MAN 113

Part 3 THEORIES OF NURSING

RESEARCH WORK
 Definitions Theory
Origin: “THOERIA” – speculate

THEORIES are set of interrelated concepts that give a systematic view of a phenomenon (an observable fact or event) that is explanatory and 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.

An explanation of a process or phenomenon based on systematic observation.

A narrative or story that describes a sequence of connected events and characters, bounded in space and time, containing implicit or explicit suggestions about decisions, motives,
barriers and facilitators associated with an event.

 NURSING THEORY
Nursing theories are organized bodies of knowledge to define what nursing is, what nurses do, and why do they do it. Nursing theories provide a way to define nursing as a unique
discipline that is separate from other disciplines. It is a framework of concepts and purposes intended to guide the practice of nursing at a more concrete and specific level.

 TWO PRINCIPLES METHODS

i) Deductive Reasoning
A specific conclusion follows a general theory.
When your using deductive reasoning, your conclusion will be correct if all statements you say is correct.

ii) Inductive Reasoning

Makes specific observations and then draws a general conclusion.
When your using inductive reasoning, correct observations won’t necessarily lead you to a correct general conclusion.

 CHARACTERISTICS OF THEORIES
 Constructs - Theories consists of a set of defined constructs.
 Relationships - Theories consist of relationships that connects the constructs in a meaningful or logically resonant way.
 Scope - Theories have a domain or scope, a field or conceptual space within the theory operates.
 Utility - Theories have utility, relevance or ultimate aim.

 Historical Perspectives in Nursing Theories

 The first nursing theories appeared in the late 1800s when a strong emphasis was placed on nursing education.

 In 1860, Florence Nightingale defined nursing in her “Environmental Theory” as “the act of utilizing the environment of the patient to assist him in his recovery.” In the 1950s,
there is a consensus among nursing scholars that nursing needed to validate itself through the production of its own scientifically tested body of knowledge.
 In 1952, Hildegard Peplau introduced her Theory of Interpersonal Relations that puts emphasis on the nurse-client relationship as the foundation of nursing practice.
 In 1955, Virginia Henderson conceptualized the nurse’s role as assisting sick or healthy individuals to gain independence in meeting 14 fundamental needs, thus her Nursing
Need Theory was developed.
 In 1960, Faye Abdellah published her work “Typology of 21 Nursing Problems” that shifted the focus of nursing from a disease-centered approach to a patient-centered
approach.
 In 1962, Ida Jean Orlando emphasized the reciprocal relationship between patient and nurse and viewed the professional function of nursing as finding out and meeting the
patient’s immediate need for help.
 In 1968, Dorothy Johnson pioneered the Behavioral System Model and upheld the fostering of efficient and effective behavioral functioning in the patient to prevent illness.
 In 1970, Martha Rogers viewed nursing as both a science and an art as it provides a way to view the unitary human being, who is integral with the universe.
explain your ideas
 In 1971, Dorothea Orem states in her theory that nursing care is required if the client is unable to fulfill biological, psychological, developmental, or social needs.
 In 1971, Imogene King‘s Theory of Goal attainment states that the nurse is considered part of the patient’s environment and the nurse-patient relationship is for meeting
goals towards good health.
 In 1972, Betty Neuman in her theory states that many needs exist, and each may disrupt client balance or stability. Stress reduction is the goal of the system model of nursing
practice.
 In 1979, Sr. Callista Roy viewed the individual as a set of interrelated systems who strives to maintain the balance between these various stimuli.
 In 1979, Jean Watson developed the philosophy of caring highlighted humanistic aspects of nursing as they intertwine with scientific knowledge and nursing practice.

 Nursing Theories Terminologies

 Philosophy. Beliefs and values that define a way of thinking and are generally known and understood by a group or discipline.

 Theory. A belief, policy, or procedure proposed or followed as the basis of action. It refers to a logical group of general propositions used as principles of explanation. Theories
are also used to describe, predict, or control phenomena.

 Concept. Concepts are often called the building blocks of theories. They are primarily the vehicles of thought that involve images.

 Models. Models are representations of the interaction among and between the concepts showing patterns. They present an overview of the thinking behind the theory and
may demonstrate how theory can be introduced into practice.

