Nursing Theories

The Environmental Theory By Florence Nightingale The goal of nursing is ―to put the patient in the best condition for nature to act upon him‖. - Nightingale Introduction  Born - 12 May 1820  Founder of modern nursing.  The first nursing theorist.  Also known as "The Lady with the Lamp"  She explained her environmental theory in her famous book Notes on Nursing: What it is, What it is not.  She was the first to propose nursing required specific education and training.  Her contribution during Crimean war is well-known.  She was a statistician, using bar and pie charts, highlighting key points.  International Nurses Day, May 12 is observed in respect to her contribution to Nursing.  Died - 13 August 1910 Assumptions of Nightingale's Theory  Natural laws  Mankind can achieve perfection  Nursing is a calling  Nursing is an art and a science  Nursing is achieved through environmental alteration  Nursing requires a specific educational base  Nursing is distinct and separate from medicine Nightingale’s Canons: Major Concepts 1. Ventilation and warming 2. Light, Noise 3. Cleanliness of rooms/walls 4. Health of houses 5. Bed and bedding 6. Personal cleanliness 7. Variety 8. Chattering hopes and advices 9. Taking food. What food? 10. Petty management/observation Nursing Paradigms  Nightingale's documents contain her philosophical assumptions and beliefs regarding all elements found in the metaparadigm of nursing. These can be formed into a conceptual model that has great utility in the practice setting and offers a framework for research conceptualization. (Selanders LC, 2010) Nursing 

Nursing is different from medicine and the goal of nursing is to place the patient in the best possible condition for nature to act.

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Nursing is the "activities that promote health (as outlined in canons) which occur in any caregiving situation. They can be done by anyone."

Person 

People are multidimensional, composed of biological, psychological, social and spiritual components.

Health Health is ―not only to be well, but to be able to use well every power we have‖. Disease is considered as dys-ease or the absence of comfort. Environment  "Poor or difficult environments led to poor health and disease".  "Environment could be altered to improve conditions so that the natural laws would allow healing to occur." Nightingale's Theory and Nursing Practice Application of Nightingale's theory in practice:  "Patients are to be put in the best condition for nature to act on them, it is the responsibility of nurses to reduce noise, to relieve patients‘ anxieties, and to help them sleep."  As per most of the nursing theories, environmental adaptation remains the basis of holistic nursing care.  

Helping Arts of Nursing or Perspective Theory By Ernestine Weidenbach Introduction  Ernestine Wiedenbach was born in August 18, 1900, in Hamburg, Germany.  Wiedenbach's conceptual model of nursing is called ' The Helping Art of Clinical Nursing".  Education: o B.A. from Wellesley College in 1922 o R.N. from Johns Hopkins School of Nursing in 1925 o M.A. from Teachers College, Columbia University in 1934 o Certificate in nurse-midwifery from the Maternity Center Association School for NurseMidwives in New York in 1946..  Career: o Wiedenbach joined the Yale faculty in 1952 as an instructor in maternity nursing. o Assistant professor of obstetric nursing in 1954 and an associate professor in 1956. o She wrote Family-Centered Maternity Nursing in 1958. o She was influenced by Ida Orlando in her works on the framework.  She died on March 8, 1998. Concept and definitions  Wiedenbach defined key terms commonly used in nursing practice. The patient  "Any individual who is receiving help of some kind, be it care, instruction or advice from a member of the health profession or from a worker in the field of health."  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  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.  It is crucial to nursing profession that a need-for-help be based on the individual perception of his own situation. Nurse  The nurse is functioning human being.  The nurse no only acts, but thinks and feels as well. Knowledge  Knowledge encompasses all that has been perceived and grasped by the human mind.  Knowledge may be : o factual o speculative or o practical Judgment  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  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. Person  Each Person (whether nurse or patient), is endowed with a unique potential to develop selfsustaining 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. Key Elements  Wiedenbach proposes 4 main elements to clinical nursing. o a philosophy o a purpose o a practice and o the art. 

The Philosophy  The nurses' philosophy is their attitude and belief about life and how that effected reality for them.  Wiedenbach believed that there were 3 essential components associated with a nursing philosophy: o Reverence for life o Respect for the dignity, worth, autonomy and individuality of each human being and o resolution to act on personally and professionally held beliefs.

The Purpose  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. The Practice  Practice are those observable nursing actions that are affected by beliefs and feelings about meeting the patient‘s need for help. The Art  The Art of nursing includes o understanding patients needs and concerns o developing goals and actions intended to enhance patients ability and o 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. Perspective Theory Wiedenbach's prescriptive theory is based on three factors:  The central purpose which the practitioner recognizes as essential to the particular discipline.  The prescription for the fullfillment of central purpose.  The realities in the immediate situation that influence the central purpose. Diagram

Fourteen Activities of Daily Living By Virginia Henderson ―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."  Born in Kansas City, Missouri, in 1897.  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, started teaching nursing at the Norfolk Protestant Hospital in Virginia

In 1929, entered Teachers College at Columbia University for Bachelor‘s Degree in 1932, Master‘s Degree in 1934.  Joined Columbia as a member of the faculty, remained until 1948.  Since 1953, a research associate at Yale University School of Nursing.  recipient of numerous recognitions.  Her work influenced the nursing profession throughout the world.  a well known nursing educator and a prolific author.  honorary doctoral degrees from the Catholic University of America, Pace University, University of Rochester, University of Western Ontario, Yale University  In 1985, honored at the Annual Meeting of the Nursing and Allied Health Section of the Medical Library Association.  Died: March 19, 1996.  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) Henderson’s Theory Background  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)  She emphasized the importance of increasing the patient‘s independence so that progress after hospitalization would not be delayed (Henderson,1991)  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).  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.  Her 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 14 components  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 are:  "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  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  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.  Basic nursing care involves providing conditions under which the patient can perform the 14 activities unaided 3. Health  Definition based on individual‘s ability to function independently as outlined in the 14 components.  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  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."  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 o Categorized Nursing : nursing care o 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 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." Twenty-One Nursing Problems Faye Glenn Abdellah

Introduction  Faye Glenn Abdellah, pioneer nursing researcher, helped transform nursing theory, nursing care and nursing education  Birth:1919  Dr Abdellah worked as Deputy Surgeon General in US and Chief Nurse Officer for the US Public Health Service , Department of Health and human services, Washington, D.C.  She was a leader in nursing research and has over one hundred publications related to nursing care, education for advanced practice in nursing and nursing research.  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 per Abdellah, nursing as a comprehensive service 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 people (In 1973, the item 3, - ―providing continuous care of the individual‘s total health needs‖ was eliminated.) 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.

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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.  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 21 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 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 deformity 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 THEORY AND THE FOUR MAJOR CONCEPTS 1. 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. 2. 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. 3. 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. 4. 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. 

Carative Nursing By Jean Watson Introduction  Theorist was born in West Virginia, US  Educated: BSN, University of Colorado, 1964, MS, University of Colorado, 1966, PhD, University of Colorado, 1973  Distinguished Professor of Nursing and endowed Chair in Caring Science at the University of Colorado Health Sciences Center.  Fellow of the American Academy of Nursing.  Previously, Dean of Nursing at the University Health Sciences Center and President of the National League for Nursing  Undergraduate and graduate degrees in nursing and psychiatric-mental health nursing and PhD in educational psychology and counseling. She has six (6) Honorary Doctoral Degrees.  Her research has been in the area of human caring and loss.  In 1988, her theory was published in ―nursing: human science and human care‖. The seven assumptions  Caring can be effectively demonstrated and practiced only interpersonally.  Caring consists of carative factors that result in the satisfaction of certain human needs.  Effective caring promotes health and individual or family growth.  Caring responses accept person not only as he or she is now but as what he or she may become.  A caring environment is one that offers the development of potential while allowing the person to choose the best action for himself or herself at a given point in time.  Caring is more ― healthogenic‖ than is curing. A science of caring is complementary to the science of curing.  The practice of caring is central to nursing. The ten primary carative factors 1. The formation of a humanistic- altruistic system of values. 2. The installation of faith-hope. 3. The cultivation of sensitivity to one‘s self and to others. 4. The development of a helping-trust relationship 5. The promotion and acceptance of the expression of positive and negative feelings. 6. The systematic use of the scientific problem-solving method for decision making 7. The promotion of interpersonal teaching-learning. 8. The provision for a supportive, protective and /or corrective mental, physical, socio-cultural and spiritual environment. 9. Assistance with the gratification of human needs. 10. The allowance for existential-phenomenological forces.

