GARCIA, Neil A. May 12, 2009

TABOR, Yolybeth S.

BSN-2E

THEORETICAL FOUNDATIONS OF NURSING

A. ENVIRONMENTAL THEORY

“I think one’s feelings waste

themselves in words; they ought all to

be distilled into actions which bring

results.”

Florence Nightingale (1860)

Florence Nightingale defined Nursing as “the act of

utilizing the environment of the patient to assist him in

his recovery” (1860/1969), that it involves the nurse's

initiative to configure environmental settings appropriate

for the gradual restoration of the patient's health, and

that external factors associated with the patient's

surroundings affect life or biologic and physiologic

processes, and his development.

Environmental Factors Affecting Health

Defined in her environmental theory are the following

factors present in the patient’s environment:

pure or fresh air

pure water

sufficient food supplies

efficient drainage

cleanliness

light (especially direct sunlight)

Adequate ventilation has also been regarded as a factor

contributing to changes of the patient’s process of illness

recovery. Any deficiency in one or more of these factors

could lead to impaired functioning of life processes or

diminished health status.

She also emphasized in her environmental theory is the

provision of a quiet or noise-free and warm environment,

attending to patient’s dietary needs by assessment,

documentation of time of food intake, and evaluating it’s

effects on the patient.

Nightingale believed that the environment was the major

component creating illness in a patient; she regarded

disease as “the reactions of kindly nature against the

conditions in which we have placed ourselves.” Her theory

Contains three major relationships:

environment to patient

nurse to environment

nurse to patient

B. INTERACTIVE THEORIES

INTERPERSONAL RELATIONS THEORY

“The kind of person that the nurse

becomes makes a substantial difference in

what each patient will learn as he or she

receives nursing care.”

Hildegard Peplau (1952)

She defined Nursing as “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.”

Dr. Peplau emphasized the nurse-client relationship as

the foundation of nursing practice. At the time, her

research and emphasis on the give-and-take of nurse-client

relationships was seen by many as revolutionary. She

described the nurse-patient relationship as a four-phase

phenomenon. Each phase is unique and has distinguished

contributions on the outcome of the nurse-patient

interaction.

Phases Of Nurse-Patient Relationship

1

. Orientation

Individual/family has a “felt need”

and seeks professional assistance from a

nurse (who is a stranger). This is the

problem identification phase.

Where the patient begins to have

2. Identificationfeelings 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.

3. Exploitation The nurse uses communication tools

to offer services to the patient, who is

expected to take advantage of all

services.

4. 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.

Nursing Roles

In the course of the nurse-patient relationship, the

nurse assumes several roles which empower and equip her in

meeting the needs of the patient.

1. Stranger Role: Receives the client the same way one

meets a stranger in other life situations; provides

an accepting climate that builds trust.

2. Resource Role: Answers questions. Interprets

clinical treatment data, gives information.

3. Teaching Role: Gives instructions and provides

training; involves analysis and synthesis of the

learner’s experience.

4. Counseling Role: Helps client understand and

integrate the meaning of current life circumstances;

provides quidance and encouragement to make changes.

5. Surrogate Role: Helps clients clarify domains of

dependence, interdependence, and independence and

acts on clients behalf as advocate.

6. Leadership Role: Helps client assume maximum

responsibility for meeting treatment goals in a

mutually satisfying way.

Additional Roles include:

1. Technical expert

2. Consultant

3. Health teacher

4. Tutor

5. Socializing agent

6. Safety agent

7. Manager of environment

8. Mediator

9. Administrator

10.Recorder observer

11.Researcher

Definition of the Unique Function of

Nursing

“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

mother, the mouthpiece for those too weak or withdrawn to

speak and so on.”

Virginia Henderson (1955)

Henderson defined Nursing as “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”.

She conceptualized the 14 Fundamental Needs of humans.

These needs are:

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.

The Nurse-Patient Relationship

Henderson stated that there are three levels comprising

the nurse-patient relationship:

1. The nurse as a substitute for the patient. In times

of illness, when the patient cannot function fully,

the nurse serves as the substitute as to what the

patient lacks such, as knowledge, will, and strength

in order to make him complete, whole and independent

once again.

