“What a comfort it was to see her
pass. She would speak to one, and
nod and smile to as many more; but
she could not do it to all you know.
We lay there by the hundreds; but
we could kiss her shadow as it fell
and lay our heads on the pillow
British nurse, hospital reformer, and humanitarian.
Born in Florence, Italy, on May 12, 1820,
Nightingale was raised mostly in Derbyshire, England, and
received a thorough classical education from her father.
In 1849 she went abroad to study the European hospital
system, and in 1850 she began training in nursing at the
Institute of Saint Vincent de Paul in Alexandria, Egypt.
She subsequently studied at the Institute for Protestant
Deaconesses at Kaiserswerth, Germany.
In 1853, she became superintendent of the Hospital for
Invalid Gentlewomen in London.
Florence Nightingale (1820 - 1910)
“It may seem a strange principle to enunciate as
the very first requirement in a Hospital that it
should do the sick no harm.”
Florence Nightingale undertook nurse’s training at the
age of 31.
The outbreak of Crimean war and a request by the
British to organize nursing care for a military hospital in
Turkey gave Nightingale an opportunity for achievement.
As she successfully overcame enormous difficulties,
Nightingale challenged prejudices against women and
elevated the status of all nurses.
After the war, she returned to England, where she
established a training school for nurses and wrote books
about healthcare and nursing education.
Florence Nightingale (1820 - 1910)
“No man, not even a doctor, ever gives
any other definition of what a nurse
should be than this—quot;devoted and
This definition would do just as well for a
porter. It might even do for a horse. It
would not do for a policeman.
FLORENCE NIGHTINGALE’S CONTRIBUTIONS
Identifying the personal needs of the patient and the role of
the nurse in meeting those needs
Establishing standards for hospital management
Establishing a respected occupation for women
Establishing nursing education
Recognizing the two components of nursing: health and illness
Believing that nursing is separate and distinct from medicine
Recognizing that nutrition is important to health
Instituting occupational and recreational therapy for sick
Stressing the need for continuing education for nurses
Maintaining accurate records, recognized as the beginnings of
Historical Influences on Nursing Theory
of FLORENCE NIGHTINGALE
Florence Nightingale developed and published a philosophy and a theory of
health and nursing that has served as a solid foundation for the nursing
Her contributions to nursing theory include identifying the role of the
nurse in meeting the patient’s personal needs, recognizing the importance
of environmental influences on the care of sick people, and elevating the
standards and acceptance of nursing by developing sound principles of
Nightingale develop her theories of nursing in the late 1800’s.
Her foundational work is what nursing theorists expanded upon, starting in
the 1950’s until the present time.
Central theme: MEETING THE PERSONAL NEEDS OF THE
PATIENT WITHIN THE ENVIRONMENT
Application to clinical practice: Concern for the environment of the patient,
including cleanliness, ventilation, temperature, light, diet, and noise.
NIGHTINGALE’S THEORY OF NURSING
PREVENTION OF DISEASES
NIGHTINGALES THEORY OF NURSING AS
RELATED TO SCIENTIFIC THEORIES
The Evolution of Nursing Research
While caring for victims of the Crimean War, Florence
Nightingale kept careful and objective records.
These records provided baseline data that she later used
to determine which nursing interventions were most
effective in treating her patients.
Since that time, nursing research has taken many different
pathways, and all nurses are involved with research either
as consumers (nurses who use and evaluate research
findings) or as actual investigators who design and
implement research studies.
Born in Baltimore,
One of America’s foremost
Father was a construction
Mother was a homemaker.
Youngest of two
Studied at Providence Hospital school of Nursing in
Washington D.C. in 1930’s
Got her B.S.N.E. in 1939 and her M.S.N.E in 1946 both
from the Catholic University of America Got her M.S.N.E.
at Catholic University of America in 1946
1958-1960 upgraded practical nursing training at
Department of Health, Education and Welfare
Was editor to several texts including Concepts
Formalization in Nursing: Process and Production, revised
in 1980, 1985, 1991, 1995, 2001
Orem’s Theory of Self Care
Each person has a need for self care in order to maintain
optimal health and wellness.
Each person possesses the ability and responsibility to
care for themselves and dependants.
Theory is separated into three conceptual theories which
include: self care, self care deficit and nursing system.
Theory of Self Care
Self care is the ability to perform activities and meet
personal needs with the goal of maintaining health and
wellness of mind, body and spirit.
Self care is a learned behaviour influenced by the
metaparadigm of person, environment, health and nursing.
Three components: universal self care needs,
developmental self care needs, and health deviation.
Universal Self Care
This includes activities which are essential to health and
Eight elements identified these include: air, water, food,
elimination, activity and rest, solitude and social
interactions, prevention of harm, and promotion of
Developmental Self Care Need
These include the interventions and teachings designed to
return a person to or sustain a level of optimal health and
Examples can include such things as toilet training a child
or learning healthy eating.
Health Deviation Self Care
This encompasses the variations in self care which may
occur as a result of disability, illness, or injury.
In other words the person with a variation is meeting self
care and maintaining health and wellness in a more
Theory of Self Care Deficit
Every mature person has the ability to meet self care
needs, but when a person experiences the inability to do
so due to limitations, thus exists a self care deficit.
A person benefits from nursing intervention when a
health situation inhibits their ability to perform self care
or creates a situation where their abilities are not
sufficient to maintain own health and wellness.
Nursing action focuses on identification of
limitation/deficit and implementing appropriate
interventions to meet the needs of person.
Theory of Nursing Systems
The ability of the nurse to aid the person in meeting
current and potential self care demands.
Focused on person
Three support modalities identified in theory including:
total compensatory, partial compensatory, and
The client’s ability for self care involvement will
determine under which support modality they would be
Wholly or Total Compensatory
Encompasses total nurse
care-client unable to do
Charlene receives constant
care from her nurse & family,
who do everything from
feeding her to taking her to
Involves both the nurse
and client sharing in the
self care requirements.
Support elicit the help of
the nurse solely as a
consultant, teacher or
resource person. Client is
responsible for their own
The nurse’s role in helping the client to achieve or
maintain a level of optimal health and wellness is to act as
an advocate, redirector, support person and teacher, and
to provide an environment conducive to therapeutic
Application of Theory To Nursing Process
Orem’s theory of self-care is applied to many
undergraduate nursing curricula.
The nursing care plan is one example of how her theory
of self-care can be applied to nursing process
Nursing Care Plan
The nursing care plan includes; assessment data pertaining
to Gordon’s Functional Assessment, a NANDA nursing
diagnosis, the identification of client expected outcomes,
the nursing interventions and evaluation.
Lydia E. Hall
Lydia E. Hall received her
basic nursing education at
York Hospital of Nursing
in York, Pennsylvania.
Both her B.S. and M.A. are
from Teacher’s College,
Columbia University, New
Lydia E. Hall
Lydia Hall was the first director of the Loeb Center for
Nursing and Rehabilitation. Her experience in nursing
spans the clinical, educational, and supervisory
components. Her publications include several articles on
the definition of nursing and quality of care.
