evident or anticipated needs to improve a
Note: ALL the written information below are
derived from the LECTURE VIDEOS of Ma’am.
Dayrit.
Culture Care: Diversity & Universality Theory
Madeleine Leininger: Transcultural
Nursing Theory
Madeleine Leininger
- Born on July 13, 1925, in Sutton, Nebraska,
USA.
- Leininger’s theory and research have helped
nursing as well as nursing students to
understand cultural differences in human care,
health, and illnesses.
- Leininger studied different cultures (at least 14
cultures); she continued to consult for research
projects and institutions that are using her
cultural care so her cultural care theory is being
used worldwide.
- Dr. Madeleine Leininger holds the following
academic degrees and titles:
➔ PhD - Doctor of Philosophy (Cultural and
Social Anthropology)
➔ LHD - Doctor of Human Sciences
➔ DS - Doctor of Science
➔ RN - Registered Nurse
➔ FAAN - Fellow American Academy of
Nursing
➢ Published books (More than 27 Books; but Accg.
to Alligood, at least 30 books)
- Basic Psychiatric Concepts in Nursing - was
released in 1960 in 11 different languages.
- Nursing and Anthropology: Two Worlds to
Blend
- Transcultural Nursing: Concepts, Theories, and
Practice
- Caring: An Essential Human Need
- Care: The Essence of Nursing and Health
- Qualitative Research Methods in Nursing
- Ethical and Moral Dimensions of Care
- The Caring Imperative in Education
➢ The goal of the Theory:
- Is to provide culturally congruent and
responsible care that reasonably fits with the
client’s cultural needs, values, beliefs, and
lifeway realities.
- “Care is the heart of nursing; Care is power,
Care is essential to healing; Care is curing, and
Care is the central and dominant focus of
nursing and transcultural nursing decisions and
actions.” - Leininger, Madeleine
➢ Major Concepts and Definitions
● Care
- The conceptual phenomena are related to
helping, supporting, or empowering
experiences or behaviors toward others with
human condition or lifeway or to face death.
- You have to provide care by helping the patient
by supporting the patient’s needs or
empowering the patient's experiences (present
illness, or other experiences that the patient is
going through [emotional, psychological,
behavior towards others, etc.)
- It is the action of giving/providing the needs of
your patient
● Caring
- Behavior directed toward assisting another
individual or group with evident or anticipated
needs to improve the human condition either to
recover or to face death.
- It is the behavior of the nurse; how the nurse
behaves/ provides care to the client, to the
certain individual or group, with evident or
anticipated needs to improve the human
condition since there is a presence of illness or
problems.
● Culture
- The studied, shared, and handed values,
beliefs, norms, and lifeways of a certain group
that directs their thinking decisions, and actions
in certain ways.
● Culture Care
- The subjectively and objectively obtained
values, beliefs, and outlines of the lifeways that
assist, support, facilitate, or empower another
individual/group to maintain well-being, health,
and deal with illness, handicaps, or death.
- A nurse provides care that is tailed or fit the
patient’s culture.
● Culture Care Diversity
- The changeable differences in meanings,
patterns, values, lifeways, or symbols of care
within concepts that are related to supporting
human care.
● Cultural Care Universality
- The common, general definitions of care with
its patterns, values, and symbols are observed
among many cultures and reflect assistive
ways to help people.
● Worldview
- The way an individual or group looks out on
and understands the world about them as a
value, stance, picture, or perspective about life
and the world.
● Cultural and Social Structure Dimensions
- Refer to the dynamic, holistic, and interrelated
patterns of structured features of culture
(subculture), including religion (or spirituality),
kinship (social), political characteristics (legal),
economics, education, technology, cultural
values, philosophy, history, and language.
● Ethnohistory
- Past facts, events, and experiences of
individuals, groups, and various cultures and
institutions that are mainly people-centered
(ethnic) and that explain, and interpret human
lifeways within particular cultural trends.
● Emic
- Refers to local, indigenous, or insiders views
and values about a phenomenon.
● Etic
- Refers to the outsider’s or more universal
views and values about a phenomenon.
● Generic (Folk or Lay) Care System
- Culturally studied and given, indigenous (or
traditional), folk (community and home-based)
knowledge and skills used to provide assistive,
supportive, enabling, or facilitative acts toward
or for another individual. Groups, or institutions
with evident or anticipated needs to ameliorate
or improve a human lifeway or health condition
(or well-being), or to deal with handicaps and
death situations.
● Professional Care System
- Formally educated, and instructed professional
care, health, illness, wellness, and related
knowledge and practice skills that exist in
professional institutions usually with
multidisciplinary personnel to give service to
clients.
● Health
- The state of well-being is defined through
cultures valued and practiced and reflects the
ability of individuals to perform their daily role
activities in culturally expressed, beneficial, and
patterned styles.
● Transcultural Nursing
- Studied scientific and humanistic profession
and discipline that centers on human care
activities that assist, support, facilitate, or
enable individuals or groups to maintain or
regain their well-being (or health) in culturally
meaningful and beneficial ways, or to help
people face handicaps or deaths.
● Three Kinds of Care:
1. Cultural Care Preservation or Maintenance
- Caring skilled actions and decisions that
people of a certain culture retain important
care values so that they can keep up their
well-being, recover from illness, or face
handicaps or death.
2. Cultural Care Accommodation or
Negotiation
- The supporting, facilitative, or enabling
specialized actions and decisions that help
people of designated culture to adapt to
others for the beneficiary or satisfying
health outcome with professional care
providers.
3. Culture Care Repatterning or Restructuring
- The assistive, sustaining, facilitative, or
enabling professional actions and
decisions that help clients greatly change
lifeways for new, different, and beneficial
healthcare patterns while regarding the
client’s cultural values and beliefs and still
giving a beneficial or healthier lifeway
before the changes were laid out with the
clients.
● Cultural Congruent Nursing Care
- The cognitively-based assistive, caring
facilitative, or empowering acts or decisions
that are made to fit with the individual, group,
or institutional cultural values, beliefs, and
lifeways to offer or carry meaningful, beneficial,
and satisfying healthcare or well-being
services.
➢ Metaparadigm: Transcultural Nursing Theory
1. Person
- Humans are thus believed to be caring and
capable of being concerned about the
desire, welfare, and continues existence of
others.
2. Environment
- Environmental framework - as being the
totality of an event, situation, or
experience. Culture is closely related to
society/environment and is the central
matter of her theory
3. Health
- Health is seen as being universal across
cultures but distinct within each culture in a
way that represents the beliefs, values,
and practices of the particular culture.
Health is both universal and distinct.
4. Nursing
- She gave three types of nursing actions
that are culturally based and thus,
consistent with the needs and values of
the clients.
- These three modes of action can lead to
the deliverance of nursing care that best
fits with the client’s culture and thus,
reduces cultural stress and the chance for
conflict between client and caregiver.
- Three modes of Nursing Actions:
➔ Cultural Care Preservation or
Maintenance
➔ Cultural Care Accommodation or
Negotiation
➔ Cultural Care Repatterning or
Restructuring
- Nursing care acts as a bridge that connects
generic (folk) care and professional care-cure
practices.
 Ida Jean Orlando-Pelletier: Nursing
Process Theory
Ida Jean Orlando
- Irish American born on August 12, 1926
- Married to Robert J. Pelletier
- Lived in the Boston Area
- Known Psychiatric Health Nurse
- Based on the Study developed at Yale University
School of Nursing, wherein she integrates mental
health concepts into the basic nursing curriculum
- Bachelor of Science degree in Public Health
Nursing in 1951
- In 1954, she completed her Masters of Arts in
Mental Health consultation
➢ Published Books
- 1958: The Dynamic Nurse-Patient Relationship:
Function, Process, and Principles of
Professional Nursing Practice (1961)
- 1972: The Discipline and Teaching of Nursing
Process: An Evaluative Study
➢ Orlando’s Deliberative Nursing Process Theory
- She proposed that “patients have their own
meanings and interpretations of situations and
therefore, nurses must validate their
interferences and analyses with patients before
drawing conclusions.”
- Informing the patient about the plan of care for
them.
➢ Five Major Interrelated Concepts
1. The function of professional nursing-
involves organizing principles, or finding out
and meeting the patient’s needs (nursing
assessment, formulate diagnosis, plan, do
such interventions)
2. The presenting behavior of the patient-
check if there’s a problem with the patient; is
your patient’s present behavior is the stimulus
that causes an automatic internal response.
3. The immediate or internal response of the
nurse- response of the nurse to the patient’s
behavior; know if you patient is physically,
psychologically, or emotionally affected.
4. The nursing process disciplines- your
interventions and responses should all be
based on the nursing care plan.
5. Improvement- evaluate if there are changes
after performing such nursing interventions
➢ Major Concepts and Definitions
● Nurse’s Responsibility
- Whatever help the patient may require for his
needs to be met.
- It is the nurse’s responsibility to see that “the
patient’s needs for help are met, either directly
by her own activity or indirectly by calling in the
help of others.”
● Need
- Situationally defined as a requirement of the
patient which, if supplied, relieves or diminishes
his immediate distressor and improves his
immediate sense of adequacy or well-being.
● Presenting Behavior of Patient
- Any observable verbal or nonverbal behavior.
● Immediate Reactions
- Include both the nurse and patient’s individual
perceptions, thoughts, and feelings
● Nurse Reactions
- The patient behavior stimulates a nurse’s
reaction
- Marks the beginning of the nursing process
discipline
● Nurse Actions
- When the nurse acts, an action process
transpires.
➔ Automatic
➔ Deliberative
● Nursing Process Discipline
- Includes the nurse communicating to the
patient his or her own immediate reaction,
clearly identifying that the item expressed
belongs to the nurse.
- It was called the deliberative nursing process in
Orlando’s 1st book and also called the nursing
process and process discipline.
● Dynamic Nurse-Patient Relationship
- This shows that the action process could be
secret or in open disclosure.
- The action process in person to person contact
functioning in secret; the person’s thoughts,
perceptions, and feelings are not directly
available to the perception of the other
individual through observable action.
- An action by open disclosure- an individual’s
perception, thoughts, and feelings are directly
available to the perception of the other person
through the observable action.
● Improvement
- Means to grow better, to turn to profit, to use to
advantage
 ● Purpose of Nursing
- Supply the help a patient requires in order for
his needs to be met.
● Automatic Nursing Action
- Nursing actions are decided upon for reasons
other than the patient’s immediate need.
● Deliberative Nursing Action
- Those actions were decided upon after
ascertaining a need and then meeting his
needs.
- Results from the correct identification of patient
needs by validation of the nurse’s reaction to
patient behavior.
- The nurse explores the meaning of the action
with the patient and its relevance to meeting
his need.
- The nurse validates the action’s effectiveness
immediately after completing it.
- Nurse is free of stimuli unrelated to the
patient’s need when she acts.
➢ Assumptions in Nursing
- When patients are unable to cope with their needs
on their own, they become distressed by feelings of
helplessness.
- In its professional character, nursing adds to the
distress of the patient.
- Patients are unique and individual in how they
respond.
- Nursing offers mothering and nursing analogous to
an adult who mothers and nurtures a child.
- The practice of nursing deals with people, the
environment, and health.
- Patients need help communicating their needs; they
are uncomfortable and ambivalent about their
dependency needs.
- People 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 the nurse and the
patient.
- People attach meanings to situations and actions
that aren’t apparent to others.
- Patients enter into nursing care through medicine.
- The patient is unable to state the nature and
meaning of his or her distress without the help of
the nurse, or without him or her first having
established a helpful relationship with the patient.
- Any observation shared and observed with the
patient is immediately helpful in ascertaining and
meeting his or her need, or finding out that he or
she is not in need at that time.
- Nurses are concerned with the needs that the
patient is unable to meet on his or her own.
➢ 5 Stages of the Deliberative Nursing Process
1. Assessment
- The nurse completes a holistic assessment of
the patient’s needs.
- The nurse uses a nursing framework to collect
both subjective and objective data about the
patient.
2. Diagnosis
- Nurse’s uses clinical judgment about health
problems
- Diagnosis can then be confirmed using links to
defining characteristics, related factors, and
risk factors found in the patient’s assessment.
3. Planning
- This stage addresses each of the problems
identified in the diagnosis.
- Each problem is given a specific goal or
outcome, and each goal or outcome is given
nursing interventions to help achieve the goal.
4. Implementation
- The nurse begins using the nursing care plan
5. Evaluation
- The nurse looks at the progress of the patient
toward the goals set in the nursing care plan.
- Changes can be made to the nursing care plan
based on how well (or poorly) the patient is
progressing toward the goals.
➢ Metaparadigm: Nursing Process Theory
1. Nursing
- Nursing is a distinct profession separate from
other disciplines.
- Professional nursing has a distinct function and
product.
- Basic Elements of Nursing Process Discipline:
➔ The Behavior of the Patient
➔ The Action of the Nurse
➔ The Nursing Actions
- Interaction of these elements with each other is
the nursing process.
- The nurse’s reaction to each patient is unique
- Nurses should help relieve physical or mental
discomfort and should not add to the patient’s
distress.
- Orlando’s concept of improvement in the
patient’s behavior is the intended outcome of
nursing actions.
- She is concerned with providing direct
assistance to individuals in whatever setting for
the purpose of avoiding, relieving, diminishing,
or curing the person’s sense of helplessness.
2. Person
- She assumes that a person behaves verbally
or nonverbally
- Patient’s needs for help are unique
- Patients have an initial ability to communicate
their needs for help.
- When patients cannot meet their own needs
they become distressed.
- The patient’s behaviors are meaningful.
- Patients are able and willing to communicate
verbally and nonverbally.
3. Health
- Orlando does not define health, but she
assumes that freedom from mental or physical
discomfort and feelings of adequacy and
well-being contribute to health.
- Repeated experiences of having been helped
undoubtedly culminate over periods of time in
greater degrees of improvement.

