Nursing theories

OUTLINE OF TOPICS
 Definitions of Theory and Nursing Theory
 Introduction
 Historical Perspective and Key concepts
 Terms used in Theory Development
 Types of Nursing Theories
 Framework of Analysis
 Significance of Nursing Theories
 Nursing Theorists and their Works
 Florence Nightingale “Environmental Theory”
 Virginia Henderson “Needs Theory”
 Faye Abdellah “21 Nursing Problems”
 Dorothea Orem “Self-care deficit Theory”

Prepared by: Mae Michelle F. Aguilar RN & Kaysie Bustamante RN
NURSING THEORIES
NRSG 202-1

By the end of the lecture, nurses will be able to:
 Define terms used in Theory Development.
 Explain the significance of Nursing Theories
(Nightingale, Henderson, Abdellah and Orem) in the Nursing
Practice.
 Examine the nursing theories and how it applies in the
clinical practice setting.
LEARNING OBJECTIVES

 ORIGIN: “THOERIA” – speculate
THEORY
GREEK WORD

 THEORIES are a set of interrelated concepts that give a
systematic view of a phenomenon (an observable fact or
event) that is explanatory & predictive in nature.
 Theory is “a creative and rigorous structuring of ideas
that projects a tentative, purposeful, and systematic view
of phenomena”. (Chinn and Kramer 1999)

 Theories are composed of concepts, definitions, models,
propositions & are based on assumptions.
 They are derived through two principal methods; deductive
reasoning and inductive reasoning.
 A theory makes it possible to “organize the relationship
among the concepts to describe, explain, predict, and control
practice” (Torres,1986,p.21).Torres (1990,pp.6–9)

Defined as a belief, policy, or procedure proposed or followed
as the basis of action. It is an organized framework of
concepts and purposes designed to guide the practice of
nursing.
NURSING THEORY

1. Theories can interrelate concepts in such a way as to create
a different way of looking at a particular phenomenon.
2. Theories must be logical in nature.
3. Theories should be relatively simple yet generalizable.
4. Theories can be the bases for hypotheses that can
be tested.
CHARACTERISTICS OF THEORIES

5. Theories contribute to and assist in increasing the general
body of knowledge within the discipline through the
research implemented to validate them.
6. Theories can be used by the practitioners to guide and
improve their practice.
7. Theories must be consistent with other validated
theories, laws, and principles but will leave open
unanswered questions that need to be investigated.

Historical Perspectives and Terminology
INTRODUCTION TO
NURSING THEORY

 Mid 1800’s – Nursing Knowledge is distinct from medical
knowledge (Nightingale)
 Nursing practices was based on principles and traditions
passed on through apprenticeship education and common
sense wisdom.
 Nursing as a Vocational heritage more than professional
vision.
 1960’s – debates and discussion regarding the proper
direction and appropriate disciple for nursing knowledge
development.
MID 1800’S AND 1960’S

CURRICULUM
ERA
• Moving nursing education from hospital-based diploma programs into
college and universities.
RESEARCH ERA
• Research is the path to new knowledge.
• Part of the curricula of developing graduate programs.
HISTORICAL ERAS

GRAD. EDU.
ERA
• Masters program in nursing emerged to meet the need for nurses with
specialized education in nursing.
• Nursing Theory and Nursing Conceptual models were included as courses in
the study of nursing.
THEORY ERA
• Outgrowth of research era.
• Research without theory produced isolated information; however research
and theory produced nursing science.

 Evaluation of 25 years of nursing research revealed that
nursing lacked conceptual connections and theoretical
frameworks.
 MILESTONES: 1. Standardization of curricula for nursing
master’s education. 2. Doctoral education for nurses should
be in nursing.
 Transition from vocation to profession.
 Nursing practice is based on Nursing Science
MID 1970’S

 Preparadigm period to Paradigm period
 Introduced an organizational structure for nursing
knowledge development to the nursing literature.
 Utilization phase of the Theory Era – emphasis shifts from
the development to the use and application of what is
known.
1980’S

KEY CONCEPTS
Nightingale 1860:
Peplau 1952:
Henderson 1955:
• To facilitate “the body’s reparative
processes” by manipulating client’s
environment
• Nursing is; therapeutic
interpersonal process.
• The needs often called
Henderson’s 14 basic needs

Abdellah 1960:
Orlando 1962:
Johnson’s Theory
1968:
• delivering nursing care for the whole
person to meet the
physical, emotional, intellectual, social, an
d spiritual needs of the client and family.
• the client is an individual; with a need;
that, when met, diminishes
distress, increases adequacy, or enhances
well-being.
• focuses on how the client adapts to illness
and how actual or potential stress can
affect the ability to adapt. The goal of
nursing to reduce stress so that; the client
can move more easily through recovery.

Rogers 1970:
Orem1971:
King 1971:
• maintain and promote
health, prevent illness, and care
for and rehabilitate ill and
disabled client through
“humanistic science of nursing”
• self-care deficit theory. Nursing
care becomes necessary when
client is unable to fulfill
biological, psychological, develop
mental, or social needs.
• use communication to help client
reestablish positive adaptation to
environment.

Neuman 1972:
Roy 1979:
Watson’s Theory
1979:
• Stress reduction is goal of system model of
nursing practice
• This adaptation model is based on the
physiological, psychological, sociological
and dependence-independence adaptive
modes.
• defines the outcome of nursing activity in
regard to the; humanistic aspects of life.

