TFN REVIEWER

BSN-1D

 FLORENCE NIGHTINGALE
 Mother of nursing
 Matriarch of modern nursing
 Born in Florence, Italy on May 12, 1820
 First nurse educator
 Vast of science, mathematics, literature and the arts; was well read in philosophy,
history, politics and economics
 Well- informed about the working of government and political science
 CHARLES DICKENS- his favorite author

FIRST NURSE EDUCATOR

 Applied for admission to the school with a 12-page, handwritten “curriculum”
 Fleidner School of Nursing
 She developed skills in both nursing care and management which she took back to
England

LADY WITH THE LAMP: CRIMEAN WAR

 Symbol of responsibility
 Battle of English versus Turkish- to look for the wounded soldiers and to heal them
with her consoling hands
 Made drastic changes in the mortality rate of soldiers and victims of war
 Very poor sanitary conditions in the hospital wards at Scutari
 Fought the bureaucracy for food, bandages, fresh bedding and cleaning supplies for
the soldiers

NIGHTINGALE: STATISTICIAN & WAR

 Wrote about sanitary improvements in hospitals & nursing notes

Theoretical Sources
EDUCATION
▪ mastery in math and philosophy
▪ learnings from her father which provided
her with conceptual thoughts

LITERATURE
▪ influenced by the writings of Charles Dickens
▪ The Adventures of Martin Chuzzlewit (he portrays Sairey Gamp, a drunken, inexpert, and
horrible nurse which provided society in an image of the terrors of the Victorian untrained
nursing)

INTELLECTUALS
▪ John Stuart Mill, Benjamin Jowett, Edwin Chadwick, and Harriet Marineu
▪ influenced theoretical and rational thinking
RELIGOUS BELIEFS
▪ believed that action for the benefit of others is a primary way of serving God which is a
basis for defining her nursing work as a religious calling
▪ provided conviction that education is a significant factor in the profession

USE OF EMPIRICAL EVIDENCE

▪ generated research throughout her lifetime on the different subjects of healthcare, nursing
and social reforms
▪ made-up the polar-area diagram (a type of statistical diagram) to noticeably represent the
point of useless death in the British military hospitals in the Crimea

METAPARADIGM IN NURSING
Person
▪ viewed as the client/patient
▪ nurse is in control of patient’s environment ▪ nurses should perform tasks to and
for the patient as well as control the patient's environment to facilitate easy recovery

Health
▪ viewed as the client/patient
▪ nurse is in control of patient’s environment ▪ nurses should perform tasks to and
for the patient as well as control the patient's environment to facilitate easy recovery
▪ "being well and using every power that the person has to the fullest extent”
▪ disease as "a reparative process that nature instituted from a want
▪ prevention of disease through environmental control will greatly uplift the maintenance of
health

Environment
▪ the sick, poor people would benefit from environmental improvements that addressed their
physical and mental aspects
▪ nurses could have a special role in uplifting the social status of the poor by improving their
living situations

THEORETICAL ASSERTION
▪ believed that disease was a reparative process; disease was nature's effort to remedy a
process of poisoning or decay or reaction against the conditions in which a person was placed
▪ nursing's role is to prevent an interruption of the reparative process and to provide optimal
conditions for its enhancement
▪ appropriate manipulations of the environment would prevent disease (underlies modern
sanitation activities)
▪ nurses should be moral agents
▪ principle of confidentiality and advocated for care to the poor
▪ concise and clear decision making regarding the patient
▪ indecision or changing the mind is more harmful to the patient that the patient having to
make a decision

ANALYSIS
Simplicity
▪ environment is the major component creating illness in a patient
▪ highlighted the benefit of good environments in preventing illness
▪ three major relationships:
• Environment to patient
• Nurse to environment
• Nurse to patient

three major relationships:

• Environment to patient
➢ ventilation, light and patient position in the room; cleanliness, darkness, noise and patient
stimulation

• Nurse to environment
➢ need to manipulate the environment to prevent disease (positioning)

