Virginia Avenel Henderson-

November 30, 1897 – March 19, 1996) was a nurse, theorist, and author
“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,”
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
Individuals
Environment
Health
Nurse

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.
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
•
• 14. Learn, discover, or satisfy the curiosity that leads to normal development and health
and use the available health facilities

Hildegard Peplau: Interpersonal Relations Theory

Hildegard Elizabeth Peplau (September 1, 1909 – March 17, 1999)
peplau was well-known for her Theory of Interpersonal Relations, which helped to revolutionize
nurses’ scholarly work. Her achievements are valued by nurses worldwide and became known to
many as the “Mother of Psychiatric Nursing” and the “Nurse of the Century.”
Hildegard Peplau’s Interpersonal Relations Theory

Hildegard Peplau’s Interpersonal Relations Theory emphasized the nurse-client relationship as

the foundation of nursing practice. It emphasized the give-and-take of nurse-client relationships
that was seen by many as revolutionary. Peplau went on to form an interpersonal model
emphasizing the need for a partnership between nurse and client as opposed to the client
passively receiving treatment and the nurse passively acting out doctor’s orders.

The four components of the theory are person environment health nurse
The nursing model identifies four sequential phases in the interpersonal
relationship: orientation, identification, exploitation, and resolution.

It also includes seven nursing roles: Stranger role, Resource role, Teaching role, Counseling role,
Surrogate role, Active leadership, and Technical expert role.

Assumptions

Hildegard Peplau’s Interpersonal Relations Theory’s assumptions are: (1) Nurse and the patient
can interact. (2) Peplau emphasized that both the patient and nurse mature as the result of the
therapeutic interaction. (3) Communication and interviewing skills remain fundamental nursing
tools. And lastly, (4) Peplau believed that nurses must clearly understand themselves to promote
their client’s growth and avoid limiting their choices to those that nurses value.

Major Concepts of the Interpersonal Relations Theory

The theory explains nursing’s purpose is to help others identify their felt difficulties and that
nurses should apply principles of human relations to the problems that arise at all levels of
experience.

Man

Peplau defines man as an organism that “strives in its own way to reduce tension generated by
needs.” The client is an individual with a felt need.

Health

Health is defined as “a word symbol that implies forward movement of personality and other
ongoing human processes in the direction of creative, constructive, productive, personal, and
community living.”

Society or Environment

Although Peplau does not directly address society/environment, she does encourage the nurse to
consider the patient’s culture and mores when the patient adjusts to the hospital routine.

Nursing

Hildegard Peplau considers nursing to be a “significant, therapeutic, interpersonal process.” She

defines it as a “human relationship between an individual who is sick, or in need of health
services, and a nurse specially educated to recognize and to respond to the need for help.”

Therapeutic nurse-client relationship

A professional and planned relationship between client and nurse focuses on the client’s needs,
feelings, problems, and ideas. It involves interaction between two or more individuals with a
common goal. The attainment of this goal, or any goal, is achieved through a series of steps
following a sequential pattern.

Four Phases of the therapeutic nurse-patient relationship:

1. Orientation Phase

The nurse’s orientation phase involves engaging the client in treatment, providing explanations
and information, and answering questions.

• Problem defining phase

• It starts when the client meets the nurse as a stranger.
• Defining the problem and deciding the type of service needed
• Client seeks assistance, conveys needs, asks questions, shares preconceptions and
expectations of past experiences.
• Nurse responds, explains roles to the client, identifies problems, and uses available
resources and services.

Factors influencing orientation phase. Click to enlarge.

2. Identification Phase

The identification phase begins when the client works interdependently with the nurse, expresses
feelings, and begins to feel stronger.
 • Selection of appropriate professional assistance
• Patient begins to have a feeling of belonging and a capability of dealing with the
problem, which decreases the feeling of helplessness and hopelessness.
3. Exploitation Phase

In the exploitation phase, the client makes full use of the services offered.

• In the exploitation phase, the client makes full use of the services offered.
• Use of professional assistance for problem-solving alternatives
• Advantages of services are used based on the needs and interests of the patients.
• The individual feels like an integral part of the helping environment.
• They may make minor requests or attention-getting techniques.
• The principles of interview techniques must be used to explore, understand and
adequately deal with the underlying problem.
• Patient may fluctuate on independence.
• Nurse must be aware of the various phases of communication.
• Nurse aids the patient in exploiting all avenues of help, and progress is made towards the
final step.
4. Resolution Phase

In the resolution phase, the client no longer needs professional services and gives up dependent
behavior. The relationship ends.

• In the resolution phase, the client no longer needs professional services and gives up
dependent behavior. The relationship ends.
• Termination of professional relationship
• The patient’s needs have already been met by the collaborative effect of patient and
nurse.
• Now they need to terminate their therapeutic relationship and dissolve the links between
them.
• Sometimes may be difficult for both as psychological dependence persists.
• The patient drifts away and breaks the nurse’s bond, and a healthier emotional balance is
demonstrated, and both become mature individuals.
Subconcepts of the Interpersonal Relations Theory

Peplau’s model has proved greatly used by later nurse theorists and clinicians in developing
more sophisticated and therapeutic nursing interventions.

The following are the roles of the Nurse in the Therapeutic relationship identified by Peplau:

Stranger: offering the client the same acceptance and courtesy that the nurse would respond to
any stranger

Resource person: providing specific answers to questions within a larger context

Teacher: helping the client to learn formally or informally

Leader: offering direction to the client or group

Surrogate: serving as a substitute for another such as a parent or a sibling

Counselor: promoting experiences leading to health for the client such as expression of feelings

Technical Expert: providing physical care for the patient and operates equipment

Peplau also believed that the nurse could take on many other roles, but these were not defined in
detail. However, they were “left to the intelligence and imagination of the readers.” (Peplau,
1952)

Additional roles include:

• Technical expert
• Consultant
• Health teacher
• Tutor
• Socializing agent
• Safety agent
• Manager of environment
• Mediator
• Administrator
• Recorder observer
• Researcher
Anxiety was defined as the initial response to a psychic threat. There are four levels of anxiety
described below.

Four Levels of Anxiety

Mild anxiety is a positive state of heightened awareness and sharpened senses, allowing the
person to learn new behaviors and solve problems. The person can take in all available stimuli
(perceptual field).

Moderate anxiety involves a decreased perceptual field (focus on the immediate task only); the
person can learn a new behavior or solve problems only with assistance. Another person can
redirect the person to the task.

Severe anxiety involves feelings of dread and terror. The person cannot be redirected to a task;
he or she focuses only on scattered details and has physiologic symptoms of tachycardia,
diaphoresis, and chest pain.
Panic anxiety can involve loss of rational thought, delusions, hallucinations, and complete
physical immobility and muteness. The person may bolt and run aimlessly, often exposing
himself or herself to injury.

Interpersonal Theory and Nursing Process

Peplau’s Interpersonal Relations Theory and the Nursing Process are sequential and focus on the
therapeutic relationship by using problem-solving techniques for the nurse and patient to
collaborate on to meet the patient’s needs. Both use observation communication and recording as
basic tools utilized by nursing.

Assessment Orientation

• Non-continuous data collection

• Continuous data collection and analysis • Felt need
• May not be a felt need • Definite needs

Nursing Diagnosis & Planning Identification

• Mutually set goals • Interdependent goal setting

Implementation
Exploitation

• Plans initiated towards achievement of mutually

set goals • Patient actively seeking and drawing help
• May be accomplished by patient, nurse, • Patient-initiated
or significant other.

Evaluation Resolution

• Based on mutually expected behaviors • Occurs after other phases are completed
• May led to termination and initiation of new successfully
plans. • Leads to termination
Analysis

Peplau conceptualized clear sets of nurse’s roles that every nurse can use with their practice. It
implies that a nurse’s duty is not just to care, but the profession encompasses every activity that
may affect the patient’s care.
The idea of a nurse-client interaction is limited to those individuals incapable of conversing,
specifically those who are unconscious.

The concepts are highly applicable to the care of psychiatric patients considering Peplau’s
background. But it is not limited to those sets of individuals. It can be applied to any person
capable and has the will to communicate.

The phases of the therapeutic nurse-client are highly comparable to the nursing process, making
it vastly applicable. Assessment coincides with the orientation phase; nursing diagnosis and
planning with the identification phase, implementation as to the exploitation phase,
and evaluation with the resolution phase.

Strengths

Peplau’s theory helped later nursing theorists and clinicians develop more therapeutic
interventions regarding the roles that show the dynamic character typical in clinical nursing.

Its phases provide simplicity regarding the nurse-patient relationship’s natural progression,
which leads to adaptability in any nurse-patient interaction, thus providing generalizability.

Weaknesses

Though Peplau stressed the nurse-client relationship as the foundation of nursing practice, health
promotion and maintenance were less emphasized.

Also, the theory cannot be used in a patient who doesn’t have a felt need, such as with withdrawn
patients.

Conclusion

Peplau’s theory has proved greatly used to later nurse theorists and clinicians in developing more
sophisticated and therapeutic nursing interventions, including the seven nursing roles, which
show the dynamic character roles typical in clinical nursing. It entails that a nurse’s duty is not
just to care, but the profession also incorporates every activity that may affect the client’s health.

However, the idea of nurse-client cooperation is found narrow with those individuals who are
unfit and powerless in conversing, specifically those who are unconscious and paralyzed.

Madeleine Leininger: Transcultural Nursing Theory

Madeleine Leininger is a nursing theorist who developed the Transcultural Nursing Theory or
Culture Care Nursing Theory.
Madeleine Leininger (July 13, 1925 – August 10, 2012) was an internationally known educator,
author, theorist, administrator, researcher, consultant, public speaker, and the developer of the
concept of transcultural nursing that has a great impact on how to deal with patients of different
culture and cultural background.

