GARCIA, Neil A.

May 12, 2009

TABOR, Yolybeth S.
BSN-2E

THEORETICAL FOUNDATIONS OF NURSING

A. ENVIRONMENTAL THEORY

“I think one’s feelings waste

themselves in words; they ought all to
be distilled into actions which bring
results.”

Florence Nightingale (1860)

Florence Nightingale defined Nursing as “the act of

utilizing the environment of the patient to assist him in
his recovery” (1860/1969), that it involves the nurse's
initiative to configure environmental settings appropriate
for the gradual restoration of the patient's health, and
that external factors associated with the patient's
surroundings affect life or biologic and physiologic
processes, and his development.

Environmental Factors Affecting Health

 Defined in her environmental theory are the following
factors present in the patient’s environment:
• pure or fresh air
• pure water
• sufficient food supplies
• efficient drainage
• cleanliness
• light (especially direct sunlight)

Adequate ventilation has also been regarded as a

factor contributing to changes of the patient’s process of
illness recovery. Any deficiency in one or more of these
factors could lead to impaired functioning of life
processes or diminished health status.

She also emphasized in her environmental theory is the

provision 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’s
effects on the patient.

Nightingale believed that the environment was the

major component creating illness in a patient; she regarded
disease as “the reactions of kindly nature against the
conditions in which we have placed ourselves.” Her theory
Contains three major relationships:
• environment to patient
• nurse to environment
• nurse to patient
B. INTERACTIVE THEORIES
INTERPERSONAL RELATIONS THEORY

“The kind of person that the nurse

becomes makes a substantial difference in
what each patient will learn as he or she
receives nursing care.”

Hildegard Peplau (1952)

She defined Nursing as “an interpersonal process of

therapeutic interactions between an individual who is sick
or in need of health services and a nurse especially
educated to recognize, respond to the need for help.”

Dr. Peplau emphasized the nurse-client relationship as

the foundation of nursing practice. At the time, her
research and emphasis on the give-and-take of nurse-client
relationships was seen by many as revolutionary. She
described the nurse-patient relationship as a four-phase
phenomenon. Each phase is unique and has distinguished
contributions on the outcome of the nurse-patient
interaction.

Phases Of Nurse-Patient Relationship

Individual/family has a “felt need”
1 and seeks professional assistance from a
. Orientation nurse (who is a stranger). This is the
problem identification phase.
 Where the patient begins to have
2. Identification feelings of belongingness and a capacity
for dealing with the problem, creating an
optimistic attitude from which inner
strength ensues. Here happens the
selection of appropriate professional
assistance.
The nurse uses communication tools
3. Exploitation to offer services to the patient, who is
expected to take advantage of all
services.
Where patient’s needs have already
been met by the collaborative efforts
between the patient and the nurse.
4. Resolution
Therapeutic relationship is terminated
and the links are dissolved, as patient
drifts away from identifying with the
nurse as the helping person.

Nursing Roles

In the course of the nurse-patient relationship, the

nurse assumes several roles which empower and equip her in
meeting the needs of the patient.

1. Stranger Role: Receives the client the same way one

meets a stranger in other life situations; provides
an accepting climate that builds trust.

2. Resource Role: Answers questions. Interprets

clinical treatment data, gives information.
 3. Teaching Role: Gives instructions and provides
training; involves analysis and synthesis of the
learner’s experience.

4. Counseling Role: Helps client understand and

integrate the meaning of current life circumstances;
provides quidance and encouragement to make changes.

5. Surrogate Role: Helps clients clarify domains of

dependence, interdependence, and independence and
acts on clients behalf as advocate.

6. Leadership Role: Helps client assume maximum

responsibility for meeting treatment goals in a
mutually satisfying way.

Additional Roles include:

1. Technical expert
2. Consultant
3. Health teacher
4. Tutor
5. Socializing agent
6. Safety agent
7. Manager of environment
8. Mediator
9. Administrator
10.Recorder observer
11.Researcher
Definition of the Unique Function of Nursing

“The nurse is temporarily the

consciousness of the unconscious, the
love of life for the suicidal, the leg of
the 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 or
withdrawn to speak and so on.”

Virginia Henderson (1955)

Henderson defined Nursing as “assisting the

individual, sick or well, in the performance of those
activities contributing to health or it’s recovery (or to
peaceful death) that an individual would perform unaided if
he had the necessary strength, will or knowledge”.

She conceptualized the 14 Fundamental Needs of humans.

