific research process: assessment,
plan, intervention, and evaluation. The assessment includes observation, identification, and review of the
problem and the formation of a hypothesis. Creating a care plan helps the nurse determine how variables would
be examined or measured and what data would be collected. Intervention is the implementation of the care plan
and data collection. Finally, the evaluation analyzes the data, interprets the results, and may lead to an
additional hypothesis.

Analysis
It is undeniable that technology has already been part of nursing’s whole paradigm with the evolving era of
development. Watson’s purely “caring” suggestion without giving much attention to technological machinery
cannot be solely applied. Her statement is praiseworthy because she dealt with the importance of the nurse-
patient interaction rather than a practice confined with technology.
Watson stated the term “soul-satisfying” when giving out care for the clients. Her concepts guide the nurse to an
ideal quality nursing care provided for the patient. This would further increase the involvement of both the
patient and the nurse when the experience is satisfying.
In providing the enumerated clinical Caritas processes, the nurse becomes an active co-participant with the
patient. Thus, the quality of care offered by the nurse is enhanced.

Strengths
Although some consider Watson’s theory complex, many find it easy to understand. The model can guide and
improve practice as it can equip healthcare providers with the most satisfying aspects of practice and provide
the client with holistic care.
Watson considered using nontechnical, sophisticated, fluid, and evolutionary language to artfully describe her
concepts, such as caring-love, carative factors, and Caritas. Paradoxically, abstract and simple concepts such as
caring-love are difficult to practice, yet practicing and experiencing them leads to greater understanding.
Also, the theory is logical in that the carative factors are based on broad assumptions that provide a supportive
framework. The carative factors are logically derived from the assumptions and related to the hierarchy of
needs.

Watson’s theory is best understood as a moral and philosophical basis for nursing. The scope of the framework
encompasses broad aspects of health-illness phenomena. Also, the theory addresses aspects of health promotion,
preventing illness, and experiencing peaceful death, thereby increasing its generality. The carative factors
provide guidelines for nurse-patient interactions, an important aspect of patient care.

Weakness
The theory does not furnish explicit direction about what to do to achieve authentic caring-healing relationships.
Nurses who want concrete guidelines may not feel secure when trying to use this theory alone. Some have
suggested that it takes too much time to incorporate the Caritas into practice, and some note that Watson’s
personal growth emphasis is a quality “that while appealing to some may not appeal to others.”
Conclusion
Watson began developing her theory while she was assistant dean of the undergraduate program at the
University of Colorado, and it evolved into planning and implementing its nursing Ph.D. program.
The Philosophy and Science of Caring addresses how nurses express care to their patients. Caring is central to
nursing practice and promotes health better than a simple medical cure. Watson believes that a holistic approach
to health care is central to the practice of caring in nursing.
This led to the formulation of the 10 carative factors: (1) forming humanistic-altruistic value systems, (2)
instilling faith-hope, (3) cultivating a sensitivity to self and others, (4) developing a helping-trust relationship,
(5) promoting an expression of feelings, (6) using problem-solving for decision-making, (7) promoting
teaching-learning, (8) promoting a supportive environment, (9) assisting with the gratification of human needs,
and (10) allowing for existential-phenomenological forces. The first three factors form the “philosophical
foundation” for the science of caring, and the remaining seven come from that foundation.
Describing her theory as descriptive, Watson acknowledges the theory’s evolving nature and welcomes input
from others. Although the theory does not lend itself easily to research conducted through traditional scientific
methods, recent qualitative nursing approaches are appropriate.
Watson’s theory continues to provide a useful and important metaphysical orientation for the delivery of
nursing care. Watson’s theoretical concepts, such as the use of self, patient-identified needs, the caring process,
and the spiritual sense of being human, may help nurses and their patients to find meaning and harmony during
a period of increasing complexity. Watson’s rich and varied knowledge of philosophy, the arts, the human
sciences, and traditional science and traditions, joined with her prolific ability to communicate, has enabled
professionals in many disciplines to share and recognize her work.
Florence Nightingale: Environmental Theory

Biography of Florence Nightingale

Florence Nightingale (12 May 1820 – 13 August 1910) was a nurse who contributed to developing and
shaping the modern nursing practice and has set examples for nurses who are standards for today’s profession.
Nightingale is the first nurse theorist well-known for developing the Environmental Theory that revolutionized
nursing practices to create sanitary conditions for patients to get care. She is recognized as the founder of
modern nursing. During the Crimean War, she tended to wounded soldiers at night and was known as “The
Lady with the Lamp.” 

Early Life
Florence Nightingale was born on May 12, 1820, in Nightingale, Italy. She was the younger of two children.
Her British family belonged to elite social circles. Her father, William Shore Nightingale, a wealthy landowner
who had inherited two estates—one at Lea Hurst, Derbyshire, and the other in Hampshire, Embley Park
Nightingale was 5 years old.

