THEORETICAL FOUNDATIONS OF NURSING

A. ENVIRONMENTAL THEORY“I think one’s feelings wastethemselves in words; they ought all tobe distilled into actions which bringresults.”Florence Nightingale (1860) Florence Nightingale defined Nursing as “the act ofutilizing the environment of the patient to assist him inhis recovery” (1860/1969), that it involves the nurse'sinitiative to configure environmental settings appropriatefor the gradual restoration of the patient's health, andthat external factors associated with the patient'ssurroundings affect life or biologic and physiologicprocesses, and his development.Environmental Factors Affecting HealthDefined in her environmental theory are the followingfactors present in the patient’s environment:pure or fresh airpure watersufficient food suppliesefficient drainagecleanlinesslight (especially direct sunlight)Adequate ventilation has also been regarded as afactor contributing to changes of the patient’s process ofillness recovery. Any deficiency in one or more of thesefactors could lead to impaired functioning of lifeprocesses or diminished health status.She also emphasized in her environmental theory is theprovision of a quiet or noise-free and warm environment,attending to patient’s dietary needs by assessment,documentation of time of food intake, and evaluating it’seffects on the patient.Nightingale believed that the environment was themajor component creating illness in a patient; she regardeddisease as “the reactions of kindly nature against theconditions in which we have placed ourselves.” Her theoryContains three major relationships:environment to patientnurse to environmentnurse to patient

B. INTERACTIVE THEORIES

INTERPERSONAL RELATIONS THEORY“The kind of person that the nursebecomes makes a substantial difference inwhat each patient will learn as he or shereceives nursing care.”Hildegard Peplau (1952) She defined Nursing as “an interpersonal process oftherapeutic interactions between an individual who is sickor in need of health services and a nurse especiallyeducated to recognize, respond to the need for help.”Dr. Peplau emphasized the nurse-client relationship asthe foundation of nursing practice. At the time, herresearch and emphasis on the give-and-take of nurse-clientrelationships was seen by many as revolutionary. Shedescribed the nurse-patient relationship as a four-phasephenomenon. Each phase is unique and has distinguishedcontributions on the outcome of the nurse-patientinteraction.Phases Of Nurse-Patient Relationship1. OrientationIndividual/family has a “felt need”and seeks professional assistance from anurse (who is a stranger). This is theproblem identification phase.2. IdentificationWhere the patient begins to havefeelings of belongingness and a capacityfor dealing with the problem, creating anoptimistic attitude from which innerstrength ensues. Here happens theselection of appropriate professionalassistance.3. ExploitationThe nurse uses communication toolsto offer services to the patient, who isexpected to take advantage of allservices.4. ResolutionWhere patient’s needs have alreadybeen met by the collaborative effortsbetween the patient and the nurse.Therapeutic relationship is terminatedand the links are dissolved, as patient

drifts away from identifying with thenurse as the helping person.Nursing RolesIn the course of the nurse-patient relationship, thenurse assumes several roles which empower and equip her inmeeting the needs of the patient.1. Stranger Role: Receives the client the same way onemeets a stranger in other life situations; providesan accepting climate that builds trust.2. Resource Role: Answers questions. Interpretsclinical treatment data, gives information.3. Teaching Role: Gives instructions and providestraining; involves analysis and synthesis of thelearner’s experience.4. Counseling Role: Helps client understand andintegrate the meaning of current life circumstances;provides quidance and encouragement to make changes.5. Surrogate Role: Helps clients clarify domains ofdependence, interdependence, and independence andacts on clients behalf as advocate.6. Leadership Role: Helps client assume maximumresponsibility for meeting treatment goals in amutually satisfying way.Additional Roles include:1. Technical expert2. Consultant3. Health teacher4. Tutor5. Socializing agent6. Safety agent7. Manager of environment8. Mediator9. Administrator10.Recorder observer11.Researcher

Definition of the Unique Function of Nursing“The nurse is temporarily theconsciousness of the unconscious, thelove of life for the suicidal, the leg ofthe amputee, the eyes of the newly blind,a means of locomotion for the infant,knowledge and confidence for the mother,the mouthpiece for those too weak orwithdrawn to speak and so on.”Virginia Henderson (1955)Henderson defined Nursing as “assisting theindividual, sick or well, in the performance of thoseactivities contributing to health or it’s recovery (or topeaceful death) that an individual would perform unaided ifhe had the necessary strength, will or knowledge”.She conceptualized the 14 Fundamental Needs of humans.These needs are:Breathing normallyEating and drinking adequatelyEliminating body wastesMoving and maintaining desirable positionSleeping and restingSelecting suitable clothesMaintaining body temperature within normal rangeKeeping the body clean and well-groomedAvoiding dangers in the environmentCommunicating with othersWorshipping according to one’s faithWorking in such a way that one feels a sense ofaccomplishmentPlaying/participating in various forms of recreationLearning, discovering or satisfying the curiosity thatleads to normal development and health and usingavailable health facilities.The Nurse-Patient RelationshipHenderson stated that there are three levelscomprising the nurse-patient relationship:1. The nurse as a substitute for the patient. In timesof illness, when the patient cannot function fully,the nurse serves as the substitute as to what thepatient lacks such, as knowledge, will, and strengthin order to make him complete, whole and independent

