N207 Theoretical PDF

Theoretical Foundations
of Nursing
Cora A. Anonuevo
Carmencita M. Abaquin
Araceli O. Balabagno
Thelma F. Corcega
Luz Barbara P. Dones
Letty G. Kuan
Cecilia M. Laurente
Merle F. Mejico
Josefina A. Tuazon
University of the Philippines

OPEN UNIVERSITY
Theoretical Foundations of Nursing
By Cora A. Anonuevo, Carmencita M. Abaquin, Araceli O. Balabagno,
Thelma F. Corcega, Luz Barbara P. Dones, Letty G. Kuan, Cecilia M.
Laurente, Merle F. Mejico, and Josefina A. Tuazon
Copyright © 2000 by Cora A. Anonuevo, Carmencita M. Abaquin, Araceli

O. Balabagno, Thelma F. Corcega, Luz Barbara P. Dones, Letty G. Kuan,
Cecilia M. Laurente, Merle F. Mejico, and Josefina A. Tuazon
and the University of the Philippines Open University
Apart from any fair use for the purpose of research or private study,
criticism or review, this publication may be reproduced, stored
or transmitted, in any form or by any means
ONLY WITH THE PERMISSION
of the authors and the UP Open University.
Published in the Philippines by the UP Open University

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ISBN 971-767-184-2
First printing, 1997

Second printing, 2000
Third printing, 2005
Layout by Dang Cadalo
Printed in the Philippines

Table of Contents
UNIT I
Module 1 Nursing Theories: Conceptual Framework

Objectives, 3
Definition of Theory, 3
Components/Elements of Theory, 5
Characteristics of a Theory, 7
Theory Development, 7
Uses of Theory, 9
Historical Development of Nursing Theories, 10
Types of Theories, 13
According to range, 13
According to orientation or focus of the theory, 14
Framework to Analyze a Nursing Theory, 15
Answers to Self-Assessment Questions, 18
References, 19
Module 2 Client-Centered Nursing Theories

Objectives, 22
Henderson’s Theory—Definition of Nursing, 22
Historical perspectives, 22
Major concepts, 24
Underlying assumptions, 27
Key concepts, 29
Interrelationship between concepts, 30
Theoretical assertions, 31
Strengths and weaknesses (Limitations), 32
Applications to nursing practice, research, and education, 33
Henderson’s theory and the nursing process, 35
The Orem Self-Care Deficit Theory of Nursing, 38
Historical perspectives, 39
Major concepts, 40
Underlying assumptions, 46
Key concepts of Orem’s theory and definitions, 47
Theoretical assertions, 58
Strengths and limitations, 59
Applications to nursing practice, research, and education
Orem’s Self-care deficit theory of nursing and the nursing, 62
Pender’s Health Promotion Model, 66
What the model is all about, 67
Major concepts and definitions, 67
The Health Promotion model, 68
Strength and limitations, 73
Summary, 74
References, 89
Module 3 Client-Centered Nursing Theories: Roy, Levine, Hall

Objectives, 91
M.E. Levine’s Four Conservation Principles of Nursing, 92
Key concepts and theoretical assertions, 95
Roy’s Adaptation Theory, 100
Key concepts and theoretical assertions, 101
Hall’s Theory of Care, Core, and Cure, 104
Major concepts, 104
Summary, 106
References, 110
Module 4 Nurse-Client Dynamics

Objectives, 111
Historical Highlights, 112
Interpersonal Relations, 115
Caring as the Essence of Nursing, 119
Model for Studying Propositions, 125
Dynamic Nurse-Patient Relationship, 129
Goal attainment Theory, 133
Elements, 141
Utilization, 142
Summary, 144
References, 154
Module 5 Client-Nurse Environment Dynamics

Objectives, 155
Leininger’s Theory of Culture Care, 156
Historical background of Leininger’s Theory of Culture Care, 158
Leininger’s Theory of Culture Care, 160
The Sunrise Model, 163
Strengths and limitations, 167
Neuman Systems Model, 169
The systems model as a conceptual framework for nursing, 170
Basic assumptions, 172
Neuman’s model and the four major concepts, 173
Strengths and limitations of the Neuman Systems Model, 178
Summary, 181
References, 186
UNIT II OVERVIEW
Module 6 The General Systems Theory

Objectives, 191
Historical Development of the General Systems Theory, 192
What is the General Systems Theory?, 192
Important aspects of a system, 194
Characteristics of a system, 194
The Systems Process, 198
System Boundary and Boundary Maintenance, 203
System States, 205
Applications of GST and Nursing Theories Concepts to Nursing Practice, 207
References, 208
Module 7 Developmental Theories

Objectives, 209
Developmental Theories, 211
Modern Perspectives in Development, 212
Environmentalism, 213
British empiricism, 213
Behaviorism, 213
Cultural anthropology, 215
Organismic Perspective, 216
Naturalism, 216
Maturalism, 216
Cognitive Development Theory, 217
Humanism, 221
Ethology, 224
Moral development, 225
Critique of organismic perspective theories, 226
Psychoanalytic Perspective, 228
Freud Psychosexual Theory, 228
Erikson’s Psychosocial Theory, 231
Critique of the Psychoanalytic Theory, 237
Summary, 241
References, 246
Module 8 Learning Theories and Other Related Theories
Objectives, 247
Defining Learning, 248
Historical Perspective, 248
Social Learning Theory, 249
Bandura’s Social Learning Theory, 252
Health Relief Model and Other Rational Belief Models, 256
Application of the HBM, 258
Deficiencies of the model, 259
Practice Implications of HBM and SLT, 260
The PRECEDE-PROCEED Framework, 261
PRECEDE framework, 262
The seven phases of PRECEDE, 263
PRECEDE to PROCEED Model, 266
A Theory of Adult Learning: Andragogy, 268
Summary, 271
References, 274
Module 9 Theories of Change

Objectives, 275
Lewin’s Change Process: Precursor of Change Theory, 276
Definition of Planned Change, 277
Lippit’s Planned Change, 279
Phase 1: The development of a need for a change, 280
Phase 2: Establishment of a change relationship, 281
Phases 3, 4 and 5: Working toward change, 281
Phase 6: Generalization and stabilization of change, 283
Phase 7: Achieving a terminal relationship, 283
General Strategies for Effecting Changes in Human Systems, 285
Summary, 288
References, 290
Module 10 Theories/Models on Communication

Objectives, 291
What is Communication, 291
Theories/Models on Communication: Their Application to the Practice
of Nursing, 292
The Process School Theories, 292
The Semiotic School, 299
Non-Verbal Communication, 302
Physical appearance, 302
Body movement, 302
Paralanguage, 304
Touching, 304
Time, 304
Space and territory, 305
References, 306
Module 11 Crisis Intervention Theory

Objectives, 307
Historical Development of Crisis Intervention, 308
General Theories Supportive of the Crises Concept, 312
Psychoanalytic Theory (Freud), 312
Ego-analytic Theory (Hartmann), 312
Adaptational psychodynamics (Rado), 312
Epigenetic development (Erikson), 313
Crisis Theories, 314
Types of Crises, 316
Phases of Crises, 319
Balancing Factors Affecting Equilibrium, 321
Crisis Intervention, 323
Crisis Intervention Model, 326
Equilibrium Model, 326
Cognitive Model, 326
Eclectic Crisis Intervention Model, 326
Psychosocial Transition Model, 327
Approaches to Crisis Intervention, 328
Settings for Crisis Intervention, 333
Nursing Care Plan in Crisis Intervention, 335
Communication During Crisis, 340
Summary, 343
References, 348
Module 12 Gender Concepts and Issues in Health

Objectives, 349
Gender vs. Sex, 350
Development of a Gender Self-Concept, 351
Gender Socialization and the Nursing Profession, 353
Gender: A Major Predictor of Health, 354
Strategies to Reduce Gender Inequalities in Health, 357
Summary, 359
References, 361
UNIT III BIOETHICS IN NURSING
Module 13 Foundation and Principles of Bioethics in Nursing

Objectives, 365
Foundation of Bioethics, 366
Development of Bioethics, 369
Justice, 370
Paternalism, 371
Autonomy, 372
Compassion and veracity, 373
Sharing and allocation of resources, 374
Filipino Primary Principles of Bioethics, 376
Goodness, 376
Beneficence, 377
Family, 377
Summary, 378
Module 14 The Beginning of Life

Objectives, 381
The Beginning of Life, 382
Conscience: Its Formation and Acquisition, 384
The nature of conscience, 384
The formation and education of conscience, 386
Conscience Situations, 391
Summary, 394
Module 15 Autonomy
Objectives, 397
Meaning and Extent of Autonomy, 398
Informed or Enlightened Consent, 402
Autonomy and the Health Care Professional, 405
Summary, 406
Module 16 Beneficence
Objectives, 411
The Concept of Beneficence, 412
Beneficence and Nonmaleficence and their Implications on
Certain Situations, 416
Summary, 421
Module 17 Justice
Objectives, 425
The Concept of Justice, 425
Allocation of Scarce Resources, 429
The Filipino Family and Its Principle of Justice, 431
Summary, 433
Module 18 Professional-Patient Relationship

Objectives, 435
Privacy, 436
Veracity, 437
Fidelity, 437
Truth Telling, 440
Virtues in Professional Life, 442
Summary, 446
Unit III References, 448
Unit I
2 Theoretical Foundations of Nursing
UP Open University
Module 1 3
Module 1
Nursing Theories:
Conceptual Framework
Thelma F. Corcega
One of the concepts you learned very early in your

undergraduate nursing program is “Man is a bio-
psychosocial being in constant interaction with a
Objectives
changing environment.” This is just one of many
theories that underpin nursing practice. At the end of this module, you
should be able to:
In this course, you will learn in depth and greater
detail the theories developed by well known nurs- 1. Define theory;
ing theorists and scholars. However, before go- 2. Describe components and
ing through their work, let me introduce you to characteristics of a theory;
theories in general and other related concepts to 3. Explain how a theory is
help you understand better how the succeeding developed;
modules are organized and presented. 4. Discuss uses of theories;
5. Trace the history of theory
development in nursing;
6. Differentiate types of
Definition of Theory theories
a. according to range;
What is a theory? When you are asked this ques- b. according to orienta-
tion, I will not be surprised if your initial reaction tion or focus of the
will be to grope for words. How often have you theory; and
used the term to explain an event that seems to 7. Describe a framework to
have either more than one explanation or no analyze a nursing theory.
obvious explanation at all? You begin your
explanation by saying, “my theory is ….” This
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behavior of knowing and seemingly not knowing can be explained by the

abstract nature of the word “theory.” This abstract nature is the reason
why it is explained in many different ways. I selected some definitions for
you. After going through each one of them, you will find that different
authors have different definitions but you can identify commonalities.
Table 1.1. Definitions of a theory
Author Definition of a Theory
Pinnel and Menesis (1986) Systematic set of interrelated concepts,

definitions and deductions that describe,
explain or predict interrelationships
Walker and Avant (1983) Internally consistent group of relational

statements (concepts, definitions and
propositions) that presents a systematic
view about a phenomenon and which is
useful for description, explanation,
prediction, and control
Chin and Krammer (1991) Creative and vigorous structuring of ideas

that project a tentative, purposeful and
systematic view of phenomena
Dickoff and James (1968) Conceptual system or framework invented

for some purpose
Ellis (1968) Coherent set of hypothetical, conceptual,

and pragmatic principles forming a
general frame of reference for a field of
inquiry
From these definitions, you will observe that some authors define theory
in terms of what it includes: purpose, concepts, definitions and proposi-
tions. These are called components or elements of a theory. Others de-
fine it in terms of characteristics like systematic and creative. Let us go
through these components and characteristics one by one.
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Module 1 5
SAQ 1-1
In your own words, define theory.
Components/Elements of Theory
Specifically mentioned in the definitions are purpose, concepts, defini-
tions and propositions. These are the components or elements of a theory.
We will also discuss a fifth one—assumptions.
Purpose answers the question, “why is the theory formulated?” It also

specifies the context and situation within which the theory is formulated.
The purpose may not be stated explicitly, but it is identifiable. In your
study of the different theories, always identify the purpose of each one.
Concepts are the building blocks of theory. They are ideas, mental images
of a phenomenon, an event or object that is derived from an individual’s
experience and perception. For the same word—for example, person—
different theorists have different concepts because they have different
experiences and perceptions. Therefore their concept of a person will be
unique to their theory.
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A theory can have major concepts and subconcepts. Analysis of the dif-
ferent nursing theories shows four common major concepts, namely:
1. Person
2. Nursing
3. Health
4. Environment
Not all authors, however, include all four concepts in their discussions.
Leininger, for example, does not include them in the discussion of her
theory. Others may not state their concepts explicitly but a close reading
of the theories will show what their concepts are. Henderson, for example,
utilized Webster’s definition of environment.
In addition to the four major concepts, each theory has key concepts.
These key concepts are unique to the theory. Most theorists are known by
their key concepts. For example, Orem’s Self-care, Roy’s Adaptation Model,
Leininger’s Transcultural Nursing and Levine’s Conservation Principle.
Some may even have several subconcepts.
Definitions give meaning to concepts. They make concepts clearer and

more understandable. There are two types of definitions, descriptive and
operational. Descriptive or conceptual refers to the accepted meaning of
the term already used, whereas operational or stipulative refers to the
specific use or definition of the term within the theory.
Concepts are defined explicitly or implicitly. An example of an explicitly

defined concept is a list of definitions or glossary of terms. Implicit defini-
tions can be derived from the narrative or text and are not stated as defi-
nitions.
Propositions are expressions of relational statements between and among

concepts. Concepts alone cannot create a theory. Specific relationships
between concepts must be stated. These provide links and connections
between and among concepts. Propositions can be expressed as state-
ments, paradigms or figures. Some authors may use the term “theoretical
assertions.” Do not be confused. Theoretical assertions are the same as
propositions.
Assumptions are accepted “truths” that are basic and fundamental to

the theory. They are what we call givens. They may be factual assump-
tions or value assumptions. Factual assumptions are those knowable or
potentially knowable by empirical experience. This implies that findings
or results of research studies support the assumption. A value assump-
tion asserts or implies what is right, good or ought to be (Chinn and
Krammer, 1991).
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Module 1 7
Characteristics of a Theory
Components of a theory are not the only ones we can derive from the
different definitions of a theory. The characteristics of a theory can also be
derived from the definitions. What are these?
1. Systematic, logical and coherent
There must be orderly reasoning and no contradictions between and

among the concepts. There must be proper sequencing of ideas and
propositions or theoretical assertions.
2. Creative structuring of ideas
We said that concepts are the building blocks of a theory and that
they are the mental images resulting from one’s experiences and per-
ceptions. Therefore, when these concepts are interrelated, they create
different ways of looking at a particular phenomenon, event or object.
3. Tentative in nature
A theory can change over time, implying that it is evolving and dy-
namic. As further research and studies are done and as they are en-
riched by practice, theory can change. However, there are also theo-
ries that remain valid despite the passage of time.
Now that you have learned the definition, components and characteris-
tics of a theory, let us study how a theory is developed.
Theory Development
How is a theory developed? Have you ever wondered how a scholar or
an intellectual begins to work and finally comes up with his or her theory?
Meleis (1985) identified four strategies of theory development in nursing.
These are:
1. theory-practice-theory
2. practice-theory
3. research-theory
4. theory-research-theory
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Theory Practice Theory
The first strategy, theory-practice-theory, implies that theory develop-

ment in nursing is based on theories developed by other disciplines and
used in nursing situations. An example of this is Peplau’s theory of Inter-
personal Relations in Nursing (Module 4) which was based on the Inter-
personal Theory of Sullivan (Module 7). She utilized the interpersonal
theory in her practice of mental health and psychiatric nursing and evolved
her own theory out of the observations and researches done in her nurs-
ing practice.
Practice Theory
Theories developed using the practice-theory strategy were based upon

and evolved from clinical practice. The theorist develops his/her ideas
through actual observations or experiences in the clinical area, either as a
care-giver herself or as an observer of other care-givers. From the data
collected, concepts are developed and relationships are defined to form
propositions. An example is Orlando’s Nursing Process Theory (Module 4).
Research Theory
The research-theory strategy is used by those who believe that theories

must evolve from research findings. This is also known as the inductive
method. Johnson’s Behavior Systems Model is an example of this. This is
not included among the theories you will study in detail. Just to let you
know, Johnson is one of those who consistently stress the importance of
research-based knowledge. She developed her model based on observa-
tional studies on children and their behavior patterns. From the empiri-
cal evidence, she developed her theory.
Theory Research Theory
The theory-research-theory strategy is another approach to theory de-

velopment. With this method, theories developed by other disciplines are
utilized but given a unique nursing perspective. Conceptual or theoretical
frameworks in nursing research studies are adapted from these theories.
The original theory is then examined using the new research findings
(Meleis, 1985 p. 117).
From the discussion above, you can see that there is interdependence
between and among theory, research and practice and that the develop-
ment of a nursing theory can be illustrated in the form of a circle (Figure
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Module 1 9
1-1). One can begin at any point in the circle. The direction can be clock-
wise or counter clockwise. This also indicates that the process of moving
from one to the other is continuous and indefinite.
R e se a rch T he o ry
P ractice
Figure 1-1. Development of nursing theory
Uses of Theory
What are the uses of theory?
1. Theory guides and improves nursing practice.
Past and present problems in nursing might be solved through theory

development. Theory provides the nurse with goals for nursing care.
By being goal directed, nursing practice is rendered more efficient and
effective. Theory helps to identify the focus, the goals, and the means
of practice. As theory evolves, nurses become more confident and gain
more control over practice because their actions are based on tested
theory.
2. Theory guides research.
According to Meleis (1985), “the primary use of theory is to guide

research.” Research validates and modifies theory. Theory forms the
basis for hypothesis testing and for the theory to be expanded. Re-
search tests hypotheses in clinical settings. Statistical analyses are used
to arrive at findings that increase the precision of the theory in de-
scribing, explaining or predicting nursing realities. Theory is a very
rich source of research problems. Now is a good time to start thinking
about your thesis. Why not use theory as the source of your research
problem?
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3. Theory contributes to the development of the discipline’s body of

knowledge.
Nursing must have a foundation of theoretical knowledge that is based

on research findings. Theory in nursing describes, explains, predicts
and controls phenomena or events in order to achieve desired out-
comes. It can show relationships between and among concepts to
create a different way of understanding a nursing phenomenon.
4. Theory enhances communication.
It provides a common language for understanding a phenomenon so

that nursing could be described and explained by common concepts.
Therefore, it creates a better link between practitioners, educators, ad-
ministrators and researchers.
Historical Development of Nursing Theories

So far, you have learned the definition, components, characteristics,
development, and uses of theory. Let us now trace the historical develop-
ment of nursing theories. When did nursing theory start to evolve? Who
were the first nurse theorists?
The history of theory development in nursing began with the writings of

Florence Nightingale. Many nurse scholars cite her as the first theorist but
there are also some who say her contribution is not a theory. Rather, her
writings should be considered as the beginning of the scientific practice of
nursing. Her Notes on Nursing, written in the mid-nineteenth century,
reflected her beliefs, observations, and practice of nursing. Her work paved
the way for modern nursing. She was the first one to insist that formal
education is needed in the preparation of a nurse. She stressed the impor-
tance of observations and recording. She recorded her observations and
used statistics to support her request for reforms.
Nightingale’s theory focused on the control of the environment of indi-

viduals requiring nursing care. She believed that disease was a reparative
process, that it was nature’s effort to remedy a process of poisoning or
decay, or a reaction against the conditions in which a person was placed.
In order to prevent the disease or hasten the healing process, the nurse
must provide a clean and quiet environment with proper ventilation and
lighting, clean air free from foul odor and unnecessary noise. She also
stressed the importance of room temperature. She emphasized the need
for appropriate nutrition in promoting a person’s well-being. Her major
concepts of ventilation, light, warmth, noise, cleanliness, and diet in rela-
tion to nursing are still valid today.
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Module 1 11
From Nightingale’s time until the 50s, the other milestone in nursing theory
development was the publication of the journal Nursing Research in 1952.
The journal encouraged nurses to pursue research, thus developing ques-
tioning attitudes and inquiries that set the stage for conceptualization of
nursing practice. With the emergence of the scientific era in the 1960s, the
nature of practice was debated as nursing leaders recognized the need to
define nursing practice, develop nursing theory, and create a substantive
body of knowledge (Deloughery, 1991).
Literature on the philosophy of nursing, as well as conceptual models

and frameworks proliferated in the 60s and 70s. Peplau’s Interpersonal
Relations in Nursing described the interpersonal process occuring between
the nurse and the patient. Abdellah developed the patient-centered ap-
proach and the Typology of Nursing Practice. Her 21 nursing problems
were conceptualized from several studies. Hall described nursing prac-
tice at the Loeb Center for Nursing at Montefiore Hospital using the core
(person), care (body) and cure (disease) model.
The role of the nurse came under scrutiny during this period. What they
do, for whom, where, and when were determined. During this scientific
era and period when the purpose of nursing was being questioned, the
process of theory development was also being discussed and was the sub-
ject of writings of a number of nurse scholars. Aside from publications,
symposia were also held dealing with subjects like Theory Development
in Nursing, and Nature of Science and Nursing. The first conference on
nursing theory was held in 1969 and another one the following year.
These conferences brought leading scholars and theorists together to dis-
cuss and debate on issues regarding nursing science and theory develop-
ment in nursing.
The writings of Dickoff, James and Wiedebach on “Theory in a Practice

Discipline” (1968) influenced the development of theoretical thinking in
nursing. They presented a definition of nursing theory and goals for theory
development in nursing. Their approaches were discussed in many writ-
ings and conferences reflecting the growing and evolving interest in de-
veloping nursing theory.
The 1980s were characterized by acceptance of the significance of theory

in nursing. There were less debates on whether or not to use theory,
whether it is practice or basic theory, borrowed or nursing theory. The
discussions were mostly related to semantics. For example, whether con-
ceptual models were the same as conceptual frameworks. The period from
1980 up to the present is characterized by the publication of numerous
books and articles on analysis, application, evaluation and further devel-
opment of nursing theories. Graduate schools of nursing developed courses
on how to analyze and apply nursing theories (Deloughery, 1991).
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SAQ 1-2
Below is a time graph to depict the development of nursing theory.
Summarize the characteristics and significant events of each pe-
riod by filling in the spaces provided.
Prior to 1960 60s and 70s 80s 80s to present
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Module 1 13
Types of Theories
What are the different types of nursing theory? The following section will
help you further understand the nature of theories.
For purposes of this course, we will differentiate types of theories:

1. according to range
2. according to orientation or focus of the theory
According to range
Theories differ in complexity and scope. They are classified as grand theory,
middle-range theory, and micro theory.
Grand theories consist of broad conceptual frameworks that reflect wide

and expansive perspectives for practice and ways of describing, explain-
ing, predicting, and looking at nursing phenomena. They are the most
complex and broadest in scope. Examples of grand theories are
Henderson’s The Nature of Nursing, Levine’s The Four Conservation Prin-
ciples of Nursing, Roy’s Adaptation Model, and Orem’s Self-Care
(Marriner-Tommey, 1994).
Middle-Range theories are less complex and narrower in scope than

grand theories. They fill the gap between the grand theory and micro
theory. Grand theories are sometimes difficult to test because of their com-
plexity. A more workable level is the middle-range theory. It has less vari-
ables, it is more limited in scope and is testable. For example, a grand
nursing theory on stress and adaptation might not yield any interpretable
hypotheses or guidelines for practice; however, if the theory is focused on
a chronic lingering illness as the stressor on family life, the stress theory
becomes more operational for both research and practice purposes. Ex-
amples of middle-range theories are Peplau’s Psychodynamic Nursing and
Orlando’s Nursing Process Theory (Morrimer-Tommey, 1994).
Micro theories are the least complex. They contain the least complex con-
cepts and are narrowest in scope. They deal with a small aspect of reality.
Generally, they are a set of theoretical statements that deal with specific
and narrowly defined phenomena (Marriner-Tommey, 1994).
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According to orientation or focus of the theory

Another way of categorizing nursing theories is according to orientation
or focus. The different theories can be categorized as client-centered, cli-
ent-nurse dynamics, and nurse-client-environment dynamics. There are
other ways to categorize but let’s use this one for our course.
There are many nursing theories but you are not going to learn all of them
in this course. What we have done is to select theories representing each
category according to focus. They are the most developed ones, most writ-
ten about, and most frequently used.
Client-centered theories are those focused on the needs and problems of

clients which are met, resolved or alleviated by nursing interventions. This
category includes theories developed by the following:
1. Nightingale
2. Abdellah
3. Henderson
4. Orem
5. Pender
6. Roy
7. Levine
8. Hall
Theories on nurse-client dynamics focus on interaction between the nurse

and client. This category includes theories developed by the following:
1. Peplau
2. Watson
3. King
4. Orlando
Theories on nurse-client-environment dynamics focus on the interac-

tion between nurse and client in an environment that includes broader
dimensions of time and space, as well as culture, cultural diversity, and
universality. Theories of Neuman and Leininger are discussed under this
category.
The categorization of the different theories is illustrated in Figure 1-2.

Client, nurse and environment are each represented by a circle. The over-
lapping indicates the area of interaction. For purposes of this course, the
different theories are grouped into three: (1) client-centered; (2) client-
nurse dynamics; and (3) client-nurse-environment dynamics.
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Module 1 15
Client Nurse
Client-centered
Client-nurse-dynamics
Client-nurse-
environment dynamics
Environment
Figure 1-2. Categories of nursing theories
At this point, let us review what you have learned so far about theory in
general and nursing theory in particular.
You learned about the definition, components, and characteristics of theory.

You also learned how a nursing theory is developed, its uses, historical
development, and different categories. These will help you understand
the nature of theory in general and nursing theory in particular. The last
section of this module will help you understand how to analyze the dif-
ferent nursing theories you will learn in the subsequent modules.
Framework to Analyze a Nursing Theory

One of the objectives of this course is that you should be able to synthesize
nursing theories in terms of concepts, structure, focus, application, and
limitations. To help you attain this objective, compare and contrast the
different theories. If you recall, the section on components of a theory
mentioned that there are four major concepts common to most nursing
theories. What are these major concepts? In case you have forgotten, they
are person, nursing, health, and environment. These four major concepts
are discussed by different theorists according to their own definitions. As
you go through the different theories, these major concepts will be dis-
cussed at length one by one.
Remember also that based on focus, the theories are grouped into three
(client-centered, nurse-client dynamics, and nurse-client-environment dy-
namics). As you study each theory, analyze how similar and different
they are from each other. For example, Henderson’s and Orem’s are both
client-centered. How similar and how different are their concepts of per-
son, nursing, health, and environment? Keep this in mind as you study
the three groups of theories.
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In addition to the four major concepts, each theory has key concepts.
These key concepts are unique to the theory. They are well explained in
the modules. Some theories may have several key concepts. Levine, for
example, has conservation, adaptation, and organismic response as key
concepts. Some key concepts also have sub-concepts. For example, sub-
concepts of organismic response include fight or flight, inflammatory
response, response to stress, and perceptual response.
Are you overwhelmed? Don’t be. You will be introduced to each theory
in such a way that you will be able to relate each theory to your “reality”,
meaning the nursing situation you are familiar with. Just remember the
four major concepts and the key concepts for each theory.
Major Concepts
Person
Nursing Key Concepts Nursing Theory
Health
+ =
Environment
Activity 1-2
Develop a worksheet that will help you organize the theoretical
thinking you will go through as you analyze each theory—com-
paring and contrasting them with one another. It can be in the
form of a matrix or table. As you study the different theories, you
will be able to put together the knowledge you are acquiring in a
manner that will not be confusing or overwhelming.
UP Open University
Module 1 17
Comments on Activity 1-2

What does your worksheet look like? Is it something similar to
this? Perhaps you were able to come up with something better
and simpler. Remember, the idea is for you to have a tool that will
facilitate organization of the knowledge you are acquiring.
Major Concepts Key

Theories
Person Nursing Health Environment Concepts
UP Open University
Answers to Self-Assessment Questions

ASAQ 1-1
If your definition includes the following ideas, congratulate yourself.
1. set of concepts, definitions and propositions that are interrelated

2. has a purpose
3. systematic, logical and coherent
4. basis for inquiry
5. creative structuring of ideas
6. dynamic and tentative
7. evolving and enriched by practice and research
If you missed two or three, it is all right. Next time you’ll get them.
ASAQ 1-2
Here is one way to summarize the characteristics of, and significant events
in, the development of nursing theory.
1. Prior to 1960
a. Nightingale’s works and writings
b. Formal education of nurses
c. Publication of Nursing Research
2. 60s and 70s

a. Scientific era: nurses questioned purpose of nursing
b. Publications dealing with philosophy of nursing, conceptual
models and frameworks
c. Process of theory development discussed among professional
nurses
d. Symposia held on theory development in nursing
e. Borrowed theories from other disciplines
3. 80s
a. Acceptance of the significance of theory in nursing
b. Revision and further development of theories
c. More substantive debate on issues related to theory deve-
lopment
4. 80s to present
a. Publication of books and articles on analysis, application, evalu-
ation, and further development of nursing theories
b. Courses on theories offered at the graduate school level
UP Open University
Module 1 19
References
Chinn, P. and Kramer, M. (1991). Theory and nursing: A systematic ap-
proach. St. Loius: Mosby Year Book, Inc.
Deloughery, G. (1991). Issues and trends in nursing. St. Louis: Mosby Year
Book, Inc.
Fawcett, J. and Donns, F. (1986). The relationship of theory and research.
Norwalk, Connecticut: Appleton-Century Crofts.
George, J. (1995). Nursing theories: The basis for professional nursing prac-
tice. 4th edition. Norwalk, Connecticut: Appleton and Lange.
Marriner-Tommey, A. (1994). Nursing theorists and their works. 3rd edi-
tion. St Louis: Mosby.
Meleis, A. (1985). Theoretical nursing: Development and progress. Philadel-
phia: JB Lippincott Co.
Nicoll, L. (Ed.). (1992). Perspectives on nursing theory. 2nd edition. Philadel-
phia: JB Lippincott Co.
Walker, L. and Avant, K. (1983). Strategies for theory construction in nurs-
ing. Norwalk, Connecticut: Appleton and Lange.
UP Open University
Module 2
Client-Centered
Nursing Theories
Carmencita M. Abaquin and Cora A. Añonuevo
Nurse Environment
Client
I n this module, we will discuss client-centered nursing theories. Ac-

tually, there are two modules covering client-centered nursing theories.
This module includes Virginia Henderson’s Definition of Nursing,
Dorothea Orem’s Self-Care Theories and Nola Pender’s Health Promo-
tion Model. The next module (Module 3) will cover other theories belong-
ing to the client-centered category such as Calixta Roy’s Adaptation theory,
Myra Levine’s Conservation theory, and Lydia Hall’s Care, Core, Cure
theory.
Virginia Henderson’s Definition of Nursing is clas-

Objectives sified as a philosophy of nursing, while Dorothea
Orem’s Self-care Theory is classified as a nursing
conceptual model (Marriner-Tomey, 1994). Vir-
At the end of this module,
ginia Henderson’s Model of Nursing has also been
you should be able to:
described as borrowing extensively from the medi-
cal model in terms of how she seeks to understand
1. Explain the various
people and their health-related needs; while
factors that influenced
Dorothea Orem’s Self-Care Model of Nursing
the development of
gives emphasis to psychological and social needs
client-centered theories,
but does not ignore the existence of physiological
specifically Virginia
mechanisms in a person.
Henderson’s Definition
of Nursing, Dorothea
In this module, I will first discuss Virginia
Orem’s Self-Care Theory
Henderson’s Definition of Nursing. Her creden-
of Nursing and Nola
tials and historical background as well as the theo-
Pender’s Health
retical sources for theory development will be dis-
Promotion Model;
cussed first to give you a short introduction. Then
2. Compare and contrast
I will explain her major concepts and definitions;
the client-centered
her major assumptions, theoretical assertions,
theories in terms of the
strengths and limitations, then the theory’s appli-
following major concepts:
cations to nursing practice, research, education
a. person
and administration. This will also be the format
b. health
for the discussion of Orem’s Self-Care theory.
c. nursing
d. environment;
3. Explain the key concepts
of each of the client- Henderson’s Theory—Definition
centered theories; of Nursing
4. Explain the theoretical
assertions of each of the
client-centered theories.
5. Identify the strengths and
limitations of the client- Historical perspectives
centered theories; and
6. Apply the client-centered For you to understand better this well-known
theories to given situa- model of nursing, let me give you a historical back-
tions/conditions in ground.
nursing practice.
Virginia Henderson, the fifth of eight children, was
born in Kansas, Missouri in 1897. During World
War I she developed an interest in nursing. Thus in 1918, she entered the
Army School of Nursing in Washington, D.C. where she graduated in
1921. Then she became a staff nurse at Henry Street Visiting Nurse
Service in New York. She began teaching nursing the following year at
Norfolk Protestant Hospital. In 1927, she entered Teacher’s College at
Columbia University where she earned her BS and MA degrees in nurs-
UP Open University
Module 2 23
ing education. In 1929, she served as a teaching supervisor in the clinics

of Strong Memorial Hospital in Rochester, New York. Then in 1930, she
returned to Teacher’s College as a faculty member, and taught courses in
nursing analytical process and clinical practice until 1948.
She enjoyed a long career as an author and researcher. As a faculty mem-

ber of Teacher’s College in 1939, she rewrote the fourth edition of Bertha
Harmer’s Textbook of the Principles and Practice of Nursing following the
author’s death. The fifth edition of the textbook was published in 1955
and this contained Henderson’s definition of nursing. She was associated
with Yale University from the early 1950’s, where she did much to fur-
ther nursing research. From 1959 to 1971, Henderson directed the Nurs-
ing Studies Index which was composed of four volumes of bibliographical,
analytical, and historical literature on nursing from 1900 to 1959. This
index was influential and was used in the publication of the International
Nursing Index.
She also authored and co-authored several other important works. Her
pamphlet, Basic Principles of Nursing Care, was published for the Interna-
tional Council for Nurses in 1960 and this was translated into more than
20 languages. Her 5-year collaboration with Leo Simmons produced a
national survey of nursing research that was published in 1964. Her book,
The Nature of Nursing, published in 1966, described her concept of nursing’s
primary, unique function. This was reprinted by the National League of
Nursing in 1991. The sixth edition of the Principles and Practice of Nursing,
published in 1978, was co-authored by Henderson and Gladys Nite, and
edited by Henderson. This book has been widely used by various nursing
schools and was translated into 25 languages. Through the 1980’s, she
remained active as a Research Associate Emeritus at Yale.
What were the major influences on Henderson’s decision to synthe-

size her own definition of Nursing?
There were three major influences that made her decide to synthesize her
own definition of nursing:
1. When she revised the Textbook of Principles and Practice of Nursing, she
realized the need for being clear about the functions of nurses.
2. During her involvement as a committee member in a regional confer-

ence of the National Nursing Council in 1946, the thinking of others
in the group inspired her to modify her point of view.
3. Henderson was not fully satisfied with the definition adopted by the
American Nurses’ Association (ANA) in 1955, which was based on
the Association’s 5-year investigation of the function of the nurse.
UP Open University
Who influenced her during her early years in nursing?
In her book, The Nature of Nursing, she acknowledged a number of forma-

tive influences on her work some of whom are mentioned below (Marriner
Tomey, 1994):
1. Annie W. Goodrich, the Dean of the Army School of Nursing, made

Henderson lift her sight above techniques and routines. She empha-
sized patient-centered care. Henderson’s early discontent with regi-
mented patient care and the concept of nursing as merely ancillary to
medicine is attributed to the inspiration of Goodrich.
2. Caroline Stackpole, a physiology professor at Teacher’s College, Co-

lumbia University when Henderson was a graduate student, impressed
upon her the importance of maintaining physiological balance.
3. Dr. Edward Thorndike’s studies in psychology at Teacher’s College

impressed upon her that illness is more than a state of disease and
that most fundamental needs are not met in hospitals.
4. Dr. George Deaver, a physician at the Institute for the Crippled and
Disabled and at Bellevue Hospital, made her realize the goal of reha-
bilitative efforts, which is to build the patient’s independence.
5. Bertha Harmer, a Canadian nurse and the original author of Textbook

of Principles and Practice of Nursing which Henderson revised, had simi-
larities in their definition of nursing. To Harmer, nursing is rooted in
the needs of humanity.
6. Ida Orlando influenced her concept of the nurse-patient relationship.

To avoid misconceptions, the nurse has to validate her interpretation
of the clinical situation with the patient.
7. Ernestine Wiedenbach’s work suggesting the need for a deliberative

approach to nursing care also influenced the development of
Henderson’s approach to nursing.
Major concepts
Let us now find out what Henderson has to say regarding the major con-
cepts of person, health, environment, and nursing.
UP Open University
Module 2 25
Person (patient/client)
Henderson considered the person to be of primary importance and that is

the reason why we categorize her theory as client-centered.
To her, the individual person or client is a whole, complete, and indepen-

dent being with biological, sociological, and spiritual components. To be
whole, the person must maintain physiological and emotional balance;
the mind and body are inseparable. These components are operationalized
in the 14 fundamental or basic human needs, namely:
1. Breathe normally
2. Eat and drink adequately
3. Eliminate body wastes
4. Move and maintain desirable position
5. Sleep and rest
6. Select suitable clothes—dress and undress
7. Maintain body temperature within normal range by adjusting cloth-
ing and modifying the environment
8. Keep the body clean and well groomed and protect the integument.
9. Avoid dangers in the environment and avoid injuring others
10. Communicate with others by expressing emotions, needs, fears or
opinions
11. Worship according to one’s faith
12. Work in such a way that there is a sense of accomplishment
13. Play or participate in various forms of recreation
14. Learn, discover, or satisfy the curiosity that leads to normal develop-
ment and health, and use the available health facilities
Henderson also stated that under conditions of positive health and well-
being, people are likely to have little difficulty in satisfying these needs by
themselves. However, in times of illness, at certain points in the life cycle
or during terminal illness, an individual may be unable to satisfy these
requirements without the assistance of others. This is where the nurse can
come in. In other words, the patient as an individual will require assis-
tance to achieve health and independence or peaceful death. She also
emphasized the importance of the family as she mentioned that the pa-
tient and his family are viewed as a unit.
Does your concept of person jive with Henderson’s view?
UP Open University
Health
Although Henderson did not state her own definition of health, she
equated health with independence. She further stated that individuals
will achieve or maintain health if they have the necessary strength, will or
knowledge. In the sixth edition of Textbook on Principles and Practice of
Nursing, she mentioned several definitions of health, including WHO’s
definition. She viewed health in terms of the patient’s ability to indepen-
dently perform the 14 basic needs which comprise the components of
nursing care.
She also stated that it is the “quality of health rather than life itself, that
margin of mental physical vigor that allows a person to work most effec-
tively and to reach his highest potential level of satisfaction in life”
(Henderson and Nite, 1978).
She described health as basic to human functioning and that promotion

of health is more important than care of the sick.
Do you agree with Henderson?
Nursing
Henderson defined nursing in functional terms. To her, the unique func-

tion of the nurse is to assist the individual, sick or well, in the performance
of those activities contributing to health or its recovery (or to a peaceful
death), that he would perform unaided if he had the necessary strength,
will or knowledge. And to do this in such a way as to help him gain
independence as rapidly as possible.
There are also special developmental situations where the nurse is needed,
such as when the very young and the very old cannot meet their basic
human needs because of physical, psychological or social factors.
She also mentioned the nurse’s function as a member of the medical team
and emphasized the nurse’s independence.
She/he functions independently of the physician, but promotes

his or her plan, if there is a physician in attendance. The nurse can
function independently and must, if she or he is the best prepared
health worker in the situation. The nurse can and must diagnose
and treat if the situation demands it.
Henderson emphasized this in the sixth edition of Principles and Practice of

Nursing.
UP Open University
Module 2 27
To be able to do her functions effectively, the nurse should be knowledge-

able in both biological and social sciences. The 14 basic needs of the pa-
tient comprise the components of nursing care.
Environment
Although Henderson did not give her own definition of environment, she
used Webster’s New Collegiate Dictionary (1961), which defines environ-
ment as “the aggregate of all the external conditions and influences af-
fecting the life and development of an organism.”
Henderson’s point of view regarding the environment can also be in-

ferred from her writings. She listed seven essentials in the environment:
light, temperature, air movement, atmospheric pressure, appropriate dis-
posal of waste, minimal quantities of injurious chemicals, and cleanliness
of surfaces and furnishings coming in contact with the individual. She
recognized the effects of these factors on man when she stated that the
environment can act either positively or negatively upon the patient. There-
fore, the nurse’s function is to alter the environment in such a way as to
support the patient.
She described what the nurse can do to help or assist the individual to be
in control of the environment. Healthy individuals may be able to control
their environment, but illness may interfere with that ability. Thus, nurses
should have safety education. Nurses must know about social customs
and religious practices to assess dangers. She should protect the patient
from mechanical injury. She can minimize the chances of injury through
recommendations regarding construction of buildings, purchase of equip-
ment and maintenance. Doctors use nurses’ observations and judgments
upon which to base prescriptions for protective devices.
Underlying assumptions
The assumptions on which Henderson’s work was based are:
1. Independence is valued by the nurse and the patient, more than de-
pendence.
2. Health has a meaning shared by the society at large.
3. Individuals desire health or a peaceful death and will act in such a
way to achieve this.
4. Individuals will perform activities leading to health if they have the
knowledge, capacity or will.
5. The individual’s goal and the nurse’s goal are congruent.
UP Open University
6. The 14 basic needs represent nursing’s basic functions.

7. Nursing’s goal may be subsumed into the medical treatment plan.
8. The major explicit assumption is Henderson’s contention that the nurse
is an independent practitioner. However, she also contends that the
nurse is the primary helper in carrying out physician’s prescriptions.
SAQ 2-1
Using the table below, indicate the major concepts of Henderson’s
Definition of Nursing Theory. Try doing this first based on your
own understanding of what you have just read, then compare
your answers to ASAQ 2-1 at the end of this module.
Henderson’s Definitions of Nursing
Major concepts Description
Person/patient/client
Health
Nursing
Environment
UP Open University
Module 2 29
Key concepts
Let us now take up the key concepts of Henderson’s theory. Her theory
revolves around her concept of nursing. As you saw in the previous sec-
tion, she defined nursing in a functional manner. To her, the nurse plans
the care appropriate to assisting the individual in activities contributing
to his/her health. She further stated that individuals will achieve or main-
tain health if they have the necessary strength, will or knowledge. She
considered the 14 fundamental or basic needs as the basis for the nurses’
basic functions.
As you can see, Henderson’s theory placed the person in a primary posi-
tion. She considered the person as a whole being having biological, psy-
chosocial, and spiritual components which are operationalized in the 14
fundamental or basic human needs. A second major component is nurs-
ing function, and the third is the interaction of the two components in
the process called nursing care. Take note that the nurse’s importance is
based on her ability to define the needs of the client and to assist him/her
rationally in meeting these needs.
Health and its restoration as it relates to the individual is ranked next in

importance. The effect of the environment on health was also mentioned
by Henderson.
The goal of nursing
The nurse should be able to assist the individual, sick or well, in the per-
formance of those activities contributing to health or its recovery (or to a
peaceful death) that he would perform unaided if he had the necessary
strength, will or knowledge. And to do this in such a way as to help him
gain independence as rapidly as possible. In other words, the goal of nurs-
ing is independence in the satisfaction of the human being’s 14 funda-
mental or basic needs.
Relationship of concepts
The definition of nursing by Henderson stated that person, health and the
functions and activities of nursing are related, in that the nurse tries to
operationalize these concepts into client-centered care.
Role of the nurse. The nurse has a complementary-supplementary role

to maintain or restore independence in the satisfaction of the client’s 14
fundamental or basic needs.
UP Open University
Source of difficulty. In a client-centered model, the source of difficulty

resides with the client and not with the nurse. Clients in health care agen-
cies have health problems that may be subcategorized as medical, nurs-
ing, dietary, etc. To Henderson, the source of difficulty is the lack of
strength, will or knowledge of the client.
Intervention focus. To Henderson, this is the deficit that is the source of

client difficulty.
Modes of intervention. These are actions to replace, complete, substitute,

add, reinforce, or increase strength, will or knowledge.
Consequences of nursing activity. These include (1) Increased inde-

pendence in satisfaction of the client’s 14 fundamental or basic needs or;
(2) Peaceful death.
Interrelationship between concepts

Henderson defined nursing in a functional manner. The nurse plans care
appropriate to “assisting the individual” in activities contributing to his/
her health. Considering the 14 care concepts, the nurse cares for the client
in a client-centered way. Nursing, client and health are related in that the
nurse attempts to operationalize these concepts into client-centered care.
Figure 2-1 shows the interrelationship of these concepts.
Nurse-Person Interaction
Goals Means
Independence Knowledge P
N
e
u Restoration Will r
r Maintenance Strength s
s
e
or o
Peaceful Death n
Environment
Figure 2-1. Interrelationship of person, nurse, and environment
To find out how much you have understood Henderson’s theory, let me
ask you a question.
UP Open University
Module 2 31
SAQ 2-2
Summarize the key concepts of Henderson’s Definition of Nursing
Theory.
Theoretical assertions
The nurse-patient relationship
In Henderson’s model, there are three levels that comprise the nurse-
patient relationship and these range from the very dependent to a quite
independent relationship:
1. The nurse is seen as a substitute for what the patient lacks to make
him independent or “whole.” To Henderson, the nurse is described
as the “consciousness of the unconscious, the love life for the suicidal,
the leg of the amputee, the eyes of the newly blind, a means of loco-
motion for the infant, knowledge and confidence for the young mother,
the mouthpiece for those too weak or withdrawn to speak.”
2. During the convalescent phase, the nurse is the helper of the patient
in acquiring or regaining independence. Take note that independence
is viewed by Henderson in a relative manner.
3. In the third level, the nurse is considered as the partner of the patient.
Together, they formulate the plan of care. The nurse and the patient
are always working towards a goal. Such goals can range from health
promotion to independence or peaceful death.
UP Open University
The nurse-physician relationship
Regarding the nurse-physician relationship, Henderson insisted that the

nurse has a unique function which is distinct from that of the physician.
According to Henderson, the care plan that is formulated by the nurse
and the patient together must be implemented in such a way as to pro-
mote the physician’s prescribed therapeutic plan. She insisted that a nurse
does not follow physician’s orders, for she “questions a philosophy that
allows a physician to give orders to patients or other health workers.” In
1978, she extended this view by emphasizing that the nurse helps the
patient with health management when the physician is not around. Like-
wise, she stated that there are many nurse and physician functions that
overlap (Henderson and Nite, 1978).
The nurse as a member of the health care team
As a member of the health care team, Henderson stated that “the nurse
works interdependently with other health care professionals. The mem-
bers of the health care team work together to carry out the total program
of care, but should not do each other’s jobs.” Henderson also reminds us
that “no one in the team should make such heavy demands on another
member that any one of them is unable to perform his or her unique func-
tion.”
Another important aspect to note is Henderson’s use of wedges on a pie

graph to represent the entire health care team, together with the family.
According to her, the size of each member’s section depends on the
patient’s current needs, and therefore this changes as the patient progresses
toward independence. In some instances, other members of the team
may not even be included. The goal is for the patient to have the largest
wedge possible or to have the whole pie. And as the patient’s needs change,
the nurse’s function also changes.
Henderson also stated that the definition of nursing may be modified in

time and depends to a great extent on what other health workers do.
Strengths and weaknesses (Limitations)

Although Henderson considered the basic or fundamental needs and the
physical and emotional aspects of a person as the basis for nursing care,
the concept of holistic nature of man was not clearly defined in her pub-
lications. For example, the effects of the person’s oxygenation needs on
the other remaining components of basic nursing care were not clearly
explained. Prioritization as far as the basic needs are concerned and their
UP Open University
Module 2 33
effects on the other components were not discussed. Her model gives the
impression that nursing care is more concerned with physical rather than
psychosocial needs. However, with the emergence of the concept of holis-
tic approach, she has since stated her belief in holism.
Another limitation was the manner by which the nurse should assist the
individual in the dying process. There was little explanation as to what
the nurse can do in this area.
Applications to nursing practice,

research, and education
Relationship to nursing research
The concept of nursing research was philosophically and practically sup-

ported by Henderson. She considered research as the most fruitful method
for decision-making in nursing. She defined research as a structured sys-
tematic investigation designed to answer a question, throw light on a
theory, or solve a problem. However, she opposed studies about the char-
acteristics of nurses, and time-motion studies that characterized nursing’s
early research base. Henderson’s examples of research questions called
for applied or prescriptive level research. If we consider the 14 funda-
mental or basic needs as the scope of nursing practice, then research ques-
tions arise from these.
Examples of research questions are: What post-operative positions

decrease pain? What kinds of teaching plans are effective in improving
nutrition of the obese patient? How may commonly used equipment be
altered to ensure patient’s comfort?
Henderson was also one of the earliest authorities in nursing to recog-

nize the need for a written individualized plan of care. This became the
precursor of the nursing process and it provided documentation for the
activities of the nurse. These care plans give the practitioners a sense of
what the recurring needs of the patient are and suggest nursing interven-
tions to meet these needs.
Relationship to nursing education
Henderson organized a curriculum around the basic needs and symp-

toms of patients. The textbook, Principles and Practice of Nursing, has been
used as a basic text in many schools of nursing including those in the
Philippines during the late 50s, 60s and 70s. If you graduated during those
years you may be familiar with Henderson’s definition of nursing.
UP Open University
She stated that the only place where a nurse can be educated and meet
the criteria for independence and creative thinking is in a college or uni-
versity. Her curriculum model spoke of structured learning experiences
that are goal-oriented. After the initial program of learning, the nurse is
considered a generalist and further education allows for specialization.
This concept is in keeping with the current professional educational model
of the Philippines.
According to Henderson, if a nurse is to function independently, she must

be taught in non-regimented creative ways during her formation as a
nurse. She also believed that students should be involved in planning their
curriculum just as patients are involved in planning their care.
Her views regarding nursing education were considered revolutionary

and were not fully endorsed by other nursing leaders during her time.
Relationship to nursing practice
Henderson’s definition considered nursing as a practice discipline. She

contributed a deliberative, decision-making approach to patient care. This
approach has current relevance as nurses routinely use the nursing pro-
cess in their practice. Documented nursing care plans are now a perma-
nent part of the patient’s record. These made it possible to collect data
about nursing practice and to develop quantitative research questions from
this qualitative data. The nurse makes individualized plans with the health
team for both short and long-term needs. Dependency is recognized as an
important period in patient care, but one which the nurse seeks to shorten.
While Henderson did not explicitly recommend the use of the nursing
process, she argued that assessment of patient needs should involve nego-
tiation between nurse and patient. The only exception where the nurse is
justified to make decisions for the patient is when the latter is in a coma-
tose state or in extreme prostration. Henderson advocated an empathetic
approach to assessment where the nurse tries to understand the situation
from the patient’s point of view (Aggleton & Chalmers, 1986).
UP Open University
Module 2 35
Henderson’s theory and the nursing process

Let me now show how the nursing process is operationalized considering
Henderson’s model.
Assessment
The first step is to identify those basic needs that are not being met. Both
client and the nurse should reach an agreement regarding these. Then,
after arriving at a common decision regarding the primary concerns, the
nurse will now make an assessment regarding the possible cause of the
priority concern.
Planning
The long term goal for the client is for him/her to once more gain inde-
pendence with respect to the basic needs. Thus, short term and interme-
diate goals should be negotiated with the client in order to meet these
long term goals. Remember that goals should be realistic and measurable.
Those behaviors that may be observed and measured later in the process
should be identified in order to evaluate the success of nursing interven-
tions.
Implementation
Henderson’s model is not very explicit with regards to nursing interven-

tions. However, later theorists have suggested several ways of interven-
ing that may be appropriate with her model (Adam, 1980). These include:
1. Positively reinforcing the client

