1.

) THE CARITAS PROCESSES

• Systematic use of a creative problem solving caring process becomes creative use of self and all
ways of knowing as part of the caring process; to engage in the artistry of caring-healing practices
(Watson, pg. 325). Promotion of transpersonal teaching learning becomes engaging in genuine
teaching-learning experience that attends to unity of being and meaning, attempting to stay within
others’ frames of reference
• Provision for a supportive, protective, and/or corrective mental, physical, societal, and spiritual
environment becomes creating a healing environment at all levels (a physical and nonphysical,
subtle environment of energy and consciousness, whereby wholeness, beauty, comfort, dignity, and
peace are potentiated)

2.) THE TRANSPERSONAL CARING RELATIONSHIP

• This portion of the theory focuses on “the one caring and the one cared for.” (Cara, 2003). The
nurse and patient can develop a deep divine relationship that blends together and promotes overall
health and well-being.
• This process requires the use of “Actions, words, behaviors, cognition, body language, feelings,
intuition, thought, senses, and the energy field” (Watson & Woodword, 2010).
• The nurse has a professional as well as a personal obligation to not only see the patient as more
than an object but to also protect and assist with improving the patient’s dignity. (Cara, 2003)
• The nurse should be using her professional experience to promote healing and bonding with the
patient. This may include the use of various communication techniques, both verbal and non-
verbal to achieve a healing and gentle relationship. (Watson & Woodward, 2010).

3.) THE CARING OCCASION/CARING MOMENT

• This portion of the theory focuses on an actual tangible moment in time in which the nurse
recognizes the connection that is developed between him/herself and the patient (Cara, 2003).
This moment dictates the ability for the nurse to have an overall impact on the patient.
• According to Cara, The Caring Moment “Consists 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.” (Cara, 2003).
• This can occur during various nursing interventions and interactions with each patient.
• The nurse and the patient are transformed together in this relationship. (Black, 2014).

4.) CARING AND HEALING MODEL

 The nurse is able to help the patient with overall well-being by assisting them with the release of
“disharmony and blocked energy” (Watson & Woodward, 2010).
 The use of this portion of the theory helps the patient with overall healing and renewal. (Black,
2014).
 Nurses can impact the patient through “health promotion, health restoration, and illness
prevention” (Black, 2014)
METAPARADIGM

PERSON – a self-interpreting being which is defined by the course of life they have lived or
experienced. A person is embodied or has the capacity to respond to meaningful situations.
Four major aspect conceptualized by Benner and Wrubel (1989) that a person must deal with:
o The role of the situation
o The role of the body
o The role of personal concerns
o The role of temporality

HEALTH – health can be defined in so many ways and can be assessed at a physical level and
objectively. Well-being is person’s experience of health or wholeness. This means that a person
may have the disease but does not feel ill, since illness is merely the experience of loss or
dysfunction.

ENVIRONMENT – Benner replaced “environment” and used the term “situation” for it
defines the person’s engaged interaction, interpretation, and understanding of the situation.
How one person interprets the situation depends on the way how that person feels bound in it.

NURSING – nursing is viewed as professional practice guided by moral art and ethics and
since caring is primary aspect in nursing, it sets the possibility of giving and receiving help. It
builds an enabling relationship of connection and concern between the nurse and the
patient.

PATRICIA BENNER LIFE AND CAREER

Patricia Benner was born on August 31, 1942 in Hampton, Virginia, but spent her childhood
in California. Her calling to become a nurse was aroused when she worked as an admitting clerk at a
hospital in Pasadena. She obtained a degree in nursing from Pasadena College in 1964 and her
master’s degree in 1970 from the University of California, San Francisco (UCSF). Benner started to
engage research as part of her career as a postgraduate nurse researcher in the UCSF School of
Nursing and in 1982, her PhD in stress, coping, and health was conferred at the University of
California, Berkeley.
Benner received various recognitions and awards in the field of nursing education and
research. To name a few, in 1985, she was inducted into the American Academy of Nursing and
received the National League for Nursing’s Linda Richards Award for leadership and education in
1989. In the field of research, she was awarded Excellence in Nursing Research and Excellence in
Nursing Education Award from the California Organization of Nurse Executives. Became an
Honorary Fellow in Royal College of Nursing, United Kingdom in 1994 and awarded with Nahm
Research Lecture Award for her invaluable contribution in the field of nursing science and research
in 1995 by the faculty of UCSF. 2002 when she was awarded by the National Council of State Boards
of Nursing for her outstanding contribution to the profession when she developed an electronic data
collection tool to capture sources and nature of nursing errors called Taxonomy of Error, Root Cause
and Practice (TERCAP).

She continued to work as a tenured professor in the different departments at UCSF and taught
at the doctoral and master’s level. She retired from full-time teaching in 2008 but still continues with
research writing, presentation, and consultations. She is currently the Chief Development Officer for
educatingnurses.com.
KATIE ERIKSSON: THEORY OF CARITATIVE CARING

THEORY AND SOURCES

Eriksson had the thought not only to develop the substance of caring but to develop caring
science as an independent discipline which is rooted from the Greek classics in which she
developed the metatheory referred to as “theory of science for caring science”. She introduced the
discipline with a structure based on Anders Nygren’s (1972) concepts of motive research, context of
meaning, and basic motive which is aimed in finding the context of caring. The basic context
according to Eriksson is caritas which gives the substance and discipline of caring science.
In her formulation of caritas-based caring ethics, her guiding principle was Emmanuel Lavinas
(1988) idea that ethics precedes ontology, the thought being called to serve precedes dialogue, and
ethics is essential in relations with other human beings.

METAPARADIGM
PERSON – based on the axiom that human being is an entity of body, soul, and spirit which
was intensified with Eriksson’s dialogue with several theologians such as Gustaf Wingren,
Antnio Barbosa da Silva, and Tage Kurten. She believed that human being is fundamentally a
religious being, holy, in constant becoming, and dependent on communion.

HEALTH – based on her analysis of the concepts for which she defined health as the
soundness, freshness, and well-being. Health is implied as being whole in body, soul, and
spirit, therefore, it is a state of wholeness and holiness. Health is both movement an
integration.
Movement and integration premises
• Implies change
• Human beings are either formed or destroyed but not completely
• Movement between actual and potential
• Movement in time and space
• Dependent on the vital force and on the vitality of body, soul, and spirit
• Direction of movement is determined by the human’s needs and desires
• Health strives toward realization of one’s potential
• Health is conceived as becoming, a movement into a deeper wholeness and
holiness
• Dimensions of health: doing, being, and becoming is visible when a person’s inner
potential is touched
 In doing, a person aims to have a healthy lifestyle and prevent the
occurrence of illness.
 In being, the aim is toward achieving harmony and balance.
 In becoming, deeper sense and level integration reflects wholeness

ENVIRONMENT – Eriksson used the concept of ethos, which refers to as home or a human
being’s innermost space where he appears in nakedness (Levinas, 1989). She believed that
people are called to serve with the idea of love, charity, respect, and honor of the holiness and
dignity of human being. She reintroduced the idea of suffering as a basic category of caring
and described it in three categories:
• Suffering related to illness
• Suffering related to care
• Suffering related to life

NURSING – Caritas is the basic motive of caring with the inclination to help and minister the
people who are in suffering (Lanara, 1981). Caring is a constituted idea of motherliness which
implies cleansing, nourishing, and spontaneous and unconditional love. She distinguished
nursing care and caring nursing. The core of caring relationship between a nurse and patient is
a constant open invitation with affirmation that the other is always welcome.

LIFE AND CAREER

 Katie Eriksson was born on November 18, 1943, in Jakobstad, Finland. Graduated in 1965
from the Helsinki Swedish School of Nursing and in 1967, has completed her public health
nursing specialty education at the same school. She received her MA degree in Philosophy at the
University of Helsinki in 1974. In 1984, appointed as Docent of Caring Science at University of
Kuopio and appointed Professor of Caring Science at Abo Akademi University in 1992. Since 1996
she has served as Director of Nursing at Helsinki University Central Hospital and centered her
responsibilities for research and development of caring science.

In 1972, Eriksson was assigned to start and develop an educational program to prepare
nurse educators and this was the beginning of the caring science didactics. Under her leadership at
the Helsinki Swedish School of Nursing, they developed a leading educational program in caring
science and nursing. In 1986, she was asked to plan an education and research program in caring
science at Abo Akademi University and a year later established the Department of Caring Science
equipped with fully developed educational program for health care. She also developed an
academic education for Doctoral and Master’s degree in Caring Science.

