Chapter 2

Frameworks for
Professional
Nursing Practice
 Definitions
• Concept
• Conceptual model
• Propositions
• Assumptions
• Theory
• Metaparadigm
 Central Concepts in Nursing
• Person receiving the nursing
• Environment within which the person
exits
• Health-illness continuum within which the
person falls at the time of the interaction
with the nurse
• Nursing actions
Nightingale’s Environmental Theory
• Person: Recipient of nursing care
• Environment: External (temperature,
bedding, ventilation) and internal (food,
water, and medications)
• Health: Not only to be well, but to be able
to use well every power we have to use
• Nursing: Alter or manage the environment
to implement the natural laws of health
 Nightingale’s 13 Canons
• Ventilation and • Bed and bedding
warmth • Light
• Health of houses • Cleanliness of rooms
• Petty management and walls
• Noise • Personal cleanliness
• Variety • Chattering hopes
• Food intake and advises
• What food? • Observation of the
sick
 Virginia Henderson: Definition of
Nursing and 14 Components of Care
• Person: Recipient of nursing care who is
composed of biological, psychological,
sociological, and spiritual components
• Environment: External environment
• Health: Based on the patient’s ability to function
independently
• Nursing: Assist the person, sick or well, in
performance of activities
Henderson’s 14 Basic Care Needs
(1 of 2)

• Breathe normally
• Eat and drink adequately
• Eliminate bodily wastes
• Move and maintain postures
• Sleep and rest
• Dress and undress
• Maintain body temperature within normal
range
Henderson’s 14 Basic Care Needs
(2 of 2)

• Keep body clean and protect integument

• Avoid dangers
• Communicate with others
• Worship according to one’s faith
• Work (sense of accomplishment)
• Recreation
• Learn and discover, leading to normal
development and health, and use health
facilities
 Jean Watson: Philosophy and
Science of Caring (1 of 2)
• Goal is to help persons attain a higher
level of harmony within the mind-body-
spirit
• Goal pursued through transpersonal
caring guided by 10 caritas processes
 Jean Watson: Philosophy and
Science of Caring (2 of 2)
• Person (human): A unity of mind-body-spirit/nature;
embodied spirit
• Healing space and environment: A nonphysical
energetic environment; a vibrational field integral with
the person where the nurse is not only in the
environment but “the nurse IS the environment”
• Health (healing): Harmony, wholeness, and comfort
• Nursing: Reciprocal transpersonal relationship in caring
moments guided by caritas processes
 Benner’s Clinical Wisdom in Nursing
Practice: 9 Domains of Critical Care Nursing
• Diagnosing and managing • Facing death: End-of-life
life-sustaining physiological care and decision making
functions in unstable patient • Communicating and
• Using skilled know-how to negotiating multiple
manage a crisis perspectives
• Providing comfort • Monitoring quality and
measures for the critically ill managing breakdown
• Caring for patients’ families • Using the skilled know-
• Preventing hazards in a how of clinical leadership
technological environment and the coaching and
mentoring of others
 Benner’s Clinical Wisdom in Nursing
Practice: 6 Aspects of Clinical Judgment and
Skilled Comportment (1 of 2)
• Reasoning-in-transition: Practical reasoning in
an ongoing clinical situation
• Skilled know-how: Also known as embodied
intelligent performance; knowing what to do,
when to do it, and how to do it
• Response-based practice: Adapting
interventions to meet the changing needs and
expectations of patients
• Agency: One’s sense of and ability to act upon
or influence a situation
 Benner’s Clinical Wisdom in Nursing
Practice: 6 Aspects of Clinical Judgment and
Skilled Comportment (2 of 2)
• Perceptual acuity and the skill of involvement:
The ability to tune into a situation and hone in
on the salient issues by engaging with the
problem and the person
• Links between clinical and ethical reasoning:
The understanding that good clinical practice
cannot be separated from ethical notions of
good outcomes for patients and families
 Benner’s Clinical Wisdom in
Nursing Practice
• Person: Embodied person living in the world who is a
“self-interpreting being, that is, the person does not
come into the world pre-defined but gets defined in the
course of living a life”
• Environment: A social environment with social
definition and meaningfulness
• Health: The human experience of health or wholeness
• Nursing: A caring relationship that includes the care
and study of the lived experience of health, illness, and
disease
 Martha Rogers’s Science of
Unitary Human Beings (1 of 2)
• Person (human being): An irreducible,
irreversible, pandimensional, negentropic
energy field identified by pattern
• Environment: An irreducible,
pandimensional, negentropic energy field,
identified by pattern and manifesting
characteristics different from those of the
parts and encompassing all that is other
than any given human field
 Martha Rogers’s Science of
Unitary Human Beings (2 of 2)
• Health: Health and illness are a part of a
continuum.
• Nursing: Seeks to promote symphonic
interaction between fields, to strengthen
the integrity of the human field, and to
direct patterning of the human and
environmental fields for realization of
maximum health potential
 Principle of Hemeodynamics
• Helicy
• Resonancy
• Integrality
Martha Rogers Interview Part I Video