4. Environment
- Orlando does not define the environment, but
she assumes that a nursing situation occurs
when there is a nurse-patient contact and that
both nurse and patient perceive, think, feel,
and act in the immediate situation.
 Margaret Newman: Model of Health
Margaret Newman
- She was born on October 10, 1933, in
Memphis, Tennessee
- Educational Background:
➔ Bachelor’s Degree - University of
Tennessee (1962)
➔ Master’s Degree - University of
California (1964)
➔ Doctorate - New York University (1971)
➢ Published Books
- Theory Development in Nursing (1979)
- Health as Expanding Consciousness (1986 &
1994)
- A Developing Discipline: Selected Works of
Margaret Newman (1995)
➢ Model of Health
- The theory of health as an expanding
consciousness stemmed from the theory of
Martha Rogers (Unitary Human Being); was
stimulated by concern for whom health is the
absence of disease or disability is not possible.
- The theory has progressed to include the
health of all persons regardless of the
presence and absence of the disease
- The theory asserts that “every person in every
situation no matter how distorted and hopeless
it may seem is still part of the universal process
of expanding consciousness. A process of
becoming more of oneself of finding greater
meaning in life and reaching new dimensions
of connectedness with other people and the
world.” (Newman, 2010)
➢ Major Concepts and Definitions
● Health
- Regarded as the evolving pattern of the person
and the environment
- The process of developing awareness of self
and environment together with an increasing
ability to perceive alternatives and respond in a
variety of ways.
- Based on the premise that life is an ongoing
process of expanding consciousness
- Health is relational and is “patterned,
emergent, unpredictable, unitary, intuitive, and
innovative.”
● Pattern
- “Information that depicts the whole
understanding of the meaning and
relationships at once”
- A fundamental attribute of all there is and gives
unity in diversity
- Characteristics of pattern include movement,
diversity and rhythm
- Somehow intimately involved in energy
exchange and transformation.
- Embedded within the concepts of movement,
time and space is the idea that an event such
as a disease occurrence is part of a larger
process
- It differentiates the person from other people; it
makes a person unique
- The pattern of interactions of persons of
person-environment constitutes health
● Consciousness
- “Informational capacity of the system; the
ability of the system to interact with its
environment.”
- The interconnectedness of the entire living
system includes physiochemical maintenance
and growth processes as well as the immune
system.
- The life process was seen as a progression
toward higher levels of consciousness.
- Three correlates of consciousness:
➔ Time - indicator in the changing level of
consciousness
- The perception of time was
seen as an indicator of
humankind’s health status.
➔ Movement - (definition below)
➔ Space
- Absolute Consciousness - a stated in which
contrasting concepts become reconciled and
fused.
➔ Movement and rest fused into one
➔ Equated with love, where all opposites
are reconciled and all experiences are
accepted equally and unconditionally
- Transcendence - a process through which the
person reaches the highest level of
consciousness
● Movement
- the means whereby one perceives reality, and
therefore, is a means of becoming aware of
self.
- Movement through space is integral to the
development of a concept of time in man and is
utilized by man as a measure of time.
- Brings about change, without which there is no
manifest reality.
- Restricted in mobility by structural or
psychological pathology, who must adapt to an
altered rate of movement.
● Time and Space
- The concept of space is inextricably linked to
the concept of time.
- Time as an index of consciousness across life
span
- Each moment has an explicate order and also
enfolds all others, meaning that each moment
of our lives contains all others of all time.
➢ Newman’s and Young’s Model ➔ Dimension of Valuing
- The pattern recognition comes from within the
observer

