Nursing Theories: An Overview

MYRRHA F. TAGANAS, RN, MNc

Clinical Instructor
An Introduction: Theoretical
Foundation of Nursing Practice

MYRRHA F. TAGANAS, RN, MNc

Clinical Instructor
• Concepts
• are basically vehicles of thought that involve images
• are words that describe objects, properties, or events and are basic
components of theory.

Types of Concepts:

• Empirical concepts
- Easily understood and measured. 

• Inferential concepts
- Indirectly observable, cannot be physically measured as easily.

• Abstract concepts
- Non-observable, not easily understood, hard to accurately
measure.
Models

• are representations of the interaction among and

between the concepts showing patterns.

• allow the concepts in nursing theory to be

successfully applied to nursing practice.
• Propositions
• are statements that explain the relationship between
the concepts

• Process
• are series of actions, changes or functions intended
to bring about a desired result.

• A particular theory or conceptual frame work

directs how these actions are carried out .
Theory
• a supposition or a system of ideas
intended to explain something, especially
one based on general principles
independent of the thing to be explained

• a set of principles on which the practice of

an activity is based

• an idea used to account for a situation or

justify a course of action
NURSING THEORY

- is a set of concepts, definitions, relationships, and

assumptions or propositions derived from nursing
models or from other disciplines and project a
purposive, systematic view of phenomena by
designing specific inter-relationships among concepts
for the purposes of describing, explaining, predicting,
and /or prescribing.
They are derived through two principal methods:

1. Deductive reasoning - arrives at a specific

conclusion based on generalizations
2. Inductive reasoning - takes events and makes
generalizations
COMMON CONCEPTS IN
NURSING THEORIES (Domains/Paradigms)

Nursing

Person Health Environment

Four concepts common in nursing theory that
influence and determine nursing practice are :
◦ The person( patient)
◦ The environment
◦ Health
◦ Nursing (goals, roles, functions)
Each of these concepts is usually defined and
described by a nursing theorist. Of the four
concepts, the most important is that of the person.
The focus of nursing is the person.

1. Person - Refers to all human being, people are

the recipient of nursing care
2. Environment – include factors that affect
individuals internally and externally
3. Health – addresses the person’s state of well
being
4. Nursing – is central to all nursing theories,
definitions of nursing describe what nursing is,
what nurses do, and how nurses interact with
clients
 Components of a theory
Concept Definitions

Phenomenon

Assumptions or Propositions
Conceptual Framework/Model
• A set of interrelated concepts that
symbolically represents and conveys a
mental image and phenomenon

• A set of concepts and the propositions that

integrate them into a meaningful
configuration (Marriner-Tomey and
Alligod,1998)
Theoretical Models or
Framework
- are highly established set of concepts that
are testable
SCIENCE
• The organized body of knowledge gained
through research
• SCIENTIFIC METHOD:
Observation
Gathering of Data
Forming of Hypothesis
Experimental Investigation
Conclusion / Theoretical Explanation
 KNOWLEDGE
• Information, skills and expertise acquired
by a person through formal / informal
learning

• SOURCES:
1. Traditional
2. Authoritative
3. Scientific
IMPORTANCE OF NURSING THEORIES
• aims to describe, predict and explain the
phenomenon of nursing (Chinn and Jacobs1978).

• provide the foundations of nursing practice, help to

generate further knowledge and indicate in which
direction nursing should develop in the future
(Brown 1964).

• Help provide better patient care. Enhanced

professional status for nurses
A.Clinical Practice

- Serves to guide assessment, intervention

and evaluation of nursing care

- Provide a rationale for collecting reliable

and valid data about the health status of
clients, which are essential for effective
decision making and implementation

- Help build a common terminology to use

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

C. Education
- Provide a general focus for curriculum
design
- Guide curricular decision making
 Fundamental Patterns of
Knowing in Nursing
1. Empirical
- Relying on experience or observation alone
- One can usefully conceptualize health as
something that normally ranges along a
continuum has led to attempts to observe,
describe and classify variations in health
or levels of wellness , as expressions of
human being relationship to the internal
and external environments.
2. Esthetics: The Art of Nursing
- The art of nursing is creative in that it
requires development of the ability to “
envision valid modes of helping in relation
to “results” which are appropriate

Empathy – capacity for participating in or

vicariously experiencing another’s feelings –
is an important mode
3. Ethics: The Moral Component

- The moral code that guides the ethical

conduct of nurses is based on the primary
principle of obligation embodied in the
concepts of service to people and respects
for human life.
4. Personal

- Nursing considered as an interpersonal

process involves interactions, relationships
and transactions between the nurse and
the patient-client.
DEVELOPMENT PROCESS
OF THEORY IN NURSING
 Nursing and Philosophy
Philosophy - studies concepts that structure
thought processes, foundations, and
presumptions.

• It is an approach for thinking about the

nature of people, the methods that should be
used to create a scientific knowledge and the
ethics involved.
 