These needs are:

• Breathing normally
• Eating and drinking adequately
• Eliminating body wastes
• Moving and maintaining desirable position
• Sleeping and resting
• Selecting suitable clothes
• Maintaining body temperature within normal range
• Keeping the body clean and well-groomed
 • Avoiding dangers in the environment
• Communicating with others
• Worshipping according to one’s faith
• Working in such a way that one feels a sense of
accomplishment
• Playing/participating in various forms of recreation
• Learning, discovering or satisfying the curiosity that
leads to normal development and health and using
available health facilities.

The Nurse-Patient Relationship

Henderson stated that there are three levels
comprising the nurse-patient relationship:

1. The nurse as a substitute for the patient. In times

of illness, when the patient cannot function fully,
the nurse serves as the substitute as to what the
patient lacks such, as knowledge, will, and strength
in order to make him complete, whole and independent
once again.
2. The nurse as a helper to the patient. In situations
where the patient cannot meet his basic needs, the
nurse 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 plan
together. Both as an advocate and as a resource
person, the nurse can empower the patient to make
effective decisions regarding his care plans.
Dynamic Nurse-Patient Relationship

“The role of the nurse is to find

out and meet the patient's immediate
need for help. The patient's presenting
behavior may be a plea for help,
however, the help needed may not be what
it appears to be.”

Ida Jean Orlando (1961)

Orlando's theory was developed in the late 1950s from

observations she recorded between a nurse and patient.
Despite her efforts, she was only able to categorize the
records as "good" or "bad" nursing. It then dawned on her
that both the formulations for "good" and "bad" nursing
were contained in the records. From these observations she
formulated the deliberative nursing process.

Therefore, nurses need to use their perception,

thoughts about the perception, or the feeling engendered
from their thoughts to explore with patients the meaning of
their behavior. This process helps the nurse find out the
nature of the distress and what help the patient needs.
Orlando's theory remains one the of the most effective
practice theories available. The use of her theory keeps
the nurse's focus on the patient. The strength of the
theory is that it is clear, concise, and easy to use. While
providing the overall framework for nursing, the use of her
theory does not exclude nurses from using other theories
while caring for the patient.

Key Concepts of Three Interlocking Circles Theory

• According to Hall, Nursing is

participation in care, core and cure
aspects, where CARE is the sole
function of nurses, whereas the CORE
and CURE are shared with other
members of the health team

• The major purpose of care is to

achieve an interpersonal
relationship with the individual
that will facilitate the development
of the core
Lydia Hall (1961)

Human-to-Human Relationship Model

“A nurse does not only seek to alleviate physical pain

or render physical care- she ministers to the whole person.
The existence of suffering, whether physical, mental or
spiritual is the proper concern of the nurse.”

Joyce Travelbee (1966)

Travelbee's experience in initial psych nursing

practice at a Catholic charity hospital led her to believe
that the care given in these type of institutions lacked
compassion. She felt nursing needed a "humanistic
revolution" and a renewed focus on caring as central to
nursing--she warned that if this didn't happen, consumers
might seek a "new and different kind of health care
worker". Travelbee's ideas have greatly influenced the
hospice movement.

In her human-to-human relationship model, the nurse

and the patient undergoes the following series of
interactional phases:

1. Original Encounter- this is described as the first

impression by the nurse of the sick person and vice-
versa The nurse and patient see each other in
stereotyped or traditional roles.
2. Emerging Identities- this phase is described by the
nurse and patient perceiving each other as unique
individual. At this time, the link of relationship
begins to form.
3. Empathy- this phase is described as the ability to
share in the person’s experience.
4. Sympathy- It happens when the nurse wants to lessen
the cause of the patient’s suffering. It goes beyond
empathy. The nurse at this time should use a
disciplined intellectual approach together with
therapeutic use of self to make helpful nursing
actions.
5. Rapport- this is described as nursing interventions
that lessens the patient’s suffering. The nurse and
the sick person are relating as human being to human
 being. The sick person shows trust and confidence in
the nurse.

C. SYSTEMS THEORIES

System Model in Nursing Practice

“Health is a condition in which

all parts and subparts are in harmony
with the whole of the client”

Betty Neuman (1972)

Her theory incorporated the concept of a whole person

and an open system approach. The concept is aimed towards
the development of a person in a state of wellness having
the capacity to function optimally. The main role of the
nurse in her theory is to help a person to adapt with
environmental stimuli causing illnesses back to a state of
wellness.

