Nursing Theory

Category: Education

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This PPT discuss about Nursing theories of XVI Unit of Nursing Foundation of B.Sc. Nursing I year as per INC Syllabus


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Unit XVI: Professional Nursing concepts and practices:

Unit XVI: Professional Nursing concepts and practices Mrs. P. Vadivukkarasi Ramanadin , Professor, Dept. Of OBG (N), Shri Vinoba Bhave College of Nursing, Shri Vinoba Bhave Civil Hospital, Silvassa, DNH.

Unit XVI: Professional Nursing concepts and practices:

Unit XVI: Professional Nursing concepts and practices SHRI VINOBA BHAVE COLLEGE OF NURSING 2 • Conceptual and theoretical models of nursing practice: Introduction to models holistic model, health belief model, health promotion model etc • Introduction to Theories in Nursing ; Peplau’s, Henderson’s Orem’s, Neumann’s Roger’s and Roy’s • Linking theories with nursing process • Complimentary and alternate healing techniques.


INTRODUCTION SHRI VINOBA BHAVE COLLEGE OF NURSING 3 The nursing profession has evolved greatly over time, moving from dependence upon total medical direction providing basic care into an independent practice modality with its own nursing theory practice, nursing models, and distinct nursing interventions. 90% of all Nursing theories are generated in the last 20 years. Nursing theories have been developed by a large number of leaders in the nursing field; below is a list of major nursing theorists who have contributed to the development of professional nursing practice into what it is today


NURSING THEORY SHRI VINOBA BHAVE COLLEGE OF NURSING 4 A theory is a group of related concepts that propose action which guide practice Nursing theory  is the term given to the body of knowledge that is used to support nursing practice . It is a set of concepts , definitions , relationships, and assumptions or propositions derived from nursing models or from other disciplines and project a purposive, systematic view of phenomena by designing specific inter-relationships among concepts for the purposes of describing, explaining, predicting, and /or prescribing

Historical perspectives and key concepts :

Historical perspectives and key concepts SHRI VINOBA BHAVE COLLEGE OF NURSING 5 Nightingale (1860): To facilitate “ the body’s reparative processes ” by manipulating client’s environment Peplau 1952: Nursing is; therapeutic interpersonal process . Henderson 1955: The needs often called Henderson’s 14 basic needs Abdellah 1960: The nursing theory developed by Faye Abdellah et al (1960) emphasizes delivering nursing care for the whole person to meet the physical, emotional, intellectual, social, and spiritual needs of the client and family. 21 basic needs. Orlando 1962: To Ida Orlando (1960), the client is an individual; with a need; that, when met, diminishes distress, increases adequacy, or enhances well-being. Johnson’s Theory 1968: Dorothy Johnson’s theory of nursing 1968 focuses on how the client adapts to illness and how actual or potential stress can affect the ability to adapt. The goal of nursing to reduce stress so that; the client can move more easily through recovery.

Cont. . . :

Cont. . . SHRI VINOBA BHAVE COLLEGE OF NURSING 6 Rogers 1970: to maintain and promote health, prevent illness, and care for and rehabilitate ill and disabled client through “humanistic science of nursing” Orem1971: This is self-care deficit theory . Nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental, or social needs. King 1971: To use communication to help client reestablish positive adaptation to environment. Neuman 1972: Stress reduction is goal of system model of nursing practice. Roy 1979: This adaptation model is based on the physiological, psychological, sociological and dependence-independence adaptive modes. Watson’s Theory 1979: Watson’s philosophy of caring 1979 attempts to define the outcome of nursing activity in regard to the; humanistic aspects of life.


METAPARADIGMS IN NURSING SHRI VINOBA BHAVE COLLEGE OF NURSING 7 1 . Person Recipient of care, including physical, spiritual, psychological, and sociocultural components. Individual, family, or community 2.  Environment All internal and external conditions, circumstances, and influences affecting the person 3. Health Degree of wellness or illness experienced by the person 4. Nursing Actions, characteristics and attributes of person giving care


COMPONENTS OF A THEORY SHRI VINOBA BHAVE COLLEGE OF NURSING 8 A theory is a group of related concepts that propose action that guide practice. A nursing theory is a set of concepts, definitions, relationships, and assumptions or propositions derived from nursing models or from other disciplines and project a purposive, systematic view of phenomena by designing specific inter-relationships among concepts for the purposes of describing, explaining, predicting, and /or prescribing Based on the knowledge structure levels the theoretical works in nursing can be studied under the following headings: Metaparadigm (Person, Environment, Health & Nursing) – (Most abstract) Nursing philosophies. Conceptual models and Grand theories. Nursing theories and Middle range theories (Least abstract)


DEFINITIONS SHRI VINOBA BHAVE COLLEGE OF NURSING 9 Theory a set of related statements that describes or explains phenomena in a systematic way Concept a mental idea of a phenomenon Concepts are the building blocks—the primary elements—of a theory. Construct- a phenomena that cannot be observed and must be inferred Constructs are concepts developed or adopted for use in a particular theory. The key concepts of a given theory are its constructs. Proposition a statement of relationship between concepts Conceptual model - made up of concepts and propositions They represent ways of thinking about a problem or ways of representing how complex things work the way that they do. Different Frameworks will emphasize different variables and outcomes and their interrelatedness.( Bordage , 2009) Models may draw on a number of theories to help understand a particular problem in a certain setting or context. They are not always as specified as theory. Variables Variables are the operational forms of constructs. They define the way a construct is to be measured in a specific situation. Match variables to constructs when identifying what needs to be assessed during evaluation of a theory-driven program. Models are representations of the interaction among and between the concepts showing patterns.

Cont. . .. :

Cont. . .. SHRI VINOBA BHAVE COLLEGE OF NURSING 10 Process it is a series of actions, changes or functions intended to bring about a desired result. During a process one takes systemic & continuous steps to meet a goal & uses both assessments & feedback to direct actions to the goal. A particular theory or conceptual frame work directs how these actions are carried out. 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. The terms ‘model’ and ‘theory’ are often wrongly used interchangeably, which further confounds matters. In nursing, models are often designed by theory authors to depict the beliefs in their theory (Lancaster and Lancaster 1981). They provide an overview of the thinking behind the theory and may demonstrate how theory can be introduced into practice, for example, through specific methods of assessment. Models are useful as they allow the concepts in nursing theory to be successfully applied to nursing practice (Lancaster and Lancaster 1981). Their main limitation is that they are only as accurate or useful as the underlying theory.

Importance of nursing theories:

Importance of nursing theories SHRI VINOBA BHAVE COLLEGE OF NURSING 11 Nursing theory aims to describe, predict and explain the phenomenon of nursing (Chinn and Jacobs1978). It should provide the foundations of nursing practice, help to generate further knowledge and indicate in which direction nursing should develop in the future (Brown 1964). 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. 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. As medicine tries to make a move towards adopting a more multidisciplinary approach to health care, nursing continues to strive to establish a unique body of knowledge. This can be seen as an attempt by the nursing profession to maintain its professional boundaries.

Basic processes in the development of nursing theories:

Basic processes in the development of nursing theories SHRI VINOBA BHAVE COLLEGE OF NURSING 12 Nursing theories are often based on & influenced by broadly applicable processes & theories. Following theories are basic to many nursing concepts. General System 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) & 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.

Classification of nursing theories :

Classification of nursing theories SHRI VINOBA BHAVE COLLEGE OF NURSING 13 A . Depending On 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 B. Depending on the Generalisability of their principles Metatheory : the theory of theory. Identifies specific phenomena through abstract concepts. Grand theory: provides a conceptual framework under which the key concepts C. Principles of the discipline can be identified. Middle range theory: is more precise and only analyses a particular situation with a limited number of variables. Practice theory: explores one particular situation found in nursing. It identifies explicit goals and details how these goals will be achieved.

Cont. . . :

Cont. . . SHRI VINOBA BHAVE COLLEGE OF NURSING 14 Based on the philosophical underpinnings of the theories “Needs “theories. “Interaction” theories. “Outcome “theories. Humanistic 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 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. 3. “Outcome” theories" Oucome 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. Humanistic theories emphasize 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.

Cont. . . :

Cont. . . SHRI VINOBA BHAVE COLLEGE OF NURSING 15 Grand nursing theories Grand nursing 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. This limits the use of grand nursing theories for directing, explaining, and predicting nursing in particular situations. Theories at this level are intended to be pertinent to all instances of nursing. Mid-range nursing theories Middle-range nursing 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.