once again.2. The nurse as a helper to the patient. In situationswhere the patient cannot meet his basic needs, thenurse serves as a helper to accomplish them.3. The nurse as a partner with the patient. As partners,the nurse and the patient formulate the care plantogether. Both as an advocate and as a resourceperson, the nurse can empower the patient to makeeffective decisions regarding his care plans.

Dynamic Nurse-Patient Relationship“The role of the nurse is to findout and meet the patient's immediateneed for help. The patient's presentingbehavior may be a plea for help,however, the help needed may not be whatit appears to be.”Ida Jean Orlando (1961)Orlando's theory was developed in the late 1950s fromobservations she recorded between a nurse and patient.Despite her efforts, she was only able to categorize therecords as "good" or "bad" nursing. It then dawned on herthat both the formulations for "good" and "bad" nursingwere contained in the records. From these observations sheformulated the deliberative nursing process.Therefore, nurses need to use their perception,thoughts about the perception, or the feeling engenderedfrom their thoughts to explore with patients the meaning oftheir behavior. This process helps the nurse find out thenature of the distress and what help the patient needs.Orlando's theory remains one the of the most effectivepractice theories available. The use of her theory keepsthe nurse's focus on the patient. The strength of thetheory is that it is clear, concise, and easy to use. Whileproviding the overall framework for nursing, the use of hertheory does not exclude nurses from using other theorieswhile caring for the patient.Key Concepts of Three Interlocking Circles TheoryAccording to Hall, Nursing isparticipation in care, core and cureaspects, where CARE is the solefunction of nurses, whereas the COREand CURE are shared with othermembers of the health teamThe major purpose of care is toachieve an interpersonalrelationship with the individualthat will facilitate the developmentof the coreLydia Hall (1961)

Human-to-Human Relationship Model“A nurse does not only seek to alleviate physical painor render physical care- she ministers to the whole person.The existence of suffering, whether physical, mental orspiritual is the proper concern of the nurse.”Joyce Travelbee (1966)Travelbee's experience in initial psych nursingpractice at a Catholic charity hospital led her to believethat the care given in these type of institutions lackedcompassion. She felt nursing needed a "humanisticrevolution" and a renewed focus on caring as central tonursing--she warned that if this didn't happen, consumersmight seek a "new and different kind of health careworker". Travelbee's ideas have greatly influenced thehospice movement.In her human-to-human relationship model, the nurseand the patient undergoes the following series ofinteractional phases:1. Original Encounter- this is described as the firstimpression by the nurse of the sick person and viceversaThe nurse and patient see each other instereotyped or traditional roles.2. Emerging Identities- this phase is described by thenurse and patient perceiving each other as uniqueindividual. At this time, the link of relationshipbegins to form.3. Empathy- this phase is described as the ability toshare in the person’s experience.4. Sympathy- It happens when the nurse wants to lessenthe cause of the patient’s suffering. It goes beyondempathy. The nurse at this time should use adisciplined intellectual approach together withtherapeutic use of self to make helpful nursingactions.5. Rapport- this is described as nursing interventionsthat lessens the patient’s suffering. The nurse andthe sick person are relating as human being to humanbeing. The sick person shows trust and confidence inthe nurse.