Terms Related to Neuman’s System Theory

Client Variables
The clients’ variables can be one or combination of
the following: physiological, sociocultural, developmental
and spiritual. These variables function to achieve
stability in relation to the environmental stressors
experienced by the client.
Lines of Resistance
Lines of Resistance act when the Normal Line of
Defense is invaded by too much stressor, producing
alterations in the client’s health.

Normal Line of Defense

To achieve the stability of the system, the Normal
Line of Defense must act in coordination with the normal
wellness state. It must reflect the actual range of
responses that is normally acted by clients in response to
any stressors. It is the baseline in determining the level
of client within the continuum of health.
Flexible Line of Disease
It serves as a boundary for the Normal Line of Defense
to adjust to situations that threaten the imbalance within
the client’s stability.

Stressors
These are forces that produce tensions, alterations or
potential problems causing instability within the client’s
system.

Reaction
These 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 of
reaction the client produces to adjust and adapt with the
situation. Neuman specified these reactions as negentropy
or entropy. Negentropy is set towards stability or wellness
while Egentropy is set towards disorganization of the
system producing illness.
Behavioral System Model

“Each individual has a predisposition

to act, with reference to the goal, in
certain ways rather than in other ways”

Dorothy Johnson (1971)

Johnson believes that each individual has a focusing

and repeating ways of acting which covers a behavioral
system distinct to that individual. These behaviors are
logical, fixed, predictable and adequately secure and
persistent to be satisfying to depiction and clarification.

Seven Behavioral Subsystems

1. The Attachment or Affiliative Subsystem is well-

known as the earliest response system to expand in
the individual. The most favorable functioning of
this subsystem allows social inclusion, closeness,
and the pattern and continuance of a strong public
bond.
2. The Dependency Subsystem are actions that trigger
nurturing behaviors from other individuals in the
 environment. The product of dependency behavior is
consent, interest or appreciation, and physical
support.
3. The Ingestive Subsystem relates to the behaviors
surrounding the ingestion of food. Behaviors related
to the ingestion of food may relate more to what is
socially satisfactory in a specified culture, than
to the biological necessities of the human being.
4. The Eliminative Subsystem relates to behaviors
surrounding the secretion of waste products from the
body. Human cultures have defined different socially
acceptable behaviors for excretion of waste, but the
continuation of such an outline remains from culture
to culture.
5. The Sexual Subsystem imitates behaviors realted to
procreation or reproduction.
6. The Aggressive Subsystem relates to behaviors
concerned with the defense and self-preservation.
7. The Achievement Subsystem contains behaviors that
attept to control the environment. Intellectual,
physical, imaginative, mechanical, and communl
skills are some of the areas that Johnson
distinguishes.

Goal Attainment Theory

“If the students can’t do the fundamentals, how can

they use advanced knowledge.”
 Imogene King (1971)

King stated that Nursing is a process

of action, reaction, and interaction
whereby nurse and client share information
about their perception in the nursing situation.

Action
Action is a means of behavior or activities that are
towards the accomplishment of certain act. It is both
physical and mental.

Reaction
In King’s theory, reaction is not specified but
somehow relates reaction as part of action. According to
her, reaction is a response to a stimuli.

Interaction
Interaction, as defined by King, is any situation
wherein the nurse relates and deals with a clientele or
patient.

Open System
It is the absence of boundary existence, where a
dynamic interaction between the internal and external
environment can exchange information without barriers or
hindrances.
 King proposed that the nurse interacts in the system
simultaneously at three different levels. These levels are
independent and at the same time co-exist to influence
over-all nursing practice.

• Personal- how the nurse views and integrates self

based from personal goals and beliefs
• Interpersonal- how the nurse interrelates with a co-
worker or patient, particularly in a nurse-patient
relationship
• Social- how the nurse interacts with co-workers,
superiors, subordinates and the client environment in
general

Self-Care Theory

“Individuals, families, groups

and communities need to be taught
self-care.”

Dorothea Orem (1971)

Orem defined Nursing as “The act of assisting others

in the provision and management of self-care to
maintain/improve human functioning at home level of
effectiveness.”
 The theory focuses on activities that adult
individuals perform on their own behalf to maintain life,
health and well-being. It has a strong health promotion and
maintenance focus.

She identified 3 related concepts:

1. Self-care - activities an Individual performs

independently throughout life to promote and
maintain personal well-being.

2. Self-care deficit - results when self-care agency

(Individual’s ability) is not adequate to meet
the known self-care needs.

3. Nursing System - nursing interventions needed

when Individual is unable to perform the
necessary self-care activities:
1. Wholly compensatory - nurse provides entire
self-care for the client.