Nursing models:

Nursing models SHRI VINOBA BHAVE COLLEGE OF NURSING 16 Nursing models  are conceptual models, constructed of theories and concepts




INTRODUCTION SHRI VINOBA BHAVE COLLEGE OF NURSING 18 Psychodynamic nursing Understanding of ones own behavior To help others identify felt difficulties To apply principles of human relations to the problems that arise at all levels of experience In her book she discussed the phases of interpersonal process, roles in nursing situations and methods for studying nursing as an interpersonal process. According to Peplau , nursing is therapeutic in that it is a healing art, assisting an individual who is sick or in need of health care . Nursing is an interpersonal process because it involves interaction between two or more individuals with a common goal. The attainment of goal is achieved through the use of a series of steps following a series of pattern . The nurse and patient work together so both become mature and knowledgeable in the process.

Theory of interpersonal relations :

Theory of interpersonal relations SHRI VINOBA BHAVE COLLEGE OF NURSING 19 Middle range descriptive classification theory Influenced by Harry Stack Sullivan's theory of inter personal relations (1953) Also influenced by Percival Symonds , Abraham Maslow's and Neal Elger Miller  Identified four sequential phases in the interpersonal relationship: 1 .      Orientation 2.      Identification 3.      Exploitation 4.      Resolution Orientation phase Problem defining phase Starts when client meets nurse as stranger Defining problem and deciding type of service needed Client seeks assistance ,conveys needs ,asks questions, shares preconceptions and expectations of past experiences Nurse responds, explains roles to client, helps to identify problems and to use available resources and services

Cont . . . .:

Cont . . . . SHRI VINOBA BHAVE COLLEGE OF NURSING 20 Identification phase Selection of appropriate professional assistance Patient begins to have a feeling of belonging and a capability of dealing with the problem which decreases the feeling of helplessness and hopelessness Exploitation phase Use of professional assistance for problem solving alternatives Advantages of services are used is based on the needs and interests of the patients Individual feels as an integral part of the helping environment They may make minor requests or attention getting techniques The principles of interview techniques must be used in order to explore, understand and adequately deal with the underlying problem Patient may fluctuates on independence Nurse must be aware about the various phases of communication Nurse aids the patient in exploiting all avenues of help and progress is made towards the final step

Cont . .. :

Cont . .. SHRI VINOBA BHAVE COLLEGE OF NURSING 21 Resolution phase Termination of professional relationship The patients needs have already been met by the collaborative effect of patient and nurse Now they need to terminate their therapeutic relationship and dissolve the links between them. Sometimes may be difficult for both as psychological dependence persists Patient drifts away and breaks bond with nurse and healthier emotional balance is demonstrated and both becomes mature individuals


ROLE OF NURSING SHRI VINOBA BHAVE COLLEGE OF NURSING 22 She also identified six nursing roles of the nurse:  Counseling Role - working with the patient on current problems. Helps to understand and integrate the meaning of current life circumstances ,provides guidance and encouragement to make changes Leadership Role - working with the patient democratically. She helps client assume maximum responsibility for meeting treatment goals in a mutually satisfying way Surrogate Role - figuratively standing in for a person in the patient's life. She helps to clarify domains of dependence interdependence and independence and acts on clients behalf as an advocate. Stranger - accepting the patient objectively. Receives the client in the same way one meets a stranger in other life situations provides an accepting climate that builds trust. Resource Person - interpreting the medical plan to the patient. One who provides a specific needed information that aids in the understanding of a problem or new situation Teaching Role - offering information and helping the patient learn. Who imparts knowledge in reference to a need or interest .

Additional Roles :

Additional Roles SHRI VINOBA BHAVE COLLEGE OF NURSING 23 1 .   Technical expert 2.   Consultant 3.   Health teacher 4.   Tutor 5.   Socializing agent .   Safety agent 7.   Manager of environment 8.   Mediator 9.   Administrator 10.  Recorder observer 11.  Researcher

Definitions :

Definitions SHRI VINOBA BHAVE COLLEGE OF NURSING 24 Person : A developing organism that tries to reduce anxiety caused by needs Environment : Existing forces outside the organism and in the context of culture Health : A word symbol that implies forward movement of personality and other ongoing human processes in the direction of creative , constructive , productive, personal and community living . Nursing: A significant therapeutic interpersonal process. It functions cooperatively with other human process that make health possible for individuals in communities 

Peplau’s work and characteristics of a theory :

Peplau’s work and characteristics of a theory SHRI VINOBA BHAVE COLLEGE OF NURSING 25 Theories can interrelate concepts in such a way as to create a different way of looking at a particular phenomenon. Four phases interrelate the different components of each phase. The nurse patient interaction can apply to the concepts of human being, health, environment and nursing. Theories must be logical in nature. This theory provides a logical systematic way of viewing nursing situations Key concepts such as anxiety, tension, goals, and frustration are indicated with explicit relationships among them and progressive phases Theories should be relatively simple yet generalizable . It provides simplicity in regard to the natural progression of the NP relationship. Leads to adaptability in any nurse patient relationship. The basic nature of nursing still considered an interpersonal process Theories can be the bases for hypothesis that can be tested.Has generated testable hypotheses. Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them. In 1950’s two third of the nursing research concentrated on N-P relation ship. Theories can be utilized by practitioners to guide and improve their practice. Peplau’s anxiety continuum is still used in anxiety patients Theories must be consistent with other validated theories, laws, and principles but will leave open unanswered questions that need to be investigated. Consistent with various theories

Interpersonal theory and nursing process :

Interpersonal theory and nursing process SHRI VINOBA BHAVE COLLEGE OF NURSING 26 Both are sequential and focus on therapeutic relationship Both use problem solving techniques for the nurse and patient to collaborate on, with the end purpose of meeting the patients needs Both use  observation communication and recording as basic tools utilized by nursing


Assessment Data collection and analysis [continuous] May not be a felt need Orientation Non continuous data collection Felt need Define needs Nursing diagnosis Planning Mutually set goals  Identification Interdependent goal setting Implementation Plans initiated towards achievement of mutually set goals May be accomplished by patient , nurse or family Exploitation Patient actively seeking and drawing help Patient initiated Evaluation Based on mutually expected behaviors May led to termination and initiation of new plans   Resolution Occurs after other phases are completed successfully Leads to termination a SHRI VINOBA BHAVE COLLEGE OF NURSING 27

Limitations :

Intra family dynamics, personal space considerations and community social service resources are considered less Health promotion and maintenance were less emphasized Cannot be used in a patient who doesn’t have a felt need eg . With drawn patients, unconscious patients  some areas are not specific enough to generate hypothesis    SHRI VINOBA BHAVE COLLEGE OF NURSING 28 Limitations

Roy's Adaptation Model:

Roy's Adaptation Model

Introduction :

Introduction SHRI VINOBA BHAVE COLLEGE OF NURSING 30 Sr.Callista Roy, a prominent nurse theorist, writer, lecturer, researcher and teacher Professor and Nurse Theorist at the Boston College of Nursing in Chestnut Hill Born at Los Angeles on October 14, 1939 as the 2nd child of Mr. and Mrs. Fabien Roy she earned a Bachelor of Arts with a major in nursing from Mount St. Mary's College, Los Angeles in 1963. a master's degree program in pediatric nursing at the University of California ,Los Angeles in 1966. She also earned a master’s and PhD in Sociology in 1973 and 1977 ,respectively. Sr. Callista had the significant opportunity of working with Dorothy E. Johnson She joined the faculty of Mount St. Mary's College in 1966, teaching both pediatric and maternity nursing. She organized course content according to a view of person and family as adaptive systems. She introduced her ideas about ‘ Adaptation Nursing ’ as the basis for an integrated nursing curriculum. Goal of nursing to direct nursing education, practice and research Model as a basis of curriculum impetus for growth--Mount St. Mary’s College 1970-The model was implemented in Mount St. Mary’s school 1971- she was made chair of the nursing department at the college.

Influencing Factors :

Influencing Factors SHRI VINOBA BHAVE COLLEGE OF NURSING 31 Family Education Religious Background Mentors Clinical Experience


THEORY DESCRIPTION SHRI VINOBA BHAVE COLLEGE OF NURSING 32 The central questions of Roy’s theory are: Who is the focus of nursing care? What is the target of nursing care? When is nursing care indicated? Roy’s first ideas appeared in a graduate paper written at UCLA in 1964. Published these ideas in "Nursing outlook" in 1970 Subsequently different components of her framework crystallized during 1970s, ’80s, and ’90s Over the years she identified assumptions on which her theory is based.