Leininger’s Transcultural Nursing Theory

The Transcultural Nursing Theory or Culture Care Theory by Madeleine Leininger involves
knowing and understanding different cultures concerning nursing and health-illness caring
practices, beliefs, and values to provide meaningful and efficacious nursing care services to
people’s cultural values health-illness context.

It focuses on the fact that different cultures have different caring behaviors and different health
and illness values, beliefs, and patterns of behaviors.

The cultural care worldview flows into knowledge about individuals, families, groups,
communities, and institutions in diverse health care systems. This knowledge provides culturally
specific meanings and expressions about care and health. The next focus is on the generic or folk
system, professional care system(s), and nursing care. Information about these systems includes
the characteristics and the specific care features of each. This information allows for the
identification of similarities and differences or cultural care universality and cultural care
diversity.

Next are nursing care decisions and actions which involve cultural care
preservation/maintenance, cultural care accommodation/negotiation, and cultural care re-
patterning or restructuring. It is here that nursing care is delivered.

Description

In 1995, Madeleine Leininger defined transcultural nursing as “a substantive area of study and
practiced focused on comparative cultural care (caring) values, beliefs, and practices of
individuals or groups of similar or different cultures to provide culture-specific and universal
nursing care practices in promoting health or well-being or to help people to face unfavorable
human conditions, illness, or death in culturally meaningful ways.”

The Transcultural Nursing Theory first appeared in Leininger’s Culture Care Diversity and
Universality, published in 1991, but it was developed in the 1950s. The theory was further
developed in her book Transcultural Nursing, which was published in 1995. In the third edition
of Transcultural Nursing, published in 2002, the theory-based research and the Transcultural
theory application are explained.

Major Concepts of the Transcultural Nursing Theory

The following are the major concepts and their definitions in Madeleine Leininger’s
Transcultural Nursing Theory.

Transcultural Nursing

Transcultural nursing is defined as a learned subfield or branch of nursing that focuses upon the
comparative study and analysis of cultures concerning nursing and health-illness caring
practices, beliefs, and values to provide meaningful and efficacious nursing care services to their
cultural values and health-illness context.

Ethnonursing

This is the study of nursing care beliefs, values, and practices as cognitively perceived and
known by a designated culture through their direct experience, beliefs, and value system
(Leininger, 1979).

Nursing

Nursing is defined as a learned humanistic and scientific profession and discipline which is
focused on human care phenomena and activities to assist, support, facilitate, or enable
individuals or groups to maintain or regain their well-being (or health) in culturally meaningful
and beneficial ways, or to help people face handicaps or death.

Professional Nursing Care (Caring)

Professional nursing care (caring) is defined as formal and cognitively learned professional care
knowledge and practice skills obtained through educational institutions that are used to provide
assistive, supportive, enabling, or facilitative acts to or for another individual or group to
improve a human health condition (or well-being), disability, lifeway, or to work
with dying clients.

Cultural Congruent (Nursing) Care

Cultural congruent (nursing) care is defined as those cognitively based assistive, supportive,
facilitative, or enabling acts or decisions that are tailor-made to fit with the individual, group, or
institutional, cultural values, beliefs, and lifeways to provide or support meaningful, beneficial,
and satisfying health care, or well-being services.

Health

It is a state of well-being that is culturally defined, valued, and practiced. It reflects individuals’
(or groups) ‘ ability to perform their daily role activities in culturally expressed, beneficial, and
patterned lifeways.
Human Beings

Such are believed to be caring and capable of being concerned about others’ needs, well-being,
and survival. Leininger also indicates that nursing as a caring science should focus beyond
traditional nurse-patient interactions and dyads to include families, groups, communities, total
cultures, and institutions.

Society and Environment

Leininger did not define these terms; she speaks instead of worldview, social structure, and
environmental context.

Worldview

Worldview is how people look at the world, or the universe, and form a “picture or value stance”
about the world and their lives.

Cultural and Social Structure Dimensions

Cultural and social structure dimensions are defined as involving the dynamic patterns and
features of interrelated structural and organizational factors of a particular culture (subculture or
society) which includes religious, kinship (social), political (and legal), economic, educational,
technological, and cultural values, ethnohistorical factors, and how these factors may be
interrelated and function to influence human behavior in different environmental contexts.

Environmental Context

Environmental context is the totality of an event, situation, or particular experience that gives
meaning to human expressions, interpretations, and social interactions in particular physical,
ecological, sociopolitical, and/or cultural settings.

Culture

Culture is learned, shared, and transmitted values, beliefs, norms, and lifeways of a particular
group that guides their thinking, decisions, and actions in patterned ways.

Culture Care

Culture care is defined as the subjectively and objectively learned and transmitted values, beliefs,
and patterned lifeways that assist, support, facilitate, or enable another individual or group to
maintain their well-being, health, improve their human condition lifeway, or deal with illness,
handicaps or death.

Culture Care Diversity

Culture care diversity indicates the variabilities and/or differences in meanings, patterns, values,
lifeways, or symbols of care within or between collectives related to assistive, supportive, or
enabling human care expressions.

Culture Care Universality

Culture care universality indicates the common, similar, or dominant uniform care meanings,
patterns, values, lifeways, or symbols manifest among many cultures and reflect assistive,
supportive, facilitative, or enabling ways to help people. (Leininger, 1991)

Subconcepts

The following are the subconcepts of the Transcultural Nursing Theory of Madeleine Leininger
and their definitions:

Generic (Folk or Lay) Care Systems

Generic (folk or lay) care systems are culturally learned and transmitted, indigenous (or
traditional), folk (home-based) knowledge and skills used to provide assistive, supportive,
enabling, or facilitative acts toward or for another individual, group, or institution with evident or
anticipated needs to ameliorate or improve a human life way, health condition (or well-being), or
to deal with handicaps and death situations.

Emic

Knowledge gained from direct experience or directly from those who have experienced it. It is
generic or folk knowledge.

Professional Care Systems

Professional care systems are defined as formally taught, learned, and transmitted professional
care, health, illness, wellness, and related knowledge and practice skills that prevail in
professional institutions, usually with multidisciplinary personnel to serve consumers.

Etic

The knowledge that describes the professional perspective. It is professional care knowledge.

Ethnohistory

Ethnohistory includes those past facts, events, instances, experiences of individuals, groups,
cultures, and instructions that are primarily people-centered (ethno) and describe, explain, and
interpret human lifeways within particular cultural contexts over short or long periods of time.
Care

Care as a noun is defined as those abstract and concrete phenomena related to assisting,
supporting, or enabling experiences or behaviors toward or for others with evident or anticipated
needs to ameliorate or improve a human condition or lifeway.

Care

Care as a verb is defined as actions and activities directed toward assisting, supporting, or
enabling another individual or group with evident or anticipated needs to ameliorate or improve a
human condition or lifeway or face death.

Culture Shock

Culture shock may result when an outsider attempts to comprehend or adapt effectively to a
different cultural group. The outsider is likely to experience feelings of discomfort and
helplessness and some degree of disorientation because of the differences in cultural values,
beliefs, and practices. Culture shock may lead to anger and can be reduced by seeking
knowledge of the culture before encountering that culture.

Cultural Imposition

Cultural imposition refers to the outsider’s efforts, both subtle and not so subtle, to impose their
own cultural values, beliefs, behaviors upon an individual, family, or group from another culture.
(Leininger, 1978)

Sunrise Model of Madeleine Leininger’s Theory

The Sunrise Model is relevant because it enables nurses to develop critical and complex thoughts
about nursing practice. These thoughts should consider and integrate cultural and social structure
dimensions in each specific context, besides nursing care’s biological and psychological aspects.
 Madeleine Leininger’s Sunrise
Model. Click to enlarge.
The cultural care worldview flows into knowledge about individuals, families, groups,
communities, and institutions in diverse health care systems. This knowledge provides culturally
specific meanings and expressions concerning care and health. The next focus is on the generic
or folk system, professional care systems, and nursing care. Information about these systems
includes the characteristics and the specific care features of each. This information allows for the
identification of similarities and differences or cultural care universality and cultural care
diversity.

Next are nursing care decisions and actions which involve cultural care preservation or
maintenance, cultural care accommodation or negotiation, and cultural care repatterning or
restructuring. It is here that nursing care is delivered.

Three modes of nursing care decisions and actions

Cultural care preservation or Maintenance

Cultural care preservation is also known as maintenance. It includes those assistive, supporting,
facilitative, or enabling professional actions and decisions that help people of a particular culture
to retain and/or preserve relevant care values so that they can maintain their well-being, recover
from illness, or face handicaps and/or death.

Cultural care accommodation or Negotiation

Cultural care accommodation, also known as negotiation, includes those assistive, supportive,
facilitative, or enabling creative professional actions and decisions that help people of a
designated culture to adapt to or negotiate with others for a beneficial or satisfying health
outcome with professional care providers.