Epistemology – a branch of philosophy that is
concerned with the nature and scope of
knowledge. It is referred to as the ‘theory of
knowledge’

• The power of reason and power of sensory

experience (Gale)
Rationalism- the power of reason

• Rationalist epistemology emphasizes the

importance of a priori reasoning as the
appropriate method for advancing knowledge.
Empiricism- the power of sensory experience

•Francis Bacon believed that scientific

knowledge was discovered through the
generalization of observed facts in the natural
world.
 Early 20th Century
Views of Science and Theory

• Philosophers focused on the analysis of theory

structure, whereas scientist focused on
empirical research.
Emergent Views of Science and Theory
in the late 20th Century

• Empiricists argue that for science to

maintain its objectivity, data collection
and analysis must be independent of a
theory.
• Brown argues that the new epistemology challenged
the empiricist view of perception by acknowledging that
theories play a significant role in determining what the
scientist will observe and how it will be interpreted.
• He identified 3 different views of the relationship
between theories and observation:

1. Scientists are merely passive observers of occurrences

in the empirical world.
2. Theories structure what the scientists perceived in the
empirical world.
3. Presupposed theories and observable data interact in
the process of scientific investigation.
 Significance of Theory for Nursing
as a Discipline and Profession

Discipline is specific to academia and a branch

of education, a department of learning or field of
knowledge.

Profession refers to specialized field of practice,

which is founded upon the theoretical structure
of the science or knowledge of that discipline
and the accompanying practice abilities. 
 Significance of theory for
nursing as a discipline
 
1. University baccalaureate
programs proliferated, masters programs in nursing
were developed, and the curricula began to be
standardized through the accreditation process.

2.       Attention to the importance of nursing

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

4. New nursing doctoral programs were beginning to open

and they reopened the discussion of the nature of
nursing science. This becomes the first classic reference
for nursing as discipline and for distinguishing between
the discipline and profession.

5. Fawcett’s conceptualization of metaparadigm of

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

6.1. Theoretical works have taken nursing to a

higher level.

6.2. The emphasis has shifted from a focus on

knowledge about how nurses function, which
concentrated on the nursing process, to focus on
what  nurses know and how they use knowledge
to guide their thinking and decision making
while concentrating on the patient. 
  
Significance of theory for
nursing as a profession
Clearly, nursing is recognize as a profession today.

1. Bixler and Bixler published a set of criteria tailored to nursing in

the American Journal of Nursing in 1959. They stated that a
profession:

a. Utilizes in its practice a well-defined and well-organized body of

specialized knowledge that is on the intellectual level of the higher
learning.
b.  Constantly enlarges the body of knowledge it uses and improves
its techniques of education and service by the use of the scientific
method.
c. Entrusts the education of its practitioners to institution of higher
education.
d. Applies its body of knowledge in practical services that are vital to
human and social welfare.
e. Functions autonomously in the formulation of
professional policy and in the control of
professional activity thereby.

f. Attracts individuals of intellectual and

personal qualities who exalt service above
personal gain and who recognizes their chosen
occupation as a life work.

g. Strives to compensate its practitioners by

providing freedom of action, opportunity for
continuous professional growth and economic
security.
2. Nursing theory is a useful tool for reasoning, critical
thinking, and decision making in nursing practice.

3.Nursing theoretical works provide a perspective of

the patient.

4. Nursing theory provides more direction for nursing

practice.

5. The conceptual models of nursing are

comprehensive and the reader to the specifics of the
practice.

6.Middle range theories contain the specifics of

nursing practice.  
CHARACTERISTICS OF THEORIES

1. Interrelate concepts in such a way as to create a

different way of looking at a particular
phenomenon.
2. Are logical in nature.
3. Are generalizable.
4. Are the bases for hypotheses that can be tested.
BASIC PROCESSES IN THE
DEVELOPMENT OF NURSING
THEORIES
A. General System Theory:

• It describes how to break whole things into parts

and then to learn how the parts work together in
" systems".

• These concepts may be applied to different kinds

of systems, e.g. Molecules in chemistry , cultures
in sociology, organs in Anatomy and health in
Nursing.
B. Adaptation Theory
• It defines adaptation as the adjustment of living
matter to other living things and to environmental
conditions.

• Adaptation is a continuously occurring process that

effects change and involves interaction and response

• Human adaptation occurs on three levels:

• --- the internal ( self )
• --- the social (others)
• --- and the physical ( biochemical reactions )
C. Developmental Theory

It outlines the process of growth and development

of humans as orderly and predictable, beginning
with conception and ending with death.

The progress and behaviors of an individual

within each stage are unique.

The growth and development of an individual are

influenced by heredity , temperament, emotional,
and physical environment, life experiences and
health status.
D. Change Theory

• People change throughout their lives. This

growth and change are evident in the
dynamic nature of basic human needs and
how they are met

• Change happens daily

• Change involves modification or alteration.

It may be planned or unplanned
 CLASSIFICATION
OF
NURSING THEORIES
• Metatheory: the theory of theory. Identifies specific
phenomena through abstract concepts.

• Grand theory: provides a conceptual framework under

which the key concepts and principles of the discipline
can be identified.

• Middle range theory: is more precise and only analyses

a particular situation with a limited number of variables.
• Descriptive theories
– are the first level of theory development
- They describe a phenomena, speculate why it occur
and describe the consequences

• Prescriptive theories
– are action oriented, which test the validity and
predictability of a nursing intervention
Theories can also be categorized as:

"Needs" theories

• These theories are based around helping

individuals to fulfill their physical and mental
needs.

"Interaction" theories

• These theories revolve around the relationships

nurses form with patients.
"Outcome" theories

• These portray the nurse as the changing force, who

enables individuals to adapt to or cope with ill health
(Roy 1980).

"Humanistic" Theories

• Humanistic theories developed in response to the

psychoanalytic thought that a person’s destiny was
determined early in life.
 School of Thoughts in Nursing Theories(1950-1970)

Need Interaction Outcome Humanistic

Theorist Theorist Theorist Theorists

Abdellah King Johnson Paterson

Henderson Orlando Levine Zderad
Orem Peplau Rogers
Travelbee Roy
Wiedenbach
CONCLUSION

• Theory and practice are related.