Lydia Hall has put forth what she considers a basic
philosophy of nursing, upon which the nurse may base
patient care. This philosophy is used as a working reality
at the Loeb Center for Nursing.
Loeb Center for Nursing and Rehabilitation
Lydia Hall originated the philosophy of care of Loeb
Center at Montefiore Hospital, Bronx, New York. Loeb
Center opened in January 1963 to provide professional
nursing care to persons who are past the acute stage of
The center’s functioning concept is that the need for
professional nursing care increases as the need for
medical care decreases.
Loeb Center has a capacity of eighty beds and is attached
to Montefiore Hospital. The rooms are arranged with
patient comfort and maneuverability as first priority.
The patient also have assess to a large communal dining
The primary care givers are professional nurses with non
patient care activities being supplied by messenger-
attendants and secretaries.
To create a nondirective selling, there are very few rules,
no routine, no schedules, and no dictated mealtimes or
specified visiting hours. The nurse at Loeb strive to help
the patient determine and clarify goals and, with patient
work out ways to achieve the goal at the individual pace,
consistent with the medical treatment plan and
congruent with the patient’s sense of self.
Lydia Hall’s Theory of Nursing
Lydia Hall presents her theory of nursing visually by
drawing three interlocking circles, each circle presenting a
particular aspect of nursing. The circles represent care,
core, and cure.
The Care Circle
The care circle represents the nurturing component of
nursing and is exclusive to nursing. Involved in nurturing is the
utilization of the factors that make up the concept of
mothering (care and comfort of the person).
When functioning in the care circle, the nurse applies
knowledge of the natural and biological sciences to provide a
strong theoretical base for nursing implementations. In
interactions with the patient the nurse’s role must be clearly
defined. A strong theory base allows the nurse to incorporate
closeness and nurturance while maintaining a professional
status rather than a mothering status. The patient views the
nurse as a potential comforter, one who provides care and
comfort through the laying on of hands.
The care circle of patient care
aspect of nursing
The Core Circle
The core circle of patient care involves the therapeutic
use of self and is shared with other members of the
The nurse uses a freely offered closeness to help the
patient bring into awareness the verbal and nonverbal
messages being sent to others. Motivations are
discovered through the process of bringing the awareness
the feelings being experienced. The patient is now able to
make conscious decisions based on understood and
accepted feelings and motivations. The motivation and
energy necessary for healing exist within the patient
rather than in the health care team.
The core circle of patient care
Therapeutic use of self
aspect of nursing
The Cure Circle
The cure circle of patient care is shared with other
members of the health team.
The nurse’s role during the entire aspect is different from
the care circle since many of the nurse’s actions take on a
negative quality of avoidance of pain rather than the
patient views the nurse as a potential cause of pain,
involved in such actions such as administering injections,
versus the potential comforter who provided care and
The core circle of patient care
Pathological and therapeutic
Seeing the patient and
through the medical care
aspect of nursing
Interaction of the Three Aspects of Nursing
The three aspects of nursing as Hall identifies them do
not function independently, but are interrelated, and they
interact and change size depending on the patient’s total
course of progress.
In philosophy of Loeb Center the professional nurse
functions most therapeutically when patients have
entered the second stage of their hospital stay (i.e., where
they are recuperating and are past the first acute stage).
Hall’s three aspects of nursing
Therapeutic use of self
Seeing the patient
and family through
Intimate bodily care
Hall’s Theory and the Nursing Process
Influences the nurse’s total approach to the five phases of
Five Phases of Nursing Process
Collection of data about the health status of the individual.
According to Hall, the process of data collection is directed for
the benefit of the nurse.
Pertains to guiding the patient through the cure aspect of
Five Phases of Nursing Process
Statement of the patient’s need or problem area.
Five Phases of Nursing Process
Involves setting priorities and mutually establishing patient-
“Patient is the best person to set goals and arrange priorities.”
Five Phases of Nursing Process
Involves the actual institution of the plan of care.
Actual giving of nursing care
Five Phases of Nursing Process
Process of assessing the patient’s progress toward the health
Process is directed toward deciding whether or not the patient
is successful in reaching the established goals.
Application and Limitations of the Theory
Stage of Illness
The description of how to help a person toward self-
The family is mentioned only in the cure circle
The theory relates only to those who are ill.
Margaret Jean Harman Watson was born in Southern
West Virginia and grew up during 1940s and 1950s in the
small town of Welch , Western Virginia in the Appalachian
Mountains. As the youngest of eight children, she was
surrounded by an extended family-community
Watson attended high school in West Virginia and then
attended the Lewis Gale School of Nursing in Roanoke,
Virginia. After graduation in 1961, she married her
husband, Douglas, and move to west to his native state in
Colorado. But Douglas died in 1998.
After moving to Colorado, Watson continued her nursing
education and graduate studies at the University of
She earned a B.S. in nursing in 1964 at the Boulder
campus; an M.S. in psychiatric mental health in 1966 at the
health science campus; an Ph.D. In educational
psychology ad counseling in 1973 at the Graduate School,
After Watson completed her Ph.D. degree she joined the
School of Nursing faculty of the University of Colorado
Health Science Center in Denver, where she had served
in both faculty and administrative position.
The Center for Human Caring at the University of
Colorado was the first interdisciplinary center with an
overall commitment to develop in use knowledge of
human caring and healing as the moral and scientific basis
of clinical practice in nursing scholarship as the
efforts to transform the current health care system.
During its existence, the center developed and sponsored
numerous clinical , educational and community
scholarship activities and project for human caring.
During her career, Watson has been active in community
programs, having served as a founder and member of the
Board of Boulder County Hospice and she has initiated
numerous collaborations with area health care facilities.
As the recipient of several research and advance
education federal grants and awards.
Watson featured in several national videos on nursing theory. These
include “Circles of Knowledge” and “Conversation on Caring with Jean
Watson and Janet Quinn”.
Watson's publications reflect the evolution of her theory of caring.
Her writings have been geared toward educating nursing students and
providing them with ontological and epistemological basis for their praxis
and research direction.
Much of her current wok begun with the 1979 publication, Nursing:
The Philosophy of Science and Caring which she says begun as class
notes for a course she was developing. She says the book “emerged from
her quest to bring new meaning and dignity to the world of nursing and
patient care- care that seemed too limited in its scope at that time, largely
defined by medicines paradigm and traditional biomedical science models”.
Nursing: Human Science and Human Care- A Theory of
Nursing, published in 1985 and re-released in 1998, was
her second major work.
The purpose of this book was to address some of the
conceptual and philosophical problems that still existed in
She hoped that others would join as she sought to
“elucidate the human care process in nursing, preserved
the concept of person in our science, and better our
contribution to society. This book has been translated to
Chinese, German, Japanese, Korean and Swedish.
In Watson's original philosophy and science of caring, she
referred to caring as the essence of nursing practice.
Caring is more ideal rather than a task oriented behavior
and include such characteristics as the actual caring
occasion and the transpersonal caring moment,
phenomena that occur when an authentic caring
relationship exist between the nurse and the patient.