CONCEPTS
 vehicles of thought that involve images. Are words that
describe objects, properties, or events & are basic
components of theory.
 Types:
 Empirical concepts
 Inferential concepts
 Abstract concepts

 Specifies the main concepts that encompass the subject
matter and the scope of discipline.
 “There is a general agreement that nursing’s metaparadigm
consists of the central concepts of
person, environment, health and nursing.” (Powers and
Knapp)
METAPARADIGM

METAPARADIGM CONCEPTS
THE PERSON
THE ENVIRONMENT
HEALTH
NURSING (GOALS, ROLES & FUNCTIONS)

 Specifies the definitions of the metaparadigm concepts in
each of the conceptual models of nursing.
 There are other theoretical works that may be considered
philosophies, works that specify philosophical approaches to
nursing.
PHILOSOPHY

 representations of the interaction among and between the
concepts showing patterns.
 In nursing, models are often designed by theory authors to
depict the beliefs in their theory (Lancaster and Lancaster
1981).
MODELS

 VERBAL MODELS – worded
statements, a form of
closely related knowledge
development.
 SCHEMATIC MODELS –
diagrams, drawings, graphs
and pictures that facilitate
understanding.

 statements that explain the relationship between the
concepts.
PROPOSITION
PROCESS
 a series of actions, changes or functions intended to bring
about a desired result.

 The delivery of nursing care within the nursing process is
directed by the way specific conceptual frameworks &
theories define the person (patient), the
environment, health & nursing.
 outlines possible courses of action or to present a preferred
approach to an idea or thought.
CONCEPTUAL FRAMEWORK

 GENERAL SYSTEMS THEORY
 describes how to break whole things into parts & then to
learn how the parts work together in “systems”.
 These concepts may be applied to different kinds of
systems, e.g. Molecules in chemistry, cultures in
sociology, and organs in Anatomy & Health in Nursing.
THE DEVELOPMENT OF NURSING THEORIES

 ADAPTATION THEORY
 defines adaptation as the adjustment of living matter to
other living things & to environmental conditions.
 Adaptation is a continuously occurring process that
effects change & involves interaction & response.
 Human adaptation occurs on three levels :
1. The internal (self)
2. The social (others) &
3. the physical (biochemical reactions)

 DEVELOPMENTAL THEORY
 It outlines the process of growth & development of humans
as orderly & predictable, beginning with conception &
ending with death.
 The progress & behaviors of an individual within each stage
are unique.
 The growth & development of an individual are influenced
by heredity, temperament, emotional, & physical
environment, life experiences & health status.

TYPES OF NURSING THEORIES
According to Scope, Functions and Philosophy

 SPECULATIVE – yet to be tested through research and found
to be consistently true, valid and reliable in answering
questions, solving problems and exploring phenomenon.
 ESTABLISHED – Accumulation of facts, principles and laws
that have been repeatedly tested through research over time
and found to be consistently valid and reliable.

 GRAND THEORY - It is the broadest in scope, represents the
most abstract level of development, and addresses the
broad phenomena of concern within the discipline.
 MIDDLE-RANGE THEORY - theory that addresses more
concrete and more narrowly defined phenomena. It is
intended to answer questions about nursing phenomena, yet
they do not cover the full range of phenomena of concern to
the discipline
 MICRO-RANGE THEORY - concrete and narrow in scope. It
explains a specific phenomenon of concern to the discipline

TYPES ACCORDING TO SCOPE

1. NURSING PHILOSOPHY
 Meaning of nursing phenomenon through analysis,
reasoning and logical argument.
 Includes works which predate or introduce the nursing
theory era and have contributed to the knowledge
development in nursing.
TYPES According to KNOWLEDGE BASE
and CHARACTERISTICS

2. NURSING CONCEPTUAL MODELS
 Works of grand theorists or pioneers in Nursing.
 “Provides a distinct frame of reference for its adherents
that tells them how to observe and interpret the
phenomena of interest to the discipline.”

3. NURSING THEORIES AND MIDDLE-RANGE THEORIES
 Addresses the specifics of nursing situations within the
perspective of the model or theory from which they are
derived.

PHILOSOPHIES CONCEPTUAL MODELS AND
GRAND THEORIES
THEORIES AND MIDDLE-RANGE
THEORIES
NIGHTINGALE
WIEDENBACH
HENDERSON
ABDELLAH
HALL
WATSON
BENNER
OREM
LEVINE
ROGERS
JOHNSON
ROY
NEUMAN
KING
ROPER, LOGAN,
TIERNEY
BARNARD
LEININGER
PARSE
MISHEL
NEWMAN
ADAM
PENDER
PEPLAU
ORLANDO
TRAVELBEE
KOLCABA
ERICKSON, TOMLIN, SWAIN
MERCER

 Descriptive-to identify the properties and workings of a
discipline
 Explanatory-to examine how properties relate and thus
affect the discipline
 Predictive-to calculate relationships between properties and
how they occur
 Prescriptive -to identify under which conditions relationships
occur
TYPES ACCORDING TO FUNCTION (Polit et. al 2001)

1. “Needs” theories
 Are based around helping individuals to fulfill their physical
and mental needs.
Based on the philosophical underpinnings of the
theories:

2.“Interaction” theories
 As described by Peplau
(1988), these theories
revolve around the
relationships nurses form
with patients.

3. “Outcome” theories"
 Outcome theories portray the nurse as the
changing force, who enables individuals to adapt
to or cope with ill health.

4. “Humanistic” Theories
 Humanistic theories
developed in response to the
psychoanalytic thought that a
person’s destiny was
determined early in life.
 Humanistic theories
emphasize a person’s capacity
for self-actualization.