The first three carative factors form the ―philosophical foundation‖ for the science of caring. The remaining seven carative factors spring from the foundation laid by these first three. 1. The formation of a humanistic- altruistic system of values  Begins developmentally at an early age with values shared with the parents.  Mediated through ones own life experiences, the learning one gains and exposure to the humanities.  Is perceived as necessary to the nurse‘s own maturation which then promotes altruistic behavior towards others. 2. Faith-hope  Is essential to both the carative and the curative processes.  When modern science has nothing further to offer the person, the nurse can continue to use faithhope to provide a sense of well-being through beliefs which are meaningful to the individual. 3. Cultivation of sensitivity to one’s self and to others  Explores the need of the nurse to begin to feel an emotion as it presents itself.  Development of one‘s own feeling is needed to interact genuinely and sensitively with others.  Striving to become sensitive, makes the nurse more authentic, which encourages self-growth and self-actualization, in both the nurse and those with whom the nurse interacts.  The nurses promote health and higher level functioning only when they form person to person relationship. 4. Establishing a helping-trust relationship  Strongest tool is the mode of communication, which establishes rapport and caring.  Characteristics needed to in the helping-trust relationship are: o Congruence o Empathy o Warmth  Communication includes verbal, nonverbal and listening in a manner which connotes empathetic understanding. 5. The expression of feelings, both positive and negative  ―Feelings alter thoughts and behavior, and they need to be considered and allowed for in a caring relationship‖.  Awareness of the feelings helps to understand the behavior it engenders. 6. The systematic use of the scientific problem-solving method for decision making  The scientific problem- solving method is the only method that allows for control and prediction, and that permits self-correction.  The science of caring should not be always neutral and objective. 7. Promotion of interpersonal teaching-learning  The caring nurse must focus on the learning process as much as the teaching process.  Understanding the person‘s perception of the situation assist the nurse to prepare a cognitive plan. 8. Provision for a supportive, protective and /or corrective mental, physical, socio-cultural and spiritual environment  Watson divides these into eternal and internal variables, which the nurse manipulates in order to provide support and protection for the person‘s mental and physical well-being.  The external and internal environments are interdependent.  Nurse must provide comfort, privacy and safety as a part of this carative factor. 9. Assistance with the gratification of human needs  It is based on a hierarchy of need similar to that of the Maslow‘s.  Each need is equally important for quality nursing care and the promotion of optimal health.  All the needs deserve to be attended to and valued.

Watson’s ordering of needs  Lower order needs (biophysical needs) o The need for food and fluid o The need for elimination o The need for ventilation  Lower order needs (psychophysical needs) o The need for activity-inactivity o The need for sexuality  Higher order needs (psychosocial needs) o The need for achievement o The need for affiliation o Higher order need (intrapersonal-interpersonal need) o The need for self-actualization 10. Allowance for existential-phenomenological forces  Phenomenology is a way of understanding people from the way things appear to them, from their frame of reference.  Existential psychology is the study of human existence using phenomenological analysis.  This factor helps the nurse to reconcile and mediate the incongruity of viewing the person holistically while at the same time attending to the hierarchical ordering of needs.  Thus the nurse assists the person to find the strength or courage to confront life or death. Watson’s theory and the four major concepts 1. Human being  Human being refers to ―….. a valued person in and of him or herself to be cared for, respected, nurtured, understood and assisted; in general a philosophical view of a person as a fully functional integrated self. He, human is viewed as greater than and different from, the sum of his or her parts‖. 2. Health  Watson adds the following three elements to WHO definition of health: o A high level of overall physical, mental and social functioning o A general adaptive-maintenance level of daily functioning o The absence of illness (or the presence of efforts that leads its absence) 3. Environment/society  According to Watson, caring (and nursing) has existed in every society.  A caring attitude is not transmitted from generation to generation.  It is transmitted by the culture of the profession as a unique way of coping with its environment. 4. Nursing  “Nursing is concerned with promoting health, preventing illness, caring for the sick and restoring health‖.  It focuses on health promotion and treatment of disease. She believes that holistic health care is central to the practice of caring in nursing.  She defines nursing as….. “a human science of persons and human health-illness experiences that are mediated by professional, personal, scientific, esthetic and ethical human transactions‖.

Self-Care Theory Dorothea Orem (1914-2007) Introduction  One of foremost nursing theorists.  Born 1914 in Baltimore.  Earned her diploma at Providence Hospital – Washington, DC  1939 – BSN Ed., Catholic University of America  1945 – MSN Ed., Catholic University of America  Involved in nursing practice, nursing service, and nursing education  During her professional career, she worked as a staff nurse, private duty nurse, nurse educator and administrator and nurse consultant  Received honorary Doctor of Science degree in 1976  Published first formal articulation of her ideas in Nursing: Concepts of Practice in 197, second in 1980, and in 1995. Development of Theory  1949-1957 Orem worked for the Division of Hospital and Institutional Services of the Indiana State Board of Health.  Her goal was to upgrade the quality of nursing in general hospitals throughout the state. During this time she developed her definition of nursing practice.  1959 Orem subsequently served as acting dean of the school of Nursing and as an assistant professor of nursing education at CUA. She continued to develop her concept of nursing and self care during this time.  Orem‘s Nursing: Concept of Practice was first published in 1971 and subsequently in 1980, 1985, 1991, 1995, and 2001. Major Assumptions  People should be self-reliant and responsible for their own care and others in their family needing care  People are distinct individuals  Nursing is a form of action – interaction between two or more persons  Successfully meeting universal and development self-care requisites is an important component of primary care prevention and ill health  A person‘s knowledge of potential health problems is necessary for promoting self-care behaviors  Self care and dependent care are behaviors learned within a socio-cultural context Definition of Domain Concept 1. 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 2. 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 psychophysiological mechanisms and a material structure and in relation to and interacting with other human beings. 3. Environment  environment components are enthronement factors, enthronement elements, conditions, and developed environment 4. 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 

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:  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 sociocultural 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 are1. 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:--

Seeking and securing appropriate medical assistance Being aware of and attending to the effects and results of pathologic conditions Effectively carrying out medically prescribed measures 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  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 endeavor ,with or without use of materials or instruments o o o o

Diagram Self care deficit Nursing system

Self care

Four Conservation Principles Myra Estrine Levine Introduction  Born in Chicago  Very fond of her father who was often ill and frequently hospitalized with GI problem. This was the reason of choosing nursing as a career  Also called as renaissance women-highly principled, remarkable and committed to patient‘s quality of care  Died in 1996 Educational Achievement  Diploma in nursing:-Cook county SON, Chicago, 1944  BSN:-University of Chicago,1949  MSN:-Wayne state University, Detroit, 1962  Publication:-An Introduction to Clinical Nursing, 1969,1973 & 1989  Received honorary doctorate from Loyola University in 1992 Achievements  Clinical experience in OT technique and oncology nursing  Civilian nurse at the Gardiner general hospital  Director of nursing at Drexel home in Chicago  Clinical instructor at Bryan memorial hospital in Lincoln, Nebraska  Administrative supervisor at university of Chicago  Chairperson of clinical nursing at cook country SON  Visiting professor at Tel Aviv university in Israel Conservational model  Goal: To promote adaptation and maintain wholeness using the principles of conservation  Model guides the nurse to focus on the influences and responses at the organismic level  Nurse accomplishes the goal of model through the conservation of energy, structure and personal and social integrity Adaptation  Every individual has a unique range of adaptive responses  The responses will vary by heredity, age, gender or challenges of illness experiences  Example: The response to weakness of cardiac muscle is an increased heart rate, dilation of ventricle and thickening of myocardial muscle  While the responses are same, the timing and manifestation of organismic responses will be unique for each individual pulse rate)  An ongoing process of change in which patient maintains his integrity within the realities of environment  Achieved through the "frugal, economic, contained and controlled use of environmental resources by individual in his or her best interest" Wholeness  Exist when the interaction or constant adaptations to the environment permits the assurance of integrity  Promoted by use of conservation principle Conservation  The product of adaptation  "Keeping together "of the life systems or the wholeness of the individual

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Achieving a balance of energy supply and demand that is with in the unique biological realities of the individual

Nursing’s paradigm 1. Person  A holistic being who constantly strives to preserve wholeness and integrity  A unique individual in unity and integrity, feeling, believing, thinking and whole system of system 2. Environment  Competes the wholeness of person  Internal  Homeostasis  Homeorrhesis  External  Preconceptual  Operational  Conceptual Internal Environment  Homeostasis: A state of energy sparing that also provide the necessary baselines for a multitude of synchronized physiological and psychological factors  A state of conservation  Homeorrhesis: A stabilized flow rather than a static state  Emphasis the fluidity of change within a space-time continuum  Describe the pattern of adaptation, which permit the individual‘s body to sustain its well being with the vast changes which encroach upon it from the environment External Environment  Preconceptual: Aspect of the world that individual are able to intercept  Operational: Elements that may physically affects individuals but not perceived by hem: radiation, micro-organism and pollution  Conceptual: Part of person's environment including cultural patterns characterized by spiritual existence, ideas, values, beliefs and tradition Person and environment  Adaptation  Organismic response  Conservation Adaptation Characteristics  Historicity: Adaptations are grounded in history and await the challenges to which they respond  Specificity: Individual responses and their adaptive pattern varies on the base of specific genetic structure  Redundancy: Safe and fail options available to the individual to ensure continued adaptation Organismic response  A change in behavior of an individual during an attempt to adapt to the environment  Help individual to protect and maintain their integrity  They co-exist They are four types:  1. Flight or fight: An instantaneous response to real or imagined threat, most primitive response  2. Inflammatory: response intended to provide for structural integrity and the promotion of healing