2. The nurse as a helper to the patient. In situations

where the patient cannot meet his basic needs, the

nurse serves as a helper to accomplish them.

3. The nurse as a partner with the patient. As partners,

the nurse and the patient formulate the care plan

together. Both as an advocate and as a resource

person, the nurse can empower the patient to make

effective decisions regarding his care plans.

Dynamic Nurse-Patient Relationship

“The role of the nurse is to find out and meet the

patient's immediate need for help. The patient's presenting

behavior may be a plea for help, however, the help needed

may not be what it appears to be.”

Ida Jean Orlando (1961)

Orlando's theory was developed in the late 1950s from

observations she recorded between a nurse and patient.

Despite her efforts, she was only able to categorize the

records as "good" or "bad" nursing. It then dawned on her

that both the formulations for "good" and "bad" nursing were

contained in the records. From these observations she

formulated the deliberative nursing process.

Therefore, nurses need to use their perception,

thoughts about the perception, or the feeling engendered

from their thoughts to explore with patients the meaning of

their behavior. This process helps the nurse find out the

nature of the distress and what help the patient needs.

Orlando's theory remains one the of the most effective

practice theories available. The use of her theory keeps the

nurse's focus on the patient. The strength of the theory is

that it is clear, concise, and easy to use. While providing

the overall framework for nursing, the use of her theory

does not exclude nurses from using other theories while

caring for the patient.

Key Concepts of Three Interlocking Circles Theory

According to Hall, Nursing is

participation in care, core and cure

aspects, where CARE is the sole

function of nurses, whereas the CORE

and CURE are shared with other

members of the health team

The major purpose of care is to

achieve an interpersonal

relationship with the individual

that will facilitate the development

of the core Lydia Hall (1961)

Human-to-Human Relationship Model

“A nurse does not only seek to alleviate physical pain

or render physical care- she ministers to the whole person.

The existence of suffering, whether physical, mental or

spiritual is the proper concern of the nurse.”

Joyce Travelbee (1966)

Travelbee's experience in initial psych nursing

practice at a Catholic charity hospital led her to believe

that the care given in these type of institutions lacked

compassion. She felt nursing needed a "humanistic

revolution" and a renewed focus on caring as central to

nursing--she warned that if this didn't happen, consumers

might seek a "new and different kind of health care worker".

Travelbee's ideas have greatly influenced the hospice

movement.

In her human-to-human relationship model, the nurse and

the patient undergoes the following series of interactional

phases:

1. Original Encounter- this is described as the first

impression by the nurse of the sick person and vice-

versa The nurse and patient see each other in

stereotyped or traditional roles.

2. Emerging Identities- this phase is described by the

nurse and patient perceiving each other as unique

individual. At this time, the link of relationship

begins to form.

3. Empathy- this phase is described as the ability to

share in the person’s experience.

4. Sympathy- It happens when the nurse wants to lessen

the cause of the patient’s suffering. It goes beyond

empathy. The nurse at this time should use a

disciplined intellectual approach together with

therapeutic use of self to make helpful nursing

actions.

5. Rapport- this is described as nursing interventions

that lessens the patient’s suffering. The nurse and

the sick person are relating as human being to human

being. The sick person shows trust and confidence in

the nurse.

C. SYSTEMS THEORIES

System Model in Nursing Practice

“Health is a condition in which

all parts and subparts are in harmony

with the whole of the client”

Betty Neuman (1972)

Her theory incorporated the concept of a whole person

and an open system approach. The concept is aimed towards

the development of a person in a state of wellness having

the capacity to function optimally. The main role of the

nurse in her theory is to help a person to adapt with

environmental stimuli causing illnesses back to a state of

wellness.

Terms Related to Neuman’s System Theory

Client Variables

The clients’ variables can be one or combination of the

following: physiological, sociocultural, developmental and

spiritual. These variables function to achieve stability in

relation to the environmental stressors experienced by the

client.

Lines of Resistance

Lines of Resistance act when the Normal Line of Defense

is invaded by too much stressor, producing alterations in

the client’s health.