 Carl Rogers developed a person –centered model of
psychotherapy that emphasizes the uniqueness of the
individual.

Criteria for Evaluating Theoretical Works
FRAMEWORK OF ANALYSIS

 Major Concepts and sub-
concepts and their definitions
are identified.
 “The danger of lost
meaning when terms are
borrowed from other
disciplines and used in a
different context.” (Ellis)
 Diagrams and examples may
facilitate clarity and should be
consistent.
“HOW CLEAR IS YOUR THEORY?”
CLARITY

 Nurse in practice need simple
theory, such as middle-range
theory to guide practice.
(Chinn and Kramer)
 “The most useful theory
provides the greatest sense of
understanding.” (Reynolds)
 “Elegant in its simplicity, even
though it may be broad in
content.” (Walker and Avant)
“How simple is this theory?”
SIMPLICITY

 Scopes of concepts and goals
within the theory are
examined.
 The situations the theory
applies to should not be
limited.
 “The broader the scope,
the greater the
significance of the
theory.” (Chinn and
Kramer)
“How general is this theory?”
GENERALITY

 “ How well the evidence
supports the theory is
indicative of empirical
adequacy.” (Hardy)
 Other scientists should be
able to evaluate and verify
results by themselves.
“How accessible is this theory?”
EMPIRICAL PRECISION

 “It is essential for a theory to
develop and guide
practice...Theories should
reveal what knowledge
nurses must and should,
spend time pursuing.”
“How important is this theory?”
DERIVABLE CONSEQUENCE

As a Discipline and Profession
SIGNIFICANCE OF THEORY
FOR NURSING

PROFESSION
 A specialized field of
practice, which is
founded upon the
theoretical structure of
the science or
knowledge of the
discipline and the
accompanying practice
abilities.
DISCIPLINE
 Specific to the academia
and refers to a branch
of education, a
department of learning
or a domain of
knowledge.

 Theories provided frameworks to structure curriculum
content or to guide the teaching of nursing practice in
nursing programs.
 Discipline is dependent upon theory.
NURSING AS A DISCIPLINE

 Focus on knowledge about how nurses function which
concentrated on the nursing process to a focus on what
nurses know and how they use knowledge to guide their
thinking and decision making while concentrating on the
patient.
 New nursing science is developed through theory based
research studies.

 Criteria of a profession by Bixler and Bixler published in the
American Journal of Nursing 1959
1. Utilizes in its practice a well defined and well-
organized body of specialized knowledge that is on the
intellectual level of higher learning.
2. Constantly enlarges the body of knowledge it uses and
improves its techniques of education and service by
the use of the scientific method.
NURSING AS A PROFESSION

3. Entrusts the education of its practioners to institutions of
higher education.
4. Applies its body of knowledge in practical services that are
vital to human and social welfare.
5. Functions autonomously in the formulation of professional
policy and in the control of professional activity thereby.

6. Attracts individuals of intellectual and personal qualities
who exalt service above personal gain and who recognize
their chosen occupation as a life work.
7. Strives to compensate its practitioners by providing freedom
of action, opportunity for continuous professional
growth, and economic security.

 Presented specific goals and achievements of the profession.
 Nurses are recognized for the contribution they make in
healthcare and the society.

 Nursing theory is a useful tool for reasoning, critical
thinking, and decision making in the nursing practice.
NURSING THEORY AND THE PRACTICE OF NURSING
Theory assists the practicing nurse to:
•Organize patient data
•Understand patient data
•Analyze patient data
•Make decisions about nursing interventions
•Plan patient care
•Predict outcomes of care
•Evaluate patient outcomes

 Professional practice requires a systematic approach that is
focused on the patient. Nursing theoretical works provide a
perspective of the patient.

 aims to describe, predict and explain the phenomenon of
nursing (Chinn and Jacobs1978).
 provides the foundations of nursing practice, help to
generate further knowledge and indicate in which direction
nursing should develop in the future (Brown 1964).
 helps us to decide what we know and what we need to know
(Parsons1949).
 helps to distinguish what should form the basis of practice by
explicitly describing nursing.
IMPORTANCE OF NURSING THEORIES

 The benefits of having a defined body of theory in nursing
include better patient care, enhanced professional status for
nurses, improved communication between nurses, and
guidance for research and education (Nolan 1996).
 The main exponent of nursing – caring – cannot be
measured, it is vital to have the theory to analyze and
explain what nurses do.

NURSING THEORISTS AND
THEIR WORKS

MODERN NURSING and
ENVIRONMENTAL THEORY
Nursing “is an act of utilizing the
environment of the patient to assist
him in his recovery.”
FLORENCE
NIGHTINGALE

 First Nursing Theorists and the
Mother of Modern Nursing.
 Born in May 12, 1820 in Italy to
a wealthy British family.
 In 1853, she accepted the
position of superintendent at
the Institute for the Care of
Sick Gentlewomen in Upper
Harley Street, London.
Biography

•She tended to wounded soldiers during
the Crimean War. She became known as
the "Lady with the Lamp" because of her
night rounds. Immortalized in the poem
“Santa Filomena” by Henry Wadsworth
Longfellow
•After the Crimean War, she established a
nursing school at St. Thomas' Hospital
and King’s College in London in 1860.

