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Nursing Theories: An Overview

are basically vehicles of
thought that involve
are words that describe
objects, properties, or
events and are basic
components of theory.
Types of Concepts:
Empirical concepts

Empirical Concepts
Easily understood and measured.

Inferential Concepts
Indirectly observable. Cannot be physically
measured as easily.

Abstract Concepts
Non-observable, not easily understood, hard to
accurately measure.


are representations of the

interaction among and between
the concepts showing patterns.
allow the concepts in nursing
theory to be successfully
applied to nursing practice.


are statements that explain the

relationship between the

are series of actions, changes

or functions intended to bring
about a desired result.
A particular theory or
conceptual frame work directs
how these actions are carried
out .


THEORY is a set of concepts,

definitions, relationships, and
assumptions or propositions derived
from nursing models or from other
disciplines and project a purposive,
systematic view of phenomena by
designing specific inter-relationships
among concepts for the purposes of
describing, explaining, predicting,
and /or prescribing.

They are derived through two principal

1. Deductive reasoning - arrives at a
specific conclusion based on
2. Inductive reasoning - takes events
and makes generalizations


aims to describe, predict and explain the
phenomenon of nursing (Chinn and
provide the foundations of nursing practice,
help to generate further knowledge and
indicate in which direction nursing should
develop in the future (Brown 1964).
Help provide better patient care. Enhanced
professional status for nurses


Interrelate concepts in such a
way as to create a different way
of looking at a particular
Are logical in nature.
Are generalizable.
Are the bases for hypotheses
that can be tested.

Purposes of Theories
A. Practice
-- Serves to guide assessment,
intervention and evaluation of nursing
-- Provide a rationale for collecting reliable
and valid data about the health status of
clients, which are essential for effective
decision making and implementation
-- Help build a common terminology to use
in communicating with other health

B. Research
- Offers a framework for generating knowledge
and new ideas
- Assist in discovering knowledge gaps in
specific field of study

C. Education
- Provide a general focus for curriculum design
- Guide curricular decision making



A. General System Theory:

It describes how to break whole things into

parts and then to learn how the parts work
together in " systems".
These concepts may be applied to different
kinds of systems, e.g.. Molecules in
chemistry , cultures in sociology, organs in
Anatomy and health in Nursing.

B. Adaptation


It defines adaptation as the adjustment of living

matter to other living things and to environmental
Adaptation is a continuously occurring process that
effects change and involves interaction and
Human adaptation occurs on three levels:

--- the internal ( self )

--- the social (others)
--- and the physical ( biochemical

C. Developmental Theory

It outlines the process of growth and

development of humans as orderly and
predictable, beginning with conception and
ending with death.
The progress and behaviors of an
individual within each stage are unique.
The growth and development of an
individual are influenced by heredity ,
temperament, emotional, and physical
environment, life experiences and health

D. Change Theory
People change throughout their lives. This
growth and change are evident in the dynamic
nature of basic human needs and how they are
Change happens daily
Change involves modification or alteration. It
may be planned or unplanned


Metatheory: the theory of theory. Identifies

specific phenomena through abstract
Grand theory: provides a conceptual
framework under which the key concepts
and principles of the discipline can be
Middle range theory: is more precise and
only analyses a particular situation with a
limited number of variables.

Descriptive theories are the first

level of theory development
- They describe a phenomena,
speculate why it occur and describe the
Prescriptive theories are action
oriented, which test the validity and
predictability of a nursing intervention


Four concepts common in nursing theory

that influence and determine nursing
practice are :
The person( patient)
The environment
Nursing (goals, roles, functions)

Theories can also be

categorized as:
"Needs" theories
These theories are based around helping
individuals to fulfill their physical and mental

"Interaction" theories
These theories revolve around the
relationships nurses form with patients.

"Outcome" theories
These portray the nurse as the changing force, who
enables individuals to adapt to or cope with ill
health (Roy 1980).

"Humanistic" Theories:
Humanistic theories developed in response to
the psychoanalytic thought that a persons
destiny was determined early in life.