Eriksson retired at the age of 68 and has received many awards and honors during her entire
career. In 1987 she received the Sophie Mannerheim Medal of the Swedish Nursing Association. In
1998, she was awarded an honorary doctorate in recognition for her promotion of inter-Nordic
cooperation from the Nordic School of Public Health in Gothenberg and Caring Science Gold Mark
for academic nursing care at Helsinki University Central Hospital. Other awards include the 2001
Aland Islands Medal for caring science, 2003 Topelius Medal for excellent research from the Abo
Akademi University, and honoured nationally as a Knight, First Class, of the Order of the White Rose
of Finland. She died on August 30, 2019, at the age of 75 and will be remembered with her great
contributions in the field of nursing.
 ROY’S ADAPTATION MODEL IN NURSING PRACTICE
Adaptation is viewed as the process and outcome whereby thinking and feeling persons, as individuals or in groups, use conscious
awareness and choice to create human and environmental integration.

Human beings incessantly respond to myriad internal and external environmental stimuli. A stimulus is any entity that provokes a
response (Andrews & Roy, 1991a) and that serves as the point of interaction between the person and the environment (Roy &
Andrews, 1999). Environmental stimuli either threaten or enhance an individual’s ability to adapt. As an example, loving, supportive
behaviors from a parent enhance a child’s ability to successfully adapt, whereas a hostile, abusive parent poses a threat to a child’s
adaptation. Nursing plays a vital role in assisting individuals who are sick or well to respond to a variety of new stressors, move
toward optimal well-being, and improve the quality of their lives through adaptation. The Roy Adaptation Model (Roy & Andrews,
1991) provides an effective framework for addressing the adaptive needs of individuals, families, and groups.

History and Background

Sister Callista Roy, a Sister of Saint Joseph of Carondelet, developed the Roy Adaptation Model (RAM) in 1964 in response to a
challenge by her professor, Dorothy E. Johnson. Since that time, the RAM has been reconceptualized for use in the twenty-first
century. The development of the model has been a dynamic process. The preliminary ideas of this conceptual framework were first
published in an article titled Adaptation: A Conceptual Framework for Nursing (Roy, 1970). The RAM continues to be refined. The
RAM is presented in its most complete and recent form in The Roy Adaptation Model (Roy & Andrews, 1999). Nurses in the United
States, in Canada, and around the world practice nursing from the perspective of RAM. The RAM has stimulated other scholars to
publish books of their own about adaptation nursing (Rambo, 1984; Randell, Poush Tedrow, & Van Landingham, 1982; Welsh &
Clochesy, 1990), has been implemented in numerous hospitals and other health care settings, and has been applied to diverse
populations, adaptive needs, and developmental stages (Fawcett, 2005; Phillips, 2006).

Overview of Roy’s Adaptation Model

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. 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 the face of these environmental stimuli. Integrity is “the degree of wholeness achieved by adapting to changes in needs”
(Roy & Andrews, 1999, p. 102). Roy, drawing on the work of Helson (1964), categorizes these types of stimuli as focal, contextual, or
residual. The first type of stimulus, focal, is defined as 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 attention. Contextual stimuli are all other stimuli
existing in a situation that strengthen the effect of the focal stimulus. 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 & Andrews, 1999).
The three types of stimuli act together and influence the adaptation level, which is a person’s “ability to respond positively in a
situation” (Andrews & Roy, 1991a, p. 10). A person’s adaptation level may be described as integrated, compensatory, or compromised
(Roy & 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 either the regulator or the cognator subsystem. The coping
mechanisms of the regulator subsystem occur through neural, chemical, and endocrine processes. The coping mechanisms of the
cognator subsystem occur through cognitive-emotive processes. Roy has identified two control processes that coincide with the
regulator and cognator subsystems when a personresponds to a stimulus. The control processes identified by Roy are the stabilizer
subsystem and the innovator subsystem. 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 purposes of society” (Roy & Andrews,
1999, p. 47). The innovator subsystem refers to cognitive and emotional strategies that allow a person to change to higher levels of
potential (Roy & Andrews, 1999).

Although direct observation of the processes of the regulator and cognator subsystems is not possible, Roy proposes that the
behavioral responses of these two subsystems can be observed in any of the four adaptive modes: physiological, self-concept, role
function, and interdependence adaptive modes. Roy and her associates describe the function of the adaptive modes in the Theory of
the Person as an Adaptive System (Andrews & Roy, 1991a).

FOUR ADAPTIVE MODES

Roy’s Theory of the Person as an Adaptive System postulates that the four adaptive modes are interrelated through perception. Either
an adaptive response or an ineffective response in one mode influences adaptation in the other modes.

The physiological adaptive mode refers to the “way a person responds as a physical being to stimuli from the environment” (Andrews
& Roy, 1991a, p. 15). The five physiological needs of this mode are oxygenation, nutrition, elimination, activity and rest, and
protection. Four complex processes that mediate the regulatory activity of this mode are senses, fluids and electrolytes, neurological
function, and endocrine function. Physiological integrity is the adaptive response of this adaptive mode (Andrews & Roy, 1991a,
1991c).

The self-concept adaptive mode refers to psychological and spiritual characteristics of the person (Andrews, 1991b; Andrews & Roy,
1991a; Roy & 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 over time 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 (Buck, 1991b). The personal self incorporates self-consistency, self-ideal, and moral-
ethical-spiritual self (Buck, 1991a). Psychic integrity is the goal of the self-concept mode (Andrews, 1991b; Andrews & Roy, 1991a).
The interdependence adaptive mode refers to coping mechanisms arising from close relationships that result in “the giving and
receiving of love, respect, and value” (Andrews & Roy, 1991a, p. 17). 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 & Andrews, 1999; Tedrow, 1991).

The role function adaptive mode refers to the primary, secondary, or tertiary roles the person performs in society. According to
Andrews and Roy (1991a), “A role, as the functioning unit of society, is defined as a set of expectations about how a person
occupying one position behaves toward a person occupying another position” (p. 16). Social integrity is the goal of the role function
mode (Andrews, 1991a; Nuwayhid, 1991; Roy & 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 & Roy, 1991a).

As described earlier, adaptation is accomplished through two main coping subsystems: regulator and cognator. The mechanisms of
regulator and cognator have not been explicated by Roy because these mechanisms cannot be directly observed and remain largely
unknown. However, the behaviors of regulator and cognator are manifested indirectly and can be observed and measured in the four
adaptive modes (Roy, 1981).

Roy and Andrews (1999) define health as “a state and a process of being and becoming an integrated and whole person” (p. 31).
Health is a reflection of how successfully an individual has adapted to environmental stimuli. The goal of nursing therefore is to help a
person achieve adaptation by helping the person survive, grow, reproduce, and master. Adaptation leads to optimum health and well-
being, to the highest quality of life possible, and to death with dignity (Andrews & Roy, 1991a). Adaptation enables the person to find
meaning and purpose in life and to become an integrated whole.

Critical Thinking in Nursing Practice with Roy’s Model

The nursing process is a goal-oriented, problem-solving approach to guide the provision of comprehensive, competent nursing care to
a person or groups of persons. According to Andrews and Roy (1991b), the 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 & Andrews, 1999):
1. Assessment of behavior
2. Assessment of stimuli
3. Nursing diagnosis
4. Goal setting
5. Intervention
6. Evaluation
Each of these phases of the nursing process is discussed within the RAM. The goal of nursing in the RAM is to promote adaptation
in each of the four adaptive modes (Roy & Andrews, 1999).
The nursing process alone is limited in promoting critical thinking; however, nursing theory serves as a guide for nursing care.
Nursing theory directs the practitioner toward important aspects of assessing, planning, goal setting, implementation, and evaluation.
Furthermore, practice within a model allows the practitioner to ignore irrelevant considerations and to selectively choose among a
variety of nursing strategies. Another way of saying this is that nursing theory promotes critical thinking. Table 14-1 illustrates how
the RAM guides the nurse through the critical thinking process.
Assessment of Behavior
From Roy’s perspective, behavior is an action or a reaction to a stimulus. A behavior may be observable or nonobservable. An
example of an observable behavior is pulse rate; a nonobservable behavior is a feeling experienced by the person and reported to the
nurse. Exploration of behaviors manifested in the four adaptive modes allows the nurse to achieve an understanding of the current
adaptation level and to plan interventions that will promote adaptation. At the beginning of thenurse-client relationship, a thorough
assessment of behavior must be performed (Roy & Andrews, 1999) and the assessment must be ongoing. Table 14-1 presents
categories of behaviors that are assessed in each of the adaptive modes.

