Handouts For Tfn

Summary of Nursing Theories

Theorist

Goal of Nursing

Framework for practice

Hildegard Peplau (1952)

To develop interpersonal interaction between client and nurse

Interpersonal theoretical model emphasizing relationship between client and nurse

Faye Abdellah (1960)

To deliver nursing care for whole individual

Problem solving based on 21 nursing problems

Virginia Henderson (1964)

To help client gain independence as rapidly as possible

Henderson’s 14 basic needs

Joyce Travelbee (1966)

To help client and family to cope with and find meaning in experience of illness

Interpersonal theory emphasizing nurse-client relationship

Dorothy Johnson (1968)

To reduce stress so that client can recover as quickly as possible

Adaptation model based on seven behavioral sub-systems

Martha Rogers (1970)

To help client achieve maximal level of wellness

“Unitary man” evolving along life process

Imogene King (1971)

To use communication to help client to reestablish positive adaptation to environment

Nursing process as dynamic interpersonal state between nurse and client

Dorothea Orem (1971)

To care for and help client to attain self-care

Self-care deficit theory

Betty Neuman (1972)

To assist individuals, families, and groups to attain and maintain maximal level of total wellness by purposeful interventions

Systems model of nursing practice having stress reduction as its goal; nursing actions in one of three levels: primary, secondary, or tertiary

Myra Levine (1973)

To use conservation activities aimed at optimal use of client’s resources

Adaptation model of human as integrated whole based on “four conservation principles of nursing”

Sister Callista Roy (1976)

To identify types o demands placed on client and client’s adaptation to them

Adaptation model based on four adaptive modes; physiological, psychological, sociological, and independence

Jean Watson (1979)

To promote health, restore clients to health, and prevent illness (Marriner-Tomey, 1989)

Philosophy and science of caring: caring is an interpersonal process comprising interventions that result in meeting human needs (Torres, 1986)

INTRODUCTION TO NURSING THEORIES INTRODUCTION

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Nursing has made phenomenal achievement in the last century that has lead to the recognition of nursing as an academic discipline and a profession. A move towards theory-based practice has made contemporary nursing more meaningful and significant by shifting nursing’s focus from vocation to an organised profession. The need for knowledge-base to guide professional nursing practice had been realised in the first half of the twentieth century and many theoretical works have been contributed by nurses ever since, first with the goal of making nursing a recognised profession and later with the goal of delivering care to patients as professionals.

Components of a theory – concepts, definitions, assumptions ---- of a phenomena  

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A theory is a group of related concepts that propose action that guide practice. A 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.. Based on the knowledge structure levels the theoretical works in nursing can be studied under the following headings: Metaparadigm (Person, Environment, Health & Nursing) – (Most abstract) Nursing philosophies. Conceptual models and Grand theories. Nursing theories and Middle range theories (Least abstract)

Nursing Theorists Definitions  Theory- a set of related statements that describes or explains phenomena in a systematic way  Concept-a mental idea of a phenomenon  Construct- a phenomena that cannot be observed and must be inferred  Proposition- a statement of relationship between concepts  Conceptual model- made up of concepts and propositions Nursing Theorists 1. Florence Nightingale, 2. Hildegard Peplau 3. Virginia Henderson 4. Fay Abdellah 5. Ida Jean Orlando 6. Dorothy Johnson 7. Martha Rogers 8. Dorothea Orem 9. Imogene King 10. Betty Neuman 11. Sister Calista Roy, 12. Jean Watson 13. Rosemary Rizzo Parse 14. Madeleine Leininger 15. Patricia Benner

Concepts in the nursing Metaparadigms 1.Person  Recipient of care, including physical, spiritual, psychological, and sociocultural components.  Individual, family, or community

2. Environment  All internal and external conditions, circumstances, and influences affecting the person 3. Health  Degree of wellness or illness experienced by the person 4. Nursing  Actions, characteristics and attributes of person giving care

Florence Nightingale- Environmental Theory   

First nursing theorist

Unsanitary conditions posed health hazard (Notes on Nursing, 1859) 5 components of environment o ventilation, light, warmth, effluvia, noise  External influences can prevent, suppress or contribute to disease or death Nightingale’s Concepts 1. Person  Patient who is acted on by nurse  Affected by environment  Has reparative powers 2. Environment  Foundation of theory. Included everything, physical, psychological, and social 3. Health  Maintaining well-being by using a person’s powers  Maintained by control of environment 4. Nursing  Provided fresh air, warmth, cleanliness, good diet, quiet to facilitate person’s reparative process

Florence Nightingale, OM, 12 May 1820 – 13 August 1910)         

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was a celebrated English nurse, writer and statistician. A Christian universalist, Nightingale believed that God had called her to be a nurse. She came to prominence for her pioneering work in nursing during the Crimean War, where she tended to wounded soldiers. Nightingale laid the foundation of professional nursing with the establishment, in 1860, of her nursing school at St Thomas' Hospital in London, the first secular nursing school in the world. The Nightingale Pledge taken by new nurses was named in her honor, and the annual International Nurses Day is celebrated around the world on her birthday. Florence Nightingale (1820–1910), considered the founder of educated and scientific nursing Widely known as "The Lady with the Lamp”, because of her habit of making rounds at night. Wrote the first nursing notes that became the basis of nursing practice and research. The notes, entitled Notes on Nursing: What it is, What is not (1860), listed some of her theories that have served as foundations of nursing practice in various settings, including the succeeding conceptual frameworks and theories in the field of nursing. Nightingale is considered the first nursing theorist.

Nightingale's environmental theory

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One of her theories was the Environmental Theory, which incorporated the restoration of the usual health status of the nurse's clients into the delivery of health care—it is still practiced today.

 Environmental effects She stated in her nursing notes that:  nursing "is an act of utilizing the environment of the patient to assist him in his recovery" (Nightingale 1860/1969),  that it involves the nurse's initiative to configure environmental settings appropriate for the gradual restoration of the patient's health,  and that external factors associated with the patient's surroundings affect life or biologic and physiologic processes, and his development. Environmental factors affecting health  Adequate ventilation has also been regarded as a factor contributing to changes of the patient's process of illness recovery  Defined in her environmental theory are the following factors present in the patient's environment:  Pure or fresh air  Pure water  Sufficient food supplies  Efficient drainage  Cleanliness  Light (especially direct sunlight) Any deficiency in one or more of these factors could lead to impaired functioning of life processes or diminished health status. Provision of care by environment  The factors posed great significance during Nightingale's time, when health institutions had poor sanitation, and health workers had little education and training and were frequently incompetent and unreliable in attending to the needs of the patients.  Also emphasized in her environmental theory is the provision of a quiet or noise-free and warm environment, attending to patient's dietary needs by assessment, documentation of time of food intake, and evaluating its effects on the patient.  Nightingale's theory was shown to be applicable during the Crimean War when she, along with other nurses she had trained, took care of injured soldiers by attending to their immediate needs, when communicable diseases and rapid spread of infections were rampant in this early period in the development of diseasecapable medicines.  The practice of environment configuration according to patient's health or disease condition is still applied today, in such cases as patients infected with Clostridium tetani (suffering from tetanus), who need minimal noise to calm them and a quiet environment to prevent seizure-causing stimulus. Notes on Nursing 1. In her "Notes on Nursing," Florence Nightingale offered her theories of patient care. Although her points may seem old-fashioned to a modern reader, they were revolutionary for a time in history when doctors were not yet convinced that washing their hands between patients was beneficial. She takes a holistic approach to patient care, asserting that the patient's psychological and human needs are as important as the medicine they are taking. Fresh Air 2. It was generally accepted that fresh air was extremely important for recovery, and "Notes on Nursing" has a long section explaining how to assure good ventilation of the patient's room by insisting on open windows. This practice can obviously lead to a chilly room and she explains how proper bed clothing can keep the patient warm. Although ventilation may not seem like an issue in a modern hospital, it apparently was in homes with chamber pots and no indoor plumbing. Cleanliness 3. Cleanliness is crucial both for preventing disease and for helping the patient recover, according to Nightingale. She points out as health hazards the practices of keeping full chamber pots by the patients' bedsides, livestock manure

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piles close to buildings, and running open sewers in the streets. She also criticizes bedding that is "well slept in" as unsanitary, and advocates regular changing, washing and airing out of bedclothes. Environment Nightingale insists that patients' human needs for light and an attractive room are important for recovery. Since patients are confined to bed and have the same view all day long, she suggests that they be able to look out of a window. She also suggests some variety to alleviate patient boredom, as well as attractive colors in the room and quiet, and she believed that pleasant background music (especially wind instruments, strings and the human voice) was helpful for patients' recovery, though she admits that it might be expensive to provide. Communication Nightingale felt that visitors' "chattering hopes" and advice were distressing to patients. This included false assurances, ignorant medical suggestions or suggestions that the patient has nothing wrong with him. She asserts that patients do like to hear good news from outside, and asks that visitors be more sensitive and empathic about the patient's current situation.

Virginia Henderson -The Nature of Nursing 

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"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. She must in a sense, get inside the skin of each of her patients in order to know what he needs".

Hildegard Peplau -Interpersonal Relations Model / Psychodynamic Nursing Theory      

Based on psychodynamic nursing using an understanding of one’s own behavior to help others identify their difficulties Applies principles of human relations Patient has a felt need Interpersonal process is maturing force for personality. Stressed the importance of nurses’ ability to understand own behavior to help others identify perceived difficulties Peplau’s Concepts 1. Person  An individual; a developing organism who tries to reduce anxiety caused by needs  Lives in instable equilibrium 2. Environment  Not defined 3. Health  Implies forward movement of the personality and human processes toward creative, constructive, productive, personal, and community living 4. Nursing  A significant, therapeutic, interpersonal process that functions cooperatively with others to make health possible  Involves problem-solving The four phases of nurse-patient relationships are:  1. Orientation  2. Identification  3. Exploitations  4. Resolution The six nursing roles are:

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1. Stranger 2. Resource person 3. Teacher 4. Leader 5. Surrogate 6. Counselor

Virginia Henderson -The Nature of Nursing “Nursing theories mirror different realities, throughout their development; they reflected the interests of nurses of that time.” Introduction  “The Nightingale of Modern Nursing”  “Modern-Day Mother of Nursing.”  "The 20th century Florence Nightingale."  "little Miss 3x5"  Born in Kansas City, Missouri, in 1897 and is the 5th child of a family of 8th children but spent her formative years in Virginia  Received a Diploma in Nursing from the Army School of Nursing at Walter Reed Hospital, Washington, D.C. in 1921.  Worked at the Henry Street Visiting Nurse Service for 2 years after graduation.  In 1923, she accepted a position teaching nursing at the Norfolk Protestant Hospital in Virginia, where she remained for several years  In 1929, Henderson determined that she needed more education and entered Teachers College at Columbia University where she earned her; Bachelor’s Degree in 1932, Master’s Degree in 1934.  Subsequently, she joined Columbia as a member of the faculty, where she remained until 1948(Herrmann,1998)  Since 1953, she has been a research associate at Yale University School of Nursing.  Died: March 19, 1996. Achievements Is the recipient of numerous recognitions for her outstanding contributions to nursing?  VH was a well known nursing educator and a prolific author.  She has received honorary doctoral degrees from the Catholic University of America, Pace University, University of Rochester,, University of Western Ontario, Yale University  Her stature as a nurse, teacher, author, researcher, and consumer health advocate warranted an obituary in the New York Times, Friday March 22. 1996. In 1985, Miss Henderson was honored at the Annual Meeting of the Nursing and Allied Health Section of the Medical Library Association. Contribution  In 1937 Henderson and others created a basic nursing curriculum for the National League for Nursing in which education was “patient centered and organized around nursing problems rather than medical diagnoses” (Henderson,1991)  In 1939, she revised: Harmer’s classic textbook of nursing for its 4th edition, and later wrote the 5th; edition, incorporating her personal definition of nursing (Henderson,1991)  Although she was retired, she was a frequent visitor to nursing schools well into her nineties. O’Malley (1996) states that Henderson is known as the modern-day mother of nursing.  Her work influenced the nursing profession in America and throughout the world The founding members of ICIRN (Interagency Council on Information Resources for Nursing) and a passionate advocate for the use and sharing of health information resources.  In 1978 the fundamental concept of nursing was revisited by Virginia Henderson from Yale University School of Nursing ( USA ).

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She argued that nurses needed to be prepared for their role by receiving the broadest understanding of humanity and the world in which they lived. Publications  1956 (with B. Harmer)-Textbook for the principles and practices of Nursing.  1966-The Nature of Nursing. A definition and its implication for practice, Research and Education  1991- The Nature of Nursing Reflections after 20 years  Analysis of Nursing Theory Images of Nursing, 1950-1970 The First School of Thought: Needs This school of thought includes theories that reflect an image of nursing as meeting the needs of clients and were developed in response to such questions as:  What do nurses do?  What are their functions?  What roles do nurses play? Answers to these questions focused on a number of theorist describing functions and roles of nurses. Conceptualizing functions led theorists to consider nursing client in terms of a Hierarchy of needs. When any of these needs are unmet and when a person is unable to fulfill his own needs, the care provided by nurses is required. Nurses then provide the necessary functions and play those roles that could help patients meet their 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. She must in a sense, get inside the skin of each of her patients in order to know what he needs".

Henderson’s Theory Background

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Henderson’s concept of nursing was derived form her practice and education therefore, her work is inductive.. She called her definition of nursing her “concept” (Henderson1991) Although her major clinical experiences were in medical-surgical hospitals, she worked as a visiting nurse in New York City.

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This experience enlarges Henderson’s view to recognize the importance of increasing the patient’s independence so that progress after hospitalization would not be delayed (Henderson,1991)

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Virginia Henderson defined nursing as "assisting individuals to gain independence in relation to the performance of activities contributing to health or its recovery" (Henderson, 1966).

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She was one of the first nurses to point out that nursing does not consist of merely following physician's orders. She categorized nursing activities into 14 components, based on human needs. She described the nurse's role as substitutive (doing for the person), supplementary (helping the person), complementary (working with the person), with the goal of helping the person become as independent as possible.

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Her famous definition of nursing was one of the first statements clearly delineating nursing from medicine: "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).

The development of Henderson’s definition of nursing

Two events are the basis for Henderson’s development of a definition of nursing.

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First, she participated in the revision of a nursing textbook. Second, she was concerned that many states had no provision for nursing licensure to ensure safe and competent care for the consumer.

In the revision she recognized the need to be clear about the functions of the nurse and she believed that this textbook serves as a main learning source for nursing practice should present a sound and definitive description of nursing. Furthermore, the principles and practice or nursing must be built upon and derived from the definition of the profession. Although official statements on the nursing function were published by the ANA in 1932 and 1937, Henderson viewed these statements as nonspecific and unsatisfactory definitions of nursing practice. Then in 1955, the earlier ANA definition was modified. Henderson's focus on individual care is evident in

that she stressed assisting individuals with essential activities to maintain health, to recover, or to achieve peaceful death. She proposed 14 components of basic nursing care to augment her definition. In 1955, Henderson’s first definition of nursing was published in Bertha Harmer’s revised nursing textbook.

The 14 components

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Breathe normally. Eat and drink adequately. Eliminate body wastes. Move and maintain desirable postures. Sleep and rest. Select suitable clothes-dress and undress. Maintain body temperature within normal range by adjusting clothing and modifying environment Keep the body clean and well groomed and protect the integument Avoid dangers in the environment and avoid injuring others. Communicate with others in expressing emotions, needs, fears, or opinions. Worship according to one’s faith. Work in such a way that there is a sense of accomplishment. Play or participate in various forms of recreation. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities.

The first 9 components are physiological. The tenth and fourteenth are psychological aspects of communicating and learning The eleventh component is spiritual and moral The twelfth and thirteenth components are sociologically oriented to occupation and recreation

Assumption

The major assumptions of the theory aret:

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"Nurses care for patients until patient can care for themselves once again. Patients desire to return to health, but this assumption is not explicitly stated. Nurses are willing to serve and that “nurses will devote themselves to the patient day and night” A final assumption is that nurses should be educated at the university level in both arts and sciences.

Henderson’s theory and the four major concepts

1. Individual :

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Have basic needs that are component of health. Requiring assistance to achieve health and independence or a peaceful death. Mind and body are inseparable and interrelated. Considers the biological, psychological, sociological, and spiritual components. The theory presents the patient as a sum of parts with biopsychosocial needs, and the patient is neither client nor consumer.

2.Environment:

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Settings in which an individual learns unique pattern for living. All external conditions and influences that affect life and development. Individuals in relation to families Minimally discusses the impact of the community on the individual and family. Supports tasks of private and public agencies Society wants and expects nurses to act for individuals who are unable to function independently. In return she expects society to contribute to nursing education.

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Basic nursing care involves providing conditions under which the patient can perform the 14 activities unaided

3. Health:

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Definition based on individual’s ability to function independently as outlined in the 14 components.

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Nurses need to stress promotion of health and prevention and cure of disease. Good health is a challenge. Affected by age, cultural background, physical, and intellectual capacities, and emotional balance Is the individual’s ability to meet these needs independently?

4. Nursing

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Temporarily assisting an individual who lacks the necessary strength, will and knowledge to satisfy 1 or more of 14 basic needs. Assists and supports the individual in life activities and the attainment of independence. Nurse serves to make patient “complete” “whole", or "independent." Henderson's classic definition of nursing: "I say that the nurse does for others what they would do for themselves if they had the strength, the will, and the knowledge. But I go on to say that the nurse makes the patient independent of him or her as soon as possible."

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The nurse is expected to carry out physician’s therapeutic plan Individualized care is the result of the nurse’s creativity in planning for care. Use nursing research

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Categorized Nursing : nursing care Non nursing: ordering supplies, cleanliness and serving food.

In the Nature of Nursing “ that the nurse is and should be legally, an independent practitioner and able to make independent judgments as long as s/he is not diagnosing, prescribing treatment for disease, or making a prognosis, for these are the physicians function.”

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“Nurse should have knowledge to practice individualized and human care and should be a scientific problem solver.” In the Nature of Nursing Nurse role is,” to get inside the patient’s skin and supplement his strength will or knowledge according to his needs.” And nurse has responsibility to assess the needs of the individual patient, help individual meet their health need, and or provide an environment in which the individual can perform activity unaided

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Henderson's classic definition of nursing "I say that the nurse does for others what they would do for themselves if they had the strength, the will, and the knowledge.

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But I go on to say that the nurse makes the patient independent of him or her as soon as possible."

Henderson’s and Nursing Process

Henderson views the nursing process as “really the application of the logical approach to the solution of a problem. The steps are those of the scientific method.” “Nursing process stresses the science of nursing rather than the mixture of science and art on which it seems effective health care service of any kind is based.

”Summarization of the stages of the nursing process as applied to Henderson’s definition of nursing and to the 14 components of basic nursing care.

Henderson’s 14 components and definition of nursing

Nursing Process Nursing Assessment

Henderson’s 14 components

Nursing Diagnosis

Analysis: Compare data to knowledge base of health and disease.

Nursing plan

Identify individual’s ability to meet own needs with or without assistance, taking into consideration strength, will or knowledge.

Nursing

Document how the nurse can assist the individual, sick or well.

implementation Nursing

Assist the sick or well individual in to performance of activities in meeting human needs to maintain health, recover from illness,

implementation

or to aid in peaceful death.

Nursing process

Implementation based on the physiological principles, age, cultural background, emotional balance, and physical and intellectual capacities.