 Nightingale wrote Notes on Nursing (1859), which was the
foundation of the curriculum for her nursing school and other
nursing schools.
 Notes on Matters Affecting the Health, Efficiency and Hospital
Administration of the British Army
Notes on Hospitals
Report on Measures Adopted for Sanitary Improvements in
India from June 1869 to June 1870

 “She helped to pioneer the revolutionary notion that social
phenomena could be objectively measured and subjected to
mathematical analysis.” (Cohen)
 Nightingale’s research skills:
Recording, Communicating, ordering, coding, conceptualizing
, inferring, analyzing and synthesizing (Palmer)
 Nightingale emphasized the concurrent use of observation
and the performance of tasks in the education of nurses.

 In 1883 - Royal Red Cross by Queen Victoria.
In 1907 - the Order of Merit.
In 1908 - Honorary Freedom of the City of London.
 She was able to work into her eighties and died in her sleep
on August 13, 1910 at age 90
 International Nurses Day is celebrated on her birthday.

 Education provided by her Father
 Family’s aristocratic social status.
 Exposure to political process of the Victorian England
 The Industrial Age
 Charles Dickens’ social commentaries and novels
 Dialogues with many political leaders
 Unitarian religious affiliation.
INFLUENCES

1. Person
 Patient who is acted on by nurse
 Emphasized that the Nurse has in
control of the patient’s
environment.
 Affected by environment
 Passive yet has reparative powers
Nightingale’s Major Concepts

2. Environment
 Foundation of theory.
 Included everything, physical,
psychological, and social
 Nurses are instruments to change
the social status of the poor by
improving their living conditions

3. Health
 “We know nothing of health, the positive of which pathology
is the negative, except from the observation and experience.”
 Given her definition that of the art of nursing is to “unmake
what God had made disease,” then the goal of all nursing
activities should be client health.

 Nursing should provide care to the healthy as well as the ill
and discussed health promotion as an activity in which
nurses should engage.
 Envisioned maintenance of health through prevention of
disease via environmental control.

4. Nursing
 “What nursing has to do… is to put the patient in the best
condition for nature to act upon him” (Nightingale,
1859/1992)
 nursing “ought to signify the proper use of fresh air, light,
warmth, cleanliness, quiet, and the proper selection and
administration of diet – all at the least expense of vital
power to the patient.”

 Nursing is having the responsibility for someone else’s
health.
 She wrote her Notes on Nursing to provide women
how to “Think like a Nurse.”

 Ventilation and warming
 Light and noise
 Health of houses
 Bed and bedding
 Personal cleanliness
 Variety
 Chattering hope and advices
 Food

•“ Keep the air he breathes as
pure as the external air, without
chilling him.”
•Recognized this environmental
component as a source of
disease and recovery.
VENTILATION
AND WARMING

• Provided description for
measuring the patient’s
body temperature through
palpation of extremities.
• Nurses were instructed to
manipulate the
environment to maintain
both ventilation and
patient warm by good fire,
opening windows and
properly positioning the
patient in the room.

•“Light has quite as real and
tangible effects upon the
human body…who has not
observed the purifying
effect of light, and
especially of direct
sunlight, upon the air of the
room?”
LIGHT

•Noises created by physical
activities in the
environment (room) was to
be avoided by the nurse.
NOISE

•Bathing of patients on a
frequent, even daily, basis.
•Nurses should wash their hands
regularly.
CLEANLINESS

• Noted that a dirty
environment (floors,
carpets, walls and bed
linens) was a source of
infection through the
organic matter it contained.
•The appropriate handling
and disposal of bodily
excretions and sewage was
required to prevent
contamination of the
environment.
BED AND BEDDINGS

•“Badly constructed houses
do for the healthy what
badly constructed hospitals
do for the sick.”
HEALTH OF
HOUSES

“To any but an old nurse, or
an old patient, the degree
would be quite
inconceivable to which the
nerves of the sick suffer
from seeing the same walls,
the same ceiling, the same
surroundings during a long
confinement to one or two
rooms”
VARIETY

• Instructed nurses to
assess dietary intake , meal
schedules and its effect on
the patient.
FOOD

•Protects patient from
receiving upsetting
new, seeing visitors who
can affect the patient’s
recovery negatively and
from suddenly receiving
disruptions from sleep.
Chattering of
Hope and Advices

 Nightingale (1860/1957/1969) believed that five points were
essential in achieving a healthful house: “pure air, pure
water, efficient drainage, cleanliness and light.”
A healthy environment is essential for healing. She stated that
“nature alone cures.”
ASSUMPTIONS

 Nurses must make accurate observations of their patients
and be able to report the state of the patient to the
physician in an orderly manner.
 Nursing is an art, whereas medicine is a science. Nurses are
to be loyal to the medical plan, but not servile.

 Disease is a reparative process. Disease is nature’s effort to
remedy a process of poisoning or decay, or a reaction against
the conditions in which a person was placed.
 Nature is synonymous with God .
 Committed to nursing education (training.) Women were to
be specifically trained to provide care for the sick and that
nurses requiring preventive healthcare requires more
training.

 Nurses should use common
sense, observation, perseverance and ingenuity.
 Persons desired good health and that they would cooperate
with the nurse.
 Did not embrace germ theory but clearly understood the
concept of contagion and contamination through organic
materials from patients and the environment.

 Believed that nurses should be MORAL AGENTS.
 Addressed Professional relationship with patients.
 Instructed nurses on principle of confidentiality and
advocated care for the poor.
 Patient decision making – indecision or changing the
mind is more harmful to the patient than the patient
having to make a decision.