- Newman drew from Prigogine’s (1980) Theory

of Dissipative Structures and Young’s (1976) 2. Person
conceptualization of the evolution of human - Person as individuals that is identified
beings to describe the levels of consciousness by their individual patterns of
in her theory and the dynamics of movement consciousness.
from one level to another. - “Centers of consciousness within an
- According to Newman, “We come into being overall pattern of expanding
from a state of potential consciousness, are consciousness.”
bound in time, find our identity in space, and
through movement, we learn the ‘law’ of the 3. Environment
way things work and make choices that - Not explicitly defined
ultimately take us beyond space and time to a - Described as being the larger whole,
state of absolute consciousness” (Newman, which contains consciousness of the
1994a, p. 26) individual
- More information here:
https://nursekey.com/newmans-theory-of-healt 4. Health
h-as-expanding-consciousness-in-nursing-prac - A fusion of disease and nondisease
tice/ creates a synthesis that is regarded as
health
- The essence of the emerging paradigm
of health is pattern recognition
➢ Metaparadigm: Model of Health - Disease and non-disease each reflect
the larger whole. Therefore, a new
1. Nursing concept of health, “pattern of the
- Study of caring in the human health experience whole,” is formed
- The role of the nurse is to help clients
recognize their own patterns
- The nurse facilitates pattern recognition in
clients by forming relationships with clients at
critical in their lives and rhythmically connecting
with them in an authentic way
- The nurse relinquishes the need to manipulate
or control, there is a greater ability to enter into
this fluctuating, rhythmic partnership with the
client
- The nurse helps an individual, family, or
community focus on one’s pattern
- Nursing involves Nine Patterns of Interaction
➔ Dimension of Choosing
➔ Dimension of Communicating
➔ Dimension of Exchanging
➔ Dimension of Feeling
➔ Dimension of Moving
➔ Dimension of Knowing
➔ Dimension of Perceiving
➔ Dimension of Relating
 Hildegard Peplau: Theory of Interpersonal model at a time when nursing theory
development is relatively new.
Relations
- The nature of Science in the nursing discipline
of nursing is mainly knowledge from the
Hildegard Peplau
biological and behavioral sciences.
- She was born on September 1, 1909, in
- In developing her theory, she borrowed
Pennsylvania
knowledge from behavioral science that can be
- She is considered to be the “Mother of
termed the psychological model, it enabled the
Psychiatric Nursing”
nurse to begin to move away from a disease
- She emphasized the importance of
orientation to one whereby the psychological
professional self-regulation through
meaning of events, feelings, and behaviors
credentialing and introduced the concept of
could be explored and incorporated into
advanced nursing practice.
nursing interventions.
- Significant contribution: the development of the
- It gave nurses an opportunity to teach patients
Theory of Interpersonal Relations
how to experience their feelings and to explore
(Relationship between the Nurse and the
with clients how to bear their feelings
Patient)
- Her theory is based on the theories of the
- Educational Background:
following:
➔ 1931 - Graduated from Pennsylvania
➔ Sullivan
School of Nursing
➔ Symonds
➔ 1943 - Bachelor’s Degree in
➔ Maslow (Hierarchy of Needs)
Interpersonal Psychology
➔ Mittleman
➔ Earned Master’s and Doctoral Degrees
➔ Miller
from Teache’s College, Columbia
➔ Freud
University
➔ Fromm
- Served as an executive director and president
➔ Adler
of American Nurses Association
➔ Pavlo
- Peplau’s scope of nursing includes her
contributions as a psychiatric nursing expert,
➢ Major Concepts and Definitions
educator, and nursing leader
- She died peacefully in her sleep 89 years later
on March 17, 1999, in her home in Sherman
● Psychodynamic Nursing
Oaks, California
- Is being able to understand one’s own behavior
to help others identify felt difficulties, and apply
➢ Published Book:
principles of human relations to the problems
- Interpersonal Relations in Nursing (1952)
that arise at all levels of experience.
- her book described the importance of the
- Four Psychobiological Experiences that
nurse-patient relationships as a significant
Compel Destructive or Constructive Patient
therapeutic interpersonal process
Responses
- recognized as the first nursing theory
➔ Needs
textbook since Nightingale’s work in the
➔ Frustrations
1850s.
➔ Conflicts
➔ Anxiety
➢ Theory of Interpersonal Relations
- She described the structural concepts of the
- Also known as the “Psychodynamic Nursing”
interpersonal process, which are the phases of
- Focuses on the Nurse-Patient relationship
the helping relationship.
which is an ever changing relationship that has
steps.
● Phases of Nurse-Patient Relationship
- Interpersonal relations involves motivational
interviewing (you have to collect information
1. Orientation
about the patient [demographics, health history,
- the patient has a felt need and
social status, occupation, etc.])
expresses the desire for professional
- Making informed decisions -- inform the patient
assistance
of your plan of care and get the client’s
- The nurse helps the patient recognize
participation in his treatment plan.
and understand his or her problem, and
- “Nurse and patient must work together so they
determine his or her need for help.
become more mature and eligible in the
process of healing” (Peplau)
2. Identification
- The nurse permits exploration of
➢ Theoretical Sources
feelings to aid the patient in undergoing
- Refers to the body of verified knowledge found
illness as an experience that reorients
within Peplau’s Theory of Interpersonal
feelings and strengthens positive forces
Relations, integrated existing theories into her
in the personality and provides needed
satisfaction.

3. Exploitation
- The patient attempts to derive full value
from what he or she is offered through
the relationship as he or she moves on
from a dependent to the independent
one
- 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.
4. Resolution
- The patient earns independence over
his or her care as he or she gradually
puts aside old goals and formulates
new ones.
- This is a process that the patient frees
himself or herself from identification
with the nurse.
- It is very apparent that the experience
leaves a lasting impression on the
patient since illness and assuming a
dependent role is a unique human
experience.
● Interpersonal Therapeutic Process
- Based on the theory proposed by Peplau and
particularly useful in psychiatric patients who
become receptive to therapy.
- Often referred to by Peplau as “Psychological
Mothering,” which includes the following steps:
➔ The patient is accepted unconditionally
as a participant in a relationship that
satisfies his needs;
➔ There is recognition of and response to
the patient’s readiness for growth, as
his initiative; and
➔ Power in the relationship shifts to the
patient, as the patient is able to delay
gratification and to invest in goal
achievement (Stuart & Laraia, 2005)
● Six Nursing Roles
- The nurse assumes several roles which
empower and equip her in meeting the needs
of the patient that are appropriately being used
by the nurse in different situations and phases
of Interpersonal Relationships.
1. Role of the Stranger
- In their initial contact, the nurse and the
patient are strangers to one another. As the
nurse attempts to know the patient better, she
must treat him with utmost courtesy, which
includes acceptance of the patient as a
person and due respect over his individuality.
This coincides with the identification phase.
2. Role of the Resource Person
- As the patient assumes a dependent role, the
nurse provides specific answers to his queries
which include health information, advice, and
a simple explanation of the healthcare team’s
course of care. It is the responsibility of the
nurse to appropriately change her responses
to the patient’s level of understanding.
3. Teaching Role
- As the interaction progresses the nurse
assumes a teaching role as she gives much
importance to self-care and in helping him
understand the therapeutic plan. In assuming
this role, the nurse must determine how the
patient understands the subject at hand. She
must develop her discussion around the
interest of the patient and his ability to use the
information provided.
4. Leadership Role
- It involves the democratic process. The nurse
helps the patient meet the tasks at hand
through a relationship of cooperation and
active participation.
5. Surrogate Role
- The patient’s dependency on his care gives the
nurse a surrogate role (temporary caregiver).
This creates an atmosphere wherein feelings
previously felt such as feelings towards his
mother. Some other relationships are
reactivated and nurtured. Although the patient
recognizes that the nurse is similar to the
person whom he recalls in previous
relationships, the nurse must assist the patient
to make sure that his surrogate role is different
and only temporary.
6. Counseling Role
- Peplau believes that the counseling role has
the greatest importance and emphasis in
nursing. This role strengthens the nurse-patient
relationship as the nurse becomes a listening
friend, an understanding family member, and
someone who gives sound and emphatic
advice. The very core of the interpersonal
technique is for the patient to remember and to
understand the experience, and how it could be
integrated into his life.
➢ Metaparadigm: Theory of Interpersonal Relations
1. Nursing
- Peplau describes nursing as “a significant,
therapeutic, interpersonal process.”
- It functions cooperatively with other human
processes that make health possible for
individuals in communities.
- “Nursing is an educative instrument, a
maturing force that aims to promote forward
movement of personality in the direction of
creative, constructive, productive, personal,
and community living.”
2. Person
- Peplau defines a person as a man who is an
organism that lives in an unstable balance of
a given system.