3. Stress: Response developed over time and influenced by each stressful experience encountered by person  4. Perceptual: Involves gathering information from the environment and converting it in to a meaning experience Nine models of guided assessment  Vital‘s signs  Body movement and positioning  Ministration of personal hygiene needs  Pressure gradient system in nursing interventions  Nursing determination in provision of nutritional needs  Pressure gradient system in nursing  Local application of heat and cold  Administration of medicine  Establishing an aseptic environment Assumption  The nurse creates an environment in which healing could occur  A human being is more than the sum of the part  Human being respond in a predictable way  Human being are unique in their responses  Human being know and appraise objects ,condition and situation  Human being sense ,reflects, reason and understand  human being action are self determined even when emotional  Human being are capable of prolonging reflection through such strategists raising questions Levine’s work & Characteristics of theory  Theories can interrelate concepts in such a way as to create a different way of looking at a particular phenomenon  The concept of illness adaptation, using interventions, and the evaluation of nursing interventions are interrelated .they are combined to look at nursing care in a different way (more comprehensive view incorporating total patient care) form previous time.  Theories must be logical in nature.  Levine‘s idea about nursing care are organized in such a way as to b sequential and logical. they can be used to explain the consequences of nursing action  Theories should be relatively simple yet generalizable.  Levine‘s theory is easy to use .  It‘s major elements are easily comprehensible and the relation ship have the potential for being complex but are easily manageable  Certain isolated aspect of the theory are the generalizable i.e. those related to the conservational principles  Theories can be the bases for hypotheses that can be tested.  Levine‘s idea can be tested  Hypothesis can be derived from them .  The principle of conservation are specific enough to be testable  Levine‘s work & Characteristics of theory  Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them.  Since Levine‘s idea have not yet been widely researched ,it is hard o determine the contribution to the general body of knowledge with in the discipline  Theories can be utilized by the practitioner to guide and improve their practice. 

Paula E.Crawford-gamble :-successfully applied Levine‘s theory to the female patient undergoing surgery for the traumatic amputation of the fingers  These ideas lend themselves to use in practice particularly in acute care setting  Theories must be consistent with other validated theories, laws and principles but will leave open unanswered questions that need to be investigated .  Levine‘s ideas seem to be consistent with other theories, laws and principles particularly those from the humanities and sciences Conservational Principle  Conservation of energy  Conservation of structural integrity  Conservation of personal integrity  Conservation of social integrity 1. Conservation of energy  Refers to balancing energy input and output to avoid excessive fatigue  includes adequate rest, nutrition and exercise Example: Availability of adequate rest Maintenance of adequate nutrition 2. Conservation of structural integrity  Refers to maintaining or restoring the structure of body preventing physical breakdown And promoting healing Example: Assist patient in ROM exercise Maintenance of patient‘s personal hygiene 3. Conservation of personal integrity  Recognizes the individual as one who strives for recognition, respect, self awareness, selfhood and self determination Example: Recognize and protect patient‘s space needs 4. Conservation of social integrity  An individual is recognized as some one who resides with in a family, a community ,a religious group, an ethnic group, a political system and a nation Example:  Position patient in bed to foster social interaction with other patients  Avoid sensory deprivation  Promote patient‘s use of news paper, magazines, radio. TV  Provide support and assistance to family 

3. Health  Health is a wholeness and successful adaptation  It is not merely healing of an afflicted part ,it is return to daily activities, selfhood and the ability of the individual to pursue once more his or her own interest without constraints  Disease: It is unregulated and undisciplined change and must be stopped or death will ensue 4. Nursing  "Nursing is a profession as well as an academic discipline, always practiced and studied in concert with all of the disciplines that together from the health sciences"  The human interaction relying on communication ,rooted in the organic dependency of the individual human being in his relationships with other human beings

 Nursing involves engaging in "human interactions" Diagram

Science of Unitary Human Beings Martha Roger Introduction  Born :May 12, 1914, Dallas, Texas  Diploma : Knoxville General Hospital School of Nursing(1936)  Graduation in Public Health Nursing : George Peabody College, TN, 1937  MA :Teachers college, Columbia university, New York, 1945  MPH :Johns Hopkins University, Baltimore, MD, 1952  Doctorate in nursing :Johns Hopkins University, Baltimore, 1954  Fellowship: American academy of nursing  Position: Professor Emerita, Division of Nursing, New York University, Consultant, Speaker  Died : March 13 , 1994 Publications of Martha Rogers  Theoretical basis of nursing (Rogers 1970)  Nursing science and art :a prospective (Rogers 1988)  Nursing :science of unitary, irreducible, human beings update (Rogers 1990)  Vision of space based nursing (Rogers 1990) Rogers nursing theory  Nursing is both a science and art. the uniqueness of nursing, like that of any other science, lies in the phenomenon central to its focus.  Nurses long established concern with the people and the world they live is in a natural forerunner of an organized abstract system encompassing people and the environments.  The irreducible nature of individuals is different from the sum of the parts.  The integral ness of people and the environment that coordinate with a multidimensional universe of open systems points to a new paradigm the identity of nursing as a science.

 The purpose of nurses is to promote health and well-being for all persons wherever they are. Evolution of abstract system  The development of the abstract system was strongly influenced by an early grounding in arts and background of science and her keen interest in space  The science of unitary human beings originated as a synthesis of facts and ideas from multiple sources of knowledge  The uniqueness is in the central phenomena : people and environment  The Rogerian view of a causality emerges from an infinite universe of open system. Overview of Rogerian model  Rogers model provides the way of viewing the unitary human being  Humans are viewed as integral with the universe  The unitary human being and the environment are one ,not dichotomous  Nursing focus on people and the manifestations that emerge from the mutual human /environmental field process  Change of pattern and organization of the human field and the environmental field is propagated by waves  The manifestations of the field patterning that emerge are observable events  The identification of the pattern provide knowledge and understanding of human experience  Basic characteristics which describes the life process of human: energy field, openness, pattern, and pan dimensionality  Basic concepts include unitary human being, environment, and homeodynamic principles Concepts of Rogers model Energy field  The energy field is the fundamental unit of both the living and nonliving  This energy field "provide a way to perceive people and environment as irreducible wholes"  The energy fields continuously varies in intensity, density, and extent Openness  The human field and the environmental field are constantly exchanging their energy  There are no boundaries or barrier that inhibit energy flow between fields Pattern  Pattern is defined as the distinguishing characteristic of an energy field perceived as a single waves  "pattern is an abstraction and it gives identity to the field" Pan dimensionality  Pan dimensionality is defined as "non linear domain without spatial or temporal attributes"  The parameters that human use in language to describe events are arbitrary.  The present is relative ;there is no temporal ordering of lives. Homeodynamic principles  The principles of homeodynamic postulates the way of perceiving unitary human beings  The fundamental unit of the living system is an energy field  Three principle of homeodynamics o Resonancy o Helicy o integrality Resonance  Resonance is an ordered arrangement of rhythm characterizing both human field and environmental field that undergoes continuous dynamic metamorphosis in the human  environmental process

Helicy Helicy describes the unpredictable, but continuous, nonlinear evolution of energy fields as evidenced by non repeating rhythmicties  The principle of Helicy postulates an ordering of the humans evolutionary emergence Integrality  Integrality cover the mutual, continuous relationship of the human energy field and the environmental field .  Changes occur by by the continuous repatterning of the human and environmental fields by resonance waves  The fields are one and integrated but unique to each other Nursing Paradigms 1. Unitary Human Being (person)  A unitary human being is an "irreducible, indivisible, pan dimensional (four-dimensional) energy field identified by pattern and manifesting characteristics that are specific to the whole and which cannot be predicted from knowledge of the parts" and "a unified whole having its own distinctive characteristics which cannot be perceived by looking at, describing, or summarizing the parts"  The people has the capacity to participate knowingly and probabilistically in the process of change 2. Environment  The environment is an "irreducible ,pan dimensional energy field identified by pattern and integral with the human field"  The field coexist and are integral. Manifestation emerge from this field and are perceived. 3. Health  Rogers defined health as an expression of the life process; they are the "characteristics and behavior emerging out of the mutual, simultaneous interaction of the human and environmental fields"  Health and illness are the part of the sane continuum.  The multiple events taking place along life's axis denote the extent to which man is achieving his maximum health potential and very in their expressions from greatest health to those conditions which are incompatible with the maintaining life process 4. Nursing  The concept Nursing encompasses two dimensions Independent science of nursing  An organized body of knowledge which is specific to nursing is arrived at by scientific research and logical analysis  Art of nursing practice: o The creative use of science for the betterment of the human o The creative use of its knowledge is the art of its practice  Nursing exists to serve people………..it is the direct and overriding responsibility to the society  The safe practice of nursing depends on the nature and amount of scientific nursing knowledge the individual brings to practice…….the imaginative, intellectual judgment with which such knowledge is made in service to the man kind  People needs knowledgeable nursing 

