INTRODUCTION TO NURSING THEORY

MODULE I

RIZZA B. EGALLA, MAN, LPT, RN

Faculty, PRMSU College of Nursing
 Theory Defined

• A set of statements that tentatively describe,

explain, or predict relationships among
concepts that have been systematically
selected and organized as an abstract
representation of some phenomenon
(McEwen & Wills, 2019).
 Nursing Theories
• Nursing theories are organized bodies of
knowledge to define what nursing is, what
nurses do, and why do they do it.

• Nursing theories provide a way to define

nursing as a unique discipline that is separate
from other disciplines (e.g., medicine).

• It is a framework of concepts and purposes

intended to guide the practice of nursing at
a more concrete and specific level.
History of Nursing Theories
• In 1860, Florence Nightingale defined
nursing in her “Environmental Theory”.

• In 1952, Hildegard Peplau introduced her

Theory of Interpersonal Relations.

• In 1955, Virginia Henderson

conceptualized the nurses’ role in assisting
sick or healthy individuals.

• In 1960, Faye Abdellah published her work

“Typology of 21 Nursing Problems”.
History of Nursing Theories
• In 1962, Ida Jean Orlando viewed the
professional function of nursing as finding out
and meeting the patients immediate need for
help.

• In 1968, Dorothy Johnson pioneered the

Behavioral System Model.

• In 1970, Martha Rogers viewed nursing as

both science and an art.

• In 1971, Dorothea Orem – nursing care is

required if the client is unable to fulfill needs.
History of Nursing Theories
• In 1971, Imogene King’s Theory of Goal
Attainment- nurse-patient relationship in
meeting goals.

• In 1972, Betty Neuman- Stress reduction is

the goal.

• In 1979, Sr. Callista Roy- maintain the balance

between various stimuli for adaptation.

• In 1979, Jean Watson developed the

philosophy of caring highlighted humanistic
aspects of nursing.
 Stages in the Development of Nursing Theory
STAGE SOURCE OF KNOWLEDGE IMPACT ON THEORY AND RESEARCH

Silent Knowledge Blind obedience to medical authority. Little attempt to develop theory. Research was
limited to collection of epidemiologic data.

Received Knowledge Learning through listening to others. Theories were borrowed from other disciplines. As
nurses required non-nursing doctoral degrees,
they relied on the authority of educators,
sociologists, psychologists, physiologists, and
anthropologists to provide answers to nursing
problems.
Subjective Knowledge Authority was internalized to foster a new sense of A negative attitude toward borrowed theories and
self. science emerged.

Nurse scholars focused on defining nursing and on

developing theories about and for nursing.

Nursing research focused on the nurse rather than

on clients and clinical situations.
 Stages in the Development of Nursing Theory
STAGE SOURCE OF KNOWLEDGE IMPACT ON THEORY AND RESEARCH

Procedural Knowledge Includes both separate and connected knowledge. Proliferation of approaches to theory
development. Application of theory in practice
was frequently underemphasized. Emphasis was
placed on the procedures used to acquire
knowledge, with focused attention to the
appropriate ness of methodology, the criteria for
evolution, and statistical procedures for data
analysis.
Constructed Knowledge Combination of different types of knowledge Recognition that nursing theory should be based
(intuition, reason, and self-knowledge). on prior empirical studies, theoretical literature,
client reports of clinical experience and feelings,
and the nurse scholar’s institution or related
knowledge about the phenomenon of concern.
Integrated Knowledge Assimilation and application of “evidence” from Nursing theory will increasingly incorporate
nursing and other health care disciplines. information from published literature with
enhanced emphasis on clinical application as
situation-specific/ practice theories and middle
range theories.
Components of a Theory

• Concepts
• Definition
• Assumptions
• Phenomenon
 Concepts
• Concepts are often called the building blocks
of theories.

• They are primarily the vehicles of thought

that involve images.

• Concepts may be abstract or concrete.

• Examples: Noise, Cleanliness, Ventilation,

Bed and Beddings, Warmth in Nightingale’s
Environmental Theory
 Definitions
• It conveys the general meaning of the
concepts in a manner that fits the theory.

• An example in Newman’s Theory , she

defined stressor as any stimuli that can
produce tension and cause instability within
the system.
 Two Types of Definition
• Theoretical definition- concepts that are
described according to how these concepts
are defined in the dictionary or based on the
theorist’s perspective.

• Operational definition- concepts that are

based on how these concepts are used or will
be used within the context of the
phenomenon being observed or
experienced.
 Example
• Theoretical definition
- Temperature is the hemothermic range of a
person’s internal environment maintained by
the thermoregulatory system of the body.

• Operational definition
- Temperature is the degree of temperature
measured by the oral thermometer taken for
one minute under the tongue.
 Assumptions
• These are statements that describe concepts
or connect two concepts that are factual.

• These are the “taken for granted” statements

that determine the nature of the concepts,
definitions, purpose, relationships and
structure of the theory.
 Example of Assumption
• For example, in Neuman’s systems model of
the assumptions include the following:
patients are dynamic.
 Phenomenon
• A phenomenon is the term, description, or
label given to describe an idea or responses
about an event, a situation, a process, a
group of events, or a group of situations.

• Examples of phenomena of nursing include

caring, self-care, and patient responses to
stress.
 Conceptual Framewok
• A set of interrelated concepts that
symbolically represents and conveys a mental
image of a phenomenon.

• Conceptual models of nursing identify

concepts and describe their relationships to
the phenomena of central concern to the
discipline: person, environment, health and
nursing.
 Hypothesis
• It is an educated guess based upon
observation.