Carry out treatment prescribed by the physician. Nursing evaluation

Henderson’s 14 components and definition of nursing

Use the acceptable definition of ;nursing and appropriate laws related to the practice of nursing.

The quality of care is drastically affected by the preparation and native ability of the nursing personnel rather that the amount of hours of care.

Successful outcomes of nursing care are based on the speed with which or degree to which the patient performs independently the activities of daily living Comparison with Maslow's Hierarchy of Need

Maslow's

Henderson Breathe normally

Physiological needs Eat and drink adequately Eliminate by all avenues of elimination Move and maintain desirable posture Sleep and rest Select suitable clothing Maintain body temperature Keep body clean and well groomed and protect the integument

Safety Needs

Avoid environmental dangers and avoid injuring other

Communicate with others Belongingness and love needs worship according to one's faith

Work at something providing a sense of accomplishment

Esteem needs

Play or participate in various forms of recreation

Learn, discover, or satisfy curiosity

Characteristic of Henderson’s theory  Theories can interrelate concepts in such a way as to create a different way of looking at a particular phenomenon.  Concepts of fundamental human needs, biophysiology, culture, and interaction, communication and is borrowed from other discipline.E.g.. Maslow’s Hierarchy of human needs; concept of interactioncommunication i.e. nurse-patient relationship  Theories must be logical in nature.  Her definition and components are logical and the 14 components are a guide for the individual and nurse in reaching the chosen goal.  Theories should be relatively simple yet generalizable.  Her work can be applied to the health of individuals of all ages.  Theories can be the bases for hypotheses that can be tested. Her definition of nursing cannot be viewed as theory; therefore, it is impossible to generate testable hypotheses.  However some questions to investigate the definition of nursing and the 14 components may be useful.  Is the sequence of the 14 components followed by nurses in the USA and the other countries?  What priorities are evident in the use of the basic nursing functions?  Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them.  Her ideas of nursing practice are well accepted throughout the world as a basis for nursing care.  However, the impact of the definition and components has not been established through research.  Theories can be utilized by practitioners to guide and improve their practice.  Ideally the nurse would improve nursing practice by using her definition and 14 components to improve the health of individuals and thus reduce illness.  Theories must be consistent with other validated theories, laws, and principles but will leave open unanswered questions that need to be investigated. Philosophical claims

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The philosophy reflected in Henderson's theory is an integrated approach to scientific study that would capitalize on nursing's richness and complexity, and not to separate the art from the science, the "doing" of nursing from the "knowing", the psychological from the physical and the theory from clinical care. Values and Beliefs  Henderson believed nursing as primarily complementing the patient by supplying what he needs in knowledge, will or strength to perform his daily activities and to carry out the treatment prescribed for him by the physician.  She strongly believed in "getting inside the skin" of her patients in order to know what he or she needs. The nurse should be the substitute for the patient, helper to the patient and partner with the patient.  Like she said... "The nurse is temporarily the consciousness of the unconscious, the love of life for the suicidal, the leg of the amputee, the eyes of the newly blind, a means of locomotion for the infant and the knowledge and confidence for the young mother..."  Henderson stated that “Thorndike’s fundamental needs of man” (Henderson, 1991, p.16) had an influence on her beliefs. Value in extending nursing science  From an historical standpoint, her concept of nursing enhanced nursing science this has been particularly important in the area of nursing education.  Her contributions to nursing literature extended from the 1930s through the 1990s and has had an impact on nursing research by strengthening the focus on nursing practice and confirming the value of tested interventions in assisting individuals to regain health. Usefulness  Nursing education has been deeply affected by Henderson’s clear vision of the functions of nurses.  The principles of Henderson’s theory were published in the major nursing textbooks used from the 1930s through the 1960s, and the principles embodied by the 14 activities are still important in evaluating nursing care in thee21st centaury.  Others concepts that Henderson (1966) proposed have been used in nursing education from the 1930s until the present O'Malley, 1996) Testability  Henderson supported nursing research, but believed that it should be clinical research (O’Malley, 1996). Much of the research before her time had been on educational processes and on the profession of nursing itself, rather than on; the practice and outcomes of nursing , and she worked to change that.  Each of the 14 activities can be the basis for research. Although the statements are not.  Written in testable terms, they may be reformulated into researchable questions. Further, the theory can guide research in any aspect of the individual’s care needs. Limitations  Lack of conceptual linkage between physiological and other human characteristics.  No concept of the holistic nature of human being.  If the assumption is made that the 14 components prioritized, the relationship among the components is unclear.  Lacks inter-relate of factors and the influence of nursing care.  Assisting the individual in the dying process she contends that the nurse helps, but there is little explanation of what the nurse does.  “Peaceful death” is curious and significant nursing role. PURPOSES OF NURSING THEORIES In Practice:  Assist nurses to describe, explain, and predict everyday experiences.  Serve to guide assessment, interventions, 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 to describe criteria to measure the quality of nursing care.  Help build a common nursing terminology to use in communicating with other health professionals.

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Ideas are developed and words are defined. Enhance autonomy (independence and self-governance) of nursing through defining its own independent functions. In Education:  Provide a general focus for curriculum design  Guide curricular decision making. In Research:  Offer a framework for generating knowledge and new ideas.  Assist in discovering knowledge gaps in the specific field of study.  Offer a systematic approach to identify questions for study; select variables, interpret findings, and validate nursing interventions.  Approaches to developing nursing theory  Borrowing conceptual frameworks from other disciplines.  Inductively looking at nursing practice to discover theories/concepts to explain phenomena.  Deductively looking for the compatibility of a general nursing theory with nursing practice.  Questions from practicing Nurse about using Nursing theory Practice  Does this theory reflect nursing practice as I know it?  Will it support what I believe to be excellent nursing practice?  Can this theory be considered in relation to a wide range of nursing situation?  Personal Interests, Abilities and Experiences  What will it be like to think about nursing theory in nursing practice?  Will my work with nursing theory be worth the effort?

Fay Abdellah- Topology of 21 Nursing Problems 

Faye Glenn Abdellah, pioneer nursing researcher, helped transform nursing theory, nursing care and nursing education  Birth:1919  Dr Abdellah worked as Deputy Surgeon General  Former Chief Nurse Officer for the US Public Health Service , Department of Health and human services, Washington, D.C.  She has been a leader in nursing research and has over one hundred publications related to nursing care, education for advanced practice in nursing and nursing research.  In 1960, influenced by the desire to promote client-centred comprehensive nursing care, Abdellah described nursing as a service to individuals, to families, and, therefore to, to society.  According to her, nursing is based on an art and science that mould 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. As a comprehensive service ,nursing includes; 1. Recognizing the nursing problems of the patient 2. Deciding the appropriate course of action to take in terms of relevant nursing principles 3. Providing continuous care of the individuals total needs 4. Providing 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. Helping the individual to become more self directing in attaining or maintaining a healthy state of mind & 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

10. Carrying out continuous evaluation and research to improve nursing techniques and to develop new techniques to meet the health needs of peop These original premises have undergone an evolutionary process. As result, in 1973, the item 3, - “providing continuous care of the individual’s total health needs” was eliminated. From these premises, Abdellah’s theory was derived. PHILOSOPHICAL UNDERPINNINGS OF THE THEORY  Abdellah’s patient-centred approach to nursing was developed inductively from her practice and is considered a human needs theory.  The theory was created to assist with nursing education and is most applicable to the education of nurses.  Although it was intended to guide care of those in the hospital, it also has relevance for nursing care in community settings. MAJOR ASSUMPTIONS, CONCEPTS & RELATIONSHIPS  The language of Abdellah’s framework is readable and clear.  Consistent with the decade in which she was writing, she uses the term ‘she’ for nurses, ‘he’ for doctors and patients, and refers to the object of nursing as ‘patient’ rather than client or consumer.  She referred to Nursing diagnosis during a time when nurses were taught that diagnosis was not a nurses’ prerogative. Assumptions were related to  change and anticipated changes that affect nursing;  The need to appreciate the interconnectedness of social enterprises and social problems;  the impact of problems such as poverty, racism, pollution, education, and so forth on health care delivery;  changing nursing education  continuing education for professional nurses  development of nursing leaders from under reserved groups Abdellah and colleagues developed a list of 21 nursing problems.They also identified 10 steps to identify the client’s problems. 11 nursing skills to be used in developing a treatment typology 10 steps to identify the client’s problems  Learn to know the patient  Sort out relevant and significant data  Make generalizations about available data in relation to similar nursing problems presented by other patients  Identify the therapeutic plan  Test generalizations with the patient and make additional generalizations  Validate the patient’s conclusions about his nursing problems  Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting his behavior  Explore the patient’s and family’s reaction to the therapeutic plan and involve them in the plan  Identify how the nurses feels about the patient’s nursing problems  Discuss and develop a comprehensive nursing care plan 11 nursing skills  Observation of health status  Skills of communication  Application of knowledge  Teaching of patients and families  Planning and organization of work  Use of resource materials  Use of personnel resources  Problem-solving  Direction of work of others  Therapeutic use of the self  Nursing procedure The twenty-one Nursing Problems

Three major categories  Physical, sociological, and emotional needs of clients  Types of interpersonal relationships between the nurse and patient  Common elements of client care 21 NURSING PROBLEMS BASIC TO ALL PATIENTS  To maintain good hygiene and physical comfort  To promote optimal activity: exercise, rest and sleep  To promote safety through the prevention of accidents, injury, or other trauma and through the prevention of the spread of infection  To maintain good body mechanics and prevent and correct deformitiy SUSTENAL CARE NEEDS  To facilitate the maintenance of a supply of oxygen to all body cells  To facilitate the maintenance of nutrition of all body cells  To facilitate the maintenance of elimination  To facilitate the maintenance of fluid and electrolyte balance  To recognize the physiological responses of the body to disease conditions  To facilitate the maintenance of regulatory mechanisms and functions  To facilitate the maintenance of sensory function. REMEDIAL CARE NEEDS  To identify and accept positive and negative expressions, feelings, and reactions  To identify and accept the interrelatedness of emotions and organic illness  To facilitate the maintenance of effective verbal and non verbal communication  To promote the development of productive interpersonal relationships  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 physical , emotional, and developmental needs RESTORATIVE CARE NEEDS  To accept the optimum possible goals in the light of limitations, physical and emotional  To use community resources as an aid in resolving problems arising from illness  To understand the role of social problems as influencing factors in the case of illness Abdellah's 21 problems are actually a model describing the "arenas" or concerns of nursing, rather than a theory describing relationships among phenomena. In this way, the theory distinguished the practice of nursing, with a focus on the 21 nursing problems, from the practice of medicine, with a focus on disease and cure. ABDELLAH’S THEORY AND NURSING  Although Abdellah’s writings are not specific as to a theoretical statement, such a statement can be derived by using her three major concepts of health, nursing problems, and problem solving.  Abdellah’s theory would state that nursing is the use of the problem solving approach with key nursing problems related to health needs of people. Such a statement maintains problem solving as the vehicle for the nursing problems as the client is moved toward health – the outcome NURSING Acc to her, nursing is based on an art and science that mould 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. HEALTH Health is a dynamic pattern of functioning whereby there is a continued interaction with internal and external forces that results in the optimum use of necessary resources that serve to minimize vulnerabilities NURSING PROBLEMS  Nursing problem presented by a client is a condition faced by the client or client’s family that the nurse through the performance of professional functions can assist them to meet . The problem can be either an overt or covert nursing problem.

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An overt nursing problem is an apparent condition faced by the patient or family, which the nurse can assist him or them to meet through the performance of her professional functions.  The covert nursing problem is a concealed or hidden condition faced, by the patient or family, which the nurse can assist him or them to meet through the performance of her professional functions  In her attempt to bring nursing practice into its proper relationship with restorative and preventive measures for meeting total client needs, she seems to swing the pendulum to the opposite pole, from the disease orientation to nursing orientation, while leaving the client somewhere in the middle. PROBLEM SOLVING The problem solving process involves identifying the problem, selecting pertinent data, formulating hypothesis, testing hypothesis through the collection of data, and revising hypothesis where necessary on the basis of conclusions obtained from the data. ABDELLAH’S THEORY AND THE FOUR MAJOR CONCEPTS NURSING  Nursing is a helping profession. In Abdellah’s model, nursing care is doing something to or for the person or providing information to the person with the goals of meeting needs, increasing or restoring self-help ability, or alleviating impairment.  Nursing is broadly grouped into the 21 problem areas to guide care and promote use of nursing judgment.  She considers nursing to be comprehensive service that is based on art and science and aims to help people, sick or well, cope with their health needs. PERSON  Abdellah describes people as having physical, emotional, and sociological needs. These needs may overt, consisting of largely physical needs, or covert, such as emotional and social needs.  Patient is described as the only justification for the existence of nursing.  Individuals (and families) are the recipients of nursing  Health, or achieving of it, is the purpose of nursing services. HEALTH  In Patient –Centered Approaches to Nursing, Abdellah describes health as a state mutually exclusive of illness.  Although Abdellah does not give a definition of health, she speaks to “total health needs” and “a healthy state of mind and body” in her description of nursing as a comprehensive service. SOCIETY AND ENVIRONMENT  Society is included in “planning for optimum health on local, state, national, and international levels”. However, as she further delineated her ideas, the focus of nursing service is clearly the individual.  The environment is the home or community from which patient comes. ABDELLAH’S WORK AND CHARACTERISTICS OF A THEORY Characteristic 1  Abdellah’s theory has interrelated the concepts of health, nursing problems, and problem solving as she attempts to create a different way of viewing nursing phenomenon  The result was the statement that nursing is the use of problem solving approach with key nursing problems related to health needs of people. Characteristic 2  Problem solving is an activity that is inherently logical in nature Characteristic 3  Framework seems to focus quite heavily on nursing practice and individuals. This somewhat limit the ability to generalize although the problem solving approach is readily generalizable to clients with specific health needs and specific nursing problems Characteristic 4  One of the most important questions that arise when considering her work is the role of client within the framework. This question could generate hypothesis for testing and thus demonstrates the ability of Abdellah’s work to generate hypothesis for testing Characteristic 5  The results of testing such hypothesis would contribute to the general body of nursing knowledge

Characteristic 6  Abdellah’s problem solving approach can easily be used by practitioners to guide various activities within their practice. This is true when considering nursing practice that deals with clients who have specific needs and specific nursing problems Characteristic 7  Although consistency with other theories exist, many questions remain unanswered USE OF 21 PROBLEMS IN THE NURSING PROCESS ASSESSMENT PHASE  Nursing problems provide guidelines for the collection of data.  A principle underlying the problem solving approach is that for each identified problem, pertinent data are collected.  The overt or covert nature of the problems necessitates a direct or indirect approach, respectively. NURSING DIAGNOSIS  The results of data collection would determine the client’s specific overt or covert problems.  These specific problems would be grouped under one or more of the broader nursing problems.  This step is consistent with that involved in nursing diagnosis PLANNING PHASE  The statements of nursing problems most closely resemble goal statements. Therefore, once the problem has been diagnosed, the goals have been established.  Given that these problems are called nursing problems, then it becomes reasonable to conclude that these goals are basically nursing goals. IMPLEMENTATION  Using the goals as the framework, a plan is developed and appropriate nursing interventions are determined. EVALUATION  According to the American Nurses’ Association Standards of Nursing Practice, the plan is evaluated in terms of the client’s progress or lack of progress toward the achievement of the stated goals.  This would be extremely difficult if not impossible to do for Abdellah’s nursing problem approach since it has been determined that the goals are nursing goals, not the client goals.  Thus, the most appropriate evaluation would be the nurse progress or lack of progress toward the achievement of the stated goals AN illustration of the implementation of Abdellah’s framework in Ryan’s care  Consider a case of Ryan who experienced severe crushing chest pain ‘shortness of breath, tachycardia and profuse diaphoresis  Stage of illness is basic to care  Selected Abdellah nursing problem  To maintain good hygiene and personal comfort  Classification and approach  Overt problem of pain; Direct and indirect method Selected Nursing Interventions  administer oxygen  elevate headrest  reposition client  administer prescribed analgesic  remain with client  Criterion measure- Amount of pain CONCEPT OF PROGRESSIVE PATIENT CARE  PPC is defined as better patient care through the organization of hospital facilities, services and staff around the changing medical and nursing needs of the patient  PPC is tailoring of hospital services to meet patients needs  PPC is caring for the right patient in the right bed with the right services at the right time  PPC is systematic classification of patients based on their medical needs

ELEMENTS OF PPC INTENSIVE CARE  Critically and seriously ill patients requiring highly skilled nursing care, close and frequent if not constant, nursing observation are assigned to the ICU. One patient in an ICU requires at least three nurses to observe him in 24 hrs  Intermediate care Patients assigned to this unit are both the moderately ill and those for whom the treatment can only be palliative  Self care Ambulatory patients who are convalescencing or require diagnosis or therapy may be cared for in this unit  Long term care unit This unit will provide services to certain patients now cared for in the general hospital, in nursing homes, or in their own homes and who would benefit by care in a hospital environment to achieve its maximum potential  Home care This programme makes it possible to extend needed services to the patient after he leaves the hospital and returns to his home in the community BENEFITS OF PPC PATIENT  better attention  better adjustment  minimized problems  life saving care  constant medical and nursing care PHYSICIAN  assuring best nursing care  drugs and equipments at hand  orders carried out effectively  better clinical an team service HOSPITAL  effective and efficient use of staff  improved public image NURSING PERSONNEL  individual skills can be used  more time with patient  helping pt. and family to solve problems  job satisfaction  in-service education COMMUNITY  continuity with hospital services  minimize the need of hospitalization IMPLICATIONS OF PPC FOR NURSING EDUCATION  Many nurse educators feel that the PPC hospital where all five phases of care are available can provide clinical experience in which the nurse can learn to solve basic nursing problems in meeting patients’ needs.  The three month assignment of professional nurses may no longer be realistic in such a setting.  Organization of hospital and community services based on patients needs  In the intensive care unit, the critically ill patients are concentrated regardless of diagnosis.  These patients are under the constant audio-visual observation of the nurse, with life saving techniques and equipment immediately available  In the intermediate care unit are concentrated patients requiring a moderate amount of nursing care, not of an emergency nature, who are ambulatory for short periods, and who are beginning to participate in he planning of their own care

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The self-care unit provides for patients who are physically self-sufficient and require diagnostic and convalescent care in hotel-type accommodations. This unit serves as a link between the hospital and the home.  In the long-term care unit are concentrated patients requiring prolonged care. The grouping of such patients will permit staffing patterns that are less costly  Home care, the fifth element of progressive patient care, extends hospital services into the home to assist the physician in the care of his patients USEFULNESS  The patient centered approach was constructed to be useful to nursing practice, with impetus for it being nursing education.  Abdellah’s publications on nursing education began with her dissertation; her interest in education for nurses continues into the present.  Abdellah has also published on nursing, nursing research, and public policy related to nursing in several international publications. She has been a strong advocate for improving nursing practice through nursing research VALUE IN EXTENDING NURSING SCIENCE  It helped to bring structure and organization to what was often a disorganized collection of lectures and experiences.  She categorized nursing problems based on the individual’s needs and developed developed a typology of nursing treatment and nursing skills.. NURSING RESEARCH  She has been a leader in nursing research and has over one hundred publications related to nursing care, education for advanced practice in nursing and nursing research. LIMITATIONS  Very strong nursing centered orientation  Little emphasis on what the client is to achieve  Her framework is inconsistent with the concept of holism Potential problems might be overlooked SUMMARY  Using Abdellah’s concepts of health, nursing problems, and problem solving, the theoretical statement of nursing that can be derived is the use of the problem solving approach with key nursing problems related to health needs of people.  From this framework, 21 nursing problems were developed   

A list of 21 nursing problems Condition presented or faced by the patient or family. Problems are in 3 categories o physical, social and emotional  The nurse must be a good problem solver Abdella’s 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 2. Health  Excludes illness  No unmet needs and no actual or anticipated impairments 3. Person  One who has physical, emotional, or social needs  The recipient of nursing care.

