Over View of Nursing Theories

Vidya V SMSc Nursing student

What is a theory?• A system of idea intended to explain something,

especially one based on general principle.- Oxford dictionary

• Principle : Fundamental truth or proposition serving as the foundation for belief or action.

What is a theory?• It may consist of one or more relatively

specific and concrete concepts and propositions that purport to account for, or organize some phenomenon (Barnum, 1988)

• A set of concepts, definitions, models, propositions, and assumptions that project a systematic view of a phenomena.

What are the components of a theory?• Concepts – Ideas and mental images that help to

describe phenomena (Alligood and Marriner-Tomey, 2002).

• Definitions – Convey the general meaning of the concepts.

• Models – These are representations of the interaction among and between the concepts showing patterns.

• Prepositions -are statements that explain the relationship between the concepts.

• Assumptions – Statements that describe concepts.

• Phenomenon – Aspect of reality that can be consciously sensed or experienced (Meleis, 1997).

Theory Vs Model• A theory is a set of statements that is developed

through a process of continued abstractions. It is a generalized statement aimed at explaining a phenomenon.

• A model, on the other hand, is a purposeful representation of reality.

What is a paradigm?• A nursing paradigm is a concept that has

developed over time from the beliefs and practices of professionals in the healthcare sector.

• According to Nursing Theories, a nursing paradigm is a pattern that shows the relationship between a person, the environment in which she lives and her health.

Nursing paradigm domains

Client

Nurse

Health

Enviro-nment

How does domain relate to nursing theory?

• Nursing has its domain in a paradigm that includes four linkages:

• Person/client• Health• Environment• Nursing (goals, roles, functions)

Each of these concepts is usually defined and described by a nursing theorist. Of the four concepts, the most important is that of the person. The focus of nursing is the person.

Importance of nursing theories

• Nursing theory aims to describe, predict and explain the phenomenon of nursing (Chinn and Jacobs 1978).

• It provides the foundations of nursing practice, help to generate further knowledge and indicate in which direction nursing should develop in the future (Brown 1964).

Importance of nursing theories

• Theory is important because it helps us to decide what we know and what we need to know (Parsons1949).

• It helps to distinguish what should form the basis of practice by explicitly describing nursing.

• This can be seen as an attempt by the nursing profession to maintain its professional boundaries.

What are the purposes of nursing theory?

• It guides nursing practice and generates knowledge.

• It helps to describe or explain nursing.

• Enables nurses to know WHY they are doing WHAT they are doing.

Characteristics of a Theory1. Systematic, logical and coherent (orderly reasoning, no contradictions)2. Creative structuring of ideas mental images of one’s experiences and create

different ways of looking at a particular event or object.

3. Tentative in nature ( change over time or evolving but some remain valid despite passage of time)

Characteristics of a Theory

4. Interrelate concepts in such a way as to create a different way of looking at a particular phenomenon.

5. Are logical in nature.6. Are generalizable.7. Are the bases for hypotheses that can be

tested.

Characteristics of a Theory

8. Increase the general body of knowledge within the discipline through the research implemented to validate them.

9. Are used by the practitioners to guide and improve their practice.

10.Are consistent with other validated theories, laws, and Principles but will leave open unanswered questions that need to be investigated.

Uses of theory

• Theory guides and improve nursing practice.

• Theory provides goal for nursing care and with

goals, nursing practice is rendered more effective

and efficient.

• Theories help to focus the goals, making nurses

more confident about the practice.

Uses of theory

• Theory guides research

• It validates and modifies the theory.

• Theory contributes to the development of the

disciplines body of knowledge.

• Theory enhances communication.

Types of nursing theories• Meta-theory - the theory of theory. Identifies specific

phenomena through abstract concepts.

• Grand theories – broad and complex

• Middle-range theories- address specific phenomena and reflect practice

• Practice theory - explores one particular situation found in nursing. It identifies explicit goals and details how these goals will be achieved.

Types...• Descriptive theories – first level of theory

development

• Prescriptive theories – address nursing interventions and predict their consequences

Grand nursing theories 

• These theories have the broadest scope and present general concepts and propositions.

• Theories at this level may both reflect and provide insights useful for practice but are not designed for empirical testing.

• Grand theories consist of conceptual frameworks defining broad perspectives for practice and ways of looking at nursing phenomena based on the perspectives.

Mid-range nursing theories

• These theories are narrower in scope than grand nursing theories and offer an effective bridge between grand nursing theories and nursing practice.

• They present concepts and propositions at a lower level of abstraction and hold great promise for increasing theory-based research and nursing practice strategies.

Nursing practice theories

• Nursing practice theories have the most limited scope and level of abstraction and are developed for use within a specific range of nursing situations.

• Nursing practice theories provide frameworks for nursing interventions, and predict outcomes and the impact of nursing practice.