 Conceptual framework. A conceptual framework is a group of related ideas, statements, or concepts. It is often used interchangeably with the conceptual model and
with grand theories.

 Proposition. Propositions are statements that describe the relationship between the concepts.

 Process. Processes are a series of organized steps, changes or functions intended to bring about the desired result.
  Paradigm. A paradigm refers to a pattern of shared understanding and assumptions about reality and the world; worldview or widely accepted value system.

 Metaparadigm. A metaparadigm is the most general statement of discipline and functions as a framework in which the more restricted structures of conceptual models
develop. Much of the theoretical work in nursing focused on articulating relationships among four major concepts: person, environment, health, and nursing.

 CONCEPTS
Concepts are basically vehicles of thought that involve images. Concepts are words that describe objects, properties, or events and are basic components of theory.
Types:
1. Empirical Concepts (Concrete Concepts) – these are directly observable objects, events, or properties, which can be seen, felt or heard e.g color of the skin, communication
skill, presence of lesion, wound status etc., These are limited by time and space (it can be viewed/measured only specific period and specific setting and variable).
2. Inferential Concepts – these are indirectly observable concepts, e.g pain, Dyspnea and temperature.
3. Abstract Concepts – these concepts are not clearly observable directly or indirectly (known as “Non-observable concepts directly”). E.g. social support, personal role, self-
esteem etc.

 METAPARADIGM
- Originates from two Greek words, Meta, meaning “with” and paradigm, meaning “pattern”.
- is the most general statement of discipline and functions as a framework in which the more restricted structures of conceptual models develop.
- It defines and describes relationships among major ideas and values.
- It guides the organization of theories and models for a profession.

 METAPARADIGM CONCEPTS
1. Person refers to the recipient of nursing care, including physical, mental and social.
2. Environment refers to all the internal and external conditions, circumstances and influences affecting the person
3. Health refers to the degree of wellness or illness experienced by the person.
4. Nursing refers to the actions, characteristics and attributes of the individual providing the nursing care.

 PHILOSOPHY
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

A philosophy of nursing is an approach to nursing, usually created by individual nurses in their own daily practice in the field. A nurse uses his or her philosophy of nursing to explain
what he or she believes nursing is, the role nursing plays in the health care field, and how he or she interacts with patients. A philosophy of nursing also addresses a nurse’s ethics as it
relates to the practice of nursing. For example, are there any “lines” a particular nurse will cross? If so, which ones? Under what circumstances? A philosophy of nursing guides a nurse
 as he or she practices each day.

 MODELS
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)
- Verbal Models, worded statements, a form of closely related knowledge development.
- Schematic Models, diagrams, drawings, graphs and pictures that facilitate understanding.
- Proposition, statements that explain the relationship between the concepts.
- Conceptual Framework, the delivery of nursing care within the nursing process is directed by the way specific conceptual frameworks and theories define the person (patient),
the environment, health and nursing. It outlines possible courses of action or to present a preferred approach to an idea or thought.

THE DEVELOPMENT OF NURSING THEORIES

Nursing theories are often based on & influenced by broadly applicable processes & theories. Following theories are basic to many nursing concepts.

 GENERAL SYSTEMS THEORY - It 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.

 ADAPTATION THEORY - It 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) and;
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 testes 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 repeatedly tested through research over time and found to be consistently valid and reliable.

TYPES ACCORDING TO SCOPE

 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 KNOWLEDGE BASE AND CHARACTERISTICS

1. NURSING PHILOSOPHY – Meaning of nursing phenomenon through analysis, reasoning and logical argument. It includes works which predate or introduce the nursing theory era and
have contributed to the knowledge development in nursing.

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.

TYPES ACCORDING TO FUNCTION (Polit et. Al 2001)

 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

Based on the philosophical underpinnings of the theories”

1. “Needs” theories
These theories are based around helping individuals to fulfill their physical and mental needs. Needs theories have been criticized for relying too much on the medical model of health
and placing the patient in an overtly dependent position.

2. “Interaction” theories
As described by Peplau (1988), these theories revolve around the relationship’s nurses form with patients. Such theories have been criticized for largely ignoring the medical model of
health and not attending to basic physical needs.