 Used Inductive Reasoning to extract laws
of health, disease and nursing from her
observations and experiences.
LOGICAL FORM

Practice, Education and Research
ACCEPTANCE BY THE
NURSING COMMUNITY

 Environmental aspects remain integral components of
current nursing care.
 Multiple authors reviewed her work Petty management
concepts and actions , again identifying some of the
timelessness and universality of her management style.
PRACTICE

 Principles of Nursing Training provided a universal template
for early nurse training schools.
 Experimental schools established in the USA 1873 : 1.
Bellevue Hospital in New York 2. New Haven Hospital 3.
Massachusetts Hospital in Boston
EDUCATION

 Advocated Nursing school’s independence from a hospital to
ensure that students would not be involved in the hospital’s
labor pool as part of their training.
 Measurement of the art of nursing could not be
accomplished through licensing examinations but she used
testing methods, including case studies (notes).

 Graphically represented data was first identified in the polar
diagrams.
 Empirical approach in solving problems of healthcare
delivery.
 Concepts Nightingale identified have served as basis for
current research.
RESEARCH

Simple?
Important?
Accessible?
General?
Clear?

Weaknesses
 There is scant information on the psychosocial
environment when compared to the physical
environment.
 The application of her concepts in the twentieth
century is in question.

Strengths
 Has broad applicability to the practitioner. Her model can
be applied in most complex hospital intensive care
environment, the home, a work site, or the community
at large.
 Reading her work raises a consciousness in the nurse
about how the environment influences client outcomes.

“I think one’s feelings waste themselves
in words; they ought all to be distilled
into actions which bring results.”
-Florence Nightingale

THE PRINCIPLES AND
PRACTICE OF NURSING
“I believe that the function the nurse performs
is primarily an independent one – that of
acting for the patient when he lacks
knowledge , physical strength, or the will to
act for himself as he would ordinarily act in
health, or in carrying out prescribed therapy.
This function is seen as complex and
creative, as offering unlimited opportunity for
the application of the physical, biological, and
social sciences and the development of skills
based on them.” (Henderson, 1960)
VIRGINIA
HENDERSON

 “The Nightingale of Modern
Nursing”. Others named her
as the “First Lady of Nursing”
and “Modern-Day Mother of
Nursing”
 Born on November 30, 1897
in Kansas City, Missouri and
lived in Virginia.
Biography

 In 1918, she entered the Army School of Nursing in
Washington, DC.
 1921, she was a staff nurse Henry Street Visiting Nurse
Service in New York
 She began her career as a nurse educator in 1924 at the
Norfolk Protestant Hospital in Virginia where she was the
first and only teacher in the school of nursing

 Five years later she entered Teacher’s College at Columbia
University where she earned her B.S. and M.A. degrees in
Nursing Education.
 1939 – rewrote the 4th edition of Bertha Hammer’s Textbook
of the Principles and Practice of Nursing.
 Henderson's career in research began when she joined the
Yale School of Nursing as Research Associate in 1953 to work
on a critical review of nursing research.

 In 1955 she published the 5th edition with her own definition
of nursing.
 1960 – Coauthored Basic of Principles in Nursing care for the
International Council of Nurses which was translated into
more than 20 languages.
 1966-The Nature of Nursing. A definition and its implication
for practice, Research and Education

 In 1985, Henderson was presented with the first Christianne
Reimann Prize from the International Council of Nurses.
 She was also an honorary fellow of the United Kingdom's Royal
College of Nursing. The same year, she was also honored at the
Annual Meeting of the Nursing and Allied Health Section of the
Medical Library Association.
 Awarded in 1988 by the American Nurses Association for her
lifelong contributions to nursing research, education and
professionalism.
 Henderson died on March of 1996 at the age of 98

 ANNIE W. GOODRICH
 Dean of the Army School of Nursing.
 Lifted her sights above techniques and routines
 Nursing is not merely ancillary to medicine.
 CAROLINE STACKPOLE
 Philosophy Professor at Teachers College
 Importance of physiological balance.
INFLUNCES

 JEAN BROADHURST
 Microbiology Professor at Teachers College
 Importance of hygiene and asepsis
 DR. EDWARD THORNDIKE
 Illness “is more than a state of disease that most
fundamental needs are not met in hospitals.”

 Dr. GEORGE DEAVER
 Physicist at Bellevue Hospital
 The Goal of rehabilitative efforts at the institute was
rebuilding the patient’s independence.
 BERTHA HARMER
 Canadian Nurse
 “Nursing is rooted in the needs of humanity.”

 IDA JEAN ORLANDO (PELLETIER)
 Influence on her Nurse-patient relationship
 “Ida Orlando made me realize how easily a nurse
can act on misconceptions of the patient’s needs
if she does not check her interpretation of them
with him.”

1. Person/ Individual
 considers the biological,
psychological,
sociological, and spiritual
components.
 She defined the patient as
someone who needs
nursing care, but did not
limit nursing to illness
care.
Henderson’s Major Concepts
NURSING NEED THEORY

2. Society or Environment
 “The aggregate of all
external conditions and
influences affecting the life
and development of an
organism.” – Webster’s
Dictionary
 maintaining a supportive
environment is one of the
elements of her 14
activities.

 She sees individuals in relation to their families but
minimally discusses the impact of the community on the
individual and family.
 She supports the tasks of private and public health agencies
keeping people healthy.
 She believes that society wants and expects the nurse’s
service of acting for individuals who are unable to function
independently.

3. Health
 Equated health
with independence.
 “The quality of health rather than life itself, that margin
of mental/physical vigor that allows a person to work
most effectively and to reach his highest potential level
of satisfaction in life.”