Assessment of Stimuli
A stimulus is any change in the internal or external environment that induces a response in the adaptive system. Stimuli that arise from
the environment can be classified as focal, contextual, or residual. In this level of assessment, the nurse analyzes subjective and
objective behaviors and looks more deeply for possible causes of a particular set of behaviors (Roy & Andrews, 1999).

Nursing Diagnosis
A nurse’s education and experience enable him or her to make an expert judgment regarding health care and adaptive needs of the
client. This judgment is expressed in a diagnostic statement that indicates an actual or a potential problem related to adaptation. The
diagnostic statement specifies the behaviors that led to the diagnosis and a judgment regarding stimuli that threaten or promote
adaptation (Roy & Andrews, 1999). The RAM defines nursing diagnosis “as a judgment process resulting in statements conveying the
adaptation status of the human adaptive system” (Roy & Andrews, 1999, p. 77).

Goal Setting
Goal setting focuses on promoting adaptive behaviors. Together the nurse and the client agree on clear statements about desired
behavioral outcomes of nursing care. The outcome statement should reflect a single adaptive behavior, be realistic, and be measurable.
The goal statement should include the behavior to be changed, the change expected, and the time frame in which the change in
behavior should occur (Roy & Andrews, 1999).

Intervention
According to Andrews and Roy (1991b), “Intervention focuses on the manner in which goals are attained” (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 (Andrews & Roy, 1991b).
Intervention is any nursing approach that is intended “to promote adaptation by changing stimuli or strengthening adaptive processes”
(Roy & Andrews, 1999, p. 86).

Evaluation
In the RAM, evaluation consists of one question: “Has the person moved toward adaptation?” Evaluation requires that analysis and
judgment be made to determine whether those behavioral changes stated in the goal statement have, or have not, been achieved by the
recipient of nursing care (Andrews & Roy, 1991b). In the evaluation phase, the nurse judges the effectiveness of the nursing
interventions that have been implemented and determines to what degree the mutually agreed upon goals have been achieved (Roy &
Andrews, 1999).
Nursing Care of Debbie with Roy’s Model
Physiological Adaptive Mode
Debbie’s health problems are complex. It is impossible to develop interventions for all of her health problems within the space of this chapter;
therefore, representative examples are presented.

Assessment of Behavior
Postoperatively, Debbie has been unable to completely empty her urinary bladder. She states that she is numb and unable to tell when she needs to
void. Catheterization for residual urine revealed that she was retaining 300 ml of urine after voiding. It will be necessary for her to perform
intermittent self-catheterization at home. Unsanitary conditions at Debbie’s home place her at high risk for developing a urinary tract infection. She
states that she is scared about performing self-catheterization.

Assessment of Stimuli
In this phase of the nursing process, the nurse searches for stimuli responsible for the observed behavior. After stimuli have been identified, they are
classified as focal, contextual, or residual.
The focal stimulus for Debbie’s urinary retention is the disease process. Contextual stimuli include tissue trauma resulting from surgery and
radiation therapy. Debbie verified anxiety as a residual stimulus.
Infection is a potential problem. The focal stimulus is the need for intermittent self-catheterization. Contextual stimuli include altered skin
integrity related to surgical incision, poor understanding of aseptic principles, and unsanitary conditions at Debbie’s home.

Nursing Diagnosis
From the assessment of behaviors and the assessment of stimuli, the following nursing diagnoses were made:
• Altered elimination: urinary retention related to surgical trauma, radiation therapy, and anxiety
• Potential for infection related to intermittent self-catheterization, altered skin integrity related to surgical incision, poor understanding of aseptic
principles, and unsanitary conditions at Debbie’s home
 DEVELOPMENT PROCESS OF THEORY IN NURSING

The process of theory development has been described in some detail by several nursing scholars (Chinn & Jacobs, 1978;
Chinn & Kramer, 1995; Jacox, 1974; Walker & Avant, 2005). Despite slight variations related to terminology and
sequencing, the sources are similar in explaining the processes used to develop theory.

The three basic steps are concept development, statement/proposition development, and theory construction. Chinn
and Kramer (2008) add two additional steps that involve validating, confirming, or testing of the theory and
application of theory in practice.

1. Concept Development: Creation of Conceptual Meaning This first step or process of theory development
involves creating conceptual meaning. This provides the foundation for theory development and includes
specifying, defining, and clarifying the concepts used to describe the phenomenon of interest (Jacox, 1974).
Creating conceptual meaning uses mental processes to create mental structures or ideas to be used to represent
experience. This produces a tentative definition of the concept(s) and a set of criteria for determining if the
concept(s) exists in a particular situation (Chinn & Kramer, 2008).

2. Statement Development: Formulation and Validation of Relational Statements Relational statements are the
skeletons of theory; they are the means by which the theory comes together. The process of formulation and
validation of relational statements involves developing the relational statements and determining empirical
referents that can validate them. After a statement has been delineated initially, it should be scrutinized or
analyzed.
 Statement analysis is a process described by Walker and Avant (2005) to thoroughly examine relational
statements. Statement analysis classifies statements and examines the relationships between the concepts and
helps direct theoretical construction. Following the process of statement analysis, the statements are refined and
may be operationalized.

3. Theory Construction: Systematic Organization of the Linkages : The third stage in theory development
involves structuring and contextualizing the components of the theory. This includes formulating systematic
linkages between and among concepts, which results in a formal, coherent theoretical structure. The format
used depends on what is known or assumed to be true about the phenomena in question (Chinn & Kramer,
2008). Aspects of theory construction include identifying and defining the concepts, identifying assumptions,
clarifying the context within which the theory is placed, designing relationship statements, and delineating the
organization, structure, or relationship among the components. Theory synthesis is a theory construction
strategy developed by Walker and Avant (2005).
In theory synthesis, concepts and statements are organized into a network or whole. The purposes of theory
synthesis are to represent a phenomenon through an interrelated set of concepts and statements, to describe
the factors that precede or influence a particular phenomenon or event, to predict effects that occur after some
event, or to put discrete scientific information into a more theoretically organized form. Theory synthesis can
be used to produce a compact, informative graphic representation of research findings on a topic of interest,
and synthesized theories may be expressed in several ways such as graphic or model form.

4. Validating and Confirming Theoretical Relationships in Research

Chinn and Kramer (2008) include the process of validating and confirming theoretical relationships as a
component of theory development. Validating theoretical relationships involves empirically refining concepts
and theoretical relationships, identifying empirical indicators, and testing relationships through empirical
methods. In this step, the focus is on correlating the theory with demonstrable experiences and designing
research to validate the relationships. Additionally, alternative explanations are considered, based on the
empirical evidence.

5. Validation and Application of Theory in Practice

An important final step in theory development identified by Chinn and Kramer (2008) is applying the theory
in practice. In this step, research methods are used to assess how the theory can be applied in practice. The
theoretical relationships are examined in the practice setting and results are recorded to determine how well
the theory achieves the desired outcomes. The research design should provide evidence of the effect of the
interventions on the well-being of recipients of care. Questions to be considered in this step include: Are the
theory’s goals congruent with practice goals? Is the intended context of the theory congruent with the practice
situation? Are explanations of the theory sufficient for use in the nursing situation? Is there research evidence
supporting use of the theory?
 Nightingale’s Philosophy in Nursing Practice

I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicine and application
of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration
of diet—all at the least expense of vital power to the patient. (Nightingale, 1969, p. 8)