Behaviour System Model Dorothy E. Johnson Introduction  Dorothy E. Johnson was born August 21, 1919, in Savannah, Georgia.  B. S. N. from Vanderbilt University in Nashville, Tennessee, in 1942; and her M.P.H. from Harvard University in Boston in 1948.  From 1949 till retirement in 1978 she was an assistant professor of pediatric nursing, an associate professor of nursing, and a professor of nursing at the University of California in Los Angeles.  Johnson stressed the importance of research-based knowledge about the effect of nursing care on clients. Behavior system model  Dorothy first proposed her model of nursing care in 1968 as fostering of ―the efficient and effective behavioral functioning in the patient to prevent illness".  She also stated that nursing was ―concerned with man as an integrated whole and this is the specific knowledge of order we require‖.  In 1980 Johnson published her conceptualization of ―behavioral system of model for nursing‖where she explains her definitions of the behavioral system model. Definition of nursing She defined nursing as “an external regulatory force which acts to preserve the organization and integration of the patients behaviors at an optimum level under those conditions in which the behaviors constitutes a threat to the physical or social health, or in which illness is found” Four goals of nursing are to assist the patient: 1. Whose behavior commensurate with social demands. 2. Who is able to modify his behavior in ways that it supports biological imperatives 3. Who is able to benefit to the fullest extent during illness from the physicians knowledge and skill. 4. Whose behavior does not give evidence of unnecessary trauma as a consequence of illness Assumptions There are several layers of assumptions that Johnson makes in the development of conceptualization of the behavioral system model viz.  Assumptions about system  Assumptions about structure  Assumptions about functions Assumptions about system There are 4 assumptions of system: 1. First, there is ―organization, interaction, interdependency and integration of the parts and elements of behaviors that go to make up the system ‖ 2. A system ―tends to achieve a balance among the various forces operating within and upon it', and that man strive continually to maintain a behavioral system balance and steady state by more or less automatic adjustments and adaptations to the natural forces impinging upon him.‖ 3. A behavioral system, which both requires and results in some degree of regularity and constancy in behavior, is essential to man that is to say, it is functionally significant in that it serves a useful purpose, both in social life and for the individual. 4. Last, ―system balance reflects adjustments and adaptations that are successful in some way and to some degree.‖. Assumptions about structure and function of each subsystem  ―from the form the behavior takes and the consequences it achieves can be inferred what ―drive‖ has been stimulated or what ―goal‖ is being sought‖

Each individual has a ―predisposition to act with reference to the goal, in certain ways rather than the other ways‖. This predisposition is called as ―set‖.  Each subsystem has a repertoire of choices or ―scope of action‖  The fourth assumption is that it produce ―observable outcome‖ that is the individual‘s behavior. Each subsystem has three functional requirements 1. System must be ―protected" from noxious influences with which system cannot cope‖. 2. Each subsystem must be ―nurtured‖ through the input of appropriate supplies from the environment. 3. Each subsystem must be ―stimulated‖ for use to enhance growth and prevent stagnation.  These behaviors are ―orderly, purposeful and predictable and sufficiently stable and recurrent to be amenable to description and explanation‖ Johnson’s Behavioral Subsystem  Attachment or affiliative subsystem: ―social inclusion intimacy and the formation and attachment of a strong social bond.‖  Dependency subsystem: ―approval, attention or recognition and physical assistance‖  Ingestive subsystem: ―the emphasis is on the meaning and structures of the social events surrounding the occasion when the food is eaten‖  Eliminative subsystem: “human cultures have defined different socially acceptable behaviors for excretion of waste ,but the existence of such a pattern remains different from culture to Culture.‖  Sexual subsystem:" both biological and social factor affect the behavior in the sexual subsystem‖  Aggressive subsystem: " it relates to the behaviors concerned with protection and self preservation Johnson views aggressive subsystem as one that generates defensive response from the individual when life or territory is being threatened‖  Achievement subsystem: " provokes behavior that attempt to control the environment intellectual, physical, creative, mechanical and social skills achievement are some of the areas that Johnson recognizes". 

Representation of Johnson's Model Goal ----- Set --- Choice of Behavior --- Behavior

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Affiliation Dependency Sexuality Aggression Elimination Ingestion Achievement

Adaptation Model By Sister Callista Roy Introduction  Sr.Callista Roy, a prominent nurse theorist, writer, lecturer, researcher and teacher

Professor and Nurse Theorist at the Boston College of Nursing in Chestnut Hill Born at Los Angeles on October 14, 1939 as the 2nd child of Mr. and Mrs. Fabien Roy she earned a Bachelor of Arts with a major in nursing from Mount St. Mary's College, Los Angeles in 1963.  a master's degree program in pediatric nursing at the University of California ,Los Angeles in 1966.  She also earned a master‘s and PhD in Sociology in 1973 and 1977 ,respectively.  Sr. Callista had the significant opportunity of working with Dorothy E. Johnson  Johnson's work with focusing knowledge for the discipline of nursing convinced Sr. Callista of the importance of describing the nature of nursing as a service to society and prompted her to begin developing her model with the goal of nursing being to promote adaptation.  She joined the faculty of Mount St. Mary's College in 1966, teaching both pediatric and maternity nursing.  She organized course content according to a view of person and family as adaptive systems.  She introduced her ideas about ‗Adaptation Nursing‘ as the basis for an integrated nursing curriculum.  Goal of nursing to direct nursing education, practice and research  Model as a basis of curriculum impetus for growth--Mount St. Mary‘s College  1970-The model was implemented in Mount St. Mary‘s school  1971- she was made chair of the nursing department at the college. Influencing Factors  Family  Education  Religious Background  Mentors  Clinical Experience THEORY DESCRIPTION  The central questions of Roy‘s theory are: o Who is the focus of nursing care? o What is the target of nursing care? o When is nursing care indicated?  Roy‘s first ideas appeared in a graduate paper written at UCLA in 1964.  Published these ideas in "Nursing outlook" in 1970  Subsequently different components of her framework crystallized during 1970s, ‘80s, and ‘90s  Over the years she identified assumptions on which her theory is based. Explicit assumptions (Roy 1989; Roy and Andrews 1991)  The person is a bio-psycho-social being.  The person is in constant interaction with a changing environment.  To cope with a changing world, person uses both innate and acquired mechanisms which are biological, psychological and social in origin.  Health and illness are inevitable dimensions of the person‘s life.  To respond positively to environmental changes, the person must adapt.  The person‘s adaptation is a function of the stimulus he is exposed to and his adaptation level  The person‘s adaptation level is such that it comprises a zone indicating the range of stimulation that will lead to a positive response.  The person has 4 modes of adaptation: physiologic needs, self- concept, role function and interdependence.  "Nursing accepts the humanistic approach of valuing other persons‘ opinions, and view points" Interpersonal relations are an integral part of nursing  There is a dynamic objective for existence with ultimate goal of achieving dignity and integrity.   

Implicit assumptions  A person can be reduced to parts for study and care.  Nursing is based on causality.  Patient‘s values and opinions are to be considered and respected.  A state of adaptation frees an individual‘s energy to respond to other stimuli. ROY ADAPTATION MODEL CONCEPTS: EARLY AND REVISED  Adaptation -- goal of nursing  Person -- adaptive system  Environment -- stimuli  Health -- outcome of adaptation  Nursing -- promoting adaptation and health Concepts-Adaptation  Responding positively to environmental changes.  The process and outcome of individuals and groups who use conscious awareness, self reflection and choice to create human and environmental integration Concepts-Person  Bio-psycho-social being in constant interaction with a changing environment  Uses innate and acquired mechanisms to adapt  An adaptive system described as a whole comprised of parts  Functions as a unity for some purpose  Includes people as individuals or in groups-families, organizations, communities, and society as a whole. Concepts-Environment  Focal - internal or external and immediately confronting the person  Contextual- all stimuli present in the situation that contribute to effect of focal stimulus  Residual-a factor whose effects in the current situation are unclear  All conditions, circumstances, and influences surrounding and affecting the development and behavior of persons and groups with particular consideration of mutuality of person and earth resources, including focal, contextual and residual stimuli Concepts-Health  Inevitable dimension of person's life  Represented by a health-illness continuum  A state and a process of being and becoming integrated and whole Concepts-Nursing  To promote adaptation in the four adaptive modes  To promote adaptation for individuals and groups in the four adaptive modes, thus contributing to health, quality of life, and dying with dignity by assessing behaviors and factors that influence adaptive abilities and by intervening to enhance environmental interactions Concepts-Subsystems  Cognator subsystem — A major coping process involving 4 cognitive-emotive channels: perceptual and information processing, learning, judgment and emotion.  Regulator subsystem — a basic type of adaptive process that responds automatically through neural, chemical, and endocrine coping channels Relationships  Derived Four Adaptive Modes  500 Samples of Patient Behavior  What was the patient doing?  What did the patient look like when needing nursing care?

Four Adaptive Modes  Physiologic Needs  Self Concept  Role Function  Interdependence Diagram

Betty Neuman's System Model

Introduction  Betty Neuman‘s system model provides a comprehensive flexible holistic and system based perspective for nursing.  It focuses on the response of the client system to actual or potential environmental stressors and the use of primary, secondary and tertiary nursing prevention intervention for retention, attainment, and maintenance of optimal client system wellness. HISTORY AND BACKGROUND OF THE THEORIST  Betty Neuman was born in 1924, in Lowel, Ohio.  BS in nursing in 1957  MS in Mental Health Public health consultation, from UCLA in 1966.  Ph.D. in clinical psychology  a pioneer in the community mental health movement in the late 1960s.  developed the model while working as a lecturer in community health nursing at University of California, Los Angeles.  The model was published in 1972 as ―A Model for Teaching Total Person Approach to Patient Problems‖ in Nursing Research.  It was refined and subsequently published in the first edition of Conceptual Models for Nursing Practice, 1974, and in the second edition in 1980.