Culture care repatterning or Restructuring

Culture care repatterning or restructuring includes those assistive, supporting, facilitative, or

enabling professional actions and decisions that help clients reorder, change, or greatly modify
their lifeways for new, different, and beneficial health care pattern while respecting the clients’
cultural values and beliefs and still providing a beneficial or healthier lifeway than before the
changes were established with the clients. (Leininger, 1991)

Assumptions

The following are the assumptions of Madeleine Leininger’s theory:

• Different cultures perceive, know, and practice care differently, yet there are some
commonalities about care among all world cultures.
• Values, beliefs, and practices for culturally related care are shaped by, and often
embedded in, “the worldview, language, religious (or spiritual), kinship (social), political
(or legal), educational, economic, technological, ethnohistorical, and environmental
context of the culture.
• While human care is universal across cultures, caring may be demonstrated through
diverse expressions, actions, patterns, lifestyles, and meanings.
• Cultural care is the broadest holistic means to know, explain, interpret, and predict
nursing care phenomena to guide nursing care practices.
• All cultures have generic or folk health care practices, that professional practices vary
across cultures, and that there will be cultural similarities and differences between the
care-receivers (generic) and the professional caregivers in any culture.
• Care is the distinct, dominant, unifying, and central focus of nursing, and while curing
and healing cannot occur effectively without care, care may occur without a cure.
• Care and caring are essential for humans’ survival and their growth, health, well-being,
healing, and ability to deal with handicaps and death.
• Nursing, as a transcultural care discipline and profession, has a central purpose of serving
human beings in all areas of the world; that when culturally based nursing care is
 beneficial and healthy, it contributes to the well-being of the client(s) – whether
individuals, groups, families, communities, or institutions – as they function within the
context of their environments.
• Nursing care will be culturally congruent or beneficial only when the nurse knows the
clients. The clients’ patterns, expressions, and cultural values are used in appropriate and
meaningful ways by the nurse with the clients.
• If clients receive nursing care that is not at least reasonably culturally congruent (that is,
compatible with and respectful of the clients’ lifeways, beliefs, and values), the client will
demonstrate signs of stress, noncompliance, cultural conflicts, and/or ethical or moral
concerns.
Analysis

In Leininger’s nursing theory, it was stated that the nurse would help the client move towards
amelioration or improvement of their health practice or condition. This statement would be of
great difficulty for the nurse because instilling new ideas in a different culture might present an
intrusive intent for the “insiders.” Culture is a strong set of practices developed over generations
that would make it difficult to penetrate.

The whole activity of immersing yourself within a different culture is time-consuming to

understand their beliefs and practices fully. Another is that it would be costly on the part of the
nurse.

Because of its financial constraints and unclear ways of being financially compensated, it can be
the reason why nurses do not engage much with this kind of nursing approach.

Because of the intrusive nature, resistance from the “insiders” might impose a risk to the nurse’s
safety, especially for cultures with highly taboo practices.

It is highly commendable that Leininger formulated a theory that is specified to a multicultural

aspect of care. On the other side, too much was given to the culture concept per se that Leininger
failed to discuss the functions or roles of nurses comprehensively. It was not stated how to assist,
support or enable the client to attuning them to an improved lifeway.

Strengths

• Leininger has developed the Sunrise Model in a logical order to demonstrate the
interrelationships of the concepts in her theory of Culture Care Diversity and
Universality.
• Leininger’s theory is essentially parsimonious in that the necessary concepts are
incorporated in such a manner that the theory and its model can be applied in many
different settings.
• It is highly generalizable. The concepts and relationships presented are at a level of
abstraction, which allows them to be applied in many different situations.
• Though not simple in terms, it can be easily understood upon the first contact.
Weakness
 • The theory and model are not simple in terms.
Conclusion

According to transcultural nursing, nursing care aims to provide care congruent with cultural
values, beliefs, and practices.

Cultural knowledge plays a vital role for nurses on how to deal with the patients. To start, it
helps nurses to be aware of how the patient’s culture and faith system provide resources for their
experiences with illness, suffering, and even death. It helps nurses understand and respect the
diversity that is often present in a nurse’s patient load. It also helps strengthen a nurse’s
commitment to nursing based on nurse-patient relationships and emphasizing the whole person
rather than viewing the patient as simply a set of symptoms or illness. Finally, using cultural
knowledge to treat a patient also helps a nurse be open-minded to treatments that can be
considered non-traditional, such as spiritually based therapies like meditation and anointing.

Nowadays, nurses must be sensitive to their patients’ cultural backgrounds when creating a
nursing plan. This is especially important since so many people’s culture is so integral in who
they are as individuals, and it is that culture that can greatly affect their health and their reactions
to treatments and care. With these, awareness of the differences allows the nurse to design
culture-specific nursing interventions.

Through Leininger’s theory, nurses can observe how a patient’s cultural background is related to
their health and use that knowledge to create a nursing plan that will help the patient get healthy
quickly while still being sensitive to his or her cultural background.

Dorothea Orem: Self-Care Deficit Theory

Dorothea Orem is a nurse theorist who pioneered the Self-Care Deficit Nursing Theory. Get to
know Orem’s biography and works, including a discussion about the major concepts,
subconcepts, nursing metaparadigm, and application of Self- Care Deficit Theory.

Biography of Dorothea E. Orem

Dorothea Elizabeth Orem (July 15, 1914 – June 22, 2007) was one of America’s foremost
nursing theorists who developed the Self-Care Deficit Nursing Theory, also known as the Orem
Model of Nursing.

Her theory defined Nursing as “The act of assisting others in the provision and management of
self-care to maintain or improve human functioning at the home level of effectiveness.” It
focuses on each individual’s ability to perform self-care, defined as “the practice of activities that
individuals initiate and perform on their own behalf in maintaining life, health, and well-being.”

Dorothea Orem’s Self-Care Deficit Theory

There are instances wherein patients are encouraged to bring out the best in them despite being
ill for a period of time. This is very particular in rehabilitation settings, in which patients are
entitled to be more independent after being cared for by physicians and nurses. Between 1959
and 2001, Dorothea Orem developed the Self-Care Nursing Theory or the Orem Model of
Nursing. It is considered a grand nursing theory, which means the theory covers a broad scope
with general concepts applicable to all instances of nursing.

Description

Dorothea Orem’s Self-Care Deficit Theory defined Nursing as “The act of assisting others in the
provision and management of self-care to maintain or improve human functioning at the home
level of effectiveness.” It focuses on each individual’s ability to perform self-care, defined
as “the practice of activities that individuals initiate and perform on their own behalf in
maintaining life, health, and well-being.”

“The condition that validates the existence of a requirement for nursing in an adult is the absence
of the ability to maintain continuously that amount and quality of self-care which is therapeutic
in sustaining life and health, in recovering from disease or injury, or in coping with their effects.
With children, the condition is the parent’s inability (or guardian) to maintain continuity for the
child the amount and quality of care that is therapeutic.” (Orem, 1991)

Assumptions of the Self-Care Deficit Theory

Dorothea Orem’s Self-Care Theory assumptions are: (1) To stay alive and remain functional,
humans engage in constant communication and connect among themselves and their
environment. (2) The power to act deliberately is exercised to identify needs and to make needed
judgments. (3) Mature human beings experience privations in the form of action in care of self
and others involving making life-sustaining and function-regulating actions. (4) Human agency
is exercised in discovering, developing, and transmitting to others ways and means to identify
needs for, and make inputs into, self and others. (5) Groups of human beings with structured
relationships cluster tasks and allocate responsibilities for providing care to group members.

Major Concepts of the Self-Care Deficit Theory

In this section are the definitions of the major concepts of Dorothea Orem’s Self-Care Deficit
Theory:

Nursing

Nursing is an art through which the practitioner of nursing gives specialized assistance to persons
with disabilities, making more than ordinary assistance necessary to meet self-care needs. The
nurse also intelligently participates in the medical care the individual receives from the
physician.
Humans

Humans are defined as “men, women, and children cared for either singly or as social units” and
are the “material object” of nurses and others who provide direct care.

Environment

The environment has physical, chemical, and biological features. It includes the family, culture,
and community.

Health

Health is “being structurally and functionally whole or sound.” Also, health is a state that
encompasses both the health of individuals and groups, and human health is the ability to reflect
on oneself, symbolize experience, and communicate with others.

Self-Care

Self-care is the performance or practice of activities that individuals initiate and perform on their
own behalf to maintain life, health, and well-being.

Self-Care Agency

Orem’s Self-Care Theory:

Interrelationship among concepts. Click to enlarge.
Self-care agency is the human’s ability or power to engage in self-care and is affected by basic
conditioning factors.

Basic Conditioning Factors

Basic conditioning factors are age, gender, developmental state, health state, socio-cultural
orientation, health care system factors, family system factors, patterns of living, environmental
factors, and resource adequacy and availability.

Therapeutic Self-Care Demand

Orem’s Self-
Care Theory – Conceptual Framework. Click to enlarge.
Therapeutic Self-care Demand is the totality of “self-care actions to be performed for some
duration to meet known self-care requisites by using valid methods and related sets of actions
and operations.”

Self-Care Deficit

Self-care Deficit delineates when nursing is needed. Nursing is required when an adult (or in the
case of a dependent, the parent or guardian) is incapable of or limited in providing continuous
effective self-care.

Nursing Agency
Nursing Agency is a complex property or attribute of people educated and trained as nurses that
enables them to act, know, and help others meet their therapeutic self-care demands by
exercising or developing their own self-care agency.

Nursing System

Nursing System is the product of a series of relations between the persons: legitimate nurse and
legitimate client. This system is activated when the client’s therapeutic self-care demand exceeds
the available self-care agency, leading to nursing.

Theories

The Self-Care or Self-Care Deficit Theory of Nursing is composed of three interrelated

theories: (1) the theory of self-care, (2) the self-care deficit theory, and (3) the theory of
nursing systems, which is further classified into wholly compensatory, partially
compensatory and supportive-educative.

Theory of Self-Care

This theory focuses on the performance or practice of activities that individuals initiate and
perform on their own behalf to maintain life, health, and well-being.

Self-Care Requisites

Self-care Requisites or requirements can be defined as actions directed toward the provision of
self-care. It is presented in three categories:

Universal Self-Care Requisites

Universal self-care requisites are associated with life processes and the maintenance of the
human structure and functioning integrity.

