Theoretical Foundation of Nursing

CITY UNIVERSITY OF PASAY
(PAMANTASAN NG LUNGSOD NG PASAY)

Pasadeña St., Pasay City
College of Nursing and School of Midwifery
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Table of Contents
Evolution of Nursing
A. Introduction to Nursing Theory ............................................................................... 3
1. History of Nursing Theory ................................................................................. 3
2. Significance for the: .......................................................................................... 7
Discipline .................................................................................................. 7
Profession .................................................................................................. 8
B. History and Philosophy of Science ......................................................................... 9

1. Rationalism ..................................................................................................... 10
2. Empiricism ...................................................................................................... 10
3. Early Twentieth Century ................................................................................. 11
4. Emergent Views ............................................................................................. 11
C. Structure of Nursing Knowledge ........................................................................... 14

1. Structure Level .............................................................................................. 14
2. Metaparadigm ................................................................................................ 15
Person ..................................................................................................... 16
Health ...................................................................................................... 16
Environment ............................................................................................ 16
Nursing ................................................................................................... 17
3. Philosophy ..................................................................................................... 19
4. Conceptual Models ........................................................................................ 19
5. Theory ........................................................................................................... 19
6. Middle-range theory ....................................................................................... 19
Nursing Theorists and their Works

A. Nursing Philosophies ............................................................................................. 20
1. Nightingale’s Environmental Theory ............................................................... 20
2. Watson's Theory of Human Caring ................................................................. 30
3. Benner Benner's Stages of Nursing Expertise Nursing Philosophies ............ 45
4. Eriksson’s Caritative Caring Theory ............................................................... 54
B. Nursing Conceptual Models ................................................................................. 63

1. Roger’s Science of Unitary Human Beings Nursing Conceptual Model .......... 63
2. Orem’ s Self —care Deficit Model................................................................... 73
3. King’s General Systems Framework Nursing Conceptual Model ................... 82
4. Neuman’s Systems Model .............................................................................. 92
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5. Roy's Adaptation Model ................................................................................ 105

6. Johnson's Behavioral System Model ............................................................ 119
C. Nursing Theories ................................................................................................. 128

1. Peplau’s Theory of Interpersonal Relationship ............................................. 128
2. Orlando’s Theory of Deliberative Nursing — Process .................................. 136
3. Travelbee's Human to Human Relationship ................................................. 149
4. Hall's CORE, CARE, CURE ......................................................................... 156
5. Abdellah's 21 Nursing Problems ................................................................... 166
6. Henderson's Need Theory ............................................................................ 177
7. Pender’s Health Promotion Model; Nursing Theories ................................... 187
8. Leininger Theory of Culture Care Diversity & Universality ............................ 196
9. Newman's Theory of Health as Expanding Consciousness .......................... 217
10. Parse’s Theory of Human Becoming .......................................................... 225
11. Watson’s Theory of Human Caring ............................................................. 230
12. Orlando’s Nursing Process ......................................................................... 234
13. Locsin’s Technological Competency as Caring ......................................... 239
Theories Relevant to Nursing Practice ................................................................... 244

1. Maslow's Human Needs Theory ................................................................... 244
2. Sullivan’s Transactional Analysis.................................................................. 252
3. Von Bertalanffy’s General Systems Theory .................................................. 261
4. Lewin’s Change Theory ................................................................................ 266
5. Erikson’s Psychosocial Development ........................................................... 271
6. Kohlberg’s Moral Development..................................................................... 277
Local Theories and Models of Nursing Intervention (Philippine Setting) ........... 284
1. Agravante’s CASAGRA Transformative Leadership Model ......................... 284
2. Divinagracia’s COMPOSURE Model ........................................................... 287
3. Kuan’s Retirement and Role Discontinuity Model ........................................ 296
4. Abaquin’s PREPARE ME Holistic Nursing Interventions” ............................ 299
5. Synchronicity in Human Space-Time: A Theory of Nursing Engagement in a
Global Community ............................................................................................ 302
References ................................................................................................................. 305
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THEORETICAL FOUNDATION OF NURSING
EVOLUTION OF NURSING
1. History of Nursing Theory
THEORY
• A set of statements that tentatively describe, explain, or predict relationships

among concepts that have been systematically selected and organized as an
abstract representation of some phenomenon (Power and Knapp, 1995). These
systematic organized perspectives serve as guides for nursing action in
administration, education, research, and practice.
• A well - substantiated explanation of some aspect of the natural world; an
organized system of accepted knowledge that applies in a variety of situations/
hypotheses.
• An expectation of what should happen, barring unforeseen circumstances.
• A coherent statement or set of statements that attempts to explain observed
phenomena.
• An explanation for some phenomena that is based on observation,
experimentation, and reasoning.
• A comprehensive explanation of a given set of data that has been repeatedly
confirmed by observation and experimentation and has gained general
acceptance within the scientific community but has not been yet decisively
proven.
• A construct (the way to put together the "parts" of something) that accounts for or
organizes some phenomena (Barnum, 1998).
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NURSING THEORY
• A body of knowledge that describes or explains nursing and is used to

support nursing practice.
• An organized and systematic articulation of a set of statements related to
questions in the discipline of nursing.
• 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.
CHARACTERISTICS OF A THEORY
A theory is
• interrelating concepts in such a way as to create a different way of looking at a
particular phenomenon
• logical in nature
• generalizable
• basis for hypotheses that can be tested
• increasing the general body of knowledge within the discipline through the
research implemented to validate them
• used by the practitioners to guide and improve their practice
• consistent with other validated theories, laws and principles but will leave open
unanswered questions that need to be investigated.
COMPONENTS OF A THEORY
The components of a theory are as follows:

1. Concepts
2. Definitions
3. Assumptions Concepts Definitions
4. Phenomenon
Phenomenon
Assumptions or propositions
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1. Concepts
A theory is composed of interrelated concepts.
Concepts help to describe or label phenomena. Using Levine's Conservation
Model in Nursing Practice as an example, there are concepts that affect the
nursing practice - the "why's of nursing actions." The three major concepts
that form the basis of the model and its assumptions are as follows:
1. conservation, (2) adaptation, and (3) wholeness.

Another example is King's Theory of Goal Attainment in Nursing Practice.
According to this model, the concepts that are critical to goal attainment in
nursing practice are as follows:
(1) personal systems, (2) interpersonal systems, and (3) social systems.
2. Definitions
The definitions within the description of a theory convey the general meaning
of the concepts in a manner that fits the theory. These definitions also
describe the activity necessary to measure the constructs, relationships, or
variables within a theory (Chinn and Kramer 2004).
For example, Levine's Conservation Model defines conservation as the
keeping together of the life system; those individuals continuously defend
their wholeness. Accordingly, wholeness exists when the interactions or
constant adaptations to the environment permit the assurance of integrity. In
addition, the Model defines adaptation as the ongoing process of change
whereby individuals retain their integrity within the realities of their
environment.
Another example, King's Theory of Goal Attainment defines personal systems
as individuals; those individuals are open, total, unique systems in constant
interaction with the environment. Interpersonal systems are defined as two or
more individuals in interaction. Social systems are defined as large groups
with common interests or goals.
3. Assumptions
Are statements that describe concepts or connect two concepts that are
factual. Assumptions are the "taken for granted" statements that determine
the nature of the concepts, definitions, purpose, relationships and structure of
the theory.
The assumptions in Levine's Conservation Model are that: individuals

continuously defend their wholeness; adaptation is an ongoing process of
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change; nursing is human interaction; nurses promote wholeness through the

use of conservation principle.
4. Phenomenon
A phenomenon is an aspect of reality that can be consciously sensed or

experienced. Nursing theories focus on the phenomena of nursing and
nursing care. Examples of phenomena in nursing include caring, self-care,
and client responses to stress.
In Levine's Conservation Model, phenomena include: person, nursing, health
and environment. In King's Goal Attainment Theory, phenomena include:
social systems, health, perception, and interpersonal relationships.
TYPES OF THEORIES
1. Metatheories.
Are theories whose subject matters are some other theories. These are theories
about theories.
2. Grand Theories.
Are broad in scope and complex and therefore require further specification
through research before they can be fully tested (Chinn and Kramer, 1999).
These are intended to provide structural framework for broad, abstract ideas
about nursing (Fawcett, 1995).
3. Middle Range Theories.

Have more limited scope, less abstraction, address specific phenomena or
concepts and reflect practice (administration, clinical or teaching). The
phenomena or concepts tend to cross different nursing fields, and reflect a wide
variety of nursing care situations, e.g.: quality of life, uncertainty in illness, social
support, incontinence, caring.
4. Descriptive Theories.
Are the first level of theory development. They describe phenomena, speculate
on why phenomena occur, and describe the consequences of phenomena. They
have the ability to explain, relate, and in some situations predict nursing
phenomena (Meleis, 1997). Example: Theories of Growth and Development.
5. Prescriptive Theories.
Address nursing interventions and predict the consequence of a specific nursing
intervention. Prescriptive theories are action oriented, which test the validity and
predictability of a nursing intervention.
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2. Significance for the:

• Discipline
• Profession
Nursing: The Discipline and the Profession
Discipline is specific to academia and refers to a branch of education, a department of

learning, or a domain of knowledge.
Profession refers to a specialized field of practice, founded upon the theoretical
structure of the science or knowledge of that discipline and accompanying practice
abilities
Significance of theory for nursing as a discipline
1. University baccalaureate programs proliferated, masters’ programs in nursing

were developed, and the curricula began to be standardized through the
accreditation process.
2. Attention to the importance of nursing conceptualizations for the research process

and the role of a conceptual framework in the purpose and design of research
production of science and nursing theoretical works also began to publish.
3. Works began to be recognized for their theoretical nature, such as Henderson,

Nightingale and etc.
4. KEYNOTE ADDRESS, New nursing doctoral programs were beginning to open and
they reopened the discussion of the nature of nursing science. This becomes the
first classic reference for nursing as discipline and for distinguishing between the
discipline and profession.
5. Fawcett’s conceptualization of metaparadigm of nursing and unifying conceptual-

theoretical structure of knowledge recognize works of major nursing theorist
as conceptual framework and paradigms of nursing.
6. MAJOR SIGNIFICANCE IS; THE DISCIPLINE IS DEPENDENT UPON THEORY

6.1. Theoretical works have taken nursing to a higher level.
6.2. The emphasis has shifted from a focus on knowledge about how nurses
function, which concentrated on the nursing process, to focus on what nurses know
and how they use knowledge to guide their thinking and decision making while
concentrating on the patient.
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Significance of theory for nursing as a profession
Clearly, nursing is recognized as a profession today.

1. Bixler and Bixler published a set of criteria tailored to nursing in the American
Journal of Nursing in 1959. They stated that a profession:
a. Utilizes in its practice a well-defined and well-organized body of specialized
knowledge that is on the intellectual level of the higher learning.
b. Constantly enlarges the body of knowledge it uses and improves its techniques
of education and service by the use of the scientific method.
c. Entrusts the education of its practitioners to institution of higher education.
d. Applies its body of knowledge in practical services that are vital to human and
social welfare.
e. Functions autonomously in the formulation of professional policy and in the
control of professional activity thereby.
f. Attracts individuals of intellectual and personal qualities who exalt service above
personal gain and who recognizes their chosen occupation as a life work.
g. Strives to compensate its practitioners by providing freedom of action,
opportunity for continuous professional growth and economic security.
These criteria have historical value because they provide an understanding of the
developmental path the nursing followed.
2. Nursing theory is a useful tool for reasoning, critical thinking, and decision making in
nursing practice.
3. Nursing theoretical works provide a perspective of the patient.
4. Nursing theory provides more direction for nursing practice.
5. The conceptual models of nursing are comprehensive and the reader to the specifics
of the practice.
6. Middle range theories contain the specifics of nursing practice.
Analysis Questions to Determine Theoretical Adequacy
• Clarity: How clear is this theory?

• Simplicity: How simple is this theory?
• Generality: How general is this theory?
• Accessibility: How accessible is this theory?
• Importance: How important is this theory?
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B. History and Philosophy of Science
“Sometimes all that is possible is to embrace the mystery, the unknown, of a

situation and allow it to be beyond reach or understanding it for a while.”
The construction of nursing theories is the formalization of attempts to describe, explain,

predict, or control states of affairs in nursing (nursing phenomena).
Historical Views of the Nature of Science
• The term epistemology is concerned with the theory of knowledge in

philosophical inquiry.
• The particular philosophical perspective selected to answer these questions will
influence how scientists perform scientific activities, how they interpret outcomes,
and even what they regard as science and knowledge.
Nursing as a Science
Science is logical, systematic, & coherent way to solve problems and answer questions.
It is a collection of facts known in area and the process used to obtain that knowledge.
• Pure or basic
• Natural, human, or social
• Applied or practical
Nursing and Philosophy
Philosophy studies concepts that structure thought processes, foundations, and

presumptions.
It is an approach for thinking about the nature of people, the methods that should be
used to create a scientific knowledge and the ethics involved. It denotes a perspective,
implying a certain broad, “taken for granted” assumptions.
• Nature of existence
• Morality
• Knowledge and reason
• Human purpose
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Nursing science has been characterized by two branching philosophies of knowledge as

the discipline developed.
Various terms are utilized to describe these two stances: empiricist and interpretive,
mechanistic and holistic, quantitative and qualitative, and deductive and inductive
forms of science.
Understanding the nature of these philosophical stances facilitates appreciation for what
each form contributes to nursing knowledge.
Epistemology a branch of philosophy that is concerned with the nature and scope of
knowledge. It is referred to as the ‘theory of knowledge’. The power of reason and
power of sensory experience (Gale)
1. Rationalism- The power of reason.
Rationalist epistemology (scope of knowledge) emphasizes the importance of a

priori reasoning as the appropriate method for advancing knowledge.
A priori reasoning utilizes deductive logic by reasoning from the cause to an
effect or from a generalization to a particular instance.
Reynolds (1971) labeled this approach the theory-then-research strategy.
In Reynolds’ view, “as the continuous interplay between theory construction
(invention) and testing with empirical research progresses, the theory becomes
more precise and complete as a description of nature and, therefore, more useful
for the goals of science” (Reynolds, 1971, p. 145).
Einstein made use of mathematical equations in developing his theories.
2. Empiricism- the power of sensory experience
The empiricist view is based on the central idea that scientific knowledge can be
derived only from sensory experience (i.e., seeing, feeling, hearing facts).
Francis Bacon (Gale, 1979) received credit for popularizing the basis for the
empiricist approach to inquiry. Bacon believed that scientific truth was discovered
through generalizing observed facts in the natural world.
This approach, called the inductive method, is based on the idea that the
collection of facts precedes attempts to formulate generalizations, or as Reynolds
(1971) called it, the research-then-theory strategy
Skinner’s work focuses on collection of empirical data.
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In summary, deductive inquiry uses the theory then-research approach, and

inductive inquiry uses the research-then-theory approach. Both approaches
are utilized in the field of nursing.
3. Early Twentieth Century Views of Science and Theory
Philosophers focused on the analysis of theory structure, whereas scientist

focused on empirical research.
Positivism, a term first used by Comte, emerged as the dominant view of
modern science (Gale, 1979)
Positivism (imposed on the mind by experience) is the philosophy of science
that information is derived from logical and mathematical treatments and reports
of sensory experience is the exclusive source of all authoritative knowledge.
Modern logical positivists believed that empirical research and logical analysis
(deductive and inductive) were two approaches that would produce scientific
knowledge (Brown, 1977).
Logical empiricist argued that theoretical propositions must be tested through
observation and experimentation.
4. Emergent Views of Science and Theory in the Late Twentieth Century
In The Phenomenology of the Social World, Schutz (1967) argued that

scientists seeking to understand the social world could not cognitively know an
external world that is independent of their own life experiences.
A phenomenological approach reduces observations or text to the meanings of
phenomena independent of their particular context.
Brown (1977), argued an intellectual revolution in philosophy that emphasized
the history of science was replacing formal logic as the major analytical tool in
the philosophy of science.
Empiricists view phenomena objectively, collect data, and analyze it to
inductively proposed theory (Brown, 1977).
Brown argues that the new epistemology challenged the empiricist view of
perception by acknowledging that theories play a significant role in determining
what the scientist will observe and how it will be interpreted.
He identified the following three different views of the relationship between
theories and observation:
1. Scientists are merely passive observers of occurrences in the empirical
world. Observable data are objective truth waiting to be discovered.
2. Theories structure what the scientist perceives in the empirical world.
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3. Presupposed theories and observable data interact in the process of

scientific investigation.
Data-Driven, or Bottom-Up Theory
Cognitive expectation is used to select input and process of incoming information

from the environment.
Conceptually-driven or Top-Down Theory
Asserts that incoming data are perceived as unlabeled input and analyzed as raw
data with increasing levels of complex until all data are classified.
Interdependence between Theory and Research
A theory is accepted when scientists agree that it provides a description of

reality that captures the phenomenon based on current research findings (Brown,
1977).
A theory should be judged based on the basis of scientific consensus.
The acceptance of scientific hypothesis through research depends on the
appraisal of the coherence of theory
Dubin identified when scientific consensus is necessary:
1. Agreement on the boundaries of the theory; that is, the phenomenon it
addresses and the phenomena it excludes (criterion of coherence).
2. Agreement on the logic used in constructing the theory to further
understanding from a similar perspective (criterion of coherence).
3. Agreement that the theory fits the data collected and analyzed through
research (criterion of correspondence).
Issues in Nursing Philosophy and Science Development
Meleis characterized the years of progress in nursing in four stages:

1. Practice
2. Education and Administration
3. Research
4. Development of Nursing Theory
Peplau developed the first theory of nursing practice in her book, Interpersonal
Relations in Nursing.
Journal of Nursing Research (1952)
1960s and 1970s – analysis and debate on the metatheoretical issues related to
theory development
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Four fundamental patterns of knowledge in Nursing (Carper, 1978)

1. Empirical knowledge (nursing science)
2. Esthetic knowledge (nursing as an art)
3. Moral knowledge (ethics in nursing)
4. Personal knowledge (therapeutic use of self)
1980s further acceptance of nursing theory and its incorporation in the nursing
curricula; publication of several nursing journals
Phenomenology is a science that describes how we experience the objects of the
external world and provides an explanation of how we construct objects of experience.
Ethnomethodology focuses on the world of “social facts” as accomplished or co-
created through people’s interpretive work.
The postpositivist and interpretive paradigms have achieved a degree of acceptance
in nursing as paradigms to guide knowledge development.
Postpositivism focuses on discovering patterns that may describe, explain, and predict
phenomena.
Postmodernism includes the particular philosophies that challenge the “objectification
of knowledge,” such as phenomenology, hermeneutics, feminism, critical theory, and
poststructuralism.
Wholism is another philosophy in understanding the patient.
Wholistic nursing views the biophysical, psychological, and sociological subsystems

as related but separate, thus the whole is equal to the sum of the parts.
Holistic nursing recognizes that multiple subsystems are in continuous interaction and
that mind-body relationships do exist.
Interpretive paradigm tends to promote understanding by addressing the meanings
the participants social interaction that emphasize situation, context and multiple
cognitive constructions that individuals create on everyday events.
Critical paradigm for knowledge development in nursing, provides framework for
inquiring about the interaction between the social, political, economic, gender and
cultural factors and experiences of health and illness.
Science as a Social Enterprise
The process of scientific inquiry may be viewed as a social enterprise (Mishler, 1979).
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C. Structure of Nursing Knowledge
1. Structure Level (Analysis of theory, clarity, simplicity, generality, accessibility,

importance).
2. Metaparadigm (Person, Health, Environment, Nursing).
3. Philosophy
4. Conceptual models
5. Theory
6. Middle range theory
1. Structure Level
❖ Structure level presents the structure and analysis of specialized nursing
knowledge.
❖ Structure of knowledge that was used to organize the units of the text and
the definitions of the analysis criteria used for the review process of the
theoretical works.
A. Analysis of Theory
 Analysis, critique and evaluation are methods used to study nursing
theoretical works critically.
 Analysis of theory is carried out to acquire knowledge of theoretical
adequacy.
 It is an important process and the first step in applying nursing theoretical
works to education research, administration or practice.
 Analysis process is useful for learning about the works and is essential for
nurse scientist who intend to test, expand, or extend the works.
 Understanding theoretical framework is vital to applying it in practice.
B. Clarity
 It speaks to the meaning of term used, and definitional consistency and
structure speak to the consistent structural form of terms in the theory.
 Words have multiple meanings within and across disciplines; therefore, a
word should be defined specifically according to the framework
(Philosophy, conceptual model, theory, or middle range theory).
C. Simplicity
 It is highly valued in nursing theory development.
 It discusses the degrees of simplicity and call for simple forms of theory,
such as middle range, to guide practice.
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 Complex practice situation may call for more complex theory.

 A theory should be sufficient, comprehensive, presented at a level of
abstraction to provide guidance, and have as few concepts possible with a
simplistic relation as possible to aid clarity.
D. Generality
 It speaks to the scope of application and the purpose within the theory
(Chinn & Krammer, 2015).
 Understanding the levels of abstraction by doctors’ students and nurse
scientist has facilitated the use of abstract frameworks and the
development of middle-range theories.
E. Accessibility
 “Accessible addresses the extent to which empiric indicators for the
concepts can be identified and to what extent the purposes of the theory
can be attained”
 It is vital to developing nursing research to test theory. It facilitates testing,
because the empirical indicators provide linkage too practice for test ability
and ultimate use of theory to describe and test aspects of practice
(Chinn&Krammer,2015).
F. Importance
 “Does this theory create understanding that is important to nursing?”.
Because research, theory, and practice are closely related, nursing theory
lends itself to research testing and research testing leads itself to
knowledge of practice.
2. Metaparadigm
❖ The broad conceptual boundaries of the discipline of nursing, human beings,
environment, and health.
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Person
❖ It is referred to the person as a patient.

❖ Nurses performed task to and for the patient
and controlled the patient’s environment to
enhance recovery.
❖ Nightingale described a passive patient in this
relationship. However, specific references are
made to the patient performing self-care
when possible and, in particular, being
involved in the timing and substance of
meals.
Health
❖ Health, a dynamic process, is the synthesis of

wellness and illness and is defined by the
perception of the client across the life span.
This view focuses on the entire nature of the
client in physical, social, aesthetic, and moral
realms. Health is contextual and relational.
Wellness, in this view, is the lived experience
of congruence between one’s possibilities and
one’s realities and is based on caring and
feeling cared for. Illness is defined as the lived
experience of loss or dysfunction that can be
mediated by caring relationships. Inherent in
this conceptualization is each client’s
approach to stress and coping. The degree or
level of health is an expression of the mutual interactive process between
human beings and their environment.
Environment
❖ Environment is the landscape and

geography of human social experience, the
setting or context of experience as everyday
life and includes variations in space, time
and quality. This geography includes
personal, social, national, global, and
beyond. Environment also includes societal
beliefs, values, mores, customs, and
expectations. The environment is an energy
field in mutual process with the human
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energy field and is conceptualized as the arena in which the nursing client
encounters aesthetic beauty, caring relationships, threats to wellness and
the lived experiences of health. Dimensions that may affect health include
physical, psychosocial, cultural, historical and developmental processes, as
well as the political and economic aspects of the social world.
Nursing
❖ Nursing is an academic discipline and a

practice profession. It is the art and science
of holistic health care guided by the values
of human freedom, choice, and
responsibility. Nursing science is a body of
knowledge arrived at through theory
development, research, and logical
analysis. Nursing and other supporting
theories are essential to guide and advance
nursing practice. The art of nursing practice,
actualized through therapeutic nursing
interventions, is the creative use of this
knowledge in human care. Nurses use
critical thinking and clinical judgment to
provide evidence-based care to individuals,
families, aggregates, and communities to
achieve an optimal level of client wellness
in diverse nursing settings/contexts. Clinical
judgment skills are therefore essential for
professional nursing practice.
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FOUR MAJOR CONCEPTS OF NURSING THEORIES
1. Person. Refers to all human beings. People are the recipients of nursing care;
they include individuals, families, communities and groups.
2. Environment. Includes factors that affect individuals internally and externally. It
means not only everyday surroundings but also settings where nursing care is
provided.
3. Health. Addresses the person's state of well-being.
4. Nursing. Is central to all nursing theories. Definitions of nursing describe what
nursing is, what nurses do, and how nurses interact with clients. It is the
"diagnosis and treatment of human responses to actual or potential health
problems" (ANA, 1995). Example: the nurse establishes nursing diagnoses of
fatigue, change in body image, and altered coping based on the medical
diagnosis of heart condition.
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3. Philosophy
❖ Philosophy is the most abstract type and sets forth the meaning of nursing
phenomena through analysis, reasoning, and logical presentation.
❖ Early works that predate the nursing theory era, such as Nightingale
(1969/1859), contributed to knowledge development by providing direction or
a basis for subsequent developments.
4. Conceptual Models
❖ Nursing conceptual models, comprises nursing works by theorists referred

to by some as pioneers in nursing.
❖ Fawcett (2005) explains, “A conceptual model provides a distinct frame of
reference for its adherents . . . that tells them how to observe and interpret
the phenomena of interest to the discipline.”
5. Theory
❖ Theory comprises works derived from nursing philosophies, conceptual
models, abstract nursing theories, or works in other disciplines (Alligood,
2010a; Wood, 2010).
❖ A work classified as a nursing theory is developed from some conceptual
framework and is generally not as specific as a middle-range theory.
Although some use the terms model and theory interchangeably, theories
differ from models in that they propose a testable action.
❖ An example of theory derived from a nursing model is in Roy’s work, where
she derives a theory of the person as an adaptive system from her
Adaptation model.
❖ Theories may be specific to a particular aspect or setting of nursing practice.
6. Middle-range theory
❖ Middle-range theory, has the most specific focus and is concrete in its level
of abstraction.
❖ Middle-range theories are precise and answer specific nursing practice
questions. They address the specifics of nursing situations within the
perspective of the model or theory from which they are derived.
❖ The specifics are such things as the age group of the patient, the family
situation, the patient’s health condition, the location of the patient, and, most
importantly, the action of the nurse (Alligood, 2010a; Wood, 2010).
❖ There are many examples of middle-range theories in the nursing literature
that have been developed inductively as well as deductively.
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NURSING THEORETICAL WORKS
1. Nightingale's Environmental Theory
Florence Nightingale (mid-1800)

Developed and described the first theory of nursing, "Environmental Model" ("Notes on
Nursing: What It Is, What It Is Not"). She focused on changing and manipulating the
environment in order to put the patient in the best possible conditions for nature to act
(nursing and the patient environment relationships). She believed that in the nurturing
environment, the body could repair itself. Client's environment is manipulated to include
appropriate noise, nutrition, hygiene, light, comfort, socialization and hope. She
provided the nursing profession the "Legacy of Caring."
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BIOGRAPHY
Florence Nightingale (12 May 1820 – 13 August 1910) was a nurse who contributed to
developing and shaping the modern nursing practice and has set examples for nurses
who are standards for today’s profession. Nightingale is the first nurse theorist well-
known for developing the Environmental Theory that revolutionized nursing practices to
create sanitary conditions for patients to get care. She is recognized as the founder of
modern nursing. During the Crimean War, she tended to wounded soldiers at night and
was known as “The Lady with the Lamp.”
EARLY LIFE
Florence Nightingale was born on May 12, 1820, in Nightingale, Italy. She was the
younger of two children. Her British family belonged to elite social circles. Her father,
William Shore Nightingale, a wealthy landowner who had inherited two estates—one at
Lea Hurst, Derbyshire, and the other in Hampshire, Embley Park Nightingale was 5
years old.
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Her mother, Frances Nightingale, hailed from a family of merchants and took pride in
socializing with prominent social standing people. Despite her mother’s interest in social
climbing, Nightingale herself was reportedly awkward in social situations. She preferred
to avoid being the center of attention whenever possible. Strong-willed, Nightingale
often butted heads with her mother, whom she viewed as overly controlling. Still, like
many daughters, she was eager to please her mother. “I think I am got something
more good-natured and complying,” Nightingale wrote in her own defense
concerning the mother-daughter relationship.
EDUCATION
Florence Nightingale was raised on the family estate at Lea Hurst, where her father
provided her with a classical education, including German, French, and Italian studies.
As for being homeschooled by her parents and tutors, Nightingale gained excellence in
Mathematics.
Nightingale was active in philanthropy from a very young age, ministering to the ill and
poor people in the village neighboring her family’s estate. At seventeen, she decided to
dedicate her life to medical care for the sick resulting in a lifetime commitment to speak
out, educate, overhaul and sanitize the appalling health care conditions in England.
Despite her parents’ objections, Nightingale enrolled as a nursing student in 1844 at the
Lutheran Hospital of Pastor Fliedner in Kaiserswerth, Germany.
PERSONAL LIFE
Only announcing her decision to enter the field in 1844, following her desire to be a
nurse, was not easy for Florence Nightingale. Her mother and sister were against her
chosen career, but Nightingale stood strong and worked hard to learn more about her
craft despite society’s expectation that she become a wife and mother.
As a woman, Nightingale was beautiful and charming that made every man like her.
However, she rejected a suitor, Richard Monckton Milnes, 1st Baron Houghton,
because she feared that entertaining men would interfere with the process. The income
given to her by her father during this time allowed her to pursue her career and still live
comfortably.
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Overview of Nightingale's Environmental Model
➢ Nightingale viewed the manipulation of the physical environment as a major

component 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. 12. Petty management
➢ The social and psychological environment that affect the physical environment
are: Variety, chattering hopes and advices, and petty management.
➢ Nightingale believed that when one or more aspects of the environment are out
of balance, the client must use increased energy to counter the environmental
stress.
These stresses drain the client of energy needed for healing.

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 stagnant air is stagnant,
sickness is certain to follow" (Nightingale, 1859, p.15).
➢ She also noted that the cleanliness outside the house affected the inside.
➢ Nightingale's advocacy is still applicable in these modern times, because
families can be still affected by toxic wastes, contaminated water and polluted
air.
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2. Ventilation and Warming

➢ Nightingale believed that it was essential to "keep the air he breathes as pure
as the external air, without chilling him."
➢ She believed that the person who repeatedly breathed his/her own air would
be sick or remain sick.
➢ Nightingale also believed that "noxious air" or "effluvia" or foul odors affect
the client's health. This comes from raw sewage, ditches, excrement,
bedpans, urinals and other utensils used to discard excrement.
➢ She believed that the offensive source, not the smell must be removed. So,
she criticized "fumigations."
➢ Nightingale also emphasized the importance of room temperature. The
patient should not be too warm or too cold.
3. Light
➢ Nightingale advocated that the sick needs both fresh air and light-direct
sunlight was what clients wanted.
➢ She noted that light has "quite real and tangible effects upon the human
body."
➢ She noted that the sick rarely lie with their face toward the wall but are much
more likely to face the window, the source of the sun.
➢ In these modern times it is still noted that lack of environmental stimuli like in
isolation rooms, NICU, ICU, etc., can lead to confusion or "intensive care
psychosis" related to the lack of the usual cycling of day and night.
4. Noise
➢ Nightingale believed that patients should never be waked intentionally or
accidentally during the first part of sleep.
➢ She averred that whispered or long conversations about patients are
thoughtless and cruel, especially when held so that the patient knows (or
assumes) the conversation is about him.
➢ In these modern times, noises that may irritate patients are jewelries worn by
nurses, keys that jingle, snapping of rubber gloves, the clank of the
stethoscope against metal bed rails, radios, TV's, telephones ringing,
machines that beep or alarm, etc.
5. Variety
➢ Nightingale stressed that variety in the environment was a critical aspect
affecting the patient's recovery.
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➢ She believed in the need for changes in color and form, including bringing the
patient brightly colored flowers or plants.
➢ She also advocated rotating 10 to 12 paintings and engravings each day,
week, or month to provide variety for the patient.
➢ She agreed that the mind greatly affects the body.
➢ She also advocated reading, needlework, writing and cleaning as activities to
relieve the sick of boredom.
6. Bed and Bedding

➢ Nightingale postulated that an adult exhales about three pints of moisture
through the lungs and skin in a 24-hour period. This organic matter, she said,
enters the sheets and stays there unless the bedding is changed and aired
frequently.
➢ She believed that the bed should be placed in the lightest part of the room
and placed so the patient could see out of the window.
➢ She reminded the caregiver never to lean against, sit upon, or unnecessarily
shake the bed of a patient.
➢ Even in these modern times, it remains important for the nurse to keep
bedding clean, neat, and dry and to position the patient for maximum comfort.
7. Cleanliness of Rooms and Walls

➢ Nightingale emphasized that "the greater part of nursing consists in
preserving cleanliness."
➢ She urges the removal of dust with the use of damp cloth (rather than a
feather duster. Floors should be easily cleaned rather than being covered with
dust trapping carpets. Furniture and walls should be easily washed and not
damaged by coming in contact with moisture.
➢ In these modern times, the concept that a clean room is a a healthy room
continues to be relevant.
8. Personal Cleanliness
➢ Nightingale viewed the function of the skin as important.
➢ She believed that unwashed skin poisoned the patient and noted that bathing
and drying the skin provided great relief to the patient.
➢ She strongly stated that "Just as it is necessary to renew the air around a sick
person frequently, to carry off morbid effluvia from the lungs and skin, by
maintaining free ventilation, so is it necessary to keep the pores of the skin
free from all obstructing excretions" (Nightingale, 1859, p.53).
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➢ She also advocated that personal cleanliness extended to the nurse and that
"every nurse ought to wash her hands very frequently during the day" (p.53).
9. Nutrition and Taking Food

➢ Nightingale addressed the importance of variety in the food served to
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.
➢ She urged that no business be done with patient while they are eating
because this was distraction. She also urged that the right food be brought at
the right time and "be taken away, eaten or uneaten, at the right time" (p.37).
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 considered it stressful for a patient to hear opinions after only brief
observations had been made. False hope was depressing to patients, she
felt, and caused them to worry and become fatigued.
➢ Nightingale encouraged the nurse 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

➢ According to Nightingale "the most important practical lesson that can be
given to nurses is to teach them what to observe-----how to observe-what
symptoms indicate improvement-----what is the reverse-----which are of
importance-----which are of none-----which are evidence of neglect-----and
what kind of neglect" (Nightingale, 1859 p.59).
➢ She felt strongly about the importance of obtaining complete and accurate
information about patients that she said, "if you cannot get the habit of
observation one way or other, you had better give up being a nurse, for it is
not your calling, however kind and anxious you maybe."
➢ She urges precise, specific, and individualized questions and observations
and warns against failure to observe and the use of averages to describe
expectations of the individual.
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➢ Finally, she urges that observation not be an end unto itself but a means for
assuring that appropriate actions are taken.
12. Petty Management
➢ Nightingale discussed "petty management" or ways to assure that "what you
do when you are there, shall be done when you are not there"(p.20).
➢ She believed that the house and the hospital needed to be well-managed-that
is organized, clean, and with appropriate supplies.
Concepts:
a. Environment: can be defined as anything that can be manipulated to

place a patient in the best possible condition for nature to act.
■ This theory has both physical and psychological components.
■ The physical components of the environment refer to ventilation,
warmth, light, nutrition, medicine, stimulation, room temperature, and
activity.
■ The psychological components of the environment include avoiding
chattering hopes and advices and providing variety.
b. Person: the one who is receiving care; a dynamic and complex being
■ Nightingale envisioned the person as comprising physical, intellectual,
emotional, social and spiritual components.
c. Health: Nightingale wrote, "Healthy is not only to be well, but to be able to
use well every power we have.
■ She believed in the prevention and health promotion in addition to
nursing patients from illness to health.
d. Nursing: Nightingale believed nursing to be a spiritual calling. Nurses
were to assist nature to repair the patient.
▪ She defined different types of nursing as "nursing proper"
(nursing the sick), "general nursing" (health promotion), and
"midwifery nursing.
▪ Nightingale viewed nursing the management." "Science of
environmental management.”
▪ Nurses were to use common sense, observation, and ingenuity
to allow nature to effectively repair the patient.
▪ Nightingale believed, "Observation may always be improved
with training---will seldom be present without training; for
otherwise the nurse does not know what to look for."
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■ Using Nightingale's philosophy in practice today fits well with the use of
the nursing process. The nurse assesses the patient situation,
identifies a need; implements a plan of care, reevaluates the situation,
and finally changes the plan to better serve the patient.
■ She expected nurses to use their powers of observation in caring for
patients.
■ She advocated for nurses to have educational background and
knowledge that were different from those of physicians.
■ She believed in and rallied for nursing education to be a combination of
clinical experience and classroom learning.
Nightingale and The Nursing Process
• Assessment
■ Nightingale recommended two essential behaviors by the nurse in the
area of assessment.
1. Ask the client what is needed or wanted.
Examples:
a. If the patient is in pain, ask where the pain is located.
b. If the patient is not eating, ask when he or she would like to eat
and what food is desired.
She recommended asking precise questions. She warned against asking leading
questions.
Correct: "How many hours of sleep did you have? At what hours of the night?"
Wrong: "Did you have a good night sleep?"
2. Observation. She used precise and specific observations

concerning all aspects of the client's physical health and
environment.
Examples:
a. How do light, noise, smells, and bedding affect the client?
b. How much food and drink had the client ingested at every meal
or snack?
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• Nursing Diagnoses
■ Nightingale believed data should be used as the basis for forming any
conclusion. The nursing diagnosis is the client's response to the
environment and not the environmental problem. It reflects the importance
of the environment to health and well-being of the client.
• Outcomes and Planning

■ Identifying the nursing actions needed to keep clients comfortable, dry,
and in the best state for nature to act on.
■ Planning is focused on modifying the environment to enhance the client's
ability to respond to the disease process.
■ The desired outcomes are derived from the environmental model-----for
example, being comfortable, clean, dry, in the best state for nature to work
on.
• Implementation
■ Takes place in the environment that affects the client and involves taking
action to modify that environment.
■ All factors of the environment should be considered, including noise, air,
odors, bedding, cleanliness, light, -----all the factors that place clients in
the best position for nature to work upon them.
• Evaluation
■ Is based on the effect of the changes in the environment on the client's
ability to regain his/her health at the least expense of energy.
■ Observation is the primary method of data collection used to evaluate the
client's response to the intervention.
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2. Watson's Theory of Human Caring
Jean Watson (1979-1985)
Conceptualized the "Transpersonal Caring Model" (Nursing: Human Science and

Human Care). She emphasized that nursing is the application of the art and human
science through transpersonal caring transactions to help persons achieve mind-body-
soul harmony, which generates self - knowledge, self-control, self-care, and self-
healing. She included health promotion and treatment of illness in nursing. She believed
that a person is a valued being to be cared for, respected, nurtured, understood and
assisted; a fully functional integrated self.
Watson identified 10 carative factors in nursing. These are as follows:
■ Forming humanistic - altruistic value system
■ Instilling faith - hope
■ Cultivating sensitivity to self and others
■ Developing helping - trust relationship
■ Promoting expression of feelings
■ Using problem-solving for decision making
■ Promoting teaching-learning
■ Promoting supportive environment
■ Assisting with gratification of human needs
■ Allowing for existential - phenomenological forces
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BIOGRAPHY
Jean Watson (June 10, 1940 – present) is an American nurse theorist and nursing
professor known for her “Philosophy and Theory of Transpersonal Caring.” She has
also written numerous texts, including Nursing: The Philosophy and Science of Caring.
Watson’s study on caring has been integrated into education and patient care to various
nursing schools and healthcare facilities worldwide.
EARLY LIFE
Jean Watson was born Margaret Jean Harmon and grew up in Welch, West Virginia, in
the Appalachian Mountains. She was the youngest of eight children and was
surrounded by an extended family–community environment. Watson attended high
school in West Virginia and then the Lewis Gale School of Nursing in Roanoke, Virginia,
where she graduated in 1961.
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EDUCATION
Jean Watson ardently and quickly progressed through her nursing education, earning
her bachelor’s degree in nursing in 1964, a master of science in psychiatric and mental
health nursing in 1966, and a Ph.D. in educational psychology and counseling in 1973,
all from the University of Colorado at Boulder.
PERSONAL LIFE
After her graduation in 1961, Jean Watson married her husband, Douglas, and moved
west to his native state of Colorado. In 1997, she experienced an accidental injury that
resulted in the loss of her left eye, and soon after, in 1998, her husband, whom she
considers as her physical and spiritual partner, and her best friend passed away and left
Watson and their two grown daughters, Jennifer and Julie, and five grandchildren.
Watson states that she is “attempting to integrate these wounds into my life and work.
One of the gifts through the suffering was the privilege of experiencing and receiving my
own theory through the care from my husband and loving nurse friends and colleagues.”
These two personal life-altering events contributed to writing her third book, Postmodern
Nursing and Beyond.
WORKS
Watson has authored 11 books, shared in the authorship of six books, and has written
countless nursing journal articles. The following publications reflect her theory of caring
from her ideas about the philosophy and science of caring.
➢ Nursing: The Philosophy and Science of Caring (1979)
➢ Human Science and Human Care – A Theory of Nursing (1985)
➢ Postmodern Nursing and Beyond (1999)
➢ Instruments for Assessing and Measuring Caring in Nursing and Health Sciences
(2002)
➢ Caring Science as Sacred Science (2005)
➢ International Research on Caritas as Healing (Nelson & Watson, 2011), Creating
a Caring Science Curriculum (Hills & Watson, 2011), and Human Caring
Science: A Theory of Nursing (Watson, 2012).
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Overview of Watson's Philosophy of Human Caring
➢ Watson views nursing as "both as human science and an art, and as such
considered qualitatively continuous with traditional, research methods, such as
reductionistic, scientific methodology" (Talento, 1995, p.327).
➢ This science with a view...leans toward employing qualitative theories and
existential-phenomenology, literary introspection, case studies, philosophical-
historical work, hermeneutics, art criticism, and other approaches that allow a
close and systematic observation of one's own experience and that seeks to
disclose and elucidate the lived world of health-illness-healing experience and
the phenomena of human caring. (Watson, p221).
➢ Human caring is...thinking related to intentionality connects with the concepts of
consciousness, energy...if our conscious intentionality is to hold thoughts that are
caring, loving, open, kind, and receptive, in contrast to an intentionality to control,
manipulate, and have power over, the consequences will be significant...based
on the different levels of consciousness... and energy associated with the
different thought" (Watson, 1999, p.121].
➢ According to Watson (2001), the major elements of her theory are
a. The carative factors
b. The transpersonal caring relationship
c. The caring occasion/caring moment
➢ Watson views the "carative factors" as a guide for the core of nursing. She uses
the term carative to contrast with conventional medicine's curative factors.
➢ The term "carative" means caring with love.
➢ It originated from the term "caritas" which means to cherish, appreciate, and give
special attention (Watson, 1991, 2005).
➢ The carative factors attempt to honor the human dimensions of nursing's work
and the inner life world and subjective experiences of the people we serve"
(Watson, 1997b, p.50).
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The following are Watson's Ten Carative Factors (Watson, 1988b, p.75)
1. The formation of a humanistic-altruistic system of values.