DEVELOPMENT OF THE MODEL Neuman‘s model was influenced by a variety of sources:  The philosophy writers deChardin and Cornu (on wholeness in system).  Von Bertalanfy, and Lazlo on general system theory.  Selye on stress theory.  Lararus on stress and coping. BASIC ASSUMPTIONS  Each client system is unique, a composite of factors and characteristics within a given range of responses contained within a basic structure.  Many known, unknown, and universal stressors exist. Each differ in it‘s potential for disturbing a client‘s usual stability level or normal LOD (Line of Defence).  The particular inter-relationships of client variables at any point in time can affect the degree to which a client is protected by the flexible LOD against possible reaction to stressors.  Each client/ client system has evolved a normal range of responses to the environment that is referred to as a normal LOD. The normal LOD can be used as a standard from which to measure health deviation.  When the flexible LOD is no longer capable of protecting the client/ client system against an environmental stressor, the stressor breaks through the normal LOD  The client whether in a state of wellness or illness, is a dynamic composite of the inter-relationships of the variables. Wellness is on a continuum of available energy to support the system in an optimal state of system stability.  Implicit within each client system are internal resistance factors known as LOR, which function to stabilize and realign the client to the usual wellness state.  Primary prevention relates to G.K. that is applied in client assessment and intervention, in identification and reduction of possible or actual risk factors.  Secondary prevention relates to symptomatology following a reaction to stressor, appropriate ranking of intervention priorities and treatment to reduce their noxious effects.  Tertiary prevention relates to adjustive processes taking place as reconstitution begins and maintenance factors move the back in circular manner toward primary prevention.  The client as a system is in dynamic, constant energy exchange with the environment. MAJOR CONCEPTS Content  the variables of the person in interaction with the internal and external environment comprise the whole client system Basic structure/Central core  The common client survival factors in unique individual characteristics representing basic system energy resources.  The basis structure, or central core, is made up of the basic survival factors that are common to the species (Neuman,2002).  These factors include:- - Normal temp. range, Genetic structure.- Response pattern. Organ strength or weakness, Ego structure  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. Degree to reaction  the amount of system instability resulting from stressor invasion of the normal LOD. Entropy  a process of energy depletion and disorganization moving the system toward illness or possible death.

Flexible LOD  It is a protective, accordion like mechanism that surrounds and protects the normal LOD from invasion by stressors.

Normal LOD  It represents what the client has become over time, or the usual state of wellness. It is considered dynamic because it can expand or contract over time. Line of Resistance-LOR  The series of concentric circles that surrounds the basic structure.  Protection factors activated when stressors have penetrated the normal LOD, causing a reaction symptomatology. E.g. mobilization of WBC and activation of immune system mechanism Input- output  The matter, energy, and information exchanged between client and environment that is entering or leaving the system at any point in time. Negentropy  A process of energy conservation that increase organization and complexity, moving the system toward stability or a higher degree of wellness. Open system  A system in which there is continuous flow of input and process, output and feedback. It is a system of organized complexity where all elements are in interaction. Prevention as intervention  Interventions modes for nursing action and determinants for entry of both client and nurse in to health care system. Reconstitution  The return and maintenance of system stability, following treatment for stressor reaction, which may result in a higher or lower level of wellness. Stability  A state of balance of harmony requiring energy exchanges as the client adequately copes with stressors to retain, attain, or maintain an optimal level of health thus preserving system integrity. Stressors  environmental factors, intra (emotion, feeling), inter (role expectation), and extra personal (job or finance pressure) in nature, that have potential for disrupting system stability.  A stressor is any phenomenon that might penetrate both the F and N LOD, resulting either a positive or negative outcome. Wellness/Illness  Wellness is the condition in which all system parts and subparts are in harmony with the whole system of the client. o Illness is a state of insufficiency with disrupting needs unsatisfied (Neuman, 2002). o Illness is an excessive expenditure of energy… when more energy is used by the system in its state of disorganization than is built and stored; the outcome may be death (Neuman, 2002). PREVENTION  the primary nursing intervention. Prevention focuses on keeping stressors and the stress response from having a detrimental effect on the body. Primary Prevention  Primary prevention occurs before the system reacts to a stressor. On the one hand, it strengthens the person (primary the flexible LOD) to enable him to better deal with stressors  Primary prevention includes health promotion and maintenance of wellness.

Secondary Prevention  Secondary prevention occurs after the system reacts to a stressor and is provided in terms of existing system.  Secondary prevention focuses on preventing damage to the central core by strengthening the internal lines of resistance and/or removing the stressor. Tertiary Prevention  Tertiary prevention 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. FOUR NURSING PARADIGMS 1. PERSON  Human being is a total person as a client system and the person is a layered multidimensional being.  Each layer consists of five person variable or subsystems: o Physiological - Refers of the physicochemical structure and function of the body. o Psychological - Refers to mental processes and emotions. o Socio-cultural - Refers to relationships; and social/cultural expectations and activities. o Spiritual - Refers to the influence of spiritual beliefs. o Developmental - Refers to those processes related to development over the lifespan. 2. ENVIRONMENT  The environment is seen to be the totality of the internal and external forces which surround a person and with which they interact at any given time.  These forces include the intrapersonal, interpersonal and extra-personal stressors which can affect the person‘s normal line of defense and so can affect the stability of the system. o The internal environment exists within the client system. o The external environment exists outside the client system. o The created environment is an environment that is created and developed unconsciously by the client and is symbolic of system wholeness. 3. HEALTH  Health as being equated with wellness. Health/wellness is defined as ―the condition in which all parts and subparts (variables) are in harmony with the whole of the client (Neuman, 1995)‖.  The client system moves toward illness and death when more energy is needed than is available. The client system moved toward wellness when more energy is available than is needed 4. NURSING  Neuman sees nursing as a unique profession that is concerned with all of the variables which influence the response a person might have to a stressor.  The person is seen as a whole, and it is the task of nursing to address the whole person.  Neuman defines nursing as ―action which assist individuals, families and groups to maintain a maximum level of wellness, and the primary aim is stability of the patient/client system, through nursing interventions to reduce stressors.‘‘  Neuman states that, because the nurse‘s perception will influence the care given, then not only must the patient/client‘s perception be assessed, but so must those of the caregiver (nurse).  The role of the nurse is seen in terms of degree of reaction to stressors, and the use of primary, secondary and tertiary interventions

Diagram Person / physiologic needs Primary Tertiary

CORE

Secondary Betty Neuman's System Model

Goal Attainment Theory By Imogene King Introduction  Imogene King was born in 1923.  Completed her Bachelor in science of nursing from St. Louis University in 1948  Completed her Master of science in nursing from St. Louis University in 1957  Completed her Doctorate from Teacher‘s college, Columbia University King’s Conceptual Framework It includes:  Several basic assumptions  Three interacting systems  Several concepts relevant for each system Basic assumptions  Nursing focus is the care of human being  Nursing goal is the health care of individuals & groups  Human beings: are open systems interacting constantly with their environment  Interacting systems: o personal system o Interpersonal system o Social system  Concepts are given for each system Concepts for Personal System  Perception  Self  Growth & development  Body image  Space  Time Concepts for Interpersonal System  Interaction  Communication  Transaction  Role  Stress

Concepts for Social System  Organization  Authority  Power  Status  Decision making Major Theses of King’s conceptual framework  ―Each human being perceives the world as a total person in making transactions with individuals and things in environment‖  ―Transaction represents a life situation in which perceiver & thing perceived are encountered and in which person enters the situation as an active participant and each is changed in the process of these experiences‖ King’s Theory of Goal Attainment  Theory of goal attainment was first introduced by Imogene King in the early 1960‘s.  Theory describes a dynamic, interpersonal relationship in which a person grows and develops to attain certain life goals.  Factors which affects the attainment of goal are: roles, stress, space & time Propositions of King’s Theory From the theory of goal attainment king developed predictive propositions, which includes:  If perceptual interaction accuracy is present in nurse-client interactions, transaction will occur  If nurse and client make transaction, goal will be attained  If goal are attained, satisfaction will occur  If transactions are made in nurse-client interactions, growth & development will be enhanced  If role expectations and role performance as perceived by nurse & client are congruent, transaction will occur  If role conflict is experienced by nurse or client or both, stress in nurse-client interaction will occur  If nurse with special knowledge skill communicate appropriate information to client, mutual goal setting and goal attainment will occur. Major concepts of king’s theory 1. Human being /person: is social being who are rational and sentient. Person has ability to :  perceive  think  feel  choose  set goals  select means to achieve goals and  to make decision According to King, human being has three fundamental needs:  (a) The need for the health information that is unable at the time when it is needed and can be used  (b) The need for care that seek to prevent illness, and  (c) The need for care when human beings are unable to help themselves. 2. Health According to King, health involves dynamic life experiences of a human being, which implies continuous adjustment to stressors in the internal and external environment through optimum use of one‘s resources to achieve maximum potential for daily living. 3. Environment Environment is the background for human interactions. It involves:

(a) Internal environment: transforms energy to enable person to adjust to continuous external environmental changes.  (b) External environment: involves formal and informal organizations. Nurse is a part of the patient‘s environment. 4. Nursing Definition: ―A process of action, reaction and interaction by which nurse and client share information about their perception in nursing situation.‖ and ― a process of human interactions between nurse and client whereby each perceives the other and the situation, and through communication, they set goals, explore means, and agree on means to achieve goals.‖  Action: is defined as a sequence of behaviors involving mental and physical action.  Reaction: not specified, but might be considered as included in the sequence of behaviors described in action. In addition, king discussed: (a) goal (b) domain and (c) functions of professional nurse  Goal of nurse: ―To help individuals to maintain their health so they can function in their roles.‖  Domain of nurse: ―includes promoting, maintaining, and restoring health, and caring for the sick, injured and dying.  Function of professional nurse: ―To interpret information in nursing process to plan, implement and evaluate nursing care. King said in her theory, ―A professional nurse, with special knowledge and skills, and a client in need of nursing, with knowledge of self and perception of personal problems, meet as strangers in natural environment. They interact mutually, identify problems, establish and achieve goals. 