• Can be supported or proven false by

experimentation or continued observation.
 Theoretical Model
• Theoretical models are representation of the
interaction among and between the
concepts showing patterns.

• Models are typically accompanied by a

pictorial representation of the variables and
their interrelationships.
Example of Theoretical Model
 Classification of Nursing
Theories
• Based on scope (complexity and degree of
abstraction).
• Based on types of Purpose.
• According to Meleis.
Types of Theory Based on
Scope
 a. Metatheory
• These are theories whose subject matters
are some other theories (theories about
theories).

• It describes the philosophical basis of the

discipline (a.k.a. Nursing Philosophies).

• The highest level of theory in terms of

abstraction thus very difficult to for
practical application.
 b. Grand Theory
• It describe the comprehensive conceptual
frameworks (a.k.a. Nursing Conceptual
Models).

• Are broad in scope and complex and

therefore requires further specification
through research before they can be tested.

• Focus on broad, nonspecific, and general

areas and concepts.

• They lack operational definitions.

 Examples of Grand
Theories
• Roy Adaptation Model
• Self-Care Theory by Orem
• Philosophy and Theory of Transpersonal
Caring- Jean Watson
• King’s Goal Attainment Theory
• Nightingale’s Environmental Theory
c. Middle-Range Theories
• They have more limited scope, less
abstraction, address specific phenomenon
or concepts and reflect practice (e.g. pain,
stress, adaptation).

• They more precise and highly specific in

nursing.
• They exhibit “best of both worlds” – i.e.
easy applicability in practice and abstract
enough to be scientifically interesting.

• They are easier to apply as frameworks for

research studies.
Examples of Middle-Range
Theories
• Benner’s Skill Acquisition Model
• Leininger’s Cultural Care
• Diversity and Universality Theory
• Pender’s Health Promotion Model
• Mercer’s Conceptualization of Maternal
Role
Attainment/ Becoming a Mother
 c. Practice Theory
• They are called situation-specific theories,
prescriptive theories, and are the least
complex and “action-oriented”.

• They are more specific than middle-range

theories and produce specific directions
for practice.

• They are usually limited to specific

populations or fields of practice.
 Examples of Practice
Theories
• Examples of practice theories developed
and used by nurses are theories of
postpartum depression, infant bonding,
and oncology pain management.
Types of Purpose Theory

1. Factor-isolating theories (descriptive

theories)
• These describe, observe, and name
concepts, properties, and dimensions but
does not explain how or why the concepts
are related.
• It is generated and tested by descriptive
research techniques (case studies,
literature review phenomenology,
ethnography).
Examples of Descriptive
Theory
• Theoretical model describing the
experience of caring for a dying spouse.
Types of Purpose Theory
1. Factor- relating theories (explanatory theories)
• They relate concepts to one another, describe the
interrelationships among concepts or
propositions.

• They attempt to tell how or why the concepts are

related and may deal with cause and effect and
correlations or rules that regulate interactions.

• They are developed by correlational research.

• Example: Theory of spirituality-based nursing

practice by Nardi & Rooda
Types of Purpose Theory

2. Situation-relating theories (predictive

theories or promoting or inhibiting theories)
• This predicts occurrence of a phenomenon
when the cause is present.
• Experimental research is used to generate
and test them in most cases.
• Example: The relationship between
spirituality and health status among adults
living with HIV by Cobb.
Types of Purpose Theory
3. Situation-producing theories (prescriptive
theories)
• Prescriptive theories address nursing
therapeutics and consequences of
interventions.

• “Prevents” occurrence of the phenomenon by

controlling or eliminating possible causes.

• Example: A prescriptive theory explaining

medical acupuncture to reduce stress and
enhance well-being.
Nursing Theories Classification
According to Meleis (2011)
• “Needs” Theories
• Interaction” Theories
• “Outcome” Theories
 LIFE OF FLORENCE
NIGHTINGALE:
MOTHER OF MODERN
NURSING

MODULE II
RIZZA B. EGALLA, MAN, LPT, RN
Faculty, PRMSU College of Nursing
 “Nursing is the art of utilizing one’s
environment for his or her own
recovery.”
Florence Nightingale
May 12, 1820- August 13, 1910

Nightingale is the first nurse

theorist well-known for developing
the Environmental Theory
EARLY LIFE

• Known as the “Mother/ Founder of Modern

Nursing”

• “The Lady with the Lamp”

• Born in Florence, Italy on the 12th day of May

1820 and was named after the city of her birth.

• The younger of two children, her older sister is

Frances Parthenope.

• Her mother, Frances (Fanny) Nightingale, hailed

from a family of merchants and took pride in
socializing with people of prominent social
standing.
• Her British family belonged to a rich, upper-
class, well-connected British family.

• Her father, William Nightingale, a wealthy

landowner who had inherited two estates-
one at Lea Hurst, Derbyshire, and other in
Hampshire, Embley Park (now a school) –
when Nightingale was 5 years old.
 Nightingale’s Education
• Her father provided her with a classical
education, including studies in German,
French and Italian.

• She is also excellent in Mathematics.

• From a very young age, Nightingale was

active in philanthropy, ministering to the ill
and poor people.
 Nightingale’s Education
• Inspired by what she took as a call
from God in February 1837 (17 y/o),
Florence announced her decision to
enter nursing in 1844 (24y/o),
despite the intense anger and
distress of her mother and sister.

• Rebelled against the expected role

for a woman of her status (become a
wife and mother).

