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Nursing Theories
INTRODUCTION TO NURSING
THEORIES
INTRODUCTION
Nursing has made phenomenal achievement in the last century that has lead to the recognition of nursing as an academic discipline and a profession. A move towards theory-based practice has made contemporary nursing more meaningful and significant by shifting nursing’s focus from vocation to an organised profession. The need for knowledge-base to guide professional nursing practice had been realised in the first half of the twentieth century and many theoretical works have been contributed by nurses ever since, first with the goal of making nursing a recognised profession and later with the goal of delivering care to patients as professionals. 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) NURSING PHILOSOPHIES Theory Key emphasis
Florence Nightingale’s Legacy of caring Focuses on nursing and the patient environment relationship. Ernestine Wiedenbach: The helping art of clinical nursing Helping process meets needs through the art of individualizing care. Nurses should identify patients ‘need-for – help’ by: Observation Understanding client behaviour Identifying cause of discomfort Determining if clients can resolve problems or have a need for help Virginia Henderson’s Definition of Nursing Patients require help towards achieving independence. Derived a definition of nursing Identified 14 basic human needs on which nursing care is based. Faye G.Abedellah’s Typology of twenty one Nursing problems Patient’s problems determine nursing care Lydia E. Hall :Care, Cure, Core model Nursing care is person directed towards self love. Jean Watson’s Philosophy and Science of caring Caring is moral ideal: mind -body – soul engagement with one and other. Caring is a universal, social phenomenon that is only effective when practiced interpersonally considering humanistic aspects and caring. Patricia Benner’s Primacy of caring Caring is central to the essence of nursing. It sets up what matters, enabling connection and concern. It creates possibility for mutual helpfulness. Caring creates - possibilities of coping possibilities for connecting with and concern for others, possibilities for giving and receiving help Described systematically five stages of skill acquisition in nursing practice – novice, advanced beginner, competent, proficient and
than health and illness Dorothy E.Johnson’s Behavioural system model Individuals maintain stability and balance through adjustments and adaptation to the forces that impinges them. Individual as a behavioural system is composed of seven subsystems. Attachment, or the affiliative subsystems – is the corner stone of social organisations. Behavioural system also includes the subsystems of dependency, achievement, aggressive, ingestive-eliminative and sexual. Disturbances in these causes nursing problems. Sister Callista: Roy‘s Adaptation model Stimuli disrupt an adaptive system The individual is a biopsychosocial adaptive system within an environment. The individual and the environment provide three classes of stimuli-the focal, residual and contextual. Through two adaptive mechanisms, regulator and cognator, an individual demonstrates adaptive responses or ineffective responses requiring nursing interventions Betty Neuman’s : Health care systems model Reconstitution is a status of adaptation to stressors A conceptual model with two theories “Optimal patient stability and prevention as intervention” Neuman’s model includes intrapersonal, interpersonal and extrapersonal stressors. Nursing is concerned with the whole person. Nursing actions (Primary, Secondary, and Tertiary levels of prevention) focuses on the variables affecting the client’s response to
stressors. Imogene King’s Goal attainment theory Transactions provide a frame of reference toward goal setting. A conceptual model of nursing from which theory of goal attainment is derived. From her major concepts (interaction, perception, communication, transaction, role, stress, growth and development) derived goal attainment theory. · Perceptions, Judgments and actions of the patient and the nurse lead to reaction, interaction, and transaction (Process of nursing). Nancy Roper, WW.Logan and A.J.Tierney A model for nursing based on a model of living Individuality in living. A conceptual model of nursing from which theory of goal attainment is derived. Living is an amalgam of activities of living (ALs). Most individuals experience significant life events which can affect ALs causing actual and potential problems. This affects dependence – independence continuum which is bi-directional. Nursing helps to maintain the individuality of person by preventing potential problems, solving actual problems and helping to cope.