Normal Line of Defense

To achieve the stability of the system, the Normal Line

of Defense must act in coordination with the normal wellness

state. It must reflect the actual range of responses that is

normally acted by clients in response to any stressors. It

is the baseline in determining the level of client within

the continuum of health.

Flexible Line of Disease

It serves as a boundary for the Normal Line of Defense

to adjust to situations that threaten the imbalance within

the client’s stability.

Stressors

These are forces that produce tensions, alterations or

potential problems causing instability within the client’s

system.

Reaction

These are the outcomes or produced results of certain

stressors and actions of the lines resistance of a client.

It can be positive or negative depending on the degree of

reaction the client produces to adjust and adapt with the

situation. Neuman specified these reactions as negentropy or

entropy. Negentropy is set towards stability or wellness

while Egentropy is set towards disorganization of the system

producing illness.

Behavioral System Model

“Each individual has a predisposition

to act, with reference to the goal, in certain ways rather

than in other ways”

Dorothy Johnson (1971)

Johnson believes that each individual has a focusing

and repeating ways of acting which covers a behavioral

system distinct to that individual. These behaviors are

logical, fixed, predictable and adequately secure and

persistent to be satisfying to depiction and clarification.

Seven Behavioral Subsystems

1. The Attachment or Affiliative Subsystem is well-

known as the earliest response system to expand in

the individual. The most favorable functioning of

this subsystem allows social inclusion, closeness,

and the pattern and continuance of a strong public

bond.

2. The Dependency Subsystem are actions that trigger

nurturing behaviors from other individuals in the

environment. The product of dependency behavior is

consent, interest or appreciation, and physical

support.

3. The Ingestive Subsystem relates to the behaviors

surrounding the ingestion of food. Behaviors related

to the ingestion of food may relate more to what is

socially satisfactory in a specified culture, than

to the biological necessities of the human being.

4. The Eliminative Subsystem relates to behaviors

surrounding the secretion of waste products from the

body. Human cultures have defined different socially

acceptable behaviors for excretion of waste, but the

continuation of such an outline remains from culture

to culture.

5. The Sexual Subsystem imitates behaviors realted to

procreation or reproduction.

6. The Aggressive Subsystem relates to behaviors

concerned with the defense and self-preservation.

7. The Achievement Subsystem contains behaviors that

attept to control the environment. Intellectual,

physical, imaginative, mechanical, and communl

skills are some of the areas that Johnson

distinguishes.

Goal Attainment Theory

“If the students can’t do the

fundamentals, how can they use advanced

knowledge.”

Imogene King (1971)

King stated that Nursing is a process of action,

reaction, and interaction whereby nurse and client share

information about their perception in the nursing situation.

Action

Action is a means of behavior or activities that are

towards the accomplishment of certain act. It is both

physical and mental.

Reaction

In King’s theory, reaction is not specified but somehow

relates reaction as part of action. According to her,

reaction is a response to a stimuli.

Interaction

Interaction, as defined by King, is any situation

wherein the nurse relates and deals with a clientele or

patient.

Open System

It is the absence of boundary existence, where a

dynamic interaction between the internal and external

environment can exchange information without barriers or

hindrances.

King proposed that the nurse interacts in the system

simultaneously at three different levels. These levels are

independent and at the same time co-exist to influence over-

all nursing practice.

Personal- how the nurse views and integrates self based

from personal goals and beliefs

Interpersonal- how the nurse interrelates with a co-

worker or patient, particularly in a nurse-patient

relationship

Social- how the nurse interacts with co-workers,

superiors, subordinates and the client environment in

general

Self-Care Theory

“Individuals, families, groups and

communities need to be taught self-

care.”

Dorothea Orem (1971)

Orem defined Nursing as “The act of assisting others in

the provision and management of self-care to

maintain/improve human functioning at home level of

effectiveness.”

The theory focuses on activities that adult individuals

perform on their own behalf to maintain life, health and

well-being. It has a strong health promotion and maintenance

focus.

She 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:

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.

Twenty-One Nursing Problems

“I never wanted to be a medical

doctor because I could do all I wanted to

do in nursing, which is a caring

profession.”