• Motivated by Elizabeth Blackwell at

St. Bartholomew’s Hospital, first
woman doctor in US.
• In 1849, Blackwell graduated first in her
class. She continued her training at several
hospitals in London and Paris, but found
most doctors were not willing to accept
her.
• Despite the objections of her parents,
Nightingale enrolled as a nursing student in
1844 at the Lutheran Hospital of Pastor
Fliedner in Kaiserswerth, Germany.
Nightingale’s Personal Life
• She was very attractive and charming but
she rejected a suitor, Richard Monckton
Milnes, 1st Baron Houghton, because she
was convinced that marriage would interfere
with her ability to follow her calling to
nursing.

• The income given to her by her father of

£500 (roughly £25, 000/ USŚ50,000 in
present terms) during this time allowed her
to still live comfortably and pursue her
career.
RICHARD MONCKTON MILNES
Works and Appointment
• She regarded the experience in the
Lutheran Hospital in Germany as A
TURNING POINT IN HER LIFE, and issued
her findings anonymously in 1851; The
Institution of Kaiserswerth on the Rhine,
for the Practical Training of Deaconesses,
etc. was her first published work.
• In 1853, Florence Nightingale accepted the
position of superintendent at the Institute
for the Care of Sick Gentlewomen (Invalid
women) in Upper Harley Street, London. She
held this position until October 1854.
 Crimean War
• In March 1853, the Crimean
War broke out between
Russia and Turkey, with
British and French forces
aiding Turkish armies in
repelling the advance of the
Russians.

• Soldiers began going down

with cholera and malaria
(around 8,000 men).

• Several nurses offered help

but rejected until public
protest was made after a
newspaper was published
concern the status of British
army.
• Florence Nightingale’s most famous
contribution came during the Crimean War,
which became her central focus when
reports began to filter back to Britain about
the horrific conditions for the wounded.

• On October 21, 1854, she and a staff of 38

women volunteer nurses, trained by
Nightingale and including her aunt Mai
Smith, were sent (under the authorization of
Sidney Herbert, the Secretary of War) across
the Black Sea from Balaklava in the Crimea,
where the main British camp was based.
• Nightingale and some of the 38 “handmaidens of the Lord”
(as she called them) to nurse wounded British soldiers in the
Crimean War.
• Nightingale arrived early in November 1854
at Selimiye Barracks in Scutari (modern-day
Uskudar in Istanbul).

• There were no female nurses stationed at

hospitals in the Crimea.

• She and her nurses found wounded soldiers

being badly cared for by overworked medical
staff in the face of official indifference.

• Medicines were in short supply, hygiene was

being neglected, and mass infections were
common, many of them fatal.
• There was no equipment to process food for
the patients.

• Rats and insects crawled the floor and

walls.

• Wounded soldiers still wearing their army

uniform “stiff with dirt.”
• During her first winter at Scutari, 4, 077
soldiers died there. Ten times more soldiers
died from illnesses such as typhus, typhoid,
cholera and dysentery than from battle
wounds.

• Conditions at the temporary barracks

hospital were so fatal to the patients
because of overcrowding and the hospital’s
defective sewers and lack of ventilation.
• Through her tireless efforts the mortality
rate among the sick and the wounded was
greatly reduced (from 42% to 2%).

• She advocated sanitary living conditions as

of great importance.

• Consequently, she reduced deaths in the

army during peacetime and turned
attention to the sanitary design of hospitals.
• During the Crimean War, Florence
Nightingale gained the nickname
“The Lady with the Lamp”, deriving
from a phrase in a report in The
Times: (by William Howard Russell).
“She is a “ministering angel” without any
exaggeration in these hospitals, and as her
slender form glides quietly along each
corridor, every poor fellow’s face softens with
gratitude at the sight of her. When all the
medical officers have retired for the night and
silence and darkness have settled down upon
those miles of prostrate sick, she may be
observed alone, with a little lamp in her
hand, making her solitary rounds”.
William Howard Russell
• Based on her observations in the Crimea,
Florence Nightingale wrote Notes on
Matters Affecting The Health, Efficiency
and Hospital Administration of the British
Army, an 830-page report analyzing her
experience and proposing reforms for other
military hospitals operating under poor
conditions.
 Letter from Queen Victoria
• Thanking “Miss
Nightingale and her
ladies” for all their hard
work.

• She was given a diamond

brooch with “Blessed are
the merciful” engraved
on it.
 Post- War Contributions
• The Nightingale Fund for the training of
nurses.

• Using the money (Ś250,000) she got from

the British government, she funded the
establishment of St. Thomas’ Hospital, and
within it, the Nightingale Training School
for Nurses, now part of the King’s College
London.
First Batch of Nursing Graduates
• In 1860, her best authored works was published,
“Notes on Nursing”, outlining principles of
nursing, a slim 136-page book that served as the
cornerstone of the curriculum at the Nightingale
School (written specifically for nursing
education).

• Considered a classic introduction to nursing.

• Notes on Hospitals, which deals with the

correlation of sanitary techniques to medical
facilities.

• Suggestions for Thought to Searchers after

Religious Truths, she argued strongly for the
removal of restrictions that prevented women
having careers.
 The First
Nursing Book
• In the 1870s, Nightingale mentored
Linda Richards “America’s first trained
nurse”, a great nursing pioneer in the
USA and Japan.
 Awards and Honors
• Crimean Monument in Waterloo Place,
London was erected in her honor.

• King Edward VII bestows the Order of Merit;

it is the first time that the Order is given to a
woman.