• The maintenance of a sufficient intake of air

• The maintenance of a sufficient intake of water
• The maintenance of a sufficient intake of food
• The provision of care associated with the elimination process and excrements
• The maintenance of a balance between activity and rest
• The maintenance of a balance between solitude and social interaction
• The prevention of hazards to human life, human functioning, and human well-being
• The promotion of human functioning and development within social groups in accord
with human potential, known human limitations, and the human desire to be normal
Normalcy is used in the sense of that which is essentially human and that which is in accord with
the genetic and constitutional characteristics and individuals’ talents.
Developmental self-care requisites

Developmental self-care requisites are “either specialized expressions of universal self-care

requisites that have been particularized for developmental processes or they are new requisites
derived from a condition or associated with an event.”

Health deviation self-care requisites

Health deviation self-care requisites are required in conditions of illness, injury, or disease or
may result from medical measures required to diagnose and correct the condition.

• Seeking and securing appropriate medical assistance.

• Being aware of and attending to the effects and results of pathologic conditions and states
• Effectively carrying out medically prescribed diagnostic, therapeutic, and rehabilitative
measures.
• Being aware of and attending to or regulating the discomforting or deleterious effects of
prescribed medical measures
• Modifying the self-concept (and self-image) in accepting oneself as being in a particular
state of health and in need of specific forms of health care
• Learning to live with the effects of pathologic conditions and states and the effects of
medical diagnostic and treatment measures in a lifestyle that promotes continued personal
development
Theory of Self-Care Deficit

This theory delineates when nursing is needed. Nursing is required when an adult (or in the case
of a dependent, the parent or guardian) is incapable of or limited in providing continuous
effective self-care. Orem identified 5 methods of helping:

• Acting for and doing for others

• Guiding others
• Supporting another
• Providing an environment promoting personal development about meet future demands
• Teaching another
Theory of Nursing System

This theory is the product of a series of relations between the persons: legitimate nurse and
legitimate client. This system is activated when the client’s therapeutic self-care demand exceeds
the available self-care agency, leading to nursing.

Wholly Compensatory Nursing System

This is represented by a situation in which the individual is unable “to engage in those self-care
actions requiring self-directed and controlled ambulation and manipulative movement or the
medical prescription to refrain from such activity… Persons with these limitations are socially
dependent on others for their continued existence and well-being.”

Example: care of a newborn, care of client recovering from surgery in a post-anesthesia care unit

Partial Compensatory Nursing System

This is represented by a situation in which “both nurse and perform care measures or other
actions involving manipulative tasks or ambulation… [Either] the patient or the nurse may have
a major role in the performance of care measures.”

Example: Nurse can assist the postoperative client in ambulating, Nurse can bring a meal tray for
a client who can feed himself

Supportive-Educative System

This is also known as a supportive-developmental system. The person “can perform or can and
should learn to perform required measures of externally or internally oriented therapeutic self-
care but cannot do so without assistance.”

Example: Nurse guides a mother on how to breastfeed her baby, Counseling a psychiatric client
on more adaptive coping strategies.

Dorothea Orem’s Theory and The Nursing Process

The Nursing Process presents a method in determining self-care deficits and defining the roles of
persons or nurses to meet the self-care demands.

Assessment

• Diagnosis and prescription; determine why nursing is needed. Analyze and interpret by
making a judgment regarding care.
• Design of a nursing system and plan for delivery of care.
• Production and management of nursing systems.
Step 1 – Collect Data in Six Areas

1. The person’s health status

2. The physician’s perspective of the person’s health status
3. The person’s perspective of his or health health
4. The health goals within the context of life history, lifestyle, and health status.
5. The person’s requirements for self-care
6. The person’s capacity to perform self-care
Nursing Diagnosis & Care Plans
Step 2

• The nurse designs a system that is wholly or partly compensatory or supportive-

educative.
• The two actions are: (1) Bringing out a good organization of the components of patients’
therapeutic self-care demands. (2) Selection of a combination of helping methods will be
effective and efficient in compensating for/overcoming the patient’s self-care deficits.
Implementation & Evaluation

Step 3

• A nurse assists the patient or family in self-care matters to identify and describe health
and health-related results. Collecting evidence in evaluating results achieved against
results specified in the nursing system design.
• The etiology component of nursing diagnosis directs actions.
Analysis of the Self-Care Deficit Theory

There is a superb focus of Orem’s work which is self-care. Even though there is a wide range of
scope seen in the encompassing theory of nursing systems, Orem’s goal of letting the readers
view nursing care to assist people was apparent in every concept presented.

From the definition of health which is sought to be rigid, it can now be refined by making it
suitable to the general view of health as a dynamic and ever-changing state.

The role of the environment in the nurse-patient relationship, although defined by Orem, was not
discussed.

Orem set nurses’ role in maintaining health for the patient with great coherence following every
individual’s life-sustaining needs.

Although Orem viewed the parent’s or guardians’ importance in providing for their dependents,
the definition of self-care cannot be directly applied to those who need complete care or
assistance with self-care activities such as the infants and the aged.

Strengths

• A major strength of Dorothea Orem’s theory is that it is applicable for nursing by the
beginning practitioner and the advanced clinicians.
• Orem’s theory provides a comprehensive basis for nursing practice. It has utility for
professional nursing in the areas of nursing practice, nursing education, and
administration.
• The terms self-care, nursing systems, and self-care deficit are easily understood by the
beginning student nurse and can be explored in greater depth as they gain more
knowledge and experience.
 • She specifically defines when nursing is needed: Nursing is needed when the individual
cannot maintain continuously that amount and quality of self-care necessary to sustain
life and health, recover from disease or injury, or cope with their effects.
• Her self-care approach is contemporary with the concepts of health promotion and health
maintenance.
• Three identifiable nursing systems were clearly delineated and are easily understood.
Limitations

• Orem’s theory, in general, is viewed as a single whole thing, while Orem defines a
system as a single whole thing.
• Orem’s theory is simple yet complex. The use of self-care in multitudes of terms, such as
self-care agency, self-care demand, self-care deficit, self-care requisites, and universal
self-care, can be very confusing to the reader.
• Orem’s definition of health was confined to three static conditions, which she refers to as
a “concrete nursing system,” which connotes rigidity.
• Throughout her work, there is a limited acknowledgment of the individual’s emotional
needs.
• Health is often viewed as dynamic and ever-changing.
Conclusion

Orem’s theory is relatively simple but generalizable to apply to a wide variety of patients. It
explains the terms self-care, nursing systems, and self-care deficit essential to students who plan
to start their nursing careers.

Moreover, this theory signifies that all patients want to care for themselves. They can recover
more quickly and holistically by performing their own self-care as much as they’re able. This
theory is particularly used in rehabilitation and primary care or other settings where patients are
encouraged to be independent.

Though this theory greatly influences every patient’s independence, the definition of self-care
cannot be directly applied to those who need complete care or assistance with self-care activities
such as infants and the aged.

Nola Pender: Health Promotion Model

Nola J. Pender (1941– present) is a nursing theorist who developed the Health Promotion
Model in 1982. She is also an author and a professor emeritus of nursing at the University of
Michigan. She started studying health-promoting behavior in the mid-1970s and first published
the Health Promotion Model in 1982. Her Health Promotion Model indicates preventative health
measures and describes nurses’ critical function in helping patients prevent illness by self-
care and bold alternatives. Pender has been named a Living Legend of the American Academy of
Nursing.
Nola Pender’s Health Promotion Model

Have you ever noticed advertisements in malls, grocery stores, or schools that advocate healthy
eating or regular exercise? Have you gone to your local centers or hospitals promoting physical
activities and smoking cessation programs such as “quit” activities and “brief interventions?”
These are all examples of health promotion. The Health Promotion Model, developed by nursing
theorist Nola Pender, has provided healthcare a new path. According to Nola J. Pender, Health
Promotion and Disease Prevention should focus on health care. When health promotion and
prevention fail to anticipate predicaments and problems, care in illness becomes the subsequent
priority.

What is Health Promotion Model?

The Health Promotion Model notes that each person has unique personal characteristics and
experiences that affect subsequent actions. The set of variables for behavioral specific
knowledge and effect have important motivational significance. These variables can be modified
through nursing actions. Health-promoting behavior is the desired behavioral outcome and is the
endpoint in the Health Promotion Model. Health-promoting behaviors should result in improved
health, enhanced functional ability, and better quality of life at all development stages. The final
behavioral demand is also influenced by the immediate competing demand and preferences,
which can derail intended health-promoting actions.

Nola Pender’s Health Promotion Model theory was originally published in 1982 and later
improved in 1996 and 2002. It has been used for nursing research, education, and practice.
Applying this nursing theory and the body of knowledge that has been collected through
observation and research, nurses are in the top profession to enable people to improve their well-
being with self-care and positive health behaviors.

The Health Promotion Model was designed to be a “complementary counterpart to models of

health protection.” It develops to incorporate behaviors for improving health and applies across
the life span. Its purpose is to help nurses know and understand the major determinants of health
behaviors as a foundation for behavioral counseling to promote well-being and healthy lifestyles.

Pender’s health promotion model defines health as “a positive dynamic state not merely the
absence of disease.” Health promotion is directed at increasing a client’s level of well-being. It
describes the multi-dimensional nature of persons as they interact within the environment to
pursue health.

The model focuses on the following three areas: individual characteristics and experiences,
behavior-specific cognitions and affect, and behavioral outcomes.

Major Concepts of the Health Promotion Model

Health promotion is defined as behavior motivated by the desire to increase well-being and
actualize human health potential. It is an approach to wellness.

On the other hand, health protection or illness prevention is described as behavior motivated
desire to actively avoid illness, detect it early, or maintain functioning within illness constraints.