2. Completing tasks for him
3. Increasing the supply of factors that are needed for recovery to health.
4. Interventions like drugs and treatments prescribed by the physician
(should also be taken into consideration)
5. Factors that can limit achievement of independence like age, physical
and psychological factors
UP Open University
Evaluation
To use formative evaluation in Henderson’s theory, find out if the client

is able to meet basic needs without nursing assistance. For the unmet
needs, there is a need to re-examine the data base and plan. To carry out
summative evaluation, there is a need to determine the capability of
Henderson’s model in directing nursing care.
Figure 2-2 shows the components of the nursing process.
Assessment
With which of the 14 basic needs Implementation
does your client need Interventions aim to help client
assistance? meet 14 basic needs.
What has caused the lack of These interventions may include
independence in the fulfillment of drug administration and treatment
these needs? prescribed by the MD.
Evaluation
Formative – Is the client able to
meet basic needs without nursing
assistance? Planning
Summative – What are the Negotiate client-centered goals
strengths and limitations of which aim for a return of the client
Henderson’s model in directing to independence.
interventions?
Figure 2-2. Henderson’s components of the nursing process
UP Open University
Module 2 37
SAQ 2-3
I will now ask you to apply Henderson’s theory using the situation
below. Read the situation carefully then fill up the table in the next
page.
Maria Jose (MJ), a 54 year old market vendor, was admitted to the
hospital because of a non-healing wound on the sole of her left foot.
She claims that she sustained that wound after she accidentally
stepped on a thumb tack in their residence two weeks prior to con-
finement. She has never been hospitalized before. Based on the
history and initial laboratory examinations, the physician’s admit-
ting impression was adult onset or Type II diabetes mellitus with
cellulitis of the left foot. Further clinical work-up was ordered to con-
firm the diagnosis. Her vital signs on admission were: BP 140/90;
HR 88/min, regular; RR 24/min. Random blood sugar was 280 mg/
dl. She expressed great anxiety over her condition. Her sleeping and
eating patterns were affected by her hospitalization.
She claims she could not do her household chores, much less go to
market to buy and sell fruits and vegetables—her routine for the past
20 years. Her husband is a foreman in a construction firm. She has
two children aged 20 and 24 years and they were delivered by a
midwife in their home. Both sons are working students taking up
automechanic in a technical school near their place. They live in a
squatters’ area and are renting their small house which has one
small bedroom, kitchen and living room. Their source of water is the
MWSS. The series of test results confirmed the diagnosis of diabe-
tes mellitus, Type II or non-insulin dependent diabetes mellitus. The
physician ordered Antibiotics IV, Regular Insulin twice a day, wound
dressing twice a day.
UP Open University
SAQ 2-3 continued
Using Henderson’s theory, apply the nursing process in the care

of MJ.
Components of Data Base Description

the Nursing Process
Assessment
Planning
Implementation
Evaluation
The Orem Self-Care Deficit Theory of Nursing

Let us now discuss another theory belonging to the client-centered cate-

gory—Dorothea Orem’s Self-Care Deficit Nursing Theory. Orem is one of
the most influential nursing leaders and her self-care theory is widely
studied and used not only in nursing practice but also in education and
research. To give you a short introduction, I will first discuss her creden-
UP Open University
Module 2 39
tials and historical background as well as her influences in theory devel-

opment. Then I will discuss her major concepts and definitions, her major
assumptions, the key concepts of the theory, theoretical assertions,
strengths and limitations. Finally, I will present the applications of her
theory to nursing practice, research, education, and administration.
Historical perspectives
Dorothea Elizabeth Orem, born in Baltimore, Maryland and the younger
of two daughters, began her nursing career at Providence Hospital School
of Nursing in Washington, D.C. where she received a diploma certificate
of nursing in 1930. Then she pursued her education further and received
a BSN and MS in nursing education from the Catholic University of
America in 1939 and 1945, respectively.
She also had varied nursing experiences which included private duty
nursing, hospital staff nursing and teaching. She occupied important nurs-
ing positions, like the directorship of both the nursing school and the de-
partment of nursing at Providence Hospital, Detroit from 1940 to 1949.
She spent seven years at the Division of Hospital and Institutional Ser-
vices of the Indiana State Board of Health (1949-1957). It was during this
time that she developed her definition of nursing practice. Then she moved
to Washington D.C. where she was employed by the Office of Education,
U.S. Department of Health, Education and Welfare as a curriculum con-
sultant from 1958 to 1960. During this time, she became more aware of
deficiencies in the training of practical nurses so she worked on a project
to upgrade practical nursing. Consequently she published her book Guide-
lines for Developing Curricula for the Education of Practical Nurses.
Orem joined the Catholic University of America first as Assistant Profes-

sor, then later became Assistant Dean and Associate Professor of the School
of Nursing. She continued to develop her theory and later wrote “The
Hope of Nursing,” published in the Journal of Nursing Education (1962).
She was the leader of the Nursing Model Committee of the School of Nurs-
ing Faculty of the Catholic University of America whose task was to de-
velop a model that would express the foundations for, and characteristics
of, research in nursing. This committee developed, reviewed, and tested
several tentative generalizations about nursing and submitted its final re-
port to the School of Nursing in May 1968. She published her second
book, Nursing Concepts of Practice in 1971, after completing her work on
the Nursing Model Committee. Then she left the university and started
her own consulting firm called Orem and Shield’s Inc. at Chevy Chase,
Maryland. In 1976, Georgetown University conferred on her the honor-
ary degree of Doctor of Science.
UP Open University
The work began by the Nursing Model Committee was continued in 1968
by a group of 11 nurses with different backgrounds and areas of practice
who formed the Nursing Development Conference Group (NDCG). This
group was formed because of their dissatisfaction with the lack of an
organizing framework for nursing knowledge. They believed that a con-
cept of nursing would help develop that framework. They held a series of
meetings and developed an approach to the structuring of nursing know-
ledge within a nursing framework (model). The concept of nursing as
formalized by the NDCG was published in 1973 in Concept Formalization:
Process and Product. The text outlined the basic assumptions of the model
concerning nursing and self-care.
Orem received the Catholic University of America Alumni Association

Award for Nursing Theory in 1980. The second edition of Nursing: Con-
cept of Practice was published in 1980. Orem retired in 1984 but she con-
tinued to work on the third edition which was published in 1985. The
fourth edition of her book was completed in 1991. Orem continues to
work on the conceptual development of Self-Care Deficit Nursing Theory.
What were the theoretical sources of her theory?
Orem claimed that no particular nursing leader during her time directly
influenced her work, although she stated that her association with many
nurses over the years provided many learning experiences. She viewed
her work with graduate students, and collaborative work with her col-
leagues as valuable endeavors (Marriner-Tomey, 1994). However, she cited
many other nurses who had valuable contributions to nursing such as
Abdellah, Henderson, Johnson, King, Levine, Nightingale, Orlando,
Peplau, Riehl, Rogers, Roy, Travelbee and Wiedenbach. She also acknow-
ledged the contribution of authors from other disciplines: Gordon Allport,
Chester Barnard, Rene Dobus, Erich Fromm, Talcott Parsons, Hans Selye,
and Ludwig von Bertalanffy.
Major concepts
Are you now ready to find out what Orem has to say regarding the major
concepts of person, health, nursing, and environment?
Man/person/individual/client: An integrated whole
Orem viewed man as an integrated whole, a unity functioning biologi-

cally, symbolically and socially. Her theory emphasized societal influence
as a determinant of expectations for man’s behavior. This is reflected in
the man-environment interaction but is not clearly defined. She also des-
UP Open University
Module 2 41
cribed man as self-reliant and responsible for self-care and well-being of

his or her dependents. Self-care is a requisite for all. Man’s capacity to
reflect on his/her own experience and the environment, and his/her use
of symbols/ideas/words distinguish him/her from other species.
She further described man as a logical organism with rational powers. As

a biologic organism, man exists and responds both as organism and ob-
ject, in an environment with physical and biologic components. As a ra-
tionally functioning being, man formulates purposes about, and acts
upon self, others, and the environment.
In general, Orem described a patient as an individual who is in need of

assistance in meeting specific health-care demands because of lack of
knowledge, skills, motivation, or orientation. The individual (with subsets
of self-care agency and therapeutic self-care demand), requires nursing
because of some health-related self-care deficits. Orem’s definition of the
patient, from the nursing point of view, requires three conditions to be
satisfied:
1. There must be some self-care demand (universal, developmental or

health-deviation) to be met for another person. This means that when
a person can manage his own self-care, nursing assistance will not be
required. Take note that this is not always the case. There may be
cultural and social differences of opinion regarding whether assistance
is required or not.
2. The individual must be motivated to do some self-care activities, or

there must be an expectation that after suitable medical and nursing
interventions, the individual will be able to adapt some self-caring
behaviors.
3. A deficit relationship must exist between a person’s self-care demands

and his ability to meet those demands. In other words, the individual
is currently unable to meet self-care requisites.
Thus, an individual constantly acts to maintain a balance between his/

her ability to achieve self-care and the various demands that are made on
his/her self-care abilities.
Health: State of wholeness
Orem defined health as a state of wholeness or integrity of the individual

human being, his parts, and his modes of functioning. This implies that
the essence of health is the capacity to live as a human being within one’s
physical, biological, and social environment, achieving some measures of
UP Open University
the human life potential that contribute to the maintenance and promo-
tion of structural integrity, functioning and development. This concept is
inherent in her nursing systems since the goal in each system is optimal
wellness relative to that system.
Orem also viewed health as the responsibility of a total society and all
its members. The health-illness continuum—with “universal self-care”
and “health deviation self-care” defining the ends of the continuum—is
implied in Orem’s theory. Self-care is a deliberate action—the care which
all persons require each day. It is an adult’s personal, continuous contri-
bution to his/her own health and well-being. Orem identified primary,
secondary, and tertiary prevention as appropriate in nursing.
A healthy person is likely to have sufficient self-care abilities to meet these

universal self-care needs. Such situations can be represented by Figure
2-3. The use of balances to describe aspects of Orem’s theory has been
adapted from Aggleton and Chalmers (1986).
Universal
Self-Care
Self-Care
Abilities
Needs
Balance
Figure 2-3. A healthy individual
Nursing: A service, an art, and a technology
Orem viewed nursing as a community service, an art, and a technology.

According to her, a community is essentially a group of individuals and
families who share not only a common geographic area and environment,
but a common interest in the institutions that govern and regulate their
way of life (George, 1980).
To her, nursing is a service of deliberately selected and performed actions

to assist individuals or groups to maintain self-care, including structural
integrity, functioning, and development. It is the giving of direct assis-
tance to a person when he is unable to meet his own self-care needs.
Requirements for nursing are modified and eventually eliminated when
there is progressive favorable change in the state of health of the indi-
UP Open University
Module 2 43
vidual, or when he learns to be self-directing in daily self-care. She also

considered health service as an interpersonal process since it requires the
social interaction of a nurse with a patient and involves transaction
between them.
Orem defined the art of nursing as the ability to assist others in the de-
sign, provision, and management of systems of self-care to improve or to
maintain human functioning at some level of effectiveness. As an art,
nursing has an intellectual aspect—the discernment of obstacles to care,
and planning for what can be done to overcome them.
Orem stated that the art of nursing needs to include:
1. The art of helping

2. The method of helping
3. Helping techniques appropriate to situations
4. Nursing systems
Before the nurse can be a helper of an individual, she must be perceived

by the person as having the knowledge and ability to help. Orem identi-
fied five different methods of helping or assisting that nurses must be
aware of:
1. Acting for or doing for another

2. Guiding another
3. Supporting another
4. Providing an environment that promotes personal development in re-
lation to becoming able to meet present or future demands for action
5. Teaching another
The nurse must be able to select the method most appropriate to the par-
ticular situation.
Orem also described nursing as a technology. She stated: Nursing has

formalized methods or techniques of practice, clearly described ways of
performing specific actions so that some particular result will be achieved.
Techniques of nursing must be learned, and skill and expertness in their
use must be developed by persons who pursue nursing as a career.
These techniques include those concerned with:
1. Communicating with persons in states of health or disease

2. Bringing about and maintaining interpersonal, intragroup, and inter-
group relations for cooperative efforts
3. Giving human assistance adapted to specific human needs and limi-
tations
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4. Bringing about, maintaining, and controlling the position and move-

ments of persons in a physical environment for therapeutic purposes
5. Sustaining and maintaining life processes
6. Promoting processes of human growth and development
7. Appraising, changing, and controlling psychological modes of human
functioning in health and disease
8. Bringing about and maintaining therapeutic relations based on psy-
chosocial mode of human functioning in heath and disease
She also stated that although these techniques are used by the nurse, they
are not confined to nursing. The nurse (1) works directly with the needs
of the patient, in close relation to his total living situation; (2) provides for
direct need fulfillment—physiologic, interpersonal, and sociocultural—
insofar as the patient is incapable of self-care; and (3) functions on the
basis of a holistic philosophy in assessing the areas of need, identifying,
and utilizing resources for need fulfillment.
Nursing has as its special concern man’s need for self-care, and the provi-
sion and management of it on a continuous basis in order to sustain life
and health, recover from disease or injury, and cope with their effects
(Orem, 1971). It is a specific type of health-care service based on the val-
ues of self-help and helping others. The goal of health-care services is the
health and well-being of individuals, families and communities. Each health
care service has a particular role and a special focus on activities contrib-
uting to the achievement of this goal. The focus of nursing is to help the
individual achieve health results through therapeutic self-care activities.
Orem further described nursing as a way of overcoming human limita-
tions. Nursing developed because man is not self-sufficient.
One major conceptualization of nursing that Orem emphasized is that

nursing arises through a mandate from society which defines the scope,
limits, and credentials of nursing practice. Through the nursing process,
the nurse can select the nursing model appropriate to the patient
(Fitzpatrick, 1983).
Environment
Orem’s concept of environment encompasses elements external to man.

She considered man and environment as an integrated system. Environ-
mental conditions conducive to development include:
1. Opportunities to be helped by being with other persons or groups where

care is offered
2. Available opportunities for solitude and companionship
UP Open University
Module 2 45
3. Provision of help for personal and group concerns without limiting

individual decisions and personal pursuits
4. Shared respect, belief, and trust
5. Recognition and fostering of developmental potential
SAQ 2-4
Using the table below, indicate the major concepts of Orem’s Self-
Care Deficit Theory of Nursing
Orem’s Self-Care Deficit Theory of Nursing
Major Concepts Description
Person/patient/client
Health
Nursing
Environment
UP Open University
Underlying assumptions
Assumptions involving the concept of self-care include:
1. Self-care is a requirement of every person.

2. Universal self-care involves meeting basic human needs.
3. Health-deviation self-care is related to disease or injury.
4. Each adult has both the right and the responsibility to care for his/her
self in order to maintain rational life and health. He/she also has res-
ponsibilities to dependents.
5. Self-care is learned behavior processed by the ego and influenced by
both self-concept and level of maturity.
6. Self-care is deliberative action.
7. Awareness of relevant factors and their meaning is a prerequisite con-
dition for self-care action (Fitzpatrick and Whall, 1983).
Orem also identified five assumptions underlying the general theory of

nursing namely:
1. Human beings require continuous deliberate inputs to themselves and

their environment to remain alive and function in accord with natu-
ral human endowments.
2. Human agency—the power to act deliberately—is exercised in the form
of care for self and others, in identifying needs, and in providing needed
inputs.
3. Mature human beings experience privations in the form of limitations
in the care of self and others, resulting in the need for life-sustaining
and function-regulating inputs.
4. Human agency is exercised in discovering, developing, and transmit-
ting to others, measures to identify and meet caring needs.
5. Groups of human beings with structured relationships cluster tasks
and allocate responsibilities for providing care to group members who
experience privation.
Can you still recall Orem’s Assumptions? Answer SAQ 2-5 to find out.
UP Open University
Module 2 47
SAQ 2-5
Describe the underlying assumptions of Orem’s Self-Care Deficit
Theory of nursing.
What do you think of her assumptions? Do they jive with yours?
Key concepts of Orem’s theory and definitions

Orem labeled her Self-Care Deficit Theory of nursing as a general theory
composed of three related theories:
1. The theory of self-care (which describes and explains self-care)

2. The theory of self-care deficit (which describes and explains why
people can be helped through nursing), and
3. The theory of nursing systems (which describes and explains relation-
ships that must be brought about and maintained).
The key concepts of these theories will be now discussed, but if you’re
interested to know more about them, they are discussed more fully in
Orem’s book Nursing: Concepts of Practice. The concepts are summarized
in Table 2.1.
UP Open University
Table 2.1. Orem’s key concepts
Self-care requisites Self-care Nursing system
Universal self-care Demands Wholly compensatory

Developmental self-care Capabilities Partly compensatory
Health-deviation self-care Deficits Supportive-educative
Orem’s conceptual framework for nursing emphasized the relationships

of the theoretical concepts and the production of self-care. These concep-
tual elements were formalized and validated as early as the 70s but con-
tinuous development was undertaken to identify secondary concepts and
relationships. This framework emerged from Orem’s own work and that
of the Nursing Development Conference Group (Orem, 1991, p.65). Her
theory of nursing includes theory of (1) self-care, (2) theory of self-care
deficit, and (3) nursing system. The Self-Care Theory postulates that self-
care and care of dependents are learned behaviors that purposely regu-
late human structural integrity, functioning, and development. On the
other hand, the Nursing System Theory postulates that nursing systems
are formed when nurses prescribe, design, and provide nursing that regu-
lates the individual’s self-care capabilities and meets therapeutic self-care
requisites. Self-care agency is a learned ability and is a deliberate action.
Nursing agency regulates or develops patient’s self-care agency and abi-
lity to meet self-care demands. Figure 2-4 shows the relationships of the
theoretical concepts of Orem’s theory.
C
O
N
D F
I A
C
Self-care
T
I T
R R C
O O
N R O
I S R N
N D F
Self-care < Self-care I A
G
agency demands T C
I T
O O
Deficit R
C N
O I S
N N
D F R R G
I A
T C Nursing
I T agency
O O (R = stands for relationship)
N R
I S
N
G
Figure 2-4. Conceptual framework of Orem’s theory

(Adapted from Orem, D.E., 1991)
UP Open University
Module 2 49
Theory of self-care
This theory is basic to the understanding of the Self-Care Deficit Theory

and the Theory of the Nursing System.
The central idea of the theory states that within the context of day-to-day
living, mature and maturing persons perform learned actions and se-
quences of actions directed toward themselves or the environment. These
actions can control factors that either promote or adversely affect or
interfere with ongoing regulation of the person’s or group’s own func-
tioning or development in order to contribute to continuance of life, self-
maintenance, and personal health and well-being. They also perform such
regulatory actions for dependent family members or others (Orem, 1991).
Self-Care, according to Orem, means the practice of activities that indi-

viduals personally initiate and perform on their own behalf in maintain-
ing life, health, and well-being. It is a learned, goal-directed activity of the
individual or group. It is a behavior that exists in concrete life situations
focused on the self, group or the environment to regulate factors that
affect their development and functioning in the interest of life, health and
well-being. It is an adult’s personal, continuous contribution to his own
health and well-being.
Self-Care Requisites are expressions of purposes to be attained, or re-

sults desired from deliberate engagement in self-care. These are the rea-
sons for doing actions that constitute self-care. These are divided into three
categories:
1. Universal self-care requisites

2. Developmental self-care requisites
3. Health-deviation self-care requisites
Universal Self-Care Requisites are common to all human beings. These

include:
1. Sufficient intake of air

2. Sufficient intake of water
3. Sufficient intake of food
4. Satisfactory eliminative functions
5. Activity balanced with rest
6. Time spent alone, balanced with time spent with others
7. Prevention of danger to the self
8. Being normal
UP Open University
To Orem, these eight requisites represent the essential physical, psycho-

logical, social and spiritual elements of life. Each is important to human
functioning. They are the kind of human activities that bring about the
internal and external conditions that maintain human structure and func-
tioning, which in turn support human development and maturation.
Orem emphasized the interaction of these requisites and that they should
not be considered in isolation. When they are provided effectively, self-
care or dependent care organized around universal self-care requisites
will bring about positive health and well-being.
For the average healthy individual, self-care can be viewed in terms of

balancing several factors. On the one hand, there is the need to be self-
caring; universal self-care needs must be met. On the other hand, the
individual must have the ability to satisfy or meet the demands placed
upon him. Orem viewed universal self-care requisites as self-care demands
placed upon an individual which he/she should actively meet through
the use of abilities learned in an appropriate cultural context. Go back to
Figure 2-3 which illustrates where universal self-care requisites and self-
care abilities are balanced in a healthy individual.
Developmental Self-Care Requisites are either specialized expressions

of universal self-care requisites that have been particularized for develop-
mental processes, or they are new requisites derived from a condition like
pregnancy or an event such as loss of a parent. They promote processes
for life and maturation and prevent conditions deleterious to maturation
or mitigate those effects. These developmental self-care requisites are clas-
sified into two categories:
1. Conditions that support life processes and promote specific develop-

mental stages. These developmental stages include:
a. Intra-uterine life and birth

b. Neonatal life, whether born term or premature, with normal or
low birth weight
c. Infancy
d. Childhood, adolescence, and early adulthood
e. Adulthood
f. Pregnancy in either childhood or adulthood
2. Conditions affecting human development. There are two subtypes

under this category:
a. The first subtype concerns the provision of care to prevent occur-

rence of deleterious effects of these adverse conditions. An example
is the provision of adequate nutrition, rest and sleep during preg-
nancy.
UP Open University
Module 2 51
b. The second subtype concerns the provision of care to prevent or

overcome existing or potential deleterious effects of particular con-
ditions or life events. Examples include responses to specific life
events such as parenting, change in social or economic conditions.
The primary consideration is the provision of care to minimize the
adverse effects of certain conditions on human development. These
conditions include:
• Educational deprivation
• Problem of social adaptation
• The loss of relatives, friends or associates
• The loss of possessions or one’s job
• A sudden change in living conditions
• A change in status, either social or economic
• Poor health, poor living conditions or disability
• Terminal illness or expected death
• Environmental hazards (Orem, 1991; Cavanagh, 1991)
Any of the above conditions can place increased demands upon the
individual’s ability to manage his/her own self-care needs.
Health Deviation Self-Care Requisites. An individual with an illness,

disease or injury is likely to have additional demands for self-care. These
are not only specific to structures and physiological or psychological
mechanisms, but also to integrated human functioning. There are six cat-
egories of health-deviation self-care requisites, namely:
1. Seeking and securing appropriate medical assistance when exposed

to specific physical, biological agents, or environmental conditions as-
sociated with human pathological states or when there is evidence of
genetic, physiological or psychological conditions known to produce
human pathology
2. Being aware and attending to the effects and results of pathological

conditions and states including effects on development
3. Effectively carrying out medically prescribed diagnostic, therapeutic

and rehabilitative measures directed towards preventing specific types
of pathology, regulation of human integrated functioning, correction
of deformities, or compensating for disabilities
4. Being aware of, attending to, or regulating the discomforts or deleteri-

ous effects of medical care measures performed or prescribed by phy-
sicians, including their effects on development
UP Open University
5. Modifying self-concept to be able to accept one’s state of health or the

need for specific forms of health care
6. Learning to live with the effects of pathological conditions and states

and the effects of medical diagnosis and treatment measures, in a
lifestyle that promotes continued personal development (Cavanagh,
1991)
Take note too that the analysis of health-deviation self-care has shown
that in abnormal states of health, self-care requisites arise from both the
disease state and the measures used in the diagnosis and treatment.
Let me illustrate the categories of self-care by means of a diagram to help

you understand the concept.
Recall that in Figure 2-3, a healthy individual maintains a balance be-

tween self-care needs and abilities.
An individual who has an illness (disease or injury) is likely to have addi-

tional demands for self-care. However, if this person is able to meet these
additional demands for self-care beyond existing self-care abilities, then
overall balance is likely to be maintained and nursing will not be required.
This is illustrated in Figure 2-5.
Health
Reserve Universal
Self-care Deviation
Self-care Self-care
Abilities Self-care
Abilities Needs
Needs
Balance
Figure 2-5. An individual subject to disease, illness or injury
When Self-Care Demands exceed Self-Care Abilities because of a disease

or an injury, a Self-Care Deficit occurs and nursing will be required. Nurs-
ing actions seek to overcome self-care deficits to enhance or prevent loss
of self-care capacities, and to enhance care capabilities for significant and
dependent others. This is illustrated in Figure 2-6.
UP Open University
Module 2 53
Self-care
Abilities Reserve
Self-care
Health
Abilities
Deviation
Self-care Universal
Needs Self-care
Needs
Figure 2-6. An individual needing nursing interventions
According to Orem, the need for nursing arises from health-related expe-
riences. Usually, adults will not require nursing to meet their Universal
Self-Care Needs unless there are also Health-Deviation Self-Care needs
affecting them. When this happens, the individual will need a nurse who
will provide nursing interventions to restore a balance between Self-Care
Abilities and the demands made on them. This is illustrated in Figure 2-7.
Reserve Health
Universal
Self-care Nursing Deviation
Self-care Self-care
Abilities Abilities Interventions Self-care
Needs Needs
+ or -
Balance
Figure 2-7. An individual receiving nursing interventions
Therapeutic Self-Care Demand is a humanly constructed entity with an

objective basis in information that describes an individual structurally,
functionally and developmentally. It is based on the theory that self-care
is a human regulatory function which is derived from facts and theories
from the social and environmental sciences. It is essentially a pres-cription
for continuous self-care action that effectively meets identified self-care
requisites (Orem, 1991, p.124).
UP Open University
Self-Care Agency is defined as the complex acquired ability to meet one’s

continuing requirements for care that regulates life processes; maintains
or promotes integrity of human structure, functioning and development;
and promotes well-being (Orem, 1991 p.145).
An agent is a person taking action.
A self-care agent is the provider of “self-care”
A dependent self-care agent is “the provider of infant care, or depen-

dent adult care”.
Theory of self-care deficit
The theory of self-care deficit is the critical constituent of Orem’s theory.

It has its origin in the proper object of nursing: human beings who are
subject to health-derived or health-related limitations for engagement in
self-care or dependent care.
System is a set of objects, the relationships between these objects, and

their attributes. The objects constituting the system behave together as a
whole; changes in any part affect the whole.
The central idea of this theory states that all limitations of persons engag-
ing in practical nursing endeavors are associated with subjectivity of ma-
ture and maturing individuals to health-related or health-derived action
limitations. These limitations render them completely or partially unable
to know existent and emerging requisites for regulatory care for them-
selves or their dependents. These limitations also prevent them from
engaging in the continuing performance of care measures to control or in
some way manage factors that are regulatory of their own or their depen-
dents’ functioning and development (Orem, 1991, p.70).
Self-Care Deficit is the qualitative or quantitative inadequacy of the self-

care agency as related to therapeutic self-care demand. It exists when
therapeutic self-care demand cannot be met entirely by the self-care agent
(patient). The self-care deficit may be actual or potential. For example:
1. In the case of premature birth, the actual infant-care deficit may be

the parent’s lack of knowledge of how to provide physical care for the
preterm infant.
UP Open University
Module 2 55
2. The potential infant-care deficit could result in increased risk of infant

abuse or neglect.
Theory of nursing systems
According to Orem, the theory of nursing systems is the essential organiz-

ing component of the Self-Care Deficit Theory of Nursing because it
establishes the form of nursing and the relationship between patient and
nurse properties.
Nursing systems are the approaches nurses use to assist patients with
deficits in self-care due to a condition of health. The nursing system for a
particular patient in the Orem model may be wholly compensatory, partly
compensatory, or supportive-educative.
In a wholly compensatory system, the patient has no active role in the

performance of his care. The nurse acts for the patient (e.g., Patient is
unconscious or totally incapacitated).
In a partly compensatory system, both nurse and patient perform care

measures requiring manipulative tasks or ambulation. Distribution of re-
sponsibility for performance of care varies with the patient’s actual physi-
cal or medically prescribed limitations, scientific or technical knowledge
required, and the patient’s psychological readiness to perform, or to learn
to perform specific activities.
In a supportive-educative system, the patient is able to perform, or can

learn to perform, required measures of therapeutic self-care but cannot
do so without assistance. The nurse’s role in this system may be consulta-
tive only. These basic nursing systems are summarized in Table 2.2.
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Table 2.2. Basic nursing system
Type of Activity Agent

Nursing System
Wholly Compensatory Accomplishes patient’s therapeutic Nurse

self-care
Compensates for patient’s inability Nurse
to engage in self-care
Supports and protects patient Nurse
Partly Compensatory Performs some self-care measures Nurse

Compensates for self-care Nurse
limitations of patient.
Assist patient as required Nurse
Regulates self-care agency Nurse
Patient
Performs some self-care measures. Patient
Accepts care and assistance from Patient
nurse
Supportive-Educative Accomplishes self-care Patient

Regulates the exercise and Patient
development of self-care agency
Self-care action is the practical response of an individual to a demand to

attend to himself. The ability to perform self-care action reflects the
individual’s power of agency. To engage in self-care activities, the indi-
vidual must have the ability and skills to initiate and sustain self-care
efforts. The individual must also have the knowledge and understanding
of self-care practices and their relationship to health and disease. The
successful performance of self-care depends upon “the individual’s level
of maturity, depth of knowledge, life experiences, habits of thought and
body, as well as mental health state” (Orem, 1971).
For self-care to be therapeutic, it must help to sustain life processes, pro-

mote normal growth and development, and prevent or control disease
and disability and their effects.
Nursing Agency is a complex set of qualities of a person acquired through

specialized study and experiences in real-world nursing situations.
UP Open University
Module 2 57
Methods of assistance include:
1. Acting or doing for

2. Guiding
3. Teaching
4. Supporting
5. Providing a developmental environment
To find out how much you have retained from the discussion of Orem’s
theory please answer the following questions. You can also take a break
after answering this question. I’m sure your mind is complaining by now.
SAQ 2-6
Using the table below, describe the Key Concepts of Orem’s Theory.
Key Concepts Description
Therapeutic Self-Care Demand
Self-Care Agency
Nursing Agency
Nursing System
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Theoretical assertions
The major unifying force is the society that defines health, mandates agency
(at times a responsibility of the adult in the society and at times the
responsibility of nursing), spells out clearly under what conditions it is
acceptable to receive service (patiency), and the credentials and scope of
the practice of nursing. Nursing is responsible for the provision of a deve-
lopmental environment when self-care deficits warrant such experience.
This is shown in Figure 2-8 below.
Society
Mandates
existence and
condition for
Patient-Agency Agency
Individual person in the Nursing system
person-environment directed by:
system Nursing – Practice
– Education
– Research
Figure 2-8. Orem’s Self-Care Theory: Interrelationships among concepts
Orem’s theory shows that when an individual’s self-care capabilities are

less than the therapeutic self-care demand, the nurse compensates for the
self-care or dependent-care deficits. The diagram in Figure 2-9 shows the
relationships of the three related theories that comprise Orem’s Self-Care
Deficit Theory of Nursing which are categorized as the key concepts in
this module.
UP Open University
Module 2 59
Theory of Theory of Theory of

Nursing Self-Care Self-Care
System Deficit
Figure 2-9. The relationship of the key concepts in Orem’s

Self-Care Deficit Theory of Nursing.
Strengths and limitations

A primary strength of Orem’s theory is the incorporation of the major
premise of self-care for individuals at various levels of health. Although
the family, community and environment are considered in self-care
action, the focus is primarily on the individual. Normally, the individual
is capable of self-care but there may be situations where the balance
between self-care abilities and demand can not be maintained by the indi-
vidual. This is particularly so in times of disease or injury. In such situa-
tions, the nurse must intervene. However, in the nursing systems, the
focus of the partly and wholly compensatory systems seems to be on physi-
cal care, and to a lesser extent, on psychological care.
Another major strength of Orem’s theory is its advocacy for the use of the
nursing process. Orem specifically identified the steps of this process. She
also mentioned that the nursing process involves intellectual and practi-
cal phases, and implied that these phases have two separate and distinct
functions. However, Step III of the nursing process does not seem to
require intellectual thoughts but rather it is a performance of nursing tech-
niques. This could be a weakness of her theory (George, 1980).
Orem’s use of multiple terms to categorize self-care (therapeutic, practi-

cal, universal, health deviation) tends to confuse the learner. Confusion
may also result in the unclear definition of other concepts.
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Orem’s Self-Care Deficit Theory of Nursing is universal. It is a theory of

nursing that can be used regardless of time, place and individuals.
Another strength is that the assumptions used in the various theories are
logically sound and acceptable by the nursing community.
Her theory has pragmatic application to nursing practice. Some nursing

curricula are even based on the premises of self-care and even an inde-
pendent nurse practitioner can use Orem’s theory as a core of his/her
nursing practice.
Although Orem referred to her ideas as “concepts of practice,” taken

together, they form a a theory. Her framework meets two basic character-
istics of a theory:
1. Theories can interrelate concepts in such a way as to create a different

way of looking at a particular phenomenon. (The premise of self-care
is incorporated with nursing in the three broad systems of wholly com-
pensatory, partly compensatory and supportive-educative).
2. Theories can contribute to, and assist in, increasing the general body
of knowledge within the discipline. (Orem focused on nursing as a
helping art—assisting the individual to meet his self-care needs is the
foundation of nursing practice.)
Applications to nursing practice,

research and education
Orem’s theory has received worldwide acceptance and recognition not
only in nursing practice but also in nursing education and research.
Practice
Many articles document the use of Orem’s theory as a basis for clinical
practice in varied settings. As early as 1971, Lucille Kinlein established an
independent nurse practice in College Park Maryland, claiming that she
was stimulated by Orem’s theory. At Johns Hopkins Hospital in Balti-
more, the Self-Care Theory was used in several outpatient clinics. It was
later used in other outpatient clinics in the United States. Orem’s theory
was also applied in nursing homes. It was also applied by Virginia Mullin
within the acute care setting, although she recognized many constraints.
Later, it was translated in different languages and utilized worldwide
UP Open University
Module 2 61
The main object of nursing practice is the individual in a variety of

contexts. Orem included skilled observation as one of the guidelines for
nursing practice—observation not only of the patient but also of other
elements in the nursing situation. Likewise, Orem delineated the profes-
sional and technical levels of nursing practice. For the professionally edu-
cated nurse, emphasis is on the intellectual aspect of the art of nursing so
that she can learn to function effectively in nursing situations where the
patient’s requirements are more complex and where techniques for assist-
ing are not well developed. The technical level develops the intellectual
aspect in relation to nursing situations where selected assisting techniques
are known to have a high degree of effectiveness.
Education
Orem’s theory has been the focus of the curriculum in many schools of
nursing in the United States (Thornton Community College, South Hol-
land, Illinois; Georgetown University, Washington, DC; University of
Southern Mississippi at Hattiesburg; and Southern Missouri State at Spring-
field). It has also been used as a basis for continuing education courses
Orem’s theory provides considerable direction to nursing education. It

delineates many of the skills, techniques and methods which must be
learned to become a nurse practitioner. It also defines the basic system
within which the nurse practices, and the group of nursing diagnoses
which are used to select and design appropriate self-care actions within
the appropriate nursing system (Fizpatrick, 1980).
Research
Orem’s theory has also provided the conceptual framework for researches
done by several authors. It has served as a basis for the outcome criteria of
researches, and as a Likert scale questionnaire for clinical assessment. It is
used for the development of criteria to measure nursing practice in vari-
ous situations.
Orem’s work has been used most often with ill adults. However, it is not
exclusive for adults since Orem also defined the dependent care agent as
a provider of infant or child care. In this arena, there are different deve-
lopmental self-care requisites. She added a section on “age-specific”
factors in nursing children. The fourth edition of Nursing: Concepts of Prac-
tice expanded the self-care agency concept by expanding on the factors
influencing development of the individual’s ability for self-care.
UP Open University
Do you want to take a breather? I know you have been working hard on
this module. So take a few minutes’ rest. Try to close your eyes and ima-
gine a restful scene—perhaps lying on a beach, listening to the sounds of
the waves and watching some birds flying over the sea. How about that?
Orem’s Self-Care Deficit Theory of Nursing and the

nursing process
Orem emphasized that nursing is action. Ideas must be translated into a
form that can be utilized in practice. One way by which this can be
achieved is through the use of the nursing process. She viewed the nurs-
ing process as one requiring the nurses’ participation in interpersonal and
social processes and technologic-professional operations.
Interpersonal and social processes refer to the appropriate social and

interpersonal style you develop while working with your clients (patients
or their families). Particularly, you begin and maintain an effective rela-
tionship with them; you answer health-related questions; and continu-
ously collaborate with your clients and other health professionals in gath-
ering and reviewing information.
Technologic-professional operations are identified as diagnostic, pres-

criptive, treatment regulatory, and case-management operations. While
there may be an inherent sequence to these operations, care can be initi-
ated and evaluated even before all the assessment information has been
obtained. Orem considered these technological-professional operations as
milestones in the nursing process. She recognized that the performance of
these operations will depend on the client, his family, the nurse and other
factors.
Let’s now consider what Orem has to say regarding the nursing process.
Orem considered nursing and self-care as having both an intellectual and

a practical phase. In the nursing process, the determination of why a
patient requires assistance and the nurse’s judgments about how this help
can be given, are essentially intellectual activities. Now, when the nurse
performs assisting acts for the patient, nursing becomes essentially a prac-
tical activity.
Let us now look at the components of the nursing process.
UP Open University
Module 2 63
Assessment
The first component of the process of assessment aims to determine whether

or not a need for nursing intervention exists. Using Orem’s theory, your
first question would be—Is there a deficit between the individual’s self-
care abilities and his demands for self-care? Now, once the deficit has
been established and we know that nursing intervention is required, the
next question would be—Is the deficit due to: lack of knowledge? lack of
skill? lack of motivation to achieve self-care? or limited range of available
behavior?
Planning
Once the nurse has identified reasons for a patient’s self-care deficit, it is
now time to set client-centered goals and to plan for interventions. Long
term goals would most likely be the restoration of the balance between
self-care abilities and self-care needs. The extent to which nursing inter-
ventions will take place will depend on the extent to which self-care can
be undertaken by the patients, their families or significant others. You
may now decide on the category of nursing system you will use: whether
it is wholly compensatory, partly compensatory, or supportive-educative.
Nursing intervention
The aim of intervention is to help the patient maintain or re-establish self-

care. It means doing for or acting for another, guiding and directing, pro-
viding physical or psychological support, providing an environment which
supports development, or teaching another.
Evaluation
Formative evaluation is focused on the extent to which the balance bet-

ween self-care abilities and self-care demands has been maintained or re-
established. By setting client-centered goals, nurses put themselves in a
position to evaluate what the patient has achieved at the end of specified
periods of time, rather than whether or not nursing interventions have
been carried out.
UP Open University
Summative evaluation includes exploring the effectiveness of Orem’s

theory in organizing the delivery of care in a particular nursing specialty.
These various components are summarized in Figure 2-10.
Assessm ent
Is there a deficit between the
client’s self-care abilities and
the demands for self-care?
Is the deficit due to: lack of Planning
knowledge; lack of skill; lack Set goals to achieve or m aintain
of motivation; or limited range self-care. Plan interventions to be:
of available behavior? 1. W holly compensatory
2. Partly compensatory
3. Supportive-educative
Evaluation Im plem entation

Formative – Has the client Intervention m ay be:
been able to re-establish 1. Doing for or acting for another
self-care? 2. Guiding or directing
Summ ative – How effective 3. Providing physical support
is Orem’s Self-Care M odel 4. Providing psychological
in organizing the delivery of support
self-care in a particular 5. Providing an environm ent that
nursing specialty? supports development
6. Teaching another
Figure 2-10. Orem’s model and the nursing process
UP Open University
Module 2 65
SAQ 2-7
Apply Orem’s theory in the case of MJ in the situation presented
earlier in SAQ 2-3. Use the table for your answers.
Components of the Description

Nursing Process
Assessment
Planning
Implementation
Evaluation
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SAQ 2-8
Now I’d like you to compare the two theories we discussed. What
commonalities can you identify between Henderson’s theory and
Orem’s theory?
Pender’s Health Promotion Model

Cora A. Añonuevo
Just like Orem, Nola J. Pender believed in the ability of the person to care
for his/her own self. But while Orem’s Theory of Self-Care can be sub-
stantially applied to people with acute or chronic conditions, Pender’s
model is more useful in enhancing prevention and promoting well-being.
You will note that Pender did not directly relate her conceptual frame-
work with the major concepts of person, health, nursing and environ-
ment. The format of discussion that we will follow is therefore a little bit
different from the rest of the modules in Unit I.
I will now discuss with you Pender’s conceptual framework. You will see
that it is very useful in terms of health promotion. The development of her
model was very much influenced by her education, personal experiences,
and life events. Her parents were strong supporters of education for women.
Her husband and children motivated her to learn more about optimizing
health. Theoretically, her model was influenced by Bandura’s Social Learn-
ing Theory (which emphasized the importance of cognitive processes in
behavior change) and by Fishbein’s Theory of Reasoned Action (which is
focused on behavior as a function of personal attitudes and social norms).
UP Open University
Module 2 67
What the model is all about

Pender’s model consists of two main domains—cognitive-perceptual
factors and modifying factors—that explain participation in health-pro-
moting behaviors in the presence of a cue to action.
Before I pursue the discussion of the model, it is important that we have a

clear understanding of the concept of health promotion. The term health
promotion elicits different interpretations and is often used interchange-
ably with health protection or disease prevention (Hartweg, 1990).
Major concepts and definitions

Pender provided the following definitions:
Health promotion is directed towards increasing the level of well-being

and self-actualization of a given individual or group. Health-promoting
behaviors increase self-awareness, self-satisfaction, enjoyment and plea-
sure (Hartweg, 1990). Pender clarified that some degree of well-being and
self-actualization may already present.
Health-promoting behaviors are continuing self-care activities that must

be an integral part of an individual’s lifestyle. These include physical ex-
ercise, proper nutrition, and stress management.
Disease Prevention or Health Protection refer to activities directed

towards decreasing the probability of experiencing illness by active pro-
tection of the body against pathological stressors. These also involve
detection of illness in the asymptomatic stage.
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SAQ 2-9
Below are some health activities that differentiate health promo-
tion from heath protection. Mark those pertaining to health pro-
motion with a check (P). Mark those pertaining to health protec-
tion or disease prevention with an (X).
_____ 1. Maintaining six to eight hours of sleep daily

_____ 2. Meal planning using the three basic food groups
_____ 3. Insulin injection for IDDM patients
_____ 4. Dental fluoridation
_____ 5. BCG vaccination for infants
_____ 6. Engaging in progressive muscle relaxation, music
therapy and imagery as stress management
Check at the end of the module whether your answers are the
same as mine.
The Health Promotion Model
Now refer to Figure 2-11 on the next page. The focus of my discussion will
be on the determinants of health-promoting behavior and their relation-
ships.
UP Open University
Module 2 69
Cognitive-Perceptual Modifying Factors Participation in

Factors Health-Promoting
Behavior
Demographic
Importance of health
characteristics
Perceived control Biologic

of health characteristics
Perceived Interpersonal
self-efficacy influences
Definition of health Situational factors

Likelihood of
engaging in health-
Perceived health promoting behaviors
Behavioral factors
status
Perceived barriers to Cues to action

health-promoting
behaviors
Figure 2-11. Health promotion model

(Source: Pender, N.J. (1987), p. 58.)
Cognitive-perceptual factors
Pender (1987) refered to the cognitive-perceptual factors within the model

as the primary motivational mechanisms for acquisition and maintenance
of health-promoting behaviors. Let us discuss briefly each factor and how
it impacts on health promotion.
Importance of Health. Individuals who place high value on health are

more likely to seek it. This was revealed by a study conducted by Wallston,
Maides and Wallston (cited by Pender, 1987). Pender opined, however,
that the role of values in motivating and directing health-promoting be-
havior needs further study.
Perceived Control of Health. The individual’s perception of his/her own

ability to improve his/her health status can motivate the desire to attain
optimum health. An example cited was a study in weight-loss conducted
by Wallston et al. (Pender, 1987). Success in weight-loss programs was
UP Open University
determined by each person’s locus of control, either internal or external.

Externally-controlled persons achieved greater weight loss in a group
program compared to internally-controlled persons because of “peer pres-
sure.” On the other hand, internally-controlled persons achieved greater
weight reduction than externally-controlled persons in a self-directed
program. Thus, perceived control of health seems to influence the effec-
tiveness of strategies employed for facilitating continued practice of health-
promoting behaviors.
Perceived Self-Efficacy. This refers to the individual’s conviction that

they can successfully execute the required behavior necessary to produce
a desired outcome. Clemente et al. (cited by Pender, 1987) made a study
on maintenance of smoking cessation. It was found that when beset with
difficulty, people who have serious doubts about their capabilities often
exert less effort in giving up smoking.
Definition of Health. The definition of health to which individuals

subscribe may influence the extent to which they engage in health-
promoting behaviors. Individuals who define health as adaptation or sta-
bility are inclined to manifest health-protecting behaviors directed toward
avoiding illness. On the other hand, those who define health primarily as
self-actualization are more likely to perform self-initiated activities to
attain higher levels of health and well-being.
Perceived Health Status. Experiences of increased well-being and im-

proved health status can be used to reinforce the value of good health and
promote more extensive changes in lifestyle. Kaplan and Comles (cited by
Pender, 1987) suggested this approach to smoking cessation—individuals
will engage first in activities such as relaxation and exercise that would
result in noticeable changes in well-being as initial steps on the pathway
leading to complete cessation of smoking.
Perceived Benefits of Health-Promoting Behaviors. Individuals may be

more inclined to begin or continue health-promoting behaviors if the ben-
efit for such behaviors are considered high. For example, a study con-
ducted by Brunner involving those who participated in a physical activity
program revealed that the perception of long-term benefits (keeping physi-
cally fit) rather then short-term benefits (relaxation at the end of the day)
may determine frequency of participation and predisposition to continue
health-enhancing behaviors (Pender, 1987).
Perceived Barriers to Health. The individual’s belief that an activity or

behavior is difficult or unavailable may influence his/her intention to en-
gage in it. Examples of these barriers (real or imagined) are: distance from
an exercise facility; perceived available time; and nature of activity as
being too strenuous for the person.
UP Open University
Module 2 71
In brief, the factors discussed above dealt with the issues of motivation—
the first step toward action.
SAQ 2-10
1. What do health-promoting behaviors refer to? How is Pender’s
concept of health-promoting behavior similar to Orem’s no-
tion of self-care activity?
2. Which among the cognitive-perceptual factors do you find as

having direct influence on the person’s health-promoting be-
haviors? Why?
You may refer to my suggested answers at the back of this module.
Modifying factors
To continue with Pender’s Health Promotion Model, I will now dwell on

the modifying factors which indirectly influence an individual’s behav-
ior. The factors identified by Pender are:
Demographic Factors. Characteristics such as age, sex, race, ethnicity,

education, and income affect cognitive-perceptual mechanisms. For ex-
ample, studies show that the more frequent users of preventive services
are women rather than men; the highly educated rather than the less well
educated; high-income rather than low-income individuals.
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Biological Characteristics. Body weight was found to be a significant pre-

dictor of intention to engage in exercise. This was revealed by a study
done by Pender and Pender (1987) which showed that the higher the
total body weight, the lower the intention to exercise regularly.
Interpersonal Influences. These include expectations of significant oth-

ers, family patterns of health care, and interactions with health profes-
sionals. By showing how parent-to-child health education is better than
child-to-child education, schools were able to influence family members
to participate in modifying health behaviors.
Situational and Environmental Factors. These include health-promoting

options or alternatives that, whenever available and accessible, increase
the opportunity of the individual to make responsible choices. For
example, a sari-sari (variety) store which sells lots of junk food gives little
option for neighborhood children to buy and eat nutritious snacks.
Behavioral Factors. Knowledge and skills acquired in the past can facili-
tate the implementation of health-promoting behaviors such as preparing
nutritious meals, meditation and relaxation, and maintaining an exercise
program.
Look again at Figure 2-11. You will note that there is a box which refers to
cues to action. These cues can be internal in origin or they may come from
the external environment. Examples of internal cues are: one’s satisfac-
tion after a physical activity, or appreciation of the benefits of stress man-
agement programs. Examples of external cues are: mass media, and con-
versations with others on health matters. Pender (1987) stated that the
intensity of the cues required to trigger action depends on the level of
readiness of the individual or group to engage in a health-promoting
activity.
UP Open University
Module 2 73
SAQ 2-11
Supposing you are a nurse practitioner applying Pender’s model.
Think of a health-promoting behavior that you would like more
people to do.
1. Which population sector/group would you work with? Why

would you choose this sector/group?
2. Which of the factors/determinants of health-promoting behav-

iors would you focus on for this particular group?

I think you’ll agree with me that the Health Promotion Model is easy to
understand. Although the focus of the model is the individual person, it
can be applied to families and communities.
The model has been developed by researchers into a body of knowledge

which can be tested further. As a tool for research, the model has been
widely used for individual assessment of the factors believed to influence
health behavior changes. However, the interactions or relationships among
the various factors in each set need further clarification.
UP Open University
Summary
Henderson’s definition of nursing was a valuable contribution to the pro-
fession. It emphasized a value system that had an impact on practice,
education and research. Its strength lies in the use of a deliberative
approach in the delivery of care and a view of the person as a complex
bio-psychosocial being. There are some limitations that have been identi-
fied: her model has the potential to encompass the whole person; how-
ever, it is limited primarily to physiological parameters. But, with the
emergence of the concept of holistic approach she has since stated her
belief in holism. Another limitation is the manner on how the nurse will
assist the individual in the dying process. There is little explanation as to
what the nurse can do in this area.
Orem’s Self-Care Deficit Theory of nursing consists of three theoretical

constructs: self-care, self-care deficit, and nursing systems. The Self-Care
Theory construct is divided into three self-care requisites: universal self-
care, developmental self-care, and health deviation self-care. The Self-
Care Deficit Theory is the core of Orem’s general theory of nursing since it
identifies when nursing is needed. The Nursing Systems Theory is divided
into wholly compensatory, partly compensatory and supportive-educa-
tive nursing systems. Her construct of self-care has some similarities with
Henderson’s general concept of nursing.
Orem’s theory has been used and validated in many situations and condi-
tions. It has also been used to generate research hypotheses. Her theory
has been found to have high consistency and pragmatic adequacy for
nursing practice.
The Health Promotion Model, considered middle range in scope, offers an

explanation of why individuals engage in health actions. The cognitive-
perceptual behaviors include: importance of health, perceived control of
health, perceived efficacy, definition of health, perceived health status,
perceived benefits, and perceived barriers to health-promoting behaviors.
Modifying factors in the model include demographic, biological, behav-
ioral, situational, and interpersonal influences. These two groups of fac-
tors are important to consider in helping a person decide whether or not
to engage in health promotion behaviors.
UP Open University
Module 2 75

ASAQ 2-1
Henderson’s definitions of nursing
Person/Patient/Client An individual person or client is a whole, complete

and independent being with biological, sociological,
and spiritual components which are operationalized
in the 14 fundamental or basic human needs,
namely: breathe normally; eat and drink adequately;
eliminate body wastes; move and maintain
desirable position; sleep and rest; select suitable
clothes—dress and undress; maintain body
temperature within normal range by adjusting
clothing and modifying the environment; keep the
body clean and well groomed and protect the
integument; avoid dangers in the environment
and avoid injuring others; communicate with
others expressing emotions, needs, fears, or
opinions; worship according to one’s faith; work in
such a way that there is a sense of accomplish-
ment; play or participate in various forms of
recreation; learn, discover, or satisfy the
curiosity that leads to normal development
and health, and use available health facilities.
The person must maintain physiological and

emotional balance: the mind and body are
inseparable.
The patient is an individual who requires

assistance to achieve health and independence
or peaceful death. The patient and his family
are viewed as a unit.
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ASAQ 2-1 continued...
Health Health is equated with independence.

Individuals will achieve or maintain health if they
have the necessary strength, will or knowledge.
Health is viewed in terms of the patient’s ability
to independently perform the 14 basic needs.
It is the “quality of health rather than life itself, that

margin of mental physical vigor that allows a person
to work most effectively and to reach his highest
potential level of satisfaction in life.” She described
health as basic to human functioning and that
promotion of health is more important than
care of the sick.
Nursing Nursing is assisting the individual, sick or well, in the

performance of those activities contributing to health
or its recovery (or to a peaceful death) so that he
would perform unaided if he had the necessary
strength, will or knowledge; and to do this in such
a way as to help him gain independence as rapidly
as possible.
Environment Environment is “the aggregate of all the external

conditions and influences affecting the life and
development of an organism.”
Henderson listed 7 essentials in the environment:

light, temperature, air movement, atmospheric
pressure, appropriate disposal of waste, minimal
quantities of injurious chemicals, and cleanliness
of surfaces and furnishings coming in contact
with the individual. She also stated that the
environment can act either positively or negatively
upon the patient. Therefore the nurses’ function is
to alter the environment in such a way as to
support the patient.
Well how did you fare? If you got them all, Congratulations! You deserve
a pat on the back. Carry on.
UP Open University
Module 2 77
If you didn’t get them all, don’t get frustrated. Sometimes it takes time to
get all these concepts into our heads. I suggest that you read the text
again and concentrate.
ASAQ 2-2
Nursing is to assist the individual, sick or well, in the performance of
those activities contributing to health or its recovery (or to a peaceful death)
so that he can perform unaided if he had the necessary strength, will or
knowledge; and to do this in such a way as to help him gain indepen-
dence as rapidly as possible. The goal of nursing is independence in the
satisfaction of the human being’s 14 fundamental or basic needs. The role
of the nurse is a complementary-supplementary role to maintain or re-
store independence in the satisfaction of the client’s 14 fundamental or
basic needs. In a client-centered model, the source of difficulty resides
with the client and not with the nurse. To Henderson, the source of diffi-
culty is the lack of strength, will or knowledge of the client. Interventions
can include actions to replace, complete, substitute, add, reinforce, or
increase strength, will or knowledge. Consequences of nursing actions
include increased independence in the satisfaction of the client’s 14 fun-
damental or basic needs or peaceful death.
How were your answers? If you got them all right, you deserve to reward
yourself. How about watching your favorite TV show? Go on, you de-
serve it.
If you didn’t get them all, don’t despair. Go over the text again and see
what you failed to understand. Concentrate on those parts that you found
difficult to understand.
UP Open University
ASAQ 2-3
Components of Data Base Description

the Nursing Process
Assessment Random blood sugar was 220 mg/dl.