https://youtu.be/V1XN3rPKndE
Martha Rogers Interview Part II Video

https://youtu.be/f6qWm8sGut0
 Dorothea Orem’s General Theory
of Nursing
• Composed of three related theories:
– Theory of self-care
– Theory of self-care deficit
– Theory of nursing systems
 Types of Self-Care Requisites
• Universal self-care requisites (found in all
human beings and associated with life
processes)
• Developmental self-care requisites
(related to different stages of human life
cycle)
• Health-deviation self-care requisites
(related to deviations in structure or
function)
 Dorothea Orem’s General
Theory of Nursing (1 of 2)
• Person (patient): A person under the care of a
nurse; a total being with universal,
developmental needs and capable of self-care
• Environment: Physical, chemical, biologic, and
social contexts within which human beings
exist; components include environmental
factors, elements, and conditions, as well as the
developmental environment
 Dorothea Orem’s General
Theory of Nursing (2 of 2)
• Health: A state characterized by soundness or
wholeness of developed human structures and
of bodily and mental functioning.
• Nursing: Therapeutic self-care designed to
supplement self-care requisites. Nursing actions
fall into one of three categories: wholly
compensatory, partly compensatory, or
supportive educative system.
 Callista Roy’s Adaptation Model
• Person (human system): A whole with parts
that function as a unity
• Environment: Internal and external stimuli; the
world within and around humans as adaptive
systems
• Health: A state and process of being and
becoming an integrated and whole human
being
• Nursing: Manipulation of stimuli to foster
successful adaptation
 Roy’s 6-Step Nursing Process
• Assessing behaviors manifested from the
4 adaptive modes
• Assessing and categorizing stimuli
• Making a nursing diagnosis
• Setting goals to promote adaptation
• Implementing interventions aimed at
managing stimuli to promote adaptation
• Evaluating achievement of adaptive goals
 Betty Neuman’s Systems Model
(1 of 3)

• Wellness model based on general systems

theory.
• Focus of the model is on the client system in
relationship to stressors.
• Client system is protected by a circular series of
buffers known as lines of defense:
– Flexible line of defense
– Normal line of defense
– Lines of resistance
 Betty Neuman’s Systems Model
(2 of 3)

• Person (client system): A composite of

physiological, psychological, sociocultural,
developmental, and spiritual variables in
interaction with the internal and external
environment
 Betty Neuman’s Systems Model
(3 of 3)

• Environment: All internal and external factors

of influences surrounding the client system;
three relevant environments identified are the
internal environment, the external environment,
and the created environment.
• Health: A continuum of wellness to illness;
equated with optimal system stability.
• Nursing: Prevention as intervention; concerned
with all potential stressors.
King’s Interacting Systems Framework
and Theory of Goal Attainment (1 of 3)
• Conceptualizes 3 levels of dynamic interacting
systems: personal systems (individuals),
interpersonal systems (groups), and social
systems (society).
• Concepts important to understanding the theory
include communication, interaction, role, stress,
and transaction.
King’s Interacting Systems Framework
and Theory of Goal Attainment (2 of 3)
• Person (human being): A personal system that
interacts with interpersonal and social systems.
• Environment: Can be both external and
internal; the external environment is the context
within which human beings grow, develop, and
perform daily activities. The internal
environment of human beings transforms
energy to enable them to adjust to continuous
external environmental changes.
King’s Interacting Systems Framework
and Theory of Goal Attainment (3 of 3)
• Health: Dynamic life experiences of a human
being, which implies continuous adjustment to
stressors in the internal and external
environment through optimum use of one’s
resources to achieve maximum potential for
daily living.
• Nursing: A process of human interaction; the
goal of nursing is to help patients achieve their
goals.
 Johnson’s Behavioral System
Model: 7 Subsystems of Behavior
• Achievement • Sexual
• Affiliative • Eliminative
• Aggressive • Ingestive
• Dependence
 Johnson’s Behavioral System Model
(1 of 2)