Faye Glen Abdellah (1960)

The concept of Nursing in this theory is generally

grouped into twenty-one problem areas for nurses to work out

their judgment and appropriate care. Abdellah considers

nursing to be an all-inclusive service that is based on the

disciplines of art and science that serves individuals, sick

or well with their health needs.

Typology of Twenty-one Nursing Problems

1. To maintain good hygiene.

2. To promote optimal activity; exercise, rest and sleep.

3. To promote safety.

4. To maintain good body mechanics.

5. To facilitate the maintenance of a supply of oxygen

6. To facilitate maintenance of nutrition

7. To facilitate maintenance of elimination

8. To facilitate the maintenance of fluid and electrolyte

balance

9. To recognize the physiologic response of the body to

disease conditions

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 illness.

14. To facilitate the maintenance of effective verbal and

non-verbal communication

15. To promote the development of productive

interpersonal relationship

16. To facilitate progress toward achievement of personal

spiritual goals

17. To create and maintain a therapeutic environment

18. To facilitate awareness of self as an individual with

varying needs.

19.To accept the optimum possible goals

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

Helping Art of Clinical Nursing

"My thesis is that nursing art is

not comprised of rational nor

reactionary actions but rather of

deliberative action."

Ernestine Wiedenbach (1964)

Wiedenbach conceptualizes nursing as the practice

identification of a patient’s need for help through

observation of presenting behaviors and symptoms,

exploration of the meaning of those symptoms with the

patient, determining the cause(s) of discomfort, and

determining the patient’s ability to resolve the discomfort

or if the patient has a need for help from the nurse or

other healthcare professionals. 

Nursing primarily consists of identifying a patient’s

need for help. If the need for help requires intervention,

the nurse facilitates the medical plan of care and also

creates and implements a nursing plan of care based on needs

and desires of the patient. In providing care, a nurse

exercises sound judgment through deliberative, practiced,

and educated recognition of symptoms. The patient’s

perception of the situation is an important consideration to

the nurse when providing competent care.

According to Wiedenbach there are four elements to

clinical nursing: (1) philosophy, (2) purpose, (3) practice,

and (4) art.

The nurses’ philosophy was their attitude and

belief about life and how that effected reality

for them. Philosophy is what motivates the nurse

to act in a certain way.

Wiedenbach also believed that there were 3

essential components associated with a nursing

philosophy:

o Reverence for life

o Respect for the dignity, worth, autonomy and

individuality of each human being

o Resolution to act on personally and

professionally held beliefs

Nurses’ purpose is that which the nurse wants to

accomplish through what she does.  It is all of

the activities directed towards the overall good

of the patient.

Practices are those observable nursing actions

that are affected by beliefs and feelings about

meeting the patient’s need for help. 

The Art of nursing includes understanding

patient’s needs and concerns, developing goals and

actions intended to enhance patient’s ability and

directing the activities related to the medical

plan to improve the patient’s condition.  The

nurses also focuses on prevention of complications

related to reoccurrence or development of new

concerns.

The Conservation Model

"Ethical behaviour is not the display of one's moral

rectitude in times of crisis. It is the day-to-day

expression of one's commitment to other persons and the ways

in which human beings relate to one another in their daily

interactions.”

Myra Levine (1977)

She defined nursing as supportive & therapeutic

interventions based on scientific or therapeutic knowledge.

Nursing actions based on four principles:

conservation of energy

structural integrity

personal integrity

social integrity

D. DEVELOPMENTAL THEORIES

Adaptation Model

“The model provides a way of thinking about people and

their environment that is useful in any setting. It helps

one prioritize care and challenges the nurse to move the

patient from survival to transformation.”

Sister Callista Roy (1979)

She viewed humans as biopsychosocial beings constantly

interacting with a changing environment and who cope with

their environment through Biopsychosocial adaptation

mechanisms. There are two categories of coping mechanisms

according to Roy namely the regulator and the cognator

subsystems:

Regulator Subsystem transpires through neutral,

chemical and endocrine processes like the increase in

vital signs-sympathetic response to stress.

Cognator Subsystem, on the other hand, occurs through

cognitive-emotive processes. For instance, are the

effects of prolonged hospitalization for a four-year

old child.