Historical Development• In the early part of nursing’s history, knowledge was

extremely limited and almost entirely task oriented.

• Role of nurses where questioned; what they do, for whom where and when were determined.

• The professionalization of nursing has been and is being brought about through the development and use of nursing theory.

First Conference in Nursing theory

Brought leading scholars and theorists to discuss and debate on issues regarding nursing science and theory development.

Nightingale (1854)Environmental theory• Pure fresh air• Pure water• Effective drainage• Cleanliness• Light(especially direct sunlight)

Any deficiency in one or more of these factors could lead to impaired functioning of life processes or diminished health status.

Application • "Patients are to be put in the best condition for nature

to act on them, it is the responsibility of nurses to reduce noise, to relieve patients’ anxieties, and to help them to sleep."

• As per most of the nursing theories, environmental adaptation remains the basis of holistic nursing care.

Virginia Henderson (1964)Nursing need theoryModern Nursing Nightingale /The 20th century Nightingale

“ The unique function of the nurse is to assist 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. And to do this in such a way as to help him gain independence as rapidly as possible" (Henderson, 1966)”

The 14 components

1. Breath normally.2. Eat and drink adequately.3. Eliminate body wastes.4. Move and maintain desirable postures.5. Sleep and rest.6. Select suitable clothes-dress and undress.7. Maintain body temperature within normal range by adjusting

clothing and modifying environment8. Keep the body clean and well groomed and protect the

integument9. 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.

Hildegard Peplau (1952)

Interpersonal theory• Focuses on the interpersonal processes and therapeutic

relationship that develops between the nurse and client.

4 phases of Nurse- patient relationship• Orientation• Identification • Exploitation• Resolution

Faye G. Abdellah (1960)21 Nursing Problems Theory1. To maintain good hygiene and physical comfort2. To promote optimal activity: exercise, rest, sleep3. To promote safety through prevention of accident, injury,

or other trauma and through prevention of the spread of infection

4. To maintain good body mechanics and prevent and correct deformity

5. To facilitate the maintenance of a supply of oxygen to all body cells

6. To facilitate the maintenance of nutrition for all body cells

7. To facilitate the maintenance of elimination8. To facilitate the maintenance of fluid and electrolyte

balance9. To recognize the physiologic responses of the body to

disease conditions—pathologic, physiologic, and compensatory

10. To facilitate the maintenance of regulatory mechanisms and functions

11. To facilitate the maintenance of sensory function12. To identify and accept positive and negative expressions,

feelings, and reactions13. To identify and accept interrelatedness of emotions and organic

illness14. To facilitate the maintenance of effective verbal and nonverbal

communication15. To promote the development of productive interpersonal

relationships16. To facilitate progress toward achievement and personal

spiritual goals17. To create or maintain a therapeutic environment18. To facilitate awareness of self as an individual with varying

physical, emotional, and developmental needs19. To accept the optimum possible goals in the light of limitations,

physical and emotional20. To use community resources as an aid in resolving problems

that arise from illness21. To understand the role of social problems as influencing factors

in the cause of illness

Imogene King (1971)Theory of Goal Attainment 

King has interrelated the concepts of interaction, perception, communication, transaction, self, role, stress, growth and development, time, and space into a theory of goal attainment. 

Nursing is a process of action, reaction, and interaction whereby nurse and client share information about their perceptions in the nursing situation. The nurse and client share specific goals, problems, and concerns and explore means to achieve a goal.

Imogene King (1971)

Concepts for Personal System• Perception• Self• Growth &

development• Body image• Space• Time

Concepts for Interpersonal System• Interaction• Communication• Transaction• Role• StressConcepts for Social System• Organization• Authority• Power• Status• Decision making

Dorothea Orem(1971)

Self care deficit theoryPeople should be self-reliant and responsible for their own care and others in their family needing care.

Composed of three interrelated theories: (1) The theory of self-care(2) The self-care deficit theory, and (3) The theory of nursing system

Dorothea Orem(1971)

• Nursing is as 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.

Betty Neuman (1972)

System modelIt provides a comprehensive flexible holistic and system based perspective for nursing.

Human being is viewed as an open system that interacts with both internal and external environment forces or stressors. The human is in constant change, moving toward a dynamic state of system stability or toward illness of varying degrees.

Myra Levine (1973)

The Conservation Model

Nursing’s role in conservation is to help the person with the process of “keeping together” the total person through the least expense of effort.

Levine proposed the following four principles of conservation:

• The conservation of energy of the individual• The conservation of the structural integrity of the individual.• The conservation of the personal integrity of the individual.• The conservation of the social integrity of the individual.

Sister Callista Roy (1976)

Adaptation model (RAM)RAM is one of the widely applied nursing models in nursing practice, education and research.