Individual characteristics and experiences (prior related behavior and personal factors).

Behavior-specific cognitions and affect (perceived benefits of action, perceived barriers to

action, perceived self-efficacy, activity-related affect, interpersonal influences, and situational
influences).

Behavioral outcomes (commitment to a plan of action, immediate competing demands and

preferences, and health-promoting behavior).

Subconcepts of the Health Promotion Model

Personal Factors

Personal factors are categorized as biological, psychological, and socio-cultural. These factors
are predictive of a given behavior and shaped by the target behavior’s nature being considered.

• Personal biological factors. Include variables such as age, gender, body mass index,
pubertal status, aerobic capacity, strength, agility, or balance.
• Personal psychological factors. Include variables such as self-esteem, self-motivation,
personal competence, perceived health status, and definition of health.
• Personal socio-cultural factors. Include variables such as race, ethnicity, acculturation,
education, and socioeconomic status.
Perceived Benefits of Action

Anticipated positive outcomes that will occur from health behavior.

Perceived Barriers to Action

Anticipated, imagined, or real blocks and personal costs of understanding a given behavior.

Perceived Self-Efficacy

The judgment of personal capability to organize and execute a health-promoting behavior.

Perceived self-efficacy influences perceived barriers to action, so higher efficacy results in
lowered perceptions of barriers to the behavior’s performance.

Activity-Related Affect
Subjective positive or negative feeling occurs before, during, and following behavior based on
the stimulus properties of the behavior itself.

Activity-related affect influences perceived self-efficacy, which means the more positive the
subjective feeling, the greater its efficacy. In turn, increased feelings of efficacy can generate a
further positive affect.

Interpersonal Influences

Cognition concerning behaviors, beliefs, or attitudes of others. Interpersonal influences include

norms (expectations of significant others), social support (instrumental and emotional
encouragement), and modeling (vicarious learning through observing others engaged in a
particular behavior). Primary sources of interpersonal influences are families, peers, and
healthcare providers.

Situational Influences

Personal perceptions and cognitions of any given situation or context can facilitate or impede
behavior. Include perceptions of options available, demand characteristics, and aesthetic features
of the environment in which given health-promoting is proposed to take place. Situational
influences may have direct or indirect influences on health behavior.

Commitment to Plan of Action

The concept of intention and identification of a planned strategy leads to the implementation of
health behavior.

Immediate Competing Demands and Preferences

Competing demands are those alternative behaviors over which individuals have low control
because of environmental contingencies such as work or family care responsibilities. Competing
preferences are alternative behaviors over which individuals exert relatively high control, such
as choice of ice cream or apple for a snack.

Health-Promoting Behavior

A health-promoting behavior is an endpoint or action-outcome directed toward attaining

positive health outcomes such as optimal wellbeing, personal fulfillment, and productive living.

Major Assumptions in Health Promotion Model

• Individuals seek to regulate their own behavior actively.

• Individuals in all their biopsychosocial complexity interact with the environment,
progressively transforming the environment and being transformed over time.
 • Health professionals constitute a part of the interpersonal environment, which influences
persons throughout their life span.
• Self-initiated reconfiguration of person-environment interactive patterns is essential to
behavior change.
Propositions

• Prior behavior and inherited and acquired characteristics influence beliefs, affect, and
enactment of health-promoting behavior.
• Persons commit to engaging in behaviors from which they anticipate deriving personally
valued benefits.
• Perceived barriers can constrain commitment to action, a mediator of behavior as well as
actual behavior.
• Perceived competence or self-efficacy to execute a given behavior increases the
likelihood of commitment to action and the behavior’s actual performance.
• Greater perceived self-efficacy results in fewer perceived barriers to specific health
behavior.
• Positive affect toward a behavior results in greater perceived self-efficacy, which can, in
turn, result in increased positive affect.
• When positive emotions or affect are associated with a behavior, the probability of
commitment and action is increased.
• Persons are more likely to commit to and engage in health-promoting behaviors when
significant others model the behavior, expect the behavior to occur, and provide
assistance and support to enable the behavior.
• Families, peers, and health care providers are important sources of interpersonal
influence that can increase or decrease commitment to and engagement in health-
promoting behavior.
• Situational influences in the external environment can increase or decrease commitment
to or participation in health-promoting behavior.
• The greater the commitments to a specific plan of action, the more likely health-
promoting behaviors will be maintained over time.
• Commitment to a plan of action is less likely to result in the desired behavior when
competing demands over which persons have little control require immediate attention.
• Commitment to a plan of action is less likely to result in the desired behavior when other
actions are more attractive and preferred over the target behavior.
• Persons can modify cognitions, affect, and the interpersonal and physical environment to
create incentives for healthy actions.
Strengths and Weaknesses

Strengths

• The Health Promotion Model is simple to understand, yet diving deeper shows its
complexity in its structure.
• Nola Pender’s nursing theory focused on health promotion and disease prevention,
making it stand out from other nursing theories.
• It is highly applicable in the community health setting.
 • It promotes the nursing profession’s independent practice, being the primary source of
health-promoting interventions and education.
Weaknesses

• The Health Promotion Model of Pender could not define the nursing metapradigm or the
concepts that a nursing theory should have, man, nursing, environment, and health.
• The conceptual framework contains multiple concepts, which may invite confusion to the
reader.
• Its applicability to an individual currently experiencing a disease state was not given
emphasis.
Conclusion

Due to its focus on health promotion and disease prevention per se, its relevance to nursing
actions given to ill individuals is obscure. But then again, this characteristic of her model also
gives the concepts its uniqueness.

Pender’s principles paved a new way of viewing nursing care, but then one should also be
reminded that nursing’s curative aspect cannot be detached from our practice.

Community health care setting is the best avenue in promoting health and preventing illnesses.
Using Pender’s Health Promotion Model, community programs may be focused on activities that
can improve people’s well-being. Health promotion and disease prevention can more easily be
carried out in the community than programs that aim to cure disease conditions.

To fully adhere to a health-promoting behavior, he or she needs to shell out financial resources.
This limits the application of Pender’s model. An individual who economically or financially
unstable might have a lesser commitment to the planning of action, decreasing the ideal outcome
of a health-promoting behavior even if the individual has the necessary will to complete it.

Although not stated in the model, for example, in the Intensive Care Unit, the health promotion
model may still be applied in one way or another. This is projected towards improving health
conditions and prevent further debilitating conditions. Diet modifications and performing passive
and active range of motion exercises are examples of its application.

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.

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.

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 and Caritas Processes

Carative Factors Caritas Process

1. “The formation of a humanistic-altruistic system “Practice of loving-kindness and equanimity within

of values.” the context of caring consciousness.”

“Being authentically present and enabling and

2. “The instillation of faith-hope.” sustaining the deep belief system and subjective life-
world of self and one being cared for.”
 3. “The cultivation of sensitivity to one’s self and “Cultivation of one’s own spiritual practices and
others.” transpersonal self going beyond the ego-self.”

4. “Development of a helping-trust relationship”

“Developing and sustaining a helping trusting,
became “development of a helping-trusting, human
authentic caring relationship.”
caring relation” (in 2004 Watson website)

“Being present to, and supportive of, the expression of

5. “The promotion and acceptance of the
positive and negative feelings as a connection with
expression of positive and negative feelings.”
deeper spirit and self and the one-being-cared for.”

6. “The systematic use of the scientific problem-

“Creative use of self and all ways of knowing as part
solving method for decision making” became
of the caring process; to engage in the artistry of
“systematic use of a creative problem solving
caring-healing practices.”
caring process” (in 2004 Watson website)

“Engaging in genuine teaching-learning experience

7. “The promotion of transpersonal teaching-
that attends to the unity of being and meaning,
learning.”
attempting to stay within others’ frame of reference.”

“Creating healing environment at all levels (physical

8. “The provision of the supportive, protective, and
as well as the nonphysical, subtle environment of
(or) corrective mental, physical, societal, and
energy and consciousness, whereby wholeness,
spiritual environment.”
beauty, comfort, dignity, and peace are potentiated)”

“Assisting with basic needs, with an intentional caring

9. “The assistance with the gratification of human consciousness, administering ‘human care essentials,’
needs.” which potentiate alignment of mind-body-spirit,
wholeness, and unity of being in all aspects of care.”

10. “The allowance for existential-

“Opening and attending to spiritual-mysterious and
phenomenological forces” became “allowance for
existential dimensions of one’s own life-death; soul
existential-phenomenological spiritual forces” (in
care for self and the one-being-cared for”
2004 Watson website)

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.

Betty Neuman: Neuman Systems Model

Betty Neuman (1924 – present) is a nursing theorist who developed the Neuman Systems
Model. She gave many years perfecting a systems model that views patients holistically. She
inquired about theories from several theorists and philosophers and applied her knowledge in
clinical and teaching expertise to develop the Neuman Systems Model that has been accepted,
adopted, and applied as a core for nursing curriculum in many areas worldwide.
Betty Neuman’s Nursing Theory

Three words frequently used concerning stress are inevitable, painful, and intensifying. It is
generally subjective and can be interpreted as the circumstances of conceivably threatening and
out of their control. A nursing theory developed by Betty Neuman is based on the person’s
relationship to stress, response, and reconstitution factors that are progressive in nature. The
Neuman Systems Model presents a broad, holistic, and system-based method to nursing that
maintains a factor of flexibility. It focuses on the patient system’s response to actual or potential
environmental stressors and maintains the client system’s stability through primary, secondary,
and tertiary nursing prevention interventions to reduce stressors.

What is the Neuman Systems Model?

Betty Neuman describes the Neuman Systems Model as “a unique, open-system-based
perspective that provides a unifying focus for approaching a wide range of concerns. A system
acts as a boundary for a single client, a group, or even several groups; it can also be defined as a
social issue. A client system in interaction with the environment delineates the domain of nursing
concerns.”

