NURSING THEORIES

For1st B.BSc nursing studentsBy prakash kumar(Msc Nsg)

– 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.

TERMINOLOGY

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)

• 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

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.

• Defined Nursing: “The act of utilizing the environment of the patient to assist him in his recovery.”

• Focuses on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act.

• Identified 5 environmental factors: fresh air, pure water, efficient drainage, cleanliness/sanitation and light/direct sunlight.

• Considered a clean, well-ventilated, quiet environment essential for recovery.

• Deficiencies in these 5 factors produce illness or lack of health, but with a nurturing environment, the body could repair itself.

Peplau’s Interpersonal Relations Theory

she is a psychiatric nurse, Introduced her interpersonal concept in 1952.

• Defined Nursing: “An interpersonal process of therapeutic interactions between an Individual who is sick or in need of health services and a nurse especially educated to recognize, respond to the need for help.

• Nursing is a “maturing force and an educative instrument”

• Identified 4 phases of the Nurse – Patient relationship:– Orientation – individual/family has a “felt need” and seeks

professional assistance from a nurse (who is a stranger). This is the problem identification phase.

– Identification – where the patient begins to have feelings of belongingness and a capacity for dealing with the problem, creating an optimistic attitude from which inner strength ensues. Here happens the selection of appropriate professional assistance.

– Exploitation – the nurse uses communication tools to offer services to the patient, who is expected to take advantage of all services.

– Resolution – where patient’s needs have already been met by the collaborative efforts between the patient and the nurse. Therapeutic relationship is terminated and the links are dissolved, as patient drifts away from identifying with the nurse as the helping person.

Virginia Henderson’s Definition of the Unique Function of Nursing

• Defined Nursing: “Assisting the individual, sick or well, in the performance of those activities contributing to health or it’s recovery (or to peaceful death) that an individual would perform unaided if he had the necessary strength, will or knowledge”.

• Identified 14 basic needs :– Breathing normally– Eating and drinking adequately– Eliminating body wastes– Moving and maintaining desirable position– Sleeping and resting– Selecting suitable clothes– Maintaining body temperature within normal range– Keeping the body clean and well-groomed– Avoiding dangers in the environment– Communicating with others– Worshipping according to one’s faith– Working in such a way that one feels a sense of accomplishment– Playing/participating in various forms of recreation– Learning, discovering or satisfying the curiosity that leads to normal development

and health and using available health facilities.

Dorothea Orem’s General Theory of Nursing

• Defined Nursing: “The act of assisting others in the provision and management of self-care to maintain/improve human functioning at home level of effectiveness.”

• Focuses on activities that adult individuals perform on their own behalf to maintain life, health and well-being.

• Has a strong health promotion and maintenance focus.

Identified 3 related concepts:1. Self-care – activities an Individual performs

independently throughout life to promote and maintain personal well-being.

2. Self-care deficit – results when self-care agency (Individual’s ability) is not adequate to meet the known self-care needs.

3. Nursing System – nursing interventions needed when Individual is unable to perform the necessary self-care activities:

Self-care theory is based on four concepts:1. Self care- refers to those activities an individual performs independently

throughout life to promote and maintain personal well-being.2. Self care agency- is the individual’s ability to perform self care activities. It

consists of two agents: a self-care agent(an individual who performs self-care independently) and a dependent care agent (a person other than the individual who provides the care)

3. Self-care requisites- are groups of needs or requirements that Orem identified. They are classified as either:

a) Universal self-care requisites - those needs that all people haveb) Developmental self-care requisites - 1. maturational: progress toward higher

level of maturation. 2. situational: prevention of deleterious effects related to development.

c) Health deviation requisites - those needs that arise as a result of a patient's condition. Result from illness, injury or disease or its treatment. They include actions such as seeking health care assistance ,carrying out prescribed therapies, and learning to live with the effects of illness or treatment.

4. Therapeutic self-care demand-refers to all self-care activities required to meet existing self-care requisites, or in other words, actions to maintain health and well-being.

Self care deficit- results when self care agency is not adequate to meet the known self-care demand. This theory explains not only nursing is needed but also how people can be assisted through five methods of helping: acting or doing for, guiding, teaching, supporting, and providing an environment that promotes individual’s abilities to meet current and future demands.

Orem’s 3 types of Nursing Systems:

1. Wholly compensatory – nurse provides entire self-care for the client.– Example: care of a new born, care of client recovering from surgery in a post-

anesthesia care unit

2. Partial compensatory – nurse and client perform care, client can perform selected self-care activities, but also accepts care done by the nurse for needs the client cannot meet independently.– Example: Nurse can assist post operative client to ambulate, Nurse can bring a

meal tray for client who can feed himself

3. Supportive-educative – nurse’s actions are to help the client develop/learn their own self-care abilities through knowledge, support and encouragement.

Example: Nurse guides a mother how to breastfeed her baby, Counseling a psychiatric client on more adaptive coping strategies.

Callista Roy’s Adaptation Theory• Sister Callista Roy defines adaptation

as the process and outcome whereby the thinking and feeling person uses conscious awareness and choice to create human and environmental integration.