• Person (human being): A

biopsychosocial being who is a behavioral
system with 7 subsystems of behavior
• Environment: Includes internal and
external environment
• Health: Efficient and effective functioning
of system; behavioral system balance and
stability
 Johnson’s Behavioral System Model
(2 of 2)

• Nursing: An external regulatory force that

acts to preserve the organization and
integrity of the patient’s behavior at an
optimal level under those conditions in
which the behavior constitutes a threat to
physical or social health or in which
illness is found
 Parse’s Humanbecoming Theory:
Themes and Processes
• Three themes: • Three processes:
– Meaning – Explicating
– Rhythmicity – Dwelling
– Transcendence – Moving beyond
 Parse’s Humanbecoming Theory
• Person: An open being, more than and different
than the sum of parts in mutual simultaneous
interchange with the environment who chooses
from options and bears responsibility for choices.
• Environment: Coexists in mutual process with the
person.
• Health: Continuously changing process of
becoming.
• Nursing: A learned discipline; the nurse uses true
presence to facilitate the becoming of the
participant.
 Leininger’s 3 Modalities
• Cultural care preservation and/or
maintenance
• Cultural care accommodation and/or
negotiation
• Cultural care repatterning or restructuring
 Madeleine Leininger’s Cultural
Diversity and Universality Theory
(1 of 2)
• Person: Human being, family, group,
community, or institution
• Environment (environmental context):
Totality of an event, situation, or
experience that gives meaning to human
expressions, interpretations, and social
interactions in physical, ecological,
sociopolitical, and/or cultural settings
 Madeleine Leininger’s Cultural
Diversity and Universality Theory
(2 of 2)
• Health: A state of well-being that is
culturally defined, valued, and practiced
• Nursing: Activities directed toward
assisting, supporting, or enabling with
needs in ways that are congruent with the
cultural values, beliefs, and lifeways of the
recipient of care
 Peplau’s Theory of
Interpersonal Relations (1 of 4)
• Six nursing roles that emerge during the
phases of a relationship:
– Teacher
– Resource
– Counselor
– Leader
– Technical expert
– Surrogate
 Peplau’s Theory of
Interpersonal Relations (2 of 4)
• Three phases in the nurse–patient
relationship:
– Orientation
– Working
– Resolution
 Peplau’s Theory of
Interpersonal Relations (3 of 4)
• Person: Encompasses the patient (who
has problems for which expert nursing
services are needed or sought) and the
nurse
• Environment: Forces outside the
organism within the context of culture
 Peplau’s Theory of
Interpersonal Relations (4 of 4)
• Health: Implies forward movement of
personality and other ongoing human
processes in the direction of creative,
constructive, productive, personal, and
community living
• Nursing: The therapeutic, interpersonal
process between the nurse and the
patient
Pender’s Health Promotion Model:
3 Major Categories to Consider
• Individual characteristics and experiences
(biological factors, psychological factors,
sociocultural factors)
• Behavior-specific cognitions and affect
(perceived benefits of action, perceived
barriers to action, perceived self-efficacy,
activity-related affect)
• Behavioral outcome
 Pender’s Health Promotion Model
(1 of 2)

• Person: The individual, who is the primary

focus of the model
• Environment: The physical, interpersonal,
and economic circumstances in which
persons live
• Health: A positive high-level state
Pender’s Health Promotion Model
(2 of 2)