• Became a Fellow of the Royal Statistical

Society because of her “Nightingale Rose
Diagram”.

• Honorary member of the American

Statistical Association.
 Became first woman to receive the
British Order of Merit
The International Nurses Day is celebrated on her
birthday each year
Crimean Monument in Waterloo Place
London was erected in her honor
Until recently her picture was on our British £10 note
“Nightingale Rose Diagram”
 Nightingale’s Death
• Despite being known as the
heroine of the Crimean War,
Florence Nightingale felt ill in
August 1910.

• She seemed to recover but she

developed an array of troubling
symptoms a week later, on the
evening of Friday, August 12, 1910.

• She died peacefully unexpectedly

in her sleep at 2:00pm, Saturday,
August 13, at her home in London.
 The grave of Florence Nightingale in the
churchyard of St. Margaret’s Church, East
Wellow, England.
The Newspaper that published
Nightingale’s death.
• Today the Nurses take the
Florence Nightingale
pledge before being
formally initiated into the
profession of Nursing.
Nightingale’s Environmental Model
• Defined Nursing as the “act of utilizing the
environment of the patient to assist him in his
recovery.”

• It involves the nurse’s initiative to configure

environmental settings appropriate for the
gradual restoration of the patient’s health.

• She viewed the manipulation of the physical

environment as a major component of nursing
care.

• Discussed in her book Notes on Nursing: What

it is, What it is Not.
Sub-Concepts of Environmental
Theory
1. Health of Houses
2. Ventilation & Warming
3. Light
4. Noise
5. Variety
6. Bed and Bedding
7. Cleanliness of Rooms & Walls
8. Personal Cleanliness
9. Nutrition and Taking Food
10. Chattering Hopes and Advices
11. Observation of the Sick
12. Petty Management
Nightingale’s Environmental Model
Nightingale’s Environmental Model
• Nightingale believed that when one or more
aspects of the environment are out of
balance, the client must use increased
energy to counter the environmental stress.

• These stresses drain the client of energy

needed for healing.
 1. Health of Houses
• Is closely related to the presence of pure air,
pure water, efficient drainage, cleanliness,
and light.

• “Badly constructed houses do for the

healthy what badly constructed hospitals do
for the sick – Nightingale”

• Cleanliness outside the house affected the

inside.
 2. Ventilation and Warning
• “Keep the air he breathes pure as the external
air, without chilling him”

• Person who repeatedly breathes his/her own

air would be sick or remain sick.

• “Noxious air”, or “effluvia” or foul odors affect

the client’s health (excrement, bedpans,
urinals).

• Emphasized the importance of room

temperature (should be too warm or too cold).
 3. Light
• The sick needs both fresh air and light- direct
sunlight was what the clients wanted.

• Has quite real and tangible effects upon the

human body.

• Lack of environmental stimuli (e.g isolation,

NICU, ICU) can lead to confusion or
“intensive care psychosis” related to the lack
of the usual cycling of day and night.
 4. Noise
• Patients should never be waked intentionally
or accidentally during the first part of sleep.

• Noises that may irritate patients are jewelries

worn by nurses, keys that jingle, snapping of
rubber gloves, the clank of the stethoscope
against metal bed rails, telephones ringing.
 5. Variety
• Affects patient recovery.

• Provide variety in the patient’s room to help

him/her avoid boredom and depression.

• Encourage significant others to engage with

the client. Need for changes in color and
form (e.g. Bringing brightly colored flowers or
plants, rotating 10-12 paintings & engravings)
(presently known as diversional therapy).

• Advocated reading, writing, and cleaning to

relieve the sick of boredom.
 6. Bed and Bedding
• An adult exhales about 3 pints of moisture
through the lungs and skin in a 24-hour period.

• This matter enter the sheets and stays there

unless the bedding is hanged and aired
frequently.

• Beds must be placed in the lightest part of the

room.

• Caregiver must never lean against, sit upon, or

unnecessarily shake the bed, wrinkle free bed.

• Nurses must keep bedding clean, neat, dry, and

to position for maximum support.
7. Cleanliness of Rooms and Walls
• The greater part of using nursing consists I
preserving cleanliness.

• Removal of dust with a damp cloth rather

than feather duster

• Floors should be easily cleaned.

• Furniture and walls be easily washed.

• Clean room is a healthy room.

 8. Personal Cleanliness
• Unwashed skin poisons the patient.

• Bathing and drying the skin provide great

relief to the patient.

• “Keep pores of the skin free from all

obstructing excretions”

• “Every nurse ought to wash her hands very

frequently during the day” – Nightingale
9. Nutrition and Taking Food
• Variety of foods served to patients.

• Individuals desire different foods at different

times of the day.

• Frequent small servings may be more

beneficial than a large breakfast or dinner.

• No business must be done with the patient

while they are eating (distraction).

• Right food at the right time.

10. Chattering Hopes and Advice

• False hopes are depressing to patients.

• Sick persons should hear good news that

would assist them in becoming healthier.
 11. Observation of the Sick
• Nurses must be taught.

• What to observe.

• How to observe (what symptoms indicate

improvement).

• What is the reverse.

• Which are of importance.

• Which are evidence of neglect.

• It is important to obtain complete and
accurate information about patients.

• “If you cannot get the habit of observation

one way or other, you had better give up
being a nurse, for it is not your calling,
however kind and anxious you maybe.”
The most important practical lesson that can
be given to nurses is to teach them what to
observe.

-Florence Nightingale
 12. Petty Management

• Continuity of the care, when the nurse is

absent.