• To develop nursing as a profession the concept of theory

must be addressed.

• If nursing theory does not drive the development of

nursing, it will continue to develop in the footsteps of
other disciplines such as medicine.
 A. ENVIRONMENTAL THEORY

“ENVIRONMENTAL PHILOSOPHY”

“Nursing ought to signify the

proper use of fresh air, light,
warmth, cleanliness, quiet,
and the proper selection and
administration of diet – all at
the least expense of vital
power to the patient”
Florence Nightingale (1860)
Who was Florence Nightingale?

• Florence Nightingale was a

truly inspirational nurse.
Why is Florence Nightingale Famous?

• Florence Nightingale is famous for her nursing work during

the Crimean War (1854 - 56). She changed the face of
nursing from a mostly untrained profession to a highly
skilled and well-respected medical profession with very
important responsibilities.
Overview of Nightingale’s Environmental Model

• Nightingale viewed the manipulation of the physical

environment as a major concept of nursing care

• She identified the following aspects as major areas of the

physical, social and psychological environment that the
nurse could control.
1. Health of houses
2. Ventilation and warming
3. Light
4. Noise
5. Variety
6. Bed and bedding
7. Cleanliness of rooms and walls
8. Personal cleanliness
9. Nutrition and taking food
10.Chattering hopes and advices
11.Observation of the sick
12.Petty management
1. Health of Houses
• Is closely related to the presence of pure
air, pure water, efficient drainage,
cleanliness and light

• According to Nightingale, “badly

constructed houses do for the healthy what
badly constructed hospitals do for the sick”.
• Once a stagnant air is stagnant, sickness is
certain to follow
2. Ventilation and Warming
• Nightingale believed that it was essential to “ keep
the air he breathes as pure as the external air,
without chilling him”.

• Believed that ‘noxious air’ or ‘effluvia’ or foul odors

affects the clients health.
3. Light
• Nightingale advocated that the sick needs both
fresh air and light – direct sunlight was what clients
wanted

• She noted that the light has “quite real and tangible
effects upon the body”
4. Noise
• Nightingale believed that patients should never be
waked intentionally or accidentally during the first
part of sleep

• She averred that whisper or long conversation

about patients are thoughtless and cruel especially
when held so that the patient knows (or assumes)
the conversation is about him
5. Variety
• Nightingale stressed that variety in environment
was a critical aspect affecting the patient’s recovery
• She believed in the need for changes in color, form,
including bringing patient brightly colored flowers
or plants
6. Bed and Bedding
• Nightingale postulated that an adult exhales about
3 pints of moisture through the lungs and skin in 24
hour period. This organic matter, enters the sheets
and stays there unless the bedding is changed and
aired frequently.
7. Cleanliness of Rooms and
Walls
• Nightingale emphasized that “the greater part of
nursing consists in preserving cleanliness”
8. Personal Cleanliness
• Nightingale viewed that function of the skin is
important and she believed that unwashed skin
poisoned the patient and noted that bathing and
drying the skin provide great relief to the patient

• She also advocated that personal cleanliness

extended to the nurse and that “ every nurse ought
to wash her hands very frequently during the day”
9. Nutrition and taking Food
• Nightingale addressed the importance of variety
in the food served to the patients

• She has proven that the attention given to the

patient affected how the patient ate

• She has observed that individuals desire different

foods at different times of the day and that
frequent small servings may be more beneficial
to the patient than a large breakfast or dinner
10. Chattering Hopes and Advices
• Nightingale perceived that to falsely cheer the sick
by making light of their illness and its danger is not
helpful

• She encourage nurses to heed what is being said by

visitors, believing that sick persons should hear
good news that would assist them in becoming
healthier
11. Observation of the Sick
• She felt strongly about the importance of obtaining
complete and accurate information about patients

12. Petty management

• Nightingale discussed ways to assure that

“ What you do when you are there, shall be done when

you are not there”
Environmental Factors Affecting Health

• · pure or fresh air

• · pure water
• · sufficient food supplies
• · efficient drainage
• · cleanliness
• · light (especially direct sunlight)
• Nightingale believed that the
environment was the major component
creating illness in a patient; she regarded
disease as “the reactions of kindly
nature against the conditions in which
we have placed ourselves.” Her theory
contains three major relationships:

• · environment to patient
• · nurse to environment
• · nurse to patient
Assumptions of Florence Nightingale’s
Theory:

• Natural laws
• Mankind can achieve perfection
• Nursing is a calling
• Nursing is an art and a science
• Nursing is achieved through environmental alteration
• Nursing requires a specific educational base
• Nursing is distinct and separate from medicine
Major Premises of Environmental Adaptation Theory:

• People are multidimensional, composed of biological,

psychological, social and spiritual components.
• Disease is more accurately portrayed as dys-ease or the
absence of comfort.
• Symptoms alert nurses to the presence of illness, which
allows for appropriate interventions.
• Breaking the natural laws will cause disease.
• Improvement in the health of individuals and families
lead to the improved health of society.
The Environmental
Adaptation Concepts:
• Florence Nightingale’s original
Six D’s of Dys-
theory for nursing practice was ease:
holistic. Dirt
Drink (need clean
• Her concepts included drinking water)
human/individual, Diet
Damp
society/environment, health/disease Draughts (Drafts)
and nursing. Drains (need
proper drainage
• She focused more on physical factors and sewer
than on psychological needs of systems)

patients because of the nature of

nursing practice during her time.
Faye Abdellah

Patient – Centered Approaches to Nursing Model

The focus of care pendulum

• Defined nursing as service to individuals and

families.