• Nurse to patient
➢ cooperation and collaboration between the nurse and patient

ANALYSIS
Generality
▪ provide general guidelines for all nurse practitioners
▪ concept of the nurse, patient and environment are still applicable and relevant in all nursing
settings

Empirical Precision
▪ stated completely and are presented as truths rather than tentative, testable statements
▪ base practice on observations and experiences

Derivable consequences
▪ provide physicians with facts and not personal opinion (assessment)
▪ observation (5 senses)

ENVIRONMENTAL THEORY
Ventilation and Warmth
▪ Check the patient’s body temperature, room temperature, ventilation and foul odors.
▪ Create a plan to keep the room well- ventilated and free of odor while maintaining the
patient’s body temperature.

Light
▪ Check room for adequate light. Sunlight is beneficial to the patient.
▪ Create and implement adequate light in the room without placing the patient in direct light.

Cleanliness
▪ Check room for dust, dampness and dirt ▪ Keep room free from dust, dirt and
dampness

Health of Houses
▪ Check surrounding environment for fresh air, pure water, drainage, cleanliness and light
▪ Remove garbage, stagnant water and ensure clean water and fresh air.
Noise
▪ Check noise level in the room and surroundings
▪ Attempt to keep noise level in minimum

Personal Cleanliness
▪ Attempt to keep the patient dry and clean at all times
▪ Frequent assessment of the patient’s skin is essential to maintain good skin integrity

Chattering hopes and Advices

▪ Avoid talking without giving advice that is without a fact
▪ Respect the patient as a person and avoid personal talk

Taking food
▪ Check the diet of the patient. Note the amount of food and fluid ingested by the patient ate
very meal.

Observation of the Sick

▪ Observe and record anything about the patient
▪ Continue observation in the patient’s environment and make changes in the plan of care if
needed

APPLICATION
Analysis of Data
Data gaps include:
▪ information about family structure
▪ who lives in the household
▪ who was present when the injury happened
▪ performance in school
▪ economic resources available for family
▪ nutritional status and evaluation

Over-all conclusion:
▪ lack of sleep
▪ infected wound

Nursing Diagnosis
▪ Disturbed sleeping pattern related to environmental light and noise and separation from the
family

Planning and Implementation

▪ changing the environment to support normal sleep patterns, that is, being awake during the
day and sleeping at night
▪ encourage to listen to her favorite music or watch her favorite television show to expose her
to normal sounds

Planning and Implementation

▪ parents are encouraged to visit more often and talk to her about the future when she will
return to home and school
▪ nurse should teach Nena about her dressing change and help her adjust in her environment
▪ adjust in her environment
➢ by dimming the lights, reducing the
noise including lowering the volume of the alarms, and keeping to a minimum activities and
procedures that would awaken Nena

Evaluation
▪ After two nights of uninterrupted sleep, normal sounds and parental encouragement, Nena
will demonstrate increased orientation to place by being able to identify that she is in the
hospital. Nena will begin participating in her dressing changes by the third day of the care
plan.

 MARGARET JEAN WATSON

▪ American
▪ Welch, West Virginia, in the Appalachian Mountains
▪ faculty and administrative positions in the School of Nursing
▪ Philosophy and Theory of Transpersonal Caring
▪ Center for human Caring (University of Colorado)

Education
▪ Bachelor: RN
▪ MSN: Psychiatric and Mental Health Nursing
▪ Ph.D: Educational Psychology and Counselling
▪ University of Colorado

METAPARADIGM IN NURSING
Person
▪ valued person
▪ must be cared for, respected nurtured,
understood, and assisted
▪ a fully functional integrated self
▪ greater than, and different from, the sum of
his parts.