Explicit assumptions (Roy 1989; Roy and Andrews 1991) :

Explicit assumptions (Roy 1989; Roy and Andrews 1991) SHRI VINOBA BHAVE COLLEGE OF NURSING 33 The person is a bio-psycho-social being . The person is in constant interaction with a changing environment . To cope with a changing world, person uses both innate and acquired mechanisms which are biological, psychological and social in origin. Health and illness are inevitable dimensions of the person’s life. To respond positively to environmental changes, the person must adapt . The person’s adaptation is a function of the stimulus he is exposed to and his adaptation level The person’s adaptation level is such that it comprises a zone indicating the range of stimulation that will lead to a positive response. The person has 4 modes of adaptation: physiologic needs, self- concept, role function and inter-dependence. "Nursing accepts the humanistic approach of valuing other persons’ opinions, and view points" Interpersonal relations are an integral part of nursing There is a dynamic objective for existence with ultimate goal of achieving dignity and integrity.

Implicit assumptions :

Implicit assumptions SHRI VINOBA BHAVE COLLEGE OF NURSING 34 A person can be reduced to parts for study and care. Nursing is based on causality. Patient’s values and opinions are to be considered and respected. A state of adaptation frees an individual’s energy to respond to other stimuli.


ROY ADAPTATION MODEL CONCEPTS: EARLY AND REVISED SHRI VINOBA BHAVE COLLEGE OF NURSING 35 Adaptation -- goal of nursing Person -- adaptive system Environment -- stimuli Health -- outcome of adaptation Nursing -- promoting adaptation and health

Concepts-Adaptation :

Concepts-Adaptation SHRI VINOBA BHAVE COLLEGE OF NURSING 36 Responding positively to environmental changes . The process and outcome of individuals and groups who use conscious awareness, self reflection and choice to create human and environmental integration

Concepts-Person :

Concepts-Person SHRI VINOBA BHAVE COLLEGE OF NURSING 37 Bio-psycho-social being in constant interaction with a changing environment Uses innate and acquired mechanisms to adapt An adaptive system described as a whole comprised of parts Functions as a unity for some purpose Includes people as individuals or in groups-families, organizations, communities, and society as a whole.

Concepts-Environment :

Concepts-Environment SHRI VINOBA BHAVE COLLEGE OF NURSING 38 Focal - internal or external and immediately confronting the person Contextual - all stimuli present in the situation that contribute to effect of focal stimulus Residual -a factor whose effects in the current situation are unclear All conditions, circumstances, and influences surrounding and affecting the development and behavior of persons and groups with particular consideration of mutuality of person and earth resources, including focal, contextual and residual stimuli

Concepts-Health :

Concepts-Health SHRI VINOBA BHAVE COLLEGE OF NURSING 39 Inevitable dimension of person's life Represented by a health-illness continuum A state and a process of being and becoming integrated and whole

Concepts-Nursing :

Concepts-Nursing SHRI VINOBA BHAVE COLLEGE OF NURSING 40 To promote adaptation in the four adaptive modes To promote adaptation for individuals and groups in the four adaptive modes, thus contributing to health, quality of life, and dying with dignity by assessing behaviors and factors that influence adaptive abilities and by intervening to enhance environmental interactions

Concepts-Subsystems :

Concepts-Subsystems SHRI VINOBA BHAVE COLLEGE OF NURSING 41 Cognator subsystem — A major coping process involving 4 cognitive-emotive channels: perceptual and information processing, learning, judgment and emotion. Regulator subsystem — a basic type of adaptive process that responds automatically through neural, chemical, and endocrine coping channels

Four Adaptive Modes :

Four Adaptive Modes SHRI VINOBA BHAVE COLLEGE OF NURSING 42 Physiologic Needs Self Concept Role Function Interdependence

Adaptive Modes :

Adaptive Modes SHRI VINOBA BHAVE COLLEGE OF NURSING 43 A . Persons Physiologic Self Concept Role Function Interdependence B.  Groups Physical Group Identity Role Function Interdependence


SHRI VINOBA BHAVE COLLEGE OF NURSING 44 Role Function Mode Underlying Need of Social integrity The need to know who one is in relation to others so that one can act The need for role clarity of all participants in group Adaptation Level A zone within which stimulation will lead to a positive or adaptive response Adaptive mode processes described on three levels: Integrated Compensatory Compromised


SHRI VINOBA BHAVE COLLEGE OF NURSING 45 Integrated Life Processes Adaptation level where the structures and functions of the life processes work to meet needs Examples of Integrated Adaptation Stable process of breathing and ventilation Effective processes for moral-ethical-spiritual growth Compensatory Processes Adaptation level where the cognator and regulator are activated by a challenge to the life processes Compensatory Adaptation Examples: Grieving as a growth process, higher levels of adaptation and transcendence Role transition, growth in a new role

Compromised Processes :

Compromised Processes SHRI VINOBA BHAVE COLLEGE OF NURSING 46 Adaptation level resulting from inadequate integrated and compensatory life processes Adaptation problem Compromised Adaptation Examples Hypoxia Unresolved Loss Stigma Abusive Relationships


THE NURSING PROCESS SHRI VINOBA BHAVE COLLEGE OF NURSING 47 RAM offers guidelines to nurse in developing the nursing process. The elements : First level assessment Second level assessment Diagnosis Goal setting Intervention evaluation

Usefulness of Adaptation Model :

Usefulness of Adaptation Model SHRI VINOBA BHAVE COLLEGE OF NURSING 48 Scientific knowledge for practice Clinical assessment and intervention Research variables To guide nursing practice To organize nursing education Curricular frame work for various nursing colleges

Summary :

Summary SHRI VINOBA BHAVE COLLEGE OF NURSING 49 5 elements -person, goal of nursing, nursing activities, health and environment Persons are viewed as living adaptive systems whose behaviours may be classified as adaptive responses or ineffective responses. These behaviors are derived from regulator and cognator mechanisms. These mechanisms work with in 4 adaptive modes. The goal of nursing is to promote adaptive responses in relation to 4 adaptive modes, using information about person’s adaptation level, and various stimuli. Nursing activities involve manipulation of these stimuli to promote adaptive responses. Health is a process of becoming integrated and able to meet goals of survival, growth, reproduction, and mastery. The environment consists of person’s internal and external stimuli.




SHRI VINOBA BHAVE COLLEGE OF NURSING 51 Dorothea Orem's Self-Care Theory Dorothea Orem (1914-2007)


INTRODUCTION SHRI VINOBA BHAVE COLLEGE OF NURSING 52 One of foremost nursing theorists. Born 1914 in Baltimore. Earned her diploma at Providence Hospital – Washington, DC 1939 – BSN Ed., Catholic University of America 1945 – MSN Ed., Catholic University of America Involved in nursing practice, nursing service, and nursing education During her professional career, she worked as a staff nurse, private duty nurse, nurse educator and administrator and nurse consultant Received honorary Doctor of Science degree in 1976 Published first formal articulation of her ideas in Nursing: Concepts of Practice in 1977 , second in 1980, and in 1995.


DEVELOPMENT OF THEORY SHRI VINOBA BHAVE COLLEGE OF NURSING 53 1949-1957 Orem worked for the Division of Hospital and Institutional Services of the Indiana State Board of Health. Her goal was to upgrade the quality of nursing in general hospitals throughout the state. During this time she developed her definition of nursing practice. 1959 Orem subsequently served as acting dean of the school of Nursing and as an assistant professor of nursing education at CUA. She continued to develop her concept of nursing and self care during this time. Orem’s Nursing: Concept of Practice was first published in 1971 and subsequently in 1980, 1985, 1991, 1995, and 2001.