Her mother, Frances Nightingale, hailed from a family of merchants and took pride in socializing with
prominent social standing people. Despite her mother’s interest in social climbing, Nightingale herself was
reportedly awkward in social situations. She preferred to avoid being the center of attention whenever possible.
Strong-willed, Nightingale often butted heads with her mother, whom she viewed as overly controlling. Still,
like many daughters, she was eager to please her mother. “I think I am got something more good-natured and
complying,” Nightingale wrote in her own defense concerning the mother-daughter relationship.

Education
Florence Nightingale was raised on the family estate at Lea Hurst, where her father provided her with a classical
education, including German, French, and Italian studies. As for being homeschooled by her parents and tutors,
Nightingale gained excellence in Mathematics.

Nightingale was active in philanthropy from a very young age, ministering to the ill and poor people in the
village neighboring her family’s estate. At seventeen, she decided to dedicate her life to medical care for the
sick resulting in a lifetime commitment to speak out, educate, overhaul and sanitize the appalling health care
conditions in England.
Despite her parents’ objections, Nightingale enrolled as a nursing student in 1844 at the Lutheran Hospital of
Pastor Fliedner in Kaiserswerth, Germany.

Personal Life
Only announcing her decision to enter the field in 1844, following her desire to be a nurse, was not easy for
Florence Nightingale. Her mother and sister were against her chosen career, but Nightingale stood strong and
worked hard to learn more about her craft despite society’s expectation that she become a wife and mother.

As a woman, Nightingale was beautiful and charming that made every man like her. However, she rejected a
suitor, Richard Monckton Milnes, 1st Baron Houghton, because she feared that entertaining men would
interfere with the process. The income given to her by her father during this time allowed her to pursue her
career and still live comfortably. Though Nightingale had several important friendships with women, including
correspondence with an Irish nun named Sister Mary Clare Moore, she had little respect for women in general
and preferred friendships with powerful men.

Environmental Theory
Florence Nightingale’s Environmental Theory defined Nursing as “the act of utilizing the patient’s environment
to assist him in his recovery.”
It involves the nurse’s initiative to configure environmental settings appropriate for the gradual restoration of
the patient’s health and that external factors associated with the patient’s surroundings affect the life or biologic
and physiologic processes and his development.
She identified 5 environmental factors: fresh air, pure water, efficient drainage, cleanliness or sanitation, and
light or direct sunlight.
Works
Based on her observations in the Crimea, Florence Nightingale wrote Notes on Matters Affecting the Health,
Efficiency, and Hospital Administration of the British Army, an 830-page report analyzing her experience and
proposing reforms for other military hospitals operating under poor conditions. The book would spark a total
restructuring of the War Office’s administrative department, including establishing a Royal Commission for the
Health of the Army in 1857.

In 1860, her best-authored works were published, “Notes on Nursing,” outlining nursing principles. It is still in
print today with translation in many foreign languages. In all, she had published some 200 books, reports, and
pamphlets. Using the money she got from the British government, she funded St. Thomas’ Hospital’s
establishment, and within it, the Nightingale Training School for Nurses.

In the 1870s, Nightingale mentored Linda Richards, “America’s first trained nurse,” and enabled her to return to
the USA with adequate training and knowledge to establish high-quality nursing schools. Linda Richards went
on to become a great nursing pioneer in the USA and Japan.

In the early 1880s, Nightingale wrote an article for a textbook in which she advocated strict precautions
designed, she said, to kill germs. Nightingale’s work served as an inspiration for nurses in the American Civil
War. The Union government approached her for advice in organizing field medicine. Although her ideas met
official resistance, they inspired the volunteer body of the United States Sanitary Commission.

Appointments
In 1853, Florence Nightingale accepted the superintendent’s position at the Institute for the Care of Sick
Gentlewomen in Upper Harley Street, London. She held this position until October 1854.
In 1854, Britain was involved in the war against the Russians (Crimean War). British battlefield medical
facilities were deplorable, prompting Minister at War Sidney Herbert to appoint Nightingale to oversee the
wounded’s care. She arrived in Constantinople, Turkey, with a company of 38 nurses. The introduction of
female nurses in military hospitals was a major success. Sanitary conditions were improved while nurses
worked as capable assistants to physicians and raised the British soldier’s morale by acting as bankers, sending
the injured man’s wages home, wrote letters to their families, and read to the wounded.

Crimean War
The Crimean War began, and soon reports in the newspapers described the desperate lack of proper medical
facilities for wounded British soldiers at the front. Sidney Herbert, the war minister, already knew Nightingale
and asked her to oversee a team of nurses in Turkey’s military hospitals. In 1854 she led an expedition of 38
women to take over the management of the barrack hospital at Scutari, where she observed the disastrous
sanitary conditions.