School of Thoughts in Nursing Theories(1950-1970)



Theorist Humanisti

c Theorists



Theory and practice are related.
To develop nursing as a profession the concept of
theory must be addressed.
If nursing theory does not drive the development
of nursing, it will continue to develop in the
footsteps of other disciplines such as medicine.

Nursing ought to signify the proper use of fresh air,
light, warmth, cleanliness, quiet, and the proper
selection and administration of diet all at the
least expense of vital power to the patient

Florence Nightingale (1860)

Who was Florence Nightingale?

Florence Nightingale was a

truly inspirational nurse.

Why is Florence Nightingale Famous?

Florence Nightingale is famous for her nursing work
during the Crimean War (1854 - 56). She changed the
face of nursing from a mostly untrained profession to a
highly skilled and well-respected medical profession
with very important responsibilities.

Overview of Nightingales Environmental Model

Nightingale viewed the manipulation of the physical
environment as a major concept of nursing care
She identified the following aspects as major areas of
the physical, social and psychological environment
that the nurse could control.

1. Health of houses
2. Ventilation and warming
3. Light
4. Noise
5. Variety
6. Bed and bedding
7. Cleanliness of rooms and walls
8. Personal cleanliness
9. Nutrition and taking food
10. Chattering hopes and advices
11. Observation of the sick
12. Petty management

1. Health of Houses
Is closely related to the presence of pure air, pure
water, efficient drainage, cleanliness and light
According to Nightingale, badly constructed
houses do for the healthy what badly constructed
hospitals do for the sick.
Once a stagnant air is stagnant, sickness is certain
to follow

2. Ventilation and Warming

Nightingale believed that it was essential to keep the air
he breathes as pure as the external air, without chilling
Believed that noxious air or effluvia or foul odors affects
the clients health.

3. Light
Nightingale advocated that the sick needs both fresh air
and light direct sunlight was what clients wanted
She noted that the light has quite real and tangible effects
upon the body

4. Noise
Nightingale believed that patients should never be waked
intentionally or accidentally during the first part of sleep
She averred that whisper or long conversation about
patients are thoughtless and cruel especially when held so
that the patient knows (or assumes) the conversation is
about him

5. Variety
Nightingale stressed that variety in environment was a
critical aspect affecting the patients recovery
She believed in the need for changes in color, form,
including bringing patient brightly colored flowers or plants

6. Bed and Bedding

Nightingale postulated that an adult exhales about 3 pints
of moisture through the lungs and skin in 24 hour period.
This organic matter, enters the sheets and stays there
unless the bedding is changed and aired frequently.

7. Cleanliness of Rooms and Walls

Nightingale emphasized that the greater part of nursing
consists in preserving cleanliness

8. Personal Cleanliness
Nightingale viewed that function of the skin is important
and she believed that unwashed skin poisoned the patient
and noted that bathing and drying the skin provide great
relief to the patient
She also advocated that personal cleanliness extended to
the nurse and that every nurse ought to wash her hands
very frequently during the day

9. Nutrition and taking Food

Nightingale addressed the importance of variety in
the food served to the patients
She has proven that the attention given to the
patient affected how the patient ate
She has observed that individuals desire different
foods at different times of the day and that frequent
small servings may be more beneficial to the
patient than a large breakfast or dinner

10. Chattering Hopes and Advices

Nightingale perceived that to falsely cheer the sick by
making light of their illness and its danger is not helpful
She encourage nurses to heed what is being said by
visitors, believing that sick persons should hear good
news that would assist them in becoming healthier

11. Observation of the Sick

She felt strongly about the importance of obtaining
complete and accurate information about patients

12. Petty management

Nightingale discussed ways to assure that
What you do when you are there, shall be done when you
are not there

Environmental Factors Affecting Health

pure or fresh air

pure water
sufficient food supplies
efficient drainage
light (especially direct sunlight)

Nightingale believed that the environment was the

major component creating illness in a patient; she
regarded disease as the reactions of kindly nature
against the conditions in which we have placed
ourselves. Her theory contains three major
environment to patient
nurse to environment
nurse to patient

Assumptions of Florence Nightingales Theory:

Natural laws
Mankind can achieve perfection
Nursing is a calling
Nursing is an art and a science
Nursing is achieved through environmental
Nursing requires a specific educational base
Nursing is distinct and separate from medicine

Major Premises of Environmental Adaptation Theory:

People are multidimensional, composed of
biological, psychological, social and spiritual
Disease is more accurately portrayed as dys-ease or
the absence of comfort.
Symptoms alert nurses to the presence of illness,
which allows for appropriate interventions.
Breaking the natural laws will cause disease.
Improvement in the health of individuals and families
lead to the improved health of society.