Watson bases her theory for nursing practice on the
following 10 Carative factor.
Each has a dynamic phenomenological component that is
relative to the individuals involved in the relationship as
encompassed by nursing.
The first three interdependent factors serve as the
“philosophical foundation for the science of caring.”
I. FORMATION OF A HUMANISTIC – ALTRUISTIC
SYSTEM OF VALUES
Humanistic and altruistic values are learned early in life,
but can be greatly influenced by nurse – educators.
2. INSTALLATION OF FAITH – HOPE
This factors, incorporating humanistic and altruistic values,
facilitates the promotion of holistic nursing care and
positive health within the patient population.
3. CULTIVATIONOF SENSITIVE TO SELF AND TO OHERS
The recognition of feelings leads to self- actualization
though self – acceptance for both the nurse and the
4. DEVELOPMENT OF A HELPING – TRUST
The development of a helping - trust relationship
between the nurse and patient is crucial for transpersonal
5. PROMOTION AND ACCEPTANCE THE EXPRESSION
OF POSITION AND NEGATIVE FEELINGS.
The sharing of feelings is a risk – taking experience for
both nurse and patient.
6. SYSTEMATIC USE OF THE SCIENTIFIC PROBLEM -
SOLVING METHOD FOR DECISION MAKING
Use of the nursing process brings a scientific problem –
solving to nursing care,
7. PROMOTION OF INTERPERSONAL TEACHING -
This factor is an important concept for nursing in that it
separates caring from curing.
8. PROVISION FOR SUPPORTIVE, PROTECTIVE, AND
CORRECTIVE MENTSL, PHYSICAL, SOCIOCULTURAL,
AND SPIRITUAL ENVIRONMENT
Nurses must recognize the influence that
internal amd external environment have on the health and
illness of individuals.
9. ASSISTANCE WITH GRATIFICATION OF HUMAN
The nurse recognizes the biophysical, psychophysical,
psychosocial, and intrapersonal needs of self and patient.
10. ALLOWANCE FOR EXISTENTIAL
Phenomology describes data of immediate situation that
help people understand the phenomena in question.
Nursing the Philosophy and Science of
Caring, Watson 28:8-9
States the major assumptions of caring in nursing:
Nursing Human Science and Human
Care, Watson 26-33
States that both Nursing education and Health care delivery
system must be based on human values and concern for the
welfare of others.
Symbolized by a light bulb in the
center. Light bulbs give light and
are productive. Light bulbs also
symbolize ideas… theories are
The hearts show dominant (dark
pink) and recessive (light pink)
Different pathways are coming
from the center of the light
bulb representing the
multiple stimulus response
If one pathway can't get the job
done, another pathway will
The Neuman Systems Model was originally
developed in 1970 at the University of California,
Los Angeles, by Betty Neuman, Ph.D., RN. The
model was developed by Dr. Neuman as a way to
teach an introductory nursing course to nursing
students. The goal of the model was to provide a
wholistic overview of the physiological,
psychological, sociocultural, and developmental
aspects of human beings. After a two-year
evaluation of the model, it was published in
Nursing Research (Neuman & Young, 1972).
Neuman has since published three editions of the
Neuman Systems Model. The Neuman Systems
Model Trustees Group was established in 1988.
This group was established for the perpetuation,
presevation, and protection of the integrity of the
model and any future changes in model must
have the consent of the trustees (George, 1996).
Born near Lowell, Ohio.
Received RN Diploma from Peoples Hospital School of Nursing, Akron, Ohio
Moved to California and gained experience as a hospital, staff, and head nurse;
school nurse and industrial nurse; and as a clinical instructor in medical-
surgical, critical care and communicable disease nursing.
Attended University of California at Los Angeles (UCLA) with double major
in psychology and public health.
Received BS in nursing from UCLA.
Received Masters degree in Mental Health, Public Health Consultation from UCLA.
Recognized as pioneer in the field of nursing involvement in community mental
Began developing her model while lecturing in community mental health at UCLA.
Her model was first published as a 'Model for teaching total person approach to
patient problems' in Nursing Research.
Received doctorate in Clinical Psychology from Pacific Western University.
Received second honorary doctorate - this one from Grand Valley State University,
Neuman’s Model was influenced by a variety of
Pierre Telhard deChardin was a catholic priest and
scientist who is credited with first proposing the idea of
spiritual evolution. He believed that spiritually humans are
evolving toward an ultimate perfection that he called the
Gestalt Theory is a theory of german origin that centers
around the concept of the gestalt or the whole. It
emphasizes the primacy of the phenomenal (the
perceived), asserting that the human world of experience
is the only immediately given reality.
General Adaptation Syndrome is quite pervasive and even
taught to high schoolers in their health class. It postulates
that there is a nonspecific response to stress involving
three stages: 1) alarm, 2) resistance, 3) exhaustion.
General Systems Theory grew out of the field of
Thermodynamics, a branch of physics, chemistry and
engineering. Thermodynamics is the study of the flow of
energy from one system to another. General systems
theory posits that the world is made up of systems that
are interconnected and are influenced by each other;
systems can also be concentric with smaller systems
forming a larger system.
Neuman's model is just that-a model, not a full theory.
It is a conceptual framework, a visual representation, for
thinking about humans and nurses and their interactions.
The goal is to achieve optimal system stability and
Prevention is the main nursing intervention to achieve
Physiological - refers of the physicochemical structure and
function of the body.
Psychological - refers to mental processes and emotions.
Sociocultural - refers to relationships; and social/cultural
expectations and activities.
Spiritual - refers to the influence of spiritual beliefs.
Developmental - refers to those processes related to
development over the lifespan.
The basic structure, or central core, is made up of the
basic survival factors that are common to the species
(Neuman, 1995, in George, 1996).
These factors include: system variables, genetic features,
and the strengths and weaknesses of the system parts.
The person's system is an open system and therefore is
dynamic and constantly changing and evolving. Stability, or
homeostasis, occurs when the amount of energy that is
available exceeds that being used by the system.
A homeostatic body system is constantly in a dynamic
process of input, output, feedback, and compensation,
which leads to a state of balance.
Flexible Lines of Defense
The flexible line of defense is the outer barrier or
cushion to the normal line of defense, the line of
resistance, and the core structure.
The flexible line of defense is dynamic and can be
changed/altered in a relatively short period of time.
Normal Line of Defense
The normal line of defense represents system stability
over time. It is considered to be the usual level of stability
in the system.
The normal line of defense can change over time in
response to coping or responding to the environment.
Lines of Resistance
The lines of resistance protect the basic structure and
become activated when environmental stressors invade
the normal line of defense.
Reconstitution is the increase in energy that occurs in
relation to the degree of reaction to the stressor.
Reconstitution begins at any point following initiation of
treatment for invasion of stressors.
Stressors are capable of having either a positive or
negative effect on the client system. A stressor is any
environmental force which can potentially affect the
stability of the system: they may be:
Intrapersonal - occur within person.
Interpersonal - occur between individuals.
Extrapersonal - occur outside the individual.