She returned to England in 1856. In 1860, she established the Nightingale Training School for nurses at St
Thomas’ Hospital in London. Once the nurses were trained, they were sent to hospitals all over Britain, where
they introduced the ideas they had learned and established nursing training on the Nightingale model.

Death
Despite being known as the heroine of the Crimean War, Florence Nightingale fell ill in August 1910. She
seemed to recover and was reportedly in good spirits. However, she developed an array of troubling symptoms
a week later, on the evening of Friday, August 12, 1910. She died unexpectedly at 2 pm the following day,
Saturday, August 13, at her home in London. She left a large body of work, including several hundred
previously unpublished notes.
Usually, well-known people with great contributions are offered national funerals, but Nightingale had
expressed the desire that her funeral is a quiet and modest affair.
Respecting her last wishes, her relatives turned down a national funeral, and the “Lady with the Lamp” was laid
to rest in her family’s plot at St. Margaret’s Church, East Wellow, in Hampshire, England.
In honor of the life and career of the “Angel of the Crimea,” the Florence Nightingale Museum sits at the site of
the original Nightingale Training School for Nurses, which houses more than 2,000 artifacts. And up to this
day, the name “Florence Nightingale” is universally recognized and known as the pioneer of modern nursing.
Nightingale’s Environmental Theory
The Environmental Theory by Florence Nightingale defined Nursing as “the act of utilizing the environment
of the patient to assist him in his recovery.” It involves the nurse’s initiative to configure environmental settings
appropriate for the gradual restoration of the patient’s health and that external factors associated with the
patient’s surroundings affect the life or biologic and physiologic processes and his development. Nightingale
discussed the Environmental Theory in her book Notes on Nursing: What it is, What it is Not. She is considered
the first theorist in nursing and paved the way in the foundation of the nursing profession we know today.

Major Concepts of Florence Nightingales Theory

The major concepts of Florence Nightingale’s Theory are:

Nursing
“What nursing has to do… is to put the patient in the best condition for nature to act upon him” (Nightingale,
1859/1992)
Nightingale stated that nursing “ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet,
and the proper selection and administration of diet – all at the least expense of vital power to the patient.” She
reflected the art of nursing in her statement that “the art of nursing, as now practiced, seems to be expressly
constituted to unmake what God had made disease to be, viz., a reparative process.”

Human Beings
Human beings are not defined by Nightingale specifically. They are defined in relation to their environment and
the impact of the environment upon them.

Environment
Nightingale stresses the physical environment in her writing. In her theory, Nightingale’s writings reflect a
community health model in which all that surrounds human beings is considered concerning their health state.

Health
Nightingale (1859/1992) did not define health specifically. She stated, “We know nothing of health, the positive
of which pathology is negative, except for the observation and experience. Given her definition that the art of
nursing is to “unmake what God had made disease,” then the goal of all nursing activities should be client
health.
She believed that nursing should provide care to the healthy and the ill and discussed health promotion as an
activity in which nurses should engage.

Subconcepts of the Environmental Theory

The following are the subconcepts of Florence Nightingale’s theory:

 Health of Houses
“Badly constructed houses do for the healthy what badly constructed hospitals do for the sick. Once ensure that
the air is stagnant and sickness is certain to follow.”

Ventilation and Warming

“Keep the air he breathes as pure as the external air, without chilling him.”
Nightingale believed that the person who repeatedly breathed his or her own air would become sick or remain
sick. She was very concerned about “noxious air” or “effluvia” and foul odors from excrement. She also
criticized “fumigations,” for she believed that the offensive source, not the smell, must be removed.
Nightingale also stressed the importance of room temperature. The patient should not be too warm or too cold.
The temperature could be controlled by an appropriate balance between burning fires and ventilation from
windows.

Light
Nightingale believed that second to fresh air, the sick needed light. She noted that direct sunlight was what
patients wanted.

Noise
She stated that patients should never be “waked intentionally” or accidentally during the first part of sleep. She
asserted that whispered or long conversations about patients are thoughtless and cruel. She viewed unnecessary
noise, including noise from the female dress, as cruel and irritating to the patient.
Variety
She discussed the need for color and form changes, including bringing the patient brightly colored flowers or
plants. She also advocated rotating 10 or 12 paintings and engravings each day, week, or month to provide
variety for the patient. Nightingale also advocated reading, needlework, writing, and cleaning to relieve the sick
of boredom.

Bed and Bedding

Nightingale noted that an adult in health exhales about three pints of moisture through the lungs and skin in a
24-hour period. This organic matter enters the sheets and stays there unless the bedding is changed and aired
frequently.

She believed that the bed should be placed in the lightest part of the room and placed so the patient could see
out of a window. She also reminded the caregiver never to lean against, sit upon, or unnecessarily shake the
patient’s bed.