14 Activities for Client Assistance
 Physiological
 Psychological Aspects of
Communicating and
Learning
 Spiritual and Moral
 Sociologically Oriented to
Occupation and
Recreation

 "nurses care for a patient until a patient can care for him or
herself."
 nurses are willing to serve and that "nurses will devote
themselves to the patient day and night."
 nurses should be educated at the college level in both
sciences and arts and should be knowledgeable in both
biological and social sciences.
ASSUMPTIONS

 Three Levels of Relationship:
 Nurse as a substitute for the patient
 Nurse as a helper to the patient
 Nurse as a partner with the patient
 “The nurse is a substitute for what the patient lacks to make
him ‘complete’, ‘whole’, or ‘independent’, by the lack of
physical strength, will or knowledge”
THE NURSE-PATIENT RELATIONSHIP

 The nurse “is temporarily the consciousness of the
unconscious, the love of life for the suicidal, the leg of
the amputee, the eyes of the newly blind, a means of
locomotion for the infant, knowledge and confidence for
the young mother, the ‘mouthpiece’ for those too weak
or withdrawn to speak and so on.”

 Nurse must able to assess not only the patient’s needs but
the condition and pathological states that alters them.
 Nurses can alter the environment whenever necessary.
 One goal of the nurse is to keep the patient’s days “as
normal as possible”
 Another goal is promotion of health. “ There is more to be
gained by helping every man learn how to be healthy than
be preparing the most skilled therapists for service to those
in crises.”

 Unique distinction from the Physician’s function
 – the CARE PLAN
 Nursing Care Plan – promotes the physician’s therapeutic
plan.
NURSE-PHYSICIAN RELATIONSHIP

 Works in interdependence with other healthcare
professionals.
 “No one of the team should make such heavy demands on
another members that any one of them is unable to perform
his or her unique functions.”
NURSE AS A MEMBER OF THE HEALTH
CARE TEAM

 Used the deductive form of logical reasoning.
 Deduced her definition of nursing
and the 14 needs from
physiological and psychological
principles.
LOGICAL FORM

 Nursing Process is the problem solving process and
is not peculiar to nursing.
 ASSESSMENT PHASE – assess pt. in 14 components of
nursing care. Use observation, smell, feeling and hearing.
Analyze collected data and differentiate normal from
abnormal.
PRACTICE

 PLANNING PHASE – Must fit individual’s needs, updating
the plan as necessary on the basis of the changes and
depending on physician’s prescribed plan.
 IMPLEMENTATION PHASE – Individualized interventions
depending on factors.
 EVALUATION PHASE – evaluate according to the degree
in which he or she performs independently.

 “ In order for a nurse to practice as an expert in her own
right and to use a scientific approach to the improvement of
practice, the nurse needs the kind of education available
only in colleges and universities.”
 3 Phases of Curriculum Development
1. Fundamental needs of the patient, the planning of
nursing care and the unique function of the nurse to
assist in pt.’s activities of daily living.
EDUCATION

2. Helping patients meet their needs during body
disturbances or pathological states that demand
modifications in the nurse’s plan of care.
3. Patient and family centered. Complete study of patient
and patient’s needs

 Believed that research was needed to evaluate and improve
practice.
 Recommended library research.
 1964 Survey and Assessment of Nursing Research identified
several reasons for the lack of research in clinical nursing.
 Major energies of the profession have gone toward
improving the preparation for nursing.
RESEARCH

 Learning how to recruit and hold sufficient numbers of
nurses to meet the growing demand has taken
considerable energy.
 The need for administrators and educators has almost
exhausted the supply of degree of nurses.
 A lack of support from the administrators, nursing service
administrators and physicians has discouraged
researchers.

Weaknesses
 Limited in a way that it can generally be applied to fully
functional individuals.
 A major shortcoming in her work is the lack of a
conceptual linkage between physiological and other
human characteristics.

Strengths
 Her work can be applied to the health of individuals of all
ages.
 Each of the 14 activities can be the basis for research.
Although the statements are not written in testable
terms, they may be reformulated into researchable
questions.
 The concept of nursing formulated by Henderson in her
definition of nursing and the 14 components of basic
nursing is uncomplicated and self-explanatory.
Therefore, it can be used without difficulty as a guide for
nursing practice by most nurses.

“Nursing must not exist in a vacuum. Nursing must
grow and learn to meet the new health needs of the
public as we encounter them.”
–Virginia Henderson

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PATIENT-CENTERED
APPROACHES TO NURSING
"Nursing is based on an art and
science that moulds 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."
FAY ABDELLAH

 Born on March 13, 1919 New
York City.
 the first nurse officer to earn
the ranking of a two-star rear
admiral. She was the first
nurse and the first woman to
serve as a Deputy Surgeon
General.
Biography

 Her work changed the focus of nursing from disease-
centered to patient-centered, and began to include the care
of families and the elderly in nursing care.
 The Patient Assessment of Care Evaluation developed by
Abdellah is now the standard used in the United States.

 Her publications include Better Nursing Care Through
Nursing Research and Patient-Centered Approaches to
Nursing.
 She was inducted into the National Women's Hall of Fame in
2000.

1. Nursing
 A helping profession
 A comprehensive service to meet patient’s needs
 Increases or restores self-help ability
 Uses 21 problems to guide nursing care
Abdellah’s Major Concepts
21 Nursing Problems

Nursing Problems
 The client’s health needs can be viewed as problems, which
may be overt as an apparent condition, or covert as a hidden
or concealed one.