Prevention focuses on keeping stressors and the stress
response from having a detrimental effect on the body.
Primary prevention occurs before the system reacts to a
On the one hand, it strengthens the person (primarily the
flexible line of defense) to enable him to better deal with
stressors, and on the other hand manipulates the
environment to reduce or weaken stressors.
Primary prevention includes health promotion and
maintenance of wellness.
Secondary prevention occurs after the system reacts to a
stressor and is provided in terms of existing systems.
Secondary prevention focuses on preventing damage to the
central core by strengthening the internal lines of resistance
and/or removing the stressor.
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.
Implications for Practice and Research
The main use of the Neuman Model in practice and in
research is that its concentric layers allow for a simple
classification of how severe a problem is.
If a stress response is perceived by the patient or assessed by
the nurse, then there has been an invasion of the normal line
of defense and a major contraction of the flexible line of
Thus, the level of insult can be quantified allowing for
The drawback of this is that there is no way to know whether
our operationalization of the person variables is a good
representation of the underlying theoretical structures.
The person is a layered multidimensional being.
The person may in fact be an individual, a family, a group,
or a community in Neuman's model.
The person, with a core of basic structures, is seen as
being in constant, dynamic interaction with the
The person is seen as being in a state of constant change
and-as an open system-in reciprocal interaction with the
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
extrapersonal stressors which can affect the person's normal
line of defense and so can affect the stability of the system.
The internal environment exists within the client system.
The external environment exists outside the client system.
Neuman also identified a created environment which is an
environment that is created and developed unconsicously by the
client and is symbolic of system wholeness.
Neuman sees health as being equated with wellness.
She defines health/wellness as quot;the condition in which all parts and
subparts (variables) are in harmony with the whole of the client
As the person is in a constant interaction with the environment, the
state of wellness (and by implication any other state) is in dynamic
equilibrium, rather than in any kind of steady state.
Neuman proposes a wellness-illness continuum, with the person's
position on that continuum being influenced by their interaction
with the variables and the stressors they encounter.
The client system moves toward illness and death when more
energy is needed than is available.
The client system moves toward wellness when more energy is
available than is needed.
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 actions 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
Neuman envisions a 3-stage nursing process:
Nursing Diagnosis - based of necessity in a thorough
assessment, and with consideration given to five variables
in three stressor areas.
Nursing Goals - these must be negotiated with the
patient, and take account of patient's and nurse's
perceptions of variance from wellness
Nursing Outcomes - considered in relation to five
variables, and achieved through primary, secondary and
King’s Conceptual Framework and Theory of Goal
The concept of self body image
growth and development
Imogene King developed a conceptual model for nursing
in the mid 1960’s with the idea that human beings are
open systems interacting with the environment. King’s
worked is considered a conceptual model because it
comprises both a conceptual framework and a theory.
King’s Conceptual Framework and Theory of Goal
Attainment. Finally, King’s work is compared to rural
nursing theory in an effort to identify common themes.
The central focus of King’s framework is man as a
dynamic human being whose perceptions of objects,
persons, and events influence his behavior, social
interaction, and health. King’s conceptual framework
includes three interacting systems with each system
having as own distinct group of concepts and
Three Interacting Systems
The Personal System
It refers to the individual.
An individual’s perceptions of self, of body image, of time
and space influence the way he or she responds to
persons, objects, and events in his or her life. As
individuals grow and develop through the life span,
experiences with changes in structure and function of
their bodies over time influence their perceptions of self.
Involve individuals interacting with one another.
Communication between the nurse and the client can be
classified as verbal or nonverbal.
Are group of people within a community or society that
share common goals, interests, and values.
Examples of social systems include the family, the school,
and the church.
The concepts that king identified as relating to social
system are organization, authority, power, status and
The relationship between the three systems led to King’s
Theory of Goal Attainment.
The conceptual framework of the interpersonal system
had the greatest influence on the development of theory.
Ten Major Concepts from the Personal and
Human interactions Growth
After careful analysis of King’s Conceptual Framework
and Theory of Goal Attainment, it is evident that this
model can be implemented in an emergency room
A busy emergency department often creates an
intimidating environment for patients and they may feel
threatened, or feel that they have no control over
decisions that affect their care.
The primary complaint of emergency room patients is the
length of waiting time.
One intervention that has proven successful in this
situation has been the installation of televisions and
telephones in patients rooms in the emergency
department. These devices seem to help the patients pass
the time and reduce some of the frustrations associated
with long waiting times.
Rural residents are a unique group of individuals
Rural residents are more likely to comply with health
care regimens that do not interfere with their daily
routines, or create inconveniences for them.
For these reasons, nurses dealing with rural populations
must be aware of the differences that exist between rural
and urban populations.
After careful consideration of the concepts associated
with King’s three interacting systems, the concept of
perception, growth and development, time,
communication and interaction are helpful to the nurse
when attempting to explain and predict the health
practices of rural clients.
Rural dwellers have a different perception of health than
that of urban dwellers.
It is important for the nurse to be non-judgmental in
these situations because this is simply a way of life for
rural residents, a way of life that they have come to
accept as the norm.
Growth and development is another concept that is
applicable to rural nursing.
King’s Concept of time can also be attributed to rural
The last two concepts from King’s framework that are
useful when working with rural clients are
communication and interaction.
Using King’s Theory of Goal Attainment in the rural
community presents some challenges in the nurse.
Mutual goal setting would only be successful if the clients
trusted that the goals would benefit them.
Because rural residents are time-oriented individuals, the
goals must be attainable without interfering with their
daily lives, or the goals will likely go unmet.
There are elements of King’s theory that are applicable to
both the emergency and to nursing practice in rural
settings. Concepts from King’s work are useful regardless
of the context in which they are used. Human beings are
dynamic individuals and they are continuously interacting
with their respective environments. King
conceptualizations in the early 1960’s continue to guide
the practice of nursing.
Science of Unitary Human Beings
Martha E. Rogers was born May 12, 1914, in Dallas, Texas, the
eldest of four children. She began her collegiate education at the
University of Tennessee in Knoxville, where she studied science
from 1931 to 1933. She received her nursing diploma from
Knoxville General Hospital School of Nursing in 1936. In 1937
she received a B.S. from George Peabody College in Nashville,
Tennessee. Her other degrees include an M.A. in public health
nursing supervision from Teacher's College, Columbia University,
New York in 1945 and an M.P.H. in 1952 and a Sc.D. in 1954,
both from Johns Hopkins University in Baltimore.
For 21 years, from 1954 to 1975, she was Professor and Head of
the Division of Nursing at New York University. In 1979 she
became Professor Emeritus and was an active member of the
nursing profession until her death on March 13, 1994.
Rogers' early nursing practice was in rural public health
nursing in Michigan and in visiting nurse supervision,
stimulating, idealistic, visionary, prophetic, philosophic,
academic, outspoken, humorous, blunt, and ethical. She has
been widely recognized and honored for her contributions and
leadership in nursing. Her nursing past colleagues consider her
one of the most original thinkers in363.
education, and practice in Connecticut. She then established
the Visiting Nurse Service of Phoenix, Arizona. Her
publications include three books and over 200 articles; she
continued to write and publish extensively. She lectured in 46
states, the District of Columbia, Brazil, Puerto Rico, Mexico,
Holland, China, Newfoundland, Columbia, and other countries.