The Environmental
Adaptation Concepts:
Florence Nightingales original
theory for nursing practice was
Her concepts included
health/disease and nursing.
She focused more on physical
factors than on psychological
needs of patients because of the
nature of nursing practice during
her time.

Six Ds of Dysease:
Drink (need clean
drinking water)
Draughts (Drafts)
Drains (need proper
drainage and sewer

Faye Abdellah
Patient Centered Approaches to Nursing Model
The focus of care pendulum
Defined nursing as service to individuals and
Conceptualized nursing as an art and a
science that molds the attitudes, intellectual
competencies and technical skills of the
individual nurse into the desire and ability to
help people, sick or well and cope with their
health needs.

21 Nursing Problems
To maintain good hygiene.

To promote optimal activity; exercise,

rest and sleep.
To promote safety.
To maintain good body mechanics and
prevent and correct deformity


To facilitate the maintenance of a supply of oxygen
to all body cells
To facilitate maintenance of nutrition of all body
To facilitate maintenance of elimination
To facilitate the maintenance of fluid and
electrolyte balance
To recognize the physiologic response of the body
to disease conditions
To facilitate the maintenance of regulatory
mechanisms and functions
To facilitate the maintenance of sensory functions


To identify and accept positive and

expressions, feelings and reactions
To identify and accept the interrelatedness
of emotions and illness.
To facilitate the maintenance of effective
verbal and non-verbal communication
To promote the development of productive
interpersonal relationship
To facilitate progress toward achievement
of personal spiritual goals
To create and/or maintain a therapeutic
To facilitate awareness of self as an


To accept the optimum possible

To use community resources as an
aid in resolving problems arising
from illness.
To understand the role of social
problems as influencing factors

10 Steps to Identify Patients Problems

1. Learn to know the patient

2. Sort out relevant and significant data
3. Make generalizations about available data in
relation to similar nursing problems presented by
other patients
4. Identify the therapeutic plan
5. Test generalizations with the patient and make
additional generalizations

6. Validate the patient's conclusions about his nursing

7. Continue to observe and evaluate the patient over a
period of time to identify any attitudes and clues
affecting his behavior
8. Explore the patient's and family's reaction to the
therapeutic plan and involve them in the plan
9. Identify how the nurses feel about the patient's
nursing problems
10. Discuss and develop a comprehensive nursing care

11 Nursing Skills

1. Observation of health status

2. Skills of communication
3. Application of knowledge
4. Teaching of patients and families
5. Planning and organization of work
6. Use of resource materials

7. Use of personnel materials

8. problem-solving
9. direction of work of others
10. therapeutic use of the self
11. nursing procedure

Nursing problem presented by a patient is a
condition faced by the patient or patients family
that the nurse through the performance of
professional functions can assist to meet them.
These problems can either be:
a. Overt
b. Covert

- Identifying the problem
- Selecting pertinent data
- Formulating hypothesis
- Testing hypothesis
- Revising hypothesis on the basis of
conclusions obtained from the data

Abdellahs Major Concepts

1. Nursing
- A helping profession
- A comprehensive service to meet patients
- Increases or restores self-help ability
- Uses 21 problems to guide nursing care and
promote use of nursing judgment

2. Health

The purpose of nursing services she speaks

of total health needs and a healthy state
of mind and body (Abdellah et al., 1960)

3. Person
One who has physical, emotional, or social
The recipient of nursing care.

4. Environment

Societyis included in planning for optimum

health on local, state, and international

As a logical and simple statement, Abdellahs
problem-solving approach can easily be used
by practitioners to guide various activities
within their nursing practice.
The problem-solving approach is readily
generalizable to client with specific health
needs and specific nursing problems

Little emphasis on what the client is to achieve was
given in terms of client care.
Abdellahs framework is inconsistent with the
concept of holism. The nature of the 21 nursing
problems attests to this. As a result, the client may
be diagnosed as having numerous problems that
would lead to fractionalized care efforts, and
potential problems might be overlooked because
the client is not deemed to be in a particular stage
of illness.