History and Background

Nightingale was born in 1820 in Florence, Italy. Her parents were very wealthy and often traveled abroad. Nightingale was
beautiful and was expected to behave like every other Victorian lady, filling her time before marriage with music, reading,
embroidery, and learning how to be the perfect hostess (Brown, 1988).
Nightingale had other ideas. She had felt different from those around her even at a young age, and by the time she was
17, believed she was called by God into His service (Woodham-Smith, 1951). She had great compassion and sympathy
for people of all types, and as she grew older, she believed she had been called to help mankind. She desired to help the
truly poor but suffered in silence for years because it was improper for someone of her upbringing to involve herself with
actual physical work (Brown, 1988). At the age of 24, Nightingale decided she needed to help the suffering masses and
wished to work in a hospital. This was met with opposition from her family, and they fought about it for years before finally
allowing her to go to Kaiserworth, Germany, to learn nursing from the Institution of Deaconesses (Brown,
1988; Woodham-Smith, 1951). She studied there for 3 months and then returned to the service of her family. It was
another 2 years before she was allowed to practice nursing (Brown, 1988; Woodham-Smith, 1951). She developed what
we have come to refer to as her nursing theory after her travel to Scutari to care for wounded soldiers during the Crimean
War. Her writings, which included philosophy and directives, were developed from a need to define nursing and reform
hospital environments rather than for the purpose of providing nursing new knowledge. Nightingale worked endlessly
during her lifetime to introduce many types of reform, in areas as diverse as the British military and the environment of
England (Brown, 1988; Woodham-Smith, 1951). Because of her work in nursing and nursing education, she is known as
the founder of modern nursing (Dennis & Prescott, 1985; Henry, Woods, & Nagelkerk, 1990). She started a school of
nursing at St. Thomas Hospital in England and wrote many manuscripts about hospital reform and nursing care (Brown,
1988; Woodham-Smith, 1951). Nightingale (1969) clarified that “nursing knowledge is distinct from medical knowledge”
(p. 3).

Overview of Nightingale’s Environmental Philosophy

Nightingale’s philosophy is environmentally oriented. This is evidenced by her many writings and her book Notes on
Nursing: What It Is and What It Is Not (Nightingale, 1969). She believed that the environment of the patient should
be altered to allow nature to act on the patient (McKenna, 1997; Nightingale, 1969). Her work focuses mostly on the
patient and the environment but also includes the nurse and health. For instance, it was the nurse’s duty to alter
the patient’s environment so that nature could act on the patient and repair health. The components of Nightingale’s
philosophy, which is now recognized as theory in this theory era, are the following:

• Environment: Environment can be defined as anything that can be manipulated to place a patient in the best
possible condition for nature to act (Selanders, 1998). 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 (Lobo, 2011; Nightingale, 1969; Reed & Zurakowski, 1996; Selanders,
1998). The psychological components include avoiding chattering hopes and advices and providing variety
• Person: Although most of Nightingale’s writings refer to the person as the one who is receiving care, she did believe
that the person is a dynamic and complex being. Reed and Zurakowski (1996) state, “Nightingale envisioned the
person as comprising physical, intellectual, emotional, social, and spiritual components” (p. 33).

• Health: Nightingale (1954b) wrote, “Health is not only to be well, but to be able to use well every power we have”
(p. 357). From this statement we can infer that she believed in prevention and health promotion in addition to nursing
patients from illness to health.

• Nursing: Nightingale believed nursing to be a spiritual calling. Nurses were to assist nature that was healing the
patient. She defined different types of nursing as nursing proper (nursing the sick), general nursing (health
promotion), and midwifery nursing . Nightingale saw nursing as the “science of environmental management” Nurses
were to use common sense, observation, and ingenuity to allow nature to effectively repair the patient

Although the model seems linear, it has been observed that the nurse initiates mutuality of care and outcome
between the nurse and the patient. Nightingale assumed that the patient wanted to be healthy and would cooperate
with and assist the nurse to allow nature to help the patient. 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 . This is done as often as
necessary until the main goal of nursing (improved health state) is accomplished. At each phase of the process,
documentation occurs to allow other caregivers to follow the plan of care.
 TRAVELBEE’S THEORY: HUMAN-TO-HUMAN RELATIONSHIP MODEL
Travelbee expresses the importance for nurses to recognize their concept of what is human, for their relationship with another human
being will be otherwise determined by that concept (Shelton, 2016). Travelbee (1971) defined human being as “a unique irreplaceable
individual, a one-time being in this world, like yet unlike any person who has ever lived or ever will live” (p. 26). The nurse should
promote patient-centered care, which recognizes the individuality of each human being. A person will respond to illness depending on
culture, symptom burden, and whether there is a correlated significance to those symptoms (Meleis, 2012; Shelton, 2016; Travelbee,
1963). Depending on the impairment of functioning as well as the health professional’s responses, a human connection that fosters
understanding of the illness is developed (Travelbee, 1971). As we know, every individual experiences suffering, as it is a part of being
human. Travelbee (1971) emphasized that “It is probable that the more an individual cares for, and about others, the greater the
possibilities of suffering” (p. 64). Communication is a requirement for good nursing and an essential part of this theory. Travelbee
(1971) expresses striving to communicate “to know ill persons, to ascertain and meet nursing needs and to achieve the purpose of
nursing” (p. 102). Human relationships become therapeutic as they pass through expected steps or stages (Meleis, 2012; Shelton,
2016). The concept of communication resonates through Travelbee’s model. Recognizing the other human being is as significant as
performing procedures. As highlighted, the nurse must establish a rapport, otherwise the nurse will not identify the patient’s needs
(Meleis, 2012; Travelbee, 1963, 1971). One could debate that in a PC setting, there would be no difference between caring for the
person at end-of-life than treating illness in a primary care setting, except the triggers of suffering occur much more often. Travelbee’s
model is very suitable for this setting. Travelbee (1971) mentioned: “Nurses who know ill persons are more apt to be able to detect not
only obvious changes in an individual’s condition but are enabled to recognize the more subtle changes that may be occurring” (p. 98).
he human-to-human relationship is, therefore, very important when the provision of nursing care occurs during the process of transition
to the PC situation. As it is a transition, it is inherently associated with vulnerabilities and “the quality of nursing care given any patient is
determined by the nurse’s beliefs about illness, suffering, and death” (Travelbee, 1966, p. 55). As mentioned by Travelbee (1963,
1964), both the nurse and the patient are human beings. A human being is a unique, irreplaceable individual, who is in the continuous
process of becoming, evolving, and changing. For that reason, attention should be given to the patient’s objective health (for example,
monitoring of vital signs, laboratory tests), but also to his/her subjective health, that is, the state of well-being in accord with self-
appraisal of physical-emotional-spiritual status. Based on this assumption, nurses will more easily understand, respect, and accept the
patient as a unique person, building a closer trust relationship (Pokorny, 2014; Travelbee, 1963, 1971). Travelbee emphasized that
nurses must be able to “assist patients to find meaning in the experience of illness, suffering and pain” (Travelbee, 1966, p. 165). By
being able to connect with the patient and form a relationship that goes beyond providing medication and checking blood pressures,
nurses can ensure a better, more productive, and meaningful experience for patients. Travelbee believed that nursing is accomplished
through human-to-human relationships (Figure 1). These relationships begin with the original encounter (first impression by the nurse
of the patient and vice-versa, and then progress through stages of emerging identities (the time when relationships begin, where nurse
and patient perceive each other’s uniqueness), developing feelings of empathy (the ability to share in the person’s experience), and
later feelings of sympathy (when the nurse wants to lessen the cause of patient’s suffering.
t this point, it seems relevant to clarify that empathy is the forerunner of sympathy. As an emotion comprehension of another person, it
is important and desirable because it helps nurses to predict that person’s behavior and to perceive accurately his thinking and feeling.
However, it is essentially a neutral process; it does not really imply that a person takes action on the basis of the comprehension which
has been gained. Sympathy, on the other hand, implies a desire, almost an urge, to assist the patient in order to relieve his/her
distress; when one sympathizes, one is involved but not incapacitated by the involvement (Travelbee, 1964). According to Travelbee,
sympathy is “a process wherein an individual is able to comprehend the distress of another, be moved or touched by another’s distress,
and desires to alleviate the cause. One ‘shares’ in the feelings of another and experiences compassion” (Travelbee, 1966, p. 146). The
empathic nurse can perceive the distress of another person, recognize its source, and anticipate the behavior that will result from it. On
the other hand, the sympathetic nurse feels the distress of another person, being touched and moved by it and actively wants to do
something to alleviate it (Travelbee, 1964, 1966). “There is a warmth, an urge to action, in sympathy that is not present in empathy”
(Travelbee, 1964, p. 69). To be sympathetic means that this human being who is capable of helping – the nurse - is concerned with this
human being who is seeking to alleviate distress – the patient (Travelbee, 1963, 1964). The nurse and the patient attain rapport in the
final stage. Rapport is a way in which the nurse perceives and relates to the other human being/patient-family; it is composed of
interrelated thoughts and feeling, interest in and concern for others, through a non-judgmental attitude, and respect for each person as
a unique human being. According to Travelbee (1963), rapport is “empathy, compassion, and sympathy; a non-judgmental attitude, and
respect for each individual as a unique human being” (p. 70). In PC settings, these aspects are very important given that the proximity
of death is a unique moment for each person and family, and the sensitivity, empathy, and sympathy of the nursing team are crucial in
the way PC care are delivered and experienced (Parola et al., 2018).There is evidence to support that empathetic care can improve
patient-reported outcomes and increase patient satisfaction (Post et al., 2014; Sinclair et al., 2017). Thus, this theory should be
addressed in every health profession. However, it is perhaps more essential in PC, where the relief of suffering, empathy, and
sympathy in patients with progressive illness are clear goals of PC (Sinclair et al., 2017; World Health Organization, 2002). Rapport is
essentially the catalyst which transforms a series of nurse-patient interactions into a meaningful nurse-patient relationship, a concern
for others and an active and genuine interest in them. However, it takes more than interest; it is necessary a belief in the worth, dignity,
uniqueness, and irreplaceability of each individual human being. It is important to refer that rapport doesn’t “just happen”; it must be
built day by day in the nurse’s contacts and interactions with the patient, and it will change as changes occur in the interpersonal
situation (Pokorny, 2014; Travelbee, 1963).
 UNITARY HUMAN BEINGS
MARTHA ROGERS