• Documentation of the plan of care and all

evaluation will ensure others give the same
care to the client in your absence.

• Ways to assure “what you do when you are

there, shall be done when you are not there.”
• Note that the client, the nurse, and the major
environment concepts are in balance; that is;
the nurse can manipulate the environment to
compensate for the client’s response to it.

• The goal of the nurse is to assist the patient

in staying balance.

• If the environment of a client is out of

balance, the client expends unnecessary
energy.
Major Concepts (Metaparadigm)
A. Environment- anything can be manipulated
to place a patient in the best possible
condition for nature to act.

• Physical components- ventilation, warmth, light,

nutrition, medicine, stimulation, room
temperature, and activity.

• Psychological- avoid chattering hopes and

advices and providing privacy.
Major Concepts (Metaparadigm)
B. Person- the one who is receiving care: a dynamic
and complex being.

C. Health- “Healthy is not only to be well, but to be

able to use well every power we have.”
- For Nightingale, 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. (Six D’s of Dys-ease are: Dirt, Drink (need
clean drinking water), Diet, Damp, Draughts and
Drains (need proper drainage and sewer systems) –
a REPARATIVE PROCESS

- Prevention of diseases and health promotion.

Major Concepts (Metaparadigm)
D. Nursing – a spiritual calling; Nurses were to assist
nature to repair the patient.
• Responsible to provide physicians with accurate
information about patients

Different Types of Nursing

a. Nursing Proper- nursing the sick
b. General Nursing- health promotion
c. Midwifery Nursing
 JEAN WATSON
Theory of Human Caring
&
DOROTHEA OREM
Self-Care Theory

MODULE III & IV

RIZZA B. EGALLA, MAN, LPT, RN
Faculty, PRMSU College of Nursing
 DR. JEAN WATSON’S

THEORY OF
HUMAN CARING
 JEAN WATSON
• Jean Watson (June 10, 1940 – present) is an
American nurse theorist and nursing professor who
is well known for her “Philosophy and Theory of
Transpersonal Caring” or “Caring Science”

• Her study on caring has been integrated into

education and patient care to various nursing
schools and healthcare facilities all over the world.
 Her Concept of Nursing
• Nursing involves the application of ART and
HUMAN SCIENCE through TRANSPERSONAL
TRANSACTIONS in order to help the person
achieve mind, body, and soul harmony.
 Personal Background
• She was born in West Virginia.

• Undergraduate and graduate degrees in nursing

and psychiatric-mental health nursing and PhD
in educational psychology and counseling.

• In 1997, she experienced an accidental injury

that resulted in the loss of her left eye.

• In 1998, her husband, whom she considers as

her physical and spiritual partner, and her best
friend passed away.
• Watson states that she is “attempting to
integrate these wounds into my life and work.
One of the gifts through the suffering was the
privilege of experiencing and receiving my own
theory through the care from my husband and
loving nurse friends and colleagues.”
 7 Assumptions of the Caring
Science
1. Caring can be effectively demonstrated and
practiced only interpersonally.

2. Caring consists of carative factors that result in

the satisfaction of certain human needs.

3. Effective caring promotes health an individual or

family growth.

4. Caring responses accept a person not only as he

or she is now but as what he or she may become.
5. A caring environment is one that offers the
development of potential while allowing the
person to choose the best action for himself at a
given point in time.

6. A science of caring is therefore complementary

to the science of curing.

7. The practice of caring is central to nursing.

Major Elements of Caring Theory
1. Transpersonal Caring Relationship
• how the nurse goes beyond an objective assessment,
showing concerns toward the person’s subjective and
deeper meaning regarding their own health care
situation.

2. Caring Occasion/ Moment

• Moment when the nurse and another person come
together in such a way that an occasion for human caring is
created.

3. Carative Factors
 Ten Carative Factors
• Guide for the core of nursing, need to be
addressed by nurses with their patients when in
a caring role.

• CARATIVE term to contrast with curative.

• It honors the human dimensions of nursing work

and the inner life world and subjective
experiences of patients.
• Watson offered a translation of the original
carative factors into clinical caritas processes
that suggested ways to apply the 10 carative
factors.
 Carative Factors
CARATIVE FACTORS CARITAS PROCESS
1. “The formation of a “Practice of loving-kindness and
humanistic- altruistic system of equanimity within the context of
values” caring consciousness”
2. “The instillation of faith-hope” “Being authentically present and
enabling and sustaining the deep
belief system and subjective life-
world of self and one being
cared for”
3. “The cultivation of sensitivity “Cultivation of one’s own
to one’s self and to others” spiritual practices and
transpersonal self-going beyond
the ego self”
4. “Development of a helping- “Developing and sustaining a
trust relationship” became helping trusting authentic caring
“development of a helping-trust, relationship”
human caring relation”
 CARATIVE FACTORS CARITAS PROCESS
5. “The promotion and “Being present to, and
acceptance of the expression of supportive of, the expression of
positive and negative feelings” positive and negative feelings as
a connection with deeper spirit
and self and the one–being
cared for”
6. “The systematic use of the “Creative use of self and all ways
scientific problem-solving of knowing as part of the caring
method for decision making” process; to engage in the artistry
became “systematic use of a of caring-healing practices”
creative problem solving caring
process” (In 2004 Watson
website)
7. “The promotion of “Engaging in genuine teaching-
transpersonal teaching-learning” learning experience that attends
to unity of being and meaning,
attempting to stay within others’
frame of reference”
 CARATIVE FACTORS CARITAS PROCESS
8. “The provision of supportive, “Creating healing environment at
protective, and (or) corrective all levels (physical as well as
mental, physical, societal, and nonphysical, subtle environment
spiritual environment” of energy and consciousness,
whereby wholeness, beauty,
comfort, dignity, and peace are
potentiated)”
9. “The assistance with “Assisting with basic needs, with
gratification of human needs” an intentional caring
consciousness, administering
“human care essentials”, which
potentiate alignment of mind
body spirit, wholeness, and unity
of being in all aspects of care”
10. “The allowance for “Opening and attending to
existential-phenomenological spiritual-mysterious and
forces” became “allowance for existential dimensions of one’s
existential-phenomenological own life-death; soul care for self
spiritual forces” and the one-being-cared for”
 Application of Theory
• Her model of nursing reflects and embodies the
TRUE ESSENCE OF THE NURSING PROFESSION to this
very day.