Dorothy Johnson
Behavioral System Model
Purpose of Systems Theory

Nurse creates balance between client and

environment to achieve an optimal level of

Johnsons 7 Subsystems
1. Attachment or affiliative subsystem serves the
need for security through social inclusion or intimacy
2. Dependency subsystem behaviors designed to
get attention, recognition, and physical assistance
3. Ingestive subsystem fulfills the need to supply
the biologic requirements for food and fluids
4. Eliminative subsystem functions to excrete

5. Sexual subsystem serves the biologic requirements of

procreation and reproduction
6. Aggressive subsystem functions in self and social
protection and preservation
7. Achievement subsystem functions to master and
control the self or the environment

A system tends to achieve a balance among the various
forces operating within and upon it and that man strives
continually to maintain a behavioral system balance and
steady states by more or less automatic adjustments and
adaptations to the natural forces impinging upon him.
The system balance reflects adjustments and adaptations
that are successful in some way and to some degree and
may or will vary from individual to individual.

1. She provided a frame of reference for nurses concerned with
specific client behaviors.
2. Johnsons behavioral model can be generalized across the lifespan
and across cultures.
1. does not clearly interrelate her concepts of subsystems.
2. Lack of clear definitions for the interrelationships among and
between the subsystems makes it difficult to view the entire
behavioral system as an entity.
3. The lack of clear interrelationships among the concepts creates
difficulty in following the logic of Johnsons work.

Imogene King

Goal Attainment Theory and Transactional Process

Described nursing as a helping profession
that assists individuals and groups in
society to attain, maintain and restore

Overview of Imogene Kings Theory

It is based on the assumption that human beings are
the focus of nursing
King states that nursings domain involves human
beings, families and communities as a framework
within which nurses make transactions in multiple
environments with health as a goal

Human Beings have 3 Fundamental Health Needs:

1. The need for health information that is usable at
the time when it is needed and can be used
2. The need for care that seeks to prevent illness
3. The need for care when human beings are
unable to help themselves

Conceptual Framework includes 3 interacting systems

A. Personal Systems
-- Individuals are personal systems. Each individual is an
open, total, unique system in constant interaction with
the environment
-- Concepts which contributes to understanding individuals
as personal systems:

Growth and development
Body image

B. Interpersonal Systems
- Two or more individuals in interaction form interpersonal
systems. As the member of individuals increases, so
does the complexity of the interaction.
- Concepts critical to understanding interactions between
individuals are as follows:


C. Social System
- Are composed of large groups with common interests
or goals. Interactions with social systems influence
individuals throughout the lifespan
- Concepts that are useful to understand interactions
within social systems and between social and personal
systems are as follows:

Decision making

Overall Assumptions of Kings Conceptual System

1. Perception, goals, needs, and values of the nurses and clients
influence interaction process
2. Individuals have the right to knowledge about themselves and to
participate in decisions that influence their lives, health and
community services.
3. Health professionals have the responsibility that helps
individuals to make informed decisions about their health care,
4. Individuals have the right to accept or reject healthcare
5. Goals of health professionals and recipients of healthcare may
not be congruent

Kings theory of goal attainment does describe a logical
sequence of events.
For the most part, concepts are clearly defined.
Although the presentation appears to be complex, Kings theory
of goal attainment is relatively simple.
King formulated assumptions that are testable hypotheses for

Kings theory contains major inconsistencies:
(1) She indicates that nurses are concerned about the health care of
groups 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 of the importance of
health maintenance.