• Nursing: The role of the nurse includes

raising consciousness related to health-
promoting behaviors, promoting self-
efficacy, enhancing the benefits of
change, controlling the environment to
support behavior change, and managing
barriers to change
 Afaf Ibrahim Meleis:
Transitions Theory (1 of 3)
• Transition is a process triggered by a change
that represents a passage from a fairly stable
state to another fairly stable state.
• Transitions can be described in terms of types
and patterns of transitions, properties of
transition experiences, transition conditions,
process indicators, outcome indicators, and
nursing therapeutics.
 Afaf Ibrahim Meleis:
Transitions Theory (2 of 3)
• Person: Persons are active beings who
experience fundamental life patterns and who
have perceptions of and attach meaning to
transition experiences.
• Environment: Environmental conditions
expose persons to potential damage,
problematic recovery, or delayed or unhealthy
coping contributing to vulnerability related to
transitions.
 Afaf Ibrahim Meleis:
Transitions Theory (3 of 3)
• Health: Health consists of complex and
multidimensional transitions that are
characterized by flow and movement over time;
healthy outcomes are defined in terms of the
transition process.
• Nursing: Nursing means being the primary
caregiver for individuals and their families
during the transition process and applying
nursing therapeutics during transitions to
promote healthy outcomes.
 Swanson’s Theory of Caring
(1 of 3)

• Five basic processes of caring:

– Maintaining belief
– Knowing
– Being with
– Doing for
– Enabling
 Swanson’s Theory of Caring
(2 of 3)

• Person: Unique beings who are in the

midst of becoming and whose wholeness
is made manifest in thoughts, feelings,
and behaviors
• Environment: Any context that influences
or is influenced by the designated client
 Swanson’s Theory of Caring
(3 of 3)

• Health and well-being: To live the

subjective, meaning-filled experience of
wholeness; wholeness involves a sense
of integration and becoming wherein all
facets of being are free to be expressed.
• Nursing: Informed caring for the well-
being of others.
 Kolcaba’s Theory of Comfort
(1 of 4)

• Comfort care encompasses 3

components:
– An appropriate and timely intervention to
meet the comfort needs of patients
– A mode of delivery that projects caring and
empathy
– The intent to comfort
 Kolcaba’s Theory of Comfort
(2 of 4)

• Comfort needs include patients’ or

families’ desire for or deficit in relief, ease,
or transcendence in the physical,
psychospiritual, sociocultural, or
environmental contexts of human
experience.
• Comfort measures refer to interventions
that are intentionally designed to enhance
patients’ or families’ comfort.
 Kolcaba’s Theory of Comfort
(3 of 4)

• Person: Recipients of care may be

individuals, families, institutions, or
communities in need of health care
• Environment: Includes any aspect of the
patient, family, or institutional setting that
can be manipulated by the nurse, a loved
one, or the institution to enhance comfort
 Kolcaba’s Theory of Comfort
(4 of 4)

• Health: Considered optimal functioning of

the patient, the family, the healthcare
provider, or the community
• Nursing: The intentional assessment of
comfort needs, design of comfort
interventions to address those needs, and
reassessment of comfort levels after
implementation compared with baseline
Reed’s Self-Transcendence Theory
(1 of 3)

• Three major concepts are central to the

theory of self-transcendence:
– Self-transcendence
– Well-being
– Vulnerability
• Additional concepts include:
– Moderating–mediating factors
– Points of intervention
Reed’s Self-Transcendence Theory
(2 of 3)

• Person: Human beings who develop over

the life span through interactions with
other persons and within an environment
• Environment: Composed of family, social
networks, physical surroundings, and
community resources
Reed’s Self-Transcendence Theory
(3 of 3)