• Conceptualized nursing as an art and a science

that molds the attitudes, intellectual
competencies and technical skills of the individual
nurse into the desire and ability to help people,
sick or well and cope with their health needs.
21 Nursing Problems

BASIC TO ALL PATIENTS

• To maintain good hygiene.
• To promote optimal activity; exercise, rest and
sleep.
• To promote safety.
• To maintain good body mechanics and
prevent and correct deformity
SUSTENAL CARE NEEDS
• To facilitate the maintenance of a supply of oxygen to all
body cells
• To facilitate maintenance of nutrition of all body cells
• To facilitate maintenance of elimination
• To facilitate the maintenance of fluid and electrolyte
balance
• To recognize the physiologic response of the body to
disease conditions
• To facilitate the maintenance of regulatory
mechanisms and functions
• To facilitate the maintenance of sensory functions
REMEDIAL CARE NEEDS
• To identify and accept positive and negative
expressions, feelings and reactions
• To identify and accept the interrelatedness of
emotions and illness.
• To facilitate the maintenance of effective verbal and
non-verbal communication
• To promote the development of productive
interpersonal relationship
• To facilitate progress toward achievement of personal
spiritual goals
• To create and/or maintain a therapeutic environment
• To facilitate awareness of self as an individual with
varying needs.
RESTORATIVE CARE NEEDS

• To accept the optimum possible goals

• To use community resources as an aid in

resolving problems arising from illness.

• To understand the role of social problems

as influencing factors
10 Steps to Identify Patient’s Problems 

1. Learn to know the patient

2. Sort out relevant and significant data

3. Make generalizations about available data in relation to

similar nursing problems presented by other patients

4. Identify the therapeutic plan

5. Test generalizations with the patient and make additional

generalizations
6. Validate the patient's conclusions about his nursing problems

7. Continue to observe and evaluate the patient over a period of time to

identify any attitudes and clues affecting his behavior

8. Explore the patient's and family's reaction to the therapeutic plan and
involve them in the plan

9. Identify how the nurses feel about the patient's nursing problems

10. Discuss and develop a comprehensive nursing care plan

11 Nursing Skills

1. Observation of health status

2. Skills of communication

3. Application of knowledge

4. Teaching of patients and families

5. Planning and organization of work

6. Use of resource materials

7. Use of personnel materials

8. problem-solving

9. direction of work of others

10. therapeutic use of the self

11. nursing procedure

NURSING PROBLEMS
Nursing problem presented by a patient is a
condition faced by the patient or patient’s family
that the nurse through the performance of
professional functions can assist to meet them.

These problems can either be:

a. Overt
b. Covert
PROBLEM SOLVING
Involves:
- Identifying the problem
- Selecting pertinent data
- Formulating hypothesis
- Testing hypothesis
- Revising hypothesis on the basis of conclusions obtained from the
data
Abdellah’s Major Concepts
1. Nursing

• A helping profession
• A comprehensive service to meet
patient’s needs
• Increases or restores self-help ability
• Uses 21 problems to guide nursing care
and promote use of nursing judgment
2. Health

•  The purpose of nursing services

she speaks of “total health needs”
and “a healthy state of mind and
body” (Abdellah et al., 1960)
3. Person

• One who has physical, emotional,

or social needs

• The recipient of nursing care.

4. Environment

• Society is included in “planning

for optimum health on local, state,
and international levels.”
Strengths

• As a logical and simple statement,

Abdellah’s problem-solving approach
can easily be used by practitioners to
guide various activities within their
nursing practice.

• The problem-solving approach is readily

generalizable to client with specific
health needs and specific nursing
problems
Weaknesses

• Little emphasis on what the client is to achieve was given in

terms of client care.

• Abdellah’s framework is inconsistent with the concept of

holism. The nature of the 21 nursing problems attests to this. As
a result, the client may be diagnosed as having numerous
problems that would lead to fractionalized care efforts, and
potential problems might be overlooked because the client is
not deemed to be in a particular stage of illness.
 Dorothy Johnson

Behavioral System Model

Purpose of Systems Theory

• Nurse creates balance between

client and environment to achieve
an optimal level of functioning.
 Johnson’s 7 Subsystems

1. Attachment or affiliative subsystem – serves the need

for security through social inclusion or intimacy

2. Dependency subsystem – behaviors designed to get

attention, recognition, and physical assistance

3. Ingestive subsystem – fulfills the need to supply the

biologic requirements for food and fluids

4. Eliminative subsystem – functions to excrete wastes

 5. Sexual subsystem – serves the biologic
requirements of procreation and
reproduction

6. Aggressive subsystem – functions in

self and social protection and
preservation

7. Achievement subsystem – functions to

master and control the self or the
environment
Assumptions
• A system tends to achieve a balance among the various
forces operating within and upon it and that man strives
continually to maintain a behavioral system balance and
steady states by more or less automatic adjustments and
adaptations to the natural forces impinging upon him.

• The system balance reflects adjustments and

adaptations that are successful in some way and to
some degree and may or will vary from individual to
individual.
Strengths:

1. She provided a frame of reference for nurses concerned with specific client
behaviors.

2. Johnson’s behavioral model can be generalized across the lifespan and

across cultures.