Kathryn E. Barnard’s Parent Child Interaction Model Growth and development of children and mother–infant relationships Individual characteristics of each member influence the parent–infant system and adaptive behaviour modifies those characteristics to meet the needs of the system. Ramona T.Mercer’s :Maternal Role Attainment Parenting and maternal role attainment in diverse populations A complex theory to explain the factors impacting the development of maternal role over time. Katharine Kolcaba’s Theory of comfort Comfort is desirable holistic outcome of care. Health care needs are needs for comfort, arising from stressful health care situations that cannot be met by recipients’ traditional support system. These needs include physical, psycho spiritual, social and environmental needs. Comfort measures include those nursing interventions designed to address the specific comfort needs. Madeleine Leininger’s Transcultural nursing, culture-care theory Caring is universal and varies transculturally. Major concepts include care, caring, culture, cultural values and cultural variations Caring serves to ameliorate or improve human conditions and life base. Care is the essence and the dominant, distinctive and unifying feature of nursing Rosemarie Rizzo Parse’s :Theory of human becoming Indivisible beings and environment co-create health. A theory of nursing derived from Roger’s conceptual model. Clients are open, mutual and in constant interaction with environment. The nurse assists the client in interaction with the environment and co creating health
Nola J.Pender’s :The Health promotion; model Promoting optimum health supersedes disease prevention. Identifies cognitive, perceptual factors in clients which are modified by demographical and biological characteristics, interpersonal influences, situational and behavioural factors that help predict in health promoting behaviour CONCLUSION The conceptual and theoretical nursing models help to provide knowledge to improve practice, guide research and curriculum and identify the goals of nursing practice. The state of art and science of nursing theory is one of continuing growth. Using the internet the nurses of the world can share ideas and knowledge, carrying on the work begun by nursing theorists and continue the growth and development of new nursing knowledge. It is important the nursing knowledge is learnt, used, and applied in the theory based practice for the profession and the continued development of nursing and academic discipline REFERENCES
- George B. Julia , Nursing Theories- The base for professional Nursing Practice, 3rd ed. Norwalk, Appleton & Lange.
- Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins.
- Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott.
- Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott.
- Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book.
- Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby, Philadelphia, 2002
- Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed. Mosby, Philadelphia, 2002.
- Their main limitation is that they are only as accurate or useful as the underlying theory. Importance of nursing theories
- 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). In addition, because
- 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. The characteristics of theories Theories are
- interrelating concepts in such a way as to create a different way of looking at a particular phenomenon.
- logical in nature.
- generalizable.
- bases for hypotheses that can be tested.
- increasing the general body of knowledge within the discipline through the research implemented to validate them.
- used by the practitioners to guide and improve their practice.
- consistent with other validated theories, laws, and principles but will leave open unanswered questions that need to be investigated. Basic processes in the development of nursing theories 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 :
- The internal (self)
- The social (others) &
- 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. Common concepts in nursing theories Four concepts common in nursing theory that influence & determine nursing practice are:
- The person (patient).
- The environment
- Health
- Nursing (goals, roles, functions) Each of these concepts is usually defined & described by a nursing theorist, often uniquely; although these concepts are common to all nursing theories. Of the four concepts, the most important is that of the person. The focus of nursing, regardless of definition or theory, is the person. Historical perspectives and key concepts
- 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.
- 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.
■Humanistic theories. “Needs” theories
- These theories are based around helping individuals to fulfill their physical and mental needs. The basis of these theories is well-illustrated in Roper, Logan and Tierney’s Model of Nursing (1980).
- 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
- 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. “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 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. Models of nursing
- Until fairly recently, nursing science was derived principally from social, biologic, and medical science theories.
- However, from the 1950s to the present, an increasing number of nursing theorists have developed models of nursing that provide bases for the development of nursing theories and nursing knowledge.
- A model, as an abstraction of reality, provides a way to visualize reality to simplify thinking.
- A conceptual model shows how various concepts are interrelated and applies theories to predict or evaluate consequences of alternative actions.
- According to Fawcett (2000),
- A conceptual model “gives direction to the search for relevant questions about the phenomena of central interest to a discipline and suggests solutions to practical problems”
- Four concepts are generally considered central to the discipline of nursing: the person who receives nursing care (the patient or client); the environment (society); nursing (goals, roles, functions); and health. These four concepts form a metaparadigm of nursing.