Nursing goals are to promote adaptation for individuals and groups in the four adaptive modes, thus contributing to health, quality of life, and dying with dignity.

1. Physiologic-physical mode2. Self-concept-group identity

mode3. Role function mode4. Interdependence mode:

Jean Watson (1979)

Theory of human caring• Caring can be effectively demonstrated

and practiced only interpersonally.• Caring consists of carative factors that

result in the satisfaction of certain human needs.

• Effective caring promotes health and individual or family growth.

The ten primary carative factors

1. The formation of a humanistic- altruistic system of values.

2. The installation of faith-hope.3. The cultivation of sensitivity to one’s self and to

others.4. The development of a helping-trust relationship5. The promotion and acceptance of the expression of

positive and negative feelings.6. The systematic use of the scientific problem-solving

method for decision making7. The promotion of interpersonal teaching-learning.8. The provision for a supportive, protective and /or

corrective mental, physical, socio-cultural and spiritual environment.

9. Assistance with the gratification of human needs.10.The allowance for existential-phenomenological

forces.

Orlando theory

The 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.

• 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 behaviour.

Hall’s theory

The Aspects of Care, Core, Cure

The theory contains of three independent but interconnected circles:• The core: The person or patient to whom

nursing care is directed and needed.• The care : The attention given to patients by

the medical professionals• The cure: The attention given to patients by

the medical professionals.

Types...Theories can also be categorized as:

– "Needs "theories.– "Interaction" theories.– "Outcome "theories.– "Humanistic theories"

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.

Interaction theories• These theories revolve around the

relationships nurses form with patients.

• Such theories have been criticized for largely ignoring the medical model of health and not attending to basic physical needs.

Outcome theories• These portray the nurse as the changing force,

who enables individuals to adapt to or cope with ill health (Roy 1980).

• Outcome theories have been criticized as too abstract and difficult to implement in practice (Aggleton and Chalmers 1988).

Humanistic Theories• Humanistic theories developed in response to the

psychoanalytic thought that a person’s destiny was determined early in life.

• Humanistic theories emphasize a person’s capacity for self actualization .

• Humanists believes that the person contains within himself the potential for healthy and creative growth.

• The major contribution that Rogers added to nursing practice is the understanding that each client is a unique individual, so person-centered approach now practice in Nursing.

Need theorists Interaction Theorists

Outcome theorists

• Abdellah• Henderson• Orem

• King• Orlando• Peterson and

Zderad• Paplau• Travelbee• Wiedenbach

• Johnson• Levine• Rogers• Roy

Commonly used non-nursing models

• Systems model

• Basic Human Needs model

• Health and Wellness Models

• Stress and Adaptation

• Developmental Theories

• Psychosocial Theories

Systems theory• Systems theory may be considered as a

specialization of systems thinking and a generalization of systems science.

• Many nursing theorists have drawn from systems theory.– Neuman's Systems Theory– Rogers 's Theory of Unitary Human Beings– Roy's Adaptation Model– Imogene King's Theory of Goal Attainment– Orem Self-care Deficit Theory– Johnson's Behavior Systems Model

Basic Human Needs model

Health and Wellness Model

Stress and Adaptation

Developmental Theories

• Freud : Psychosexual theory

• Erikson : Psychosocial theory

• Piaget : Cognitive theory

• Kohlberg : Theory of moral development

Why do we study nursing theory?

• Everyday practice enriches theory• Both practice and theory are guided by

values and beliefs• Theory helps to reframe our thinking about

nursing• Theory guides use of ideas and techniques• Theory can close the gap between theory

and research• To envision potentialities (Gordon, Parker, &

Jester, 2001)

So how do nurses use theory in everyday practice?

• Organize patient data• Understand patient data• Analyze patient data• Make decisions about nursing interventions• Plan patient care• Predict outcomes of care• Evaluate patient outcomes (Alligood, 2001)

Current trends that influence nursing theory

• Medical science• Nursing education• Professional nursing organizations• Evolving research approaches• Global concerns• Consumer demands• Technologies

Theory development They are derived through two principal methods:

1. Deductive reasoning

2. Inductive reasoning.

Four strategies of theory development• Theory → practice → theory Theory developed in other discipline and used in nursing situations• Practice → theory : theory evolved from clinical

practice• Research → theory or inductive method Must evolve from research findings or empirical evidence.• Theory → research → theory . Original theory examined

and given a new research findings.

Criticisms of nursing theories

• Nursing theory is generally neglected on the wards.• A nursing theory should have the characteristics of

accessibility and clarity.• It is important that the language used in the development

of nursing theory be used consistently.• Many nurses have not had the training or experience to

deal with the abstract concepts presented by nursing theory.

• Majority of nurses fail to understand and apply theory to practice (Miller 1985).

“Nursing theories mirror different realities, throughout their

development; they reflected the interests of nurses of that time”