3. Health
- Peplau considers “health” as a word that
symbolizes the movement of the personality
and other ongoing processes that direct the
person towards creative, constructive,
productive, personal, and community living.
She also gave importance to the belief that
one’s health to be achieved and maintained,
his needs must be met.

4. Environment
- Defined as forces outside the organism and in
the context of the socially-approved way of
living, from which vital human social
processes are derived such as norms,
customs, and beliefs. However, these given
conditions that lead to health always include
the interpersonal process.
 Joyce Travelbee: Human-to-Human
Relationship Model
Joyce Travelbee
- Travelbee was born in 1926 and died in 1973.
- 1956: she completed her BSN degree at
Louisiana State University.
- 1959: she completed her Master of Science
Degree in Nursing at Yale University
- 1952: Psychiatric Nursing Instructor at Depaul
Hospital Affiliate School, New Orleans. Later in
Charity Hospital School of Nursing in Louisiana
State University, New York University, and the
University of Mississippi.
➢ Published Books:
- 1st (1966 and 1971): Interpersonal Aspects of
Nursing
- 2nd (1969): Intervention in Psychiatric Nursing:
Process in the One-to-One Relationship
➢ Human-to-Human Relationship Model
- Is the means through which the purpose of
nursing is being fulfilled.
➢ Major Concepts and Definitions
● Five Phases of Interaction Process:
1. The Inaugural Meeting or Original Encounter
- Described as the first impression by the
nurse to the sick person and vice versa. The
nurse and patient see each other in
stereotyped or traditional roles.
2. Visibility of Personal Identities or Emerging
Identities
- Described by the nurse and patient
perceiving each other as unique individuals.
At this time, the link of the relationship
begins to form.
- The patient has a deeper identification with
the nurse and vice versa.
3. Empathy
- Travelbee proposed that two qualities that
enhance the empathy process are
similarities of experience and the desire to
understand another person.
- Described as the ability to share in the
person’s experience.
- The result of the emphatic process is the
ability to expect the behavior of the
individual with whom he/she empathized.
- The ability of the nurse to understand the
feelings of the patients. You only understand
their feelings but you don’t actually feel how
does the patient feel.
- Empathy is characterized by the ability to
predict the behavior of another.
4. Sympathy
- It happens when the nurse wants to lessen
the cause of the patient’s suffering.
- It goes beyond empathy. “When no 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.
- At this time, the ability of the nurse is to take
part in someone else feelings, or the
feelings of the patient. However, you have to
know yourself better to know your limitations
(There may be instances where you feel
more emotional than the patient).
- There is a sharing of feelings and
experiences.
- Sympathy demonstrates an emotional
involvement.
5. Establishing Mutual Understanding and
Contact or Rapport
- Described as nursing interventions that
lessen the patient’s suffering. The nurse and
the sick person are related as a human
being to a 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.”
- Establishing rapport is not just based on
your own feelings as a nurse, but, it should
be based on what you have learned and
what knowledge and skills you have gained
during your practice and during your BSN
program.
- A nurse should be equipped with knowledge
and skills to be able to establish rapport, to
be able to respond to the needs of the client,
to be able to have therapeutic
communication with your client.
➢ Metaparadigm: Human-to-Human Relationship
Model
1. Person
- Identified as a human being. Both the
nurse and patient are human beings.
- A human being is a unique, irreplaceable
individual who is in the continuous process
of becoming, evolving, and changing.
2. Health
- Measured by subjective and objective
health.
- “A person’s subjective health status 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 ➢ Diagram of Human-to-Human Relationship
measured by physical examination, Model
laboratory tests, assessment by a spiritual
director, or psychological counselor.”

3. Environment
- The definition was not clearly defined in
this theory. She defined human conditions
and life experiences encountered by all
men as suffering, hope, pain, and illness.
These conditions are associated with the
environment.

● Illness is a category and

classification, both objective and
subjective criteria.
➔ Objective criteria are determined
by the outward effects of illness on
the individuals.
➔ Subjective criteria refer to the way
in which a human being perceives
himself or herself as ill.

● Suffering is a feeling of displeasure

that ranges from simple transitory
mental, physical, or spiritual
discomfort to extreme anguish, and to
those phases beyond anguish,
namely, the malignant phase of
despairful “not caring” and the - She expressed that achieving the goal of
terminal phase of apathetic nursing necessitates a genuine
indifference. human-to-human relationship, which can only
● Pain itself is not observable-- only its be established by an interaction process, this
effects are noted. The experience of process is further divided into five phases. The
pain is unique to each individual. 5 interactional phases of Travelbee’s model
● Hope is a mental state characterized are in consecutive order and developmentally
by the desire to gain an end or achieved by the nurse and the patient as their
accomplish a goal combined with relationship with each other goes deeper and
some degree of expectation that what more therapeutic.
is desired or sought is attainable. It is - More information here:
related to dependence on others, https://pmhealthnp.com/joyce-travelbee-interpe
choice, wishing, trust and rsonal-theory-of-nursing/
perseverance, and courage and is
future-oriented.

4. Nursing
- Defined 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.
 Joyce Fitzpatrick: Life Perspective Rhythm others, and the rules for combining those
concepts permit thoughts to be shared through
Model
language.

Joyce Fitzpatrick ➢ Metaparadigm: Life Perspective Rhythm Model

- She was born in 1944
- Gained BSN - Georgetown University
- MS in Psychiatric-Mental Health Nursing - Ohio
State University
- Ph.D. in Nursing - New York University
- MBA from Case Western Reserve University
- Fellow in the American Academy of Nursing -
1981
- Presently, Elizabeth Brooks Ford Professor of
Nursing, Frances Payne Bolton School of
Nursing, Case Western Reserve University,
Cleveland, OH.
➢ Published Books
- Advanced Practice Psychiatric Nursing:
Integrating Psychotherapy,
Psychopharmacology, and
Alternative/Complementary Approaches.
- Theories Guiding Nursing Research and
Practice: Making Nursing Knowledge
Development Explicit (2014)
- Nursing Concepts Analysis: Application to
Research and Practice (2016)
➢ Life Perspective Model
- Based on the theory of Martha Rogers which is
the theory of Unitary Human Being which
focuses on a set of basic assumptions that
describes the life process in human beings:
● Wholeness
● Openness
● Unidirectionaility
● Pattern and organization
● Thought and Sentience
- She conceptualized her model from Martha
Roger’s theory which correlates human
development as the basis for differentiation,
organizing, and ordering life’s reality.
1. Person
- Includes both self and others.
- Seen as an open system, a unified whole
characterized by a basic human rhythm.
- Having unique biological, psychological,
emotional, social, cultural, and spiritual
attitudes.
2. Health
- A dynamic state of being that results
from the interaction of a person and the
environment.
- A human dimension under continuous
development, a heightened awareness
of the meaningfulness of life.
- Optimum health is the actualization of
both innate and obtained human
potential gathered from rewarding
relationships with others, goal-directed
behavior, and expert personal care.
- If an individual has a negative
environment, it would affect his health.
Thus, the environment and stressors
have a huge impact on one’s health.
3. Nursing
- “A developing discipline whose central
concern is the meaning attached to life
(health”
- The primary purpose of nursing is the
promotion and maintenance of an
optimal level of wellness.