2. The instillation of faith-hope.
3. The cultivation of sensitivity to one's self and to others.
4. The development of a helping-trust relationship.
5. The promotion and acceptance of the expression of positive and negative
feelings.
6. The systematic use of the scientific problem-solving method for decision making.
7. The promotion of interpersonal teaching-learning.
8. The provision for a supportive, protective, and corrective mental, physical,
sociocultural, and spiritual environment.
9. Assistance with the gratification of human needs.
10. The allowance of existential-phenomenological forces.
➢ The first three carative factors form the "philosophical foundation" for the science of
caring. The remaining seven carative factors spring from the foundation laid by these
first three.
1. The formation of a humanistic-altruistic system of values

■ Begins developmentally at an early age with values shared with the parents.
■ Mediated through ones own life experiences, the learning one gains and
exposure to the humanities.
■ Is perceived as necessary to the nurse's own maturation which then promotes
altruistic behavior towards others.
2. Faith-hope
■ Is essential to both the carative and the curative processes.
■ When modern science has nothing further to offer the person, the nurse can
continue to use faith-hope to provide a sense of well- being through beliefs
which are meaningful to the individual.
3. Cultivation of sensitivity to one's self and to others

■ Explores the need of the nurse to begin to feel an emotion as it presents
itself.
■ Development of one's own feeling is needed to interact genuinely and
sensitively with others.
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■ Striving to become sensitive, makes the nurse more authentic, which

encourages self-growth and self-actualization, in both the nurse and those
with whom the nurse interacts.
■ The nurses promote health and higher-level functioning only when they form
person to person relationship.
4. Establishing a helping-trust relationship

■ Strongest tool is the mode of communication, which establishes rapport and
caring.
■ She has defined the characteristics needed in the helping-trust relationship
These are:
✓ Congruence
✓ Empathy
✓ Warmth
■ Communication includes verbal, nonverbal and listening in a manner which
connotes empathetic understanding.
5. The expression of feelings, both positive and negative

■ According to Watson, "feelings alter thoughts and behavior, and they need to
be considered and allowed for in a caring relationship".
■ According to her such expression improves one's level of awareness.
■ Awareness of the feelings helps to understand the behavior it engenders.
6. The systematic use of the scientific problem-solving method for decision

making
■ According to Watson, the scientific problem-solving method is the only
method that allows for control and prediction, and that permits self-correction.
■ She also values the relative nature of nursing and supports the need to
examine and develop the other methods of knowing to provide a holistic
perspective.
■ The science of caring should not be always neutral and objective.
7. Promotion of interpersonal teaching-learning

■ The caring nurse must focus on the learning process as much as the teaching
process.
■ Understanding the person's perception of the situation assists the nurse to
prepare a cognitive plan.
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8. Provision for a supportive, protective and/or corrective mental, physical,

socio-cultural and spiritual environment
■ Watson divides these into external and internal variables, which the nurse
manipulates in order to provide support and protection for the person's mental
and physical well-being.
■ The external and internal environments are interdependent.
■ Watson suggests that the nurse also must provide comfort, privacy and safety
as part of this carative factor.
9. Assistance with the gratification of human needs

■ It is grounded in a hierarchy of need similar to that of Maslow's.
■ She has created a hierarchy which she believes is relevant to the science of
caring in nursing.
■ According to her each need is equally important for quality nursing care and
the promotion of optimal health. All the needs deserve be attended to and
valued.
Watson's Ordering of Needs
• Lower order needs (biophysical needs)

■ The need for food and fluid
■ The need for elimination
■ The need for ventilation
• Lower order needs (psychophysical needs)
■ The need for activity-inactivity
■ The need for sexuality
• Higher order needs (psychosocial needs)
■ The need for achievement
■ The need for affiliation
• Higher order need (intrapersonal-interpersonal need)
■ The need for self-actualization
• Research findings have established a correlation between emotional distress

and illness. According to Watson, the current thinking of holistic care
emphasizes that:
■ Factors of the etiological component interact and produce change through
complex neuro-physiological and neuro-chemical pathways.
■ Each psychological function has a physiological correlate.
■ Each physiological component has a psychological correlate.
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Example:
Bulimia, anorexia and gastro-intestinal ulcers are just a few of the
disorders that indicate a complex interaction between the physiological
and psychological.
10. Allowance for existential-phenomenological forces

■ Phenomenology is a way of understanding people from the way things appear
to them, for their frame of reference.
■ Existential psychology is the study of human existence using
phenomenological analysis.
■ This factor helps the nurse to reconcile and mediate the incongruity of viewing
the person holistically while at the same time attending to the hierarchical
ordering or needs.
■ Thus, the nurse assists the person to find the strength or courage to confront
life or death.
■ Later, Watson introduced the concept of "clinical caritas" which has now
replaced her carative factors.
• The following factors are Watson's (2001) translation of the "carative

factors" into "clinical caritas" processes (CCP):
1. Practice of loving kindness and equanimity within context of caring
consciousness.
2. Being authentically present, and enabling and sustaining the deep belief
system and subjective life world of self and the one-being- cared for.
3. Cultivation of one's own spiritual practices and transpersonal self, going
beyond ego self, opening to others with sensitivity and compassion.
4. Developing and sustaining a helping-trusting, authentic caring relationship.
5. Being present to, and supportive of, the expression of positive and
negative feelings as a connection with deeper spirit of self and the one-
being-cared for.
6. Creative use of self and all ways of knowing as part of the caring process;
to engage in artistry of caring-healing practices.
7. Engaging in genuine teaching-learning experience that attends to unity of
being and meaning, attempting to stay within others' frames of reference.
8. Creating healing environment at all levels (physical as well as non-
physical), subtle environment of energy and consciousness, whereby
wholeness, beauty, comfort, dignity and peace are potentiated.
9. Assisting with basic needs, with an intentional caring consciousness,
administering "human care essentials," which potentiate alignment of mind
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body spirit, wholeness, and unity of being in all aspects of care; tending to
both the embodied spirit and evolving spiritual emergence.
10. Opening and attending to spiritual---mysterious and existential dimensions
of one's own life-death; soul care for self and the one- being-cared-for
(Watson, 2001, p.347).
Transpersonal Caring Relationship
• For Watson (1999), the transpersonal caring relationship characterizes a

special kind of human care relationship that depends on:
■ The nurse's moral commitment in protecting and enhancing human dignity
as well as the deeper/higher self.
■ The nurse's caring consciousness communicated to preserve and honor
the embodied spirit, therefore, not reducing the person to the moral status
of an object.
■ The nurse's caring consciousness and connection having the potential to
heal since experience, perception, and intentional connection are taking
place.
■ This relationship describes how the nurse goes beyond an objective
assessment, showing concerns toward the person's subjective and deeper
meaning regarding their own health care situation. The nurse's caring
consciousness becomes essential for the connection and understanding
of the other person's perspective. This approach highlights the uniqueness
of both the person and the nurse, and also the mutuality between the two
individuals, which is fundamental to the relationship. As such, the one
caring and the one cared-for, both connect in mutual search for meaning
and wholeness, and perhaps for the spiritual transcendence of suffering
(Watson, 2001). The term "transpersonal" means to go beyond one's own
ego and the here and now, as it allows one to reach deeper spiritual
connections in promoting the patient's comfort and healing. Finally, the
goal of a transpersonal caring relationship corresponds to protecting,
enhancing, and preserving the person's dignity, humanity, wholeness, and
inner harmony.
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Caring Occasion/Caring Moment
■ According to Watson (1988b, 1999), a caring occasion is the moment

(focal point in space and time) when the nurse and another person come
together in such a way that an occasion for human caring is created. Both
persons, with their unique phenomenal fields, have the possibility to come
together in a human-to-human transaction. For Watson (1988b, 1999), a
phenomenal field corresponds to the person's frame of reference or the
totality of human experience consisting of feelings, bodily sensations,
thoughts, spiritual beliefs, goals, expectations, environmental
considerations, and meanings of one's perceptions---all of which are
based upon one's past life history, one's present moment, and one's
imagined future.
■ Not simply a goal for the cared-for, Watson (1999) insists that the nurse,
i.e., the caregiver, also needs to be aware of her own consciousness and
authentic presence of being in a caring moment with her patient.
Moreover, both the cared-for and the one caring can be influenced by the
caring moment through the choices and actions decided within the
relationship, thereby influencing and becoming part of their own life
history. The caring occasion becomes "transpersonal" when "it allows for
the presence of the spirit of both---then the event of the moment expands
the limits of openness and has the ability to expand human capabilities"
(Watson, 1999, pp.116-117).
Watson's Theory and the Nursing Process
■ Watson points out that nursing process contains the same steps as the
scientific research process. They both try to solve a problem. Both
provide a framework for decision making. Watson elaborate the two
processes as:
1. Assessment
■ Involves observation, identification and review of the problem, use of
applicable knowledge in literature.
■ Also includes conceptual knowledge for the formulation and
conceptualization of framework.
■ Includes the formulation of hypothesis, defining variables that will be
examined in solving the problem.
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2. Plan
■ It helps to determine how variables would be examined or measured;
includes a conceptual approach or design for problem solving. It
determines what data would be collected and how on whom.
3. Intervention
■ It is the direct action and implementation of the plan.
■ It includes the collection of the data from subjects.
4. Evaluation
■ Analysis of the data as well as the examination of the effects of
interventions based on the data. Includes the interpretation of the results,
the degree to which positive outcome has occurred and whether the
result can be generalized. It may also generate additional hypothesis or
may even lead to the generation of a nursing theory.
Concepts
(Watson's language had been used)
Personhood (Human Being).

A leaf, a drop, a crystal, a moment in time is related to the whole and partakes of the
perfection of the whole"
(Ralph Waldo Emerson)
■ Person is viewed holistically wherein the body, mind, and soul are
interrelated; each part a reflection of the whole, yet the whole is greater
than and different from the sum of parts (Watson, 1979, 1989).
■ The person possesses three spheres of being-body, mind, and soul.
■ The human being is..."a valued person in and of him or herself to be
cared for, respected, nurtured, understood and assisted; a fully functional
integrated self."
■ The soul fully participates in healing. We need to continue to explore the
spiritual, nonphysical, inner, and extrasensory (beyond the five senses)
realms to learn of the dynamic and creative energy currents of the soul's
existence and to learn of the inner healing journey toward wholeness
(Watson, 1999).
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Healing Space and Environment
■ The nurse's role in the environment:

"Attending to supportive, protective and or corrective mental, physical,
societal, and spiritual environments" (Watson, 1979, p.10)
■ Watson's early emphasis on environment focused on stress, comfort,
privacy, safety, and clean aesthetic surroundings--- a much limited focus
than her more recent work (Watson, 1979, 1985).
■ More recently, Watson (1999, 2005) broadened her focus from the
immediate environment to an energetic, vibrational field integral with the
person.
■ The nurse becomes the environment in which "sacred space" is created.
■ This environment promotes the intentional healing role of architecture (or
surroundings) alongside conscious, intentional caring, healing modalities.
■ Conscious attention to healing space shifts the health care facility from
being simply a place for bodies to be treated to a place in which there is
conscious promotion of Mind body spirit wholeness; attention to the
relationship between stress and illness; hospital stress factors; and
acknowledgment of the key role that emotions and the senses play in
healing.
■ Through the intentional introduction of arts, music, color, smell, views of
nature, mythology, ritual, and symbol as expressions of humanity and
culture, healing spaces can assist in transcending illness, pain, and
suffering.
■ Watson describes a caring/love that radiates in a concentric circle from
self, to others, the community and planet, and the universe. Yet, she
recognizes the environmental challenges to concepts of caring, including
diminishing workforce; admission of more acute patients with complex
needs; cultural differences; economic factors; and organizational, social,
and health care policy. All influence the amount and quality of time a
nurse has with her client/patients (Watson, 1999, 2005).
■ According to Watson, caring (and nursing) has existed in every society. A
caring attitude is not transmitted from generation to generation. It is
transmitted by the culture of the profession as a unique way of coping
with its environment.
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Health, Illness, and Disease
■ Healing and wholeness become the starting points, the midpoints, and
the open endings for the ongoing, evolving and unfolding of the human
condition" (Watson, 1999, p.97).
■ Health is redefined as the unity and harmony within the body, mind, and
soul - harmony between self and others and between self and nature and
openness to increased possibility.
■ Health is a process of adapting, coping, and growing throughout life and
is associated with the degree of congruence between self as perceived
and self as experienced.
■ Health focuses on physical, social, aesthetic, and moral realms and is
viewed as consciousness and a human-environmental energy field as
part of the new cosmology (Watson, 1989, 1999).
■ Health reflects a person's basic striving to actualize the real self and
develop the spiritual essence of self (Watson, 1988a).
■ Health is a search to connect with deeper meanings and truths and to
"embrace the near and far in the instant and to seize the tangible,
manifestly real, and the divine" (Watson, 1999a).
■ Illness is a subjective turmoil or disharmony within a person's inner self or
soul at some level of disharmony within spheres of mind, body, and soul.
■ Illness connotes a felt incongruence within the person such as
incongruence between the self as experienced (Watson, 1985, 1988).
■ Illness can lead to disease but they are not necessarily on a continuum.
■ Disease is associated with disharmony between the person and the
environment or nature.
■ Within the transpersonal caring relationship and the caring moment, there
is healing potential.
■ The agent for change in terms of healing is the person's internal mental-
spiritual consciousness, which allows the self to be healed.
Transpersonal Nursing-Caring-Healing
■ Nursing's goal is to help persons gain a higher degree of harmony within

the mind body sprit, which generates self-knowledge, self-reverence, self-
healing, and self-care processes while allowing for diversity and
possibility.
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■ The greater "the degree of genuineness and sincerity" of the nurse within
the context of the caring act, the greater the efficacy of caring (Watson,
1985, p.69)
■ The nurse pursues this goal through transpersonal caring, relationship,
and the human care process and responds to persons' subjective worlds
in such a way that individuals can find meaning in their existence through
exploring the meaning of their disharmony, suffering, and turmoil within
the lived experience.
■ This exploration promotes self-knowledge, self-control, self-love, choice
based on subjective intent, and self-determination.
■ Watson emphasizes the act of helping persons while preserving their
dignity and worth regardless of their external and environmental situation
(Watson, 1979, 1985, 1999, 2005).
■ "Caring science is an evolving-philosophical-ethical-epistemic field of
study that is grounded in the discipline of nursing and informed by related
fields (Watson and Smith, 2002, p.456).
■ Caring science allows nurses and others to approach the sacred in
caring- helping work (Watson, 2005).
■ Within a framework of caring sciences, compassionate human service
and caring is motivated by love. The general goal is mental-spiritual
evolution for self and others as well as discovery of inner power and self-
control through caring.
■ Shifting the focus from illness, diagnosis, and treatment to human caring,
healing and promoting spiritual health potentiates health, healing, and
transcendence (Watson, 1999).
■ As the essence of nursing, "caring is the most central and unifying focus
for nursing practice" (Watson, 1988a, p.53).
■ "Caring and love are the most universal, the most tremendous, and the
most mysterious of cosmic forces; they comprise the primal and universal
psychic energy" (p.32).
■ Caring as an ethic and moral ideal, encourages the nurse to hold or
attempt to hold the conscious intent to preserve wholeness; potentiate
healing; and preserve dignity, integrity, and life-generating processes at
the level of human nature and universe (Watson, 1999).
■ According to Watson, a single caring moment becomes a moment of
possibility.
"Transpersonal describes an intersubjective, human-to-human

relationship that encompasses two unique individuals, both the
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nurse and the patient, in a given moment. Simultaneously the

relationship transcends the two subjectivities, connecting to other
higher dimensions of being and a higher/deeper consciousness that
accesses the universal field and planes of inner wisdom, the human
spirit realm" (p.115).
■ Watson notes that the transpersonal caring moment honors the premise
that
"The power of love, faith, compassion, caring community, and
intention, consciousness and access to a deeper/higher energy
source, etc... one's God, are as significant sources of healing as
our conventional treatment approaches, and may indeed be more
powerful in the long run" (p.115).
■ On the whole, Watson defines nursing as

"A human science of people and human health-illness experiences
that are mediated by professional, personal, scientific, esthetic and
ethical human transactions"
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3. Benner’s Stages of Nursing Expertise Nursing Philosophies
Patricia Benner (1989)
Proposed the "Primacy of Caring Model". She believed that caring is central to the
essence of nursing. Caring creates the possibilities for coping and creates possibilities
for connecting with and concern for others. Benner described systematically five stages
of skill acquisition in nursing practice - novice, advanced beginner, competent, proficient
and expert (From Novice to Expert Model).
• Novice. A nursing student who has not experienced enough real situations
make judgments about them. Performance is limited.
• Advanced Beginner. Has marginally acceptable performance. Has experienced
enough real situations to make a judgment. Consciously and deliberately plans
nursing care.
• Competent. Has been in a similar job situation for 2 to 3 years. Has
organizational and planning activities.
• Proficient. Has 3 to 5 years experience in a similar job situation. Has holistic
understanding and perception of the client. Perceives situation as a whole.
• Expert. Has intuitive and analytic ability in new situations. Performance is fluid.
Is flexible. No longer requires rules or guidelines to understand current situation.
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Patricia Benner
BIOGRAPHY
Patricia Benner (August 1942-Present) is American Nursing Theorist from Hampton,

Virginia. She was born on January 01, 1942 in Hampton, Virginia. Patricia Sawyer
Benner is a nursing theorist academic and author. She is known for one of her books
From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Benner
described the stages of learning and skill acquisition across the careers of nurses
applying the Dreyfus model of skill acquisition to nursing practice. Benner is a professor
emerita at the University of California San Francisco School of Nursing.
EARLY LIFE
Patricia Benner was born Patricia Sawyer in August 1942 in Hampton, Virginia.
Benner, her parents and her two sisters moved to California when she was a child. Her
parents were divorced when she was in high school, which she described as a difficult
event for her entire family.
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EDUCATION
Patricia Benner is a Professor in the Department of Physiological Nursing in the School

of Nursing at the University of California, San Francisco. Dr. Benner received her
bachelor's degree in nursing from Pasadena College, her master's degree in medical
surgical nursing from the University of California, San Francisco, and the Ph.D. from the
University of California, Berkeley, in Stress and Coping and Health under the direction
of Hubert Dreyfus and Richard Lazarus.
PERSONAL LIFE
Patricia Benner is the author of nine books including From Novice to Expert, named an
American Journal of Nursing Book of the Year for nursing education and nursing
research in 1984, and The Primacy of Caring, co-authored with Judith Wrubel, named
Book of the Year in 1990, also in two categories. Her books have been translated into
eight languages. Her most recent books are: Interpretative Phenomenology:
Embodiment, Caring and Ethics in Health and Illness, and The Crisis of Care, with
Susan Philips, both published in 1994, Expertise in Nursing Practice: Caring, Clinical
Judgment, and Ethics, with Christine Tanner and Catherine Chesla, also named a Book
of the Year in 1996, and Caregiving, with Suzanne Gordon and Nel Noddings, also
published in 1996. Published in December, 1998, is Clinical Wisdom and Interventions
in Critical Care: A Thinking-In Action Approach, with Pat Hooper-Kyriakidis and Daphne
Stannard (W.B. Saunders)
Dr. Benner is an internationally noted researcher and lecturer on health, stress and
coping, skill acquisition and ethics. Her work has had wide influence on nursing both in
the United States and internationally, for example in providing the basis for new
legislation and design for nursing practice and education for three states in Australia.
She was recently elected an honorary fellow of the Royal College of Nursing. Her work
has influence beyond nursing in the areas of clinical practice and clinical ethics.
She has been a staff nurse in the areas of medical-surgical, emergency room, coronary
care, intensive care units and home care. Currently, her research includes the study of
nursing practice in intensive care units and nursing ethics.
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Overview of Patricia Benner's Philosophy in Nursing
Benner proposed seven domains of nursing practice which are as follows:

1. The helping role.
2. The teaching-coaching function.
3. The diagnostic and patient-monitoring function.
4. Effective management of rapidly changing situations.
5. Administering and monitoring therapeutic interventions and regimens.
6. Monitoring and ensuring the quality of health care practices.
7. Organizational and work-role competencies.
Benner's Domains of Nursing Practice
1. The Helping Role Domain

▪ This includes competencies related to establishing a healing relationship,
providing comfort measures, and inviting active patient participation and
control in care.
2. The Teaching-Coaching Function Domain

▪ This includes timing, readying patients for learning, motivating, change,
assisting with lifestyle alterations, and negotiating agreement on goals.
3. The Diagnostic and Patient-Monitoring Function Domain

▪ This refers to competencies in ongoing assessment and anticipation of
outcomes.
4. The Effective Management of Rapidly Changing Situations Domain

▪ This includes the ability to contingently match demands with resources
and to assess and manage care during crisis situations.
5. The administering and Monitoring Therapeutic Interventions and

Regimens Domain
▪ This includes competencies related to preventing complications during
drug therapy, wound management and hospitalization.
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6. The Monitoring and Ensuring the Quality of Health Care Practices

Domain
▪ This includes competencies with regard to maintenance of safety,
continuous quality improvement, collaborative and consultation with
physicians, self-evaluation, and management of technology.
7. The Organizational and Work-Role Competencies Domain

▪ This includes competencies in priority setting, team building, coordinating,
and providing for continuity.
■ According to Benner, clinical nursing requires theoretical knowledge and

practical knowledge. Theoretical knowledge can be acquired in an abstract
fashion through reading, observing or discussing. On the other hand, the
development of practical knowledge requires actual experience in a situation
because it is contextual and transactional.
■ In this interpretative phenomenological perspective, the body is indispensable

for intelligent behavior rather than getting in the way of thinking and
reasoning. According to Dreyfus (1992), the following are three areas that
underlie all intelligent behavior:
1. The role of the body in organizing and unifying our experience of objects.
2. The role of situation in providing a background against which behavior can be
orderly without being rule-like.
3. The role of human purposes and needs in organizing the situation so that
objects are recognized as relevant and accessible.
■ Finally intuition, rather than being mystical, is defined as immediate situation

recognition (Dreyfus & Dreyfus, 1986). This definition is based on
MerleauPonty's ideas that "the body allows for attunement, fuzzy recognition
of problems, and for moving in skillful, agentic, embodied ways" (Benner,
1995, p.31). Intuition functions on a background understanding of prior similar
and dissimilar situations and depends on the performer's capacity to be
confident in and trust his or her perceptual awareness.
■ Benner avers that clinical reasoning is necessarily reasoning in transition, and
the intuitive powers of understanding and recognition only set up the condition
of possibility for confirmatory testing or a rapid response to a rapidly changing
clinical situation" (p.673).
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■ Practice and theory are seen as interrelated and interdependent.

■ Brykcznski furthered Benner's work and continued the articulation of the
competencies of the nursing practice.
■ Excerpts from Brykczynski's (1998) study of peer-identified expert staff nurses
can be used to depict the connections between descriptions of practical
knowledge and descriptions of competencies of nursing practice.
Domains and Competencies of Peer-identified Expert Staff Nurses
Domain: The Diagnostic and Monitoring Function

Areas of Skilled Practice
■ Detecting and documenting significant changes in a patient's condition
■ Providing an early warning signal:
Anticipating breakdown and deterioration prior to explicit confirming
diagnostic signs
Anticipating problems: Future think
■ Understanding the particular demands and experiences of an illness:
Anticipating patient care needs
■ Assessing the patient's potential for wellness and for responding to
various treatment strategies
■ Thinking critically about data collection
Domain: The Health role of the Nurse

■ The healing relationship: Creating a climate for an establishing a
commitment to healing, establishing rapport, managing conflicts
■ Providing comfort measures and preserving personhood in the face of
extreme breakdown.
■ Presencing: Being with a patient.
■ Maximizing the patient's participation and control in his/her own
health/illness, care, existential advocacy (Gadow, 1980).
■ Interpreting kinds of pain and selecting appropriate strategies for pain
management and pain control.
■ Providing comfort and touch communication through providing
emotional and informational support to patients' families.
■ Maximizing the family's role in care.
■ Normalizing the situation.
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■ Managing frustrations when limited options constrain the ability to help.

■ Participating in significant intimate life events.
■ Healing through communicating.
Domain: Organization and Work-role Competencies

■ Coordinating, ordering, and meeting multiple patients needs and
requests: Setting priorities.
■ Orchestrating the whole situation, contingency management.
■ Providing for continuity and discharge planning.
■ Building and maintaining a therapeutic team to provide optimum
therapy, conflict management.
■ Coping with staff shortages and high turnover.
Contingency planning.
Anticipating and preventing periods of extreme work overload.
Using and maintaining team spirit: gaining social support from other
nurses.
Maintaining a caring attitude toward patients even in absence of
close and frequent contact.
■ Making the bureaucracy respond to patients' and families' needs.
■ Coaching other nurses; role-modeling.
Domain: Administering and monitoring Therapeutic Interventions and

Regimens
■ Starting and maintaining intravenous therapy with minimal risks and
complications.
■ Administering medications accurately and safely: Monitoring untoward
effects, reactions, therapeutic responses, toxicity, and incompatibilities.
■ Combating the hazards of immobility: Preventing and intervening with
skin breakdown, ambulating and exercising patients to maximize
mobility and rehabilitation, preventing respiratory complications.
■ Creating a wound management strategy that fosters healing, comfort,
and appropriate drainage.
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Domain: Monitoring and Ensuring the Quality of Healthcare Practices

■ Providing a back-up system to ensure safe medical and nursing care.
■ Formulating own perspective on what should be done and using this as
a yardstick for interpreting the course of events.
■ Maintaining environmental safety: attending to principles of asepsis,
infection control, body mechanics, and general safety.
■ Participating in Continuous Quality Improvement monitoring and
evaluation for safety, efficiency, effectiveness and cost containment.
■ Monitoring documentation for quality and accuracy.
■ Assessing what can be safety omitted from or added to medical orders.
■ Getting appropriate and timely responses from physicians.
■ Using physician consultation effectively.
■ Collaborative consultation-"Dr. shopping".
■ Self-monitoring and seeking consultation as necessary.
■ Giving constructive feedback to physicians and other care providers to
ensure safe care practices.
■ Critically evaluating and incorporating relevant research into practice.
■ Managing technology, preventing unnecessary technological
intrusions.
Domain: The Teaching-Coaching Function of the Nurse

■ Timing: Capturing a patient's readiness to learn.
■ Motivating a patient to change.
■ Assisting patients to integrate the implications of their illnesses and
recovery into their lifestyles.
■ Assisting patient to alter their lifestyles to meet changing healthcare
needs and capacities: Teaching for self-care.
■ Eliciting an understanding of the patient's interpretation of his/her
illness.
■ Negotiating agreement about how to proceed when priorities of patient
and provider conflict.
■ Providing an interpretation of the patient's condition and giving a
rationale for procedures.
■ The coaching function: Making culturally avoided and uncharted health
and illness experiences approachable and understandable.
■ Guiding a patient through emotional and developmental change.
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■ Providing new options, closing off old ones: Channeling, teaching,

mediating:
Acting as a psychological and cultural mediator.
Using goals therapeutically.
Working to build and maintain a therapeutic community.
■ Debriefing with patient after rounds.
Domain: Effective Management of Rapidly Changing Situations

Areas of Skills Practice
■ Skilled performance in extreme life-threatening emergencies: Rapid
grasp of a problem.
■ Identifying and managing a patient crisis until physician assistance is
available.
■ Contingency management: Rapid matching of demands and resources
in emergency situations.
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4. Eriksson’s Caritative Caring Theory
Katie Eriksson
(Theory of Caritative Caring)
Eriksson has been a guide and visionary who has gone before and “ploughed new
furrows” in theory development for many years. Eriksson’s caritas-based theory and her
whole caring science thinking have developed over the course of 30 years.
Characteristic of her thinking is that while she is working at an abstract level developing
concepts and theory, the theory is rooted in clinical reality and teaching. The whole
caritative theory and the caring that are built up around the theoretical core get their
distinctive character and deeper meaning. The ultimate goal of caring is to alleviate
suffering and serve life and health. Knowledge formation, which Eriksson sees as a
hermeneutic spiral, starts from the thought that ethics precedes ontology. In a concrete
sense, this implies that the thought of human holiness and dignity is always kept alive in
all phases of the search for knowledge. Ethics precedes ontology in theory as well as in
practice. Eriksson’s caring science tradition and discipline of caring science form a basis
for the activity at the Department of Caring Science at Åbo Akademi University.
Eriksson’s caritative caring theory and the discipline of caring science have inspired
many in the Nordic countries, and they are used as the basis for research, education,
and clinical practice. Many of her original textbooks, published mainly in Swedish, have
been translated into Finnish, Norwegian, and Danish.
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Katie Eriksson
BIOGRAPHY
Katie Eriksson was born on November 18, 1943, in Jakobstad, Finland. She
belongs to the Finland Swedish minority in Finland, and her native language is
Swedish.
EDUCATION
Katie Eriksson is a 1965 graduate of the Helsinki Swedish School of Nursing, and in
1967, she completed her public health nursing specialty education at the same
institution. She graduated in 1970 from the nursing teacher education program at
Helsinki Finnish School of Nursing. She continued her academic studies at University of
Helsinki, where she received her MA degree in philosophy in 1974 and her licentiate
degree in 1976; she defended her doctoral dissertation in pedagogy (The Patient Care
Process—An Approach to Curriculum Construction within Nursing Education: The
Development of a Model for the Patient Care Process and an Approach for Curriculum
Development Based on the Process of Patient Care) in 1982 (Eriksson, 1974, 1976,
1981).
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CAREER
Katie Eriksson was appointed Docent of Caring Science (part time) at University of
Kuopio, the first docentship in caring science in the Nordic countries. She was
appointed Professor of Caring Science at Åbo Akademi University in 1992. Between
1993 and 1999, she held a professorship in caring science at University of Helsinki,
Faculty of Medicine, where she has been a docent since 2001. Since 1996, she has
also served as Director of Nursing at Helsinki University Central Hospital, with
responsibilities for research and development of caring science in connection with her
professorship at Åbo Akademi University. Eriksson’s scientific career and professional
experience comprise two periods: the years 1970 to 1986 at Helsinki Swedish School of
Nursing, and the period from 1986, when she founded the Department of Caring
Science at Åbo Akademi University, which she has directed since 1987. Eriksson has
been a very popular guest and keynote speaker, not only in Finland, but in all the Nordic
countries and at various international congresses. Eriksson served as chairperson of the
Nordic Academy of Caring. Eriksson’s caritative theory of caring came into clearer focus
internationally in 1997, when the IAHC for the first time arranged its conference in a
European country. Science from 1999 to 2002. Eriksson has produced an extensive list
of textbooks, scientific reports, professional journal articles, and short papers. Her
publications started in the 1970s and include about 400 titles. Some of her publications
have been translated into other languages, mainly into Finnish. Vårdandets Idé [The
Idea of Caring] has been published in Braille. Her first English translation, The Suffering
Human Being [Den Lidande Människan], was published in 2006 by Nordic Studies
Press in Chicago.
AWARDS
Katie Eriksson has received many awards and honors for her professional and
academic accomplishments. In 1975, she was nominated to receive the 3M-ICN
(International Council of Nurses) Nursing Fellowship Award in Finland; in 1987, she
received the Sophie Mannerheim Medal of the Swedish Nursing Association in Finland;
and in 1998, she received the Caring Science Gold Mark for academic nursing care at
Helsinki University Central Hospital. Also in 1998, she received an Honorary Doctorate
in Public Health from the Nordic School of Public Health in Gothenburg, Sweden. Other
awards include the 2001 Åland Islands Medal for caring science and the 2003 Topelius
Medal, instituted by Åbo Akademi University for excellent research. In 2003, she was
honored nationally as a Knight, First Class, of the Order of the White Rose of Finland.
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Overview of Katie Eriksson’s Theory of Caritative Caring
Caritas
 Caritas means love and charity. In caritas, eros and agapé are united, and
caritas is by nature unconditional love.
 Caritas, which is the fundamental motive of caring science, also constitutes the
motive for all caring. It means that caring is an endeavor to mediate faith, hope,
and love through tending, playing, and learning.
Caring Communion
 Caring communion constitutes the context of the meaning of caring and is the
structure that determines caring reality.
 Caring gets its distinctive character through caring communion (Eriksson, 1990).
It is a form of intimate connection that characterizes caring. Caring communion
requires meeting in time and space, an absolute, lasting presence (Eriksson,
1992c).
 Caring communion is characterized by intensity and vitality, and by warmth,
closeness, rest, respect, honesty, and tolerance. It cannot be taken for granted
but presupposes a conscious effort to be with the other.
 Caring communion is seen as the source of strength and meaning in caring.
The Act of Caring
 The act of caring contains the caring elements (faith, hope, love, tending, playing,
and learning), involves the categories of infinity and eternity, and invites to deep
communion. The act of caring is the art of making something very special out of
something less special.
Caritative Caring Ethics
 Caritative caring ethics comprises the ethics of caring, the core of which is
determined by the caritas motive. Eriksson makes a distinction between caring
ethics and nursing ethics. She also defines the foundations of ethics in care and
its essential substance.
 Caring ethics deals with the basic relation between the patient and the nurse—
the way in which the nurse meets the patient in an ethical sense.
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Dignity
 Dignity constitutes one of the basic concepts of caritative caring ethics. Human
dignity is partly absolute dignity, partly relative dignity.
 Absolute dignity is granted the human being through creation, while relative
dignity is influenced and formed through culture and external contexts.
 A human being’s absolute dignity involves the right to be confirmed as a unique
human being (Eriksson, 1988, 1995, 1997a).
Invitation
 Invitation refers to the act that occurs when the carer welcomes the patient to the
caring communion. The concept of invitation finds room for a place where the
human being is allowed to rest, a place that breathes genuine hospitality, and
where the patient’s appeal for charity meets with a response (Eriksson, 1995;
Eriksson & Lindström, 2000).
Suffering
 Suffering is an ontological concept described as a human being’s struggle

between good and evil in a state of becoming. Suffering implies in some sense
dying away from something, and through reconciliation, the wholeness of body,
soul, and spirit is re-created, when the human being’s holiness and dignity
appear. Suffering is a unique, isolated total experience and is not synonymous
with pain (Eriksson, 1984, 1993).
Suffering Related to Illness, to Care, and to Life
 These are three different forms of suffering. Suffering related to illness is

experienced in connection with illness and treatment. When the patient is
exposed to suffering caused by care or absence of caring, the patient
experiences suffering related to care, which is always a violation of the patient’s
dignity. Not to be taken seriously, not to be welcome, being blamed, and being
subjected to the exercise of power are various forms of suffering related to care.
In the situation of being a patient, the entire life of a human being may be
experienced as suffering related to life (Eriksson, 1993, 1994a; Lindholm &
Eriksson, 1993).
The Suffering Human Being
 The suffering human being is the concept that Eriksson uses to describe the
patient. The patient refers to the concept of patiens (Latin), which means
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“suffering.” The patient is a suffering human being, or a human being who suffers
and patiently endures (Eriksson, 1994a; Eriksson & Herberts, 1992).
Reconciliation
 Reconciliation refers to the drama of suffering. A human being who suffers wants
to be confirmed in his or her suffering and be given time and space to suffer and
reach reconciliation. Reconciliation implies a change through which a new
wholeness is formed of the life the human being has lost in suffering. In
reconciliation, the importance of sacrifice emerges (Eriksson, 1994a). Having
achieved reconciliation implies living with an imperfection with regard to oneself
and others but seeing a way forward and a meaning in one’s suffering.
Reconciliation is a prerequisite of caritas (Eriksson, 1990).
Caring Culture
 Caring culture is the concept that Eriksson (1987a) uses instead of environment.
It characterizes the total caring reality and is based on cultural elements such as
traditions, rituals, and basic values. Caring culture transmits an inner order of
value preferences or ethos, and the different constructions of culture have their
basis in the changes of value that ethos undergoes.
Major Assumptions
Eriksson distinguishes between two kinds of major assumptions: axioms and theses.
She regards axioms as fundamental truths in relation to the conception of the world;
theses are fundamental statements concerning the general nature of caring science,
and their validity is tested through basic research. Axioms and theses jointly constitute
the ontology of caring science and therefore also are the foundation of its epistemology
(Eriksson, 1988, 2001). The caritative theory of caring is based on the following axioms
and theses, as modified and clarified from Eriksson’s basic assumptions with her
approval (Eriksson, 2002).
The axioms are as follows:
The human being is fundamentally an entity of body, soul, and spirit.

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

The basic motive of caring is the caritas motive.
The basic category of caring is suffering.
Caring communion forms the context of meaning of caring and derives its
origin from the ethos of love, responsibility, and sacrifice, namely, caritative
ethics.
Health means a movement in becoming, being, and doing while striving for
wholeness and holiness, which is compatible with endurable suffering.
Caring implies alleviation of suffering in charity, love, faith, and hope. Natural
basic caring is expressed through tending, playing, and learning in a sustained
caring relationship, which is asymmetrical by nature.
The Human Being
The conception of the human being in Eriksson’s theory is based on the axiom
that the human being is an entity of body, soul, and spirit (Eriksson, 1987a,
1988).
She emphasizes that the human being is fundamentally a religious being, but all
human beings have not recognized this dimension.
The human being is fundamentally holy, and this axiom is related to the idea of
human dignity, which means accepting the human obligation of serving with love
and existing for the sake of others. Eriksson stresses the necessity of
understanding the human being in his ontological context.
The human being is seen as in constant becoming; he is constantly in change
and therefore never in a state of full completion. He is understood in terms of the
dual tendencies that exist within him, engaged in a continued struggle and living
in a tension between being and nonbeing.
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Eriksson sees the human being’s conditional freedom as a dimension of

becoming.
According to Eriksson (1987b), the human being we meet in care is creative and
imaginative, has desires and wishes, and is able to experience phenomena;
therefore, a description of the human being only in terms of his needs is
insufficient.
Nursing
Love and charity, or caritas, as the basic motive of caring has been found in
Eriksson (1987b, 1990, 2001) as a principal idea even in her early works.
The caritas motive can be traced through semantics, anthropology, and the
history of ideas (Eriksson, 1992c).
The history of ideas indicates that the foundation of the caring professions
through the ages has been an inclination to help and minister to those suffering
(Lanara, 1981).
Caritas constitutes the motive for caring, and it is through the caritas motive that
caring gets its deepest formulation. This motive, according to Eriksson, is also
the core of all teaching and fostering growth in all forms of human relations. In
caritas, the two basic forms of love—eros and agapé (Nygren, 1966)—are
combined. When the two forms of love combine, generosity becomes a human
being’s attitude toward life and joy is its form of expression.
Caritas constitutes the inner force that is connected with the mission to care. A
carer beams forth what Eriksson calls claritas, or the strength and light of
beauty.
The core of the caring relationship, between nurse and patient as described by
Eriksson (1993), is an open invitation that contains affirmation that the other is
always welcome. The constant open invitation is involved in what Eriksson
(2003) today calls the act of caring.
Environment
Eriksson uses the concept of ethos in accordance with Aristotle’s (1935, 1997)
idea that ethics is derived from ethos.
In Eriksson’s sense, the ethos of caring science, as well as that of caring,
consists of the idea of love and charity and respect and honor of the holiness and
dignity of the human being. Ethos is the sounding board of all caring.
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Ethos is ontology in which there is an “inner ought to,” a target of caring “that has
its own language and its own key” (Eriksson, 2003, p. 23).
Good caring and true knowledge become visible through ethos. Ethos originally
refers to home, or to the place where a human being feels at home. It symbolizes
a human being’s innermost space, where he appears in his nakedness (Lévinas,
1989). Ethos and ethics belong together, and in the caring culture, they become
one (Eriksson, 2003).
Eriksson has described three different forms: suffering related to illness, suffering
related to care, and suffering related to life (Eriksson, 1993, 1994a, 1997a).
Health
Eriksson considers health in many of her earlier writings in accordance with an

analysis of the concept in which she defines health as soundness, freshness,
and well-being. The subjective dimension, or well-being, is emphasized strongly
(Eriksson, 1976).
In the current axiom of health, health implies being whole in body, soul, and
spirit. Health means as a pure concept wholeness and holiness (Eriksson, 1984).
In accordance with her view of the human being, Eriksson has developed various
premises regarding the substance and laws of health, which have been summed
up in an ontological health model. She sees health as both movement and
integration.
As a human being’s inner health potential is touched, a movement occurs that
becomes visible in the different dimensions of health as doing, being, and
becoming with a wholeness that is unique to human beings (Eriksson, Bondas-
Salonen, Fagerström, et al., 1990).
In doing, the person’s thoughts concerning health are focused on healthy life
habits and avoiding illness; in being, the person strives for balance and
harmony; in becoming, the human being becomes whole on a deeper level of
integration.
Importance
Eriksson’s work on developing her caritative caring theory for 30 years has been
successful, and particularly in the Nordic countries there is abundant evidence
that her thinking is of great importance to clinical practice, research, and
education, and also to the development of the caring discipline.
By her development of the caritative theory of care, Eriksson created her own
caring science tradition, a tradition that has grown strong and has set the tone for
nursing advancement and caring science.
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NURSING CONCEPTUAL MODELS
1. Roger’s Science of Unitary Human Beings Nursing Conceptual Model
Martha Rogers (1970)

Conceptualized the "Science of Unitary Human Beings". To Rogers, unitary man is an
energy field in constant interaction with the environment. She asserted that human
beings are more than and different from the sum of their parts; the distinctive properties
of the whole are significantly different from those of its parts. Furthermore, she believed
that human being is characterized by the capacity for abstraction and imagery,
language and thought, sensation and emotion.
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Martha Rogers
BIOGRAPHY
Martha Elizabeth Rogers (May 12, 1914 – March 13, 1994) was an American
nurse, researcher, theorist, and author widely known for developing the Science of
Unitary Human Beings and her landmark book, An Introduction the
Theoretical Basis of Nursing.
She believes that a patient can never be separated from their environment when
addressing health and treatment. Her knowledge about the coexistence of the
human and his or her environment contributed a lot in changing toward better health.
EARLY LIFE
Martha Rogers was born on May 12, 1914, sharing a birthday with Florence
Nightingale. She was the eldest of four children of Bruce Taylor Rogers and Lucy
Mulholland Keener Rogers. She had a thirst for knowledge at an early age. She found
Kindergarten to be “terribly exciting” and had a love and passion for books that her
parents fostered. Her father introduced her to the public library at the age of 3, where
she loved story time. She liked to go off by herself with a book. And by the fourth grade,
she had read every book in her school library. She used to go to the public library
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before I was 6, even before she could read. She was well acquainted with the public
library and started reading eight books at a time. Her father used to be bothered if she
was skimming, but he, later on, discovered that the young Rogers was learning fast.
In fact, Rogers already knew the Greek alphabet by age 10. By the sixth grade, she
already finished reading all 20 volumes of The Child’s Book of Knowledge and was into
the Encyclopedia Britannica.
She also loved to read various topics like anthropology, archaeology, cosmology,
ethnography, astronomy, ethics, psychology, eastern philosophy, and aesthetics. By her
senior year, she had completed all the high school math courses and took a college-
level algebra course where she was the only female in the class.
EDUCATION
Initially, Martha Rogers wanted to do something that would hopefully contribute to social
welfare like law and medicine. However, she only studied medicine for a couple of years
because women in medicine were not particularly desirable during her time. Instead,
along with her friend, Rogers entered a local hospital that had a school of nursing. But
just like Nightingale, her parents weren’t really any happier over that decision than they
had between over medicine. She then transferred to Knoxville General Hospital’s
nursing program and was one of 25 students in her class. She described her training as
at times as being miserable because the training was like the “Army, pre-Nightingale.”
She even spent a week at home, thinking of not returning to school but eventually
enjoyed working with people and patients.
Rogers received her nursing diploma from the Knoxville General Hospital School of
Nursing in 1936, then earned her Public Health Nursing degree from George Peabody
College in Tennessee in 1937. She sold her car to pay for tuition and entered a Master’s
degree program full-time.
Her Master’s degree was from Teachers College at Columbia University in 1945, and
her Doctorate in Nursing was given to her from Johns Hopkins University in Baltimore in
1954. She completed her studies in 1954, and the title of her dissertation was “The
association of maternal and fetal factors with the development of behavior problems
among elementary school children.”
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WORKS
Martha Rogers wrote three books that enriched the learning experience and influenced
nursing research for countless students: Educational Revolution in Nursing
(1961), Reveille in Nursing (1964).
In about 1963, Rogers edited a journal called Nursing Science. During that time, Rogers
was beginning to formulate ideas about the publication of her third book, An Introduction
to the Theoretical Basis of Nursing (1970), the last of which introduced the four
Rogerian Principles of Homeodynamics.
Her publications include Theoretical Basis of Nursing (1970), Nursing Science and Art:
A Prospective (1988), Nursing: Science of Unitary, Irreducible, Human Beings Update
(1990), and Vision of Space-Based Nursing (1990).
AWARDS AND HONORS
Martha Rogers was honored with numerous awards and citations for her sustained
contributions to nursing and science. In 1996, she was posthumously inducted into
the American Nurses Association’s Hall of Fame.
THEORY
Martha Rogers’ theory is known as the Science of Unitary Human Beings (SUHB).
The theory views nursing as both a science and an art as it provides a way to view the
unitary human being, who is integral with the universe. The unitary human being and his
or her environment are one. Nursing focuses on people and the manifestations that
emerge from the mutual human-environmental field process.
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Overview of Roger's "Science of Unitary Human Beings"
 Nursing is considered as an art and a science.

 The science of nursing is "a body of abstract knowledge emerging from
scientific research and logical analysis." (Rogers, 1970, p.86).
 The emergent knowledge is translated into nursing practice.
 Nursing is a science because the term nursing signifies a body of knowledge.
 According to Rogers' model, there are several assumptions regarding the

nature of nursing, which are as follows:
1. Nursing science is an organized body of abstract scientific knowledge

that develops from research and analysis. This science of nursing helps
explain the human experience (Rogers, 1970).
2. Nursing is learned profession and therefore must be based on solid
scientific information.
3. Emphasis on "the essentials, potentials, and possibilities that exist within
the wholeness of life". This provides the foundation for outlining practice.
Theoretical structures that subsequently guide practice and research are
formulated.
4. Formulated knowledge is to be used creatively for human betterment
(Rogers, 1970). Nursing knowledge provides the tools for the emergent
artistic application for nursing care of the unitary human beings. Nurse
uses this scientific knowledge to care for and improve the lived
experience of the unitary human being. Nursing is the creative use of
nursing knowledge in caring for the unitary human being.
• Roger's model contends that the human being and the environment are
energy fields that are irreducible and equal to more than the sum of their parts.
• The unitary human being and the environment are integral and therefore are
viewed as a whole. This wholistic perspective differentiates nursing from other
sciences and identifies nursing focus.
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• Nursing's focus is the care of people and the life process of human beings. Its
purpose is to identify and examine the phenomenon that is central to its
concern, the unitary human being.
• Nursing aims to accompany people while they achieve their maximum health
potential. Maintenance and promotion of health, prevention of disease, nursing
diagnosis, intervention, and rehabilitation encompasses the scope of nursing.
• "Professional practice in nursing seeks to promote symphonic interaction
between human and environmental fields, to strengthen the integrity of the
human field, and to direct and redirect patterning of the human and
environment fields for realization of maximum potential." (Rogers, 1972,
p.122).
• The life process of the unitary human being is one of wholeness and continuity
as well as dynamic and creative change. Health and illness are viewed as
pattern manifestations and as continuous expression of the life process.
• The following basic characteristics that describe the basic life process in
human are proposed:
a. Energy field
b. Openness
c. Pattern
d. Pandimensionality
• Other concepts that provide clarity to the basic precepts of the Rogerian model
include: the unitary human being, environment, and homeodynamic principles.
•
A. ENERGY FIELD
■ Energy is the "potential for process, movement, and change." (Leddy,
203 p.21).
■ The energy field is the conceptual boundary of all that is.
■ The energy field is the fundamental unit of both the living and the
nonliving. This energy field provides a way to perceive people and their
environment as irreducible wholes." (Rogers, 1986, p.4).
■ The energy field continuously varies in intensity, density, and extent.
B. OPENNESS
■ The human field and the environment field are constantly exchanging
energy. There are no boundaries or barriers to inhibit energy flow
between fields (Rogers, 1970).
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■ "The human beings openly participate in energy transformation with the

environment creating mutual change." (Leddy, 2004, p. 16).M
C. PATTERN
■ Pattern is defined as the distinguishing characteristic of an energy field
perceived as a single wave. Roger calls it "an abstraction" that gives
identity to the field."
■ Patterning "is the dynamic or active process of the life of the human
being" that is "accessible to the senses." (Alligood and Fawcett, 2004,
p.11).
■ Pattern manifestations include "a person's experiences, expressions,
perceptions, and physical, mental, social and spiritual data." (Davidson,
001, p. 103)
D. PANDIMENSIONALITY
■ "A nonlinear domain without spatial or temporal attributes." (Rogers,
1990, p.7)
■ The parameters in language that humans use to describe events are
arbitrary.
■ The present is relative, there is no temporal ordering of lives.
E. HOMEODYNAMIC PRINCPLES
■ The principles of homeodynamics postulate the way of perceiving unitary
human beings.
■ The fundamental unit of the living system is an energy field.
■ The three principles of homeodynamics as proposed by Rogers are:
(1) resonancy, (2) helicy, (3) integrality. These principles describe the
nature of the person/environment process involving change and
growth.
1. Resonancy
The intensity of change, embraces the continuous variability of the human
energy field as it evolves.
"An ordered arrangement of rhythms characterizing both human field and
the environmental field that undergoes continuous dynamic
metamorphosis in the human-environment process."
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2. Helicy
Describes the unpredictable but continuous, nonlinear evolution of energy
fields as evidenced by nonrepeating rhythmicities.
The life process evolves in sequential stages along a curve that has the
same general shape.
The principle of helicy postulates an ordering of the human's evolutionary
emergence.
3. Integrality
Encompasses the mutual, continuous relationship of the human energy
field and the environment energy field.
Change occurs by continuous repatterning of the human and
environmental fields by resonance waves.
The fields are one and integrated but unique to each other.
"Helicy is the nature of change, integrality is the process by which change takes
place, and resonancy is how change takes place." (Philips, 1994, p.15).
HUMAN
ENVIRONMENTAL FIELD
FIELD
Conceptualization of human/environmental energy field

(From Bultemeier, K., 1993)
Human/Environmental Energy Field Characteristics
OPENNESS PATTERN PANDIMENSIONALITY
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Assumptions/Principles
RESONANCY HELICY INTEGRALITY
Concepts
• Person (Unitary human being)

■ A unitary human being is an "irreducible, indivisible, pan- dimensional (four-
dimensional) energy field identified by pattern and manifesting characteristics
that are specific to the whole and which cannot be predicted from knowledge
of the parts," a unified whole having its own distinctive characteristics which
cannot be perceived by looking at describing, or summarizing the parts"
■ The person has the capacity to participate knowingly in the process of
change.
• Environment
■ The environment is an "irreducible pan- dimensional energy field identified by
pattern and integral with the human field."
■ The field coexist and are integral. Manifestation emerges from this field and
are perceived.
• Health
■ Rogers defined health as an expression of the life process: they are the
"characteristics and behavior emerging out of the mutual, simultaneous
interaction of the human and environment fields".
■ Health and illness are the part of the same continuum.
■ The multiple events taking place along life's axis denote the extent to which
man is achieving his maximum health potential and vary in their expressions
from greatest health to those conditions which are incomparable with the
maintaining life process.
• Nursing
■ The concept Nursing encompasses two dimensions:
Independent science of nursing
➢ An organized body of knowledge which is specific to nursing is
arrived at by scientific research and logical analysis.
Art of nursing practice
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➢ The creative use of science for the betterment of the human.