 Example: care of a new born, care of

client recovering from surgery in a
post-anesthesia care unit

2. Partial compensatory - nurse and client

perform care, client can perform selected
self-care activities, but also accepts care
done by the nurse for needs the client
cannot meet independently.
  Example: Nurse can assist post
operative client to ambulate, Nurse can
bring a meal tray for client who can
feed himself

3. Supportive-educative - nurse’s actions are

to help the client develop/learn their own
self-care abilities through knowledge,
support and encouragement.

 Example: Nurse guides a mother how to

breastfeed her baby, Counseling a
psychiatric client on more adaptive
coping strategies.

Twenty-One Nursing Problems

“I never wanted to be a medical

doctor because I could do all I wanted to
do in nursing, which is a caring
profession.”

Faye Glen Abdellah (1960)

The concept of Nursing in this theory is generally

grouped into twenty-one problem areas for nurses to work
out their judgment and appropriate care. Abdellah considers
nursing to be an all-inclusive service that is based on the
disciplines of art and science that serves individuals,
sick or well with their health needs.

Typology of Twenty-one Nursing Problems

1. 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 oxygen
6. To facilitate maintenance of nutrition
7. To facilitate maintenance of elimination
8. To facilitate the maintenance of fluid and electrolyte
balance
9. To recognize the physiologic response of the body to
disease conditions
10.To facilitate the maintenance of regulatory mechanisms
and functions.
11.To facilitate the maintenance of sensory functions
12.To identify and accept positive and negative
expressions, feelings and reactions
13.To identify and accept the interrelatedness of
emotions and illness.
14.To facilitate the maintenance of effective verbal and
non-verbal communication
15.To promote the development of productive interpersonal
relationship
16.To facilitate progress toward achievement of personal
spiritual goals
17.To create and maintain a therapeutic environment
18.To facilitate awareness of self as an individual with
varying needs.
 19.To accept the optimum possible goals
20.To use community resources as an aid in resolving
problems arising from illness.
21.To understand the role of social problems as
influencing factors

Helping Art of Clinical Nursing

"My thesis is that nursing art is

not comprised of rational nor
reactionary actions but rather of
deliberative action."

Ernestine Wiedenbach (1964)

Wiedenbach conceptualizes nursing as the practice

identification of a patient’s need for help through
observation of presenting behaviors and symptoms,
exploration of the meaning of those symptoms with the
patient, determining the cause(s) of discomfort, and
determining the patient’s ability to resolve the discomfort
or if the patient has a need for help from the nurse or
other healthcare professionals.

Nursing primarily consists of identifying a patient’s

need for help. If the need for help requires intervention,

the nurse facilitates the medical plan of care and also

creates and implements a nursing plan of care based on

needs and desires of the patient. In providing care, a nurse

exercises sound judgment through deliberative, practiced,

and educated recognition of symptoms. The patient’s

perception of the situation is an important consideration

to the nurse when providing competent care.

According to Wiedenbach there are four elements to

clinical nursing: (1) philosophy, (2) purpose, (3)
practice, and (4) art.

• The nurses’ philosophy was their attitude and

belief about life and how that effected reality
for them. Philosophy is what motivates the nurse
to act in a certain way.

Wiedenbach also believed that there were 3

essential components associated with a nursing
philosophy:

○ Reverence for life

○ Respect for the dignity, worth, autonomy and
individuality of each human being
○ Resolution to act on personally and
professionally held beliefs

• 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.

• Practices are those observable nursing actions

that are affected by beliefs and feelings about
meeting the patient’s need for help.

• The Art of nursing includes understanding

patient’s needs and concerns, developing goals
and actions intended to enhance patient’s ability
and directing the activities related to the
medical plan to improve the patient’s condition.
The nurses also focuses on prevention of
complications related to reoccurrence or
development of new concerns.

The Conservation Model

"Ethical behaviour is not the display of one's moral

rectitude in times of crisis. It is the day-to-day
expression of one's commitment to other persons and the
ways in which human beings relate to one another in their
daily interactions.”

Myra Levine (1977)

She defined nursing as supportive & therapeutic

interventions based on scientific or therapeutic knowledge.
Nursing actions based on four principles:
 • conservation of energy
• structural integrity
• personal integrity
• social integrity

D. DEVELOPMENTAL THEORIES

Adaptation Model

“The model provides a way of thinking

about people and their environment that is
useful in any setting. It helps one
prioritize care and challenges the nurse
to move the patient from survival to
transformation.”