4. Environment  Did not discuss much  Includes room, home, and community

Ida Jean Orlando- Deliberative Nursing Process / Ida Jean Orlando’s Nursing Process Theory 

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She received her nursing diploma from New York Medical College, Lower Fifth Avenue Hospital, School of Nursing, her BS in public health nursing from St. John's University, Brooklyn, NY, and her MA in mental health nursing from Teachers College, Columbia University, New York. Orlando was an Associate Professor at Yale School of Nursing where she was Director of the Graduate Program in Mental Health Psychiatric Nursing. While at Yale she was project investigator of a National Institute of Mental Health grant entitled: Integration of Mental Health Concepts in a Basic Nursing Curriculum. It was from this research that Orlando developed her theory which was published in her 1961 book, The Dynamic Nurse-Patient Relationship. She furthered the development of her theory when at McLean Hospital in Belmont, MA as Director of a Research Project: Two Systems of Nursing in a Psychiatric Hospital. The results of this research are contained in her 1972 book titled: The Discipline and Teaching of Nursing Processs. Deliberative Nursing Process - Orlando's theory was developed in the late 1950s from observations she recorded between a nurse and patient. (Information from Nursingtheory.net) Nursing Process Theory. Ida Jean Orlando. Dr Norma Jean Schmieding. University of Rhode Island College of Nursing.

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The deliberative nursing process is set in motion by the patient’s behavior All behavior may represent a cry for help. Patient’s behavior can be verbal or non-verbal. The nurse reacts to patient’s behavior and forms basis for determining nurse’s acts. Perception, thought, feeling Nurses’ actions should be deliberative, rather than automatic Deliberative actions explore the meaning and relevance of an action. Interpersonal process alleviates distress. Nurses must stay connected to patients and assure that patients get what they need, focused on patient’s verbal and non verbal expressions of need and nurse’s reactions to patient’s behavior to alleviate distress. Theory of the Nursing Process Discipline Orlando's theory was developed in the late 1950s from observations she recorded between a nurse and patient. Despite her efforts, she was only able to categorize the records as "good" or "bad" nursing. It then dawned on her that both the formulations for "good" and "bad" nursing were contained in the records. From these observations she formulated the deliberative nursing process. The role of the nurse is to find out and meet the patient's immediate need for help. The patient's presenting behavior may be a plea for help, however, the help needed may not be what it appears to be. Therefore, nurses need to use their perception, thoughts about the perception, or the feeling engendered from their thoughts to explore with patients the meaning of their behavior. This process helps the nurse find out the nature of the distress and what help the patient needs. Orlando's theory remains one the of the most effective practice theories available Elements of nursing situation: 1. Patient 2. Nurse reactions 3. Nursing actions ASSUMPTIONS

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When patients cannot cope with their needs without help, they become distressed with feelings of helplessness  Nursing , in its professional character , does add to the distress of the patient  Patients are unique and individual in their responses  Nursing offers mothering and nursing analogous to an adult mothering and nurturing of a child  Nursing deals with people, environment and health  Patient need help in communicating needs, they are uncomfortable and ambivalent about dependency needs  Human beings are able to be secretive or explicit about their needs, perceptions, thoughts and feelings  The nurse – patient situation is dynamic, actions and reactions are influenced by both nurse and patient  Human beings attach meanings to situations and actions that are not apparent to others  Patients entry into nursing care is through medicine  The patient cannot state the nature and meaning of his distress for his need without the nurses help or without her first having established a helpful relationship with him  Any observation shared and observed with the patient is immediately useful in ascertaining and meeting his need or finding out that he is not in need at that time  Nurses are concerned with needs that patients cannot meet on their own DOMAIN CONCEPTS 1. Nursing – is responsive to individuals who suffer or anticipate a sense of helplessness 2. Process of care in an immediate experience….. for avoiding, relieving, diminishing or curing the individuals sense of helplessness. Finding out meeting the patients immediate need for help 3. Goal of nursing – increased sense of well being, increase in ability, adequacy in better care of self and improvement in patients behavior 4. Health – sense of adequacy or well being . Fulfilled needs. Sense of comfort 5. Environment – not defined directly but implicitly in the immediate context for a patient 6. Human being – developmental beings with needs, individuals have their own subjective perceptions and feelings that may not be observable directly 7. Nursing client – patients who are under medical care and who cannot deal with their needs or who cannot carry out medical treatment alone 8. Nursing problem – distress due to unmet needs due to physical limitations, adverse reactions to the setting or experiences which prevent the patient from communicating his needs 9. Nursing process – the interaction of 1)the behavior of the patient, 2) the reaction of the nurse and 3)the nursing actions which are assigned for the patients benefit 10. Nurse – patient relations – central in theory and not differentiated from nursing therapeutics or nursing process 11. Nursing therapeutics – Direct function : initiates a process of helping the patient express the specific meaning of his behavior in order to ascertain his distress and helps the patient explore the distress in order to ascertain the help he requires so that his distress may be relieved. 12. Indirect function – calling for help of others , whatever help the patient may require for his need to be met 13. Nursing therapeutics - Disciplined and professional activities – automatic activities plus matching of verbal and nonverbal responses, validation of perceptions, matching of thoughts and feelings with action 14. Automatic activities – perception by five senses, automatic thoughts, automatic feeling, action STRENGTHS  Use of her theory assures that patient will be treated as individuals and that they will have active and constant input into their own care  Prevents inaccurate diagnosis or ineffective plans because the nurse has to constantly explore her reactions with the patient  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  Make evaluation a less time consuming and more deliberate function, the results of which would be documented in patients charts  Nursing can pursue Orlando's work for retesting and further developing her work

Dorothy Johnson- Behavioral Systems Model     

The person is a behavioral system comprised of a set of organized, interactive, interdependent, and integrated subsystems Constancy is maintained through biological, psychological, and sociological factors. A steady state is maintained through adjusting and adapting to internal and external forces. Individuals maintain stability and balance through adjustments and adaptation to the forces that impinges them. Individual as a behavioral system is composed of seven subsystems. Disturbances in these causes nursing problems.

Johnson’s 7 Subsystems Affiliative subsystem - Attachment, or the affiliative subsystems – is the corner stone of social organizations  social bonds Dependency  helping or nuturing

Ingestive 

food intake

Eliminative 

excretion

Sexual 

procreation and gratification

Aggressive 

self-protection and preservation

Achievement 

efforts to gain mastery and control

Johnson’s Concepts 1. Person  A behavioral system comprised of subsystems constantly trying to maintain a steady state 2. Environment  Not specifically defined but does say there is an internal and external environment 3. Health  Balance and stability. 4. Nursing  External regulatory force that is indicated only when there is instability.

Martha Rogers -Unitary Human Beings  Diploma in nursing, 1936  Bachelor of Science degree, 1937  MSN from Teacher’s College, 1945  Doctorate degree in science at John Hopkins University, 1954  Public Health Nurse  Visiting Nurse  Head of Nursing, NYU The Science of Rogerian Nursing  Rogers labeled her work as a “science”, or conceptual model.

 “She reinforced the idea that nursing is based on a science.” However, she was openly critical of evidencebased practice.  References to quantum physics are apparent attempts to legitimize the concepts.  Existing scientific methodology fails to capture the “immeasurable” components of the theory.

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4 Basic Concepts Energy fields Fundamental unit of living and non-living. Energy refers to dynamic nature, i.e., continuous motion or change. Infinite. Humans and environment do not HAVE energy fields. THEY ARE ENERGY FIELDS.

2. Openness • Openness is a characteristic of both humans and environment. • Transcend time and space. • The energy fields of man and environment are integral with one another. Universe of open systems  Energy fields are open, infinite, and interactive 3. • • 

Pattern Characteristics of an energy field perceived as a single wave Refers only to an energy field (man and environment). Changes continuously A wave that changes, becomes complex and diverse

4. Four-dimensionality  Energy fields (man and environment) are not bound by time or space.  Also referred to as pandimensionality Pandimensionality  A nonlinear domain with out time or space Essence of Theory  The energy field of the human being interacts with the energy field environment. (The human being and the environment cannot be understood in isolation of each other).  Nursing Client: Human beings-environment energy fields relationship. Nursing therapeutics: “Repatterning of man and environment for more effective fulfillment of life’s capabilities”  Person environment are energy fields that evolve negentropically  Martha proposed that nursing was a basic scientific discipline  Nursing is using knowledge for human betterment.  The unique focus of nursing is on the unitary or irreducible human being and the environment (both are energy fields) rather than health and illness  Energy fields  Fundamental unity of things that are unique, dynamic, open, and infinite  Unitary man and environmental field

Roger’s Definitions Integrality  Continuous and mutual interaction between man and environment Resonancy  Continuous change longer to shorter wave patterns in human and environmental fields Helicy  Continuous, probabilistic, increasing diversity of the human and envrionmental fields.

 Characterized by nonrepeating rhymicities  Change Unitary: Her theory is called the science of Unitary Human Beings. Unitary refers to being a whole which cannot be broken down into parts, or irreducible. Nursing: While the energy fields of man and environment are outside of time, nursing takes place along a space-time continuum

Clinical Applications  Others have expanded on Rogers’ theory.  Use of an assessment framework  Living in the Relative Present  Experiencing comfort from past/present  Shared Communication  Sense of Rhythm  Connection to Environment  Sense of Self-Identity  Creation of Nursing Diagnoses  Disturbed Energy Field  Nursing Interventions  Therapeutic Touch  Meditation/Imagery  Light, Color and Music Therapy Contributions  Identified people and the world they live in as the core focus of nursing Focus on patterns and repatterning.  Introduced concept of energy to nursing theory  Emphasized nursing as a unique empirical science.  Advocated nursing-specific body of knowledge. Scope of the Science of Unitary Human Beings  Relatable to ADLs and daily human needs Inspiration for environment-patient interactionist theories and practice methods.  Therapeutic touch  Barret’s theory of power as “knowing participation in change” Zahourek’s theory of intentionality  Nursing focus on holism  Empowers the patient and the professional nurse as agents for change 

Dorothea Orem- Self-Care Model Self–care maintains wholeness. 

Self-care comprises those activities performed independently by an individual to promote and maintain person well-being  Self care agency is the individual’s ability to perform self care activities  Self- care deficit occurs when the person cannot carry out self-care  The nurse then meets the self-care needs by acting or doing for; guiding, teaching, supporting or providing the environment to promote patient’s ability Three Theories: 1. Theory of Self-Care 2. Theory of Self-Care Deficit

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Theory of Nursing Systems Wholly compensatory (doing for the patient) Patient dependent

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Partly compensatory (helping the patient do for himself or herself) Patient can meet some needs but needs nursing assistance

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Supportive- educative (Helping patient to learn self care and emphasizing on the importance of nurses’ role). Patient can meet self care requisites, but needs assistance with decision making or knowledge

Dorothea Orem's Self-Care Theory DEFINITIONS OF DOMAIN CONCEPTS Nursing – is art, a helping service, and a technology  Actions deliberately selected and performed by nurses to help individuals or groups under their care to maintain or change conditions in themselves or their environments  Encompasses the patient’s perspective of health condition ,the physician’s perspective , and the nursing perspective  Goal of nursing – to render the patient or members of his family capable of meeting the patient’s self care needs  To maintain a state of health  To regain normal or near normal state of health in the event of disease or injury  To stabilize ,control ,or minimize the effects of chronic poor health or disability Health – health and healthy are terms used to describe living things …  It is when they are structurally and functionally whole or sound … wholeness or integrity. .includes that which makes a person human,…operating in conjunction with physiological and psycho-physiological mechanisms and a material structure and in relation to and interacting with other human beings Environment  environment components are environmental factors, environmental elements, conditions, and developmental environment Human being – has the capacity to reflect, symbolize and use symbols  Conceptualized as a total being with universal, developmental needs and capable of continuous self care  A unity that can function biologically, symbolically and socially Nursing client  A human being who has "health related /health derived limitations that render him incapable of continuous self care or dependent care or limitations that result in ineffective / incomplete care.  A human being is the focus of nursing only when a self –care requisites exceeds self care capabilities Nursing problem  deficits in universal, developmental, and health derived or health related conditions Nursing process  a system to determine (1)why a person is under care (2)a plan for care ,(3)the implementation of care Nursing therapeutics  deliberate, systematic and purposeful action OREM’S GENERAL THEORY OF NURSING Orem’s general theory of nursing in three related parts: Theory of self care  Theory of self care deficit  Theory of nursing system A. Theory of Self Care This theory Includes :--

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Self care – practice of activities that individual initiates and perform on their own behalf in maintaining life ,health and well being  Self care agency – is a human ability which is "the ability for engaging in self care" -conditioned by age developmental state, life experience socio-cultural orientation health and available resources  Therapeutic self care demand – "totality of self care actions to be performed for some duration in order to meet self care requisites by using valid methods and related sets of operations and actions"  Self care requisites-action directed towards provision of self care. 3 categories of self care requisites are:-1. Universal  Developmental  Health deviation 2. Universal self care requisites  Associated with life processes and the maintenance of the integrity of human structure and functioning  Common to all , ADL  Identifies these requisites as:  Maintenance of sufficient intake of air ,water, food  Provision of care assoc with elimination process  Balance between activity and rest, between solitude and social interaction  Prevention of hazards to human life well being and  Promotion of human functioning 3. Developmental self care requisites  Associated with developmental processes/ derived from a condition…. Or associated with an event o E.g. adjusting to a new job o adjusting to body changes  Health deviation self care o Required in conditions of illness, injury, or disease .these include:-o Seeking and securing appropriate medical assistance o Being aware of and attending to the effects and results of pathologic conditions o Effectively carrying out medically prescribed measures o Modifying self concepts in accepting oneself as being in a particular state of health and in specific forms of health care o Learning to live with effects of pathologic conditions B. Theory of self care deficit  Specifies when nursing is needed  Nursing is required when an adult (or in the case of a dependent, the parent) is incapable or limited in the provision of continuous effective self care. Orem identifies 5 methods of helping:-o Acting for and doing for others o Guiding others o Supporting another o Providing an environment promoting personal development in relation to meet future demands o Teaching another C. Theory of Nursing Systems  Describes how the patient’s self care needs will be met by the nurse , the patient, or both  Identifies 3 classifications of nursing system to meet the self care requisites of the patient: Wholly compensatory system  Partly compensatory system  Supportive – educative system  Design and elements of nursing system define  Scope of nursing responsibility in health care situations  General and specific roles of nurses and patients  Reasons for nurses’ relationship with patients and

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The kinds of actions to be performed and the performance patterns and nurses’ and patients’ actions in regulating patients’ self care agency and in meeting their self care demand Orem recognized that specialized technologies are usually developed by members of the health profession A technology is systematized information about a process or a method for affecting some desired result through deliberate practical endeavour ,with or without use of materials or instruments

Categories of technologies 1. Social or interpersonal  Communication adjusted to age, health status  Maintaining interpersonal, intragroup or intergroup relations for coordination of efforts  Maintaining therapeutic relationship in light of psychosocial modes of functioning in health and disease  Giving human assistance adapted to human needs ,action abilities and limitations 2. Regulatory technologies  Maintaining and promoting life processes  Regulating psycho physiological modes of functioning in health and disease  Promoting human growth and development  Regulating position and movement in space OREM’S THEORY AND NURSING PROCESS  Orem’s approach to the nursing process presents a method to determine the self care deficits and then to define the roles of person or nurse to meet the self care demands.  The steps within the approach are considered to be the technical component of the nursing process. Orem emphasizes that the technological component "must be coordinated with interpersonal and social processes within nursing situations. OREM’S WORK AND THE CHARACTERISTICS OF A THEORY  Theories can interrelate concepts in such a way as to create a different way of looking at a particular phenomenon  Theories must be logical in nature  Theories must be relatively simple yet generalizable  Theories are the basis for hypothesis that can be tested  Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them  Theories can be used by the practitioners to guide and improve their practice  Theories must be consistent with other validated theories ,laws and principles Theory Testing  Orem’s theory has been used as the basis for the development of research instruments to assist researchers in using the theory  A self care questionnaire was developed and tested by Moore(1995) for the special purpose of measuring the self care practice of children and adolescents  The theory has been used as a conceptual framework in assoc. degree programs (Fenner 1979) also in many nursing schools Strengths  Provides a comprehensive base to nursing practice  It has utility for professional nursing in the areas of nursing practice nursing curricula ,nursing education administration ,and nursing research  Specifies when nursing is needed  Also includes continuing education as part of the professional component of nursing education  Her self care approach is contemporary with the concepts of health promotion and health maintenance  Expanded her focus of individual self care to include multiperson units

Limitations  In general system theory a system is viewed as a single whole thing while Orem defines a system as a single whole ,thing  Health is often viewed as dynamic and ever changing .Orem’s visual presentation of the boxed nursing systems implies three static conditions of health  Appears that the theory is illness oriented rather with no indication of its use in wellness settings

Summary  Orem’s general theory of nursing is composed of three constructs .Throughout her work , she interprets the concepts of human beings, health, nursing and society .and has defined 3 steps of nursing process. It has a broad scope in clinical practice and to lesser extent in research ,education and administration

Imogene King-Goal Attainment Theory       

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Transactions provide a frame of reference toward goal setting. A conceptual model of nursing from which theory of goal attainment is derived. From her major concepts (interaction, perception, communication, transaction, role, stress, growth and development) derived goal attainment theory. Perceptions, Judgments and actions of the patient and the nurse lead to reaction, interaction, and transaction (Process of nursing). Open systems framework Human beings are open systems in constant interaction with the environment Personal System o individual; perception, self, growth, development, time space, body image o Interpersonal o Society Personal System o Individual; perception, self, growth, development, time space, body image Interpersonal o Socialization; interaction, communication and transaction Society o Family, religious groups, schools, work, peers The nurse and patient mutually communicate, establish goals and take action to attain goals Each individual brings a different set of values, ideas, attitudes, perceptions to exchange

Betty Neuman - Health Care Systems Model  

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Born 1924 near Lowell, Ohio. In 1947 she received RN Diploma from Peoples Hospital School of Nursing, Akron, Ohio. She then moved to California and gained experience as a hospital, staff, and head nurse; school nurse and industrial nurse; and as a clinical instructor in medical-surgical, critical care and communicable disease nursing. In 1957 Dr. Neuman attended the University of California at Los Angeles (UCLA) with double major in psychology and public health. She received BS in nursing from UCLA. In 1966 she received Masters degree in Mental Health, Public Health Consultation fom UCLA. Dr. Neuman is recognized as pioneer in the field of nursing involvement in community mental health. She began developing her model while lecturing in community mental health at UCLA. In 1972 her model was first published as a 'Model for teaching total person approach to patient problems' in Nursing Research. In 1985 she received her doctorate in Clinical Psychology from Pacific Western University.