Rogers received honorary doctorates in Science, Letters, and
Humane Letters from such renowned institutions as Duquesne
University, University of San Diego, Iona College, Fairfield
University, Mercy College, and Washburn University of Topeka.
In addition, she received numerous awards and citations for
her contributions and leadership in nursing. She received
citations for quot;Inspiring Leadership in the Field of Intergroup
Relationsquot; by Chi Eta Phi Sorority, quot;In Recognition of Your
Outstanding Contribution to Nursingquot; by New York University.
quot;For Distinguished Service to Nursingquot; by Teachers College,
and many others. She was honored by the many awards, funds,
and scholarships that have been established in her name.
A verbal portrait of Rogers might include such descriptive
The Science of Unitary Human Beings
Washburn University utilizes Dr. Martha Rogers' Science
of Unitary Human Beings as a conceptual framework in
its course of study. Conceptual models give students a
quot;hookquot; to which they can hang theories and evolve
abstraction (a lens through which they view the
profession of nursing).
In order to understand the Rogerian Dr. Rogers
presented her evolutionary model in 1970 with the
publication of An Introduction to the Theoretical Basis of
Nursing. This view presented a drastic but attractive way
of viewing human interaction and the nursing process.
Her concepts are derived from the view of the universe
as a collection of open systems of which we interact
independently and continuously without causality.
framework a set of definitions must be defined as a
building block for the larger abstract system.
Energy is irreducible, indivisible and has a definable
pattern. Energy is the continuous interaction between a
person with the environment. Each individual has their
own degree, identity and intensity of interaction with the
environment. The combined energy between individual
and environment is inseparable and integrated completely.
Both human and environmental systems are open. This
also implies that the systems exchange energy
continuously and remain open--always. Change affects
both systems mutually. People today are different then
they had been the day before and can never return to the
person they were. Humans do not adapt to their
environment but are integral with the environment
Human beings have unique properties that enable them
to be irreducible and indivisible. Though we live in a
three-dimensional world we are aware of other
dimensions that affect our lives. A three-dimensional
world fails to take into account the concept of time.
Rogers coined the term pandimensionality to describe a
reality without any spatial or time restraints. This better
describes a reality without linear, spatial or temporal
Human energy can be differentiated from environmental
energy by its pattern. Patterns cannot be seen but
manifestations of the pattern can be observable. Human
patterns can be described as a single weave that is dynamic,
unpredictable, creative and continuous. An analogy would be a
kaleidoscope. As the kaleidoscope is rotated (simulating time)
each piece of colored glass falls in an unpredictable manner,
with the collection of pieces creating a unique form with
equally unique color distribution. There is some order in the
turning of the kaleidoscope but the changes of pattern are
never predictable or the same. Human patterns are also
unpredictable within a degree of order. Each human perceives
and interacts with their environment with a different degree of
Principles of Homeodynamics
The principles of homeodynamics postulate a way of
perceiving unitary man. Change in the life process in man are
predicted to be inseparable from environmental changes and
to reflect the mutual and simultaneous interaction between
the two at any point space-time. Changes are irreversible,
nonrepeatable. They are rhythmical in nature and evidence
growing complexity of pattern and organization. Change
proceeds by the continuous repatterning of both man and
environment by resonating waves. Evidence of conditions
under which these principles hold arises out of examination of
the real world. Investigations of a range of phenomena are
necessary to provide the substantive data which can further
the translation of these principles into practical application.
. Scientific research in nursing is beginning to underwrite
the moving boundaries of nursing advances. Maintenance
and promotion of health, disease prevention, diagnosis,
intervention, and rehabilitation-nursing's goals-take on
added dimensions as theoretical knowledge provides new
direction to practice.
Principles of Homeodynamics derive from the abstract
system and postulate the nature of change. The principles
are listed as follows:
Principle of Resonancy
The continuous change from lower to higher frequency
wave patterns in human and environmental fields.
Principle of Helicy
The continuous innovative, unpredictable, increasing
diversity of human and environmental field patterns.
Principle of Integrality
The continuous mutual human field and environmental
Although Abdellah’s writings are not specific as to a
theoretical statement can be derived by using her three
major concepts of health, nursing problems, and problem
solving. Using the definition that a theory states the
relationship between concepts, Abdellah’s theory would
state that nursing is the use of the problem solving
approach with key nursing problems related to the health
needs of people. Such a theoretical statement maintains
problem solving as the vehicle for the nursing problems
as the client is moved toward health-the outcome.
The 21 Nursing Problems
To maintain good hygiene and physical comport
To promote optimal activity exercise, rest, and sleep.
To promote safely 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 deformities.
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-pathological,
physiological, and compensatory.
To facilitate the maintenance of regulatory mechanism and function.
To facilitate the maintenance of sensory function.
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
To promote the development of productive interpersonal
To facilitate progress towards achievement of personal spiritual
To create and/or maintain therapeutic environment.
To facilitate awareness of self as an individual with varying physical,
emotional, and developmental 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
To understand the role of social problems as influencing factors in
the cause of illness.
An early nursing theorist who contributed a lot to the
Attempted to define nursing in its unique focus.
The unique function of a nurse is to assist the individual,
sick or well, in the performance of those activities
contributing to health or its recovery (or to a peaceful
death) that he would perform unaided if he had the
necessary strength, will, or knowledge. And to this in
such a way as to help him gain independence as rapidly as
Wrote one of the first nursing textbooks, “Textbook of
the Principles and Practice of Nursing”.
The 14 components of basic human needs:
Eat and drink adequately.
Eliminate body wastes.
Move and maintain desirable postures./
Sleep and rest.
Select suitable clothing, dress, and undress.
Maintain body temperature within normal range by adjusting
clothing and modifying the environment.
Keep the body clean and well-groomed and protect the
Avoid dangers in the environment and void injuring others.
Communicate with others in expressing emotions, needs, fears,
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 of the available health
nursing is caring for someone in fashion
nursing is a helping service that is rendered with compassion
skills and understanding to those in need of care, counsel and
confidence in area of health.
the practice of nursing comprises a wide variety of
services towards attainment of 3 components.
Identification of patient need for health.
Ministration of the health needed.
Validation that the help provided was indeed helpful to
Characteristics of professional person that are essential
for the professional nurse
Clarity of purpose.
Mastery of skills and knowledge.
Wiedenbach prescriptive theory
a situation-producing theory
Is the one that conceptualize both the desired situation
and the prescription used to bring about the desired
Central factors- which the practitioner recognizes
essential to the particular discipline.
Prescription- for the fulfillment of the central purpose.
Realities in the immediate situation- that influence the
fulfillment of the central purpose.
Wiedenbach second concept of Respect for individual she
Each human being is with unique potential to develop
himself, the resources that enable him to maintain and
The human being basically strives toward self-direction
and relative independence and desires not only the best
use of his capabilities and potentialities but to fulfill his
responsibilities as well.