Sister Callista Roy (1979)

She viewed humans as biopsychosocial beings constantly

interacting with a changing environment and who cope with
their environment through Biopsychosocial adaptation
mechanisms. There are two categories of coping mechanisms
according to Roy namely the regulator and the cognator
subsystems:

• Regulator Subsystem transpires through neutral,

chemical and endocrine processes like the increase in
vital signs-sympathetic response to stress.
 • Cognator Subsystem, on the other hand, occurs through
cognitive-emotive processes. For instance, are the
effects of prolonged hospitalization for a four-year
old child.

The degree of internal or external environmental

change and the person’s ability to cope with that change is
likely to determine the person’s health status. Nursing
interventions are aimed at promoting physiologic,
psychologic, and social functioning or adaptation.

Transcultural Theory

“Care is the heart of nursing; Care

is power; Care is essential to healing;
Care is curing; and Care is the central
and dominant focus of nursing and
transcultural nursing decisions and
actions.”

Madeleine Leininger (1985)

She stated that Nursing is a learned humanistic and

scientific profession and discipline which is focused on
human care phenomena and activities in order to assist,
support, facilitate, or enable individuals or groups to
maintain or regain their well being (or health) in
culturally meaningful and beneficial ways, or to help
people face handicaps or death.
Transcultural nursing as a learned subfield or branch
of nursing which focuses upon the comparative study and
analysis of cultures with respect to nursing and health-
illness caring practices, beliefs and values with the goal
to provide meaningful and efficacious nursing care services
to people according to their cultural values and health-
illness context. It focuses on the fact that different
cultures have different caring behaviors and different
health and illness values, beliefs, and patterns of
behaviors. Awareness of the differences allows the nurse to
design culture-specific nursing interventions.

Philosophy and Science of Caring

“Caring in nursing conveys physical

Acts but embraces the mind-body-spirit
as it reclaims the embodied spirit as
its focus attention.”

Margaret Jean Watson (1979)

Watson proposes seven assumptions about the science of

caring and ten primary carative factors to form the
framework of her theory. The basic assumptions are:

• Caring can be effectively demonstrated and practiced

only interpersonally;
• Effective caring promotes health and individual or
family growth;
• Caring responses accept a person not only as he or she
is now but as what he or she may become;
• A caring environment is one that offers the
development of potential while allowing the person to
 choose the best action for himself or herself at a
given point in time
• Caring is more “healthogenic” than is curing. The
practice of caring integrates biophysical
knowledge of human behavior to generate or promote
health and to provide care to those who are ill. A
science of caring is therefore complementary to the
science of curing.
• The practice of caring is central to nursing

Ten Carative Factors

1. The promotion of a humanistic-altruistic system of

values
2. Instillation of faith-hope
3. The cultivation of sensitivity to one’s self and others
4. The development of a helping-trusting, human caring
relationship
5. Promotion and acceptance of the expression of positive
and negative feelings.
6. The systemic use of the scientific problem-solving
method for decision making
7. The promotion of interpersonal teaching-learning
8. The provision for supportive, protective and
corrective mental, physical, socio-cultural and
spiritual environment
9. Assistance with the gratification of human needs
10.The allowance for existential phenomenological forces
The Science of Unitary Human Beings, and Principles of
Homeodynamics
“Nursing is an art and science that is humanistic and
humanitarian. It is directed toward the
unitary human and is concerned with the
nature and direction of human development.”

Martha Rogers (1970)

Nursing interventions seek to promote

harmonious interaction between persons and their
environment, strengthen the wholeness of the individual and
redirect human and environmental patterns or organization
to achieve maximum health. There are 5 Basic Assumptions:

1. The human being is a unified whole, possessing

individual integrity and manifesting characteristics
that are more than and different from the sum of parts.

2. The individual and the environment are

continuously exchanging matter and energy with each
other
3. The life processes of human beings evolve irreversibly
and unidirectionally along a space-time continuum
4. Patterns identify human being and reflect their
innovative wholeness
5. The individual is characterized by the capacity for
abstraction and imagery, language and thought,
sensation and emotion

Theory of Human Becoming

 “Nursing is a scientific
discipline, the practice of which is a
performing art.”

Rosemarie Rizzo Parse (1981)

Three assumptions about Human Becoming

• Human becoming is freely choosing personal meaning
in situation in the inter-subjective process of
relating value priorities
• Human becoming is co-creating rhythmic patterns or
relating in mutual process in the universe
• Human becoming is co-transcending multidimensionally
with 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.com
http:// http://en.wikipedia.org/wiki/