Weaknesses:

1. does not clearly interrelate her concepts of subsystems.

2. Lack of clear definitions for the interrelationships among and between the
subsystems makes it difficult to view the entire behavioral system as an entity.

3. The lack of clear interrelationships among the concepts creates difficulty in

following the logic of Johnson’s work.
Imogene King

Goal Attainment Theory and Transactional Process

• Described nursing as a helping

profession that assists individuals and
groups in
society to attain, maintain and
restore health
 Overview of Imogene King’s Theory

• It 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 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”
Human Beings have 3 Fundamental Health Needs:

1. The need for health information that is usable at the

time when it is needed and can be used

2. The need for care that seeks to prevent illness

3. The need for care when human beings are unable to

help themselves
Conceptual Framework includes
3 interacting systems
A. Personal Systems
- Individuals are personal systems. Each individual is an open, total, unique system in constant
interaction with the environment

- Concepts which contributes to understanding individuals as personal systems:

1. Perception
2. Self
3. Growth and development
4. Body image
5. Space
6. Time
B. Interpersonal Systems
- Two or more individuals in interaction form interpersonal systems. As
the member of individuals increases, so does the complexity of the
interaction.

- Concepts critical to understanding interactions between individuals are

as follows:
1. Communication
2. Interaction
3. Role
4. Stress
5. Stressors
6. Transaction
C. Social System
- Are composed of large groups with common interests or goals.
Interactions with social systems influence individuals throughout
the lifespan

- Concepts that are useful to understand interactions within social

systems and between social and personal systems are as follows:
1. Organization
2. Authority
3. Power
4. Status
5. Decision making
Overall Assumptions of King’s
Conceptual System
1. Perception, goals, needs, and values of the nurses and
clients influence interaction process
2. Individuals have the right to knowledge about themselves
and to participate in decisions that influence their lives,
health and community services.
3. Health professionals have the responsibility that helps
individuals to make informed decisions about their health
care,
4. Individuals have the right to accept or reject healthcare
5. Goals of health professionals and recipients of healthcare
may not be congruent
Strengths:

King’s theory of goal attainment does describe a logical

sequence of events.

For the most part, concepts are clearly defined.

Although the presentation appears to be complex, King’s

theory of goal attainment is relatively simple.

King formulated assumptions that are testable hypotheses for

research.
Weaknesses:

King’s theory contains major inconsistencies:

(1) She indicates that nurses are concerned about the

health care of groups but concentrates her discussion on
nursing as occurring in a dyadic relationship.

(2) King says that the nurse and client are strangers, yet
she speaks of their working together for goal attainment
and of the importance of health maintenance.
Madeleine Leininger
• “The purpose of transcultural nursing is to
discover and establish a body of knowledge
and skills focused on transcultural care,
health(or well-being) and illness in order to
assist nurses giving culturally competent, safe,
and congruent care to people of diverse
cultures worldwide”
(Leininger, 1995a p.11)
• Developed the Transcultural Nursing Model. She
advocate that nursing is a humanistic and scientific
mode of helping a client through specific cultural caring
process (cultural values, beliefs and practices) to
improve or maintain a health condition.
Roles of the Nurse

• The nurse should begin the assessment by attempting

to determine the client’s cultural heritage and language
skills.

• Nurses should evaluate their attitudes toward ethnic

nursing care .
Strengths:

Leininger’s theory is essentially parsimonious in that

the necessary concepts are incorporated in such a
manner that the theory and its model can be applied in
many different settings.

Weakness:

The theory and model are not simple in terms.

Overview

Levine’s Conservation model is based on 3 major

concepts and assumptions:

1. Conservation
2. Adaptation
3. Wholeness
Conservation

• Is the keeping together of the life system

• The goal of conservation is health and the

strength to confront disability

• The primary focus of conservation is keeping

together of the wholeness of individual
4 Conservation Principles

1. Conservation of energy
2. Conservation of structural integrity
3. Conservation of personal integrity
4. Conservation of social integrity
 (1)Conservation of Energy
- The human body functions by using
energy. The human body needs energy
producing input(food, oxygen, fluids) to
allow energy utilization as an output.

(2) Conservation of Structural Integrity.

-The human body has physical boundaries
(skin and mucous membrane)that must be
maintained to facilitate health and prevent
harmful agents from entering the body.
 (3) Conservation of Personal Integrity.
- The nursing intervention are base on the
conservation of an individual clients personality.
Every individual has sense of identity, self-worth
and self-esteem, which must be preserved and
enhanced by nurses.

(4) Conservation of Social Integrity

- The social integrity of the client reflects the family
and the community in which the client functions.
Health care institutions may separate individuals
from their family. It is important for nurses to
consider the individual in the context of the family.
Adaptation
• Is achieved through the “frugal,
economic, contained, and
controlled use of environmental
resources by the individual in his or
her best interest
Wholeness
• Exists when the interactions or
constant adaptations to the
environment permit the assurance
of integrity
Strengths:

- Levine has interrelated the concepts of adaptation, conservation

and integrity in a way that provides a nursing view different from that
of the adjunctive disciplines with which nursing shares these
concepts.

- Levine’s work is logical. One thought or idea flows from the previous
one and into the next.