➢ Major Assumptions
- The process of human development is
characterized by the rhythms that occur within
the context of continuous person-environment
interaction.
● Remember that Roger’s theory focused on
rhythms. She correlates shorter higher
frequency wave that manifests shorter
rhythm and approaches, seemingly
continuous pattern serves as Fitzpatrick’s
main focus for hypothesizing the existence
of the rhythmic pattern.
- The nursing activity focuses on enhancing the
developmental process toward health.
- A central concern of nursing science and the
nursing profession is the meaning attributed to
life as the basic understanding of human
existence.
- The identification and labeling of concepts
allow for recognition and communication with
 Patricia Benner: From Novice to Expert:
Excellence and Power in Clinical Nursing
Practice
Patricia Benner
- Born on August 31, 1942, in Hampton, Virginia
- 1964: Earned her Bachelor of Arts in Nursing
from Pasadena College
- 1960: worked in Nursing Field
- 1970-1975: research associate at the
University of California at San Francisco
School of Nursing
➢ Published Books
- From Novie to Expert: Excellence and Power in
Clinical Nursing Practice
- Nursing Pathways For Patient Safety
- The Primary of Caring
- Co-authored Books:
● Expertise in Nursing Practice: Caring,
Clinical Judgment, and Ethics
● Clinical Wisdom in Critical Care: A
Thinking-in-Action Approach
➢ From Novice to Expert
- Patricia Benner’s theory is known as “From
Novice to Expert,” and it talks about excellence
and power in clinical nursing practice.
➢ 5 Levels of Skill Acquisition and Skill
Development
1. Novice
- the person has no background experience of
the situation in which he or she is involved.
- Context-free rules and objective attributes
must be given to guide performance.
- There is difficulty discerning between relevant
and irrelevant aspects of a situation.
- Generally, this level applies to students of
nursing, but Benner has suggested that
nurses at higher levels of skill in one area of
practice could be classified at the novice level
if placed in an area or situation
- Novice tends to follow rules; thus, there
should be a person ordering the rules. The
expert can tell them what to do and the
novice will follow their instructions.
- Task-oriented; They follow rules but they are
not flexible.
2. Advanced Beginner
- The person can demonstrate marginally
acceptable performance, having coped with
enough real situations to note, or to have
pointed out by a mentor, the recurring
meaningful components of the situation.
- The advanced beginner has enough
experience to grasp aspects of the situation
- Nurses functioning at this level are guided by
rules and are oriented by task completion.
- They have difficulty grasping the current patient
situation in terms of the larger perspective.
- Clinical situations are viewed by nurses who
are in the advanced beginner stage as a test of
their ability
- Advanced beginners feel highly responsible for
managing patient care, yet they still rely on the
help of those who are more experienced
- Most newly graduated nurses are placed in this
level.
- At least 1 year of experience
3. Competent
- Through learning from actual practice
situations and by following the actions of
others, the advanced beginner moves to this
level
- Typified by considerable conscious and
deliberate planning that determines which
aspects of current and future situations are
important and which can be ignored.
- Consistency, predictability, and time
management are important, and gaining a
sense of mastery through planning and
predictability is the accomplishment.
- There is an increased level of efficiency but
the focus is on time management and the
nurse’s organization of the task world
- The competent nurse may display
hyper-responsibility for the patient, often more
than is realistic, and may exhibit an
ever-present and critical view of the self
- This stage is most pivotal in clinical learning
because the learner must begin to recognize
patterns and determine which elements of the
situation warrant attention and which can be
ignored.
- They devise new rules and reasoning
procedures for a plan while applying learned
rules for action on the basis of relevant facts
of that situation.
- More than 1 year of experience
4. Proficient
- The performer recognizes the most salient
aspects and has an intuitive grasp of the
situation based on background understanding
- Nurses at this level demonstrate a new ability
to see changing relevance in a situation,
including recognition and implementation of
skilled responses to the situation as it
evolves.
- They no longer rely on preset goals for the
organization, and they demonstrate increased
confidence in their knowledge and abilities
- There is much more involvement with the
patient and family.
- This stage is a transition into expertise
- More than 3 years of experience
 5. Expert
- The expert performer no longer relies on
analytical principle (i.e., rule, guideline, maxim)
to connect an understanding of the situation to
an appropriate action
- The expert nurse as having an intuitive grasp
of the situation and as being able to identify the
region of the problem without wasting
consideration on a range of alternative
diagnoses and solutions.
- There is a qualitative change as the expert
performer “knows the patient,” meaning
knowing typical patterns of responses and
knowing the patient as a person.
- Their actions come naturally.
- Key aspects of expert practice include the
following:
1. A clinical grasp and resource-based
practice
- They are very good at assessing
the situation. Their practice is
based on evidence, based on
their experiences
2. Embodied know-how
- They know how to perform a
certain task. Hot to address a
certain situation.
3. Seeing the big picture
- They know how to see the bigger
picture. They know different
possible solutions. There is Plan
A, Plan B, Plan C, and so on.
4. Seeing the unexpected
- They know the possibilities that
might happen.
- The expert nurse has the ability of pattern
recognition on the basis of deep experiential
background.
- Meeting the patient’s actual concerns and
needs is of utmost importance, even if it means
planning and negotiating for a change in the
plan of care.
- There is almost a transparent view of the self.
➢ Major Concepts and Definitions
● Aspects of a Situation
- the recurring meaningful situational
components recognized and understood in
context because the nurse has previous
experience.
● Attribute of a Situation
- Measurable properties of a situation that can
be explained without previous experience in
the situation
● Competency
- It is “an interpretively defined area of skilled
performance identified and described by its
intent, functions, and meanings”
● Domain
- An area of practice having a number of
competencies with similar intents, functions,
and meanings.
- In the nursing program, the professors and the
universities check their nursing students’
competencies in terms of performing a certain
skill, and even in attitude and knowledge.
● Exemplar
- An example of a clinical situation that conveys
one or more intents, meanings, functions, or
outcomes easily translated to other clinical
situations
● Experience
- An active process of refining and changing
preconceived theories, notions, and ideas
when confronted with actual situations; it
implies there is a dialog between what is found
in practice and what is expected
● Maxim
- Cryptic description of skilled performance that
requires a certain level of experience to
recognize the implications of the instructions
● Paradigm Case
- A clinical experience that stands out and alters
the way the nurse will perceive and understand
future clinical situations
- Paradigm cases create new clinical
understanding and open new clinical
perspectives and alternatives.
● Salience
- A perceptual stance or embodied knowledge
whereby aspects of a situation stand out as
more or less important
➢ Metaparadigm: From Novice to Expert
1. Nursing
- Described as an “enabling condition of
connection and concern” which shows a high
level of emotional involvement in the
nurse-client relationship.
- As a nurse, you have to make sure that your
emotion is positive for the patient towards the
recovery of your patient.
- Viewed nursing practice as the care and study
of the lived experience of health, illness, and
disease and the relationships among these
three elements.
- Illness means something you can manage such
as the feeling of pain, discomfort, distress,
weakness, fatigue, etc. While disease means
something that needs to be cured or there is
already a diagnosis that needs medical
treatment.
- In illness, your independent nursing function
could help, address, or manage it. While in
 disease, your nursing intervention, as well as
the medical intervention from the doctor and
other healthcare teams, are needed.
2. Person
- Stated that “a self-interpreting being, that is, the
person does not come into the world
predefined but gets defined in the course of
living a life. A person also has… an effortless
and non-reflective understanding of the self in
the world. The person is viewed as a
participant in common meanings.”
- A person could learn from his environment.
- Believed that there are significant aspects that
make up a person.
- She conceptualized the major aspects of
understanding that the person must deal with
as:
1. The role of the situation
- What is happening within the
surroundings of the client
2. The role of the body
- What is happening in the whole
system of the human being;
Functions of the different systems
of your body and its organs
3. The role of personal concerns
- Emotional involvement with a
certain person
4. The role of temporality
- Everything is temporary. If you are
sick now, you may be healed.
- Goal: Overcome the Cartesian dualism, the
view that the mind and body are distinct,
separate entities.
- Embodiment is the capacity of the body to
respond to meaningful situations.
- 5 Dimensions of the Body (Merleau, Ponty,
& Dreyfus
computer
5. The phenomenal body
- the body aware of itself with the
ability to imagine and describe
kinesthetic sensations
● According to Benner, the nurse must attend to
all these five dimensions and seek to
understand the role of embodiment in particular
situations of health, illness, and recovery.
3. Health
- Focused “on the lived experience of being
healthy and ill.”
- Defined health as what can be assessed, while
well-being is the human experience of health or
wholeness.
- Well-being and being ill are recognized as
different ways of being in the world.
- Health is described as not just the absence of
disease and illness. Also, a person may have a
disease and not experience illness because
illness is the human experience of loss or
dysfunction, whereas disease is what can be
assessed at the physical level.
4. Environment
- Used the term “situation” instead, because it
suggests a social environment with social
definition and meaning.
- Used the phenomenological terms of being
situated and situated meaning, which is defined
by the person’s engaged interaction,
interpretation, and understanding of the
situation.