The human being needs stimulation in order to make the
best use of his capabilities well.
Whatever the individual does represents his best
judgment at the moment of doing it.
may indicate the broad general action appropriate to
implementation of the basic concept, as well as suggest the
kind behavior needed to carry out those action in accordance
with the central purpose.
Voluntary action – an intended response
Involuntary action – unintended responses
3 kinds of voluntary action
Mutually understood and agreed upon action
Recipient directed action
Practitioner directed action
the matrix w/c the action occurs.
Realities – offer uniqueness in every situation
Wiedenbach conceptualization of the nursing process
is the visible portion of nursing practice in w/c the nurse
interacts by the word, look, manner or deed with the another
Nursing process – is the essentially an internal
Wiedenbach’s 7 levels of awareness
Sensation – experience sensory impression
Perception – the interpretation of the sensory impression
Assumption – the meaning the nurse attaches to the
Realization – in w/c the nurse begins to validate the
assumption she had previously made about the patient
Insight – w/c includes joint planning and additional knowledge
about the cause of the problem
Design – the plan of action decided upon by the nurse and
confirmed by the patient
Decision – the nurse performance of action
Comparison of Wiedenbachs theory and the nursing
Nursing Process Wiedenbach Model
Assessment – consider The nurse is stimulated,
the patient holistically then assess at the
and requires extensive sensation and
data collection perception level w/c is
Goal – Weidenbach does Goal as part of
not directly incorporate prescriptive theory as a
the concept of goal as part component of nurse
of a nursing process central purpose
Design level – the nurse
plan a course of action.
Nursing diagnosis - made Assumption – compared
after much conscious to the nursing diagnosis
thought and deliberation •should be validated by
about the assessment data gathering more data
Insight level – includes
Evaluation After the plan decided on, the
nurse confirmed it with the
patient. Once the plan has been
decided it on and confirmed
the nurse perform the action
Wiedenbach and the concept of man, health, society and
Wiedenbach – emphasize that the human being process
unique potential, strives towards self-direction, need
stimulation and whatever the individual does represent
his best judgment at that moment.
Nurse – central purpose determines that her role will be
that of a helper.
is the application of knowledge end shall toward meeting a
need for health express by a patient.
is a helping process with action directed toward providing
something the patient requires on desire.
a process that will restore on extend the patient ability to
cope with demand implicit in his healthy situation.
Hildegard Peplau used the term, psychodynamic nursing,
to describe the dynamic relationship between a nurse and
a patient, and it is also called as the nurse-patient
orientation, in which the person and the nurse mutually
identify the person's problem
identification, in which the person identifies with the
nurse, thereby accepting help
exploitation, in which the person makes use of the nurse's
resolution, in which the person accepts new goals and
frees herself or himself from the relationship.
The six nursing roles of a nurse
Counseling Role - working with the patient on current
Leadership Role - working with the patient
Surrogate Role - figuratively standing in for a person in
the patient's life
Stranger - accepting the patient objectively
Resource Person - interpreting the medical plan to the
Teaching Role - offering information and helping the
At age 14 she began working at a large general hospital,
first as a pantry girl, then as a maid, and finally as a nurse's
aid. After a soul-searching process of discernment, she
decided to enter the Sisters of Saint Joseph of
Carondelet, of which she has been a member for more
than 40 years. Her college education began in a liberal
arts program, where she earned a Bachelor of Arts with a
major in nursing at Mount St. Mary's College, in Los
Dr. Roy is best known for developing and continually
updating the Roy Adaptation Model as a framework for
theory, practice, and research in nursing. Two recent
publications that Dr. Roy considers of great significance
are The Roy Adaptation Model (second edition) written
with Heather Andrews (Appleton & Lange) and The Roy
Adaptation Model-Based Research: Twenty-five Years of
Contributions to Nursing Science being published as a
research monograph by Sigma Theta Tau.
Theory of Callista Roy
The Roy Adaptation Model has some of the
characteristics of systems theory and some of the
characteristics of interaction theory. The model was first
presented in periodical literature (Roy, 1970) and has
been used as a conceptual framework for nursing
curriculum, nursing practice, and nursing research.
Roy borrowed and expanded on theories from other
disciplines: Erickson, Selye, Lazarus (coping concept),
Helson's (1964) theory of adaptation, Maslow's hierarchy
of needs, Raprot's systems theory and other biological
and behavioral sciences (Marriner & Tomey;quot;Nursing
theorist & their works, 2nd ed, p. 325-327)
Sister Callista Roy has continuously expanded her model form it's inception
to the present. Her work is studied and utilized frequently in nursing
Roy focuses on the individual (person) as a biopsychosocial adaptive
system and describes nursing as a humanistic discipline that quot;places
emphasis on the person's own coping abilitiesquot; (1984, p. 32). She believes
hat the person's own coping abilities will enhance wellness (health).
Roy's Adaptation Model of nursing relies heavily on the stress theory, the
concept of adaptation, and the ability of the nurse to facilitate adaptation to
stress. The term adaptation appears frequently throughout the model and
is used to describe that which promotes the integrity of the person in
terms of survival, growth, reproduction and mastery.
According to Roy, environment is all conditions,
circumstances, and influences surrounding and affecting
the development and behavior of persons and
groups. Environment has both internal and external
components, and is constantly changing.
Health results with adaptation to reach optimal levels of
individual potential in meeting physical, psychosocial, and
self actualization needs. The individual is in constant
interaction with the changing environment and to
respond positively that person must adapt.
The person's adaptation level is determined by combined
effect of three classes of stimuli (input): 1) Focal stimuli,
2) contextual stimuli, and 3) residual stimuli.
Focal stimuli--immediate threats/confrontations.
Contextual stimuli--all other stimuli present that
precipitated or contributed to the focal stimuli.
Residual stimuli--relevant factors that cannot be validated
(subjective), e.g. beliefs, values, etc.....
The individual uses both innate and acquired biological,
psychological, or social adaptive mechanisms.
Roy's Model postulates that there is an interchange
between the adaptive system (individual) and various
stimuli (input) from the environment and itself.
The response to stimuli (stress) is processed through
subsystems that include two control mechanisms (coping
processes) and four adaptive modes.
First subsystem: Two Control Mechanisms (coping processes)
Regulator--(physiological responses) concerned with the
Receives input from external environment and from changes in
the person's internal state.
Cognator--(psychological responses) concerned with the
process of perception (the link between the
regulator/cognator), learning, judgment, and emotion.
Receives input from external and internal stimuli that involve
psychological, social, physical factors and processes it though
Second subsystem: Effect or (Adaptive) Modes
Additionally, four modes for effecting adaptation of the system include:
Physiological function--determined by physiological integrity derived from
the basic physiological needs.
Self-Concept--determined by need of interaction with others and psychic
integrity regarding perception of self.
Role function--determined by need for social integrity, refers to the
performance of duties based on given positions within society.