➢ The creative use of its knowledge is the art of its practice.
■ Nursing is a learned profession: it is a science and art.

■ Nursing is the study of unitary, irreducible, indivisible human and environment
energy fields.
■ The art of nursing involves the imaginative and creative use of nursing
knowledge.
■ The purpose of nurses is to promote health and well-being for all persons and
groups wherever they are using the art and science of nursing.
■ The health services should be community based.
■ Rogers challenges nurses to consider nursing needs of all people including
future generation of space kind: as life continuous to evolve from earth to
space and beyond.
■ Her view provides a different world view that encompasses a practice of
nursing for the present time and for the imagined and for the yet to be
imagined future.
■ Rogers envisions a nursing practice of noninvasive modalities, such as
therapeutic touch, humor, guided imagery, use of color, light, music,
medication focusing on health potential of the person.
■ Professional practice in nursing seeks to promote symphonic interaction
between man and environment, to strengthen the coherence and integrity of
the human field, and to direct and redirect patterning of the human and
environmental fields for realization of maximum health.
Assumptions about people and nursing

■ Nursing exists to serve people.......it is the direct and overriding responsibility
to the society.
■ The safe practice of nursing depends on the nature and amount of scientific
nursing knowledge the individual brings to practice...the imaginative,
intellectual judgment with which such knowledge is made in service to the
mankind.
■ People needs knowledgeable nursing.
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2. Orem’s Self-Care Deficit Model
Dorothea Orem (1970, 1985)

Developed the "Self-Care and Self-Care Deficit Nursing Theory". She defined self-
care as "the practice of activities that individuals initiate and perform on their own
behalf in maintaining life, health and well-being."
She conceptualized three nursing systems as follows:
1. Wholly Compensatory: when the nurse is expected to accomplish all the

patient's therapeutic self-care or to compensate for the patient's inability to
engage in self-care or when the patient needs 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 to learn self-care.
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Dorothea Orem
BIOGRAPHY
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.”
EARLY LIFE
Dorothea Orem was born on July 15, 1914, in Baltimore, Maryland. Her father was a
construction worker, and her mother is a homemaker. She was the youngest among two
daughters.
In the early 1930s, she earned her nursing diploma from the Providence Hospital
School of Nursing in Washington, D.C. She completed her Bachelor of Science in
Nursing in 1939 and her Masters of Science in Nursing in 1945, both from the Catholic
University of America in Washington, D.C.
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EDUCATION
Dorothea Orem attended Seton High School in Baltimore and graduated in 1931. She
received a diploma from the Providence Hospital School of Nursing in Washington,
D.C., in 1934. She went on to the Catholic University of America to earn a B.S. in
Nursing Education in 1939 and an M.S. in Nursing Education in 1945.
She had a distinguished career in nursing. She earned several Honorary Doctorate
degrees. She was given Honorary Doctorates of Science from Georgetown University in
1976 and Incarnate Word College in 1980. She was given an Honorary Doctorate of
Humane Letters from Illinois Wesleyan University in 1988 and a Doctorate Honoris
Causa from the University of Missouri in Columbia in 1998.
WORKS
Dorothea Orem helped publish the “Guidelines for Developing Curricula for the
Education of Practical Nurses” in 1959. In 1971 Orem published Nursing:
Concepts of Practice, the work in which she outlines her nursing theory, the Self-
care Deficit Theory of Nursing. This work’s success and the theory it presents
established Orem as a leading theorist of nursing practice and education. She also
served as chairperson of the Nursing Development Conference Group, and in 1973
edited that group’s work in the book Concept Formalization in Nursing. She authored
many other papers and, during the 1970s and 1980s, spoke at numerous conferences
and workshops around the world. The International Orem Society was founded to foster
research and the continued development of Orem’s nursing theories. The second
edition of Nursing: Concept of Practice was published in 1980. Orem retired in 1984, but
she continued to work on the third edition, published in 1985; the fourth edition of her
book was completed in 1991. She continued to work on the conceptual development of
Self-Care Deficit Nursing Theory.
AWARDS AND HONORS

Dorothea Orem was also given many awards during her career: the Catholic University
of America Alumni Achievement Award for Nursing Theory in 1980, the Linda Richards
Award from the National League for Nursing in 1991, and an Honorary Fellow of the
American Academy of Nursing in 1992.
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Overview of Orem's "Self-Care Deficit Nursing Theory" (SCDNT)
 Nursing practice oriented by the SCDNT represents a caring approach that

uses experiential and specialized knowledge (Science) to design and produce
nursing care (Art).
 The body of knowledge that guides the art and science incorporates empirical
and antecedent knowledge (Orem, 1995).
 Empirical knowledge is rooted in experience and addresses specific events
and related conditions that have relevance for health and well- being. It is
empirical knowledge that supports observations, interpretations of the meaning
of those observations, and correlations of the meaning with potential courses
of action.
 Antecedent knowledge includes previously mastered knowledge and identified
fields of knowledge, conditions, and situations.
 Orem (1955) Identified eight fields of knowledge essential for understanding
nursing practice. These include: (1) sociology, (2) profession/occupation, (3)
jurisprudence, (4) history, (5) ethics, (6) economics, (7) administration,
and (8) nursing science – the knowledge about nursing practice created by
nurses through scientific investigations that yield an understanding of the field
of nursing and provide foundations for nursing practice.
 Orem's general theory of nursing is expressed in three related parts:
A. Theory of Self-Care
B. Theory of Self-Care Deficit
C. Theory of Nursing Systems
A. Theory of Self-Care
This theory includes:
1. Self-Care. Practice of activities that individuals initiate and perform
independently on their behalf in maintaining life, health, and well-being.
2. Self-Care Agency. Is a human ability which is the "ability for engaging in
self-care activities" - conditioned by age, developmental state, life
experience, sociocultural orientation, health, and available resources.
3. Therapeutic Self-Care Demand. "Totality of self-care actions to be
performed for some duration in order to meet self-care requisites by using
valid methods and related sets of operations and actions."
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4. Self-Care Requisites. Actions directed towards provision of self-care.

The three categories of self-care requisites are: (1) universal, (2)
developmental, and (3) health deviation.
1. Universal self-care requisites

Associated with life processes and the maintenance of the
integrity of human structure and functioning.
Common to all, ADL (activities of daily living)
Identify these requisites as:
a. Maintenance of sufficient intake of air, water, food
b. Provision of care associated with elimination process
c. Balance between activity and rest, between solitude and
social interaction
d. Prevention of hazards to human life and well being
e. Promotion of human functioning.
2. Developmental self-care requisites)

Associated with developmental processes, derived from a
condition, or associated with an event.
Examples: Adjusting to a new job
Adjusting to body changes
3. Health deviation self-care requisites

Required in conditions of illness, injury or disease. These
include:
a. Seeking and securing appropriate medical assistance.
b. Being aware of and attending to the effects and results of
pathologic conditions.
c. Effectively carrying out medically prescribed measures.
d. Modifying self-concepts in accepting oneself as being in a
particular state of health and in specific forms of health care.
e. Learning to live with effects of pathologic conditions.
B. Theory of Self-Care Deficit

o Specific when nursing is needed because the person cannot carry out
self-care.
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o Nursing is required when an adult (or in the case of a dependent, the

parent) is incapable or limited in the provision of continuous effective self-
care.
o Orem identified 5 methods of helping:
1. Acting for and doing for others
2. Guiding others
3. Supporting another
4. Providing an environment to promote patient's ability.
5. Teaching another
C. Theory of Nursing Systems

o Describes how the patient's self-care needs will be met by the nurse, the
patient or both.
o Identifies 3 classifications of nursing systems to meet the self-care to
requisites of the patient:
1. Wholly compensatory system
2. Partially compensatory system
3. Supportive-educative system
1. Wholly Compensatory System. The patient is dependent. The

nurse is expected to accomplish all the patient's therapeutic
self- care or to compensate for the patient's inability to engage
in self- care or when the patient needs continuous guidance in
self-care.
Examples:
a. The patient is unconscious because he had stroke
(Cerebrovascular accident). The nurse provides total
care for the patient feeding, hygiene, turning, elimination,
suctioning of secretions to maintain effective respiration,
promoting safety, providing exercises of joints and body
parts.
b. The patient has paralysis of his four extremities
(quadriplegia) because of spinal cord injury after falling
from the roof of their house. The patient will be
dependent on the nurse's care for his needs air, water,
food, elimination, activity/rest, solitude/social interaction,
prevention of hazards, promotion of normalcy, maintain
developmental environment, prevent/manage
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developmental threats, maintenance of health status,

awareness/management of disease process, adherence
to medical regimen, awareness of potential problems,
modify self-image to incorporate changed health status,
adjust lifestyle to accommodate health status changes
and medical regimen.
2. Partially Compensatory System. The patient can meet some

needs. Needs nursing assistance. Both the nurse and the
patient engage in meeting self-care needs.
Examples:
a. The patient fell from the stairs in his school and had
fracture of his right leg, His leg is now on cast. The
patient can do self- care activities like eating, drinking,
but needs assistance with bathing, toileting transfer and
mobility until he learns how to use crutches properly.
b. The patient had undergone surgery (appendectomy) a
day ago. He has slight fever (temperature is 37.7°C), still
in pain and needs analgesic to relieve the pain. He is
advised to still remain in bed but may be out of bed this
afternoon. He is still on NPO (nothing by mouth). The
patient can do self-care activities like changing position in
bed, but needs nursing care for relief of pain and fever,
assistance for ambulating in the afternoon, assistance for
hygienic measures.
3. Supportive-educative System. The patient can meet self-care

requisites, but needs assistance with decision making or
knowledge and skills to learn self-care.
Examples:
a. The patient is pregnant for the first time. The physician
told her that her pregnancy is normal. The patient is
capable of self-care but she needs to learn self-care for
pregnancy -nutrition, activity/rest/exercise, relief of
common discomfort of pregnancy, schedule for prenatal
check-up, labor and delivery, postpartum care, baby
care.
b. The patient had been newly diagnosed to have diabetes
mellitus. The patient is capable of self-care but she
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needs self-care knowledge on how to live well with

diabetes- nutrition, activity/exercise, self-monitoring of
blood glucose, footcare, prevention of complications,
medications.
o SCDNT involves four structured cognitive operations as follows:

(1) Diagnostic
(2) Prescriptive
(3) Regulatory
(4) Control
CONCEPTS
o Person (Human Being, Nursing Client). A total being with universal,

developmental needs and capable of continuous self-care.
■ A unity that can function biologically, symbolically and socially.
■ Has the capacity to reflect, symbolize, and use symbols.
■ A nursing client is a human being who has "health related/health
derived limitations that render him incapable of continuous self- care or
dependent care or limitations that results in ineffective/incomplete care.
■ A human being is the focus of nursing only when self-care requisites
exceed self-care capabilities.
o Environment. Components are environmental factors, environmental

elements, conditions, and developmental environment.
o Health. When human beings are structurally and functionally whole or
sound.
■ Wholeness or integrity includes that which makes a person human
operating in conjunction with physiological and psychophysiological
mechanisms and a material structure and in relation to and interacting
with other human beings.
o Nursing. Is an art, a helping service, and a technology.
■ Actions deliberately selected and performed by nurses to help
individuals or groups under their care to maintain or change conditions
in themselves or their environment
■ Encompasses the patient's perspective of health condition, the
physician's perspective, and the nursing perspective.
■ The goal of nursing is to render the patient or members of his family,
capable of meeting the patient's self-care needs:
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a. To maintain a state of health

b. To regain normal or near normal state of health in the event of
disease or injury
c. To stabilize control or minimize the effects of chronic poor
health or disability.
■ A nursing problem is deficit in universal, developmental, and health
derived or health related conditions.
■ Nursing therapeutics are deliberate, systematic and purposeful actions.
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3. King’s General Systems Framework Nursing Conceptual Framework
Imogene King (1971, 1981)

Postulated the "Systems Framework and Goal Attainment Theory". She
described nursing as a helping profession that assists individuals and groups in
society to attain, maintain, and restore health. If this is not possible, nurses help
individuals die with dignity. In addition, King viewed nursing as an interaction
process between client and nurse whereby during perceiving, setting goals, and
acting on them, transactions occur and goals are achieved.
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Imogene King
BIOGRAPHY
Imogene Martina King (January 30, 1923 – December 24, 2007) was one of the
pioneers and most sought nursing theorists for her Theory of Goal
Attainment, which she developed in the early 1960s. Her work is being taught to
thousands of nursing students worldwide and is implemented in various service
settings.
As a recognized global leader, King truly made a positive difference for the nursing
profession with her significant impact on nursing’s scientific base. She made an
enduring impact on nursing education, practice, and research while serving as a
consummate, active leader in professional nursing.
EARLY LIFE
Imogene King was born on Jan. 30, 1923, in West Point, Iowa. During her early high
school years, she decided to pursue a career in teaching. However, her uncle, the town
surgeon, offered to pay her tuition to nursing school. She eventually accepted the offer,
seeing nursing school as a way to escape life in a small town. Thus began her
remarkable career in nursing.
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EDUCATION
Imogene King excelled in her nursing studies even though it was not her first choice to
consider. In 1945, she received a nursing diploma from St. John’s Hospital School of
Nursing in St. Louis, Missouri.
While working in various staff nurse roles, King started coursework toward a Bachelor of
Science in Nursing Education, which she received from St. Louis University in 1948. In
1957, she received a Master of Science in Nursing from St. Louis University.
She went on to study with Mildred Montag as her dissertation chair at Teacher’s
College, Columbia University, New York and received her EdD in 1961.
CAREER AND APPOINTMENTS

After receiving her diploma in 1945, Imogene King worked in a variety of staff nurse
roles. From 1947 to 1958, she worked as an instructor in Medical-Surgical nursing and
was an assistant director at St. John’s Hospital School of Nursing. King developed a
master’s degree program in nursing based on a nursing conceptual framework from
1961 to 1966 at Loyola University in Chicago. Her first theory article appeared in 1964
in the journal Nursing Science, which nurse theorist Martha Rogers edited.
Under Jessie Scott, King served as an Assistant Chief of Research Grants Branch,
Division of Nursing at the U.S. Department of Health, Education, and Welfare between
1966 and 1968. While King was in Washington, DC, her article “A Conceptual Frame of
Reference for Nursing” was published in Nursing Research (1968).
In 1969, King conducted a World Health Organization nursing research seminar in
Manila, Philippines, where she met Midori Sugimori of Japan. From then on, the two
nurses kept in touch. Sugimori translated King’s two theory books into Japanese, and
the books strongly influenced nursing education in Japan. The doctoral dissertation of
Tomomi Kameoka tested the theory of goal attainment in Japan. King was present
when Kameoka presented her research at the honor society’s 2001 Biennial
Convention. King was a long-time member of the American Nurses Association (ANA),
first with the Missouri Nurses Association, and she was also active in Illinois and Ohio.
Upon her move to Tampa, Florida, she became a Florida Nurses’ Association (FNA)
member and FNA District 4, Tampa. King held offices such as the Florida Nurses
Foundation president, served on the FNA and the FNA District IV boards, and was a
delegate from the FNA to the ANA House of Delegates.
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Overview of Imogene King's "Conceptual System and Theory of

Goal Attainment"
King's conceptual system is based on the assumption that human beings are
the focus of nursing. The goal of nursing is health promotion maintenance,
and/or restoration; care of the sick or injured; and care of the dying (King,
1992).
King states that "nursing's domain involves human beings, families, and
communities as a framework within which nurses make transactions in
multiple environments with health as a goal" (p.61)
The link between interactions and health is behavior, or human acts. Nurses
must have the knowledge and skill to observe and interpret behavior and
intervene in the behavioral realm to assist individuals and groups cope with
health, illness, and crisis (King, 1981)
Human beings have three 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, and
(3) the need for care when human beings are unable to help
themselves.
Propositions of King's Theory
From the theory of goal attainment King developed predictive propositions,

which include:
■ If perceptual interaction accuracy is present in nurse-client interactions,
transaction will occur
■ If nurse and client make transaction, goal will be attained
■ If goals are attained, satisfaction will occur
■ If transactions are made in nurse-client interactions, growth and
development will be enhanced
■ If role expectations and role performance as perceived by nurse and
client are congruent, transaction will occur
■ If role conflict is experienced by nurse or client or both, stress in nurse-
client interaction will occur
■ If nurse with social knowledge and skill communicate appropriate
information to client, mutual goal setting and goal attainment will occur.
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King's conceptual framework includes three interacting systems namely: (a)

personal system, (b) interpersonal system, and (c) social system.
A. Personal Systems
■ Individuals are personal systems (King, 1981). Each individual is an open,
total, unique system in constant interaction with the environment.
■ The following concepts provide foundational knowledge that contributes to
understanding individuals as personal systems:
1. Perception
2. Self
3. Growth and development
4. Body image
5. Space
6. Time
■ Perception. "A process of organizing, interpreting, and transforming

information from sense data and memory" (King, 1981, p.24)
■ Self: "The self is a composite of thoughts and feelings which constitute a
person's awareness of his/her individual existence, his/her conception of who
and what he/she is. A person's self is the sum total of all he/she can call
his/hers. 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" (Jersild, 1952, pp 9-10).
■ Growth and development. "The processes that take place in an individual's
life that help the individual move from potential capacity for achievement to
self-actualization (King, 1981, p.31).
■ Body image. "An individual's perceptions of his/her own body, others' reaction
to his/her appearance which results from others' reactions to self" (King,
1981, pp33)
■ Learning. "A process of nursing perception, conceptualization, and critical
thinking involving multiple experiences in which changes in from concepts,
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skills, symbols, habits, and values can be evaluated in observable behaviors

and inferred from behavioral manifestation" (King, 1986, p.24).
■ Time. "Duration between the occurrence of one event and occurrence of
another event" (King, 1981, p.24).
■ Personal space. "Existing in all directions and is the same everywhere"
(King, 1981, p. 37).
■ Coping. "The constantly changing cognitive and behavioral efforts to manage
specific external and internal demands that are appraised as taxing or
exceeding the resources (Lazarus and Folkman, 1984, p.141). This definition
seemed very consistent with King's view of stress and individuals.
B. Interpersonal Systems
■ Two or more individuals in interaction form interpersonal systems (King,
1981). As the member of individuals increases, so does the complexity of the
interaction. King's process of nursing occurs primarily within the interpersonal
systems between the nurse and patient.
■ Concepts critical to understanding interactions between individuals are as
follows:
1. Communication
2. Interaction
3. Role
4. Stress
5. Stressors
6. Transaction
■ Communication. "Information processing, a change of information from one

state to another" (King, 1981, p.69)
■ Interaction. "Acts of two or more persons in mutual presence" (King, 1981,
p.85).
■ Role. "Set of behaviors expected when occupying a position in a social
system (King, 1981, p.93).
■ Stress. "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 (King, 1981, p.98)
■ Stressors. "Events that produce stress (King, 1981)
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■ Transaction. "Observable behaviors of human beings interacting with their

environment" (King, 1981, p.147).
C. Social Systems
■ Social systems are composed of large groups with common interests or
goals.
■ A social system is "an organized boundary system of social role, behaviors
and practices developed to maintain values and the mechanisms to regulate
the practice and rules (King, 1981, p.115).
■ Examples of social systems include health care settings, workplaces,
educational institutions, religious organizations, and families (King, 1981).
■ 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:
1. Organization
2. Authority
3. Power
4. Status
5. Decision making
■ Organization. "A system whose continuous activities are conducted to

achieve goals" (King, 1981, p.119)
■ Authority. "Transactional process characterized by active, reciprocal
relations in which members' values, backgrounds, and perceptions play a role
in defining, validating, and accepting the (directions) of individuals within an
organization (King, 1981, p.124).
■ Power. "The capacity or ability of a group to achieve goals" (King, 1981,
p.124)
■ Status. "The position of an individual in a group or a group in relation to other
groups in an organization" (King, 1981, p.129).
■ Decision making. "Dynamic and systematic process by which a goal-
directed choice of perceived alternatives is made, and acted upon, by
individuals or groups to answer a question and attain a goal" (King,1981,
p.132).
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Overall assumptions of King's Conceptual System are as follows:
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 health care.
5. Goals of health professionals and recipients of health care may not be
congruent.
Theory of Goal Attainment
■ Basic assumption of goal attainment theory is that nurse and client

communicate information, set goal mutually and then act to attain those
goals. This is also the basic assumption of nursing process.
Assessment
■ King indicates that assessment occur during interaction. The nurse brings
special knowledge and skills whereas client brings knowledge of self and
perception of problems of concern, to this interaction.
■ During assessment nurse collects data regarding client (his/her growth and
development perception of self and current health status, roles, etc.)
■ Perception is the base for collection and interpretation of data.
■ Communication is required to verify accuracy of perception, for interaction
and transaction.
Nursing diagnosis
■ The data collected by assessment are used to make nursing diagnosis in

nursing process. According to King, in process of attaining goal the nurse
identifies the problems, concerns and disturbances about which person seeks
help.
Planning
■ After diagnosis, planning for interventions to solve those problems is done.

■ In goal attainment, planning is represented by setting goals and making
decisions about and being agreed on the means to achieve goals.
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■ This part of transaction and client's participation is encouraged in making

decision on the means to achieve goals.
Implementation
■ In nursing process implementation involves the actual activities to achieve

goals.
■ In goal attainment it is the continuation of transaction.
Evaluation
■ It involves the finding out whether goals are achieved or not.

■ In King's description, evaluation speaks about attainment of goal and
effectiveness of nursing care.
Nursing Process and Theory of Goal Attainment
Nursing process method Goal Attainment theory

A system of oriented actions A system of oriented concepts
Assessment Perception, communication interaction of
nurse and client
Planning Decision making about the goals
Agree on the means to attain the goals
Implementation Transaction made
Evaluation Goal attained
Concepts
1. Human being/person: is social being who is rational and sentient.

Person has ability to:
■ Perceive
■ Think
■ Feel
■ Choose
■ Set goals
■ Select means to achieve goals
■ And to make decision
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According to King, human being has three fundamentals needs:

■ The need for the health information that is available at the time when it
is needed and can be used.
■ The need for care that seek to prevent illness, and
■ The need for care when human beings are unable to help themselves.
2. Environment
Environment is the background for human interactions. It involves:
■ (a) Internal environment: transforms energy to enable person to
adjust to continuous external environmental changes.
■ (b) External environment: involves formal and informal
organizations. The nurse is a part of the patient's environment.
3. Health
■ According to King, health involves dynamic life experiences 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 potential for daily living.
4. Nursing
Nursing: is defined as "A process of action, reaction and interaction by which

nurse and client share information about their perception in 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."
■ Action: is defined as a sequence of behaviors involving mental and
physical actions.
■ Reaction: not specified, but might be considered as included in the
sequence of behaviors described in action.
■ In addition, King discussed:
Goal
Domain and
Functions and professional nurse
■ Goal of nurse: "To help individuals to maintain their health so they can
function in their roles".
■ Domain of nurse: "includes promoting, maintaining, and restoring
health, and caring for the sick, injured and dying.
■ Function of professional nurse. "To interpret information in nursing
process to plan, implement and evaluate nursing care.
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4. Neuman’s System Model
Betty Neuman (1982, 1989, 1992)
Proposed the "Health Care Systems Model." She asserted that nursing is a
unique profession in that it is concerned with all the variables affecting an individual's
response to stresses, which are intra- (within the individual), inter- (between one or
more other people), and extrapersonal (outside the individual) in nature. The
concern of nursing is to prevent stress invasion, to protect the client's basic structure
and to obtain or maintain a maximum level of wellness. The nurse helps the client,
through primary, secondary and tertiary prevention modes, to adjust to
environmental stressors and maintain client stability.
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Betty Neuman
BIOGRAPHY
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.
EARLY LIFE
Betty Neuman was born in 1924 near Lowell, Ohio. She grew up on a farm which later
encouraged her to help people who are in need. Her father was a farmer who became
sick and died at the age of 36. Her mother was a self-educated midwife that led the
young Neuman to be always influenced by the commitment that took her away from
home from time to time. She had one older brother and a younger brother, which makes
her the middle child among her siblings. Her love for nursing started when she took care
of her father, which later created her compassion in her chosen career path.
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EDUCATION
As a young girl, she attended the same one-room schoolhouse that her parents had
attended and were excited to go to a high school library. She was always engaged and
fascinated with the study of human behavior. During World War II, she had her first job
as an aircraft instrument technician. In 1947, she received her RN Diploma from
Peoples Hospital School of Nursing, Akron, Ohio.
CAREER
Betty Neuman moved to California and worked in various capacities as a hospital

nurse and head nurse at Los Angeles County General Hospital, school nurse, industrial
nurse, and clinical instructor at the University of Southern California Medical Center, Los
Angeles.
In 1957, she received a baccalaureate degree in public health and psychology with
honors. Amidst her hectic life as a nurse, she also managed to work as a fashion model
and learned to fly a plane. She got married, supported her husband’s medical practice,
and had their daughter in 1959. She also earned a master’s degree in mental health,
public health consultation in 1966 from the University of California, Los Angeles (UCLA).
After her graduation, she was hired as a department chair in the UCLA School of
Nursing graduate program. Neuman developed the first community mental health
program for graduate students in the LA area from 1967 to 1973.
In 1985, Betty Neuman concluded a doctoral degree in clinical psychology at Pacific
Western University. She was a pioneer of nursing involvement in mental health. She
and Donna Aquilina were the first two nurses to develop the nurse counselor role within
community crisis centers in Los Angeles.
Neuman persisted in starting a private practice as a marriage and family therapist,
specializing in Christian counseling. She is a Fellow of the American Association of
Marriage and Family Therapy and the American Academy of Nursing. Until 2009, she
was the Neuman Systems Model Trustees Group, Inc. that she established in 1988 and
still attends as a consultant. The Trustees Group was created to preserve and maintain
the message of her nursing theory for the health care community.
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AWARDS AND HONORS
Betty Neuman has done many things, including a nurse, educator, health counselor,
therapist, author, speaker, and researcher. Throughout the years, she earned many
awards and honors, including several honorary doctorates, and was an honorary
member of the American Academy of Nursing. The profound effect of her work on the
nursing profession is well known throughout the world.
■ Honorary Doctorate of Letters, Neumann College, Aston, PA (1992)
■ Honorary Member of the Fellowship of the American Academy of Nursing
(1993)
■ Honorary Doctorate of Science, Grand Valley State University, Michigan
(1998)
She was honored by President Richard Jusseaume and Provost Dr. Laurence Bove
with the Walsh University Distinguished Service Medal, which is awarded to those who
have contributed outstanding professional or voluntary service to others within the
national, regional or local community.
In an annual Nursing Research Day sponsored by Walsh’s Phi Eta Chapter of Sigma
Theta Tau, Byers School of Nursing Dean Dr. Linda Linc granted Neuman with the first
annual Neuman Award, named in her honor, for outstanding service in the nursing
profession.
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.
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Overview of Neuman's "Systems Model"
 The aim of the Neuman model "...is to set forth a structure that depict the parts
and subparts and their interrelationships for the whole of the client as a complete
system" (Neuman, 2002 p.11).
 The Neuman's systems model has two major components--- stress and
reactions to stress.
 The client in the Neuman's model is viewed as an open system in which repeated
cycles of input, process, output, and feedback, constitute a dynamic
organizational pattern. The client may be an individual, a group, a family, a
community, or an aggregate.
Assumptions in the Neuman's Systems Model
1. Though each individual client or group as a client system is unique, each

system is a composite of common known factors in innate characteristics
within a normal, given range of response contained within a basic structure.
2. Many known, unknown, and universal environmental 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---
physiological, psychological, sociocultural, developmental, and spiritual 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 a single stressor or combination of
stressors.
3. Each individual client/client system, overtime, has evolved a normal range of

response to the environment that is referred to as a normal line of defense, or
usual wellness/stability state.
4. When the cushioning, accordion like effect of 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. The
interrelationships of variable physiological, psychological, sociocultural,
developmental, and spiritual – determine the nature and degree of the system
reaction or possible reaction to the stressor invasion.
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5. The client, whether in a state of wellness or illness, is a dynamic composite of

the interrelationships of variables - physiological, psychological, sociocultural,
developmental, and spiritual. Wellness is on a continuum of available energy
to support the system in its optimal state.
6. Implicit within each client system is a set of internal resistance factors, known
as lines of resistance (resources), which function to stabilize and return the
client to the usual wellness state (normal line of defense) or possibly to as
higher level of stability following an environmental stressor reaction.
7. Primary prevention relates to general knowledge that is applied in the client

assessment and intervention in identification and reduction or mitigation of
risk factors associated with environmental stressors to prevent possible
stressor reaction.
8. Secondary prevention relates to symptomatology following a reaction to

stressors, appropriate ranking of intervention priorities, and treatment to
reduce their noxious effects.
9. Tertiary prevention relates to the adjustive processes taking place as

reconstitution begins and maintenance factors move the client back in a
circular manner toward primary prevention.
10. The client is in dynamic constant energy exchange with the environment
Major Concepts of Neuman's Systems Model
■ Neuman's model concentrates on explaining a person's reaction to stressors

in the environment. Six major concepts are used to describe this
phenomenon. The major concepts in the phenomenon are the client,
variables, environment, stressors, wellness, and nursing intervention.
■ The major aspects of the Neuman's Systems Model are as follows:
(1) The basic structure and energy resources
(2) Physiological, psychological, sociocultural, developmental,
and spiritual variables
(3) Lines of resistance
(4) Normal line of defense
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(5) Flexible line of defense

(6) Stressors
(7) Reaction
(8) Primary, secondary, and tertiary prevention
(9) Inter- and extrapersonal factors
(10) Reconstitution
client System
The Neuman Systems Model Client System. (From Neuman, B., & Fawcett, J.
(2002). The Neuman Systems Model. (4th ed., p. 15). Upper Saddle River, NJ:
Prentice Hall.)
■ A series of concentric circles surrounding a core, or basic structure, depicts the
client system in the Neuman's model. Each line of defense or resistance has
certain distinct properties, but the main function is to protect the basic structure
and help maintain the system in a stable state.
■ In Neuman's model, the term client is synonym for the nursing metaparadigm
concept "person". The term client indicates a collaborative relationship between
caregiver and care receiver and focuses on the wellness perspective of the
model.
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■ Neuman defines client as "an unlimited entity with an active personality system
whose evolution follows principles, symbolism, and systematic organizations...It
is not always possible to see the potential expansions of this entity and the
ramifications of its actions" (Neuman, 1989, p.11).
■ In Neuman model, the client can be defined as any system that interacts with the
environment. Therefore, the client maybe defined as an individual, family, group,
or community.
■ Because Neuman believes the client to be open, the relationship of the client to
the environment is reciprocal. Therefore, the client both influences and is
influenced by the environment. For example, if a non-smoker works in an office
surrounded by smokers, the individual will be influenced by the environment.
He/she may have increased risk in respiratory illness due to inhalation of
secondary smoke. However, if the nonsmoker circulates a petition to designate
smoking and nonsmoking sections within the office environment, he or she is
influencing the environment to decrease the stressors.
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Betty Neuman's Systems Model

I. Person Variables
Each layer of the concentric circle of the Neuman's model is made up
of five person variables, which are as follows:
1. Physiological Variable. Refers to the "physiochemical structure and function

of the body" (Neuman, 2002, p.16).
Examples:
a. Individual system. Circulation as reflected by vital signs, peripheral
pulses, heart sounds, skin color, skin temperature.
b. Community system. Reflected as vital statistics, morbidity, mortality,
and general environmental health (Hassel, 1998)
2. Psychological Variable. Refers to the "mental processes and emotions."

(Neuman, 2002. p. 16)
Example:
Self-esteem and its effect on relationships for the individual and
communication patterns for a family.
3. Developmental Variable. Refers to those processes related to development

over the lifespan.
Examples:
a. "Empty Nest Syndrome" adjustment for aging parents as their children
move out of the home and establish their own families. This may be
manifested by: unhappiness with life and the lifestyle that may have
provided them with happiness for many years; boredom with people
and things that may have been of interest to them before; feeling a
need for adventure and change; questioning the choices, they have
made in their lives and the validity of decisions they made; confusion
about who they are and where they are going; anger at their spouse
and blame for feeling tied down; unable to make decisions about
where they want to go with their life; doubt that they ever loved their
spouse and resentment over the marriage; a desire for a new and
passionate, intimate relationship.
b. "Sandwich generation" among middle adults as they are caught
between the responsibilities of caring for dependent children and those
of caring for aging and ailing parents.
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4. Sociocultural Variable. Refers to the relationships; and social and cultural

expectations and activities.
Examples: 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
5. Spiritual variable. Refers to the influence of spiritual beliefs.
Examples:
a. Anointing the sick or dying with oil, among Roman Catholics.
b. Avoiding scavenger fishes (shrimp, squids, crabs, fishes with scales)
among Seventh Day Adventists
c. Prohibiting blood transfusion among Jehovah's Witnesses
II. Central Core

➢ The basic structure or central core is made up of the basic "survival
factors" (Neuman, 2002, p.17).
➢ These factors include system variables, genetic features, and the
strengths and weaknesses of the system parts. Examples are hair color,
body temperature regulation ability, functioning of body systems
homeostatically, cognitive ability, physical strength, and value systems,
The person's system is an open system and therefore is dynamic and
constantly changing and evolving. Stability or homeostasis occurs when
the amount of energy that is available exceed that being used by the
system. A homeostatic body system is consistently in a dynamic process
of input, output, feedback, and compensation which leads to a state of
balance.
III. Flexible Line of Defense

➢ The flexible line of defense 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 activated. The flexible line of
defense acts as a cushion and is described as accordion-like as it
expands away from or contracts closer to the normal line of defense. The
flexible line of defense is dynamic and can be changed/ altered in
relatively short period of time.
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IV. Normal Line of Defense

➢ The normal line of defense represents system stability over time. It is
considered to be the usual level of stability in the system. The normal line
of defense can change over time in response to coping or responding to
the environment. An example is the skin, which is stable and fairly
constant but can thicken into a callus over time.
V. Lines of Resistance
➢ The lines of resistance protect the basic structure and become activated
when environmental stressors invade the normal line of defense.
Example: activation of the immune response after invasion of
microorganisms.
If the lines of resistance are effective, the system can reconstitute and if
the lines of resistance are not effective, the resulting energy loss can
result in death.
VI. Reconstitution
➢ Is the increase in energy that occurs in relation to the degree of reaction to
the stressor. Reconstitution begins at any point following initiation of
treatment for invasion of stressors. Reconstitution may expand the normal
line of defense beyond its previous level, stabilize the system at a lower
level, or return it to the level that existed before the illness.
VII. Stressors
➢ The Neuman Systems Model focuses on the impact of stressors on health
and addresses stress and the reduction of stress (in the form of stressors).
Stressors are capable of having either a positive or negative effect on the
client system. A stressor is any environmental force which can potentially
affect the stability of the system; they may be:
■ Intrapersonal - occur within the person (e.g., emotions and
feelings, hypertension, low blood glucose)
■ Interpersonal - occur between individuals (e.g., role expectations,
perceptions of caregiver, friend relationships)
■ Extrapersonal - occur outside the individual (e.g., job or finance
pressures)
The person has a certain degree of reaction to any given stressor at any
given time. The nature of the reaction depends in part on the strength of
the lines of resistance and defense. By means of primary, secondary, and
tertiary interventions, the person (or the nurse) attempts to restore or
maintain the stability of the system.
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VIII. Prevention
➢ Neuman defines prevention as the primary nursing intervention.
Prevention focuses on keeping stressors and the stress response from
having a detrimental effect on the body.
■ Primary Prevention. Occurs before the system reacts to a stressor.
On one hand, it strengthens the person (primarily the flexible line of
defense) to enable him to better deal with stressors, and on the other
hand manipulates the environment to reduce or weaken stressors.
Primary prevention includes health promotion and maintenance of
wellness.
■ Secondary Prevention. Occurs after the system reacts to a stressor
and is provided in terms of existing systems. Secondary prevention
focuses on preventing damage to the central core by strengthening the
internal lines of resistance and/or removing the stressor.
■ Tertiary Prevention. Occurs after the system has been treated through
secondary prevention strategies. Tertiary prevention offers support to
the client and attempts to add energy to system or reduce energy
needed in order to facilitate reconstitution.
Concepts
A. Person
The person is a layered multidimensional being. Each layer consists of the
person variables or subsystem:
o Physical/physiological
o Psychological
o Socio-cultural
o Developmental
o Spiritual
The layers usually represented by concentric circle, consist of the central core, lines
of resistance, lines of defense, and lines of flexible defense. The basic core structure
is comprised of survival mechanism including, organ function, temperature control,
genetic structure, response patterns, ego, and what Neuman terms "knowns and
commonalities". Lines of resistance and two lines of defense protect this core. The
person may in fact be an individual, a family, a group, or a community in Neuman's
model. The person, with a core of basic structures, is seen as being in constant,
dynamic interaction with environment. Around the basic core structures are lines of
defense and the resistance shown diagrammatically as concentric circles, with the
lines. nearer to the core. The person is seen as being in a state of constant change
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and as an open-system in reciprocal interaction with the environment (i.e., affecting,

and being affected by it).
B. The Environment
The environment is seen to be the totality of the internal and external forces
which surround a person and with which they interact at any given time. These
forces include the intrapersonal, interpersonal and extrapersonal stressors which
can affect the person's normal line of defense and so can affect the stability of
the system.
■ The internal environment exists within the client system (Intrapersonal)
■ The external environment exists outside the client system (Interpersonal
and extrapersonal)
Neuman also identified a created environment which is an environment that is
created and developed unconsciously by the client and it is symbolic of system
wholeness.
C. Health
Neuman sees health as being equated with wellness. She defines
health/wellness as "the condition in which all parts and subparts (variables) are in
harmony with the whole of the client (Neuman 1995)" As the person is in a
constant interaction with the environment, the state of wellness (and by
implication any other state) is in dynamic equilibrium, rather than in any kind of
steady state. Neuman proposes a wellness-illness continuum, with the persons
position on that continuum being influenced by their interaction with the variables
and the stressors they encounter. The client system moves toward illness and
death when more energy is needed than is available. The client system moves
toward wellness when more energy is available than is needed.
D. Nursing
Neuman sees nursing as a unique profession that is concerned with all of the
variables which influence the response a person might have to stressor. The
person is seen as a whole, and it is the task of nursing to address the whole
person. Neuman defines nursing as actions which assist individuals, families and
groups to maintain a maximum level of wellness, and the primary aim is stability
of the patient/client system, through nursing interventions to reduce stressors.
Neuman states that because the nurse's perception will influence the care given,
then not only must the patient/client's perceptions be assessed, but so must
those of the caregiver (nurse). The role of the nurse is seen in terms of degrees
of reaction to stressors, and the use of primary, secondary and tertiary
interventions.
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5. Roy’s Adaptation Model
Sister Callista Roy (1979, 1984)
Presented the "Adaptation Model". She viewed each person as a unified

biopsychosocial system in constant interaction with a changing environment. She
contended that the person as an adaptive system, functions as a whole through
interdependence of its parts. The system consists of input, control processes, output
and feedback. In addition, she advocated that all people have certain needs which
they endeavor to meet in order to maintain integrity. These needs are divided into
four different modes, the physiological, self-concept, role function, and
interdependence. Accordingly, Roy believed that adaptive human behavior is
directed as an attempt to maintain homeostasis or integrity of the individual by
conserving energy and promoting the survival, growth, reproduction and mastery of
human system.
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Sister Callista Roy
BIOGRAPHY
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.
EDUCATION AND CAREER
Callista Roy received her Bachelor of Arts Major in Nursing from Mount Saint Mary’s
College in Los Angeles in 1963 and her master’s degree in nursing from the University
of California in 1966. After earning her nursing degrees, Roy began her sociology
education, receiving both a master’s degree in sociology in 1973 and a doctorate in
sociology in 1977 from California.
During her time working toward her master’s degree, Roy was challenged in a seminar
with Dorothy E. Johnson to develop a conceptual model for nursing. Roy worked as a
pediatric nurse and noticed a great resiliency of children and their ability to adapt to
major physical and psychological changes. Impressed by this adaptation, Roy worked
towards an appropriate conceptual framework for nursing.
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She developed the model’s basic concepts while she was a graduate student at the
University of California from 1964 to 1966. In 1968, she began operationalizing her
model when Mount Saint Mary’s College adopted the adaptation framework as the
nursing curriculum’s philosophical foundation.
Roy was an associate professor and chairperson of the Department of Nursing at Mount
Saint Mary’s College until 1982 and was promoted to the professor’s rank in 1983 at
both Mount Saint Mary’s College and the University of Portland. She helped initiate and
taught in a summer master’s program at the University of Portland.
She was a Robert Wood Johnson postdoctoral fellow at the University of California, San
Francisco, from 1983 to 1985 as a clinical nurse scholar in neuroscience. During this
time, she researched nursing interventions for cognitive recovery in head injuries and
the influence of nursing models on clinical decision making.
From 1987 to the present, Roy began the newly created resident nurse theorist position
at Boston College School of Nursing, where she teaches doctoral, master’s, and
undergraduate students.
In 1991, she founded the Boston Based Adaptation Research in Nursing Society
(BBARNS), which would later be renamed the Roy Adaptation Association.
Roy’s other scholarly work includes conceptualizing and measuring coping and
developing the philosophical basis for the adaptation model and nursing’s epistemology.
Roy belongs to the Sisters of St. Joseph of Carondelet.
WORKS
Sr. Callista Roy has numerous publications, including books and journal articles, on
nursing theory and other professional topics. Her works have been translated into many
languages all over the world.
Roy and her colleagues at Roy Adaptation Association have critiqued and synthesized
the first 350 research projects published in English based on her adaptation model.
Her most famous work is on the Roy adaptation model of nursing.
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AWARDS AND HONORS
Sr. Callista Roy has received numerous honors due to her work and contribution to the
nursing profession.
In 2007, Roy was named a Living Legend by the American Academy of Nursing and the
Massachusetts Registered Nurses Association.
Roy is also a Sigma Theta Tau member, and she received the National Founder’s
Award for Excellence in Fostering Professional Nursing Standards in 1981.
Among her achievements include an Honorary Doctorate of Humane Letters from
Alverno College in 1984, honorary doctorates from Eastern Michigan University (1985),
and St. Joseph’s College in main (1999).
She also received the American Journal of Nursing Book of the Year Award for the Roy
Adaptation Model Essentials.
Here are more of her awards & honors:
■ 2013 – Distinguished Graduate Award, Bishop Conaty/Our Lady of Loretto High
School
■ 2013 – Honorary Doctoral Degree, Holy Family University
■ 2013 – Alumni Award for Professional Achievement, UCLA
■ 2013 – Excellence in Nursing, The University of Antioquia, Medellin Colombia
■ 2011 – Nursing Science Quarterly Special Issue Honoring the work of Callista
Roy, Vol. 24, Num. 4, Oct. 2011
■ 2011 – Faculty Senior Scientist Poster Exemplar Award, Yvonne L. Munn
Center for Nursing Research and the Nursing Research Expo Committee,
Massachusetts General Hospital
■ 2011 – The Sigma Mentor Award, Sigma Theta Tau International Alpha Chi
Chapter
■ 2010 – University of Southern Alabama Picture Gallery of Theorist, University
of Alabama
■ 2010 – Inducted to Nurse Researcher Hall of Fame, Inaugural Class, Sigma
Theta Tau International, Honor Society of Nursing
■ 2010 – “Sixty Who have Made a Difference,” UCLA School of Nursing, 6th
Anniversary
■ 2010 – Inductee, Sigma Theta Tau International Nurse Researcher Hall of
Fame
■ 2007 – American Academy of Nursing Living Legend Award
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Overview of Roy's Adaptation Model (RAM)
■ The RAM provides a useful framework for providing nursing care for
persons in health and in acute, chronic, and terminal illness.
■ The RAM views the person as an adaptive system in constant interaction
with an internal and external environment.
■ A system is a set of parts connected to function as a whole for some
purpose.
■ The environment is the source of a variety of stimuli that either threaten or
promote the person's unique wholeness.
■ The person's major task is to maintain integrity in face of these
environmental stimuli.
■ Integrity is "the degree of wholeness achieved by adapting to changes in
needs" (Roy and Andrews, 1999, p. 102)
■ Roy categorizes environmental stimuli as focal, contextual, or residual.
o Focal stimulus is the internal or external stimulus most
immediately challenging the person's adaptation. The focal stimulus
is the phenomenon that attracts the most of one's attentions.
o Contextual stimuli are all other stimuli existing in a situation that
strengthen the effect of the focal stimulus.
o Residual stimuli are any other phenomena arising from a person's
internal or external environment that may affect the focal stimulus
but whose effects are unclear (Roy and Andrews, 1999).
■ These three types of stimuli act together and influence the adaptation
level, which is a person's "ability to respond positively in a situation"
(Andrews and Roy, 1991a, p.10).
■ A person's adaptation level may be described as integrated,
compensatory, or compromised (Roy and Andrews, 1999).
■ A person does not respond passively to environmental stimuli; the
adaptation level is modulated by a person's coping mechanisms and
control processes.
■ Roy categorizes the coping mechanisms into regulator or the cognator
subsystems.
o The coping mechanisms of the regulator subsystem occur through
neural, chemical, and endocrine processes. These are automatic
responses to stimuli.
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■ The coping mechanisms of the cognator subsystem occur through

cognitive-emotive processes - perceptual and information processing,
learning, judgment, and emotion.
■ The two control processes that coincide with the regulator and cognator
subsystem when a person responds to a stimulus are the stabilizer
subsystem and the innovator subsystem.
o The stabilizer subsystem refers to "the established structures,
values, and daily activities whereby participants accomplish the
primary purpose of the group and contribute to common purpose of
society. (Roy and Andrews, 1999, p.47).
o The innovator subsystem refers to cognitive and emotional
strategies that allow a person to change to higher levels of potential
(Roy and Andrews, 1999).
■ Roy proposed that the behavioral responses of the regulator and cognator
subsystems can be observed in any of the four adaptive modes:
1. Physiological
2. Self-concept
3. Role function
4. Interdependence
1. The physiological adaptive mode refers to the "way a person responds as

a physical being to stimuli from the environment" (Andrews and Roy, 1991a
p.15). The five physiological needs of this mode are oxygenation, nutrition,
elimination, activity and rest, and protection.
2. The self-concept adaptive mode refers to psychological and spiritual
characteristics of the person (Andrews, 1991b; Andrews and Roy, 1991a; Roy
and Andrews, 1999). A person's self-concept consists of all the beliefs and
feelings that one has formed about oneself. The self-concept is formed both
from internal perceptions and from the perceptions of others. The self-concept
changes overtime and guides one's actions.
The self-concept incorporates two components: the physical self and the
personal self. The physical self-incorporates body sensation and body
image. The personal self-incorporates self-consistency, self-ideal, and
moral-ethical-spiritual self. Psychic integrity is the goal of the self-concept
mode (Andrews, 1991b; Andrews and Roy, 1991, a).
3. The role function adaptive mode refers to the primary, secondary, or
tertiary roles the person performs in society. According to Andrews and Roy,
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"a role, as the functioning unit of society is a set of expectations about how a
person occupying one position behaves toward a person occupying another
position" (p16). Social integrity is the goal of the role function (Roy and
Andrews, 1999).
4. The interdependence adaptive mode refers to the coping mechanisms
arising from close relationship that result in "the giving and receiving of love,
respect, and value". (Andrews and Roy, 1991a p17). In general, these
contributive and receptive behaviors occur between the person and the most
significant other or between the person and his or her support system.
Affectional adequacy is the goal of the interdependence adaptive mode (Roy
and Andrews, 1999)
■ Adaptive or ineffective responses result from these coping
mechanisms.
Adaptive responses promote the integrity of the person and the goals
of adaptation
■ The major task of a person is to adapt to environmental stimuli to
achieve survival, growth, development and mastery.
■ Ineffective responses neither promote integrity nor contribute to the
goals of adaptation (Andrews and Roy, 1991a).
Concepts-Adaptation
■ Responding positively to environmental changes.
■ The process and outcome of individuals and groups who use
conscious awareness, self- reflection and choice to create human and
environmental integration.
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Environmental Modes of
Control Processes
Stressors Adaptation
(Stimuli)
(Cognator/ Physiological
regulator
subsystems) Biological
Focal Contextual
indicators
Symptom
Perception of report
symptom Effect on daily
Physiologic Contextual
distress
stress Demographic &
Perception of
Acute other data
disability Psychosocial
illness Health promotion
Perception of
Chronic activities
illness Patient
control over Self-Concept
life events Self-esteem
education
Perception Hopelessness
programs
influenced by Powerlessness
Current stress
hardiness
level
Ability to tolerate Role Function
stress Work, social,
Anxiety level recreational
Health-related activities.
hardiness
Interdependence
Intrapsychic
function
Family
relations
Social support
Classification of Study Variables According to the Roy Adaptation Model
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Health and Adaptation
■ Health: a state and process of being and becoming integrated and whole that
reflects person and environmental mutuality.
■ Adaptation: the process and outcome whereby thinking and feeling persons, as
individuals and in groups, use conscious awareness and choice to create human
and environment integration.
■ Adaptive responses: responses that promote integrity in terms of the goals of
the human system, that is, survival, growth, reproduction, mastery, and personal
and environmental transformation.
■ Ineffective responses: responses that do not contribute to integrity in terms of
the goals of the human system.
■ Adaption levels represent the condition of the life processes described on three
different levels: integrated, compensatory, and compromised.
Assumptions of Roy's Adaptation Model
■ Scientific
o Systems of matter and energy progress to higher level of complex self-
organization.
o Consciousness and meaning are constitutive of person and environment
integration.
o Awareness of self and environment is rooted in thinking and feeling.
o Humans by their decisions are accountable for the integration of creative
processes.
o Thinking and feeling mediate human action.
o System relationships include acceptance, protection, and fostering of
interdependence.
o Persons and the earth have common patterns and integral relationships.
o Persons and environment transformation are created in human
consciousness.
o Integration of human and environment meanings results in adaptation.
■ Philosophical
o Persons have mutual relationships with the world and God.
o Human meaning is rooted in an omega point convergence of the universe.
o God is intimately revealed in the diversity of creation and is the common
destiny of creation.
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o Persons use human creative abilities of awareness, enlightenment, and

faith.
o Persons are accountable for the processes of deriving, sustaining, and
transforming the universe.
Critical Thinking in the Roy's Adaptation Model (RAM)
■ RAM utilizes the nursing process to promote critical thinking.