MAJOR ASSUMPTIONS SHRI VINOBA BHAVE COLLEGE OF NURSING 54 People should be self-reliant and responsible for their own care and others in their family needing care People are distinct individuals Nursing is a form of action – interaction between two or more persons 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 necessary for promoting self-care behaviors Self care and dependent care are behaviors learned within a socio-cultural context


DEFINITIONS OF DOMAIN CONCEPTS SHRI VINOBA BHAVE COLLEGE OF NURSING 55 Nursing – is art, a helping service , and a technology Actions deliberately selected and performed by nurses to help individuals or groups under their care to maintain or change conditions in themselves or their environments Encompasses the patient’s perspective of health condition ,the physician’s perspective , and the nursing perspective Goal of nursing – to render the patient or members of his family capable of meeting the patient’s self care needs To maintain a state of health To regain normal or near normal state of health in the event of disease or injury To stabilize, control or minimize the effects of chronic poor health or disability


SHRI VINOBA BHAVE COLLEGE OF NURSING 56 Health – health and healthy are terms used to describe living things … It is when they are structurally and functionally whole or sound … wholeness or integrity. . includes that which makes a person human,…operating in conjunction with physiological and psycho physiological mechanisms and a material structure and in relation to and interacting with other human beings


SHRI VINOBA BHAVE COLLEGE OF NURSING 57 Environment Environment components are enthronement factors, enthronement elements, conditions, and developed environment Human being – has the capacity to reflect, symbolize and use symbols Conceptualized as a total being with universal, developmental needs and capable of continuous self care A unity that can function biologically, symbolically and socially


SHRI VINOBA BHAVE COLLEGE OF NURSING 58 Nursing client / Person A human being who has "health related /health derived limitations that render him incapable of continuous self care or dependent care or limitations that result in ineffective / incomplete care. A human being is the focus of nursing only when a self –care requisites exceeds self care capabilities


SHRI VINOBA BHAVE COLLEGE OF NURSING 59 Nursing problem Deficits in universal, developmental, and health derived or health related conditions Nursing process A system to determine (1) why a person is under care (2) a plan for care ,(3) the implementation of care Nursing therapeutics Deliberate,  systematic and purposeful action


OREM’S GENERAL THEORY OF NURSING SHRI VINOBA BHAVE COLLEGE OF NURSING 60 Orem’s general theory of nursing in three related parts:- Theory of self care Theory of self care deficit Theory of nursing system A. Theory of Self Care This theory Includes: Self care – practice of activities that individual initiates and perform on their own behalf in maintaining life health and well being Self care agency – is a human ability which is "the ability for engaging in self care" - conditioned by age developmental state, life experience socio cultural orientation health and available resources Therapeutic self care demand – "totality of self care actions to be performed for some duration in order to meet self care requisites by using valid methods and related sets of operations and actions" Self care requisites-action directed towards provision of self care . 3 categories of self care requisites are-


SHRI VINOBA BHAVE COLLEGE OF NURSING 61 1.  Universal 2. Developmental 3. Health deviation 1. Universal self care requisites Associated with life processes and the maintenance of the integrity of human structure and functioning Common to all, ADL Identifies these requisites as: Maintenance of sufficient intake of air ,water, food Provision of care associated with elimination process Balance between activity and rest, between solitude and social interaction Prevention of hazards to human life well being and Promotion of human functioning


SHRI VINOBA BHAVE COLLEGE OF NURSING 62 2. Developmental self care requisites Associated with developmental processes / derived from a condition…. Or associated with an event E.g. adjusting to a new job adjusting to body changes 3. Health deviation self care: Required in conditions of illness, injury, or disease .these include:-- Seeking and securing appropriate medical assistance Being aware of and attending to the effects and results of pathologic conditions Effectively carrying out medically prescribed measures Modifying self concepts in accepting oneself as being in a particular state of health and in specific forms of health care Learning to live with effects of pathologic conditions


SHRI VINOBA BHAVE COLLEGE OF NURSING 63 B. Theory of self care deficit Specifies when nursing is needed Nursing is required when an adult (or in the case of a dependent, the parent) is incapable or limited in the provision of continuous effective self care. Orem identifies 5 methods of helping: Acting for and doing for others Guiding others Supporting another Providing an environment promoting personal development in relation to meet future demands Teaching another

C. Theory of Nursing Systems :

C. Theory of Nursing Systems SHRI VINOBA BHAVE COLLEGE OF NURSING 64 Describes how the patient’s self care needs will be met by the nurse , the patient, or both Identifies 3 classifications of nursing system to meet the self care requisites of the patient:- Wholly compensatory system Partly compensatory system Supportive – educative system Design and elements of nursing system define Scope of nursing responsibility in health care situations General and specific roles of nurses and patients Reasons for nurses’ relationship with patients and The kinds of actions to be performed and the performance patterns and nurses’ and patients’ actions in regulating patients’ self care agency and in meeting their self care demand


SHRI VINOBA BHAVE COLLEGE OF NURSING 65 Orem recognized that specialized technologies are usually developed by members of the health profession. A technology is systematized information about a process or a method for affecting some desired result through deliberate practical endeavor, with or without use of materials or instruments.

Categories of technologies :

Categories of technologies SHRI VINOBA BHAVE COLLEGE OF NURSING 66 1 . Social or interpersonal Communication adjusted to age, health status Maintaining interpersonal, intra group or inter group relations for coordination of efforts Maintaining therapeutic relationship in light of psychosocial modes of functioning in health and disease Giving human assistance adapted to human needs, action abilities and limitations 2 . Regulatory technologies Maintaining and promoting life processes Regulating psycho physiological modes of functioning in health and disease Promoting human growth and development Regulating position and movement in space


OREM’S THEORY AND NURSING PROCESS SHRI VINOBA BHAVE COLLEGE OF NURSING 67 Orem’s approach to the nursing process presents a method to determine the self care deficits and then to define the roles of person or nurse to meet the self care demands. The steps within the approach are considered to be the technical component of the nursing process. Orem emphasizes that the technological component "must be coordinated with interpersonal and social processes within nursing situations.”


Personal factors Universal self care Developmental self care Health deviation Medical problem & plan Self care deficits 29 yr. Female Early adulthood transition 32pack /yr Water-no restrictions Food –nil Wt89lb Wt loss-19% nauseated Teenage pregnancy-2 OC-10 yrs Husband emotionally away Seeks medical attention for overt s/s Aware of disease No evidence     8th grade Teenage pregnancy No work Married Child-2 Urinary retention Intermittent self catheterization Pain No BSE Infrequent physical examination No HRT Poor health ability to manage effects Surgery on reproductive organs Difference between knowledge base & lifestyle Lives at mother’s home. Environment unclean Limited resources Tearful Husband abusive Dissatisfied with home RT EDU deprivation Oppressive living conditions   Will receive RT ,perform intermittent catheterization   Comparison of Orem ’ s Nursing Process and the Nursing Process Application of Orem ’ s theory to nursing process SHRI VINOBA BHAVE COLLEGE OF NURSING 68


Nursing Process Orem’s Nursing. Process Assessment   Diagnosis and prescription; determine why nursing is needed. analyze and interpret –make judgment regarding care Design of a nursing system and plan for delivery of care Production and management of nursing systems Step 1-collect data in six areas:- The person’s health status The physician’s perspective of the person’s health status The person’s perspective of his or her health The health goals within the context of life history ,life style, and health status The person’s requirements for self care The person’s capacity to perform self care Nursing diagnosis Plans with scientific rationale   Step 2 Nurse designs a system that is wholly or partly compensatory or supportive-educative. The 2 actions are:- Bringing out a good organization of the components of patients’ therapeutic self care demands Selection of combination of ways of helping that will be effective and efficient in compensating for/ overcoming patient’s self care deficits Implementation evaluation   Step 3 Nurse assists the patient or family in self care matters to achieve identified and described health and health related results. collecting evidence in evaluating results achieved against results specified in the nursing system design Actions are directed by etiology component of nursing diagnosis evaluation SHRI VINOBA BHAVE COLLEGE OF NURSING 69


Personal factors Universal self care Developmental self care Health deviation Medical problem & plan Self care deficits 29 yr. Female Early adulthood transition 32pack /yr Water-no restrictions Food –nil Wt89lb Wt loss-19% nauseated Teenage pregnancy-2 OC-10 yrs Husband emotionally away Seeks medical attention for overt s/s Aware of disease No evidence     8th grade Teenage pregnancy No work Married Child-2 Urinary retention Intermittent self catheterization Pain No BSE Infrequent physical examination No HRT Poor health ability to manage effects Surgery on reproductive organs Difference between knowledge base & lifestyle Lives at mother’s home. Environment unclean Limited resources Tearful Husband abusive Dissatisfied with home RT EDU deprivation Oppressive living conditions   Will receive RT ,perform intermittent catheterization   Application of Orem ’ s theory to nursing process SHRI VINOBA BHAVE COLLEGE OF NURSING 70