She expressed great anxiety over her condition.
Her sleeping and eating patterns were affected
by her present condition and hospitalization.
She claims she could not do her household
chores, much less go to market to buy and sell
fruits and vegetables—her routine for the last
20 years.
Planning Short term goals: Blood sugar will normalize

Wound will heal
Long term goals: Will resume independence in
doing activities of daily living
Learn to manage her diabetes
Implementation Give Antibiotics IV, Regular Insulin twice a day,

wound dressing twice a day
Provide supportive care regarding the 14 basic
needs
Evaluation Formative: MJ will be able to provide the basic

needs without assistance
How did you fare? If you got them all, you deserve to treat yourself. I’m so
glad you can keep up with the discussion.
If you missed some of the correct answers, it’s okay. Read the text again
and find the problem areas.
UP Open University
Module 2 79
ASAQ 2-4
Orem’s Self-Care Deficit Theory of Nursing
Person/Patient/Client Orem viewed man as an integrated whole—

a unity functioning biologically, symbolically
and socially.
She also described man as self-reliant and
responsible for self-care and well-being of his or
her dependents. Self-care is a requisite for all.
She considered man’s capacity to reflect on his/her
own experience and the environment and his/her
use of symbols/ideas/words that distinguished
him/her from other species.
She saw man as a logical organism with rational
powers.
Orem described a patient as an individual who
is in need of assistance in meeting specific
health-care demands because of lack of knowledge,
skills, motivation, or orientation.
Health Orem defined health as a state of wholeness or

integrity of the individual human being, his parts,
and his modes of functioning. This concept is
inherent in her nursing systems since the goal
in each system is optimal wellness relative to
that system.
Orem also viewed health as the responsibility
of a total society and all its members.
A healthy person is likely to have sufficient self-care
abilities to meet his/her universal self-care needs.
UP Open University
ASAQ 2-4 continued
Nursing Orem viewed nursing as a community service,

an art, and a technology.
To her, nursing is a service of deliberately selected
and performed actions to assist individuals or
groups to maintain self-care, including structural
integrity, functioning, and development. It is the
giving of direct assistance to a person when he
is unable to meet his own self-care needs.
Requirements for nursing are modified and
eventually eliminated when there is progressive
favorable change in the state of health of the
individual, or when he learns to be self-directing
daily self-care. She also considered health
service as an interpersonal process since it
requires the social interaction of a nurse with a
patient and involves transaction between them.
Orem defined the art of nursing as the ability

to assist others in the design, provision, and
management of systems of self-care to improve
or maintain human functioning at some level of
effectiveness. As an art, nursing has an intellectual
aspect—the discernment of obstacles to care and
planning how these obstacles can be overcome.
Orem also described nursing as a technology. She

stated: Nursing has formalized methods or
techniques of practice, clearly described ways of
performing specific actions so that some particular
result will be achieved. Techniques of nursing must
be learned, and skill and expertness in their use
must be developed by persons who pursue
nursing as a career.
To Orem, nursing arises through a mandate from

society which defines the scope, limits, and
credentials of nursing practice (agency). Through
the nursing process, the nurse can select the
nursing model appropriate to the patient.
UP Open University
Module 2 81
ASAQ 2-4 continued
Environment Orem’s concept of environment encompassed the

elements external to man. But she consdered man
and environment as an integrated system related
to self-care. Environmental conditions conducive
to development include opportunities to be helped:
being with other persons or groups where care
is offered; opportunities for solitude and
companionship; provision of help for personal and
group concerns without limiting individual
decisions and personal pursuits; shared respect,
belief, and trust; recognition and fostering of
developmental potential.
Well how were your answers? If you got them all, congratulations! See, it
pays to study and understand your lessons very well.
If you didn’t get them all, don’t worry. Take your time to read the text
again and really understand the discussion. Then try to answer it again.
I’m confident you’ll get them all right the next time.
ASAQ 2-5
Assumptions involving the concept of self-care include:
1. Self-care is a requirement of every person.

2. Universal self-care involves meeting basic human needs.
3. Health-deviation self-care is related to disease or injury.
4. Each adult has both the right and the responsibility to care for him/
herself in order to maintain rational life and health; he/she may also
have responsibilities for dependents.
5. Self-care is learned behavior processed by the ego and influenced by
both self-concept and level of maturity.
6. Self-care is deliberative action.
7. Awareness of relevant factors and their meaning is a prerequisite con-
dition for self-care action
UP Open University
Orem also identified five assumptions underlying the general theory of

nursing, namely:
1. Human beings require continuous deliberate inputs to themselves and

their environment to remain alive and function in accordance with
natural human endowments.
2. Human agency, the power to act deliberately, is exercised in the form

of care of self and others—identifying needs and making needed in-
puts.
3. Mature human beings experience privations in the form of limitations

for action in care of self and others involving the making of life-sus-
taining and function-regulating inputs.
4. Human agency is exercised in discovering, developing, and transmit-

ting to others, the ability to identify needs and make inputs to self and
others.
5. Groups of human beings with structured relationships tend to cluster

tasks and allocate responsibilities. These include responsibilities for
providing care to group members who experience privation. The group
can require deliberate input to self and others.
Did you get them all? That’s good. For this, you deserve a thunderous
applause. Carry on.
If you didn’t get them all, don’t feel bad. My advice is go back and read
the text. If you feel that you need to read other books, then do so. It pays
to gather a lot of ideas to understand the concept.
UP Open University
Module 2 83
ASAQ 2-6
Key Concepts of Orem’s Theory
Self-Care Self-care means the practice of activities that

individuals personally initiate and perform on their own
behalf in maintaining life, health, and well-being. It is a
learned, goal-directed activity of individual or groups. It is
a behavior that exists in concrete life situations focused
on the self, group or the environment to regulate factors
that affect their development and functioning in the
interest of life, health and well-being.
Self-care requisites are expressions of purposes to be
attained, and results desired from deliberate engagement
in self-care. They are the reasons for doing actions that
constitute self-care. They are divided into three
categories:
1. Universal self-care requisites
2. Developmental self-care requisites
3. Health-deviation self-care requisites
Therapeutic Therapeutic Self-Care Demand—is a humanly

Self-Care constructed entity, with an objective basis in information
Demand that describes an individual structurally, functionally, and
developmentally. It is based on the theory that self-care
is a human regulatory function. It is also based on facts
and theories from the social and environmental sciences.
It is essentially a prescription for continuous self-care
action through which identified self-care requisites can
be met with stipulated degrees of effectiveness.
Self-Care Self-Care Agency is “the complex acquired ability to

Agency meet one’s continuing requirements for care that
regulates life processes, maintains or promotes integrity
of human structure, functioning and development, and
promotes well-being.”
UP Open University
ASAQ 2-6 continued
Key Concepts of Orem’s Theory
Self-Care The central idea of this theory states that all limitations
of persons engaging in practical nursing endeavors are
associated with subjectivity of mature and maturing
individuals to health-related or health-derived action
limitations. These limitations render them completely or
partially unable to know existent and emerging
requisites for regulatory care for themselves or their
dependents. These also prevent them from engaging in
the continuing performance of care measures to control
or in some way manage factors that are regulatory of
their own or their dependents’ functioning and
development.
Self-Care Deficit is the qualitative or quantitative
inadequacy of the self-care agency as related to
therapeutic self-care demand. It exists when therapeutic
self-care demand cannot be met entirely by the
self-care agent (patient). The self-care deficit may be
actual or potential.
Nursing Agency This refers to complex property or attribute of persons

educated and trained as nurses. It is enabling when
exercised for knowing and helping others know their
therapeutic self-care demands; for meeting or helping
others meet their therapeutic self-care demands; and
for helping others regulate or develop their self-care
agency or dependent care agency.
Nursing Systems The theory of nursing system is the essential

organizing component of the self-care deficit theory of
nursing because it establishes the form of nursing and
the relationship between patient and nurse properties.
Nursing systems are the approaches nurses use to
assist patients with deficits in self-care due to a
condition of health. The nursing system for a particular
patient in Orem’s model may be wholly compensatory,
partly compensatory, or supportive-educative.
Well, how was it? Did you get them all again? Now, I’m impressed.
You didn’t get them all? It’s all right. Go back to the text and see where
you failed. Correcting your mistakes early is a good practice. In that way,
you learn better.
UP Open University
Module 2 85
ASAQ 2-7
Application of Orem’s Theory in M.J.’s Case

Nursing Process
Assessment Is there a deficit between the individual’s self-care

abilities and the demands for self-care?
Data base:
1. Non-healing wound on the sole of left foot
2. Diagnosis of Type II DM with cellulitis left
foot
3. Vital signs - BP 140/90; HR 88/min.,
RR 24/min., RBS 220 mg/dl
4. Expressed great anxiety over her condition
5. Could not do her household chores and
sell fruits and vegetables
Based on the above data base, a self-care deficit
has been established.
Is the deficit due to: lack of knowledge? lack of
skill? lack of motivation to achieve self-care? or
limited range of available behavior?
The cause of the deficit is impaired physical
mobility because of the non-healing wound on the
left foot; lack of knowledge and skills on what to
do with this wound.
Planning Formulate client-centered goals and intervention

plans.
The long term goal is to restore the balance
between self-care abilities and needs through
health education regarding diabetes management.
Initially, what M.J. needs is a partly compensatory
nursing system. Family members should also
be involved in her care.
The extent to which nursing interventions will take
place will depend on the extent to which self-care
can be undertaken by M.J. and her family.
UP Open University
ASAQ 2-7 continued

Nursing Process
Implementation The aim of the intervention is to help the patient

maintain or re-establish self-care.
Interventions include:
1. explaining the need for wound dressing and
doing the procedure for her
2. then later guiding her as she participates in
wound dressing
3. providing physical and psychological
support to both M.J. and her family
4. providing environmental restructuring to
support development
Evaluation Orem’s theory clearly emphasized a

commitment to the value of self-care. Formative
evaluation focuses on the extent to which the
balance of self-care abilities and self-care
demands has been maintained or re-established.
By setting client-centered goals, nurses put
themselves in a position to evaluate what the
patient has achieved at the end of specified
periods of time. These include:
1. monitoring changes in her vital signs, blood
sugar level
2. observing for:
a. progress of wound healing
b. client’s response to the treatment
c. coping with diabetes mellitus
d. M.J.’s progress in maintaining the
balance between self-care abilities and
her needs.
Summative evaluation using Orem’s theory
includes exploring the effectiveness of the theory
in organizing the delivery of care in a particular
nursing specialty. This may not be possible
at this time.
Were you able to answer the SAQ correctly? Congratulations! Keep up

the good work.
UP Open University
Module 2 87
ASAQ 2-8
Orem’s and Henderson’s theories appear to be closely related.
1. Both focus primarily on the individual.

2. Both emphasize assisting the individual with activities that he/she
cannot do for himself or herself. This includes assisting the individual
toward independence from nursing or assistance toward a peaceful
death.
How were your answers? Were your answers similar to mine?
If you got 50% of the answers, it’s okay. If it would help you, why not
discuss this with your peers and colleagues?
ASAQ 2-9
Numbers 1, 2 and 6 are health promotive activities while numbers 3, 4
and 5 are health protective/disease preventive activities.
To clarify further, health promotion:

1. is not disease– or health problem–specific
2. is an “approach” behavior
3. seeks to expand positive potential for health
On the other hand, health prevention/protection:

1. is disease-specific
2. is an “avoidance” behavior
3. seeks to thwart the occurrence of pathogenic insults to health and
well-being
ASAQ 2-10
1. Pender described health-promoting behaviors as continuing activities
that must be an integral part of an individual’s lifestyle. These are
activities that are purposefully done to increase an individual’s level
of well-being. These views are akin to Orem’s concept of self-care ac-
tivity where self-care is defined as “activities that individuals initiate
and perform on their own behalf.” Orem also emphasized one’s ac-
tive role in maintaining a healthy lifestyle.
UP Open University
2. I have encountered smokers who somehow tried to stop smoking but

they were unsuccessful even if they believed smoking was dangerous
to their health. The problem was related to perceived self-efficiency.
When they ceased smoking, they thought they could not work well or
their output was low. They claimed that they could not effectively
give up smoking because they would be ineffective in the workplace.
Are your answers similar to mine? I congratulate you. If they are very
different, please read the text again to find out why you answered the
way you did.
ASAQ 2-11
Here’s my answer:
1. I will work with children and the youth sector. Nowadays, they live
in an environment that encourages risk-taking behaviors through the
mass media, advertising, peer pressure, poor role models, among oth-
ers. Burns (1996) states that teaching and modeling healthy b ehaviors
will help children learn to promote their own health. Furthermore,
since many health problems are carried into adulthood, working with
children has long-term effects on the whole population. As they say,
healthy children produce healthy adults.
2. I think educating children will have to start with teaching them the
value of health. We assist in shaping health attitudes, beliefs and hab-
its early in life. Hence, we shape one’s definition of health by empha-
sizing on daily activities that promote health such as personal
hygiene, exercise and choosing the right food.
UP Open University
Module 2 89
References
Aggleton, P. and Chalmers, H. (1986). Nursing models and the nursing pro-
cess. London: The Macmillan Press Ltd.
Burns, C.E. et al. (1996). Pediatric primary care—A handbook for nurse prac-
titioners. Philadelphia: WB Saunders Co.
Cavanagh, S.J. (1991). Orem’s model in action. London: The Macmillan
Press Ltd.
Christensen, P. and Kenney, J.W. (1990). Nursing process application of
conceptual models. 3rd Edition. St. Louis: C.V. Mosby Company.
Fitzpatrick, J. and Whall, A. (1983). Conceptual models of nursing analysis
and application. Maryland: Prentice-Hall Publishing and Communica-
tions Company.
George, J.B. (1980). Nursing theories: The base for professional nursing prac-
tice. Englewood Cliffs, New Jersey: Prentice-Hall Inc.
Hartweg, D.L. (1990). “Health promotion self-care within Orem’s theory
of nursing.” Journal of Advanced Nursing, 15 (1), 35-41.
Henderson, V. and Nite, G. (1978). The principles and practice of nursing.
New York: Macmillan.
Henderson, V. (1982, March). “The nursing process: Is the title right?”
Journal of Advanced Nursing. 103-109.
Marriner-Tomey, A. (1994). Nursing theorists and their work. 3rd Edition.
St. Louis: Mosby Year Book.
Orem, D.E. (1991). Nursing concepts of practice. 4th Edition. St. Louis: Mosby
Year Book.
Pender, N.J. (1987). Health promotion in nursing practice. 2nd Edition.
Norwalk, Connecticut: Appleton & Lange.
Riehl, J.P. and Roy, C. (1980). Conceptual models for nursing practice. 2nd
Edition. New York: Appleton-Century-Crofts.
Tillett, L.A. (1994). “The health promotion model.” In A. Marriner-Tomey,
Nursing theorists and their work. 3rd Edition. St. Louis, Missouri: Mosby.
UP Open University
Module 3 91
Module 3
Client-Centered Nursing
Theories: Roy, Levine, Hall
Cecilia M. Laurente
T his module deals with the client-centered

nursing theories of Calixta Roy, Myra Levine
and Lydia Hall.
Objectives
Do you know why these theorists focused on the you should be able to:
client and why they capitalized on the
personhood of the client in the healing process? 1. Analyze the nursing
theories of Roy, Levine,
If you study their backgrounds, you will note that and Hall in terms of their
all of them underwent varied and intensive ex- major assumptions as to:
periences in direct patient care. Their teachings a. person
in later years were enriched by their experiences b. health
in bedside nursing. They believed that changes c. nursing
occur when the person accepts himself and his d. environment;
feelings more fully. Only when physiological and 2. Discuss relationships
psychological tensions are reduced can there be among concepts and
any lasting change in the person. The client is seen the mechanics involved to
as an active participant in health care; not a pas- reach the nursing goal;
sive recipient. They are themselves the “healers,” 3. Explain theoretical
the partners in health care. They decide on how assertions given a hypo-
to participate in patient care. thetical situation; and
4. Discuss commonalities
and differences among
the theories.
UP Open University
Let me now discuss these client-centered theories separately to include

major assumptions, key concepts and theoretical assertions using illustra-
tions based on hypothetical situations. In later discussions, I will cite their
commonalities, differences, strengths and limitations. Again, please be
reminded that for you to fully understand the mechanism involved in
specific theories, you have to have a good grasp of the theory, especially
the interplay between or among concepts.
Are you ready now to study these client-centered theories?
M.E. Levine’s Four Conservation

Principles of Nursing
This theory reflects Levine’s views about a person, health, environment,
and nursing. Her assumptions are as follows:
1. Person
A person is a holistic being who has open and fluid boundaries that
coexist with the environment. He/she is “whole”; a unified social be-
ing who remains conserved and integral. Being “whole” does not only
include the physical being but also the psychosocio-cultural and spiri-
tual aspects. For example, even though a patient’s fracture is healed,
when anxiety is present, she is not considered a “whole” person.
2. Health
Health is a state of being “whole” and not just an absence of disease.

Health is socially determined and modified by a person’s interaction
or relationship with other people, particularly family and peers.
3. Environment
The environment is where a person is constantly and actively involved.

Each individual has his/her own environment, both internal and ex-
ternal. The internal environment involves the physiologic element,
while the external includes three levels: perceptual, operational, and
conceptual. The perceptual level includes those elements of the envi-
ronment that the person is able to intercept and interpret with his/
her own sense organs. For example, when a person has diminished
vision, she will not be able to see a person very well from a distance.
She may interpret that person as being a bush or trunk of a tree. The
UP Open University
Module 3 93
operational level includes those elements that affect a person physi-

cally, such as a traumatic blow on the body. At the conceptual level,
the environment is formed from socio-cultural patterns which may be
in the form of history, religious exercises, and the like. For example,
eating pork may be considered taboo by some people because of cul-
tural/religious beliefs. A patient with severe hemorrhage may not find
blood transfusion an acceptable treatment because this may be against
his religion. An alternative treatment has to be given in this case to
ensure “wholeness” of the patient.
4. Nursing
Nursing is a human interaction designed to promote “wholeness”

through adaptation. It occurs at the interface between the open and
fluid boundaries of the person and his/her environment. Nursing care
is seen as both supportive and therapeutic. The supportive aspect is
designed to maintain a state of wholeness in the face of a clients’ fail-
ing health. For example, if a patient has diminished vision, then his
room can be re-arranged to prevent injury. The therapeutic aspect is
designed to promote adaptation that contributes to health or restora-
tion of health of clients. For example, high blood pressure is controlled
by stress management.
I have just explained to you the four assumptions of Levine as to person,

health, environment, and nursing. These influenced her selection of key
concepts in the development of her theory.
Before you read further, may I tickle your mind by asking you to do SAQ
3-1? Take your time. Make sure you understand the questions before you
answer them.
UP Open University
SAQ 3-1
You have a client, Mang Carlos, a 50 year old construction worker
who sustained fractures on both legs and therefore will have mo-
bility problems for the next two months. Using Levine’s assump-
tions, how would you describe Mang Carlos as your client? Re-
member that you must view Mang Carlos as a “whole person,”
not just a patient with a fracture. How do you think he would feel
if he cannot walk anymore? When he cannot earn a living? Or see
a movie with his family? What will be your goal for this patient?
How are you going to meet your nursing goal? Do you have any
strategies/techniques to help Mang Carlos become “whole”?
Were you able to relate the assumptions of Levine with Mang Carlos? I
hope so.
Once you are ready to continue working on this module, read the next
section where I will discuss the key concepts utilized by Levine in her
theory. Take note that her theory is based on the four conservation prin-
ciples. What are these concepts and how do they relate to one
another?
The goal of nursing in Levine’s Conservation Principle is the promotion

of “wholeness” of the person by improving the client’s patterns of adap-
tive responses. The entirety of the person is to be kept together—his physi-
cal, physiological and psychosocial being.
UP Open University
Module 3 95
Key concepts and theoretical assertions

To attain the nursing goal, the nurse has to promote conservation of
energy, structural integrity, personal integrity and social integrity of
the client. If I were to make a paradigm to illustrate Levine’s theory, I
would illustrate it this way:
Conservation of: Promotion of

Energy “wholeness” of the
Structural integrity client towards health
Personal integrity maintenance or
Social integrity health restoration
Figure 3-1. Promotion of “wholeness” through

the Four Conservation Principles
To attain the nursing goal of promoting “wholeness” of the client, the

nurse has to receive and interpret messages from the client and use her
observations. Utilizing the nursing process approach, this activity exer-
cises her skills in nursing assessment and nursing diagnosis. The result
of her assessment will serve as the basis of her nursing interventions fo-
cused on the four conservation principles.
I am sure, in one way or the other, you yourself have used these prin-
ciples. Try to recall those situations in your clinical experiences as I ex-
plain each one.
Conservation of energy
Each person requires a balance of energy but there are factors within the
person and in the external environment that may cause depletion of
energy. For example, an adolescent is considered to be very active, very
adventurous and always “on-the-go” so that his energy loss has to be
replaced immediately.
When you take care of a patient with a myocardial infarction, he needs to

conserve energy so that the healing process can be hastened. The nurse
therefore has to think of measures to conserve the client’s energy. Will this
mean keeping the client in bed without toilet privileges? Or, will this mean
just limiting the client’s movement to toilet privileges?
But since Levine’s assumption of a person is not limited to the physical

being, the nurse’s intervention will not be limited only to physical conser-
vation of physical energy. It will have to include measures to keep the
UP Open University
client away from emotional/psychological stressors. The use of the social

support system, e.g., the family and significant others, will be of great
help to ease the client’s emotional stress, or keep him/her from being psy-
chologically/emotionally drained.
SAQ 3-2
Make a list of some techniques that you have used to conserve the
energy of your clients. I am sure you have used or observed seve-
ral techniques in the past. Recall some of them. What were the
effects on your clients?
Conservation of structural integrity
For a person to function, he/she has to conserve his/her structural integ-

rity. What is this “structural integrity?” This pertains to preserving the
anatomical structure of the body. For example, the skin is needed to regu-
late body temperature; protect the body from harmful organisms and
maintain fluid and electrolyte balance. But once the skin is damaged—for
example when large areas are badly burned—it will not be able to do its
function. Body temperature may rise, infection may set in, and fluid and
electrolyte loss may cause renal failure and hypovolemic shock.
Because it is important to conserve structural integrity, the nurse has to

institute measures to prevent damage to the anatomical structure. For
example, when an elderly client with a long-term illness develops a bed-
sore, the nurse can initiate measures to prevent further skin breakdown
by turning the client from side to side, improving nutritional and hydra-
tion status, etc. In the case of Mang Carlos, the fractured leg must be kept
immobilized and in good alignment for a certain period of time.
UP Open University
Module 3 97
SAQ 3-3
Make a list of some techniques which you have used to conserve
structural integrity. What were the effects of these measures on
your client?
Conservation of personal integrity
Each person has his/her own sense of identity and self-worth. How do
you value yourself? How do you feel when your client tells you “maraming
salamat po... ang bait-bait niyo!” (Thank you very much...you are very kind!)
Do you feel good? Elated? Does your spirit perk up when you hear these
words? These may be simple words but they are meaningful to you.
Have you noticed how a patient reacts when he is called by his bed num-
ber and not by his name? Does he smile or does he just stare?
What Levine is saying is that the client is a person with dignity. He/she
needs to be respected, provided with privacy, encouraged and psycho-
logically supported. The client’s personhood has to be preserved. The nurse
should not only look at the client as an object but rather as a being with
feelings and spirit.
Pause for a moment and reflect on your own experiences with your pa-
tients related to this particular concept.
UP Open University
SAQ 3-4
Make a list of some techniques which you have used to conserve a
person’s personal integrity. What were the effects of these mea-
sures on your clients? How did they react?
Conservation of social integrity
Conservation of social integrity involves the presence and recognition of

human interaction, particularly with the client’s significant others who
comprise his support system. His day is a good day if his wife and chil-
dren or friends are at his bedside, if he is able to talk with his loved ones
before his operation or before he is brought to a diagnostic room. The
comforting words of his loved ones give him a feeling of security and
strength.
SAQ 3-5
Make a list of some techniques which you have used to conserve
social integrity. What were the effects on your clients? How did
they react?
UP Open University
Module 3 99
The critical components of Levine’s theory are:
1. The patient is in a state of illness.

2. The nurse is the patient’s significant environment.
3. The nurse must be able to recognize the organismic manifestation of
the patient’s adaptation to illness.
4. The nurse must initiate appropriate actions based on the four conser-
vation principles and she must evaluate the intervention to determine
whether it is therapeutic or supportive.
Activity 3-1
Utilizing the same situation on SAQ 3-1, how would you utilize
the four conservation principles in the care of Mang Carlos?
Table 3.1 further operationalizes Levine’s Theory.
Table 3.1. Application of Levine’s theory: an example
Conservation Evaluation, Rationale

Principle Supportive/
Therapeutic
1. Trining, an asthmatic Energy Therapeutic/ Limit the expen-

patient, is placed on Supportive diture of energy
high-Fowler’s position
2. Trining needs to a. Structural Supportive/ a. Maintain

receive oxygen. She integrity Therapeutic adequate
is given a choice as oxygen sup-
to how she prefers ply to reduce
to receive it (nasal difficulty of
cannula or mask). breathing
b. Personal b. Maintain
integrity individuality
and autonomy
3. Trining’s mother Social integrity Supportive Provide support

accompanies her system during
to the Pulmonary diagnostic/thera-
Room peutic procedures
UP Open University
The nurse monitors Trining’s response to the nursing interventions to de-

termine how she is adjusting to her altered state of health. Her breathing
difficulty is relieved, her anxieties are reduced, she feels comfortable and
is able to cooperate with the health team in the therapeutic regimen.
Levine’s theory is grounded not only on sciences but also on the humani-
ties, with an underlying belief that people are dependent on their rela-
tionships with other people. Nursing care therefore is a process in which
interventions are based on the assessment of the client within the bound-
aries of the conservation principles, recognizing physio-behavioral changes
in the patient’s attempt to adapt to illness. These nursing interventions
are evaluated in terms of their effect on the health state of the patient,
whether these are therapeutic or supportive. If the intervention is thera-
peutic, the patient is able to progress toward a state of health.
If you need further clarification on Levine’s Theory, don’t hesitate to dis-

cuss this with your tutor on your next learning session.
Are you now ready for another client-centered theory? Let’s now study
Roy’s Adaptation Theory. It has many similarities to Levine’s.
Roy’s Adaptation Theory

Like Levine, Roy’s theory is grounded on humanism with the belief that a
person has his own creative power and has coping abilities to enhance
wellness.
Let me explain Roy’s major assumptions in developing the Adaptation

Model.
1. A person is an adaptive system with coping mechanisms manifested

by the adaptive modes: physiologic, self-concept, role function and
interdependence. How are these differentiated from each other?
2. The physiologic adaptive mode is determined by physiologic needs,

e.g., sleeping after a day’s work. In the physiologic mode, the focus is
on five needs (oxygenation, nutrition, elimination, activity, rest and
protection), and on four regulatory processes (the senses, fluids and
electrolytes, neurologic, and endocrine functions).
3. The self-concept mode is determined by interaction with others. For

example, it’s nice to hear someone say, “You’re beautiful in your suit.”
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Module 3 101
4. The role function mode refers to the performance of duties based on

given societal norms or expectations. For example, in today’s society,
a “mothering” role often includes being a breadwinner and so a work-
ing woman needs to return to her work soon after the delivery of her
baby.
5. The interdependence mode involves ways of seeking help, affection,

and attention. It is also the ability to love, respect, value and accept.
6. The environment encompasses all conditions, circumstances, and in-

fluences surrounding and affecting the development and behavior of
persons and groups.
7. Health is a state of being and becoming an integrated whole. Con-

versely, illness is lack of integration.
8. Nursing is an external regulatory force that can modify stimuli which

produce adaptations. Nursing can either maintain, increase or decrease
stimuli. The consequence of nursing is the person’s adaption to these
stimuli depending on his position on the health-illness continuum.
Key concepts and theoretical assertions

Let me now explain the key concepts in the model and how they relate to
one another. These key concepts are illustrated in Figure 3-2.
Stimuli Coping mechanisms

Adaptation level Regulators
Cognators
Adaptive/Effective
Physiologic function
response
Self-concept
or
Role function
Maladaptive/
Interdependence
Ineffective response
Figure 3-2. Adaptive/effective response through four adaptation models
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The goal of nursing is to promote the person’s adaptation along the four
adaptive modes (physiologic, self-concept, role function, and interdepen-
dence).
The person is able to adapt if he is able to cope with the constantly chang-
ing environment. There are two types of systems at work: regulators and
cognators. Regulators are external stimuli that are processed through the
neural-chemical-endocrine channels. Cognators refer to internal and ex-
ternal stimuli processed through cognition pathways.
The level of adaptation of a person is determined by the combined effect

of stimuli which could either be focal, contextual or residual.
1. Focal stimuli are those that immediately confront the person, e.g.,
pricking of skin tissue during injection of drugs.
2. Contextual stimuli are all other stimuli present or contributing fac-

tors in the situation, e.g., inability to explain the procedure and the
need for the drug.
3. Residual stimuli are unknown factors such as beliefs, attitudes or

traits that have an intermediate effect or influence on the present
situation. For example, the false belief that a patient cannot bathe
after an injection.
Roy’s model revolves around the concept of man as an adaptive system.

The person scans the environment for stimuli and ultimately adapts. The
nurse, as part of his environment, assists the person in his effort to adapt
by appropriately managing his environment.
Pause for a while, reflect on your clinical experience and answer SAQs
3-6 and 3-7.
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Module 3 103
SAQ 3-6
Think of one particular client who was under your care. How did
he adapt to his condition? Describe what measures you did to help
him adapt. Classify your answers according to the four adaptive
modes.
SAQ 3-7
Based on your answer to SAQ 3-6, can you recall your client’s
words and actions that made you realize he was able to adapt to
his situation?
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Do you now realize how important the role of the nurse is in making the
patient adapt to attain a level of wellness? When you do something for
your patient, you will observe that the level of satisfaction of your patient
is increased. He may feel “secure.” There is decreased level of anxiety or
pain. He is able to interact with other people. He does not “pressure” the
nurse to stay by the bedside during his pain experience.
We are now done with Roy’s Adaptation Theory. Let’s now move on to
the third client-centered theory, Hall’s Theory of Care, Core and Cure.
Hall’s Theory of Care, Core, and Cure
Lydia Hall illustrated her theory of nursing using three interlocking circles,
each circle representing a particular aspect of nursing—care, core, and
cure. Before discussing these, let me first explain her basic assumptions
that served as bases for the development of this theory.
Major concepts
1. A person strives to attain her own goals, not goals others set for her.
She behaves on the basis of her feelings, not on the basis of know-
ledge. A patient is composed of three elements: Body, Pathology and
Person.
2. Environment is focused on hospital nursing services that are orga-

nized to accomplish tasks efficiently. The nurse is an important part
of the environment—an educated professional taking direct care of
patients.
3. Health is a state of being able to move in the direction of self-aware-

ness (true feelings and motivations) thereby releasing one’s own power
of healing.
4. Nursing is helping clients move in the direction of self-awareness.

Nursing care is given exclusively by nurses educated in the behavioral
sciences who take the responsibility and opportunity to coordinate
and deliver the total care of their patients. This includes nursing, teach-
ing and advocacy in fostering healing.
Hall’s theory consists of three major elements: care, core, cure which con-
stitute the three aspects of the client (body, person, and disease). The nurse
functions differently in these three interrelated aspects (Figure 3-3). Nurs-
ing operates in all these circles, but shares them with other professions in
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Module 3 105
different degrees. Disease (cure) is shared with physicians. The person

aspect (core) is shared with psychologists, psychiatrists, social workers,
and religious ministers. The body of the client is exclusively for nursing
(care). The care circle represents the nurturing component of nursing.
Nurturing includes the concepts of mothering (caring for and comforting
the person) and provision of teaching-learning activities. The nurse’s goal
is the comfort of the patient.
The Person (Core)

Therapeutic Use of
Self
The Body
The Disease
(Care)
(Cure)
Intimate
Medical Care
Bodily Care
Figure 3-3. Interdependent aspects of nursing care
These three aspects of nursing are interdependent and interrelated. These

circles change size depending on the patient’s progress. This is the phi-
losophy of care in the Loeb Center established by Hall—nursing care is
increasingly needed as medical care decreases and vice versa (Figure 3-4).
Cure Care
(medical care) (nursing care)
Figure 3-4. Changing demands for care
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SAQ 3-8
In tabular form, enumerate the commonalities and differences of
the three theories in relation to:
1. assumptions about man
2. goal of nursing
3. key concepts to attain the nursing goal
4. applicability
Summary
Let us now summarize the theories of Levine, Roy, and Hall. Take note
that all of them see the patient as a person who is a bio-psychosocial and
spiritual being. This means that the nurse has to view the patient as a
person who is a “whole” being, not a fragmented one.
Can you now connect your nursing practice with the theories of Levine,
Hall or Roy? If you have difficulty doing this, read this module again, take
note of the important concepts in each theory and think of how these can
be applied in clinical nursing. If you need to consult reference materials,
these are listed at the end of this module.
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ASAQ 3-1
Mang Carlos is a person, a biopsychosocial, cultural and spiritual being.
Any physical trauma may also evoke psychological/spiritual trauma as
he is a human being with feelings and with dignity.
Your nursing goal therefore is to keep him a “whole” being, and to pro-
mote “wholeness” through adaptation. Some nursing measures that you
may employ are:
1. immobilization to relieve pain allowing him to verbalize what he is

feeling
2. listening actively to his verbalizations
3. presencing – just being at his side, offering words of comfort
4. providing opportunities for meditation or prayer with him and his
family.
ASAQs 3-2, 3-3, 3-4, 3-5

I have tabulated my answers as follows for easy reference.
Principles Some Nursing Measures
Conservation of
1. energy immobilization, limit visitors, allow time to relax
2. structural integrity make sure that traction is in place and in proper
alignment
3. personal integrity call him by his preferred name, e.g., Mang Carlos
4. social integrity allow relatives and friends to see him during
visiting hours
Have you noticed that your patients brighten up every time you institute
appropriate nursing measures?
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ASAQ 3-6
Here are some examples of answers to SAQ 3-6. You may add to the list
other experiences and observations gathered in your practice of clinical
nursing.
1. Physiologic — the client needs to eat when hungry, drink water when
thirsty, assume high back rest when having difficulty breathing, etc.
2. Self-concept — answering client’s questions about his condition, lis-

tening when client expresses his feelings, etc.
3. Role function — giving client opportunities to make decisions and to

care for self, etc.
4. Interdependence — helping him feed self or bathe self when unable

to do so, etc.
ASAQ 3-7
Examples of these manifestations are: the patient smiled; expressed grati-
tude; verbalized “I feel good today,” “I feel strong now”; was able to
participate in self-care activities like grooming, feeding and bathing.
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Module 3 109
ASAQ 3-8
Below is a tabular summary of the three theories in terms of commonali-
ties and differences.
Levine Roy Hall
Man a biopsychosocial same same

being
Goal of nursing Wholeness of man Wholeness of Wholeness of man

thru: man thru: thru:
Key concepts Conservation of Adaptation in Care, core, cure

energy, structural physiological inter-elements
integrity, personal mode, self-
integrity, social concept mode,
integrity interdependence
mode, role
factor mode
Applicability Limited to patients Limited to adult Limited to patients

in acute stage; clients in any who are recupera-
dependent on stage of illness ting in subacute
stage of illness or altered state stage of illness
of health where they are
able to participate
in health care and
establish mutual
goal setting
Are our answers similar? You may have other ways of describing each
concept but our general ideas are the same. If you had difficulty answer-
ing this SAQ, go through the module again or consult references listed on
the next page.
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References
Chinn, P.L. and Kramer, M. (1991). Theory and practice: A systematic ap-
proach. St. Louis: Mosby Co.
Flynn, J. and Heffron, P. (1988). Nursing: From concept to practice. Con-
necticut: Appleton and Lange.
George, J. (1990). Nursing theories: The base for professional nursing practice.
New Jersey: Prentice-Hall.
Marriner, A. (1986). Nursing theorists and their works. St. Louis: Mosby
Co.
Schaefer, K. and Pond, J. (1991). Levine’s conservation model: A framework
for nursing practice. Philadelphia: Davis.
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Module 4 111
Module 4
Nurse-Client Dynamics
Araceli V. Ocampo-Balabagno
N ursing paradigms or models explain inhe-

rent beliefs about man, health, nursing, and
environment as nurse scientists find ways to bet-
Objectives
ter understand nursing science. Four theories on
nurse-client dynamics will be presented in this
module. These are the interaction theories as ex-
plained by Hildegard E. Peplau (1952), Ida Jean
1. Explain the historical
Orlando (1961), Imogene M. King (1971) and Jean
components inherent in
Watson (1979). (The year after the names indi-
the development of the
cate the time the first presentation of the theory
interaction theories;
was made.) Recent developments as well as cri-
2. Compare and contrast
tiques of the theories shall also be explained.
salient concepts in four
interaction theories in
Figure 4-1 was conceptualized by the course team
terms of assumptions
to illustrate the interaction theories. After careful
about health, man,
discussion, we decided to use the phrase “nurse-
nursing, and
client dynamics” to explain the interaction theo-
environment; and
ries, thus the module title. The shaded portion in
3. Explain the theoretical
the figure represents the dynamics of interaction
propositions (i.e., rela-
between the nurse and the client.
tionship between
concepts) of four
interaction theories.
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Person Person
(Nurse) (Client)
Environment
Figure 4-1. Model for nurse-client dynamics
Nursing is a structured and deliberate process. It is an interpersonal pro-

cess occurring between a person (client) in need of help, and a person
(nurse) capable of giving help and assistance. Let’s use the term “patient”
to refer to clients who are confined in a hospital, and the term “client” to
refer to any person in need of help for a health problem. There are mul-
tiple factors in the environment that influence nurse-client dynamics. These
factors will be elaborated on in the module.
Historical Highlights
I think you have many questions in your mind about nursing theories.
Questioning is good. It helps us probe, find out, and discover. Recalling
past events offers us insights on the origins of the schools of thought on
nurse-patient interaction dynamics. However, it may be difficult to iden-
tify the exact date of the formulation of a theory. You have learned that
Florence Nightingale’s ideas directed nursing practice for over a hundred
years since 1859. Since then, the development of nursing theories have
been influenced by many factors like status of education, the common
situations of clients, the socio-political and cultural environment, and even
technology. The need to prepare nurses at the graduate level for admin-
istrative and faculty positions also serves as a pulling force for the deve-
lopment of nursing knowledge.
You learned in the past modules about the “needs theorists” mostly
coming from the United States of America. They focused their efforts on
the problems and needs of patients. They wanted to find answers to the
question “What do nurses do?” Hildegard Peplau (1952) provided the
initial theoretical constructs for understanding nursing, and in the pro-
cess began the interaction process. Peplau, a practicing nurse in mental
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Module 4 113
health, was among the first graduates in the 1950s from Columbia
University’s Teacher’s College, where the first theoretical concep-
tualization of nursing science came from (George, 1995, p.5). A biomedi-
cal model was used then, and the primary focus was patient problems.
The theories developed in the 1950s somehow influenced Henderson (1964)

to develop the widely accepted definition of nursing and the fourteen
basic components of nursing care. Also, in the 1960s, there was a varia-
tion in theoretical thinking in nursing, from focusing on problems, needs
and functional roles, to focusing on the relationship between the nurse
and the patient. The nursing profession was interested in psychoanalytic
theory and the biomedical model of man.
Peplau, with her experiences and academic preparation in graduate school

and psychiatric nursing, proposed a direction in the discussion of ques-
tions about the purpose of nursing. Nursing leaders developed a process
of inquiry by asking “How do nurses do whatever it is they do?” Another
school of thought on the interaction process came about in response to
the “how” of nursing (Meleis, 1991). Theorists began to look at how nurses
do what they do and how the patient perceives his or her situation.
Interaction theories borrow concepts from sociology and psychology and

even anthropology. Margaret Mead (1934), a noted anthropologist, worked
extensively in areas of understanding different cultures and people and
their patterns of interaction. Gaining insight about another person’s feel-
ings and thoughts allows one to anticipate the other’s behavior and react
accordingly. The first meeting between a nurse and a patient predicts the
image that the nurse projects. If the relationship between the nurse and
patient must progress, then this interaction should be valued as a process
that will help explain a process of intervention.
The early 1960s up to the 1970s in the United States was characterized by
movements to discuss and develop theories. In the 1970s, there were al-
ready revisions of the original postulated theories. These developments
influenced the perspectives and visions of the interaction theorists Peplau,
Orlando, King, and Watson. Table 4-1 outlines the key emphasis of the
theorists.
The 1980s were characterized by periods of theory revision based on re-

search findings. Theories expounded in the 1990s were mainly formu-
lated on the basis of research.
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Table 4.1. Key emphasis of four interaction theories
Year of First Theorist Key Emphasis

Major Publication
1952 Hildegard E. Peplau Interpersonal process is a

maturing force for
personality development
1961 Ida Jean Orlando Interpersonal process

alleviates distress
1971 Imogene M. King Transactions provide a

frame of reference toward
goal setting
1979 Jean Watson Caring is a moral ideal:

mind-body-soul
engagement with another
Adapted from Chinn, P.L. and Kramer, M.K. (1991). Theory and nursing: A systematic
approach. St. Louis: Mosby Year Book. p.52.
The discussion of nursing theories in the Philippines gained ground in the

early 1970s mainly because of interest in the academe. The University of
the Philippines College of Nursing’s graduate program, most especially
the doctoral program established in 1981, propelled the study of theory
development and theory grounding. Interaction as an intervention has
since been integrated in the Bachelor of Science in Nursing (BSN) curricu-
lum. And there are more nursing researches discussing interaction
concepts. It is therefore important that Filipino nurses have a good under-
standing of the interaction theories.
SAQ 4-1
Enumerate and discuss some factors that influenced the develop-
ment of interaction theories.
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Module 4 115
It is nice to know that you can relate to the theory development process.
You will discover that these things are discussed and applied daily in
your work setting.
Interpersonal Relations
(Peplau, 1952, 1988)
Peplau formulated theories on interpersonal relations in nursing (1952)

and the art and science of nursing (1988).
Imagine yourself working in a hospital-based setting, such as an outpa-

tient department. The common scenario would be that of a patient com-
ing in because of a felt need related to his health. You as a nurse will
assess the reasons for this consultation. At this point, the process of nurs-
ing begins—it is both an interpersonal and a therapeutic process. It is
both an art and a science, as you apply the scientific knowledge you have
acquired for the therapeutic component of care.
Peplau (Chinn and Kramer, 1991) explained that the purpose of nursing is
to educate and be a maturing force so that the patient (person) gets a new
view of himself given the need that he has presented. This is achieved
when the nurse enters into a relationship with the person. The nurse is
viewed as a medium for change. The relationship brings together two
persons with different goals. The idea is for both to develop or assume
congruent goals (Figure 4-2).
Nurse Patient
counselor (with a health need)
resource person
surrogate congruent goals
Figure 4-2. Nurse-patient relationship
The nurse functions as a resource person, a counselor, and a surrogate.

These are the roles that the nurse assumes to carry out the purpose of
nursing. The product of the interaction is the identification of congruent
goals as bases for problem identification and appropriate interventions.
The nurse-patient relationship occurs in four phases, namely:
1. orientation
2. identification
3. exploitation
4. resolution
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Orientation Phase
During phase one, the Orientation Phase, the nurse assists the patient by
orienting him to the problem. The patient learns about the problem and
the extent of the need for help. It is also during this phase that orientation
to the use of services, exploring anxiety responses, and learning the limits
of necessary space and freedom are done. This phase allows time for the
patient to express himself.
Phase of Identification
Once a given degree of orientation is achieved, the Phase of Identifica-

tion begins. The nurse provides assistance by assuring the patient that the
nurse can understand the meaning of the patient’s situation. In this phase,
the patient assumes the posture of interdependence, dependence and/or
independence in relation to the nurse.
Exploitation Phase
Phase 3 or the Exploitation Phase is characterized by the patient deriving

full value from the relationship by using the services available on the basis
of self-interest and needs.
Resolution Phase
Phase 4 or the Resolution Phase occurs when old needs are met. As older
needs are resolved, newer and more mature ones emerge. During the pe-
riod of resolution, the person is freed from dependence on others.
When does the maturing force in nursing occur? Remember the key em-
phasis of Peplau’s interpersonal process (see Table 4-1).
The maturing force of nursing is realized as the personality develops

through the educational, therapeutic, interpersonal process of nursing.
The phases of the relationship involve a series of processes and the client
assumes an active role.
In community settings, the nurse may assume many roles to attain a

greater dyadic nurse-client relationship. In addition, she may be a teacher
and a leader. These roles are brought about by multiple client problems,
team function, and social and professional expectations.
According to this theory, the professional nursing goal is the same as the
nurse-client dyads. That is, to implement a process that facilitates person-
ality development by helping persons use forces and experiences to
ensure maximum productivity.
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SAQ 4-2
Imagine yourself again in the out-patient department of a hospital
and a 46-year old obese woman comes in—anxious, agitated, high-
strung. You take her blood pressure and the reading is 165/100
mmHg.
In this case, explain the orientation phase in the initiation of an

effective nurse-patient interaction.
Compare your answers with mine. See ASAQ 4-2.
SAQ 4-3
(Given the same situation in SAQ 4-2)
When can you say that an effective interpersonal relationship has

been developed?
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I think you will agree with me that communication—and how to main-

tain an effective one—is crucial. Within this perspective, the nurse should
not limit communication or interaction to the client but should extend it
to family members or significant others, as well. Mutual agreement as to
the client’s needs should be well established between the client’s family
members and the nurse. Other factors come into play. Take for instance,
the client’s culture and beliefs.
George (1995, p. 52) illustrated a model showing factors influencing the

development of the nurse-patient relationship. I agree with her. I also
added some aspects particular to the Filipino setting—factors like cus-
toms, traditions and ethnicity (Figure 4-3), to replace the “factor-race”
component.
values values
culture customs culture customs
traditions ethnicity traditions ethnicity
dialect spoken dialect spoken
Nurse nurse-client Client
preconceived ideas relationship preconceived ideas
beliefs beliefs
past experiences past experiences
expectations expectations
Figure 4-3. Factors influencing the development of

the nurse-patient relationship (Adapted from George, J.B. (Ed). (1995).
Nursing theories: A base for professional practice. Connecticut: Appleton and
Lange. (Words in italics were added by the author.)
In this model, note that several factors influence nurse-patient interac-

tion, most especially when you apply this to the Philippine setting.
Ethnicity and dialect spoken may greatly affect how the interaction can
be carried out.
Recall the framework that the course team has proposed for the interac-
tion theories (see Figure 4-1). I said then, that there are multiple factors
that may influence nurse-client dynamics. Recall also that in Module 1,
you learned that you may derive implications about man, health, nurs-
ing, and environment from the different theories. You may note that some
theories are not very explicit about these elements. You have to derive the
implications.
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Module 4 119
I am sure that given your rich clinical experiences, you will be able to cite
examples of the factors that influence your process of establishing inter-
action with your clients. What you can do is list the factors that in your
experience influence nurse-client dynamics. Compare your listing with
your colleagues. This way, you develop a consensus on the common fac-
tors that influence nurse-client dynamics.
Caring as the Essence of Nursing

(Watson, 1979)
Watson viewed caring as the essence of nursing. Caring connotes respon-

siveness between the nurse and the person. The nurse co-participates with
the person. The purpose of caring is to assist the person in gaining control
and becoming knowledgeable, and in the process promote health changes.
If you thought of the concept of empowerment while reading this, yes, I

believe it is similar to that. By allowing the client to be knowledgeable, the
nurse provides an environment for better decision-making, better self-con-
trol, and better self-respect. The concept is common to Filipino culture:
kakayahan or patibayin ang kakayahan, meaning assisting the person in gain-
ing control.
While it is true that caring as an attribute in nursing has been described

and clarified by many others, there is uniqueness in Watson’s science of
caring. Basic assumptions for the science of caring are supported by ten
carative factors that provide structure to the concept of caring.
Watson (in George, 1995, p. 318) proposed the following assumptions

about the science of caring:
1. Caring can be effectively demonstrated and practiced only interper-

sonally.
2. Caring consists of carative factors that result in the satisfaction of cer-

tain human needs.
3. Effective caring promotes health, and individual or family growth.
4. Caring responses accept a person not only as what he or she is now.
5. A caring environment is one that offers the development of one’s po-

tential while allowing the person to choose the best action for himself
or herself at a given point in time.
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6. Caring is more “healthogenic” than curing. The practice of caring

integrates biophysical knowledge to generate or promote health and
to provide ministrations to those who are ill. The science of caring is
therefore complementary to the science of curing.
7. The practice of caring is central to nursing.
Several studies have been done to explain “caring.” I would like to men-
tion in particular a study done in a Philippine emergency room setting
(Laurente, 1996) where caring behaviors of nurses were used to explain
the relief from anxiety of patients in the emergency room. Carative fac-
tors, such as therapeutic touch (a pat on the back or shoulder, holding a
person’s hand when in pain) and explaining medical procedures were
effective in reducing patients’ anxiety.
The framework for the science of caring consists of ten carative factors.
(George, 1995). According to Watson, the first three carative factors pro-
vide the philosophical foundation for the science of caring. After going
through these factors, I think you will agree with me that carative factors
four to ten are those that relate to competencies of the professional nurse.
The 10 carative factors are:
Carative Factor 1: Formation of a Humanistic-Altruistic Value System.

The value of altruism (regard for others as a personal action) is learned at
an early age. It is a value shared with parents. One’s own life experiences
are learning opportunities help to gain insights about dealing with others.
Caring based on humanistic values and altruistic behavior “can be devel-
oped through examination of one’s own views, beliefs, interactions with
various cultures, and personal growth experiences.” This development is
perceived necessary for the nurse’s own maturation.
Carative Factor 2: Faith-Hope. This factor is deemed essential to both

carative and curative processes. To nurses, this provides a basis for look-
ing into the healing power of belief, or the spiritual dimension, when cur-
ing is not possible. The use of Faith-Hope as a nursing intervention allows
nurses to explore alternative methods of healing, like meditation. It seems
that the goal for this activity is the provision of a sense of well-being through
belief systems that are meaningful to the client.
Carative Factor 3: Cultivation of Sensitivity to Self and Others. Nurses

promote “health and higher level functioning only when they perform
person-to-person relationships as opposed to manipulative relationships.”
There is a need for the nurse to develop and examine his or her own
feelings. Through this process, increased sensitivity to others is developed.
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Module 4 121
The nurse becomes honest and promotes self-growth and self-actualiza-

tion. Watson’s premise further states that “at the highest level of nursing,
the nurse’s human care responses, human care transactions, and pres-
ence in the relationship transcend the physical material world.” The ex-
planation makes it clear that interactions between the nurse and the cli-
ent deal with the person’s emotional and subjective world as a means to
learn the inner self.
Well, let’s pause and see what we have discussed so far about Watson’s
theory of human science and human care. Answer the SAQ below.
SAQ 4-4
I’m sure that you have your own definition of “caring.” Write it
down. What can you say about the first three carative factors pro-
posed by Watson? How do they relate to your own concept?
Find out if your answers are similar to mine. Look at ASAQ 4-4.
I hope the exercise allowed you to examine your own thoughts about
caring. Now, let us continue.
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Carative Factor 4: Establishing A Helping-Trust Relationshp. Commu-

nication, both verbal and non-verbal, is a mode of accomplishing a help-
ing-trust relationship to establish rapport and caring. Characteristics
common to this carative factor are congruence, empathy, warmth and
honesty. Positive acceptance of another is most often expressed by body
language, touch and tone of voice. I’m sure that given your clinical expe-
riences, you can think of many situations to relate to this fourth carative
factor.
Carative Factor 5: Expression of Feelings, Both Positive and Negative.

According to Watson, it is important to facilitate awareness of both nega-
tive and positive feelings to improve on one’s level of awareness. Feelings
need to be considered in a caring environment. Being aware of both posi-
tive and negative feelings leads to better understanding of behavior.
Carative Factor 6: Research and Systematic Problem-Solving. This fac-

tor highlights the limitations nurses have in addressing the issue of devel-
oping a scientific base because most of our time is dedicated to the perfor-
mance of nursing tasks such as procedures and treatments. Thus, recog-
nition is given to the use of the systematic problem-solving method in
building nursing knowledge. In the same way, the argument extends to
other methods of knowing like utilizing research-based findings in order
to improve nursing practice and provide holistic care.
Carative Factor 7: Promotion of Interpersonal Teaching-Learning.