■ Nursing process is a goal-oriented, problem-solving approach to guide the
provision of comprehensive, competent nursing care to a person or group of
persons.
■ According to Andrews and Roy (1991b), nursing process "relates directly to the
view of the person as an adaptive system" (p.27).
■ Roy has conceptualized the nursing process to comprise the following six
simultaneous, ongoing, and dynamic steps (Roy and Andrews, 1999):
1. Assessment of behavior
2. Assessment of stimuli
3. Nursing diagnosis
4. Goal setting
5. Intervention
6. Evaluation
■ The goal of nursing in the RAM is to promote adaptation in each of the four
adaptive modes.
Assessment of Behavior
■ Assessment of behavior involves gathering data about the behavior of the person
as an adaptive system in each of the adaptive mode.
■ Behavior is an action or a reaction to a stimulus.
■ A behavior may be observable or non-observable.
■ An example of observable behavior is blood pressure; a non-observable behavior
is a feeling of anxiety experienced by the person and reported to the nurse.
Assessment of Stimuli
■ Assessment of stimuli involves the identification of internal and external stimuli

that are influencing the person's adaptive behaviors.
■ A stimulus is any change in the internal and external environment that provokes
a response in the adaptive system.
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■ Stimuli that arise from the environment are classified as: focal, contextual, or
residual.
1. Focal - those most immediately confronting the person.
2. Contextual - all other stimuli present that are affecting the situation
3. Residual - those stimuli whose effect on the situation are unclear.
■ During this level of assessment, the nurse analyzes subjective and objective
behaviors and delves more deeply for possible causes of a particular set of
behaviors (Roy and Andrews, 1999).
Nursing Diagnosis
■ Nursing diagnosis involves the formulation of statements that interpret data about
the adaptation status of the person, including the behavior and most relevant
stimuli.
■ This is an expression of the nurse's expert judgment regarding health care and
adaptive needs of a client.
■ The diagnostic statement indicates an actual or a potential problem related to
adaptation.
■ The diagnostic statement specifies the behaviors that led to the diagnosis and
judgment regarding the stimuli that threaten or promote adaptation (Roy and
Andrews, 1999).
Goal Setting
■ Goal setting involves the establishment of clear statements of the behavioral

outcomes for nursing care.
■ This process focuses on promoting adaptive behaviors.
■ Both the nurse and the client agree on desired behavioral outcomes of nursing
care.
■ The outcome statement should reflect a single adaptive behavior, the realistic,
and the measurable.
■ The goal statement should include the behavior to be changed, the change
expected, and the timeframe in which the change in behavior should occur (Roy
and Andrews, 1999).
Intervention
■ Intervention involves the determination of how best to assist the person in

attaining established goals.
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■ "Intervention focuses on the manner in which goals are attained" (Andrews and
Roy, 1991b, p.44).
■ A nursing intervention is any action taken by a professional nurse that he or she
believes will promote adaptive behavior by a client.
■ Nursing interventions arise from a solid knowledge base and are aimed at the
focal stimulus whenever possible.
■ Intervention is any nursing approach that is intended "to promote adaptation by
changing stimuli or strengthening adaptive processes. (Roy and Andrews, 1999,
p.86).
Evaluation
■ Evaluation involves judging the effectiveness of the nursing intervention in

relation to the behavior after the nursing intervention in comparison with the goal
established.
■ In the RAM, evaluation consists of one question - "has the person moved toward
adaptation?
INDICATIONS OF ADAPTATION DIFFICULTY
Signs of pronounced regulator activity:

1. Increase in heart rate or blood pressure
2. Tension
3. Excitement
4. Loss of appetite
5. Increase in serum cortisol
Signs of cognator ineffectiveness include:

1. Faulty perception and information processing
2. Ineffective learning
3. Poor judgment
4. Inappropriate affect
Source: Adapted from Roy, C., & Andrews, H. A. (eds.). (1999). The Roy Adaptation
Model (2nd ed., p. 70). Stamford, CT: Appleton & Lange.
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COMMON STIMULI AFFECTING ADAPTATION
Culture. Socioeconomic status, ethnicity, belief system.
Family/aggregate participants. Structure and tasks.
Developmental stage. Age, sex, tasks, heredity, genetic factors, longevity of

aggregate, vision.
Integrity of adaptive modes. Physiologic (including disease pathology): physical
(Including basic operating resources); self-concept-group identity; role function;
interdependence modes.
Cognator-Innovator effectiveness. Perception, knowledge, skill.
Environmental considerations. Change in internal or external environment; medical

management; use of drugs, alcohol, tobacco; political or economic stability.
Concepts
Person
■ Bio-psycho-social being in constant interaction with a changing environment.

■ Uses innate and acquired mechanisms to adapt.
■ An adaptive system described as a whole comprised of parts.
■ Functions as a unity of some purpose.
■ Includes people as individuals or in groups- families, organizations, communities,
and society as a whole.
Environment
■ Focal-internal or external and immediately confronting the person.

■ Contextual-all stimuli present in the situation that contribute to effect of focal
stimulus.
■ Residual-a factor whose effects in the current situation are unclear.
■ All conditions, circumstances, and influences surrounding and affecting the
development and behavior of persons and groups with particular consideration of
mutuality of person and earth resources, including focal, contextual and residual
stimuli.
Health
■ Inevitable dimension of person's life.

■ Represented by a health-illness continuum.
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■ A state and a process of being and becoming integrated and whole.
Nursing
■ To promote adaptation in the four adaptive modes.

■ To promote adaptation for individuals and groups in the four adaptive modes,
thus contributing to health, quality of life, and dying with dignity by assessing
behaviors and factors that influence adaptive abilities and by intervening to
enhance environmental interactions.
Roy's Adaptation Model
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6. Johnson's Behavioral System Model
Dorothy E. Johnson (1960, 1980)
Conceptualized the "Behavioral System Model". According to Johnson, each

person as a behavioral system is composed of seven subsystems namely:
1. Ingestive. Taking in nourishment in socially and culturally acceptable
ways.
2. Eliminative. Ridding the body of waste in socially and culturally
acceptable ways.
3. Affiliative. Security seeking behavior.
4. Aggressive. Self-protective behavior.
5. Dependence. Nurturance - seeking behavior.
6. Achievement. Master of oneself and one's environment according to
internalized standards of excellence.
7. Sexual and role identity behavior.
Disturbances in these subsystems cause nursing problems.
In addition, she viewed that each person strives to achieve balance and stability both
internally and externally and to function effectively by adjusting and adapting to
environmental forces through learned patterns of response.
Furthermore, Johnson believed that the patient strives to become a person whose
behavior is commensurate with social demands; who is able to modify his behavior
in ways that support biologic imperatives; who is able to benefit to the fullest extent
during illness from the health care professional's knowledge and skills; and whose
behavior does not give evidence of unnecessary trauma as a consequence of
illness.
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Dorothy E. Johnson
BIOGRAPHY
Dorothy E. Johnson (August 21, 1919 – February 1999) was one of the greatest
nursing theorists who developed the “Behavioral System Model.” Her theory of
nursing defines nursing as “an external regulatory force which acts to preserve the
organization and integration of the patients’ behaviors at an optimum level under those
conditions in which the behavior constitutes a threat to the physical or social health, or
in which illness is found.”
EARLY LIFE
Dorothy Johnson was born on August 21, 1919, in Savannah, Georgia. She was the
youngest of seven children. Her father was the superintendent of a shrimp and oyster
factory, and her mother was very involved and enjoyed reading. In 1938, she finished
her associate’s degree at Armstrong Junior College in Savannah, Georgia. Due to the
Great Depression, she took a year off from school to be a governess, or teacher, for two
children in Miami, Florida. This was when she began to realize her love for children,
nursing, and education.
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EDUCATION
Dorothy Johnson’s professional nursing career began in 1942 when she graduated
from Vanderbilt University School of Nursing in Nashville, Tennessee. She was the top
student in her class and received the prestigious Vanderbilt Founder’s Medal.
In 1948, she received her master’s in public health from Harvard University in Boston,
Massachusetts.
CAREER AND APPOINTMENTS
After graduation, Dorothy Johnson’s professional experiences involved mostly teaching,

although she was a staff nurse at the Chatham-Savannah Health Council from 1943 to
1944. She was an instructor and an assistant professor in pediatric nursing at Vanderbilt
University School of Nursing. From 1949 until her retirement in 1978 and her
subsequent move to Key Largo, Florida, Johnson was an assistant professor of
pediatric nursing, an associate professor of nursing, and a nursing professor at the
University of California, Los Angeles.
In 1955 and 1956, Johnson was a pediatric nursing advisor assigned to the Christian
Medical College School of Nursing in Vellore, South India. From 1965 to 1967, she
served as chairperson on the California Nurses Association committee that developed a
position statement on specifications for the clinical specialist.
AWARDS AND HONORS
Of the many honors she received, Dorothy Johnson was proudest of the 1975 Faculty
Award from graduate students, the 1977 Lulu Hassenplug Distinguished Achievement
Award from the California Nurses Association, and the 1981 Vanderbilt University
School of Nursing Award for Excellence in Nursing.
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Overview of Johnson's "Behavioral System Model"

■ According to Johnson, there are four goals of nursing which are as follows:
To assist the patient
1. Whose behavior is commensurate with social demands
2. Who is able to modify his behavior in ways that supports biological
imperatives
3. Who is able to benefit to the fullest extent during illness from the
physician's knowledge and skill
4. Whose behavior does not give evidence of unnecessary trauma as a
consequence of illness. (Johnson, 1980, p.207)
■ Johnson proposed that the client is a behavioral system, organized into
seven subsystems of behavior which are as follows:
1. Attachment or affiliative subsystem: "social inclusion, intimacy, and

the formation and attachment of a strong social bond." Its ultimate
function is survival.
2. Dependency subsystem: "approval, attention or recognition, and
physical assistance (helping or nurturing).
3. Ingestive subsystem: "the emphasis is on the meaning and
structures of the social events surrounding the occasion when the
food is eaten. Its function is appetite satisfaction.
4. Eliminative subsystem: human cultures have defined different
socially acceptable behaviors for excretion of waste but the
existence of such a pattern remains different from culture to culture.
5. Sexual subsystem: "both biological and social factor affect the
behavior in the sexual subsystem." E.g., role identity, courting,
mating. The function is procreation and gratification.
6. Aggressive subsystem: "related to the behavior concerned with
protection and self-preservation; one that generates defensive
response from the individual when life or territory is being
threatened.
7. Achievement subsystem: "provokes behavior that attempt to control
the environment; intellectual, physical, creative, mechanical and
social skills; (efforts to gain mastery and control).
Note: An eighth subsystem, restorative is added. The restorative to subsystem

is concerned with rest, sleep, comfort/freedom from pain.
Each subsystem has three functional requirements, as follows:

1. System must be "protected" from noxious influences with which system
cannot cope."
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2. Each subsystem must be "nurtured" through the input of appropriate to

supplies from the environment.
3. Each subsystem must be "stimulated" for use to enhance growth and
prevent stagnation
■ Johnson believes each individual has patterned, purposeful, repetitive ways of

acting that comprise a behavioral system specific to that individual. These
actions and behaviors form an organized and integrated functional unit that
determines and limits the interaction between the person and his environment
and establishes the relationship of the person to the objects, events, and
situations in the environment. These behaviors are "orderly, purposeful,
predictable, sufficiently stable, and recurrent to be amenable to description and
explanation" (p. 209).
Johnson's Model. (From Torres, G. (1986). Theoretical Foundations of Nursing Norwalk,

CT: Appleton-Century-Crofts, p.121. Used with permission.)
There are 4 assumptions of the Behavioral System model:

1. There is "organization, interaction, interdependency, and integration of the
parts and elements of behaviors that make up the system"
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2. A system tends to achieve a balance among the various forces operating

within and upon it, and that man continually strive to maintain a behavioral
system balance and steady state by more or less automatic adjustments and
adaptations to the natural forces impinging upon him.
3. A behavioral system, which both requires and results in some degree of
regularity and constancy in behavior is essential to man that is to say, it is
functionally significant in that it serves a useful purpose, both in social life and
for the individual.
4. The final assumption states "system balance reflects adjustments and
adaptations that are successful in some ways and to some degree."
■ According to Johnson each subsystem comprises four structural characteristics:

a goal based on (1) a universal drive; (2) set; (3) choice; and (4) action
(behavior). Each of these four factors contributes to the observable activity of a
person.
Goal Set Choice of Behavior Behavior (Action)
■ The goal of a subsystem is defined as "the ultimate consequence of

behaviors" (Grubbs, 1974, p. 226).
■ The basis for the goal is a universal drive, the existence of which is supported
by existing theory or research.
■ The set is a tendency to act in a certain way in a given situation. Set formation is
influenced by societal norms and variables as culture, family, values, perception,
and perseveratory sets. The preparatory set describes one's focus in a particular
situation. The perseveratory set, which implies persistence, refers to the habits
one maintains. Set plays a major role in determining the choices a person makes
and actions eventually taken.
■ Choice refers to the alternate behaviors the person considers in any given
situation. Options are influenced by such variables as age, sex, culture, and
socioeconomic status.
■ The action is the observable behavior of the person.
■ For the subsystem to develop and maintain stability, each must have a constant
supply of "functional requirements" or sustenal imperatives (Johnson, 1980, p.
212). The environment must supply the functional requirements/sustenal
imperatives of protection from unwanted, disturbing stimuli; nurturance through
giving input from the environment (e.g., food, caring, conditions that support
growth and development); encouragement; and stimulation by experiences,
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events, and behaviors that would enhance growth and prevent stagnation."
(Johnson, 1980, p. 212)
■ The subsystems maintain behavioral system balance as long as both the internal
and external environments are orderly, organized and predictable and each of
the subsystem's goals are met.
■ Behavioral subsystem imbalances occur when structure, function, or functional
regimen is disturbed. The Johnson's Behavioral System Model differentiates four
diagnostic classifications to delineate these disturbances: insufficiency,
discrepancy, incompatibility, and dominance.
Nursing has the goal of maintaining or restoring stability in the behavioral system or in
the system as a whole. Interventions directed toward restoring behavioral system
balance are directed toward repairing damaged structural units, with the nurse
temporarily imposing regulatory and control measures or helping the client develop or
enhance his or her supplies of essential functional requirements.
Examples:
1. Affiliative Subsystem
■ FUNCTION
To form cooperative and interdependent role relationships within human
social systems
To enjoy interpersonal relationships
To belong to something other than oneself
To share
To achieve intimacy and inclusion
■ STRUCTURAL COMPONENTS
Goal: To relate or belong to something or someone than oneself, to achieve
intimacy and inclusion.
Perseveratory Set: A consistent approach (or pattern of behavior) to
establishing affiliative relationships; a consistent tendency to select a certain
individual or group for the purpose of affiliation; inherited generic
characteristics that determine the influence of affiliative behaviors;
development of self-identity and self- concept to a group; cultural beliefs and
customs.
Preparatory Set: Perception of a situation as requiring particular role
behaviors required by the interaction setting; selective inattention to social
behaviors; mood.
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Choice: Selection from among the alternatives available in the situation as

perceived through set, the behaviors considered appropriate to meet the
goal. Within the context of the situation, the behaviors range from affiliation,
avoidance, nonreciprocated relationships, noncontingent social relationships,
maintenance of a relationship, and affiliation with animals or other objects.
Acts: Any directly observable behavior that facilitates movement toward
others in the environment. Specific acts include, smiling, visual contact,
talking (social greeting, conversation, extending invitations), facial
expression, motor behaviors (touching, holding, hugging), and other actions
that establish or maintain a reciprocal relationship between two or more
individuals.
Sustenal Imperatives: Conditions that serve to protect, stimulate, and
mature behaviors related to affiliation. Included are learned behaviors to
initiate and maintain a social exchange: presence of an environment where
these skills can be taught and nurtured; development of trust; kinship;
awareness of one's self-identity; self-esteem; ability to communicate verbally
and nonverbally; membership in groups; knowledge of formal and informal
guidelines for interpersonal processes; and secure parent-infant attachment.
2. Ingestive Subsystem
■ FUNCTION
To sustain life through the intake of food and fluids and oxygen.
To obtain knowledge or information useful to the self.
To obtain pleasure or gratification through taking in nonfunctional materials
such as smoking, alcohol, or drugs.
To restore a felt deficiency within the self-system.
To relieve pain or other psychophysiological systems.
■ STRUCTURAL COMPONENTS
Goal: To internalize the external environment.
Perseveratory Set: Status of sensory modalities, digestive system,
respiratory system, fluid and electrolyte balance; oral cavity conditions;
socialization into food types; drinking habits, smoking use; oral
medications; subcutaneous, intravenous, and intramuscular injections;
sensory assistance, such as hearing aids, glasses, and dentures. Beliefs
and values about times and places for eating and drinking; types of foods
and beverages preferred by the social group, attitudes toward alcohol and
smoking, beliefs about efficiency of oral, intravenous, and subcutaneous
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medications. Perception of self as fat or thin; abstainer or alcoholic, addict,

smoker, asthmatic.
Preparatory Set: Awareness of being hungry of thirsty, in need of a
drink, wish to be high, relief of pain, time for eating, availability of food,
fluid or medication resources; barriers to respiration, desire for
information, awareness of ignorance.
Choice: Behavioral options available for food and fluid, medication, air
supply, tobacco, alcohol, marijuana, narcotics; supplies available in the
environment selections are made on the basis of set and situation. Choice
includes deferred gratification and overindulgence. Options available for
taking in information.
Acts: Behavior may include visual, auditory, olfactory, and gustatory acts
of overindulgences (or less than optimal) and preferences for particular
substances. Ingestive acts may be directed toward goals other than
ingestion. Sensory acts (seeing, hearing, smelling, tasting, and
sensations) are used in all other subsystems to serve other goals. When
sensory acts are directed toward getting information, the acts are ingestive
goal-oriented. The process of hearing also requires ingestive acts. The
ingestion may be for achievement goals.
CONCEPTS
a. Person. A behavioral system comprised of subsystem constantly trying to

maintain a steady state.
■ A "human being" having two major systems, the biological system and the
behavioral system. Nursing's focus is the behavioral system; Medicine's
focus is on biological system.
b. Environment (Society). Relates to the environment on which the individual
exists. According to Johnson, an individual's behavior is influenced by the
events in the environment.
c. Health. Is a purposeful adaptive response, physically, mentally, emotionally,
and socially to internal and external stimuli in order to maintain stability and
comfort.
d. Nursing. Has a primary goal that is to foster equilibrium within the individual.
An external regulatory force that is indicated only when there is instability.
She stated that nursing is concerned with the organized and integrated whole,
but that the major focus is on maintaining a balance in the Behavioral System
when illness occurs in an individual.
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NURSING THEORIES
1. Peplau’s Theory of Interpersonal Relationship
Hildegard Peplau (1952)

Introduced the "Interpersonal Relations in Nursing Model" (Psychodynamic
Nursing Model). She defined nursing as an interpersonal process of therapeutic
interactions between an individual who is sick or in need of health services and a nurse
especially educated to recognize and respond to the need for help. She identified four
phases of the nurse-client relationship namely:
1. Orientation: the nurse and the client initially do not know each other's goals
and testing the role each will assume. The client attempts to identify
difficulties and the amount of nursing help that is needed;
2. Identification: the client responds to the professionals or the significant
others who can meet the identified needs. Both the client and the nurse plan
together an appropriate program to foster health;
3. Exploitation: the client utilizes all available resources to move toward a goal
of maximum health or functionality;
4. Resolution: refers to the termination phase of the nurse- client relationship. It
occurs when the client's needs are met and he/she can move toward a new
goal. Peplau further assumed that nurse- client relationship fosters growth in
both the client and the nurse.
Peplau stated that there are six nursing roles which are as follows stranger,
resource person, teacher, leader, surrogate, counselor.
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Hildegard Peplau
BIOGRAPHY
Hildegard Elizabeth Peplau (September 1, 1909 – March 17, 1999) was an
American nurse who is the only one to serve the American Nurses Association
(ANA) as Executive Director and later as President. She became the first
published nursing theorist since Florence Nightingale.
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.”
EARLY LIFE
Hildegard Peplau was born on September 1, 1909. She was raised in Reading,
Pennsylvania, by her parents of German descent, Gustav and Otyllie Peplau. She was
the second daughter, having two sisters and three brothers. Though illiterate, her father
was persevering while her mother was a perfectionist and oppressive. With her young
age, Peplau’s eagerness to grow beyond traditional women’s roles was precise. She
considers nursing was one of few career choices for women during her time. In 1918,
she witnessed the devastating flu epidemic that greatly influenced her understanding of
the impact of illness and death on families.
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EDUCATION
When the autonomous, nursing-controlled, Nightingale era schools came to an end in

the early 1900s, schools then were handled by hospitals, and the so-called formal “book
learning” was put down. Hospitals and physicians considered women in nursing as a
source of free or inexpensive labor. Exploitation was widespread by nurse’s employers,
physicians, and educational providers.
In 1931, she graduated from Pottstown, Pennsylvania School of Nursing. Peplau earned
a Bachelor’s degree in interpersonal psychology in 1943 at Bennington College in
Vermont. She studied psychological issues with Erich Fromm, Frieda Fromm-
Reichmann, and Harry Stack Sullivan at Chestnut Lodge, a private psychiatric hospital
in Maryland. Peplau held master’s and doctoral degrees from Teachers College,
Columbia University, in 1947.
AWARDS AND HONORS

Peplau was acknowledged with numerous awards and honors for her contributions to
nursing and held 11 honorary degrees. She was awarded honorary doctoral degrees
from universities including Alfred, Duke, Indiana, Ohio State, Rutgers, and the
University of Ulster in Ireland.
She was named one of “50 Great Americans” in Who’s Who in 1995 by Marquis. She
was also elected fellow of the American Academy of Nurse and Sigma Theta Tau, the
national nursing honorary society.
Peplau, universally regarded as the “Mother of Psychiatric Nursing.”
In 1996, the American Academy of Nursing honored Peplau as a “Living Legend.” She
received nursing’s highest honor, the “Christiane Reimann Prize,” at the ICN
Quadrennial Congress in 1997.
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Overview of Peplau's "Theory of Interpersonal Relations"
■ According to Peplau's "Theory of interpersonal Relations," the three

sequential phases in the interpersonal nurse-patient relationship are as
follows:
1. Orientation Phase
Problem defining phase.
Starts when client meets nurse as stranger.
Defining problem and deciding type of service needed.
Client seeks assistance, conveys needs, asks questions, shares
preconceptions and expectations of past experiences.
Nurse responds, explains roles to client, helps to identify
problems and to use available resources and services.
During the orientation phase, the individual has a felt need and
seeks professional assistance. The nurse helps the individual to
recognize and understand his/her problem and determine the
need for help.
Factors influencing orientation phase
Nurse Patient
Values Nurse Values

Culture race patient Culture race
Beliefs relation- Beliefs
Past experiences Past experiences
ship Expectations
Expectations
Preconceived Ideas Preconceived Ideas
Preconceived ideas
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2. Working Phase
A. Identification Phase
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.
The patient identifies with those who can help him/her. The
nurse permits exploration of feelings to and the patient in
undergoing illness as an experience that reorients feeling and
strengthens positive forces in the personality and provides
needed satisfaction.
B. Exploitation Phase
Use of professional assistance for problem solving
alternatives.
Advantages of services are used and based on the needs and
interests of the patients.
Individual feels as an integral part of the helping environment.
The individual may make minor requests or attention getting
techniques.
The principles of interview techniques must be used in order to
explore, understand and adequately deal with the underlying
problem.
Patient may fluctuate on independence.
During this phase, the patient attempts to derive full value from
what he/she is offered through the relationship. The nurse can
project new goals to be achieved through personal effort and
power shifts from the nurse to the patient as the patient delays
gratification to achieve the newly formed goals.
Nurse must be aware various phases of about the
communication.
Nurse aids the patient in exploiting all avenues of help and
progress is made towards the final step.
3. Resolution Phase
Termination of professional relationship.
The patient's needs have already been met by the
collaborative effort of patient and nurse.
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Now they need to terminate their therapeutic relationship and

dissolve the links between them.
Sometimes may be difficult for both as psychological
dependence persists.
Patient drifts away and breaks bond with nurse and healthier
emotional behavior is demonstrated and both become mature
individuals.
The patient gradually puts aside old goals and adopts new
goals. This is a process in which the patient frees himself from
identification with the nurse.
In capsule:
■ Orientation: Nurse and patient come together as strangers; meeting

initiated by patient who expresses a "felt need", work together to
recognize, clarify, and define facts related to the need.
■ Identification: Patient participates in goal setting; has feeling of
belongingness and selectively responds to those who can meet his/her
needs.
■ Exploitation: Patient actively seeks and draws knowledge and expertise
of those who can help.
■ Termination (Resolution): Occurs after other phases are completed
successfully. This leads to termination of the relationship.
Peplau advocates that the roles of the nurse in the nurse-patient interpersonal
relationship are as follows:
■ Stranger receives the client in the same way one meets a stranger in
other life situations. Provides an accepting climate that builds trust.
■ Teacher who imparts knowledge in reference to a need or interest.
■ Resource Person: one who provides a specific needed information that
aids in the understanding of a problem or new situation.
■ Counselor: helps to understand and integrate the meaning of current life
circumstances; provides guidance and encouragement to make changes.
■ Surrogate: helps to clarify domains of dependence, interdependence and
independence and acts on client's behalf as an advocate.
■ Leader: helps client assume maximum responsibility for meeting
treatment goals in a mutually satisfying way.
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Additional Roles include:
1. Technical expert
2. Consultant
3. Health teacher
4. Tutor
5. Socializing agent
6. Safety agent
7. Manager of environment
8. Mediator
9. Administrator
10. Recorder observer
11. Researcher
Interpersonal Theory and Nursing Process
■ Both are sequential and focus on therapeutic relationship.

■ Both use problem solving techniques for the nurse and patient to
collaborate on with the end purpose of meeting the patients needs.
■ Both use observation, communication, and recording as basic tools
utilized by nursing.
Assessment Orientation
• Data collection and analysis • Non continuous data collection
(continuous) • Felt need
• May not be a felt need • Define needs
Nursing diagnosis Identification

Planning • Interdependent goal setting
• Mutually set goals
Implementation Exploitation
• Plans initiated towards achievement • Patient actively seeking and
of mutually set goals drawing help
• May be accomplished by patient, • Patient initiated
nurse or family
Evaluation Resolution
• Based on mutually expected • Occurs after other phases are
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behaviors completed successfully

• May lead to termination and • Leads to termination
initiation of new plans
Concepts
■ Person. A developing organism that tries to reduce anxiety caused by needs.

■ Environment. Existing forces outside the organism and in the context of
culture.
■ Health. 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.
■ Nursing. A significant therapeutic interpersonal process. It functions
cooperatively with other human processes that make health possible for
individuals in communities.
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.
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2.NUOrlando’s Theory of Deliberative Nursing Process
Ida Jean Orlando (1961)
Conceptualized "Nursing Process Discipline" (The Dynamic Nurse - Patient

Relationship Model). She believed that the nurse helps patients meet a perceived
need that the patients cannot meet for themselves. Orlando observed that the nurse
provides 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 outcomes. 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 effectiveness of the actions
taken to meet the need). She also advocated that the three elements composing
nursing situation are: client behavior, nurse reaction and nurse action.
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Ida Jean Orlando
BIOGRAPHY
Ida Jean Orlando-Pelletier (August 12, 1926 – November 28, 2007) was an
internationally known psychiatric health nurse, theorist, and researcher who developed
the “Deliberative Nursing Process Theory.” Her theory allows nurses to create an
effective nursing care plan that can also be easily adapted when and if any
complications arise with the patient.
EARLY LIFE
Ida Jean Orlando was a first-generation Irish American born on August 12, 1926. She
dedicated her life to studying nursing and graduated in 1947 and received a Bachelor of
Science degree in public health nursing in 1951. In 1954, she completed her Master of
Arts in Mental Health consultation. While studying, she also worked intermittently and
sometimes concurrently as a staff nurse in OB, MS, ER, as a general hospital
supervisor, and as an assistant director and a teacher of several courses. And in 1961,
she was married to Robert Pelletier and lived in the Boston area.
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EDUCATION
Being a respectable and credible role-model, Orlando was well educated with many
advanced nursing degrees.
In 1947, she received a nursing diploma from the Flower Fifth Avenue Hospital School
of Nursing in New York. In 1951, she received a Bachelor of Science degree in public
health nursing from St. John’s University in Brooklyn, New York. And in 1954, Orlando
received her Master of Arts degree in mental health consultation from Teachers
College, Columbia University.
WORKS
After working as a researcher, she wrote a book on her findings from Yale, entitled “The
Dynamic Nurse-Patient Relationship: Function, Process, and Principles.” Her book was
published in 1961. A year later, she also continued her research studies published her
second book, “The Discipline and Teaching of Nursing Process,” in 1972.
Ida Jean Orlando’s goal is to develop a theory of effective nursing practice. The theory
explains that the nurse’s role is to find out and meet the patient’s immediate needs for
help. According to the theory, all patient behavior can be a cry for help. Through these,
the nurse’s job is to determine the nature of the patient’s distress and provide the help
he or she needs.
AWARDS AND HONORS
Ida Jean Orlando retired from nursing in 1992. After becoming well-educated,
researching over 2,000 nurse-patient interactions, and coming up with a theory that
changed nursing, she was recognized as a “Nursing Living Legend” by the
Massachusetts Registered Nurse Association.
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Overview of Orlando's Nursing Process Theory
■ The major dimensions of Orlando's Nursing Process Theory are as follows:

1. Professional nursing function - organizing principle.
2. The patient's presenting behavior - problematic situation.
3. Immediate reaction - internal response.
4. Deliberative nursing process-reflective inquiry.
5. Improvement - resolution.
1. Professional Nursing Function - Organizing Principle

■ The nurse's unique function is "finding out and meeting the patient's immediate
needs for help" (Orlando, 1972, p. 20).
■ "Nursing... is responsive to individuals who suffer or anticipate a sense of
helplessness, it is focused on the process of care in an immediate experience, it
is concerned with providing direct assistance to individuals in whatever setting
they are found for the purpose of avoiding, relieving, diminishing, or curing the
individual's sense of helplessness" (Orlando, 1972, p.12).
■ The patient's sense of helplessness, stress, or need originates from physical
limitations, adverse reaction to the setting, and experiences that prevent a patient
from communicating his or her needs.
■ "Need is situationally defined as a requirement of the patient which, if supplied,
relieves or diminishes his immediate distress or improving his immediate sense
of adequacy or well-being" (p.5).
■ It is the nurse's responsibility to meet the patient's immediate needs for help
either by supplying it directly or by calling in the services of others.
■ The central core of the nurse's practice is to understand what is happening
between the patient and the nurse that provides framework for the help the nurse
gives the patient (Orlando, 1961).
■ Nursing thought: "Does the patient have an immediate need for help or not?"
"First, the nurse must take the initiative in helping the patient express the
specific meaning of his behavior in order to ascertain his distress."
"Second, she must help the patient explore the distress in order to
ascertain the help he requires for his (immediate) need (for help) to be
met" (Orlando, 1961, p.26).
■ The nurse's focus of inquiry is always on the patient's immediate experience.
■ If the patient is in need and the need is fulfilled, the nursing function has been
fulfilled.
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■ "The product of meeting the patient's immediate need for help is...'improvement'
in the immediate verbal and nonverbal behavior of the patient. This observable
change allows the nurse to believe or disbelieve that her activity relieved,
prevented, or diminished the patient's sense of helplessness" (Orlando, 1961,
p.26).
2. The Patient's Presenting Behavior - Problematic Situation

■ To find out the immediate need for help the nurse must first recognize the
situation as problematic.
■ "The presenting behavior of the patient, regardless of the form in which it
appears, may be a plea for help" (Orlando, 1961, p.40).
■ Both the patient and the nurse participate in the exploratory process to identify
the problem as well as the solution.
■ The nurse-patient situation is a dynamic whole; each is affected by behavior of
the other. The interaction is unique for each situation.
■ The patient's behavior stimulates the nurse's immediate reaction and becomes
the starting point of the investigation.
3. Immediate Reaction - Internal Response

■ The problematic situation, in the form of the patient's presenting behavior (e.g.,
requests, comments, complaints, questions, moaning, crying, wheezing,
clinching fist, pallor, reddened face, difficulty of breathing, increased blood
pressure), triggers an automatic immediate med reaction in the nurse that is both
cognitive and affective.
■ The reaction comprises the nurse's perceptions, thoughts about the perceptions,
and the feelings evoked from the thoughts; they cannot be controlled. These
items occur in an automatic, almost instantaneous and sequence (Orlando,
1972).
■ In any person's process of action, four distinct items occur sequentially:
1. The person perceives with any one of his five sense organs an object or objects;
2. The perceptions stimulate automatic thought;
3. Each thought stimulates an automatic feeling; and
4. Then, the person acts (Orlando 1972, p.5).
■ The interactions of these items is called the nursing process. The first three
items cannot be observed; only the action can. The action is what to the person
says verbally or conveys nonverbally.
■ The nurse's immediate reaction is unique for each situation. What the nurse
perceives, thinks, or feels reflects his or her individuality. The automatic thoughts
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come from the nurse's interpretation or meaning attached to the perception. It

may or may not be correct from the patient's point of view (Orlando, 1961).
■ Regardless of the extent of nurse's accuracy, the perceptions that evoked the
thoughts are communications from the patient and or represent the raw data for
the nurse to use in investigating or exploring the patient's behavior. (Orlando,
1961).
4. Deliberative Nursing Process - Reflective Inquiry

■ The deliberative nursing process views the nurse-patient situation as a dynamic
whole.
■ The nurse's behavior affects the patient, and the nurse is affected by the patient's
behavior. Understanding the patient's behavior is a complex process in which
observations and thoughts are used in a serial responsive way to get the "facts of
the case."
■ To be successful, the nurse's focus must be on the patient rather than on an
assumption that he/she knows what the patient's problems are and on arbitrary
decisions about what action to take.
■ The use of Orlando's (1961) deliberative process requires that there is a shared
communication process between the nurse and the patient to a determine the
following:
1. The meaning of the patient's behavior
2. The help required by the patient
3. Whether the patient was helped by the nurse's action
■ Orlando (1972) describes the components of a person's action process.

In a person-to person encounter, each experiences an immediate reaction.
This contains the following:
The person's perception of the other person's behavior
The thought about this perception
The feelings associated with the thought
■ Unless the content of a person's reaction is openly disclosed, it remains a secret
from the other person.
■ If a nurse makes a statement to the patient and does not disclose what
perceptions, thoughts, or feelings led to his or her action, the patient remains
unaware of it because it was not expressed. This action process often functions
in secret (Orlando, 1972).
■ Guidelines that specify a person's use of the content or his/her reaction in a
deliberative way are as follows:
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a. "In a situation a person verbally states to the other person any or all of
the items of his or her immediate reaction;
b. The stated items must be expressed as self-designated; and
c. The person asks the other person to verify or correct the item verbally
expressed" (Schmieding 1993, p.24).
■ The deliberative nursing process describes as follows: "Whatever the nurse
perceives about the patient with any one of the five sense organs and thinks and
feels about the perception must, at least in part be verbally expressed as self-
designated to the patient and then asked about" (Schmieding 1993, p.25).
■ According to Orlando (1961) "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" (p.56)
■ The nurse will find it more efficient to find out what the patient's immediate need
for help is by first exploring and understanding the meaning of his/her perception.
■ The patient is more likely to agree with the correctness of the perception and
often explains its meaning to the nurse.
■ The longer it takes to find out the patient's immediate need for help, the more
distressed the patient becomes (Orlando, 1961).
■ The nurse uses thoughts to try to understand the nature of the patient's distress.
When using thoughts, the nurse must give the perception from which the thought
was derived and ask the patient whether it is valid or not.
■ Feelings come from the thought about the perception. The nurse must state the
perception that evoked the thought from which the feeling was derived.
Example:
Nurse: "I'm concerned that you keep asking for the bedpan. But I don't
think you really need it. Am I right or not?"
Patient: "Yes, but I'm afraid I might have chest pain again and then I
wouldn't be able to call for the nurse."
■ If nurses do not resolve their feelings with patients, these same feelings occur
each time they are in contact with the patients.
■ Furthermore, unexpressed feelings may show in the nurse's verbal or nonverbal
behavior.
■ Regardless of what aspect of his/her reaction the nurse uses, the patient is
affected by the action. Therefore "the nurse initiates a process of exploration to
ascertain how the patient is affected by what she says or does. Only this way can
she be clearly aware of how and whether her actions are helping the patient"
(Orlando, 1961, p.67).
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■ When nurses explain their immediate actions to the patients in a deliberative

way, they are more likely to meet the patient's immediate needs for help because
when they use it, patients are more likely to use it also.
■ This approach minimizes the nurse's opportunity to make private interpretations
about patients and maximizes the chance to correct or verify his or her private
interpretation of the patient's action. Therefore, both nurses and patients have a
better understanding of how each experience the immediate situation (Orlando,
1972). If this is not done, patients remain distressed because the communication
between them is unclear since the nurse stated an automatic response to the
patient (Orlando, 1961).
■ Orlando (1961) noted that automatic personal responses contribute to situation
conflicts. Thus, it is important to understand them so that problems associated
with their use can be avoided.
■ Basing her ideas on Orlando (1972, Schmieding (1993) emphasizes the following
reasons that automatic personal responses are not helpful:
1. When the nurse withholds his or her immediate reaction, the patient
cannot verify or correct it. The withholding of the nurse's perceptions,
thoughts or feelings allows the patient to make assumptions about the
nurse's verbal and nonverbal behavior.
2. If the nurse's response is not stated as self-designated, the patient is
allowed to make assumptions about the origin of what is heard (the use of
"we" does not clearly provide the origin).
3. If the nurse's response is not in the form of a question, the other person
may not feel free to correct or verify what she or he heard. As a result
neither person in the contact knows the immediate reaction of the other;
therefore each is left with an unverified understanding of the other's action
(p.28).
■ Actions based on the nurse's conclusion, without the patient's participation, are
often not helpful. Therefore, the nurse decides for reasons other than the
meaning of the patient's behavior. Thus, if actions are carried out automatically,
even though they could be correct, they are ineffective in helping the patient
because the patient was not involved (Orlando, 1961).
■ A nurse's past experiences are not sufficient as the basis for understanding the
patient's immediate behavior.
■ Therefore, in each nurse-patient experience, a deliberative process of inquiry is
required to prevent the use of automatic responses and arbitrary actions. When
this occurs, the patient's immediate behavior improves.
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5. Improvement-Resolution
■ When a situation becomes clear, it loses its problematic character and a new
equilibrium is established.
■ When the patient's immediate need for help have been determined and met,
there is improvement (Orlando, 1961).
■ If the patient's behavior has not changed, the function of nursing has not been
met and the nurse continues with the inquiry process until there is improvement.
(Orlando, 1961).
■ This change is observable both in patient's verbal and nonverbal behavior.
■ This allows the nurse to conclude that the patient's sense of helplessness has
been relieved, prevented, or diminished (Orlando, 1972).
■ If the patient's behavior has not changed, the function of nursing has not been
met and the nurse continues with the inquiry process until there is improvement.
■ According to Orlando, it is not then nurse's activity that is evaluated but rather its
results - namely whether the nurse's action helped the patient communicate his
or her need for help and whether that need was met.
■ In each contact the nurse repeats a process of learning how to help the individual
patient.
■ The nurse's own individuality and that of the patient requires that she go through
this each time she is called upon to render service to those who need her.
Assumptions
■ When patients cannot cope with their needs without help, they become
distressed with feelings of helplessness.
■ Nursing, in its professional character, does add to the distress of the patient.
■ 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 needs 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.
■ Human beings attach meanings to situations and actions that are not apparent to
others.
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■ Patient's entry into nursing care is through medicine.

■ The patient cannot state the nature and meaning of the distress for his need
without the nurse's help or without her first having established a helpful
relationship with him.
■ Any observation shared and observed with the patient is immediately useful in
ascertaining and meeting his need or finding out that he is not in need at that
time.
■ Nurses are concerned with needs that patients cannot meet on their own.
The action process in a person-to person contacts functioning in secret. The

perceptions, thoughts and feelings of each individual are not directly available to the
perception of the other individual through the observable action (Orlando, 1972).
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The action process in a person-to person contact functioning by open

disclosure. The perceptions, thoughts, and feelings of each individual are
directly available to the perception of the other individual through the observation
action (Orlando, 1972).
Concepts
■ Person (Human Being).

A developmental being with needs.
Nursing clients are patients who are under medical care and who cannot deal
with their needs or who cannot carry out medical treatment alone.
■ Environment
Not defined directly in Orlando's Theory but implicitly in the immediate context
for a patient.
■ Health
A sense of adequacy or wellbeing.
Fulfilled needs.
Sense of comfort
■ Nursing
Is a dynamic nurse-patient relationship.
Is responsive to individuals who suffer or anticipate a sense of helplessness.
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The goal of nursing is increased sense of wellbeing, increase in ability,

adequacy in better care of self and improvement in patient's behavior.
Nursing therapeutics are composed of direct function indirect function,
disciplined and professional activities and automatic activities.
a. Direct function: initiates a process of helping the patient express
the specific meaning of his behavior in order to ascertain his
distress and helps the patient explore the distress in order to
ascertain the help he requires so that his distress may be relieved.
b. Indirect function: calling for help of others, whatever help the
patient may require for his need to be met.
c. Disciplined and professional activities: automatic activities plus
matching of verbal and nonverbal responses, validation of
perceptions, matching of thoughts and feelings with action.
d. Automatic activities: perception by five senses, automatic
thoughts, automatic feeling and automatic action
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3. Travelbee’s Human-to-Human Relationship Model
Joyce Travelbee (1966, 1971)

She postulated the "Interpersonal Aspects of Nursing Model". She advocated
that the goal of nursing is to assist individual or family in preventing or coping with
illness, regaining health, finding meaning in illness, or maintaining maximal degree
of health. She further viewed that interpersonal process is a therapeutic human-to-
human relationship formed during illness and "experience of suffering". She believed
that a person is a unique, irreplaceable individual who is in a continuous process of
becoming, evolving and changing.
Nurses and patients go through several stages to achieve the goal of established
nurse-patient relationships. Each stage has certain tasks, and a healthy
development of the relationship is accomplished by mastering each task. The stages
are:
1. Phase of the original encounter: Emotional knowledge colors. impressions
and perceptions of both nurse and patient during initial encounters. The task is
"to break the bond of categorization in order to perceive the human being in the
patient" and vice versa (Travelbee, 1966, p. 133).
2. Phase of emerging identities: Both nurse and patient begin to transcend their
respective roles and perceive uniqueness in each other. Tasks include
separating oneself and one's experiences from others and avoiding "using
oneself as a yardstick" by which to evaluate others. Barriers to such tasks may
be due to role envy, lack of interest in others, inability to transcend the self, or
refusal to initiate emotional investment.
3. Phase of empathy: This phase involves sharing another's psychological state
but standing apart and not sharing feelings. It is characterized "by the ability to
predict the behavior of another" (Travelbee, 1966, p.143).
4. Phase of sympathy: Sharing, feeling, and experiencing what others are feeling
and experiencing is accomplished. This phase demonstrates emotional
involvement and discredits objectivity as dehumanizing. The task of the nurse is
to translate sympathy into helpful nursing actions (Travelbee, 1964).
5. Phase of rapport: All previous phases culminate into rapport, defined as all
those experiences, thoughts, feelings, and attitudes that both nurse and patient
undergo and are able to perceive, share, and communicate (Travelbee, 1963,
1966, pp.133-162)
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Joyce Travelbee
BIOGRAPHY
Joyce Travelbee (1926-1973) was an American nurse who in 1960 dealt with the
interpersonal aspects of nursing. She had based on psychiatric nursing. Travelbee's
theory anticipated a showdown with the positivist view of human nature. She
believed that the patients were largely become objects of care and so was not seen
as human beings. Her main aspiration was the Danish existentialist Soren
Kiekegaard and the German psychologist Viktor Frankl.