 Problem-solving process involves identifying the problem,
selecting pertinent data, formulating hypotheses, testing
hypotheses through the collection of data, and revising
hypotheses when necessary on the basis of conclusions
obtained from the data. (Abdellah & Levine, 1986)
Problem Solving

2. Health
 No unmet needs and no actual or anticipated impairments
 The purpose of nursing services.
 she speaks of “total health needs” and “a healthy state of
mind and body.” (Abdellah et al., 1960)
3. Person
 One who has physical, emotional, or social needs
 The recipient of nursing care.

4. Environment
 Did not discuss much
 Includes room, home, and community
 Society is included in “planning for optimum health on local,
state, and international levels.”

The focus of care pendulum
 In her attempt to bring nursing practice to its proper
relationship with restorative and preventive measures for
meeting total client needs, she seems to swing the
pendulum to the opposite pole, from the disease orientation
to nursing orientation, while leaving the client somewhere in
the middle.

1. Learn to know the patient
2. Sort out relevant and significant data
3. Make generalizations about available data in relation to
similar nursing problems presented by other patients
4. Identify the therapeutic plan
5. Test generalizations with the patient and make additional
generalizations
10 Steps to Identify Patient’s Problems

6. Validate the patient's conclusions about his nursing
problems
7. Continue to observe and evaluate the patient over a period
of time to identify any attitudes and clues affecting his
behavior
8. Explore the patient's and family's reaction to the
therapeutic plan and involve them in the plan
9. Identify how the nurses feel about the patient's nursing
problems
10. Discuss and develop a comprehensive nursing care plan

1. Observation of health status
2. Skills of communication
3. Application of knowledge
4. Teaching of patients and families
5. Planning and organization of work
6. Use of resource materials
7. Use of personnel materials
8. problem-solving
9. direction of work of others
10. therapeutic use of the self
11. nursing procedure
11 Nursing Skills

 BASIC NEEDS
 SUSTENAL CARE NEEDS
 REMEDIAL CARE NEEDS
 RESTORATIVE CARE NEEDS
4 Categories of Needs

1. To maintain good hygiene and physical comfort.
2. To promote optimal activity: exercise, rest, and sleep.
3. To promote safety through the prevention of accidents,
injury, or other trauma and through the prevention of the
spread of infection.
21 Nursing Problems

4. To maintain good body mechanics and prevent and
correct deformities.
5. To facilitate the maintenance of a supply of oxygen to all
body cells.
6. To facilitate the maintenance of nutrition of all body cells.
7. To facilitate the maintenance of elimination.

8. To facilitate the maintenance of fluid and electrolyte
balance.
9. To recognize the physiological responses of the body to
disease conditions – pathological, physiological, and
compensatory.
10. To facilitate the maintenance of regulatory mechanisms
and functions.
11. To facilitate the maintenance of sensory functions.

12. To identify and accept positive and negative
expressions, feelings, and reactions.
13. To identify and accept the interrelatedness of emotions
and organic illness.
14. To facilitate the maintenance of effective verbal and
nonverbal communication.
15. To promote the development of productive interpersonal
relationships.

16. To facilitate progress toward achievement of personal
spiritual goals.
17. To create and/or maintain a therapeutic environment.
18. To facilitate awareness of self as an individual with
varying physical, emotional, and developmental needs.

19. To accept the optimum possible goals in the light of
limitations, physical and emotional.
20. To use community resources as an aid in resolving
problems arising from illness.
21. To understand the role of social problems as influencing
factors in the case of illness.

Weaknesses
 Little emphasis on what the client is to achieve was given
in terms of client care.
 Failure of the framework to provide a perspective on
humans and society in general limits the generalizability
of the theory.
 Abdellah’s framework is inconsistent with the concept of
holism.

Strengths
 As a logical and simple statement, Abdellah’s problem-
solving approach can easily be used by practitioners to
guide various activities within their nursing practice.
 The theoretical statement places heavy emphasis on
problem solving, an activity that is inherently logical in
nature.
 The problem-solving approach is readily generalizable to
client with specific health needs and specific nursing
problems.

OREM’S MODEL OF
NURSING
DOROTHEA OREM

 Born in 1914 in
Baltimore, Maryland
 In the early 1930s, she earned
her nursing diploma from the
Providence Hospital School of
Nursing in Washington, D.C.

 She went on to complete her Bachelor of Science in Nursing
in 1939 and her Master's of Science in Nursing in 1945, both
from the Catholic University of America in Washington, D.C.
 Dorothea Orem had a distinguished career in nursing. She
earned several Honorary Doctorate degrees.
 the Catholic University of America Alumni Achievement
Award for Nursing Theory in 1980, the Linda Richards Award
from the National League for Nursing in 1991, and was
named an honorary Fellow of the American Academy of
Nursing in 1992.

1. Nursing
 an art through which the practitioner of nursing gives
specialized assistance to persons with disabilities which
makes more than ordinary assistance necessary to meet
needs for self-care.
 The nurse also intelligently participates in the medical care
the individual receives from the physician.
Orem’s Major Concepts
Self-Care Deficit Theory

2. Human/Person
 are defined as “men, women, and children cared for
either singly or as social units,” and are the “material object”
of nurses and others who provide direct care.
3. Environment
 has physical, chemical and biological features. It
includes the family, culture and community.

4. Health
 “Being structurally and functionally whole or sound.”
Also, health is a state that encompasses both the health of
individuals and of groups, and human health is the ability to
reflect on one’s self, to symbolize experience, and to
communicate with others.

 Orem developed the Self-Care Deficit Theory of
Nursing, which is composed of three interrelated theories:
(1) the theory of self-care, (2) the self-care deficit
theory, and (3) the theory of nursing systems.