Through this factor, persons (clients) gain control over their own health
because it provides them with both information and alternatives. Learn-
ing offers opportunities to individualize information dissemination. The
caring nurse focuses on the learning and teaching process, as well as in
understanding the client’s perception of the situation. This provides for a
cognitive plan workable within the client’s frame of reference.
Carative Factor 8: Provision for A Supportive, Protective, and/or Cor-

rective Mental, Physical, Sociocultural, and Spiritual Environment.
There are two divisions or categorizations relative to this factor: external
variables which include physical, safety and environmental factors; and
internal variables which refer to mental, spiritual or cultural activities
which the nurse may manipulate for the person’s well-being. An interde-
pendence exists between internal and external factors since the person
perceives the situation in the environment as either threatening or non-
threatening. There are events in a person’s life that can arouse a sense of
threat. The person appraises the situation and copes to the best of his
ability. The nurse’s assessment capabilities can be valuable in helping the
person appraise the situation and cope with it. The nurse’s intervention is
aimed at helping the person develop a more accurate perception to help
strengthen coping capabilities.
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Module 4 123
Provision of comfort, safety and privacy are major aspects of this carative
factor. A clean and esthetic environment is considered a basic element.
Esthetics is deemed essential in the promotion of increased self-worth and
dignity.
Carative Factor 9: Assistance with the Gratification of Human Needs.

The hierarchy of human needs is the essence of this carative factor. I thought
it important to illustrate this concept using a “makopa” diagram (Figure 4-
4). This way, you can better visualize the ordering of needs. Do you re-
member Maslow’s hierarchy of needs? There is some similarity between
the two.
Growth-Seeking Needs
Higher Order Needs
(Intrapersonal-Interpersonal Needs)
The need for self-actualization
4
Integrative Needs
Higher Order Needs (Psychosocial Needs)
The need for achievement
The need for affiliation
3
Functional Needs
Lower Order Needs (Psychophysical Needs)
The need for activity-inactivity
The need for sexuality
2
Survival Needs
Lower Order Needs (Biophysical Needs)
The need for food and fluid
The need for elimination
The need for ventilation
1
Figure 4-4. Ordering of needs as proposed by Watson, 1979

(Adapted from George, J.B. (Ed). (1995). Nursing theories: A base for
professional practice. Connecticut: Appleton and Lange.
It is important to view the person in the context of the whole, since other
needs may be manifested more than others. There are many studies corre-
lating emotional distress and illness. Watson used these findings to
describe holistic care: (1) etiological components have many factors and
these interact to produce change through complex neurophysiological
functions and neurochemical pathways, (2) each psychological function
has a physiological correlate, and (3) each physiological function has a
psychological correlate.
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Carative Factor 10: Allowance for Existential Phenomenological Fac-

tors. Watson described phenomenology as a way of understanding people
from the way things appear to them, from their frame of reference.
Existential psychology is the study of human existence using phenom-
enology analysis. In incorporating these factors in the science of caring
the nurse is able to understand the meaning that the person finds in life.
This makes it easier to help the person gain strength to confront life or
death. Watson also suggested that nurses look inward to resolve their
own existential questions before assisting others. Finding meaning in life
and death is the focus of the tenth carative factor.
You will learn later that the phenomenological approach in descriptive

research is a common method that is used to study human responses.
All the ten carative factors are interdependent. Understanding these al-
lows for holistic care. As you were studying the carative factors, thoughts
must have come to your mind about things that you have been doing as a
nurse. That is good—it means you have been trying to integrate theory
and practice.
SAQ 4-5
Human needs are interrelated. Explain the relationship between
lower order biophysical needs and higher order psychosocial needs.
Compare your answers with ASAQ 4-5 at the end of the module. Did the
carative factors help you develop your own cognitive structure or frame-
work for caring?
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Module 4 125
SAQ 4-6
The purpose of caring is to help the person (client) gain control
and knowledge to be able to make decisions about health changes.
Which among the 10 carative factors clearly supports this idea?
Describe briefly why you think this is so.
Find out how you did by comparing your answers with those in ASAQ 4-6.
Did you find similarities between Peplau’s interpersonal relations and

Watson’s essence of caring? I’m sure you did. Both theories advanced the
idea that the person (client) must be allowed to gain a certain degree of
control over his own health. Cognitive information gained by the client
provides a basis for effective decision making.
Model for Studying Propositions

Now that you have studied two of the nurse-patient dynamic theories,
let’s try to synthesize the concepts presented. This will help you answer
objectives 2 and 3 of this module as you proceed.
In module 1, you will recall that salient commonalities about theories were
defined. Theories are sets of concepts that are interrelated. They are logi-
cal, consistent, serve a purpose, and represent a creative structuring of
ideas. Propositions explain the interrelationship of these ideas.
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Look at Figure 4-5 below. My aim in presenting the model is for you to be
able to interrelate the concepts of Peplau (Interpersonal Relations Theory)
and Watson (Essence of Caring Theory). Later on you can use this to
guide you in analyzing the other two theories.
Nurse Patient/client
To help To be helped
How is the interaction process

initiated between the nurse and the
patient?
What initiates or
What are the
What are the processes brings the
goals (objectives)
(phases/components) patient/client to
of the nurse? or
involved? the interaction
nursing?
process?
What is the outcome of nurse-

patient dynamics (interaction
process)?
Purpose of the theory
Figure 4-5. A Model to study propositions of

the nurse-patient dynamic theories
Five major questions in the model will guide you as you start interrelating
the concepts. As you answer these questions, several other questions may
pop into your mind. These will help focus attention on the salient features
of the theory.
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Module 4 127
To start, recall what you studied about Peplau’s Interpersonal Relations

Theory. See how the flowchart analysis below (Figure 4-6) can be used to
summarize Peplau’s theory.
Nurse Client/Patient
Orientation phase
(allow time for
patient to express
himself)
Observes
Process
Assists/ Has a problem

orients patient
to the problem Phase of identification
(the nurse assures the
patient that he/she
understands the meaning
of the situation)
Phase of exploitation
Phase of resolution
Professional Learns about the

nursing: teaches/ “Old” needs are problem and extent
counsels/leads/ resolved “newer” of help needed
acts as a and “more mature”
surrogate needs emerge. The
client is freed from
dependence on
others.
Figure 4-6. Flow chart analysis of Peplau’s Interpersonal Relations Theory
Did the flowchart make it easier for you to understand Peplau’s Theory?
The model should help you organize concepts in a systematic way.
UP Open University
SAQ 4-7
Develop a flowchart analysis using the model (Figure 4-5) show-
ing the interrelationships of the concepts in Watson’s Essence of
Caring Theory.
Now I know you might be tempted to just turn to the back of this
module and view the answers, but this means you won’t be able to
practice your critical thinking and analysis skills. Don’t be afraid
to make mistakes. This will help you learn.
Refer to ASAQ 4-7 and compare your answers with mine.
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Module 4 129
Dynamic Nurse-Patient Relationship

(Orlando, 1961-1990)
Have you been confronted with a situation in your nursing practice where
you were asked “What was your initial nursing action?” I’m sure you
have been. A nurse can act in two ways: automatic or deliberative.
Consider the following example. You administer 3L of oxygen by nasal

cannula to a patient who complained to the physician of shortness of
breath. In this situation, the physician writes down an order to adminis-
ter 3L of oxygen by nasal cannula. Your carrying out of the physician’s
order describes an automatic action. This is an example of an “automatic
personal response.” The purpose of your action was to carry out the
physician’s order. In acting automatically, you may not have determined
why the patient was having shortness of breath, or whether oxygen ad-
ministration was appropriate as an initial intervention. Or you can say
that there was no client assessment done before you acted. Most likely,
you did not adequately meet the patient’s need for help.
The other type of response is deliberative. It is a “disciplined professional

response” which leads to effective nursing care. Orlando provides the
following principle to guide nursing actions: “The nurse initiates a pro-
cess of exploration to ascertain how the patient is affected by what she
does.”
For a nursing action to be deliberative, the following criteria must be met

(George, 1995, p. 167):
1. Deliberative actions result from the correct identification of patient

needs by validation of the nurse’s reaction to patient behavior.
2. The nurse explores the meaning of the action with the patient and its
relevance to meeting a need.
3. The nurse validates the action’s effectiveness immediately after com-
pleting it.
4. The nurse is free of stimuli unrelated to the patient’s need when per-
forming the action.
The deliberative nursing approach provides the explanation for the nurse-
patient relationship. Nursing interaction is necessary to ascertain that the
needs of the patient are met. These concepts support Orlando’s belief about
nursing—that nursing is unique and independent because it concerns it-
self with an individual’s need for help, real or potential, in an immediate
situation. Orlando’s view defines the nursing function as being “concerned
with providing direct assistance to individuals in whatever setting they
are found for the purpose of avoiding, relieving, diminishing or curing
the individual’s sense of helplessness” (George, 1995, p. 161).
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The need for help is equated with the sense of helplessness. This helpless-
ness reflects a patient behavior causing the interaction discipline to begin.
Interaction serves as a tool for nurses to fulfill their function. The purpose
of the interaction process discipline is to meet the patient’s immediate
need for help. The patient’s need will be considered resolved when there
is an improvement in the patient’s behavior (of helplessness).
Patient behavior serves as an expression of the need for help. It may be

verbal or non-verbal. Verbal behavior utilizes the patient’s use of language.
Non-verbal expressions may take the form of complaints, requests, refus-
als, demands, or physiological manifestations, such as increased heart
rate, perspiration, or difficulty of breathing. When there is ineffective ex-
pression of patient behavior, problems in nurse-patient interaction may
arise. The behavior may not communicate the need or the nurse may
inaccurately identify the patient’s behavior. This ineffectiveness may
prevent the nurse from doing her function. Priority should be given to
dealing with this ineffective nurse-patient relationship to prevent a wors-
ening situation.
Let us illustrate further the above concepts. Answer the following SAQ.
SAQ 4-8
Cite clinical examples of patient behaviors as expressions of the
need for help in the following case situations:
1. An elderly patient with COPD (chronic obstructive pulmonary

disease) having difficulty breathing
2. An immobilized patient post major surgery
3. A middle-aged male patient admitted for fatigue on exertion

and chest discomfort
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Module 4 131
I am sure that you can think of many more situations pertaining to pa-
tient behaviors as expressions of the need for help. Compare your an-
swers with mine. See ASAQ 4-8.
Let me follow up that exercise with another SAQ.
SAQ 4-9
Given the above situations, when can you say that the nurse’s re-
action follows the deliberative approach?
See ASAQ 4-9 to find out how you did.
The expression of a patient’s behavior stimulates a nurse’s reaction, which

now marks the beginning of the nurse-patient relationship. There are three
sequential parts to the nurse’s reaction (George, 1995, p.164):
1. The nurse perceives the behavior through any of her senses.

2. The perception leads to automatic thought.
3. The thought produces an automatic feeling.
Recall the given example of the immobilized patient. When the nurse sees
the patient grimace, the nurse thinks he is in pain. The nurse validates
this thought to ascertain that the problem has been correctly identified.
The nurse does not assume, but rather validates observations. By virtue of
education and training, the nurse has competencies to validate observa-
tions and come up with logical explanations.
Once the nurse has validated the patient’s behavior through exploration,
then the nurse’s deliberative action follows. Orlando emphasized patient
participation in planning care by allowing the patient to give feedback.
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The paradigm below highlights Orlando’s key concepts, based on the above
discussion.
Patient has a need

Patient Behavior: Sense of Helplessness
Nurse validates to correctly identify the problem

Nurse Reaction: Exploration with the Patient
Nurse performs a deliberative action -

interactive, disciplined, requires training
Nurse Action: Deliberative Approach
The need for help is relieved

Resolution: Improvement in Health
Figure 4-7. Key concepts as proposed by Orlando
The over-all characteristics of the nursing process and Orlando’s nurse-

patient process discipline are similar. Both require deliberate intellectual
processes, and are described in a series of sequential steps (see Figure 4-8).
Evaluation is inherent in Orlando’s nurse-action phase. For the action to
be deliberative, the nurse must evaluate its effectiveness when it is com-
pleted. It appears, however, that the nursing process outlines a more for-
mal and detailed process.
Nursing Process Orlando’s Process
Assessment Nurse Reaction

(explored with patient; encouraged
patient participation)
Nursing Diagnosis
(patient problem)
Planning
(goals/objectives) Need for Help
Implementation
(selection/carrying planned action)
Nurse Action
Evaluation (all actions directed at resolving
immediate need for help)
Figure 4-8. Features of the nursing process and Orlando’s process discipline
(Adapted from George, J.B. (Ed). (1995). Nursing theories: A base for profes-
sional practice. Connecticut: Appleton and Lange, p. 170.)
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Module 4 133
Orlando’s theory is useful in nursing practice. It guides nurses through

their interactions with patients. In practice, it assures holistic and indi-
vidualized care. The theory asserts nursing interdependence as a profes-
sion. The interactive nature of the theory has its strengths, as well as limi-
tations. There may be limited application in the area of physical care like
nursing practice in intensive care units, and in areas of long-term plan-
ning.
The nurse-patient relationship theory is consistent with the interaction

theory and can serve and guide nursing practice.
SAQ 4-10
Use the model (Figure 4-5) to interrelate the concepts in Orlando’s
Dynamic Nurse-Patient Relationship Theory. Again, try doing this
exercise on your own, then validate your answer by looking at
ASAQ 4-10.
Goal Attainment Theory

(King, 1981)
The nature of bedside nursing care places the nurse in a strategic position.
You are usually the first health professional to meet the patient (client). It
is possible that you and the patient are looking at the same situation, but
you perceptions of the situation differ.
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Consider this example. A post-thoracic surgery patient may not want to

be moved due to discomfort and pain. You may have observed that even
a slight movement can make post-thoracic surgery patients complain. Yet
the nurse thinks that coughing exercises and turning to sides may be ben-
eficial. To the nurse, these actions are important since these will improve
circulation and thus facilitate early recovery. The patient may not know
the implications of prolonged immobilization; complications like pneu-
monia may develop. Both nurse and the patient realize that something
has to be done. However, they differ in the perception of the situation.
Communication may be initiated, but may not be effective. A reciprocal
relationship and a shared perception of the situation are required for
goal attainment; then interaction can be said to be effective. The nurse
should clarify to the patient the reason why coughing and turning to
sides are important. This way, a common perception is developed in both.
Nursing, according to King (Parse, 1987, p. 113) is a process of human

interaction between the nurse and the client whereby each person per-
ceives the other and the situation, and through communication, they set
goals, explore the means to achieve them, agree to the means, and per-
form appropriate actions. These processes indicate movement toward goal
achievement.
Goal achievement is explained by a background framework. Let us go

over the highlights of this framework. This will enhance understanding
of the theory. A conceptual framework provides a system of organizing
concepts. It provides explanations for the essential elements or compo-
nents of the framework. Basic to King’s conceptual framework are
several assumptions. The assumptions state that human beings are open
systems in constant interaction with their environment; that the focus of
nursing is on human beings interacting with their environment; and that
the goal is to help individuals and groups maintain health.
Nursing Focus Human Beings Interacting

with Environment
Nursing Goal Health Maintenance

(Individual and Groups)
Three interacting components are present in King’s theoretical framework

(Table 4-2)—personal systems, interpersonal systems and social systems.
Specific elements or concepts characterize each of these components.
I look at the interacting components as a core expanding to a bigger sys-

tem which is organized and regulated. Think about the ripples that are
created when a pebble is thrown into a body of water. The ripples are
organized and regulated from the center out.
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Table 4-2 will introduce you to many new terms. Don’t be intimidated—
we will discuss these concepts in the following pages and you will have a
clearer understanding of the theory.
Table 4.2. Interacting components and elements of

King’s theoretical framework
Components Elements / Concepts
Personal Systems a. perception – influences all behaviors

— when personal systems b. self – person’s awareness of his
come in contact with one existence
another, they form inter- c. growth and development – cellular,
personal systems molecular, and behavioral changes in
human beings
d. body-image – changes as person
redefines self
e. space – physical area or “territory” and
corresponding behavior of those who
occupy it
f. learning – treated as a subconcept
g. time – duration between events as
experienced by human beings
Interpersonal Systems a. interaction – values and mechanisms

— formed by human beings for establishing human relationships
interacting: b. communication – verbal, non-verbal,
2 interacting individuals - dyad situational, transactional, moves
3 interacting individuals - triad forward in time
4 or more interacting individuals c. transactions – process of interaction
– small to large groups d. role – functions as “giver” and “taker”
e. stress – objects, persons, events that
evoke energy response from the person
Social Systems a. organization – structure, roles,

– organized boundary system positions, resources
of social roles, behaviors, b. authority – observable, provision of
practices developed to maintain order, guidance, responsibility of
values and the mechanisms to actions, reciprocal/cooperation
regulate the practices and rules c. power – capacity to use resources to
achieve goals
d. status – position in group in relation
to others
e. decision-making – dynamic, systema-
tic, goal-directed choice of alternatives
Adapted from George, J.B. (1995). pp. 212-213
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Pause for a few minutes. Read the SAQ below. I’m sure that this will help
you organize your thoughts at this point.
SAQ 4-11
Using Figure 4-1 as a guide, picture in your mind how you can put
together the three interacting components of King’s conceptual
framework. Write them down to illustrate your idea through a
model or a paradigm. Compare your idea with my conceptuali-
zation in ASAQ 4-11.
All of the elements or concepts mentioned are interrelated in the human-

environment interaction. Each integrating system is composed of major
elements. Perception, a major element in personal systems, influences all
behaviors. It is universal (experienced by all), subjective, selective for each
person, and action oriented based on the information available. Percep-
tion is involved in transactions where individuals are active participants.
It involves a process where data obtained by the senses are processed,
organized, and transformed.
Interaction is an element of the interpersonal system. It is influenced by

perceptions and characterized by values. Interaction is a mechanism for
establishing human relations through verbal and non-verbal communica-
tion, and includes learning when communication is effective. Interaction
is also defined as the observable behaviors of two or more persons in mu-
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Module 4 137
tual presence. Communication has several characteristics. It may be ver-

bal or non-verbal. Touch is a form of non-verbal communication, as well
as distance, posture, facial expression, physical appearance, and body
movements. Transaction refers to the process of interaction in which hu-
man beings communicate with the environment to achieve goals that are
valued. It encompasses all goal-directed human behaviors.
The elements of the social systems also include those of the personal and
interpersonal systems. Social systems include families, religious groups,
educational systems, work systems and peer groups. King proposed four
parameters for organization (George, 1995, p. 215):
1. Human values, behavior patterns, needs, goals, expectations

2. A natural environment in which material and human resources are
essential for achieving goals
3. Employers and employees, or parents and children, who form groups
that collectively interact to achieve goals
4. Technology that facilitates goal attainment
Organizations are made up of human beings who have prescribed roles

and positions and who make use of resources to meet both personal and
organizational goals.
Goal attainment
The major elements of the theory of goal attainment are seen in the inter-
personal systems. Two people, the nurse and the patient, come to a health
care organization to help and be helped in order to maintain a state of
health that allows functioning (King in George, 1995, p. 217).
Goal Attainment Theory Interpersonal Systems

Focus – the practice of nursing is
differentiated from that of
other health professions by
what nurses do with and
for individuals.
Reading through the elements of goal attainment, I thought of presenting

the interrelatedness of these concepts through a circular model (Figure
4-9).
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Interaction
Transactions Perception
(observable behavior of (person’s representation
human beings) of reality)
communication
Role (information between
(behaviors expected of persons Interrelatedness of persons)
in a social system) elements in every
nursing situation
Time
Stress (sequence fo events)
(dynamic state, human being
interacting with environment) Personal space
(physical area or territory)
Growth and development

(continuous changes in the
person – physiological/
behavioral)
Figure 4-9. Elements of goal attainment theory
Interaction (Figure 4-10) is defined as a process of perception and com-

munication between a person and the environment or between persons
represented by verbal and non-verbal behaviors that are goal directed
(King 1981 in George 1995, 217).
In the interaction process as explained by King’s theory, individuals have

different ideas, attitudes and perceptions. The individuals come together
for a purpose and perceive each other; each makes a judgment and takes
mental action or decides to act. Each then reacts to the other and the
situation. It brings about the following elements—perception, judgment,
action, reaction (see Figure 4-10). According to King, only interaction and
transaction are directly observable.
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Module 4 139
“Observable behaviors of human beings with their environment”
Action Reaction Interaction Transaction

(Goal Outcome = HEALTH)
— ability to function in social roles
Figure 4-10. Interaction process as proposed by King

(Adapted from George, J.B. (1995). p. 218.)
Communication refers to the “process whereby information is given from

one person to another either directly in face-to-face meetings or indirectly
through telephone, television, or the written word” (King in George,
p. 217). Communication is the information component of interaction. Let
me explain further. Transactions represent the valuation component of
human interactions and involve bargaining, negotiating, and social ex-
change. When transactions occur between nurses and clients, goals are
attained.
King’s operational definition of transaction describes further the elements

of interaction (see Figure 4-11). These elements are:
Action
Reaction
Disturbance (problem)
Interpersonal dyad
(nurse-client)
Mutual goal setting or decision-making
in Interaction
Exploration of means to achieve the goal
Agreement on Means to Achieve the Goal
Transaction (directly observable)
Goal Attainment
Figure 4-11. King’s definition of interaction and transaction

(Adapted from George, J.B. (1995). p. 217.)
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SAQ 4-12
How will you translate or interpret your understanding of the con-
cept of goal attainment? Illustrate this through a model or para-
digm.
(Hint: Build on the model we made in SAQ 4-11).
I’m sure that you were able to illustrate the general idea of goal attain-
ment. Did you note that it was a building up process from the paradigm
you developed in SAQ 4-11?
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Module 4 141
Elements
The elements of the conceptual framework further explain the concept of
goal attainment. The assumptions about human beings, health, environ-
ment/society, and nursing, according to King are the following (King in
George, 1995, p. 221):
1. Human beings are social, sentient, rational, reacting, perceiving, con-

trolling, purposeful, action-oriented and time-oriented. Human beings
have three fundamental health needs:
a. the need for health information that is usable at the time when it is
needed and can be used
b. the need for care that seeks to prevent illness
c. the need for care when human beings are unable to help them-
selves
Nurses, according to King, are in a position to assess what people

know about their health, what they think about their health, how
they feel about it, and how they can act to maintain it.
2. Health is a functional, holistic state. Illness is an interference of that

functional state. Health refers to the dynamic life experiences of a
human being, which call for continuous adjustment to stressors in the
internal and external environment through optimum use of one’s re-
sources. This allows the achievement of the maximum potential for
daily living.
3. Environment was described by King as a function of the balance be-

tween internal and external interactions. The term is often used to
refer to the external environment. The idea of open systems proposes
that each system or unit has a boundary that separates internal com-
ponents from other existing boundaries. The external environment of
a system is the portion of the world that exists outside the boundary.
In King’s theory, the term environment is not clearly defined and cor-
related with other major components.
Nursing is defined as “a process of action, reaction, and interaction

whereby nurse and client share information about their perceptions in
the nursing situation.” Nursing is also defined as “a process of human
interaction between nurse and client whereby each perceives the other
and the situation; and through communication, they set goals, explore
means and agree on means to achieve goals” (King in George, p. 222).
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Relationship with nursing process

The nursing process is a series of thoughts and actions to attain a goal.
This description is similar to the theory of goal attainment—that nurses
and clients communicate information, set goals mutually, and then act to
attain those goals.
Presented here is an illustration of these correlations:
Nursing Process Theory of Goal Attainment
Assessment Interaction of nurse and client [action and

reaction: perception, communication,
interaction]
Nursing Diagnosis Information shared during assessment

[identification of disturbances or concerns about
which patients seek help]
Plan of Care Decision-making about goals

a. Exploration of means to achieve goal
b. Identification of means
Implementation Transactions
Evaluation Attainment of outcomes

Evaluation of effectiveness of nursing care
King described an application of her theory of goal attainment in the use

of “goal-oriented nursing records.” This is similar to nursing records used
to document the nursing process (George, 1995, p. 224).
Utilization
The theory of goal attainment may be applicable to any dyadic nursing
situation. It can be used to guide and improve nursing practice. There are
several hypotheses derived from the theory of goal attainment (George,
1995, p. 225). Some are presented here:
1. Mutual goal setting will increase the ability to perform activities of

daily living.
2. Mutual goal setting by the nurse and patient leads to goal attainment.
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Module 4 143
3. Goal attainment will be greater in patients who participate in goal

setting than in those who do not participate.
4. Mutual goal setting will increase the elderly patient’s morale.
5. Goal attainment decreases stress and anxiety in nursing situations.
To summarize, the framework of the theory of goal attainment consists of

three interacting systems—personal, interpersonal and social—which are
in continuous exchange with their environment. The open systems frame-
work provides an explanation for the interaction of the systems. (The
open system theory will be discussed further in a separate module.)
From the interplay of the three systems, abstract conceptualization of

human beings, health, environment and society provided the framework
for King’s theory of goal attainment. The major concepts of the theory of
goal attainment are interaction, perception, communication, transaction,
role, stress, growth and development.
Comparison of the major components of the theory of goal attainment

and the nursing process shows how the theory can be applied in nursing
process situations.
SAQ 4-13
Use the model guide (Figure 4-5) to summarize and interrelate the
propositions in King’s Theory of Goal Attainment.
Compare your answers to mine. See ASAQ 4-13.
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Summary
1. Four theories explaining nurse-client dynamics provided the content
of Module 4. Insights from historical perspectives serve to explain the
development process of the interaction theories.
2. Some conceptualization and interpretation processes were included.

A model (Figure 4-5) with five main questions provided a framework
for comparing, contrasting and explaining the interrelatedness of the
concepts and propositions.
3. The key points of the four theories are: the interpersonal process is a
maturing force for personality (Peplau), the interpersonal process
alleviates distress (Orlando), transactions provide a frame of refer-
ence toward goal setting (King), and caring is a moral ideal of mind-
body-soul engagement with another (Watson).
4. A summary table (Table 4.3) featuring salient points is given at the

end of this module.
What can we derive so far from the interaction (nurse-client dynamics)

theories? Nursing is a deliberate process which can be described in differ-
ent ways. Nursing encompasses two important key concepts—help and
assistance. Nursing is an interpersonal process occurring between a
person (client/or patient) needing help and the nurse (professional) pro-
viding assistance and services (caring).
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Table 4.3 Summary
Peplau Orlando King Watson
Interpersonal Relations Dynamic Nurse-Patient Goal Attainment Essence of Caring

Relationship Interaction Process
Assumptions The purpose of nursing is to Nurse deals with the Health is an outcome; so Caring is central to nursing.
educate and be a maturing individual when there is is ability to function in The purpose of caring is to
force, so that the patient a need for help. The social roles. Transaction assist the person gain control,
(person) gets a new view (individual’s) sense of between nurse and become knowledgeable and
of himself. helplessness explains the patient allows for mutual promote health changes. The
concept of health or illness. goal setting for attainment person is viewed as fully
of outcomes. functional integrated self.
Concepts Phases of nurse-patient Nursing is unique and inde- Interaction is a process Caring can be effectively
relationship: pendent and efforts to meet of communication bet- demonstrated and practiced
a. Orientation the individual’s needs for ween person and environ- only intepersonally. Health
b. Identification help are carried out in an ment, and person to per- refers to a general adaptive-
c. Exploitation interactive situation and in a son, represented by verbal maintenance level of daily
d. Resolution disciplined manner that and non-verbal behaviors functioning. Environment
requires proper training. that are goal-directed. and society provide values
Deliberative nursing action Transaction refers to the that determine how one
results from correct identi- observable behavior of should behave and what
fication of patient needs. human beings interacting goals to attain.
with their environment.
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Module 4
145
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146
Table 4.3 continued
Peplau Orlando King Watson

Comparison Is sequential and focused Is interactive Organization of thoughts Identical with scientific pro-
with the on the therapeutic interac- Assessment — nurse and actions to attain a cess the purpose of which is
Nursing tions; uses problem sol- reaction goal; nurse and client to solve a problem or answer
Process ving through observation, Diagnosis — need for help communicate information, a question
communication, recording, Implementation — nurse set goals mutually, act to
as basic tools for nursing action attain goals
Strengths and Theory was introduced Deals largely with the inter- Environment and society Uniqueness: the carative
Weaknesses early, before the focus on action between the nurse have limited elaboration factors form the structure for
nursing research; con- and the patient in an imme- in relation to external envi- the science of caring; “caring”
crete descriptions are diate situation; does not ronment has many dimensions
further needed discuss nursing action
with families and groups;
The interpersonal does not include long-term
process is an integral part planning
of present day nursing
Application Communication and Nursing practice: when Applicable to any dyadic Holistic care
interviewing skills remain patient is admitted, dis- nursing situation (pro- Psychological needs of
fundamental nursing tools. charged or in need of imme- posed hypotheses are persons
Studies on anxiety and re- diate attention for a help- listed in the module text)
lated nursing interventions lessness behavior
are part of its clinical prac-
tice application
Module 4 147
ASAQ 4-1
Check whether your answers reflect the following.
The need to prepare nurses at the graduate level for administrative and
faculty positions determined the development of nursing theories and
nursing science. For nursing to develop fully as a profession, theory, de-
velopment and testing/grounding (the research component) must go hand
in hand. Research findings must be the guiding force to refocus theory
development and nursing practice. It must be remembered that in all these,
nursing practice becomes the outcome criterion. Values derived from such
study should benefit the recipients of care.
The interaction theorists utilized their nursing practice experiences to draw

implications and propositions, and develop a process of inquiry as to how
nurses do whatever it is they do.
When a nurse meets the patient for the first time, an interaction begins
between the care provider (the nurse) and the person (patient/client) with
a health problem or a symptom experience. The nurse is viewed as a com-
petent person capable of providing care. This process may be valued as
an interaction when properly recognized, structured, and evaluated. The
process when analyzed provides an explanation of the “how” of nursing.
When we gain insight about another person’s feelings and thoughts, we
are able to anticipate the other’s behavior and act accordingly.
What have you deduced from the above statements? Do you see that we
should be concerned not just with the patient’s problems but also the
person having the problem? Do you see the changes that have occurred
in the practice of the nursing profession?
ASAQ 4-2
This is the case of the 46-year old, obese woman in the OPD with a BP of
165/100 mmHg, who is anxious, agitated, high strung.
Your client is in need of immediate help. Trust between client and nurse
must exist. The nurse must be competent, adequately prepared and aware
of her role. The nurse is the knowledgeable person who begins and sus-
tains a therapeutic and interpersonal relationship. During the orientation
phase, the nurse assists the patient by orienting her to the problem. The
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patient is allowed to express herself, verbalize her emotional state. True,

the problem is increase in BP, however, note that the patient is anxious.
Resolving this anxiety may help both nurse and patient get a good grasp
of the extent of the problem. The patient needs to understand the extent
of the need for help. Once a certain degree of orientation is achieved, the
nurse assures the patient that she (nurse) understands the meaning of the
situation and is in a position to help.
ASAQ 4-3
Other than trust and maturity, name other components essential for ef-
fective interaction. Think of the role of communication. Allowing the pa-
tient to express herself, to ask questions, is essential. The nurse clarifies.
When goals are congruent and understood by both, an interpersonal rela-
tionship is developed. The idea is for the nurse to be competent enough to
provide and sustain an interpersonal and therapeutic relationship.
ASAQ 4-4
I’m sure your concept of “caring” is very interesting. Share this with your
peers. You will learn that there are perceptions of caring that are com-
mon to a group. Take time to discuss them. For now, did it make you
ponder the word “caring”? I’m sure you have been through a lot of
caring situations where you received or provided care to others.
Did you relate to the three philosophical foundations of the carative fac-
tors? To review, these are:
1. Formation of an altruistic value system

2. Faith-hope
3. Cultivation of sensitivity to self and others
The question makes me recall the caring persons close to me, as a child
and now as a mother. Their genuine concern strikes me. I also believe that
as a nurse the three factors above are very important in interacting with
patients and promoting their self-worth.
ASAQ 4-5
In Maslow’s hierarchy of needs, the lower level needs have to be met first
before the higher level needs. According to Watson (George, 1995) the
needs are interrelated.
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Module 4 149
For example, the need for air, nutrition, fluid, and safety, are lower order
biophysical needs that have to be met first. However, the presence of clean
air, the intake of good food, and the provision of safety, are strongly re-
lated to concern, love, security, culture and self concept. Caring suggests
that the nurse assist the client in recognizing the inter-relatedness of needs
in order to reach the higher order need of self-actualization.
ASAQ 4-6
The carative factor on promotion of interpersonal teaching-learning al-
lows persons (clients) to gain control over their own health. Through the
teaching-learning process, cognitive information and alternatives are
gained by the person as basis for effective decision-making. The nurse’s
task is to gain insight about the person’s perception of the situation so
that a workable cognitive plan can be developed between the nurse and
the person (client).
ASAQ 4-7
Watson’s Essence of Caring Theory
Nurse Client (Patient)
• Nurse provides • Caring: interpersonal • Different level

environment for process needs: lower
decision-making, • Responsiveness level needs
better self-control, between nurse and (biophysical) to
promoting self- client higher level
respect needs
Process
• Essence of caring
• Carative factors
• Satisfaction of certain
human needs
• Core of caring –
intrinsic to nurse-client
relationship
• Therapeutic result
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ASAQ 4-8
Patient behaviors expressing the need for help:
1. When the elderly patient with COPD slumps on a chair, holds her
breath or stops between verbal responses when answering questions
asked by the nurse.
These are examples of non-verbal forms of patient behavior indicating

difficulty in breathing and anxiety.
2. When the immobilized patient rings the call bell several times and
complains of pain or asks many questions.
These are examples of verbal and non-verbal behavior indicating dis-

comfort, pain or need to be turned.
3. When making a statement like “I’m here only for a couple of days for
check-up.”
This is a verbal expression of denial which may indicate the need for
information about the condition causing chest discomfort.
ASAQ 4-9
Recall the criteria for deliberative approach given at the beginning of the
discussion.
Initiating a process of exploration is crucial. It leads to correct identifica-

tion of the patient’s needs. I prefer to call it a correct interpretation of the
patient’s problem. For example, in the situation where a patient with COPD
has difficulty breathing: as a deliberate action, the nurse assesses the pa-
tient by using two common parameters—eliciting a good patient’s history
and performing a physical examination.
Did it make you recall the assessment phase of the nursing process? Good!
You will learn that the interaction theories have corresponding correlates
in the nursing process.
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Module 4 151
ASAQ 4-10
Orlando’s Dynamic Nurse-Patient Relationship Theory
• Nurse reaction Beginning of • Nurse reaction

Interaction Discipline
Exploration
• Direct assistance • Sense of helplessness
Deliberative Actions
• Meets the patient’s • Learns about the problem
need for help and extent of help needed
Resolved
Several explanations can be derived from this mapping of concepts. Re-

member that you can at this point derive implications too about the inter-
relationship between man, health, environment, and nursing.
ASAQ 4-11
Conceptual frameworks help organize ideas. Your organization of the
three interacting components may be similar to this paradigm below. The
main goal is for you to have a clear picture of how these elements interact
to provide direction and explanation.
Personal System Personal System

Interpersonal
(the nurse) (the patient/client)
System
Social System
I’m sure you can correlate this paradigm with the model given at the
beginning of this module.
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ASAQ 4-12
Start from the one you made for SAQ 4-11. This second paradigm should
include the elements of the major concepts and components. Write the
elements that you can recall. Provide explanations for the propositions.
We said earlier that propositions explain the interrelatedness of the con-
cepts.
Elements Theory of Goal Attainment

(Adapted from Parse, 1987, 112)
Transactions
Elements
Perception Perception
or
Nurse communication Client communication
Components
Mutual goal
setting
Think about the idea of the open systems elements from which King de-
rived these concepts. The concepts of the open systems theory will be
presented in a separate module. This gives you a chance later on to make
further synthesis.
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Module 4 153
ASAQ 4-13
King’s Goal Attainment Theory
• To help Perception • To be helped

Communication
Interaction
(DYAD)
• Organization of • Behaviors: verbal and

thoughts and non-verbal
actions
Transactions
Mutual goal setting
Goal Attainment
• Effectiveness of nursing care
• Attainment of outcomes
• Patient’s ability to function in
social roles
Build up your explanations from the above concept maps. How did King
elaborate on the interplay of the elements—man, health, environment,
nursing? Cite examples of how transaction can promote mutual goal set-
ting. Think in particular about a post-operative patient. What outcomes
will you extract?
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References
Chinn, P.L. and Kramer, M.K. (1991). Theory and nursing: A systematic
approach. St. Louis: C.V. Mosby.
Christensen, P.J. and Kenny, J.W. (1990). Nursing process—application of
conceptual models. 3rd edition. St. Louis: C.V. Mosby Co.
Garvin, B.J. and Kennedy, C.W. (1990). Interpersonal communication
between nurses and patients. In Annual Review of Nursing Research.
(J.J. Fitzpatrick, R.L. Taunton and J.Q. Beroliel. Eds.), Vol. 8 (pp. 213-
234). New York: Springer Publishing Co.
George, J.B., (Ed). (1995). Nursing theories: A base for professional nursing
practice. Connecticut: Appleton and Lange.
Fitzpatrick, J.J. and Whall, A. L. (1983). Conceptual models of nursing: Analy-
sis and application. Maryland: Robert J. Brady Co.
Laurente, C.M. (1996). Effects of caring behaviors of nurses on anxiety of
clients in the emergency room. Unpublished doctoral dissertation, Uni-
versity of the Philippines Manila. College of Nursing.
Marriner-Tomey, A. (1989). Nursing theorists and their work. 2nd edition.
St. Louis: Mosby.
Meleis, A.I. (1991). Theoretical nursing development and progress. 2nd edi-
tion. Philadelphia: J.B. Lippincott.
Parse, R.R. (1987). Nursing science major paradigms, theories and critiques.
Philadelphia: W.B. Saunders.
Spross, J.A. and Baggerly, J. (1989). Models of advanced nursing practice.
In The clinical nurse specialist in theory and practice. (A.B. Hamric and
J.A. Spross. Eds.), pp.19-40. New York: Springer Publishing Co.
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Module 5 155
Module 5
Client-Nurse-Environment
Dynamics
Cora A. Añonuevo
Objectives
Nurse Client
At the end of this module, you
should be able to:
1. Discuss the historical

Environment backgrounds of
Leininger’s Theory of
Culture Care and
Neuman’s Systems Model;
S ome of the nursing theories you studied in the
previous modules focused on man as a bio-
logical system, a behavioral composite and an or-
2. Discuss the major
assumptions of the
ganism with stages of development. The other Theory of Culture Care
modules discussed nursing theories that high- and the Systems Model;
lighted one-to-one client-nurse relationships 3. Explain key concepts
which depicted persons as interactive beings. and propositions relevant
to the above theories/
Two particular theories, those of Madeleine models;
Leininger and Betty Neuman, considered all these 4. Discuss the strengths and
dimensions simultaneously and comprehensively limitations of the above
within a cultural and systems perspective. They theories/models; and
viewed the environment as encompassing fam- 5. Describe a personal or
ily, society, culture, health care professionals, sig- work experience that will
nificant others, as well as the socio-economic and illustrate the key concepts
of the Leininger and
Neuman models.
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social conditions surrounding the client. Neuman asserted that man is in

constant interaction with the environment and that any change occur-
ring in one affects the other. Leininger stated that culture guides a par-
ticular group’s thinking, decisions and actions in patterned ways.
Leininger’s Theory of Culture Care

Look at the cartoon strip below (Figure 5-1). It tells you about childbear-
ing practices of women from three Filipino indigenous cultures—the
Negritos, the Ilongots, and the Badjaos. In what ways are they different
from each other?
Figure 5-1. Childbearing practices in different cultures in the Philippines
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Module 5 157
The first frame illustrates the childbearing ways of Negrito women. The
mother sits down on her heels when her child is being born. The Negrito
mother brings forth her child kneeling down on the floor and she is as-
sisted by women who have the necessary experience in delivering babies
(Morales and Monar, 1979).
A pregnant Ilongot woman, shown in the second frame, has usually no

need of a midwife to assist her during delivery. The moment she feels that
delivery is near, she proceeds to a tree in the premises and stands beside
it, holding on to its trunk (Anima, 1978).
It is different among Badjao women (third frame). The moment the ex-
pectant mother feels labor pains, the midwife is notified immediately by
any member of the family. As the baby emerges, every member of the
family is exceedingly happy and joyful. Neighbors make noises like tap-
ping the floor, yelling and beating a drum or a gong signifying that the
baby has come out alive and kicking (Teo, 1989).
Madeleine Leininger introduced the concept that care and health prac-
tices have cultural dimensions. Although I cited indigenous cultures as
examples, in this modern day and age, nurses encounter different kinds
of clients in different health care settings.
There may be instances perhaps, that in your interactions with your cli-
ents, you found some of them difficult, demanding, or passive. You must
have felt exasperated with the way these clients behaved and reacted
even to your “tender loving care.” You must have asked, who really is
causing the problem here—the client or myself, the caregiver? Am I being
sensitive to the needs of my clients? You, as a nurse, should be especially
aware of the cultural aspects of nursing care because you have constant
and more direct interactions with clients compared to other members of
the health team.
For many years, studies have been conducted along this line of thinking
with the purpose of helping nurses work more effectively with clients
from different cultures. The work of Leininger on human care theory was
a result of extensive studies of many cultures, both western and non-west-
ern. Let’s now look at this theory more closely.
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Historical background of Leininger’s

Theory of Culture Care
How was the theory of Culture Care developed?
In the historical account that you are about to read, you will be amazed at
how Madeleine Leininger devoted her career to studying the cultural di-
mensions of human care and caring. Her theory was developed through
insights gained from personal experiences, extensive readings in anthro-
pology, and in-depth studies of the caring behavior and values of selected
cultures.
Personal experiences
Leininger first realized the importance of culture care to nursing practice

in the mid-1940s. She was then a young graduate staff nurse in a large
general hospital in the United States. While providing care, she received
different remarks and comments from her patients regarding the care she
provided and realized that there were differences in the way patients
responded to her caregiving practices. She thought that being sensitive to
their responses was important to human care. During that time, many
nurses like her believed that caring meant spending time with patients
and listening to their stories about themselves, their families, work and
home life.
During the mid-1950s, while working as a psychiatric clinical nurse

specialist in a child guidance home, she observed recurrent behavioral
differences among the children she looked after. She concluded that these
differences in the way they played, ate, slept, and interacted were rooted
in their culture. On the other hand, she identified in the staff a lack of
knowledge of the children’s cultures as the reason why nurses were un-
able to respond appropriately to the children’s behavior and expressed
needs. This time, she recognized the need to develop nursing strategies
that would incorporate different cultures, patterns and lifeways. Toward
this end, Leininger pursued doctoral studies at the University of Wash-
ington, focusing on cultural anthropology (George, 1990).
So you see that Leininger was always keen on developing insights from
her experiences as a professional nurse and on exploring the “whys and
wherefores” of her clients’ behavior.
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Module 5 159
In 1978, Leininger defined 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 practices, beliefs, and values with the
goal to provide meaningful and efficacious nursing services to
people according to their cultural values and health-illness con-
text.”
The term transcultural means across all world cultures. It applies to the
evolving knowledge and practices related to this new field of study and
practice. According to her, transcultural nursing theory and ethnoscience
methods allow one to discover and learn about people’s views and prac-
tice of caring. Ethnomethods use people-centered data sources that focus
on emic (insider’s) views, as opposed to the researcher’s etic (outsider’s)
views.
Leininger clarified that her Culture Care Theory was not just an applica-
tion of anthropological concepts to nursing. She explained that while the
roots of culture are discussed mainly in anthropology, and concepts of
care are discussed largely in nursing, the theory was developed to
discover knowledge that will serve mainly the discipline of nursing
(Leininger, 1991).
Well, you may be thinking that this mission that Leininger decided to
undertake was easy. But according to her, it took tremendous leadership
skills to introduce anthropological insights in nursing, and in the process
develop a Culture Care Theory. First, there were no nurses who had
interest in conceptualizing the actual or potential relationship between
anthropology and nursing. Second, after formulating and disseminating
some ideas and hunches related to her theory, there were still very few
nurses interested in “such a strange idea in nursing.” She realized that
“nurses relied too heavily on biophysical and psychological explanations”
with virtually no awareness of how culture could influence nursing and
nursing care.
Challenged as she was to continue developing her theory, she envisioned

helping nurses discover new knowledge and different perspectives of
nursing. Leininger encouraged many students and faculty to pursue gradu-
ate studies in anthropological nursing practice. She saw nursing in the
21st century as multicultural because of the global changes that would
bring people closer to each other due to changes in social, cultural, politi-
cal, economic, health care, and technological forces.
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SAQ 5-1
To summarize the discussions above, I prepared a number of state-
ments related to how Leininger developed her theory. Put a check
(ü) on those statements which you think are true and a cross (X)
on those which you believe are false.
Leininger developed her theory through:
1. working on the potential interrelationships between culture

and care through creative thinking
2. philosophizing from her past professional nursing experiences
3. applying anthropological concepts to nursing
4. formulating insights from her extensive knowledge on anthro-
pology and belief in the nature of nursing
5. pondering on the future of nursing as a discipline with its
instinctive knowledge
Check your answers against the key at the end of the module.
Leininger’s Theory of culture care

In this section of the module, you will have a glimpse of what Leininger
wanted to emphasize in her theory. She called her theory Culture Care
Diversity and Universality.
According to her, the purpose of the Culture Care Theory is to discover

human care similarities (universality) and differences (diversity) in rela-
tion to worldview, social structure and other dimensions. The goal of the
theory is to improve and provide culturally congruent care that is benefi-
cial, fitting, and useful to the client, family or culture group.
In conceptualizing the theory, Leininger held this as the central tenet:

Care is the essence of nursing, and is its central, dominant and unifying
focus. She stated that culture care would provide a distinctive feature by
which to know, interpret and explain nursing as a discipline and profes-
sion (Leininger, 1991, p. 35).
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Module 5 161
In her book, Leininger (1991, pp. 36-37) wrote about her insights and
beliefs regarding culture care:
“I viewed culture as learned and transmitted values, beliefs and

practices that provided a critical means to establish culture care
patterns from the people... Culture was seen as the blueprint for
living, remaining healthy, or for dying. Care was culturally de-
fined and known to the people and especially how they saw and
knew care from their context... And since human beings are born,
live, become ill, survive, experience life rituals and die within a
cultural care frame of reference, these life experiences have mean-
ings and significance to them ... Moreover, these cultural care life
experiences were influenced by specific cultural values, views about
the world, social structure factors, language, ethnohistory, envi-
ronmental context and health care systems. These dimensions
needed to be fully discovered over time to see their influence on
human caring, well being, health or illness and to use this know-
ledge in people caring modes.”
Leininger theorized that all cultures of the world had folk, indigenous
and naturalistic lay care systems and that some people were exposed to
professional health care systems. Folk and professional health care sys-
tems greatly influenced individual or group access to quality care in
favorable or less favorable ways. She further stated that what was simi-
lar or different between folk and professional systems was yet to be dis-
covered.
According to Leininger, the theory and its assumptive premises were best
discovered and confirmed continuously with the people in their familiar
and naturalistic context. She did not offer rigid theoretical formulations
or hypotheses for these were inconsistent with the inductive open discov-
ery method of learning.
To support her theory, she formulated several assumptive premises which

included (Marriner-Tomey, 1994):
1. Human caring is a universal phenomenon, but the expressions, pro-

cesses, structural forms, and patterns of caring vary among cultures.
2. Caring acts and processes are essential for human birth, development,
growth, survival, and peaceful death.
3 Care has a biophysical, cultural, psychological, social, and environ-

mental dimension, and the concept of culture provides the broadest
means to know and understand care.
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4. Nursing is a transcultural phenomenon as nurses interact with cli-

ents, staff, and other groups, and requires that nurses identify and use
intercultural nurse-client and system data.
5. Care behaviors, goals, and functions vary transculturally because of

the social structure, worldview, and cultural values of people from
different cultures.
6. Self and other care practices vary in different cultures and in different
folk and professional care systems.
7. The identification of universal and non universal folk and professional

caring behaviors, beliefs and practices is essential to discover the epis-
temological and ontological base of nursing care knowledge.
8. Care is largely culturally derived and requires culturally based knowl-

edge and skills for satisfying and efficacious nursing practices.
9. There can be no curing without caring but there can be caring with-
out curing.
SAQ 5-2
1. What is the purpose and goal of the Theory of Culture Care?
2. Explain the statement: There can be no curing without caring but

there can be caring without curing.
Perhaps you’ll be interested to know my own understanding of the above

statement. Turn to ASAQ 5-2 at the end of this module.
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Module 5 163
The Sunrise Model

Leininger depicted her theory using the Sunrise model. Examine the model
very well. What does this model suggest to you?
Cultural values and

d Po
an rs lifeways
leg litica
ip
in sh facto al l
fac and
K ial tor
c s
so
cto hi d
fa sop s an
rs cal
Ec fact
ilo ou
on ors
ph ligi
om
Re
ic
facto gical
Educ rs
Influences care
rs
nolo
facto
patterns and
ation
Tech
expressions
al
Health (well-being)
of
Individuals, families, groups and institutions

in
Diverse health systems
Folk Professional
Nursing
systems systems
Nursing care decisions and actions
Cultural care preservation/maintenance

Cultural care accommodation/negotiation
Cultural care repatterning/restructuring
Culture congruent nursing care
Figure 5-2. Leininger’s Sunrise Model to depict Theory of

Cultural Care and Universality (Source: Leininger, 1991)
Leininger viewed her model as “the rising of the sun.” The upper half of
the circle depicts components of the socio-cultural structure and worldview
factors that influence care and health through language and environ-
ment. These factors influence folk, professional, and nursing systems which
are in the lower half of the model. The nursing subsystem acts as a bridge
between folk and professional health systems. Through the three types of
nursing care decisions and actions, it is possible to provide culture con-
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gruent care that is beneficial, satisfying and meaningful to people. These

nursing decisions and actions are: cultural care preservation, cultural care
accommodation and cultural repatterning.
The arrows on the model indicate influences which flow in different ar-
eas and across major factors. The factors are closely interrelated to each
other, very much like a view of the total functioning of human beings.
The dotted lines indicate an open world or an open system of living. Do
you find the model helpful in capturing the essential dimensions or com-
ponents of the theory?
Let’s now focus on the three models of actions and decisions. I will first
give you Leininger’s definitions of the three modes. Then I will give my
own examples of how nurses provide care with cultural considerations.
Cultural Care Preservation or Maintenance refers to those assistive, sup-

portive, facilitative, or enabling professional actions and decisions that
help individuals preserve or maintain favorable health and caring lifeways.
A good example is promotion of breastfeeding practices. Another is main-
taining the involvement of families/relatives in caring for the client.
Cultural Care Accommodation or Negotiation refers to those culturally

based assistive, supporting, facilitative, or enabling professional actions
and decisions that help people of a particular culture adapt to, or negoti-
ate with others, a beneficial or satisfying health outcome.
We can cite as an example the training of hilots or traditional birth atten-

dants on the use of sterile techniques in delivering babies. We can also
consider a nurse’s action as negotiation when she advises a client about
the positive and negative aspects of seeking help from an indigenous spiri-
tual healer.
Cultural Care Restructuring or Repatterning refers to those assistive,

supportive, facilitative, or enabling professional actions and decisions that
help people change or modify their lifeways to accommodate new or dif-
ferent health care patterns that are culturally meaningful and satisfying
to them. For example, a client who is a chronic smoker can work together
with a nurse so that the former will stop smoking for his own health and
well being.
Leininger’s Sunrise Model guides nurses in discovering knowledge about

culture-specific care practices that can be used to improve nursing care.
In using this Model, you may work either from the top or bottom depend-
ing on the scope of your interest or inquiry. You may want to begin the
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Module 5 165
exploration by focusing your study on the care of individuals or groups in

hospitals or homes (lower part of the Model). Then you gradually move
the exploration upward to include specific cultures. Finally, you move on
to discover large scale phenomena including the worldview, cultural, and
social structural dimensions of several cultures (Leininger, 1991, p. 51).
Let me illustrate this by an example. You may be interested in discovering

the caring ways of the Aetas of Zambales in Central Luzon. Specifically,
you may want to explore their childbirth practices. Then you may want
to expand your study to include other Filipino indigenous cultures such
as the Mangyans of Southern Tagalog and the Tinguians of Northern
Luzon, or the Subanons and Maranaws of Mindanao because you want
to discover similarities and differences in childbirth folk beliefs, practices
and taboos. If you are interested in doing a large-scale study, then you
would look into the bigger aspects of life—economy or production, social
structure and political organization—and how these factors influence their
health, well-being, and caring practices.
SAQ 5-3
Leininger illustrated her theory using the Sunrise Model. Can you
think of another way by which the essential components of the
theory can be presented by means of a diagram? Try it.
UP Open University
SAQ 5-4
Below are examples of nurses’ actions and decisions. Identify which
of these illustrate (A) culture care preservation, (B) care accommo-
dation, or (C) care restructuring by writing your answer on the
blank before each statement.
_______________ 1. Allowing the display of religious relics

in a hospital room because these are sig-
nificant to the patient
_______________ 2. Planning a low-fat and low-cholesterol

diet with a family at risk for hyperten-
sion
_______________ 3. Encouraging use of herbal plants proven

useful for common ailments
_______________ 4. Allowing relatives to pray over a sick per-

son
_______________ 5. Teaching a young mother aseptic tech-

nique in cleaning her baby’s umbilical
stump
From 1960 to 1990, Leininger and other nurses studied 54 cultures in

Western and non-Western societies. They were able to identify 172 care
constructs with specific meanings, usages, and interpretations which can
guide nursing actions and decisions. The studies revealed in general that
(Leininger, 1991, p. 57-58):
1. Emic culture care knowledge from Western and non-Western cultures

showed more differences than similarities in culture values, usage,
and meanings;
2. The social structure and worldview of Western and non-Western cul-

tures strongly influenced care practices leading to health or well-be-
ing;
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Module 5 167
3. Major differences existed between the clients’ cultural care knowl-

edge (emic viewpoint) and that of professional nurses and other health
personnel (etic viewpoint) in hospital contexts; and
4. Culture care differences between the client and health personnel gave
rise to conflicts, stresses, noncompliance and slower client recovery.
Other theories generated by studies conducted by Leininger and several

graduate transcultural students reveal the following (George, 1996, p. 344):
1. Nursing care decisions or actions that reflect the use of the client’s
cultural care values, beliefs, and practices were positively related to
client’s satisfaction with care received.
2. High dependency of the clients upon technological nursing care ac-
tivities were closely related to cultural care that reflected decreased
personalized care actions.
3. Religion and kinship care factors were more resilient to change than
technological factors.
4. Self-care practices were evident in cultures that value individualism
and independence; other care practices were evident in cultures that
support human interdependence.