• It viewed the patient as the Mind-Body-Spirit entity

that needs holistic nursing care.

• One major implication of the theory is in the realm

of BEDSIDE NURSING, where nurses of today have
particularly began to neglect.

• The essence of nursing is in the caring aspect and

caring is taking the wholeness. The totality of patient
into consideration.

• It is every nurse’s duty and obligation to care for his

patient not by merely looking into and caring for his
physical disease but try to care for the patient for
who he is.
Dorothy Orem’s Self-Care Theory
Dorothea Elizabeth Orem (1914-2007)
• One of the foremost nursing theorists.
• Born in 1914 in Baltimore, Maryland.
• 1939- BSN, Catholic University of America
• 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 1971, second in
1980, and in 1995.
• Orem died on June 22, 2007 at 92.
• “There are instances wherein patients are
encouraged to bring out the best in them
despite being ill for a period of time. This is very
particular in rehabilitation settings in which
patients are entitled to be more independent
after being cared for by physicians and nurse.”

• It is considered a grand nursing theory which

means that theory covers a broad scope with
general concepts that can be applied to all
instances of nursing.
• Orem’s theory defined NURSING as “The act of
assisting others in the provision and
management of self-care to maintain or improve
human functioning at home level of
effectiveness.”

• It focuses on each individual’s ability to perform

SELF-CARE, defined as “the practice of activities
that individuals initiate and perform on their
own behalf in maintaining life, health, and well-
being.”
• 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.

• SELF-CARE REQUISITES – action directed

towards provision pf self-care.
OREM’S SELF-CARE THEORY
3 Categories of Self-Care Requisites
• Universal
• Developmental
• Health deviation
a. Universal Self-Care Requisites
• Common to all, ADL (needs that all people have).
• Identifies these requisites as:
a. Maintenance of sufficient intake of air,
water, food.
b. Provision of care associated with
elimination process.
c. Balance between activity and rest,
between solitude and social interaction.
d. Prevention of hazards to human life well-
being and;
e. Promotion of human functioning.
 b. Developmental Self-Care
Requisites
• Needs associated with developmental
processes/ derived fro a condition… Or
associated with an event.
• E.g. adjusting to a new job
• Adjusting to body changes
 c. Health Deviation Self-Care
Requisites
• 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.
• Learning to live with effects of pathologic conditions.
• Nursing Agency is a complex property or
attribute of people educated and trained as
nurses that enables them to act, to know, and to
help others meet their therapeutic self-care
demands by exercising or developing their own
self-care agency.
 Theory of Self-Care Deficit
• Specific when nursing is needed because the
person cannot carry out self-care activities.

• 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:
1. Acting for and doing for others
2. Guiding others
3. Supporting another
4. Providing an environment promoting personal
development in relation to meet future
demands
5. Teaching another
 Theory of Nursing Systems
• 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 requisite of patient:
a. Wholly compensatory system
b. Partly compensatory system
c. Supportive- educative system
a. Wholly Compensatory System
• Patient is DEPENDENT.
• Nurses accomplish ALL the patient’s therapeutic
self-care.
• Nurses compensate for the patient’s inability to
engage in self-care.
• Example: care of a new born, care of client
recovering from surgery in a post-anesthesia
care unit
b. Partially Compensatory System
• Patient can meet SOME needs.
• Patient NEEDS NURSING assistance.
• Both the nurse and the patient engage in
meeting self-care needs.
• Example: Nurse can assist post-operative client
to ambulate.
• Nurse can bring a meal tray for client who can
feed himself.
b. Supportive Educative System
• Patient CAN MEET self-care requisites, but needs
assistance with decision making or knowledge
and skills to learn self-care.
• Example: Nurse guides a mother how to
breastfeed her baby.
• Counseling a psychiatric client on more adaptive
coping strategies.
Application of Orem’s Theory
• It emphasizes the need to understand the
importance of self- care in promotion of health.
• Focus on the patient’s capacity to perform self-
care activities.
• It also becomes clear that nurses today should
not move away education and supportive
measures- HEALTH TEACHINGS.
LYDIA HALL ERNESTINE WIEDENBACH DOROTHY JOHNSON

MODULE V, VI, VII

RIZZA B. EGALLA, MAN, LPT, RN
Faculty, PRMSU College of Nursing
 LYDIA E. HALL:
CARE, CORE, CURE THEORY
CARE, CORE, CURE THEORY
• Lydia Eloise Hall (September 21, 1906-
February 27, 1969) was a nursing theorist
who developed the CARE, CURE, CORE
MODEL of NURSING.
 Her Concept of Nursing
“Nursing is a distinct body of knowledge
that provides nursing care to patients who
are in need of medical interventions, in
collaboration with the members of the
health team, or exclusively and
independently by the nurse herself.”
 Hall’s Personal Background
• Born in New York City on September 21,
1906.
• She derived from her knowledge of
psychiatry and nursing experiences in the
Loeb Center the framework she used in
formulating her theory of nursing.
• She did not consider herself a nurse
theorist, but instead talked about her
transparent thoughts and remarkable ideas
of nursing care as she learned it over the
years.
 CARE, CORE, CURE MODEL
• This theory proposed that nursing
functions differ in so far as aspects of
patient care is concerned.