3. “Outcome” theories
Outcome theories portray the nurse as the changing force, who enables individuals to adapt to or cope with ill health. Outcome theories have been criticized as too abstract and
difficult to implement in practice.

4. “Humanistic” theories
 Humanistic theories developed in response to the psychoanalytic thought that a person’s destiny was determined early in life. It also emphasizes a person’s capacity for self-
actualization. Humanists believe that the person contains within himself the potential for healthy & creative growth.

Carl Rogers developed a person –centered model of psychotherapy that emphasizes the uniqueness of the individual. The major contribution that Rogers added to nursing practice is
the understandings that each client is a unique individual, so, person-centered approach now practice in nursing.

FRAMEWORK OF ANALYSIS
Criteria for Evaluating Theoretical Works
 CLARITY “How clear is your theory?”
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.

 SIMPLICITY “How simple is this theory?”

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

 GENERALITY “How general is this theory?”

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

 EMPIRICAL PRECISION “How accessible is this theory?”

“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.

 DERIVABLE CONSEQUENCE “How important is this theory?”

“It is essential for a theory to develop and guided practice. Theories should reveal what knowledge nurses and should spend time pursuing.”
SIGNIFICANCE OF THEORY FOR NURSING
As a Discipline and Profession
 DISCIPLINE – specific to the academia and refers to a branch of education, a department of learning or a domain of knowledge.

 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.

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

It focuses 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.

 NURSING AS A PROFESSION
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.
3. Entrusts the education of its practitioners 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.

IMPORTANCE OF NURSING THEORIES

o It aims to describe, predicts and explain the phenomenon of nursing (Chinn and Jacobs 1978).
o Provides the foundations of nursing practice, help to generate further knowledge and indicate in which direction nursing should develop in the future (Brown 1964)
o Helps us to decide what we know and what we need to know (Parsons 1949)
o Helps to distinguish what should form the basis of practice by explicitly describing nursing.
 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:

 FLORENCE NIGHTINGALE
MODERN NURSING & ENVIRONMENTAL THEORY

Nursing “is an act of utilizing the environment of the patient to assist him in his recovery.”

ENVIRONMENTAL THEORY
Nightingale’s Major Concepts
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

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 has 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
“Keep the air he breathes as pure as the external air, without chilling him.”
o Recognized this environmental component as a source of disease and recovery.
o Provided description for measuring the patient’s body temperature through palpation of extremities.
o 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
“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?”

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

 CLEANLINESS
Bathing of patients on a frequent, even daily, basis.

Nurses should wash their hands regularly.

 BED AND BEDDINGS

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.

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

 VARIETY
“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”

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

 CHATTERING OF HOPE AND ADVICES

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

ASSUMPTIONS
  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.”

 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.

LOGICAL FORM ACCEPTABLE BY THE NURSING COMMUNITY

Used inductive Reasoning to extract laws of health, disease and nursing from her observations and experiences.
 PRACTICE
- 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.

 EDUCATION
- 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.
- 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).

 RESEARCH
- 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.

CRITIQUE:
 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.
VIRGINIA HENDERSON
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)

Biography
“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.
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 in 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.

Influences:
o Annie W. Goodrich
- Dean of the Army School of Nursing
- Lifted her sights above techniques and routines
- Nursing is not merely ancillary to medicine

o Caroline Stackpole
- Philosophy Professor at Teachers College
- Importance of physiological balance.

o Jean Broadhurst
- Microbiology Professor at Teachers College
- Importance of hygiene and asepsis

o Dr. Edward Thorndike

- Illness “is more that a state of disease that most fundamental needs are not met in hospitals.”
 o Dr. George Deaver
- Physicist at Bellevue Hospital
- The Goal of rehabilitative efforts at the institute was rebuilding the patient’s independence.

o Bertha Harmer
- Canadian Nurse
- “Nursing is rooted in the needs of humanity.”

o 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.”

NURSING NEED THEORY

Henderson’s Major Concepts
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.

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 his life.”

4. Nursing
- “The unique function of the nurse is to assists the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that
he would perform unaided if he had the necessary strength, will or knowledge.” (Virginia Henderson)

14 Activities for Client Assistance

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

ASSUMPTIONS
 “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 ne knowledgeable in both biological and social sciences.