Environment
▪ provides the values that determine how one should behave and what goals one should strive
toward
▪ values are affected by change in the social, cultural, and spiritual arenas, which in turn
affects the perception of the person and can lead to stress
▪ caring (and nursing) has existed in every society
▪ every society has had some people who have cared for others
▪ caring attitude is not transmitted from generation to generation by genes
▪ caring is transmitted by the culture of the profession as a unique way of coping with its
environment

Health
▪ unity and harmony within the mind, body, and soul
▪ associated with the degree of congruence between self as perceived and as experienced

three elements:
1. high level of over-all physical, mental,
and social functioning;
2. general adaptive-maintenance level of
daily functioning, and
3. absence of illness (or the presence of
efforts that lead to its absence)

Nursing
▪ areas of stress and developmental conflicts to provide holistic health care (central to the
practice of caring in Nursing)
▪ asserts that nursing's social, moral and scientific contributions to humankind and society lie
in its commitment to human care ideals in theory, practice, and research
▪ "a human science of people and human health-illness experiences that are mediated by
professional, personal, scientific, aesthetic, and ethical human care transactions”

Philosophy and Science of Caring

▪ beginnings as a textbook that was originally planned to present an integrated curriculum for
undergraduate nursing programs
▪ evolved instead into an original structure for basic nursing process
▪ began with the question of the relationship between human caring and nursing (laid the
foundation for what was to become the Theory of Human Caring (1977) and Nursing: Human
Science and Human Care)

SCIENCE OF CARING: 7 ASSUMPTIONS

1. Caring can be effectively demonstrated and practiced only interpersonally;
2. Effective caring promotes health and individual or family growth;
3. Caring responses accept a person not only as he or she is now but as what he or she may
become,
4. A caring environment is one that offers the development of potential while allowing the
person to choose the best action for himself or herself at a given point in time
5. Caring is more "healthogenic" than is curing (caring integrates biophysical knowledge of
human behavior to generate or promote health and to provide care to the sick)
6. A science of caring is therefore complementary to the science of curing.
7. The practice of caring is central to nursing.

10 CARATIVE FACTORS
▪ focus of nursing is on caring factors that are derived from a humanistic perspective
combined with scientific knowledge base

1. Formation of a Humanistic-altruistic system of values

2. Instillation of faith-hope
3. Cultivation of sensitivity to one's self and to others
4. Development of a helping-trusting, human caring relationship
5. Promotion and acceptance of the expression of positive and negative feelings;
6. Systematic use of a creative problem- solving caring process
7. Promotion of transpersonal teaching- learning
8. Provision for a supportive, protective, and corrective mental, physical, societal, and
spiritual environment
9. Assistance with gratification of human needs
10.Allowance for existential- phenomenological-spiritual forces

WATSON-Hierarchy of Needs
Lower-order biophysical needs
▪ survival needs
▪ need for food and fluid, elimination, and ventilation
▪ functional needs
▪ need for activity, inactivity, and sexuality.

WATSON-Hierarchy of Needs
Higher order psychosocial needs
▪ integrative needs
▪ need for achievement, and affiliation

WATSON-Nursing Process
Assessment
▪ observation, identification, and review of the problem, as well as the formation of a
hypothesis

Care Plan
▪ 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

Evaluation
▪ analyzes the data, interprets the results, and may lead to an additional hypothesis

ACCEPTANCE IN THE NSG. COMMUNITY

Acceptance in the Nursing Practice
▪ "How will / sustain and nurture my caring consciousness?"
▪ "Who will care for me?"

Education
▪ “Nursing qua Nursing” model
➢ unique nursing knowledge rather than
knowledge developed by members of other disciplines

Research
▪ focus both on subjective and objective patient outcomes to determine whether or not caring
is indeed the truest essence of nursing

ANALYSIS
Simplicity
▪ use of sophisticated language to put forth subtle thoughts about caring, and this entails
“reading between the lines" to decipher its profound meaning
Generality
▪ provides moral and philosophical basis for nursing
▪ scope of the framework encompasses all aspects of the health illness continuum
▪ addresses aspects of preventing illness and experiencing a peaceful death, thereby
increasing its generality

Empirical Precision
▪ descriptive and she acknowledges the evolving nature of the theory and welcomes input by
others
▪ transpersonal caring
▪ developing nursing as a human Science and Art can be classified as qualitative, naturalistic
or phenomenological

Derivable consequences
▪ concepts such as use of self, patient- identified needs, the caring process, and the spiritual
sense of human being, may help nurses and their patients find meaning and harmony in a
period of increasing complexity