Therapeutic self care demand Adequacy of self care agency Nursing diagnosis Methods of helping Air Maintain effective respiration Water No problem Food maintain sufficient intake Inadequate   Adequate Inadequate Potential for impaired respiratory status P F fluid imbalance Actual nutritional deficit r/t nausea Guiding & directing   Teaching Providing physical support   Hazards Prevent spouse abuse Promotion of normalcy   Inadequate   Inadequate   P/F injury   A/d in environment Shared housing Personal development Guiding & directing Guiding & directing Maintain developmental environment Support ­ed normalcy in environment Prevent /manage dev threat Inadequate    Inadequate Actual delay in normal dev. R/T early parenthood Level of education Dev deficit r/t loss of reproductive organs Guiding & directing Providing psy support Providing physical, psy support Maintenance of health status Management of disease process Inadequate    Inadequate P/F contd. alterations in health status  P/F UTI  Guiding & directing, teaching  Guiding & directing, teaching  Adherence to med regimen Awareness of potential problems Inadequate    Inadequate P/F ¯ adherence in self catheterization & OPD RT  Actual deficit in awareness of advisability of HRT & RT effects  teaching      teaching  Adjust to loss of reproductive ability & dev healthy view of illness Adjust life style to cope with change Inadequate    Inadequate Actual threat to self image Actual self deficit in planning for future needs Providing  psy support  Guiding & directing SHRI VINOBA BHAVE COLLEGE OF NURSING 71

Strengths :

Strengths SHRI VINOBA BHAVE COLLEGE OF NURSING 72 Provides a comprehensive base to nursing practice It has utility for professional nursing in the areas of nursing practice nursing curricula, nursing education, administration and nursing research Specifies when nursing is needed Also includes continuing education as part of the professional component of nursing education Her self care approach is contemporary with the concepts of health promotion and health maintenance Expanded her focus of individual self care to include multi person units

Limitations :

Limitations SHRI VINOBA BHAVE COLLEGE OF NURSING 73 In general system theory a system is viewed as a single whole thing while Orem defines a system as a single whole, thing Health is often viewed as dynamic and ever changing. Orem’s visual presentation of the boxed nursing systems implies three static conditions of health Appears that the theory is illness oriented rather with no indication of its use in wellness settings

Summary :

Summary SHRI VINOBA BHAVE COLLEGE OF NURSING 74 Orem’s general theory of nursing is composed of three constructs. Throughout her work she interprets the concepts of human beings, health, nursing and society and has defined 3 steps of nursing process. It has a broad scope in clinical practice and to lesser extent in research, education and administration




SHRI VINOBA BHAVE COLLEGE OF NURSING 76 Theory of Florence Nightingale

Introduction :

Introduction SHRI VINOBA BHAVE COLLEGE OF NURSING 77 Born - 12 May 1820 Founder of mordern nursing. The first nursing theorist. Also known as "The Lady with the Lamp"  She explained her environmental theory in her famous book Notes on Nursing: What it is, What it is not . She was the first to propose nursing required specific education and training. Her contribution during Crimean war is well-known. She was a statistician , using bar and pie charts, highlighting key points . International Nurses Day, May 12 is observed in respect to her contribution to Nursing. Died - 13 August 1910

Assumptions of Nightingale's Theory :

Assumptions of Nightingale's Theory SHRI VINOBA BHAVE COLLEGE OF NURSING 78 Natural laws Mankind can achieve perfection Nursing is a calling Nursing is an art and a science Nursing is achieved through environmental alteration Nursing requires a specific educational base Nursing is distinct and separate from medicine

Nightingale’s Canons: Major Concepts :

Nightingale’s Canons: Major Concepts SHRI VINOBA BHAVE COLLEGE OF NURSING 79 Ventilation and warming Light, Noise Cleanliness of rooms/walls Health of houses Bed and bedding Personal cleanliness Variety Chattering hopes and advices Taking food.  What food? Petty management/observation

Nursing Paradigms :

Nursing Paradigms SHRI VINOBA BHAVE COLLEGE OF NURSING 80 Nightingale's documents contain her philosophical assumptions and beliefs regarding all elements found in the metaparadigm of nursing.  These can be formed into a conceptual model that has great utility in the practice setting and offers a framework for research conceptualization. (Selanders LC, 2010)

Nursing :

Nursing SHRI VINOBA BHAVE COLLEGE OF NURSING 81 Nursing is different from medicine and the goal of nursing is to place the patient  in the best possible condition for nature to act. Nursing is the " activities that promote health (as outlined in canons) which occur in any caregiving situation.  That can be done by anyone."

Person :

Person SHRI VINOBA BHAVE COLLEGE OF NURSING 82 People are multidimensional, composed of biological, psychological, social and spiritual components.

Health :

Health SHRI VINOBA BHAVE COLLEGE OF NURSING 83 Health is “ not only to be well, but to be able to use well every power we have”. Disease is considered as dys-ease or the absence of comfort.  

Environment :

Environment SHRI VINOBA BHAVE COLLEGE OF NURSING 84 " Poor or difficult environments led to poor health and disease". " Environment could be altered to improve conditions so that the natural laws would allow healing to occur."

Nightingale's Theory and Nursing Practice :

Nightingale's Theory and Nursing Practice SHRI VINOBA BHAVE COLLEGE OF NURSING 85 Application of Nightingale's theory in practice: "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 sleep.” As per most of the nursing theories, environmental adaptation remains the basis of holistic nursing care.

Criticisms :

Criticisms SHRI VINOBA BHAVE COLLEGE OF NURSING 86 She emphasized subservience to doctors. She focused more on physical factors than on psychological needs of patient.

Conclusion :

Conclusion SHRI VINOBA BHAVE COLLEGE OF NURSING 87 Florence Nightingale provided a professional model for nursing organization. She was the first to use a theoretical founation to nursing. Her thoghts have influenced nursing significantly.


Pioneer of Patient safety - Florence nightingale (Environmental nursing theory) LIGHT / DIRECT SUNLIGHT CLEANLINESS FRESH AIR PURE WATER PROPER DRAINAGE SHRI VINOBA BHAVE COLLEGE OF NURSING 88


SHRI VINOBA BHAVE COLLEGE OF NURSING 89 Virginia Henderson's Need Theory

Introduction :

Introduction SHRI VINOBA BHAVE COLLEGE OF NURSING 90 “ The Nightingale of Modern Nursing” “ Modern-Day Mother of Nursing.” "The 20th century Florence Nightingale." Born in Kansas City, Missouri, in 1897. Received a Diploma in Nursing from the Army School of Nursing at Walter Reed Hospital, Washington, D.C. in 1921. Worked at the Henry Street Visiting Nurse Service for 2 years after graduation. In 1923, started teaching nursing at the Norfolk Protestant Hospital in Virginia In 1929, entered Teachers College at Columbia University for  Bachelor’s Degree in 1932, Master’s Degree in 1934. Joined Columbia as a member of the faculty, remained until 1948 .

Cont . . .:

Cont . . . SHRI VINOBA BHAVE COLLEGE OF NURSING 91 Since 1953, a research associate at Yale University School of Nursing. Recipient of numerous recognitions. Her work influenced the nursing profession throughout the world. a well known nursing educator and a prolific author. honorary doctoral degrees from the Catholic University of America, Pace University, University of Rochester, University of Western Ontario, Yale University  In 1985, honored at the Annual Meeting of the Nursing and Allied Health Section of the Medical Library Association. Died: March 19, 1996. In 1939, she revised: Harmer’s classic textbook of nursing for its 4th edition, and later wrote the 5th; edition, incorporating her personal definition of nursing (Henderson,1991)

Henderson’s Theory Background :

Henderson’s Theory Background SHRI VINOBA BHAVE COLLEGE OF NURSING 92 Henderson’s concept of nursing was derived from her practice and education therefore, her work is inductive.. She called her definition of nursing her “concept” (Henderson1991) She emphasized the importance of increasing the patient’s independence so that progress after hospitalization would not be delayed (Henderson,1991) Virginia Henderson defined nursing as " assisting individuals to gain independence in relation to the performance of activities contributing to health or its recovery"  (Henderson, 1966). She categorized nursing activities into 14 components , based on human needs. 