THE NURSE-PATIENT RELATIONSHIP

Three Levels of Relationship:
1. Nurse as a substitute for the patient
2. Nurse as a helper to the patient
3. Nurse as a partner with the patient

o 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”
o 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.”
o Nurse must be able to assess not only the patient’s needs but the condition and pathological states that alters them.
o Nurses can alter the environment whenever necessary.
o One goal of the nurse is to keep the patient’s day “as normal as possible”
o 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.”

THE NURSE-PHYSICIAN RELATIONSHIP

 Unique distinction from the Physician’s function
- The CARE PLAN
  Nursing Care Plan – promotes the physician’s therapeutic plan.

NURSE AS A MEMBER OF THE HEALTH CARE TEAM

 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.”

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

ACCEPTANCE BY THE NURSING COMMUNITY

Practice, Education and Research
PRACTICE
- Nursing Process is the problem solving process and is not peculiar to nursing.

Nursing Process:
 ASSESMENT PHASE
- Assess pt. in 14 components of nursing care. Use observation, smell, feeling and hearing. Analyze collected data and differentiate normal from abnormal.

 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

EDUCATION
o “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.”

Three (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.
2. Helping patients meet their needs during body disturbances of 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

RESEARCH
 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.
 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.

CRITIQUE:
 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
FAY ABDELLAH
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.”

Biography
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 Deputy Surgeon General.
Her work change 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.

Abdellah’s Major Concepts

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

Nursing Problems – the client’s health needs can be viewed as problems, which may be overt as an apparent condition, or convert as a hidden or concealed one.
Problem Solving – 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)

2. Health
- No unmet needs and no actual or anticipated impairments
- The purpose of nursing services
- She speaks “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 preventative 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.

Ten (10) Steps to Identify Patient’s Problems

1. Learn to know the patient
2. Sort our relevant and significant data
3. Make generalizations about available data in relation to similar nursing problems presented by other patients
4. Identify the therapeutic plan
5. Test generalizations with the patient and make additional generalizations
6. Validate the patient’s conclusions about his nursing problems
7. Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting his behavior
8. Explore the patient’s and family’s reaction to the therapeutic plan and involve them in the plan
9. Identify how the nurses feel about the patient’s nursing problems
10. Discuss and develop a comprehensive nursing care plan.

Eleven (11) Nursing Skills

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

Four (4) Categories of Needs

 BASIC NEEDS
 SUSTENAL CARE NEEDS
 REMEDIAL CARE NEEDS
 RESTORATIVE CARE NEEDS

Twenty-One (21) Nursing Problems

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.
4. To maintain good boy 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.
 o 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.

o 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.

DOROTHEA OREM
OREM’S MODEL OF NURSING

Biography
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.

Orem’s Major Concepts

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.

2. Human/Person
- Defined as “men, women, and children cared for either singly or as social units,” and are the “materials 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 (3) interrelated theories:
(1) the theory of self-care,
 (2) the self-care deficit theory, and
(3) the theory of nursing systems.

THEORY OF SELF-CARE
 Self-care is the performance or practice of activities that individuals initiate and perform on their own behalf to maintain life, health and well-being.

 Self-care agency is the human’s ability or power to engage in self-care and is affected by basic conditioning factors.

Basic conditioning factors:

 Age
 Gender
 Developmental State
 Health State
 Socio-cultural Orientation
 Health Care System Factors
 Family System Factors
 Patterns of licing
 Environmental Factors
 Resource adequacy and availability.

 Therapeutic Self-Care 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
demands exceed 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

 Eight (8) 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
derive 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 diagnoses 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 o 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 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

THEORY OF SELF-CARE DEFICIT

According to Orem, nursing is required when an adult is incapable or limited in the provision of continuous, effective self-care.

FOUR (4) METHODS OF HELPING

 Acting for and doing for others
 Guiding others
 Supporting another
 Providing and environment promoting personal development in relation to meet future demands
 Teaching another.

THEORY OF NURSING SYSTEMS

 Describes how the patient’s self-care needs will be met by the nurse, the patient, or by both.

Orem identifies three (3) classifications of nursing system to meet the self-care requisites of the patient:
 Wholly compensatory 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 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.”

ASSUMPTIONS
 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.
 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.