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In 1998 she received a second honorary doctorate, this one from Grand Valley State University, Allendale, Michigan. The Neuman Systems Model was originally developed in 1970 at the University of California, Los Angeles, by Betty Neuman, Ph.D., RN. The model was developed by Dr. Neuman as a way to teach an introductory nursing course to nursing students. 1970 - Started developing The Systems Model as a way to teach an introductory nursing course to nursing students. The goal was to provide a Holistic overview of the physiological, psychological, sociocultural, and developmental aspects of human beings. After a two-year evaluation of the model, it was published in Nursing Research Neuman Systems Model - The Neuman Systems Model was originally developed in 1970 at the University of California, Los Angeles, by Betty Neuman, Ph.D., RN Neuman Systems Model - This model was originally developed in 1970 at the University of California, Los Angeles, by Betty Neuman, Ph.D., RN. The model was developed by Dr. Neuman as a way to teach an introductory nursing course to nursing students. The Neuman Systems Model - provides a comprehensive, system based conceptual framework. Originally designed to be used in nursing it can be used by other health professions. (Dr. Betty Neuman) Reconstitution is a status of adaptation to stressors A conceptual model with two theories “Optimal patient stability and prevention as intervention” Neuman’s model includes intrapersonal, interpersonal and extrapersonal stressors. Nursing is concerned with the whole person. Nursing actions (Primary, Secondary, and Tertiary levels of prevention) focuses on the variables affecting the client’s response to stressors.

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The person is a complete system, with interrelated parts maintains balance and harmony between internal and external environment by adjusting to stress and defending against tension-producing stimuli  Focuses on stress and stress reduction  Primarily concerned with effects of stress on health  Stressors are any forces that alter the system’s stability  Flexible lines of resistance - Surround basic core  Internal factors that help defend against stressors  Normal line of resistance - Normal adaptation state  Flexible line of defense - Protective barrier, changing, affected by variables  Wellness is equilibrium Nursing interventions are activates to:  strengthen flexible lines of defense  strengthen resistance to stressors  maintain adaptation

KEY CONCEPTS   1. 2. 3. 4. 5.

Viewed the client as an open system consisting of a basic structure or central core of energy resources which represent concentric circles Each concentric circle or layer is made up of the five variable areas which are considered and occur simultaneously in each client concentric circles. These are: Physiological - refers of bodily structure and function. Psychological - refers to mental processes, functioning and emotions. Sociocultural - refers to relationships; and social/cultural functions and activities. Spiritual - refers to the influence of spiritual beliefs. Developmental - refers to life’s developmental processes.

Basic Structure Energy Resources This is otherwise known as the central core, which is made up of the basic survival factors common to all organisms. These include the following: 1. Normal temperature range – body temperature regulation ability 2. Genetic structure – Hair color and bodily features 3. Response pattern – functioning of body systems homeostatically 4. Organ strength or weakness 5. Ego structure 6. Knowns or commonalities – value system  The person's system is an open system - dynamic and constantly changing and evolving  Stability, or homeostasis, occurs when the amount of energy that is available exceeds that being used by the system.  A homeostatic body system is constantly in a dynamic process of input, output, feedback, and compensation, which leads to a state of balance Flexible Lines of Defense  

Is the outer boundary to the normal line of defense, the line of resistance, and the core structure. Keeps the system free from stressors and is dependent on the amount of sleep, nutritional status, as well as the quality and quantity of stress an individual experiences.  If the flexible line of defense fails to provide adequate protection to the normal line of defense, the lines of resistance become activated. Normal Line of Defense  Represents client’s usual wellness level.  Can change over time in response to coping or responding to the environment, which includes intelligence, attitudes, problem solving and coping abilities. Example is skin which is constantly smooth and fair will eventually form callous over times. Lines of Resistance  

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the last boundary that protects the basic structure Protect the basic structure and become activated when environmental stressors invade the normal line of defense. An example would is that when a certain bacteria enters our system, there is an increase in leukocyte count to combat infection. If the lines of resistance are effective, the system can reconstitute and if the lines of resistance are not effective, the resulting energy loss can result in death.

Stressors  Are capable of producing either a positive or negative effect on the client system.  Is any environmental force which can potentially affect the stability of the system: 1. Intrapersonal - occur within person, example is infection, thoughts and feelings 2. Interpersonal - occur between individuals, e.g. role expectations 3. Extrapersonal - occur outside the individual, e.g. job or finance concerns  A person’s reaction to stressors depends on the strength of the lines of defense.  When the lines of defense fails, the resulting reaction depends on the strength of the lines of resistance.  As part of the reaction, a person’s system can adapt to a stressor, an effect known as reconstitution. Reconstitution  Is the increase in energy that occurs in relation to the degree of reaction to the stressor which starts after initiation of treatment for invasion of stressors.  May expand the normal line of defense beyond its previous level, stabilize the system at a lower level, or return it to the level that existed before the illness.  Nursing interventions focus on retaining or maintaining system stability.

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By means of primary, secondary and tertiary interventions, the person (or the nurse) attempts to restore or maintain the stability of the system. Prevention  Is the primary nursing intervention.  Focuses on keeping stressors and the stress response from having a detrimental effect on the body. 1. Primary prevention focuses on protecting the normal line of defense and strengthening the flexible line of defense. This occur before the system reacts to a stressor and strengthens the person (primarily the flexible line of defense) to enable him to better deal with stressors and also manipulates the environment to reduce or weaken stressors. Includes health promotion and maintenance of wellness. 2. Secondary prevention focuses on strengthening internal lines of resistance, reducing the reaction of the stressor and increasing resistance factors in order to prevent damage to the central core. This occurs after the system reacts to a stressor. This includes appropriate treatment of symptoms to attain optimal client system stability and energy conservation. 3. Tertiary prevention focuses on readaptation and stability, and protects reconstitution or return to wellness after treatment. This occurs after the system has been treated through secondary prevention strategies. Tertiary prevention offers support to the client and attempts to add energy to the system or reduce energy needed in order to facilitate reconstitution. APPLICATION  The main use of the Neuman Model in practice and in research is that its concentric layers allow for a simple classification of how severe a problem is.  For example, since the line of normal defense represents dynamic balance, it represents homeostasis, and thus a lack of stress.  If a stress response is perceived by the patient or assessed by the nurse, then there has been an invasion of the normal line of defense and a major contraction of the flexible line of defense.  Infection or other invasion of the lines of resistance indicates failure of both lines of defense.  Thus, the level of insult can be quantified allowing for graduated interventions.  Furthermore each person variable can be operationalized and the relationship to the normal line of defense or stress response can be analyzed.  The drawback of this is that there is no way to know whether our operationalization of the person variables is a good representation of the underlying theoretical structures. (For example, Eileen Gigliotti published a research article in 1999 based on the Neuman Systems Model. The study investigated the relationship of multiple role stress to the psychological and sociocultural variables of the flexible line of defense. If multiple role stress had occurred, then the normal line of defense had been invaded. Questionnaire instruments were used to operationalize the psychological component with perceived role as a student and as a mother; the sociocultural component with social support, the normal line of defense as perceived multiple role stress. Upon analysis, no conclusions could be made about the normal line of defense simply on the basis of the psychological component and sociocultural component. By dichotomizing the data by median age, however, a relationship between them could be described. Thus the relationship between the normal line of defense and the psychological and sociocultural components could only be described by taking into account the developmental component. It indicates that the components of the flexible line of defense interact in very complex ways and it may be difficult and dangerous to over generalize their interaction.)

Sister Calista Roy - Adaptation Model Five Interrelated Essential Elements 1. 2. 3. 4. 5.

Patiency- The person receiving care Goal of nursing- Adapting to change Health-Being and becoming a whole person Environment Direction of nursing activities- Facilitating adaptation

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The person is an open adaptive system with input (stimuli), who adapts by processes or control mechanisms (throughput) The output can be either adaptive responses or ineffective responses Stimuli disrupt an adaptive system The individual is a biopsychosocial adaptive system within an environment. The individual and the environment provide three classes of stimuli-the focal, residual and contextual. Through two adaptive mechanisms, regulator and cognator, an individual demonstrates adaptive responses or ineffective responses requiring nursing interventions

Jean Watson - Philosophy and Science of Caring       

Caring can be demonstrated and practiced Caring consists of carative factors Caring promotes growth A caring environment accepts a person as he is and looks to what the person may become A caring environment offers development of potential Caring promotes health better than curing Caring is central to nursing

Watson’s 10 Carative Factors  Forming humanistic-altruistic value system  Instilling faith-hope  Cultivating sensitivity to self and others  Developing helping-trust relationship  Promoting expression of feelings  Using problem-solving for decision making  Promoting teaching-learning  Promoting supportive environment  Assisting with gratification of human needs  Allowing for existential-phenomenological forces Watson’s Concepts  Person o Human being to be valued, cared for, respected, nurtured, understood and assisted  Environment o Society  Health o Complete physical, mental and social well-being and functioning  Nursing o Concerned with promoting and restoring health, preventing illness

Rosemary Parse - Human Becoming Theory  

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Rosemarie Rizzo Parse is professor and Niehoff Chair at Loyola University Chicago. She is founder and editor of Nursing Science Quarterly, president of Discovery International, Inc., which sponsors international nursing theory conferences, and founder of the Institute of Human Becoming, where she teaches the ontological, epistemological, and methodological aspects of the human becoming school of thought. Dr. Parse is a graduate of Duquesne University in Pittsburgh and received her master's and doctorate from the University of Pittsburgh. Dr. Parse's theory is a guide for practice in healthcare settings in Canada, Finland, South Korea, Sweden, and the United States; her research methodology is used as a method of inquiry by nurse scholars in Australia, Canada, Denmark, Finland, Greece, Italy, Japan, South Korea, Sweden, the United Kingdom, and the United States.

Human Becoming: - Rosemarie Rizzo Parse. Loyola University Chicago.  Human Becoming Theory - Rosemarie Rizzo Parse first published the theory in 1981 as the "Man-livinghealth" theory.  The name was officially changed to "the human becoming theory" in 1992 to remove the term "man," after the change in the dictionary definition of the word from its former meaning of "humankind."  Rosemarie Rizzo Parse first published the theory in 1981 as the "Man-living-health" theory.  The name was officially changed to "the human becoming theory" in 1992 to remove the term "man," after the change in the dictionary definition of the word from its former meaning of "humankind."  The theory is structured around three abiding themes: meaning, rhythmicity, and transcendence. 

The first theme, MEANING, is expressed in the first principle of the theory, which states that "Structuring meaning multidimensionally is cocreating reality through the languaging of valuing and imaging." This principle means that people coparticipate in creating what is real for them through self-expression in living their values in a chosen way.

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The second theme, RHYTHMICITY, is expressed in the second principle of the theory, which states that "Cocreating rhythmical patterns of relating is living the paradoxical unity of revealing-concealing and enabling-limiting while connecting-separating." This principle means that the unity of life encompasses apparent opposites in rhythmic patterns of relating. It means that in living moment-to-moment one shows and does not show self as opportunities and limitations emerge in moving with and apart from others.

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The third theme, TRANSCENDENCE, is expressed in the third principle of the theory, which states that "Cotranscending with the possibles is powering unique ways of originating in the process of transforming." This principle means that moving beyond the "now" moment is forging a unique personal path for oneself in the midst of ambiguity and continuous change.

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Human Becoming Theory includes Totality Paradigm o Man is a combination of biological, psychological, sociological and spiritual factors Simultaneity Paradigm o Man is a unitary being in continuous, mutual interaction with environment Originally Man-Living-Health Theory Indivisible beings and environment co-create health. A theory of nursing derived from Roger’s conceptual model. Clients are open, mutual and in constant interaction with environment. The nurse assists the client in interaction with the environment and co creating health

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Parse’s Three Principles  Meaning o Man’s reality is given meaning through lived experiences o Man and environment cocreate  Rhythmicity o Man and environment cocreate ( imaging, valuing, languaging) in rhythmical patterns  Cotranscendence o Refers to reaching out and beyond the limits that a person sets o One constantly transforms  Person o Open being who is more than and different from the sum of the parts  Environment o Everything in the person and his experiences o Inseparable, complimentary to and evolving with  Health o Open process of being and becoming. Involves synthesis of values

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Nursing o A human science and art that uses an abstract body of knowledge to serve people

Madeleine Leininger - Culture Care Diversity and Universality Transcultural nursing, culture-care theory 

Based on transcultural nursing, whose goal is to provide care congruent with cultural values, beliefs, and practices  Caring is universal and varies transculturally.  Major concepts include care, caring, culture, cultural values and cultural variations  Caring serves to ameliorate or improve human conditions and life base. o Care is the essence and the dominant, distinctive and unifying feature of nursing  Sunrise model consists of 4 levels that provide a base of knowledge for delivering cultural congruent care  Modes of nursing action  Cultural care preservation o help maintain or preserve health, recover from illness, or face death  Cultural care accommodation o help adapt to or negotiate for a beneficial health status, or face death  Cultural care re-patterning o help restructure or change lifestyles that are culturally meaningful .

Patricia Benner Patricia Benner’s Primacy of caring (Key emphasis)  

Caring is central to the essence of nursing. It sets up what matters, enabling connection and concern. It creates possibility for mutual helpfulness. Caring creates - possibilities of coping possibilities for connecting with and concern for others, possibilities for giving and receiving help

Patricia Benner - From Novice to Expert Described systematically five stages of skill acquisition in nursing practice – novice, advanced beginner, competent, proficient and expert.  1. 2. 3. 4. 5. 

Described 5 levels of nursing experience and developed exemplars and paradigm cases to illustrate each level Novice Advanced beginner Competent Proficient Expert Levels reflect: o movement from reliance on past abstract principles to the use of past concrete experience as paradigms o change in perception of situation as a complete whole in which certain parts are relevant

Importance of Theoretical Frameworks   

Foundation of any profession is the development of a specialized body of knowledge. Theories should be developed in nursing, not borrow theories form other disciplines Responsibility of nurses to know and understand theorists Critically analyze theoretical frameworks

Additional Theorists Joan Riehl-Sisca Joan Riehl was born in Davenport, Iowa but spent most of her childhood and young adult life in a Chicago suburb, she attended the University of Illinios, where she obtained her BSN. Riehl theory and model adapt four key concepts. People – “people, individually and collectively, are prepared to act on the basis of the meaning of the objects that comprise their world. The term person includes the patient, the nurse, and other health professionals. Riehl describes the nurse as one who knows her capabilities, is self-directed, and assumes than one role in a given period. Association – “The association of people is necessarily in the form of a process in which they are making indications to one another and interpreting each others indication.” Riehl summarizes tis as the defining process of role taking. Role taking occurs when an individual cognitively internalises another person’s perceptions of reality in varied situations. The nurse-patient interface is an example of this interaction. Social Acts – “Social acts, whether individual or collective, are constructed through a process in which the actors note, interpret, and assess the situations confronting them.” Their interpretation of these situations influence their social acts toward each other. This concept allows the nurse to assess and respond more appropriately to a patient’s behaviour. Interlinkages – “The complex interlinkages of acts that comprise organizations, institutions, division of labour, and networks of interdependency are moving and not static affairs.” From this concept Riehl derives that patient assessment is a dynamic process that often necessitates the use of several resources in meeting patient’s needs, particularly in long term care.

Myra Estrin Levine’s: The conservation model          

Holism is maintained by conserving integrity Proposed that the nurses use the principles of conservation of: Client Energy Personal integrity Structural integrity Social integrity A conceptual model with three nursing theories – Conservation Redundancy Therapeutic intention

Joyce Travelbee’s Human To Human Relationship Model  FAR ahead of her time with her call (in 1949!) for natural childbirth, prenatal instruction, father participation in birth process, and rooming-in! Joyce Travelbee 1966 "Human to Human Relationship Model" Art and Science of Humanistic Nursing A theory A unique, irreplaceable individual Life Story A psychiatric nurse, educator and writer born in 1926.  1956, she completed her BSN degree at Louisiana State University  1959, she completed her Master of Science Degree in Nursing at Yale University Working Experiences:

 1952, Psychiatric Nursing Instructor at Depaul Hospital Affilliate School, New Orleans.  Also she taught at Charity Hospital School of Nursing in Louisiana State University, New York University and University of Mississippi.  1970, the Project Director of Graduate Education at Louisiana State University School of Nursing until her death. Publications:  1963, started to publish articles and journals in nursing.  1966 and 1971, publication of her first book entitled Interpersonal Aspects of Nursing.  1969, when she published her second book Intervention in Psychiatric Nursing: Process in the One-to-One Relationship. She started Doctoral program in Florida in 1973. Unfortunately, she was not able to finish it because she died later that year. She passed away at the prime age of 47 after a brief sickness. Theoretical Sources  Catholic charity institutions  Ida Jean Orlando, her instructor—“The nurse is responsible for helping the patient avoid and alleviate the distress of unmet needs.” The nurse and patient interrelate with each other.  Viktor Frankl, a survivor of Auschwitz and other Nazi concentration camps—proposed the theory of logotherapy in which a patient is actually confronted with and reoriented toward the meaning of his life. Nursing Metaparadigm Person - Person is defined as a human being. - Both the nurse and the patient are human beings. - A human being is a unique, irreplaceable individual who is in continuous process of becoming, evolving and changing. Health - Health is subjective and objective. - Subjective health—is an individually defined state of well being in accord with self-appraisal of physical-emotionalspiritual status. - Objective health—is an absence of discernible disease, disability of defect as measured by physical examination, laboratory tests and assessment by spiritual director or psychological counselor. Environment - Environment is not clearly defined. - She defined human conditions and life experiences encountered by all men as sufferings, hope, pain and illness. Illness – being unhealthy, but rather explored the human experience of illness ㅐ Suffering – is a feeling of displeasure which ranges from simple transitory mental, physical or spiritual discomfort to extreme anguish and to those phases beyond anguish—the malignant phase of dispairful “not caring” and apathetic indifference Pain – is not observable. A unique experience. Pain is a lonely experience that is difficult to communicate fully to another individual. Hope – the desire to gain an end or accomplish a goal combined with some degree of expectation that what is desired or sought is attainable Hopelessness – being devoid of hope Nursing - Nursing is an interpersonal process whereby the professional nurse practitioner assists an individual, family or

community to prevent or cope with experience or illness and suffering, and if necessary to find meaning in these experiences.”

"Human to Human Relationship Model"  Travelbee's experience in initial psych nursing practice at a Catholic charity hospital led her to believe that the care given in these type of institutions lacked compassion. She felt nursing needed a "humanistic revolution" and a renewed focus on caring as central to nursing--she warned that if this didn't happen, consumers might seek a "new and different kind of health care worker." Travelbee's ideas have greatly influenced the hospice movement. Travelbee died tragically young at age 47 while beginning doctoral study.  Know thyself is a basic principle of psychiatric nursing - Travelbee (1971) described the instrument for delivery of the process of interpersonal nursing as the therapeutic use of self.

Therapeutic human relationships. 

Nursing is accomplished through human to human relationships that began with: The original encounter and then progressed through stages of  Emerging identities  Developing feelings of empathy and sympathy, until the nurse and patient attained rapport in the final stage. Interactional Phases of Human-to-Human Relationship Model: 1. Original Encounter - First impression by the nurse of the sick person and vice-versa. - Stereotyped or traditional roles 2. Emerging Identities - the time when relationship begins - the nurse and patient perceives each others uniqueness 3. Empathy - the ability to share in the person’s experience 4. Sympathy - when the nurse wants to lessen the cause of patient’s suffering. - it goes beyond empathy—“When one sympathizes, one is involved but not incapacitated by the involvement.” - therapeutic use of self 5. Rapport - Rapport is described as nursing interventions that lessens the patient’s suffering. - Relation as human being to human being - “A nurse is able to establish rapport because she possesses the necessary knowledge and skills required to assist ill persons and because she is able to perceive, respond to and appreciate the uniqueness of the ill human being.” *phases are in consecutive and developmental process.