SHRI VINOBA BHAVE COLLEGE OF NURSING 93 She described the nurse's role as substitutive (doing for the person), supplementary (helping the person), complementary (working with the person), with the goal of helping the person become as independent as possible. Her definition of nursing was one of the first statements clearly delineating nursing from medicine: "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 :

The 14 components SHRI VINOBA BHAVE COLLEGE OF NURSING 94 Breathe normally. Eat and drink adequately. Eliminate body wastes. Move and maintain desirable postures. Sleep and rest. Select suitable clothes-dress and undress. Maintain body temperature within normal range by adjusting clothing and modifying environment Keep the body clean and well groomed and protect the integument Avoid dangers in the environment and avoid injuring others. Communicate with others in expressing emotions, needs, fears, or opinions. Worship according to one’s faith. Work in such a way that there is a sense of accomplishment. Play or participate in various forms of recreation. Learn, discover, or satisfy the curiosity that leads to normal development and health Use the available health facilities.

Henderson’s theory and the four major concepts :

Henderson’s theory and the four major concepts SHRI VINOBA BHAVE COLLEGE OF NURSING 95 Individual Have basic needs that are component of health. Requiring assistance to achieve health and independence or a peaceful death. Mind and body are inseparable and interrelated. Considers the biological, psychological, sociological, and spiritual components. The theory presents the patient as a sum of parts with biopsychosocial needs, and the patient is neither client nor consumer. Environment Settings in which an individual learns unique pattern for living. All external conditions and influences that affect life and development of individuals in relation to families Minimally discusses the impact of the community on the individual and family. Supports tasks of private and public agencies Society wants and expects nurses to act for individuals who are unable to function independently. In return she expects society to contribute to nursing education. Basic nursing care involves providing conditions under which the patient can perform the 14 activities unaided

Cont . . . :

Cont . . . SHRI VINOBA BHAVE COLLEGE OF NURSING 96 Health Definition based on individual’s ability to function independently as outlined in the 14 components. Nurses need to stress promotion of health and prevention and cure of disease. Good health is a challenge. Affected by age, cultural background, physical, and intellectual capacities, and emotional balance Is the individual’s ability to meet these needs independently? Nursing Temporarily assisting an individual who lacks the necessary strength, will and knowledge to satisfy 1 or more of 14 basic needs. Assists and supports the individual in life activities and the attainment of independence . Nurse serves to make patient “complete” “whole", or "independent." Henderson's classic definition of nursing: "I say that the nurse does for others what they would do for themselves if they had the strength, the will, and the knowledge. But I go on to say that the nurse makes the patient independent of him or her as soon as possible." The nurse is expected to carry out physician’s therapeutic plan Individualized care is the result of the nurse’s creativity in planning for care.

Cont . .. :

Cont . .. SHRI VINOBA BHAVE COLLEGE OF NURSING 97 Use nursing research Categorized Nursing : nursing care Non nursing: ordering supplies, cleanliness and serving food. In the Nature of Nursing “ that the nurse is and should be legally, an independent practitioner and able to make independent judgments as long as she/he is not diagnosing, prescribing treatment for disease, or making a prognosis, for these are the physicians function.” “Nurse should have knowledge to practice individualized and human care and should be a scientific problem solver.” In the Nature of Nursing Nurse role is,” to get inside the patient’s skin and supplement his strength will or knowledge according to his needs.” And nurse has responsibility to assess the needs of the individual patient, help individual meet their health need, and or provide an environment in which the individual can perform activity unaided Henderson's classic definition of nursing "I say that the nurse does for others what they would do for themselves if they had the strength, the will, and the knowledge. But I go on to say that the nurse makes the patient independent of him or her as soon as possible."


Nursing Process Henderson’s 14 components and definition of nursing Nursing Assessment Henderson’s 14 components Nursing Diagnosis Analysis: Compare data to knowledge base of health and disease. Nursing plan Identify individual’s ability to meet own needs with or without assistance, taking into consideration strength, will or knowledge. Nursing implementation Document how the nurse can assist the individual, sick or well. Nursing implementation Assist the sick or well individual in to performance of activities in meeting human needs to maintain health, recover from illness, or to aid in peaceful death. Nursing process Implementation based on the physiological principles, age, cultural background, emotional balance, and physical and intellectual capacities. Carry out treatment prescribed by the physician. Nursing evaluation Henderson’s 14 components and definition of nursing Use the acceptable definition of ;nursing and appropriate laws related to the practice of nursing. The quality of care is drastically affected by the preparation and native ability of the nursing personnel rather that the amount of hours of care. Successful outcomes of nursing care are based on the speed with which or degree to which the patient performs independently the activities of daily living SHRI VINOBA BHAVE COLLEGE OF NURSING 98

Limitations :

Limitations SHRI VINOBA BHAVE COLLEGE OF NURSING 99 Lack of conceptual linkage between physiological and other human characteristics. No concept of the holistic nature of human being. If the assumption is made that the 14 components prioritized, the relationship among the components is unclear. Lacks inter-relate of factors and the influence of nursing care. Assisting the individual in the dying process she contends that the nurse helps, but there is little explanation of what the nurse does. “Peaceful death” is curious and significant nursing role.




INTRODUCTION SHRI VINOBA BHAVE COLLEGE OF NURSING 101 Betty Neuman’s system model provides a comprehensive flexible holistic and system based perspective for nursing . It focuses on the response of the client system to actual or potential environmental stressors and the use of primary, secondary and tertiary nursing prevention intervention for retention, attainment and maintenance of optimal client system wellness.


HISTORY AND BACKGROUND OF THE THEORIST SHRI VINOBA BHAVE COLLEGE OF NURSING 102 Betty Neuman was born in 1924, in Lowel, Ohio. BS in nursing in 1957 MS in Mental Health Public health consultation, from UCLA in 1966. Ph.D. in clinical psychology a pioneer in the community mental health movement in the late 1960s. Developed the model while working as a lecturer in community health nursing at University of California, Los Angeles. The models was initially developed in response to graduate nursing students expression of a need for course content that would expose them to breadth of nursing problems prior to focusing on specific nursing problem areas.

Cont . . .:

Cont . . . SHRI VINOBA BHAVE COLLEGE OF NURSING 103 The model was published in 1972 as “A Model for Teaching Total Person Approach to Patient Problems” in Nursing Research. It was refined and subsequently published in the first edition of Conceptual Models for Nursing Practice, 1974, and in the second edition in 1980. DEVELOPMENT OF THE MODEL Neuman’s model was influenced by a variety of sources. The philosophy writers de Chardin and cornu (on wholeness in system). Von Bertalanfy, and Lazlo on general system theory. Selye on stress theory. Lararus on stress and coping.


MAJOR CONCEPTS SHRI VINOBA BHAVE COLLEGE OF NURSING 104 Content - the variables of the person in interaction with the internal and external environment comprise the whole client system

Basic structure/Central core :

Basic structure/Central core SHRI VINOBA BHAVE COLLEGE OF NURSING 105 Common client survival factors in unique individual characteristics representing basic system energy resources. The basis structure, or central core, is made up of the basic survival factors that are common to the species (Neuman,2002). These factors include:- - Normal temp. range, Genetic structure.- Response pattern. Organ strength or weakness, Ego structure 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. Degree to reaction the amount of system instability resulting from stressor invasion of the normal LOD.


SHRI VINOBA BHAVE COLLEGE OF NURSING 106 Entropy a process of energy depletion and disorganization moving the system toward illness or possible death. Flexible LOD a protective, accordion like mechanism that surrounds and protects the normal LOD from invasion by stressors. Normal LOD It represents what the client has become over time, or the usual state of wellness. It is considered dynamic because it can expand or contract over time. 


SHRI VINOBA BHAVE COLLEGE OF NURSING 107 Line of Resistance-LOR The series of concentric circles that surrounds the basic structure. Protection factors activated when stressors have penetrated the normal LOD, causing a reaction symptomatology . E.g. mobilization of WBC and activation of immune system mechanism Input- output The matter, energy, and information exchanged between client and environment that is entering or leaving the system at any point in time. Negentropy A process of energy conservation that increase organization and complexity, moving the system toward stability or a higher degree of wellness. Open system A system in which there is continuous flow of input and process, output and feedback. It is a system of organized complexity where all elements are in interaction.


SHRI VINOBA BHAVE COLLEGE OF NURSING 108 Prevention as intervention Interventions modes for nursing action and determinants for entry of both client and nurse in to health care system. Reconstitution The return and maintenance of system stability, following treatment for stressor reaction, which may result in a higher or lower level of wellness. Stability A state of balance of harmony requiring energy exchanges as the client adequately copes with stressors to retain, attain, or maintain an optimal level of health thus preserving system integrity. Stressors environmental factors, intra (emotion, feeling), inter (role expectation), and extra personal (job or finance pressure) in nature, that have potential for disrupting system stability. A stressor is any phenomenon that might penetrate both the F and N LOD, resulting either a positive or negative outcome.