A major strength of Leininger’s theory is the recognition of the impor-
tance of culture in providing nursing care. Unlike other nursing theorists
who held that person, nursing, health, and environment are the basic
concepts in nursing, Leininger focused on care as the central aspect of
nursing. She asserted that the use of the term person may be controver-
sial particularly in non-Western cultures because the concepts of family
or institutions are more important and meaningful to them. She stated
that there are disciplines such as the humanities and the sciences which
already focus on man or person. She further said that while the concept
of environment is important to nursing, it is not really unique to the pro-
fession. She likewise believed that the concept of health is not distinct to
nursing because many disciplines and fields have studied health. She found
it senseless to define nursing as a distinct concept. The theory is useful
and applicable to both individuals and groups of clients because the goal
is the same—rendering culture-specific nursing care. The Sunrise Model
can be used as a guide for the study of any culture or for the comparative
study of several cultures.
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While this theory does not provide specific directions for nursing care, it
provides guidelines for the gathering of knowledge, and a framework for
decision-making that would be of great benefit to the client. Leininger did
not use the term nursing intervention because she believed that the term
communicates some sort of interference or imposition on people’s cul-
tural practices. Even the term nursing problems is not part of her vocabu-
lary for the reason that nursing problems may not necessarily be the
people’s problems; or the problems may be viewed differently by people
of different cultures.
If the theory can be applied in planned nursing experiences, it can help

nurses become culture-sensitive health care professionals. However, as
Leininger herself pointed out, there are only few nurses who are aca-
demically prepared to conduct transcultural investigations, the results of
which can contribute to the increasing knowledge about transcultural
nursing care.
Some critics of Leininger believe that her focus on culture omits other
variables such as class and gender differences which can be sources of
conflict and stress within a society and among people (Bruni, 1988 as
cited by Wilkins, 1993). Another comment is that culture-specific nursing
care may divert attention from the uniqueness of the individual. Wilkins
suggested that nurses should use cultural awareness, sensitivity and a
good knowledge base in asking the right questions so they can make a
realistic and proper assessment of the needs of each individual.
Activity 5-1
Interview at least two nurses working in a hospital or health cen-
ter. Ask them what problems they have encountered in providing
care to clients of different cultures, especially those whose values,
beliefs and practices differ from their own. Ask them also how
they reacted to or handled those differences. Perhaps it will help
you to write down the specific questions you may want to ask
during the interview. Then discuss briefly the interviewees’
answers to these questions.
UP Open University
Module 5 169

With this activity, I hope you can stimulate awareness of cultural
differences among your nurse-interviewees. You may discover that
some nurses tend to gloss over the existence of folk or traditional
care values and practices of their clients to the extent that they
experience stress when dealing with “difficult” clients. Hence, pro-
vision of appropriate care suffers. Nurses, I believe, must learn to
confront their own cultural biases and discrimination.
SAQ 5-5
How is Leininger’s theory different from the other nursing theo-
ries you studied in the previous modules? Give at least two diffe-
rences
Turn to ASAQ 5-5 at the end of this module and see how your answers
compare to mine.
Neuman Systems Model

Let me begin this section of the module by presenting briefly the historical
background of the Neuman Systems model. It all began as a response by
Betty Neuman (then a lecturer in community health nursing at the Uni-
versity of California, Los Angeles), to the expressed needs of graduate
students for a course that would expose them to the larger scope of nurs-
ing problems prior to focusing on specific nursing problem areas.
UP Open University
Neuman first presented her conceptual model in 1972, during the time
when several other conceptual models of nursing were being published
by King (1971), Orem (1971), and Rogers (1970). She explained that her
conceptual model was the result of her observations during her clinical
experiences in mental health nursing as well as from a synthesis of knowl-
edge from several theoretical sources, including Chardin (philosophical
beliefs about the wholeness of life); Marx (views of the oneness of man
and nature); Gestalt (interaction between person and environment);
Bertalanffy (general systems theory of the nature of living open systems);
Selye (concepts of stress); and Caplan (levels of prevention).
Neuman claimed her model was a comprehensive, wholistic view of the

client system. According to Cross (1990), Neuman applied the wholistic
perspective to her own life. She managed her time wisely. She maintained
a wellness program for herself. And she practiced marriage and family
counseling jointly with her husband.
SAQ 5-6
In not more than two sentences, summarize the factors that influ-
enced the development of Neuman’s Model.
The systems model as a conceptual

framework for nursing
According to Neuman (1989), the purpose of the model is to help nurses
organize their nursing actions within a broad systems perspective. The
model addresses the complexity of the health care system, not to mention
rapid societal changes and demands.
Her model, as shown in Figure 5-3, may look complicated but it is actually
based on just two major components: stress and reaction to stress. The
client (individual, group, community or society), is an open system in in-
teraction and total interphase with the environment.
UP Open University
Module 5 171
The environment is composed of forces both internal and external to the

client system. These factors have the potential to cause a reaction, such as
an obvious symptomatic reaction to stress. These can also affect reconsti-
tution following treatment of a stress reaction. The client system is there-
fore viewed as one that is capable of interacting and adjusting to the envi-
ronment which results in varying degrees of harmony, stability, or bal-
ance between the client and environment.
Primary Stressors Basic Structure

Stressor Stressor
prevention • Identified • Basic factors common to all
• Reduce • Classified as to known or organisms, i.e.
possibility possibilities, i.e., - Normal temperature range
of encounter - Loss - Genetic structure
with stressors - Pain - Response pattern
• Strengthen - Sensory deprivation - Organ strength
flexible line of - Cultural change - Weakness
defense - Ego structure
Inter - Knowns or commonalities
Intra Personal
Extra factors
Basic
Secondary Degree of Structure
prevention reaction
Energy
• Early case Reaction
Resources
finding
• Treatment of
symptoms Reaction
• Individual intervening
Reconstitution
variables
- Basic structure
indiosyncracies Stressors:
- Natural and learned • More than one stressor
Tertiary resistance could occur simultaneously
prevention - Time of encounter • Same stressors could vary
• Readaption with stressor as to impact or reaction
Reconstruction • Normal defense line varies
• Reeducation • Could begin at any
to prevent Inter with age and development
degree or level of reaction
future Intra Personal • Range of possibility may
Extra factors Note:
occurrences extend beyond normal line • Physiological,
• Maintenance of defense psychological, socio-
of stability Interventions cultural, development and
• Can occur before or after Inter spiritual variables are
resistance lines are considered simul-
Intra Personal taneously in each client
penetrated both reaction Extra factors concentric circle.
and reconstitution phases
• Interventions are based on:
- Indiosyncracies
- Degree of reaction
- Resources
- Goals
- Anticipated outcome
Figure 5-3. The Neuman Systems Model

(Source: Neuman, B. The Neuman Systems Model)
UP Open University
Basic assumptions
On what assumptions were the conceptual model based? Cross (1989)
summarized the assumptions which describe and link the concepts of the
model. As you read through the following statements, I suggest that you
refer again to the diagram (Figure 5-3) that shows the relationships bet-
ween the concepts.
1. Client systems are unique but each has a set of common known fac-
tors or innate characteristics within a normal range of responses con-
tained within a basic structure.
2. Environmental stressors exist. They vary in their potential for dis-

turbing a client’s normal lines of defense which in turn vary with age
and development. A client is protected by the flexible line of de-
fense against the stressor.
3. Each client has evolved a normal range of responses to the environ-

ment that is referred to as a normal line of defense, or usual wellness/
stability state.
4. The client, whether in a state of illness or wellness, is a dynamic com-

posite of the interrelationship of variables—physiological, psychologi-
cal, sociocultural, developmental, and spiritual. Wellness is the avail-
ability of energy that can support the system in an optimal state.
5. When the flexible line of defense is no longer capable of protecting

the client against the stressor, the latter breaks through the normal
lines of defense. The interrelationship of variables determines the
nature and degree of the system reaction to the stressor.
6. Within each client system is a set of internal factors known as lines

of resistance which stabilize and return the client to the usual state
of wellness following an environment stressor reaction.
7. Primary prevention relates to general knowledge that is applied in

client assessment and in identification and reduction of risk factors
associated with environmental stressors to prevent possible reaction.
UP Open University
Module 5 173
8. Secondary prevention relates to symptomatology following a reac-

tion to stressors, appropriate ranking of intervention priorities, and
treatment to reduce their noxious effects.
9. Tertiary prevention relates to the adjustive processes taking place as

reconstitution begins and maintenance factors move the client back
in a circular manner toward primary prevention.
10. The client is in dynamic constant energy exchange with the environ-
ment.
Activity 5-2
Take a few minutes to study Figure 5-3, The Neuman Systems
Model. How do you find it? Are the concepts and their relation-
ships easily identified in the diagram?

At first glance, I found the graphic presentation too complicated
to understand. After close scrutiny, I came to appreciate its whole-
ness and comprehensiveness. The figure helped me connect the
different concepts and how they relate to each other: stressors, the
person’s resistance and defenses, levels of prevention and factors
of reconstitution.
Neuman’s model and the four major concepts

For clarity, Neuman’s model can be segmented into four major concepts
of nursing: client, environment, health, and nursing. Let me give you
the important points under each major concept. Each concept is also ac-
companied by a simple illustration.
UP Open University
The client
Flexible line
Physiological
of defense
Normal line
of defense
Socio ua l
-cult
ural Spirit
Core Lines of
resistance
l
nta
Ps
p me
yc
elo
h
ev
ol
D
og
ic
al
Figure 5-4. Client/client system
The illustration has a core of basic structure and energy resources sur-
rounded by three concentric rings or circles. They function as protective
mechanisms for the basic structure, and maintain client system stability.
1. Flexible line of defense — forms the outer boundary of the client

system that protects the normal (solid) line of defense. It keeps the
system free from stressor reactions, or symptomatology. Its intensity
can change in a relatively short time and is dependent on such factors
as amount of sleep, level of nutrition, and quality and quantity of stress.
2. Normal line of defense — represents the client’s usual wellness level.

It includes such aspects as intelligence, attitudes, and problem-solving
and coping abilities.
3. Lines of resistance — form the last wall or boundary that protects

the basic structure. These lines consist of internal defensive processes
such as the body’s mobilization of white blood cells or activation of
immune system mechanisms.
The model contains five variable areas:
1. Physiological – refers to bodily structure and function

2. Psychological – refers to mental processes and functioning
3. Socio-cultural – refers to combined social and cultural functions
4. Developmental – refers to life developmental processes
5. Spiritual – refers to spiritual belief influence
UP Open University
Module 5 175
The client or client system is constantly subject to stressors from within

the system and from the environment. These stressors can cause disequi-
librium, situational crises, disease, or death.
The environment
S
T
R Extrapersonal
E
S
S Interpersonal
O
R Intrapersonal
Core S
Figure 5-5. Environment
The environment consists of internal and external forces or stressors. The

environment has the potential to alter system stability.
Stressors can be:
1. Extrapersonal — forces that occur outside the system, e.g., unem-

ployment, peer pressure, job performance, microorganisms, radiation
2. Interpersonal — forces occurring between one or more individuals,

e.g., parent-child expectations, developmental differences, conflicts
among colleagues
3. Intrapersonal — forces that occur within the individual, e.g., anger

or emotional status, physical abilities, financial condition
The environment provides resources for managing stressors and includes

various entities such as a functioning immunologic system, good coping
skills, strong family support, a community health center.
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Health
y Sta
mon bili
ty
H ar
Core
Ba
lan
ce ness
Well
Health
Figure 5-6. Health
Health
1. Health is a condition in which all parts and subparts (variables) are in

harmony with the whole of the client (Figure 5-6).
2. Health is equated with stability of the normal line of defense.
3. Conversely, illness is the opposite of wellness; a state of insufficiency

or instability.
4. Reconstitution is the process by which a person progresses from his

normal lines of defense to a higher or lower state of wellness. Wellness
occurs after adaptation to stressors.
Nursing
1. Nursing is a unique profession that concerns itself with all the vari-
ables affecting an individual response to stress.
2. Its goal is to facilitate optimal wellness for the client through reten-
tion, attainment, or maintenance of client system stability.
3. A nurse assists individuals, families, and groups in attaining and main-

taining a maximum level of total wellness by purposeful intervention
aimed at reducing stress factors and adverse conditions that affect
optimal functioning in any given client situation.
UP Open University
Module 5 177
Nursing is a process which contains three basic components:
1. Nursing diagnosis — consists of client data collection and use of these

data to formulate diagnostic statements concerning the client condi-
tion;
2. Nursing goals — statement of expected outcomes in terms of desir-

able behavioral responses of the client to planned interventions;
3. Nursing outcomes — actual interventions carried out by the nurse

and include evaluation to determine attainment of expected outcomes.
4. Nursing consists of intervention modalities of prevention which can

be:
a. Primary — promotion of client wellness or protection of client’s

normal line of defense by strengthening the flexible line of defense
through stress prevention and risk factors reduction;
b. Secondary — protection of client’s basic structure by strengthen-

ing the internal lines of resistance. This includes appropriate treat-
ment of symptoms to attain optimal client system stability and
energy conservation;
c. Tertiary — promotion of client system reconstitution or return to

wellness following treatment by supporting existing strengths and
resources, and facilitating optimal wellness level.
Primary
prevention
Secondary
prevention
Core Tertiary
prevention
Figure 5-7. Nursing
UP Open University
SAQ 5-7
A. After going through the major concepts of client, health, nurs-
ing and environment as defined in the Systems model, can you
now state the goal of Neuman’s model?
B. Give examples of primary, secondary and tertiary levels of pre-

vention.
Strengths and limitations of

the Neuman Systems Model
The Systems Model is a broad, comprehensive, wholistic, and systematic
approach to the care of clients. As such, it can be applied to an individual
client, a group, a larger community or even to a social issue.
Its emphasis on prevention accentuates the wellness feature of the model.

The focus on the client’s perception of stressors and his active participa-
tion in his own care underscores the importance of the person in nursing
situations.
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Module 5 179
Neuman’s conceptual model provides the professional nurse with impor-

tant guidelines for use of the nursing process, for the assessment of the
whole person, and the implementation of preventive intervention. The
model is also appropriate for interdisciplinary use to give wholistic and
comprehensive client care (Beckman, et. al., 1994).
The model has many uses. Beckman, et al. (1994) cited its application in
various fields and settings. In the workplace, the concepts can be incorpo-
rated into a systems management tool where work goals and preventive
strategies can be developed to deal with stressors present within the orga-
nization. In education, it can be used as a curriculum guide with an em-
phasis on collaboration with clients, interdisciplinary approach to care,
prevention as intervention, and wholistic approach to client conditions.
In research, Neuman’s model has been widely used in the conduct of
studies such as Ziemer’s research on preoperative information, client cop-
ing behaviors, distress, and symptoms of surgical complications. Neuman
suggested that her model can be used for nursing research on alternative
health care delivery services to clients, home-based and long-term care
clients and evaluation of multidisciplinary health promotion programs.
On the other hand, Neuman’s Systems Model has its drawbacks. The
model (Figure 5-3) appears too complicated and may not be easily under-
stood by the reader since it presents too many variables, components and
relationships. It is a challenge to make it simpler without losing its com-
prehensiveness.
SAQ 5-8
Why do you think Neuman’s Systems Model is considered a
“Wellness Model”?
UP Open University
SAQ 5-9
This exercise is related to prevention as a nurse’s mode of action in
assisting the client system cope with stressors. The client in this
case is an elderly couple. Mr. Villa, 66 years old and his wife, 65
years old are presently living with their daughter who is single.
Mr. Villa used to be a government employee while his wife is a
retired teacher. Lately however, Mr. Villa has been complaining of
loss of appetite, chest pains, and low energy level so he started to
confine himself at home. Their daughter has indicated her desire
to go abroad and make a life of her own.
Identify possible risk factors and stressors experienced by Mr. Villa.

Indicate the possible interventions of the nurse and the correspond-
ing levels of prevention.
Risk factors/Stressors Levels of prevention/intervention
UP Open University
Module 5 181
Summary
Let me now summarize the two nursing theories which describe nurse-
client-environment dynamics.
Leininger’s Theory
The major concepts of Leininger’s theory are culture, culture care, culture
care diversity and universality, worldview, social structure, environmen-
tal context, folk health system, professional health system, culture care
preservation, culture care accommodation, and culture care repatterning.
These concepts and their interrelationships provide the basis for the Sun-
rise Model of the theory.
The Sunrise Model presents levels of focus which move from the cultural
and social structure through individuals, families, groups, and institu-
tions in diverse health systems where nursing care decisions and actions
can involve culture care preservation, accommodation and repatterning.
Leininger said that care patterns and processes may be universal or di-
verse. Universal care are those care patterns, values and behaviors that
are common across cultures. Care diversities are those patterns and pro-
cesses that are unique or specific to an individual, family, or cultural group.
A basic tenet of Leininger’s theory is that human beings are inseparable
from their cultural background and the society to which they belong.
The Neuman Systems Model
The Neuman’s Systems Model is an open systems model that focuses on

an individual’s relationship to stress and his reaction to stressors. It views
nursing as primarily concerned with defining appropriate actions in stress-
related situations. Through purposeful intervention, the nurse helps the
client attain and maintain the highest possible level of health, that is, sta-
bility and integrity of the client.
The model serves as a comprehensive framework in the assessment of the

client’s needs, in developing nursing care plans and in determining nurs-
ing interventions.
UP Open University

ASAQ 5-1
If you checked numbers 1, 2, 4 and 5, then congratulations! You got it
right. Leininger clarified that the Culture Care Theory evolved not by
simply applying anthropological concepts to nursing but by creatively
discovering people’s “truth” view, beliefs and patterned lifeways.
Leininger herself studied various cultures in depth. Her experiences en-
riched her theory.
If you missed some of the answers, don’t get frustrated. I suggest that you
go back to the text and see what you failed to understand. I’m confident
that you will be able to get it right next time.
ASAQ 5-2
1. According to Leininger, the purpose of the Culture Care theory is to
discover caring behaviors, values and beliefs based on people’s views,
cultural values, environmental contexts, and social structure. The goal
is to provide nursing care that is effective, satisfying and culturally
congruent.
2. The statement means that curing activities must go with caring activi-
ties. As Leininger herself said, “care is the nurses’ way of being with
and helping people.” Caring can be done not only in illness states but
also in wellness conditions in order to improve the human health con-
dition.
UP Open University
Module 5 183
ASAQ 5-3
1. A figure of an open fan can be used to show the essential components
of the theory. When I first saw the figure, the said object quickly came
to my mind. Here’s my own version:
Cultural values and lifeways
s
to r
f ac
Kin
al
s
eg
hip ctor
dl
fa
an s
an
ds
al
ph R
tic
oc
ilo elig
rs
li
s o io
i al
Po
ph us c to
ica an fa
lf d ic
ac om
to
r on
Te s Ec
c hn
olo
g o rs
ic a fact
l fa
o nal
cto cati
rs Language and Edu
Environment Context
Care Expression
Patterns and Practices
Health (well-being) of individuals

Families, groups and institutions
In
Various health systems
Folk Professional
systems Nursing systems
Nursing care decisions and

actions
Cultural care preservation/
maintenance
Cultural care accommodation/
negotiation
Cultural care repatterning/
structuring
Culture congruent nursing care
I’m sure you were able to come up with your own illustration and inter-
pretation.
UP Open University
ASAQ 5-4
Numbers 1 and 3 are examples of culture care preservation (A) because
these are helpful practices which are handed down from generation to
generation. Numbers 2 and 5 are examples of culture care restructuring
(C) because the nurse attempts to introduce alternative health measures
that are beneficial and yet culturally acceptable to the client. Item num-
ber 4 is a sample of culture care accommodation (B) wherein the nurse
shows respect for a religious value.
Well, how were your answers? Did you get it all again? I’m impressed.
If you didn’t get them all, it’s okay. Try to read the text again and concen-
trate. Sometimes it takes a little while to understand all the concepts.
ASAQ 5-5
Leininger’s Theory of Culture Care is different from other nursing theo-
ries on two counts:
1. It moves beyond client-focused and nurse-client interaction to that of

focusing on care for families, groups, communities, cultures and insti-
tutions; and
2. It does not focus on medical symptoms, disease entities and treatment

but rather on cultural care factors and ways by which nursing actions
become meaningful to people.
Now compare your answers with mine. If you got them all, you deserve
to treat yourself. Remember that the words need not exactly be the same
as mine. As long as the idea is the same, that’s all right. If you only got
one out of two, you still deserve a treat. If you didn’t get any correct
answer, I suggest that you read the text again.
ASAQ 5-6
Neuman’s conceptualization of her model was stimulated by the need of
her graduate students to have a broad view of patient problems. It was
also a result of a synthesis of knowledge from science disciplines as well
as an integration of her clinical experiences in mental health nursing.
UP Open University
Module 5 185
ASAQ 5-7
1. The goal of Neuman’s Systems Model is to attain/maintain the stabil-
ity and integrity of the client system. From this perspective, the nurse
assists the client in attaining and maintaining his maximum level of
functioning.
2. My examples for the levels of prevention:

a. Primary — healthy lifestyle; good living and working conditions;
b. Secondary — case finding; prompt and effective treatment of symp-
toms;
c. Tertiary — education of client; avoiding complications; rehabili-
tation
ASAQ 5-8
Neuman’s Systems Model emphasizes the individual’s relationship to three
levels of stress (i.e., those affecting the concentric rings surrounding the
core structure) and offers three levels of purposeful intervention to help
the patient reduce stress factors and thereby attain and maintain maxi-
mum levels of health. In this sense, the model is health-oriented rather
than illness-oriented.
ASAQ 5-9
Risk factors/Stressor Level of prevention and Intervention
Physical changes of aging Primary: Identify community resources that

Psychological changes of might interest the elderly such as a club
aging and effects of of senior citizens to maintain social
retiring life. The club could conduct regular
seminars on coping with changes and
potential crises that go with aging.
Secondary: Suggest medical consult for
possible clinical problems.
“Loss” of daughter who Primary: Facilitate dialogue between

will go abroad parents and daughter to ease the
former’s anxiety; identify potential
problems and solutions/alternatives
related to daughter’s leaving home.
UP Open University
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Neuman, B. (1989). The Neuman systems model. 2nd edition. Norwalk, Con-
necticut: Appleton and Lange.
Noval-Morales, D. and Monar, J. (1991). A Primer on the Negritos of the
Philippines. Philippine Business for Social Progress.
Teo, S. (1989). The lifestyle of the Badjaos: Study of education and culture. ESP
Printers, Inc.
Wilkins, H. (1993). Transcultural nursing: A selective review of literature.
Journal of advanced nursing, 18(4), 602-609.
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Unit II 187
Unit II
Overview
Luz Barbara Dones
Y ou’ve just gone through the many theories that have shaped and deve-
loped the profession of nursing into what it is today. Many of the
nursing theorists that you have just studied were influenced by other dis-
ciplines. It is in this light that we will now take a closer look at other
theories that are relevant to, and have an impact on, nursing practice. In
this unit, we will bring to you seven modules on theories from different
disciplines—biology, psychology, social sciences, and anthropology. The
discussion that will follow is premised on the fact that the nurse utilizes
these theories with the ultimate goal of understanding her clients, whether
individual, family, population group or community, and assisting them
in developing their own capabilities towards optimal health.
The sixth module of this course discusses The General Systems Theory
(GST). The objective is to equip you with knowledge in understanding the
client who is in constant interaction with the environment. It is important
to understand how a system operates, and identify factors that may give
rise to problems in the unity of the system. The GST is relevant in the
nursing process and can be used not only in understanding biologic
systems of individual clients but also in examining interrelationships in
families, population groups, communities, and health care systems. The
influence of Bertalanffy’s GST can be seen in the works of Imogene King,
Betty Neuman, Callista Roy and Hildegard Peplau, to name a few. The
premise that any living system grows and develops continually enables us
to explain the behavior of our clients and the phenomena that continu-
ously unfold in our external environment.
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The seventh module will introduce you to different Developmental Theo-

ries. Interestingly, each theorist takes a look at development from differ-
ent perspectives. We will discuss Erikson’s Psychosocial Theory, Piaget’s
Cognitive Theory, and Gesell’s Maturational Theory. In addition, the psy-
choanalytical perspective of Freud, and Kohlberg’s moral perspective will
help us explain psychobehavioral manifestations. All these theories can
help us assist our client in attaining optimum well-being.
In order for change to take place, the client needs to learn and acquire
new knowledge and skills and develop positive attitudes. The nurse has
to consider different factors that may enhance or impede the learning
process. The eighth module will discuss several learning and related theo-
ries. I’m sure you’re familiar with some of them—Bandura’s Social Learn-
ing Theory; Hochbaum, Rosenstock and Becker’s Health Belief Model;
Green’s PRECEDE Framework for Health Education Planning and Evalu-
ation; and Knowles’ Adult Learning Theory. These are fairly recent theo-
ries that have great impact on our health education programs nowadays.
In Module 9, we will discuss the Change Theories proposed by Lewin and

Lippitt and by Chin and Benne. When the nurse grasps the dynamics of
movement within a system, she is able to pinpoint actual or potential
problems. This leads her to consider options in order to help the client
reverse a problematic situation. However, she needs to know how she
will go about changing the situation by understanding the dynamics of
behavior of individuals. This will make it easier for the nurse to identify
strategies in order to effect individual change and hopefully, social change
as well.
The effectiveness of the nursing process depends on the quality of the

communication process. The tenth module on Communication Theories
tackles two types of communication models: Shannon and Weaver’s Math-
ematical Theory of Communication and Newcomb’s Symmetry Model.
Any system that has become overloaded with stimuli may not be able to
apply appropriate controls and this may eventually disrupt the normal
functioning of that system. This is what we call a crisis. Module 11 pro-
vides us with two models of Crisis Intervention—the Psychoanalytical
and Systems Models. You will find this module interesting because I’m
sure you encounter all sorts of crises not only in the workplace but even at
home and in your personal life.
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Unit II 189
The last module on Gender Concepts and Gender Issues in Health takes
into account the role of gender in the socialization of women in general
and nurses in particular. It will look into how gender plays a major role in
predicting health.
I am sure you will appreciate this unit as you did the previous unit as
these modules will give you a broader outlook or perspective. So, what
are you waiting for? Read on!
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Module 6 191
Module 6
The General Systems Theory
Luz Barbara Dones
T he previous units introduced you to selected

nursing theories several of which were highly
influenced by the work of Ludwig von Objectives
Bertalanffy, one of the major proponents of the
Systems Theory. I’m sure you’ve come across the At the end of this module, you
General Systems Theory or the GST. In fact, should be able to:
there were numerous occasions that you might
have used the GST as framework of analysis not 1. Briefly discuss the histori-
only in your nursing practice but in your daily cal development of the
life as well. However, most people I’ve talked to, General Systems Theory;
students and colleagues alike, often say that GST 2. Describe a system;
is difficult to fathom, intimidating even, because 3. Explain the characteris-
of the mathematical formulations that character- tics of a system;
ize von Bertalanffy’s discourse. If you should feel 4. Discuss the systems
this way as you go through this module, don’t process;
worry, you’re not alone. I, myself, had to read 5. Discuss the uses of
his work several times before I could understand boundaries and boundary
it fully. Reading other people’s work about their maintenance;
understanding of Bertalanffy’s theory also made 6. Explain the different
me appreciate the GST better. systems states; and
7. Discuss the applications
Why do we need to study the General Systems of GST concepts to
Theory? Well, the GST is a universal theory which nursing practice.
is applicable to many fields of study including
nursing. We can use it not only to understand the biologic system of our
individual client but also systems in families, population groups and com-
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munities. The GST also provides a framework of analyzing relationships

in organizations such as what we have in nursing and even in the entire
health care network. So, brace yourself and let me take you to the world
of the General Systems Theory.
Historical Development of
the General Systems Theory
Did you know that the concept of systems originated as early as Aristotle’s
time, yet, it was only in the 1930s when systems thinking came into
being? Ludwig von Bertalanffy, a biologist by profession, came upon the
notion of systems in the early 1920s when he was experimenting on me-
tabolism and growth in biophysics. Cannon, later in 1929 and 1932, stud-
ied the homeostatic state of organism to illustrate the concepts and prin-
ciples of the systems theory. This was further developed when Kohler in
1927 investigated and consequently differentiated the dynamics of open
and closed systems by comparing thermodynamics and machine systems.
This led Weiner to the introduce the theory of cybernetics, also known as
the principle of feedback or circular causal chain for goal-seeking behav-
ior. From this point on, several other theories evolved. Among these were:
the Information Theory of Shannon and Weaver (1949), the Game Theory
of Neumann and Morgenstern (1947), decision theory, topology on ratio-
nal mathematics, and factor analysis. All these led to recent develop-
ments in computer, information, and engineering technology (Bertalanffy,
1968).
Not surprisingly, a lot of our nursing theorists found practical applica-

tions of GST in nursing. These theorists included Imogene King, Dorothy
Johnson, Callista Roy, Martha Rogers and Betty Neumann, among
others.
What is the General Systems Theory?

We can only begin to understand what the GST is all about if we start by
defining and giving the characteristics of a system.
Defining a System
A system is a set of components or units interacting with each other within a

boundary that filters both the kind and rate of flow of inputs and outputs to
and from the system (Hall and Weaver, 1985).
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Module 6 193
Does the statement overwhelm you? Don’t worry and don’t panic yet. I
will now flesh out the major points in the definition in order for you to
understand what was just stated, okay?
1. A system is made up of identifiable elements or parts that are interre-

lated.
I guess this is something which we can all understand and identify

with. Visualize elementary pupils saying that “matter is made up of
molecules”. Let me give you more examples.
Example 1. There are millions of cells that make up a tissue. Tissues

with similar structure and function make up an organ. Several organs
make up a body system while the different body systems, each with a
definite function and use, keep the human body in perfect harmony.
Example 2. Individuals make up a family. Although members of the

family have their own personal identities, each has a role to perform
and contribute in order to attain the goals that the family has set to
achieve.
Example 3. Families, organizations and institutions make up a society.

Each entity in the community has a specific role to play. They also
have specific contributions and objectives. But all of them need to work
with and be supportive of each other in order to maintain peace,
order and harmony.
2. Each identifiable part or element is differentiated from others by a real

or imaginary line called a boundary. This line sets each element apart
and gives it its own identity.
The most simple illustration of a boundary is when we talk about the

“boundary” between two municipalities. One knows that a Bulakeña
comes from the Calumpit side of the boundary while a Kapampangan
comes from the Apalit side.
Let us go back to the illustrations I cited earlier. In a human body

system, the organs of the digestive system can be differentiated by
their anatomical structure and function. Definitely, the intestines are
different from the liver. However, their functions complement each
other in order to achieve their goal of nourishing the human body.
Likewise, members of the family are differentiated according to the

roles society traditionally ascribes to them. The father is the “bread-
winner” while the mother is the “homemaker.” Parents are the pro-
tectors of their children and are responsible for their upbringing, while
children are expected to show respect and love to their parents.
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3. A system interacts or relates with its environment by receiving some-

thing from it and by giving something in return. The rate and quality
of exchange to and from the system will depend on the system itself.
In order for a system to survive, a “give-and-take” relationship must

occur. One has to give something in order to benefit from others. This
may be in the form of matter, energy, or information. The system has
the power to control what and how much to give to others. It also
determines what and how much it wants from others.
So, there you have it. I have just discussed the three major points that
make up the definition of a system. A system has many parts that can be
differentiated by boundaries. The parts of the system interact with one
another while the whole system itself interacts with its environment.
Now, let me just continue describing the system.
Important aspects of a system

All systems have both structure and function or process. These are two
important aspects of a system. Structure refers to the static arrangement
of a system’s parts at any moment in a three-dimensional space. Function
or process, on the other hand, refers to dynamic change in matter, en-
ergy, or information contained in a system over time (Hall and Weaver,
1985). Allow me to expound on that by giving you an example.
Let us examine the family as a system. The presence of a father, a mother,

a son and a daughter make up what we call the structure of the system.
This is something that we will not be able to change. (Remember the joke
about how a person can choose friends but does not have the power to
choose parents or siblings?) The quality of family relationships, however,
is something that can be altered at any point in time depending on how
the family controls the flow of influence from its environment and how
the members respond to this influence. The changes that occur within the
system will ultimately change the identity of the entire system. So, a con-
servative family adapting to the influences of a highly urbanized society
may find itself becoming a more liberal or modern family.
Characteristics of a system
Generally, systems have three important characteristics: openness, whole-
ness, and hierarchical arrangement (Hall and Weaver, 1985).
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Module 6 195
Openness
There are two general types of systems: closed and open. A closed sys-
tem does not exchange matter, energy, or information with its environ-
ment. Hence, a closed system does not receive input from the environ-
ment and does not give output to the environment. In reality, there’s no
such thing as a closed system. On the other hand, an open system ex-
changes matter, energy, and information across its boundaries. It receives
input from the environment and gives output to the environment. Such is
the case in all living systems. Why should systems be open? This is be-
cause the survival of the system depends on the continuous exchange of
matter, energy, and information across environmental boundaries.
What comes to your mind when we talk about openness of a system?

How often have you heard people say “no man is an island?” What hap-
pens to a living organism which cannot take in oxygen and cannot breathe
out carbon dioxide? What happens to a business which cannot sell its
goods and cannot infuse new capital to its operations? This is the entire
idea of openness in a system.
Matter, energy,
information
System
Matter, energy,
information
Environment
Figure 6-1. Exchange of matter, energy, and information in and out

of systems across environmental boundaries
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Wholeness
A system is a unified whole which is identifiable and is greater than the

sum of its parts. The whole possesses a unique or distinctive property
altogether different from the quality each component part possesses or
even the quality the sum of these parts may produce. This implies that the
integrated larger system is more important or has a greater impact.
Neuman explained that to understand wholeness, one must see clients or

persons. An individual client is viewed as a whole whose parts are in
constant or dynamic interaction. There are several variables that affect
client systems, namely, physiological, psychological, socioeconomic, cul-
tural, and spiritual. In providing care for the client, the nurse considers
the totality of the person. She should not try to meet the client’s physi-
ological needs alone. She should also regard other factors that may
enhance or speed up recovery.
This is how Roger viewed wholeness in the analysis of organizations or

communities. The nurse will have to go beyond solving problems by look-
ing at isolated individual events. For instance, the success or failure of a
health care delivery system cannot be attributed to the efforts of just one
person. The nurse has to analyze how these parts of the system interact
and how such interaction can spell success or failure.
Hierarchical order or arrangement
Each system has a subsystem or a suprasystem. This is so because all liv-

ing systems attempt to move towards a higher order of complexity.
As one system undertakes a more complex task, the structure also needs
to be modified so that the system will not be overburdened with work.
Then, as the structure becomes more complex, the function of parts of the
system will become more specialized.
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Module 6 197
Cells
Tissues
Organs
System
Figure 6-2. Hierarchy of systems

(Adapted from Hall and Weaver, 1985)
Subsystem
Nurses in
System
the Ward
Suprasystem
Nursing Service
Hospital
Figure 6-3. Groups as target system within an organization context

(Adapted from Hall and Weaver, 1985)
I have just given you the definition of a system, its two important aspects
and the three system characteristics. Having understood all these, we can
say that the GST offers a perspective for looking at the individual and
nature as an interacting whole with integrated sets of properties and rela-
tionships. Rogers said that the GST is a “general science of wholeness”
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while Erb and Kozier further added that the theory “explains the rela-
tionship between wholes and parts, describes concepts about them, and
predicts how the parts will behave and react.”
Activity 6-1
At this point, I’d like you to think about your present work situa-
tion. Using the concepts that we have just taken up, identify and
describe the system structure and system functions or process in
your workplace. Are the three system characteristics present? How
are they manifested?

Perhaps you will describe your work situation in the hospital com-
munity or within the Philippine health care delivery system. De-
pending on the position that you now hold, identify your sub-
system and suprasystem. The organizational structure of the nurs-
ing department in your institution will be the structure or static
aspect, while the character of the relationships within the depart-
ment (as manifested by the pattern of leadership, communication,
promotions and rewards, and so on) will spell the dynamic aspect
of the system. Looking at the system characteristics, can you say
that your institution is open to new ideas, innovations and tech-
nology (Openness)? Does the nursing department contribute to
the generally good impression people have of the institution (Whole-
ness)? Does the organizational structure contribute to the accom-
plishment of complex and highly specialized tasks of the institu-
tion (Hierarchical order or arrangement)?
The Systems Process

Systems have two important aspects—structure and function or process.
Both are important but the function or process aspect is critical for the
system’s survival. Let me refresh your memory on the definition of a func-
tion or process: it is the dynamic exchange of matter, energy or informa-
tion contained in a system over time. A system should be able to perform
three essential processes: adaptation to the environment, integration of
system parts and decision-making about allocation of resources
(Bredemeier in Hall and Weaver, 1985).
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Module 6 199
1. Adaptation to the Environment
This is the process of interaction or exchange between the system and

its environment in which the system is influenced by and in turn in-
fluences its environment. This process is necessary as the system tries
to alter its environment in order to obtain what it needs for its own
survival.
This process occurs in our daily life. Take for example a nurse who
badly needs to have a day off so she can finish the module she is work-
ing on. In order to satisfy her needs at the moment, she tries to think of
all sorts of strategies to manipulate her environment into giving her
what she wants. She can be straightforward with her head nurse and
tell her the real reason why she will be absent or she can lie.
2. Integration of System Parts
This refers to the process of control exerted by the system upon its
subsystems to ensure the harmonious functioning of all its parts. It is
necessary that the system is capable of integrating other subsystems,
otherwise, the functioning of the total system is threatened and may
ultimately lead to non-realization of the system’s purpose.
At home, in school, or in the workplace, we always depend on some-

one who ensures that everything will go on without a hitch. It does
not matter how that person will demand compliance from others as
long as the system continues to survive and serves its purpose.
3. Decision-making about Allocation of Resources
This is the process whereby a system makes choices about allocation

of its resources in order to adapt to the environment and integrate its
subsystems.
A system always takes stock of its capabilities and limitations. If re-

sources are meager, then one has to conserve and optimize whatever
is available. The important thing is that the system doesn’t lose control
over its subsystems because of inadequate resources.
This is something that we always do. We endlessly try to weigh how

we can use our meager resources in getting more from the environ-
ment to benefit more people.
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In order to carry out the system’s processes, the system must decide
whether or not to exchange matter, energy, or information depending on
specific premises. This is what we refer to as transactional modes. Trans-
actional modes were described by Bredemeier (Hall and Weaver, 1985) as
follows:
1. Gemeinschaft
This is a transactional mode based on the premise that the system and
its environment are committed to each other. It is exemplified by rela-
tionships in which solidarity, loyalty, and care prevail. It is commonly
found among primary groups such as the family and kinship networks.
Exchange between the system and the environment occur “for the
common good of the system.”
2. Legal-bureaucratic
In this particular transactional mode, the system and its environment

respond to each other because “it is their duty” or “it is the policy.”
Transaction or exchange take place depending on whether a specific
system has the authority and power to ensure conformity. This is what
we commonly see in our workplace where we are obliged to comply
with rules and regulations set by the institution.
3. Team-cooperative
The system, subsystem, and the environment recognize that each sys-
tem has something to contribute in order to achieve a common goal.
4. Bargaining
When a system has needs and goals different from those of its sub-
systems or its environment, it can negotiate in order to meet these
needs and goals.
5. Coercion
In some situations, a system makes use of force, threat, or deception to

obtain what is necessary for the system’s survival. This type of trans-
actional mode lessens the opportunity for growth and learning be-
cause of its punitive character.
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Module 6 201
Activity 6-2
Again, examine your work situation. Describe how the system in
your workplace carries out processes in order to meet its needs
and achieve its goals.

Wherever your work setting is, I am sure that the end goal of your
organization is quality patient care through provision of excellent
nursing services. In order to realize this, however, the nursing de-
partment has to demand resources (manpower, money, materi-
als) from the suprasystem. To ensure maximum utilization of these
resources, there has to be some form of control over the use of
these resources. At the same time, nurses are expected to conform
to the standards of safe nursing practice. In the process of satisfy-
ing needs and achieving the goals of the system, different transac-
tional modes may be used depending on the situation in which the
nurse finds herself. For example, if a nurse violates the standards
of safe nursing practice, she can expect a legal-bureaucratic ex-
change. But if the issue is related to the economic and general
welfare of nurses, we can expect a Gemeinschaft transactional
mode.
So far, I have dealt with the three system processes and the transactional
modes that may be used to enable the exchange of matter, energy, and
information between systems. Once the system opens itself to continuous
exchange, it needs to regulate the rate, quantity, and quality of matter,
energy and information that it receives from and gives to the environ-
ment. The task of adapting, integrating, and decision-making will be dealt
with by the system through the input-throughput-output exchange.
input throughput output
Input is the process of importing matter, energy, or information. It

consists of a measurable event or series of events occurring outside a sys-
tem. Once this matter, energy, or information has entered the system, it is
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transformed, created, and recognized. This process of transformation is

called throughput. New matter, energy, or information created from this
process may be retained by the system if it still finds this useful. If the
matter, energy, or information will be exported or transported out of the
system continuously, this is what we refer to as output.
Let me illustrate this exchange with the following examples:
Example 1
Ingestion of food Digestion in the Caloric energy

and fluids GIT Feces/Urine
Input Throughput Output
Example 2
Maintenance of high
Recruitment of high standards of academic Caring,
school graduates with excellence through competent
physical, mental and qualified teachers, nurses
emotional maturity relevant nursing
curriculum and
adequate learning
facilities
Input Throughput Output
Activity 6-3
In your last two activities, we’ve been using your work situation to
illustrate how a system works. You were able to identify the struc-
ture and functions of the system where you belong. You were also
able to describe processes which allow the system to meet needs
and achieve goals. Now, try giving examples of the input-through-
put-output exchange in the system you’re working with.
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Module 6 203

In our effort to provide quality patient care in any setting, we take
into account the things we need from the environment that will be
useful to us within the system, and for creating new products to
be transported out to the environment. Let me give you an
example. Quality patient care is our product. To produce this prod-
uct, we need quality nurses (among other things). Sometimes, how-
ever, we are not able to hire the best possible people. This is where
the process of throughput becomes important. This process may
improve the “bad” elements, or the situation can worsen and ad-
versely affect the entire system. So, a decision has to be made
whether to retain a nurse who is not functioning very well or take
him/her out of the system.
System Boundary and Boundary Maintenance

A system is defined as a set of components or units interacting with each
other within a boundary that filters both the kind and rate of flow of
inputs and outputs to and from the system.
Now, let’s talk about boundaries and the functions of boundaries. I

mentioned previously that a boundary is a real or imaginary line that
separates the system from its subsystems or from its environment. Bound-
aries are represented by the “hyphen” in role relationships, say for
example, nurse-patient relationship, mother-daughter relationship and
so on. Boundaries are important because they mark the interface between
systems and allow for the exchange process of input-throughput-output
to occur (Hall and Weaver, 1985).
Since continuous exchange of matter, energy, or information occurs be-

tween systems, it is important to ensure boundary maintenance. Bound-
ary maintenance is necessary so that systems will prevent overload of
matter, energy, or information that may affect their continuum of bal-
ance and purposeful direction within the environment (Hall and Weaver,
1985). Bredemeier (Hall and Weaver, 1985) describes the following as
functions of boundary maintenance:
1. Retaining within the system the matter, energy or information re-

quired by the system
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2. Obtaining from the environment the needed matter, energy and in-
formation
3. Containing within the environment that which is not required
4. Disposing of matter, energy and information
Thus, boundary maintenance can be exercised depending on how the

system wants to utilize the matter, energy, and information that have
entered the system.
How do we maintain boundaries? According to Thompson and McEven

(Hall and Weaver, 1985) there are four modes of maintaining boundaries.
Again, the nurse within the system utilizes each mode depending on the
situation.
1. Competition — Boundaries can be maintained when two functional

components share a common relationship with a third party. For
example, a nurse can delineate her role from that of a doctor or a
physical therapist as they care for a common patient.
2. Co-optation — Another mode of defining boundaries is when leader-

ship elements in one system attempt to take over another. An example
of this is when doctors begin telling nurses what nursing functions
they will be allowed to do. In this situation, the nursing system loses
its own identity as nursing will be dictated upon by the medical pro-
fession. The medical profession is able to maintain its boundary, though.
3. Bargaining — When an agreement exists between two systems con-

cerning the exchange of goods and services, bargaining occurs. “I’ll
do this for you, if you’ll do that for me.” Both systems are able to
satisfy their goals and needs and yet manage to maintain their own
boundaries.
4. Coalition-formation — Two systems or parts or functional compo-

nents of a system become formally committed to joint decisions. In
this particular mode of boundary maintenance, both systems lose their
respective boundaries but, a new system created from the melding of
the two systems.
Activity 6-4
Two systems which need to co-exist should be conscious of the
boundaries that separate them. In your workplace, can you ex-
plain how you as a subsystem are able to ensure boundary main-
tenance?
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Module 6 205

The four models of maintaining boundaries can be used by the
nurse depending on the situation. If the nurse wants her role to be
appreciated by other members of the health team, then she must
be able to compare and contrast the different roles.
Co-optation is one mode that members of the health team should

refrain from using. Each profession has something to contribute.
Therefore, one should not dominate others. Bargaining is a mode
that may perhaps benefit two different systems when both are not
ready to give up their own boundaries. It is a more acceptable
option than co-optation or coalition-formation when both systems
want to retain their own boundaries.
System States
With the continuous flow of matter, energy, and information in and out
of the system, what do you expect the system to become? Well, as we
have discussed, it depends on how the system will utilize these materials
for its survival. I will now describe three systems states: negentropy,
equifinality and steady-state (Hall and Weaver, 1985).
1. Negentropy — In open systems, continuous exchange leads to increas-

ing order and complexity of the system. Eventually, the former status
is altered as the system adjusts or modifies some of its elements based
on the dynamics of the past. Negentropy is achieved by a process
known as feedback mechanism.
This is a system state nurses will always want to achieve for their
clients. Our encounters with clients are initiated because of their dis-
ease condition. But as we work with them through the nursing pro-
cess, we manage to achieve a certain degree of improvement in our
clients’ conditions resulting from continuous and sustained nursing
care. Thus, sick patients become well after benefiting from the caring
hands of the nurse.
2. Equifinality — This is the tendency to reach a characteristic final state

from the different initial states in various ways based on the dynamic
interaction in an open system.
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In our effort to improve the health status of our clients, we try to make
use of different strategies and approaches in the delivery of health
care that will ultimately lead to one final state of getting back the
patient’s health status.
3. Steady State — In a steady state, there are certain processes that al-
low a system to achieve some constancy in the input-output exchanges.
The structure of the system remains the same.
There are systems which may not be able to handle continuous ex-
changes and may only be overwhelmed, resulting in the breakdown
of that system. Hence to achieve stability for the system, a steady state
is maintained by closing down exchanges when there is no need and
opening them up once again when necessary.
Activity 6-5
For the final activity, let us take one last look at our subsystems.
Can you discuss which of the system states your organization will
end up with considering the factors that we discussed earlier?