Contributions The conceptual and theoretical nursing models help to provide knowledge to improve practice, guide research and curriculum and identify the goals of nursing practice. The state of art and science of nursing theory is one of continuing growth. Using the internet the nurses of the world can share ideas and knowledge, carrying on the work begun by nursing theorists and continue the growth and development of new nursing knowledge. It is important the nursing knowledge is learnt, used, and applied in the theory based practice for the profession and the continued development of nursing and academic discipline.

Kathryn E. Barnard’s Parent Child Interaction Model   

Therapeutic human relationships. Nursing is accomplished through human to human relationships that began with: The original encounter and then progressed through stages of Emerging identities Developing feelings of empathy and sympathy, until the nurse and patient attained rapport in the final stage.

Ernestine Wiedenbach's Helping Art of Clinical Nursing   

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Wiedenbach believed that there were 4 main elements to clinical nursing. They included: a philosophy, a purpose, a practice and the art. The nurses philosophy was their attitude and belief about life and how that effected reality for them. Philosophy is what motivates the nurse to act in a certain way (Tomey & Alligood, 2002). Wiedenbach also believed that there were 3 essential components associated with a nursing philosophy (George, J. 2002): Reverence for life, Respect for the dignity, worth, autonomy and individuality of each human being and resolution to act on personally and professionally held beliefs. Nurses purpose is that which the nurse wants to accomplish through what she does. It is all of the activities directed towards the overall good of the patient Practice are those observable nursing actions that are affected by beliefs and feelings about meeting the patient’s need for help. The Art of nursing includes understanding patients needs and concerns, developing goals and actions intended to enhance patients ability and directing the activities related to the medical plan to improve the patients condition. The nurses also focuses on prevention of complications related to reoccurrence or development of new concerns. Wiedenbach defined key terms commonly used in nursing practice. These definitions themselves do not fully define the profession, however confusion over commonly used terms continues to plaque nursing even today as we see with the lack of a uniform nursing language and the difficulties in coding data and reimbursement issues. In specifically defining what each of these terms mean within the context of her theory Wiedenbach imparts clarity and power to her work, and sets the stage for productive exploration and debate. She defined the following: The patient is any person who has entered the healthcare system and is receiving help of some kind, such as care, teaching, or advice. The patient need not be ill since someone receiving health-related education would qualify as a patient. A need-for-help is defined as any measure desired by the patient that has the potential to restore or extend the ability to cope with various life situations that affect health and wellness. [Clinical] Judgment represents the nurse’s likeliness to make sound decisions. Sound decisions are based on differentiating fact from assumption and relating them to cause and effect. Sound Judgment is the result of disciplined functioning of mind and emotions, and improves with expanded knowledge and increased clarity of professional purpose. Nursing Skills are carried out to achieve a specific patient-centered purpose rather than completion of the skill itself being the end goal. Skills are made up of a variety of actions, and characterized by harmony of movement, precision, and effective use of self. Each Person (whether nurse or patient), is endowed with a unique potential to develop self-sustaining resources. People generally tend towards independence and fulfillment of responsibilities. Self-awareness and self-acceptance are essential to personal integrity and self-worth. Whatever an individual does at any given moment represents the best available judgment for that person at the time. Wiedenbach conceptualizes nursing as the practice of identification of a patient’s need for help through observation of presenting behaviors and symptoms, exploration of the meaning of those symptoms with the patient, determining the cause(s) of discomfort, and determining the patient’s ability to resolve the discomfort or if the patient has a need for help from the nurse or other healthcare professionals.

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Nursing primarily consists of identifying a patient’s need for help. If the need for help requires intervention, the nurse facilitates the medical plan of care and also creates and implements a nursing plan of care based on needs and desires of the patient. In providing care, a nurse exercises sound judgment through deliberative, practiced, and educated recognition of symptoms. The patient’s perception of the situation is an important consideration to the nurse when providing competent care

Lydia Eloise Hall  The "Core, Care, and Cure" Theory was developed in the late 1960's. She postulated that individuals could be conceptualized in three separate domains: the body (care), the illness, (cure), and the person (core).  Hall believed patients should receive care ONLY from professional nurses.  Nursing involves interacting with a patient in a complex process of teaching and learning.  Hall was not pleased with the concept of team nursing--she said that "any career that is defined around the work that has to be done, and how it is divided to get it done, is a "trade" (rather than a profession).  Nursing functions in all three of the circles (core, care, and cure) but shares them to different degrees with other disciplines.  For example, the nurse's function in the cure circle is limited to helping patients/families deal with the measures instituted by the physician. She felt that the care circle was exclusive to nursing. The core circle was shared with social workers, psychologists, clergy, etc. Care, Core & Cure - Nursing functions in all three of the circles (core, care, and cure) but shares them to different degrees with other disciplines. 

Lydia Hall’s model for nursing provides a framework to encourage open communication between patients and nurses.  The model has three interrelated circles that represent medical and clinical management nurses give to patients  The care circle is the intimate care nurses provide to patients to assist in bathing, dressing and assistance with daily activities.  The disease management and treatment of the patient and quality of life.  An essential role of nurses in the healthcare plan is to assist with management of congestive heart failure patients by providing medical, physical, and social care.  The framework of Lydia Hall is used in the following care plan to assist in meeting the personal, medical, and social needs of congestive heart failure patients The three components of her theory are care, core, and cure. Care is based in the natural and biological sciences, includes the intimate aspects of bodily care, and is exclusive to nursing. Core is based in the social sciences, involves the therapeutic use of self, and is shared with other members of the health care team. Cure is based in the pathological and therapeutic sciences, involves working with the patient and family in relation to the medical care, and is shared with other members of the health care team.

Anne Boykin and Sarvina O. Schoenhofer Nursing As Caring The theory of Nursing As Caring is a general or grand nursing theory that can be used as a framework to guide nursing practice. The theory is grounded in several key assumptions: 1. persons are caring by virtue of their humanness 2. persons live their caring moment to moment 3. persons are whole or complete in the moment

4. personhood is living life grounded in caring 5. personhood is enhanced through participating in nurturing relationships with caring others 6. nursing is both a discipline and a profession The most basic premise of the theory is that all humans are caring persons, that to be human is to be called to live one’s innate caring nature. Developing the full potential of expressing caring is an ideal and for practical purposes, is a lifelong process.  

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Anne Boykin and Savina Schoenhofer’s theory of Nursing as Caring is a grand theory, intended to be used with other theories as needed. Nursing as Caring is based on seven assumptions about persons, caring, personhood, and nursing. Persons are caring by virtue of being human, are caring moment to moment, are continually growing while also whole in the moment. Personhood is a process of living, grounded in caring, and enhanced by nurturing relationships with others. Nursing is a discipline and a profession that focuses on nurturing, living in caring, and growing in caring in the nursing situation. Again, the nursing process is not compatible with Nursing as Caring since the focus is not problem solving.

Joyce Fitzpatrick Joyce Fitzpatrick is the Elizabeth Brooks Ford Professor of Nursing, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland Ohio.  Fitzpatrick was dean of nursing at CWRU from 1982 through 1997, during which time the School of Nursing's endowment grew from $8 million to more than $50 million.  She earned her BSN at Georgetown University, MS in psychiatric-mental health nursing at Ohio State University, PhD in nursing at New York University and an MBA from Case Western Reserve University. In 1990, she received an honorary Doctor of Humane Letters degree from Georgetown.  She was elected a fellow in the American Academy of Nursing in 1981, received the American Journal of Nursing Book of the Year Award 13 times and has been honored by many other organizations. In 1997, she was appointed editor of the National League for Nursing's journal, Nursing and Healthcare Perspectives.  She was president of the American Academy of Nursing from 1997 to 1999. From 1998 to 2000, while on sabbatical from CWRU, she was a visiting scholar at New York University and consultant to Springer Publishing Company.  During this time she proposed and implemented a project focused on improving nursing care for hospitalized elders and their families, a project now funded by two major health systems in the New York area, Mount Sinai NYU Health and North Shore-Long Island Jewish Health System.  Fitzpatrick is widely published in nursing and healthcare literature  The primary purpose of nursing is the promotion and maintenance of an optimal level of wellness. The professional nurse participates in a multi-disciplinary approach to health in assessing, planning, implementing, and evaluating programs in regards to how they affect optimum wellness for patients. When assessing health care needs, the professional nurse incorporates the physical, emotional, social, environmental and spiritual aspects of the profession into her daily routine.  As a direct result of theories such as Joyce Fitzpatrick’s, today some of the best measures of the contribution of an information system to nurses' clinical decision making have been implemented. Despite disagreements on the classes as well as the language describing the parts of the nursing diagnosis, Fitzpatrick’s approach to taxonomy in nursing has been considered a primary basis for the development of the substantive structure of the discipline.  Classification is a relatively new concept within the realm of the nursing profession. It started out as an effort to develop a language that would define the clinical judgments made by nurses, but it ultimately evolved into a broader range of categories, including the coordination of data set for health statistics, the development of computerized patient records, and advanced education and research. Consequently, Joyce Fitzpatrick’s theory and its major concepts are determinedly applicable.

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Though nurses have obviously based their work on knowledge arising from some source, many scholars in nursing have claimed that the nursing profession does not have a strong theoretical basis. They also complain that many of the difficulties experienced in classification development are due to theoretical pluralism in nursing. However, to the extent that the classifications help to better define the concept of the discipline, deriving the theoretical relationships among the concepts in the taxonomies and systematically testing them quickly builds the systematic knowledge that has been sought after for such a long period of time. Even basic structures for knowledge development in nursing had to wait on the introduction of theories and philosophies of nursing until 1950s.  The systematic use of the term "nursing diagnosis" (clinical judgments about individual, family, or community responses to actual or potential health problems and life processes that reflect patient behaviors or patient status and provide the basis for selection of nursing interventions to achieve desired outcomes) along with early attempts to comprehensively list the diagnoses that nurses treat began in 1973. This is when the first classification conference was held, however, research was minimal and substantive literature on concepts of this type were few and far between. Yet as nursing knowledge development increased and diagnostic categories were identified, interest in organizing knowledge for practice, education, and research also increased.  According to Fitzpatrick, the identification and labeling of concepts allows for recognition and communication with others, and the rules for combining those concepts permits thoughts to be shared through language. Thus the concepts within a classification system sanction the organization of ideas. Recognition occurs when what is observed is placed into previously learned classes, or categories, on the basis of observed characteristics. It is therefore important to remember that classification system development parallels knowledge development in a discipline. Moreover, the taxonomies of nursing diagnoses, interventions, and outcomes provide an anchoring framework for nursing knowledge.  The four content concepts that comprise Fitzpatrick’s theory are person, health, wellness-illness and metaparadigm. These concepts are defined as follows: Person: The term person integrates the concepts of both self and others, and recognizes individuals as having unique biological, psychological, emotional, social, cultural, and spiritual attitudes. They thrive on honor and dignity, selfevaluation and growth and development. Throughout a person’s life, many factors develop within a social setting and interact with a multitude of environments that can significantly influence that person’s health and wellness. Health: Health is a dynamic state of being that results from the interaction of person and the environment. Optimum health is the actualization of both innate and obtained human potential gleaned from rewarding relationships with others, goal directed behavior, and expert personal care. Adjustments can be made on an “as needed” basis in order to maintain stability and structural integrity. A person's state of health can vary from wellness to illness, disease, or dysfunction, and it changes continuously throughout the person's life span. Wellness-Illness: Professional nursing is rooted in the promotion of wellness practices, the attentive treatment of those who are acutely or chronically ill or dying, and restorative care of people during convalescence and rehabilitation. Other dimensions of professional nursing include the teaching and evaluation of those who perform or are learning to perform nursing functions, the support and conduction of research to extend knowledge and practice, and the management of nursing practice in health care delivery systems. Nursing is a practice discipline and a profession that is based upon a synthesized body of knowledge, which is derived from inquiry and clinical evaluation promoting wellness and diminishing illness. Professional nurses acquire and maintain current knowledge, are willing to participate in peer review and other activities that insure quality of care, and communicate effectively with recipients of care and other health care providers. Thus the nursing practice centers on the application of this body of knowledge in an effort to maintain, restore, or enhance the interactions between people and their environment. Metaparadigm: Transition is one of the core concepts of nursing theory, derived from and related to the basic metaparadigm concepts of person, environment, health and nursing. While much of the research in nursing has been focused on assisting individuals in their life transitions, whether through phases of growth and development, or experiences with health and illness, the conceptualizations of the nursing profession as focused on transitions has not been adequately researched.  Nursing is both a practice discipline and a profession. A fundamental part of nursing is concerned with concepts, categories, and classification systems. This body of knowledge is continuously developed and refined as an outcome of scientific, historical, philosophical, and ethical inquiry and clinical evaluation. Nursing knowledge is generated about health through behaviors of persons across the life span. Clinical evaluation

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advances nursing knowledge through the testing and validation of interventions that are used in nursing practice, nursing education, and nursing administration. Nursing shares, with other health professions, a commitment to the well being of the patient and to a professional practice based on codes of ethics. Over the past two decades, national and international nurses associations have refined their principles to reflect an increasing commitment to human rights and the protection of the patient. However, because of the growing databases of information and the constant advancements of technology, a viable framework for assessments and evaluations must be firmly in place. Joyce Fitzpatrick’s model provides a foundation for these classifications.

Margaret Newman  Margaret Newman was born on October 10, 1933 in Memphis Tennessee. In 1954 She earned her first Bachelors degree in Home Economics and English from Baylor University in Waco, Texas -Margaret Newman felt a call to nursing for a number of years prior to her decision to enter the field. -During that time she became the primary caregiver for her mother, who became ill with Lou Gehrig's Disease. -Upon entering nursing at the University of Tennessee, Memphis, Dr. Newman knew almost immediately that nursing was right for her Education • In 1962 she received her Bachelors degree in Nursing from the University of Tennessee, Memphis. • In 1964 she received her Masters Degree of Medical-Surgical Nursing and Teaching at the University of California in San Francisco. • In 1971 she completed her Doctorate of Nursing Science and Rehabilitation at New York University

Employment Ø 1971 to 1976- She completed her graduate studies at New York University. She also worked and taught alongside nursing theorist Martha Rogers. Ø Rehabilitation Nursing stemmed her interest in health, movement & time. Ø 1977- Professor in charge of graduate study in nursing at Pennsylvania State. Ø 1984- Nurse theorist at the University of Minnesota. Ø 1996- Retired from teaching. Margaret Newman 1933Theory of Health as Expanding Consciousness

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The theory of health as expanding consciousness stems from Rogers' theory of unitary human beings. Rogers' assumptions regarding patterning of persons in interaction with the environment are basic to the view that consciousness is a manifestation of an evolving pattern of person-environment interaction. Consciousness is defined as the informational capacity of the system (in this case, the human being); that is, the ability of the system to interact with the environment. Consciousness includes not only the cognitive and affective awareness normally associated with consciousness, but also the interconnectedness of the entire living system, which includes physiochemical maintenance and growth processes as well as the immune system. This pattern of information, which is the consciousness of the system, is part of a larger, undivided pattern of an expanding universe.

Newman’s theory of pattern recognition provides the basis for the process of nurse-client interaction. Newman suggested that the task in intervention is a pattern recognition accomplished by the health professional becoming aware of the pattern of the other person by becoming in touch with their own pattern. Newman suggested that the professional should focus on the pattern of the other person , acting as the “reference beam in a hologram”.

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Relationship to the Metaparadigm Concepts

Newman has designated “caring in the human health experience” as the focus of nursing discipline and has specified the focus as the metaparadigm of the discipline. Nursing -to help clients get in touch with the meaning of their lives by the identification of their patterns of relating -Intervention is a form of non intervention whereby the nurse’s presence assists clients to recognize their own patterns of interacting with the environment. -facilitates pattern recognition in clients by forming relationships with them at critical points n their lives and connecting with them in an authentic way. -The nurse-client relationship is characterized by “a rhythmic coming together and moving apart as clients encounter disruption of their organized predictable state.” -Nurses are seen as partners in the process of expanding consciousness. Person -Person as individuals are identified by their individual patterns of consciousness. -Persons are further defined as “centers of consciousness” within an overall pattern of expanding consciousness” -The definition of person has also been expanded to include family and community.

Environment -Environment is not explicitly defined but is described as being the larger whole, which is beyond the consciousness of the individual. Health -A fusion of disease and non-disease creates a synthesis that is regarded as health. -Disease and non-disease are each reflections of the larger whole; therefore a new concept “pattern of the whole” is formed. -Newman has stated that pattern recognition is the essence of the emerging health. Manifest health, encompassing disease and non-disease can be regarded as the explication of the underlying pattern of person-environment. Essence of Margaret Newman's Theory: • An individual person in each situation, no matter how disordered and hopeless, is part of the universal

process of expanding consciousness. • The expanding consciousness is a process wherein an individual becomes more of his real self, as he finds greater meaning in his life and the lives of those people around him. • In his/her search for his/her real self, the individual's awareness expands to include the interests of those people around him and the rest of the world. • Self-awareness may eventually lead to acceptance of one's self and one's circumstances and limitations. • With self-awareness and self-acceptance, an in-depth understanding of one's condition may pave the way for a person to engage into activities leading to positive progression transcending Supporting Theory • The health of a human being is a unitary phenomenon, an evolving pattern of human-environment (Rogers, 1970). • Life is a process of expanding consciousness. Consciousness is the informational capacity of the system and can be seen in the quality of interaction of the system with the environment (Bentov, 1978). • The explicate order is a manifestation of the implicate order (Bohm, 1980). Assumptions 1. Health encompasses conditions heretofore described as illness, or, in medical terms, pathology 2. These pathological conditions can be considered a manifestation of the total pattern of the individual 3. The pattern of the individual that eventually manifests itself as pathology is primary and exists prior to structural or functional changes 4. Removal of the pathology in itself will not change the pattern of the indivdual 5. If becoming ill is the only way an individual's pattern can manifest itself, then that is health for that person 6. Health is an expansion of consciousness. Critique Clarity Semantic clarity is evident in the definitions, descriptions, and dimensions of the concepts of the theory. Simplicity The deeper meaning of the theory of health as expending consciousness is complex. The theory as a whole must be understood, nut just the isolated concepts. If an individual wanted to use a positivist approach, Newman’s original propositions would serve as guides for hypothesis development. However, researchers who tried that approach have concluded that it is inadequate to study the theory. As Newman have advocated in the 1994 edition of her book, Health as Expanding Consciousness, the holistic approach of the hermeneutic dialectic method is consistent with the theory and requires a high level of understanding the theory in praxis research. Generality The concepts in Newman’s theory are broad in scope because they all relate to health. The theory has been

applied in several different cultures and is applicable across the spectrum of nursing care situations. This renders her theory generalizable. Empirical Precision In the early stages of development, aspects of the theory were operationalized and tested within a traditional scientific method. However, quantitative methods are inadequate in capturing the dynamic, changing nature of this theory. Derivable Consequences The focus of Newman’s theory of health as expanding consciousness provides an evolving guide for all healthrelated disciplines. In the quest for understanding the phenomenon of health, this unique view of health challenges nurses to make a difference in nursing practice by the application of this theory.