Interdependence--involves ways of seeking help, affection, and
attention. Involves relationships with significant others and support
The major focus of Roys theory is on behavioral science
concepts with the individual described as participants in
bio-psycho-social adaptive systems. Patients are described
as being under varying degrees of stress and their goal is
to adopt to that stress.
Roys identifies four adaptive modes which are used in this
The role of the nurse in this system is to identify the stress in
the patients life: classify the adaptive mode being used and help
patients adapt to stress by manipulating the environment.
Orlando’s nursing process
Theory in nursing process
Overview of Orlando’s Nursing Process Theory
A theory organizes a phenomenon and identifies the
salient features, separating the critical elements from the
It is like a road map that highlights the important parts to
guide the user.
Each theory uses a different map.
Different theories use alternate ways to categorize and
make sense of the phenomenon.
However, each nursing theory influences the nurses
thoughts and action in his approach in nursing.
Frame work of her theory
As a reflective practice theory, Orlando’s theory contains
concepts that are interrelated but are described
professional nursing function organizing principle.
the patient’s presenting behavior-problematic situation.
immediate reaction-internal response
deliberative nursing process reflective inquiry
Professional nursing function-organizing principle.
She conceptualized the nurse’s unique function of meeting
patient’s immediate needs for help.
Which constitutes the nursing organizing principle.
Thus the patient is the local point of the nurse’s
Orlando states that: “nursing is responsive to individuals
who suffer or anticipate a sense of helplessness; it is
focused on the process of care in an immediate
It is concerned with providing direct assistance to
individuals in whatever setting they are found, for the
purpose of avoiding, relieving, diminishing, or curing of the
individual’s sense of helplessness.”
The patient’s presenting behavior-problematic
Nursing practice comprises frequent patient-nurse
contacts in which the patient manifests verbal and/or
non-verbal behavior, these come in verbal forms (e.g.
requests, comments, complains, questions, moaning, crying,
wheezing,) in the non-verbal forms, (e.g. skin, respirations,
color, silence, clinching fists, reddened face…) these
situations disrupt the equilibrium and make the nurse
take a notice; they are cues to the nurse.
Immediate reaction-internal response
The problematic situation, in the form of the patient’s
presenting behaviors, triggers and automatic immediate
reaction to the nurse that is both cognitive and affective.
The reaction comprises the nurse’s perceptions, thoughts
about the perceptions and feelings evoked from the
thoughts they cannot be controlled.
These separate items reside within an individual and at
any given moment occur in the following automatic,
sometimes instantaneous sequence;
the person perceives with any one of his five sense organs an
object or objects;
the perceptions stimulate automatic thought;
each thought stimulates an automatic feelings; and
then the person acts.
Deliberative nursing process-reflective inquiry
Deliberative nursing process views the nurse-patient
situation as a dynamic whole.
The nurse’s behavior affects the patient, and the nurse is
affected with the patient’s behavior.
To be successful, the nurse focus must be on the patient
rather than on an assumption that he or she knows what
the patient’s problem is and on arbitrary decisions about
what action to take. Use of this process requires that
there is a shared communication process between the
nurse and patient.
The action process in a person to person contact
functioning in secret. The perception, thought and feelings
of each individual are not directly available to another
person through the observable action.
the action process in a person to person contact
functioning by open disclosure. The feelings of each other
are directly available to another person.
Action based on the nurse’s conclusion, without the
patient’s participation, are often not helpful.
Therefore, the nurse decides for reasons other than the
meaning of the patients behavior.
Thus if actions are carried out automatically, even though
they could be correct, they are ineffective in helping the
patient because the patient was not involved.
When a situation becomes clear, it loses its problematic
character and a new equilibrium is established. When the
patient’s immediate needs for help have been determined
and met, there is improvement. This change is observable
in both the patient’s verbal and non verbal behavior. This
allows the nurse to conclude that the patient’s sense of
helplessness has been relieved, prevented or diminished.
Assessing a patient using Orlando’s
theory in nursing process
The nurses focus is on the
Guiding principle finding
patient. The nurse’s mind
out and meeting patients
is free from distracting
immediate need for help.
Problematic situation and
The nurse recognizes cues
that a patient problem
may exist before the next
step in the process
The nurse uses terms the
patient can understand
and explores immediate
reactions with the patient
to discover physical and
non physical problems.
With patient, the nurse
Identifying specific plans
determines action, needed
for each problem
and develop plans for each
action. Nurse explores if
patient will agree o refuse.
The nurse implements the
plan and ask patient
whether the action is
helpful, if not, the nurse
explores the basis.
The nurse ask patient if
action did helped and
observes verbal and non
verbal behavior. If he or
she improve then the
needs has been met, if not,
nurse continues to use the
contents of immediate
reaction to explore if
patient’s positive change is
Comparison Of Ida Jean Orlando’s Nursing Theory to
Johnson’s first paper on this topic outlined her philosophy of nursing, arguing that
the key element was hands-on nursing services. She defined these services as caring
for, rather then curing the patient.
The definition of caring Johnson used defined caring as basic nursing procedures:
comfort measures, environmental management, emotional support, and teaching.
She believe that the physicians could be as kind as nurses but they focused their
work on curing, rather than sustaining the patient.
Nursing problems arise when there are disturbances in the system or subsystem or
the behavioral function is below an optimal level.
APPLICATION TO CLINICAL PRACTICE
Nursing interventions are designed to support/maintain, educate, counsel, and
Dorothy Johnson and the University of California
Contemporary with the Yale theorist were a group of grand
theorist of nursing who defined nursing in broad outlines.
They intended to be concentrated in certain centers, with the
University of California at Los Angeles (UCLA) and New York
University (NYU) furnishing the leadership to the movement.
Dorothy Johnson, a UCLA faculty member, started working on
a theoretical framework for nursing in the 1950’s.
Her most important contribution was probably not her Grand
theory which was published later, but her definition of nursing
as focusing on the “caring elements of patient management”,
in this distinction to the physician’s role, which was said to be
the treatment of illness.
Johnson’s Behavioral System Model
Dorothy Johnson used her observations of behavior over
many years to formulate a general theory of man as a
The theory was originally resented orally in 1968 but was
not published until 1980.
Johnson defines a system as a whole that functions as a
whole by virtue of the interdependence of its part.
Individuals strive to maintain stability and balance in these
parts through adjustments and adaptations to the forces
that impinge on them.
A behavioral system is patterned, repetitive, and
Johnson’s Behavioral System Model
Johnson’s key concepts describe the individual as a
behavioral system composed of seven subsystems:
The attachment-affiliative subsystem provides survival and
security. Its consequences are social inclusion, intimacy, and the
formation and maintenance of a strong social bond.
The dependency subsystem promotes helping behavior that
calls for a nurturing response. Its consequences are approval,
attention or recognition, and physical assistance.
The ingestive subsystem satisfies appetite. It is governed
by social and physiologic consideration as well as
The eliminative subsystem excretes body wastes.
The sexual subsystem functions dually for procreation
The achievement subsystem attempts to manipulate the
environment. It controls or masters an aspect of the self
or environment to some standard of excellence.
The aggressive subsystem protects and preserves the self
and society within the limits imposed by society.