Madeleine Leininger

The purpose of transcultural nursing is to

discover and establish a body of
knowledge and skills focused on
transcultural care, health(or well-being) and
illness in order to assist nurses giving
culturally competent, safe, and congruent
care to people of diverse cultures
(Leininger, 1995a p.11)

Developed the Transcultural Nursing Model. She

advocate that nursing is a humanistic and scientific
mode of helping a client through specific cultural
caring process (cultural values, beliefs and
practices) to improve or maintain a health

Roles of the Nurse

The nurse should begin the assessment by
attempting to determine the clients cultural
heritage and language skills.
Nurses should evaluate their attitudes toward
ethnic nursing care .

Leiningers 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.
The theory and model are not simple in terms.

Levines Conservation model is based on 3 major
concepts and assumptions:
1. Conservation
2. Adaptation
3. Wholeness


Is the keeping together of the life system

The goal of conservation is health and the strength to
confront disability
The primary focus of conservation is keeping together
of the wholeness of individual

4 Conservation Principles


Conservation of energy
Conservation of structural integrity
Conservation of personal integrity
Conservation of social integrity

(1)Conservation of Energy
- The human body functions by using energy. The
human body needs energy producing input(food,
oxygen, fluids) to allow energy utilization as an
(2) Conservation of Structural Integrity.
-The human body has physical boundaries (skin and
mucous membrane)that must be maintained to
facilitate health and prevent harmful agents from
entering the body.

(3) Conservation of Personal Integrity.

- The nursing intervention are base on the
conservation of an individual clients personality.
Every individual has sense of identity, self-worth and
self-esteem, which must be preserved and enhanced
by nurses.
(4) Conservation of Social Integrity
- The social integrity of the client reflects the family and
the community in which the client functions. Health
care institutions may separate individuals from their
family. It is important for nurses to consider the
individual in the context of the family.

Is achieved through the frugal, economic,
contained, and controlled use of environmental
resources by the individual in his or her best

Exists when the interactions or constant
adaptations to the environment permit the
assurance of integrity

- Levine has interrelated the concepts of adaptation,
conservation and integrity in a way that provides a nursing
view different from that of the adjunctive disciplines with
which nursing shares these concepts.
- Levines work is logical. One thought or idea flows from the
previous one and into the next.
- There are many concepts with comparatively unspecified
relationships and unstated assumptions.

Health Care Systems Model

She asserted that nursing is a unique profession in that it

is concerned with all the variables affecting an individuals
response to stresses, which are intra- (within the
individual), inter-(between one or more other people), and
extra personal (outside the individual) in nature.

Major Concepts
1. Person Variables
1.1 Physiological variable refers to physiochemical structure and
function of the body
1.2. Psychological variable refers to mental processes and
Ex. Self esteem
1.3. Developmental Variable refers to those processes related to
development over the lifespan

1.4. Sociocultural variable refers to the relationships and social

and cultural expectations and activities
Ex. Ethnic cultural practices and health belief practices on:
a. Birthing
b. Food preferences in different regions of the country
c. Care of the dying and dead
1.5. Spiritual Variable refers to the influence of spiritual beliefs
d. Anointing the sick or dying with oil
e. Avoiding scavenger fishes(shrimp, crabs, squids, fishes with no
f. Prohibiting blood transfusion

2. Central Core

- The basic structure or central core is made up of the basic

survival factors
These includes:
- System variables
- Genetic features and strengths and weaknesses of the
systems parts
Hair color, body temperature regulation ability, physical strength
and value system

3. Flexible line of Defense

- It is the outer barrier or cushion to the normal line of defense, the
line of resistance, and the core structure
- If the flexible line of defense fails to provide adequate protection
to the normal line of defense, the lines of resistance become

4. Normal Line of Defense

- Represents system stability over time.
- It can change over time in response to coping or responding to
the environment

5. Lines of Resistance
- Protect the basic structure and become activated when environmental
stressors invade the normal line of defense
Ex. Activation of the immune response after invasion of microorganisms