The degree of internal or external environmental change

and the person’s ability to cope with that change is likely

to determine the person’s health status. Nursing

interventions are aimed at promoting physiologic,

psychologic, and social functioning or adaptation.

Transcultural Theory

“Care is the heart of nursing; Care

is power; Care is essential to healing;

Care is curing; and Care is the central

and dominant focus of nursing and

transcultural nursing decisions and

actions.”

Madeleine Leininger (1985)

She stated that Nursing is a learned humanistic and

scientific profession and discipline which is focused on

human care phenomena and activities in order to assist,

support, facilitate, or enable individuals or groups to

maintain or regain their well being (or health) in

culturally meaningful and beneficial ways, or to help people

face handicaps or death.

Transcultural nursing as a learned subfield or branch

of nursing which focuses upon the comparative study and

analysis of cultures with respect to nursing and health-

illness caring practices, beliefs and values with the goal

to provide meaningful and efficacious nursing care services

to people according to their cultural values and health-

illness context. It focuses on the fact that different

cultures have different caring behaviors and different

health and illness values, beliefs, and patterns of

behaviors. Awareness of the differences allows the nurse to

design culture-specific nursing interventions.

Philosophy and Science of Caring

“Caring in nursing conveys physical

Acts but embraces the mind-body-spirit

as it reclaims the embodied spirit as

its focus attention.”

Margaret Jean Watson (1979)

Watson proposes seven assumptions about the science of

caring and ten primary carative factors to form the

framework of her theory. The basic assumptions are:

Caring can be effectively demonstrated and practiced

only interpersonally;

Effective caring promotes health and individual or

family growth;

Caring responses accept a person not only as he or she

is now but as what he or she may become;

A caring environment is one that offers the development

of potential while allowing the person to choose the

best action for himself or herself at a given point in

time

Caring is more “healthogenic” than is curing. The

practice of caring integrates biophysical knowledge of

human behavior to generate or promote health and to

provide care to those who are ill. A science of caring

is therefore complementary to the science of curing.

The practice of caring is central to nursing

Ten Carative Factors

1. The promotion of a humanistic-altruistic system of

values

2. Instillation of faith-hope

3. The cultivation of sensitivity to one’s self and others

4. The development of a helping-trusting, human caring

relationship

5. Promotion and acceptance of the expression of positive

and negative feelings.

6. The systemic use of the scientific problem-solving

method for decision making

7. The promotion of interpersonal teaching-learning

8. The provision for supportive, protective and corrective

mental, physical, socio-cultural and spiritual

environment

9. Assistance with the gratification of human needs

10. The allowance for existential phenomenological

forces

The Science of Unitary Human Beings, and

Principles of Homeodynamics

“Nursing is an art and science that is

humanistic and humanitarian. It is directed

toward the unitary human and is concerned

with the nature and direction of human

development.”

Martha Rogers (1970)

Nursing interventions seek to promote harmonious

interaction between persons and their environment,

strengthen the wholeness of the individual and redirect

human and environmental patterns or organization to achieve

maximum health. There are 5 Basic Assumptions:

1. The human being is a unified whole, possessing

individual integrity and manifesting characteristics

that are more than and different from the sum of parts.

2. The individual and the environment are

continuously exchanging matter and energy with each

other

3. The life processes of human beings evolve irreversibly

and unidirectionally along a space-time continuum

4. Patterns identify human being and reflect their

innovative wholeness

5. The individual is characterized by the capacity for

abstraction and imagery, language and thought,

sensation and emotion

Theory of Human Becoming

“Nursing is a scientific discipline,

the practice of which is a performing

art.”

Rosemarie Rizzo Parse (1981)

Three assumptions about Human Becoming

Human becoming is freely choosing personal meaning

in situation in the inter-subjective process of

relating value priorities

Human becoming is co-creating rhythmic patterns or

relating in mutual process in the universe

Human becoming is co-transcending multidimensionally

with emerging possibilities.

References:

Octaviano, Eufemia F., RN, RM, MN, EdD, Balita, Carl E., RN,

RM, MAN, DrHum. “Theoretical Foundations of Nursing: The

Philippine Perspective”, 2008.

http://nursingcrib.com

http:// http://en.wikipedia.org/wiki/