The Neuman Systems Model views the client as an open system that responds to stressors in the
environment. The client variables are physiological, psychological, sociocultural, developmental,
and spiritual. The client system consists of a basic or core structure that is protected by lines of
resistance. The usual health level is identified as the normal defense line protected by a flexible
line of defense. Stressors are intra-, inter-, and extra personal in nature and arise from the
internal, external, and created environments. When stressors break through the flexible line of
defense, the system is invaded, and the lines of resistance are activated. The system is described
as moving into illness on a wellness-illness continuum. If adequate energy is available, the
system will be reconstituted with the normal defense line restored at, below, or above its
previous level.

Nursing interventions occur through three prevention modalities. Primary prevention occurs
before the stressor invades the system; secondary prevention occurs after the system has
reacted to an invading stressor; tertiary prevention occurs after secondary prevention as
reconstitution is being established.

Assumptions

The following are the assumptions or “accepted truths” made by Neuman’s Systems Model:

• 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 is internal resistance factors known as lines of
resistance, which function to stabilize and realign the client to the usual wellness state.
 • 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.
• The client as a system is in dynamic, constant energy exchange with the environment.
(Neuman, 1995)
Major Concepts of Neuman Systems Model

This section will define the nursing metaparadigm and the major concepts in Betty Neuman’s
Neuman Systems Model.

Human being

The human being is an open system that interacts with internal and external environment forces
or stressors. The human is constantly changing, moving toward a dynamic state of system
stability or illness of varying degrees.

Environment

The environment is a vital arena that is germane to the system and its function. The environment
may be viewed as all factors that affect and are affected by the system. In Neuman Systems
Model identifies three relevant environments: (1) internal, (2) external, and (3) created.

• The internal environment exists within the client system. All forces and interactive
influences that are solely within the client system’s boundaries make up this
environment.
• The external environment exists outside the client system.
• The created environment is unconsciously developed and is used by the client to support
protective coping.
Health

In Neuman’s nursing theory, Health is defined as the condition or degree of system stability and
is viewed as a continuum from wellness to illness. When system needs are met, optimal wellness
exists. When needs are not satisfied, illness exists. When the energy needed to support life is not
available, death occurs.

Nursing

Nursing’s 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. Nursing interventions
aim to help the system adapt or adjust and retain, restore, or maintain some degree of stability
between the client system variables and environmental stressors, focusing on conserving energy.

Open System

A system in which there is a continuous flow of input and process, output and feedback. It is a
system of organized complexity, where all elements are in interaction.

Basic Stricture and Energy Resources

The basic structure, or central core, comprises those basic survival factors common to the
species. These factors include the system variables, genetic features, and strengths and
weaknesses of the system parts.

Client Variables

Neuman views the individual client holistically and considers the variables simultaneously and
comprehensively.

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

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

Normal line of defense

An adaptational level of health developed over time and is considered normal for a particular
individual client or system; it becomes a standard for wellness-deviance determination.

Lines of resistance

Protection factors are activated when stressors have penetrated the normal line of defense,
causing reaction symptomatology.

Subconcepts of Neuman Systems Model

Stressors
A stressor is any phenomenon that might penetrate both the flexible and normal lines of defense,
resulting in either a positive or negative outcome.

• Intrapersonal stressors are those that occur within the client system boundary and
correlate with the internal environment.
• Interpersonal stressors occur outside the client system boundary, are proximal to the
system, and impact the system.
• Extrapersonal stressors also occur outside the client system boundaries but are at a
greater distance from the system than are interpersonal stressors. An example is a social
policy.
Stability

A 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.

Entropy

A process of energy depletion and disorganization moving the system toward illness or possible
death.

Negentropy

An energy conservation process that increases organization and complexity, moving the system
toward stability or a higher degree of wellness.

Input/Output

The matter, energy, and information exchanged between the client and environment entering or
leaving the system at any point in time.

Reconstitution

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

Prevention as Intervention

Intervention modes for nursing action and determinants for both client and nurse entry into the
health care system.
 • Primary prevention occurs before the system reacts to a stressor; it includes health
promotion and wellness maintenance. Primary prevention focuses on strengthening the
flexible line of defense through preventing stress and reducing risk factors. This
intervention 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. Secondary prevention focuses on strengthening the internal
lines of resistance and, thus, protects the basic structure through appropriate treatment of
symptoms. The 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. Its purpose is to maintain wellness or protect the client system
reconstitution by supporting existing strengths and preserving energy. Tertiary prevention
may begin at any point after system stability has begun reestablished (reconstitution has
begun). Tertiary prevention tends to lead back to primary prevention. (Neuman, 1995)
Strengths and Weaknesses

Betty Neuman reports her nursing model was designed for nursing but can be used by other
health disciplines, which have pros and cons. As a strength, if multiple health disciplines use
Neuman’s System Model, a consistent approach to client care would be facilitated. As a con, if
the model is useful to various disciplines, it is not specific to nursing. It thus may not
differentiate the practice of nursing from that of other disciplines.

Strengths

• The Neuman Systems Model’s major strength is its flexibility for use in all areas of
nursing – administration, education, and practice.
• Neuman has presented a view of the client equally applicable to an individual, a family, a
group, a community, or any other aggregate.
• The Neuman Systems Model, particularly presented in the model diagram, is logically
consistent.
• The emphasis on primary prevention, including health promotion, is specific to this
model.
• Once understood, the Neuman Systems Model is relatively simple and has readily
acceptable definitions of its components.
Weaknesses

• The major weakness of the model is the need for further clarification of the terms used.
• Interpersonal and extrapersonal stressors need to be more clearly differentiated.
Analysis

The delineation of Neuman’s three defense lines was not clearly explained. In reality, the
individual resists stressors with internal and external reflexes, which were made complicated by
the formulation of different resistance levels in Neuman’s open systems model.
Neuman made mention of energy sources in her model as part of the basic structure. It can be
more of help when Neuman has enumerated all the energy sources that she is about. With such,
new nursing interventions regarding the provision of the client’s needed energy can be
conceptualized.

The holistic and comprehensive view of the client system is associated with an open system.
Health and illness are presented on a continuum with the movement toward health described as
negentropic and toward illness as entropic. Her use of entropy is inconsistent with the
characteristics of entropy that is closed rather than an open system.

Imogene King: Theory of Goal Attainment

Imogene King was a nursing pioneer and renowned for her development of the nursing theory:
“Theory of Goal Attainment.” Get to know Imogene King’s biography, major concepts of her
theory, and its application and impact in nursing.
Theory of Goal Attainment

The Theory of Goal Attainment states that “Nursing is a process of action, reaction, and
interaction whereby nurse and client share information about their perception in the nursing
situation.”

Imogene King’s Theory of Goal Attainment was first introduced in the 1960s. From the title
itself, the model focuses on the attainment of certain life goals. It explains that the nurse and
patient go hand-in-hand in communicating information, set goals together, and then take actions
to achieve those goals. The factors that affect the attainment of goals are roles, stress, space, and
time. On the other hand, the nurse’s goal is to help patients maintain health so they can function
in their individual roles. The nurse’s function is to interpret information in the nursing process,
plan, implement, and evaluate nursing care.

Theory of Goal Attainment of Imogene King

Some people consider their “success” after being hired in a great and well-known institution. But
when someone decides to pursue a career in nursing, one should set his or her mind that they
should be an instrument in helping patients get healthy. And to achieve that, it’s important to set
health goals with the patient, then take steps to achieve those goals.

Imogene M. King’s Theory of Goal Attainment focuses on this process to guide and direct
nurses in the nurse-patient relationship, going hand-in-hand with their patients to meet good
health goals.

King’s Theory of Goal Attainment was first introduced in the 1960s. From the title itself, the
model focuses on the attainment of certain life goals. It explains that the nurse and patient go
hand-in-hand in communicating information, set goals together, and then take actions to achieve
those goals.
King has interrelated the concepts of interaction, perception, communication, transaction, self,
role, stress, growth and development, time, and space into a goal attainment theory. Her theory
deals with a nurse-client dyad, a relationship to which each person brings personal perceptions of
self, role, and personal growth and development levels. The nurse and client communicate, first
in interaction and then in the transaction, to attain mutually set goals. The relationship takes
place in space identified by their behaviors and occurs in forward-moving time.

What is Theory of Goal Attainment?

The Theory of Goal Attainment states that “Nursing is a process of action, reaction, and
interaction by which nurse and client share information about their perception in a nursing
situation” and “a process of human interactions between nurse and client whereby each
perceives the other and the situation, and through communication, they set goals, explore means,
and agree on means to achieve goals.”

In this definition, the action is a sequence of behaviors involving mental and physical activity,
and the reaction is included in the sequence of behaviors described in action. King states that a
nurse’s goal is to help individuals maintain their health so they can function in their roles. The
domain of the nurse “includes promoting, maintaining, and restoring health, and caring for the
sick, injured and dying.” The function of a professional nurse is “to interpret information in the
nursing process to plan, implement, and evaluate nursing care.”

Propositions

The following propositions are made in Imogene King’s Theory of Goal Attainment: (1) If
perceptual interaction accuracy is present in nurse-patient interactions, the transaction will occur.
(2) If the nurse and patient make the transaction, the goal or goals will be achieved. (3) If the
goal or goals are achieved, satisfaction will occur. (4) If the goal or goals are achieved, effective
nursing care will occur. (5) If transactions are made in nurse-patient interactions, growth and
development will be enhanced. (6) If role expectations and role performance perceived by the
nurse and patient are congruent, the transaction will occur. (7) If role conflict is experienced by
either the nurse or the patient (or both), stress in the nurse-patient interaction will occur. (8) If a
nurse with special knowledge communicates appropriate information to the patient, mutual goal-
setting and goal achievement will occur.