• Also known as “The Three Cs of Lydia Hall”

• The theory contains of three independent

but interconnected circles:
• The care;
• The core; and
• The cure
 The “CORE” Circle –
Interdependent
• This refers to the person or recipient of care.

• Includes the therapeutic use of self to relate with

the patient and is shared with other members of the
health team.

• The motivation an energy necessary for healing exist

WITHIN THE PATIENT.

• Emphasizes the social, emotional, spiritual, and

intellectual needs of the patient.

• Able to help the patient verbally express feelings

regarding the disease process and its effects by the
use of reflective technique.
• It is anchored in social sciences.

• Shared with social workers, psychologists,

clergy, and professions.

• Reflective technique is used by the

professional nurse in a way he or she acts
as a mirror to the patient to help the latter
explore his or her own feelings regarding
his or her current health status and related
potential changes in lifestyle.
The “CARE” Circle – Independent
• The exclusive domain of nursing.

• The nursing component of care.

• It is anchored in natural and biological sciences.

• This circle solely represents the role of nurses,

and is focused on performing the task of
nurturing patients.

• The professional nurse provides bodily care for

the patient and helps the patient complete such
basic daily biologic activities (e.g. eating,
elimination, bathing, and dressing)
The “CURE” Circle – Dependent
• This refers to medical interventions that are
performed on the patient.

• The foundation of this concept stems from

pathological and therapeutic sciences that
include microbiology, parasitology, and
pathology.

• It includes nursing activities that are

dependent upon the orders of the physician.
Hall’s Three Aspects of Nursing
 Assumptions
• The motivation and energy necessary for
healing exist within the patient, rather
than in the healthcare team.

• The three aspects of nursing should not be

viewed as functioning independently but
as interrelated. Lastly,

• The three aspects interact, and the circles

representing them change in size,
depending on the patient’s total course of
progress.
 Application of the Theory
• This laid the foundation for classifying the
professional nurses’ functions today.

• Care- independent nursing functions

(e.g. taking vital signs, bed bathing)

• Cure- dependent nursing functions (e.g.

medication administration

• Core- interdependent nursing functions

(working with social workers, clergy)
 ERNESTINE WIEDENBACH:
HELPING ART OF CLINICAL
NURSING
Helping Art of Clinical Nursing
Ernestine Wiedenbach
August 18, 1900- March 8, 1998
“Nursing is the art of nurturing or caring for
someone in a motherly fashion.”
 Personal Background
• Born in August 18, 1900, in Hamburg,
Germany.

• BSN – John Hopkins School of Nursing.

• Wiedenbach joined the Yale faculty in

1952 as an instructor in maternity
nursing.

• Died on March 8, 1998.

 Personal Background
• Ernestine Wiedenbach was born on
August 18, 1900 into a well-refined and
gentle manor family, the youngest of four
daughters, that had immigrated from
Germany when she was just a young
child.

• As a child she watched how her sick

grandmother was taken care of and then
later was influenced after hearing
accounts of hospital experiences from a
family friend.
 A Need-for-Help Defined
• A need-for-help is defined as “any
measure desired by the patient that has
the potential to restore or extend the
ability to cope with various life situations
that affect health and wellness.

• It is crucial to nursing profession that a

need-for-help be based on the individual
perception of his own situation.

• The goal of nursing consists primarily of

identifying a patient’s need for help.
4 Main Elements of Clinical Nursing
• Wiedenbach proposes 4 main elements to
clinical nursing:
a philosophy
a purpose
a practice
and the art (Burst, 1998).
 1. The Philosophy
• The nurses’ philosophy is their attitude and
belief about life and how that affected reality for
them
• 3 essential components associated with a nursing
philosophy:
1. Reverence for life
2. Respect for the dignity, worth, autonomy and
individuality of each human being and
3. Resolution to act on personally and professionally
held beliefs.
 2. The Purpose
• Nurses’ purpose is that which the nurse wants to
accomplish through what she does.

• It is all of the activities directed towards the

overall good of the patient.
 3. The Practice
• Practice are those observable nursing actions
that are affected by beliefs and feelings about
meeting the patient’s need for help.
 4. The Art
• The Art of nursing includes
• Understanding patients needs and concerns
• Developing goals and actions intended to enhance
patients ability and
• Directing the activities related to the medical plan
to improve the patients condition.

• The nurses also focus on prevention of complications

related to reoccurrence or development of new
concerns.
 PRESCRIPTIVE THEORY
• Three (3) factors:
• The central purpose which the practitioner
recognizes as essential to the particular discipline.
• The prescription for the fulfillment of central
purpose.
• The realities in the immediate situation that
influence the central purpose.
CLINICAL NURSING MODEL
 CENTRAL PURPOSE
• It is that which the nurse wants to accomplish
through what she does.