Joyce Travelbee (1926-1973), was a psychiatric nurse, educator and a writer. In 1956,
she graduated from Louisiana State University with her BSN degree. In 1959, she
earned her Master's of Science Degree from Yale University. In 1963 she started to
issue articles and journals in nursing. In 1966 she issued her 1st book titled
Interpersonal Aspects of Nursing followed by a continuation of that book published in
1971. Her next book Intervention in Psychiatric Nursing: Process in the One-to-One
Relationship, was published in 1969. In the year 1973 she began her Doctoral program
in Florida, which she would not live to finish. In the summer of 1973, at the age of 47
Joyce Travelbee died after a brief sickness. She was continually developing new
methods and was far ahead of her time in the development of these concepts. Joyce
Travelbee believes that nursing requires a holistic approach that considers all factors
affecting a client's health—physical, physiological, psychological, mental, social,
cultural, developmental and spiritual well-being.
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Overview of Joyce Travelbee Interpersonal Theory of Nursing
“A nurse does not only seek to alleviate physical pain or render physical care – she
ministers to the whole person. The existence of the suffering whether physical, mental
or spiritual is the proper concern of the nurse.” – Joyce Travelbee
Interpersonal Assumptions and Phases
Joyce Travelbee assumes that nursing is fulfilled by means of human-to-human

relationships. She defined nursing as “an interpersonal process whereby the
professional nurse practitioner assists an individual, family or community to
prevent or cope with the experience of illness and suffering, and if necessary, to
find meaning in these experiences”.
Inspired by being a psychiatric nurse, she struggles for a “Humanistic Revolution”
in nursing, with devotion to caring and compassion for patients. She expressed
that achieving the goal of nursing necessitates a genuine human-to-human
relationship, which can only be established by an interaction process, this
process is further divided into five phases.
The 5 interactional phases of Travelbee’s model are in consecutive order and

developmentally achieved by the nurse and the patient as their relationship with each
other goes deeper and more therapeutic.
■ The phase of the Original Encounter: Emotional knowledge colors

impressions and perceptions of both nurse and patient during initial encounters.
The task is “to break the bond of categorization in order to perceive the human
being in the patient” and vice versa. Patients are the same human beings as us
and families; only, that they need other human beings specifically nurses and
doctors for maintaining health. Health, which, Travelbee defines in two
categories: subjective and objective. Subjective health is an individually defined
state of well-being in accord with self-appraisal of physical-emotional-spiritual
status. Objective health is an absence of discernable disease, disability of defect
as measured by physical examination, laboratory tests, and assessment by the
spiritual director or psychological counselor.
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1. The phase of Emerging Identities: Tasks in the second phase (visibility of

personal or emerging identities) include separating oneself and one’s
experiences from others AND recognizing the different qualities that each
possesses, transcending roles by separating self and experiences from one
another – not using oneself to judge others. The nurse nor the patient is not to
stereotype the other as having a particular vexatious characteristic as this is not
facilitative to building a relationship. Tasks include and avoiding “using oneself as
a yardstick” by which to evaluate others. Barriers to such tasks may be due to
role envy, lack of interest in others, inability to transcend the self, or refusal to
initiate emotional investment. This phase is described by the nurse and patient
perceiving each other as unique individuals. At this time, the link of the
relationship begins to form.
2. The phase of Empathy: This phase involves sharing another’s psychological

state but standing apart and not sharing feelings. It is characterized “by the ability
to predict the behavior of another”.
3. The phase of Sympathy: Sharing, feeling, and experiencing what others are
feeling and experiencing is accomplished. This phase demonstrates emotional
involvement and discredits objectivity as dehumanizing. The task of the nurse is
to translate sympathy into helpful nursing actions. Sympathy happens when the
nurse wants to lessen the cause of the patient’s suffering. It goes beyond
empathy. “When one sympathizes, one is involved but not incapacitated by the
involvement.” The nurse should use a disciplined intellectual approach together
with the therapeutic use of self to make helpful nursing actions.
4. The phase of Rapport: Rapport is described as nursing interventions that

lessen the patient’s suffering. The nurse and the sick person are relating as
human being to human being. The sick person shows trust and confidence in the
nurse. “A nurse is able to establish rapport because she possesses the
necessary knowledge and skills required to assist ill persons and because she is
able to perceive, respond to, and appreciate the uniqueness of the ill human
being.”
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Description of the Interpersonal Theory
Travelbee believed nursing is accomplished through human-to-human relationships that

begin with the original encounter and then progress through stages of emerging
identities, developing feelings of empathy, and later feelings of sympathy. Travelbee’s
ideas have greatly influenced the hospice movement in the west.
The nurse and patient attain a rapport in the final stage. For meeting the goals of
nursing, it is a prerequisite to achieving genuine human-to-human relationships. This
relationship can only be established by an interaction process. It has five phases:
1. The inaugural meeting or original encounter
2. Visibility of personal identities/ emerging identities.
3. Empathy
4. Sympathy
5. Establishing mutual understanding and contact/ rapport
Basic Concepts & Definitions
• Suffering: “An experience that varies in intensity, duration and depth … a

feeling of unease, ranging from mild, transient mental, physical or mental
discomfort to extreme pain and extreme tortured …”
• Meaning: reason as oneself attributes
• Nursing: is to help man to find meaning in the experience of illness and

suffering. has a responsibility to help individuals and their families to find
meaning. The nurses’ spiritual and ethical choices and perceptions of illness and
suffering are crucial in helping to find meaning.
• Hope: The nurse’s job is to help the patient to maintain hope and avoid
hopelessness. Hope is a faith that can and will change that would bring
something better with it. Hope’s core lies in a fundamental trust in the outside
world, and a belief that others will help someone when you need it.
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Six important factors characteristics of hope are:
1. It is strongly associated with dependence on other people.
2. It is future-oriented.
3. It is linked to elections from several alternatives or escape routes out of its

situation.
4. The desire to possess any object or condition, to complete a task or have an

experience.
5. Confidence that others will be there for you when you need them.
6. The hoping person is in possession of courage to be able to acknowledge their

shortcomings and fears and go forward towards their goal.
• Communications: “a strict necessity for good nursing care” and “one is able to
use itself therapeutic.”
• Using “self” therapeutically”: Self-awareness and self-understanding,

understanding of human behavior, the ability to predict one’s own and others’
behavior are important in this process.
• Targeted intellectual approach: nurses must have a systematic intellectual

approach to the patient’s situation.
Nursing Metaparadigms
• Person: person is defined as a human being. Both the nurse and the patient are
human beings.
• Health: Health is subjective and objective. Subjective health is an individually

defined state of well-being in accord with self-appraisal of physical-emotional-
spiritual status.
Objective health is an absence of discernible disease, disability, or defect as
measured by physical examination, laboratory tests, and assessment by a
spiritual director or psychological counselor.
• Environment: NOT clearly defined.
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• Nursing: “an interpersonal process whereby the professional nurse practitioner

assists an individual, family or community to prevent or cope with experience or
illness and suffering, and if necessary to find meaning in these experiences.”
Travelbee’s theory extended the interpersonal relationship theories of Peplau and

Orlando, and her unique synthesis of their ideas differentiated her work in terms of the
therapeutic human relationship between nurse and patient. Travelbee’s emphasis on
caring stressed empathy, sympathy, rapport, and the emotional aspects of nursing
(Travelbee, 1963, 1964). Rich (2003) revisited Travelbee’s argument on the value of
sympathy in nursing and updated it with a reminder that compassion is central to holistic
nursing care. Bunkers (2012) recently examined her human relationship model to
explore the meaning of presence. Travelbee’s work is categorized as a nursing theory.
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4.NUHall’s CORE, CARE, CURE
Lydia Hall (1962)
Introduced the model on "CARE, CORE and 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 physician's orders. Core
and cure are shared with the other health care providers. She articulated her views
in nursing in her book "Nursing-What is it?"
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Lydia Hall
BIOGRAPHY
Lydia Eloise Hall (September 21, 1906 – February 27, 1969) was a nursing theorist
who developed the Care, Cure, Core model of nursing. Her theory defined
Nursing as “a participation in care, core and cure aspects of patient care, where
CARE is the sole function of nurses, whereas the CORE and CURE are shared with
other members of the health team.”
She was an innovator, motivator, mentor to nurses in all phases of their careers, and
an advocate for chronically ill patients. She worked to involve the community in
public health issues.
EARLY LIFE
Lydia Hall was born on September 21, 1906, in New York City as Lydia Eloise
Williams. She was the eldest child of Louis V. Williams and Anna Ketterman Williams
and was named after her maternal grandmother. Her brother, Henry, was several years
younger. At a young age, her family decided to move to York, Pennsylvania, where her
father was a general practice physician.
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EDUCATION
Lydia Hall graduated from York Hospital School of Nursing in 1927 with a diploma in
nursing. However, she felt as if she needed more education. She entered Teacher’s
College at Columbia University in New York and earned a Bachelor of Science degree
in public health nursing in 1932. After several years in clinical practice, she resumed her
education and received a master’s degree in the teaching of natural life sciences from
Columbia University in 1942. Later, she pursued a doctorate and completed all of the
requirements except for the dissertation.
In 1945, she married Reginald A. Hall, who was a native of England.
WORKS
Aside from being a nurse, Lydia Hall also managed to balance her time in writing. In the
1960s, she authored 21 publications and many articles regarding the Loeb Center and
her long-term care and chronic disease control theories. Her work was presented in
“Nursing: What Is It?” in The Canadian Nurse. In 1969, it was discussed in “The Loeb
Center for Nursing and Rehabilitation” in the International Journal of Nursing Studies. In
her innovative work at the Loeb Center, Hall argued that a need exists in society to
provide hospital beds grouped into units that focus on the delivery of therapeutic
nursing. The Loeb plan has been seen in many ways as similar to what later emerged
as “primary nursing.”
AWARDS AND HONORS

In 1967, Lydia Hall received the Teacher’s College Nursing Education Alumni
Association (TCNEAA) Achievement in Nursing Practice Award and was their Nursing
Hall of Fame inductee. In 1984, she was inducted into the American Nurses Association
(ANA) Hall of Fame.
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Overview of Lydia Hall's Care, Core and Cure Model
■ Lydia Hall represented her theory of nursing by drawing three interlocking circles,
each circle representing a particular aspect of nursing: CARE, CORE, and
CURE.
■ The Care Circle

o The nurturing component of care and is exclusive to nursing.
o It involves the concept of "mothering" (care and comfort of the person) and
provide for teaching-learning activities.
o The professional nurse provides bodily care for the patient and helps the patient
to complete such basic daily biologic activities like eating, bathing, elimination,
and dressing.
o The nurse's goal is the comfort of the patient.
o Providing care for the patient at the basic needs level presents the nurse and the
patient with an opportunity for closeness. As closeness develops the patient can
share and explore feelings with the nurse. This opportunity to explore feelings
represents the teaching-learning aspect of nurturing.
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o When functioning in the care circle, the nurse applies knowledge of the natural
and biologic sciences to provide a strong theoretical base for nursing
implementations.
o In interactions with the patient, the nurse's role reaches a professional status
rather than a mothering status through strong theory base. At the same time, the
nurse incorporates closeness and nurturance in giving care. The patient views
the nurse as a potential comforter, one who provides care and comfort through
the laying on of hands.
The Body
Natural and Biologic
Sciences
Intimate bodily care

aspect of nursing
"The CARE"
The Care Circle of Patient Care (Hall)
■ The Core Circle

o The core circle of patient care is based on the social sciences.
o Involves the therapeutic use of self.
o The nurse is able to help the patient verbally express feelings regarding the
disease process and its effects, as well as discuss the patient's role in
recovery or healing process.
o The patient is able to maintain who they are (self-identity).
o The patient is able to develop a maturity level when the nurse listens to
him/her and acts as sounding board.
o The patient is able to make informed or conscious decisions based on
understood and accepted feelings and motivations.
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o The professional nurse, by use of the reflective technique (acting as a mirror

for the patient) helps the patient look at and explore feelings regarding his or
her current health status and related potential changes in life style.
o The motivation and energy necessary for healing exist within the patient,
rather than in the health care team.
The Person
Social Sciences
Therapeutic use of self

aspect of nursing
"The CORE"
The Core Circle of Patient Care (Hall)
■ The Cure Circle

o The cure circle of patient care is based in the pathological and therapeutic
sciences and is shared with other members of the health team.
o The professional nurse helps the patient and family through the medical,
surgical, and rehabilitative prescriptions made by the physician. During this
aspect of nursing care, the nurse is an active advocate of the patient.
o The nurse's role during the cure aspect takes on a negative quality like
avoidance of pain rather than a positive quality like comforting.
o This is negative in the sense that the patient views the nurse as a potential
cause of pain, e.g., one who is involved in such actions as administering
injections, versus the potential comforter who provides care and comfort in
the care circle.
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The Disease
Pathological and therapeutic

Sciences
Seeing the patient and family

through the medical care
aspect of nursing
"The CURE"
The Cure Circle of Patient Care (Hall)
■ Interaction of the Three Aspects of Nursing

o Hall emphasizes the importance of total person approach.
o Likewise, importance is placed on all three aspects of nursing be viewed as
functioning in an interrelated manner.
o The three aspects interact and the circles representing them change size,
depending on the patient's total course of progress.
o In the philosophy of Loeb's Center, the professional nurse functions most
therapeutically when patients have entered the second stage of their hospital
stay (i.e., they are recuperating and are past the acute stage of illness).
o During this recuperation stage, the care and core aspects are the most
prominent, and the cure aspect is less prominent.
o The size of the circles represents the degree to which the patient is
progressing in each of the three areas.
o Only nursing is defined as the function necessary to carry out care, core, and
cure.
o Philosophical views of humans as having energy and motivation for self-
awareness and growth.
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Lydia Hall's Theory and the Nursing Process
■ Hall's theory influences the nurse's total approach to the six phases of the
nursing process: assessment, diagnosis, outcomes, planning, implementation,
and evaluation.
■ The assessment phase involves collection of data about the health status of the
individual. According to Hall, the process of data collection is directed for the
benefit of the patient rather than for the benefit of the nurse. Data collection
should be directed toward increasing the patient's self-awareness. Through the
use of observation and reflection, the nurse is able to assist the patient in
becoming aware of both verbal and nonverbal behaviors. In the individual,
increased awareness of feelings and needs in relation to health status increases
the ability for self-healing. The assessment phase also pertains to guiding the
patient through the cure aspect of nursing. The health team collects biologic data
(physical and laboratory) to help the patient and family understand and progress
through the medical regimen.
■ The nursing diagnosis phase is a statement of the patient's need or problem

area. In Hall's theory, the patient is the one in control, the one who identifies the
need.
■ Outcomes and Planning involve setting priorities and mutually establishing

patient-centered outcome and goals. The patient decides what is of highest
priority and also what outcomes and goals are desirable. The core is involved in
outcomes and planning. The role of the nurse is to use reflection to help the
patient become aware of and understand needs, feelings, and motivations. Once
motivations are clarified, Hall indicates that the patient is the best person to
identify outcomes, set goals, and arrange priorities. The nurse works with the
patient to help keep the goals consistent with the medical prescription. The nurse
needs to draw on a knowledge base in the social and scientific areas to present
the patient with creative alternatives from which to choose.
■ Implementation involves the actual institution of the plan of care. This phase is
the actual giving of nursing care. In the care and core circles, the nurse works
with the patient, helping with bathing, dressing, eating, and other care and
comfort needs. The professional nurse uses a "permissive non-directive
teaching-learning approach" to implement nursing care, thus helping the patient
achieve the established goals. This includes "helping the patient with his feelings,
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providing requested information and supporting patient-made decisions." The

nurse also helps the patient and the family through the cure aspect of nursing,
working with them and helping them understand and implement the medical plan.
■ Evaluation is the process of assessing the patient's progress toward the health
goals. The evaluation phase of the process is directed toward deciding whether
or not the patient is successful in reaching the established goals. The following
questions apply to the use of Hall's theory in the evaluation phase:
1. Is the patient learning "who he is, where he wants to go, and how he wants to
get there"? (Bowar-Ferres, 1975, p.813).
2. Is the patient learning to understand and explore the feelings that underlie
behavior?
3. Is the nurse helping the patient see motivations more clearly?
4. Are the patient's goals congruent with the medical regime? Is the patient
successful in meeting the goals?
5. Is the patient physically more comfortable?
Whether or not a person is growing in self-awareness regarding his or her feelings and
motivations can be recognized through changes in his or her outward behavior.
Concepts
Person. The individual human who is 16 years old or older and past the acute stage of
long-term illness is the focus of nursing care in hall's theory.
■ The source of energy and motivation for healing is the individual care for
recipient, not the health care provider.
■ The individual is unique, capable of growth and learning, and requiring a total
person approach.
Health. A state of self-awareness with conscious selection of behaviors that are

optimal for that individual.
■ Hall stresses the need to help the person explore the meaning of his or her
behavior to identify and overcome problems through developing self-identity and
maturity.
Environment/Society. Is dealt with in relation to the individual.
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■ Hall is credited with developing the concept of Loeb Center because she
assumed that the hospital environment during treatment of acute illness creates
a difficult psychological experience for the ill individual.
■ Loeb Center focuses on providing an environment that is conducive to self-
development. In such setting, the focus of the action of the nurses is the
individual, so that any action taken in relation to society or environment are for
the purpose of assisting the individual in attaining a personal goal.
Nursing. Is identified as consisting of participation in the care, core, and cure aspects
of patient care.
■ Care is the sole function of nurses, whereas core and cure are shared with other
members of the health care team.
■ The major purpose of care is to achieve an interpersonal relationship with the
individual that will facilitate the development of core (i.e., the development of self-
identity and self-direction by the patient).
Note: The concept of nursing is clearly identified by Hall, she does not speak directly to
the other three concepts: person, health, and environment. However, inferences can be
made from her work.
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5. Abdellah’s 21 Nursing Problems
Faye Abdellah (1960)
Introduced "Patient - Centered Approaches to Nursing Model". She identified

twenty-one nursing problems which determine nursing care. She defined nursing as
service to individuals and families; therefore, to society. Furthermore, she
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.
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Faye Abdellah
BIOGRAPHY
Faye Glenn Abdellah (March 13, 1919 – present) is a nursing research pioneer
who developed the “Twenty-One Nursing Problems.” Her nursing model was
progressive for the time in that it refers to a nursing diagnosis during a time in which
nurses were taught that diagnoses were not part of their role in health care.
She was the first nurse officer to rank a two-star rear admiral, the first nurse, and the
first woman to serve as a Deputy Surgeon General.
EARLY LIFE
On March 13, 1919, Faye Abdellah was born in New York to a father of Algerian
heritage and a Scottish mother. Her family subsequently moved to New Jersey, where
she attended high school.
Years later, on May 6, 1937, the German hydrogen-fueled airship Hindenburg exploded
over Lakehurst.
Abdellah and her brother witnessed the explosion, destruction, and fire after the ignited
hydrogen killed many people. That incident became the turning point in Abdellah’s life. It
was that time when she realized that she would never again be powerless to assist
when people were in such a dire need of assistance. It was at that moment she vowed
that she would learn to nurse and become a professional nurse.
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EDUCATION
Faye Abdellah earned a nursing diploma from Fitkin Memorial Hospital’s School of
Nursing, now known as Ann May School of Nursing.
It was sufficient to practice nursing during her time in the 1940s, but she believed that
nursing care should be based on research, not hours of care.
Abdellah went on to earn three degrees from Columbia University: a bachelor of science
degree in nursing in 1945, a master of arts degree in physiology in 1947, and a doctor
of education degree in 1955.
With her advanced education, Abdellah could have chosen to become a doctor.
However, as she explained in one of her interviews that she wanted to be an M.D.
because she could do all she wanted to do in nursing, which is a caring profession.
CAREER
Dr. Abdellah, pioneer nursing researcher, helped transform nursing theory, nursing
care and nursing education. After receiving her nursing certificate from the Ann May
School of Nursing and her Bachelor’s, Master’s, and Doctoral degrees in Education
from Columbia University, Dr. Abdellah embarked on her distinguished career in health
care. She was the first nurse officer to receive the rank of a two-star rear admiral. Her
more than 150 publications, including her seminal works, Better Nursing Care Through
Nursing Research and Patient-Centered Approaches to Nursing, changed the focus of
nursing theory from a disease-centered to a patient-centered approach and moved
nursing practice beyond the patient to include care of families and the elderly. Her
Patient Assessment of Care Evaluation method to evaluate health care is now the
standard for the nation. Her development of the first tested coronary care unit has saved
thousands of lives.
As the first nurse and the first woman to serve as Deputy Surgeon General, Dr.
Abdellah developed educational materials in many key areas of public health, including
AIDS, disabilities, violence, hospice care, smoking cessation, alcoholism, and drug
addiction.
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Dr. Abdellah, after teaching at several prestigious universities, founded the Graduate
School of Nursing at the Uniformed Services University of the Health Sciences and
served as the school’s first dean. Beyond the classroom, Dr. Abdellah presented at
workshops around the world on nursing research and nursing care.
Dr. Abdellah’s work has been recognized with almost 90 professional and academic
honors, including the prestigious Allied Signal Award for her pioneering research in
aging. She is also the recipient of eleven honorary degrees.
As a leader in health care, she has helped transform the practice of nursing and raised
its standards by introducing scientific research into nursing and patient care. Her
leadership, her publications and her accomplishments have set a new standard for
nursing and for women in the health care field.
WORK
As a consultant and educator, Faye Abdellah shared her nursing theories with
caregivers around the world. She led seminars in France, Portugal, Israel, Japan,
China, New Zealand, Australia, and the former Soviet Union. She also served as a
research consultant to the World Health Organization. From her global perspective,
Abdellah learned to appreciate nontraditional and complementary medical treatments
and developed the belief such non-Western treatments deserved scientific research.
Also, she has been active in professional nursing associations and is a prolific author,
with more than 150 publications. Her publications include Better Nursing Care
Through Nursing Research and Patient-Centered Approaches to Nursing. She
also developed educational materials in many areas of public health, including AIDS,
hospice care, and drug addiction.
Abdellah considers her greatest accomplishment being able to “play a role in
establishing a foundation for nursing research as a science.” Her book, Patient-
Centered Approaches to Nursing, emphasizes nursing science and has elicited
changes throughout nursing curricula. Her work, which is based on the problem-solving
method, serves as a vehicle for delineating nursing (patient) problems as the patient
moves toward a healthy outcome.
Additional works written by Abdellah include: Preparing Nursing Research for the 21st
Century: Evolution , Methodologies, Challenges; New directions in Patient-Centered

Nursing: Guidelines for Systems of Service, Education, and Research; Effect of Nurse
Staffing on Satisfactions with Nursing Care: A Study of How Omissions in Nursing
Services, as Perceived by Patients and Personnel, Are Influenced by the Number of
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Nursing Hours Available; Patients and Personnel Speak, A Method of Studying Patient
Care in Hospitals; Appraising the Clinical Resources in Small Hospitals; Nursing’s Role
in the Future: The Case for Health Policy Decision Making; Overview of Nursing
Research, 1955-1968; Surgeon General’s Workshop, Health Promotion, and Aging
proceedings. March 20-23, 1988; and Words of Wisdom from Pivotal Nurse Leaders.
AWARDS AND HONORS
Faye Abdellah is recognized as a leader in nursing research and nursing as a

profession within the Public Health Service (PHS) and as an international expert on
health problems. She was named a “living legend” by the American Academy of Nursing
in 1994 and was inducted into the National Women’s Hall of Fame in 2000 for a lifetime
spent establishing and leading essential health care programs for the United States. In
2012, Abdellah was inducted into the American Nurses Association Hall of Fame for a
lifetime of contributions to nursing.
Her contributions to nursing and public health have been recognized with almost 90
professional and academic honors, such as the Allied Signal Achievement Award for
pioneering research in aging and Sigma Theta Tau’s Lifetime Achievement Award.
Abdellah’s leadership, her publications, and her lifelong contributions have set a new
standard for nursing and health care. Her legacy of more than 60 years of extraordinary
accomplishments lives nationally and globally.
Aside from being the first nurse and the first woman to serve as a Deputy Surgeon
General, Faye Glenn Abdellah also made a name in the nursing profession to
formulate her “21 Nursing Problems Theory.” Her theory changed the focus of nursing
from disease-centered to patient-centered and began to include the care of families and
the elderly in nursing care. The Patient Assessment of Care Evaluation developed by
Abdellah is now the standard used in the United States.
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Overview of Abdellah's "Patient-Centered Approaches to Nursing Model"
Abdellah and colleagues developed a list of 21 nursing problems. They also identified
10 steps to identify the client's problems and 11 nursing skills to be used in developing a
treatment typology.
10 steps to identify the client's problems:
■ Learn to know the patient

■ Sort out relevant and significant data
■ Make generalizations about available data in relation to similar nursing problems
presented by other patients
■ Identify the therapeutic plan
■ Test generalizations with the patient and make additional generalizations
■ Validate the patient's conclusions about his nursing problems
■ Continue to observe and evaluate the patient over a period of time to identify any
attitudes and clues affecting his behavior
■ Explore the patient's and family's reaction to the therapeutic plan and involve
them in the plan
■ Identify how the nurse feels about the patient's nursing problems
■ Discuss and develop a comprehensive nursing care plan.
11 nursing skills
■ Observation of health status

■ Skills of communication
■ Application of knowledge
■ Teaching of patients and families
■ Planning and organization of work
■ Use of resource materials
■ Use of personnel resources
■ Problem-solving
■ Direction of work of others
■ Therapeutic use of the self
■ Nursing procedures
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The Twenty-one Nursing Problems
Three major categories

■ Physical sociological and emotional needs of clients
■ Types of interpersonal relationships between the nurse and patient
■ Common elements of client care
Classification of the Twenty-one Nursing Problems (Faye Abdellah, et al, 1960,

1965)
BASIC TO ALL PATIENTS
1. To maintain good hygiene and physical comfort.

2. To promote optimal activity: exercise, rest and sleep.
3. To promote safety through the prevention of accidents, injury or other trauma
and through the prevention of the spread of infection.
4. To maintain good body mechanics and prevent and correct deformity.
SUSTENAL CARE NEEDS
5. To facilitate the maintenance of a supply of oxygen to all body cells.

6. To facilitate the maintenance of nutrition of all body cells.
7. To facilitate the maintenance of elimination.
8. To facilitate the maintenance of fluid and electrolyte balance.
9. To recognize the physiological responses of the body to disease conditions.
10. To facilitate the maintenance of regulatory mechanisms and functions.
11. To facilitate the maintenance of sensory function.
REMEDIAL CARE NEEDS
12. To identify and accept positive and negative expressions, feelings, and
reactions.
13. To identify and accept the interrelatedness of emotions and organic illness.
14. To facilitate the maintenance of effective verbal and nonverbal
communication.
15. To promote the development of productive interpersonal relationships. 0x9
16. To facilitate progress toward achievement of personal spiritual goals.
17. To create and / or maintain a therapeutic environment.
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18. To facilitate awareness of self as an individual with varying physical,

emotional, and developmental needs.
RESTORATIVE CARE NEEDS
19. To accept the optimum possible goals in the light of limitations, physical and
emotional.
20. To use community resources as an aid in resolving problems arising from
illness.
21. To understand the role of social problems as influencing factors in the case of
illness.
Abdellah's 21 problems are actually a model describing the "arenas" or concerns

of nursing, rather than a theory describing relationships among phenomena. In this way,
the theory distinguished the practice of nursing, with focus on the 21 nursing problems,
from the practice of medicine, with a focus on disease and cure.
Abdellah's theory states that nursing is the use of the problem-solving approach
with key nursing problems related to health needs of people. This statement maintains
problem solving as the vehicle for the nursing problems as the patient is moved toward
health---the outcome.
Nursing Problems
■ Nursing problem presented by a patient is a condition faced by the patient or
patient's family that the nurse through the performance of professional functions
can assist them to meet.
The problem can be either an overt or covert nursing problem.

■ An overt nursing problem is an apparent condition faced by the patient or family,
which the nurse can assist him or them to meet through the performance of her
professional functions.
■ The covert nursing problem is concealed or hidden condition faced, by the
patient or family, which the nurse can assist him or them to meet through the
performance of her professional functions.
■ In her attempt to bring nursing practice into its proper relationship with restorative
and preventive measures for meeting total client needs, she seems to swing the
pendulum to the opposite pole, from the disease orientation to nursing
orientation, while leaving the client somewhere in the middle.
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PROBLEM SOLVING
The problem-solving process involves identifying the problem, selecting pertinent data,
formulating hypothesis, testing hypothesis through the collection of data, and revising
hypothesis where necessary on the basis of conclusions obtained from the data.
CONCEPTS
Purpose: To deliver nursing care for the whole individual.
a. PERSON
■ Abdellah describes people as having physical, emotional, and sociological
needs. These needs may be overt, consisting of largely physical needs or covert
such as emotional and social needs.
■ Patient is described as the only justification for the existence of nursing
■ Individuals (and families) are the recipients of nursing
■ Health or achieving of it, is the purpose of nursing services.
b. SOCIETY AND ENVIRONMENT

■ Society is included in "planning for optimum health on local state, national, and
international levels". However, as Abdellah further delineated her ideas, the focus
of nursing service is clearly the individual.
■ The environment is the home or community from which patient comes.
c. HEALTH
■ In Patient-Centered Approaches to Nursing, Abdellah describes health as state
mutually exclusive of illness.
■ Although Abdellah does not give a definition of health, she speaks to "total health
needs" and "a healthy state of mind and body" in her description of nursing as a
comprehensive service.
d. NURSING
■ Nursing is a helping profession. In Abdellah's model, nursing care is doing
something to or for the person or providing information to the person with the
goals of meeting needs, increasing or restoring self-help ability, or alleviating
impairment.
■ Nursing is broadly grouped into the 21 problem areas to guide care and promote
use of nursing judgment.
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■ She considers nursing to be comprehensive service that is based on art and

science and aims to help people, sick or well, cope with their health needs.
USE OF 21 PROBLEMS IN THE NURSING PROCESS
ASSESSMENT PHASE
■ Nursing problems provide guidelines for the collection of data.

■ A practice underlying the problem-solving approach is that for each identified
problem, pertinent data are collected.
■ The overt or covert nature of the problems necessitates a direct or indirect
approach, respectively.
NURSING DIAGNOSIS
■ The results of data collection would determine the client's specific overt or covert
problems
■ These specific problems would be grouped under one or more of the broader
nursing problems.
■ This step is consistent with that involved in nursing diagnosis.
PLANNING PHASE
■ The statements of nursing problems most closely resemble goal statements.

Therefore, once the problem has been diagnosed, the goals have been
established.
■ Given that these problems are called nursing problems, then it becomes
reasonable to conclude that these goals are basically nursing goals.
IMPLEMENTATION
■ Using the goals as the framework, a plan is developed and appropriate nursing
interventions are determined.
EVALUATION
■ According to the American Nurses' Association Standards of Nursing Practice,

the plan is evaluated in terms of the client's progress or lack of progress toward
the achievement of the stated goals.
■ This would be extremely difficult if not impossible to do for Abdellah's nursing
problem approach since it has been determined that the goals are nursing goals,
not the client goals.
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■ Thus, the most appropriate evaluation would be the nurse progress or lack of
progress toward the achievement of the stated goals.
Abdellah has suggested the following criteria might be used to determine the
effectiveness of patient-centered care:
1. The patient is able to provide for the satisfaction of his own needs.
2. The nursing care plan makes provision to meet four needs-sustenal care, remedial
care, restorative care, and preventive care.
3. The care plan extends beyond the patient's hospitalization and makes provision for
continuation of the care at home.
4. The levels of nursing skills provided vary with the individual patient care
requirements.
5. The entire care plan is directed at having the patient help himself.
6. The care plan makes provision for involvement of members of the family throughout
the hospitalization and after discharge. (Abdellah & Levine, 1965, pp. 77-78).
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6.NUHenderson’s Need Theory
Virginia Henderson (1955)
Introduced "The Nature of Nursing Model" ("Definitions and Components of

Nursing"). She identified fourteen basic needs on which nursing care is based. She
postulated that the unique function of the nurse is to assist the clients, sick or well, in
the performance of those activities contributing to health or its recovery, that clients
would perform unaided if they had the necessary strength, will or knowledge. She
further believed that nursing involves assisting the client in gaining independence as
rapidly as possible, or assisting him achieve peaceful death if recovery is no longer
possible.
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Virginia Henderson
BIOGRAPHY
Virginia Avenel Henderson (November 30, 1897 – March 19, 1996) was a nurse,
theorist, and author known for her Need Theory and defining nursing as: “The
unique function of the nurse is to assist the individual, sick or well, in the
performance of those activities contributing to health or its recovery (or to peaceful
death) that he would perform unaided if he had the necessary strength, will or
knowledge.” Henderson is also known as “The First Lady of Nursing,” “The
Nightingale of Modern Nursing,” “Modern-Day Mother of Nursing,” and
“The 20th Century Florence Nightingale.”
EARLY LIFE
Virginia Henderson was born in Kansas City, Missouri, in 1897, the fifth of the eight
children of Lucy Minor Abbot and Daniel B. Henderson. She was named after the State
her mother longed for. At age four, she returned to Virginia and began her schooling at
Bellevue, a preparatory school owned by her grandfather William Richardson Abbot.
Her father was a former teacher at Bellevue and was an attorney representing the
Native American Indians in disputes with the U.S. Government, winning a major case
for the Klamath tribe in 1937.
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EDUCATION
Virginia Henderson received her early education at home in Virginia with her aunts,
and uncle Charles Abbot, at his school for boys in the community Army School of
Nursing at Walter Reed Hospital in Washington D.C. In 1921, she received her Diploma
in Nursing from the Army School of Nursing at Walter Reed Hospital, Washington D.C.
In 1923, Henderson started teaching nursing at the Norfolk Protestant Hospital in
Virginia. In 1929, she entered Teachers College at Columbia University for her
Bachelor’s Degree in 1932 and took her Master’s Degree in 1934.
WORKS
In 1939, she was the author of three editions of “Principles and Practices of
Nursing,” a widely used text. Her “Basic Principles of Nursing,” published in 1966 and
revised in 1972, has been published in 27 languages by the International Council of
Nurses.
Her most formidable achievement was a research project in which she gathered,
reviewed, cataloged, classified, annotated, and cross-referenced every known piece of
research on nursing published in English, resulting in the four-volume “Nursing
Research: Survey and Assessment,” written with Leo Simmons and published in 1964,
and her four-volume “Nursing Studies Index,” completed in 1972.
AWARDS AND HONORS

There are numerous honors and awards bestowed upon Virginia Henderson.
She received honorary doctorate degrees from the Catholic University of America, Pace
University, University of Rochester, University of Western Ontario, Yale University,
Rush University, Old Dominion University, Boston College, Thomas Jefferson
University, Emory University, and many others.
In 1977 she created an Honorary Fellow of the American Academy of Nursing. In the
subsequent year, she has created an Honorary Fellow of the Royal College of Nursing
of the United Kingdom for her unique contribution to nursing’s art and science.
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In 1985, Henderson was honored at the Nursing and Allied Health Section of the
Medical Library Association. In the same year, she received the first Christiane
Reimann prize from the International Nursing Council (ICN), the highest and most
prestigious nursing award due to her work’s international scope.
In 1988, she was honored by the Virginia Nurses Association when the Virginia
Historical Nurse Leadership Award was presented to her.
The Virginia Henderson Global Nursing e-Repository or The Virginia Henderson
International Nursing Library was named in her honor by Sigma Theta Tau International
for the global impact on nursing research. The library in Indianapolis has been available
in electronic form through the Internet since 1994.
In 2000, the Virginia Nurses Association recognized Henderson as one of the 51
Pioneer Nurses in Virginia. She is also a member of the American Nurses Association
Hall of Fame.
NEED THEORY
Henderson’s widely known contributions to nursing are the Need Theory, among her
other works. The Need Theory emphasizes the importance of increasing the patient’s
independence and focusing on the basic human needs so that progress after
hospitalization would not be delayed. The Need Theory is discussed further below.
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Overview of Henderson's "The Nature of Nursing Model"
The Henderson theory of nursing encompasses a definition of nursing, a

description of the function of a nurse, and the enumeration of the 14 components that
make up basic nursing care.
The definition of nursing is the fundamental part of Henderson's theory of Nursing.

Henderson defined nursing as "doing things for patients that they would do for
themselves if they could, that is if they were physically able or had the required
knowledge. Nursing helps the patient become healthy or die peacefully, and also helps
people work toward independence, so that they can begin to perform the relevant
activities for themselves as quickly as possible.” Rather than focus on a particular task,
Henderson focused on the patient. She saw how nursing could focus on the patient, and
how it was possible to focus on developing a good nurse-patient relationship. She
deeply believed that patient-focused nursing was the most beneficial kind of nursing for
the patient.
Henderson enumerated the 14 components that make up the basic nursing care
(fundamental needs), which are as follows:
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
10. Communicate with others in expressing emotions, needs, fears, or opinions
11. Worship according to one's faith
12. Work in such a way that there is a sense of accomplishment
13. Play or participate in various forms of recreation
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14. Learn, discover, or satisfy the curiosity that leads to normal development and
health and use the available health facilities.
The first 9 components are physiological. The tenth and fourteenth are
psychological aspects of communicating and learning. The eleventh component
is spiritual and moral. The twelfth and thirteenth components are sociologically
oriented to occupation and recreation.
The major assumptions of the theory are as follows:

■ Nurses care for patients until patients can care for themselves once again.
Patients desire to return to health.
■ Nurses are willing to serve and that nurses will devote themselves to the patient
day and night.
■ Nurses should be educated at the university level in both arts and od sciences.
CONCEPTS
A. Person. Individual requiring assistance to achieve health and independence or a

peaceful death. Mind and body are inseparable.
B. Environment. All external conditions and influences that affect life and
development.
C. Health. Equated with independence, viewed in terms of the client's ability to
perform 14 components of nursing care unaided.
■ Nurses need to stress promotion of health and prevention and cure of
disease.
■ Good health is a challenge. Affected by age, cultural background, physical
and intellectual capacities, and emotional balance.
D. Nursing. Assists and supports the individual in life activities and the attainment
of independence.
Purpose: To assist the client in gaining independence as rapidly as possible.
■ Nurse serves to make patient "complete" "whole" or "independent"
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■ Henderson's classic definition of nursing:

"I say that the nurse does for others what they would do for themselves if they
had the strength, the will, and the knowledge. But I go on to say that the
nurse makes the patient independent of him or her as soon as possible."
■ The nurse is expected to carry out physician's therapeutic plan.
Individualized care is the result of the nurse's creativity in planning for care.
■ Using nursing research
o Categorized Nursing: nursing care
o Non nursing: ordering supplies, cleanliness and serving food
■ In the Nature of Nursing "that the nurse is and should be legally, an
independent practitioner and able to make independent judgments as long as
she is not diagnosing, prescribing treatment for disease, or making a
prognosis, for these are the physician's function"
■ "Nurse should have knowledge to practice individualized and humane care
and should be a scientific problem solver"
■ In the Nature of Nursing, nurse role is, "to get inside the patient's skin and
supplement his strength, will, or knowledge according to his needs"
■ And nurse has responsibility to assess the needs of the individual patient,
help individual meet their health need, and/or provide an environment in
which the individual can perform activity unaided.
Henderson's Model and Nursing Process
Henderson views the nursing process as "really the application of the logical
approach to the solution of a problem. The steps are those of the scientific method."
Nursing process stresses the science of nursing rather than the mixture of science and
art on which it seems effective health care service of any kind is based.
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"Summarization of the stages of the nursing process as applied to Henderson's

definition of nursing and to the 14 components of basic nursing care.
Nursing Process Henderson's 14 components and definition

of nursing
Nursing Assessment Henderson's 14 components of basic
nursing care
Nursing Diagnosis Analysis: Compare the data to knowledge
base of health and disease.
Nursing plan Identify individual's ability to meet own
needs with or without assistance, taking
into consideration strength, will, or
knowledge
Nursing implementation Document how the nurse can assist the
individual, sick or well
Assist the sick or well individual in the
performance of activities in meeting
human needs to maintain health, recover
from illness, or to aid in peaceful death.
Implementation based on the physiological
principles, age, cultural background,
emotional balance, and physical and
intellectual capacities.
Carry out treatment prescribed by the
physician.
Nursing evaluation Henderson's 14 components and definition
of nursing use the acceptable definition of
nursing and appropriate laws related to the
practice of nursing.
The quality of care is drastically affected
by the preparation and native ability of the
nursing personnel rather that the amount
of hours of care.
Successful outcomes of nursing care are
based on the speed with which or degree
to which the patient performs
independently the activities of daily living
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7.NUPender’s Health Promotion Model; Nursing Theories
Nola Pender
Designed the "Health Promotion Model". She advocated that promoting optimum
health supersedes disease prevention. The model attempts to explain the reasons
why individuals engage in health activities. Pender identified cognitive perceptual
factors in clients which are modified by demographical and biological characteristics,
interpersonal influences, situational and behavioral factors that help predict in heath
promoting behavior. Furthermore, Pender advocated that health promotion involves
activities that promote healthful lifestyles, activities directed toward increasing the
level of well-being and self- actualization and ultimately improve quality of life.
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Nola Pender
BIOGRAPHY
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.
EARLY LIFE
On August 16, 1941, Nola Pender was born in Lansing, Michigan, to parents who
advocated education for women. Her first encounter with the nursing profession was
when she was 7 years old and witnessed the care given to her hospitalized aunt by
nurses. This situation led her to the desire to care for other people, and her goal was to
help people care for themselves.
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EDUCATION
With her parents’ support, Nola Pender entered the School of Nursing at West
Suburban Hospital in Oak Park, Illinois, and received her nursing diploma in 1962. In
1965, she received her master’s degree in human growth and development from the
same university. She moved to Northwestern University in Evanston, Illinois, to obtain a
Ph.D. in psychology and education in 1969. Pender’s dissertation research investigated
developmental changes in the encoding process of short-term memory in children.
Years later, she finished masters-level work in community health nursing at Rush
University.
WORKS
As regards health promotion, Nola Pender has written and issued various articles on
exercise, behavior change, and relaxation training. She also has served on editorial
boards and as an editor for journals and books.
Pender is also known as a scholar, presenter, and consultant in health promotion. She
has collaborated with nurse scientists in Japan, Korea, Mexico, Thailand, the Dominican
Republic, Jamaica, England, New Zealand, And Chile.
By contributing leadership as a consultant to research centers and giving scholar
consultations, Pender resumes influencing nursing. She also collaborates with the
American Journal of Health Promotion editor, promoting legislation to support health
promotion research.
Selected Publications Related to Nola Pender
■ Health Promotion in Nursing Practice (6th Edition)

■ Pender, Nola J. Study Guide for Health Promotion in Nursing Practice
■ Philosophies and Theories for Advanced Nursing Practice
■ Robbins, L.B., Gretebeck, K.A., Kazanis, A.S. and Pender, Nola.J. Girls on the
Move
■ Program to Increase Physical Activity Participation, Nursing Research, 2006
■ Pender, Nola.J., Bar-Or, O., Wilk, B. and Mitchell, S. Self-Efficacy and Perceived
Exertion of Girls During Exercise, Nursing Research, 2002
■ Eden, K.B., Orleans, C.T., Mulrow, C.D., Pender, Nola.J. and Teutsch, S.M.
Does Counseling by Clinicians Improve Physical Activity? A Summary of the
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Evidence for the U.S. Preventive Services Task Force, Annals of Internal
Medicine, 2002
■ Robbins, L.B., Pender, Nola.J., Conn, V.S., Frenn, M.D., Neuberger, G.B., Nies,
M.A., Topp, R.V. and Wilbur, J.E. Physical Activity Research in Nursing, Nursing
School Journal, 2001
AWARDS AND HONORS

Pender has received numerous recognitions and awards that include the 1972
Distinguished Alumni Award from Michigan State University School of Nursing. In 1988,
she received the Midwest Nursing Research Society’s Distinguished Contributions to
Research Award. She also obtained an Honorary Doctorate of Science degree from
Widener University, Chester, Pennsylvania, in 1992.
In 1997, the American Psychological Association awarded her the Distinguished
Contributions to Nursing and Psychology Award. She was awarded the Mae Edna
Doyle Teacher of the Year Award from the University of Michigan School of Nursing the
following year. In 2005, she received the Lifetime Achievement Award from the Midwest
Nursing Research Society.
Pender was designated a Living Legend of the American Academy of Nursing in 2012.
The award has only been awarded to nurses who have made outstanding contributions
to the profession. Pender was the president of the academy from 1991 to 1993.
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.
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The Health Promotion Model of Nursing (HPM Model)
Features
1. This model is based on the idea that human beings are rational, and will
seek their advantage in health. But the nature of this rationality is tightly
bounded by things like self-esteem, perceived advantages of healthy
behaviors, psychological states and previous behavior. As for the medical
profession in general, the main purpose here is not merely to cure
disease, but to promote healthy lifestyles and choices that affect the
health of individuals,
Function
2. The central function of this theory is to show the individual as self-

determining, but as also determined by personal history and general
personal characteristics. Health is a dynamic process, not a static state.
Health, to put it differently, is a lifestyle conditioned by a number of
choices made by the individual to actually live a healthy lifestyle. The
medical profession itself is only a small part of this world. The individual is
posited in this model as “being” healthy, “living” it, rather than considering
health a static state. Health is a lifestyle.
Effects
3. The main effect of Pender’s model is that it puts the onus of healthcare
reform on the person, not on the profession. Healthcare is a series of
intelligent, rational choices that promote health concerning things like diet,
exercise and positive thinking. All of these are choices and ingredients in
living healthy. The real struggle of the health profession, doctors and
nurses included, is to eliminate the self-destructive nature of unhealthy
choices and replace them with healthy ones. Unhealthy lifestyles, in other
words, are the results of distorted thinking that may be derived from
ignorance of lack of self-esteem. If these thoughts can be reformed (which
is itself a life-long process), then rational choices can take their place,
leading to a truly healthy lifestyle.
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Significance
4. Health is up to the person. The significance here is profession that the

medical is really not the main ingredient in living a healthy lifestyle. They
might be an important part, but always serve a secondary role to the basic
rational choice of healthy living. The health profession, in others words is
useless unless individuals reform their own lives and perception of what is
healthy.
Considerations
5. As healthcare costs continue to climb, a rational alternative to dependency

on the medical profession is the living of a rational, i.e., healthy life. A
healthy lifestyle is the ultimate antidote to rising healthcare costs, since a
rational population is a healthy one, which would naturally drive down
healthcare costs. Pender is an advocate of preventive medicine, which is
another word for rational, healthy thinking and therefore, healthy and
rational living.
Nola J. Pender’s Health Promotion Model
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ASSUMPTIONS OF THE HEALTH PROMOTION MODEL
The HPM is based on the following assumptions, which reflect both nursing and
behavioral science perspectives:
1. Individuals seek to actively regulate their own behavior.

