Chapter 18Models and Theories

Focused on a Systems Approach

Introduction

• Development and use of theories and models is a way to practice and generate new knowledge in nursing.

• Conceptual models in particular keep theory at the forefront of the profession and lead advanced practice nurses.

• In clinical practice, these models expand the ways of delivering health care.

General Systems Theory• General systems theory developed from

thermodynamics and is based on the premise that the world is composed of interrelated systems that influence one another.

• There theory has two main assumptions:– Energy is needed to maintain organization– Dysfunction in one system impacts the other system

• Roy, King, and Neuman all based nursing models on this basic theory.

The Roy Adaptation Model: Philosophy and Assumptions

• Callista Roy described how adaptation helps people conserve energy to heal and cope.

• Based theory on the philosophical assumptions of humanism and veritivity.

• Veritivity is the purpose of human existence, humankind’s shared purpose, activity for the common good, and life sense value.

• Nurses must believe in each person’s life purpose and contribute to the common good through knowledge application.

The Model• Focuses on changes in the human adaptive

system and the environment.• Posits that adaptation problems arise when

systems are unable to respond to stimuli.• Relies on five major elements of nursing:– Adaptation– Person– Environment– Health– Goals

Coping Processes• Coping processes are innate or acquired

methods of responding to the change environment and take four forms:– Cognator processes: Cognitive and emotional

responses– Regulator processes: Neurochemical and

endocrine responses– Stabilizer processes: System maintenance

responses– Innovator processes: Personal change and growth

responses

Modes

• Coping processes lead to four interrelated modes of adaptive behavior:– Physiological mode: Individual interaction with the

environment– Self-concept/group mode: Personal or group

aspects related to behavior– Role function mode: Personal roles in society– Interdependence mode: Individual relationships

with others

The Nursing Process• Roy proposed that the nursing process assess

behavior of the holistic system with an eye to the stimulus that prompted the behavior.

• The process includes 6 collaborative steps:– Assessment of behavior– Assessment of stimuli– Nursing diagnosis– Goal setting– Intervention– Evaluation

The King Conceptual System and Theory of Goal Attainment: Philosophy

• Imogene King developed her system based on Aristotelian-Thomistic philosophical ideals of individuals striving for the end goal of happiness.

• Focused on the general system theory perspective and the concept of wholeness.

• Encouraged guidance and motivation in introducing behaviors to facilitate goal attainment.

The Models• King relied on four models in her work:– Conceptual system: Humans are open systems

constantly interacting with the environment– Personal system: Response and coping are based on

expectations, others, events, and objects– Interpersonal system: Perceptions shape

interactions but communication governs transactions

– Social system: Behavior and practices are organized by social roles for the regulation of rules

Other Concepts (1 of 2)

• King posited that authority, communication, perception, power, and self also impact the individual as a system.

• Proposed that the environment is holistic and transformative and that health is a process of growth and development.

• Described the focus of nursing as the human being and human acts.

Other Concepts (2 of 2)

• Emphasized that the nursing process will differ according to the nurse and patient involved, but should include five components:– Nursing judgment– Nursing action– Communication– Evaluation– Coordination

Theory of Goal Attainment

• Derived from the conceptual framework, King’s theory focuses on holism and describes nursing as an interactional process.

• Interactions lead to the critical transactions that result in goal attainment.

• Goals become the criteria for measuring the effectiveness of nursing care.

Assumptions• King’s theory is based on 18 assumptions that

focus on several specific areas:– The nature of individuals– The perceptions and needs of the nurse and

patient– The rights of the individual– The responsibility and goals of the nurse

• The major concepts involved are communication, growth, interaction, perception, and transaction.

Propositions• King’s assumptions are embedded in

propositions related to eight areas:– Perceptual accuracy in transactions– Goal attainment through transactions– Satisfaction through goal attainment– Effective nursing through goal attainment– Growth and development through transactions– Transactional congruence and performance– Role conflict and interactional stress– Goal setting and attainment via communication

Hypothesis• King’s theory led to a seven-part hypothesis:– Perceptual accuracy in nurse-client interactions

increases mutual goal setting– Communication also increases mutual goal setting

and leads to satisfaction– Satisfaction increase likelihood of goal attainment– Goal attainment decreases stress and anxiety– Goal attainment increases client coping ability– Role conflict decreases transactions– Congruence in role expectations increases

transactions

The Neuman Systems Model: Philosophy and Assumptions

• Betty Neuman focused her model on client response to environmental stressors and multiple levels of nursing prevention.

• Based on wholeness and the gestalt concept of reality.

• Concentrated on dynamic equilibrium, where parts of the system work together as a whole.

• Proposed that wellness is a negotiation between the client and the nurse.

The Model• The patient is considered an open system in

which continual cycles of input, process, output, and feedback make up a pattern.

• Posits that the client is an individual and part of a group, and knowing about one part of this system enables knowing about the other part.

• Proposes five variables of the person—physiological, psychological, sociocultural, developmental, and spiritual.

Structure of the Model

• Accounts for all variables that affect a client’s response to stressors to explain how stability is obtained.

• Considers system variables and unique person variables, and the interplay of humans and their environment.

• Homeostasis occurs when available energy exceeds the amount being used by the system.

Prevention as Intervention

• Primary prevention is the point of entry into the health care system and strengthens clients to help them deal with stressors.

• Secondary prevention occurs after clients have reacted to stressors and focuses on protecting the basic structures of the system.

• Tertiary prevention occurs after the client has been treated and helps the system equalize energy and become reconstituted.

Neuman’s Perception of Nursing• Neuman’s model emphasizes three steps in the

nursing process:– Nursing diagnosis– Nursing goals– Nursing outcomes

• Nursing practice should focus on promoting system stability by guiding the client in energy conservation, by synthesizing data into goal-based interventions, and by evaluating intervention outcomes.

Education, Practice, and Research

• Neuman’s model encourages students to use logic, deduction, and induction in developing nursing plans.

• It promotes the use of practical clinical tools to guide holistic assessment in practice.

• It contributes to the understanding of the influence of prevention on the relationship between stressors and system stability in research.

Analysis of the Models• Roy, King, and Neuman depicted nursing as a

science that relies on the connections between mind and intuition.

• Drew attention to the diversity of practical aspects that make nursing both a science and an art.

• Integrated systems concepts with nursing phenomena to clarify and define nursing knowledge in relation to science.

Summary

• Systems models are useful for viewing nursing from different perspectives, but are focused through the same lens.

• Models function largely as conceptual models that provide nurses with conceptual arrangements for practice.

• Application of these models emphasizes subsystems within the individual that contribute to the whole.