Diagram Social system Interpersonal Personal Goal Attainment Theory

Theory of Interpersonal Relations Hildegard. E. Peplau Introduction  Born in Reading, Pennsylvania [1909]  Graduated from a diploma program in Pottstown, Pennsylvania in 1931.  Done BA in interpersonal psychology from Bennington College in 1943.  MA in psychiatric nursing from Colombia University New York in 1947.  EdD in curriculum development in 1953.

Professor emeritus from Rutgers university Started first post baccalaureate program in nursing Published Interpersonal Relations in Nursing in 1952 1968 :interpersonal techniques-the crux of psychiatric nursing Worked as executive director and president of ANA. Worked with W.H.O, NIMH and nurse corps. Died in 1999. Psychodynamic nursing  Understanding of ones own behavior  To help others identify felt difficulties  To apply principles of human relations to the problems that arise at all levels of experience  In her book she discussed the phases of interpersonal process, roles in nursing situations and methods for studying nursing as an interpersonal process.  According to Peplau, nursing is therapeutic in that it is a healing art, assisting an individual who is sick or in need of health care.  Nursing is an interpersonal process because it involves interaction between two or more individuals with a common goal.  The attainment of goal is achieved through the use of a series of steps following a series of pattern.  The nurse and patient work together so both become mature and knowledgeable in the process. Definitions  Person :A developing organism that tries to reduce anxiety caused by needs  Environment : Existing forces outside the organism and in the context of culture  Health : A word symbol that implies forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal and community living.  Nursing: A significant therapeutic interpersonal process. It functions cooperatively with other human process that make health possible for individuals in communities Roles of nurse  Stranger: receives the client in the same way one meets a stranger in other life situations provides an accepting climate that builds trust.  Teacher: who imparts knowledge in reference to a need or interest  Resource Person : one who provides a specific needed information that aids in the understanding of a problem or new situation  Counselors : helps to understand and integrate the meaning of current life circumstances ,provides guidance and encouragement to make changes  Surrogate: helps to clarify domains of dependence interdependence and independence and acts on clients behalf as an advocate.  Leader : helps client assume maximum responsibility for meeting treatment goals in a mutually satisfying way Additional Roles include: 1. Technical expert 2. Consultant 3. Health teacher 4. Tutor 5. Socializing agent 6. Safety agent 7. Manager of environment 8. Mediator 9. Administrator 10. Recorder observer 11. Researcher       

Theory of interpersonal relations  Middle range descriptive classification theory  Influenced by Harry Stack Sullivan's theory of inter personal relations (1953)  Also influenced by Percival Symonds , Abraham Maslow's and Neal Elger Miller Identified four sequential phases in the interpersonal relationship: 1. Orientation 2. Identification 3. Exploitation 4. Resolution Orientation phase  Problem defining phase  Starts when client meets nurse as stranger  Defining problem and deciding type of service needed  Client seeks assistance ,conveys needs ,asks questions, shares preconceptions and expectations of past experiences  Nurse responds, explains roles to client, helps to identify problems and to use available resources and services Factors influencing orientation phase

Identification phase Selection of appropriate professional assistance Patient begins to have a feeling of belonging and a capability of dealing with the problem which decreases the feeling of helplessness and hopelessness Exploitation phase  Use of professional assistance for problem solving alternatives  Advantages of services are used is based on the needs and interests of the patients  Individual feels as an integral part of the helping environment  They may make minor requests or attention getting techniques  The principles of interview techniques must be used in order to explore, understand and adequately deal with the underlying problem  Patient may fluctuates on independence  Nurse must be aware about the various phases of communication  Nurse aids the patient in exploiting all avenues of help and progress is made towards the final step Resolution phase  Termination of professional relationship  The patients needs have already been met by the collaborative effect of patient and nurse  

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Now they need to terminate their therapeutic relationship and dissolve the links between them. Sometimes may be difficult for both as psychological dependence persists Patient drifts away and breaks bond with nurse and healthier emotional balance is demonstrated and both becomes mature individuals

Nursing Process Theory By Ida Jean Orlando Introduction  Theorist, Ida Jean Orlando was born in 1926.  Ida J. Orlando was one of the first nursing theorists to write about the nursing process.  Nursing diploma - New York Medical College  BS in public health nursing - St. John's University, NY,  MA in mental health nursing - Columbia University, New York.  Associate Professor at Yale School of Nursing and Director of the Graduate Program in Mental Health Psychiatric Nursing.  Project investigator of a National Institute of Mental Health grant entitled: Integration of Mental Health Concepts in a Basic Nursing Curriculum.  Her theory was published in her 1961 book, The Dynamic Nurse-Patient Relationship.  Further development of her theory at McLean Hospital in Belmont, MA as Director of a Research Project: Two Systems of Nursing in a Psychiatric Hospital. The results were conceptualized in her 1972 book titled: The Discipline and Teaching of Nursing Processes  A board member of Harvard Community Health Plan, and served as both a national and international consultant. Theoretical Sources  Peplau‘s focus of interpersonal relationships in nursing  Peplau acknowledged the influence of Harry Stack Sullivan on the development of her ideas  Symbolic interactionism – Chicago school  Use of field methodology  John Dewey‘s theory of inquiry Major Dimensions  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 nurse find out the nature of the distress and what help the patient needs. Terms  Distress is the experience of a patient whose need has not been met.  Nursing role is to discover and meet the patient‘s immediate need for help. o Patient‘s behavior may not represent the true need. o The nurse validates his/her understanding of the need with the patient.  Nursing actions directly or indirectly provide for the patient‘s immediate need.

An outcome is a change in the behavior of the patient indicating either a relief from distress or an unmet need. o Observable verbally and nonverbally. CONCEPTS  Function of professional nursing - organizing principle  Presenting behavior - problematic situation  Immediate reaction - internal response  Nursing process discipline – investigation  Improvement - resolution Function of professional nursing - organizing principle  Finding out and meeting the patients immediate needs for help Nursing….is responsive to individuals who suffer or anticipate a sense of helplessness, it is focused on the process of care in an immediate experience, it is concerned with providing direct assistance to individuals in whatever setting they are found for the purpose of avoiding, relieving, diminishing or curing the individuals sense of helplessness  The purpose of nursing is to supply the help a patient requires for his needs to be met.  If the patient has an immediate need for help and the nurse finds out and meets that need ,the function of professional nursing is achieved Presenting behavior - problematic situation  To find out the immediate need for help the nurse must first recognize the situation as problematic  The presenting behavior of the patient, regardless of the form in which it appears, may represent a plea for help  The presenting behavior of the patient, the stimulus, causes an automatic internal response in the nurse, and the nurses behavior causes a response in the patient Immediate reaction - internal response  Person perceives with any one of his five sense organs an object or objects  The perceptions stimulate automatic thought  Each thought stimulates an automatic feeling  Then the person acts  The first three items taken together are defined as the person‘s immediate reaction  Reflects how the nurse experiences her or his participation in the nurse patient situation Domain concept 1. Nursing – is responsive to individuals who suffer or anticipate a sense of helplessness 2. Health – sense of adequacy or well being . Fulfilled needs. Sense of comfort 3. Environment – not defined directly but implicitly in the immediate context for a patient 4. Person – patients who are under medical care and who cannot deal with their needs or who cannot carry out medical treatment alone 

Human-To-Human Relationship Model Joyce Travelbee(1926-1973) ―The nurse is responsible for helping the patient avoid and alleviate the distress of unmet needs.‖ - Travelbee Introduction  Joyce Travelbee (1926-1973) developed the Human-to-Human Relationship Model presented in her bookInterpersonal Aspects of Nursing (1966, 1971).  She dealt with the interpersonal aspects of nursing.