Rogers’ grounding in the liberal arts and sciences is apparent in both the origin and the development of her conceptual
model, published in 1970 as an Introduction to the Theoretical Basis of Nursing (Rogers, 1970). Aware of the
interrelatedness of knowledge, Rogers credited scientists from multiple disciplines with influencing the development of
the Science of Unitary Human Beings. Rogerian science emerged from the knowledge bases of anthropology, psychology,
sociology, astronomy, religion, philosophy, history, biology, physics, mathematics, and literature to create a model of
unitary human beings and the environment as energy fields integral to the life process. Within nursing, the origins of
Rogerian science can be traced to Nightingale’s proposals and statistical data, placing the human being within the
framework of the natural world. This “foundation for the scope of modern nursing” began nursing’s investigation of the
relationship between human beings and the environment (Rogers, 1970, p. 30). Newman (1997) describes the Science of
Unitary Human Beings as “the study of the moving, intuitive experience of nurses in mutual process with those they
serve”

MAJOR CONCEPTS and DEFINITIONS

 In 1970, Rogers’ conceptual model of nursing rested on a set of basic assumptions that described the life process
in human beings. Wholeness, openness, unidirectionality, pattern and organization, sentience, and thought
characterized the life process (Rogers, 1970).
 Rogers postulates that human beings are dynamic energy fields integral with environmental fields. Both human
and environmental fields are identified by pattern and characterized by a universe of open systems. In her 1983
paradigm, Rogers postulated four building blocks for her model: energy field, a universe of open systems, pattern,
and four dimensionalities.
 Rogers consistently updated the conceptual model through revision of the homeodynamic principles. Such
changes corresponded with scientific and technological advances. In 1983, Rogers changed her wording from that
of unitary man to unitary human being, to remove the concept of gender. Additional clarification of unitary
human beings as separate and different from the term holistic stressed the unique contribution of nursing to health
care. In 1992, four dimensionality evolved into pandimensionality. Rogers’ fundamental postulates have remained
consistent since their introduction; her subsequent writings served to clarify her original ideas.

ENERGY FIELD - An energy field constitutes the fundamental unit of both the living and the nonliving. Field is a
unifying concept, and energy signifies the dynamic nature of the field. Energy fields are infinite and pandimensional. Two
fields are identified: the human field and the environmental field. “Specifically human beings and environment are energy
fields” (Rogers, 1986b, p. 2). The unitary human being (human field) is defined as an irreducible, indivisible,
pandimensional energy field identified by pattern and manifesting characteristics that are specific to the whole and that
cannot be predicted from knowledge of the parts. The environmental field is defined as an irreducible, pandimensional
energy field identified by pattern and integral with the human field. Each environmental field is specific to its given
human field. Both change continuously, creatively, and integrally (Rogers, 1994a).

UNIVERSE OF OPEN SYSTEMS - The concept of the universe of open systems holds that energy fields are infinite,
open, and integral with one another (Rogers, 1983). The human and environmental fields are in continuous process and
are open systems.

PATTERN - Pattern identifies energy fields. It is the distinguishing characteristic of an energy field and is perceived as a
single wave. The nature of the pattern changes continuously and innovatively, and these changes give identity to the
energy field. Each human field pattern is unique and is integral with the environmental field (Rogers, 1983).
Manifestations emerge as a human-environmental mutual process. Pattern is an abstraction; it reveals itself through
manifestation. “Manifestations of pattern have been described as unique and refer to behaviors, qualities, and
characteristics of the field” (Clarke, 1986, p. 30). A sense of self is a field manifestation, the nature of which is unique to
each individual. Some variations in pattern manifestations have been described in phrases such as “longer vs. shorter
rhythms,” “pragmatic vs. imaginative,” and time experienced as “fast” or “slow.” Pattern is changing continually and may
manifest disease, illness, or well-being. Pattern change is continuous, innovative, and relative.

PANDIMESIONALITY - Rogers defines pandimensionality as a nonlinear domain without spatial or temporal

attributes. The term pandimensional provides for an infinite domain without limit. It best expresses the idea of a unitary
whole.

MAJOR ASSUMPTIONS

NURSING - Nursing is a learned profession and is both a science and an art. It is an empirical science and, like other
sciences, that lies in the phenomenon central to its focus. Rogerian nursing focuses on concern with people and the world
in which they live—a natural fit for nursing care, as it encompasses people and their environments. The integrality of
people and their environments, operating from a pandimensional universe of open systems, points to a new paradigm and
initiates the identity of nursing as a science. The purpose of nursing is to promote health and well-being for all persons.
The art of nursing is the creative use of the science of nursing for human betterment (Rogers, 1994b). “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 environmental fields for realization of
maximum health potential” (Rogers, 1970, p. 122). Nursing exists for the care of people and the life process of humans.
PERSON - Rogers defines person as an open system in continuous process with the open system that is the environment
(integrality). She defines unitary human being as an “irreducible, indivisible, pandimensional energy field identified by
pattern and manifesting characteristics that are specific to the whole” (Rogers, 1992, p. 29). Human beings “are not
disembodied entities, nor are they mechanical aggregates.Man is a unified whole possessing his own integrity and
manifesting characteristics that are more than and different from the sum of his parts” (Rogers, 1970, pp. 46-47). Within a
conceptual model specific to nursing’s concern, people and their environment are perceived as irreducible energy fields
integral with one another and continuously creative in their evolution.

HEALTH - Rogers uses health in many of her earlier writings without clearly defining the term. She uses the term
passive health to symbolize wellness and the absence of disease and major illness (Rogers, 1970). Her promotion of
positive health connotes direction in helping people with opportunities for rhythmic consistency (Rogers, 1970). Later,
she wrote that wellness “is a much better term…because the term health is very ambiguous” (Rogers, 1994b, p. 34).
Rogers uses health as a value term defined by the culture or the individual. Health and illness are manifestations of pattern
and are considered “to denote behaviors that are of high value and low value” (Rogers, 1980). Events manifested in the
life process indicate the extent to which a human being achieves maximum health according to some value system. In
Rogerian science, the phenomenon central to nursing’s conceptual system is the human life process. The life process has
its own dynamic and creative unity, inseparable from the environment, and is characterized by the whole (Rogers, 1970).
In “Dimensions of Health: A View from Space,” Rogers (1986b) reaffirms the original theoretical assertions, adding
philosophical challenges to the prevailing perception of health. Stressing a new worldview that focuses on people and
their environment, she lists iatrogenesis, nosocomial conditions, and hypochrondriasis as the major health problems in the
United States. Rogers (1986b) writes, “A new world view compatible with the most progressive knowledge available is a
necessary prelude to studying human health and to determining modalities for its promotion whether on this planet or in
the outer reaches of space” (p. 2).