1. The unborn complex

- Refers to the unacculturated body
of the fetus and newborn baby.
2. The habitual skilled body
- complete with socially learned
postures, gestures, customs, and
skills evident in bodily skills such
as sense perception and “body
language” that are “learned over
time through identification,
imitation, and trial and error”
- Your body movements, a proper
way of moving
3. The projected body
- (predisposed) to act in specific
situations (e.g., opening a door or
walking)
4. The actual projected body
- indicating an individual’s current
bodily orientation or projection in a
situation that is flexible and varied
to fit the situation, such as when
an individual is skillful in using a

Letty G. Kuan: Theory of Retirement and
Role of Discontinuities or Theory of
Graceful Aging
Letty G. Kuan
- Born on November 19, 1936 in
Katipunan-Dipolog, Zamboanga del Norte
- Master in degree in Nursing and Guidance and
Counseling
- She also holds a Doctoral degree in Education
- Has a vast contribution to the University of the
Philippines College of Nursing Faculty and
Academic achievements
- She was a Professor Emeritus, a title awarded
only to a few who met the strict criteria
- She has two Master's Degree, M.A in Nursing
and M.S in Education, Major in Guidance and
Counseling, culminating in Doctor of Education
(Guidance and Counseling)
- Has a Clinical Fellowship and Specialization in
Neuropsychology in the University of Paris,
France (Salpetriere hospital)
- NeuroGerontology in Watertown, New York
(Good Samaritan Hospital) and Syracuse
University, New York
- She also had Bioethics formal training at the
Institute of Religion, Ethics, and Law at Baylor
College of Medicine in Houston, Texas
- She is a recipient of the Metrobank Foundation
“Outstanding Teachers Award” in 1995 and an “
Award of Continuing Integrity and Excellence in
Service” in 2004
- (ACIES) Her religious community is the Notre
Dame de Vie founded in France in 1932
- As a former member of the Board of Nursing her
latest legacy the Nursing Community is without a
doubt, indisputable
➢ Published Books
- She authored several books giving her insights in
the areas of Gerontology, Care of Older Persons
and Bioethics and Essence of Caring:
● Concepts of Illness and health care intervention
in an urban community by Kuan, Letty Gurdiel;
[Quezon City]: 1975
● Understanding the Filipino elderly: A textbook
for nurses and related health professionals by
Kuan, Letty G.; Dipolog CIty: Jesus G. Kuan
Foundation, 1993
● Essence of Caring by Letty G. Kuan, National
Teacher Training Center for the Health
Professions, University of the Philippines
Manila, Learning Resources Unit, 1993
➢ Theory of Retirement and Role of Discontinuities
or Theory of Graceful Aging
- She has met an interesting old people which
initiated her to formulate a theory for the purpose
of knowing the reasons and variables on how to
make people happy at their retirement age by
conceptualizing a framework
- According to her, graceful aging is dependent on
positive childhood acquisitions; so 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
acquisition to the person
- According to her, this acquisition comprises how
we acquire the manner of speaking, talking, and
our attitudes; the kind of acquisition from
education also plays a major role
- Kuan stated that if you have a very happy and
nice childhood you will have a very fruitful aging,
happy retirement, and ultimately legacy
- Kuan defines legacy as an act of giving, sharing,
and blend of honesty, feeling of fulfillment, and
motivation
➢ Retirement and Role of Discontinuities Theory
(Background/Major Concepts and Definitions)
● Retirement
- An inevitable change in one’s life. It is evident
in the increasing statistics of the aging
population accompanied by related disabilities
and increased dependence.
- This developmental stage, even at the later
part of life, must be considered desirable and
satisfying through the determination of factors
that will help the person enjoy his remaining
years of life.
- It is of primary importance to prepare early in
life by cultivating other roles of options at age
50-60 in order to have a rewarding retirement
period even amidst the presence of role
discontinuities experienced by this age group
● Role
- 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
- Set 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 a complementary
set of roles in the social structure among which
interaction constantly occurs
● Role Discontinuity
- The interruption in the line of status enjoyed or
performed. The interruption may be brought
about by an accident, emergency, and change
of position or retirement
➢ Retirement and Role of Discontinuities Theory ➢ Metaparadigm: Retirement and Role of
(Conceptual Framework) Discontinuities Theory

1. Person
- (Elderly) - is a classification of age group to
any person reaching the mid 70's up to the
‘80s
- (Gerone) - given to people who are old but
gracefully able to function as useful citizens
at home and in the community and an
exemplar in fidelity to prayer life

2. Nursing
- Is preparing the person to have fulfillment
in their retirement years, and assisting
them in their elderly years in leaving a
legacy
- During retirement and the role of discontinuities
during aging and process, there is a sudden
3. Environment
interruption of the usual role that a person
- Society that supports the aged to feel
performs.
needed.
- There would be a Change of Life. These changes
can lead to outcome fruitful retirement and aging
4. Health
(Depends on the determinants of origin)
- Defined as aging. It is a slow process of
- Determinants of Fruitful Aging includes the
growth towards maturity of mind, body and
following:
spirit. Growing old is reaching a "happy
● Prepared retirement
plateau" but one must understand and
● Health status
accept what is aging. It brings a
● Income
decreasing amount of energy over long
● Family Constellation
periods of activities; hence slowing down
● Self-preparation
and moderation in our activity involvement
is one reality of aging we all must realize
➢ Determinants Positive Perceptions in Retirement
and accept it is a fact to reckon with that
and Positive Reactions Toward Role
what is desirable is to feel comfortable with
Discontinuities (This section explains the diagram
one's age and never should one aspire to
above)
become caricatures of either age or youth.
- Aging is a reality and must be accepted as
● Health Status - Physiological and mental state
a process towards fulfillment of a total self.
of the respondents, classified as either sickly or
Developing positive attitudes towards
healthy.
aging while still young contributes a great
● Income - Financial affluence of the respondent
deal to feel comfortable while growing old.
which can be classified as poor, moderate, or
- Graceful aging leads the person in leaving
rich.
a legacy. Legacy is influenced by elements
● Work Status - Status of an individual according
of life early imprints and the factors of the
to job/source of income
aging process. Surviving the struggles and
● Family Constellation - Type of family
crises in life enables the person to leave a
composition described either close-knit or
legacy.
extended family where three or more
generations of family members live under one
➢ Assertions
roof; or distanced family, whose members live in
separate dwelling units; or nuclear type of family
● Aging Process is Dependent Upon Many
where only husband, wife and children live
Factors:
together.
- Healthy genetic background
● Self-Preparation - Preparation of self to the
- Happy, fulfilled, childhood foundation
possible outcomes in life.
- Successful middle-aged life experience
● Change of Life - The period between near
- Healthy surroundings
retirement and post-retirement years. In
- Relaxation
medico-psychological terms, this equates with
- Recreation and nutrition
the climacteric period of adjustment and
- Had been the recipient of being recognized,
readjustment to another tempo of life.
appreciated, and honored with love
 - Has attained mastery of knowing oneself and
mastery of a skill, in any category so long as
the person feels recognized and appreciated
for the contribution done to self, family,
community, and society
- Grows closer to divine worship regardless of
religious affiliation; the person is attuned to
God who is all goodness, kindness, humility,
and love
- Connectedness with others, it is big social
support that makes life worth living for

● Elements of Life’s Early Imprints

- Importance of Love
- The hug-factor
- Good parental and sibling modeling roles
- The sense of humor and relaxation
- The value of work and prayer life, growing
closer to God who loves us tremendously

● Application: Clinical Perspective

- After establishing a nurse-patient relationship,

nurses need to assess the aged health status,
economic level, work status, family
constellation, and self-preparation. Nurses
gather information of their developmental
stages of life such as childhood, adolescence,
adulthood, and their present state. We facilitate
them in identifying their needs that influence
the factors in the aging process. Once they
identify their needs and are motivated to
survive their struggles and crisis in life, nurses
work with them towards their goal to attain
graceful aging that makes them useful citizens
in the home and community leaving a legacy.