- The term metaparadigm comes from the Greek prefix “meta,” which means more comprehensive or transcending, and the word Greek word “paradigm,” which means a philosophical or theoretical framework of a discipline upon which all theories, laws, and generalizations are formulated (Merriam- Webster’s Collegiate Dictionary, 1994). Growth and Stability Models of Change
- There are two major differences in philosophical beliefs, or world views, about the nature of change.
- “The world view of change uses the growth metaphor, and the persistence view focuses on stability” (Fawcett, 1989,).
- Within the change world view, change and growth are continual and desirable, “progress is valued, and realization of one’s potential is emphasized” (Fawcett).
- Persistence is endurance in time
- Persistence world view emphasizes equilibrium and balance. Categories of Conceptual Models
- Ten conceptual models of nursing have been classified according to two criteria:
- the world view of change reflected by the model (growth or stability); and
- the major theoretical conceptual classification with which the model seems most consistent (systems, stress/adaptation, caring, or growth/development). Systems Theory as a Framework
- Systems theory is concerned with changes caused by interactions among all the factors (variables)
- General systems theory is emphasized
- A system is defined as “a whole with interrelated parts, in which the parts have a function and the system as a totality has a function” (Auger, 1976,
- A general systems approach allows for consideration of the subsystems levels of the human being, as a total human being, and as a social creature who networks himself with others in hierarchically arranged human systems of increasing complexity. Thus the human being, from the level of the individual to the level of society, can be conceptualized as the client and becomes the target system for nursing intervention (Sills & Hall, 1977). An example of systems interaction
- Normal line of defense: an adaptational level of health considered normal for an individual
- Lines of resistance: protection factors activated when stressors have penetrated the normal line of defense
- Neuman’s model, organized around stress reduction, is concerned primarily with how stress and the reactions to stress affect the development and maintenance of health.
- The person is a composite of physiologic, psychological, sociocultural, developmental, and spiritual variables considered simultaneously.
- “Ideally the five variables function harmoniously or are stable in relation to internal and external environmental stressor influences” (Neuman, 2002).
- A person is constantly affected by stressors from the internal, external, or created environment.
- Stressors are tension-producing stimuli that have the potential to disturb a person’s equilibrium or normal line of defense.
- This normal line of defense is the person’s “usual steady state.”
- It is the way in which an individual usually deals with stressors.
- Stressors may be of three types: Intrapersonal: forces arising from within the person Interpersonal: forces arising between persons Extrapersonal: forces arising from outside the person
- Resistance to stressors is provided by a flexible line of defense, a dynamic protective buffer made up of all variables affecting a person at any given moment the person’s resistance to any given stressor or stressors.
- If the flexible line of defense is no longer able to protect the person against a stressor, the stressor breaks through, disturbs the person’s equilibrium, and triggers a reaction. The reaction may lead toward restoration of balance or toward death.
- Neuman intends for the nurse to “assist clients to retain, attain, or maintain optimal system stability” (Neuman, 1996).
- Thus, health (wellness) seems to be related to dynamic equilibrium of the normal line of defense, where stressors are successfully overcome or avoided by the flexible line of defense.
- Neuman defines illness as “a state of insufficiency with disrupting needs unsatisfied” (Neuman, 2002).
- Illness appears to be a separate state when a stressor breaks through the normal line of defense and causes a reaction with the person’s lines of resistance. Stress/Adaptation Theory as a Framework
- In contrast to systems theory, stress and adaptation theories view change caused by person–environment interaction in terms of cause and effect.
- The person must adjust to environmental changes to avoid disturbing a balanced existence. Adaptation theory provides a way to understand both how the balance is maintained and the possible effects of disturbed equilibrium.
- This theory has been widely applied to explain, predict, and control biologic (physiologic and psychological) phenomenon.
A unique body of knowledge
- The drive for a unique body of knowledge is based on the assumption that ‘borrowed’ knowledge is less worthy.