Wellness/Illness :

Wellness/Illness SHRI VINOBA BHAVE COLLEGE OF NURSING 109 Wellness is the condition in which all system parts and subparts are in harmony with the whole system of the client. Illness is a state of insufficiency with disrupting needs unsatisfied (Neuman, 2002). Illness is an excessive expenditure of energy… when more energy is used by the system in its state of disorganization than is built and stored; the outcome may be death (Neuman, 2002).

Prevention :

Prevention SHRI VINOBA BHAVE COLLEGE OF NURSING 110 The primary nursing intervention. Prevention focuses on keeping stressors and the stress response from having a detrimental effect on the body. PRIMARY PREVENTION Primary prevention occurs before the system reacts to a stressor. On the one hand, it strengthens the person (primary the flexible LOD) to enable him to better deal with stressors On the other hand manipulates the environment to reduce or weaken stressors. Primary prevention includes health promotion and maintenance of wellness. SECONDARY PREVENTION Secondary prevention occurs after the system reacts to a stressor and is provided in terms of existing system. Secondary prevention focuses on preventing damage to the central core by strengthening the internal lines of resistance and/or removing the stressor. TERTIARY PREVENTION Tertiary prevention 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.


FOUR NURSING PARADIGMS SHRI VINOBA BHAVE COLLEGE OF NURSING 111 PERSON human being is a total person as a client system and the person is a layered multidimensional being. Each layer consists of five person variable or subsystems: Physiological- Refer of the physicochemical structure and function of the body. Psychological- Refers to mental processes and emotions. Socio-cultural- Refers to relationships; and social/cultural expectations and activities. Spiritual- Refers to the influence of spiritual beliefs. Developmental- Refers to those processes related to development over the lifespan. ENVIRONMENT The environment is seen to be the totality of the internal and external forces which surround a person and with which they interact at any given time. These forces include the intrapersonal, interpersonal and extra-personal stressors which can affect the person’s normal line of defense and so can affect the stability of the system. The internal environment exists within the client system. The external environment exists outside the client system. Neuman also identified a created environment which is an environment that is created and developed unconsciously by the client and is symbolic of system wholeness.

Cont . . .:

Cont . . . SHRI VINOBA BHAVE COLLEGE OF NURSING 112 HEALTH Neuman sees health as being equated with wellness. She defines health/wellness as “ the condition in which all parts and subparts (variables) are in harmony with the whole of the client ( Neuman , 1995)”. The client system moves toward illness and death when more energy is needed than is available. The client system moved toward wellness when more energy is available than is needed NURSING Neuman sees nursing as a unique profession that is concerned with all of the variables which influence the response a person might have to a stressor. The person is seen as a whole, and it is the task of nursing to address the whole person. Neuman defines nursing as “ action which assist individuals, families and groups to maintain a maximum level of wellness, and the primary aim is stability of the patient/client system, through nursing interventions to reduce stressors.’’ Neuman states that, because the nurse’s perception will influence the care given, then not only must the patient/client’s perception be assessed, but so must those of the caregiver (nurse). The role of the nurse is seen in terms of degree of reaction to stressors, and the use of primary, secondary and tertiary interventions




SHRI VINOBA BHAVE COLLEGE OF NURSING 114 Martha Roger's Science of Unitary Human Beings

Introduction :

Introduction SHRI VINOBA BHAVE COLLEGE OF NURSING 115 Born :May 12, 1914, Dallas, Texas Diploma :Knoxville General Hospital School of Nursing(1936) Graduation in Public Health Nursing, George Peabody College, TN, 1937 MA :Teachers college, Columbia university, New York, 1945 MPH :Johns Hopkins University, Baltimore, MD, 1952 Doctorate in nursing :Johns Hopkins University, Baltimore, 1954 Fellowship: American academy of nursing Position: Professor Emerita , Division of Nursing, New York University, Consultant, Speaker Died : March 13 , 1994

Rogers nursing theory :

Rogers nursing theory SHRI VINOBA BHAVE COLLEGE OF NURSING 116 Nursing is both a science and art. the uniqueness of nursing, like that of any other science, lies in the phenomenon central to its focus. Nurses long established concern with the people and the world they live is in a natural forerunner of an organized abstract system encompassing people and the environments. The irreducible nature of individuals is different from the sum of the parts. The integralness of people and the environment that coordinate with a multidimensional universe of open systems points to a new paradigm :the identity of nursing as a science. The purpose of nurses is to promote health and well-being for all persons wherever they are. Evolution of abstract system The development of the abstract system was strongly influenced by an early grounding in arts and background of science and her keen interest in space The science of unitary human beings originated as a synthesis of facts and ideas from multiple sources of knowledge The uniqueness is in the central phenomena : people and environment The Rogerian view of a causality emerges from an infinite universe of open system.


SHRI VINOBA BHAVE COLLEGE OF NURSING 117 Concepts of Rogers model Energy field The energy field is the fundamental unit of both the living and nonliving This energy field "provide a way to perceive people and environment as irreducible wholes" The energy fields continuously varies in intensity, density, and extent Openness The human field and the environmental field are constantly exchanging their energy There are no boundaries or barrier that inhibit energy flow between fields Pattern Pattern is defined as the distinguishing characteristic of an energy field perceived as a single waves "pattern is an abstraction and it gives identity to the field"


SHRI VINOBA BHAVE COLLEGE OF NURSING 118 Pan dimensionality Pan dimensionality is defined as "non linear domain without spatial or temporal attributes" The parameters that human use in language to describe events are arbitrary. The present is relative ;there is no temporal ordering of lives. 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 people has the capacity to participate knowingly and probabilistically in the process of change


SHRI VINOBA BHAVE COLLEGE OF NURSING 119 Environment The environment is an "irreducible ,pan dimensional energy field identified by pattern and integral with the human field" The field coexist and are integral. Manifestation emerge from this field and are perceived. Health Rogers defined health as an expression of the life process; they are the "characteristics and behavior emerging out of the mutual, simultaneous interaction of the human and environmental fields" Health and illness are the part of the sane continuum. The multiple events taking place along life's axis denote the extent to which man is achieving his maximum health potential and very in their expressions from greatest health to those conditions which are incompatible with the maintaining life process


SHRI VINOBA BHAVE COLLEGE OF NURSING 120 Nursing The concept Nursing encompasses two dimensions Independent science of nursing An organized body of knowledge which is specific to nursing is arrived at by scientific research and logical analysis Art of nursing practice The creative use of science for the betterment of the human The creative use of its knowledge is the art of its practice


SHRI VINOBA BHAVE COLLEGE OF NURSING 121 Rogers concepts of nursing Nursing is a learned profession-it is a science and art Nursing is the study of unitary. Irreducible, indivisible human and environmental energy fields The art of nursing involves the imaginative and creative use of nursing knowledge The purpose of nurses is to promote health and well-being for all person and groups wherever they are using the art and science of nursing The health services should be community based Rogers challenges nurses to consider nursing needs of all people, including future generation of space kind ;as life continuous to evolve from earth to space and beyond. Her view provides a different world view that encompasses a practice of nursing for the present time and for the imagined and for the yet to be imagined future Rogers proposes a nursing practice of noninvasive modalities, such as therapeutic touch, humor, guided imagery, use of color, light, music, meditation focusing on health potential of the person.