Carmelita Divinagracia: Theory of
Composure Behavior or Nursing
Intervention Model (Advance Nurse
Practitioner’s COMPOSURE BEHAVIOR &
Patient’s Wellness Outcome)
Carmelita Divinagracia
- 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.
College of Nursing
- Member of CHED’s Technical Committee on
Nursing Education
- Has been lauded for developing the art and
competency of teaching nursing.
- 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 used 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.
- Educational Background:
➔ 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
➔ Recipient of the Anastacia Giron Tupas
Award given by the Philippine Nursing
Association (PNA) in 2008
➢ Composure Behavior Model: Assertions
- Coordination, communication, and interpersonal
relationships are major components of
collaboration.
- Quality patient care and training of students can
be at best only if nursing service and education
can truly operationalize the meaning of
collaboration and put it into real action.
- The connectedness of nursing service and
education calls for a new wave of visionary
leadership, empowerment, and an environment
of trust and openness.
- Nursing as a profession can draw power based
only if a unification model can be crafted which is
culture-based, practical, relevant,
acceptable to the concerned
professionals.
➢ Composure Behavior
- Sets of Behaviors or Nursing Measures that the
Nurse Demonstrates to Selected Patients
● COMpetence - the ability to do something
successfully or efficiently
● Presence and Prayer - the state or fact of
existing, occurring, or being present in a place or
thing and religious service, especially a regular
one, at which people gather in order to pray
together.
● Openmindedness - receptiveness to new ideas;
the willingness to search actively for evidence
against one’s favored beliefs, plans, or goals,
and to weigh such evidence fairly when it’s
available.
● Stimulation - the raising of levels of
physiological or nervous activity in the body or
any biological system.
● Understanding - the ability to understand
something; comprehension.
● Respect and Relaxation - the process of
honoring someone by exhibiting care, concern,
or consideration for their needs or feelings and
decreasing the effects of stress on your mind
and body.
● Empathy - the ability to understand and share
the feelings of another.
➢ Three Main Themes and Sub-Themes were
Identified
1. Coordination
- Intra-Organizational Coordination
➔ Harmonious relationship of Students
and Teacher/C.I.
➔ Unified Concept and Implementation
- Inter-Organizational Coordination
➔ Collegial Relationship
➔ Consultative Relationship
➔ Balance/Synergy between Theory
and Practice
- Reciprocal Interdependence
➔ Views on Leadership Capabilities
➔ Community-based vs.
Hospital-based Learning
➔ Facilitating Process
2. Communication
- Environmental Factors
➔ Power and Status relationship
between Nursing Education and
Nursing Service
➔ Common Language
➔ Complementary Philosophy
- Personal Factors
➔ Trust
➔ Openness
➔ Harmony/Unity
and
nursing 3. Interpersonal Relationship
- Engagement
- Esprit (Morale)
- Concern
- Support
➢ Conclusion (Same as the Assertions)
 - Coordination, communication, and
interpersonal relationships have been identified
as major components of collaboration based on
the lived experiences of the respondents.
- Quality patient care and training of students
can be at best only if nursing service and
education can truly operationalize the meaning
of collaboration and put it into real action.
- The connectedness of nursing service and
education calls for a new wave of visionary
leadership, empowerment, and an environment
of trust and openness.
- Nursing as a profession can draw power based
only if a unification model can be crafted which
is culture-based, practical, relevant, and
acceptable to the concerned nursing
professionals.
- Recommend “unification model for
collaboration”

➔ Beneficial Effects of Collaboration:

- Harmony and Unity of Vision-Mission of
Nursing Education and Service
- Quality of Nursing Service is Enhanced.
- Quality of Nursing Education is
Attained.
- Presence for Customer Satisfaction
both for Education and Services

*Diagrams of Major and Minor Themes:

 Sister Carolina Agravante: The CASAGRA
Transformative Leadership Concept or the
Transformational Leadership Model
Sister Carolina S. Agravante SPC, RN, PhD
- She is famous for being the first Filipina
theorist for writing the CASAGRA
Transformative Leadership Model
- The title of the theory was derived from her
name, CArolina S. AGRAvante. “Focus on the
type of leadership in nursing that can challenge
the values of the changing world.”
- Educational Background:
➔ She finished her secondary education at
St. Paul University-Manila as a class
salutatorian.
➔ In 1964, she earned her BS Nursing
degree in the same school as Magna Cum
Laude. In the same year, she passed the
nurse licensure examinations as the board
top notcher.
➔ From 1967 to 1969, she studied for a
Master's Degree in Nursing Education at ➢ Conceptual Paradigm of Care Complex Theory of
the Catholic University of America as a
full-fledged scholar.
➔ In 200, she earned her Doctoral Degree in
Philosophy at the University of the
Philippines Manila - the same year her
theory was published.
➢ The model is a Three-Fold Transformation
Leadership Concept rolled into one, comprising
of the following elements:
1. Servant-Leader Spirituality
2. Self-Mastery
3. Special Expertise
➢ The CASAGRA Transformative Leadership
Concept is classified as Practice Theory
- It is classified as a Practice Theory because it has
the following:
➔ Complexity/Abstractness, Scope
➔ Generalizability/Specificity
➔ Characteristics of Scope
➔ Characteristic of Proposition
➔ Testability
➔ Source of Development
➢ Concepts
● Servant-leader formula
- is the enrichment package prepared as an
intervention for the study which has three parts
that parallel the three concepts of the CASAGRA
Transformative Leadership Model namely: the
care complex primer, a retreat-workshop on
Servant-leadership, and a seminar-workshop on
Transformative Teaching for nursing faculty.
● Special Expertise
- The level of competence in the particular
nursing is that the professional nurse is
engaged in a workshop is the spiritual exercise
organized in an ambiance of prayer where the
main theme is the contemplation of Jesus
Christ as a Servant Leader.
● Servant-leadership Behavior
- Refers to the perceived behavior of nursing
faculty manifested through the ability to model
the servant leadership qualities to students,
ability to bring out the best in students,
competence in nursing skills, commitment to
the nursing profession, and sense of collegiality
with the school, other health professionals, and
the local community.
● Care Complex
- Is the nucleus of care experiences in the
personality of a nurse formed by a combination
of maternal care experiences, culture
based-care practices indigenous to a race and
people, and the professional training on care
acquired in a formal course of nursing.
Sr. Carolina Agravante
- The conceptual framework is logical because
the variables are very well explained on how
the transformative-leadership model can be
applied through care complex, transformative
teaching, servant-leader spirituality, and
servant-leader behavior.
- A person with a dynamic care complex is the
cornerstone of nursing leadership. According to
the care complex of Agravante, a caring
personality rests on the possession of a care
complex within a person as an energy source
of caring.
- Personal care - The care that a person
acquired since childhood (from his family, etc.)
- Folk care - influenced by their culture or
practices
- Professional Care - Care that you acquired
while learning how to properly provide patient
care while utilizing the nursing process.
- Care complex - it is in the middle since it is
dynamic and is the combination of the said
three types of care.
 Non-Nursing Theories: Systems Theory,
Change Theory, and Developmental Theory

➢ Systems Theory
- It provides another approach for studying
individuals in their environments and is used by
many disciplines.
- General System Theory includes purpose,
content, and process, breaking down the “whole”
and analyzing the parts. The relationships
between the parts of the whole are examined to
learn how they work together.
- Von Bertalanffy (1969, 1976) developed general
systems theory which assumes the following:
➔ All systems must be goal-directed
➔ A system is more than the sum of its parts
➔ A system is ever-changing, and any change
in one part affects the whole
➔ Boundaries are implicit, and human systems
are open and dynamic.

➢ Change Theory
- People grow and change throughout their lives.
This growth and change are evident in the
dynamic nature of basic human needs and how
they are met.
- Change happens daily. Change involves a
modification or alteration. It may be planned or
unplanned. Although a variety of change theories
exist.
- Kurt Lewin (1962) developed the classic theory of
change, which identifies the following six
components:
➔ Recognition of the area where change is
needed.
➔ Analysis of a situation to determine what
forces exist to maintain the situation and what
forces are working to change it.
➔ Identification of methods by which change
can occur.
➔ Recognition of the influence of group mores
or costumes on change.
➔ Identification of the methods that the
reference group uses to bring about change.
➔ The actual process of change.
- Lewin identified three states of change:
1. Unfreezing - is the recognition of the need for
change and the dissolution of previously held
patterns of behavior.
2. Movement - is the shift of behavior toward a
new and more healthful pattern. Movement
marks the initiation of change.
3. Refreezing - is the long-term solidification of
the new pattern of behavior.
➢ Developmental Theory: Human Need Theory
- Human needs are any physiologic or
psychological factors necessary for healthy
existence.
- The most prominent theorist to focus on human
needs has been Abraham Maslow. Maslow’s
Hierarchy of Human Needs (1970) states that
all humans are born with instinctive needs.
- These needs, grouped into five categories, are
arranged in order of importance from those
essential for physical survival to those
necessary to develop a person’s fullest
potential. Maslow’s hierarchy provides a
framework for recognizing and prioritizing basic
needs.
- People must meet lower-level needs to some
degree before they can address higher-level
needs:
- 5 Categorization of Needs:
➔ Physiologic Needs
- Fundamental motivating forces and
provide the base for Maslow’s pyramid.
Oxygen, food, water, elimination,
activity, rest, temperature maintenance,
and sexuality are essential for
existence.
➔ Safety Needs
- Human needs to be physically safe and
should be free from the fear and anxiety
that result from a lack of security and
protection.
 ➔ Love Needs
- People need to feel that they belong
and are loved to avoid loneliness and
isolation. To meet this need, a person
must give and receive love.
➔ Esteem Needs
- There are two types of esteem needs:
esteem derived from others and
self-esteem. People need to know that
others think well of, admire and respect
them. Self-esteem is a person’s sense
of his or her own adequacy and worth.
➔ Self-Actualization Needs
- The need for self-actualization is the
innate need to realize fully all of one’s
abilities and qualities, that is, to
maximize one’s potential.