Assumptions

Imogene King’s personal philosophy about human beings and life influenced her assumptions
about the environment, health, nursing, individuals, and nurse-patient interactions. King’s
conceptual system and Theory of Goal Attainment were “based on an overall assumption that the
focus of nursing is human beings interacting with their environment, leading to a state of health
for individuals, which is an ability to function in social roles.”

The assumptions are: (1) The focus of nursing is the care of the human being (patient). (2) The
goal of nursing is the health care of both individuals and groups. (3) Human beings are open
systems interacting with their environments constantly. (4) 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. (5) Patients perceive the world as a complete person making
transactions with individuals and things in the environment. (6) 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.

Major Concepts and Subconcepts

The following are the major concepts and subconcepts of Imogene King’s Theory of Goal
Attainment:

Nursing

Nursing is a process of action, reaction, and interaction whereby nurse and client share
information about their perceptions in the nursing situation. The nurse and client share specific
goals, problems, and concerns and explore how to achieve a goal.

Health

Health is a dynamic life experience of a human being, which implies continuous adjustment to
stressors in the internal and external environment through optimum use of one’s resources to
achieve maximum daily living potential.

Individual

Individuals are social beings who are rational and sentient. Humans communicate their thoughts,
actions, customs, and beliefs through language. Persons exhibit common characteristics such as
the ability to perceive, think, feel, choose between alternative courses of action, set goals, select
the means to achieve goals, and make decisions.

Environment

The environment is the background for human interactions. It is both external to, and internal to,
the individual.

Action

Action is defined as a sequence of behaviors involving mental and physical activity. The
sequence is first mental action to recognize the presenting conditions; then physical action to
begin activities related to those conditions; and finally, mental action to exert control over the
situation, combined with physical action seeking to achieve goals.
Reaction

The reaction is not specifically defined but might be considered in the sequence of behaviors
described in action.

Interacting Systems of Theory of Goal Attainment

According to King, there are three interacting systems in the Theory of Goal Attainment. These
are the personal system, the interpersonal system, and the social system. Each system is given
different concepts. The personal system concepts are perception, self, growth and development,
body image, space, and time. The concepts for the interpersonal system are interaction,
communication, transaction, role, and stress. The social system concepts are organization,
authority, power, status, and decision-making.

1. Personal Systems

Each individual is a personal system. King designated an example of a personal system as a

patient or a nurse. King specified the concepts of body image, growth,
development, perception, self, space, and time to comprehend human beings as persons.

“The self is a composite of thoughts and feelings which constitute a person’s awareness of his
individual existence, his conception of who and what he is. A person’s self is the total of all he
can call his. The self includes, among other things, a system of ideas, attitudes, values, and
commitments. The self is a person’s total subjective environment. It is a distinctive center of
experience and significance. The self constitutes a person’s inner world as distinguished from the
outer world consisting of all other people and things. The self is the individual as known to the
individual. It is that to which we refer when we say “I.”

Growth and development can be defined as the processes in people’s lives through which they
move from a potential for achievement to the actualization of self.

King defines body image as to how one perceives both one’s body and others’ reactions to one’s
appearance.

Space includes that space exists in all directions, is the same everywhere, and is defined by the
physical area known as “territory” and by the behaviors of those occupying it.

Time is defined as “a duration between one event and another as uniquely experienced by each
human being; it is the relation of one event to another event.”

King (1986) added learning as a subconcept in the personal system but did not further define it.

2. Interpersonal Systems
These are formed by human beings interacting. Two interacting individuals form a dyad; three
form a triad, and four or more form small or large groups. As the number of interacting
individuals increases, so does the complexity of the interactions. Understanding the interpersonal
system requires the concepts of communication, interaction, role, stress, and transaction.

Interactions are defined as the observable behaviors of two or more individuals in mutual
presence.

King (1990) defines communication as “a process whereby information is given from one
person to another either directly in a face-to-face meeting or indirectly through telephone,
television, or the written word.”

King defines transactions as “a process of interactions in which human beings communicate

with the environment to achieve goals that are valued… goal-directed human behaviors.

The characteristics of the role include reciprocity. A person may be a giver at one time and a
taker at another time, with a relationship between two or more individuals functioning in two or
more, learned, social, complex, and situational roles.

Stress is “a dynamic state whereby a human being interacts with the environment to maintain
balance for growth, development, and performance, which involves an exchange of energy and
information between the person and the environment for regulation and control of stressors.”

3. Social Systems

A more comprehensive interacting system consists of groups that make up society, referred to as
the social system. Religious, educational, and health care systems are examples of social
systems. An extended family’s influential behavior on an individual’s growth and development
is another social system example. Within a social system, the concepts of authority, decision
making, organization, power, and status guide system understanding.

Power is the capacity to use resources in organizations to achieve goals… is the process
whereby one or more persons influence other persons in a situation… is the capacity or ability of
a person or a group to achieve goals… occurs in all aspects of life. Each person has potential
power determined by individual resources and the environmental forces encountered. Power is a
social force that organizes and maintains society. Power is the ability to use and mobilize
resources to achieve goals.

Status is “the position of an individual in a group or a group concerning other groups in an

organization,” It is identified that status is accompanied by “privileges, duties, and obligation.”

Decision making is “a dynamic and systematic process by which goal-directed choice of

perceived alternatives is made and acted upon by individuals or groups to answer a question and
attain a goal” (King, 1990).
King (1986) added control as a subconcept in the social system but did not further define the
concept.

Dynamic Conceptual Systems

The figure below demonstrates the conceptual system that provided “one approach to studying
systems as a whole rather than as isolated parts of a system” and was “designed to explain the
organized wholes within which nurses are expected to function.”

King has interrelated the concepts of interaction, perception, communication, transaction, self,
role, stress, growth and development, time, and space into a goal attainment theory. Her theory
deals with a nurse-client dyad, a relationship to which each person brings personal perceptions of
self, role, and personal growth and development levels. The nurse and client communicate, first
in interaction and then in the transaction, to attain mutually set goals. The relationship takes
place in space identified by their behaviors and occurs in forward-moving time.

She believed that her “framework differs from other conceptual schemas in that it is concerned
not with fragmenting human beings and the environment but with human transactions in
different kinds of environments.”

Process of Interaction
Process of Interaction
The figure above represents a process of human interactions that lead to transactions: A model of
transaction. According to King, “The human process of interactions formed the basis for
designing a model of transactions that depicted theoretical knowledge used by nurses to help
individuals and groups attain goals.”

Interaction

Interaction is a process of perception and communication between a person and environment and
between person and person represented by verbal and nonverbal behaviors that are goal-directed.

Transaction

The transaction is a process of interactions in which human beings communicate with the
environment to achieve valued goals; transactions are goal-directed human behaviors.
Perception is “each person’s representation of reality.”

Communication

Communication is defined as “a process whereby information is given from one person to

another either directly in face-to-face meetings or indirectly through telephone, television, or the
written word.”

Role

The role is defined as “a set of behaviors expected of persons occupying a position in a social
system; rules that define rights and obligations in a position; a relationship with one or more
individuals interacting in specific situations for a purpose.”

Stress
Stress is “a dynamic state whereby a human being interacts with the environment to maintain
balance for growth, development, and performance… an energy response of an individual to
persons, objects, and events called stressors.”

Growth and Development

Growth and development can be defined as the “continuous changes in individuals at the
cellular, molecular, and behavioral levels of activities… the processes that take place in the life
of individuals that help them move from potential capacity for achievement to self-
actualization.”

Time

Time is “a sequence of events moving onward to the future… a continuous flow of events in
successive order that implies a change, a past and a future… a duration between one event and
another as uniquely experienced by each human being… the relation of one event to another.”

Space

Space exists in every direction and is the same in all directions. Space includes that physical area
called territory. Space is defined by the behaviors of those individuals who occupy it.

Theory of Goal Attainment and The Nursing Process

Imogene King emphasizes the nursing process in her model of nursing. The steps of the nursing
process are assessment, nursing diagnosis, planning, implementations, and evaluation.

The theory explains that assessment takes place during the interaction. The nurse uses his or her
special knowledge and skills while the patient delivers knowledge of him or herself and the
perception of problems of concern to the interaction. During this phase, the nurse gathers data
about the patient, including their growth and development, the perception of self, and current
health status. Perception is the basis for the collection and interpretation of data. Communication
is required to verify the accuracy of the perception, as well as for interaction and translation.

The next phase is the nursing diagnosis. This phase is developed using the data collected in the
assessment. In attaining goals, the nurse identifies problems, concerns, and disturbances about
which the patient is seeking help.

The planning phase arises after the diagnosis. The nurse and other health care team members
create a care plan of interventions to solve the problems identified. This phase is represented by
setting goals and making decisions about the means to achieve those goals. This part of the
transaction and the patient’s participation are encouraged in making decisions on the means to
achieve the goals.
The actual activities done to achieve the goals make up the implementation phase of the nursing
process. Whereas in this model of nursing, it is the continuation of transaction.

Finally, in the evaluation phase, the nurse evaluates the patient to determine whether the goals
were achieved. Evaluation involves determining whether or not goals were achieved. The
explanation of evaluation in King’s theory addresses meeting goals and the effectiveness of
nursing care.

In the healthcare field, the nurse-patient relationship’s final goal is to help the patient achieve his
or her goals for getting healthy. Using the nursing process described in King’s Theory of Goal
Attainment, a nurse can be more effective in working with a patient to achieve those goals and
truly help patients.