2. Individuals in all their biopsychosocial complexity interact with the environment,
progressively transforming the environment and being transformed over time.
3. Health professionals constitute a part of the interpersonal environment, which
exerts influence on persons throughout their lifespan.
4. Self-initiated reconfiguration of person-environment interactive patterns is
essential to behavior change
THEORETICAL PROPOSITIONS OF THE HEALTH PROMOTION MODEL
Theoretical statements derived from the model provide a basis for investigative work on
health behaviors. The HPM is based on the following theoretical propositions:
1. Prior behavior and inherited and acquired characteristics influence beliefs,

effect, and enactment of health-promoting behavior.
2. Persons commit to engaging in behaviors from which they anticipate deriving
personally valued benefits.
3. Perceived barriers can constrain commitment to action, a mediator of
behavior as well as actual behavior.
4. Perceived competence or self-efficacy to execute a given behavior increases
the likelihood of commitment to action and actual performance of the
behavior.
5. Greater perceived self-efficacy results in fewer perceived barriers to a specific
health behavior.
6. Positive affect toward a behavior result in greater perceived self-efficacy,
which can in turn, result in increased positive effect.
7. When positive emotions or affect are associated with a behavior, the
probability of commitment and action is increased.
8. 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.
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9. 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.
10. Situational influences in the external environment can increase or decrease
commitment to or participation in health-promoting behavior.
11. 11.The greater the commitments to a specific plan of action, the more likely
health-promoting behaviors are maintained over time.
12. 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.
13. Commitment to a plan of action is less likely to result in the desired behavior
when other actions are more attractive and thus preferred over the target
behavior.
14. Persons can modify cognitions, affect, and the interpersonal and physical
environment to create incentives for health actions.
THE MAJOR CONCEPTS AND DEFINITIONS OF THE HEALTH

PROMOTION MODEL
1. Individual characteristics and experience.

2. Prior related behavior.
3. Frequency of the similar behavior in the past. Direct and indirect effects on
the likelihood of engaging in health promoting behaviors.
PERSONAL FACTORS
Personal factors categorized as biological, psychological and socio-cultural.

These factors are predictive of a given behavior and shaped by the nature of the target
behavior being considered.
Personal biological factors
■ Include variables such as age, gender, body mass index, pubertal status, aerobic
capacity, strength, agility, or balance.
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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, socioculturation, education and

socioeconomic status.
■ Behavioral specific cognition and affect
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.
PERCIEVED SELF EFFICACY
Judgment of personal capacity to organize and execute a health-promoting behavior.

Perceived self-efficacy influences perceived barriers to action so higher efficacy result in
lowered perceptions of barriers to the performance of the behavior.
ACTIVITY RELATED AFFECT
Subjective positive or negative feeling that occur 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 the feeling of efficacy. In turn, increased feelings of efficacy can generate further
positive effect.
INTERPERSONAL INFLUENCES
Cognition concerning behaviors, beliefs, or attitudes of the 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.
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SITUATIONAL INFLUENCES
Personal perceptions and cognitions of any given situation or context that can facilitate
or impede behavior. Include perception 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.
Behavioral Outcome:
COMMITMENT TO PLAN OF ACTION
The concept of intention and identification of a planned strategy leads to implementation

of health behavior.
IMMEDIATE COMPETING DEMANDS AND PREFERENCES
Competing demands are those alternative behavior over which individuals have low
control because there are environmental contingencies such as work or family care
responsibilities. Competing preferences are alternative behavior over which individuals
exert relatively high control, such as choice of ice cream or apple for a snack.
HEALTH PROMOTING BEHAVIOR
End point or action outcome directed toward attaining positive health Outcome such as
optimal! well-being, personal fulfillment, and productive living.
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8.NULeininger Theory of Culture Care Diversity & Universality
Madeleine Leininger (1978, 1984)
Developed the "Theory of Culture Care Diversity and Universality"

(Transcultural Nursing Model). She advocated that nursing is a humanistic and
scientific mode of helping a client through specific cultural caring processes (cultural
values, beliefs and practices) to improve or maintain a health condition.
Advocated that caring is universal and varies transculturally. Major concepts include
care, caring, culture, cultural values and cultural variations.
Furthermore, Leininger believed that caring serves to ameliorate or improve human
conditions and life base. And that care is the essence and the dominant, distinctive and
unifying feature of nursing.
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Madeleine Leininger
BIOGRAPHY
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.
She is a Certified Transcultural Nurse, a Fellow of the Royal College of Nursing in

Australia, and a Fellow of the American Academy of Nursing. Her theory is now a
nursing discipline that is an integral part of how nurses practice in the healthcare
field today.
EARLY LIFE
Madeleine Leininger was born on July 13, 1925, in Sutton, Nebraska. She lived on a
farm with her four brothers and sisters and graduated from Sutton High School. After
graduation from Sutton High, she was in the U.S. Army Nursing Corps while pursuing a
basic nursing program. Her aunt, who had congenital heart disease, led her to pursue a
career in nursing.
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EDUCATION
In 1945, Madeleine Leininger, together with her sister, entered the Cadet Nurse Corps,
a federally-funded program to increase the number of nurses trained to meet anticipated
needs during World War II.
She earned a nursing diploma from St. Anthony’s Hospital School of Nursing, followed
by undergraduate degrees at Mount St. Scholastica College and Creighton University.
Leininger opened a psychiatric nursing service and educational program at Creighton
University in Omaha, Nebraska. She earned the equivalent of a BSN through her
studies in biological sciences, nursing administration, teaching, and curriculum during
1951-1954.
She received a Master of Science in Nursing from the Catholic University of America in
1954.
And in 1965, Leininger embarked upon a doctoral program in Cultural and Social
Anthropology at the University of Washington in Seattle and became the first
professional nurse to earn a Ph.D. in anthropology.
WORKS
Leininger wrote and edited 27 books and founded the Journal of Transcultural Nursing
to support the Transcultural Nursing Society’s research, which she started in 1974. She
published over 200 articles and book chapters, produced numerous audio and video
recordings, and developed a software program. She has also given over 850 keynote
and public lectures in the US and around the world.
She also established the Journal of Transcultural Nursing and served as editor from
1989 to 1995. She also initiated and promoted transcultural nurses’ worldwide
certification (CTN) for client safety and knowledgeable care for people of diverse
cultures.
Her web pages now reside on a discussion board. Leininger has provided downloads
and answers to many common questions. Board users are encouraged to post
questions to her discussion board about transcultural nursing, her theory, and her
research. During her time, Leininger enjoys helping students, and she responds to
questions as her time permits.
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AWARDS AND HONORS

In 1960, Leininger was awarded a National League of Nursing Fellowship for fieldwork
in the Eastern Highlands of New Guinea. She studied the convergence and divergence
of human behavior in two Gadsup villages.
While at Wayne State, Leininger won numerous awards, including the
prestigious President’s Award for Excellence in Teaching, the Board of Governors
Distinguished Faculty Award, and the Gershenson Research Fellowship Award.
In 1998, she was honored as a Living Legend by the American Academy of Nursing and
Distinguished Fellow, Royal College of Nursing in Australia.
The Leininger Transcultural Nursing Award was established in 1983 to recognize
outstanding and creative leaders in transcultural nursing. This prestigious award will
continue as the Leininger Transcultural Nursing Award under the Transcultural Nursing
Society’s auspices in Madeleine Leininger’s honor.
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.
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Overview of Madeleine Leininger’s Transcultural Nursing Theory
■ Leininger advocated that the essential features of the Theory of Cultural Diversity
and Universality and articulated as follows:
“Transcultural nursing is a substantive area of study and practice focused on
comparative human care (caring) differences and similarities of the beliefs,
values, and practices of individuals or groups of similar or different cultures.
Transcultural nursing’s goal is to provide culture specific and universal nursing
care practices for the health and well-being of people or to help them face
unfavorable human conditions, illness, or death in culturally meaningful ways”
(Leininger, 2002 p. 46)
Definitions In Transcultural Nursing
Culture
■ Broadly define set of values, beliefs and traditions that are held by a specific
group of people and handed down from generation to generation. Culture is also
beliefs, habits, likes, dislikes, customs and rituals learned from one’s family
(specter, 1991).
■ Culture is the learned, shared and transmitted values, beliefs, norms and
practices of a particular group that guide thinking, decisions, and actions in
patterned ways.
Religion:
■ Is a set of belief in a divine or super human power or powers) to be obeyed and

worshipped as the Creator and ruler of the universe. Ethical values and religion
system of beliefs and practices, difference within the culture and across culture
are found.
Ethnic
■ Refers to the group of people who share a common and distinctive culture and
who are members of a specific group.
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Ethnicity
■ A consciousness of belonging to a group.
Cultural identify
■ The sense of being part of an ethnic group or culture.
Culture-universals
■ Commonalities of values, norms of behavior, and life patterns that ar are ‘Similar
among different cultures.
Culture-specifies
■ Values, beliefs, and patterns of behavior that tend to be unique to a designate

culture.
Material culture
■ Refers to objects (dress, art, religious artifacts).
Non-material culture
■ Refers to beliefs, customs, languages, social institutions.
Subculture
■ Composed of people who have a distinct identity but are related to a larger
cultural group.
Bicultural
■ A person who crosses two cultures, lifestyles, and sets of values.
Diversity
■ Refers to the fact or state of being different. Diversity can occur between cultures
and within a cultural group.
Acculturation
■ Individuals who have taken on usually observable, features of another culture.

People of a minority group tend to assume the attitudes, values, beliefs, and
practices of the dominant society resulting in a blended cultural pattern.
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Cultural shock
■ The state of being disoriented or unable to respond to a different cultural

environment because of its sudden strangeness, unfamiliarity and incompatibility
to the stranger's culture and expectations that is differentiated from others by
symbolic markers (cultures, biology, territory, religion).
Ethnic groups
■ Share a common social and cultural heritage that is passed on to successive

generations.
Ethnic identity
■ Refers to a subjective perspective of the person's heritage and to a sense of

belonging to a group that is distinguishable from other groups.
Race
■ The classification of people according to shared biologic characteristics, genetic

markers, or features. Not all people of the same race have the same culture.
Culture care diversity
■ Indicates the "variabilities and /or differences in meanings, patterns, values,

lifeways or symbols of care within or between collectives that are related to
assistive, supportive, or enabling human care expressions"
Culture care universality
■ Indicates the "common, similar, or dominant uniform care meanings, patterns,

values, lifeways or symbols that are manifest among many cultures and reflect
assistive, supportive, facilitative, or enabling ways to help people."
TRADITIONAL CONCEPTS OF HEALTH AND DISEASE
When viewed across a variety of multicultural groups, explanations for health and
disease that characterized many traditional beliefs about disease causation, treatment,
and general health practices can be seen as highly complex, dynamic, and interactive.
These explanations often involve family, community and/or supernatural agents in
cause and effect, placation, and treatment rituals to prevent, control, or cure illness. A
failure to understand and appreciate these "differences" can have serious implications
for the success of any Health Promotion and Disease Prevention (HPDP) effort.
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■ Be aware that the health concepts held by many cultural, groups may result in
people choosing not to seek Western medical treatment procedures because
they do not view the illness or disease as coming from within themselves.
■ Be aware that in many Eastern cultures and other cultures in the developing
world, the focus of control for disease causality often is centered outside the
individual, whereas in Western cultures, the focus of control tends to be more
internally oriented.
■ Remember that if the more traditional person does seek Western medical
treatment, then that person might not be able to provide or describe his or her
symptoms in precise terms that the Western medical practitioner can readily treat
(Landline & Logoff, 1992). Recognize that individuals from other cultures might
not follow through with health-promoting or treatment recommendations because
they perceive the medical or other health-promoting encounter as a negative or
perhaps even hostile experience.
■ Acknowledge that many individual patients and health care practitioners have
specific notions about health and disease causality and treatment called
explanatory models. These models are generally a conglomeration of the
respective cultural and social training, beliefs and values, the personal beliefs,
values and behaviors, and the understanding of biomedical concepts that each
group holds (Kleinman, 1980).
■ Recognize that the more disparate the differences are between the biomedical
model and the lay/popular explanatory models, the greater the potential for, or to
encounter resistance to Western HPDP programs.
■ Be aware of the need to be flexible in the design of programs, policies, and
services to meet the needs and concerns of the culturally diverse population,
groups that are likely to be encountered.
Care
■ Refers to assisting, supporting, or enabling behaviors that ease or improve a

person's condition.
■ Is essential for a person's survival, development, and ability to deal with life's
events.
■ Has different meanings in different cultures which can be determined by
examining the group's view of the world, social structure, and language.
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Cultural Care
■ Refers to the values and beliefs that assist, support, or enable another person or
group to maintain well-being, improve personal condition, or face death or
disability.
■ Is universal, but the actions, expressions, patterns, lifestyles, and meanings of
care may be different.
■ Knowledge of cultural diversity is essential for nursing to provide appropriate care
to clients, families, and communities.
■ Diverse Care: different meanings, patterns, values, beliefs or symbols of care
indicative of health for a specific culture (such as role of sick person).
■ Universal Care: commonalities or similarities in meanings, patterns, values,
beliefs, or symbols of care between different cultures.
World View
■ Refers to the outlook of a person or group based on a view of the world or

universe.
■ Consists of social structure and environmental context.
■ Social structure: organizational factors of a particular culture (e.g., religion,
economics, education), and how these factors give meaning and order to the
culture.
■ Environmental Context: any event, situation, or experience that give meaning to
human expressions.
Folk Health or Well-being Systems
■ Refers to care or care practices that have a special meaning in the culture.
■ These practices are used to heal or assist people in the home or community.
■ Are supplemental by professional health systems that operate in cultures.
Traditional Concepts of Illness Causality
■ Be aware that folk illnesses are generally learned syndromes that individuals
from particular cultural groups claim to have and from which their culture defines
the etiology, behaviors, diagnostic procedures, prevention methods, and
traditional healing or caring practices.
■ Remember the most cases of lay illness have multiple causalities and may
require several different approaches to diagnosis, treatment, and cure including
folk and Western medical interventions.
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■ Recognize that folk illnesses, which are perceived to arise from a variety of
causes, may require the services of a folk healer who may be a local coriander,
shaman, native healer, spiritualist, root doctor, or other specialized healer.
■ Recognize that the use of traditional or alternate models of health care delivery is
widely varied and may come into conflict with Western models of health care
practice.
Understanding these differences may help us to be more sensitive to the special beliefs
and practices of multicultural target groups when planning a program. Culture guides
behavior into acceptable ways for the people in a specific group as such culture
originates and develops within the social structure through interpersonal interactions.
CONCEPT OF CULTURE
Culture is learned by each generation through both formal and informal life experiences.
Language is primary through means of transmitting culture. The practices of a particular
culture often arise because of the group's social and physical environment. Culture
practices and beliefs are adapted over time but they mainly remain constant as long as
they satisfy needs.
Cultural awareness
It is an in-depth examination of one's own background, recognizing biases and

prejudices and assumptions about other people.
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PURPOSES OF KNOWING THE PATIENT’S CULTURE AND RELIGION

FOR HEALTH CARE PERSONNEL
Cultural background affects a person’s health in all dimensions, so the nurse

should consider the client’s cultural background when planning care. Although basic
human needs are the same for all people, the way a person seeks to meet those needs
is influenced by culture. e
■ To heighten awareness of ways in which their own faith system provides
resources for encounters with illness, suffering and death.
■ To foster understanding, respect and appreciation for the individuality and
diversity of patients’ beliefs, values, spirituality and culture regarding illness, its
meaning, cause, treatment, and outcome.
■ To strengthen in their commitment to relationship-centered medicine that
emphasizes care of the suffering person rather than attention simply more to the
pathophysiology of disease, and recognizes the physician as a dynamic
component of that relationship.
■ To facilitate in recognizing the role of the hospital chaplain and the patient’s
clergy as partners in the health care team in providing care for the patient.
■ To encourage in developing and maintaining a program of physical,
■ emotional and spiritual self-care that include therapies from the East, such as
ayurveda and pancha karma.
Leininger (1991, 2002a) has defined transcultural nursing as a comparative study of

cultures to understand similarities (culture universal) and difference (culture-specific)
across human groups.
Culturally congruent care
Care that fits the people’s valued life practices and set of meanings--which is
generated from the people themselves, rather than based on predetermined criteria.
Discovering client’s culture care values, meanings, beliefs and practices as they relate
to nursing and health care requires nurses to assume the roles of learners of client’s
culture and copartners with clients and families in defining the characteristics of
meaningful and beneficial health Care patterns.
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Culturally competent care is the ability of the practitioner to bridge cultural gaps
in caring, work with cultural differences and enable clients and families to achieve
meaningful and supportive caring. Culturally competent care requires specific
knowledge, skills, and attitudes in the delivery of culturally congruent care and
awareness.
Nursing Decisions
Leininger (1991) identified three nursing decision and action models to achieve
culturally congruent care. All the models of professional decisions and actions are
aimed to assist, support, facilitate, or enable people of particular cultures. The three
models for congruent decisions and actions proposed in the theory are predicted to lead
to health and wellbeing, or to face illness and death.
1. Cultural preservation or maintenance. Retain and or preserve relevant care

values so that clients can maintain their well-being, recover from illness, or
face handicaps and/or death.
2. Cultural care accommodation or negotiation. Adapt or negotiate with the
others for a beneficial or satisfying health outcome.
3. Cultural care repatterning or restructuring. Change or greatly modify client’s
life ways for a new, different and beneficial health care pattern.
PURPOSE AND GOAL OF THE THEORY
■ The central purpose of the theory is to discover and explain diverse and universal
culturally based care factors influencing the health, wellbeing, illness, or death of
individual or groups.
■ The purpose and goal of the theory is to use research findings to provide
culturally congruent, safe, and meaningful care to clients of diverse or similar
cultures.
Status Traditional Practices
Many traditional practices are used to prevent illness and harm, treat illness,
including protective objects and substances and religious practices. (Morgenstern,
1966)
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USE OF THE PROTECTIVE PRACTICES
Protective objects can be worn or carried or hung in the home. Amulets are
objects with magical powers. For all walks of life and cultural and ethnic backgrounds
for example, charms are worn on a string or chain around the neck, wrist, or waist to
protect the wearer from the evil eye or evil spirits. Amulets exist in societies all over the
world and are associated with protection from trouble. (Budge, 1978)
Substances are ingested in certain ways or amounts as part of the treatment
regimen. The practice uses diet and consists of many different observances. It is
believed that the body is kept in balance or harmony by the type of food eaten so many
food taboos and combinations exist in traditional belief systems. For example, it is
believed that some food substances can be ingested to prevent illness. People from
many ethnic backgrounds eat raw garlic or onion in an effort to prevent illness or hang
them in the home.
RELIGIOUS PRACTICES
Another traditional approach to illness prevention centers around religion and

include practices such as form of a divine source the burning of candies, rituals of
redemption, and in many instances a heritage consistent person may prayer. Religions
strongly affects the way people attempt to prevent illness, and it plays a strong role in
rituals associated with health protection. Religion dictates social, moral and dietary
practices designed to keep a traditional healing (Kaptchuck and Croucher 1987).
Traditional Remedies
The admitted use of folk or traditional medicine is increasing, and the practice is
seen among people from all walks of life and cultural ethnic background. Use of folk
medicine is not a new practice among heritage consistent people, so many of the
remedies have been used and passed on for generations. The pharmaceutical, must be
made to determine properties of vegetation---plants, roots, stems, flowers, seeds, and
herbs---have been studied, tested, cataloged, and used for countless centuries. Many of
these plants are used by specific communities.
When patients do not adhere to pharmacological regimen, an effort must be
made to determine if they are taking traditional remedies. Frequently, the active
ingredients of traditional remedies are unknown. If a client is believed to be taking them,
an effort must be made to determine the remedy as well as its active ingredients. Often,
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these ingredients can be antagonistic or synergistic to prescribed medications.

Overdose may also occur.
Healers
In the traditional context, healing is the restoration of the person to a State of
harmony within the body. Within a given community, specific people are known to have
the power to heal. The healer may be male or female and is thought to have received
the gift of healing. In many instances a heritage consistent person may consult a
traditional healer before, instead of, or in Conjunction with a modern health care
provider. Many differences exist between the Western physician and the Eastern
physician. A broad range of health and illness beliefs exist. Many of these beliefs have
roots in the culture, ethnic, religious, or social background of a person, family, or
community. When people anticipate fear or experience an illness or crisis, they may use
a modern or traditional approach toward prevention and healing.
These approaches may originate in culture, ethnicity or religion. These Meliefs and
practices may be internal or personal and the person may be able to define or describe
them. However, they may be due to external social forces not within the person’s
control. Examples of external social forces include communication barriers, such as
language differences, or economic barriers causing limited access or lack of access to
modern health care facilities.
IMMIGRATION
Every immigrant group has its own cultural attitudes, with ranging beliefs and
practices regarding these areas. Health and illness can be interpreted in terms of
personal experience and expectations. There are countless ways to explain health and
illness, and people base their respective responses on cultural, religious, and ethnic
background. The responses are culture specific, based on a client’s experience and
perception.
Gender Roles
In many cultures, the male is dominant figure. Males make decisions for other
family members as well as for themselves. For example, no matter which family
member is involved, in cultures where the male dominates, the female usually is
passive. In African-American families, however, as well as in many Caucasian families,
the female often is dominant. Knowledge of the dominant member of the family is
important consideration in planning. Illnesses, which are perceived to arise from a
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variety of causes, often require the services of a folk healer who may be a local
curandero, shaman, native healer, spiritualist, root doctor, or other specialized healer.
Recognize that the use of traditional or alternate models of health care deliveries are
widely varied and may come into conflict with Western models of health care practice.
Understanding these differences may help the nurse to be more sensitive to the special
beliefs and practices of multicultural target groups when planning a program.
ILLNESS CAUSE AND PREVENTION RELATED TO FOOD
Several factors cause illness. A hot-cold imbalance, for example, is primarily

caused by improper diet. Food substances are classified as hot or cold with and without
regard to their actual temperature. This classification can vary from person to person,
but essentially, certain foods are known to be hot, and others are known to be cold.
Examples of cold foods are, honey, avocados, bananas, and lima beans. Examples of
hot foods are chocolate, coffee, corn meal, garlic, kidney beans, onions, and peas.
Illness can occur if these foods are eaten in improper combinations or amounts.
Traditional beliefs about mental health

In the traditional belief system, mental illnesses are caused by a lack of harmony
of emotions, or sometimes, by evil spirits. Mental wellness occurs when psychological
and physiologic functions are integrated. Some elderly Asians share the Buddhist belief
that problems in this life are most likely related to transgressions committed in a past
life. In addition, our previous life and our future life are as much as part of the life cycle.
ECONOMIC BARRIERS
Several economic barriers, such as unemployment, underemployment,

homelessness, lack of health insurance, poverty prevent people from entering the
health care system. Poverty is by far the most critical factor. Poverty is a relative term
and changes from time and place. In many countries, poverty is pervasive and found
extensively among people in certain geographical areas, such as rural and urban
populations. Poor health, crippling diseases, drug and alcohol abuse, poor education is
contributing social causes of poverty.
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Several programs both governmental and private, aid people with short-and-long-term
problems. It is important for the nurse to be aware of clients’ needs and financial
resources available in the local community.
Time Orientation
It varies for different cultures groups. A client may be late for an appointment not
because of reluctance or lack of respect for the nurse but because he is less concerned
about planning ahead to be on time than with the activity in which he is currently
engaged.
PERSONAL SPACE AND TERRITORIALITY:
Personal space involves a person’s set of behaviors and attitudes toward the
space around himself. Staff members and other clients frequently encroach on a client’s
territory in the hospital, which includes his room, closet, and belongings. The nurse
should try, to respect the client’s territory as much as possible especially when
performing nursing procedures. The nurse should also welcome visiting members of the
family and extended family. This can remind the client of home, lessening the effects of
isolation and shock from hospitalization.
SOCIOCULTURAL FACTORS AND THE NURSING PROCESS
Religious beliefs that affect the care Nursing:

■ Beliefs about birth and death
■ Beliefs about diet and food Practices
■ Beliefs regarding medical care
ROLES OF THE NURSE
The nurse should begin the assessment by attempting to determine the client’s
cultural heritage and language skills. The client should be asked if any of his health
beliefs relate to the cause of the illness or to the problem. The nurse should then
determine what, if any, home remedies the person is taking to treat the symptoms.
Nurses should evaluate their attitudes toward ethnic nursing care. Some nurses
may believe they should treat all clients the same and simply act naturally, but this
attitude fails to acknowledge that cultural differences do exist and that there is not one
“natural” human behavior. The nurse cannot act the same with all clients and still hope
to deliver effective, individualized holistic care.
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Sometimes, inexperienced nurses are so self-conscious about cultural

differences and so afraid of making mistakes that they impede the nursing process by
not asking questions about areas of difference or by asking so many questions that they
seem to try into the client personal life.
The process of self-evaluation can help the nurse become more comfortable
when providing care to clients from diverse backgrounds.
Culture is the sum total of mores, traditions and beliefs about how people
function. It encompasses other products of human works and thoughts specific to
members of an intergenerational group, community or population.
■ Nurses have a responsibility to understand the influence of culture, race and

ethnicity on the development: of social emotional relationships, child rearing
practices and attitudes toward health.
■ A child’s self-concepts evolve from ideas about his or her social roles.
■ Primary groups are characterized by intimate contact, mutual support and
pressure for conformity.
■ Important subculture influences on children include ethnicity, social class
occupation, school peers and mass culture.
■ Socioeconomic influences play major role in ability to seek opportunity for health
promotion for wellness.
■ Religious practice greatly influences health promotion beliefs in families.
■ Many ethnic and cultural groups in a country retain the cultural heritage of their
original culture.
■ How culture influences behaviors, attitudes, and values depend on many factors
and thus is not the same for different members of a cultural group.
■ Ethnocentrism can impede the delivery of care to ethnic minority clients, and
when pervasive, can become cultural racism.
■ Stereotyping ethnic group members can lead to mistaken assumptions about a
client
■ The nurse should have an understanding of the general characteristics of the
major ethnic groups, but should always individualize care rather than generalize
about all clients in these groups.
■ Before assessing the cultural background of a client, nurses should assess how
they are influenced by their own culture.
■ The nursing diagnosis for clients should include potential problems in their
interaction with the health care system and problems involving the effects of
culture.
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■ The planning and implementation of nursing interventions should be adapted as

much as possible to the client’s cultural background.
■ Evaluation should include the nurse’s self-evaluation of attitudes and emotions
toward providing nursing care to clients from diverse sociocultural backgrounds.
When nurses provide care to clients from a background other than their own, they
must be aware of and sensitive to the clients’ sociocultural background, assess and
listen carefully to health and illness beliefs and practices, and respect and not challenge
cultural, ethnic, or religious values and health care beliefs. The nursing process enables
to provide individualized care.
The nurse should begin the assessment by attempting to determine the client’s
cultural heritage and language skills. The client should be asked if any of his health
beliefs relate to the cause of the illness or to the problem. The nurse should then
determine what, if any, home remedies the person is taking to treat the symptoms.
Assessment enables the nurse to cluster relevant data and develop actual or
potential nursing diagnoses related to the cultural or ethnic needs of the client. In
addition, the nursing diagnosis should state the probable cause. The identification of the
cause of the problem further individualizes the nursing care plan and encourages
selection of appropriate interventions--cultural variables as they relate to the client. The
extended family should be involved in the care. They are the client’s strongest support
group. Cultural beliefs and practices can be incorporated into the therapy.
■ The client’s educational level and language skills should be considered when
planning teaching activities.
■ Explanations of and practices into nursing therapies, aspects of care usually not
questioned by acculturated clients may be required for non-English speaking or
non-acculturated clients to avoid confusion, misunderstanding or cultural conflict.
■ The nurse may have to alter her usual ways of interacting with clients to avoid
offend ignore alienating a client with different attitudes toward social interaction
and etiquette. A client who is modest and self-conscious about the body may
need psychological preparation before some procedures and tests.
■ The nurse can find out what care the client considers appropriate by involving
him and his family in planning care and asking about their expectations. This
should be done in every case, even if the nursing care cannot be modified.
Because both the nurse and the client are likely to take many aspects of their
cultures for granted, questions should be clear and explanations should be
explicit.
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■ Discussing cultural questions related to care with the client and family during the
planning stage helps the nurse understand how cultural variables are related to
the client’s health beliefs and practices, so that interventions can be
individualized for the client.
■ The nurse evaluates the results of nursing care for ethnic clients as for all clients,
determining the extent to which the goals of care have been met.
Evaluation continues throughout the nursing process and should include feedback
from the client and family. With an ethnic minority client, however, self-evaluation by the
nurse is crucial as he or she increases skills for interaction. The nurse should consider
questions such as the following.
■ Am open to understanding ways in which the client’s values differ from me?
■ Have I given sufficient attention to communicating with the client with limited
language skills?
■ Have I included the client’s family in the nursing process?
■ Am I incorporating the client's traditional beliefs and practices into nursing
therapies?
■ Is my therapeutic relationship with the client grounded on respect client
regardless of cultural differences?
CONCLUSION
Nurses need to be aware of and sensitive to the cultural needs of clients. The body of
knowledge relevant to this sensitive area is growing, and it is imperative that nurses
from all cultural backgrounds be aware of nursing implications in this area. The practice
of nursing today demands that the nurse identify and meet the cultural needs of diverse
groups, understand the social and cultural reality of the client, family, and community,
develop expertise to implement culturally acceptable strategies to provide nursing care,
and identify and use resources acceptable to the client (Boyle, 1987).
Concepts
A. Person
■ Is referred to as a human being
■ Is caring and capable of being concerned about others
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B. Environment
■ Not specifically defined by Leininger
■ The concepts of world view, social structure, and environmental
■ context are discussed
■ Is closely related to the concept of culture
C. Health
■ Is viewed as a state of well-being
■ Is culturally defined, valued, and practiced
■ Reflects the ability of individuals to perform their daily roles
■ Includes health systems, health care practices, health patterns, and health
promotion and maintenance
■ Is universal across all cultures yet defined differently by each to reflect its
specific values and beliefs
D. Nursing
■ Is defined as a learned humanistic art and science that focuses on personalized
behaviors, functions, processes to promote and maintain health or recovery from
illness
■ Has physical, psycho-cultural, and social significance for those being assisted
■ Uses 3 modes of action to deliver care
• Ethnonursing 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, p.15).
3 Modes of Nursing Action
1. Culture care preservation or maintenance.

2. Culture care accommodation or negotiation
3. Culture care restructuring or repatterning
• Uses the Sunrise Model when caring for clients

• Requires understanding of values, beliefs, and practices of a client's culture’
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9.NUNewman’s Theory of Health as Expanding Consciousness
Margaret A. Newman
“The theory of health as expanding consciousness (HEC) was stimulated by

concern for those for whom health as the absence of disease or disability is not
possible. Nurses often relate to such people: people facing the uncertainty, debilitation,
loss and eventual death associated with chronic illness. The theory has progressed to
include the health of all persons regardless of the presence or absence of disease. The
theory asserts that every person in every situation, no matter how disordered and
hopeless it may seem, is part of the universal process of expanding consciousness – a
process of becoming more of oneself, of finding greater meaning in life, and of reaching
new dimensions of connectedness with other people and the world” (Newman, 2010).
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Margaret A. Newman
BIOGRAPHY
Margaret Newman is a prominent nursing theorist and leader. She was recognized for
creating Theory of Health as Expanding Human Consciousness in 1978; her theory
greatly influenced the nursing perspective on health, illness and human consciousness
(Why I want to be a nurse, 2014).
PERSONAL BACKGROUND AND SOCIOCULTURAL INFLUENCES
Margaret Newman was born on October 10, 1933 in Memphis, Tennessee. Her mother
was a secretary at Baptist Church – thus Dr. Newman was raised in a Christian
community. It influenced her decision to join missionary service later in life; there she
realized for the first time she could not address people’s spiritual needs without
attempting to take care of their physical needs as well. Newman did not choose a
nursing major after high school. However, it appeared that one of her roommates at the
college was a nursing student who once was asked to assist injured victims after a huge
tornado. It made Newman to think over a nursing career for herself again. Later she had
to come back home when she learned her mother was diagnosed with a chronic
irreversible health condition – amyotrophic lateral sclerosis. She decided to become a
primary caregiver for her mother. Newman realized that “simply having a chronic
disease does not make a person unhealthy” (Parker& Smith, 2010, p. 291). Newman
became convinced that her mother could still experience health in spite of her having
degenerative neurological disease; she formulated that her mother’s life was “confined”
by the condition but not “defined” by it. Also Newman discovered that during the
hardships of the disease process when she was giving care to her mother she started
experiencing similar symptoms and alterations in “movement, space, time,
consciousness” (Parker&Smith 2010, p. 291). Both mother and daughter developed
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great connectedness and came to know each other better and deeper than before. This
experience helped Margaret Newman to make her final decision – to come back to
school again to become a nurse.
EDUCATION
■ 1954 - Baccalaureate degree in Economics and English from Baylor University in

Waco, Texas
■ Mid 1950s - after serving as a primary caregiver for her mother who got sick with
amyotrophic lateral sclerosis, Margaret Newman felt big passion for nursing field
and decided to become a nurse
■ 1962 - Bachelor of Science in Nursing (BSN) from the University of Tennessee.
■ 1964 - Master’s Degree in medical-surgical nursing from the University of
California in San Francisco
■ Mid 1960s – Margaret Newman served as a joint director of a clinical research
center and also an assistant professor at the University of Tennessee in
Memphis.
■ 1971 – received Ph.D. at New York University
■ 1971-1977 – was teaching at New York University
■ At New York University Dr. Newman met another nursing theorist - Martha
Rodgers (Theory of Unitary Human Beings). Rodgers served as a teacher and
mentor for Margaret Newman inspiring her for creating Theory of Expanding
Human Consciousness in 1978
■ 1984 - she became the nurse theorist at the University of Minnesota
■ Continued teaching until retired in 1996.
AWARDS AND HONORS

■ Fellow in the American Academy of Nursing; Dr. Newman won their Living
Legend award as well
■ An outstanding alumnus by both the University of Tennessee and New York
University
■ The Distinguished Scholar in Nursing Award from New York University
■ The Founders Award for Excellence in Nursing Research from Sigma Theta Tau
International
■ E. Louise Grant Award for Nursing Excellence from the University of Minnesota
■ Sigma Theta Tau International created a Margaret Newman Scholar Award to
fund doctoral students who wish to continue to research Newman's theory
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Overview of Margaret Newman: Theory of Health as Expanding

Consciousness (HEC)
■ The theory of health as expanding consciousness stems from Rogers’ theory of

unitary human beings & was stimulated by concern for those for whom health as
the absence of disease or disability is not possible, (Newman, 2010).
■ The theory has progressed to include the health of all persons regardless of the
presence or absence of disease, (Newman, 2010).
■ The theory asserts that every person in every situation, no matter how disordered
and hopeless it may seem, is part of the universal process of expanding
consciousness – a process of becoming more of oneself, of finding greater
meaning in life, and of reaching new dimensions of connectedness with other
people and the world, (Newman, 2010).
A Description of the Expanding Consciousness Theory
■ “The theory of health as expanding consciousness (HEC) was stimulated by

concern for those for whom health as the absence of disease or disability is not
possible. Nurses often relate to such people: people facing the uncertainty,
debilitation, loss, and eventual death associated with chronic illness. The theory
has progressed to include the health of all persons regardless of the presence or
absence of disease. The theory asserts that every person in every situation, no
matter how disordered and hopeless it may seem, is part of the universal process
of expanding consciousness – a process of becoming more of oneself, of finding
greater meaning in life, and of reaching new dimensions of connectedness with
other people and the world” (Newman, 2010).
■ Humans are open to the whole energy system of the universe and constantly
interacting with the energy. With this process of interaction, humans are evolving
their individual patterns of the whole. According to Newman’s understanding, the
pattern is essential.
■ The expanding consciousness is the pattern recognition.
Nursing Paradigms
Health: “Health and illness are synthesized as health – the fusion on one state of being
(disease) with its opposite (non-disease) results in what can be regarded as health”.
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Nursing:
■ Nursing is “caring in the human health experience”.

■ Nursing is seen as a partnership between the nurse and client, with both
growing in the “sense of higher levels of consciousness”
Human:
■ “The human is unitary, that is cannot be divided into parts, and is inseparable
from the larger unitary field”.
■ “Persons as individuals and human beings as a species are identified by their
patterns of consciousness” …
■ “The person does not possess consciousness-the person is consciousness”.
■ Persons are “centers of consciousness” within an overall pattern of expanding
consciousness”.
Environment: described as a “universe of open systems”.
How Newman Viewed Everything as Patterns
Patterns have dimensions of movement and space-time. It is constantly moving

unidirectionally and evolving and maybe enfolded in a larger pattern that is in the
process of unfolding. Using Rogers’ (1970) conceptualization of pattern, Newman
(1986) states, “Pattern is information that depicts the whole, understanding of the
meaning and relationships at once. It is a fundamental attribute of all there is and gives
unity in diversity” (p. 13). Patterns are also a characteristic of wholeness and reveal the
meaning of life (Newman, 1999). According to Newman (1987b), “Whatever manifests
itself in a person’s life is the explication of the underlying implicate pattern…the
phenomenon we call health is the manifestation of that evolving pattern” (p. 37). This
phenomenon also includes concepts of health and disease.
Time, as a dimension of pattern, is conceptualized as either subjective or objective and
also is viewed in a holographic sense. According to Newman (1994a), “Each moment
has an explicate order and also enfolds all others, meaning that each moment of our
lives contains all others of all time” (p. 62). Further, time is considered an index of
consciousness (Newman, 1983) because as consciousness expands, space-time
transcends limitations of linear and physical boundaries to extend beyond what is the
here-and-now. However, what is truly important is that one be fully present at the
moment knowing that all experiences are manifestations of the process of evolution to
higher consciousness (Newman, 1994a).
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Time and timing are further described as a function of movement (Newman, 1983) and
part of the rhythm of living (Newman, 1994a). Time has importance in revealing patterns
because extending the time frame helps nurses and patients recognize patterns and
reorganize activities (Newman, 1994a). Temporal pattern synchronicity between human
beings and health care workers is also important to receptivity and health because
these patterns are highly individualistic and influence how people respond to each
other. Nurses who attempt to practice within this theoretical framework must be
sensitive to synchronize their rhythms with those of clients with whom they are working.
Newman refers to this as “the rhythm of relating” (1999, p. 227) and states that it is an
indicator of the pattern of interacting consciousness. By attuning themselves to the
rhythms of others, nurses assist individuals to identify patterns and move to higher
levels of consciousness.
The dimensions of space and time are complementary and inextricably linked to each
other as space-time or time-space, with time being increased as one’s life space
decreases (Newman, 1979, 1983). Space has further been identified as life-space,
personal space, and inner space (Newman, 1979), with personal space or territory very
much involved in a person’s struggles for self-determination and status (Newman,
1990a). As consciousness expands, the distinction between the self and the world
becomes blurred as one recognizes that essence extends “beyond the physical
boundaries and is in effect boundarylessness, as one move to higher levels of
consciousness” (Newman, 1994a, p. 47).
According to Newman (1994a), movement is a reflection of consciousness, indicates
inner organization or disorganization of people, and communicates the harmony of a
person’s pattern with the environment. It is integral to relationships and “is a means
whereby time and space become a reality” (Newman, 1983, p. 165). The rate of
movement is seen as a reflection of pattern (Newman, 1995b). Space, time, and
movement are linked. In fact, “the intersection of movement-space-time represents the
person as a center of consciousness and varies from person to person, place to place,
and time to time” (Newman, 1986, p. 49). When natural movement is altered, space and
time are also altered. When movement is restricted (physically or socially), it is
necessary for one to move beyond oneself, thereby making movement an important
choice point in the process of evolving human consciousness (Newman, 1994a).
The evolution of consciousness is identified by patterns of increased quality and
diversity of interaction with the environment (Newman, 1994a). Wholeness is identified
in patterns of dynamic relatedness with one’s environment (Newman, 1999). Expanding
consciousness is seen in the evolving pattern, and episodes of pattern recognition are
turning points in the process of an individual evolving to higher levels of consciousness.
Newman states that an individual’s current pattern is a composite of “information
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enfolded from the past and information which will enfold in the future” (Newman, 1990a,
p. 39). Viewing this pattern in relation to previous patterns represents an opportunity for
new action and expansion of consciousness.
Strengths: the model can be applied in any setting & can “generate caring
interventions”
Weaknesses: abstract, multi-dimensional, qualitative, & little discussion on

environment.
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10.
NU
Parse’s Theory of Human Becoming
Rosemarie Rizzo Parse (1981, 1987, 1992)
Introduced the "Theory of Human Becoming". She emphasized free choice of

personal meaning in relating value priorities, co creating of rhythmical patterns, in
exchange with the environment, and cotranscending in many dimensions as
possibilities unfold. She also believed that each choice opens certain opportunities
while closing others. Thus, she referred to revealing-concealing, enabling-limiting,
and connecting-separating. Since each individual makes his or her own personal
choices, the role of the nurse is that of guide, not decision maker.
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Rosemarie Rizzo Parse
BIOGRAPHY
Rosemarie Rizzo Parse, a member of the American Academy of Nursing, is

Distinguished Professor Emeritus at Loyola University Chicago. She is founder and
editor of Nursing Science Quarterly, and president of Discovery International, which
sponsors international nursing theory conferences. Dr. Parse is also founder of the
Institute of Human becoming, where she teaches the ontological, epistemological, and
methodological aspects of the human becoming school of thought (Parse, 1981, 1992,
1996, 1998, 2007b). She consults throughout the world with doctoral programs in
nursing and with healthcare settings that are utilizing her theory as a guide to research,
practice, education, and regulation of standards for quality in practice and education.
Parse is a graduate of Duquesne University in Pittsburgh and received her master's and
doctorate from the University of Pittsburgh. She was a member of the faculty of the
University of Pittsburgh, dean of the nursing school at Duquesne, professor and
coordinator of the Center for Nursing Research at Hunter College of the City University
of New York (1983-1993), and professor and Niehoff Chair at Loyola University Chicago
(1993-2006). Before coming to Binghamton University, she was a consultant, visiting
scholar and adjunct faculty at the New York University College of Nursing.
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Founder and editor of Nursing Science Quarterly, Parse is also president of Discovery
International, Inc., and founder of the Institute of Human becoming. In addition, she is a
fellow in the American Academy of Nursing, where she initiated and is past chair of the
nursing theory-guided practice expert panel. In her role as editor of Nursing Science
Quarterly, she has spearheaded a well-known, highly cited venue for nurse scholars to
share and debate matters important to nursing research and theory development.
Throughout her career, Parse has made outstanding contributions to the profession of
nursing through her progressive leadership in nursing theory, research, education and
practice. She has explored the ethics of human dignity; set forth human becoming
tenets of human dignity; and developed leading-following, teaching-learning, mentoring
and family models that are used worldwide. She has published 10 books and more than
100 articles and editorials about matters pertinent to nursing.
Parse is a sought-after speaker who has shared her knowledge and passion in more
than 300 presentations and workshops around the globe. She regularly consults with
educational programs in nursing and with multiple disciplines in healthcare settings that
are using her work as a guide to research, practice, leadership, education and
regulation of quality standards. She has also planned and implemented international
conferences on nursing theory, the human becoming school of thought, qualitative
research and quality of life.
Parse has chaired 35+ doctoral dissertations, guided 200+ students with creative
conceptualization regarding their research, and mentored numerous faculty and
students working on qualitative and quantitative research proposals, grant applications
and manuscripts for publications. She has conducted and published multiple qualitative
research studies about lived experiences of health and quality of life, and taught a
variety of theory and research courses in multiple institutions of higher learning.
AWARDS AND HONORS

■ Parse has received several honors including
Two lifetime achievement awards — one from the Midwest Nursing Research
Society and one from the Asian American Pacific Islander Nurses Association
The Rosemarie Rizzo Parse Scholarship was endowed in her name at the
Henderson State University School of Nursing
Her books were twice named to the "best pick" list of theory books by Sigma
Theta Tau International Honor Society in Nursing
The Society of Rogerian Scholars honored her with the Martha E. Rogers Golden
Slinky Award
In 2008 she received The New York Times Nurse Educator of the Year Award
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Overview of Rosemarie Rizzo Parse’s Theory of Human Becoming
Concepts of The Human Becoming Theory
■ Human Becoming Theory includes Totality Paradigm; Man is a combination of

biological, psychological, sociological, and spiritual factors
■ Simultaneity Paradigm; Man is a unitary being in continuous, mutual interaction
with the environment
■ Originally Man-Living-Health Theory
Nursing Paradigms
■ Person: Open being who is more than and different from the sum of the parts.
■ Environment: Everything in the person and his experiences and inseparable,
complementary to, and evolving with.
■ Health: Open process of being and becoming. Involves synthesis of values.
■ Nursing: A human science and art that uses an abstract body of knowledge to
serve people.
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Strengths
■ Differentiates nursing from other disciplines

■ Practice – Provides guidelines of care and useful administration
■ Useful in Education
■ Provides research methodologies
■ Provides a framework to guide inquiry of other theories (grief, hope, laughter,
etc.)
Weaknesses
■ Research considered to be in a “closed circle”

■ Rarely quantifiable results – Difficult to compare to other research studies, no
control group, standardized questions, etc.
■ Does not utilize the nursing process/diagnoses
■ Negates the idea that each person engages in a unique lived experience
■ Not accessible to the novice nurse
■ Not applicable to acute, emergent care
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11.
NU
Watsons Theory of Human Caring
Overview of Jean Watson Theory of Human Science and Human

Caring
The 7 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 a person not only as he or she is now but as what he or
she may become.
5. A caring environment is one that offers the development of potential while
allowing the person to choose the best action for himself or herself at a given
point in time.
6. Caring is more “healthogenic” than is curing. The science of caring is
complementary to the science of curing.
7. The practice of caring is central to nursing.
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Watson’s Theory Metaparadigm
Human Being: refers to “…. a valued person in and of him or herself to be cared for,
respected, nurtured, understood and assisted; in general, a philosophical view of a
person as a fully functional integrated self. He, human is viewed as greater than and
different from, the sum of his or her parts”.
Health: Watson adds the following three elements to WHO definition of health:
1. A high level of overall physical, mental, and social functioning.