Personal Cleanliness
“Just as it is necessary to renew the air around a sick person frequently to carry off morbid effluvia from the
lungs and skin, by maintaining free ventilation, so it is necessary to keep pores of the skin free from all
obstructing excretions.”
“Every nurse ought to wash her hands very frequently during the day.”

Nutrition and Taking Food

Nightingale noted in her Environmental Theory that individuals desire different foods at different times of the
day and that frequent small servings may be more beneficial to the patient than a large breakfast or dinner. She
urged that no business be done with patients while they are eating because this was a distraction.

Chattering Hopes and Advice

Florence Nightingale wrote in her Environmental Theory that to falsely cheer the sick by making light of their
illness and its danger is not helpful. She encouraged the nurse to heed what is being said by visitors, believing
that sick persons should hear the good news that would help them become healthier.

Social Considerations
Nightingale supported the importance of looking beyond the individual to the social environment in which they
lived.

Environmental Factors
In Florence Nightingale’s Environmental Theory, she identified five (5) environmental factors: fresh air, pure
water, efficient drainage, cleanliness or sanitation, and light or direct sunlight.
1. Pure fresh air – “to keep the air he breathes as pure as the external air without chilling him.”
2. Pure water – “well water of a very impure kind is used for domestic purposes. And when
the epidemic disease shows itself, persons using such water are almost sure to suffer.”
3. Effective drainage – “all the while the sewer may be nothing but a laboratory from
which epidemic disease and ill health are being installed into the house.”
4. Cleanliness – “the greater part of nursing consists in preserving cleanliness.”
5. Light (especially direct sunlight) – “the usefulness of light in treating disease is very important.”
The factors posed great significance during Nightingale’s time when health institutions had poor sanitation, and
health workers had little education and training and were frequently incompetent and unreliable in attending to
the patients’ needs.
Also emphasized in her environmental theory is providing a quiet or noise-free and warm environment,
attending to patient’s dietary needs by assessment, documentation of time of food intake, and evaluating its
effects on the patient.
Deficiencies in these five factors produce illness or lack of health, but the body could repair itself with a
nurturing environment.
Analysis of the Environmental Theory
In the era that we are in today, we are faced with environmental conditions beyond what ought to be natural and
nurturing. Some of the global environmental issues we have now are global warming, nuclear radiation threats,
human-made environmental calamities, and pollution. From these occurrences, Nightingale’s model seemed to
be ideal. Her concept of providing fresh air to patients is in question with today’s industrialization effects.
In addition to the analysis of the concept of ventilation, it is not always beneficial for all clients to have fresh
air. Natural air has its impurities which in turn may infect open wounds and drainages such as in burns.
With the idea of providing light, the light emitted by the sun today is proven to be harmful already because of
the destruction of the Earth’s ozone layer. Exposing the patient constantly to direct sunlight may be more
destructive to the patient’s betterment than beneficial.
A healthy environment indeed heals, as Nightingale stated. Still, the question now is how our environment
would remain healthy amidst the negative effects of the progress of technology and industrialization.
Since the applicability of some of the concepts to specific situations today is non-feasible, this theory’s
development is utterly needed to accommodate the changes in the environment that we currently have. Still,
above all this, it is very clear that Nightingale’s Environmental Theory is superb as a starting point of our
profession’s progression and catalyzed nursing improvement.

Assumptions of Florence Nightingale’s Theory

The assumptions of Florence Nightingale in her Environmental Theory are as follows:
 Florence Nightingale believed that five points were essential in achieving a healthful house: “pure air,
pure water, efficient drainage, cleanliness, and light.”
 A healthy environment is essential for healing. She stated that “nature alone cures.”
 Nurses must make accurate observations of their patients and report the state of the patient to the
physician in an orderly manner.
 Nursing is an art, whereas medicine is a science. Nurses are to be loyal to the medical plan but not
servile.

Strengths
Florence Nightingale’s language to write her books was cultured and flowing, logical in format, and elegant in
style. Nightingale’s Environmental Theory has broad applicability to the practitioner. Her model can be applied
in most complex hospital intensive care environments, the home, a worksite, or the community. Reading
Nightingale’s Environmental Theory raises consciousness in the nurse about how the environment influences
client outcomes.

Weaknesses
In Nightingale’s Environmental Theory, there is scant information on the psychosocial environment compared
to the physical environment. The application of her concepts in the twentieth century is in question.

Conclusion
The Environmental Theory of Nursing is a patient-care theory. It focuses on altering the patient’s environment
to affect change in his or her health. Caring for the patient is of more importance than the nursing process, the
relationship between patient and nurse, or the individual nurse.
In this way, the model must be adapted to fit the needs of individual patients. The environmental factors affect
different patients unique to their situations and illnesses. The nurse must address these factors on a case-by-case
basis to make sure the factors are altered to best care for an individual patient and his or her needs.