Alison Tierney

Note: More Background in Tickler

 Alison Tierney was one of the first nurses to earn a PhD in the United Kingdom.
 Director of Nursing Research at the University of Edinburgh for 10 years later promoted as a
personal chair in nursing research (McEwen & Wills, 2011).
 She joined Roper and Logan as they began to develop, refine, and publish the Activities of Living
(ALs) model.
 She contributed to the development of research in nursing in the United Kingdom and
throughout Europe.

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Importance and connection to metaparadigm

The purpose of the theory is as an assessment used throughout the patient's care. It has been reduced
to being used simply as a checklist. It is often used to assess how the life of a patient has changed due to
illness, injury, or admission to a hospital rather than as a way of planning for increasing independence
and quality of life(IMPORTANCE).

The theory attempts to define what living means. It categorizes the discoveries into activities of living
through complete assessment, which leads to interventions that support independence in areas that
may be difficult for the patient to address alone. The goal of the assessment and interventions is to
promote maximum independence for the patient.

The nurse uses the model to assess the patient's relative independence and potential for independence
in the activities of daily living. The patient's independence is looked at on a continuum that ranges from
complete dependence to complete independence. This helps the nurse determine what interventions
will lead to increased independence as well as what ongoing support is needed to offset any
dependency that still exists.

The activities of daily living should not be used as a checklist. Instead, Roper states they should be
viewed "As a cognitive approach to the assessment and care of the patient, not on paper as a list of
boxes, but in the nurse's approach to and organization of her care," and that nurses deepen their
understanding of the model and its application. The patient should be assessed on admission, and his or
her dependence and independence should be reviewed throughout the care plan and evaluation. By
looking at changes in the dependence-independence continuum, the nurse can see whether the patient
is improving or not, and make changes to the care provided based on the evidence presented.

The activities of living listed in the Roper-Logan-Tierney Model of Nursing are:

maintaining a safe environment

communication
breathing
eating and drinking
elimination
washing and dressing
controlling temperature
mobilization
working and playing
sleeping
The list also includes death and sexuality as activities of daily living, but these are often disregarded
depending on the setting and situation for the individual patient.
According to the model, there are five factors that influence the activities of living. The incorporation of
these factors into the theory of nursing makes it a holistic model. If they aren't considered, the resulting
assessment is incomplete and flawed. The factors are used to determine the individual patient's relative
independence in regards to the activities of daily living.

They are: biological, psychological, sociocultural, environmental, and politicoeconomic. The biological
factor addresses the impact of the overall health, of current injury and illness, and the scope of the
patient's anatomy and physiology. The psychological factor addresses the impact of emotion, cognition,
spiritual beliefs, and the ability to understand. According to Roper, this is about "knowing, thinking,
hoping, feeling and believing."(METAPARADIGM- PERSON? HEALTH?)

The sociocultural factor is the impact of society and culture as experienced by the individual patient.
This includes expectations and values based on class and status, and culture within the sociocultural
factor relates to the beliefs, expectations, and values held by the individual patient for him or herself, as
well as by others pertaining to independence in and ability to carry out the activities of daily living.

The environmental factor in Roper's theory of nursing makes it a "green" model. The theory takes into
consideration the impact of the environment on the activities of daily living, but also examines the
impact of the activities of daily living on the environment. The politicoeconomic factor is the impact of
the government, politics, and economy on the activities of daily living. This factor addresses issues such
as funding, government policies and programs, war or conflict, availability to benefits, political reforms,
interest rates, and availability of public and private funding, among others.(METAPARADIGM-
ENVIRONMENT)
Roper herself objects to the model being used as a checklist. She states that if nurses are uncomfortable
discussing certain factors, they assume the patients are, as well. This leads to the nurses attributing the
lack of assessment to the patient's preference, when in actuality, the patient's preferences were not
addressed.

Her assertion leads to the conclusion that rather than deleting or disregarding activities of daily living, it
can benefit the individual being assessed if the nurse uses the model more thoroughly and assesses the
patient using the five factors in conjunction with the activities of daily living, regardless of the area in
which the care is being received.(METAPARADIGM- NURSING) Roper stated, "The patient is the patient,
they are not a different patient because they are in a different clinical area. Their needs are the same-
it's who will meet those needs that changes."
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PATRICIA BENNER

Biography

Patricia Benner
R.N., Ph.D., F.A.A.N, F.R.C.N.