Weakness:

- There are many concepts with comparatively unspecified

relationships and unstated assumptions.
 Health Care Systems Model

• She asserted that nursing is a unique profession in that it is

concerned with all the variables affecting an individual’s
response to stresses, which are intra- (within the individual),
inter-(between one or more other people), and extra personal
(outside the individual) in nature.
Major Concepts
1. Person Variables

1.1 Physiological variable –refers to physiochemical

structure and function of the body

1.2. Psychological variable – refers to mental

processes and emotions
Ex. Self esteem

1.3. Developmental Variable –refers to those

processes related to development over the lifespan
1.4. Sociocultural variable – refers to the relationships and social
and cultural expectations and activities
Ex. Ethnic cultural practices and health belief practices on:
a. Birthing
b. Food preferences in different regions of the country
c. Care of the dying and dead

1.5. Spiritual Variable – refers to the influence of spiritual beliefs

Ex.
d. Anointing the sick or dying with oil
e. Avoiding scavenger fishes(shrimp, crabs, squids, fishes with
no scales)
f. Prohibiting blood transfusion
2. Central Core

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

basic “ survival factors”
These includes:
- System variables
- Genetic features and strengths and weaknesses of the
systems parts
Ex.
Hair color, body temperature regulation ability, physical
strength and value system
3. Flexible line of Defense
- It is the outer barrier or cushion to the normal line of defense,
the line of resistance, and the core structure

- If the flexible line of defense fails to provide adequate

protection to the normal line of defense, the lines of resistance
become activated.

4. Normal Line of Defense

- Represents system stability over time.
- It can change over time in response to coping or responding to
the environment
5. Lines of Resistance
- Protect the basic structure and become activated when environmental stressors
invade the normal line of defense
Ex. Activation of the immune response after invasion of microorganisms

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

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

- The primary nursing intervention focuses on keeping

the stressors and the stress response from having a
detrimental effect on the body

Modalities:
• Primary prevention – occurs before the system reacts
to a stressor
• Secondary prevention –occurs after the system reacts
to a stressor and is provided in terms of existing
systems
• Tertiary prevention – occurs after the system has been
treated through secondary prevention strategies
Strengths:

The major strength of the model is its flexibility for use in all areas of nursing –
administration, education, and practice.

Neuman has presented a view of the client that is equally applicable to an

individual, a family, a group, a community, or any other aggregate.

The emphasis on primary prevention, including health promotion is specific to

this model.

Weakness:

The major weakness of the model is the need for further clarification of terms
used. Interpersonal and extrapersonal stressors need to be more clearly
differentiated.
Major Concepts
Self-care is the performance or practice of activities that
individuals initiate and perform on their own behalf to
maintain life, health and well-being.

Self-care agency is the human’s ability or power to engage in

self-care and is affected by basic conditioning factors.

Basic conditioning factors are age, gender, developmental

state, health state, sociocultural orientation, health care system
factors, family system factors, patterns of living, environmental
factors, and resource adequacy and availability.
Therapeutic Self-care Demand is the totality of “self-
care actions to be performed for some duration in
order to meet known self-care requisites by using
valid methods and related sets of actions and
operations.”

Self-care Deficit delineates when nursing is needed.

Nursing is required when an adult (or in the case of a
dependent, the parent or guardian) is incapable of or
limited in the provision of continuous effective self-
care.
Subconcepts

A. Universal self-care requisites are associated

Self-care Requisites or requirements can be defined as actions directed toward the provision of self-care. It is presented in three categories:

with life processes and the maintenance of the

integrity of human structure and functioning.

1. The maintenance of a sufficient intake of air

2. The maintenance of a sufficient intake of water

3. The maintenance of a sufficient intake of food

4. The provision of care associated with elimination
process and excrements

5. The maintenance of a balance between activity and

rest

6. The maintenance of a balance between solitude and

social interaction

7. The prevention of hazards to human life, human

functioning, and human well-being

8. The promotion of human functioning and

development within social groups in accord with human
potential, known human limitations, and the human
desire to be normal
B. Developmental self-care requisites are “either
specialized expressions of universal self-care
requisites that have been particularized for
developmental processes or they are new requisites
derived from a condition or associated with an
event.”
C. Health deviation self-care requisites are required
in conditions of illness, injury, or disease or may
result from medical measures required to diagnose
and correct the condition.

1. Seeking and securing appropriate medical

assistance

2. Being aware of and attending to the effects and

results of pathologic conditions and states

3. Effectively carrying out medically prescribed

diagnostic, therapeutic, and rehabilitative measures
4. Being aware of and attending to or regulating the
discomforting or deleterious effects of prescribed medical
measures

5. Modifying the self-concept (and self-image) in accepting

oneself as being in a particular state of health and in need of
specific forms of health care

6. Learning to live with the effects of pathologic conditions and

states and the effects of medical diagnostic and treatment
measures in a life-style that promotes continued personal
development
Orem developed the Self-Care Deficit Theory of Nursing, which
is composed of three interrelated theories:
(1)the theory of self-care
(2)the self-care deficit theory
(3)the theory of nursing systems.