- However, nurse education is based on theory borrowed from other disciplines, such as sociology and psychology.
- It has been argued that applying knowledge from different disciplines only serves to dilute nursing practice.
- Nevertheless, as the occupation is focused on humans, perhaps it is inevitable that nursing uses knowledge from other social sciences.
- It has been argued that no knowledge is exclusive, and because of nursing’s diverse nature it is impossible for it to have a unique body of knowledge and one unified body of theory (Castledine 1994, Levine 1995). Criticisms of nursing theories To understand why nursing theory is generally neglected on the wards it is necessary to take a closer look at the main criticisms of nursing theory and the role that nurses play in contributing to its lack of prevalence in practice. Use of language
- Scott (1994) states that the crucial ingredients of nursing theory should be accessibility and clarity. However, one of the main criticisms of nursing theory is its use of overtly complex language (Kenny 1993). It is important that the language used in the development of nursing theory be used consistently. Not part of everyday practice
- Despite theory and practice being viewed as inseparable concepts, a theory- practice gap still exists in nursing (Upton 1999). Yet despite the availability of a vast amount of literature on the subject, nursing theory still means very little to most practicing nurses. Perhaps this is because the majority of nursing theory is developed by and for nursing academics (Lathlean 1994). It has been recognised that traditionally nurses are used to ‘speaking with their hands’ (Levine 1995). Therefore, many nurses have not had the training or experience to deal with the abstract concepts presented by nursing theory. This makes it difficult for the majority of nurses to understand and apply theory to practice (Miller 1985). Summarization
- Definition
- Importance of Nursing Theories
- The characteristics of theories:
- Basic Processes in the Development Of Nursing Theories:
- Nursing theories are often based on & influenced
- ANA definition of Nursing Practice
- Common concepts in Nursing Theories:
- Historical Perspectives & Key Concepts
- Clasification of Nursing Theories
Nursing Theorists
Definitions Theory- a set of related statements that describes or explains phenomena in a systematic way Concept-a mental idea of a phenomenon Construct- a phenomena that cannot be observed and must be inferred Proposition- a statement of relationship between concepts Conceptual model- made up of concepts and propositions Nursing Theorists
- Florence Nightingale,
- Hildegard Peplau
- Virginia Henderson
- Fay Abdella
- Ida Jean Orlando
- Dorothy Johnson
- Martha Rogers
- Dorothea Orem
- Imogene King
- Betty Neuman
- Sister Calista Roy,
- Jean Watson
- Rosemary Rizzo Parse
- Madeleine Leininger
Patricia Benner Concepts in the nursing Metaparadigm
- Person
- Recipient of care, including physical, spiritual, psychological, and sociocultural components
- Individual, family, or community
- Environment
- All internal and external conditions, circumstances, and influences affecting the person
- Health
- Degree of wellness or illness experienced by the person
- Nursing
- Actions, characteristics and attributes of person giving care Florence Nightingale- Environmental Theory
- First nursing theorist
- Unsanitary conditions posed health hazard (Notes on Nursing, 1859)
- 5 components of environment
- ventilation, light, warmth, effluvia, noise
- External influences can prevent, suppress or contribute to disease or death Nightingale’s Concepts
- Person o Patient who is acted on by nurse o Affected by environment o Has reparative powers
- Environment o Foundation of theory. Included everything, physical, psychological, and social
- Health o Maintaining well-being by using a person’s powers o Maintained by control of environment
- Nursing o Provided fresh air, warmth, cleanliness, good diet, quiet to facilitate person’s reparative process Hildegard Peplau -Interpersonal Relations Model
- Based on psychodynamic nursing
- using an understanding of one’s own behavior to help others identify their difficulties
- Applies principles of human relations
- Patient has a felt need Peplau’s Concepts
- Person o An individual; a developing organism who tries to reduce anxiety caused by needs o Lives in instable equilibrium
- Environment- Not defined
- Health o Implies forward movement of the personality and human processes toward creative, constructive, productive, personal, and community living