ENVIRONMENT -Rogers (1994a) defines environment as “an irreducible, pandimensional energy field identified by
pattern and manifesting characteristics different from those of the parts. Each environmental field is specific to its given
human field. Both change continuously and creatively” (p. 2). Environmental fields are infinite, and change is
continuously innovative, unpredictable, and characterized by increasing diversity. Environmental and human fields are
identified by wave patterns manifesting continuous mutual change.

CONCLUSION
 The Science of Unitary Human Beings. Rogers envisions the human being as a system of energy in motion within
other such systems, themselves forming more complex systems. Each human being is said to be "unitary" and he
or she can not be considered in isolation, separate from his or her environment
 In "rogerian" perspective, nurses' work is to be done with unitary human beings in a state of continuous mutual
exchange with their environment. And nursing's goal is to participate in this process of change in order to
maximise each client's health potential. The model application accompanying the article illustrates the concepts
and theoretical principles described.
 GOAL ATTAINMENT THEORY
IMOGENE KING

OVERVIEW
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
(1996) 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 linkage 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).
Concepts gleaned from an extensive review of the nursing literature organize knowledge about individuals, groups, and
society (King, 1971, 1992). King notes that the concepts are often interrelated and can be applied across systems.
According to King (1981, 1988, 1991), concepts are critical because they provide knowledge that is applicable to practice.
Systems and concepts within King’s conceptual system and Theory of Goal Attainment are described and defined in the
following section.

PERSONAL SYSTEMS
Individuals are personal systems (King, 1981). Each individual is an open, total, unique system in constant interaction
with the environment. Interactions between and among personal systems are the focus of King’s conceptual system.
Patients, family members, friends, other health care professionals, clergy, and nurses are just a few examples of
individuals who interact in the nursing practice environment. The following concepts provide foundational knowledge that
contributes to understanding individuals as personal systems:

 Perception: “A process of organizing, interpreting, and transforming information from sense data and memory” (King, 1981,
p. 24).
 Self: King (1981) cites developmental psychologist’s A. T. Jersild’s (1952) definition of self when explaining that
“knowledge of self is a key to understanding human behavior because self is the way I define me to myself and to others. Self
is all that I am. I am a whole person. Self is what I think of me and what I am capable of being and doing. Self is subjective in
that it is what I think I should be or would like to be” (p. 26). Self is a dynamic, action-oriented open system.
 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’ reactions to his/her appearance which results from
others’ reactions to self” (King, 1981, p. 33).
 Learning: “A process of sensory perception, conceptualization, and critical thinking involving multiple experiences in which
changes in concepts, 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: King (1981) used the term coping in her discussion of the concept of stress in the interpersonal system and in later
discussions of the Theory of Goal Attainment (King, 1992, 1997) without explicit definition.

INTERPERSONAL SYSTEMS
Interpersonal systems are formed by the interactions of two or more individuals (King, 1981). As the number of
individuals increases, so does the complexity of the interaction. These groups may range in size from two or three
interacting individuals to small or large groups. King’s process of nursing occurs primarily within the interpersonal
systems between the nurse and patient. Concepts critical to understanding interactions between individuals are defined as
follows:

 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). “The process of interactions
between two or more individuals represents a sequence of verbal and nonverbal behaviors that are goal-directed”
(King, 1981, p. 60).
 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).
 Transaction: “Observable behaviors of human beings interacting with their environment” (King, 1981, p. 147).
“In the interactive process, two individuals mutually identify goals and the means to achieve them. When they
agree to the means to implement the goals, they move toward transactions…. Transactions are defined as goal
attainment” (King, 1981, p. 61).
 SOCIAL SYSTEMS
Social systems are composed of large groups with common interests or goals. A social system is defined as “an organized
boundary system of social roles, 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 life span. Concepts that are useful to understand interactions within social systems and between social and
personal systems are defined as follows:

 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 playa 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).

CONCLUSION
The Theory of Goal Attainment addresses nursing as a process of human interaction. Indeed, King (1981) stated that the
Theory of Goal Attainment is a normative theory; that is, it should set the standard of practice for all nurse-patient
interactions. King (1997) recalled finding an index card on which she had written the following 15 years previously:
“King’s law of nurse-patient interaction: Nurses and patients in mutual presence, interacting purposefully, make
transactions in nursing situations based on each individual’s perceptions, purposeful communication, and valued goals”
(p. 184).

The nurse and patient form an interpersonal system in which each affects the other and in which both are affected by
situational factors in the environment. Drawn from both the personal and interpersonal system concepts, the Theory of
Goal Attainment comprises the concepts of perception, communication, interaction, transaction, self, role, growth and
development, stress/stressors, coping, time, and personal space. King (1981, 1991) identified that perception,
communication, and interaction are essential elements in transaction. When transactions are made, goals are usually
attained. The human interaction and conceptual focus dimensions of the theory guide the nursing process dimension
(Figure 9-1).

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
(1996) 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 linkage 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).
Concepts gleaned from an extensive review of the nursing literature organize knowledge about individuals, groups, and
society (King, 1971, 1992). King notes that the concepts are often interrelated and can be applied across systems.
According to King (1981, 1988, 1991), concepts are critical because they provide knowledge that is applicable to practice.
Systems and concepts within King’s conceptual system and Theory of Goal Attainment are described and defined in the
following section.
 INTERPERSONAL RELATIONSHIP
HILDEGARD PEPLAU

A n INTERPERSONAL RELATIONSHIP (often referred to as an IPR) is the connection that exists between two or more individuals.
Observation, assessment, communication, and evaluation skills serve as the foundation for an interpersonal relationship. Development
of any interpersonal relationship requires the individual to have a basic understanding of self and what that individual brings to the
relationship. The second most important skill is that of communication, including both verbal and nonverbal communication.
The relationship that nurses have with their patients is considered the cornerstone of all other components of nursing. Regardless
of the patient’s health status—ranging from well individuals living in the community to patients who are critically or terminally ill—
establishing a nurse−patient relationship is one of the nurse’s primary goals. It is this relationship that is reflected and integrated into
the plan of care for any patient of any age, culture, or socioeconomic background.
The interpersonal relationship in nursing is often considered to be the one-to-one relationship between the nurse and patient.
However, the nurse also needs to develop interpersonal relationships with the patient’s family and key individuals in the patient’s
environment.
Interpersonal relationships form the basis of nursing interventions for psychiatric-mental health nursing. To do this, nurses must
learn how to build the relationship and develop the skills for enhancing the interaction among the nurse, patient, family, and other
important individuals in the patient’s life.

PEPLAU THEORY
 Peplau viewed nursing as an interpersonal process between two or more persons directed toward a therapeutic
goal. Therapeutic goal attainment is achieved by the nurse’s deliberate actions that occur along a sequence of
phases.
 The environment also plays a key role in human development (Peplau, 1992). The environment included factors
such as culture, adult presence, economic status, and prenatal environment, as well as the interactions between the
patient and the others, that is, family, parents, or nurse.
 Anxiety is another key component of Peplau’s theory. (See Chapter 13 for a more in-depth discussion of anxiety.)
Drawing on the work by Sullivan and his interpersonal theory, she identified different levels of anxiety and their
effects on an individual. Peplau emphasized the need for nurses to recognize anxiety and intervene accordingly to
improve the individual’s state.
 Peplau believed that the interpersonal competencies of nurses are essential to assisting patients to regain health
and well-being. These interpersonal competencies are based on the nurse’s ability to understand his or her own
behavior. Peplau stressed the need for nurses to be able to feel within themselves the feelings that others are
communicating verbally or nonverbally. Most commonly, these feelings are anxiety or panic. Nurses then
integrate this understanding and self-awareness to assist others in identifying their problems. (See Chapter 3 for
more information on developing self-awareness.)