- A person is not motivated by all five categories

of human needs at the same time. The
category most relevant to the person’s
circumstances at a particular time is the
primary motivator.
- Meeting needs is a dynamic process that
involves continual resolution of, progression
beyond and return to any given category
needs.
- Human needs are motivational forces (Yura &
Walsh, 1988). Culture, socio-economic factors,
personal values, and health influence the
motivational strength for and manner of
expression of these needs. They can learn to
delay meeting their needs and modify the
specific behaviors that satisfy needs,
depending on each need’s motivational
strength. If a need goes unmet, physical
illness, psychological disequilibrium or death
can occur.
 Health as a Multifactorial Phenomenon promotes safety, order, and cleanliness through
structural and manpower support.
➢ Factors Affecting Health
➢ Healthy Resort
- Place providing rest, recreation, relaxation, and
A. Political
wholesome entertainment that is clean, safe,
- Refers to one’s leadership, how he/she rules,
accessible, and affordable to most Filipino
manages and how other people concerned are
families. It promotes, provides, and maintains
followed to actively participate in the
conditions addressing social, environmental, and
decision-making process.
health concerns.
- Related concepts:
➔ Political Will - the determination to pursue
➢ Healthy Hospitals
something that is in the interest of the majority.
- One that provides comprehensive care. It is not
➔ Empowerment - the ability of the person to do
only a center for care but also of preventive care,
something; it involves creating the
hence, the concept of hospitals as the center of
circumstances where people can use their
wellness.
faculties and abilities at the maximum level in the
- Clean and adequate resources, competent
pursuit of common goals.
hospitals personnel, affordable and accessible
services are some of its key features. It is
B. Economic Factors
patient-centered and has provisions for health
- This refers to the production, distribution, and
education for patients, watchers, and the visiting
consumption of goods and services and how
public.
these affect health and development. A study of
this factor leads one to look into economic factors
➢ Healthy Vehicles
that influence how, and at what point, the client
- Clean, safe, comfortable, well-ventilated, and in
enters the health care system.
good running condition; manned by reliable and
dependable licensed operators who are physically
C. Socio-cultural Factors
and mentally fit; has one or two-health information
- Social and cultural variables influence a client’s
giving posters, stickers, or other educational
health practices, the dynamics of health care, and
materials and are smoke-free.
the client-care provider relationship.

➢ Healthy Streets
D. Environment
- Well-maintained roads and public waiting areas
- This refers to the sum total of all the conditions
- Well-marked traffic signs and pedestrian crossing
and elements that make up the surroundings and
lanes
influence the health and health practices of
- Clean and obstruction-free sidewalks
clients.
- Free or has minimal traffic problems
- The environment with which the client lives and
- Fight air pollution by being a part of the clean and
works either promotes and maintains health or
green initiative
increases the likelihood of illness or even death.
- Proper and visible street names
- With adequate and strict law enforcement
➢ Health Workplace
- Clean, orderly, well-ventilated, adequately lighted,
➢ Healthy Hotels
smoke-free, and adequately secured. It promotes
- Clean and pleasant place that provides comfort,
and protects the health and safety of workers and
security, conforms to a set of guidelines and
their families.
standards, and promotes a healthy lifestyle.
➢ Healthy Barrios
➢ Healthy Schools
- People work together towards attaining
- Provides health instruction through classroom
sustainable improvement in their lives and
learning/non-curricular activities and maintains
aspirations.
adequate basic health services to both pupils and
teachers and other personnel.
➢ Healthy Prison
- It promotes healthy school living through the
- Clean and safe detention place with adequate
creation and maintenance of supportive structures
facilities and services address the physical,
for positive health behavior change.
mental, spiritual, social, and economic needs of
inmates.
➢ Healthy Eating Places
- It is a temporary home that promotes justice,
- serve/cater food and drinks that are safe,
peace, rehabilitation, and a healthy lifestyle.
nutritious, properly prepared, stored, and
transported, and complies with sanitary
➢ Healthy Cities
standards.
- One where the physical environment especially
the workplace, street, and other public places
➢ Healthy Movie Houses
- Place providing rest, creation, and wholesome
entertainment.
- It’s safe and has competent and friendly
employees who are available to assist moviegoers
with their needs.
- It promotes and maintains conditions addressing
social, developmental, and healthy concerns.
- It has sanitary toilets and adequate
communication facilities.

➢ Healthy Ports
- Clean, spacious, and secure with facilities for
public waiting areas, passenger terminals, safe
drinking water, sanitary food shops, and public
toilets;
- Control disease-causing vectors, minimize
unnecessary hazards, and with medical facilities
conveniently and economically accessible to
public transport and communication.

➢ Healthy Markets
- There is enough water supply, proper drainage,
and well-maintained toilet facilities.
- Quality food is sold within the reach of the
common people.
- Market vendors, buyers, supervisory teams, and
sanitary inspectors are working together for a
well-organized and honest market system.
 Interlinking Relationships of Factors
Affecting Health
➢ Factors Affecting Health and Illness
● Physical Dimension
- Genetic make-up, age, developmental level, race,
and sex are all part of an individual’s physical
dimension and strongly influence health status
and health practices.
- Examples:
➔ The toddler just learning to walk is prone to fail
and injure himself.
➔ The young woman who has a family history of
breast cancer and diabetes and therefore, is at
higher risk to develop these conditions.
● Emotional/Psychological Dimension
- How the mind and body interact to affect body
function and to respond to body conditions also
influences health. Long term stress affects the
body systems and anxiety affects health habits;
conversely, calm, acceptance, and relaxation can
actually change body responses to illness.
- It involves awareness and acceptance of a wide
range of feelings in oneself and others, the ability
to express emotions, to function independently
and to cope with the challenges of daily stressors.
- Examples:
➔ Prior to a test, a student always has diarrhea.
➔ Extremely nervous about a surgery, a man
experiences severe pain following his
operation.
➔ Using relaxation techniques, a young woman
reduces her pain during the delivery of her
baby.
● Mental/Intellectual Dimension
- The intellectual dimension encompassess
cognitive abilities, educational background, and
past experiences. These influence a client’s
responses to teaching about health and reactions
to health care during illness. They also play a
major role in health behaviors.
- Being open to new ideas, and the ability of one to
question and evaluate information.
- An individual with good intellectual health skills will
be able to make decisions, set realistic yet
challenging goals, and figure out how to handle a
problem.
- Examples:
➔ An elderly woman who has only a third-grade
education who needs teaching about a
complicated diagnostic test.
➔ A young college student with diabete who
follows a diabetic diet but continues to drink
beer and eat pizza with friends several times a
week.
● Environmental Dimension
- The environment has many influences on health
and illness. Housing, sanitation, climate and
pollution of air, food, and water are aspects of the
environmental dimension.
- Examples:
➔ Increased incidence of asthma and respiratory
problems in large cities with smog.
● Socio-cultural Dimension
- Health practices and beliefs are strongly
influenced by a person’s economic level, lifestyle,
family and culture. Low-income groups are less
likely to seek health care to prevent or treat
illness; high-income groups are more prone to
stress-related habits and illness. The family and
the culture to which the person belongs determine
patterns of livings and values about health and
illness that are often unalterable.
- It implies living in harmony with fellow human
beings, developing positive independent
relationships with others, and practicing healthy
sexual behaviors.
- Examples:
➔ The adolescent who sees nothing wrong with
smoking or drinking because his parents
smoke and drink.
➔ The person of Asian descent who uses herbal
remedies and acupuncture to treat an illness.
● Sexual Dimension
- Refers to acceptance and ability to achieve
satisfactory expression of one’s sexuality.
● Spiritual Dimension
- Spiritual and religious beliefs are important
components of the way the person behaves in
health and illness.
- People with good spiritual health identify their own
basic purpose in life; learn how to experience
love, jou, peace, and fulfillment; and help
themselves and others achieve their full potential.
- Examples:
➔ Roman Catholics require baptism for both live
births and stillborn babies.
➔ Jehovah Witnesses’ and Iglesia ni Cristo are
opposed to blood transfusions.
➔ Buddhist practice on death, the body of the
deceased should not be touched, disturbed, or
moved in any way because they believe the
soul doesn’t leave the body immediately after
breathing stops.