“The condition that validates the existence of a requirement

for nursing in an adult is the absence of the ability to
maintain continuously that amount and quality of self-care
which is therapeutic in sustaining life and health, in
recovering from disease or injury, or in coping with their
effects. With children, the condition is the inability of the
parent (or guardian) to maintain continuously for the child
the amount and quality of care that is therapeutic.” (Orem,
1991)
She conceptualized three nursing system as follows:

(1) Wholly Compensatory: when the nurse is

expected to accomplish all the patient’s therapeutic
self-care or to compensate for the patient’s inability
to engage in self-care or when the patient need
continuous guidance in self-care;

(2) Partially Compensatory: when both nurse and

patient engage in meeting self-care needs;

(3)Supportive-Educative: the system that requires

assistance in decision making, behavior control and
acquisition of knowledge and skills.
STRENGTHS:
- It is applicable for nursing by the beginning practitioner as well as the
advanced clinicians

- The term self care, nursing system and self care deficit are easily
understood by the beginning student nurse and can be explored in
greater depth as the nurse gains more knowledge and experience

- She specifically defines when nursing is needed: Nursing is needed

when the individual cannot maintain continuously that amount and
quality of self-care necessary to sustain life and health, recover from
disease or injury or cope with their effects.
WEAKNESS:

- Orem’s theory is simple yet complex. The use of self

care in multitude terms can be confusing to the reader

• Self care agency

• Self care demand
• Self care deficit
• Self care requisites
• Universal self care
According to Peplau (1952/1988), nursing is therapeutic because it
is a healing art, assisting an individual who is sick or in need of
health care.

Nursing can be viewed as an interpersonal process because it

involves interaction between two or more individuals with a
common goal.

In nursing, this common goal provides the incentive for the

therapeutic process in which the nurse and patient respect each
other as individuals, both of them learning and growing as a result
of the interaction.

An individual learns when she or he selects stimuli in the

environment and then reacts to these stimuli.
Therapeutic nurse-client relationship

A professional and planned relationship between client

and nurse that focuses on the client’s needs, feelings,
problems, and ideas.

Nursing involves interaction between two or more

individuals with a common goal. The attainment of this
goal, or any goal, is achieved through a series of steps
following a sequential pattern.
Four Phases of the therapeutic nurse-patient relationship:

1. The orientation phase is directed by the nurse and involves

engaging the client in treatment, providing explanations and
information, and answering questions.

2. The identification phase begins when the client works

interdependently with the nurse, expresses feelings, and begins
to feel stronger.

3. In the exploitation phase, the client makes full use of the

services offered.

4. In the resolution phase, the client no longer needs

professional services and gives up dependent behavior. The
relationship ends.
Roles of the Nurse in the Therapeutic
relationship
The primary roles she identified are as follows:

Stranger: offering the client the same  acceptance and courtesy that the nurse
would to any stranger

Resource person: providing specific answers to questions within a larger context

Teacher: helping the client to learn formally or informally

Leader: offering direction to the client or group

Surrogate: serving as a substitute for another such as a parent or a sibling

Counselor: promoting experiences leading to health for the client such as

expression of feelings
 4 LEVELS OF ANXIETY
1. Mild anxiety is a positive state of heightened
awareness and sharpened senses, allowing the
person to learn new behaviors and solve problems.
The person can take in all available stimuli
(perceptual field).
3. Severe anxiety involves feelings of dread and
terror. The person cannot be redirected to a task;
he or she focuses only on scattered details and has
physiologic symptoms of tachycardia, diaphoresis,
and chest pain.
2. Moderate anxiety involves a decreased
perceptual field (focus on immediate task only);
the person can learn new behavior or solve
problems only with assistance. Another person
can redirect the person to the task.
4. Panic anxiety can involve loss of rational
thought, delusions, hallucinations, and complete
physical immobility and muteness. The person
may bolt and run aimlessly, often exposing
himself or herself to injury.
• Assumptions

Nurse and patient can interact.

Peplau stresses that both the patient and nurse
mature as the result of the therapeutic interaction.
Communication and interviewing skills remain
fundamental nursing tools.
Peplau believed that nurses must clearly
understand themselves to promote their client’s
growth and to avoid limiting client’s choices to
those that nurses value.
Strengths:
The phases provide simplicity regarding the natural
progression of the nurse-patient relationship.
This simplicity leads to adaptability in any nurse-patient
interaction, thus providing generalizability.
Weaknesses:
Health promotion and maintenance were less emphasized.
The theory cannot be used in a patient who doesn’t have a
felt need such as with withdrawn patients.
• conceptualized the Science of
Unitary Human Beings.

• To Rogers unitary man is an energy

field constant interaction with the
environment. She asserted that
human being are more than and
different from the sum of their parts.
• Strengths:

Rogers’ concepts provide a worldview from which nurses

may derive theories and hypotheses and propose
relationships specific to different situations.

Rogers’ work is not directly testable due to lack of concrete

hypotheses, but it is testable in principle.
Weaknesses:

It is an abstract, unified, and highly derived framework

and does not define particular hypotheses or theories.

Concepts are not directly measurable thus testing the

concepts’ validity is questionable.

It is difficult to comprehend because the concepts are

extremely abstract.

Nurses’ roles were not clearly defined.

No concrete definition of health state

• She views each person as a unified biopsychosocial system in
constant interaction with a changing environment.

• She contended that the person as an adaptive system,

functions as a whole through interdependence of its parts.
The system consist input,control process, output and
feedback.

• Adaptation

The “process and outcome whereby thinking and feeling

persons as individuals or in groups use conscious awareness
and choice to create human and environmental integration.”
Four Adaptive Modes

1. Physiologic-physical mode: physical and chemical processes involved in the

function and activities of living organisms; the underlying need is physiologic
integrity as seen in the degree of wholeness achieved through adaptation to
changes in needs

2. Self-concept-group identity mode: focuses on psychological and spiritual

integrity and a sense of unity, meaning, purposefulness in the universe.

3. Role function mode: refers to the roles that individuals occupy in society

fulfilling the need for social integrity; it is knowing who one is, in relation to
others.