6. Reconstruction
- Is the increase in energy that occurs in relation t the degree of reaction to
the stressor.

7. Stressors
-focuses on the impact of stressors on health and addresses stress and the
reduction of stress.
A stressor is any environmental force which can potentially affect the stability
of the system:
- Intrapersonal
- Interpersonal
- Extrapersonal

8. Prevention
- The primary nursing intervention focuses on keeping the
stressors and the stress response from having a
detrimental effect on the body
Primary prevention occurs before the system reacts to
a stressor
Secondary prevention occurs after the system reacts to
a stressor and is provided in terms of existing systems
Tertiary prevention occurs after the system has been
treated through secondary prevention strategies

The major strength of the model is its flexibility for use in all areas of
nursing administration, education, and practice.
Neuman has presented a view of the client that is equally applicable
to an individual, a family, a group, a community, or any other
The emphasis on primary prevention, including health promotion is
specific to this model.
The major weakness of the model is the need for further clarification
of terms used. Interpersonal and extrapersonal stressors need to be
more clearly differentiated.

Major Concepts
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 is the humans ability or power to engage
in self-care and is affected by basic conditioning factors.
Basic conditioning factors are age, gender, developmental
state, health state, sociocultural orientation, health care
system factors, family system factors, patterns of living,
environmental factors, and resource adequacy and

Therapeutic Self-care Demand is the totality of self-care

actions to be performed for some duration in order to meet
known self-care requisites by using valid methods and
related sets of actions and operations.
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 the provision of continuous effective self-care.

Self-care Requisites or requirements can be defined as actions
directed toward the provision of self-care. It is presented in three
A. Universal self-care requisites are associated with life
processes and the maintenance of the integrity of human
structure and functioning.
1. The maintenance of a sufficient intake of air
2. The maintenance of a sufficient intake of water
3. The maintenance of a sufficient intake of food

4. The provision of care associated with elimination process

and excrements
5. The maintenance of a balance between activity and rest
6. The maintenance of a balance between solitude and
social interaction
7. The prevention of hazards to human life, human
functioning, and human well-being
8. 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

B. 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.

C. 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
1. Seeking and securing appropriate medical assistance
2. Being aware of and attending to the effects and results of
pathologic conditions and states
3. Effectively carrying out medically prescribed diagnostic,
therapeutic, and rehabilitative measures

4. Being aware of and attending to or regulating the

discomforting or deleterious effects of prescribed medical
5. 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
6. Learning to live with the effects of pathologic conditions
and states and the effects of medical diagnostic and
treatment measures in a life-style that promotes continued
personal development

Orem developed the Self-Care Deficit Theory of Nursing, which is

composed of three interrelated theories:
(1) the theory of self-care
(2) the self-care deficit theory
(3) the theory of nursing systems.
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 inability of the parent (or guardian) to maintain
continuously for the child the amount and quality of care that is
therapeutic. (Orem, 1991)

She conceptualized three nursing system as follows:

(1) Wholly Compensatory: when the nurse is expected
to accomplish all the patients therapeutic self-care or
to compensate for the patients inability to engage in
self-care or when the patient need continuous
guidance in self-care;
(2) Partially Compensatory: when both nurse and
patient engage in meeting self-care needs;
(3)Supportive-Educative: the system that requires
assistance in decision making, behavior control and
acquisition of knowledge and skills.

- It is applicable for nursing by the beginning practitioner as well as
the advanced clinicians
- The term self care, nursing system and self care deficit are easily
understood by the beginning student nurse and can be explored
in greater depth as the nurse gains more knowledge and
- 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.

- Orems theory is simple yet complex. The use of
self care in multitude terms can be confusing to
the reader

Self care agency

Self care demand
Self care deficit
Self care requisites
Universal self care

According to Peplau (1952/1988), nursing is therapeutic

because it is a healing art, assisting an individual who is sick
or in need of health care.
Nursing can be viewed as an interpersonal process because
it involves interaction between two or more individuals with a
common goal.
In nursing, this common goal provides the incentive for the
therapeutic process in which the nurse and patient respect
each other as individuals, both of them learning and growing
as a result of the interaction.
An individual learns when she or he selects stimuli in the
environment and then reacts to these stimuli.