Generally, nursing is an open system characterized by continuous
exchange of matter, energy, and information within and outside
its boundary. Nursing will not be what it is today if it existed in
isolation from fast changing social, economic, political, and tech-
nological realities. The profession’s openness to influence is an at-
tempt to continuously improve the quality of health care services
provided to the populace with the ultimate goal of uplifting the
quality of life of every citizen. As social realities change, so do the
roles of a nurse. As we respond to the needs of the times, we find
ourselves upgrading our own systems to become more competent,
efficient and effective. We improve existing strategies and ap-
proaches; we develop and create new ones. But we also take stock
of what is not appropriate and good for our profession, and not
join in any bandwagon of new ideas.
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Module 6 207
Applications of GST and Nursing

Theories Concepts to Nursing Practice
If we are to review the nursing theories, we will find that the systems
theories and models are the ones most widely used as frameworks.
Neuman, Roy, Orem, Rogers, and Johnson are just examples of those works
that are considered to be based on systems theory.
How and where in our nursing practice can we apply the GST concepts?
1. The GST is a universal theory. It provides conceptual links across dif-

ferent disciplines and therefore, offers a common language unrestricted
by subject matter boundaries. This is even more relevant nowadays
because the trend in responding to health-related problems is through
the multidisciplinary approach. Hence, if professionals from diverse
disciplines share a common perspective, then, they can also set mu-
tual goals for health.
2. The GST views human beings as a holistic and goal-directed. Indi-

viduals with intrinsic worth make the nurse value the client-centered
approach in her provision of nursing care. This is the basic premise of
Roy’s Adaptation Model.
3. The GST views persons as open systems who strive to maintain har-
mony and balance between their internal and external environments.
This is the so-called ecologic view and includes the concepts of inter-
relatedness, interdependence and dynamic interaction among organ-
isms. This is the foundation of Neuman’s Health Care System Model
(Chinn, 1991) and Johnson’s Behavioral System Model for Nursing
(George, 1990).
4. The GST also holds that individuals at the subsystems level carry out
networking activities with their environment in hierarchically arranged
systems of increasing complexity. In King’s work, the patient is seen
as a personal system who co-exists with other personal systems. Indi-
viduals form a group that will now comprise the so-called interper-
sonal system. Interpersonal systems contribute to social systems (Chinn,
1991).
5. The GST emphasizes relationships as well as components of the sys-

tem. This is the premise of Peplau’s model (George, 1990) where im-
portance is given to the nurse and the patient as systems interacting
with one another, processing inputs, throughputs, and outputs to
achieve a specific goal.
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There, do you see the great contribution von Bertalanffy made to the nurs-
ing profession with his GST? I am sure there are other nursing theorists
which in one way or another made use of the systems theories and mod-
els to enrich the knowledge base of the nursing profession. Whether in a
hospital or in a community setting, the GST always has its use in nursing
practice.
References
Kozier, B., Erb, G., and Blais, K. (1992). Concepts and issues in nursing
practice. 2nd Edition. Benjamin/Cummings Publishing Co.
Bertalanffy, L.V. (1968). General systems theory. New York: George Brazills,
Inc.
George, J.B. (Ed.). (1990). Nursing theories: The base for professional nursing
practice. 3rd Edition. Norwalk, Connecticut: Appleton and Lange.
Chapman, C.M. (1985). Theory of nursing: Practical application.
Hall, J. and Weaver, B.R. (1985). Distributive nursing practice: A systems
approach to community health. 2nd Edition. Philadelphia: J.B. Lippincott
Co.
UP Open University
Module 7 209
Module 7
Developmental Theories
Merle F. Mejico
W hat is the basic nature of human beings? Is

he primarily a rational creature or a crea-
ture driven by passions? Is human behavior self- Objectives
regulated from within or largely determined by
external factors? These are the basic questions At the end of this module,
which this module will attempt to answer. Indi- you should be able to:
vidual theories of human development seem too
numerous to make sense of, but they are consid- 1. Discuss the history of
erably more cohesive than they often appear. How developmental theory;
people explain development depends on how 2. Compare and contrast
they view the fundamental nature of human be- the different perspectives
ings. There are different explanations or theories of developmental
about why people behave the way they do. theories; and
3. Explain applications of
Theories of human development are ways of or- such theories in nursing
ganizing “facts” of human behavior into formu- situations/practice.
lations or assumptions about development. They
are used to generate testable hypotheses about
human development from many perspectives which can lead to an ap-
preciation of both strengths and weaknesses of various theories. Both learn-
ing and maturation are significant influences in development. Generally,
researchers agree that neither heredity nor environment can explain the
developmental process; rather, both elements interact.
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Being in a profession which relates with people, sick or well, the nurse
will always be confronted by the very nature of man’s uniqueness. The
effectiveness of her approaches will always depend on how she appreci-
ates diversities and common processes that an individual undergoes.
Abraham Lincoln said, “Human action can be modified to some extent,
but human nature cannot be changed.”
For a better understanding of the discussion, go over these important ba-

sic terms we will be using as we go along.
1. Behaviorism — theoretical view that environmental factors are

largely responsible for influencing observable changes during human
development
2. Development — progressive series of changes that occur in a pre-
dictable pattern as a result of an interaction between biological and
environmental factors
3. Empiricism — philosophical position that the only source of knowl-
edge is sensory information
4. Environmentalist perspective — viewing people to be what they
are made to be by the environments
5. Humanism — philosophical view that sees freedom, subjectivity and
creativity as essential for understanding the process of development;
6. Idealism — philosophical view that reality cannot be known inde-
pendently from the mind that is perceiving it
7. Learning — more or less permanent modifications of behavior re-
sulting from experience
8. Maturation — automatic unfolding of biological potential in an irre-
versible sequence; it considers human development as the result of
the unfolding of a human being’s genetic inheritance
9. Maturationism — theoretical view that hereditary mechanisms are
largely responsible for influencing the path of development
10. Naturalism — philosophical stand that nature provides a child with
a plan for development and that no harm will result if the child is
allowed to develop with little adult supervision
11. Organismic perspective — viewing experience as less important than
developmental influences from within the organism itself; thus people
grow to be what they make themselves to be
12. Psychoanalytic perspective — viewing the significance of uncon-
scious mechanisms in development
UP Open University
Module 7 211
Developmental Theories
Human beings themselves may have changed little throughout the centu-
ries, but interest in development and attitudes toward children, adoles-
cents and the elderly have certainly changed.
According to Plato’s philosophy of idealism, human beings never come to

know reality as it is but only acquire images that are filtered through, and
possibly distorted by, the senses. Thus, any two people might have differ-
ent perceptions of the real world because the world is filtered thru their
individual thought processes. Aristotle, on the other hand, did not believe
that the fundamental meaning of the world could be discovered in im-
ages or predetermined ideals in the mind. He felt that experiences can
help clarify reality rather than introduce distortions as Plato contended.
In the eighteenth century, the period known as the Enlightenment, new
and more optimistic views of human freedom and potential were put
forward. Children were not seen as incomplete adults but special crea-
tures worthy of attention and study.
Charles Darwin, leading advocate of the theory of evolution, maintained

that human beings should be viewed as part of nature. His concept of
natural selection and survival of the fittest were major influences in our
understanding of the developmental process. Adaptability was seen as
the most valuable characteristic a person can have. Darwin’s most devel-
opmentally oriented contribution was to suggest a relationship between
evolution of species and the child’s growth. Indeed, the notion of seeking
the origins of adult behaviors and attributes in childhood experiences is
still widely accepted. However, the scientific study of complex patterns of
change during adult life would have to wait until the twentieth century.
Developmental researchers were recognized as legitimate scientists. The
study of child development was no longer regarded as a set of philosophi-
cal problems but rather as a part of scientific enterprise.
Developmentalists were concerned with explaining the mechanisms of

how and why changes take place. The mid-twentieth century saw a grow-
ing recognition of the need for an interdisciplinary approach—bringing
together a variety of disciplinary perspectives, to obtain a balanced pic-
ture of human functioning at various points in the life span. Major em-
phasis was placed on the so-called contextual approaches to human de-
velopment. This approach tries to identify the multiple influences (e.g.,
social, historical, cultural, and biological) that affect the developing hu-
man organism, the ways in which change occurs, and the complex inter-
actions among them.
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Modern Perspectives in Development

(Hughes and Noppe, 1991)
With such an array of developmental theories, you probably feel lost by

now. Don’t panic. The important thing is for you to have a direction in
your studies. We shall now examine three general perspectives that differ
in their assessment of the relative importance of heredity and environ-
ment, of nature and nurture on human development. They differ also in
another way: the first two perspectives, environmentalist and organis-
mic theories, view the human being as essentially rational, while the third,
the psychoanalytic theory, sees us as creatures of appetite and emotion
rather than of reason. Pay attention to the grouping of theorists and the
assumptions underlying each perspective.
Table 7.1. Modern perspectives in human development
Perspective Representative Theories Basic Beliefs About

Human Development
Environmentalist British empiricism The human being is an

(John Locke); Behaviorism empty organism at birth.
(John Watson, B.F. Skinner,
A. Bandura, H. and T. Kendler); The human being is pas-
Cultural anthropology (M. Mead, sive, and development is
R. Benedict). totally achieved by ex-
periencing the environment.
The adult’s role is to

shape the child according
to socially accepted stan-
dards of behavior.
Organismic Naturalism (Jean-Jacques The human being is active

Rousseau); Maturationism in determining its own
(G.S. Hall, A. Gesell); Cogni- course of development.
tive-developmental theory
(J. Piaget); Humanism Interaction occurs bet-
(C. Rogers, A. Maslow, ween organism and envi-
C. Buhler); Ethology ronment so that both are
(J. Bowlby); Moral-develop- involved in varying degrees
mental theory (Kohlberg) in the process of develop-
ment.
Psychoanalytic Psychoanalysis (S. Freud, The human being is not

A. Freud, M. Klein, E. Erikson) rational but is governed by
emotion or appetite.
Development is a process
of continuous compromise
between the individual’s
needs and society’s expec-
tations.
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Module 7 213
Now that you have a general view of three perspectives, let us spend
some time understanding the major details of each one.
Environmentalism
This view emphasizes that people grow to be what they are made to be by
their environments. Rejecting inborn tendencies and the concept of free-
dom of choice, the proponents of this theory see the human organism as
almost completely determined by external forces, much as a piece of clay
is molded in a sculptor’s hands. There are three schools of thought that
represent this view—Empiricism, Behaviorism, and Cultural Anthropol-
ogy.
British empiricism
The origin of modern environmentalist perspectives can be traced to the
ideas of John Locke (1632-1704) whose philosophy of empiricism changed
the direction of scientific thought forever. Locke believed that the human
mind is a “blank slate” at birth, and that all knowledge of the world comes
to us through our senses. The ultimate extension of Locke’s theory is that
children are uncivilized creatures who need adults to shape them into
everything they will eventually become. They are incomplete versions of
adult human beings, and society’s role is to civilize them.
Behaviorism
John B. Watson (1878-1958) believed that the only way to understand the
human organism is through objective observation of behaviors. He re-
jected the methods of subjective introspection or analysis of the uncon-
scious, as well as explanations that relied on instincts or other interpreta-
tions that could not be scientifically proven. For him, environmental ex-
perience imposes itself on the person through principles of conditioning
and reinforcement. A prominent example of such principles is the view
that rewarded behaviors are more likely to appear in the future while
punished behaviors are likely to diminish. Thus, Watson believed that the
only behavior worth studying is learned behavior.
Because a person’s pattern of development is determined by what he or

she learns and not by instinctive or inherited tendencies, parents play a
crucial role in shaping their children into the kinds of adults they will
become.
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Another variation on behaviorism was stimulated by the work of Albert

Bandura in the 1960s. This perspective is known as social learning and
the key concept is that development is guided by the initiation or avoid-
ance of behavior that is modeled by other people. By observing the conse-
quences of someone else’s actions, people could learn how to brush their
teeth, how to ride a bicycle, how to solve a puzzle, or how to discipline a
child. The major significance of the social learning approach is that it
described learning as taking place without the presence of any obvious
reward or punishment.
A third variation in Watson’s behaviorism was inspired by the work of

Howard and Tracey Lendler in the 1950s and 1960s. The Lendlers disco-
vered developmental differences in the ways children and adults learn
and solve problems in laboratory settings. Young children seem to respond
to a learning task exactly as Watson predicted—they repeat rewarded
behaviors and delete behaviors that are not rewarded. Older children and
adults, perhaps as a result of their greater verbal skills, seem to develop
mental strategies when solving problems and verbalize these strategies to
themselves. Older children and adults do not always repeat rewarded
behavior and often repeat those that are punished or ignored as part of a
long range strategy for maximizing reward.
Another contributor in this filed is B.F. Skinner. Like Watson, Skinner is

an environmentalist. Although he recognized that organisms enter the
world with genetic endowments, he was primarily concerned with how
environment controls behavior. B.F. Skinner is famous for his definition of
operant conditioning. It is a learning process that depends on reward
and punishment. The major difference between classical conditioning and
operant conditioning is that behavior in the latter cannot be automati-
cally or naturally produced. This means that the behavior must first occur
before any learning can take place. In other words, the behavior to be
conditioned must first occur so that it can be strengthened or reinforced.
For example, a child goes to the bathroom by himself and this behavior is
then reinforced with candy. Reinforcement, or the perceived consequences
of behavior, influences the frequency with which the behavior occurs.
For example, if a child is positively rewarded for mowing the lawn, then
he will want to do it again in the future. On the other hand, if a child is
punished or gets no reward for a behavior, he/she will do it less frequently
or not at all (the behavior is then said to be extinguished).
UP Open University
Module 7 215
SAQ 7-1
1. What do you think are the positive aspects of behaviorism??
2. Behaviorism has its limitations too. Can you identify some?
3. What are the unique features of behaviorism?
Were you able to answer all the questions? Who among the behaviorists
you influenced you most? Your answer is as good as mine.
Cultural anthropology
Margaret Mead (1901-1978) and Ruth Benedict (1887-1948) emphasized
the experiential factors in development and claimed that different pat-
terns of child rearing that reflect diverse cultural values would result in
a considerable variety of adult characteristics. Mead and Benedict
questioned the universality of developmental stages advocated by psy-
choanalytic theorists and they minimized the significance of hereditary
mechanisms in the developmental process. Since cultural variation is so
widespread, human development must be influenced not only by inner
biological mechanisms but also by environmental factors.
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Organismic Perspective
This perspective puts considerably less emphasis on the role of experience
than environmentalism does. Instead, organismically oriented theorists
stress the importance of factors within the organism itself. Thus, people
grow to be what they make themselves to be rather than what the envi-
ronment makes them.
Some organismic theorists almost totally ignored environmental influences

believing that the entire plan for development is innate. Advocates of this
extreme position were maturation theorists G. Stanley Hall and Arnold
Gesell. The prevailing trend in organismic theory today is to stress the
organism-environment interaction with each side simultaneously and
continuously influencing the other.
Naturalism
Jean Jacques Rousseau’s (1712-78) philosophy of naturalism stresses that
children are innately good unless corrupted by society’s evils. They come
into the world equipped by God with a plan for their development and no
harm will come to them if they are allowed to grow with a minimum of
supervision. Development, from Rousseau’s perspective, consists of five
stages that correspond to the evolution of human culture:
1. Animal feelings of pleasure and pain (0-5 yrs.)

2. Savage sensory awareness (5-12 yrs.)
3. Rational functioning and exploration (12-15 yrs.)
4. Emotional and social interests (15-20 yrs.)
5. Spiritual maturity during adulthood
Maturationism
This perspective has the belief that the plan of development is innate and
environment is a distant secondary influence. Hall believed that the indi-
vidual development of a child repeats, in brief, the phases of human evo-
lution. He described adolescence as a period of “storm and stress” corre-
sponding to a turbulent state of Western civilization before the modern
era. Gesell regarded behaviorism with suspicion and emphasized internal
biological factors in development while virtually ignoring the role of the
environment. He advocated the “normative tradition” of developmental
data analysis, an approach using developmental norms for behavior,
UP Open University
Module 7 217
often with little interest in the analysis of deviations from those norms.
Gesell’s belief in typical behaviors for every age during childhood and
adolescence became very popular with the general public in the 1920s
and is still widely circulated today.
Cognitive Development Theory

This is the most significant of all organismic perspectives to emerge. As
opposed to focusing on learned behavior, cognitive developmentalists
attempt to explain how the individual thinks and how human processes
vary. This perspective is organismic because it emphasizes internal men-
tal processes and their interactions with the environment rather than the
influence of the environment itself. Intellectual development is seen as an
active, dynamic, constructive process. The most influential theorist in this
perspective was Jean Piaget (1896-1980), who believed that intellectual
development is not merely a quantitative accumulation and association
of learned events but a universal sequence of qualitatively different stages
of interpreting the world. He suggested that we do not simply react to our
environments; we each construct our own understanding of the world
around us, which is based on an interaction of experience and inherent
human characteristics. His influence has been considerable and many of
his basic assumptions are still widely accepted. Although his theory is
being criticized for failing to account for intellectual change during adult
life, in general, we should never take for granted that any point in a par-
ticular person’s cognitive development represents more than, or at least
something different from, the sum of accumulated bits of learning.
There are four general stages or periods in Piaget’s theory. The sensorimo-
tor period represents the first two years of life. The infant’s initial schemes
are simple reflexes. Gradually, these reflexes are combined into larger,
more flexible units of action. Knowledge of the world is limited to physi-
cal interactions with people and objects. Most of the examples of actions
like grasping, sucking and so on occur during infancy.
During the preoperational period, from roughly 2 to 6 years, a child be-

gins to use symbols to represent the world cognitively. Words and num-
bers take the place of objects and events, and actions that formerly had to
be carried out overtly can now be performed mentally, through the use of
internal symbols. The preoperational child is not yet skilled at symbolic
problem solving; various gaps and confusions are evident in the child’s
attempts to understand the world.
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Many of these limitations are overcome when the child reaches the period
of concrete operations, which lasts approximately from 6 to 11 years of
age. Concrete operational children are able to perform mental opera-
tions on the bits of knowledge they possess. They can add them, subtract
them, put them in order, reverse them and so on. These mental operations
permit a kind of logical problem solving that was not possible during the
preoperational period.
The final stage is the period of formal operations, which extends from
about age 11 through adulthood. It includes all of the higher-level ab-
stract operations that do not require concrete objects or materials. The
clearest example of this operation is the ability to deal with hypothetical
events or relationships as opposed to those that actually exist. Mentally
considering all of the ways certain objects could be combined, or attempt-
ing to solve a problem by cognitively examining all of the ways it could be
approached, are two operations that typically cannot be performed until
this last stage.
UP Open University
Module 7 219
Table 7.2. Piaget’s stages of cognitive development

(Piaget’s Theory of Cognitive Development by Wadeworth, Barry, 1971.)
Period Characteristics of Major Change of

the Period the period
Sensorimotor
(0-2 yrs.)
Stage 1 Reflex activity only; no diffe- Development proceeds from

(0-1 mo.) rentiation reflex activity to represen-
tation and sensorimotor
solutions to problems
Stage 2 Hand-mouth coordination;

(1-4 mos.) differentiation via sucking
reflex
Stage 3 Hand-eye coordination;
(4-8 mos.) repeats unusual events
Stage 4 Coordination of two schemata;
(8-12 mos.) object permanence attained
Stage 5 New means through experi-
(12-18 mos.) mentation - follows sequential
displacements
Stage 6 Internal representation; new
(18-24 mos.) means through mental
combinations
Preoperational Problems solved through Development proceeds

(2-7 yrs.) representation; language from sensorimotor repre-
development (2-4 yrs.); sentation to prelogical
thought and language both thought and solutions to
egocentric; cannot solve problems
conservation problems
Concrete Reversibility attained; can Development proceeds

Operational solve conservation problems from prelogical thought to
(7-11 yrs.) (logical operations developed logical solutions to con-
and applied to concrete crete problems
problems); cannot solve
complex verbal problems
Formal Logically solves all types of Development proceeds

Operational problems-thinks scientifically; from logical solutions to
(11 yrs. – solves complex verbal concrete problems to
Adulthood) problems; cognitive structures all classes of problems
mature
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SAQ 7-2
Match Column A with Column B. Write your answers on the blank
spaces in Column A. Read them carefully.
Column A Column B
_______ 1. Cognition a. Processes such as perception and

retention
_______ 2. Cognitive Theory b. Sequential periods associated

with evolution and thinking
_______ 3. Cognitive stages c. Focus on how organisms receive,

store, transform, and use
information
_______ 4. Preoperational d. Complex mental mechanisms like

memory, attention, and abstraction
_______ 5. Cognitive e. Observational or social learning

developmentalists
_______ 6. Cognitive processes f. Stage where the child develops

capacity to use symbols
_______ 7. Formal operation g. Specialists on how individuals

think and how human processes
vary
_______ 8. Cognitive learning h. Permits logical problem-solving

between ages 6 to 11 years
_______ 9. Concrete i. Includes higher level abstract

operational operations not requiring concrete
materials
_______ 10. Stages of j. Crucial variable in Piaget’s theory

development serving as predictor of the kind of
experience a child can learn from
Did you get 100%? Congratulations! If not, review the parts of the text
that you did not understand too well.
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Module 7 221
Humanism
This focuses on the dignity and freedom of all individuals. It is a perspec-
tive that maintains that subjectivity and creativity are essential for under-
standing the process of development. Humanists such as Abraham Maslow
(1890-1970), Charlotte Buhler (1893-1974), and Carl Rogers (1902-1988)
rejected the view of human nature that emphasizes environmental con-
trol and observable actions. Instead, they stressed internal factors and
self-perception. Although they did not believe that scientific standards
of objectivity are useless, they pointed out that the phenomenological per-
spective (an immediate, personal intuition) of the individual must also be
considered. Humanists feel that people should choose their own destinies
and achieve their creative potentials by their own actions. Thus, they share
with other organismic theorists an interest in the internal workings of the
human organism and a belief in the active role of the individual in deter-
mining its own path of development.
Let’s talk in detail of Abraham Maslow’s hierarchy of needs as the best

representative of this group. According to him, only when people have
satisfied the most basic needs can they strive to meet higher needs. The
first need is physiological survival. Starving persons will take great risks
to get food; only when they have obtained it can they worry about the
next level of needs, those concerning personal safety and security. These
needs in turn, must be met (at least in part) before people can seek love
and acceptance, and finally self-actualization, or full realization of po-
tential. Maslow’s ideal, self-actualized person shows high levels of all the
following characteristics: perception of reality; acceptance of self, of
others and of nature; spontaneity; problem solving ability; self-direction;
detachment and the desire for privacy; freshness of appreciation and rich-
ness of emotional reaction; frequency of peak experiences; identification
with other human beings; satisfying and changing relationships with other
people; democratic character structure; creativity and a sense of values.
Only about one person in 100 is said to attain this lofty ideal (Thomas,
1979). But no one is ever completely self-actualized; the healthy person is
always moving up to levels that are even more fulfilling (Papalia and
Wendkos, 1996).
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Self-actualization
needs: to find self-
fulfillment and realize
one’s potential
Esteem needs: to achieve, be

competent, and gain approval and
recognition
Belongingness and love needs: to affiliate with

others, be accepted, and belong
Safety needs: to feel secure and safe, out of danger
Physiological needs: hunger, thirst, and so foth
Figure 7-1. Maslow’s hierarchy of needs

(Source: Maslow, 1954)
Have you fallen in love with the humanistic viewpoints? I cannot help
but be inspired by humanism’s abundant beliefs and tremendous confi-
dence in the human organism. The phenomenological aspect of it makes
it so unique and much more welcoming than other theories.
UP Open University
Module 7 223
SAQ 7-3
1. Briefly explain Maslow’s hierarchy of needs.
2. Describe a self-actualized person.
3. Explain how individuals choose their own destinies and achieve

their creative potentials.
4. Explain the phenomenon of self-sacrifice using Maslow’s

theory.
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Ethology
A small group of naturalists called ethologists describe human behavior/
development in real life settings. They are primarily concerned with the
role of human behavior in the survival of human species. They recognize
the importance of human beings’ living in harmony with their environ-
ment; in other words, they view development as a process of adaptation
to the environment. The contribution of ethology to the study of human
development centers on the suggestion that human as well as lower ani-
mal behavior may have biological origins. John Bowlby suggested that
biological mechanisms are responsible for parent-child attachment in hu-
man beings, similar to those that occur in lower animals. When the infant
is threatened or fears separation from its mother, an automatic attach-
ment system is activated. The child displays behaviors such as calling,
crying, reaching, and following that trigger maternal reactions such as
approaching, smiling, touching and so on. We note that the merits of
Bowlby’s point of view is the emphasis that certain behaviors are “wired
into” the organism by virtue of its being human. This presents a chal-
lenge to the environmentalists’ view that human beings are “empty” at
birth and are gradually shaped by cultural experiences.
Activity 7-1
In a hospital setting, how would you develop a better and closer
mother-child relationship? Aside from “rooming-in”, suggest other
ways to enhance attachment of children to their parents.
Have you observed reactions of both babies and mothers in room-

ing-in procedures? Was extra care allowed? Do babies cry less?
Do mothers feel more confident in their handling of babies? A lot
of studies have documented positive effects/results of such inter-
actions.

In this time of widespread complaints about disturbance in
parenting and people’s inability to maintain lasting relationships,
it would seem wise to do whatever we can to see that attachments
get off to the best possible start.
UP Open University
Module 7 225
Moral development
(Crais, 1963)
Piaget basically described two stages of moral thinking, the second of

which emerges in early adolescence. Lawrence Kohlberg, a follower of
Piaget, offered a new, more detailed sequence for moral thinking. Kohlberg
suggested that some people reach a postconventional level of moral think-
ing where they think in terms of universal ethical principles which take
priority over society’s laws and values.
The suggestion of a postconventional morality is unusual in the social

sciences. Perhaps it took a cognitive-developmentalist to suggest such a
thing. Whereas most social scientists have been impressed by the ways
in which societies mold and shape children’s thinking, cognitive-
developmentalists are more impressed by the capacities for independent
thought. If children engage in enough independent thinking, Kohlberg
suggested that they will eventually begin to formulate universal principles
which they consider higher than social laws and values. This thinking
characterizes some religious and moral leaders who have at times advo-
cated civil disobedience for the sake of higher ethical considerations.
Kohlberg believed that his stages unfold in an invariant sequence. Chil-

dren always go from stage 1 to stage 2 to stage 3, and so forth. They do
not skip stages or move through them in a mixed-up order. Not all chil-
dren eventually attain the highest stages, but to the extent that they do go
through them, they proceed in order.
At stage 1, children assume that one must unquestioningly obey author-

ity, or one will get punished. At stage 2, children are no longer so im-
pressed by any single authority; they see that there are different sides to
every issue. As long as everything is relative to a person’s viewpoint, one
is free to make decisions according to one’s wishes, hedonistically, that is.
At stages 3 and 4, young people judge conduct in terms of conventional

society. At stage 3, children assume that good members of the community
will approve of one’s behavior so long as one’s motives are pure. At stage
4, the main concern is adherence to laws for the sake of social order.
At stages 5 and 6, the person considers rights and principles that may
override society’s values and its need for order. At stage 5, the individual
has some inkling of personal values that may take priority over the law,
whereas, at stage 6, the individual conceptualizes such values as abstract,
universal principles.
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Table 7.3. Kohlberg’s stages of moral development
Level I Preconventional Morality

Stage 1 Obedience and punishment orientation
Stage 2 Relativistic hedonism
Level II Conventional Morality

Stage 3 Good boy/good girl orientation
Stage 4 Maintenance of social order and authority
Level III Postconventional Morality

Stage 5 Democratically accepted law
Stage 6 Universal principles
Kohlberg’s stages become more differentiated and abstract at each point.

The highest stages are the most difficult to understand. It also appears
that people have a preference for the highest stages, whether they fully
understand them or not. People may instinctively sense the greater ade-
quacy of the highest stages, which Kohlberg claimed embody the kinds of
reasoning which can handle the widest range of moral problems in the
most abstract and differentiated way.
Critique of organismic perspective theories

Piaget was the forerunner of today’s “cognitive revolution” in psychol-
ogy, with its emphasis on internal cognitive processes, as opposed to the
emphasis of learning on outside influences and overt behaviors. He
inspired more researches on children’s cognitive development than any
other theorist. Piaget’s careful observations provided a wealth of infor-
mation, including some surprising insights. He pointed out unique ele-
ments of children’s thoughts and made us aware of how different these
are from adult thought. Yet, critics fault Piaget on several counts. He
underemphasized the role of education and culture in affecting children’s
performance. Many of his ideas emerged from his highly personal
observations of his own three children and from his idiosyncratic way of
interviewing children, rather than from established, standardized experi-
mental procedures. Today, psychologists generally view cognitive growth
as gradual and continuous rather than as changing abruptly from one
stage to the next.
Humanistic theory offers a positive, optimistic model of humankind and

its potential for development, as opposed to the negative Freudian view-
point. It goes deeper than learning theory by considering internal factors
like feelings, values, and hopes. Humanistic theories promote child rear-
ing approaches that consider one’s uniqueness. Its limitations as a scien-
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Module 7 227
tific theory have to do with its subjectiveness. Since its concepts are not
clearly defined, they are hard to communicate and use as basis for re-
search designs. Furthermore, since humanistic theories do not focus on
different times of life, they do not provide insights into the process of
development.
The ethologists underscore the need to view human development in an

evolutionary context. They make us realize that we cannot change
children’s behavior in any way we wish. Evolution has provided children
with responses and signals that must be heeded if development is to pro-
ceed properly. Its limitation, though, is its failure to extend analyses to
adolescents and provide more insights into family life and other behav-
iors in the adult years.
Kohlberg’s idea of moral development uncovered a developmental stage

in addition to those described by Piaget. Kohlberg emphasized that some
people reach the postconventional level in terms of universal ethical prin-
ciples which take priority over society’s laws and values. Many psycholo-
gists are skeptical of Kohlberg’s claims. They find it hard to believe that
moral reasoning develops in an invariant sequence, regardless of the cul-
ture, and find it equally hard to accept his sixth stage. To an extent, argu-
ments over Kohlberg’s research may reflect differences in values. Many
psychologists may be philosophically opposed to a morality which places
itself above the need for social order. More researches are needed on the
relationship between moral thoughts and moral behavior.
SAQ 7-4
True or False. Write T if the statement is correct and F if it is incor-
rect.
_______ 1. If children are allowed independent thinking, they

eventually begin to formulate universal principles
which are higher than social laws and values.
_______ 2. Civil disobedience for the sake of ethical consider-
ations is a characteristic example of stage 6 of
Kohlberg’s moral development.
_______ 3. According to Kohlberg, moral reasoning develops
in an invariant sequence, regardless of culture.
_______ 4. Following Kohlberg’s tradition of moral develop-
ment, Socrates’ style of teaching must be adopted
to induce cognitive change.
_______ 5. Kohlberg’s moral development takes into consider-
ation cultural experiences without altering the stage
sequence.
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How many correct answers did you get? If you got less than 3 correct
answers, I suggest you go back to the previous discussion.
Psychoanalytic Perspective
This is the view that stresses the importance of unconscious mechanisms

in development and sees the human organism as a creature of appetite
rather than reason. The psychoanalytic theory resembles organismic theo-
ries in many of its features—the emphasis on internal psychological pro-
cesses rather than external behaviors, the belief that human development
proceeds through a series of qualitatively different stages, the view that
human nature is constructed from a dynamic interaction between the
individual and the environment. The major difference between the two is
in their assumptions about human rationality. According to the psycho-
analytic perspective, rationality and conscious understanding of behav-
ior plays only a secondary role in motivation and development. The
human being is a creature of appetite rather than reason, and develop-
ment is a process whereby people try to resolve inner conflicts that result
from attempting to reach a compromise between their own needs and
society’s expectations (Langer, 1969).
The irrationality of human nature becomes evident from an examination

of two of the major assumptions of the psychoanalytic theory—the sig-
nificance of unconscious motivation and psychic determinism. That there
are forces in the unconscious mind that shape and guide human behav-
ior, was a truly revolutionary belief and is one of the major contributions
of the theory to the modern conceptualization of human nature. Psychic
determinism, on the other hand, refers to the belief that early childhood
experience plays a major role in determining adult personality. If human
behavior is heavily influenced by psychological forces beneath the level of
consciousness, many of which have their origins at an early point in de-
velopment, it is meaningless to suggest that humans are rational organ-
isms.
Freud’s Psychosexual Theory

Freud is believed to have produced the “most influential psychological
theory in history.” He combined the energy model from nineteenth cen-
tury physics, a concept of instinctual drives from evolutionary biology,
and various literary and philosophical references to the unconscious and
to sexuality with a variety of techniques (e.g., free association to verbal
UP Open University
Module 7 229
suggestions, dream analysis, hypnosis, discussion of childhood experiences,

memories). His theory of human development assumes that children
progress through a series of psychosexual stages, which is a relatively
predictable pattern.
The first three stages, oral, anal and phallic occur prior to puberty and
are characterized by the child’s focusing on different areas of the body
known as erogenous zones. According to Freud, the oral stage is cha-
racterized by the child’s mouth as the most stimulating area of sensation.
The infant enjoys sucking and puts many different objects into his mouth,
including feeding nipples, toys, rattles, and clothes. During the anal stage,
the stimulating zone shifts to the anus and the process of controlling de-
fecation. Parental reactions during the oral and anal periods can have
implications for later personality development. At the phallic stage, the
child’s primary sensory zone becomes the genitalia. According to him,
the critical feature of this stage is parental reaction. He felt that the pa-
rents of his time were likely to react restrictively because of the wide-
spread social taboos about sex. This reaction would certainly have been
highly likely during the Victorian era in which Freud lived. The first three
stages have been collectively called the pregenital period. The child’s sexual
behavior and attitudes are not directed toward reproduction. From age
six until the onset of puberty, the child is in a calm period of latency. This
means that pregenital issues have been largely resolved, including the
child’s initial sexual identification. The latency period is the longest psy-
chosexual stage prior to onset of adolescence (genital phase). The period
coincides with the child’s entrance into formal school where he or she
learns the cultural tools of communication. The genital period begins with
adolescence when the individual begins to organize his or her personality
in terms of directed sexual activity and reproduction.
Freud’s theory is far more complex than it appears, as evidenced by his

voluminous writing; however, we wish only to focus on the relevant con-
tributions to the developmental process. As a whole, his basic assumption
is that development consists of dynamic, structural, and sequential com-
ponents, each influenced by a continuously renewed need for gratifica-
tion of basic instincts.
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Table 7.4. Freud’s psychosexual stages of development
Stage Source of Primary Conflict Tasks

(age) Satisfaction
Oral Mouth Weaning Mastery of gratification

(0-1 year) (sucking, biting, of oral needs; begin-
chewing) ning of ego develop-
ment (4-5 mos.)
Anal Anal region Toilet training Beginning to gain sense

(1-3 yrs.) (expulsion and of control over instinctual
retention of feces) drives; learns to delay
immediate gratification to
gain a future goal
Phallic Genitals Oedipus and Sexual identity with

(3-6 yrs.) (masturbation) Electra com- parent of same sex;
plexes beginning of superego
development
Latency Growth of ego functions

(6-12 yrs.) (social, intellectual, me-
chanical) and the ability
to care about and relate
to others outside the
home (peers of the same
sex)
Genital Genitals Developing satisfying

(13-20 (sexual inter- sexual and emotional re-
yrs.) course) lationships with members
of the opposite sex;
emancipation from
parents; planning life
goals and gaining a
strong sense of personal
identity
Source: Gleitman, H. (1981). Psychology.
In your role as a nurse, I’m sure you have had experiences dealing with
children in the pedia ward, in a health center or in the out-patient depart-
ment.
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Module 7 231
Let’s say you have a six year-old male client and one day you observe him
masturbating. How would you feel? Would you feel self-conscious? What
if you see the mother slap the boy’s hand fondling the penis because she
felt embarrassed about what was going on. What would you do? I know
it’s not that easy to handle the situation. Even though you have know-
ledge of Freud’s psychosexual development, it is different when one actu-
ally operationalizes the analyses because you have your own perceptions
of sexuality based on your values, culture, and experiences.
Let me suggest some steps to lessen your feeling of discomfort and thus be
able to handle the situation as a nurse.
1. Be in control of yourself by increasing your self-awareness. You are

expected to be able to promote healthy strategies.
2. Remember/recall immediately that masturbation among children aged

3 to 6 years is normal according to Freudian theory. They do that
because castration fear is a normal reaction during the phallic or fam-
ily triangle period.
3. Educate the mother that the behavior is normal though it should not
be encouraged. Usually, children of this age masturbate when not
doing anything, when anticipating fear, when experiencing anxiety
or pain. It’s a protective maneuver and slapping will not help but
merely produce guilt in the child.
4. Be reminded that any unresolved Oedipus complex will need further

gratification at an older stage.
5. Share your experience with other hospital staff and educate others
regarding Freud’s theory and psychosexual development.
How do you feel after you have done all these steps? I hope you feel GREAT!
Erikson’s Psychosocial Theory

(Schiamberg and Smith, 1982)
Erikson is perhaps the most influential psychoanalytic theorist of the mid-

to late twentieth century. Erikson believed that Freudian theory under-
valued the influence of society on the developing personality. He saw
society as a potentially positive force, which shapes the development of
the ego or self. He moved away from the sexual orientation that charac-
terized early psychoanalytic theory, and toward a greater balance
between biological and social factors. He gave us a new, enlarged picture
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of the child’s tasks at each of Freud’s stages. And beyond this, he added
three new stages—those of adult years—so his theory encompasses the
entire life span of eight stages, each of which is represented by a special
conflict between the needs of the self (ego) and society’s demands.
His psychosocial theory stresses that crises emerge in a predetermined

order according to a timetable that is in turn determined by maturation
(epigenetic principle). Healthy ego development involves adjusting to
the demands of the particular crisis which characterizes each stage. If the
conflict is not satisfactorily resolved, the person will continue to struggle
with it and healthy ego development will be impeded. Success in each
stage lays the ground work for resolving the crises of later stages.
Successful resolution of each of the eight crises requires balancing a

positive trait and a corresponding negative trait, e.g., trust and mistrust
during infancy. Although the positive quality should predominate, some
element of the negative is needed, too. Healthy people, for example, basi-
cally trust their world, but they need to learn some mistrust to be pre-
pared for dangerous or uncomfortable situations. According to Erikson,
conflict and challenge over each of the psychosocial issues are needed for
healthy growth and development. For him, maturation promotes the
growth of the ego modes and the general ego qualities. By suggesting that
healthy development is tied to a maturational ground plan, Erikson moved
Freudian theory in the developmental direction of Rousseau, Gesell and
others.
Erikson’s eight stages are points where each individual’s adjustment may
lean toward one of two directions. The first stage from birth to 1.5 years
of age corresponds to Freud’s oral stage and focuses on the formation of
a basic sense of trust (or the opposite, mistrust) in the environment. If
the infant comes to expect that its needs will be met with some regularity
(i.e., that the world is largely a predictable and friendly place: food is
given when one is hungry, clean diapers are put on regularly and so on)
then a basic foundation of trust will be formed. Although feeding or oral
interaction is surely important, it is only one mode of reassuring the child.
Erikson built on oral needs but did not overlook other ways of regulating
infants like touching or holding the child.
In the second stage, the child is faced with another important step:
autonomy versus shame and doubt. This corresponds to Freud’s anal
stage in that the child wants to become independent by gaining control
of eliminative activities. Erikson expanded on the child’s newly emerg-
ing motor and language skills and sense of self as a separate being. The
child now develops feelings about his or her ability to do things. Again,
the child’s parents are critical at this point, as they may facilitate or frus-
trate the development and use of skills.
UP Open University
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The 3 to 6 year old child is faced with another dilemma—initiative ver-

sus guilt. The child is exploring beyond himself or herself. He or she
begins to deal with people and things and sees how the world works. This
period corresponds to Freud’s phallic stage, in which exploration and
manipulation of the genitals become a source of pleasure for the young
child. Erikson expanded Freud’s notion of genital exploration to explora-
tion of the child’s world. The child’s initiative is reflected in the increasing
number of questions asked, and the child’s ability to imagine a make-
believe world. Reactions of caretakers and parents are significant too, as
they may influence the child’s sense of initiative or guilt during explora-
tion.
The next stage is called the period of industry versus inferiority during
elementary school years and coincides with Freud’s latency period. At
this stage, the child develops skills in deductive reasoning as well as play-
ing games according to established rules. Industry refers to the sense of
accomplishment the child gets from applying his or her skills to see how
things work. Inferiority refers to the sense of hopelessness or lack of con-
trol the child feels when he or she senses that his or her skills and abilities
are no match for the tasks at hand. Teachers, parents and caretakers play
a critical role because they help the child develop a sense of productivity.
At about the age of 11 to 18, the adolescent develops an initial stance

toward the world or an identity. He begins to ask, “Who am I in relation
to society? What do I wish to become? What values or beliefs will guide
my life? What lifestyle do I prefer? Do I have a choice in these matters?”
Two changes occur during this period and they result in the adolescent’s
ability to deal with such identity questions. The first change is physical.
The onset of puberty results in body changes that may cause the adoles-
cent to view himself or herself, at least physically, as a potential adult.
The second change has to do with the development of abstract reason-
ing, which helps the individual deal with abstractions such as justice,
truth, and identity. Thus, Erikson sees this period of identity as involving
more than just sexual development. From the vast array of possible roles,
the adolescent attempts to develop a reasonably organized description of
the self and the world. The social environment plays an important role in
identity formation since it can provide opportunities for self development.
From infancy to the stage of identity, Erikson broadened the psychosexual

stages of Freud, although he adopted them as his basic orientation to child
and adolescent development.
Before Erikson, the periods of young adulthood and beyond were largely
overlooked by classical psychoanalytical theorists. At this point, the per-
son is beginning to find his or her place in society. Erikson pointed out
that the real and true test of one’s identity is the ability to share it with
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another person in an intimate relationship. The major characteristic of

an individual who successfully negotiates young adulthood is the ability
to share oneself openly with another person (of either the same or oppo-
site sex) without fear of losing one’s identity. The period of middle age
offers the opportunity to share concern for others in a broadened sense.
The individual has the choice of becoming absorbed or involved in his or
her own needs, comforts and health; or of actively generating concern
and constructive effort for others’ welfare. The ability to help others
depends partly on how well the previous stages have been negotiated.
Toward the end of this period, parents find more time for themselves as
children in the family unit grow to maturity and develop extensive affili-
ations outside the family. This is also a decision point at which the indi-
vidual has a choice between using this new freedom for developing
personal interests or for becoming involved in activities outside the home.
The eighth and final stage occurs in old age, when the individual looks
back on his/her life. If the individual is satisfied that life has been worth-
while and meaningful, he or she has what Erikson calls integrity. Integ-
rity means life has had some discernible pattern of wholeness, unity or
“fitting together.” If on the contrary, the person sees life as a disorganized
and meaningless array of events, then a sense of despair may follow.
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Table 7.5. Erikson’s eight stages of development
Approximate Developmental Psychosocial Successful resolution Unsuccessful resolution

age task crisis of crisis of crisis
0-1.5 years Attachment to mother, Trust versus mstrust Sound basis for relating to General difficulties relating
which lays foundation for other people; trust in people; to people effectively; suspi-
later trust in others faith and hope about the envi- cion; trust-fear conflict; fear
ronment and the future of the future
1.5-3 years Gaining some basic con- Autonomy versus Sense of self-control and Independence-fear conflict;
trol of self and environ- shame and doubt adequacy; willpower severe feelings of self-doubt
ment (e.g., toilet training,
exploration)
3-6 years Becoming purposeful Initiative versus guilt Ability to initiate one’s own Aggression-fear conflict;
and directive activities; sense of purpose sense of inadequacy or guilt
6 years-puberty Developing socially, and Industry versus Competence; ability to learn Sense of inferiority; difficulty
physically; schooling inferiority and work learning and working
Adolescence Making a transition from Identity versus role Sense of personal identity; Confusion about who one is;
childhood to adulthood; confusion fidelity identity submerged in rela-
developing a sense of tionships or group member-
identity ships
Early adulthood Establishing intimate Intimacy versus Ability to love deeply and Emotional isolation;
bonds of love and friendship isolation commit oneself egocentricity
Middle age Fulfilling life goals that Generativity versus Ability to give and care for Self-absorption; inability to
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involve family, career, self-absorption others grow as a person

and society; developing
Module 7
concerns that embrace
future generatios
Later years Looking back over one’s Integrity versus Sense of integrity and ful- Dissatisfaction with life;
235
life and accepting its despair fillment; willingness to face denial of or despair over
meaning death; wisdom prospect of death
Adapted from Erikson, E.H., 1963 and Altrocchi, J., 1980.

Table 7.6. Comparison of Freud’s and Erikson’s stages
Age Freud’s Stages Erikson’s General Stages
Birth to 1.5 years Oral Trust vs. Mistrust

1.5 to 3 years Anal Autonomy vs. Shame and
Doubt
3 to 6 years Phallic (Oedipal) Initiative vs. Guilt
6 to 11 years Latency Industry vs. Inferiority
Adolescence Genital Identity vs. Role Confusion
Young adulthood ----- Intimacy vs. Isolation
Adulthood ----- Generativity vs. Stagnation
Old age ----- Integrity vs. Despair
Source: Crain, W.C. (1963). Theories of development concepts and principles. 2nd edition.
New Jersey: Prentice Hall.
SAQ 7-5
1. What are the strengths of Erikson’s Psychosocial theory?
2. What is the basis of his theory of development?
3. What is his rationale for formulating the negative aspect of the

developmental task or psychosocial crisis?
4. Must one go through all his stages as a measure of successful

development?
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Module 7 237
Critique of the Psychoanalytic Theory

Freud’s original and creative thinking made immense contributions to our
understanding of children, and had a major impact on child-rearing prac-
tices. He made us aware of infantile sexuality, the nature of unconscious
thoughts and emotions, importance of parent-child relationships, and
many other aspects of emotional functioning. However, he based his theory
about normal development not on average children but on his clientele of
upper-middle class adults in therapy. His concentration on the resolution
of psychosexual conflict as the key to healthy development seems too nar-
row. The subjective way in which he phrased his theories has made them
hard to test. Research has questioned or invalidated many of his con-
cepts.
Erikson’s theory has stood up much better to scrutiny. One strength is its
emphasis on how social and cultural experiences affect development,
which takes it beyond Freud’s narrow focus on biological and matura-
tional factors. Also, it covers the entire lifespan, while Freud’s theory
stops at adolescence. But Erikson too has been criticized for an anti-fe-
male bias, since he uses the male as the norm for healthy development.
Some of his concepts are also hard to assess objectively or to use as basis
for research; and there is no real evidence that his stages unfold in the
sequence he proposed.
Generally, the strength of psychoanalytic theory is that it takes a holistic

approach to human development. Many of the theoretical formulations
look at specific aspects of human development such as thinking and overt
behavior, while ignoring other areas like emotion, feelings, or motivation.
Other neo-Freudian theorists like Adler, Horney, and Jung did contribute
in aspects of development but focused more on the personality variable.
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Activity 7-2
A. Conduct a developmental analysis of your own life by creating
a developmental autobiography. Be creative in your approach.
However, regardless of the style, it is important that you di-
vide your activity into two phases. In Phase I, do some back-
ground work; attempt to discover information about your past
development. Do not exclude the seemingly insignificant or
trivial happenings in your life. In Phase II, use your background
research to construct an autobiography. Be as comprehensive
or as focused as you want.
B. Choose from any of the approaches below:
1. Factual Chronology — assemble facts of your life. You may

begin with your birth but you could also include informa-
tion about your conception and prenatal development.
From birth onward, record important facts from each stage
of your physical, cognitive, and psychosocial development.
A partial listing might include answers to the following
questions.
a. What were the conditions of your mother’s pregnancy?

b. What were your vital statistics at birth?
c. Were you an “easy” or “difficult” baby?
d. Were you breast- or bottle-fed?
e. When were you weaned, toilet trained, etc.?
f. When did you sit up, crawl, walk, talk, etc.?
g. What childhood illnesses did you have, and when did
you have them?
h. Who were your first playmates?
i. When did you have growth spurts?
j. What were your most favorite and least favorite sub-
jects in school?
k. How would you rate your progress in school? Was school
easy or difficult?
l. Who were your friends in the fifth grade?
m. What are your best and worst memories of school?
n. When did puberty begin for you? When did your voice
change?
o. When did your body shape change? When did your
menstruation begin?
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Module 7 239
Activity 7-2 continued
p. When did the changes that accompany the onset of ado-

lescence stabilize?
q. Are you still growing, and is your body still changing
shape?
r. Have you found making friends easy? Do you consider
yourself a shy person?
s. When did you begin dating? What were the circum-
stances of your first serious romance?
t. Who were your idols or models?
u. How many times have you changed residence?
v. What was your first job? What jobs have you held since
then?
w. How many times have you changed your career plans?
x. Are you married? Divorced?
y. Do you have children?
z. Where are you now in your development?
Obviously, this list can be limited or expanded as your own

situation dictates. This factual chronology may also serve
as the background research for the autobiography that you
will eventually create.
2. Document File — instead of recording the facts of your life,

you can collect your actual life records. As in factual chro-
nology, begin at your beginning. Include birth announce-
ment and newspaper clippings, if you can find them. Did
your parents keep a baby book? Put in copies of personal
medical records. Do you have records of your childhood
immunizations? Search diligently for documents that record
your physical, cognitive, and psychosocial development.
Use photos, school records and papers, programs for edu-
cational and religious activities in which you participated,
newspaper clippings, and personal letters.
3. Oral Interview — this is an oral record of your life, the

basis of which is a structured interview. Working from a
set of prepared questions about which the interviewee has
had time to think, the interviewer records the interview on
tape. If interviewing yourself seems awkward, ask another
person to do it for you. With this approach, you will likely
create a more personal account of your life, one that not
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Activity 7-2 continued
only includes facts of your life but also personal and family
anecdotes, special memories and stories about events in your
earlier development. You may want to avail of video re-
corders or audio equipment to make it a more creative fam-
ily project.
4. Life narratives — write down the stories that you have

heard about your early development or that you recall from
old experiences. In essence, you create a collection of short
stories about your life. Emphasis here is not on the accu-
racy of the account but in telling the stories as you recall
them. You may decide to tell stories from across your lifespan,
or perhaps, focus on the stories from just one period of your
life. The life narrative approach is your opportunity to be a
storyteller. Focus on your best, favorite and most meaning-
ful stories to create a collection that provides insight about
you and your development.
C. Begin your development analysis by applying one or more psy-

chological perspectives to your life. Look for examples, behav-
ioral, psychodynamic, cognitive and humanistic/existential
perspectives in what you have written about your life. From
the biological perspective, what has been the impact of inher-
ited characteristics on your development? From the behavioral
perspective, how have you been influenced by your parent’s
use of specific rewards and punishments? Similar analyses can
be made for each of the perspectives. Analyze the material you
have collected about yourself that illustrate the different per-
spectives.
D. From the general perspectives, move to specific theories. For

example, Erikson’s psychosocial stages provide a convenient
framework for analyzing your development at different ages.
You may be able to apply theories such as those of Kohlberg’s
in the area of moral development, to draw a clearer picture of
the factors that influenced your development. You now have,
what you call a psychobiography.
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Module 7 241

In choosing your style of writing a psychobiography, begin with
the idea that the project will be an enjoyable experience. Have fun
exploring your development. Do not be conscious about making
“correct” analyses, instead, view the project as an opportunity for
further growth and development. Pause often in your work to re-
flect, as Henry Murray did over 50 years ago, on the uniqueness of
being you:
In the organism, the passage of time is marked by rhythms of as-

similation, differentiation and integration. The environment
changes. Success and failure produce their effects. There is learn-
ing and there is maturation. Thus, new and previously precluded
combinations come into being and with the perishing of each mo-
ment, the organism is left a different creature, never to repeat itself
exactly. No moment nor epoch is typical of the whole. Life is an
irreversible sequence of non-identical events (Murray, 1948).
Summary
Human development is a process both individual and continuous, influ-
enced by a complex mix of heredity and environment. Its study is inter-
disciplinary and includes contributions from psychologists, sociologists,
anthropologists, developmentalists and other professionals in different
fields. Those who concentrate on human development are primarily in-
terested in qualitative change over time that results when one state of
affairs evolves from what has come before. Quantitative change, on the
other hand, is less likely to be of interest to developmentalists. The focus
on developmental stages was highlighted by particular clusters of physi-
cal, emotional, intellectual, and social characteristics in a period within
the lifespan.
The appropriateness of various perspectives in explaining human deve-

lopment depends on the particular aspect of development we are consi-
dering. In most cases, no one theory can provide complete answers to the
complex question of how a person develops. In many situations, the best
answer we can arrive at involves a synthesis of all three points of view—
the environmentalist, the organismic, and the psychoanalytic perspec-
tives. A few common themes emerge clearly from this array of develop-
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mental theories. First, human growth and development is regular; sec-

ond, behavior is at least potentially predictable; and third, with the ex-
ception of conditioning theorists who see the individual as passive and
merely reacting to environmental changes, all theorists see the individual
as being at least reasonably active. But the moment we set theories side
by side, making comparisons becomes difficult.
These theories were divided into cohesive categories, namely, environ-

mentalist perspective, organismic perspective and psychoanalytic perspec-
tive with corresponding subclassifications. The history of developmental
theory was discussed from Plato and Aristotle’s time to the current time
where emphasis was on the how and why rather than the what of human
development. Focus on growth and development from infancy to adult-
hood was touched in a more integrated presentation. The strengths and
limitations of major theories were discussed.
Finally, I wish to mention what Kluckhohn said about human beings.