2. A general adaptive-maintenance level of daily functioning.
3. The absence of illness (or the presence of efforts that leads to its absence).
Environment/society: According to Watson, caring (and nursing) has existed in every

society. A caring attitude is not transmitted from generation to generation. It is
transmitted by the culture of the profession as a unique way of coping with its
environment.
Nursing: “Nursing is concerned with promoting health, preventing illness, caring for the
sick and restoring health”. It focuses on health promotion and treatment of disease. She
believes that holistic health care is central to the practice of caring in nursing. She
defines nursing as…. “a human science of persons and human health-illness
experiences that are mediated by professional, personal, scientific, aesthetic and ethical
human transactions”.
The 10 Primary Carative Factors
According to Watson (1997), the core of the Theory of Caring is that “humans cannot be
treated as objects and that humans cannot be separated from self, other, nature, and
the larger workforce.” Her theory encompasses the whole world of nursing; with the
emphasis placed on the interpersonal process between the caregiver and care
recipient. The theory is focused on “the centrality of human caring and on the caring-to-
caring transpersonal relationship and its healing potential for both the one who is caring
and the one who is being cared for” (Watson, 1996). The structure for the science of
caring is built upon ten carative factors. These are:
1. Embrace: Altruistic Values and Practice Loving Kindness with Self and
Others
2. Inspire: Faith and Hope and Honor Others
3. Trust: Self and Others by Nurturing Individual Beliefs, Personal Growth and
Practices
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4. Nurture: Helping, Trusting, Caring Relationships

5. Forgive: and Accept Positive and Negative Feelings – Authentically Listen to
Another’s Story
6. Deepen: Scientific Problem-Solving Methods for Caring Decision Making
7. Balance: Teaching and Learning to Address the Individual Needs, Readiness
and Learning Styles
8. Co-Create: a Healing Environment for the Physical and Spiritual Self which
Respects Human Dignity
9. Minister: To Basic Physical, Emotional and Spiritual Human Needs
10. Open: to Mystery and Allow Miracles to Enter
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Strengths
■ This theory places the client in the context of the family, community, and
culture.
■ It places the client as the focus of practice rather than the technology.
Limitations
■ Biophysical needs of the individual are given less importance.

■ The ten carative factors primarily delineate the psychosocial needs of the
person.
■ Needs further research to apply in practice and may be considered too
abstract.
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12.
NU
Orlando’s Nursing Process
Overview of Orlando's Nursing Process Theory
MAJOR DIMENSIONS
■ The role of the nurse is to find out and meet the patient's immediate need for
help.
■ The patient's presenting behavior may be a plea for help, however, the help
needed may not be what it appears to be.
■ Therefore, nurses need to use their perception, thoughts about the
perception, or the feeling engendered from their thoughts to explore with
patients the meaning of their behavior.
■ This process helps nurse find out the nature of the distress and what help the
patient needs.
TERMS
■ Distress is the experience of a patient whose need has not been met.
■ Nursing role is to discover and meet the patient’s immediate need for help.
Patient’s behavior may not represent the true need.
The nurse validates his/her understanding of the need with the patient.
■ Nursing actions directly or indirectly provide for the patient’s immediate need.
■ An outcome is a change in the behavior of the patient indicating either a relief
from distress or an unmet need.
Observable verbally and nonverbally.
CONCEPTS
■ Function of professional nursing - organizing principle

■ Presenting behavior - problematic situation
■ Immediate reaction - internal response
■ Nursing process discipline – investigation
■ Improvement – resolution
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FUNCTION OF PROFESSIONAL NURSING - ORGANIZING PRINCIPLE
■ Finding out and meeting the patients immediate needs for help
"Nursing….is responsive to individuals who suffer or anticipate a sense of
helplessness, it is focused on the process of care in an immediate experience, it
is concerned with providing direct assistance to individuals in whatever setting
they are found for the purpose of avoiding, relieving, diminishing or curing the
individuals sense of helplessness." - Orlando
PRESENTING BEHAVIOR - PROBLEMATIC SITUATION
■ To find out the immediate need for help the nurse must first recognize the
situation as problematic
■ The presenting behavior of the patient, regardless of the form in which it appears,
may represent a plea for help
■ The presenting behavior of the patient, the stimulus, causes an automatic
internal response in the nurse, and the nurses behavior causes a response in the
patient
IMMEDIATE REACTION - INTERNAL RESPONSE
■ Person perceives with any one of his five sense organs an object or objects
■ The perceptions stimulate automatic thought
■ Each thought stimulates an automatic feeling
■ Then the person acts
■ The first three items taken together are defined as the person’s immediate
reaction
NURSING PROCESS DISCIPLINE – INVESTIGATION
■ Any observation shared and explored with the patient is immediately useful in
ascertaining and meeting his need or finding out that he is not in need at that
time
■ 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
■ The nurse initiates a process of exploration to ascertain how the patient is
affected by what she says or does.
■ When the nurse does not explore with the patient her reaction it seems
reasonably certain that clear communication between them stops.
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IMPROVEMENT - RESOLUTION
■ It is not the nurses activity that is evaluated but rather its result: whether the
activity serves to help the patient communicate her or his need for help and how
it is met.
■ In each contact the nurse repeats a process of learning how to help the individual
patient.
ASSUMPTIONS
■ 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
■ Human beings attach meanings to situations and actions that are not apparent to
others
■ Nurses are concerned with needs that patients cannot meet on their own
DOMAIN CONCEPTS
1. Nursing – is responsive to individuals who suffer or anticipate a sense of

helplessness
2. Process of care in an immediate experience…. for avoiding, relieving,
diminishing or curing the individuals sense of helplessness. Finding out
meeting the patients immediate need for help
3. Goal of nursing – increased sense of wellbeing, increase in ability, adequacy
in better care of self and improvement in patients behavior
4. Health – sense of adequacy or wellbeing. Fulfilled needs. Sense of comfort
5. Environment – not defined directly but implicitly in the immediate context for
a patient
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6. Human being – developmental beings with needs, individuals have their own
subjective perceptions and feelings that may not be observable directly
7. Nursing client – patients who are under medical care and who cannot deal
with their needs or who cannot carry out medical treatment alone
8. Nursing problem – distress due to unmet needs due to physical limitations,
adverse reactions to the setting or experiences which prevent the patient from
communicating his needs
9. Nursing process – the interaction of 1) the behavior of the patient, 2) the
reaction of the nurse and 3) the nursing actions which are assigned for the
patients benefit
10. Nurse – patient relations – central in theory and not differentiated from
nursing therapeutics or nursing process
11. Nursing therapeutics – Direct function: initiates a process of helping the
patient express the specific meaning of his behavior in order to ascertain his
distress and helps the patient explore the distress in order to ascertain the
help he requires so that his distress may be relieved.
12. Indirect function – calling for help of others, whatever help the patient may
require for his need to be met
13. Nursing therapeutics - Disciplined and professional activities – automatic
activities plus matching of verbal and nonverbal responses, validation of
perceptions, matching of thoughts and feelings with action
14. Automatic activities – perception by five senses, automatic thoughts,
automatic feeling, action
CHARACTERISTICS OF THE THEORY
■ Orlando's theory interrelates concepts

■ Orlando's theory has a logical nature
■ Orlando's theory is simple and applicable in the daily practice.
■ Orlando's theory contributes to the professional knowledge.
■ Orlando's theory is applicable in clinical practice
STRENGTHS
■ Use of her theory assures that patient will be treated as individuals and that they
will have active and constant input into their own care
■ Prevents inaccurate diagnosis or ineffective plans because the nurse has to
constantly explore her reactions with the patient
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■ Assertion of nursing’s 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
outcome
NURSING PROCESS
■ Assessment
■ Diagnosis
■ Planning
■ Implementation
■ Evaluation
CONCLUSION TO THEORY
■ Orlando's Deliberative Nursing Process Theory focuses on the interaction

between the nurse and patient, perception validation, and the use of the nursing
process to produce positive outcomes or patient improvement. Orlando's key
focus was to define the function of nursing. (Faust C., 2002)
■ Orlando's theory remains one the of the most effective practice theories
available.
■ The use of her theory keeps the nurse's focus on the patient.
■ The strength of the theory is that it is clear, concise, and easy to use.
■ While providing the overall framework for nursing, the use of her theory does not
exclude nurses from using other theories while caring for the patient.
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13. Locsin’s Technological Competency as Caring
Rozzano Locsin
My commitment to service in nursing is evident in my current and future endeavors.

I sustain a program of service that includes teaching and research in various
settings, particularly in the international arena. I believe that the smallness of the
world has created a more diverse global citizenry. Appreciating this diversity further
one’s commitments to knowing others as participants in the drama of what it is to be
in this world. Further, I exercise my vision of service in nursing as the appreciation
of the integral nature and value of globalization.” - Dr. Rozzano Locsin
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Rozzano Locsin
BIOGRAPHY
Rozzano C. de Castro Locsin, American Nurse educator, administrator. Certified
gerontological nurse Scholar Silliman U., 1977-1978, U. Philippines, 1982-1984, Kellog
Foundation,1986. Member New York Academy Sciences, Society Rogerian Scholars,
Sigma Theta Tau (international). Locsin, Rozzano C. de Castro was born on May 25,
1954 in Manila, The Philippines. Son of Vicente Teves and Maria Luisa Locsin. came to
the United States, 1984.
EDUCATION
Bachelor of science in nursing, Silliman U., Dumaguete, The Philippines, 1976; Master
of Arts in Nursing, Silliman U., Dumaguete, The Philippines, 1978; Doctor of Philosophy
in Nursing, University of The Philippines, Manila, 1988.
CAREER
Assistant professor nursing, Silliman U., Dumaguette, 1978-1980; nurse clinician, M. D.
Anderson Hospital and Tumor Institute, Houston, 1980-1981; instructor IV, University of
Philippines, Manila, 1982-1984; staff nurse, Goldwater Member Hospital, New York
City, 1984-1985; supervisor of nurses, Goldwater Member Hospital, New York City,
1985-1988; assistant director nursing, Goldwater Member Hospital, New York City,
1988-1991; assistant professor, Florida Atlantic U., Boca Raton, since 1991. Adjunct
instructor CUNY, 1988-1990. Board directors Philippine Nurses assosiation, New York.
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Overview of Locsin’s Technological Competency as Caring
Assumptions
Technological Competency as Caring in Nursing is a middle range theory grounded

in Nursing as Caring (Boykin & Schoenhofer), 2001). It is illustrated in the practice of
nursing grounded in the harmonious coexistence between technology and caring in
nursing. The assumptions of the theory are:
■ Persons are caring by virtue of their humanness (Boykin & Schoenhofer, 2001).
■ Persons are whole or complete in the moment (Boykin & Schoenhofer, 2001).
■ Knowing persons is a process of nursing that allows for continuous appreciation
of persons moment to moment (Locsin, 2005).
■ Technology is used to know wholeness of persons moment to moment (Locsin,
2004).
■ Nursing is a discipline and a professional practice (Boykin & Schoenhofer, 2001)
Dimensions of Technological Value in the Theory
■ Technology as completing human beings to re-formulate the ideal human

being such as in replacement parts, both mechanical (prostheses) or organic
(transplantation of organs.)
■ Technology as machine technologies, e.g., computers and gadgets enhancing
nursing activities to provide quality patient care such as Penelope or Da Vinci in
the Operating Theatres;
■ Technologies that mimic human beings and human activities to meet the
demands of nursing care practices, e.g., cyborgs (cybernetic organisms) or
anthropomorphic machines and robots such as ‘nursebots’ (Locsin & Barnard,
2007).
Technological Competency as Caring in Nursing
■ Technological competency as caring in nursing is the harmonious coexistence

between technologies and caring in nursing.
■ The harmonization of these concepts places the practice of nursing within the
context of modern healthcare and acknowledges that these concepts can co-
exist.
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■ Technology brings the patient closer to the nurse. Conversely, technology can
also increase the gap between the nurse and nursed.
■ When technology is used to know persons continuously in the moment, the
process of nursing is lived.
The Process of Nursing the Process of Nursing
A. Knowing: The process of knowing person is guided by technological knowing in

which persons are appreciated as participants in their care rather than as objects
of care. The nurse enters the world of the other. In this process, technology is
used to magnify the aspect of the person that requires revealing – a
representation of the real person. The person’s state change moment to moment
- person is dynamic, living, and cannot be predicted.
B. Designing: Both the nurse and the one nursed (patient) plan a mutual care
process from which the nurse can organize a rewarding nursing practice that is
responsive to the patient’s desire for care
C. Participation in appreciation: The simultaneous practice of conjoined
activities which are crucial to knowing persons. In this stage of the process is the
alternating rhythm of implementation and evaluation. The evidence of continuous
knowing, implementation and participation is reflective of the cyclical process of
knowing persons.
D. Verifying knowledge: The continuous, circular process demonstrates the ever-
changing, dynamic nature of knowing in nursing. Knowledge about the person
that is derived from knowing, designing, and implementing further informs the
nurse and the one nursed.
There are 4 metaparadigm concepts. Health, Nursing, Environment and Person
In relations to Locsin’s theory within the health paradigm

The concept of Health is having the Patient participate in their own health. And in using
technologies to better understand the hemodynamics of the patient to provide the best
care and meet their individual needs
Nursing is described as a discipline and a specialized practice that uses technologies
to individualize care to meet the unique needs of the person
Environment is in the surroundings that use technology. such as a critical care unit to
understand the persons as a complete moment by moment. Increased technological
monitoring allows for greater insight of whole state of health. Nurses must be efficient
and proficient with technologies without losing focus on the person as a whole.
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The last concept is Person. The person who is also the recipient of nursing care has
desires, dreams, and ambitions are to live life completely as caring persons. They also
want to feel acknowledged as a unique person with hopes and dreams and not as an
object.
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THEORIES RELEVANT TO NURSING PRACTICE
1. Maslow’s Human Needs Theory
Abraham Maslow
Abraham Maslow's hierarchy of needs is one of the best-known theories of motivation.
Maslow's theory states that our actions are motivated by certain physiological and
psychological needs that progress from basic to complex. Maslow (1954) formulated the
hierarchy of needs, in which he used a pyramid to arrange and illustrate the basic drives
or needs that motivate people.
■ The most basic needs- the physiologic needs of food, water, sleep, shelter,
sexual expression, and freedom from pain– must be met first.
■ The second level involves safety and security needs, which include protection,
security, and freedom from harm or threatened deprivation.
■ The third level is love and belonging needs, which includes enduring intimacy,
friendship, and acceptance.
■ The fourth level involves esteem needs, which include the need for self-respect
and esteem from others.
■ The highest level is self-actualization, the need for beauty, truth, and justice.
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Abraham Maslow
BIOGRAPHY
Abraham Harold Maslow (April 1, 1908 – June 8, 1970) psychologist and psychiatrist,
founder of humanistic psychology. Abraham Maslow emerged from obscurity to become
one of the most important and influential psychologists of the 20th century. His
development of the “Hierarchy of Needs” and contributions to humanistic psychology
changed the way the field of psychology approached the study of human behavior and
modeled the human mind.
EARLY LIFE
Abraham Maslow was the son of Jewish immigrants from Russia. His parents were
barely educated and established a life on the lower rungs of the social-economic ladder
of Brooklyn, New York.
Born in 1908, Maslow’s early life was miserable. As a Jew, he was frequently
persecuted and bullied by local gangs in a racist environment. He was the first of seven
children. He later developed a sense of “loathing” and even “hatred” for his own mother.
He was also emotionally troubled. At one point he was classified as “mentally unstable”
by a New York psychologist.
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EDUCATION
Although his parents were basically uneducated, they strongly believed that higher
education was the key for their children to escape the ghetto and grind of life. Maslow
enrolled in City College of New York where his parents urged him to study law, which
Maslow hated.
In less than a year, he dropped out of law school and transferred to Cornell, but did not
fare well there either. In the meantime, Maslow married his first cousin, Bertha
Goodman, over the severe objections of his parents.
Maslow continued on, however, and returned to City College to earn his degree. He
moved with his wife and first child to Wisconsin where he enrolled as a graduate student
in psychology. He earned his master’s degree from the University of Wisconsin,
finishing his thesis in 1931.
CONTRIBUTIONS
Maslow’s education was grounded in the mainstream theories of the day, which meant
heavy doses of Freudian theory and the highly influential behaviorism ideals of B.F.
Skinner.
But Maslow proved to be a thinker of extreme innovation. He proved to be a maverick in
his field. He was a respected academic who was not afraid to challenge the basic
assumptions held by the majority of the psychological community of the day.
For example, Maslow thought it wrong that Sigmund Freud had developed his theory of
the human personality primarily through the study of the mentally ill or socially
maladjusted people. Rather, Maslow reasoned that we should look to successful,
happy, and well-adjusted people to formulate the basic theories of what makes people
“normal.” Abraham Maslow is sometimes referred to as the “anti-Sigmund Freud.”
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Overview of Maslow’s Hierarchy of Needs
Maslow’s Hierarchy of Needs Theory
Abraham Maslow’s Hierarchy of Needs Theory is a health model based on the

organization of needs rather than the typical medical or illness model. Maslow (1908 –
1970) believed certain needs are more important than others and people will try to
obtain more important needs first before satisfying other needs. Therefore, Maslow’s
Hierarchy of Needs is also considered a “motivational theory”.
Maslow’s theory is important because he felt as though traditional theories did not
adequately capture the complexity of human behavior. In a 1943 paper called A Theory
of Human Motivation, Maslow presented the idea that human actions are directed
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toward goal attainment. He also proposed that any given behavior could satisfy several
functions at the same time; for instance, going to a bar could satisfy one’s needs for
self-esteem and social interaction. (-Envision Your Evolution)
Interestingly, later in life, Maslow was concerned with questions such as, “Why don’t
more people self-actualize if their basic needs are met? How can we humanistically
understand the problem of evil?” Therefore, despite self-actualization, human behavior
can still be perplexing and misunderstood.
Key Takeaways
 According to Maslow, humans have 5 categories of needs: physiological, safety,

love, esteem, and self-actualization.
 In this theory, higher needs in the hierarchy begin to emerge when people feel
they have sufficiently satisfied the previous need.
 Although later research does not fully support all of Maslow’s theory, his research
has impacted other psychologists and contributed to the field of positive
psychology.
About the Hierarchy of Needs Pyramid
Maslow called the bottom four levels of the pyramid ‘deficiency needs’ because a
person does not feel anything if they are met, but becomes anxious if they are not.
Thus, physiological needs such as eating, drinking, and sleeping are deficiency needs,
as are safety needs, social needs such as friendship and sexual intimacy, and ego
needs such as self-esteem and recognition.
In contrast, Maslow called the fifth level of the pyramid a ‘growth need’ because it
enables a person to ‘self-actualize’ or reaches his fullest potential as a human being.
Once a person has met his deficiency needs, he can turn his attention to self-
actualization; however, only a small minority of people are able to self-actualize
because self-actualization requires uncommon qualities such as honesty,
independence, awareness, objectivity, creativity, and originality.
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B and D Needs
Deficiency or Deprivation Needs:
 The first four levels are considered deficiency or deprivation needs (“D-needs”) in
that their lack of satisfaction causes a deficiency that motivates people to meet
these needs
Growth Needs or B-Needs or Being Needs:
 The needs Maslow believed to be higher, healthier, and more likely to emerge in
self-actualizing people were being needs or B-needs.
 Growth needs are the highest level, which is self-actualization, or self-fulfillment.
 Maslow suggested that only two percent of the people in the world achieve self-
actualization. E.g., Abraham Lincoln, Thomas Jefferson, Albert Einstein, Eleanor
Roosevelt.
 Self-actualized people were reality and problem-centered.
 They enjoyed being by themselves and having deeper relationships with a few
people instead of more shallow relations with many people.
 They tended to be spontaneous and simple.
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Application in Nursing
Maslow’s hierarchy of needs is a useful organizational framework that can be applied to

the various nursing models for the assessment of a patient’s strengths, limitations, and
need for nursing interventions. (Smeltzer SC, Bare BG, 2004)
Contributions to Psychology & Criticisms
 Pros: At a time when most psychologists focused on aspects of human nature

that were considered abnormal, Abraham Maslow shifted focus to look at the
positive sides of mental health. His interest in human potential, seeking peak
experiences, and improving mental health by seeking personal growth had a
lasting influence on psychology.
 Cons: As Maslow suggested, theories can only explain human behavior so much
and frequently people are left with more questions than answers. It is difficult to
understand evil or people who are “self-actualized” that still can commit heinous
crimes and violence. Furthermore, factors such as traditions, environment, and
cultures may not share the same qualities of self-actualization or basic needs.
The needs of someone in a 3rd world country can be significantly different in
other societies, yet feel completely content or self-actualized. Nonetheless,
Maslow gave insight into the importance of basic needs regardless of a person’s
background or intentions.
The Transcendence Level
In his later years, Maslow explored a further dimension of motivation, while criticizing his
original vision of self-actualization. By this later theory, one finds the fullest realization in
giving oneself to something beyond oneself—for example, in altruism or spirituality.
He equated this with the desire to reach the infinite. “Transcendence refers to the very
highest and most inclusive or holistic levels of human consciousness, behaving and
relating, as ends rather than means, to oneself, to significant others, to human beings in
general, to other species, to nature, and to the cosmos”
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2. Sullivan’s Interpersonal Theory
Harry Stack Sullivan

The theory identifies six developmental stages called “epochs” or “heuristic stages in
development.” They are: infancy, childhood, juvenile era, preadolescence, early
adolescence, and late adolescence.
Infancy, which takes place from birth to 18 months, focuses on the gratification of
needs. Childhood occurs between 18 months and six years. The main characteristic of
this stage is delayed gratification. The juvenile era is between six and nine years, and is
characterized by the formation of a peer group. Preadolescence, which takes place
between the ages of nine and 12 years old, is characterized by developing relationships
within the same gender. Early adolescence is from 12 to 14 years old, and during this
stage, people develop individual identities. Late adolescence takes place between 14
and 21 years. The main characteristic of this stage is the formation of lasting, intimate
relationships.
Stack-Sullivan explains three types of self: the “good me,” the “bad me,” and the “not
me.” The “good me” versus the “bad me” is based on social appraisal and the anxiety
that results from negative feedback. The “not me” refers to the unknown, repressed
aspect of the self.
In terms of anxiety, self-system, and self-esteem, the theory explains that security
operations are the measures that the individual employs to reduce anxiety and enhance
security. The self-system is all of the security operations an individual uses to defend
against anxiety and ensure self-esteem.
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Harry Stack Sullivan
BIOGRAPHY
One of the great figures of the psychodynamic currents, Harry Stack Sullivan is known
for the creation of interpersonal psychoanalysis, based on the importance of interaction
between people in personal development and in the creation of identity and personality,
and his expansion of psychoanalysis in the population with psychotic disorders and the
application of a more empirical methodology in comparison to other psychoanalysts.
The development of his theories is largely influenced by his life experience.
EARLY LIFE
Harry Stack Sullivan was born on February 21, 1892 in Norwich, New York. Son of
Timothy Sullivan and Ella Stack Sullivan , he was born into a family of Irish origin of
Catholic beliefs with few resources. His relationship with his parents was apparently
rocky, with no close relationship with his father and little affection from his mother.
However, he would have a better relationship with his Aunt Margaret, who would be
very supportive.
The family had to move due to lack of resources to a farm owned by the mother’s family
in Smyrna. His early years were not easy, feeling rejected and socially isolated (it is
believed that he did not have a true friendship until the age of eight, with the young
Clarence Belliger) living in a majority Protestant population where Catholics were not
welcome, possessing a shy nature and excelling in studies.
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After graduating from the Smyrna Union School, he spent two years at Cornell
University, beginning in 1909. In 1917, Stack-Sullivan earned his medical degree from
the Chicago College of Medicine and Surgery.
Between 1925 and 1929, Stack-Sullivan worked at the Sheppard Pratt Hospital, treating
schizophrenic patients with treatments considered experimental. He was a founder of
the William Alanson White Institute, as well as of the journal Psychiatry in 1937. From
1936 until 1947, he was the head of the Washington School of Psychiatry in
Washington, D.C. In 1940, he and a colleague, Winifred Overholser, formulated
guidelines used by the United States military for the psychological screening of
inductees.
CONTRIBUTIONS
Sullivan's approach to psychiatry emphasized the social factors which contribute to the
development of personality. He differed from Sigmund Freud in viewing the significance
of the early parent-child relationship as being not primarily sexual but, rather, as an
early quest for security by the child. It is here that one can see Sullivan's own childhood
experiences determining the direction of his professional thought.
Characteristic of Sullivan's work was his attempt to integrate multiple disciplines and
ideas borrowed from those disciplines. His interests ranged from evolution to
communication, from learning to social organization. He emphasized interpersonal
relations. He objected to studying mental illness in people isolated from society.
Personality characteristics were, he felt, determined by the relationship between each
individual and the people in his environment. He avoided thinking of personality as a
unique, individual, unchanging entity and preferred to define it as a manifestation of the
interaction between people.
On January 14, 1949, while returning from a meeting of the executive board of the
World Federation for Mental Health, Sullivan died in Paris. He was buried in Arlington
National Cemetery.
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Overview of Sullivan’s Interpersonal Theory
Harry Stack Sullivan’s Interpersonal Psychodynamic Theory
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Assumptions and Key Concepts
 Anxiety: the “main disruptive force” in interpersonal relations

 Basic Anxiety: fear of rejection by significant persons
 Interpersonal Security: feelings associated with relief of anxiety, the point
when all needs are met, or a sense of total well-being
 Parataxic Distortion: a person’s fantasy perception of another person’s
attributes without consideration important personality differences
 Selective Inattention: how people cope with the anxiety caused by the
undesired traits
Sullivan focused on anxiety as being a consequence of faulty social interactions. He

believed people developed a personification of self and others through the integration of
“good me, bad me, and not me” perception (the self-system):
Self-System: The collection of experiences or security measures to protect against

anxiety
 Good Me: represents what people like about themselves and is willing to share
with others
 Bad Me: what people don’t like about themselves and are not willing to share.
Develops in response to negative feedback with feelings of discomfort,
displeasure, and distress. The “Bad Me” creates anxiety.
 Not Me: the aspects of self that are so anxiety-provoking that the person does
not consider them a part of the person. It contains feelings of horror, dread,
dread. This part of the self is primarily unconscious (dissociative coping).
Sullivan believed that all psychological disorders have an interpersonal origin and can
be understood only with reference to the patient’s social environment. To understand a
person’s drives for behavior, 2 needs are involved; satisfaction (sleep, sex, hunger) &
security (conforming to social norms of the person’s reference group). If the 2 drives of
the “self-system” are interfered with, mental illness occurs.
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Stages of Interpersonal Development
Stage (Epochs) Time-Period Developmental Task

Infancy 0-18mths Oral gratification; anxiety
first occurs
Childhood 18mths-6y Delayed gratification
Juvenile 6-9y Forming peer-relationships
Preadolescence 9-12y Same-sex relationships
Early Adolescence 12-14y Opposite-sex relationships
Late Adolescence 14-21y Self-identity is developed
Summary of Sullivan’s Stages of Development
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Summary of Sullivan’s Theory of Personality
Key Terms and Concepts
■ People develop their personality through interpersonal relationships.

■ Experience takes place on three levels—prototaxic (primitive, presymbolic),
parataxic (not accurately communicated to others), and syntaxic (accurate
communication).
■ Two aspects of experience are tensions (potential for action) and energy
transformations (actions or behaviors).
■ Tensions are of two kinds—needs and anxiety.
■ Needs are conjunctive in that they facilitate interpersonal development.
■ Anxiety is disjunctive in that it interferes with the satisfaction of needs and is the
primary obstacle to establishing healthy interpersonal relationships.
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■ Energy transformations become organized into consistent traits or behavior

patterns called dynamisms.
■ Typical dynamisms include malevolence (a feeling of living in enemy country),
intimacy (a close interpersonal relationship with a peer of equal status, and lust
(impersonal sexual desires).
■ Sullivan’s chief contribution to personality was his concept of various
developmental stages.
■ The first developmental stage is infancy (from birth to the development of
syntaxic language), a time when an infant’s primary interpersonal relationship is
with the mothering one.
■ During childhood (from syntaxic language to the need for playmates of equal
status), the mother continues as the most important interpersonal relationship,
although children of this age often have an imaginary playmate.
■ The third stage is the juvenile era (from the need for playmates of equal status
to the development of intimacy), a time when children should learn competition,
compromise, and cooperation—skills that will enable them to move successfully
through later stages of development.
■ The most crucial stage of development is preadolescence (from intimacy with a
best friend to the beginning of puberty). Mistakes made during this phase are
difficult to overcome later.
■ During early adolescence young people are motivated by both intimacy (usually
for someone of the same gender) and lust (ordinarily for a person of the opposite
gender).
■ People reach late adolescence when they are able to direct their intimacy and
lust toward one other person.
■ The successful completion of late adolescence culminates in adulthood, a stage
marked by a stable love relationship.
■ With Sullivan’s psychotherapy, the therapist serves as a participant observer
and attempts to improve patients’ interpersonal relations.
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3. Von Bertalanffy’s General System Theory
Ludwig von Bertalanffy’

The first call for a general systems theory came from Ludwig von Bertalanffy’s research
in the 1940s-50s. In 1968, he published “General System Theory: Foundations,
Development, Applications.” The goal of this book was to outline certain basic laws
that can be applied to virtually every scientific field. From his perspective, the way
individual components within a complex system cyclically are both affected by and
causing an effect on the system can be applied and reveal crucial information in multiple
settings. Following this thought process, Bertalanffy reasoned there ought to be
universal guidelines or principles that are applied across the sciences and within
educational settings to further unify certain fields—specifically the natural and social
sciences—and relate them to one another, rather than looking at them individually.
Bertalanffy is considered one of the founders of systems theory as it’s known and
applied today. Bertalanffy briefly described systems theory as follows:
“General system theory, therefore, is a general science of wholeness. … The meaning

of the somewhat mystical expression, ‘The whole is more than the sum of its parts’ is
simply that constitutive characteristics are not explainable from the characteristics of the
isolated parts. The characteristics of the complex, therefore, appear as new or
emergent.”
— Ludwig von Bertalanffy
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Ludwig von Bertalanffy
BIOGRAPHY
Karl Ludwig von Bertalanffy (September 19, 1901, Atzgersdorf near Vienna,
Austria – June 12, 1972, Buffalo, New York, USA) was an Austrian-born biologist
known as one of the founders of general systems theory (GST). GST is an
interdisciplinary practice that describes systems with interacting components,
applicable to biology, cybernetics, and other fields. Bertalanffy proposed that the
laws of thermodynamics applied to closed systems, but not necessarily to "open
systems," such as living things. His mathematical model of an organism's growth
over time, published in 1934, is still in use today.
Von Bertalanffy grew up in Austria and subsequently worked in Vienna, London,

EARLY LIFE
Canada and the USA.
Ludwig von Bertalanffy was born and grew up in the little village of Atzgersdorf (now
Liesing) near Vienna. The Bertalanffy family had roots in the 16th century nobility of
Hungary which included several scholars and court officials. His grandfather Charles
Joseph von Bertalanffy (1833–1912) had settled in Austria and was a state theatre
director in Klagenfurt, Graz, and Vienna, which were important positions in imperial
Austria. Ludwig's father Gustav von Bertalanffy (1861–1919) was a prominent railway
administrator. On his mother's side Ludwig's grandfather Joseph Vogel was an imperial
counsellor and a wealthy Vienna publisher. Ludwig's mother Charlotte Vogel was
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seventeen when she married the thirty-four-year-old Gustav. They divorced when
Ludwig was ten, and both remarried outside the Catholic Church in civil ceremonies.
Ludwig von Bertalanffy grew up as an only child educated at home by private tutors until
he was ten. When he went to the gymnasium/grammar school he was already well
trained in self-study, and kept studying on his own. His neighbor, the famous biologist
Paul Kammerer, became a mentor and an example to the young Ludwig.[3] In 1918 he
started his studies at the university level with the philosophy and art history, first at the
University of Innsbruck and then at the University of Vienna. Ultimately, Bertalanffy had
to make a choice between studying philosophy of science and biology, and chose the
latter because, according to him, one could always become a philosopher later, but not
a biologist. In 1926 he finished his PhD thesis (translated title: Fechner and the problem
of integration of higher order) on the physicist and philosopher Gustav Theodor
Fechner.
Von Bertalanffy met his future wife Maria in April 1924 in the Austrian Alps, and were
almost never apart for the next forty-eight years.[4] She wanted to finish studying but
never did, instead devoting her life to Bertalanffy's career. Later in Canada she would
work both for him and with him in his career, and after his death she compiled two of
Bertalanffy's last works. They had one child, who would follow in his father's footsteps
by making his profession in the field of cancer research.
Von Bertalanffy was a professor at the University of Vienna from 1934–48, University of
London (1948–49), Université de Montréal (1949), University of Ottawa (1950–54),
University of Southern California (1955–58), the Menninger Foundation (1958–60),
University of Alberta (1961–68), and State University of New York at Buffalo (SUNY)
(1969–72). In 1972, he died from a sudden heart attack.
WORKS
Today, Bertalanffy is considered to be a founder and one of the principal authors of the
interdisciplinary school of thought known as general systems theory. According to
Weckowicz (1989), he "occupies an important position in the intellectual history of the
twentieth century. His contributions went beyond biology, and extended into
cybernetics, education, history, philosophy, psychiatry, psychology and sociology. Some
of his admirers even believe that this theory will one day provide a conceptual
framework for all these disciplines".[1] Spending most of his life in semi-obscurity,
Ludwig von Bertalanffy may well be the least known intellectual titan of the twentieth
century.
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Overview of Von Bertalanffy's General System Theory
General systems theory (GST) was outlined by Ludwig von Bertalanffy (1968). Its
premise is that complex systems share organizing principles which can be discovered
and modeled mathematically. The term came to relate to finding a general theory to
explain all systems in all fields of science. To quote Bertalanffy, ""...there exist models,
principles, and laws that apply to generalized systems or their subclasses, irrespective
of their particular kind, the nature of their component elements, and the relations or
""forces"" between them. It seems legitimate to ask for a theory, not of systems of a
more or less special kind, but of universal principles applying to systems in general.""
(Bertalanffy, 1968, pp 32).
■ Bertalanffy was proposing a new way of doing science. What he was proposing
with his general systems theory goes beyond the meanings of 'theory' and
'science'. Bertalanffy's GST refers more to an organized body of knowledge - any
systematically presented set of concepts, whether empirical, axiomatic, or
philosophical. Being more than a theory, it is a new paradigm for conducting
inquiry.
Systems science description (from Bertalanffy, 1968) --
The scientific exploration and theory of systems [in the various sciences] and general
systems theory as doctrine of principles applying to all systems (or defined subclasses
of systems).
■ an understanding of not only elements but their interrelationships is required
(e.g., the structure and dynamics of social systems).
■ there are general aspects, correspondences and isomorphisms (similarities in
form or appearance in different systems) common to ""systems""...
Systems technology (from Bertalanffy, 1968) --
The hardware of computers, automation, self-regulating machinery, etc. and the

software of new theoretical developments and disciplines.
■ previous technology could not handle the complexity related to systems.
■ systems problems are problems of interrelations of a great number of variables.
■ concepts involved - information, feedback, control, stability, circuit theory, ...
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Systems philosophy (from Bertalanffy, 1968) --
The reorientation of thought and worldview as a result of introducing system as a new

scientific paradigm - as contrasted with the blind laws of nature of the mechanistic
worldview. There are three parts of systems philosophy –
■ Systems Ontology -- What is the nature of the beast, what is meant by
system. What is defined and described as ""system"" is not a question with an
obvious trivial answer. (Ontology - nature of existence and being).
■ Systems Epistemology -- The underlying principles or theories that form the
basis of the field of knowledge of systems. (Epistemology - the origin, nature,
methods, and limits of human knowledge. How much can one know about reality
and how does one obtain that knowledge?).
■ Values -- The relations of man and world. If reality is a hierarchy of organized
wholes, the image of man will be different from what is in a world of physical
particles governed by chance events as ultimate and only true reality.
Systems, and models, as guiding ideas (from Bertalanffy, 1968, p 24) --
“Models in ordinary language therefore have their place in systems theory. The system
idea retains its value even where it cannot be formulated mathematically, or remains a
“guiding idea” rather than being a mathematical construct.”
Necessity of a systems approach (from Bertalanffy, 1968, p 11) --
“...the necessity and feasibility of a systems approach became apparent only recently.
Its necessity resulted from the fact that the mechanistic scheme of isolable (isolatable)
causal trains and meristic (segmental division) treatment had proved insufficient to deal
with theoretical problems, especially in the biosocial sciences, and with the practical
problems posed by modern technology. Its feasibility resulted from various new
developments - theoretical, epistemological, mathematical, etc. - which, although still in
their beginnings, made it progressively realizable.”
Assumptions of Systems Theory
■ The main assumption of systems theory is that a complex system is made up of

multiple smaller systems, and it is the interactions between these smaller
systems that create a complex system as it’s known.
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■ Systems theory assumes certain underlying concepts and principles can be

applied universally in different fields, even if these fields evolved separately. This
assumption is a crucial factor in systems theory because it is this reasoning that
enables people like social workers and psychologists to employ systems theory
in a way that benefits those they’re assisting.
■ Following that assumption, a general systems theory that provides universal
guidelines for scientific research and education will enable further integration and
unification of the natural and social sciences. This will yield a better
understanding of how these sciences are interrelated and affect our daily lives.
■ Systems theory plays a key role in the advancement of society. Only by looking
at all the moving parts can we have a greater understanding of the whole and
how it works—a principle that holds true in physical sciences and social sciences
alike. By applying these broad truths across disciplines, we can further integrate
our understanding of separate phenomena.
■ As it applies to social science, systems theory is crucial because it looks
holistically at the individual to draw insights and use them to take steps forward.
Some of the concepts of systems theory as they apply to psychology, sociology

and social work:
■ System: An entity that’s made up of interrelated/interdependent parts.

■ Complex system: The greater, whole system made up of individual, smaller
systems. Generally used in social sciences.
■ Ecological systems: The various systems in an individual’s life that influence
their behavior.
■ Homeostasis: The state of steady conditions within a system. A system is
always moving toward homeostasis.
■ Adaptation: A system’s tendency to make changes that will protect itself when
presented with new environmental factors.
■ Feedback loop: When the outputs of a system ultimately affect its inputs,
causing the system to feed back into itself circularly.
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4. Lewin’s Change Theory
Kurt Lewin
The Change Theory has three major concepts: driving forces, restraining forces, and
equilibrium. Driving forces are those that push in a direction that causes change to
occur. They facilitate change because they push the patient in a desired direction. They
cause a shift in the equilibrium towards change. Restraining forces are those forces that
counter the driving forces. They hinder change because they push the patient in the
opposite direction. They cause a shift in the equilibrium that opposes change.
Equilibrium is a state of being where driving forces equal restraining forces, and no
change occurs. It can be raised or lowered by changes that occur between the driving
and restraining forces.
There are three stages in this nursing theory: unfreezing, change, and refreezing.
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Kurt Lewin
BIOGRAPHY
Kurt Lewin was an influential psychologist who is today recognized as the founder of
modern social psychology. His research on group dynamics, experiential learning, and
action research had a tremendous influence on the growth and development of social
psychology. He is also recognized for his important contributions in the areas of applied
psychology and organizational psychology. In a 2002 review of some of the most
influential psychologists of the 20th century, Lewin was ranked as the 18th most
eminent psychologist.
Von Bertalanffy grew up in Austria and subsequently worked in Vienna, London,

EARLY LIFE
Canada and the USA.
Born in Prussia to a middle-class Jewish family, Kurt Lewin moved to Berlin at the age
of 15 to attend the Gymnasium. He enrolled at the University of Frieberg in 1909 to
study medicine before transferring to the University of Munich to study biology. He
eventually completed a doctoral degree at the University of Berlin.
He originally began his studies with an interest in behaviorism, but he later developed
an interest in Gestalt psychology. He served in the German army and was later injured
in combat. These early experiences had a major impact on the development of his field
theory and later study of group dynamics.
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EDUCATION
In 1921, Kurt Lewin began lecturing on philosophy and psychology at the Psychological
Institute of the University of Berlin. His popularity with students and prolific writing drew
the attention of Stanford University, and he was invited to be a visiting professor in
1932. Eventually, Lewin emigrated to the U.S. and took a teaching position at the
University of Iowa, where he worked until 1945.
While Lewin emphasized the importance of theory, he also believed that theories
needed to have practical applications. Lewin established the Research Center for Group
Dynamics at Massachusetts Institute of Technology (MIT) and the National Training
Laboratories (NTL). Lewin died of a heart attack in 1947.
CAREER
Kurt Lewin contributed to Gestalt psychology by expanding on gestalt theories and

applying them to human behavior. He was also one of the first psychologists to
systematically test human behavior, influencing experimental psychology, social
psychology, and personality psychology. He was a prolific writer, publishing more than
80 articles and eight books on various psychology topics. Many of his unfinished papers
were published by his colleagues after his sudden death at age 56.
Lewin is known as the father of modern social psychology because of his pioneering
work that utilized scientific methods and experimentation to look at social behavior.
Lewin was a seminal theorist whose enduring impact on psychology makes him one of
the preeminent psychologists of the 20th century.
SELECTED PUBLICATIONS
■ Lewin, K. (1935) A dynamic theory of personality. New York: McGraw-Hill.

■ Lewin, K. (1936) Principles of topological psychology. New York: McGraw-Hill.
■ Lewin, K. (1951) Field theory in social science: Selected theoretical papers. D.
Cartwright (ed.). New York: Harper & Row.
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Overview of Kurt Lewin’s Change Theory

Considered the father of social
psychology, Kurt Lewin developed the
Kurt Lewin’s Contribution to Nursing Theory: Change Theory
nursing model known as Change Theory.
He■ theorized
Considered a three-stage
the model
father of social of Kurt Lewin developed the nursing
psychology,
change
modelthat is known
known as Change asTheory.
the “unfreezing-
He theorized a three-stage model of change
that is known as the “unfreezing-change-refreeze model” that requires prior
change-refreeze model” that requires prior
learning to be rejected and replaced. It states behavior as “a dynamic balance of
learning
forces to be rejected
working in opposing and replaced. It
directions.”
states behavior as “a dynamic balance of
forces working in opposing directions.”
The three concepts identified in Lewin’s Change Theory are driving forces,
restraining forces, and equilibrium.
The three
Driving forcesconcepts
are forces identified indirection
that push in a Lewin’s that causes change to occur. They
Change
facilitate Theory
change are they
because driving
pushforces,
the person in the desired direction. They cause a
restraining
shift forces,towards
in the equilibrium and equilibrium.
change. Restraining forces are those forces that
counter driving forces. They hinder change because they push the person in the
opposite direction. They cause a shift in the equilibrium which opposes change.
Equilibrium is a state of being where driving forces equal restraining forces and no
Driving forces are forces that push in a
change occurs. Equilibrium can be raised or lowered by changes that occur between
direction
the driving andthat causes
restraining change to occur.
forces.
They facilitate change because they push
the person in the desired direction. They
This model of nursing consists of three distinct stages which are vital to the
cause a shift in the equilibrium towards
theory. They are unfreezing, moving to a new level or changing (or movement),
change.
and Restraining forces are those
refreezing.
forces that counter driving forces. They
hinder change because they push the
person inisthe
Unfreezing the opposite
process which direction. They a method of making it possible for
involves finding
people to let go of an old pattern that was somehow counterproductive. It is necessary
cause a shift in the equilibrium which
to overcome the strains of individual resistance and group conformity. There are three
opposes
methods thatchange. Equilibrium
can lead to is a of
the achievement state of
unfreezing. The first is to increase the
being where driving forces equal
driving forces that direct behavior away from the existing situation or status quo.
restraining
Second, decreaseforces and no forces
the restraining change thatoccurs.
negatively affect the movement from the
existing equilibrium. Thirdly, finding a combination of the first two methods.
Equilibrium can be raised or lowered by
changes that occur between the driving
and restraining forces. Page 269 of 313
This model of nursing consists of three

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The change stage, which is also called “moving to a new level” or “movement,”
involves a process of change in thoughts, feeling, behavior, or all three, that is in some
way more liberating or more productive.
The refreezing stage is establishing the change as the new habit, so that it now
becomes the “standard operating procedure.” Without this final stage, it can be easy for
the patient to go back to old habits.
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5. Erikson's Psychosocial Development
Erik Erikson
Erik Erikson was an ego psychologist who developed one of the most popular and
influential theories of development. While his theory was impacted by psychoanalyst
Sigmund Freud's work, Erikson's theory centered on psychosocial development rather
than psychosexual development.
The stages that make up his theory are as follows:
■ Stage 1: Trust vs. Mistrust (Infancy from birth to 18 months)

■ Stage 2: Autonomy vs. Shame and Doubt (Toddler years from 18 months to
three years)
■ Stage 3: Initiative vs. Guilt (Preschool years from three to five)
■ Stage 4: Industry vs. Inferiority (Middle school years from six to 11)
■ Stage 5: Identity vs. Confusion (Teen years from 12 to 18)
■ Stage 6: Intimacy vs. Isolation (Young adult years from 18 to 40)
■ Stage 7: Generativity vs. Stagnation (Middle age from 40 to 65)
■ Stage 8: Integrity vs. Despair (Older adulthood from 65 to death)
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Erik Erikson
BIOGRAPHY
Erik Erikson is best known for his famous theory of psychosocial development and
the concept of the identity crisis. His theories marked an important shift in thinking
on personality; instead of focusing simply on early childhood events, his
psychosocial theory looks at how social influences contribute to our personalities
throughout our entire lifespans.
"Hope is both the earliest and the most indispensable virtue inherent in the state of
being alive. If life is to be sustained hope must remain, even where confidence is
wounded, trust impaired."—Erik Erikson, The Erik Erikson Reader, 2000
Erikson's stage theory of psychosocial development generated interest and research

on human development through the lifespan. An ego psychologist who studied with
Anna Freud, Erikson expanded psychoanalytic theory by exploring development
throughout life, including events of childhood, adulthood, and old age.
EARLY LIFE
Erik Erikson was born on June 15, 1902, in Frankfurt, Germany. His young Jewish
mother, Karla Abrahamsen, raised Erik by herself for a time before marrying a
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physician, Dr. Theodore Homberger. The fact that Homberger was not his biological
father was concealed from Erikson for many years. When he finally did learn the truth,
Erikson was left with a feeling of confusion about who he really was.
"The common story was that his mother and father had separated before his birth, but
the closely guarded fact was that he was his mother's child from an extramarital union.
He never saw his birth father or his mother's first husband." — Erikson's obituary, The
New York Times, May 13, 1994
CONTRIBUTIONS
Erik Erikson spent time studying the cultural life of the Sioux of South Dakota and the
Yurok of northern California. He utilized the knowledge he gained about cultural,
environmental, and social influences to further develop his psychoanalytic theory.
While Freud’s theory had focused on the psychosexual aspects of development,
Erikson’s addition of other influences helped to broaden and expand psychoanalytic
theory. He also contributed to our understanding of personality as it is developed and
shaped over the course of the lifespan.
His observations of children also helped set the stage for further research. "You see a
child play," he was quoted as saying in his New York Times obituary, "and it is so close
to seeing an artist paint, for in play a child says things without uttering a word.
You can see how he solves his problems. You can also see what's wrong. Young
children, especially, have enormous creativity, and whatever's in them rises to the
surface in free play."
SELECTED PUBLICATIONS
Here are some of Erikson's works for further reading:

■ Erikson EH. Childhood and Society. New York: Norton; 1950.
■ Erikson EH. Identity: Youth and Crisis. New York: Norton; 1968.
■ Erikson EH. Life History and the Historical Moment. New York: Norton; 1975.
■ Erikson EH. Dialogue With Erik Erikson. Evans RI, ed. Jason Aronson, Inc.;
1995.
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Overview of Erick Erikson’s Stages of Development

Considered the father of social psychology, Kurt Lewin
developed the nursing model known as Change Theory.
Hetheorized
Erik Erikson (1902-1994) is probably most famous for coining the term “identity
a three-stage model of change that is
crises” and describing basic human development in a series of 8 psychological
known as the
stages. As a“unfreezing-change-refreeze
student of Freudian theories, this model”
marked athat
stark contrast by
requires priordevelopment
suggesting learning to bebeyond
is far rejected and
the age replaced. It
of adolescence (genital stage).
states behavior
 Erickson as “a dynamic
also considered balance
a person’s of environmental
social and forces factors that may
working in opposing
also influence directions.”
the personality or cause a crisis. While Freud’s Ego philosophy
was supposed to resolve internal conflicts, Erickson’s believed that outcomes
were not fixed. Therefore, regression and pathology can occur, as well as virtues
and goals with every developmental task.
The three concepts identified in Lewin’s Change
Theory are driving forces, restraining forces, and
equilibrium.
Driving forces are forces that push in a direction that

causes change to occur. They facilitate change
because they push the person in the desired direction.
They cause a shift in the equilibrium towards change.
Restraining forces are those forces that counter
driving forces. They hinder change because they push
the person in the opposite direction. They cause a shift
in the equilibrium which opposes change. Equilibrium
is a state of being where driving forces equal
restraining forces and no change occurs. Equilibrium
can be raised or lowered by changes that occur
between the driving and restraining forces.
This model of nursing consists of three distinct stages

which are vital to the theory. They are unfreezing,
moving to a new level or changing (or movement), and
refreezing. Page 274 of 313
Unfreezing is the process which involves finding a

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Erickson’s Stages and Considerations
Stage 1: Trust vs. Mistrust, Infancy (birth-1y/o)
■ Corresponds with Freud’s oral stage of development.