 Self-care is the performance or practice of activities that
individuals initiate and perform on their own behalf to
maintain life, health and well-being.
 Self-care agency is the human’s ability or power to engage in
self-care and is affected by basic conditioning factors.
THEORY OF SELF-CARE

 Basic conditioning factors:
 age
 Gender
 Developmental state
 Health state,
 Socio-cultural orientation
 Health care system factors
 Family system factors
 Patterns of living
 Environmental factors
 Resource adequacy and availability.

 Therapeutic Self-care Demand is the totality of “self-care
actions to be performed for some duration in order to meet
known self-care requisites by using valid methods and
related sets of actions and operations.”
 Self-care Deficit delineates when nursing is needed. Nursing
is required when an adult (or in the case of a dependent, the
parent or guardian) is incapable of or limited in the provision
of continuous effective self-care.

 Nursing Agency is a complex property or attribute of people
educated and trained as nurses that enables them to act, to
know, and to help others meet their therapeutic self-care
demands by exercising or developing their own self-care
agency.
 Nursing System is the product of a series of relations
between the persons: legitimate nurse and legitimate client.
This system is activated when the client’s therapeutic self-
care demand exceeds available self-care agency, leading to
the need for nursing.

 SELF-CARE REQUISITES or requirements can be defined as
actions directed toward the provision of self-care.
 Universal self-care requisites
 Developmental self-care requisites
 Health deviation self-care requisites

 Universal self-care requisites are associated with life
processes and the maintenance of the integrity of human
structure and functioning.
 1. The maintenance of a sufficient intake of air
2. The maintenance of a sufficient intake of water
3. The maintenance of a sufficient intake of food
4. The provision of care associated with elimination process
and excrements

5. The maintenance of a balance between activity and rest
6. The maintenance of a balance between solitude and social
interaction
7. The prevention of hazards to human life, human
functioning, and human well-being
8. The promotion of human functioning and development
within social groups in accord with human potential, known
human limitations, and the human desire to be normal

Developmental self-care requisites are “either specialized
expressions of universal self-care requisites that have been
particularized for developmental processes or they are new
requisites derived from a condition or associated with an
event.”

 Health deviation self-care requisites are required in
conditions of illness, injury, or disease or may result from
medical measures required to diagnose and correct the
condition.
1. Seeking and securing appropriate medical assistance
2. Being aware of and attending to the effects and results
of pathologic conditions and states
3. Effectively carrying out medically prescribed
diagnostic, therapeutic, and rehabilitative measures

4. Being aware of and attending to or regulating the
discomforting or deleterious effects of prescribed medical
measures
5. Modifying the self-concept (and self-image) in accepting
oneself as being in a particular state of health and in need of
specific forms of health care
6. Learning to live with the effects of pathologic conditions
and states and the effects of medical diagnostic and
treatment measures in a life-style that promotes continued
personal development

 According to Orem, nursing is required when an adult is
incapable or limited in the provision of continuous, effective
self-care.
 5 METHODS OF HELPING:
 Acting for and doing for others
 Guiding others
 Supporting another
 Providing an environment promoting personal development in
relation to meet future demands
 Teaching another.
THEORY OF SELF-CARE DEFICIT

 Describes how the patient's self-care needs will be met by
the nurse, the patient, or by both.
 Orem identifies three classifications of nursing system to
meet the self-care requisites of the patient:
 wholly compensatory system
 partly compensatory system
 supportive-educative system.
THEORY OF NURSING SYSTEMS

 Wholly compensatory nursing system
 represented by a situation in which the
individual is unable “to engage in those
self-care actions requiring self-directed
and controlled ambulation and
manipulative movement or the medical
prescription to refrain from such
activity… Persons with these limitations
are socially dependent on others for
their continued existence and well-
being.”

 Partly compensatory nursing system
 represented by a situation in which “both nurse and
patient perform care measures or other actions involving
manipulative tasks or ambulation… *Either+ the patient
or the nurse may have the major role in the performance
of care measures.”

 Supportive-educative system
 also known as supportive-developmental system, the
person “is able to perform or can and should learn to
perform required measures of externally or internally
oriented therapeutic self-care but cannot do so without
assistance.”

 People should be self-reliant, and responsible for their
care, as well as others in their family who need care.
 People are distinct individuals.
 Nursing is a form of action. It is an interaction between two
or more people.
ASSUMPTIONS

 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
needed for promoting self-care behaviors.
 Self-care and dependent care are behaviors learned within a
socio-cultural context.

Weaknesses
 Simple yet complex. The use of self-care in multitude of
terms.
 Orem’s definition of health was confined in three static
conditions which she refers to a “concrete nursing
system,” which connotes rigidity.
 Throughout her work, there is limited acknowledgement
of the individual’s emotional needs.

Strengths
 applicable for nursing by the beginning practitioner as
well as the advanced clinicians.
 specifically defines when nursing is needed: Nursing is
needed when the individual cannot maintain
continuously that amount and quality of self-care
necessary to sustain life and health, recover from disease
or injury, or cope with their effects.
 Three identifiable nursing systems were clearly
delineated and are easily understood.

 George B. Julia , Nursing Theories- The base for professional Nursing
Practice , 3rd ed. Norwalk, Appleton & Lange.
 Betty M. Johnson and Pamela B. Webber, Theory and Reasoning in
Nursing., 2nd ed. New York, Williams & Wilkins
 Mariner 5th edition
 http://nursingtheories.weebly.com/index.html
 http://nursing-theory.org/articles/nursing-theory-definition.php
 http://currentnursing.com/nursing_theory/development_of_nursing_the
ories.html
REFERENCES

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