SHRI VINOBA BHAVE COLLEGE OF NURSING 122 Professional practice in nursing seeks to promote symphonic interaction between man and environment, to strengthen the coherence and integrity of the human field, and to direct and redirect patterning of the human and environmental fields for realization of maximum health potential Nursing intervention seeks to coordinate environmental field and human field rhythmicities, participates in the process of change , to help people move toward better health Nursing aims to assist people in achieving their maximum potential. Nursing practice should be emphasized on pain management, supportive psychotherapy motivation for rehabilitation. Maintenance and promotion of health, prevention of disease, nursing diagnosis, intervention, and rehabilitation encompasses the scope of nursing


SHRI VINOBA BHAVE COLLEGE OF NURSING 123 Homeodynamic principles The principles of homeodynamic postulates the way of perceiving unitary human beings The fundamental unit of the living system is an energy field Three principle of homeodynamics Resonancy Helicy integrality Resonance Resonance is an ordered arrangement of rhythm characterizing both human field and environmental field that undergoes continuous dynamic metamorphosis in the human environmental process Helicy Helicy describes the unpredictable, but continuous, nonlinear evolution of energy fields as evidenced by non repeating rhythmicties The principle of Helicy postulates an ordering of the humans evolutionary emergence Integrality Integrality cover the mutual, continuous relationship of the human energy field and the environmental field . Changes occur by by the continuous repatterning of the human and environmental fields by resonance waves The fields are one and integrated but unique to each other




SHRI VINOBA BHAVE COLLEGE OF NURSING 125 INTRODUCTION The health promotion model (HPM) proposed by Nola J Pender (1982; revised, 1996) was designed to be a “complementary counterpart to models of health protection.” It defines health as a positive dynamic state not merely the absence of disease. Health promotion is directed at increasing a client’s level of well being. The health promotion model describes the multi dimensional nature of persons as they interact within their environment to pursue health. The model focuses on following three areas: ·  Individual characteristics and experiences · Behavior-specific cognitions and affect · Behavioral outcomes The health promotion model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The set of variables for behavioral specific knowledge and affect have important motivational significance. These variables can be modified through nursing actions. Health promoting behavior is the desired behavioral outcome and is the end point in the HPM. Health promoting behaviors should result in improved health, enhanced functional ability and better quality of life at all stages of development. The final behavioral demand is also influenced by the immediate competing demand and preferences, which can derail an intended health promoting actions.


SHRI VINOBA BHAVE COLLEGE OF NURSING 126 THEORETICAL PROPOSITIONS OF THE HEALTH PROMOTION MODEL Theoretical statements derived from the model provide a basis for investigative work on health behaviors. The HPM is based on the following theoretical propositions:  Prior behavior and inherited and acquired characteristics influence beliefs, affect, and enactment of health-promoting behavior. Persons commit to engaging in behaviors from which they anticipate deriving personally valued benefits. Perceived barriers can constrain commitment to action, a mediator of behavior as well as actual behavior. Perceived competence or self-efficacy to execute a given behavior increases the likelihood of commitment to action and actual performance of the behavior. Greater perceived self-efficacy results in fewer perceived barriers to a specific health behavior.


SHRI VINOBA BHAVE COLLEGE OF NURSING 127 Positive affect toward a behavior results in greater perceived self-efficacy, which can in turn, result in increased positive affect.  When positive emotions or affect are associated with a behavior, the probability of commitment and action is increased. Persons are more likely to commit to and engage in health-promoting behaviors when significant others model the behavior, expect the behavior to occur, and provide assistance and support to enable the behavior.  Families, peers, and health care providers are important sources of interpersonal influence that can increase or decrease commitment to and engagement in health-promoting behavior.  Situational influences in the external environment can increase or decrease commitment to or participation in health-promoting behavior.  The greater the commitments to a specific plan of action, the more likely health-promoting behaviors are to be maintained over time.  Commitment to a plan of action is less likely to result in the desired behavior when competing demands over which persons have little control require immediate attention. 13. Commitment to a plan of action is less likely to result in the desired behavior when other actions are more attractive and thus preferred over the target behavior.  Persons can modify cognitions, affect, and the interpersonal and physical environment to create incentives for health actions.


SHRI VINOBA BHAVE COLLEGE OF NURSING 128 THE MAJOR CONCEPTS AND DEFINITIONS OF THE HEALTH PROMOTION MODEL Individual Characteristics and Experience Prior related behaviour Frequency of the similar behaviour in the past. Direct and indirect effects on the likelihood of engaging in health promoting behaviors. PERSONAL FACTORS Personal factors categorized as biological, psychological and socio-cultural. These factors are predictive of a given behavior and shaped by the nature of the target behaviour being considered. Personal biological factors Include variable such as age gender body mass index pubertal status, aerobic capacity, strength, agility, or balance. Personal psychological factors Include variables such as self esteem self motivation personal competence perceived health status and definition of health.


SHRI VINOBA BHAVE COLLEGE OF NURSING 129 Personal socio-cultural factors Include variables such as race ethnicity, accuculturation, education and socioeconomic status. Behavioural Specific Cognition and Affect PERCEIVED BENEFITS OF ACTION Anticipated positive out comes that will occur from health behaviour. PERCEIVED BARRIERS TO ACTION Anticipated, imagined or real blocks and personal costs of understanding a given behaviour PERCEIVED SELF EFFICACY Judgment of personal capability to organise and execute a health-promoting behaviour. Perceived self efficacy influences perceived barriers to action so higher efficacy result in lowered perceptions of barriers to the performance of the behavior. 


SHRI VINOBA BHAVE COLLEGE OF NURSING 130 ACTIVITY RELATED AFFECT Subjective positive or negative feeling that occur before, during and following behavior based on the stimulus properties of the behaviour itself. Activity-related affect influences perceived self-efficacy, which means the more positive the subjective feeling, the greater the feeling of efficacy. In turn, increased feelings of efficacy can generate further positive affect. INTERPERSONAL INFLUENCES Cognition concerning behaviours , beliefs, or attitudes of the others. Interpersonal influences include: norms (expectations of significant others), social support (instrumental and emotional encouragement) and modelling (vicarious learning through observing others engaged in a particular behaviour ). Primary sources of interpersonal influences are families, peers, and healthcare providers. SITUATIONAL INFLUENCES Personal perceptions and cognitions of any given situation or context that can facilitate or impede behaviour . Include perceptions of options available, demand characteristics and aesthetic features of the environment in which given health promoting is proposed to take place. Situational influences may have direct or indirect influences on health behaviour . Behavioural Outcome 


SHRI VINOBA BHAVE COLLEGE OF NURSING 131 COMMITMENT TO PLAN OF ACTION The concept of intention and identification of a planned strategy leads to implementation of health behaviour .  IMMEDIATE COMPETING DEMANDS AND PREFERENCES Competing demands are those alternative behaviour over which individuals have low control because there are environmental contingencies such as work or family care responsibilities. Competing preferences are alternative behaviour over which individuals exert relatively high control, such as choice of ice cream or apple for a snack HEALTH PROMOTING BEHAVIOUR Endpoint or action outcome directed toward attaining positive health outcome such as optimal well-being, personal fulfillment, and productive living.






SHRI VINOBA BHAVE COLLEGE OF NURSING 134 INTRODUCTION The Health Belief Model (HBM) is one of the first theories of health behavior. It was developed in the 1950s by a group of U.S. Public Health Service social psychologists who wanted to explain why so few people were participating in programs to prevent and detect disease. HBM is a good model for addressing problem behaviors that evoke health concerns (e.g., high-risk sexual behavior and the possibility of contracting HIV) ( Croyle RT, 2005) The health belief model proposes that a person's health-related behavior depends on the person's perception of four critical areas: the severity of a potential illness, the person's susceptibility to that illness, the benefits of taking a preventive action, and the barriers to taking that action. HBM is a popular model applied in nursing, especia


THE MAJOR CONCEPTS AND DEFINITIONS OF THE HEALTH PROMOTION MODEL SHRI VINOBA BHAVE COLLEGE OF NURSING 135 Perceived Susceptibility: refers to a person’s perception that a health problem is personally relevant or that a diagnosis of illness is accurate. Perceived severity:   even when one recognizes personal susceptibility, action will not occur unless the individual perceives the severity to be high enough to have serious organic or social complications. Perceived benefits : refers to the patient’s belief that a given treatment will cure the illness or help to prevent it. Perceived Costs: refers to the complexity, duration, and accessibility and accessibility of the treatment. Motivation: includes the desire to comply with a treatment and the belief that people should do what. Modifying factors: include personality variables, patient satisfaction, and socio-demographic factors.  

Cirticisms of HBM :

Cirticisms of HBM SHRI VINOBA BHAVE COLLEGE OF NURSING 136 Is health behaviour that rational? Its emphasis on the individual (HBM ignores social and economic factors) ·The absence of a role for emotional factors such as fear and denial. Alternative factors may predict health behaviour, such as outcome expectancy (whether the person feels they will be healthier as a result of their behaviour) and self-efficacy (the person’s belief in their ability to carry out preventative behaviour) (Seydel et al. 1990; Schwarzer 1992.




Peplau’s interpersonal model SHRI VINOBA BHAVE COLLEGE OF NURSING 138

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