Josephine Paterson and Loretta Zderad  

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Dr. Josephine Paterson is originally from the east coast and Dr. Loretta Zderad is from the mid-west. They both were graduates of diploma schools and subsequently earned their bachelor's degree in Nursing Education. Dr. Paterson did her graduate work at Johns Hopkins and Dr. Zderad did hers at Catholic University. In the mid-fifties they were both employed at The Catholic University and were assigned the task of working together to create a new program that would encompass the community health component and the psychiatric component of the graduate program. Subsequently they developed a collaboration and dialogue and friendship that have lasted for almost 40 years.

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Josephine Paterson and Loretta Zderad retired in 1985 and moved South where they are currently enjoying life. Although they are no longer active, they are pleased at the on going interest in their theory. HUMANISTIC NURSING: ITS MEANING “Humanistic nursing embraces more than a benevolent technically competent subject- object one-way relationship guided by a nurse in behalf of another. Rather it dictates that nursing is a responsible searching, transactional relationship whose meaningfulness demands conceptualization founded on a nurse's existential awareness of self and of the other” “Humanistic nursing theory is multidimensional in humanistic nursing theory the components identified as human are the patient (can refer to the person, family, community or humanity); and the nurse • Patient sends call for help person receiving and recognizing is the nurse Nurse has made a decision and dedicated themselves to helping others with their health care needs • Humanistic nursing term exists known as “all- at-once” • Nurses and patients have their own ‘gestalts’, or concept of wholeness • Nurse bring their whole self when helping in patient treatment, i.e. experience, education etc, to create a type of mosaic to use with nursing interventions • Humanistic nursing theory accepts the likeness in our differences, but attempts to identify the sameness in each other or our unifying links that make up the soul or essence of nursing. Paterson and Zderad describe five phases in their study of nursing: 1. Preparation of the nurse knower for coming to know • Understanding own viewpoint/angle helps to make sense and aid in acquiring meaning of experience • By identifying own views they can be withheld, so that they do not interfere with one’s attempts to describe the experiences of another

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Being open to new and different ideas/understandings is a necessary position in being able to get to know the other intuitively 2. Nurse knowing the other intuitively • Paterson and Zderad describe this as “moving back and forth between the impressions the nurse becomes aware of herself and the recollected real experience of the other” • Dialogue back and forth between patient and nurse allows for clearer understanding further generalization in developing process 3. Nurse knowing the other scientifically Implies need for objectivity in coming to know the other scientifically Reflective practice validates patterns and themes “This is the time when the nurse mulls over, analyses, sorts out, compares, contrasts, relates, interprets, gives names to and categorizes 4. Nurse complimentarily synthesizing known others The ability of the nurse to develop or see themselves as a source of knowledge, to continually develop the nursing community through education, and increased understanding of their owned learned experiences 5. Succession with the nurse from the many to the paradoxical one. “Nurse comes up with a conception or abstraction that is inclusive of and beyond the multiplicities and contradictions Process that allows for reflection, correction and expansion of own angular interpretation Implies universal understanding from the simplest to most complex dialogue and interactions between the nurse and assimilates patient experiences No member of this interaction or experience is the same as beforecoming together of patient and nurse The Concept of Community Definition of community as presented by Paterson and Zderad is “Two or more persons struggling together toward a centre Humanistic Nursing Theory suggests that there is an obligation on the part of the nurse to each other, along with other members of the community openness, sharing and caring leads to expansion of individual or group angular views each becoming more than before Clinical Application of the theory  Encourages reflection, reflection being a learned process that can help enhance the experience of the nurse and prepare them for similar situations in the clinical environment.  The ability to be with and travel with the patient in the routine of living is often overlooked, but is an essential part of the professional life of a nurse.

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Understanding the professional differences between other medical staff and allied health professionals, respect the difference and accept responsibility for challenges of nursing Encourages reflection, reflection being a learned process that can help enhance the experience of the nurse and prepare them for similar situations in the clinical environment. The ability to be with and travel with the patient in the routine of living is often overlooked, but is an essential part of the professional life of a nurse. Understanding the professional differences between other medical staff and allied health professionals, respect the difference and accept responsibility for challenges of nursing

An Oversimplified Version of General Systems Theory  

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Systems theory is a transdisciplinary approach that abstracts and considers a system as a set of independent and interacting parts. The main goal is to study the general principles of systems functioning, so that they can be applied to all types of systems, and in all fields of research. As a technical and general academic area of study it predominantly refers to the science of systems that resulted from Bertalanffy's General System Theory (GST), among others, in initiating what became a project of systems research and practice. Systems theoretical approaches were later appropriated in other fields, such as in the structural functionalist sociology of Talcott Parsons and Niklas Luhmann

General systems theory is known by several names - systems theory, theory of open systems, systems model, family systems theory. The author of systems theory was Ludwig von Bertalanffy in the 1950’s. A system is a complex of elements in interaction, which on first appearance does not seem interconnected or related. Picture a baby’s mobile hanging above the crib. If you focus on the black and white cow only, the other parts of the mobile do not appear related. But if you pull on the cow’s leg, all parts including the brown cow, the moon, the star, and the heart all begin to move too. By suddenly letting go of the cow’s leg, all parts are in motion, bumping into one another. When the black and white cow moves up, the brown cow moves down-to accommodate their movement, the moon and heart move sideways. Movement continues for a long time until they all look still; although motionless, all parts are positioned differently from the first time you saw them. The slightest current of air can change the shape of the mobile again. OK, the mobile represents a system. Let’s translate our baby’s mobile to a patient situation. Our primary focus on the black and white cow can translate to be an AIDS patient—the system of concern having boundaries between internal and external environments. Within the internal and external environments are the other elements of the system. Those elements in the AIDS patient’s internal environment (mind, body, spirit) are called sub-systems. Those elements in the AIDS patient’s external environment are called supra-systems. Input and output from both internal and external environments are free-flowing, thus called an open-system. Free energy needed for self-regulation is called

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negentropy; entropy, on the other hand, is bound energy and not free for use. Negative and positive feedback is information coming into the system that affects its balance. Physically, mentally, and spiritually, the AIDS patient receives input and feedback to realize that his internal systems (sub-systems) have changed and are less vital and not regenerating (entropy). His supra-system includes his single parent mother (brown cow), his advanced practice nurse (APN)(star), his significant other (heart), and his physician (moon). This same system can be applied on a larger scale, since systems explain individuals, families, communities, and cultures. On a community scale, AIDS and gay rights groups represent the black and white cow, the American Nurses Association represents the APN (brown cow), disapproving religious groups (moon), and the American Medical Association (star). When the issue of assisted suicide is desired by the system (a topic we are focusing on in Module 2), the internal and external environments play major roles in how the system relates with its sub-and supra-systems.

Developmental Theory Piaget's theory of cognitive development is a comprehensive theory about the nature and development of human intelligence first developed by Jean Piaget. It is primarily known as a developmental stage theory, but in fact, it deals with the nature of knowledge itself and how humans come gradually to acquire it, construct it, and use it. Moreover, Piaget claims the idea that cognitive development is at the centre of human organism and language is contingent on cognitive development. Below, there is first a short description of Piaget's views about the nature of intelligence and then a description of the stages through which it develops until maturity.

Piaget's four stages According to Jean Piaget's theory of cognitive development, intelligence is the basic mechanism of ensuring equilibrium in the relations between the person and the environment. This is achieved through the actions of the developing person on the world. At any moment in development, the environment is assimilated in the schemes of action that are already available and these schemes are transformed or accommodated to the peculiarities of the objects of the environment plus of the surroundings and entire universe, if they are not completely appropriate. Thus, the development of intelligence is a continuous process of assimilations and accommodations that lead to increasing expansion of the field of application of schemes, increasing coordination between them, increasing interiorization, and increasing abstraction. The mechanism underlying this process of increasing abstraction, interiorization, and coordination is reflecting abstraction. That is, reflecting abstraction gradually leads to the rejection of the external action components of sensorimotor operations on objects and to the preservation of the mental, planning or anticipatory, components of operation. These are the mental operations that are gradually coordinated with each other, generating structures of mental operations. These structures of mental operations are applied on representations of objects rather than on the objects themselves. Language, mental images, and numerical notation are examples of representations standing for objects and thus they become the object of mental operations. Moreover, mental operations, with development, become reversible. For instance, the counting of a series of objects can go both forward and backward with the understanding that the number of objects counted is not affected by the direction of counting because the same number can be retrieved both ways.[2] Piaget described four main periods in the development towards completely reversible equlibrated thought structures. These are the periods described below. As shown below, for Piaget intelligence is not the same at different ages. It changes qualitatively, attaining increasingly broader, more abstract, and more equlibrated structures thereby allowing access to different levels of organization of the world.

Sensorimotor stage The sensorimotor stage is the first of the four stages of cognitive development. "In this stage, infants construct an understanding of the world by coordinating sensory experiences (such as seeing and hearing) with physical, motoric actions. Infants gain knowledge of the world from the physical actions they perform on it. An infant progresses from reflexive, instinctual action at birth to the beginning of symbolic thought toward the end of the stage. Piaget divided the sensorimotor stage into six sub-stages Sub-Stage

Age

Description

1 Simple Reflexes

2 First habits and primary circular reactions phase

Birth6 weeks

"Coordination of sensation and action through reflexive behaviors" Three primary reflexes are described by Piaget: sucking of objects in the mouth, following moving or interesting objects with the eyes, and closing of the hand when an object makes contact with the palm (palmar grasp). Over the first six weeks of life, these reflexes begin to become voluntary actions; for example, the palmar reflex becomes intentional grasping..

6 weeks4 months

"Coordination of sensation and two types of schemes: habits (reflex) and primary circular reactions (reproduction of an event that initially occurred by chance). Main focus is still on the infant's body." As an example of this type of reaction, an infant might repeat the motion of passing their hand before their face. Also at this phase, passive reactions, caused by classical or operant conditioning, can begin.

Development of habits. "Infants become more object-oriented, moving beyond self-preoccupation; repeat actions that bring interesting or pleasurable results." This stage is associated primarily with the development of coordination between vision and prehension. Three new abilities occur at this stage: intentional grasping for a desired object, secondary circular reactions, and differentiations 3 Secondary circular 4–8 months between ends and means. At this stage, infants will intentionally grasp the air in reactions phase the direction of a desired object, often to the amusement of friends and family. Secondary circular reactions, or the repetition of an action involving an external object begin; for example, moving a switch to turn on a light repeatedly. The differentiation between means and ends also occurs. This is perhaps one of the most important stages of a child's growth as it signifies the dawn of logic.

8– 12 months

"Coordination of vision and touch--hand-eye coordination; coordination of schemes and intentionality." This stage is associated primarily with the development of logic and the coordination between means and ends. This is an extremely important stage of development, holding what Piaget calls the "first proper intelligence." Also, this stage marks the beginning of goal orientation, the deliberate planning of steps to meet an objective.

5 Tertiary circular reactions, novelty, and curiosity

12– 18 months

"Infants become intrigued by the many properties of objects and by the many things they can make happen to objects; they experiment with new behavior." This stage is associated primarily with the discovery of new means to meet goals. Piaget describes the child at this juncture as the "young scientist," conducting pseudo-experiments to discover new methods of meeting challenges.

6 Internalization of Schemes

18– 24 months

"Infants develop the ability to use primitive symbols and form enduring mental representations." This stage is associated primarily with the beginnings of insight, or true creativity. This marks the passage into the preoperational stage.

4 Coordination of secondary circular reactions stage

"By the end of the sensorimotor period, objects are both separate from the self and permanent." "Object permanence is the understanding that objects continue to exist even when they cannot be seen, heard, or touched." [3] "Acquiring the sense of object permanence is one of the infant's most important accomplishments, according to Piaget." Preoperational stage The preoperative stage is the second of four stages of cognitive development By observing sequences of play, Piaget was able to demonstrate that towards the end of the second year, a qualitatively new kind of psychological functioning occurs. (Pre)Operatory Thought is any procedure for mentally acting on objects. The hallmark of the preoperational stage is sparse and logically inadequate mental operations. During this stage, the child learns to use and to represent objects by images, words, and drawings. The child is able to form stable concepts as well as mental reasoning and magical beliefs. The child however is still not able to perform operations; tasks that the child can do mentally rather than physically

Thinking is still egocentric: The child has difficulty taking the viewpoint of others. Two substages can be formed from preoperative thought.  The Symbolic Function Substage  Occurs between about the ages of 2 and 7.  The child is able to formulate designs of objects that are not present Other examples of mental abilities are language and pretend play  Although there is an advancement in progress, there are still limitations such as egocentrism and animism.  Egocentrism occurs when a child is unable to distinguish between their own perspective and that of another person's.  Children tend to pick their own view of what they see rather than the actual view shown to others. An example is an experiment performed by Piaget and Barbel Inhelder  Three views of a mountain are shown and the child is asked what a traveling doll would see at the various angles; the child picks their own view compared to the actual view of the doll.  Animism is the belief that inanimate objects are capable of actions and have lifelike qualities. An example is a child believing that the sidewalk was mad and made them fall down.  The Intuitive Thought Substage  Occurs between about the ages of 2 and 7.  Children tend to become very curious and ask many questions; begin the use of primitive reasoning. ]  There is an emergence in the interest of reasoning and wanting to know why things are the way they are.  Piaget called it the intuitive substage because children realize they have a vast amount of knowledge but they are unaware of how they know it.  Centration and conservation are both involved in preoperative thought.  Centration is the act of focusing all attention on one characteristic compared to the others.  Centration is noticed in conservation; the awareness that altering a substance's appearance does not change its basic properties.  Children at this stage are unaware of conservation.  In Piaget's most famous task, a child is presented with two identical beakers containing the same amount of liquid.  The child usually notes that the beakers have the same amount of liquid  When one of the beakers is poured into a taller and thinner container, children who are typically younger than 7 or 8 years old say that the two beakers now contain a different amount of liquid.  The child simply focuses on the height and width of the container compared to the general concept.  Piaget believes that if a child fails the conservation-of-liquid task, it is a sign that they are at the preoperational stage of cognitive development.  The child also fails to show conservation of number, matter, length, volume, and area as well.  Another example is when a child is shown 7 dogs and 3 cats and asked if there are more dogs than cats.  The child would respond positively. However when asked if there are more dogs than animals, the child would once again respond positively. Such fundamental errors in logic show the transition between intuitiveness in solving problems and true logical reasoning acquired in later years when the child grows up. Piaget considered that children primarily learn through imitation and play throughout these first two stages, as they build up symbolic images through internalized activity. Concrete operational stage  The concrete operational stage is the third of four stages of cognitive development in Piaget's theory. This stage, which follows the Preoperational stage, occurs between the ages of 7 and 11 years and is characterized by the appropriate use of logic. Important processes during this stage are: Seriation—the ability to sort objects in an order according to size, shape, or any other characteristic. For example, if given different-shaded objects they may make a color gradient.

Transitivity- The ability to recognize logical relationships among elements in a serial order, and perform 'transitive inferences' (for example, If A is taller than B, and B is taller than C, then A must be taller than C). Classification—the ability to name and identify sets of objects according to appearance, size or other characteristic, including the idea that one set of objects can include another. Decentering—where the child takes into account multiple aspects of a problem to solve it. For example, the child will no longer perceive an exceptionally wide but short cup to contain less than a normally-wide, taller cup. Reversibility—the child understands that numbers or objects can be changed, then returned to their original state. For this reason, a child will be able to rapidly determine that if 4+4 equals t, t−4 will equal 4, the original quantity. Conservation—understanding that quantity, length or number of items is unrelated to the arrangement or appearance of the object or items. Elimination of Egocentrism—the ability to view things from another's perspective (even if they think incorrectly). For instance, show a child a comic in which Jane puts a doll under a box, leaves the room, and then Melissa moves the doll to a drawer, and Jane comes back. A child in the concrete operations stage will say that Jane will still think it's under the box even though the child knows it is in the drawer. (See also False-belief task). Children in this stage can, however, only solve problems that apply to actual (concrete) objects or events, and not abstract concepts or hypothetical tasks. Formal operational stage  The formal operational period is the fourth and final of the periods of cognitive development in Piaget's theory.  This stage, which follows the Concrete Operational stage, commences at around 11 years of age (puberty) and continues into adulthood.  In this stage, individuals move beyond concrete experiences and begin to think abstractly, reason logically and draw conclusions from the information available, as well as apply all these processes to hypothetical situations  The abstract quality of the adolescent's thought at the formal operational level is evident in the adolescent's verbal problem solving ability  The logical quality of the adolescent's thought is when children are more likely to solve problems in a trialand-error fashion.  Adolescents begin to think more as a scientist thinks, devising plans to solve problems and systematically testing solutions.  They use hypothetical-deductive reasoning, which means that they develop hypotheses or best guesses, and systematically deduce, or conclude, which is the best path to follow in solving the problem.  During this stage the adolescent is able to understand such things as love, "shades of gray", logical proofs and values. During this stage the young person begins to entertain possibilities for the future and is fascinated with what they can be  Adolescents are changing cognitively also by the way that they think about social matters.  Adolescent Egocentrism governs the way that adolescents think about social matters and is the heightened self-consciousness in them as they are which is reflected in their sense of personal uniqueness and invincibility.[9] Adolescent egocentrism can be dissected into two types of social thinking, imaginary audience that involves attention getting behavior, and personal fable which involves an adolescent's sense of personal uniqueness and invincibility.

The concept of psychosexual development, as envisioned by Sigmund Freud at the end of the 19th and the beginning of the 20th century, is a central element in his sexual drive theory, which posits that, from birth, humans have instinctual sexual appetites (libido), which unfold in a series of stages. Each stage is characterized by the erogenous zone that is the source of the libidinal drive during that stage. These stages are, in order: oral, anal, phallic, latency, and genital. Freud believed that if, during any stage, the child experienced anxiety in relation to that drive, that themes related to this stage would persist into adulthood as neurosis

Freud's model of psychosexual development Stage Age Range Erogenous zone(s)

Consequences of Fixation

Oral

Birth-1 year

Mouth

Orally aggressive: Signs include chewing gum or ends of pens. Orally Passive: Signs include smoking/eating/kissing/fellatio/cunnilingus[3] Fixation at this stage may result in passivity, gullibility, immaturity and manipulative personality

Anal

1–3 years

Bowel and bladder elimination

Anal retentive: Obsession with organization or excessive neatness Anal expulsive: Reckless, careless, defiant, disorganized, Coprophiliac

Genitals

Oedipus complex (in boys only according to Freud) Electra complex (in girls only, later developed by Carl Jung)

Dormant sexual feelings

(People do not tend to fixate at this stage, but if they do, they tend to be extremely sexually unfulfilled.)