• Health (well-being): A sense of feeling

whole and healthy, according to one’s
own criteria for wholeness and health
• Nursing: The role of nursing activity is to
assist persons through interpersonal
processes and therapeutic management
of their environment to promote health
and well-being
 Merle Mishel:
Uncertainty in Illness Theory (1 of 4)
• Uncertainty is defined as the “inability to
determine the meaning of illness-related
events inclusive of inability to assign
definite value and/or to accurately predict
outcomes.”
• Second central concept, cognitive
schema, defined as a “person’s subjective
interpretation of illness-related events.”
 Merle Mishel:
Uncertainty in Illness Theory (2 of 4)
• The revised theory incorporates two new
concepts: self-organization and
probabilistic thinking
• Uncertainty in illness theory is organized
around 3 themes:
– Antecedents of uncertainty
– Appraisal of uncertainty
– Coping with uncertainty
 Merle Mishel:
Uncertainty in Illness Theory (3 of 4)
• Person: The concept of the person is the
central focus of the theory and may be an
individual or the family of an ill individual; the
individual is viewed as a biopsychosocial being
who is an open system exchanging energy with
the environment.
• Environment: Not explicitly defined, but is
acknowledged to exchange energy with the
person system.
 Merle Mishel:
Uncertainty in Illness Theory (4 of 4)
• Health: Defined in terms of uncertainty in
the context of the illness experience, with
the concept of health or well-being being
congruent with the formulation of a new
life view and probabilistic thinking.
• Nursing: Nurses are viewed as a part of
the antecedent variable of structure
providers.
 Cheryl Tatano Beck:
Postpartum Depression Theory (1 of 3)
• Two major concepts: Postpartum mood
disorders and loss of control
• Four stages in the coping process
• Postpartum Depression Screening Scale
(PDSS) used in screening
 Cheryl Tatano Beck:
Postpartum Depression Theory (2 of 3)
• Person: Described in terms of wholeness
with biological, sociological, and
psychological aspects, with personhood
understood in the context of family and
community
• Environment: Viewed broadly in terms of
individual factors and external factors
 Cheryl Tatano Beck:
Postpartum Depression Theory (3 of 3)
• Health: Not defined explicitly; traditional
ideas of physical and mental health are
viewed as a consequence of women’s
responses to the contexts of their lives
and environments.
• Nursing: A caring profession with caring
obligations; the nurse accomplishes the
goals of health and wholeness through
interpersonal interactions.
 Synergy Model for Patient Care
(1 of 4)

• Framework for designing practice

competencies to care for critically ill
patients
• Goal of optimizing outcomes for patients
and families
• Optimal outcomes realized when the
competencies of the nurse match the
patient and family needs
 Synergy Model for Patient Care
(2 of 4)

• 8 patient characteristics: resiliency,

vulnerability, stability, complexity, resource
availability, participation in care,
participation in decision making, and
predictability
• 8 nurse characteristics: clinical judgment,
advocacy, caring practices, collaboration,
systems thinking, response to diversity,
clinical inquiry, and facilitation of learning
 Synergy Model for Patient Care
(3 of 4)

• Persons: Viewed in the context of

patients who are biological, social, and
spiritual entities who are present at a
particular developmental stage.
• Environment: The concept is not
explicitly defined; however, included in the
assumptions is the idea that environment
is created by the nurses for the care of
the patient.
 Synergy Model for Patient Care
(4 of 4)

• Health: The concept of health is not

explicitly defined; an optimal level of
wellness as defined by the patient is
mentioned as a goal of nursing care.
• Nursing: The purpose of nursing is to
meet the needs of patients and families
and to provide safe passage through the
healthcare system during a time of crisis.
 Overview of Selected
Nonnursing Theories
• General system theory (von Bertalanffy)
• Social cognitive theory (Bandura)
• Stress and coping process theory
(Lazarus)
• General adaptation syndrome (Selye)
 Guide for Selecting a Framework
for Theory-Based Practice (1 of 3)
• Consider the values and beliefs that you
truly hold in nursing.
• Write a philosophy of nursing that clarifies
your beliefs related to person,
environment, health, and nursing.
• Survey definitions of person, environment,
health, and nursing in nursing models.
 Guide for Selecting a Framework
for Theory-Based Practice (2 of 3)
• Select 2 or 3 frameworks that best fit with
your beliefs related to the concepts of
person, environment, health, and nursing.
• Review the assumptions of the
frameworks that you have selected.
• Make applications of those frameworks in
a selected area of nursing practice.
 Guide for Selecting a Framework
for Theory-Based Practice (3 of 3)
• Compare the frameworks on client focus,
nursing action, and client outcome.
• Review the nursing literature written by
persons who have used the frameworks.
• Select a framework and develop its use in
your nursing practice.