Analysis

• The social systems portion of the open systems framework is less clearly connected to
goal attainment than personal and interpersonal systems.
The citation of the individual being in a social system was not clearly explained,
considering that the social system encompasses other concepts and subconcepts in her
theory.
The model presents dyadic interaction in nature which implies that its applicability
cannot be adapted to unconscious individuals.
• A multitude of views and definitions is confusing for the reader. Because of multiple
views on one concept, such as what has been discussed in her concept of power, it blurs
the point that the theorist is trying to relate to the readers.
Strengths

A major strong point of King’s conceptual system and Theory of Goal Attainment is how nurses
can understand goal attainment theory and describe a logical sequence of events.

For most parts, concepts are concretely defined and illustrated.

King’s definitions are clear and are conceptually derived from the research literature. Her Theory
of Goal Attainment presents ten major concepts. The concepts are easily understood and derived
from the research literature, which clearly establishes King’s work as important for knowledge
building in nursing.

Weaknesses

Theory of Goal Attainment has been criticized for having limited application in nursing areas in
which patients are unable to interact competently with the nurse. King maintained the broad use
of the theory in most nursing situations.
Another limitation relates to the lack of development of applying the theory in providing nursing
care to groups, families, or communities.

King’s theory also contains some inconsistencies: (1) She indicates that nurses are concerned
about groups’ health care but concentrates her discussion on nursing as occurring in a dyadic
relationship. (2) King says that the nurse and client are strangers, yet she speaks of their working
together for goal attainment and the importance of health maintenance.

Conclusion

King contributed to the advancement of nursing knowledge by developing her conceptual system
and middle-range Theory of Goal Attainment. By focusing on attaining goals or outcomes by
nurse-patient partnerships, King provided a conceptual system and middle-range theory that has
demonstrated its usefulness to nurses. Nurses working in various settings with patients from
around the world continue to use King’s work to improve the quality of patient care.

Callista Roy’s Adaptation Model of Nursing

Sister Callista L. Roy (born October 14, 1939) is a nursing theorist, professor, and author. She
is known for her groundbreaking work in creating the Adaptation Model of Nursing

The Adaptation Model of Nursing is a prominent nursing theory aiming to explain or define the
provision of nursing science. In her theory, Sister Callista Roy’s model sees the individual as a
set of interrelated systems that maintain a balance between various stimuli.

The Roy Adaptation Model was first presented in the literature in an article published in Nursing
Outlook in 1970 entitled “Adaptation: A Conceptual Framework for Nursing.” In the same year,
Roy’s Adaptation Model of Nursing was adapted in Mount St. Mary’s School in Los Angeles,
California.

Roy’s model was conceived when nursing theorist Dorothy Johnson challenged her students to
develop conceptual models of nursing during a seminar. Johnson’s nursing model was the
impetus for the development of Roy’s Adaptation Model.

Roy’s model incorporated concepts from Adaptation-level Theory of Perception from renowned
American physiological psychologist Harry Helson, Ludwig von Bertalanffy’s System Model,
and Anatol Rapoport’s system definition.

First, consider the concept of a system as applied to an individual. Roy conceptualizes the person
in a holistic perspective. Individual aspects of parts act together to form a unified being.
Additionally, as living systems, persons are in constant interaction with their environments.
Between the system and the environment occurs an exchange of information, matter, and energy.
Characteristics of a system include inputs, outputs, controls, and feedback.
Assumptions

Scientific Assumptions

• Systems of matter and energy progress to higher levels of complex self-organization.

• Consciousness and meaning are constructive of person and environment integration.
• Awareness of self and environment is rooted in thinking and feeling.
• Humans, by their decisions, are accountable for the integration of creative processes.
• Thinking and feeling mediate human action.
• System relationships include acceptance, protection, and fostering of interdependence.
• Persons and the earth have common patterns and integral relationships.
• Persons and environment transformations are created in human consciousness.
• Integration of human and environmental meanings results in adaptation.
Philosophical Assumptions

• Persons have mutual relationships with the world and God.

• Human meaning is rooted in the omega point convergence of the universe.
• God is intimately revealed in the diversity of creation and is the common destiny of
creation.
• Persons use human creative abilities of awareness, enlightenment, and faith.
• Persons are accountable for the processes of deriving, sustaining, and transforming the
universe.
Major Concepts of the Adaptation Model

The following are Callista Roy’s Adaptation Model’s major concepts, including the definition of
the nursing metaparadigm as defined by the theory.

Person

“Human systems have thinking and feeling capacities, rooted in consciousness and meaning, by
which they adjust effectively to changes in the environment and, in turn, affect the environment.”

Based on Roy, humans are holistic beings that are in constant interaction with their environment.
Humans use a system of adaptation, both innate and acquired, to respond to the environmental
stimuli they experience. Human systems can be individuals or groups, such as families,
organizations, and the whole global community.

Environment

“The conditions, circumstances and influences surrounding and affecting the development and
behavior of persons or groups, with particular consideration of the mutuality of person and
health resources that includes focal, contextual and residual stimuli.”
The environment is defined as conditions, circumstances, and influences that affect humans’
development and behavior as an adaptive system. The environment is a stimulus or input that
requires a person to adapt. These stimuli can be positive or negative.

Roy categorized these stimuli as focal, contextual, and residual. Focal stimuli are that confront
the human system and require the most attention. Contextual stimuli are characterized as the
rest of the stimuli present with the focal stimuli and contribute to its effect. Residual stimuli are
the additional environmental factors present within the situation but whose effect is unclear. This
can include previous experience with certain stimuli.

Health

“Health is not freedom from the inevitability of death, disease, unhappiness, and stress, but the
ability to cope with them in a competent way.”

Health is defined as the state where humans can continually adapt to stimuli. Because illness is a
part of life, health results from a process where health and illness can coexist. If a human can
continue to adapt holistically, they will maintain health to reach completeness and unity within
themselves. If they cannot adapt accordingly, the integrity of the person can be affected
negatively.

Nursing

“[The goal of nursing is] the promotion of adaptation for individuals and groups in each of the
four adaptive modes, thus contributing to health, quality of life, and dying with dignity.”

In Adaptation Model, nurses are facilitators of adaptation. They assess the patient’s behaviors for
adaptation, promote positive adaptation by enhancing environment interactions and helping
patients react positively to stimuli. Nurses eliminate ineffective coping mechanisms and
eventually lead to better outcomes.

Adaptation

Adaptation is the “process and outcome whereby thinking and feeling persons as individuals or
in groups use conscious awareness and choice to create human and environmental integration.”

Internal Processes

Regulator

The regulator subsystem is a person’s physiological coping mechanism. The body attempts to
adapt via regulation of our bodily processes, including neurochemical and endocrine systems.

Cognator
The cognator subsystem is a person’s mental coping mechanism. A person uses his brain to
cope via self-concept, interdependence, and role function adaptive modes.

Four Adaptive Modes

Diagrammatic Representation of Roy’s Human Adaptive Systems. Click to enlarge.

The subsystem’s four adaptive modes are how the regulator and cognator mechanisms are
manifested; in other words, they are the external expressions of the above and internal processes.

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.

Self-Concept Group Identity Mode

In this 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.

Role Function Mode

This mode focuses on the primary, secondary, and tertiary roles that a person occupies in society
and knowing where they stand as a member of society.
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.

Levels of Adaptation

Integrated Process

The various modes and subsystems meet the needs of the environment. These are usually stable
processes (e.g., breathing, spiritual realization, successful relationship).

Compensatory Process

The cognator and regulator are challenged by the environment’s needs but are working to meet
the needs (e.g., grief, starting with a new job, compensatory breathing).

Compromised Process

The modes and subsystems are not adequately meeting the environmental challenge (e.g.,
hypoxia, unresolved loss, abusive relationships).

Six-Step Nursing Process

A nurse’s role in the Adaptation Model is to manipulate stimuli by removing, decreasing,

increasing, or altering stimuli so that the patient.

1. Assess the behaviors manifested from the four adaptive modes.

2. Assess the stimuli, categorize them as focal, contextual, or residual.
3. Make a statement or nursing diagnosis of the person’s adaptive state.
4. Set a goal to promote adaptation.
5. Implement interventions aimed at managing the stimuli.
6. Evaluate whether the adaptive goal has been met.
Analysis

As one of the weaknesses of the theory that applying it is time-consuming, applying the model to
emergencies requiring quick action is difficult to complete, the individual might have completed
the whole adaptation process without the benefit of having a complete assessment for thorough
nursing interventions.

Adaptive responses may vary in every individual and may take a longer time compared to others.
Thus, the span of control of nurses may be impeded by the time of the patient’s discharge.
Unlike Levine, although the latter tackled adaptation, Roy focused on the whole adaptive system
itself. Each concept was linked with the coping mechanisms of every individual in the process of
adapting.

When an individual presents an ineffective response during his or her adaptation process, the
nurses’ roles were not clearly discussed. The main point of the concept was to promote
adaptation, but none were stated on preventing and resolving maladaptation.

Strengths of the Roy’s Adaptation Model

• The Adaptation Model of Callista Roy suggests the influence of multiple causes in a
situation, which is a strength when dealing with multi-faceted human beings.
• The sequence of concepts in Roy’s model follows logically. In the presentation of each of
the key concepts, there is the recurring idea of adaptation to maintain integrity. Every
concept was operationally defined.
• The concepts of Roy’s model are stated in relatively simple terms.
• A major strength of the model is that it guides nurses to use observation and interviewing
skills in doing an individualized assessment of each person. The concepts of Roy’s model
are applicable within many practice settings of nursing.
Weaknesses

• Painstaking application of the model requires a significant input of time and effort.
• Roy’s model has many elements, systems, structures, and multiple concepts.