She explains ―human-to-human relationship is the means through which the purpose of nursing if fulfilled‖ Abou the Theorist  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.  1952, Psychiatric Nursing Instructor at Depaul Hospital Affilliate School, New Orleans.  Later in Charity Hospital School of Nursing in Louisiana State University, New York University and University of Mississippi.  Travelbee died at age 47. Development of the Theory  Travelbee based the assumptions of her theory on the concepts of existentialism by Soren Kierkegaard and logotherapy by Viktor Frankl.  Existential theory believes that that humans are constantly faced choices and conflicts and is accountable to the choices we make in life  Logotherapy theory was first proposed by Viktor Frankel, a survivor of Auschwitz, in his book Man's Search for Meaning (1963).  Logotherapy Basic Concepts  Suffering o "An experience that varies in intensity, duration and depth ... a feeling of unease, ranging from mild, transient mental, physical or mental discomfort to extreme pain and extreme tortured ..."  Meaning o Meaning is the reason as oneself attributes  Nursing o is to help man to find meaning in the experience of illness and suffering. o has a responsibility to help individuals and their families to find meaning. o The nurses' spiritual and ethical choices, and perceptions of illness and suffering, is crucial to helping to find meaning.  Hope o Nurse's job is to help the patient to maintain hope and avoid hopelessness. o Hope is a faith that can and will be change that would bring something better with it. o Hope's core lies in a fundamental trust the outside world, and a belief that others will help someone when you need it. o Six important factors charecteristics of hope are:  It is strongly associated with dependence on other people.  It is future oriented.  It is linked to elections from several alternatives or escape routes out of its situation.  The desire to possess any object or condition, to complete a task or have an experience.  Confidence that others will be there for one when you need them.  The hoping person is in possession of courage to be able to acknowledge its shortcomings and fears and go forward towards its goal 

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Communications o "a strict necessity for good nursing care" Using himself therapeutic

" one is able to use itself therapeutic." Self-awareness and self-understanding, understanding of human behavior, the ability to predict one's own and others' behavior are imporatnt in this process.  Targeted intellectual approach o Nurse must have a systematic intellectual approach to the patient's situation. Nursing Metaparadigms 1. Person o Person is defined as a human being. o Both the nurse and the patient are human beings. 2. Health o Health is subjective and objective. o Subjective health is an individually defined state of well being in accord with self-appraisal of physical-emotional-spiritual status. o 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. 3. Environment o Environment is not clearly defined. o o

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Nursing o

"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.‖

Description of the theory  Travelbee believed nursing is accomplished through human-to-human relationships that begin with the original encounter and then progress through stages of emerging identities, developing feelings of empathy, and later feelings of sympathy.  The nurse and patient attain a rapport in the final stage. For meeting the goals of nursing it is a prerequisite to achieving a genuine human-to-human relationships.  This relationship can only be established by an interaction process.  It has five phases. o The inaugural meeting or original encounter o Visibility of personal identities/ emerging identities. o Empathy o Sympathy o Establishing mutual understanding and contact/ rapport  Travelbee's ideas have greatly influenced the hospice movement in the west

Transcultural Nursing By Madeleine Leininger Introduction  Transcultural nursing is both a specialty and a general practice area. It focuses on worldwide cultures and comparative cultural caring, health, and nursing phenomena. ( Murphy, 2006).

Madeleine Leininger is considered as the founder of the theory of transcultural nursing. Her theory has now developed as a discipline in nursing. Her theory first appeared in her theory book Culture Care Diversity and Universality (1991) but originated in the 1950s. The theory was further expanded in her book Transcultural Nursing (1995)  In the third edition of her book Transcultural Nursing (2002) explains the theory-based research and practice applying the concepts of the transcultural theory.  Transcultural nursing theory is also known as Culture Care theory.  Theoretical framework is depicted in her model called the Sunrise Model (1997). ABOUT THE THEORIST  a pioneering nursing theorist and transcultural global nursing consultant.  MSN from Catholic University in Washington DC.  PhD in anthropology from the University of Washington.  She developed the concept of transcultural nursing and the ethnonursing research model.   

DEFINITIONS Transcultural Nursing  Transcultural nursing is a comparative study of cultures to understand similarities (culture universal) and difference (culture-specific) across human groups (Leininger, 1991). Culture  Set of values, beliefs and traditions, that are held by a specific group of people and handed down from generation to generation.  Culture is also beliefs, habits, likes, dislikes, customs and rituals learn from one‘s family.  Culture is the learned, shared and transmitted values, beliefs, norms and life way practices of a particular group that guide thinking, decisions, and actions in patterned ways.  Culture is learned by each generation through both formal and informal life experiences.  Language is primary through means of transmitting culture.  The practices of particular culture often arise because of the group's social and physical environment.  Culture practice and beliefs are adapted over time but they mainly remain constant as long as they satisfy needs. Religion  Is a set of belief in a divine or super human power (or powers) to be obeyed and worshipped as the creator and ruler of the universe. Ethnic  refers to a group of people who share a common and distinctive culture and who are members of a specific group. Ethnicity  a consciousness of belonging to a group. Cultural Identify  the sense of being part of an ethnic group or culture Culture-universals  commonalities of values, norms of behavior, and life patterns that are similar among different cultures. Culture-specifies  values, beliefs, and patterns of behavior that tend to be unique to a designate culture. Material culture  refers to objects (dress, art, religious arti1acts)

Non-material culture  refers to beliefs customs, languages, social institutions. Subculture  composed of people who have a distinct identity but are related to a larger cultural group. Bicultural  a person who crosses two cultures, lifestyles, and sets of values. Diversity  refers to the fact or state of being different. Diversity can occur between cultures and within a cultural group. Acculturation  People of a minority group tend to assume the attitudes, values, beliefs, find practices of the dominant society resulting in a blended cultural pattern. Cultural shock  the state of being disoriented or unable to respond to a different cultural environment because of its sudden strangeness, unfamiliarity, and incompatibility to the stranger's perceptions and expectations at is differentiated from others by symbolic markers (cultures, biology, territory, religion). Ethnic groups  share a common social and cultural heritage that is passed on to successive generations. Ethnic identity  refers to a subjective perspective of the person's heritage and to a sense of belonging to a group that is distinguishable from other groups. Race  the classification of people according to shared biologic characteristics, genetic markers, or features. Not all people of the same race have the same culture. Cultural awareness  It is an in-depth self-examination of one's own background, recognizing biases and prejudices and assumptions about other people. Culturally congruent care  Care that fits the people's valued life patterns and set of meanings -which is generated from the people themselves, rather than based on predetermined criteria. Culturally competent care  is the ability of the practitioner to bridge cultural gaps in caring, work with cultural differences and enable clients and families to achieve meaningful and supportive caring. Nursing Decisions Leininger (1991) identified three nursing decision and action modes to achieve culturally congruent care. 1. Cultural preservation or maintenance. 2. Cultural care accommodation or negotiation. 3. Cultural care repatterning or restructuring. MAJOR CONCEPTS  Illness and wellness are shaped by a various factors including perception and coping skills, as well as the social level of the patient.  Cultural competence is an important component of nursing.  Culture influences all spheres of human life. It defines health, illness, and the search for relief from disease or distress.  Religious and Cultural knowledge is an important ingredient in health care.  The health concepts held by many cultural, groups may result in people choosing not to seek modern medical treatment procedures.

Health care provider need to be flexible in the design of programs, policies, and services to meet the needs and concerns of the culturally diverse population, groups that are likely to be encountered.  Most cases of lay illness have multiple causalities and may require several different approaches to diagnosis, treatment, and cure including folk and Western medical interventions..  The use of traditional or alternate models of health care delivery is widely varied and may come into conflict with Western models of health care practice.  Culture guides behavior into acceptable ways for the people in a specific group as such culture originates and develops within the social structure through inter personal interactions.  For a nurse to successfully provide care for a client of a different cultural or ethnic to background, effective intercultural communication must take place. PURPOSES OF KNOWING THE PATIENTS CULTURE AND RELIGION FOR HEALTH CARE PERSONNEL  To heighten awareness of ways in which their own faith system. Provides resources for encounters with illness, suffering and death.  To foster understanding, respect and appreciation for the individuality and diversity of patients beliefs, values, spirituality and culture regarding illness, its meaning, cause, treatment, and outcome.  To strengthen in their commitment to relationship-centered medicine that emphasizes care of the suffering person rather than attention simply more to the pathophysiology of disease, and recognizes the physician as a dynamic component of that relationship.  To facilitate in recognizing the role of the hospital chaplain and the patient's clergy as partners in the health care team in providing care for the patient.  To encourage in developing and maintaining a program of physical, emotional and spiritual selfcare introduce therapies such as ayurveda and pancha karma 

HEALTH PRACTICES IN DIFFERENT CULTURES Use of Protective Objects  Protective objects can be worn or carried or hung in the home- charms worn on a string or chain around the neck, wrist, or waist to protect the wearer from the evil eye or evil spirits. Use of Substances .  It is believed that some food substances can be ingested to prevent illness.  People from many ethnic backgrounds eat raw garlic or onion In an effort to prevent illness or wear them on the body or hang them in the home. Religious Practices  practices such as from a divine source the burning of candles, rituals of redemption, and In many instances a heritage consistent person may prayer. Traditional Remedies  The use of folk or traditional medicine is seen among people from all walks of life and cultural ethnic back ground.  Many plants are used by specific communities. Healers  Within a given community, specific people are known to have the power to heal.  These approach may originate in culture, ethnicity or religion. Immigration  Every immigrant group has its own cultural attitudes ranging beliefs and practices regarding these areas. Gender Roles  In many cultures, the male is dominant figure and often they take decisions.The female usually is passive.