Therapeutic nurse-client relationship

A professional and planned relationship between client and
nurse that focuses on the clients needs, feelings, problems,
and ideas.
Nursing 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. The orientation phase is directed by the nurse and involves
engaging the client in treatment, providing explanations and
information, and answering questions.
2. The identification phase begins when the client works
interdependently with the nurse, expresses feelings, and begins to
feel stronger.
3. In the exploitation phase, the client makes full use of the services
4. In the resolution phase, the client no longer needs professional
services and gives up dependent behavior. The relationship ends.

Roles of the Nurse in the Therapeutic relationship

The primary roles she identified are as follows:
Stranger: offering the client the same acceptance and courtesy that the
nurse would to any stranger
Resourceperson:providing specific answers to questions within a larger
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
Counselor: promoting experiences leading to health for the client such as
expression of feelings

1. Mildanxiety 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).

2. Moderateanxiety involves a decreased

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

3. Severeanxiety 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.

4. Panicanxiety 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.

Nurse and patient can interact.
Peplau stresses that both the patient and nurse mature as the
result of the therapeutic interaction.
Communication and interviewing skills remain fundamental
nursing tools.
Peplau believed that nurses must clearly understand themselves
to promote their clients growth and to avoid limiting clients
choices to those that nurses value.

The phases provide simplicity regarding the natural
progression of the nurse-patient relationship.
This simplicity leads to adaptability in any nurse-patient
interaction, thus providing generalizability.
Health promotion and maintenance were less emphasized.
The theory cannot be used in a patient who doesnt have a
felt need such as with withdrawn patients.

conceptualized the Science of Unitary Human

To Rogers unitary man is an energy field constant
interaction with the environment. She asserted that
human being are more than and different from the
sum of their parts.

Rogers concepts provide a worldview from which nurses may derive
theories and hypotheses and propose relationships specific to different
Rogers work is not directly testable due to lack of concrete hypotheses,
but it is testable in principle.

It is an abstract, unified, and highly derived framework
and does not define particular hypotheses or theories.
Concepts are not directly measurable thus testing the
concepts validity is questionable.
It is difficult to comprehend because the concepts are
extremely abstract.
Nurses roles were not clearly defined.
No concrete definition of health state

She views each person as a unified biopsychosocial

system in constant interaction with a changing
She contended that the person as an adaptive
system, functions as a whole through
interdependence of its parts. The system consist
input,control process, output and feedback.
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.

Four Adaptive Modes

1. Physiologic-physical mode: physical and chemical processes involved
in the function and activities of living organisms; the underlying need is
physiologic integrity as seen in the degree of wholeness achieved through
adaptation to changes in needs
2. Self-concept-group identity mode: focuses on psychological and
spiritual integrity and a sense of unity, meaning, purposefulness in the
3. Role function mode: refers to the roles that individuals occupy in
society fulfilling the need for social integrity; it is knowing who one is, in
relation to others.
4. Interdependence mode: the close relationships of people and their
purpose, structure and development individually and in groups and the
adaptation potential of these relationships.

Coping mechanisms describe the control processes of the person as an

adaptive system. Some coping mechanisms are inherited or genetic, such
as white blood cell defense mechanism against bacteria that seek to invade
the body. Other mechanisms are learned, such as the use of antiseptics to
cleanse a wound.
Two Coping Subsytems
A. Cognator subsystem
A major coping process involving four cognitive-emotive channels: perceptual and
information processing, learning, judgment, and emotion.

B. Regulator subsystem
A basic type of adaptive process that responds automatically through neural, chemical, and
endocrine coping channels.

Focal stimuli
Those stimuli that are the proximate causes of the situation.
Contextual stimuli
All other stimuli in the internal or external environment, which
may or may not affect the situation.
Residual stimuli
Those immeasurable and unknowable stimuli that also exist
and may affect the situation

A major strength of the model is that it guides nurses to use observation
and interviewing skills in doing an individualized assessment of each
The concepts of Roys model are applicable within many practice settings of
Painstaking application of the model requires significant input of time and
Roys model has many elements, systems, structures and multiple

Introduce the notion that nursing centers around three

components of CARE, CORE, CURE.
Care represents nurturance and is exclusive to nursing.
Core involves the therapeutic use of self and emphasizes
the use of reflection.
Cure focuses on nursing related to the physicians orders.
Core and cure are shared with other health care

The motivation and energy necessary for healing
exist within the patient, rather than in the health care
The three aspects of nursing should not be viewed
as functioning independently but as interrelated.
The three aspects interact, and the circles
representing them change size, depending on the
patients total course of progress.