“Each individual is in some ways completely unique, in other ways simi-
lar to others in behavior and values, and still in other respects like all
other human beings.”
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Module 7 243

ASAQ 7-1
1. Behaviorism has the following strengths:
a. It facilitates better control of the self by creating a conducive envi-
ronment.
b. It focuses on objective observation of behaviors - making it more
measurable for evaluation purposes.
c. It helps modify behaviors for more positive result thru condition-
ing.
d. It follows a more scientific approach in the area of research and
experimentation.
e. Learning is considered an intervening variable between experi-
ences and changed behavior.
2. Limitations of behaviorism:
a. It disregards complex mental structures and internal events
described by Piaget and Freud, respectively.
b. It doubts the validity of stages as general, distinct ways of thinking
or behaving; for the environment shapes behavior in a gradual
and continuous manner.
c. It limits its focus to the external environment as the major determi-
nant of behavior
3. Mastering the strengths and limitations of behaviorism will allow you

to appreciate its uniqueness. Its most distinguishing characteristic is
its focus on objective, overt behavior which makes it basically scien-
tific. The mind cannot be observed directly and so measurable, overt
behaviors are easier to document.
ASAQ 7-2
1. a
2. c
3. b
4. f
5. g
6. d
7. i
8. e
9. h
10. j
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ASAQ 7-3
1. Maslow’s hierarchy of needs was taken from his theory of motivation
arranged in hierarchical order such that the fulfillment of lower needs
propels the organism to the pusuit of the next higher level. These needs
are physiological, safety, love, self-esteem and self-actualization.
2. According to Maslow, self-actualizers are primarily motivated by their

own inner growth, development of their potentials and their personal
mission in life. They are good phenomenologists. They can suspend or
go beyond conventional ways of ordering experience. They have at-
tained a certain independence from their culture, they are not con-
fined to conventional, abstract or stereotyped modes of operation.
3. According to Maslow, humans possess an essential biological inner

nature which is partly idiosyncratic for we all have special interests,
temperaments and abilities. It is a positive force which presses toward
realization of full potentials and humaneness.
4. Maslow believed that people have an inner life potential for growth,
creativity and free choice. Through self-sacrifice, which is man’s free
choice, he will allow his full potential for creative growth.
ASAQ 7-4
1. True — If children are given more independent thinking opportuni-
ties, they begin to form universal principles above social laws, order
and values.
2. True — Civil disobedience, common among activists, is motivated by

the postconventional principles of Kohlberg.
3. True — This was much asserted by Kohlberg; however, that is one

limitation also of his theories. Critics say there is a need for longitudi-
nal research on the question of invariant sequence.
4. True — Kohlberg’s method of ensuring cognitive growth requires a

good method of teaching using Socrates’ style. Students are motivated
to resolve confusion and revive their thinking.
5. True — Kohlberg asserted that cultural factors stimulate children to

move through stages. Culture can alter the rate and extent of moral
development by stimulating thinking without altering the stage se-
quence.
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Module 7 245
ASAQ 7-5
1. Strengths of Erikson’s theory:
a. It covers the entire lifespan across cultures.
b. It has more healthy insights as implications for development.
c. It underscores the contribution of society in development.
d. His subjects were all healthy, normal children.
e. His writings are so rich and profound that it is very rewarding to
master it to gain personal insights into human nature and for sci-
entific progress.
2. His psychosocial theory stresses that crises emerge in a predetermined

order according to a timetable that is in turn determined by matura-
tion, which represents an application of the epigenetic principle.
3. Successful resolution of each crisis requires balancing a positive trait

and a corresponding negative trait, which is needed to be able to handle
dangerous and uncomfortable situations. Conflict is necessary as a
challenge for healthy growth and development.
4. Yes. In Erikson’s theory, one must, if one lives long enough, go through
all the stages. The reason has to do with the forces that move a person
from one stage to another—biological maturation and social expecta-
tions. These forces push one along according to a certain timetable,
whether one has been successful at earlier stages or not. Success at
earlier stages affects the chances of success at later ones.
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References
Crain, W.C. (1985). Theories of development concepts and application. 2nd
Edition. New Jersey: Prentice Hall.
Dacey, J. and Travers, J. (1994). Human development across the life span.
Madison, Wisconsin: Brown and Benchmark Publishers.
Erikson, E.H. (1963). Childhood and society. New York: Norton and Co.
Inc.
Hoffman, L., Paris, S. and Hall, E. (1994). Developmental psychology today.
New York: Mc Graw Hill Inc.
Hughes, F.P. and Noppe, L.D. (1991). Human development across life span.
New York: Mac Millan Publishing Co.
Irwin, J.A. and Simons, H.A. (1994). Lifespan developmental psychology.
Madison, Wisconsin: Brown & Benchmark Publishers.
Kail, R.V., and Wisk-Nelson, R. (1990). Developmental psychology. 5th Edi-
tion. New Jersey: Prentice Hall.
Langer, J. (1968). Theories of development. New York: Holt Renehart &
Winston.
Miller, P.H. (9189). Theories of developmental psychology. 2nd Edition. New
York: W.A. Freeman.
Papalia, O. (1992). Human development. International Edition. New York:
Mc Graw Hill Book Inc.
Pikunas, J. (1976). Human development-An emergent science. 3rd Edition.
Mc Graw Hill. New York.
Salkind, N.J. (1985). Theories of human development. 2nd Edition. USA: John
Wiley and Sons Inc.
Schamberg, L., and Smith, K. (1982). Human development. New York:
McMillan Publishing Co. Inc.
Vasta, R., et al. (1992). Child psychology-The modern science. New York:
John Wiley and Sons Inc.
Zanden, J. (1985). Human development. 3rd Edition. USA: Alfred A. Knoff,
Inc.
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Module 8 247
Module 8
Learning Theories
and Other Related Theories
Josefina A. Tuazon
H ave you sometimes wondered why people

behave the way they do? How does learn-
ing occur? What factors influence the repetition
Objectives
of learned behavior? I myself have always won-
dered, for example, why smokers, despite receiv-
ing adequate information on the risk of lung can-
cer, still continue to smoke. More importantly, I
1. Compare the selected
ask myself, “How do I influence other people’s
learning theories in terms
behavior toward positive health changes?”
of their similarities and
differences; and
These questions may be answered by looking at
2. Cite some of the applica-
the dynamics of learning since learning is a key
tions of selected learning
process in the development of human behavior.
theories and related
If you understand how learning takes place, you
theories to nursing
will understand the dynamics of behavior and
practice.
therefore, you will know how to influence behav-
ior. To a certain extent, knowing the learning
theories in this module will facilitate understanding the change theories
which follow in Module 9.
For this module, I have selected some of the more current and widely
accepted learning theories that are applicable in nursing. These include:
1. Bandura’s Social learning Theory

2. Hochbaum, Rosenstock and Becker’s Health Belief Model
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3. Green’s PRECEDE Framework for Health Education Planning and

Evaluation
4. Knowles’ Adult Learning Theory
The Health Belief Model and the PRECEDE Framework are not really
considered learning theories per se. However, I have included these two
because they are widely used in a lot of disciplines, particularly in nurs-
ing, as basis for understanding health-related behavior (Health Belief
Model) and health education planning and evaluation (the PRECEDE
Framework).
I hope that you will gain insight into the dynamics of attitudes and be-
havior just as I have learned a lot by studying these theories. As a teacher,
not only do I understand my students better, I also use various strategies
to make my teaching more effective using the learning theories. As a nurse,
the learning theories help me in my assessment of clients and improve my
interventions. Even as an administrator, because we deal with people, the
learning theories will come in handy. In fact, these theories have a wide
application in whatever setting or situation, especially in nursing.
Defining Learning
What is learning? Most psychology books define learning as “any rela-
tively permanent change in behavior or behavior potential that results
from experience or practice.” It includes all behavior changes that cannot
be accounted for solely by growth. It also does not include behavior
changes due to temporary conditions like acute illness or injury.
When a child imitates the way her mother dresses, this is learning. When
you read and learn from the experiences of others, this is also learning.
When you feel anxious whenever the teacher calls on you, this is a result
of learning. From the day you were born to this very minute, you are
learning, whether you are aware of it or not. Although it is true that
learning cannot be observed, it is usually inferred from a person’s behav-
ior.
Historical Perspective
The earlier known learning theories include classical conditioning (also
called Pavlovian conditioning), and operant conditioning (also called
Skinnerian conditioning). Both of these kinds of learning must be very
familiar to you. If you recall, these theories were taught in the basic psy-
UP Open University
Module 8 249
chology courses in your undergraduate years. Just remember that these

two theories, particularly the latter, form the basis of behaviorism. Clas-
sical conditioning is learning based on pairing of conditioned and un-
conditioned stimuli resulting in a conditioned response. Operant condi-
tioning is learning based on consequences—behavior that is rewarded is
most likely to be repeated.
These two learning theories seem simplistic in today’s knowledge of be-

havior. They operate on the assumption that man acts either by reflex or
based on rewards. What about learning that takes place when we do not
directly experience something and yet still learn as when you read a book
or study this module? This type of learning cannot be explained simply by
classical or operant conditioning.
This third type of learning is cognitive learning. In cognitive learning

theories, for the first time, emphasis is placed on the cognitive processes
— our thoughts, the way we perceive, store and process information. A
number of psychologists have contributed to this group of theories. Fore-
most was E.C. Tolman, an American psychologist who conducted a clas-
sic experiment in 1930. Hungry rats were made to wander through a
complicated maze every day for more than a week to reach food. Tolman
concluded that rats make mental or cognitive maps to reach the goal.
This however does not negate the function of reward. Learning was even
faster in the presence of a reward.
Now I come to the meat of this module. From these three types of learning
evolved other learning theories that are now widely accepted and prac-
ticed by nurses and health educators.
I will first discuss the Social Learning Theory.
Social Learning Theory

Social learning theories (SLT) are offshoots of cognitive learning. Although
social learning theorists recognized the contribution of Pavlovian and
Skinnerian conditioning, they emphasized the significance of learning by
imitating, observing others, or by learning vicariously. In other words,
learning is not only based on automatic reflexes or rewards. The cognitive
processes of man are important as well.
To illustrate the similarities and differences of classical, operant condi-

tioning, and SLT, look at the Venn diagram on the next page. Do you see
that SLT has elements of classical and operant conditioning but a larger
portion of it is derived from the cognitive theories?
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Classical Operant
Conditioning Conditioning
Social Learning
Theory
Cognitive
Conditioning
Figure 8-1. Similarities and differences of classical,

operant conditioning and SLT
So what are the components of the social learning theory? The SLT states
that there is a continuous and reciprocal relationship between these fac-
tors: (1) a person’s behavior; (2) the environmental consequences of that
behavior; and (3) the cognitive processes going on inside the person. This
interaction can be represented as a triangle shown below:
Cognitive Processes
Behavior Environmental
Consequences
(Outcome)
UP Open University
Module 8 251
Consider the following hypothetical situation:
Tonton is a 14 year old boy and his friends are all smoking. His
friends have been convincing him to start smoking. Tonton has
seen a lot of people of his age smoking. His teacher whom he idol-
izes, smokes. His parents have told him the harmful effects of smok-
ing yet his friends are very important to him and he values their
opinions too. He is processing all these information in his mind
(the cognitive aspect). One day, he tried to smoke one cigarette
with his friends (behavior). He started to cough and had an un-
pleasant sensation after smoking (consequence). His friends ap-
plauded his effort to try smoking (consequence). When he got home,
his mother punished him (consequence). All these consequences
and environmental influences will again be processed in his mind
and will affect his future behavior. Tonton might choose never to
smoke again or he may try smoking a second or a third time.
Can you appreciate the three elements of the SLT in the above situation?
I have actually pointed them out for you this time. Can you also see how
the three elements interact with each other?
SAQ 8-1
Consider the earlier theories of classical conditioning and operant
conditioning. Note the similarities and differences between these
two kinds of learning and the social learning theory by filling up
the comparative table below using checks (P).
Classical Operant Social Learning

Conditioning Conditioning Theory
Behavioral
component is
considered
Behavior is
based on
rewards/conse-
quences
Cognitive pro-
cess is consi-
dered
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Check your answers with my answers at the end of this module. Did you
get most of the answers right? I knew you would. You may now proceed
to reading about Bandura’s Social Learning Theory which is the most
widely used cognitive theory.
Bandura’s Social Learning Theory

One of the more popular social learning theories, if not the most popular,
is Albert Bandura’s. In fact, when we say SLT, it usually refers to Bandura’s
SLT. Bandura is a Stanford University psychologist and a leading re-
searcher in social learning who did most of his studies in aggressive re-
sponses of children. Like other social learning theories, Bandura’s SLT is
an offshoot of cognitive learning. In fact, he later relabelled SLT into so-
cial cognitive theory (SCT).
Please take note that further references made to SLT for this module will
refer mostly to Bandura’s SLT or SCT.
More specifically, Bandura’s SLT holds that behavior is determined by

expectancies and incentives:
1. Expectancies may include:
a. Expectancies about environmental cues, that is, beliefs about how

events are connected—what leads to what
b. Expectancies about the consequences of one’s own actions, that is,
opinions about how individual behavior is likely to influence out-
comes; this is called outcome expectation
c. Expectancies about one’s own competence to perform the behav-
ior needed to influence outcomes; this is termed efficacy expecta-
tion or self-efficacy
2. Incentive (or reinforcement) is defined as the value of a particular

object or outcome. The outcome may be health status, physical
appearance, approval of others, economic gain, etc. Yes, behavior is
regulated by its consequences, but only as those consequences are in-
terpreted and understood by the individual (Rosenstock, et al, 1988).
Behavior, in this perspective, is a function of the subjective value of an

outcome and other subjective expectations, or the probability that a par-
ticular action will achieve that outcome. Such formulations are generally
termed “value-expectancy” theories. Reinforcements or consequences of
behavior are believed to operate by influencing expectations regarding
the situation.
UP Open University
Module 8 253
For example, individuals who value the perceived effects of changed

lifestyle (incentives) will attempt to change if they believe that (a) their
current lifestyle poses a threat to a personally valued outcome such as
physical appearance; (b) particular behavioral changes such as exercise
and eating less meat will reduce the threat (outcome expectation); and (c)
they are personally capable of adopting the new behaviors (self-efficacy).
According to Rosenstock et al. (1988), social cognitive theory has made at

least two contributions to explanations of health-related behavior theo-
ries. The first is the emphasis on the use of several sources of information
for acquiring expectations, particularly on the informative and motiva-
tional role of reinforcement and on the role of observational learning
through modeling (imitating) the behavior of others. The delineation of
sources of expectations suggests a number of potentially effective strate-
gies for altering behavior by modifying expectations.
A second major contribution of SLT that is largely attributed to Bandura

is the concept of self-efficacy (efficacy expectation) as distinct from out-
come expectation. Outcome expectation is defined as a person’s estimate
that a given behavior will lead to certain outcomes. This is quite similar to
the concept of “perceived benefits of the Health Belief Model.” Efficacy is
defined as the conviction that one can successfully execute the behavior
required to produce the outcomes. The distinction between outcome and
efficacy expectations is important because both are required for behavior.
The following diagram from Bandura (1977) shows the relationship:
Person Behavior Outcome
Efficacy Outcome
Expectations Expectations
For example, for a particular man (Person) to quit smoking (Behavior) for
health reasons (Outcome), he must believe that cessation will benefit his
health (Outcome Expectation) and also that he is capable of quitting (Ef-
ficacy Expectation).
For Bandura, self-efficacy is different from Rotter’s locus of control. You

may have heard of this term before. It will be good for you to be familiar
with this concept and to distinguish it from self-efficacy.
Locus of control is a generalized concept about the self and usually refers
to two kinds: internal versus external locus of control. A person is said
to have an internal locus of control if he believes that personal behavior
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would influence outcomes. An externally controlled person on the other

hand, believes that there are larger forces such as fate or God which affect
outcomes and these are not within his control.
When you teach your diabetic female client the proper preparation of a
diabetic diet, for example, it will be good for you to assess both her locus
of control and self-efficacy. If she believes that she will not be able to
comply with her diet and that her mother-in-law exerts a strong influ-
ence on her husband and the rest of the household, then the client has an
external locus of control. Your teachings will most likely not be effective
because your client feels helpless and believes she cannot do anything to
improve her situation.
What about self-efficacy? What if this same client feels she lacks the requi-
site skills to prepare and follow a diabetic diet? If she has low self-efficacy,
again, your teaching would be ineffective. She will be better off if you
train and develop her skills in calorie computation, use of the diabetic
exchange list, and menu planning. These new skills will increase the client’s
self-efficacy.
Activity 8-1
Try to apply the social learning theory in the assessment of a cli-
ent. Select one client, either an actual patient or any one within
access who has a health behavior that requires modifying. It may
be a neighbor whom you want to convince about immunization,
or a friend who wants to quit smoking, or your asthmatic mother
who does not take her medicines regularly. Interview the person
and try to obtain information regarding his/her expectancies and
incentives using the guide below:
1. Expectancies about environment cues—what leads to what

2. Outcome expectancies or beliefs about the consequences of his
actions—how his behavior is likely to influence the outcome
3. Efficacy expectations or beliefs about one’s own competence
to perform the behavior
4. Incentives — how he values the outcome
List your questions and the answers you gathered from your inter-
view. See if you can use these data for planning your health teach-
ing.
Make sure you keep this record of your interview because you’ll
use this later for your tutor-marked assignment.
UP Open University
Module 8 255

How did your interview go? Was it easy to apply Bandura’s SLT
in assessing a client’s need for health education? Look at the ques-
tions you formulated for each expectancy and incentive. Were you
able to distinguish your questions for assessing outcome expect-
ancy, efficacy expectation and incentive?
In the asthmatic client, questions would go something like this:
1. Do you think there is something you can do to prevent asthma

attacks? Is this something within your control? (Outcome Ex-
pectancy)
2. Do you know how to prevent asthma attacks? Do you think
you can do it? Will you be able to take your medicines? (Self-
efficacy)
3. How much do you want to prevent asthma attacks? What do
you gain if your asthma is controlled? (Incentive)
SAQ 8-2
If your client’s responses were something like the following, how
would you assess his outcome expectancy and self-efficacy?
1. “I don’t know how to use my inhaler.”

2. “I’m too busy, I don’t think I can take my medicines regularly.”
3. “Anyway, people say I will outgrow my asthma.”
4. “Bahala na!”
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Well, so far you have been reading about learning theories. Now, I will
move on to other theoretical models which have been very useful in influ-
encing behavioral change. One of these is the Health Belief Model.
Health Belief Model and

Other Rational Belief Models
Several theories have attempted to explain the influence of different vari-
ables on an individual’s health related behavior. One of the best-known
theoretical models highlighting the function of beliefs in health-related
decision-making is the Health Belief Model (HBM). The model was origi-
nally proposed by Godfrey M. Hochbaum in 1958 as a theoretical model
of preventive health behavior, later developed by Rosenstock in 1966 who
coined the term “Health Belief Model” and further modified by Becker in
1974.
Perceived Perceived benefits of

susceptibility to recommended action
disease “X”
minus
plus
Perceived barriers or
Perceived costs to recommended
severity of action
disease “X”
Perceived threat of disease

“X”
Cues to action
• Mass media
• Advise from others
• Illness of family
member or friend
• Newspaper article
Likelihood of taking recommended

action or preventive health behavior
Figure 8-2. Health belief model
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Module 8 257
What does HBM say about behavior? It suggests that the decision whether
or not to change a behavior will be influenced by an evaluation of its
feasibility and its benefits weighed against its costs. In other words, the
belief influences behavior.
What kinds of beliefs do this? HBM hypothesizes that health-related

action depends upon the simultaneous occurrence of three classes of fac-
tors: (1) perceived susceptibility to and perceived severity of disease or
injury, and (2) perceived benefits or efficacy of preventive/recommended
action vis-à-vis (3) the perceived costs or barriers.
The Health Belief Model suggests that behaviors reflect a person’s subjec-
tive view of a situation, readiness to take action, and perception that
benefits outweigh “cost.” It also assumes the existence of sufficient moti-
vation or concern to make health issues salient or relevant. Let me go
through each of these points one by one.
1. Perceived Susceptibility — Does the person feel susceptible or vul-

nerable to the negative consequences of the illness? The more suscep-
tible or vulnerable a person feels, according to this theory, the more
likely that the person will adhere to good self-care practices or adopt
the recommended action. This is also called perceived threat.
For example, a mother might know that her 9 month old child is vul-
nerable to measles infection. If she didn’t know this, she may ignore
the campaign for measles immunization.
2. Perceived Severity — Perceived threat is also related to the extent

that the person perceives the severity of the illness or its sequelae. For
example, does the person believe that the illness or its consequence
will cause serious changes in him or in his quality of life? He may feel
vulnerable yet not take positive action because he does not think the
consequences are significant. The greater the perceived severity, the
more likely the person will adhere to self-care practices or adopt
recommended action.
Again, let us look at measles immunization. Would a mother bring

her child for measles immunization if she doesn’t know that the com-
plications of measles can be fatal? Yes, she may know that her child is
vulnerable to measles infection, but if she thinks measles is a child-
hood disease her child can “safely” experience, then there is no
perceived severity of the disease.
3. Perceived Benefits or Effectiveness of Treatment — Does the per-

son believe that treatment will make a difference in the outcome of the
disease? To promote self-care, the patient needs to believe that the
benefits of the treatment outweigh the “cost” of going through it.
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Does the mother believe that measles immunization can prevent the
more fatal complications of measles? The child may still contract the
measles infection but it will be a milder form and this definitely re-
duces the possibility of measles death.
4. Perceived Cost or Barriers — Cost refers to perceived barriers that

must be overcome in order to follow the health recommendation. It
includes, but is not limited to, financial cost.
Will the measles vaccine be available when the mother brings her child
to the health center? Is the health center accessible? Will the mother
be free to bring her child herself, or will it entail loss of a day’s income?
All these will be weighed in the mind of the mother and will influence
her behavior of bringing the child for immunization.
5. Cue to Action — A stimulus, either internal (e.g., the perception of

bodily states like loss of weight) or external (e.g., interpersonal inter-
actions, mass media, personal knowledge of someone affected by the
condition) must occur to trigger the appropriate health behavior.
In the measles campaign, an important cue to action for many was

the mass media campaign of then Secretary of Health, Senator Juan
Flavier.
The product of the first two dimensions (perceived susceptibility and per-
ceived severity) generate the individual’s perception of risk and motiva-
tion for action. The latter two dimensions of perceived benefits and per-
ceived cost reflect the cost-benefit analysis of the recommended action.
The HBM is a rational belief model. It assumes that human behavior is

determined by objective and rational thought processes. Given the appro-
priate information on health risks and the benefits and consequences of
various behaviors, HBM theorizes that individuals will modify their
actions to preserve health. It assumes that motivation is a necessary con-
dition for action and motives selectively determine an individual’s per-
ceptions of the environment.
Application of the HBM

The application of HBM has generally been in the study of compliance to
health recommendations and therapeutic regimens, particularly in pre-
ventive health behavior such as immunizations. Non-compliance then,
based on the HBM, results from insufficient knowledge of the benefits
and/or hazards of engaging or not engaging in prescribed behaviors.
UP Open University
Module 8 259
The HBM has enjoyed wide popularity in health education, nursing, and
other health professions. The model provides a way for assessing health
beliefs and motivations of individuals in order to promote behavior change.
A vast body of research has been generated by this model. In nursing,

quite a number of research have utilized the HBM as a conceptual frame-
work for studying compliance. In general, research findings show consis-
tent but modest associations between health beliefs and compliance
behavior. This modest association is to be expected since the model only
accounts for variance in compliance due to attitudes and beliefs. There
are other variables that affect compliance behavior.
Deficiencies of the model

The Health Belief Model conceptualizes the perception of risk as some
combination of susceptibility and severity beliefs. However, these dimen-
sions may not even be considered by the individual. Clearly, there is more
to motivation than the combination of likelihood and severity beliefs.
The Theory of Reasoned Action developed by Fishbein and Ajzen in

1975, argues that perceived social norms also play a role in determining
motivation. Here, motivation to act is seen as a product of perceived group
norms and one’s private beliefs about the action. Unfortunately, the theory
of reasoned action focuses only on the norms of daily activity. This deficit
seems particularly serious in understanding, changing, or maintaining
lifestyle behaviors such as smoking and eating lean foods.
This particular deficiency of the HBM, which is in fact the strength of the
SLT, is the concept of self-efficacy. Rosenstock, et al. (1988) go so far as to
say that the HBM and SLT, particularly the self-efficacy concept, comple-
ment each other. The weakness of one is the strength of the other. To
quote him:
For behavioral change to succeed, people must (as the HBM theo-
rizes) have an incentive to take action, feel threatened by their
behavioral patterns and believe that change of a specific kind will
be beneficial by resulting in a valued outcome at acceptable cost,
but they must also feel themselves competent (self-efficacious) to
implement change.
A growing body of literature supports the importance of self-efficacy in

helping to account for initiation and maintenance of behavioral change.
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Activity 8-3
Describe briefly a case you have handled/experienced which de-
monstrates the applicability of the Health Belief Model.
Practice Implications of HBM and SLT
In planning programs, many health educators and nurses have found it

useful to assess educational needs partly in terms of the concepts described
in the Health Belief Model. Thus, they seek to ascertain how many and
which members of the target population are interested in health matters,
feel that they are at risk of developing a serious health problem (or believe
they currently have the problem), and believe that the threat could be
reduced by some action on their part, at an acceptable cost. The assess-
ment of such educational needs can be used to strengthen program plan-
ning and health education methods. In addition, information about self-
efficacy should be obtained—the extent to which clients feel competent to
carry out the prescribed actions, ability to do these over long periods of
time, and the strength of their belief in their own competence.
Assessment of learning needs is needed for more effective program plan-

ning. For example, if a group of people believe they are susceptible to a
disease like cancer, and if they also believe that there are few cures for
cancer, we can tailor educational interventions to increase perceived ben-
efits of making lifestyle changes.
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Module 8 261
HBM has been most useful in preventive health actions such as immuni-
zations. For chronic diseases, more emphasis is placed on skills training
to enhance self-efficacy. In diabetes education, for example, several skills
are needed by the client ranging from computation of insulin dose, to
actual self-injections and self-blood glucose monitoring, to menu plan-
ning. With mastery of the simpler skills, self-efficacy is enhanced for the
more complex tasks.
Patient-provider contracting is a highly effective approach for enhanc-

ing self-efficacy. You can easily do this in your practice. You and your
client discuss and agree on a treatment goal and a time limit for achieving
this goal. Both of you sign a document specifying the agreement. This is
true partnership. When the client accomplishes the goal, the sense of self-
efficacy is enhanced and he is now ready to contract for a new, more
difficult goal.
Actual performance of a task is the most influential source of efficacy

information because it is based on a personal mastery experience. Self-
efficacy may also be enhanced through vicarious experience, verbal per-
suasion, and psychological state. Verbal persuasion may also influence
outcome expectations and incentives. Vicarious experience includes ob-
servation of peers and other role models.
Enhancing efficacy may not always be required. Where a health practice

is easy to accomplish (e.g., swallowing a tablet), no major concentration
on efficacy is needed. But where complex behavior patterns are required,
such as the use of condom for safe sex among commercial sex workers,
skills training will definitely be required. In changes involving lifestyle
practices such as smoking, weight reduction, exercise and dietary habits,
self-efficacy enhancement is essential.
The PRECEDE-PROCEED Framework

The PRECEDE-PROCEED Framework was developed by the so-called
father of public health education based at the University of British
Columbia in Canada, Lawrence W. Green. The framework is a compre-
hensive model for planning and evaluating health education and health
promotion programs. It developed from the original PRECEDE Frame-
work (Green, 1980) into the PRECEDE-PROCEED Model which recog-
nized the integration of health promotion as an extension of health
education (Green, 1991).
Green’s framework is perhaps the most recognized model for health edu-
cation planning and evaluation. Its wide application led to its use as a
framework for many research papers. As of 1995, there have been over
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400 published applications of the model. Because of this, I feel that you
will gain a lot in your practice as a nurse and as a health educator by
understanding Green’s framework.
PRECEDE framework
PRECEDE is an acronym for predisposing, reinforcing, and enabling
causes in educational diagnosis and evaluation. It is a model intended for
the planning and evaluation of health education and addresses the ac-
knowledged problem of disjointed planning (Green, 1980, p. 10).
Phase 6 Phases 4-5 Phase 3 Phases 1-2

Administrative Educational Behavioral Epidemiological and Social
Diagnosis Diagnosis Diagnosis Diagnosis
Predisposing factors:
Knowledge
Attitudes
Direct communication: Values Non-health
public; patients Perceptions Factors
Non-behavioral
causes Quality of
Life
Health
Enabling factors: Problems
Subjectively defined
Health Availability of
Training: problems of individuals
Education resources
community Behavioral or communities
Components of Accessibility
organization causes
Health Program Referrals Social indicators:
Skills Illegitimacy
Population
Behavioral indicators: Welfare
Utilization Unemployment
Preventive actions Absenteeism
Consumption patterns Alienation
Compliance Hostility
Self-care Discrimination
Reinforcing factors: Votes
Indirect Attitudes and Dimensions: Riots
communication: behavior of health Earliness Crime
staff development and other personnel, Frequency Crowding
training, supervision, peers, parents, Quality
consultation, feedback employers, etc. Range
Persistence
Figure 8-3. The PRECEDE framework
What is health education in the first place? It is not the intention of this
module to discuss health education as a specialty field of practice. But I
feel that the discussion of learning theories in the previous modules will
be pointless if we cannot apply these in our everyday lives as nurses by
engaging in health education, either as practitioners, educators, adminis-
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trators or researchers. As educators, we are often faced with problems of

changing behaviors and lifestyles not only of our patients, but also our
students, or our co-nurses. The application of theories and principles of
health education has therefore wide applicability in nursing.
Green (1980) defined health education as “any combination of learning

experiences designed to facilitate voluntary adaptations of behavior
conducive to health.” This is the most widely accepted definition of health
education so far and is the tenet of most professional health education
specialists.
This definition emphasizes the scope as well as the purpose of health edu-
cation. The goal of health education is voluntary behavior change and the
scope is any combination of learning experiences. Other forms and meth-
ods of health education that define its scope are community organization,
in-services training, consultation, group work, computer-assisted instruc-
tion, noncomputerized teaching machines and audiovisual methods,
patient teaching, health fairs, exhibits, libraries, conferences, and routine
health provider-consumer interactions. The scope of health education is
defined as much by its expected outcomes as by its methods and forms.
The PRECEDE component of the model begins ideally with an appraisal

of the quality-of-life in the population of interest and the education fac-
tors affecting the behavior of interest. Figure 8-3 provides a schematic
representation of the model as presented by Green (1980).
Planning starts with outcomes first rather than inputs. This method en-
courages the educator to ask “why” first before asking “how.” Factors
important to an outcome must be diagnosed (or assessed) first before the
intervention is designed. This is not very different from our nursing pro-
cess and the nursing diagnosis. Isn’t it true that we need to determine the
problem and its possible etiologies (the “why”) before we can plan the
nursing interventions (the “how”)?
The seven phases of PRECEDE

(Green, 1980)
Phase 1: Social diagnosis
Ideally, one begins with a consideration of “quality of life” by assessing

some of the general problems of concern to the target population of pa-
tients, students, workers, or consumers. The kinds of social problems a
given community experiences are good barometers of the quality of life
there.
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Phase 2: Epidemiological diagnosis
The task in Phase 2 is to identify those specific health problems that ap-
pear to contribute to the social problems noted in Phase 1. The non-health
factors are not the primary concerns of the health educator. Using avail-
able data and data generated by appropriate investigations together with
epidemiological and medical findings, the health educator ranks the iden-
tified health problems and selects the health problem that should be
addressed first, given scarce educational resources.
We should point out here that many health educators, particularly those
working in school health education or patient education programs, will
be given the task of developing a program after someone else has already
gone through Phases 1 and 2 and concluded that educational interven-
tion is needed. We appreciate that situation but advise practitioners to be
certain that the first two steps have been done well. Such precautionary
action ensures that the existing data are valid and also familiarizes the
practitioner with crucial baseline information and assumptions.
Phase 3: Behavioral diagnosis
Phase 3 consists of identifying the specific health-related behaviors that

appear to be linked to the health problem chosen as deserving of most
attention in Phase 2. As these are the behaviors that the intervention will
be tailored to affect, it is essential that these be identified very specifically
and carefully ranked. Economic, genetic, and environmental factors are
acknowledged here because of the power they have, however indirect, to
influence health. Being cognizant of such forces will enable educators to
be more realistic about the limitations of their programs. It will also en-
able them to recognize that powerful social factors might be affected when
the principles of PRECEDE are applied by well-organized health groups
and coalitions on the national level. Even at the local level, health-related
behaviors influenced by health education can include collective behavior
directed at economic or environmental factors.
Phases 4-5: Educational diagnosis
On the basis of cumulative research on health behavior, Green identified

three “classes” of factors that potentially affect health behavior: predis-
posing factors, enabling factors, and reinforcing factors. Predisposing fac-
tors include a person’s attitudes, beliefs, values and perceptions. These
factors facilitate or hinder personal motivation for change. Enabling
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factors are barriers created mainly by societal forces or systems such as

limited facilities, inadequate personal or community resources, lack of in-
come or health insurance, and even restrictive laws and statutes. The skills
and knowledge required for a desired behavior to occur also qualify as
enabling factors. Reinforcing factors are those related to the feedback
the learner receives from others, the result of which may either encourage
or discourage behavioral change.
The fourth phase, then, is sorting and categorizing, according to the three
classes just cited, the factors that seem to have direct impact on the be-
havior selected in Phase 2.
Study of the predisposing, enabling, and reinforcing factors automati-

cally takes the educator into the fifth phase of PRECEDE. At this point he
or she is called on to decide exactly which of the factors making up the
three classes are to be the focus of the intervention. The decision is based
on their relative importance and the resources available to influence them.
Phase 6: Administrative diagnosis
Armed with pertinent and systematically organized diagnostic informa-

tion, the health educator is ready for Phase 6, which is the actual develop-
ment and implementation of a health education program. If he or she
keeps firmly in mind the limitations of his or her resources, time con-
straints and abilities, the appropriate educational interventions will
almost be self-evident from the diagnosis of predisposing, enabling and
reinforcing factors. All that remains is the selection of the right combina-
tion of interventions and an assessment of administrative problems and
resources.
Phase 7: Evaluation
Listing evaluation as the last phase is misleading. Evaluation is an inte-

gral and continuous part of working with the entire framework. Evalua-
tion now proceeds from process evaluation of the program, to impact
evaluation in terms of changing the predisposing, enabling, reinforcing
factors as well as the behavior itself; and lastly to outcome evaluation
dealing with changes in health status and quality of life. This completes
the full cycle of the PRECEDE Framework.
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PRECEDE to PROCEED Model

There has been a major modification in the well-known Green Frame-
work since the publication of his second book in 1991. This was the devel-
opment of the PRECEDE-PROCEED Model for health promotion planing
and evaluation. This development recognized rapid developments in
policy, research, and practice. It was important to maintain the integrity
of the PRECEDE planning framework because it was already widely tested
in various settings—national, provincial, state, and community levels. The
expanded model accommodated the more comprehensive field of health
promotion. Thus, the diagnostic approach now encompasses the social
forces (including political, organizational, economic, and environmental)
that influence lifestyle and health, as well as the more specific behavioral
influences on health and the more immediate educational influences on
behavior.
Figure 8-4 represents the expanded model of the PRECEDE-PROCEED

model for health promotion, planning and evaluation. Can you see the
major differences between this paradigm and Figure 8-3?
PRECEDE
Phase 5 Phase 4 Phase 3 Phase 2 Phase 1
Administrative and Educational and Behavioral and Epidemiological Social diagnosis
policy diagnosis organizational environmental diagnosis
diagnosis diagnosis
Predisposing
Health Promotion factors
Health
education Reinforcing Behavior and
component factors lifestyle
Quality of
Health
Policy life
Regulation
Enabling Environment
Organization
factors
PROCEED
Phase 6 Phase 7 Phase 8 Phase 9
Implementation Process evaluation Impact evaluation Outcome evaluation
Figure 8-4. PRECEDE-to-PROCEED framework

for health promotion and planning
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Phases 1 and 2 are still the same. However, Phase 3 now includes envi-
ronmental diagnosis in addition to behavioral diagnosis. Both behavioral
and environmental factors are identified and appraised in terms of rela-
tive importance and changeability. Intervention goals and health objec-
tives are then specified.
Phase 4 involves the educational and organizational diagnosis and phase

5 includes administrative and policy diagnosis.
Phase 5 marks the transition to the PROCEED component of the model.

PROCEED is an acronym for policy, regulatory and organization con-
structs in educational and environmental developments. (The PRECEDE
component marked the planning process.) This phase reviews and recon-
ciles existing and required resources such as personnel, time, and finances.
It also analyzes political, bureaucratic, and organizational supports and
barriers that must be addressed to develop and implement the series of
required and possible strategies.
Phase 6 is the implementation phase. The exact point where planning

and policy formation leave off and implementation begins is virtually
undefinable. The implementation phase proceeds naturally as a conse-
quence of coherent structuring of the planning process. The model
recognizes that a program under implementation needs to be flexible and
adaptable to circumstances.
Phases 7, 8, and 9 concern evaluation; particularly process, impact, and

outcome evaluation. Criteria for evaluation arise naturally from the
objectives defined in the corresponding steps in PRECEDE during the plan-
ning process.
Why the change? The expanded model of PRECEDE-PROCEED takes

into consideration behavioral and lifestyle changes. As Green (1991) said,
“Behavior is seen increasingly not as isolated acts under the autonomous
control of the individual, but rather as socially conditioned, culturally
embedded, economically constrained patterns of living.” He further clari-
fied that health promotion emerged out of health education and is aimed
at encouraging complementary social and political actions that will facili-
tate the necessary organizational, economic and other environmental sup-
ports for the conversion of individual actions into health enhancements
and quality of life gains (Green, 1991, p. 14).
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Therefore, the definition of health promotion according to Green (1991)

is:
the combination of educational and environmental supports for

actions and conditions of living conducive to health. Environmen-
tal support refers to the social, political, economic, organizations,
policy and regulatory circumstances bearing on the behavior of
people or more directly, on health (p. 17).
Within this expanded model, emphasis is still on an educational approach

to health promotion as the essential starting point. Even if the ultimate
interventions must be coercive, regulatory, or economic. Indeed, the pub-
lic support and acceptance of new legislation and regulations depends on
adequate preparation of the citizenry through an educational process.
Many good legislative bills that would have improved the public’s health
have failed to pass or have been repealed because their sponsors failed to
build an educated constituency for them.
A Theory of Adult Learning: Andragogy

The concept of a unified theory of adult learning had been evolving in
Europe for sometime. The term andragogy, has been coined to differenti-
ate it from pedagogy, the art and science of teaching children. The label
andragogy was first used in 1967 by a Yugoslavian adult educator, Dusan
Savicevic and introduced to the American literature in April 1968 by
Malcolm Knowles with his article, “Andragogy, not Pedagogy.” How-
ever, the origins and use of the term andragogy go as far back as 1833 to
German grammar school teacher, Alexander Kapp. The root word comes
from the Greek word, “aner,” meaning man (as distinguished from boy).
The field of adult education has been expanding and more and more adult
educators find that the accepted assumptions of pedagogy do not fit in
anymore. Knowles recognized the need for a unifying theory for adult
education. Andragogy seemed the perfect unifying concept for his Theory
of Adult Learning. To quote Knowles (1978):
For over two decades, I have been trying to formulate a theory of

adult learning that takes into account what we know from experi-
ence and research about the unique characteristics of adult learn-
ers.
The assumptions of adult learning differ from the concepts of pedagogy.

Andragogical theory is based on at least four main assumptions.
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Module 8 269
1. Changes in Self-Concept. The first assumption is that as a person

grows and matures, his self-concept moves from one of total depen-
dency (as with infants) to one of increasing self-directedness.
Andragogy assumes that the point of self-direction is the point at which
a person psychologically becomes an adult. One implication of this is
that when an adult is placed in a situation in which he is treated as a
child, he becomes resentful and resistant to learning.
2. The Role of Experience. The next assumption is that as an individual

matures, he accumulates a vast range of experiences. This experience
can be a rich resource for learning, and at the same time provides him
with a broadening base to relate new learning. Implications of this
assumption include decreasing emphasis on the transmittal techniques
of traditional teaching and increasing emphasis on experiential tech-
niques which tap the experience of learners and involve them in
analyzing their experiences. The use of lectures, canned audio-visual
presentations, and assigned readings tend to fade in favor of discus-
sion, laboratory work, simulation, field experience, team project and
other action-learning techniques. Also, as a person matures, he in-
creasingly defines who he is by his experience. So in a situation where
an adult’s experience is being devaluated or ignored, the adult per-
ceives this as rejecting him as a person (Knowles, 1978).
3. Readiness to Learn. As an individual matures, his readiness to learn

is less a product of biological and academic development (as is true in
childhood) but more a product of the developmental tasks required
for the performance of his evolving social roles. The motivation to learn
is no longer that he “ought to learn” but more of the “need to learn”
because of the changes in his role as worker, spouse, parent, and others.
The critical implication is the timing of learning experiences to coin-

cide with learner’s developmental tasks. There are also ways to stimu-
late readiness through exposure to better models of performance, higher
levels of aspiration, and self-diagnostic procedures.
4. Orientation to Learning. Adults have a problem-centered orientation

whereas children have a subject-centered orientation to most learn-
ing. The difference is primarily the result of the difference in time
perspective. The child’s time perspective toward learning is one of
postponed application. For the adult, it is one of immediacy of appli-
cation. The adult comes into an educational activity largely because
he is experiencing some inadequacy in coping with current life prob-
lems. He needs his learning NOW, not for some undetermined tomor-
row.
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This assumption has major implications regarding the organization of the

curriculum and its learning experiences. For health education, the learner
needs practical knowledge, something he will find useful. He does not
want to waste his time. This implies involving him in the selection of prob-
lem areas to be discussed, and in the learning activities to be utilized.
Experiential learning using a group may also be helpful.
I will limit our discussion on Knowles’ adult education theory to these

four major assumptions. Brief as it may seem, these assumptions can al-
ready spell a lot of implications for the educator when he is faced with
adult learners.
Activity 8-4
Recall one situation where you were faced with an adult learner.
This is not limited to a formal classroom setting. It may be in the
clinical setting or even in the community. If you were to encounter
a similar situation after reading this section on adult education,
what would you change/modify in dealing with this learner?
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Summary
Briefly, this module presented a selection of learning theories on health
education that are widely accepted today. Present-day learning theories
recognize that learning and behavior are much more complex than sim-
ply stimulus-response.
Cognitive theories recognized that the cognitive processes of a person are

just as important. The most popular cognitive theory is Albert Bandura’s
Social Learning Theory. This theory hypothesized that behavior is deter-
mined by expectancies and incentives. An important contribution of SLT
is the concept of self-efficacy. Self-efficacy refers to personal beliefs about
one’s capabilities to be successful in tasks with novel or ambiguous ele-
ments.
Another important model is the Health Belief Model. In HBM, health-

related action depends on the person’s evaluation of three factors:
perceived susceptibility to disease/injury, perceived severity of disease/
injury or its consequences, and perceived benefits of the recommended
action vis-à-vis the perceived cost or barriers.
Lawrence W. Green’s PRECEDE-PROCEED Model is presented as an in-

tegrated, comprehensive framework for planning and evaluating health
education and health promotion. Its application in various settings and
disciplines makes its use in nursing particularly useful.
Lastly, I introduced you to Malcolm Knowles’ Andragogy or the science

and art of educating adults. Adults learn best when learning is problem-
centered, meaningful, and experiential.
Given these selected theories of learning and behavior, I hope that you
can understand how behavior develops and more importantly, you can
get valuable tips from these theories on influencing behavior towards posi-
tive change.
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ASAQ 8-1
Classical Operant Social Learning
Conditioning Conditioning Theory
Behavioral PP PP P
Component is
considered
Behavior is PP P
based on rewards/
consequences
Cognitive process PP
is considered
ASAQ 8-2
Compare your answers with my suggested answers. Did you get similar
answers?
1. “I don’t know how to use my inhaler.”

Answer: low self-efficacy; refers to lack of ability to use the inhaler
2. “I’m too busy, I don’t think I can take my medicines regularly.”

Answer: low self-efficacy; refers to lack of ability to schedule intake
of medicines within her regular time schedule
3 “Anyway, people say I will outgrow my asthma.”

Answer: low outcome expectancy; whether she does anything for
her asthma or not, the outcome will be the same and therefore her
behavior is not likely to influence the outcome; this is also a good
example of external locus of control
4. “Bahala na!”
Answer: low outcome expectancy; leaves the outcome to fate or forces
outside of her control; also an example of external locus of control
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Glossary
Andragogy — root word from the Greek word, “aner” meaning man; the
art and science of teaching adults
Classical (reflex) conditioning — procedure by which physiological re-

actions to particular stimuli (e.g., salivation) are trained to respond to
new stimuli; also called Pavlovian conditioning
Health education — any combination of learning experiences designed

to facilitate voluntary adaptations of behavior conducive to health (Green,
1980)
Health promotion — the combination of educational and environmental

supports for actions and conditions of living conducive to health (Green,
1991)
Learning — processes by which humans acquire a range and variety of

skills, knowledge, and attitudes
Operant conditioning — learning based on reinforcement; also known

as Skinnerian conditioning
Outcome expectation — expectancies about the consequences of one’s

own actions, that is, opinions about how individual behavior is likely to
influence outcomes
Pedagogy — art and science of teaching children
Self-efficacy — the personal belief that one can perform successfully the
behaviors that lead to positive outcomes; term attributed to Bandura’s
Social Learning Theory; also called efficacy by Bandura
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References
Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice
Hall.
Becker, M.H. (1974). The health belief model: Origins and correlates in
psychological theory. Health education monographs, 2(4), 36-353.
Green, L.W. & Kreuter, M.W. (1991). Health promotion planning: An educa-
tional and environmental approach. Mountail View, CA: Mayfield Pub-
lishing House.
Green, L.W., Kreuter, M.W. et. al. (1990). Health education planning: A
diagnostic approach. The John Hopkins University: Mayfield Publish-
ing Co.
Knowles, M. (1978). The adult learner: A neglected species. 2nd Edition. Texas:
Gulf Publising Company.
Levanthal, H., Cameron, L. (1987). Behavioral theories and the problem
of compliance. Patient education and counseling, 10, 117-138.
Rosenthal, I.M., Stretcher, V.J., Becker, M.H. (1988, Summer). Social learn-
ing theory and the health belief model. Health education quarterly, 15(2),
175-183.
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Module 9
Theories of Change
Josefina A. Tuazon
I ’m sure you have found yourself in a situation

that you wished you could change. Isn’t it
exasperating to want change and yet you could Objectives
not influence others to adopt your point of view?
I have been in this situation many times, not only At the end of this module,
in my practice as a nurse and teacher, but also in you should be able to:
my personal life. By learning more about the dy-
namics of behavior, the relationship between be- 1. Compare and contrast
liefs and attitudes, the influence of behavior and selected change theories;
environment (physical and psychological), I and
learned to influence my own behavior and the 2. Suggest change strate-
behavior of others. Of course, influencing change gies that are applicable in
may have either positive or negative conse- various situations.
quences. As nurses and good citizens of our coun-
try and the world, I hope that you will put to
good use the information contained in this mod-
ule.
The change theories I have included in this module will help you to select
principles and strategies towards changing the status quo. Some of them
may be applicable to individual change, and some will be more applicable
to social change.
In particular, this module will include a discussion of the following theo-

ries of change:
1. Lewin’s Change Theory

2. Lippitt’s Change Theory
3. Chin and Benne’s Planned Change
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It is not enough to know and understand the learning theories. The more
important reason for studying these learning theories is to understand the
dynamics of behavior in order to influence behavior and promote social
change.
Let me stress the difference between of behavior change and social change.
Behavior change is often directed at individuals while social change
refers to a group or community. There are many occasions when influ-
encing individuals is not enough to effect change. To illustrate, in my
favorite example of cigarette smoking, convincing the smoker to stop smok-
ing may not be effective. Another strategy is to focus attention on policies
and legislature to create ordinances against smoking and tobacco adver-
tisements. Another is influencing high school students that not smoking is
the “in” thing. The latter is intended to effect social change.
If you have ever felt powerless in the face of people and situations, or if
you’ve ever felt you needed to change something in the status quo, go
right ahead and read this module. I hope that afterwards, you will feel
more able to effect change.
Lewin’s Change Process: Precursor of Change

Theory
Kurt Lewin (1890-1947) was a social scientist who used a systematic theory
to analyze causal relationships and to build scientific constructs. Prior to
his work, most social science was based on speculative systems. Lewin
formulated a general theory of change that he used to study diverse situ-
ations of planned change such as psychotherapy, childrearing, industrial
management, race relations, and community development.
Lewin (1951) theorized that there are three basic steps in the change pro-
cess: (1) unfreezing the present level, (2) moving to the new level, and (3)
refreezing on the new level.
He described unfreezing as the stage in which the motivation for change

is created. Moving refers to planning for and initiating change. Refreez-
ing is the stage in which change is integrated and stabilized. For change
to be permanent, there must be internalization of the change into the
target’s value system (Lewin, 1951).
Lewin used the concept of mathematical force fields to explain the forces
involved in the change process. The present state, or status quo, is defined
as a dynamic equilibrium of simultaneously driving and restraining forces.
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Lewin’s premise is that increasing driving forces and decreasing restrain-

ing forces makes change possible. Thus, unfreezing occurs when the sta-
tus quo is interrupted, and moving occurs when driving forces are in-
creased and restraining forces are decreased.
Lewin’s theory has been modified many times, but all its modifications
seem to include the concept of planned change.
From the field theory and change process of Kurt Lewin emanated other
theories of planned change. I have included in this module Lippitt’s Change
Process, and Chin and Benne’s Planned Change. From this point on, when
I talk of change, it usually refers to planned change.
Let me show you some of the more popular definitions of planned change.
Definitions of Planned Change

The following definitions of planned change have been summarized by
social scientists:
1. Change is an alteration in the structure and function of a social sys-

tem (Rogers, 1962).
2. Change is the method that employs social technology to help solve

problems of society (Bennis, Benne, and Chin, 1969).
3. Change is the induction of new patterns of action, belief, and atti-

tudes among substantial segments of a population (Schein, 1969).
4. Planned change is the result of a conscious, deliberate, and collabora-

tive effort intended to improve the operation of a system and to facili-
tate acceptance of the improvement by involved parties (Havelock,
1973).
5. Developmental social change is change within an existing social sys-

tem, adding to it or improving it rather than replacing some of its key
elements (Gerlach and Hine, 1973).
6. Change is the conscious, deliberate, and collaborative effort to

improve the operations of a system, whether it be self-system, social
system, or cultural system through the use of scientific knowledge
(Bennis et al., 1976).
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7. Change is relearning on the part of an individual or group in response

to newly perceived requirements of a given situation requiring action
and resulting in a change in the structure or functioning of social sys-
tems (Zaltman and Duncan, 1977).
8. Planned change is defined as a deliberate effort to improve the client

system, which is composed of four subsystems: the individual person-
ality, the group, the organization, and the community. The help of an
outside agent is engaged to make this improvement. Problem solving
is a major thrust of planned change (Lippitt, Watson, and Westley,
1958).
More recently, definitions of the change process have also been adapted
to nursing. Some of these definitions are found in the nursing literature:
1. The change process is deliberate and collaborative, involving a change

agent (the health provider) and a target system (the client) (Brooten,
Hayman, and Naylor, 1978).
2. Planned change is a process of deliberate and collaborative action bet-

ween the nurse and the client resulting in alterations in the behavior
of both, within the health care setting.
SAQ 9-1
Not all change is planned change. Planned change is something
deliberate and usually involves a change agent, the target system
or client, and a change relationship between the change agent and
the target. Think of a recent change in your life, either in your
personal or professional life. Was this planned change or did it
happen by chance? What elements make it a planned or unplanned
change?
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Lippit’s Planned Change

Ronald Lippitt worked closely with Kurt Lewin and was greatly influ-
enced by Lewin’s thinking. Lippitt expanded Lewin’s three phases of
change to seven general phases of the change process. These are:
1. Development of a need for change

2. Establishment of a change relationship
3. Working toward change
4. Clarification or diagnosis of the client system’s problem
5. Examination of alternative routes and goals; establishing goals, and
intentions of action
6. Transformation of intentions into actual change efforts
7. Generalization and stabilization of change
8. Achieving a terminal relationship
SAQ 9-2
Can you see the parallelism between Kurt Lewin’s change process
and that of Ronald Lippitt’s? Try to identify Lewin’s three steps of
change (unfreezing, moving, and refreezing) in the seven phases
of change by Lippitt.
This was an easy one, huh? After all, Lippitt merely expanded Lewin’s
three phases of change. And by doing so, professional change agents like
us nurses have more specific information and strategies to guide us in
effecting and stabilizing change. An important component here is the
establishment of a relationship between the change agent and the client.
Such a relationship should be voluntary and based on trust and respect.
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I will now discuss the seven phases of Lippitt’s planned change in greater
detail. As you read, think of situations where change was implemented.
Maybe your regular duty hours increased from 8 to 12 hours per day, or a
new system of endorsement was implemented. Consider the seven phases
and see whether you can pinpoint what made these changes successes or
failures.
Phase 1: The development of a need for change

Before a process of planned change can begin, there should first be an
awareness of a problem or difficulty and this awareness should translate
into a desire to change and a desire to seek help from outside the system.
Unfortunately, problem awareness is not automatically translated into a
desire for change. First, there must be some confidence in the possibility of
a more desirable state of affairs. Next, problem awareness and desire for
change lead to an explicit desire for help from outside the system. Again,
before this can happen, the person should believe that external help is
relevant and even available. Often, there is an awareness of a problem
and a genuine desire to do something about it, but this is accompanied by
resistance to the idea of help from outside. A parent, for example, may
feel that asking for help in counselling a problem child is an admission of
failure as a parent.
In some cases, the person is ready to ask for help but may not know where
to find it. Persons with asthma may want to join an asthma club but may
not know where to go. Smokers may want to quit smoking but don’t know
where to seek help to do it.
This first or “unfreezing” phase in the change process usually occurs in

one of three different ways:
1. A change agent discovers or hypothesizes a certain difficulty in a po-

tential client. The change agent offers his help directly or takes steps
to stimulate an awareness of the difficulty in the system.
2. A third party connected with both the change agent and the potential
client system becomes aware of the system’s difficulty and brings the
two together. For example, a mother who is disturbed by the fact that
her ten-year-old child refuses to eat takes him to see a child therapist.
3. The potential client becomes aware of his own difficulty and seeks
help from an outside source. This is the most common way of initiat-
ing the change process.
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Phase 2: Establishment of a change relationship

One of the most crucial features of this second phase is the way in which
the client first begins to think about the potential change agent. First im-
pressions can do a good deal to determine the future of any human rela-
tionship. Often, the client seeks assurance that the change agent is a real
expert yet understanding and approachable. If the client is a group, an
organization, or a community, this phase is likely to raise important orga-
nizational or procedural questions within the client system. Usually, one
subpart is more ready to change than others. Hence this subpart must
attempt to engage the sympathy of the other subparts toward the pro-
jected plan of establishing a working relationship with an outside source
of help. The success or failure of almost any change project depends heavily
upon the quality and the workability of the relationship between the change
agent and the client system.
Phases 3, 4 and 5: Working toward change

Lewin referred to this part of the change process as “moving.” Lippitt,
however, further divided this part into three phases as follows:
Phase 3 — clarification or diagnosis of the client system’s problem

Phase 4 — examination of alternative routes and goals and establishing
goals and intentions of action
Phase 5 — transformation of intentions into actual change efforts
Phase 3: Clarification or diagnosis

of client’s problem
One important task of the client is to collaborate with the change agent in
diagnosing the nature of the problem. First of all, the change agent needs
information. As data are collected and analyzed, the problem which
seemed simple at first is likely to be more complicated. This is the point
where vested interests are likely to be aroused and the client becomes
aware of the threat posed by the change, and defensive reactions may
occur. The client system may begin to think that his problem, as it is newly
defined, is too pervasive or too fundamental to be remedied, and decide
to give up without a struggle. On the other hand, the client may become
hostile, close up sources of information and reject the agent’s diagnoses.
This is a trying time for both client system and change agent.
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Phase 4: Examination of alternative routes

and goals; Establishing goals and intentions of action
In this phase, both cognitive and motivational problems are likely to arise.
Before definite action can be taken, various alternative actions have to be
considered. Even more interesting are the problems of motivation which
arise when the client begins to consider actual intentions. The decision
must be in the nature of an investment—emotional as well as material.
For example, present satisfaction with the status quo may have to be given
up if change is to be accomplished.
Another type of motivational problem is the client system’s anxiety about

awkwardness or failure in attempting new patterns of behavior. Often
these anxieties can be eased by having the client test innovations before
these are permanently adopted. In this way, some of the strangeness wears
off and the client acquires confidence in his ability to do what is expected.
Phase 5: Transformation of intentions

into actual change efforts
Real success or failure in any change effort is measured by the way in

which plans and intentions are transformed into actual achievements.
The active work of changing is the keystone of the whole change process.
A number of problems arise in this phase. One of the most common is that
of eliciting support from the change agent while the movement toward
change is beginning. By this time, the relationship with the change agent
may have already ended, leaving the client to imagine what the change
agent might expect. In other cases where relationship with the change
agent may still continue, actual day-to-day efforts of the client system to
change may occur only in situations which permit no direct contact with
the change agent. Another problem is that of securing sympathetic ac-
ceptance of the change efforts from the various subparts of the system or
from adjacent systems. Obtaining adequate feedback on the consequences
of the change effort may also prove difficult.
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Phase 6: Generalization and stabilization of change

Often, change which has been produced by painstaking and costly efforts
tends to disappear after the change effort ceases. The system which wanted
to change slips back instead into its old ways.
One critical factor in the stabilization of change is the spread or non-

spread of change to neighboring systems or to subparts of the client sys-
tem. If a teacher who has adopted a new teaching method finds that
others on the teaching staff have adopted the new method, then he/she
will be encouraged to continue the new practices. Usually, however, more
direct kinds of positive evaluation and reward are necessary.
Another factor favoring stabilization is a process of institutionalization.