• It is the overall goal toward which she is

striving.
 THE PRESCRIPTION
• It is a directive to activity.
• It specifies both the nature of the action
(voluntary or involuntary) that will most likely
lead to fulfillment of the nurse’s central
purpose.
 3 Kinds of Voluntary Action
1. Mutually understood and agreed upon
action (the patient and the nurse)
2. Recipient- directed action – the patient
directs the way it is to be carried out.
3. Practitioner- directed action- the nurse
carries out the action.
 The Realities
• Realities consist of all factors- physical,
psychological, physiological, emotional,
spiritual- that influence the situation in which
nursing actions occur at any given moment.
1. The agent
2. The recipient
3. The goal
4. The means
5. The framework
The Agent
• It is the practicing nurse or her delegate, is
characterized by personal attributes,
capacities, and most importantly, commitment
and competence in nursing.

The Recipient
• It is the patient, who is characterized by
personal attributes, problems, capabilities and
most importantly, the ability to cope with the
concerns or problems being experienced.
The Goal
• It is the desired outcome the nurse wishes to
achieve. It is the end result to be attained by
nursing action.

The Means
• It comprises the activities and devices through
which the nurse is enabled to attain her goal.

The Framework
• It consists of environmental, professional, and
organizational facilities that not only make up
the context within which nursing is practiced
but also constitute its currently existing limits.
 DOROTHY E. JOHNSON:
BEHAVIORAL SYSTEM
MODEL
 Personal Background
• Born on August 21, 1919 in Savannah,
Georgia.
• She took a year off from school to be a
teacher in Florida. This is when she began to
realize her love for children, nursing and
education.
• From 1949 till retirement in 1978 she was an
assistant professor of pediatric nursing, an
associate professor of nursing at the
University of California in Los Angeles.
 Behavioral System Model
• Proposed that Nursing Care facilitates the
client’s maintenance of a STATE OF
EQUILIBRIUM.

• Clients are “STRESSED” by a stimulus of either

an internal or external nature.

• These stressful stimuli created such

disturbances or “tensions” in the patient that
a state of disequilibrium occurred.
 Human Beings (patient)
• Johnson views human beings as having two
major systems: the biological system and the
behavioral system. It is the role of medicine to
focus on the biological system, whereas
nursing’s focus is the behavioral system.
• Equilibrium- state wherein the person is in
harmony with himself and with his
environment.

• Tension- state of being strained and can be

viewed as an end-product of a disturbance in
equilibrium.

• Stressor- stimuli (external/internal) that

produce tension and result in a degree of
instability.

• It is nursing’s role to assist the client to return

to a state of equilibrium.
• Two (2) Areas of Focus to return the client to a
state of equilibrium
1. Reduce stressful stimuli
2. Support natural and adaptive processes
• Dorothy E. Johnson (August 21, 1919-
February 1999) was one of the greatest
nursing theorists who developed the
“Behavioral System Model.”

• When the behavioral system has balance and

stability, the individual’s behaviors will be
purposeful, organized, and predictable.
 Seven (7) Subsystems
1. Attachment/ Affiliation
2. Dependency
3. Sexuality
4. Aggression
5. Elimination
6. Ingestion
7. Achievement
 Each subsystem has three
functional requirements
• System must be “PROTECTED” from noxious
influences with which systems cannot cope”.

• Each subsystem must be “NURTURED”

through the input of appropriate supplies
from the environment.

• Each subsystem must be “STIMULATED” for

use to enhance growth and prevent
stagnation.
• When there is an alteration in the equilibrium
that exists, this model tends to diagnose to a
subsystem.

• This model states that it is as this point when

the nurse is needed in order to return the
client to homeostasis.
 1. Attachment or Affiliation
subsystem
• It forms the basis of all social organization.

• It provides survival and security.

• Its consequences are social inclusion, intimacy

and the formation and maintenance of a
strong social bond.

• Example: Allowing family members to visit

patients.
 2. Achievement subsystem
• Control or mastery of an aspect of self or
environment to some standard of excellence.

• Intellectual, physical, creative, mechanical and

social skills achievement are some of the areas
that Johnson recognizes.

• Example: Giving positive feedback such as

praises after completing a task.
 3. Ingestion Subsystem
• Emphasis on the meaning and structures of
the social events surrounding the occasion
when the food is eaten.

• Has to do with when, how, what, how much,

and under what conditions we eat.

• Example: Considering patient preferences in

food choices
 4. Elimination Subsystem
• “Human cultures have defined different
socially acceptable behaviors for excretion of
waste, but the existence of such a pattern
remains different from culture to culture.”

• It addresses “when, how, and under what

conditions we eliminate.”

• Example: Promoting regular bowel elimination

(e.g. every morning)
 5. Aggressive Subsystem
• It relates to the behaviors concerned with
protection and self-preservation.

• Johnson views aggressive subsystem as one that

generates defensive response from the individual
when life or territory is being threatened.

• Society has placed limits when dealing with self-

protected (people and property be respected and
protected).

• Example is when a patient refuses to take the

medication as she thinks it is more harmful to her
and the nurse explains its mechanism to her.
 6. Dependency Subsystem
• Promotes helping behavior that calls for a
nurturing response.

• Approval, attention, or recognition and

physical assistance.

• Dependency behavior develops from the

complete reliance on others for certain
resources essential for survival.

• Example are giving approval, attention, or

recognition and physical assistance.
 7. Sexual Subsystem
• Has dual functions of procreation and
gratification.

• It begins with the development of gender role

identity and includes the broad range of sex
role behaviors.

• Both biological and social factor affect the

behavior.

• Example is promoting a mother perform her

maternal role in the sexual subsystem.