The use of the terms care, core, and cure are unique to Hall.
Halls work appears to be completely and simply logical.
Halls work is simple in its presentation. However, the openness
and flexibility required for its application may not be so simple for
nurses whose personality, educational preparation, and
experience have not prepared them to function with minimal
structure. This and the self-imposed age and illness
requirements limit the generalizability

Believe that the nurse helps patients meet a

perceived need that the patients cannot meet for
Orlando observed that nurse provide direct
assistance to meet an immediate need for help in
order to avoid or to alleviate distress or helplessness.
She emphasized the importance of validating the
need and evaluating care based on observable
She also indicated that nursing actions can be
automatic (those chosen for reasons other than the
immediate need for help) or deliberative (those
resulting from validating the need for help, exploring
the meaning of the need, and validating the
effectiveness of the actions taken to meet the need.)

Patient Behavior
This sets the nursing process discipline in motion.
All patient behavior, no matter how insignificant, must be
considered an expression of need for help until its meaning to a
particular patient in the immediate situation is understood.
The presenting behavior of the patient, regardless of the form in
which it appears, may represent a plea for help (Orlando, 1990).
Patient behavior may be verbal or nonverbal. Inconsistency
between these two types of behavior may be the factor that alerts
the nurse that the patient needs help.

The patients behavior reflects distress when the patient
experiences a need that he cannot resolve, a sense of
helplessness occurs.
Some categories of patient distress are: physical limitations,
adverse reactions to the setting and experiences which
prevent the patient from communicating his needs (Orlando,

Nurse Reaction
The patient behavior stimulated a nurse reaction, which
marks the beginning of the nursing process discipline.
This reaction is comprised of three sequential parts
(Orlando, 1972). First, the nurse perceives the behavior
through any of her senses. Second, the perception leads to
automatic thought. Finally, the thought produces an
automatic feeling.

The nurse does not assume that any aspect of her reaction
to the patient is correct, helpful, or appropriate until she
checks the validity of it in exploration with the patient
(Orlando, 1990).
The nurse must learn to identify each part of her action so
the process becomes logical rather than intuitive and thus,
disciplined rather than automatic

Orlando (1972) also provides three criteria to ensure that the

nurses exploration of her reaction with the patient is unsuccessful:
1. What the nurse says to the individual in the contact must match
any or all of the items contained in the immediate reaction, and
what the nurse does nonverbally must be verbally expressed and
the expression must match one or all of the items contained in the
immediate reaction.
2. The nurse must clearly communicate to the individual that the
item being expressed belongs to herself.
3. The nurse must ask the individual about the item expressed in
order to obtain correction or verification from that same individual.

When patients cannot cope with their needs without help, they become distressed
with feelings of helplessness.
Patients are unique and individual in their responses.
Nursing offers mothering and nursing analogous to an adult mothering and nurturing
of a child.
Nursing deals with people, environment and health.
Patient need help in communicating needs, they are uncomfortable and ambivalent
about dependency needs.
Human beings are able to be secretive or explicit about their needs, perceptions,
thoughts and feelings.
The nurse patient situation is dynamic, actions and reactions are influenced by both
nurse and patient.

Use of her theory assures that the patient will be treated as individuals and they
will have an active and constant input into their own care.
Assertion of nursings independence as a profession and her belief that this
independence must be based on a sound theoretical frame work.
Guides the nurse to evaluate her care in terms of objectively observable patient
Lack the operational definitions of society or environment which limits the
development of research hypothesis.
The theory focuses on short term care, particularly aware and conscious
individuals and on the virtual absence of reference group or family members.