THEORY OF HUMAN CARING

▪ primary purpose/reason is taking care of the patients’ needs
▪ how nurses care for their patients, and how that caring progresses into better plans to
promote health and wellness, prevent illness and restore health

▪ TODAY’S WORLD
➢ nursing responds to the various demands of the machinery with less consideration of the
needs of the person attached to the machine

▪ WATSON’S VIEW
➢ 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
➢ caring can assist the person to gain control, become knowledgeable, and promote health
changes

Strengths
▪ easy to understand
▪ used to guide and improve practice as it can equip healthcare providers with the most
satisfying aspects of practice
▪ can provide the client with holistic care
▪ addresses aspects of health promotion, preventing illness and experiencing peaceful death
(generality)
 ▪ provide guidelines for nurse-patient interactions, an important aspect of patient care

ENVIRONMENTAL THEORY
Weakness
▪ 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
▪ that it takes too much time to incorporate the Caritas into practice
▪ “that while appealing to some may not appeal to others”

 PATRICIA BENNER
▪ American
▪ Bachelor of Arts-Nursing (Pasadena College,1964)
▪ Master of Science in Medical-Surgical Nursing from the University of California at San
Francisco-1970
▪ Ph.D. from the University of California at Berkeley-1982

NOVICE TO EXPERT MODEL

▪ Stages of Clinical Competence
▪ Adapted from the Dreyfus Model of Skill Acquisition

NOVICE TO EXPERT MODEL

▪ experience in the clinical setting is key to nursing
▪ allows a nurse to continuously expand their knowledge base and to provide holistic,
competent care to the patient

Skill Acquisition
▪ the art of learning to do something in order to earn a living and or to survive
▪ skills can be acquired from several sources depending on the skills and the environment

NOVICE
▪ has no background experience of the situation in which he or she is involved
▪ difficulty discerning between relevant and irrelevant aspects of the situation
▪ applies to nursing students, new graduates or those just returning to the clinical field

Advanced Beginner
▪ demonstrates marginally acceptable performance having coped with enough real situations
▪ are guided by rules and oriented by task completion
▪ still requires mentor or experienced nurse to assist with defining situations, to set priorities,
and to integrate practical knowledge in pratice

Competent
▪ two to three years in the same area of nursing
▪ begins to recognize patterns and determine which elements of the situation warrant attention
and which can be ignored
▪ devises new rules and reasoning procedures for a plan while applying learned rules for
action on the basis of the relevant facts of that situation

Proficient
▪ 3-5 years in the same area ▪ deep understanding of situations as they occur, less conscious
planning, critical thinking and decision-making skills have developed
▪ perceives information as a whole
▪ demonstrates new ability to situations including recognizing and implementing responses as
situation arise

Expert
▪ five years of greater (nurses changes area)
▪ no longer relies on analytic principle (rule, guidance and maxim)
▪ has intuitive grasp of situation ▪ operates from deep understanding of the total situation

METAPARADIGM IN NURSING
Person
▪ self-directing being
▪ person does not come into a predetermined
world but gets defined through life

Environment
▪ uses situation rather than environment because situation conveys a social environment with
social definition
▪ a situation (past, present and future) influences current situation

Health
▪ focuses on the lived experience of being healthy and being ill
▪ defined as what can be assessed, whereas well being is the human experience of health or
wholeness
▪ well-being and being ill are distinct ways of being in the world

Nursing
▪ Nursing is described as a caring relationship, an “enabling condition of connection and
concern”
▪ Caring is primary because caring sets up the possibility of giving and receiving help
▪ viewed as a caring practice whose science is guided by the moral art and ethics of care and
responsibility
▪ as the care and study of the lived experience of health, illness, and disease and the
relationships among the three elements

ROLES of Nurses:
▪ Advocating for transition or residency programs to competency, confidence & satisfaction
of new RNs
▪ Maintaining a healthy working environment
▪ Zero tolerance for lateral violence or bullying
▪ Supporting experienced RNs
  Dorothy Johnson’s Behavioral Systems Model
Profile
▪ born August 21st 1919
▪ Associates Degree in 1938 from Armstrong Junior College in Savannah Georgia
▪ 1942 BSN Vanderbilt University in Nashville Tennessee
▪ 1948 Masters in public health Harvard University Boston Massachusetts

Influences
• Florence Nightingale
– focus on the person and not the disease (environment)

• Hans Selye
– work on stress ( considered to be noxious agents)

• Teaching
– experience ( determine course content that constitutes to nursing knowledge)

• Empirical approach to nursing

– Nurses is what Nurses do.