■ Virtue/Strength vs Failure: HOPE vs poor relationships, suspicious withdrawn.
■ Possible etiology with schizoid and depressive states
Stage 2: Autonomy vs. Shame/Doubt, Early Childhood (1-3y/o)
■ Corresponds with Freud’s anal stage of development.

■ Doubt is the fear of being attacked or overpowered
■ Shame leads to repressed rage and defiance
■ Virtue/Strength vs Failure: WILL POWER, SELF-CONTROL vs lack of
independence.
Stage 3: Initiative vs. Guilt, Late Childhood (3-6y/o)
■ Corresponds with Freud’s phallic stage of development.

■ Guilt is the sense of badness
■ Virtue/Strength vs Failure: A SENSE OF PURPOSE vs lack of goals and self-
initiation.
■ Possible etiology with conversion and psychosomatic disorders.
Stage 4: Industry vs. inferiority, School-age (6-12y/o)
• Corresponds with Freud’s latency stage of development.

• “Hero Worship” and same-sex admiration is common, needs good role models
outside of the family.
• Virtue/Strength vs Failure: COMPETENCE, ACHIEVEMENTS vs difficulty
learning or mastering skills.
Stage 5: Identity vs. Role Confusion, Adolescence (12-20y/o)
■ Corresponds with Freud’s genital stage of development.

■ The most important stage according to Erikson r/t the sense of belonging.
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■ Sexual identity/role is formed, personal philosophy of life, morals, and values is

developed.
■ Virtue/Strength vs Failure: SELF-BELIEF & FIDELITY vs. identity confusion.
Stage 6: Intimacy vs. Isolation, Early Adulthood (20-35y/o)
■ Virtue/Strength vs Failure: LOVE, COMMITMENTS vs emotional isolation, self-

absorb, distancing oneself.
Stage 7: Generativity vs. Self-Absorption/Stagnation, Middle Adulthood (35-

65y/o)
■ Coping with life changes or endures a midlife crisis; creating the need for new
meaning and purpose.
■ Virtue/Strength vs Failure: CARE FOR OTHERS vs self-absorption (stagnation),
inability to change/care for others.
Stage 8: Integrity vs. Despair, Late Adulthood (>65y/o)
■ Consists of a life review that’s either meaningful versus disappointing with

perceived failures (despair).
■ Virtue/Strength vs Failure: WISDOM, FULFILLMENT vs. bitter, dissatisfied with
life.
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6. Kohlberg's Moral Development
Lawrence Kohlberg (1927-1987)
There were three levels of moral reasoning that encompassed the six stages. Like
Piaget, subjects were unlikely to regress in their moral development, but instead,
moved forward through the stages: pre-conventional, conventional, and finally post-
conventional. Each stage offers a new perspective, but not everyone functions at the
highest level all the time. People gain a more thorough understanding as they build
on their experiences, which makes it impossible to jump stages of moral
development.
Stage 1 (Pre-Conventional)
Obedience and punishment orientation (How can I avoid punishment?)
Self-interest orientation (What’s in it for me? aiming at a reward)
Stage 2 (Conventional)
Interpersonal accord and conformity (Social norms, good boy – good girl attitude)
Authority and social-order maintaining orientation (Law and order morality)
Stage 3 (Post-Conventional)
Social contract orientation (Justice and the spirit of the law)
Universal ethical principles (Principled conscience)
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Lawrence Kohlberg
BIOGRAPHY
Lawrence Kohlberg (October 25, 1927 – January 19, 1987) was born in Bronxville,
New York. He served as a professor at the University of Chicago as well as Harvard
University. He is famous for his work in moral development and education. Being a
close follower of Jean Piaget's theory of cognitive development, Kohlberg's work reflects
and extends the work of his predecessor. A brilliant scholar, Kohlberg was also
passionate about putting theory into practice. He founded several "just community"
schools in an attempt to stimulate more mature moral thinking in young people, with the
hope that they would become people who would create a more just and peaceful
society.
EARLY LIFE
Lawrence Kohlberg was born on October 25, 1927, in Bronxville, NY. His parents did
not have a good relationship and divorced when Kohlberg was in his early teens. The
young man put a lot of work into his studies and enrolled in the Phillips Academy in
Andover, Massachusetts, for his high school education.
At the end of WWII, Kohlberg joined the Merchant Marines. As part of his duties, he
helped Jewish refugees escape from Romania and into Palestine. This way, the
refugees could avoid persecution. These activities were not actually approved and
Kohlberg ended up spending time in an internment camp in Cyprus when British forces
captured him. Kohlberg eventually escaped from the internment camp and found his
way back to the United States.
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EDUCATION
Upon returning to the United States, Kohlberg once again continued his studies and
enrolled in the University of Chicago. At the time, the passing of placement tests could
allow a student to gain credit for courses. Kohlberg did so well on the tests that he was
awarded his bachelor’s degree in only one year, graduating in 1948. Soon after
receiving his degree, Kohlberg enrolled in a doctoral program at the university in the
area of psychology. In 1958, he received his Ph.D.
Kohlberg was very much influenced by the Swiss developmental psychologist Jean
Piaget. Piaget worked extensively in areas related to the moral development of children.
Lawrence Kohlberg would try to build on the work that Piaget had previously performed.
CAREER
Kohlberg maintained a very distinguished academic career. From 1958 to 1961, he
served as an assistant professor of psychology at Yale University. He went on and
worked a year at the Center for Advanced Study in the Behavioral Sciences in California
and then, from 1962 to 1967, he held the position of an assistant and then associate
professor at the University of Chicago. In 1968, he was named Professor of Education
and Social Psychology at Harvard University.
PRINCIPAL PUBLICATIONS
■ Essays on Moral Development. Vol. 1, The Philosophy of Moral Development.

San Francisco: Harper & Row, 1981.
■ Essays on Moral Development. Vol. 2, The Psychology of Moral Development.
San Francisco: Harper & Row, 1984.
■ With Anne Colby. The Measurement of Moral Judgment. Cambridge, UK:
Cambridge University Press, 1987.
■ With F. C. Power and Ann Higgins. Lawrence Kohlberg's Approach to Moral
Education. New York: Columbia University Press, 1989
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Overview of Lawrence Kohlberg’s of Moral Development

Considered the father of social psychology, Kurt Lewin
developed the nursing model known as Change Theory. He
6 Stages of Moral Development
theorized a three-stage model of change that is known as
the “unfreezing-change-refreeze
Kohlberg’s model”
Theory of Moral Development defined that
three requires
levels of moralprior
development;
pre-conventional, conventional, and post-conventional. Each level has two distinct
learning to be rejected and replaced. It states behavior as
stages:
“a dynamic balance of forces working in opposing
directions.”
Preconventional Morality:
■ Stage 1: Obedience and punishment. The child is motivated to avoid punishment

The and
three concepts identified in Lewin’s Change Theory are
has little or no independent moral reasoning.
driving
■ Stageforces, restraining
2: Individualism forces, and
and exchange. equilibrium.
Individuals are focused on fulfilling their
own self-interests while acknowledging that different people have different views.
Driving forces are forces that push in a direction that

Conventional
causes change Morality:
to occur. They facilitate change because
they push 3:
■ Stage theMaintaining
person ininterpersonal
the desired direction.AtThey
relationships. this cause
stage, aindividuals
shiftemphasize
in the equilibrium
the importancetowards
of beingchange. Restraining
kind to other forcesin “good”
people, engaging
are those forces
behavior, that counter
and showing concern fordriving forces.
others. This stageThey hinder
includes a strong emphasis
on gaining approval.
change because they push the person in the opposite
■ Stage 4: Law and order. The individual is determined to obey the rules, focusing
direction. Theythat
on the value cause a shift
the law adds toinhuman
the equilibrium
life. A person atwhich
this stage might argue
opposes change.
that breaking the Equilibrium is a state
law is wrong because of being
the law where
is designed to protect people.
driving
Stageforces equalfocus
4 individuals restraining forces
on maintaining the and
socialno change
order and upholding cultural
occurs.
norms.Equilibrium can be raised or lowered by changes
that occur between
Post-Conventional the driving and restraining forces.
Morality:
■ Stage 5: Social contract. People at this stage of development focus on doing

what is best for society as a whole and respecting individual rights. Civil
Thisdisobedience
model of nursing
would be consists
endorsed by ofpeople
threeindistinct stages
both stages of post-conventional
which are vital to the theory. They are unfreezing, moving
morality.
to a new level
■ Stage or changing
6: Universal principles. (or movement),
At this and are
stage, individuals refreezing.
focused on upholding
principles of universal justice, fairness, and ethics. They believe in the
democratic process, but also endorse disobeying unjust laws.
Unfreezing is the process which involves finding a method

Page 280 of 313
of making it possible for people to let go of an old pattern
that was, in some way, counterproductive. It is necessary
to overcome the strains of individual resistance and group
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A Quick Summary
■ The first level of moral thinking is generally found at the elementary school level.
In the first stage of this level, people behave according to socially acceptable
norms because they are told to do so by some authority figure (e.g., a parent or
teacher). This obedience is compelled by the threat or application of punishment.
The second stage of this level is characterized by a view that the right behavior
means acting in one’s own best interests.
■ The second level of moral thinking is generally found in society, hence the name
“conventional.” The first stage of this level (stage 3) is characterized by an
attitude that seeks to do what will gain the approval of others. The second stage
is one oriented toward abiding by the law and responding to the obligations of
duty.
■ The third level of moral thinking is one that Kohlberg felt is not reached by the
majority of adults. Its first stage (stage 5) is an understanding of social mutuality
and a genuine interest in the welfare of others. The last stage (stage 6) is based
on respect for universal principles and the demands of individual conscience.
While Kohlberg always believed in the existence of Stage 6 and had some
nominees for it, he could never get enough subjects to define it, much less
observe their longitudinal movement to it.
■ Kohlberg believed that individuals could only progress through these stages one
stage at a time. That is, they could not “jump” stages. They could not, for
example, move from an orientation of selfishness to the law-and-order stage
without passing through the good boy/girl stage. They could only come to a
comprehension of a moral rationale one stage above their own. Thus, according
to Kohlberg, it was important to present them with moral dilemmas for discussion
which would help them to see the reasonableness of a “higher stage” morality
and encourage their development in that direction.
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Level of Moral Stage of Reasoning Approximate

development Age
Preconventional Stage 1: (Punishment and Obedience <11

“do’s and don’ts” Orientation).
▪ Right is obedience to power and
avoidance of punishment.
▪ (“I must follow the rules otherwise I
will be punished”).
Stage 2: Instrumental Relativist Orientation.
▪ Right is taking responsibility and
leaving others to be responsible for
themselves.
▪ (”I must follow the rules for the reward
and favor it gives”).
Conventional Stage 3: Good-Boy-Nice Girl Orientation. adolescence and
▪ Right is being considerate: “uphold adulthood
the values of other adolescents and
adults” rules of society”.
▪ (”I must follow the rules so I will be
accepted”)
Stage 4: Society-Maintaining Orientation.
▪ Right is being good, with the values
and norms of family and society at
large.
▪ (” I must follow rules so there is order
in the society”).
Postconventional Stage 5: Social Contract Reorientation. after 20

▪ Right is finding inner “universal rights”
balance between self-rights and
societal rules – a social contract.
▪ (”I must follow rules as there are
reasonable laws for it”).
Stage 6: Universal Ethical Principle
orientation.
▪ Right is based on a higher order of
applying principles to all human-kind;
being non-judgmental and respecting
all human life.
▪ (”I must follow rules because my
conscience tells me”).
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LOCAL THEORIES AND MODELS OF NURSING INTERVENTION

(PHILIPPINES SETTING)
1. Agravante’s CASAGRA Transformative Leadership Model
Sr. Carolina S. Agravante
BIOGRAPHY
The author of the theory is Sr. Carolina Agravante, SPC, RN, PhD and the theory was
published in 2002. Sr. Carol Agravante finished her baccalaureate degree in Nursing at
St. Paul College of Manila in 1964. She then took up her Masteral Degree in Nursing
Education at the Catholic University of America in 1970, and finally earned her Doctoral
Degree in Philosophy in University of Manila on April 2002, the same time her Theory
was published. She was a class salutatorian when she graduated from high school at
St. Paul College of Manila. She earned her Bachelor’s degree as a Magna Cum Laude
and a first place in the Board exam for Nurses on the year 1964. She was a university
scholar while studying for her Master’s degree at CUA for 1967 to 1969. Currently, Sr.
Carol is the president of the St. Paul University of Iloilo since her installation last 2004.
Aside from that she is the current president of the Association of the Deans of the
Philippine Colleges of Nursing. She had represented the said association during the
International Nursing Congress in Brunei in 1996 and became a delegate at the
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International Council of Nursing in Vancouver, Canada in 1997. She is also an

accreditor of the Philippine Accreditation Association of Schools, Colleges and
Universities up to now to which she also obtained a Service Award from the said
accrediting body. She had been a dean of several nursing colleges in the Philippines
before her current assignment namely: Bethlehem University, St. Paul College of
Manila, De La Salle University College of Nursing and Midwifery, a former Principal of
St. Paul School of Nursing, and eventually Director of St. Paul College of Iloilo. She was
also a founding member of the Integrated Registered Nurses of the Philippines and a
Secretary of the Friendly Care Foundation from 2000 to present.
Overview of Agravante’s CASAGRA Transformative Leadership Model
The CASAGRA Transformative Leadership Model: Servant – Leader Formula &

the Nursing Faculty’s Transformative Leadership Behavior.
The Casagra Transformational Leadership Model is suitable for nursing educators,
particularly those who are administrators in the educational setting (Magallanes, 2009).
It has a psycho-spiritual model which can be utilized as a formula for faculty and
administrators to become better teachers and servant leaders.
The model is a powerful tool in achieving the organization’s vision and mission as it is
designed and aimed in developing a network of innovative, competent and empowered
educators towards excellence and nation building. Since it is spiritual and religious, a
paradigm of peace is embedded to engage and prepare nursing administrators and
educators to modern world-challenges today. The theory is based on Biblical teachings
of Jesus Christ, which would impact on the ethical practice that must be followed in the
nursing field. In contrast, the theory might not be accepted in Muslim countries as it is
Bible-Based and does not conform to diversities in culture, which might face hesitation
among other theorists, and scholars in the field of Nursing particularly among those that
are based in the GCC countries. The theory is designed to transform a servant leader;
an example would be, Agravante possesses Jesus.
The theory “CASAGRA Transformative Leadership” is a psycho spiritual model. It is

coined after the name of the investigator: Sr. Carolina S. Agravante
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The model is a Three-Fold Transformation Leadership Concept rolled into one,

comprising of the following elements:
1. Servant-Leader Spirituality;
2. Self-Mastery expressed in a vibrant care complex;
3. Special Expertise level in the nursing field one is engaged in.
These elements rolled into one make-up the personality of the modern professional
nurse who will challenge the demands of these crucial times in society today.
The CASAGRA Transformative Leadership Theory is classified as a Practice Theory

basing on the characteristics of a Practice Theory stated by McEwen (2007), which are
the following:
A. Complexity / Abstractness, Scope - Focuses on a narrow view of reality,

simple and straightforward;
B. Generalizability /Specificity - Linked to a special population or an identified field
of practice;
C. Characteristic of Scope – Single, concrete concept that is operationalized;
D. Characteristic of Proposition – Propositions defined;
E. Testability – Goals or outcomes defined and testable;
F. Source of Development – Derived from practice or deduced from middle range
theory or grand theory.
These functions, once utilized accordingly will be an effective leadership tool in the
nursing academe and administration fields. And also would be applicable to those who
are interested to be a nursing educators in the future. This theory can serve as a guide
for nursing administrators and teachers to learn something new, and it would be
beneficial to those who would like to learn more about transformational leadership.
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2. Divinagracia’s COMPOSURE Model
Carmelita Divinagracia
BIOGRAPHY
■ Filipino Nurse Theorist

■ Association of the Deans Philippine Colleges of Nursing (ADPCN) Former
President
■ Dean of University of the East Ramon Magsaysay Memorial Medical Center,
Inc. (UERMMMC) College of Nursing
■ Member of CHED ‘s Technical committee on Nursing Education
■ Has been lauded for developing the art and competency of teaching nursing.
■ Has been a clinic nurse, staff nurse, head nurse, instructor, assistant dean
and dean
■ Expert in Research and Education
■ Has lectured and written about her work as a nurse and has use her hands-
on experience to develop better ways to teach nursing.
■ Her love for nursing and her dedication to carve out learning tools for nursing
students has been a commendable and rare field of discipline.
Education
■ Bachelor’s degree in Nursing at the University of the East Ramon Magsaysay
Memorial Medical Center in 1962
■ Master’s degree in Nursing at the University of the Philippines in 1975
■ Doctorate’s degree in Nursing at the University of the Philippines in 2001
Award
■ Recipient of the Anastacia Giron Tupas Award given by the Philippine Nursing
Association (PNA) in 2008.
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Overview of Divinagracia’s COMPOSURE Model
ADVANCE NURSE PRACTICIONERS’ COMPOSURE BEHAVIOR AND

PATIENT’S WELLNESS OUTCOME
Objective of the study

Determine the effects of composure behavior of the advance nurse practitioner on the
wellness outcome of the selected cardiac patients
Significance of the Study
Nursing as a healthcare profession would prove its worth of being at par in quality
performance with other healthcare professionals.
Study Population
Adult Cardiac Patients admitted and confined at the Philippines Heart center, Coronary
Care Unit.
Definition of Terms
■ Advance Nurse Practioners
■ BSN graduate
■ Licensed and has a clinical experience of at least 2 years in the clinical area
■ Has undergone special training in critical area
■ Set of behaviors or nursing measures that the nurse demonstrates to selected
cardiac patients
■ Composure Behaviors
■ A condition of being in a state of well-being, a coordinated and integrated living
pattern that involves the dimension of wellness.
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Theory of COMPOSURE Behaviors

Dr. Carmelita C. Divinagracia conducted a study to determine the effects of
COMPOSURE behaviors of the advanced practitioner on the recovery of selected
patients at the Philippine Heart Center. Behaviors include: competence, presence and
prayer, open-mindedness, stimulation, understanding, respect and relaxation, and
empathy.
COMPOSURE Behaviors
COMpetence
■ An in-depth knowledge and clinical expertise demonstrated in caring for patients.

■ This is also stands for consistency and congruency of words and deeds of the
nurse.
Presence and Prayer
■ A form of nursing measure which means being with another person during times
of need.
■ This includes therapeutic communication, active listening, and touch.
■ It is also a form of nursing measure which is demonstrated through reciting a
prayer with the patient and concretized through the nurse’s personal relationship
and faith in God.
Open-mindedness
■ A form of nursing measure which means being receptive to new ideas or to

reason.
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■ It conveys a manner of considering patient’s preferences and opinions related to

his current health condition and practices and demonstrate the flexibility of the
nurse to accommodate patient’s views.
Stimulation
■ a form of nursing measure demonstrated by means of providing encouragement

that conveys hope and strength, guidance in the form of giving explanation and
supervision when doing certain procedures to patient, use of complimentary
words or praise and smile whenever appropriate.
■ Appreciation of what patient can do is reinforced through positive encouraging
remarks and this is done with kind and approving behavioral approach.
Understanding
■ According to her, it conveys interest and acceptance not only of patient’s

condition but also his entire being.
■ This is manifested through concerned and affable facial approach; this is a way
of making the patient feel important and unique.
Respect
■ Acknowledging the 31 patient’s presence.

■ Use of preferred naming in addressing the patient, po and opo, is a sign of
positive regard.
■ It is also shown through respectful nods and recognition of the patient as
someone important.
Relaxation
■ Entails a form of exercise that involves alternate tension and relaxation of

selected group of muscles.
Empathy
■ Senses accurately other person’s inner experience.

■ The empathic nurse perceives the current positive thought and feelings and
communicates by putting himself in the patient’s place.
Through the COMPOSURE behaviors of the nurse, holism is guaranteed to the patient.
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Divinagracia (2001) stated that nursing is a profession that surpasses time and aspects
of the individual as one of its clients. From the time the nurse admits a patient to the
time of his discharge, the nurse’s presence becomes a meaningful occasion for the two
parties to develop mutual trust, acceptance, and eventually satisfying relationships.
This framework represents the orthopedic patients, COMPOSURE behaviors of novice
nurses, and the patient wellness outcome such as physiologic and biobehavioral. The
innermost part of the oval is the orthopedic patients. Being the recipient of care, they
are being influenced by many factors and one of those are the behaviors of nurses in
implementing quality nursing care. As the COMPOSURE behaviors of novice nurses’
envelopes, the orthopedic patients as shown above, the researcher believe that there
will be an essential improvement in the patient wellness outcome, may it be on
physiologic and/or biobehavioral wellness outcome.
Patient Wellness Outcome
■ This refers to the perceived wellness of selected orthopedic patients after

receiving nursing care in terms of physiologic and biobehavioral.
■ Many illnesses are curable and may have only a temporary effect on health.
Others, such as diabetes, are not curable but can be managed with proper
eating, physical activity, and sound medical supervision. It should be noted that
those possessing manageable conditions may be more at risk for other health
problems, so proper management is essential. For example, unmanaged
diabetes is associated with high risk for heart disease and other health problems.
Two patient wellness outcomes which have been categorized as:
■ Biobehavioral
■ Physiologic
These patient wellness outcomes reflect their needs as their illness turn to recovery and
rehabilitation. These needs must be met through high quality nursing care, none other
than through COMPOSURE behaviors. COMPOSURE behaviors have been inspired to
the principle of holistic care wherein a patient wellness outcome can be achieved
through series of quality attributes of nurses, which caters to every aspect of patient
wellness, may it be biobehavioral or physiologic wellness outcome.
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Physiologic Wellness Outcome
■ This refers to the perceived wellness of selected orthopaedic patients after

receiving nursing care in terms of vital signs, bone pain sensation, and complete
blood count.
Biobehavioral Wellness Outcome
■ This refers to the perceived wellness of selected orthopaedic patients after

receiving nursing care in terms physical, intellectual, emotional, and spiritual.
Divinagracia (2001) as cited by Leocadio (2009), conceptualized forty statements that

represented the dimensions of wellness which include the physical, emotional,
intellectual, and spiritual domain. Physical domain involves muscle strength, mobility,
posture, gait exercise, and activity tolerance and cardio-respiratory endurance.
Emotional domain includes awareness, orientation, understanding of own and other
personal feelings and ability to control and cope with emotions. Intellectual domain
refers knowledge and perception of a healthy self and ability to recognize the presence
of risk factors and preventive measures and spiritual domain is defined as development
of inner self or one’s soul through a relationship with God and others.
The most basic form of holistic communication is "Active listening". Active listening is a
specific way of hearing what a person says and feels, and reflecting that information
back to the speaker. Its goal is to listen to the whole person and provide her with
empathic understanding. It is the skill of paying gentle, compassionate attention to what
has been said or implied. When you listen in this way to patients, you just try to reflect
the other person's feelings and deeper meanings, which helps them feel heard and
understood. You don't analyze, interpret, judge, or give advice. When patients are
listened to in this way, they are less anxious, complain less about their caregivers, and
are more likely to comply with their treatment plan.
A cardiac patient might be angry and complaining. As the nurse, you may try to avoid
his room, and, when you have to be there, move in and out as quickly as possible.
Avoidance is one solution, but there might be a different approach.
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Active listening helps patients clarify and articulate their inner process. For a patient,
being carefully listened to can be a moving and profound experience, one that
transforms the relationship between patient and nurse. Active listening is particularly
relevant in a hospital setting, where patients often report 132 that they feel isolated and
invisible. It can make a difference in rebuilding a patient's sense of self. It can also be
rewarding for the nurse.
A positive total outlook on life is essential to wellness and each of the wellness
dimensions. A “well” person is satisfied in his/her work, is spiritually fulfilled, enjoys
leisure time, is physically fit, is socially involved, and has a positive emotional-mental
outlook. This person is happy and fulfilled. Many experts believe that a positive total
outlook is a key to wellness
The way one perceives each of the dimensions of wellness affects total outlook.
Researchers use the term self-perceptions to describe these feelings. Many
researchers believe that self-perceptions about wellness are more important than actual
ability. For example, a person who has an important job may find les meaning and job
satisfaction than another person with a much less important job. Apparently, one of the
important factors for a person who has achieved high level wellness and a positive life’s
outlook is the ability to reward himself/herself. Some people, however, seem unable to
give themselves credit for their life’s experiences. The development of a system that
allows a person to positively perceive the self is important. Of course, the adoption of
positive perceive lifestyles that encourage improved self-perception is also important.
Emotional wellness is a person’s ability to cope with daily circumstances and to deal
with personal feelings in a positive, optimistic, and constructive manner. A person with
emotional wellness is generally characterized as happy, as opposed to depressed.
 A person with intellectual health is free from illnesses that invade the brain and
other systems that allow learning. A person with intellectual health also
possesses intellectual wellness.
Intellectual wellness is a person’s ability to learn and to use information to enhance

the quality of daily living and optimal functioning. A person with intellectual wellness is
generally characterized as informed, as opposed to ignorant.
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 A person with intellectual health is free from illnesses that invade the brain and
other systems that allow learning. A person with intellectual health also
possesses intellectual wellness.
Physical wellness is a person’s ability to function effectively in meeting the demands of

the day’s work and to use free time effectively. Physical wellness includes good physical
fitness and the possession of useful motor skills. A person with physical wellness is
generally characterized as fit versus unfit.
 A person with physical health is free from illnesses that affect the physiological
systems of the body such as the heart, the nervous system, and the like. A
person with physical health possesses an adequate level of physical fitness and
physical wellness
Spiritual wellness is a person’s ability to establish a values system and act on the
system of beliefs, as well as to establish and carry out meaningful and constructive
lifetime goals. It is often based on a belief in a force greater than the individual that
helps one contribute to an improved quality of life for all people. A 138 person with
spiritual wellness is generally characterized as fulfilled as opposed to unfulfilled
 Spiritual health is the one component of health that is totally comprised of the
wellness dimension; for this reason, spiritual health is considered to be
synonymous with spiritual wellness.
Optimal health includes many areas, thus the term holistic (total) is appropriate. In fact,
the word health originates from a root word meaning “wholeness”
The holistic nurse is an embodiment of the care she renders. The nurse creates the
calm environment in any setting that facilitates treatment, healing and recovery from any
pain or discomfort.
In terms of the COMPOSURE behaviors of advanced beginner nurses.
A. Competence
They always manifest good interpersonal and communication skills in dealing
with patients and able to extract significant information to aid in planning and
delivery of effective nursing care. However, they rarely develop health education
plan based on the assessed and anticipated needs of the patients.
B. Prayer
The advanced beginner nurses always allows some moment of silence. But they
rarely pray with the patients.
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C. Presence
Indeed, the advanced beginner nurses often establish the purpose of the
interaction and often display interest to the 279 patients. Moreover, they
sometimes spend time with patient even in silence
D. Open-mindedness
The advanced beginner nurses often create an environment of trust and rapport.
On the other hand, they sometimes listen attentively to patient.
E. Stimulation
Likewise, the advanced beginner nurses always tell patient what he can do, what
he is supposed to do, and how to do it. More so, they often encourage patient to
evaluate his action.
F. Understanding
The advanced beginner nurses to often encourage the patient to feel comfortable
in the nurse-patient relationship. More so, they often clarify the message through
the use of question and feedback.
G. Respect
The advanced beginner nurses always call the patient by his/her preferred name
and utilize “po” and “opo” when being asked and they also provide options before
making decisions.
H. Relaxation
They always evaluate and document the patient’s response to the intervention,
observe his/her breathing, and ask if he/she is feeling relaxed yet they
sometimes take note of facial expression and unnecessary body movements.
I. Empathy
Shows that they always encourage expression of feelings; focus on verbal and
nonverbal behavior and they often provide continuous feedback
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3. Kuan’s Retirement and Role Discontinuity Model
Sister Letty G. Kuan

BIOGRAPHY
 Sister Letty G. Kuan is a nurse with Master’s Degree in Nursing and

Guidance Counseling.
 She also holds a Doctoral Degree in Education. For her vast
contributions to the University of the Philippines College of Nursing
faculty and academic achievements, she is now Professor Emeritus, a
title awarded only to a few who met the strict criteria.
 She had two Master’s Degrees, MA in Nursing and MS Education, Major in
Guidance Counseling, culminating in Doctor of Education (Guidance and
Counseling).
 She has clinical fellowship and specialization in Neuropsychology in
University of Paris, France (Salpetriere Hospital). Neurogerontology in
Waterson, New York (Good Samaritan Hospital) and Syracuse University,
New York. She also had Bioethics formal training at Institute of Religion,
Ethics and Law at Baylor College of Medicine in Houston, Texas.
 She authored several books giving her insight in the areas of Gerontology,
Care of Older Persons and Bioethics.
 She is a recipient of the Metrobank Foundation Outstanding Teachers Award
in 1995 and an Award for Continuing Integrity and Excellence in Service
(ACIES) in 2004. Her religious community is the Notre Dame de Vie founded
in France in 1932.
 As a former member of the Board of Nursing, her legacy to the Nursing
Community is without a doubt, indisputable.
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Overview of Divinagracia’s COMPOSURE Model
“Retirement and Role Discontinuities”
Basic Assumptions and Concepts:
Physiological Age is the endurance of cells and tissues to withstand the wear-and-tear
phenomenon of the human body. Some individuals are gifted with strong genetic affinity
to stay young for a long time.
Role refers to the set of shared expectations focused upon a particular position. These
may include beliefs about what goals or values the position incumbent is to pursue and
the norms that will govern his behavior. It is also the set of shared expectations from the
retiree’s socialization experiences and the values internalized while preparing for the
position as well as the adaptations to the expectations socially defined for the position
itself. For every social role, there is complementary set of roles in the social structure
among which interaction constantly occurs.
Change of Life is the period between near retirement and post retirement years. In
medico-physiologic terms, this equates with the climacteric period of adjustment and
readjustment to another tempo of life.
Retiree is an individual who has left the position occupied for the past years of
productive life because he/she has reached the prescribed retirement age of has
completed the required years of service.
Role Discontinuity is the interruption in the line of status enjoyed or role performed.
The interruption may be brought about by an accident, emergency, and change of
position or retirement.
Coping Approaches refer to the interventions or measures applied to solve a

problematic situation or state in order to restore or maintain equilibrium and normal
functioning.
Determinants of positive perceptions in retirement and positive reactions toward role
discontinuities:
1. Health Status – refer to physiological and mental state of the respondents,
classified as either sickly or healthy.
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2. Income – (economic level) refers to the financial affluence of the respondent

which can be classified as poor, moderate or rich.
3. Work Status
4. Family Constellation – means the type of family composition described either
close knit or extended family where three more generations of family members
live under one roof; or distanced family, whose member live in separate dwelling
units; or nuclear type of family where only husband, wife and children live
together.
5. Self-Preparation
The Theory of Sister Letty G. Kuan is about “Graceful Aging”. Her interest in old people
initiated her to formulate a theory for the purpose of knowing the reasons and variables
on how to make people happy at retirement by conceptualizing a framework:
Acquisition, Struggles and Legacy.
According to her, “Graceful Aging” is dependent on positive childhood acquisitions. It
pertains to the quality of what you have acquired from the beginning. An acquisition that
starts from the womb of the pregnant mother, the love and support of the father to his
family reflects good acquisitions to the person. This acquisition comprises how we
acquired the manner of speaking, talking and attitudes. The kind of acquisition from
education also plays a major role. She emphasized the importance of a good school for
better education which develops perseverance and hard work in an individual and
equips him or her when trials, crisis or life struggles come in. She said, “If you have a
very happy and nice childhood, you will have a very fruitful aging, happy retirement and
ultimately Legacy.” She defined legacy as an act of giving, sharing, emblem of honesty
and feeling of fulfillment and motivation.
Application to Nursing
The theory of Sister Letty G. Kuan stated that without positive acquisitions during
childhood, the person (patient) will be “in a pathological state” to delinquency. Now, this
is the challenge that nurses will face. The role of the nurse is to put back what they have
missed during childhood and to fill this gap. Nurses need to let them acquire good
things through setting an example and to make them feel loved and important. The role
of the nurse is to become a therapeutic self and spiritual self by showing empathy and
compassion.
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4. Abaquin’s PREPARE ME Holistic Nursing Interventions
Carmencita M. Abaquin
BIOGRAPHY
 Carmencita M. Abaquin is a nurse with Master’s Degree in Nursing obtained

from the University of the Philippines College of Nursing.
 An expert in Medical Surgical Nursing with subspecialty in Oncologic Nursing,
which made her known both here and abroad.
 She had served the University of the Philippines College of Nursing, as
faculty and held the position as Secretary of the College of Nursing.
 Her latest appointment as Chairman of the Board of Nursing speaks of her
competence and integrity in the field she has chosen.
Overview of Abaquin’s PREPARE ME Holistic Nursing Interventions

“Retirement and Role Discontinuities”
“PREPARE ME” Interventions and the Quality-of-Life Advance

Progressive Cancer Patients.
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Basic Assumptions and Concepts:

PREPARE ME (Holistic Nursing Interventions) are the nursing interventions provided
to address the multi-dimensional problems of cancer patients that can be given in any
setting where patients choose to be confined. This program emphasizes a holistic
approach to nursing care. PREPARE ME has the following components:
▪ Presence – being with another person during the times of need. This includes
therapeutic communication, active listening, and touch.
▪ Reminisce Therapy – recall of past experiences, feelings and thoughts to
facilitate adaptation to present circumstances.
▪ Prayer
▪ Relaxation-Breathing – techniques to encourage and elicit relaxation for the
purpose of decreasing undesirable signs and symptoms such as pain, muscle
tension, and anxiety.
▪ Meditation – encourages an elicit form of relaxation for the purpose of altering
patient’s level of awareness by focusing on an image or thought to facilitate inner
sight which helps establish connection and relationship with God. It may be done
through the use of music and other relaxation techniques.
▪ Values Clarification – assisting another individual to clarify his own values
about health and illness in order to facilitate effective decision-making skills.
Through this, the patient develops an open mind that will facilitate acceptance of
disease state or may help deepen or enhance values. The process of values
clarification helps one become internally consistent by achieving closer between
what we do and what we feel.
The Theory: PREPARE ME

“To Nursing… may be able to provide the care that our clients need in maintaining their
quality of life and being instrumental in “birthing” them to external life.”
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Quality of Life is a multifaceted construct that encompasses the individual's capacity

and abilities with an aim of enriching life when it cannot longer be prolonged. This
includes proper care of the body, mind, and spirit to maintain integrity of the whole
person despite limitations brought by the present situation. This can be seen with the
following dimensions brought by the present situation. This can be seen with the
following dimensions of man - physical, psychological, social, religious, level of
independence, environment, and spiritual.
Findings and Recommendations
1. Terminally-ill patients require holistic approach of nursing that encompasses the

different aspects of man namely physical, psychological, social, religious, level of
independence, environment, and spiritual. in this premise, patients with incurable
illness, especially cancer patients, require a whole faceted care that will improve
the quality of their life.
2. PREPARE ME Interventions are said to be effective in improving the quality of

life of cancer patients. this can be further applied not only with terminally-ill
patients but also promisingly introduced to those patients with acute and chronic
diseases and those with prolonged hospital stays.
3. The utilization of the intervention as a basic part of care given to cancer patients
is recommended, as well as the incorporation of the intervention in the basic
nursing curriculum in the care of these patients. the said components of
PREPARE ME must be introduced and focused during the training of nurses both
in the academe and practice to answer the needs of this special kind of clients.
4. Development of training programs for care providers, as well as health care

professionals where intervention is a part of treatment modalities, is also
recommended.
5. For patients, an honest view and feedback regarding their illness and
management, and obtaining their perceptions can lead to improvement of
services and communication between patients with advanced progressive
cancer, their families and health team.
6. Supportive environment where patients with advanced progressive cancer and

the terminally-ill patients can attain dignity of dying with peace while their families
are given the necessary support they need to cope up with.
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5. Synchronicity in the Human-Space-Time: A Theory of Nursing

Engagement in a Global Community
The four life principles of the Synchronicity in the Human-Space-Time Theory of Nursing
Engagement (SHSTTNE) are interconnectivity, equitability, emancipation and human
transcendence. They guide the nurses in translating the theoretical assumptions and
caring elements of the SHSTTNE into practice.
Interconnectivity is a principle of human interconnectedness of energy. Energy is

continuously moving from “subatomic particles to the biosphere, including the planet
Earth, all forming a whole” (Patterson, 1998, p. 289). Interconnectivity leads to the
understanding of holism that the bio-psycho-social-spiritual dimensions of persons are
interrelated (Lai & Hsieh, 2003) and that the whole being is more than the sum of its
organs or systems. The nurse does not focus only on biological curing but considers the
healing aspect of the whole person’s being. The nurse becomes more cognizant of the
whole integrated person interacting with and influenced by both internal and external
environments (Lai & Hsieh, 2003). Applying the principle of interconnectivity through
Interpersonal Relating (IR), Technological Knowing (TK), Rhythmical Connecting (RC) &
Transformational Engaging (TE), the nurse embraces meaningful connectedness with
their patients as whole persons, with the coexistence of human caring and technologies,
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with the synchronicity among modernist and postmodernist nursing care approaches,
and with transformations across nursing engagements.
Equitability is a principle of justice and fairness in human caring across healthcare

systems. It revolves around the value-based concept of equity implying fairness in
access to health care related to the situated context despite differences in methods,
utilization, and outcomes (Cloninger et al., 2014). It can also mean fairness in access to
services within an organization. An understanding of the interconnections among space,
time, movement and consciousness as health manifestations (Pharris, 2015) leads to
meaningful relationships within the HST and beyond. When there are meaningful
relationships of persons (i.e., among patients, family, and healthcare team), the nurse is
enabled to express equity in nursing care through prioritization, triage, and cost-
effective measures in the processes of nursing engagement. In applying equitability, the
nurse is cognizant of the difference between equality and equity.
Emancipation is a principle of liberating the self and others from the limits of
human-space-time realities. The human-space-time realities of health care could
include human factors or attributes such as fear, shame, lack of communication skills,
lack of knowledge, powerlessness and human resources. Space factors could mean
internal and external environmental limitations. Internal environmental limitations are
physiologic, psychologic, emotional and spiritual conditions while the external
environment limitations refer to the socio-economic-political challenges as well as the
organizational dynamics that influence the nurse and the nursed. The time limit is
indicated by the constraints it has on every person such as how long it takes for the
nurse to spend for every patient before his/her shift ends, or on the part of the patient
how long it takes for him/her to stay in the hospital bed. As described by Chin and
Kramer (2011), emancipatory knowing is applied in praxis and in the integration of
knowing, doing and being (Parker & Smith, 2015). In the application of the NEP, to
emancipate is to know what the nurse can know, doing what one can do, and be with
the patient in the present given the limitations of the HST. Both principles of equitability
and emancipation are essential in the application of the NEP when “unveiling the
dynamics that sustain inequity creates (the) freedom to see and act in a way that
improves the health for all” (Parker & Smith, 2015, p.30).
“When people transcend their own egos, dedicate their energy to something greater
than the individual self, and learn to build order against the trend of disorder” (Pharris,
2015, p. 285), then the principle of human transcendence is applied. Human
transcendence indicates personal growth of persons and professional growth among
nurses. Pharris (2015) described the characteristics of growth as “assertion of self, to
emancipation of self, to transcendence of self” (p. 292). Through human transcendence,
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nurses and the nursed can rise beyond their present difficulties. Just as self-
transcendence is revealed in the expansion of self-boundaries that enhances well-being
(Reed, 2015), human transcendence is also evident in the ability to go beyond the limits
of the HST through nursing engagement that fosters human health and well-being.
Resilience, for example, is meaningfully connected with well-being through human
transcendence.
The four life principles of interconnectivity, equitability, emancipation, and human
transcendence are threaded through all the processes in the NEP. As an iterative,
nonlinear process of nursing engagement, IR, TK, RC, and TE can co-exist and overlap.
Amidst technological advancement in health care, the five caring elements of the dance
of caring persons, caring moment, responsive sensing, expression of caring intentions
and technological competency (Lim-Saco, Kilat, & Locsin, in press) are emphasized in
the application of human caring through the NEP and across healthcare systems
worldwide.
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Theoretical Foundation of Nursing

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Theoretical Foundation of Nursing

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CITY UNIVERSITY OF PASAY

(PAMANTASAN NG LUNGSOD NG PASAY)

B. History and Philosophy of Science ......................................................................... 9

C. Structure of Nursing Knowledge ........................................................................... 14

Nursing Theorists and their Works

B. Nursing Conceptual Models ................................................................................. 63

5. Roy's Adaptation Model ................................................................................ 105

C. Nursing Theories ................................................................................................. 128

Theories Relevant to Nursing Practice ................................................................... 244

References ................................................................................................................. 305

THEORETICAL FOUNDATION OF NURSING

1. History of Nursing Theory

• A set of statements that tentatively describe, explain, or predict relationships

• A body of knowledge that describes or explains nursing and is used to

The components of a theory are as follows:

1. conservation, (2) adaptation, and (3) wholeness.

The assumptions in Levine's Conservation Model are that: individuals

change; nursing is human interaction; nurses promote wholeness through the

A phenomenon is an aspect of reality that can be consciously sensed or

3. Middle Range Theories.

2. Significance for the:

Discipline is specific to academia and refers to a branch of education, a department of

Significance of theory for nursing as a discipline

1. University baccalaureate programs proliferated, masters’ programs in nursing

2. Attention to the importance of nursing conceptualizations for the research process

3. Works began to be recognized for their theoretical nature, such as Henderson,

5. Fawcett’s conceptualization of metaparadigm of nursing and unifying conceptual-

6. MAJOR SIGNIFICANCE IS; THE DISCIPLINE IS DEPENDENT UPON THEORY

Significance of theory for nursing as a profession

Clearly, nursing is recognized as a profession today.

Analysis Questions to Determine Theoretical Adequacy

• Clarity: How clear is this theory?

B. History and Philosophy of Science

“Sometimes all that is possible is to embrace the mystery, the unknown, of a

The construction of nursing theories is the formalization of attempts to describe, explain,

Historical Views of the Nature of Science

• The term epistemology is concerned with the theory of knowledge in

Nursing and Philosophy

Philosophy studies concepts that structure thought processes, foundations, and

Nursing science has been characterized by two branching philosophies of knowledge as

1. Rationalism- The power of reason.

Rationalist epistemology (scope of knowledge) emphasizes the importance of a

2. Empiricism- the power of sensory experience

In summary, deductive inquiry uses the theory then-research approach, and

3. Early Twentieth Century Views of Science and Theory

Philosophers focused on the analysis of theory structure, whereas scientist

4. Emergent Views of Science and Theory in the Late Twentieth Century

In The Phenomenology of the Social World, Schutz (1967) argued that

3. Presupposed theories and observable data interact in the process of

Data-Driven, or Bottom-Up Theory

Cognitive expectation is used to select input and process of incoming information

Interdependence between Theory and Research

A theory is accepted when scientists agree that it provides a description of

Issues in Nursing Philosophy and Science Development

Meleis characterized the years of progress in nursing in four stages:

Four fundamental patterns of knowledge in Nursing (Carper, 1978)

Wholistic nursing views the biophysical, psychological, and sociological subsystems

Science as a Social Enterprise

C. Structure of Nursing Knowledge

1. Structure Level (Analysis of theory, clarity, simplicity, generality, accessibility,

 Complex practice situation may call for more complex theory.

❖ It is referred to the person as a patient.

❖ Health, a dynamic process, is the synthesis of

❖ Environment is the landscape and