• Current Professor Emerita at the University of California, San Francisco

• Has taught and been involved in research since 1979.

• Well published in journals and books.

• Named one of the American Academy of Nursing’s “Living Legends” in August, 2011.

• Introduced her “Novice to Expert” theory in 1982.

• Many publications refer to her nursing practice model.

Benner’s Explanation of the Four Paradigms

Person

“…the person does not come into the world predefined but gets defined in the course of living a life”

Benner believed that there are significant aspects that make the being. She conceptualized these as the
roles of:

• the situation

• the body

• personal concerns

• temporality

Health

Benner focused “on the lived experience of being healthy and being ill”

• Health can be assessed

 • Well-being is the human experience of health or wholeness

• Illness is the human experience of loss or dysfunction

Nursing

Benner viewed nursing as the care and study of the lived experience and the relationship of these three
elements:

• Health

• Illness

• Disease

Environment

Benner uses the term situation rather than environment. “Personal interpretation of the situation is
bounded by the way the individual is in it.”

A person’s past, present, and future influences their current situation

This model can be applied to all areas of nursing. It looks at the education and development of a nurse
and how they become an expert.

Patricia Benner examined how nurses learn to nurse (Nursingtimes.net, 2010)

ADD-ONS

This model can be applied to all areas of nursing. It looks at the education and development of a nurse
and how they become an expert.

Patricia Benner examined how nurses learn to nurse (Nursingtimes.net, 2010)

IMPORTANCE

Theory’s contribution to education

Benner has described a variety of approaches to education and clinical expertise development including:
clinical knowledge development seminars, dialogue around clinical narratives, exchanges, research
participation and the writing of paradigm cases (Benner, 1984). The National Organization of Nurse
Practitioner Faculties (NONPF) is the organization that provides leadership in promoting nurse
practitioner (NP) education. In 2004, NONPF released four curriculum models. The models they suggest
follow the theoretical basis of Benner’s novice to expert concepts. Each model has the same level of
competencies starting with a preprofessional level moving into basic nursing, clinical leader, nurse
specialist and finally to the doctoral competencies (National Organization of Nurse Practitioner Faculties
[NONPF], 2004). Balancing teaching and maintaining clinical practice competence are among the
greatest challenges of nurse educators. It is an expectation that nurse educators are experts in clinical
Theory in Practice: 8 practice and education concurrently. Benner’s (1984) description of the
development of nursing practice can give nurse educators guidance in their dual roles. Little and Milliken
(2007) state, it would be difficult for nurses to gain experience, knowledge and skills in the educational
and clinical areas at the same time to achieve the dual expert levels that are expected. Therefore, they
have proposed “that the term „competence‟ is more accurate and achievable than expert‟ when
describing the clinical practice requirements for a full-time faculty member”.

Theory’s contribution to practice

Benner’s work, for the most part through the use of narratives, has been able to show other ways of
uncovering and seeing much of the value, depth, and complexity of skilled nursing practice (Darbyshire,
1994). Benner’s entire project, her research, writing, speaking, promotion of narratives and clinical-
ladders development in hospitals . . . has been to understand better and re-vision skilled nursing practice
as shared and common understandings. It has been to learn more about how nurses develop expertise
and practice expertly and it has been to encourage and enable nurses to describe, uncover and share
their expertise (Darbyshire, 1994, p. 758). In 1990, NONPF published a set of domains and core
competencies for primary care NP‟s. There are seven domains and within each domain are 75 specific
competencies. The competencies were based on Benner’s (1984) domains of expert care nursing. She
“described domains and competencies for advanced nursing practice” (National Organization of Nurse
Practitioner Faculties [NONPF], 2002, p. 2)

Theory’s contribution to research

Benner studied clinical nursing practice as she was trying to find and describe the knowledge that nurses
hold and gain over time in practice. She describes the difference between practical and theoretical
knowledge that “knowing how” is practical knowledge and “knowing that” is theoretical knowledge. She
has given nursing a unique way to understand that theory is derived from practice and practice is then
altered or extended by theory. “Knowledge development in a practice discipline consists of extending
practical knowledge (know-how) through theory-based scientific investigations and through the charting
of the existent , knowhow ‟ developed through clinical experience in the practice of that discipline”
(Tomey, 1994, p. 164). Benner believes that nurses have failed to document their clinical experiences
and observations and in turn this has deprived nursing theory from the unique knowledge embedded in
expert practice (Tomey, 1994).

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