Definitions

▪ Person
➢A behavioral system comprised of subsystems constantly trying to maintain a
steady state

▪ Environment
➢Not clearly defined.

▪ Health
➢Balance and stability.

▪ Nursing
➢External regulatory force that is only indicated when there is instability.

4 Assumptions
1. Goal - form of behavior can infer what drive or what goal
2. Set - Predisposition to act
3. Choice- Different choices/scope of choices
4. Behavior - Outcomes are produced

VALIDITY
▪1980 Damus tested the validity of Johnson’s model which assisted in sustaining the
utilization of model
➢Relationship exists between the patient’s unbalanced physiologic state and behavioral
conduct
➢Alterations in behavioral patterns could be recognized/hypothesized
➢Nursing diagnosis and interventions were interrelated concepts

CRITIQUE
Cons
▪ Focused on hospitalized and ill stricken patient
▪ Health promotion and patient education
▪ Failure to incorporate the nursing process
▪ Limited publication
▪ Difficult to use in high level research
▪ Undefined outcomes

Pros
▪ Values/Ethics
▪ Concepts are interrelated
▪ Assumptions are descriptive
▪ Simple
▪ Very little “new language”
▪ Significant impact of
nursing

 BETTY NEUMAN’S HUMAN SYSTEM MODEL

Profile

▪1924 - born in Lowell, Ohio.

▪1947- earned diploma, Ohio

▪1957- completed bachelor’s degree in nsg, UCLA

▪late 1960s - pioneer in community mental health movement

▪1966 - Master’s degree in Mental Health & Public Health Consultation, UCLA.

▪1985 - Ph.D. in Clinical Psychology, Pacific Western University

▪1992 - Doctorate of Letters, at the Neumann College, Aston, Pennsylvania

▪1993 - Dr. Neuman named Member of the Fellowship of the American Academy of
Nursing.

History

▪ 1970 - Started developing ‘The Systems Model’

▪ 1972 - published in Nursing Research.

▪ 1974 - published in 1st edition of Conceptual Models for Nursing Practice & in 2nd edition
in 1980

▪ 1988 - She founded the Neuman Systems Model Trustee Group, Inc.

Human System’s Model

▪ encourages prevention as the main source of nursing intervention
▪ prevention focuses on keeping stressors and the stress response from having a detrimental
effect on the body
▪ nurse is responsible for helping the different levels of clientele to achieve and maintain an
optimal wellness through intervention (goal of reducing stress factors and their adverse
affects on the client)
➢consists of three modalities to promote optimal health and aid prevention
▪ focuses on the response of the patient system to actual or potential environmental stressors
▪ use of primary, secondary, and tertiary nursing prevention intervention for retention,
attainment, and maintenance of patient system wellness

The Model: Concepts

Open System
▪there is a continuous flow of input and process, output and feedback
▪organized complexity, where all elements are in interaction

Basic Structure and Energy Resources

▪central core
▪comprises those basic survival factors common to the species
▪factors include the system variables, genetic features, and strengths and weaknesses of the
system parts

Client Variables
• physiological variable refers to the structure and functions of the body
• psychological variable refers to mental processes and relationships
• sociocultural variable refers to system functions that relate to social and cultural
expectations and activities
• developmental variable refers to those processes related to development over the lifespan
• spiritual variable refers to the influence of spiritual beliefs

Flexible line of Defense

▪ protective accordion-like mechanism that surrounds and protects the normal line of defense
from invasion by stressors