Phallic 3–6 years Latency

6-puberty years

Puberty- end Sexual interests Frigidity, impotence, unsatisfactory relationships of life mature Oral phase  The first stage of psychosexual development is the oral stage, which lasts from the beginning of one’s life up to 2 years. During this stage, the focus of gratification is on the mouth and pleasure is the result of nursing, but also of exploration of the surroundings (as infants tend to put new objects in their mouths). In this stage the Id is dominant since neither the ego nor the super ego is yet fully formed. Thus the baby does not have a sense of self and all actions are based on the pleasure principle.  The ego, however, is under formation during this first stage. There are two factors that contribute to the formation of the ego. Firstly, body image is developed, which implies that the infant recognizes that the body is distinct from the outer world. For instance, one starts understanding that one feels pain only when force is applied on one’s own body. By the identification of the body boundaries, one starts developing the sense of ego. Ego formation is attributed to a second factor: experiences that involve delay of gratification and that lead to the understanding that specific behaviors can satisfy some needs. The infant gradually realizes that gratification is not immediate, and that he or she must produce certain behaviors to initiate actions that lead to gratification. An example of such behavior is crying, which seems to be purposeless during the first 2 months of the baby’s life, but later seems to be used productively and is connected to certain needs. [4]  The key experience in this stage is weaning, during which the child loses much of the intimate contact with the mother and leads to the first feeling of loss ever experienced by the baby. Weaning also adds to the baby’s awareness of self, since he or she learns that not everything is under his or her control, but also that gratification is not always immediate.  In this stage, the gratification of needs lead to the formation of independence (since the baby forms a clear idea about the limits of the self and has formed his or her ego), and trust (since the baby learned that specific behaviors lead to gratification).  On the other hand, a fixation can lead to passivity, gullibility, immaturity and unrealistic optimism, and also to the formation of a generally manipulative personality due to improper formation of the ego. This can be the result of either too much or too little gratification.  In the case of too much gratification, the child does not learn that not everything is under his or her control and that gratification is not always immediate (which are the results of weaning), forming an immature personality.  On the other hand, the child’s needs may be insufficiently met, and thus the child becomes passive since he or she has learned that whether producing behavior or not, no gratification comes. In some societies it is common for a child to be nursed by his or her mother for several years, whereas in others the stage is much shorter.  Sucking and eating, however, compose the earliest memories for infants in every society. Genital

Anal phase 

In the anal stage of the psychosexual development the focus of drive energy (erogenous zone) moves from the upper digestive tract to the lower end and the anus. This stage lasts from about the 15th month to the third year of age. In this stage, the formation of ego continues.

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According to the theory, the major experience during this stage is toilet training. This occurs around the age of two (there may be fluctuations among different societies as to the age in which toilet training occurs), and results to conflict between the id, which asks for immediate gratification of its drives that involves elimination and activities related to it (such as handling feces) and the demands of their parents. The resolution of this conflict can be gradual and non-traumatic, or intense and stormy, depending on how the parents handle the situation. The ideal resolution comes if the child tries to adjust and the parents are moderate, so that the child learns the importance of cleanliness and order gradually, which leads to a self-controlled adult. If the parents put too much emphasis on toilet training while the child decides to accommodate, this may lead to the development of compulsive personality, extensively concerned about order and neatness. On the other hand, if the child decides to heed the demands of the id and the parents give in, the child may develop a messy and self-indulgent personality. If the parents react, the child must comply, but it develops a weakened sense of self, since the parents were the ones who controlled the situation, not the ego.

Phallic phase        

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The phallic stage extends from about three to five years of age, and the erogenous zone associated with it as the area of the genitals. Even though the gratification is focused on the genitals, this is not in the form of adult sexuality, since the children are physically immature. However, stimulation of genitals is welcomed as pleasurable and boys, like adult males, may have erections during their sleep. Children become increasingly aware of their body and are curious about the bodies of other children, but also their parents. Freud observed that children of this age can very often be observed taking off their clothes and playing “doctor” with each other, or asking their mothers whether she has a penis. These observations persuaded Freud that the gratification is focused on and around the genitals during this period. The major conflict of this stage is called Oedipal conflict, the name deriving from Oedipus, who killed his father and unintentionally slept with his mother. Freud used the term Oedipal for both sexes, but other analysts proposed the female variant to be referred to as "Electra complex". In the beginning, for both sexes the primary care giver (at least in most societies) and main source of gratification is the mother. As the child develops, however, it starts forming a sexual identity and the dynamics for boys and girls alter. For both sexes, the parents become the focus of drive energy. For the boy, the mother becomes more desired, while the father is the focus of jealousy and rivalry, since he is the one who sleeps with the mother, but still he is one of the main caregivers. The id wants to unite with the mother and kill the father (like Oedipus did), but the ego, based on the reality principle, knows that the father is stronger. The child also feels affectionate towards the father, one of the caregivers, and his feelings are ambivalent. The fear that the father will object to the boy’s feelings is expressed by the id as fear that the father will castrate him. The castration fear is not rational, and occurs in a subconscious irrational level. Freud argued that young girls followed more or less the same psychosexual development as boys. Whereas the boy would develop a castration anxiety , the girl would go on to develop penis envy, envy felt by females toward the males because the males possess a penis. The envy is rooted in the fact that without a penis, the female cannot sexually possess the mother as driven to by the Id. As a result of this realization, she is driven to desire sexual union with the father. After this stage, the woman has an extra stage in her development when the clitoris should wholly or in part hand over its sensitivity and its importance to the vagina. The young girl must also at some point give up her first object-choice, the mother, in order to take the father as her new proper object-choice. Her eventual move into heterosexual femininity, which culminates in giving birth, grows out of her earlier infantile desires, with her own child taking place of the penis in accordance with an ancient symbolic equivalence. Generally, Freud considered the Oedipal conflict experienced by girls more intense than that experienced by boys, potentially resulting in a more submissive and less confident personality.

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In both cases the conflict between the id drives and the ego is resolved through two basic defense mechanisms of the ego. One of them is repression, which involves the blocking of memories, impulses and ideas from the conscious mind, but does not lead to resolution of the conflict. The second is identification, which involves incorporation of characteristics of the same-sex parent into the child’s own ego. The boy by adopting this mechanism seeks for the reduction of castration fears, since his similarity with the father is thought to protect the boy from him. The identification of girls with the mother is easier, since the girl realizes that neither she, nor her mother have a penis. Freud's theory regarding the psychosexual dynamic present in female children in this point of their psychosexual development is termed, though not by Freud himself, the Electra complex. Freud's theory of feminine sexuality, particularly penis envy, has been sharply criticized in both gender theory and feminist theory. If the conflict is not resolved, a fixation in this stage may lead to adult women striving for superiority over men, if she had overwhelming feelings of devastation due to lack of penis, being seductive and flirtatious, or very submissive and with low self-esteem. On the other hand, men can exhibit excessive ambition and vanity. Overall, the Oedipal conflict is very important for the super-ego development, since by identifying with one of the parents, morality becomes internalized, and compliance with rules is not any more the result of punishment fear. A poor identification with the same sex parent may lead to recklessness or even immorality.

Latency phase 

The latency stage is typified by a solidifying of the habits that the child developed in the earlier stages. Whether the Oedipal conflict is successfully resolved or not, the drives of the Id are not accessible to the Ego during this stage of development, since they have been repressed during the phallic stage. Hence the drives are seen as dormant and hidden (latent), and the gratification the child receives is not as immediate as it was during the three previous stages. Now pleasure is mostly related to secondary process thinking. Drive energy is redirected to new activities, mainly related to schooling, hobbies and friends. Problems however might occur during this stage, and this is attributed to inadequate repression of the Oedipal conflict, or to the inability of the Ego to redirect the drive energy to activities accepted by the social environment.

Genital phases 

The fifth and last stage of psycho-sexual development, the genital stage, lasts from puberty onward (i.e. starting at 12 years of age). It is said to continue until development stops which is supposedly at 18 years of age when adulthood starts. This stage represents a major portion of life and the basic task for the individual is detachment from parents. It is also the time when the individual tries to come to terms with unresolved residues of early childhood. In this stage, the focus is again on the genitals, like in the phallic stage, but this time the energy is expressed in terms of adult sexuality. Another crucial difference between these two stages is that, while phallic gratification is linked with satisfaction of primary drives, the ego in the genital stage is well-developed. It uses secondary, process thinking, which allows for symbolic gratification. This symbolic gratification may include the formation of love relationships, development of families, or acceptance of responsibilities associated with adulthood.

Erikson's stages of psychosocial development 

Erik Erikson explain eight stages through which a healthily developing human should pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future. The stages Hope: Trust vs. Mistrust (Infants, 0 to 1 year)  Psychosocial Crisis: Trust vs. Mistrust  Virtue: Hope The first stage of Erik Erikson's theory centers around the infant's basic needs being met by the parents. The infant depends on the parents, especially the mother, for food, sustenance, and comfort. The child's relative understanding of world and society come from the parents and their interaction with the child. If the parents expose the child to warmth, regularity, and dependable affection, the infant's view of the world will be one of trust. Should the parents fail to provide a secure environment and to meet the child's basic need a sense of mistrust will result. According to Erik

Erikson, the major developmental task in infancy is to learn whether or not other people, especially primary caregivers, regularly satisfy basic needs. If caregivers are consistent sources of food, comfort, and affection, an infant learns trustthat others are dependable and reliable. If they are neglectful, or perhaps even abusive, the infant instead learns mistrust- that the world is in an undependable, unpredictable, and possibly dangerous place. Will: Autonomy vs. Shame & Doubt (Toddlers, 2 to 3 years)  Psychosocial Crisis: Autonomy vs. Shame & Doubt  Main Question: "Can I do things myself or must I always rely on others?"  Virtue: Will As the child gains control over eliminative functions and motor abilities, they begin to explore their surroundings. The parents still provide a strong base of security from which the child can venture out to assert their will. The parents' patience and encouragement helps foster autonomy in the child. Highly restrictive parents, however, are more likely to instill the child with a sense of doubt and reluctance to attempt new challenges. As they gain increased muscular coordination and mobility, toddlers become capable of satisfying some of their own needs. They begin to feed themselves, wash and dress themselves, and use the bathroom. If caregivers encourage selfsufficient behavior, toddlers develop a sense of autonomy- a sense of being able to handle many problems on their own. But if caregivers demand too much too soon, refuse to let children perform tasks of which they are capable, or ridicule early attempts at self-sufficiency, children may instead develop shame and doubt about their ability to handle problems. Purpose: Initiative vs. Guilt (Preschool, 4 to 6 years)  Psychosocial Crisis: Initiative vs. Guilt  Main Question: "Am I good or am I bad?"  Virtue: Purpose  Related Elements in Society: ideal prototypes/roles Initiative adds to autonomy the quality of undertaking, planning and attacking a task for the sake of being active and on the move. The child is learning to master the world around him, learning basic skills and principles of physics. Things fall down, not up. Round things roll. He learns how to zip and tie, count and speak with ease. At this stage, the child wants to begin and complete his own actions for a purpose. Guilt is a confusing new emotion. He may feel guilty over things that logically should not cause guilt. He may feel guilt when his initiative does not produce desired results. The development of courage and independence are what set preschoolers, ages three to six years of age, apart from other age groups. Young children in this category face the challenge of initiative versus guilt. As described in Bee and Boyd (2004), the child during this stage faces the complexities of planning and developing a sense of judgment. During this stage, the child learns to take initiative and prepare for leadership and goal achievement roles. Activities sought out by a child in this stage may include risk-taking behaviors, such as crossing a street alone or riding a bike without a helmet; both these examples involve self-limits. Within instances requiring initiative, the child may also develop negative behaviors. These behaviors are a result of the child developing a sense of frustration for not being able to achieve a goal as planned and may engage in behaviors that seem aggressive, ruthless, and overly assertive to parents. Aggressive behaviors, such as throwing objects, hitting, or yelling, are examples of observable behaviors during this stage. Preschoolers are increasingly able to accomplish tasks on their own, and with this growing independence comes many choices about activities to be pursued. Sometimes children take on projects they can readily accomplish, but at other times they undertake projects that are beyond their capabilities or that interfere with other people's plans and activities. If parents and preschool teachers encourage and support children's efforts, while also helping them make realistic and appropriate choices, children develop initiative- independence in planning and undertaking activities. But if, instead, adults discourage the pursuit of independent activities or dismiss them as silly and bothersome, children develop guilt about their needs and desires. Competence: Industry vs. Inferiority (Childhood, 7 to 11 years)  Psychosocial Crisis: Industry vs. Inferiority  Main Question: "Am I successful or worthless?"  Virtue: Competence  Related Elements in Society: division of labor The aim to bring a productive situation to completion gradually supersedes the whims and wishes of play. The

fundamentals of technology are developed. To lose the hope of such "industrious" association may pull the child back to the more isolated, less conscious familial rivalry of the oedipal time. "Children at this age are becoming more aware of themselves as individuals." They work hard at "being responsible, being good and doing it right." They are now more reasonable to share and cooperate. Allen and Marotz (2003) also list some perceptual cognitive developmental traits specific for this age group: Children understand the concepts of space and time, in more logical, practical ways, beginning to grasp, gain better understanding of cause and effect and understand calendar time. At this stage, children are eager to learn and accomplish more complex skills: reading, writing, telling time. They also get to form moral values, recognize cultural and individual differences and are able to manage most of their personal needs and grooming with minimal assistance (Allen and Marotz, 2003). At this stage, children might express their independence by being disobedient, using back talk and being rebellious. Erikson viewed the elementary school years as critical for the development of self-confidence. Ideally, elementary school provides many opportunities for children to achieve the recognition of teachers, parents and peers by producing things- drawing pictures, solving addition problems, writing sentences, and so on. If children are encouraged to make and do things and are then praised for their accomplishments, they begin to demonstrate industry by being diligent, persevering at tasks until completed, and putting work before pleasure. If children are instead ridiculed or punished for their efforts or if they find they are incapable of meeting their teachers' and parents' expectations, they develop feelings of inferiority about their capabilities. Fidelity: Identity vs. Role Confusion (Adolescents, 12 to 19 years)  Psychosocial Crisis: Identity vs. Role Confusion  Main Question: "Who am I and where am I going?"  Ego quality: Fidelity  Related Elements in Society: ideology The adolescent is newly concerned with how they appear to others. Superego identity is the accrued confidence that the outer sameness and continuity prepared in the future are matched by the sameness and continuity of one's meaning for oneself, as evidenced in the promise of a career. The ability to settle on a school or occupational identity is pleasant. In later stages of Adolescence, the child develops a sense of sexual identity. As they make the transition from childhood to adulthood, adolescents ponder the roles they will play in the adult world. Initially, they are apt to experience some role confusion- mixed ideas and feelings about the specific ways in which they will fit into society- and may experiment with a variety of behaviors and activities (e.g. tinkering with cars, baby-sitting for neighbors, affiliating with certain political or religious groups). Eventually, Erikson proposed, most adolescents achieve a sense of identity regarding who they are and where their lives are headed. Erikson is credited with coining the term "Identity Crisis"[1] Each stage that came before and that follows has its own 'crisis', but even more so now, for this marks the transition from childhood to adulthood. This passage is necessary because "Throughout infancy and childhood, a person forms many identifications. But the need for identity in youth is not met by these."[2] This turning point in human development seems to be the reconciliation between 'the person one has come to be' and 'the person society expects one to become'. This emerging sense of self will be established by 'forging' past experiences with anticipations of the future. In relation to the eight life stages as a whole, the fifth stage corresponds to the crossroads: What is unique about the stage of Identity is that it is a special sort of synthesis of earlier stages and a special sort of anticipation of later ones. Youth has a certain unique quality in a person's life; it is a bridge between childhood and adulthood. Youth is a time of radical change—the great body changes accompanying puberty, the ability of the mind to search one's own intentions and the intentions of others, the suddenly sharpened awareness of the roles society has offered for later life. Adolescents "are confronted by the need to re-establish [boundaries] for themselves and to do this in the face of an often potentially hostile world."[4] This is often challenging since commitments are being asked for before particular identity roles have formed. At this point, one is in a state of 'identity confusion', but society normally makes allowances for youth to "find themselves," and this state is called 'the moratorium': The problem of adolescence is one of role confusion—a reluctance to commit which may haunt a person into his mature years. Given the right conditions—and Erikson believes these are essentially having enough space and time, a psychological moratorium, when a person can freely experiment and explore—what may emerge is a firm sense of identity, an emotional and deep awareness of who he or she is. As in other stages, bio-psycho-social forces are at work. No matter how one has been raised, one’s personal ideologies are now chosen for oneself. Oftentimes, this leads to

conflict with adults over religious and political orientations. Another area where teenagers are deciding for themselves is their career choice, and oftentimes parents want to have a decisive say in that role. If society is too insistent, the teenager will acquiesce to external wishes, effectively forcing him or her to ‘foreclose’ on experimentation and, therefore, true self-discovery. Once someone settles on a worldview and vocation, will he or she be able to integrate this aspect of self-definition into a diverse society? According to Erikson, when an adolescent has balanced both perspectives of “What have I got?” and “What am I going to do with it?” he or she has established their identity: Dependent on this stage is the ego quality of fidelity—the ability to sustain loyalties freely pledged in spite of the inevitable contradictions and confusions of value systems. Given that the next stage (Intimacy) is often characterized by marriage, many are tempted to cap off the fifth stage at 20 years of age. However, these age ranges are actually quite fluid, especially for the achievement of identity, since it may take many years to become grounded, to identify the object of one's fidelity, to feel that one has "come of age." In the biographies Young Man Luther and Gandhi's Truth, Erikson determined that their crises ended at ages 25 and 30, respectively: Erikson does note that the time of Identity crisis for persons of genius is frequently prolonged. He further notes that in our industrial society, identity formation tends to be long, because it takes us so long to gain the skills needed for adulthood’s tasks in our technological world. So… we do not have an exact time span in which to find ourselves. It doesn't happen automatically at eighteen or at twenty-one. A very approximate rule of thumb for our society would put the end somewhere in one's twenties. Love: Intimacy vs. Isolation (Young Adults, 20 to 34 years)  Main Question: "Am I loved and wanted?" or "Shall I share my life with someone or live alone?"  Virtue: Love  Related Elements in Society: patterns of cooperation (often marriage) Body and ego must be masters of organ modes and of the other nuclear conflicts in order to face the fear of ego loss in situations that call for self-abandonment. Avoiding these experiences leads to openness and self-absorption The Intimacy vs. Isolation conflict is emphasized around the ages of 20 to 34. At the start of this stage, identity vs. role confusion is coming to an end, and it still lingers at the foundation of the stage (Erikson, 1950). Young adults are still eager to blend their identities with friends. They want to fit in. Erikson believes we are sometimes isolated due to intimacy. We are afraid of rejections such as being turned down or our partners breaking up with us. We are familiar with pain, and to some of us, rejection is painful; our egos cannot bear the pain. Erikson also argues that "Intimacy has a counterpart: Distantiation: the readiness to isolate and if necessary, to destroy those forces and people whose essence seems dangerous to our own, and whose territory seems to encroach on the extent of one's intimate relations. Once people have established their identities, they are ready to make long-term commitments to others. They become capable of forming intimate, reciprocal relationships (e.g. through close friendships or marriage) and willingly make the sacrifices and compromises that such relationships require. If people cannot form these intimate relationships – perhaps because of their own needs – a sense of isolation may result. Care: Generativity vs. Stagnation (Middle Adulthood, 35 to 65 years)  Psychosocial Crisis: Generativity vs. Stagnation  Main Question: "Will I produce something of real value?"  Virtue: Care  Related Elements in Society: parenting, educating, or other productive social involvement Generativity is the concern of establishing and guiding the next generation. Socially-valued work and disciplines are expressions of generativity. Simply having or wanting children does not in and of itself achieve generativity. During middle age the primary developmental task is one of contributing to society and helping to guide future generations. When a person makes a contribution during this period, perhaps by raising a family or working toward the betterment of society, a sense of generativity- a sense of productivity and accomplishment- results. In contrast, a person who is self-centered and unable or unwilling to help society move forward develops a feeling of stagnation- a dissatisfaction with the relative lack of productivity. Central tasks of Middle Adulthood  Express love through more than sexual contacts.  Maintain healthy life patterns.  Develop a sense of unity with mate.  Help growing and grown children to be responsible adults.