C. SYSTEMS THEORIES

System Model in Nursing Practice“Health is a condition in whichall parts and subparts are in harmonywith the whole of the client”Betty Neuman (1972)Her theory incorporated the concept of a whole personand an open system approach. The concept is aimed towardsthe development of a person in a state of wellness havingthe capacity to function optimally. The main role of thenurse in her theory is to help a person to adapt withenvironmental stimuli causing illnesses back to a state ofwellness.Terms Related to Neuman’s System TheoryClient VariablesThe clients’ variables can be one or combination ofthe following: physiological, sociocultural, developmentaland spiritual. These variables function to achievestability in relation to the environmental stressorsexperienced by the client.Lines of ResistanceLines of Resistance act when the Normal Line ofDefense is invaded by too much stressor, producingalterations in the client’s health.Normal Line of DefenseTo achieve the stability of the system, the NormalLine of Defense must act in coordination with the normalwellness state. It must reflect the actual range ofresponses that is normally acted by clients in response toany stressors. It is the baseline in determining the levelof client within the continuum of health.Flexible Line of DiseaseIt serves as a boundary for the Normal Line of Defenseto adjust to situations that threaten the imbalance withinthe client’s stability.StressorsThese are forces that produce tensions, alterations orpotential problems causing instability within the client’ssystem.ReactionThese are the outcomes or produced results of certain

stressors and actions of the lines resistance of a client.It can be positive or negative depending on the degree ofreaction the client produces to adjust and adapt with thesituation. Neuman specified these reactions as negentropyor entropy. Negentropy is set towards stability or wellnesswhile Egentropy is set towards disorganization of thesystem producing illness.

Behavioral System Model“Each individual has a predispositionto act, with reference to the goal, incertain ways rather than in other ways”Dorothy Johnson (1971)Johnson believes that each individual has a focusingand repeating ways of acting which covers a behavioralsystem distinct to that individual. These behaviors arelogical, fixed, predictable and adequately secure andpersistent to be satisfying to depiction and clarification.Seven Behavioral Subsystems1. The Attachment or Affiliative Subsystem is wellknownas the earliest response system to expand inthe individual. The most favorable functioning ofthis subsystem allows social inclusion, closeness,and the pattern and continuance of a strong publicbond.2. The Dependency Subsystem are actions that triggernurturing behaviors from other individuals in theenvironment. The product of dependency behavior isconsent, interest or appreciation, and physicalsupport.3. The Ingestive Subsystem relates to the behaviorssurrounding the ingestion of food. Behaviors relatedto the ingestion of food may relate more to what issocially satisfactory in a specified culture, thanto the biological necessities of the human being.4. The Eliminative Subsystem relates to behaviorssurrounding the secretion of waste products from thebody. Human cultures have defined different sociallyacceptable behaviors for excretion of waste, but thecontinuation of such an outline remains from cultureto culture.5. The Sexual Subsystem imitates behaviors realted toprocreation or reproduction.6. The Aggressive Subsystem relates to behaviorsconcerned with the defense and self-preservation.7. The Achievement Subsystem contains behaviors thatattept to control the environment. Intellectual,physical, imaginative, mechanical, and communlskills are some of the areas that Johnsondistinguishes.

Goal Attainment Theory“If the students can’t do the fundamentals, how canthey use advanced knowledge.”Imogene King (1971)King stated that Nursing is a processof action, reaction, and interactionwhereby nurse and client share informationabout their perception in the nursing situation.ActionAction is a means of behavior or activities that aretowards the accomplishment of certain act. It is bothphysical and mental.ReactionIn King’s theory, reaction is not specified butsomehow relates reaction as part of action. According toher, reaction is a response to a stimuli.InteractionInteraction, as defined by King, is any situationwherein the nurse relates and deals with a clientele orpatient.Open SystemIt is the absence of boundary existence, where adynamic interaction between the internal and externalenvironment can exchange information without barriers orhindrances.King proposed that the nurse interacts in the systemsimultaneously at three different levels. These levels areindependent and at the same time co-exist to influenceover-all nursing practice.Personal- how the nurse views and integrates selfbased from personal goals and beliefsInterpersonal- how the nurse interrelates with a coworkeror patient, particularly in a nurse-patientrelationshipSocial- how the nurse interacts with co-workers,superiors, subordinates and the client environment ingeneral

Self-Care Theory“Individuals, families, groupsand communities need to be taughtself-care.”Dorothea Orem (1971)Orem defined Nursing as “The act of assisting othersin the provision and management of self-care tomaintain/improve human functioning at home level ofeffectiveness.”The theory focuses on activities that adultindividuals perform on their own behalf to maintain life,health and well-being. It has a strong health promotion andmaintenance focus.She identified 3 related concepts:1. Self-care - activities an Individual performsindependently throughout life to promote andmaintain personal well-being.2. Self-care deficit - results when self-care agency(Individual’s ability) is not adequate to meetthe known self-care needs.3. Nursing System - nursing interventions neededwhen Individual is unable to perform thenecessary self-care activities:1. Wholly compensatory - nurse provides entireself-care for the client.Example: care of a new born, care ofclient recovering from surgery in apost-anesthesia care unit2. Partial compensatory - nurse and clientperform care, client can perform selectedself-care activities, but also accepts caredone by the nurse for needs the clientcannot meet independently.Example: Nurse can assist postoperative client to ambulate, Nurse canbring a meal tray for client who canfeed himself3. Supportive-educative - nurse’s actions are

to help the client develop/learn their ownself-care abilities through knowledge,support and encouragement.Example: Nurse guides a mother how tobreastfeed her baby, Counseling apsychiatric client on more adaptivecoping strategies.