Normal line of Defense

▪ adaptational level of health developed over time and is considered normal for a particular
individual client or system
▪ becomes a standard for wellness-deviance determination Lines of Resistance
▪ protection factors
▪ activated when stressors have penetrated the normal line of defense, causing physiologic
response
 The Model: Sub-concepts
Stressors
▪ any phenomenon that might penetrate both the flexible and normal lines of defense,
resulting in either a positive or negative outcome

o Intrapersonal stressors - occur within the client system boundary and correlate with the
internal environment

o Interpersonal stressors- occur outside the client system boundary, are proximal to the
system, and impact the system

o Extra-personal stressors - occur outside the client system boundaries but are at a greater
distance from the system than are interpersonal stressors (ex. social policy)

Stability
▪state of balance or harmony requiring energy exchanges as the client adequately copes with
stressors to retain, attain, or maintain an optimal health level, thus preserving system integrity

Degree of Reaction
▪The amount of system instability resulting from stressor invasion of the normal line of
defense.

Reconstitution
▪Following treatment of stressor reaction, the return and maintenance of system stability may
result in a higher or lower wellness level

Primary Prevention
▪occurs before the system reacts to a stressor
▪ includes health promotion and wellness maintenance.
▪ focused on strengthening the flexible line of defense through preventing stress and reducing
risk factors
▪occurs when the risk or hazard is identified but before a reaction occurs.
▪strategies that might be used include immunization, health education, exercise, and lifestyle
changes

Secondary Prevention
▪ occurs after the system reacts to a stressor and is provided in terms of existing symptoms
▪ focuses on strengthening the internal lines of resistance and, thus, protects the basic
structure through appropriate treatment of symptoms
▪intent is to regain optimal system stability and conserve energy in doing so. If secondary
prevention is unsuccessful and reconstitution does not occur, the basic structure will be
unable to support the system and its interventions, and death will occur.

Tertiary Prevention
▪occurs after the system has been treated through secondary prevention strategies
▪purpose is to maintain wellness or protect the client system reconstitution by supporting
existing strengths and preserving energy
▪may begin at any point after system stability has begun re-established (reconstitution has
begun)
▪tends to lead back to primary prevention

Metaparadigm
PERSON
▪human being
▪open system that interacts with internal and external environment forces or stressors
▪constantly changing, moving toward a dynamic state of system stability or illness of varying
degrees
▪use of primary, secondary, and tertiary nursing prevention intervention for retention,
attainment, and maintenance of patient system wellness

ENVIRONMENT
▪vital arena that is germane to the system and its function
▪may be viewed as all factors that affect and are affected by the system
➢internal
➢external, and
➢created

ENVIRONMENT
➢Internal
 exists within the client system.
 made up of all forces and interactive influences that are solely within the client
system’s boundaries
➢External
 environment exists outside the client system
➢Created Environment
 unconsciously developed and is used by the client to support protective coping.

NURSING
▪primary concern is to define the appropriate action in situations that are stress-related or
concerning possible reactions of the client or client system to stressors
▪intervention is important
▪aims to help the system adapt or adjust and retain, restore, or maintain some degree of
stability between the client system variables and environmental stressors,
▪focused on conserving energy

Assumptions
▪each client system is unique
▪many known, unknown, and universal stressors exist
▪stressors differ in its potential for disturbing a client’s usual stability level or normal line of
defense
▪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.
▪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.
▪Primary prevention relates to general knowledge applied in client assessment and
intervention in identifying and reducing or mitigating possible or actual risk factors
associated with environmental stressors to prevent a possible reaction.
▪Secondary prevention relates to symptomatology following a reaction to stressors, an
appropriate ranking of intervention priorities, and treatment to reduce their noxious effects.
▪Tertiary prevention relates to the adjustive processes as reconstitution begins and
maintenance factors move the client back in a circular manner toward primary prevention.

Analysis
▪three defense lines was not clearly explained
▪(reality) individual resists stressors with internal and external reflexes, which were made
complicated by the formulation of different resistance levels
▪energy sources as part of the basic structure but not all are enumerated