 Relinquish central role in lives of grown children.  Accept children's mates and friends.  Create a comfortable home.  Be proud of accomplishments of self and mate/spouse.  Reverse roles with aging parents.  Achieve mature, civic and social responsibility.  Adjust to physical changes of middle age.  Use leisure time creatively.  Love for others Wisdom: Ego Integrity vs. Despair (Seniors, 65 years onwards)  Psychosocial Crisis: Ego Integrity vs. Despair  Main Question: "Have I lived a full life?"  Virtue: Wisdom As we grow older and become senior citizens we tend to slow down our productivity and explore life as a retired person. It is during this time that we contemplate our accomplishments and are able to develop integrity if we see ourselves as leading a successful life. If we see our life as unproductive, or feel that we did not accomplish our life goals, we become dissatisfied with life and develop despair, often leading to depression and hopelessness. The final developmental task is retrospection: people look back on their lives and accomplishments. They develop feelings of contentment and integrity if they believe that they have led a happy, productive life. They may instead develop a sense of despair if they look back on a life of disappointments and unachieved goals. Evolution from Freudian theory Erikson was a student of Sigmund Freud, whose psychoanalytic theory contributed to the basic outline of the eight stages, at least those concerned with childhood. Namely, the first through fourth of Erikson's life stages correspond to Freud's oral, anal, phallic, and latency phases, respectively. Also, the fifth stage of adolescence is said to parallel the genital stage in psychoanalytic theory: Although the first three phases are linked to those of the Freudian theory, it can be seen that they are conceived along very different lines. The emphasis is not so much on sexual modes and their consequences as on the ego qualities which emerge from each stages. There is an attempt also to link the sequence of individual development to the broader context of society. Erikson saw a dynamic at work throughout life, one that did not stop at adolescence. He also viewed the life stages as a cycle: the end of one generation was the beginning of the next. Seen in its social context, the life stages were linear for an individual but circular for societal development: In Freud's view, development is largely complete by adolescence. In contrast, one of Freud's students, Erik Erikson (1902-1994) believed that development continues throughout life. Erikson took the foundation laid by Freud and extended it through adulthood and into late life. Value of the theory One value of this theory is that it illuminated why individuals who had been thwarted in the healthy resolution of early phases (such as in learning healthy levels of trust and autonomy in toddlerhood) had such difficulty with the crises that came in adulthood. More importantly, it did so in a way that provided answers for practical application. It raised new potential for therapists and their patients to identify key issues and skills that required addressing. But at the same time, it yielded a guide or yardstick that could be used to assess teaching and child rearing practices in terms of their ability to nurture and facilitate healthy emotional and cognitive development. "Every adult, whether he is a follower or a leader, a member of a mass or of an elite, was once a child. He was once small. A sense of smallness forms a substratum in his mind, ineradicably. His triumphs will be measured against this smallness, his defeats will substantiate it. The questions as to who is bigger and who can do or not do this or that, and to whom—these questions fill the adult's inner life far beyond the necessities and the desirabilities which he understands and for which he plans."

Kohlberg's stages of moral development constitute an adaptation of a psychological theory originally conceived of by the Swiss psychologist Jean Piaget. Lawrence Kohlberg began work on this topic while a psychology postgraduate student at the University of Chicago[1], and expanded and developed this theory throughout the course of his life.

The theory holds that moral reasoning, the basis for ethical behavior, has six identifiable developmental stages, each more adequate at responding to moral dilemmas than its predecessor. [2] Kohlberg followed the development of moral judgment far beyond the ages studied earlier by Piaget,[3] who also claimed that logic and morality develop through constructive stages.[2] Expanding on Piaget's work, Kohlberg determined that the process of moral development was principally concerned with justice, and that it continued throughout the individual's lifetime, [4] a notion that spawned dialogue on the philosophical implications of such research.[5][6] Kohlberg relied for his studies on stories such as the Heinz dilemma, and was interested in how individuals would justify their actions if placed in similar moral dilemmas. He then analyzed the form of moral reasoning displayed, rather than its conclusion,[6] and classified it as belonging to one of six distinct stages.[7][8][9] There have been critiques of the theory from several perspectives. Arguments include that it emphasizes justice to the exclusion of other moral values, such as caring[10]; that there is such an overlap between stages that they should more properly be regarded as separate domains; or that evaluations of the reasons for moral choices are mostly post hoc rationalizations (by both decision makers and psychologists studying them) of essentially intuitive decisions. Nevertheless, an entirely new field within psychology was created as a result of Kohlberg's theory, and according to Haggbloom et al.'s study of the most eminent psychologists of the 20th century, Kohlberg was the 16th most frequently cited psychologist in introductory psychology textbooks throughout the century, as well as the 30th most eminent overall.[11] Kohlberg's scale is about how people justify behaviors and his stages are not a method of ranking how moral someone behaves: there should however be a correlation between how someone scores on the scale and how they behave and the general hypothesis is that moral behaviour is more responsible, consistent and predictable from people at higher levels Stages Kohlberg's six stages can be more generally grouped into three levels of two stages each: pre-conventional, conventional and post-conventional.[7][8][9] Following Piaget's constructivist requirements for a stage model, as described in his theory of cognitive development, it is extremely rare to regress backward in stages—to lose the use of higher stage abilities.[13][14] Stages cannot be skipped; each provides a new and necessary perspective, more comprehensive and differentiated than its predecessors but integrated with them. [13][14] Level 1 (Pre-Conventional) 1. Obedience and punishment orientation (How can I avoid punishment?) 2. Self-interest orientation (What's in it for me?) Level 2 (Conventional) 3. Interpersonal accord and conformity (Social norms) (The good boy/good girl attitude) 4. Authority and social-order maintaining orientation (Law and order morality) Level 3 (Post-Conventional) 5. Social contract orientation 6. Universal ethical principles (Principled conscience) Pre-Conventional The pre-conventional level of moral reasoning is especially common in children, although adults can also exhibit this level of reasoning. Reasoners at this level judge the morality of an action by its direct consequences. The preconventional level consists of the first and second stages of moral development, and is solely concerned with the self in an egocentric manner. A child with preconventional morality has not yet adopted or internalized society's conventions regarding what is right or wrong, but instead focuses largely on external consequences that certain actions may bring.[7][8][9] In Stage one (obedience and punishment driven), individuals focus on the direct consequences of their actions on themselves. For example, an action is perceived as morally wrong because the perpetrator is punished. "The last time I did that I got spanked so I will not do it again." The worse the punishment for the act is, the more "bad" the act is perceived to be.[15] This can give rise to an inference that even innocent victims are guilty in proportion to their suffering.

It is "egocentric", lacking recognition that others' points of view are different from one's own.[16] There is "deference to superior power or prestige".[16] Stage two (self-interest driven) espouses the "what's in it for me" position, in which right behavior is defined by whatever is in the individual's best interest. Stage two reasoning shows a limited interest in the needs of others, but only to a point where it might further the individual's own interests. As a result, concern for others is not based on loyalty or intrinsic respect, but rather a "you scratch my back, and I'll scratch yours" mentality. [2] The lack of a societal perspective in the pre-conventional level is quite different from the social contract (stage five), as all actions have the purpose of serving the individual's own needs or interests. For the stage two theorist, the world's perspective is often seen as morally relative. Conventional The conventional level of moral reasoning is typical of adolescents and adults. Those who reason in a conventional way judge the morality of actions by comparing them to society's views and expectations. The conventional level consists of the third and fourth stages of moral development. Conventional morality is characterized by an acceptance of society's conventions concerning right and wrong. At this level an individual obeys rules and follows society's norms even when there are no consequences for obedience or disobedience. Adherence to rules and conventions is somewhat rigid, however, and a rule's appropriateness or fairness is seldom questioned. [7][8][9] In Stage three (interpersonal accord and conformity driven), the self enters society by filling social roles. Individuals are receptive to approval or disapproval from others as it reflects society's accordance with the perceived role. They try to be a "good boy" or "good girl" to live up to these expectations,[2] having learned that there is inherent value in doing so. Stage three reasoning may judge the morality of an action by evaluating its consequences in terms of a person's relationships, which now begin to include things like respect, gratitude and the "golden rule". "I want to be liked and thought well of; apparently, not being naughty makes people like me." Desire to maintain rules and authority exists only to further support these social roles. The intentions of actions play a more significant role in reasoning at this stage; "they mean well ...".[2] In Stage four (authority and social order obedience driven), it is important to obey laws, dictums and social conventions because of their importance in maintaining a functioning society. Moral reasoning in stage four is thus beyond the need for individual approval exhibited in stage three; society must learn to transcend individual needs. A central ideal or ideals often prescribe what is right and wrong, such as in the case of fundamentalism. If one person violates a law, perhaps everyone would—thus there is an obligation and a duty to uphold laws and rules. When someone does violate a law, it is morally wrong; culpability is thus a significant factor in this stage as it separates the bad domains from the good ones. Most active members of society remain at stage four, where morality is still predominantly dictated by an outside force. Post-Conventional The post-conventional level, also known as the principled level, consists of stages five and six of moral development. There is a growing realization that individuals are separate entities from society, and that the individual’s own perspective may take precedence over society’s view; they may disobey rules inconsistent with their own principles. These people live by their own abstract principles about right and wrong—principles that typically include such basic human rights as life, liberty, and justice. Because of this level’s “nature of self before others”, the behavior of postconventional individuals, especially those at stage six, can be confused with that of those at the pre-conventional level. People who exhibit postconventional morality view rules as useful but changeable mechanisms—ideally rules can maintain the general social order and protect human rights. Rules are not absolute dictates that must be obeyed without question. Contemporary theorists often speculate that many people may never reach this level of abstract moral reasoning. In Stage five (social contract driven), the world is viewed as holding different opinions, rights and values. Such perspectives should be mutually respected as unique to each person or community. Laws are regarded as social contracts rather than rigid edicts. Those that do not promote the general welfare should be changed when necessary to meet “the greatest good for the greatest number of people”. This is achieved through majority decision, and inevitable compromise. Democratic government is ostensibly based on stage five reasoning. In Stage six (universal ethical principles driven), moral reasoning is based on abstract reasoning using universal ethical principles. Laws are valid only insofar as they are grounded in justice, and a commitment to justice carries with it an obligation to disobey unjust laws. Rights are unnecessary, as social contracts are not essential for deontic moral action. Decisions are not reached hypothetically in a conditional way but rather categorically in an absolute way, as in the philosophy of Immanuel Kant.

This involves an individual imagining what they would do in another’s shoes, if they believed what that other person imagines to be true. The resulting consensus is the action taken. In this way action is never a means but always an end in itself; the individual acts because it is right, and not because it is instrumental, expected, legal, or previously agreed upon. Although Kohlberg insisted that stage six exists, he found it difficult to identify individuals who consistently operated at that level Further stages In Kohlberg's empirical studies of individuals throughout their life Kohlberg observed that some had apparently undergone moral stage regression. This could be resolved either by allowing for moral regression or by extending the theory. Kohlberg chose the latter, postulating the existence of sub-stages in which the emerging stage has not yet been fully integrated into the personality.[8] In particular Kohlberg noted a stage 4½ or 4+, a transition from stage four to stage five, that shared characteristics of both. In this stage the individual is disaffected with the arbitrary nature of law and order reasoning; culpability is frequently turned from being defined by society to viewing society itself as culpable. This stage is often mistaken for the moral relativism of stage two, as the individual views those interests of society that conflict with their own as being relatively and morally wrong.[8] Kohlberg noted that this was often observed in students entering college. Kohlberg suggested that there may be a seventh stage—Transcendental Morality, or Morality of Cosmic Orientation— which linked religion with moral reasoning. Kohlberg's difficulties in obtaining empirical evidence for even a sixth stage, however, led him to emphasize the speculative nature of his seventh stage

Maslow's hierarchy of needs is a theory in psychology, proposed by Abraham Maslow in his 1943 paper A Theory of Human Motivation.[2] Maslow subsequently extended the idea to include his observations of humans' innate curiosity. His theories parallel many other theories of human developmental psychology, all of which focus on describing the stages of growth in humans. Maslow studied what he called exemplary people such as Albert Einstein, Jane Addams, Eleanor Roosevelt, and Frederick Douglass rather than mentally ill or neurotic people, writing that "the study of crippled, stunted, immature, and unhealthy specimens can yield only a cripple psychology and a cripple philosophy." Maslow also studied the healthiest 1% of the college student population

Hierarchy Maslow's hierarchy of needs is often portrayed in the shape of a pyramid, with the largest and lowest levels of needs at the bottom, and the need for self-actualization at the top. The lower four layers of the pyramid contain what Maslow called "deficiency needs" or "d-needs": esteem , friendship and love, security, and physical needs. With the exception of the lowest (physiological) needs, if these "deficiency needs" are not met, the body gives no physical indication but the individual feels anxious and tense. 1. Self-actualization  “What a man can be, he must be.”  This forms the basis of the perceived need for self-actualization.  This level of need pertains to what a person's full potential is and realizing that potential. Maslow describes this desire as the desire to become more and more what one is, to become everything that one is capable of becoming.  This is a broad definition of the need for self-actualization, but when applied to individuals the need is specific.  For example one individual may have the strong desire to become an ideal parent, in another it may be expressed athletically, and in another it may be expressed in painting, pictures, or inventions.  As mentioned before, in order to reach a clear understanding of this level of need one must first not only achieve the previous needs, physiological, safety, love, and esteem, but master these needs. Below are Maslow’s descriptions of a self-actualized person’s different needs and personality traits. Maslow also states that even though these are examples of how the quest for knowledge is separate from basic needs he warns that these “two hierarchies are interrelated rather than sharply separated” (Maslow 97). This means that this level of need, as well as the next and highest level, are not strict, separate levels but closely related to others, and this is possibly the reason that these two levels of need are left out of most textbooks.

2. Esteem  All humans have a need to be respected and to have self-esteem and self-respect. Also known as the belonging need, esteem presents the normal human desire to be accepted and valued by others.  People need to engage themselves to gain recognition and have an activity or activities that give the person a sense of contribution, to feel accepted and self-valued, be it in a profession or hobby. Imbalances at this level can result in low self-esteem or an inferiority complex.  People with low self-esteem need respect from others. They may seek fame or glory, which again depends on others.  Note, however, that many people with low self-esteem will not be able to improve their view of themselves simply by receiving fame, respect, and glory externally, but must first accept themselves internally. Psychological imbalances such as depression can also prevent one from obtaining self-esteem on both levels. Most people have a need for a stable self-respect and self-esteem. Maslow noted two versions of esteem needs, a lower one and a higher one. The lower one is the need for the respect of others, the need for status, recognition, fame, prestige, and attention. The higher one is the need for self-respect, the need for strength, competence, mastery, self-confidence, independence and freedom. The latter one ranks higher because it rests more on inner competence won through experience. Deprivation of these needs can lead to an inferiority complex, weakness and helplessness. 3. Love and belonging  After physiological and safety needs are fulfilled, the third layer of human needs are social and involve feelings of belongingness.  This aspect of Maslow's hierarchy involves emotionally based relationships in general, such as:  Friendship  Intimacy  Family Humans need to feel a sense of belonging and acceptance, whether it comes from a large social group, such as clubs, office culture, religious groups, professional organizations, sports teams, gangs, or small social connections (family members, intimate partners, mentors, close colleagues, confidants). They need to love and be loved (sexually and non-sexually) by others. In the absence of these elements, many people become susceptible to loneliness, social anxiety, and clinical depression. This need for belonging can often overcome the physiological and security needs, depending on the strength of the peer pressure; an anorexic, for example, may ignore the need to eat and the security of health for a feeling of control and belonging.[citation needed] 4. Safety needs  With their physical needs relatively satisfied, the individual's safety needs take precedence and dominate behavior.  These needs have to do with people's yearning for a predictable orderly world in which perceived unfairness and inconsistency are under control, the familiar frequent and the unfamiliar rare.  In the world of work, these safety needs manifest themselves in such things as a preference for job security, grievance procedures for protecting the individual from unilateral authority, savings accounts, insurance policies, reasonable disability accommodations, and the like. Safety and Security needs include:  Personal security  Financial security  Health and well-being  Safety net against accidents/illness and their adverse impacts 5. Physiological needs  For the most part, physiological needs are obvious—they are the literal requirements for human survival. If these requirements are not met (with the exception of clothing, shelter, and sexual activity), the human body simply cannot continue to function.

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Physiological needs include: Breathing Food Shelter Water Homeostasis Sex Sleep Air, water, and food are metabolic requirements for survival in all animals, including humans. Clothing and shelter provide necessary protection from the elements. The intensity of the human sexual instinct is shaped more by sexual competition than maintaining a birth rate adequate to survival of the species

Change Theories in Nursing   

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Change means making something different from the way it was originally. Change may be planned or unplanned. Unplanned changes bring about unpredictable outcomes, while planned change is a sequence of events implemented to achieve established goals. In nursing a change agent is a person who brings about changes that impact nursing services. The change agent may be a nurse leader, staff nurse or someone who works with nurses. Change theories are used to bring about planned change in nursing. Nurses and nurse leaders must have knowledge of change theories and select the right change theory as all the available change theories in nursing do not fit all nursing change situations.

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Lewin's Change Theory         

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Kurt Lewin's change theory is widely used in nursing and involves three stages: the unfreezing stage, moving stage, and refreezing stage. Lewin's theory depends on the presence of driving and resistant forces. The driving forces are the change agents who push employees in the direction of change. The resistant forces are employees or nurses who do not want the proposed change. For this theory to be successful, the driving force must dominate the resistant force. Rogers' Change Theory Everette Rogers modified Lewin's change theory and created a five-stage theory of his own. The five stages are awareness, interest, evaluation, implementation and adoption. This theory is applied to long-term change projects. It is successful when nurses who ignored the proposed change earlier adopt it because of what they hear from nurses who adopted it initially. Spradley's Change Theory This is an eight-step process for planned change based on Lewin's theory of change. It makes provision for constant evaluation of the change process to ensure its success. The steps are: recognize the symptoms, diagnose the problem, analyze alternative solutions, select the change, plan the change, implement the change, evaluate the change and stabilize the change. Other Theories Reddin's, Lippitt's and Havelock's theories are based on Lewin's theory and can be used to implement planned change. The first two have seven stages, while the third has six. Real Life Application An article titled "Managing change in the nursing handover from traditional to bedside handover---a case study from Mauritius" details the use of Lewin's and Spradley's theories to implement a change in the process of handover reports between nurses. The driving force in this case was dissatisfaction with the traditional handover method, while the resistant forces were a fear of accountability, lack of confidence and fear that this change

would lead to more work. Evaluation of the implemented change showed that the new process was successfully implemented

Reference 1. Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed. Mosby, Philadelphia, 2002. 2. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby, Philadelphia, 2002. 3. George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton and Lange. 4. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williamsand wilkins. 5. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development and Progress 3rd ed. Philadelphia, Lippincott. 6. Taylor Carol,Lillis Carol (2001)The Art and Science Of Nursing Care 4th ed. Philadelphia, Lippincott. 7. Potter A Patricia, Perry G Anne (1992)Fundamentals Of Nursing –Concepts Process and Practice 3rd ed. London Mosby Year Book.