• This model comprises the four domain concepts of person, health, environment, and nursing and involves a six step nursing process

1) Roy's models sees the person as "a biopsychosocial being in constant interaction with a changing environment“

• The person is an open, adaptive system who uses coping skills to deal with stressors.

2) Roy sees the environment as "all conditions, circumstances and influences that surround and affect the development and behaviour of the person".

• Roy describes stressors as stimuli and uses the term 'residual stimuli' to describe those stressors whose influence on the person is not clear .

3) Originally, Roy wrote that health and illness are on a continuum with many different states or degrees possible. More recently, she states that health is the process of being and becoming an integrated and whole person

4) Roy's goal of nursing is "the promotion of adaptation in each of the four modes, thereby contributing to the person's health, quality of life and dying with dignity". These four modes are physiological, self-concept, role function and interdependence.

A. In the Physiologic mode, adaptation involves the maintenance of physical integrity. Basic human needs such as nutrition, oxygen, fluids, and temperature regulation are identified with this mode.

In assessing a family, the nurse would ask how the family provides for the physical and survival needs of the family members.

B. A function of the Self-concept mode is the need for maintenance of psychic integrity. Perceptions of one’s physical and personal self are included in this mode.

Families also have concepts of themselves as a family unit. Assessment of the family in this mode would include the amount of understanding provided to the family members, the solidarity of the family. the values of the family, the amount of companionship provided to the members, and the orientation (present or future) of the family.

C. The need for social integrity is emphasized in the Role function mode. When human beings adapt to various role changes that occur throughout a lifetime, they are adapting in this mode.

According to Hanson, the family’s role can be assessed by observing the communication patterns in the family.

Assessment should include how decisions are reached, the roles and communication patterns of the members, how role changes are tolerated, and the effectiveness of communication.

For example, when a couple adjusts their lifestyle appropriately following retirement from full-time employment, they are adapting in this mode.

D.The need for social integrity is also emphasized in the interdependence mode.

Interdependence involves maintaining a balance between independence and dependence in one’s relationships with others.

Dependent behaviors include affection seeking, help seeking, and attention seeking.

Independent behaviors include mastery of obstacles and initiative taking.

According to Hanson, when assessing this mode in families, the nurse tries to determine how successfully the family lives within a given community.

The nurse would assess the interactions of the family with the neighbors and other community groups, the support systems of the family, and the significant others .

The goal of nursing is to promote adaptation of the client during both health and illness in all four of the modes.

Actions of the nurse begin with the assessment process, The family is assessed on two levels. First, the nurse makes a judgment with regard to the presence or absence of maladaptation.

Then, the nurse focuses the assessment on the stimuli influencing the family’s maladaptive behaviors. The nurse may need to manipulate the environment, an element or elements of the client system, or both in order to promote adaptation .

Roy employs a six-step nursing process which includes: assessment of behaviour, assessment of stimuli, nursing diagnosis, goal setting, intervention and evaluation.

In the first step, the person's behaviour in each of the four modes is observed. This behaviour is then compared with norms and is deemed either adaptive or ineffective.

The second step is concerned with factors that influence behaviour. Stimuli are classified as focal, contextual or residual.

The nursing diagnosis is the statement of the ineffective behaviours along with the identification of the probable cause.

In the fourth step, goal setting is the focus. Goals need to be realistic and attainable and are set in collaboration with the person.

Intervention occurs as the fifth step, and this is when the stimuli are manipulated. It is also called the 'doing phase'.

In the final stage, evaluation takes place. The degree of change as evidenced by change in behaviour, is determined. Ineffective behaviours would be reassessed, and the interventions would be revised

Betty Neuman's Systems Model “Health is a condition in

which all parts and subparts are in harmony with the whole of the client.”

Developed this model based on the individual’s relationship to stress, the reaction to it, and reconstitution factors that are dynamic in nature.

Reconstitution is the state of adaptation to stress.

KEY CONCEPTS• Viewed the client as an open system consisting of a basic

structure or central core of energy resources which represent concentric circles

• Each concentric circle or layer is made up of the five variable areas which are considered and occur simultaneously in each client concentric circles. These are:

1. Physiological - refers of bodily structure and function.2. Psychological - refers to mental processes, functioning and

emotions.3. Sociocultural - refers to relationships; and social/cultural

functions and activities.4. Spiritual - refers to the influence of spiritual beliefs.5. Developmental - refers to life’s developmental processes.

Basic Structure Energy Resources-This is otherwise known as the central core, which is made up of the basic survival factors common to all organisms. These include the following:

1. Normal temperature range – body temperature regulation ability2. Genetic structure – Hair color and bodily features3. Response pattern – functioning of body systems homeostatically4. Organ strength or weakness5. Ego structure6. Knowns or commonalities – value system• The person's system is an open system - dynamic and constantly

changing and evolving• Stability, or homeostasis, occurs when the amount of energy that is

available exceeds that being used by the system.• A homeostatic body system is constantly in a dynamic process of input,

output, feedback, and compensation, which leads to a state of balance

• Central core of energy resources surrounded by two concentric boundaries or rings referred to as lines of resistance.