 In some other cultures females are dominant. Beliefs about mental health  In the traditional belief system, mental illnesses are caused by a lack of harmony of emotions or by evil spirits.  Another belief that problems in this life are most likely related to transgressions committed in a past life. Economic Factors  Factors such as unemployment, underemployment, homelessness, lack of health insurance poverty prevent people from entering the health care system. Time orientation  It is varies for different cultures groups.  People from different cultures have there own time management plans. Personal Space  The nurse should try, to respect the client's personal space as much as possible, especially when performing nursing procedures.  The nurse should also welcome visiting members of the family and extended family.

NURSING PROCESS AND ROLE OF NURSE  The nurse should begin the assessment by attempting to determine the client's cultural heritage and language skills.  The client should be asked if any of his health beliefs relate to the cause of the illness or to the problem.  The nurse should then determine what, if any, home remedies the person is taking to treat the symptoms.  Nurses should evaluate their attitudes toward ethnic nursing care.  The process of self-evaluation can help the nurse become more comfortable when providing care to clients from diverse backgrounds  Nurses have a responsibility to understand the influence of culture, race ðnicity on the development of social emotional relationship child rearing practices &attitude toward health.  A child's self concepts evolves from ideas about his or her social roles  Important sub culture influences on children include ethnicity social class, occupation school peers and mass culture  Socioeconomic influences play major role in ability to seek opportunity for health promotion for wellness  Religious practices greatly influences health promotion belief in families.  Many ethnic and cultural groups in country retain the cultural heritage of their original culture.  How culture influences behaviors, attitudes, and values depends on many factors and thus is not the same for different members of a cultural group.  The nurse should have an understanding of the general characteristics of the major ethnic groups, but should always individualize care rather than generalize about all clients in these groups.  Before assessing the cultural background of a client, nurses should assess how they are influenced by their own culture.  The nursing diagnosis for clients should include potential problems in their interaction with the health care system and problems involving the effects of culture.  The planning and implementation of nursing interventions should be adapted as much as possible to the client's cultural background.  Evaluation should include the nurse's self-evaluation of attitudes and emotions toward providing nursing care to clients from diverse sociocultural backgrounds.  The client‘s educational level and language skills should be considered when planning teaching activities.

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Discussing cultural questions related to care with the client and family during the planning stage helps the nurse understand how cultural variables are related to the client's health beliefs and practices, so that interventions can be individualized for the client. Evaluation continues throughout the nursing process and should include feedback from the client and family. Self-evaluation by the nurse is crucial as he or she increases skills for interaction. Human Becoming Theory Rosemarie Rizzo Parse

Introduction  The Parse theory of human becoming guides nurses In their practice to focus on quality of life as it is described and lived (Karen & Melnechenko, 1995).  The human becoming theory of nursing presents an alternative to both the conventional bio-medical approach and the bio-psycho-socialspiritual (but still normative) approach of most other theories of nursing.(ICPS)  The human becoming theory posits quality of life from each person's own perspective as the goal of nursing practice.(ICPS)  Rosemarie Rizzo Parse first published the theory in 1981 as the "Man-living-health" theory (ICPS)  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." ABOUT THE THEORIST  Educated at Duquesne University, Pittsburgh  MSN and Ph.D. from University of Pittsburgh  Published her theory of nursing, Man-Living-Health in 1981  Name changed to Theory of Human Becoming in 1992  Editor and Founder, Nursing Science Quarterly  Has published eight books and hundreds of articles about Human Becoming Theory  Professor and Niehoff Chair at Loyola University, Chicago THEORY DEVELOPMENT  The human becoming theory was developed as a human science nursing theory in the tradition of Dilthey, Heidegger, Sartre, Merleau-Ponty, and Gadamer and Science of Unitary Human Beings by Martha Rogers .  The assumptions underpinning the theory were synthesized from works by the European philosophers, Heidegger, Sartre, and Merleau-Ponty, along with works by the pioneer American nurse theorist, Martha Rogers.  The theory is structured around three abiding themes: meaning, rhythmicity, and transcendence. ASSUMPTIONS About man  The human is coexisting while coconstituting rhythmical patterns with the universe.  The human is open, freely choosing meaning in situation, bearing responsibility for decisions.  The human is unitary, continuously coconstituting patterns of relating.  The human is transcending multidimensionally with the possibles About Becoming

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Becoming is unitary human-living-health. Becoming is a rhythmically coconstituting human-universe process. Becoming is the human‘s patterns of relating value priorities. Becoming is an intersubjective process of transcending with the possibles. Becoming is unitary human‘s emerging

Three Major Assumptions of Human Becoming  Meaning o Human Becoming is freely choosing personal meaning in situations in the intersubjective process of living value priorities. o Man‘s reality is given meaning through lived experiences o Man and environment cocreate  Rhythmicity o Human Becoming is cocreating rhythmical patterns of relating in mutual process with the universe. o Man and environment cocreate ( imaging, valuing, languaging) in rhythmical patterns  Transcendence o Human Becoming is cotranscending multidimensionally with emerging possibles. o Refers to reaching out and beyond the limits that a person sets o One constantly transforms SUMMARY OF THE THEORY  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 NURSING PARADIGMS AND PARSE'S THEORY  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  Nursing o A human science and art that uses an abstract body of knowledge to serve people SYMBOL OF HUMAN BECOMING THEORY

Black and white = opposite paradox significant to ontology of human becoming and green is hope Center joined =co created mutual human universe process at the ontological level & nurse-person process  Green and black swirls intertwining = human-universe co creation as an ongoing process of becoming STRENGTH AND WEAKNESSES Strengths  Differentiates nursing from other disciplines  Practice - Provides guidelines of care and useful administration  Useful in Education  Provides research methodologies  Provides framework to guide inquiry of other theories (grief, hope, laughter, etc.) Weaknesses  Research considered to be in a ―closed circle‖  Rarely quantifiable results - Difficult to compare to other research studies, no control group, standardized questions, etc.  Does not utilized the nursing process/diagnoses  Negates the idea that each person engages in a unique lived experience  Not accessible to the novice nurse  Not applicable to acute, emergent care  

Life Perspective Rhythm Model Joyce Fitzpatrick Introduction  Life Perspective Rhythm Model is a nursing model developed by Joyce J Fitzpatrick.  She conceptualized her model from Martha Rogers' Theory of Unitary Human beings. About the Theorist  Born in 1944  BSN - Georgetown University  MS in psychiatric-mental health nursing - Ohio State University  PhD in nursing - New York University and an MBA from Case Western Reserve University.  Fellow in the American Academy of Nursing - 1981  Presently, Elizabeth Brooks Ford Professor of Nursing, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH. Major Assumptions  "The process of human development is characterized by rhythms that occur within the context of continuous person-environment interaction."  Nursing activity focuses on enhancing the developmental process toward health.  A central concern of nursing science and the nursing profession is the meaning attributed to life as the basic understanding of human existence.  The identification and labeling of concepts allows for recognition and communication with others, and the rules for combining those concepts permits thoughts to be shared through language. Core Concepts Rhythm Model includes four content concepts and they are:

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person health wellness-illness and metaparadigm. Person Person includes both self and others. Person is seen as an open system , a unified whole characterized by a basic human rhythm. The model recognizes individuals as having unique biological, psychological, emotional, social, cultural, and spiritual attitudes. Health Health is a dynamic state of being that results from the interaction of person and the environment. a human dimension under continuous development, a heightened awareness of the meaningfullness of life. Optimum health is the actualization of both innate and obtained human potential gathered from rewarding relationships with others, goal directed behavior, and expert personal care. Wellness-llness Professional nursing is rooted in the promotion of wellness practices. Nursing "A developing discipline whose central concern is the meaning attached to life (health) Primary purpose of nursing is the promotion and maintenance of an optimal level of wellness. Metaparadigm It refers to the transitions through basic metaparadigm concepts of person, environment, health and nursing. Margaret Newman

Introduction -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 1971 to 1976- She completed her graduate studies at New York University. She also worked and taught alongside nursing theorist Martha Rogers. Rehabilitation Nursing stemmed her interest in health, movement & time.

1977- Professor in charge of graduate study in nursing at Pennsylvania State. 1984- Nurse theorist at the University of Minnesota. 1996- Retired from teaching. HEALTH AS AN EXPANDING CONSCIOUSNESS Newman's Health as Expanding Consciousness was influenced by Martha Rogers. Newman (2003) writes: 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 environement are basic to the view that consciousness is a manifestation of an evolving pattern of person-environment interaction...Consciouness includes not only the cognitive and affective awareness normally associated with consciousness, but also the interconnectedness of the entire libing system, which includes physiochemical maintenance and growth processes as well as teh 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”. 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. 1. 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. 2. 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. 3. Environment -Environment is not explicitly defined but is described as being the larger whole, which is beyond the consciousness of the individual. 4. 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

Project In Theoretical Foundations Of Nursing Submitted by: Irish Jane B. Cubillo BSN 1-1 Submitted to: Mr. Reymund Kristopher Samonte, RN.