Twenty-One Nursing Problems“I never wanted to be a medicaldoctor because I could do all I wanted todo in nursing, which is a caringprofession.”Faye Glen Abdellah (1960) The concept of Nursing in this theory is generallygrouped into twenty-one problem areas for nurses to workout their judgment and appropriate care. Abdellah considersnursing to be an all-inclusive service that is based on thedisciplines of art and science that serves individuals,sick or well with their health needs.Typology of Twenty-one Nursing Problems1. To maintain good hygiene.2. To promote optimal activity; exercise, rest and sleep.3. To promote safety.4. To maintain good body mechanics.5. To facilitate the maintenance of a supply of oxygen6. To facilitate maintenance of nutrition7. To facilitate maintenance of elimination8. To facilitate the maintenance of fluid and electrolytebalance9. To recognize the physiologic response of the body todisease conditions10.To facilitate the maintenance of regulatory mechanismsand functions.11.To facilitate the maintenance of sensory functions12.To identify and accept positive and negativeexpressions, feelings and reactions13.To identify and accept the interrelatedness ofemotions and illness.14.To facilitate the maintenance of effective verbal andnon-verbal communication15.To promote the development of productive interpersonalrelationship16.To facilitate progress toward achievement of personalspiritual goals17.To create and maintain a therapeutic environment

18.To facilitate awareness of self as an individual withvarying needs.19.To accept the optimum possible goals20.To use community resources as an aid in resolvingproblems arising from illness.21.To understand the role of social problems asinfluencing factors

Helping Art of Clinical Nursing"My thesis is that nursing art isnot comprised of rational norreactionary actions but rather ofdeliberative action."Ernestine Wiedenbach (1964)Wiedenbach conceptualizes nursing as the practiceidentification of a patient’s need for help throughobservation of presenting behaviors and symptoms,exploration of the meaning of those symptoms with thepatient, determining the cause(s) of discomfort, anddetermining the patient’s ability to resolve the discomfortor if the patient has a need for help from the nurse orother healthcare professionals.Nursing primarily consists of identifying a patient’sneed for help. If the need for help requires intervention,the nurse facilitates the medical plan of care and alsocreates and implements a nursing plan of care based onneeds and desires of the patient. In providing care, a nurseexercises sound judgment through deliberative, practiced,and educated recognition of symptoms. The patient’sperception of the situation is an important considerationto the nurse when providing competent care.According to Wiedenbach there are four elements toclinical nursing: (1) philosophy, (2) purpose, (3)practice, and (4) art.The nurses’ philosophy was their attitude andbelief about life and how that effected realityfor them. Philosophy is what motivates the nurseto act in a certain way.Wiedenbach also believed that there were 3essential components associated with a nursingphilosophy:○ Reverence for life○ Respect for the dignity, worth, autonomy and

individuality of each human being○ Resolution to act on personally andprofessionally held beliefsNurses’ purpose is that which the nurse wants toaccomplish through what she does. It is all ofthe activities directed towards the overall goodof the patient.Practices are those observable nursing actionsthat are affected by beliefs and feelings aboutmeeting the patient’s need for help.The Art of nursing includes understandingpatient’s needs and concerns, developing goalsand actions intended to enhance patient’s abilityand directing the activities related to themedical plan to improve the patient’s condition.The nurses also focuses on prevention ofcomplications related to reoccurrence ordevelopment of new concerns.

The Conservation Model"Ethical behaviour is not the display of one's moralrectitude in times of crisis. It is the day-to-dayexpression of one's commitment to other persons and theways in which human beings relate to one another in theirdaily interactions.”Myra Levine (1977)She defined nursing as supportive & therapeuticinterventions based on scientific or therapeutic knowledge.Nursing actions based on four principles:conservation of energystructural integritypersonal integritysocial integrity

D. DEVELOPMENTAL THEORIES

Adaptation Model“The model provides a way of thinkingabout people and their environment that isuseful in any setting. It helps oneprioritize care and challenges the nurseto move the patient from survival totransformation.”Sister Callista Roy (1979) She viewed humans as biopsychosocial beings constantlyinteracting with a changing environment and who cope withtheir environment through Biopsychosocial adaptationmechanisms. There are two categories of coping mechanismsaccording to Roy namely the regulator and the cognatorsubsystems:Regulator Subsystem transpires through neutral,chemical and endocrine processes like the increase invital signs-sympathetic response to stress.Cognator Subsystem, on the other hand, occurs throughcognitive-emotive processes. For instance, are theeffects of prolonged hospitalization for a four-yearold child.The degree of internal or external environmentalchange and the person’s ability to cope with that change islikely to determine the person’s health status. Nursinginterventions are aimed at promoting physiologic,psychologic, and social functioning or adaptation.