4. Interdependence mode: the close relationships of people and their purpose,

structure and development individually and in groups and the adaptation
potential of these relationships.
Coping mechanisms describe the control processes of the person as
an adaptive system. Some coping mechanisms are inherited or
genetic, such as white blood cell defense mechanism against bacteria
that seek to invade the body. Other mechanisms are learned, such as
the use of antiseptics to cleanse a wound.

Two Coping Subsytems

A. Cognator subsystem
“A major coping process involving four cognitive-emotive channels: perceptual and information processing, learning, judgment, and
emotion.”

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

Those stimuli that are the proximate causes of the situation.

Contextual stimuli

All other stimuli in the internal or external environment, which

may or may not affect the situation.

Residual stimuli

Those immeasurable and unknowable stimuli that also exist

and may affect the situation
• Strengths:

A major strength of the model is that it guides nurses to use observation

and interviewing skills in doing an individualized assessment of each
person.

The concepts of Roy’s model are applicable within many practice settings of
nursing.

• Weaknesses:

Painstaking application of the model requires significant input of time and

effort.

Roy’s model has many elements, systems, structures and multiple concepts.
• Introduce the notion that nursing centers around three
components of CARE, CORE, CURE.

Care represents nurturance and is exclusive to nursing.

Core involves the therapeutic use of self and emphasizes

the use of reflection.

Cure focuses on nursing related to the physician’s orders.

• Core and cure are shared with other health care

providers.
• Assumptions

• The motivation and energy necessary for healing exist

within the patient, rather than in the health care team.

The three aspects of nursing should not be viewed as

functioning independently but as interrelated.

The three aspects interact, and the circles representing

them change size, depending on the patient’s total
course of progress.
Strengths:

The use of the terms care, core, and cure are unique to Hall.

Hall’s work appears to be completely and simply logical.

Weaknesses:

Hall’s work is simple in its presentation. However, the openness

and flexibility required for its application may not be so simple
for nurses whose personality, educational preparation, and
experience have not prepared them to function with minimal
structure. This and the self-imposed age and illness
requirements limit the generalizability
• Believe that the nurse helps patients meet a
perceived need that the patients cannot meet for
themselves.
• Orlando observed that nurse provide direct
assistance to meet an immediate need for help in
order to avoid or to alleviate distress or helplessness.
• She emphasized the importance of validating the
need and evaluating care based on observable
outcomes.
• She also indicated that nursing actions can be
automatic (those chosen for reasons other than the
immediate need for help) or deliberative (those
resulting from validating the need for help, exploring
the meaning of the need, and validating the
effectiveness of the actions taken to meet the need.)
• Subconcepts

Patient Behavior
This sets the nursing process discipline in motion.

All patient behavior, no matter how insignificant, must be considered an expression of need
for help until its meaning to a particular patient in the immediate situation is understood.

“The presenting behavior of the patient, regardless of the form in which it appears, may
represent a plea for help” (Orlando, 1990).

Patient behavior may be verbal or nonverbal. Inconsistency between these two types of

behavior may be the factor that alerts the nurse that the patient needs help.
Distress

The patient’s behavior reflects distress when

the patient experiences a need that he cannot
resolve, a sense of helplessness occurs.

Some categories of patient distress are:

“physical limitations,… adverse reactions to
the setting and … experiences which prevent
the patient from communicating his needs”
(Orlando, 1990).
Nurse Reaction

The patient behavior stimulated a nurse reaction,

which marks the beginning of the nursing process
discipline.

This reaction is comprised of three sequential

parts (Orlando, 1972). First, the nurse perceives
the behavior through any of her senses. Second,
the perception leads to automatic thought.
Finally, the thought produces an automatic
feeling.
“The nurse does not assume that any
aspect of her reaction to the patient is
correct, helpful, or appropriate until she
checks the validity of it in exploration with
the patient” (Orlando, 1990).

The nurse must learn to identify each part

of her action so the process becomes
logical rather than intuitive and thus,
disciplined rather than automatic
Orlando (1972) also provides three criteria to ensure that the
nurse’s exploration of her reaction with the patient is
unsuccessful:

1. What the nurse says to the individual in the contact must

match any or all of the items contained in the immediate
reaction, and what the nurse does nonverbally must be
verbally expressed and the expression must match one or all
of the items contained in the immediate reaction.

2. The nurse must clearly communicate to the individual that

the item being expressed belongs to herself.

3. The nurse must ask the individual about the item

expressed in order to obtain correction or verification from
that same individual.
• Assumptions

When patients cannot cope with their needs without help, they become distressed with feelings of
helplessness.

Patients are unique and individual in their responses.

Nursing offers mothering and nursing analogous to an adult mothering and nurturing of a child.

Nursing deals with people, environment and health.

Patient need help in communicating needs, they are uncomfortable and ambivalent about
dependency needs.

Human beings are able to be secretive or explicit about their needs, perceptions, thoughts and
feelings.

The nurse – patient situation is dynamic, actions and reactions are influenced by both nurse and
patient.
Strengths:

Use of her theory assures that the patient will be treated as individuals and they will
have an active and constant input into their own care.

Assertion of nursing’s independence as a profession and her belief that this

independence must be based on a sound theoretical frame work.

Guides the nurse to evaluate her care in terms of objectively observable patient
outcomes.

Weaknesses:

Lack the operational definitions of society or environment which limits the development
of research hypothesis.

The theory focuses on short term care, particularly aware and conscious individuals and
on the virtual absence of reference group or family members.