PHASES OF INTERPERSONAL PROCESS

ORIENTATION

 The first phase of Peplau’s interpersonal process is the ORIENTATION PHASE. This phase includes the initial
contact the nurse has with the patient. During this phase, the patient seeks assistance. The nurse identifies himself
or herself and the purpose and nature of the relationship. It is in this orientation phase that the nurse also
communicates the temporal dimension of the relationship to the patient; that is, he or she informs the patient about
the time frame available for the therapeutic interaction.
 Peplau emphasizes that the patient is the focus of the communication. Personal information about the nurse is not
needed. The patient conveys his or her needs, asks questions, and shares information. The nurse observes the
patient and makes assessments of the patient’s status and needs during this phase of the relationship. Acting as a
participant observer, the nurse uses his or her knowledge about influencing factors and takes into account the
patient’s previous experiences, values, beliefs, culture, and expectations. The nurse also is cognizant of his or her
own previous personal experiences, values, beliefs, culture, preconceived ideas, and expectations; assesses his or
her own self; and determines how these may influence the nurse–patient relationship. This knowledge of self is an
important factor in the relationship.
 At the beginning of the orientation phase, the nurse and the patient meet as strangers, but as the relationship is
developed, the problem is identified. The nurse explains routines, roles, and expectations to elicit the full
participation of the patient. Subsequently, the patient begins to develop a sense of belonging and the ability to
deal with the present difficulties. The patient and the nurse are ready to move to the next phase of the relationship.
IDENTIFICATION

 in the identification phase, the patient recognizes the health care needs for which the nurse can provide assistance.
the patient views the nurse as a skilled provider of care capable of helping the patient to meet these needs and
accepts the nurse’s help. the nurse, in turn, senses that the patient has identified the needs and has cast the nurse in
the role of the care provider. additionally, the nurse identifies personal knowledge, attributes, and skills that he or
she can bring to the relationship when providing nursing care. together, the patient and nurse develop mutual
goals and begin working together to address the patient’s needs. expression and exploration of the patient’s
feelings are key during this time.

EXPLOITATION
 During the EXPLOITATION PHASE, the bulk of the work in the nurse–patient relationship is accomplished with
the patient taking full advantage of the nursing services offered. This phase encompasses all of the therapeutic
activities that are initiated to reach the identified goal. Throughout this phase, the nurse and the patient must
continue to clarify expectations and goals and to define the work to be done based on identification of patient
needs
 Open communication is essential during this time and requires a trusting relationship between nurse and patient.
Without this trust, the work essential to meeting the therapeutic goals cannot be completed.
 The relationship between the nurse and the patient during this phase is intense as the patient begins to take
responsibility for his or her own health goals. This shift in responsibility from the nurse to the patient
characterizes this phase. However, this transition to greater responsibility may be the most difficult point in the
nurse–patient relationship. The exploitation phase requires that the nurse begins to foster independence in the
nurse–patient relationship and starts the process of “letting go” in preparation for the next phase. Health care
providers, including nurses, sometimes have difficulty in relationships when their clients are not dependent on
them. This may indicate a boundary issue. (For more information on health boundary management in therapeutic
relationships, see Chapter 4.) Although the patient may initially be dependent on the nurse, as the exploitation
phase progresses the patient develops independence.

RESOLUTION
 the resolution phase of the relationship occurs when the patient’s needs have been met through the collaborative
work of nurse and patient. the nurse’s evaluation of the patient’s readiness to move through termination of the
relationship is crucial to resolution. during a successful termination, the patient moves away from the nurse and
understands that he or she can manage independently. the patient assumes the power to meet his or her needs and
set new goals. however, if the relationship is terminated prematurely, the patient may relapse and thus require a
rebuilding of the therapeutic relationship.
 NURSING NEED THEORY
VIRGINIA HENDERSON
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. Virginia Henderson developed the Nursing Need Theory
to define the unique focus of nursing practice. The theory focuses on the importance of increasing the patient’s
independence to hasten their progress in the hospital. Henderson’s theory emphasizes the basic human needs and how
nurses can meet those needs.
"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. And to do this in such a way as to help him gain independence as rapidly as possible"
(Henderson, 1966).

14 COMPONENTS OF THE NEED THEORY

Physiological Components
1. Breathe normally
2. Eat and drink adequately
3. Eliminate body wastes
4. Move and maintain desirable postures
5. Sleep and rest
6. Select suitable clothes – dress and undress
7. Maintain body temperature within normal range by adjusting clothing and modifying environment
8. Keep the body clean and well-groomed and protect the integument
9. Avoid dangers in the environment and avoid injuring others
Psychological Aspects of Communicating and Learning
10. Communicate with others in expressing emotions, needs, fears, or opinions.
14. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health
facilities.
Spiritual and Moral
11. Worship according to one’s faith
Sociologically Oriented to Occupation and Recreation
12. Work in such a way that there is a sense of accomplishment
13. Play or participate in various forms of recreation

MAJOR CONCEPT
INDIVIDUAL
 Henderson states that individuals have basic health needs and require assistance to achieve health and
independence or a peaceful death. According to her, an individual achieves wholeness by maintaining
physiological and emotional balance.
 she defined the patient as someone who needs nursing care but did not limit nursing to illness care. Her theory
presented the patient as a sum of parts with biopsychosocial needs, and the mind and body are inseparable and
interrelated.

ENVIRONMENT
 Although the Need Theory did not explicitly define the environment, Henderson stated that maintaining a
supportive environment conducive to health is one of her 14 activities for client assistance.
 Henderson’s theory supports the private and public health sector’s tasks or agencies to keep people healthy. She
believes that society wants and expects the nurse’s act for individuals who cannot function independently.

HEALTH
 Although not explicitly defined in Henderson’s theory, health was taken to mean balance in all realms of human
life. It is equated with the independence or ability to perform activities without aid in the 14 components or basic
human needs.
 On the other hand, nurses are key persons in promoting health, preventing illness, and curing. According to
Henderson, good health is a challenge because it is affected by numerous factors such as age, cultural
background, emotional balance, and others.

NURSING
 Virginia Henderson wrote her definition of nursing before the development of theoretical nursing. She defined
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 that he would perform unaided if he had the necessary strength,
will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.” The
nurse’s goal is to make the patient complete, whole, or independent. In turn, the nurse collaborates with the
physician’s therapeutic plan.
 Nurses temporarily assist an individual who lacks the necessary strength, will, and knowledge to satisfy one or
more of the 14 basic needs. She states: “The nurse is temporarily the consciousness of the unconscious, the love
life for the suicidal, the leg of the amputee, the eyes of the newly blind, a means of locomotion for the infant,
knowledge, and confidence of the young mother, the mouthpiece for those too weak or withdrawn to speak.”
 21 NURSING PROBLEMS
FAYE ABDELLAH
She views nursing as an art and a science that molds the attitude, intellectual competencies, and technical skills of the
individual nurse into the desire and ability to help individuals cope with their health needs, whether they are ill or well.
She used Henderson’s 14 basic human needs and nursing research to establish the classification of nursing problems.

According to Faye Glenn Abdellah’s theory, “Nursing is based on an art and 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, cope with
their health needs.”
The patient-centered approach to nursing was developed from Abdellah’s practice, and the theory is considered a human
needs theory. It was formulated to be an instrument for nursing education, so it most suitable and useful in that field. The
nursing model is intended to guide care in hospital institutions but can also be applied to community health nursing, as
well.
MAJOR CONCEPT
 Individual - She describes nursing recipients as individuals (and families), although she does not delineate her
beliefs or assumptions about the nature of human beings.
 Health - Health, or the achieving of it, is the purpose of nursing services. Although Abdellah does not define
health, she speaks to “total health needs” and “a healthy state of mind and body.” Health may be defined as the
dynamic pattern of functioning whereby there is a continued interaction with internal and external forces that
results in the optimal use of necessary resources to minimize vulnerabilities.
 Society - Society is included in “planning for optimum health on local, state, and international levels.” However,
as Abdellah further delineates her ideas, the focus of nursing service is clearly the individual.
 Nursing Problems - The client’s health needs can be viewed as problems, overt as an apparent condition, or
covert as a hidden or concealed one.

21 BASIC NURSING PROCEDURES

PHYSIOLOGIC (pain, hygiene, safety, elimination, healing)
1. Maintain good hygiene and physical comfort
2. Achieve optimal activity, exercise, rest and sleep
3. Prevent accident, injury or other trauma and prevent the spread of infection
4. Maintain good body mechanics and prevent and correct deformities
5. Facilitate the supply of oxygen to all body cells
6. Facilitate the maintenance of nutrition to all body cells
7. Facilitate the maintenance of elimination
8. Facilitate the maintenance of fluid and electrolyte balance
9. Recognise the physiological responses of the body to disease conditions, pathological, physiological and compensatory
10. Facilitate the maintenance of regulatory mechanisms and functions
11. Facilitate the maintenance of sensory functions
PSYCHOLOGICAL (trauma, emotions, cognitive, function)
12. Identify and accept positive and negative expressions, feelings and reactions
13. Identify and accept the interrelatedness of emotions and organic illness
14. Facilitate the maintenance of effective verbal and non-verbal communication
SOCIOLOGICAL (Environmental Factors, Family Dynamics)
15. Facilitate the development of productive interpersonal relationships
16. Facilitate progress towards achievement of personal spiritual goals
17. Create and/or maintain a therapeutic environment
18. Facilitate awareness of self as an individual with varying physical, emotional and developmental needs
19. Accept the optimal possible goals in light of limitations — physical and emotional
20. Use community resources as an aid in resolving problems arising from illness
21. Understand the role of social problems as influencing factors in the cause of illness.