Transcultural Theory“Care is the heart of nursing; Careis power; Care is essential to healing; Care is curing; and Care is the centraland dominant focus of nursing andtranscultural nursing decisions andactions.”Madeleine Leininger (1985)She stated that Nursing is a learned humanistic andscientific profession and discipline which is focused onhuman care phenomena and activities in order to assist,support, facilitate, or enable individuals or groups tomaintain or regain their well being (or health) inculturally meaningful and beneficial ways, or to helppeople face handicaps or death.Transcultural nursing as a learned subfield or branchof nursing which focuses upon the comparative study andanalysis of cultures with respect to nursing and healthillnesscaring practices, beliefs and values with the goalto provide meaningful and efficacious nursing care servicesto people according to their cultural values and healthillnesscontext. It focuses on the fact that differentcultures have different caring behaviors and differenthealth and illness values, beliefs, and patterns ofbehaviors. Awareness of the differences allows the nurse todesign culture-specific nursing interventions.

Philosophy and Science of Caring“Caring in nursing conveys physicalActs but embraces the mind-body-spiritas it reclaims the embodied spirit asits focus attention.”Margaret Jean Watson (1979)Watson proposes seven assumptions about the science ofcaring and ten primary carative factors to form theframework of her theory. The basic assumptions are:Caring can be effectively demonstrated and practicedonly interpersonally;Effective caring promotes health and individual orfamily growth;Caring responses accept a person not only as he or sheis now but as what he or she may become;A caring environment is one that offers thedevelopment of potential while allowing the person tochoose the best action for himself or herself at agiven point in timeCaring is more “healthogenic” than is curing. Thepractice of caring integrates biophysicalknowledge of human behavior to generate or promotehealth and to provide care to those who are ill. Ascience of caring is therefore complementary to thescience of curing.

The practice of caring is central to nursingTen Carative Factors1. The promotion of a humanistic-altruistic system ofvalues2. Instillation of faith-hope3. The cultivation of sensitivity to one’s self and others4. The development of a helping-trusting, human caringrelationship5. Promotion and acceptance of the expression of positiveand negative feelings.6. The systemic use of the scientific problem-solvingmethod for decision making7. The promotion of interpersonal teaching-learning8. The provision for supportive, protective andcorrective mental, physical, socio-cultural andspiritual environment9. Assistance with the gratification of human needs10.The allowance for existential phenomenological forces

The Science of Unitary Human Beings, and Principles ofHomeodynamics“Nursing is an art and science that is humanistic andhumanitarian. It is directed toward theunitary human and is concerned with thenature and direction of human development.” Martha Rogers (1970)Nursing interventions seek to promoteharmonious interaction between persons and theirenvironment, strengthen the wholeness of the individual andredirect human and environmental patterns or organizationto achieve maximum health. There are 5 Basic Assumptions:1. The human being is a unified whole, possessingindividual integrity and manifesting characteristicsthat are more than and different from the sum of parts.2. The individual and the environment arecontinuously exchanging matter and energy with eachother3. The life processes of human beings evolve irreversiblyand unidirectionally along a space-time continuum4. Patterns identify human being and reflect their

innovative wholeness5. The individual is characterized by the capacity forabstraction and imagery, language and thought,sensation and emotion

Theory of Human Becoming“Nursing is a scientificdiscipline, the practice of which is aperforming art.”Rosemarie Rizzo Parse (1981) Three assumptions about Human BecomingHuman becoming is freely choosing personal meaningin situation in the inter-subjective process ofrelating value prioritiesHuman becoming is co-creating rhythmic patterns orrelating in mutual process in the universeHuman becoming is co-transcending multidimensionallywith emerging possibilities.References:Octaviano, Eufemia F., RN, RM, MN, EdD, Balita, Carl E.,RN, RM, MAN, DrHum. “Theoretical Foundations of Nursing:The Philippine Perspective”, 2008.http://nursingcrib.comhttp:// http://en.wikipedia.org/wiki/