Each of the above subsystems has the same functional
requirements: protection, nurturance, and stimulation. The
subsystems’ responses are developed through motivation,
experience, and learning and are influenced by
Other concepts associated with Johnson’s model are
equilibrium, a stabilized but more or less transitory
resting state in which the individual is in harmony with
the self and environment; tension, a state of being
stretched or strained; the stressor, internal or external
stimuli that produce tension and result in a degree of
Dorothy E. Johnson BSN, MPH (1919-1999)
Dorothy Johnson’s professional nursing career began in 1942 when she graduated
from Vanderbilt University School of Nursing. She was the top student in her class
and received the prestigious Vanderbilt Founder’s medal. She worked briefly as a
public health nurse and in 1944 returned to Vanderbilt as an instructor in Pediatric
In 1949 she joined the faculty of UCLA where she and Lulu K. Wolf Hassenplug
developed the “ first four year generic basic nursing program” in the United States.
Dorothy Johnson was a prolific writer on the subject of nursing theory. Her many
publications on this subject profoundly influenced theoretical thinking in nursing
during the second half of the 20th century.
She held a strong conviction that continuing improvement of care was the ultimate
goal of nursing. Her 1968 paper, entitled, “ One Conceptual Model of Nursing “ is a
classic contribution to Nursing Literature.
After her retirement from UCLA she moved to the Florida coast to pursue her
hobby of the study of sea shells. She remained active in retirement as a speaker and
advocate for nursing education.
Credentials and Background of the Theorist
Catherine Kolcaba was born in Cleveland Ohio, where
she spent most of her life. In 1965 she received her
diploma in nursing from St. Luke’s Hospital School of
Nursing in Cleveland. She practiced part time for many
years in medical-surgical nursing, long term care and
home care before returning to school. In 1987, she
graduated in the first RN to MSN class at the Frances
Payne Bolton School of Nursing, Case Western Reserved
University, with a specialty in gerontology. While going to
school, Kolcaba job shared a head nurse position on a
dementia unit. In the context of that unit, she begun
theorizing about the outcome of comfort.
Following graduation with her master’s degree in nursing,
Kolcaba joined the faculty at the University of Akron College
of Nursing. Since that time she has maintained American
Nurses Association Certification in Gerontology. She returned
to Case Western Reserved University to pursue her
doctorate in nursing on a part time basis while continuing to
teach full time. Over the next ten years, she used coursed
work from her Doctoral program to develop and explicate her
theory. During that time, Kolcaba published a concept analysis
of comfort with her philosopher husband, diagrammed the
aspects of comfort, operationalized comfort as an outcome of
care, contextualized comfort in a midrange theory and tested
the theory in an intervention study.
Kolcaba originally begun her theoretical work when she
diagrammed her nursing practiced early in her Doctoral
work. When Kolcaba presented her framework for
dementia care, an audience member asked, “have you
done a concept analysis of comfort?” Kolcaba’s reply was
“No but that is my next step.” This begun her long
investigation on the concept of comfort.
The first step, the promised concept analysis, begun with an
extensive review of the literature about comfort from the
disciplines of nursing, medicine, psychology, psychiatry,
ergonomics and English ( specifically Shakespeare’s use of
comfort and the Oxford English dictionary, which traces
origins of words.) from 1900 to 1929, comfort was the central
goal of nursing and medicine because, through comfort
The nurse was duty bound to attend to details influencing
patient comfort. Comfort of the patient was the nurse’s first
and last consideration. A good nurse made patients
comfortable and the provision of comfort was the primary
determining factor of the nurse ability and character.
Comfort is positive, it is achieved with the help of nurses
and in some cases, in indicates an improvement from
previous state or condition. Intuitively, comfort is
associated with a nurturing activity.
From its origins, Kolcaba explicated its strengthening
features and from ergonomics, comforts direct link to job
However, often its meaning is implicit, hidden in context
and ambiguous. The concept varies semantically as a verb,
noun, adjective, adverb, process and outcome.
Four Major Tenets about the Nature of Holistic
Comfort is generally state specific.
The outcome of comfort is sensitive to changes over
Any consistently applied holistic nursing intervention with
established history for effectiveness enhances comfort
Total comfort is greater than the sum of its part.
Major Concepts and Definitions
Health Care Needs
Kolcaba defines health care needs as needs for comfort,
arising from a stressful healthcare situations, that cannot
be met by recipient’s traditional support systems.
These needs include physical, psychospiritual, social and
environmental needs made apparent through monitoring
and verbal or non verval reports, needs related to
pathophysiological parameters, needs for education and
support and needs for financial counseling and
Comfort measures are defined as nursing interventions
designed to address specific comfort needs of recipients,
including physiological, social, financial, psychological,
spiritual, environmental and physical.
Intervening variables are defined as interacting forces that
influence recipients perception of total.
These consist of variables such as past experiences, age,
attitude, emotional state, support system, prognosis,
finances and the totality of elements in recipients
Comfort is defined as the state that is experienced by
recipients of comfort measures. It is the immediate and
holistic experience of being strengthened through having
the needs met for the three types of comfort ( relief,
ease, and transcendence) in four context of experience (
physical, psychospiritual, social and environmental)
TYPES OF COMFORT ARE DEFINED AS:
Relief: the state of a recipient who has had a specific need
Ease: the state of calm or contentment.
Transcendence: the state in which an individual rises
above his or her problem or pain.
Kolcaba derived the context on which comfort is
experienced from the literature on holism and she
defined them as:
Physical: pertaining to bodily sensation.
Psychospiritual: pertaining to internal awareness of self,
including esteem, self concept, sexuality and meaning in
life; relationship to a higher order or being.
Environmental: pertaining to external surroundings,
conditions and influences.
Social: pertaining to interpersonal, family, and societal
The Mediocre teacher tells.
The good teacher explains.
The superior teacher
The great teacher inspires.
The need for Nurse Mentors
Causes of this decline includes:
“Inadequate salary increases
“Dissatisfaction with the
hospital work environment.”
“Opening of traditionally male
dominated professions to women”
From Novice to Expert
In her landmark work From Novice to Expert:
Excellence and Power in Clinical Nursing Practice,
Dr. Patricia Benner introduced the concept that expert nurses
develop skills and understanding of patient care over time
through a sound educational base as well as a multitude of
She proposed that one could gain knowledge and skills
(“knowing how”) without ever learning the theory (“knowing
that”). Her premise is that the development of knowledge in
applied disciplines such as medicine and nursing is composed
of the extension of practical knowledge (know how) through
research and the characterization and understanding of the
“know how” of clinical experience.
In short, experience is a prerequisite for becoming an expert.
What does an Expert Nurse look like in the
Clinical setting ?
5 Levels of Development :
Mentors do more than teach skills
They facilitate new learning experiences
Help new nurses make career decisions
Introduce them to networks of colleagues who can
provide new professional challenges and opportunities
Mentors are interactive sounding boards who help others
5 CORE competencies of
Leaders and Mentors
Risk-Taking and Creativity
Interpersonal and Communication Effectiveness