Lines of Resistance The last boundary that protects the basic structure or it represents

the internal factors that help client defend against s stressor Protect the basic structure and become activated when

environmental stressors invade the normal line of defense. An example is that when a certain bacteria enters our system, there is an increase in leukocyte count to combat infection.

If the lines of resistance are effective, the system can reconstitute and if the lines of resistance are not effective, the resulting energy loss can result in death.

Outside the lines of resistance are two lines of defense:

1. Normal Line of Defense

• Represents client’s usual wellness level.• Can change over time in response to coping or responding to the

environment, which includes intelligence, attitudes, problem solving and coping abilities. Example is skin which is constantly smooth and fair will eventually form callous over times.

2. Flexible Lines of Defense

• Is the outer boundary to the normal line of defense, the line of resistance, and the core structure.

• Keeps the system free from stressors and is dependent on the amount of sleep, nutritional status, as well as the quality and quantity of stress an individual experiences.

• If the flexible line of defense fails to provide adequate protection to the normal line of defense, the lines of resistance become activated.

Neuman categorizes Stressors as: Stressors Are capable of producing either a positive or negative effect on the client

system. Is any environmental force which can potentially affect the stability of the

system:1. Intrapersonal - occur within person, example is infection, thoughts and

feelings2. Interpersonal - occur between individuals, e.g. role expectations3. Extrapersonal - occur outside the individual, e.g. job or finance concerns A person’s reaction to stressors depends on the strength of the lines of

defense. When the lines of defense fails, the resulting reaction depends on the

strength of the lines of resistance. As part of the reaction, a person’s system can adapt to a stressor, an effect

known as reconstitution.

Reconstitution

Is the increase in energy that occurs in relation to the degree of reaction to the stressor which starts after initiation of treatment for invasion of stressors.

May expand the normal line of defense beyond its previous level, stabilize the system at a lower level, or return it to the level that existed before the illness.

Nursing interventions focus on retaining or maintaining system stability.

By means of primary, secondary and tertiary interventions, the person (or the nurse) attempts to restore or maintain the stability of the system.

Prevention Is the primary nursing intervention. Focuses on keeping stressors and the stress response from having a detrimental effect on

the body.1. Primary prevention -focuses on protecting the normal line of defense and strengthening

the flexible line of defense. This occur before the system reacts to a stressor and strengthens the person (primarily the flexible line of defense) to enable him to better deal with stressors and also manipulates the environment to reduce or weaken stressors. Includes health promotion and maintenance of wellness.

2. Secondary prevention- focuses on strengthening internal lines of resistance, reducing the reaction of the stressor and increasing resistance factors in order to prevent damage to the central core. This occurs after the system reacts to a stressor. This includes appropriate treatment of symptoms to attain optimal client system stability and energy conservation.

3. Tertiary prevention -focuses on readaptation and stability, and protects reconstitution or return to wellness after treatment. This occurs after the system has been treated through secondary prevention strategies. Tertiary prevention offers support to the client and attempts to add energy to the system or reduce energy needed in order to facilitate reconstitution.

MARTHA ROGERS' SCIENCE OF UNITARY HUMAN BEINGS

• Described the irreducible nature of individuals as being different from the sum of their parts

• She theorized that the identity of nursing as a science arises from the integrality of people and the environment that coordinates with a multidimensional universe of open systems

• Rogers' model provides the way of viewing the unitary human being. Humans are viewed as integral with the universe: the unitary human being and the environment are one, not dichotomous

• The basic characteristics that describe the life process of human include energy field, openness, pattern, and pan-dimensionality. The basic concepts of the theory include unitary human being, environment, and homeodynamic principles.

Concepts of Rogers' mode

1. Energy field The energy field is the fundamental unit of both the living and nonliving. This energy field "provides a way to perceive people and environment as irreducible wholes". The energy fields continuously varies in intensity, density, and extent.

2. Openness The human field and the environmental field are constantly exchanging their energy back and forth. There are no boundaries or barriers that inhibit energy flow between the fields.

3. Pattern Pattern is defined as the distinguishing characteristic of an energy field. "Pattern is an abstraction and it gives identity to the field“.

4. Pan-dimensionality Pan-dimensionality is defined as "non linear domain without spatial or temporal attributes". The parameters that humans use in language to describe events are arbitrary. The present is relative; there is no temporal ordering of lives.

5. Unitary Human Being (person A unitary human being is an "irreducible, indivisible, pan-dimensional (four-dimensional) energy field identified by pattern and manifesting characteristics that are specific to the whole and which cannot be predicted from knowledge of the parts" and "a unified whole having its own distinctive characteristics which cannot be perceived by looking at, describing, or summarizing the parts". The person has the capacity to participate knowingly and probabilistically in the process of change.

6. Environment The environment is an "irreducible, pan-dimensional energy field identified by pattern and integral with the human field". The two fields coexist and are integral. Manifestations emerge from this field and are perceived by the person.