10 NURSING SKILLS TO BE USED IN IN DEVELOPING A TREATMENT TYPOLOGY

1. Recognize the nursing problems of the patient.
2. Deciding the appropriate courses of action to take in terms of relevant nursing principles.
3. Provide continuous care of the individual’s total health needs.
4. Provide continuous care to relieve pain and discomfort and provide immediate security for the individual
5. Adjusting the total nursing care plan to meet the patient’s individual needs
6. Help individual to become more self-directing in attaining or maintaining a healthy state of mind and body.
7. Instructing nursing personnel and family to help the individual do for himself that which he can within his
limitations.
8. Helping the individual to adjust to his limitations and emotional problems
9. Working with allied health professions in planning for optimum health on local, state, national, and
international levels; and
10. Carrying out continuous evaluation and research techniques to meet the health needs of people.
 CONCLUSION
 Abdellah’s typology of 21 nursing problems is a conceptual model mainly concerned with patient’s needs and
nurses’ role in problem identification using a problem analysis approach.
 The 21 Problems theorized by Faye Abdellah directly relate to nursing care in all specialties. It focuses on patient
care overall and can be utilized in nursing to provide an outline that encompasses all aspects of psychological ,
physiological, and sociological needs. The theory also ensures that the nurse taking care of the patient practices
competent care and makes precise nursing judgements.
 According to the model, patients are described as having physical, emotional, and sociological needs. People are
also the only justification for the existence of nursing. Without people, nursing would not be a profession since
they are the recipients of nursing.
 The conceptual model of Abdellah's typology of the Twenty-One Nursing Problems is mainly concerned with
the patient's needs and the role of nurses in problem identification using a problem analysis approach. The
improvement of nursing education is Abdellah's main goal. She believed that as the education of nurses improves,
nursing practice improves as well. It transformed the focus of the profession from being “disease-centered” to
“patient-centered.” The patient-centered approach was constructed to be useful to nursing practice as it
helped bring structure and organization to what has often been a disorganized collection of nursing care
experiences. Individual needs were the basis of the nursing problem, a typology of nursing treatment and
nursing goals were formulated which served as a basis for determining and organizing nursing care
 THEORY OF NURSING PROCESS (CULTURE CARE THEORY)
IDA JEAN ORLANDO
 This theory attempts to provide culturally congruent nursing care through “cognitively based assistive, supportive,
facilitative, or enabling acts or decisions that are mostly tailor-made to fit with the individual, group’s, or
institution’s cultural values, beliefs, and lifeways.”
 Leininger’s theory’s main focus is for nursing care to fit with or have beneficial meaning and health outcomes for
people of different or similar cultural backgrounds. With these, she has developed the Sunrise Model in a logical
order to demonstrate the interrelationships of the concepts in her theory of Culture Care Diversity and
Universality
 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.
 “Leininger defined nursing as a learned scientific and humanistic profession and discipline focused on human
care phenomena and caring activities in order to assist, support, facilitate or enable individuals or groups to
maintain or regain their health or well being in culturally meaningful and beneficial way.

OVERVIEW
The construct of culture in Leininger’s theory borrows its meaning from anthropology. Culture is the “learned, shared, and
transmitted knowledge of values, beliefs, norms, and lifeways of a particular group that are generally transmitted
intergenerationally and influence thinking, decisions, and actions in patterned or certain ways” (Leininger, 2002a, p. 47).
Culture can be discovered in the actions, practices, language, norms or rules for behavior (values and beliefs), and in the
symbols that are important to the people. As Leininger has stated, culture is learned and then passed down from
generation to generation.

The most significant effect of Leininger’s theory has been on the construct of caring in relation to nursing practice
(Clarke, et al., 2009, p. 234). The goal of the culture care theory (CCT) is to provide culturally congruent nursing care,
which refers to “culturally based care knowledge, acts, and decisions used in sensitive and knowledgeable ways to
appropriately and meaningfully fit the cultural values, beliefs, and lifeways of clients for their health and wellbeing, or to
prevent illness, disabilities, or death” (Leininger, 2006, p. 15). As a companion to her theory Leininger developed enablers
to guide nurses in gathering relevant assessment data or conducting a culturalogical assessment. The culturalogical
assessment consists of a comprehensiveholistic overview of the client’s background including communication and
language, gender and interpersonal relationship customs, appearance, dress, use of space, food preferences, meal
preparation, and other lifeways. Leininger’s theory is applicable in the nursing care of clients from racially and ethnically
diverse backgrounds as well as the culture care needs of individuals or groups belonging to cultures and subcultures
identified on the basis of sexual orientation (lesbian, gay, bisexual, transgendered groups); ability or disability (the deaf or
hearing impaired or blind or visually impaired); occupation (nursing, medicine, or the military); age (youth, adolescents,
elders); or socioeconomic status (poverty or affluence; homelessness).

A key construct of Leininger’s theory is cultural diversity which refers to differences that can be found among and
between different cultures. By recognizing variations, the nurse can avoid stereotyping or assuming that all people will
respond positively or in the same way to the standards or routines in nursing care. Another construct is that of cultural
universality, which refers to the commonalities that exist in different cultures. These ideas led to an important goal of the
theory—that is, “to discover similarities and differences about care and its impact on the health and well-being of groups”
(Leininger, 1995c, p. 70). Nurses are familiar with professional care, and a construct of generic care is introduced.
Generic care or folk care includes remedies passed down from generation to generation within a particular culture.
Leininger (1995c) stated, “Interfacing generic and professional care into creative and meaningful nursing may well unlock
the essential ingredients for quality healthcare” (p. 81).
 MAJOR CONCEPTS

 Culture care - Culture Care refers to the synthesized and culturally constituted assistive, supportive, enabling, or
facilitative caring acts toward self or others focused on evident or anticipated needs for the client’s health or well-
being, or to face disabilities, death, or other human conditions.
 Culture care diversity - Culture Care diversity refers to cultural variability or differences in care beliefs,
meanings, patterns, values, symbols, and lifeways within and between cultures and human beings.
 Culture care universality - Culture Care universality refers to commonalities or similar culturally based care
meanings (“truths”), patterns, values, symbols, and lifeways reflecting care as a universal humanity.
 Emic - Emic refers to local, indigenous, or the insider’s views and values about a phenomenon.
 Etic - Etic refers to the outsider’s or more universal views and values about a phenomenon. The knowledge that
describes the professional perspective.
 Health - Health refers to a state of well-being or a restorative state that is culturally constituted, defined, valued,
and practiced by individuals or groups and that enables them to function in their daily lives.
 Transcultural nursing - Transcultural nursing refers to a formal area of humanistic and scientific knowledge and
practices focused on holistic Culture Care (caring) phenomena and competencies to assist individuals or groups to
maintain or regain their health (or well-being) and to deal with disabilities, dying, or other human conditions in
culturally congruent and beneficial ways.
 Cross Cultural Nursing—the study of the lifeways and patterns of persons of various cultures from an
anthropological perspective that is being applied to nursing.

THREE MODES OF NURSING CARE DECISIONS AND ACTIONS

Culture care preservation or maintenance

Culture Care preservation or maintenance refers to those assistive, supportive, facilitative, or enabling professional actions
and decisions that help people of a particular culture to retain or maintain meaningful care values and lifeways for their
well-being, to recover from illness, or to deal with handicaps or dying.

Culture care accommodation or negotiation

Culture Care accommodation or negotiation refers to those assistive, supportive, facilitative, or enabling professional
actions and decisions that help people of a designated culture (or subculture) to adapt to or to negotiate with others for
meaningful, beneficial, and congruent health outcomes.

Culture care repatterning or restructuring

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