Many systems possess an inherent momentum which tends to perpetuate
a change once it has attained a certain state of equilibrium in the system’s
normal operations. Also, procedural change may become stabilized be-
cause it is supported by structural change such as the adoption of a policy
or putting up of a suggestion box.
Phase 7: Achieving a terminal relationship

The end of the change relationship may come as early as the third phase
of the change process. If the client system has come to depend heavily
upon the change agent for support and guidance throughout the change
process, then the end is likely to be somewhat painful. Other questions
arise. Has the client system learned problem-solving techniques well enough
to cope with new and different problems?
In any given case, although seven distinct phases were presented, the
phases often overlap and repeat themselves. The seven phases are useful
not only for the purposes of systematic analysis but also for professional
change agents who want to clarify and understand the requirements of
their job.
UP Open University
SAQ 9-3
Think of a situation where change was implemented. It may be
the adoption of the 12-hour shift in the hospital, or a new system
of endorsement, or an attempt you have made to enhance your
health. This may be the same situation you thought of in SAQ 9-1
or another situation. Again, it may be a situation in your personal
life or in your workplace. Write this down on the space provided.
Now try to analyze this situation by answering the following guide
questions:
1. Was the change a failure or a success?
2. What factors influenced its success or failure?
3. Look at the seven phases of Lippitt’s planned change. Do any

of these help to explain the success or failure in making the
change?
So, were you able to trace where the problem was in your situation? And
if the change situation was a success, I hope you can now appreciate
some of the factors that made this possible. As you analyze this and other
change situations, try to maximize your learning by identifying ways and
strategies to improve your own approach in effecting change because YOU
are a CHANGE AGENT!
UP Open University
Module 9 285
General Strategies for Effecting Changes in

Human Sytems
Now that we have discussed the phases of change according to Lewin
and Lippitt, you must be asking yourself, so how do I now go about mak-
ing change happen? What strategies do I use?
There are three general strategies identified by Robert Chin and Kenneth
Benne (1976). These are the following:
1. Empirical — rational strategies

2. Normative — re-educative strategies
3. Power — coercive strategies
The first group of strategies, and probably the most frequently employed,
are the empirical—rational strategies. The fundamental assumption here
is that people are rational beings. Another assumption is that people will
follow reason once this is revealed to them. In this situation, a change is
proposed by some person or group (change agent) who knows of a situa-
tion that is desirable, more effective, and in line with the self-interest of
the person, group, organization, or community that will be affected by
the change (client or target system). Because the client is assumed to be
rational and moved by self-interest, it is assumed that the client or target
will adopt the proposed change if it can be rationally justified and if it can
be shown that the client will gain by the change.
Let us consider a common example of a patient diagnosed with pulmo-

nary tuberculosis. The nurse (change agent) who will employ the empiri-
cal-rational strategy will explain the need for compliance to anti-TB medi-
cations for at least six months. He or she will point out how the long-term
therapy will cure the disease and that irregular intake of medications will
result in developing resistant strains of the tubercle bacilli. The latter will
entail use of more expensive medications later on and probably, the de-
velopment of complications due to uncontrolled tuberculosis.
Do you think that this first group of strategies will be effective? In the
early 1970s, health education was mainly focused on the provision of
information. Most health professionals and educators thought that giving
information was enough to effect behavior change such as regular intake
of anti-TB drugs. But experience has proven this to be inadequate. Yes,
knowledge is important and basic— but it is not sufficient to effect change.
A second group of strategies for change is called normative—re-educa-
tive. These strategies build upon assumptions about human motivation
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different from those underlying the first group of strategies. The rational-
ity and intelligence of humans are not denied. However, other factors
influencing behavior are considered. Behavior and practice are supported
by sociocultural norms and by commitments of individuals to these norms.
In turn, sociocultural norms are supported by the attitude and value sys-
tems of individuals. Change in behavior or practice, according to this
view, will occur only as the persons involved are brought to change their
normative orientations to old patterns and develop commitments to new
ones. Changing normative orientations, likewise, will involve changes in
attitudes, values, skills, and significant relations—not just changes in
knowledge or information.
Applying this to our example of the TB patient, you as the change agent,
will have to consider the attitudes and values of the patient concerned as
well as the prevailing norms. It may not be enough to explain the ratio-
nale for the use of anti-TB drugs, you might need to consider his attitude
to being labeled as “having TB.” If he is ashamed of having TB, he might
not go to the health center to get his medications. On the other hand, you
can also use the norms to persuade and re-educate this person by point-
ing out that a lot of people have TB and that TB is now curable, unlike
before.
Can you think of other ways to apply the normative—re-educative strat-

egies in our example? I’m sure you can. Make sure you can differentiate
the first group of strategies from this group, okay?
The third group of strategies is based on the application of power in some

form and is referred to as power—coercive strategies. The influence pro-
cess involved is basically that of compliance of those with lesser power to
the plans, directions, and leadership of those with greater power. Power
here is not limited to political power. However, often the power to be
applied is legitimate power or authority such as the power of the nurse
supervisor or headnurse over the staff nurse or that of the teacher over
the student. The strategy may also involve getting the authority of law or
administrative policy behind the change to be effected.
Again, in our example, some form of coercion may be used by the nurse in
the health center to go after TB patients who are non-compliant. I have
not seen this actually implemented in the Philippines, but I do know that
in certain states in the United States like Massachusetts, non-compliant
TB patients are confined, with the assistance of law enforcers if needed,
just to ensure that the patient will take his medications.
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Now, let’s go to the two strategies of social change proposed by Richard

E. Walton (1969). Walton grouped the strategies into two: power strat-
egy and attitude change strategy.
Walton’s power strategy is very similar to Chin and Benne’s power—

coercive strategy and is usually advanced by game theorists, diplomatic
strate-gists, and students of revolution. Often, the change is sought by
groups with a relative power disadvantage. To command attention and
establish a basis for a quid pro quo, they must threaten the other with
harm, loss, inconvenience, or embarrassment.
A good example of this is the attempt of consumer groups (group with

less power) to boycott products of certain companies (group with greater
power). Another example is the People Power Revolution of 1986 in EDSA.
People in massive numbers went to EDSA as a show of defiance and
became an embarrassment for the prevailing Marcos regime. In both these
cases, the group with lesser power were able to improve the probable
outcome for itself by building its power vis-à-vis the other.
Attitude change strategy, on the other hand, involves overtures of love

and trust, and gestures of good will. These are all intended to result in
attitude change and concomitant behavior change. How is this possible?
This can be done by increasing the level of trust between persons and
minimizing the perceived differences between the goals and characteris-
tics of members of the two groups.
Now, why don’t you take a break by answering this self-assessment ques-
tion and see if you can apply the above learning to your own change
strategy.
SAQ 9-4
Consider the three general strategies identified by Chin and Benne
as well as Walton’s two strategies. If you were made to choose,
which group of strategies would you adopt for yourself as a change
agent?
UP Open University
Summary
So far, I have discussed planned change and the change relationship be-
tween the change agent and the target or client system. I also presented
the different phases of change according to Kurt Lewin and Ronald Lippitt.
It is not enough to talk about phases of change. Strategies of change are
also important. There are three groups of strategies according to Chin
and Benne: rational—empirical, normative—re-educative, and power—
coercive strategies. Walton only named two groups: attitude change which
is similar to normative—re-educative, and power strategy.
In most cases, you will need to use any or all of these strategies depending
on the situation. Start with attitude and normative-re-educative strate-
gies first. This will lessen the substantive conflict and lessen the need for
power—coercive strategies. However, in some cases, use of power strat-
egy may also lead to attitude change. For example, ordinances that limit
where cigarette smokers can smoke, and increasing taxes on cigarettes
may make smoking difficult and may even change the attitude of the
smoker eventually.
The agent of change needs to know how to simultaneously or sequen-

tially mix strategies. This has implications on the training of leaders of
groups and the training of professional change agents like nurses. We
always say that the nurse has an important role to play as a change agent.
But this does not happen by chance. Education and training of nurses,
especially those in advanced nursing practice, must involve training for
change.
Can you now picture yourself as a change agent? You now have some
tools at your fingertips. Use them. You may not be able to change the
world, but you can surely change yourself and your immediate environ-
ment.
UP Open University
Module 9 289

ASAQ 9-1
To determine if this was planned change, identify the change agent and
the target system or client. Remember that the client may be an individual,
small group, family, or even companies or institutions. Was there a delib-
erate attempt at change? Was there a “change relationship” between the
change agent and the client? If yes, then, that was a planned change.
We go through life experiencing change. I hope that this module will make
you realize that we can make change happen and that there are tech-
niques and strategies to effect change, particularly planned change.
ASAQ 9-2
Compare your answer with mine. The parallelism can best be shown by
the following table:
Lewin’s Change Process Lippit’s Planned Change
Unfreezing Development of a need for change

Establishment of a change relationship
Moving Working toward change:

1. Clarification or diagnosis of client
system’s problem
2. Examination of alternative routes
and goals; establishing goals and
intentions of action
3. Transformation of intentions into
actual change efforts
Refreezing Generalization and stabilization of

change
Achieving a terminal relationship
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ASAQ 9-3
Each phase of planned change is important for lasting and meaningful
change to occur. An important phase is the development of a need for
change and the establishment of a change relationship. Working towards
change, particularly phase 3 which involves the diagnosis of the prob-
lem, is also crucial to the change process. To a certain extent, this is very
much like the assessment phase in our nursing process. Without careful
assessment and diagnosis, the plan will not be an effective and efficient
one.
ASAQ 9-4
There is really no right or wrong answer to this question. In most cases,
the strategies to be used will depend on the situation and the problem
that is being addressed. Also, these strategies can be used in combination.
Personally though, and with my training and preparation as a profes-
sional health educator, I must admit that I am partial to the normative—
re-educative strategies. Power—coercive strategies have their uses but make
sure these are not overdone. Health education programs should adhere to
the principle of choice and voluntariness.
References
Bennis, W., Benne, D. and Chin, R. (1969). The planning of change. 2nd
Edition. New York: Holt, Rinehart, and Winston.
Bennis, W, Benne, D, Chin, R and Corey, K. (1976). The planning of change.
3rd Edition. New York: Holt, Rinehart, and Winston.
Lewin, K. (1951). Field theory in social science. New York: Harper and Row.
Lippitt, R., Watson, J., and Westley, B. (1958). The dynamics of planned
change. New York: Harcourt Brace.
UP Open University
Module 11 307
Module 11
Crisis Intervention Theory
Merle F. Mejico
C risis is an inevitable aspect of human exist-

ence. Individuals are constantly confronted
with potential crisis laden situations which can
Objectives
threaten one’s coping and functioning. The on-
going pressures and demands in today’s society At the end of this module,
test the person’s ability to use problem-solving be- you should be able to:
haviors and may lead to crisis situations that need
professional intervention. Crisis occurs when an 1. Discuss the historical
individual faces a problem that cannot be solved, development of crisis
and where previous coping mechanisms are not intervention theories;
workable. At this turning point, tension and anxi- 2. Explain the important
ety increase, one feels helpless and caught in a theories, concepts, and
state of great emotional upset and is unable to principles of crisis and
take appropriate actions. Crisis intervention of- crisis intervention; and
fers immediate help to establish equilibrium. Its 3. Apply the use of crisis
immediate goal is to reinforce the individual’s intervention in nursing
strengths and minimize weakness, to move him practice/situations.
from a state of being passive and dependent to
an adult, independent state in a short period of
time. This module focuses on crisis theory, its concepts and principles and
problem solving approach to crisis intervention.
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To be able to understand this module fully, you should be familiar with

the following important terms:
1. Balancing factors — interrelated factors contributing to the produc-

tion of crisis and its outcome
2. Cognition — individual’s understanding of a stressful event. It plays
a major role in perceiving threat and in determining the degree of
coping behaviors.
3. Coping skills — ways of solving a problem situation; style or mecha-
nism of handling stressful events
4. Crisis — a turning point in an individual whose previous means of
coping is no longer working to solve a problem. It can be both a posi-
tive and negative growth opportunity.
5. Crisis Intervener — worker or therapist in crisis situations, an indi-
vidual who is assisting, helping people in crisis
6. Equilibrium — balance or homeostasis where the body is maintained
to achieve normal functioning
7. Intervention — measure/strategy used to assist individuals in crisis.
It provides specific approaches and techniques in crisis resolution.
8. Stress — something of varied nature which enables an individual to
cope. It can trigger or precipitate a crisis.
9. Support system — individuals, family or group considered as an im-
portant balancing factor in crisis. They are people available to help
solve the problem.
10. Therapeutic use of self — ability to establish trust quickly and to
assist clients to deal with their emotions. It requires tremendous self-
awareness and conscious use of one’s personality in the process.
Historical Development of Crisis Intervention

Crisis intervention was not really a new thing even during Freud’s time in
1900 during which he recorded the first “crisis intervention” in treating
his clients with arm paralysis. It was extended as a supportive technique
during World War II in assisting soldiers and in dealing with survivors of
civil and military disasters. In 1944, it was the only time that crisis inter-
vention was formally developed by Lindemann in handling bereaved fire
victims. The concept was later elaborated by Caplan who later became
the father of modern crisis treatment measures intervention. By 1950, cri-
sis intervention as a therapy paralleled psychotherapy. The Community
Mental Health Act of 1963 influenced the development of crisis interven-
tion by providing emergency services in the community.
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Module 11 309
Parad, Rapoport, Jacobson and Aguilera refined crisis theory and devel-
oped treatment models for crisis in marital, family conflicts, and suicide
prevention. It was in the mid 1960s that crisis intervention became a treat-
ment modality in its own right. Caplan continued expanding the theory
by identifying the significance of the support system in crisis situations.
In the 1980s, nurses actively involved themselves in assisting in crisis in

both in-patient and out-patient settings. The 1990s introduced complex
social changes that threatened people’s stability and coping behaviors,
increasing the need to give priority to crisis intervention as a means of
preventing problems and disorders. It is anticipated that a lot of mobile
crisis intervention services will be used as an outreach approach for indi-
viduals who cannot or will not use other types of crisis services. More
demands brought by industrial and technological revolutions will make
nurses confront a lot of potential crisis laden situations affecting them-
selves, clients and others. Regardless of the area in which they work, nurses
by virtue of their preparation should always be available, capable and
able to make these individuals benefit from the opportunity that can ei-
ther be growth promoting or expose one’s vulnerability.
Table 11.1. Historical highlights of development of crisis intervention
1906 First recorded instance of “crisis intervention” concerned

Freud’s six visits to a client with partial paralysis in an arm.
1940s Principles and techniques of crisis intervention were derived

from the use of supportive techniques to treat soldiers
suffering from crises related to combat during World
War II. Psychiatrists, on their return home after the war,
used the techniques that were effective with soldiers to deal
with survivors of civil and military disasters.
1944 Lindemann’s classic study of bereaved victims of the

Coconut Grove nightclub fire established a format for the
study and development of crisis theory and practice.
1948 Lindemann refined his crisis concepts and organized an

innovative community mental health program in Boston.
Caplan elaborated on Lindemann’s model and became
known as the father of modern crisis intervention.
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Table 11.1 continued
1950s The development of crisis intervention paralleled brief or

short-term psychotherapy.
1950s-1960s Caplan developed an interest in crisis situations out of his

early work with immigrant mothers and children in Israel
after World War II. Caplan’s approach to crisis intervention
was set in the format of primary, secondary and tertiary levels
of intervention at the Harvard School of Public Health.
Parad, Rapoport, Jacobson and Aguilera, building on the
work of Lindemann and Caplan, refined crisis theory and
developed treatment models for crisis in marital and family
conflicts, and in suicide prevention.
The Community Mental Health Act of 1963 spurred the
development of crisis intervention. One requirement of the
Act was that community facilities provide emergency
services.
Mid-1960s Crisis intervention became a treatment modality in its

own right.
1970s Caplan focused his attention on natural and mutual support

systems in the community that could be used to prevent
or ameliorate the destructive aspects of crisis situations.
1980s Nurses increased their involvement with crises in a variety

of in-patient and out-patient settings.
1990s Rapid, increasingly complex social changes threaten

people’s stability and coping behavior, increasing the need
for nurses to give priority to crisis intervention as a means
of preventing psychiatric problems.
The need for the increased use of crisis interventions to prevent rehospi-
talization of individuals with chronic mental illness is much recognized.
In the future, outreach programs using mobile crisis intervention services
can be anticipated. Training of both non-professionals and professionals
as crisis interveners will become a felt need among varied disciplines or
professions. The ongoing changes as a result of technology and develop-
ment will demand that the individual exhaust his coping skills. That
future is near and one should not be caught unprepared for that crisis
event.
UP Open University
Module 11 311
SAQ 11-1
As a review, can you recall important events/dates showing the
development of the concept and techniques of crisis intervention?
Arrange them chronologically and write the dates before the events.
__________ 1. Crisis intervention became a modality in its own

right.
__________ 2. Crisis intervention paralleled short-term psycho-
therapy.
__________ 3. Provision of emergency services in community
facilities.
__________ 4. Recognition of support system to prevent crises.
__________ 5. Nurses’ gave priority to crisis intervention in
preventing psychiatric problems.
__________ 6. First recorded event of crisis intervention among
a patient with paralysis of the arm.
__________ 7. Development of treatment models for crises in-
volving marital and family conflicts and suicide
prevention.
Activity 11-1
Before we move on to crisis theory and intervention, recall a crisis
laden situationthat you experienced. How did you feel? Did you
feel helpless? Do you remember what you did?
I’m sure after you recalled a crisis situation, you realized that everybody
experiences crises of one form or another. Your feeling is very normal. I
experience it too, every now and then. Can you challenge yourself to
benefit from the next crisis situation by making it an added learning
opportunity? You would be helped in that direction as you go on with
this module.
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General Theories Supportive

of the Crises Concept
(Aguilera, D., 1986)
Psychoanalytic Theory (Freud)

His principle of causality states that every act of human behavior has its
cause or source in the history and experience of the individual. Present
behavior is influenced by one’s past experiences. Disequilibrium that ac-
companies a person’s crisis can be understood through gaining access to
the individuals unconscious thought and conditional experiences.
Ego-analytic Theory (Hartmann)

He considered reality functions important in the adaptation of the indi-
vidual to the environment. He emphasized that an individual’s adapta-
tion in early childhood affects his ability to continue adapting to the
environment in later life. The fitting together of an individual and the
society is important. He believed that although the behavior of the indi-
vidual is strongly experienced by culture, a part of the personality
remains relatively free of the influence.
Adaptational psychodynamics (Rado)

Rado provided a new approach to the unconscious as well as new goals
and techniques of therapy. Rado saw human behavior as being based on
the dynamic principle of motivation and adaptation. Behavior is viewed
in terms of its effects on the welfare of the individual, not just in terms of
cause and effect. Rado’s adaptational psychotherapy emphasizes the im-
mediate present without neglecting the influence of the developmental
past. Primary concern is with failures in adaptation “today,” what caused
them, and what the client must do to learn to overcome them. Through
practice, the client instinctively reacts with new patterns of healthy be-
havior in the reality of daily living.
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Module 11 313
Epigenetic development (Erikson)

Erikson developed the theories of ego psychology by focusing on the epi-
genesis of the ego. Epigenetic development is characterized by an orderly
sequence of development at particular stages, depending on the previous
stages for successful completion. Solutions achieved in each previous phase
are applied in subsequent phases. Erikson’s theory offers an explanation
of individual social development as a result of encounters with the social
environment.
All of the theorists mentioned above emphasized the role of the environ-
ment in crisis theory and intervention. Freud underscored the aspect of
past experiences; Rado emphasized the interaction of adaptation with
culture; and Hartmann and Erikson mentioned society and social envi-
ronment as part of the reality concept in social development. Thus in sum-
mary—
Freud’s
Psychoanalytic
Theory
Past Experience
E
Culture Social
milieu 1. Hartman’s
Ego-analytic
Radio’s theory
Adaptational 2. Erikson’s
Psychodynamics Epigenetic
developmental
theory
Figure 11-1. The role of environment in crisis

(as supported by Freud, Erikson, Rado, and Hartmann)
UP Open University
Crisis Theories
(Aguilera, 1986)
Lindemann
Lindemann’s first concern was to develop strategies in maintaining good
mental health and prevention of emotional disorganization on a commu-
nity-wide level. He studied bereavement reactions in his search for social
events that predictably would be followed by emotional disturbances in a
portion of the population. In his study of bereavement reactions among
survivors of the Coconut Grove nightclub fire, he described brief and pro-
longed reactions among different individuals as a result of the loss of a
significant person in their lives. He postulated that life experiences and
situations that generate emotional strain can present stress and thus a
series of adaptive mechanisms occur which can lead to mastery of new
situations or to failure with more or less lasting impairment to function.
By virtue of the individual’s personality, previous experience and other
factors in present situations, individuals go into crisis especially those vul-
nerable to stress and whose emotional resources are taxed beyond their
usual adaptive resources.
Lindemann’s theoretical frame of reference led to the development of

crisis intervention techniques and in 1946, he and Caplan created a com-
munity wide program of mental health in the Harvard area known as the
Wellesley Project.
Caplan
Caplan asserted that the most important aspects of mental health are the
state of ego, stage of maturity and quality of its structure. Assessment is
based on three additional areas:
1. capacity of the person to withstand stress and anxiety and maintain

equilibrium
2. degree of reality recognized and faced in problem solving
3. stock of coping mechanisms used to maintain balance
Caplan believed that all elements in the total emotional milieu of the per-
son must be assessed. It includes thr material, physical, social demands of
reality as well as needs, instincts and impulses which are also determi-
nants of crisis intervention. Crisis ensues when a person faces an obstacle
to important life goals that cannot be resolved by using the usual coping
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Module 11 315
strategies. Thus, a period of disorganization results during which many

abortive attempts at a solution are made. The individual is viewed as
living in a state of emotional equilibrium with a goal of always returning
to that state. This is upset when the usual problem solving strategies are
not workable. There is a rise in inner tension, signs of anxiety and disor-
ganization of function, resulting in emotional upset called crisis.
For a summary of important contributions on the concepts of crisis and

crisis intervention, see Table 11.2.
Table 11.2. Important contributions in defining crisis and crisis intervention
Grief and bereavement due There are specific characteristics

to death lead to crisis. of crisis-prone individuals.
– Lindemann (1944) – Hendricks (1985)
The two basic treatment There are six types of emotional

approaches to crisis intervention crises in relation to psychopatho-
are generic and individual. logy, cause and implications for
interventions (dispositional, anti-
– Jocobsen, Stricker cipated, traumatic, developmen-
and Morley (1968) tal, psychopathological, and
psychiatric emergency).
– Baldwin (1987)
Crises undergoes a time period Balancing factors for a crisis state

Sequence = precrisis, crisis, are perception of the event, pre-
postcrisis. vious coping mechanisms and
availability of support systems.
– Parad and Resnik – Aguilera and
(1975) Messick (1982)
Crisis occurs when a person faces Crisis intervention undergoes prob-

an obstacle to important life goals. lem solving steps or stages.
There are two general types of – Dewey, Merrifield

crises— developmental and and Guilford (1967)
situational.
Crisis intervention is a major technique

of preventive psychiatry.
- Caplan (1964)
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SAQ 11-2
1. Now, do you appreciate the theories of crisis? Can you enu-
merate them?
2. Compare Lindemann’s contribution to Caplan’s in the formu-

lation of crisis theories.
Types of Crises
The important contribution of Erikson’s (1964) theory is the elaboration
of particular types of crises. He dealt, in particular, with the problem of
adolescence and saw the period as a normative crisis, that is, a matura-
tional phase of increased conflicts, with apparent fluctuations in ego
strength. His theories provided a basis for the work of others who further
developed the concept of types of crises.
Caplan acknowledged the influence of Erikson’s model of developmental

and situational crisis on his theories about life crisis. He defined develop-
mental crises as transitional periods in personality development charac-
terized by disturbances in cognitive and affective functioning. These are
experiences by someone who is learning to adjust to the new expectations
related to various maturational periods in life. On the other hand, situ-
ational crises are sudden unexpected threats to, or loss of basic resources
or life goals. They are not as common as developmental crises and are
characterized by periods of psychological and behavioral disorganization
that occurs when an individual is unable to cope by his usual behaviors.
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Table 11.3. General types of crises (by Caplan)
Type Characteristics Examples
Developmental a. Precipitated by normal Birth, mastering control

or maturational stress of development of body functions,
b. May occur at any tran- school age, puberty,
sitional period in normal marriage, parenthood,
growth stages loss of physical youth-
c. Are predictable and fulness, and retirement
occur gradually; thus,
it is possible to prepare
for the stressful periods
and prevent occurrence
of crisis
Situational or a. Response to a traumatic Loss of a job, loss of

accidental event, usually sudden a spouse, birth of de-
and unavoidable fective child, chronic
b. Usually follows the loss illness, failures,
of established support divorce, death
c. It threatens physical,
emotional and social
integrity of the individual
SAQ 11-3
What is the difference between developmental and situational
crises? What are the other categories/terms for them? Cite other
examples not given in the discussion.
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Baldwin (1978) developed a classification system that describes six

general types of crises in relation to the degree of psychopathology, the
cause of the crisis and implications for effective interventions. As each
type moves from a lesser to a greater degree of psychopathology, the cause
becomes more internal than external. The model is based on the assump-
tion that crisis intervention requires assessing the emotional crisis rather
than making a diagnosis in a traditional psychiatric sense. The classifica-
tion of the crisis, characteristics and examples are presented in Table 11.4.
Table 11.4. Types of emotional crises by Baldwin (Williams, 1990)
Class Type Characteristics Source Example
1 Dispositional Caused by distress External Providing

crises that arises from a prob- information to
lematic situation in which a mother about
intervention is not direc- parenting
ted at the emotional classes
level
2 Anticipated Relate to normal life External Getting married;

life transition transitions over which mid-life career
crises the person may or may changes;
not have control retirement
3 Crises resul- Precipitated by externally External Rape; sudden

ting from trau- imposed stressors that death of a family
matic stress are unexpected and un- member;
expected and uncon- sudden loss of
trolled job
4 Maturational Relate to an attempt to Internal Emancipation

or develop- achieve emotional matu- from an over-
mental crises rity by completing deve- protective parent
lopmental tasks; involves
struggle with a deep-
seated, unresolved issue
5 Psychpatho- Preexisting psychopatho- Internal Client with

logical crises logical condition precipi- severe anxiety
tates the crises or com- disorder or
plicates resolution of pathological
crises dependence
6 Psychiatric Severe psychiatric dis- Internal Psychosis; drug

emergency order with severe impair- overdose;
crises ment; incompetent; acutely suicidal
danger to self or others
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Phases of Crises
To understand how crisis occurs, you have to examine the stages or steps
that lead to active crisis situations. The first phase is a rise in anxiety as a
response to trauma. The individual tries to use his usual coping mecha-
nisms to resolve the feeling of increased anxiety. If the coping strategies
prove unsuccessful, he’ll go into the second phase which is characterized
by increased anxiety due to failure coping. In the third phase, the person’s
anxiety continues to escalate and he usually feels forced to reach out for
help. If the individual is emotionally isolated before he experiences the
event, it is usually impossible for him to avert a crisis. The fourth phase is
the active state of crisis wherein the individual’s inner resources and sup-
port systems are inadequate. The precipitating event is not resolved and
stress and anxiety rise to an intolerable level leading to disorganization.
The individual in crisis might have a short attention span. He may rumi-
nate, and look inwardly for possible reasons for the traumatic event and
how he might have avoided it. This rumination is accompanied by great
deal of anguish, apprehension and distress. His behavior becomes more
impulsive and unproductive. He becomes less aware of his environment
and begins to view others in terms of their ability to help solve his prob-
lem. His searching behavior appears confused and disoriented. Due to
the high level of anxiety, the individual thinks he is “losing his mind” or
“going crazy.” His perceptive ability is greatly affected by high anxiety.
He often needs reassurance that when he feels less anxious, he will be
able to think clearly again. The developmental phases of crises are sum-
marized in Figure 11-2.
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Crisis event
Use of habitual problem

First stage:
solving responses
rise in tension or feeling of anxiety
(if ineffective/unsuccessful)
Second stage: Habitual problem solving responses

increased tension/anxiety (if still ineffective in resolving crisis)
Third stage: (needs assistance and help)

level of tension/anxiety continues Emergency problem solving
to increase activated (if still ineffective)
Redefinition and resolution of

problem or
Discontinuance of efforts to
achieve goal
or
Avoidance of problem by
distorting reality
Innate resources and support
Fourth stage: system are inadequate
tension continues to increase
(active state of crises) Disorganization of
personality
Figure 11-2. Caplan’s developmental phases of a crisis

(Williams, 1990)
SAQ 11-4
True or false?
__________ 1. Every individual has to undergo the four phases

of crises to be able to experience the crisis situa-
tion.
__________ 2. In the first stage, the individual tries to seek as-
sistance/help already.
__________ 3. Inability to resolve the crisis in the fourth stage
may lead to personality disorganization or mal-
adaptive behavior.
__________ 4. The concept of crisis stages/phases helps one to
anticipate and prevent further crises.
__________ 5. Lessening anxiety would be the initial step in
the resolution of the entire crisis.
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Module 11 321
Balancing Factors Affecting Equilibrium

There are three interrelated factors contributing to the production of a
crisis and influencing the crisis outcome. Aguilera and Messick (1942)
devised a paradigm to illustrate how these factors influence the crisis in-
tervener in analyzing and resolving a crisis situation. These factors are:
1. Perception of the event — If the event is realistically perceived, there

is the recognition of the relationship between the event and feelings
of stress. If the perception of the event is distorted, then no recognition
of the relationship is made between the event and the feeling of stress.
Thus the problem is not solved and tension continues. Perception of
the crisis event is determined partly by the extent to which the event is
a threat to the individual’s values and life goals. A crisis event may be
perceived as a threat or as a challenge where one is able to mobilize
energies and engage in purposeful problem solving.
2. Situational support — This refers to the persons in the environment

who can be depended on to help the individual solve problems. They
are the significant others in a person’s life from whom one seeks ad-
vise and support. Individuals readily develop dependent relationships
with support persons who protect them from feelings of insecurity
and reinforce their feelings of ego integrity. Lack of a support system
makes the individual vulnerable, and increases disequilibrium. This
situation can lead to a crisis.
3. Coping mechanisms — Lifestyles are developed around patterns of

response which in turn are established to cope with stressful situa-
tions. These lifestyles are highly individual and quite necessary to pro-
tect and maintain equilibrium. Tension-reducing mechanisms can be
overt or covert and can be consciously or unconsciously activated.
Available coping mechanisms are what people usually resort to when
they have a problem. Individuals are confronted with minor emer-
gencies or problems that create disequilibrium. Through experience,
and learning about their potentialities, individuals develop techniques
for dealing with minor external and internal stresses. One way to deal
with stresses is by using coping mechanisms in everyday living.
According to Bandura, the strength of the individual’s belief in of his or

her own effectiveness in overcoming or mastering a problematic situation
determines whether the coping behavior will even be attempted. People
fear and avoid stressful, threatening situations that they believe exceed
their ability to cope. They behave with assurance in situations in which
they judge themselves able to manage and expect success eventually. The
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perceived ability to master problem situations can influence the choice of

coping behaviors, as well as the persistence used once a behavior is cho-
sen. See the paradigm below as a guide to help the intervener assist per-
sons in crisis.
State of equilibrium
State of disequilibrium
Felt need to restore

equilibrium
A B
Balancing factors present One or more balancing factors
absent
Realistic perception of the event Distorted perception of the event
Adequate situational support Inadequate situational support
Adequate coping mechanism Inadequate coping mechanisms
Resolution of the problem Problem not resolved
Realistic perception of the event Disequilibrium continues
No crisis Crisis
Figure 11-3. Paradigm: Effect of balancing factors in crisis

(Aguilera & Messick, 1986)
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Module 11 323
Activity 11-2
Think of an event or situation where you could apply this para-
digm of balancing factors by Aguilera and Messick. Be sure to
specify in each box the actual factors involved. If you are having a
difficult time thinking, may I suggest you try to develop from any
of the following common situations:
1. Taking the board examination

2. Death of a loved one
3. Divorce/separation
4. Calamity/disaster (natural)
5. Birth of a handicapped/retarded child
You may want to try all of them. If you are able to try the paradigm in the
first two situations, the others should be easier. By working through these
five situations, you will develop skills in paradigm application. You can
also use your own examples.
Crisis Intervention
The goal of intervention in crisis is to assist the individual to resolve his
immediate problem and regain emotional equilibrium. The role of the in-
tervener is one of active participation with the individual in solving the
present problem. Crisis intervention is partnership. The underlying phi-
losophy of crisis intervention is that with varying degrees of assistance,
people can help themselves. To maximize the opportunity for growth, a
person in crisis must be actively involved in resolving the problem. Crisis
intervention is a thinking, problem-solving approach.
There are always difficulties whenever we must respond to a person in

his or her social context. The perspective of the one responding to the
emergency may be distorted early in the situation if he or she is enlisted
prematurely on the side of one of those involved. Non-professionals
(using the generic approach) can dangerously compromise themselves
and their effectiveness by letting themselves be drawn off-side by those
changes. Such negative statements should cause us to bear in mind the
need to contact or establish a working relationship with the previous thera-
pist or counselors.
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A rule of thumb for amateurs in crisis management is to use the previous

provider of assistance as immediate source of information. The story that
the individual tells may lead one to make incorrect judgments about the
efficacy of the previous treatment. This becomes complicated for some
ethical and professional reasons. Complaints generally represent what
we understand as a transference phenomenon. These are actions which
have their origin in the individual’s psychic structure. They may only re-
peat the fact that he or she has been actively engaged in a treatment that,
because of unresolved conflicts, he or she is resisting. Non-professional
helpers/interveners should maintain enough distance from the emergency
to judge it dispassionately and avoid choosing sides or making a moral
judgment in situations about which they are in fact, just beginning to
learn.
Laid-back indifference is not ideal for crisis counseling. “Wait and see”
works well in certain situations, but it is not helpful in dealing with emer-
gencies. By its nature, crisis waits for no one. Nothing takes the place of
the individual with basically healthy instincts who has both the right in-
formation, and if possible, some training. The calm generated by these
individuals is not that of a defensive individual but is rather the outcome
of good sense and good ideas, properly integrated for the situation on
hand. Chandler (1990) mentioned basic characteristics of the crisis inter-
vener as follows:
1. Must demonstrate calmness and empathy. The intervener must be able

to identify the facts in a situation and think clearly to plan solutions.
Most often, people in crises are confused.
2. Should be nonjudgmental and aware of different cultural values. Since

there are different patterns of responses to crisis situations, the inter-
vener should be careful not to impose a different lifestyle or value
system.
3. Should possess courage. Pain involved in crisis is not pleasant. It is

always difficult to listen to tragic things; thus, the intervener should
tolerate discomfort, sadness and anger.
4. Should have commitment to work with the person in crisis until the
problem is resolved.
The intervener, be he a professional or non-professional, should help the

person in crisis analyze the stressful event. He encourages the individual
in crisis to express his feelings and tells him that he has a right to his
feelings no matter what they are. He explores methods of dealing with
stress and reinforces client’s strengths and abilities. The person is encour-
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Module 11 325
aged to seek support from friends, family and other resource groups in
the community. Planning designed to avert possible crises in the future is
accomplished through anticipatory guidance.
It is also a must that we are capable of making necessary referrals espe-

cially during emergencies. By remaining ourselves and keeping some dis-
tance from potential entanglement or over-ambitious involvement in the
situation, we can step aside and let someone else take over without caus-
ing unnecessary trauma in the process. When we have been perceived
unambiguously and with minimum distortion, and when we exercise dis-
cipline in our response to the situation, we remain free enough to be truly
helpful.
Activity 11-3
At this point, let’s do an exercise that will help develop self-aware-
ness. Try to answer these questions as honestly as possible.
1. What are your strengths as a person?
2. Can you depend on the these strengths as you become a crisis

intervener?
3. What are your weaknesses? (Yes, interveners have weaknesses

too and you have to be conscious of them!)
4. As a nurse with much background in relating to people, sick

or well, do you think you have an edge over other disciplines
in becoming an intervener in times of crisis? Why?
5. List down all possible characteristics of crisis interveners. Par-

allel to these, write your own characteristics for comparison.
I hope you ended up with something positive and productive. Let us now
continue reading the remaining text for more information. Let me remind
you that as you learn more, you develop a feeling of confidence and this
helps your client feel secure. You must be able to project and transfer that
feeling to him. Along the way, I hope you will become more aware of
your own personal resources for coping.
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Crisis Intervention Model

Equilibrium Model
(Lindemann, 1944; Caplan, 1961; Leitner, 1974)
This model underscores that the emotional state during equilibrium leads
to a person’s stability, being in control and psychologically mobile. The
focus of the intervener in this model is to help people remain in a state of
precrisis. Any disturbance will automatically lead to disorganization be-
cause the individual becomes emotional. The person must then have the
ability to use coping mechanisms and a problem solving approach.
Cognitive Model
(Ellis, Meichenbaum, Beck and Shaw)
This model proceeds from the assumption that crises are rooted in faulty
thinking about events or situations surrounding crises—not on the events
themselves. The goal of this model is to help people become aware of and
to change their views and beliefs about crisis events or situations. Cropley
and Field suggest that there is uniqueness in the way people take in, pro-
cess and use information from the environment. According to Inkeles, a
person’s cognitive style helps to set limits on information-seeking in stress
situations. If the event is perceived realistically, relationships between the
event and feelings of stress will be recognized. Problem-solving can be
appropriately oriented toward reduction of tension, and it is more likely
that the stressful situation will be resolved.
Eclectic Crisis Intervention Model

(Gelliland, James, Bowman, Thorne)
This refers to the intentional and systematic selection and integration of

valid concepts and strategies from all available approaches in helping
clients. It is a task-oriented model which aims to do the following:
1. Identify valid elements in all systems and integrate them into an inter-
nally consistent whole that does justice to the behavioral data to be
explained.
2. Consider all pertinent theories, methods and standards for evaluating

and manipulating clinical data according to the most recent develop-
ment.
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Module 11 327
3. Identify with no specific theory, keep an open mind and continuously

experiment and choose formulations and strategies that produce suc-
cessful results.
Psychosocial Transition Model

(Adler, Erikson, and Minuchin)
This model states that people are products of their hereditary endowment
and the learning they have absorbed from their social environment. The
experiences which the individual has gone through will help him adjust
to situations. Significant others assist the individual welcoming challenges.
The more successful the exposure of people to life experiences, the more
positive the interventions become.
After discussing the models for intervention, we are now better guided on
what to use or what to blend together to become successful crisis inter-
veners. We all have different ways of viewing situations and we have our
own philosophies of intervening. Well, you are free to make decisions.
However, it is important to understand that outside ourselves, not within
our control, are certain characteristics of our potential clients.
Hendricks (1985) reported that some individuals are crisis-prone. Crisis

prone people may have one or more of the following characteristics:
1. Unemployment, underemployment or dissatisfaction with their

present occupation or position
2. Drug abuse (including alcohol)
3. Difficulty in coping with minor problems, i.e., problems encountered
by the general population on an everyday basis
4. Low self-esteem, persistent feelings of insecurity
5. History of unresolved crises or emotional disorders
6. Underutilization of support systems or minimal access to support
systems (personal, family, social)
7. Few permanent relationships (personal, employment, home)
8. Feelings of alienation from others (family, friends, society)
9. Impulsiveness and uncaring attitude
10. History of frequent personal injuries and/or frequent involvement in
property damage incidents
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Approaches to Crisis Intervention

Intervention during crises can have basic approaches—depending on one’s
preparation and skill. Non-professionals or amateurs tend contribute much
because of their accessibility to the client. These persons could be family,
friends or any group who can give general support. The professional or
well trained crisis intervener can make a difference by applying her spe-
cialty/expertise to individual situations.
The generic approach is based on the premise that certain identifiable

patterns of behavior are characteristic of each type of crisis. In addition,
psychological tasks specific to the type of crisis are required if the crisis is
to be successfully resolved. Treatment is focused on the characteristic course
of the particular kind of crisis rather than on the psychodynamics of each
individual in crisis. For example, in the case of a child with terminal can-
cer, the mother must accomplish the psychological task of accepting that
the child will likely die and must prepare for the impending loss. The
client and the intervener work together in the problem-solving process.
This generic approach encourages the use of adaptive behavior and
general support, and allows for manipulation of the environment. This
intervention mode can be learned and implemented by non-mental health
professionals. It does not require a mastery of knowledge of the intrapsy-
chic and interpersonal processes of an individual in crisis.
The individual approach involves assessment by a mental health profes-

sional of the intrapsychic and interpersonal processes of the person in
crisis. The intervener focuses on identification of the precipitating factors
and examines reasons why the individual’s usual coping mechanisms are
no longer effective. Once the intervener achieves these goals, she deter-
mines the intervention that is necessary to improve the client’s coping
abilities. The intervener should know the psychodynamics of crisis. Vari-
ous situational crises that a person experiences may be treated effectively
with the individual approach, because it is directed toward the individual’s
unique situation. Intervention is planned to meet the unique needs of the
individual in crisis to reach a solution for the particular situation that
precipitated the crisis.
Some specific techniques facilitate crisis intervention in a more successful

manner within a shorter period of time. The intervener needs to develop
skills in these techniques to make the situation comfortable between her
and the person in crisis. Most of these seem familiar and are being used in
our routine transactions. However, trying to exert effort deliberately and
knowing the situations uniqueness can make so much difference. Please
go over the technique listed in Table 11.5. I’m sure you have used them at
times, you just didn’t know what they were called.
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Module 11 329
Table 11.5. Techniques of crisis intervention
Technique Definition Example
Abreaction The release of feelings that “Tell me about how you have
takes place as the patient been feeling since you lost
talks about emotionally your job.”
charged situations.
Clarification Encouraging the patient to “I’ve noticed that after you

express more clearly the have an argument with your
relationship between cer- husband you become sick
tain events in his/her life adn can’t leave your bed.”
Suggestion Influencing an individual so “Many people have found it

that he accepts an idea or helpful to talk about this and
belief, particularly the belief I think you will too.”
that the nurse can help and
that he will feel better
Manipulation Using the patient’s “You seem to be very com-

emotions, wishes, or values mitted to your marriage and
to his benefit in the I’m thinking that you will
therapeutic process work through these issues
and have a stronger relation-
ship in the end.”
Reinforcement Giving the patient positive “That’s the first time you
of behavior responses to adaptive were able to defend yourself
behavior with your boss and it went
very well. I’m so pleased
that you were able to do it.”
Support of Encouraging the use of “Going for a bicycle ride

defenses healthy, adaptive defenses when you were so angry was
and discouraging those very helpful, since when you
that are unhealthy or returned, you and your wife
maladaptive were able to talk things
through.”
Raising Helping the patient to “You are a very strong person

self-esteem regain feelings of self- to be able to manage the
worth family all this time. I think
you will be able to handle
this situation, too.”
Exploration of Examining alternative “You seem to know many

solutions ways of solving the imme- people in the computer field.
diate problem Maybe you can contact some
of them to see if they might
know of available jobs.”
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Activity 11-4
Which among the techniques mentioned are you familiar with?
Regardless of how you call them, I’m sure with the definitions and
examples, you realized that you have used them even in ordinary
situations.
Please think of your own examples. Cite at least two for every
technique.
Did you have difficulty thinking of examples? If not, congratulations! I’m

sure with more practice, you’ll be skilled in it. Which among the tech-
niques are easy for you to do? Go back to those difficult ones for review
purposes.
Sometimes, the most difficult aspect of intervening is starting off. This

portion will help you feel directed and systematic in deriving needed in-
formation. Good assessment makes crisis intervention successful. The five
areas of assessment include the following:
1. Physical
Most clients generally manifest physical problems of depression and

anxiety. The individual in crisis may be unable to sleep, or sleep with
frequent awakening or early morning awakening. He or she may have
poor appetite which may lead to weight loss. A direct result of all the
above disturbances may be changes in body image. He may be debili-
tated, with low energy and general physical deterioration. A client
may express his anxiety through physical symptoms such as unusual
behavior or hyperventilation.
2. Emotional
Emotionally, the client has varying reactions and thus requires careful
assessment. He may feel out of control. Crisis creates disequilibrium
and anxiety. Depression is another emotional state experienced dur-
ing crisis. The intervener should know whether the client has engaged
in self-destructive acts. The person in crisis often feels hopeless be-
cause of his inability to resolve the crisis and the belief that no one can
help.
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3. Intellectual component
It is a must that we elicit the individual’s perception of the crisis event.

His perception may be realistic or distorted. According to Caplan (1961),
the opportunity for distortion increases as the client waits for his re-
quest for assistance to be met. The less distorted the perception of the
crisis event, the more likely the problem can be solved. The individual’s
level of motivation to participate is assessed in terms of the willingness
to help himself.
4. Social dimension
The person in crisis has to be assessed in relation to his interrelation-

ship with family, friends and co-workers. They are important when
making plans to prevent or minimize recurrence of the problem. The
accessibility and reliability of social support is essential. The composi-
tion of social support is not as crucial as its accessibility.
5. Spiritual dimension
The role of religion in the client’s life is important. The client in crisis
may think that his life is meaningless because he is unable to resolve
the crisis. Because of his feelings of helplessness and hopelessness,
he may think God or his spiritual leader has forsaken him. The
disorganizaton, with loss of control in response to the impact of the
crisis, may further increase his doubt about his self-worth.
The following questions may be asked to elicit explanations on the five

dimensions of a client in crisis:
Physical Dimension
How is your appetite?
When did you first notice a change in your appetite?
What is your sleeping pattern?
How long have you had restless nights?
How much weight have you lost?
Intellectual Dimension
What does the crisis event mean to you?
In what way is the crisis event going to affect your future?
What do you usually do when you are upset?Anxious?Depressed?
How did you try to cope with this crisis situation?
If you used your usual method, what are your thoughts about why it
didn’t work?
What do you think would help you feel better now?
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Emotional Dimension
What changes have recently taken place in your life?
Loss of a significant other?
Loss of a job?
Job promotion?
Illness?
Accident?
How do you feel about having to seek help?
How do you feel about your life situation?
Scared?
Anxious?
Depressed?
Overwhelmed?
Fearful you might hurt yourself or someone else?
Social Dimension
With whom do you live?
Where does your closest friend live?
How often do you see your best friend?
Whom do you trust?
Who is your closest friend in your family?
How long have you lived in your present neighborhood?
How do you feel about yourself?
Spiritual Dimension
What is your religion?
What kind of religious activities do you participate in when you are
upset?
How often do you talk with your clergyman?
How has life treated you?
What are your purposes in life?
You now know the basic fundamentals of intervening during crises. Let
me now try to project the whole picture. The recommended steps in crisis
intervention outlined below should make the concept clearer. Definitely,
skills related to these actions will make much difference in actual prac-
tice.
Steps in Crisis Intervention
1. Begin with comfort strategies.

2. Work first with feelings; then you will be able to get the facts.
3. Help the person confront the crisis by talking about current feelings.
4. Encourage the person to talk about the losses and the changes in-
volved.
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Module 11 333
5. Clarify the person’s perception of current difficulties.

6. Explain to the person the relationship between the crisis situation
and present behaviors and feelings.
7. Recognize denial as a normal reaction during defensive retreat from
the crisis.
8. Help the person find facts.
9. Give the person time to experience the feelings and to freely express
them.
10. Avoid giving false reassurances.
11. Help the person to confront the crisis at a manageable level.
12. Do not encourage the person to blame or shove responsibility on oth-
ers for the crisis events.
13. Encourage the person to do what he can for himself.
14. Strengthen/reinforce previously learned behavior patterns that can
be effective but were not used.
15. Involve the client in decision making and working on specific tasks.
16. Reinforce useful suggestions.
17. Help the person establish social relationships and effective personal
behaviors.
18. Assist the person in seeking and accepting help.
19. Be familiar with community resources to which the person or family
can be referred for additional services.
May I remind you that the steps are not strictly sequenced as such. It
depends on your versatility as an intervener.
Settings for Crisis Intervention

Crisis intervention can be done in a variety of settings. As a nurse, you
have many opportunities to perform crisis intervention in formal settings
like emergency rooms, crisis centers, community crisis units and the gen-
eral medical hospital setting. In some instances, the nurse refers a client to
a crisis team in the emergency room after she does a cursory assessment
and establishes that the client may be in crisis. Telephone hotlines are
semi-formal approaches to crisis intervention. Generally, trained non-pro-
fessional volunteers operate telephone services in consultation with mem-
bers of a professional mental health staff.
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Activity 11-5
Can you identify specific examples in your work setting/situation
that will necessitate crisis intervention? What are they?

I hope you were able to describe some crisis situations. Do you
think you will be able to intervene in these situations or will you
have to refer to other professionals? Will it necessitate a generic or
individual approach? Remember, crises happen in all areas of nurs-
ing practice.
Here are some common nursing settings for crisis intervention:
1. The psychiatric setting

Examples:
A crisis unit
An observation unit
With suicidal/homicidal clients
With clients who have just gained some difficult emotional
insight
With staff who meet with a psychiatric nurse to discuss
staff burnout as a result of working in a crisis environ-
ment
2. The medical setting

Examples:
The emergency unit
Medical/surgical units where clients are informed of diag-
noses or prognoses
Medical/surgical units where clients experience side-effects
of drugs or the worsening of a condition
With staff who meet with a psychiatric liaison nurse to dis-
cuss staff burnout as a result of working in a crisis envi-
ronment
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Module 11 335
Comments on Activity 11-5 continued
3. Labor and delivery

Examples:
With the pregnant woman who is afraid of delivery
With the mother and father following the delivery of a child
with a birth defect
4. The Community
Examples:
The psychiatric nurse doing home care or working in a com-
munity mental health center
The community health nurse who also visits clients in the
home, although not for identified psychiatric problems
of clients
Community disaster teams
The nurse serving as liaison to the police department
The nurse serving as co-worker/trainer of crisis hotline staff
Nursing Care Plan in Crisis Intervention

Nursing is a unique profession. It is important to integrate these crisis
intervention strategies in the making of a nursing care plan. I think you
should be feeling more comfortable about these concepts now. The nurs-
ing care plan consists of the diagnosis, goals (long- and short-term), out-
come criteria, interventions and rationale. In the nursing care plan I will
be providing, please focus on the interrelationship between diagnosis and
interventions. I hope that you will recognize how these concepts are re-
lated to the crisis intervention strategies we have just discussed.
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336
Table 11.6. Nursing diagnosis: Alteration in role performance related to ineffective social adjustment after divorce
Goals Outcome Criteria Interventions Rationale

Long Term
To develop plans for a Establishes other forms of life Encourage to participate in Involvement in such activities
satisfying life after satisfaction activities of interest such as contribute to resolving feelings
marital separation. sports, social organizations related to loss
Uses existing support Encourage to maintain contact Social support (relatives and
system with relatives and friends friends) can help client feel
he is not alone
Develops new relationships Assist in identifying approaches Knowledge of ways to meet

to meeting people people may hasten integra-
tion of new people into his life
Short Term
To deal with feelings Verbalizes feelings about the Provide a safe environment Client needs to feel he will
that accompany the separation in which to express feelings not be rejected or lose
separation: anger, control if he expresses
grief, guilt feelings
Accepts realistic responsibility Provide opportunity for Realistic appraisal of blame

for the separation without realistic evaluation of feelings may enhance self-esteem
feelings of self-blame of self-blame and resolution of feelings
related to the separation
Module 11 337
Activity 11-6
Go back to Activity 11-2 about balancing factors in crises. Remem-
ber I cited five examples there. Pick one and develop a nursing
care plan on for that situation. Present your answer in a format
similar to our example in the previous page about helping a client
adjust after a divorce.
To develop your skills as crisis intervener, try making nursing care

plans for all the five example situations.
At this point in time, maybe you could now summarize the overall work-
ing concepts and principles of crisis theory and interventions as high-
lights of our discussions. Crises are crucial points in our lives that can be
seen both positively and negatively. An event becomes a crisis when it
blocks our life goals. It can make or break and individual. Most often, a
crises occur as part of our development but there are those which come
our way by accident. However, a crisis can be predicted in some ways
since it undergoes phases. People can learn new coping skills, either from
a professional or non-professional intervener. A successful intervener must
have courage, calmness, empathy and non-judgmental attitudes, among
others. The goal of intervention is the resolution of an immediate crisis
through the problem-solving approach focusing on the immediate prob-
lem of the client. A major concern is the social structure of the individual
rather than personality dynamics; the attention is on the here and now.
The client’s perception of the event, his previous coping and presence of
support system determine whether a situation will be a crisis or not.
Major Concepts and Principles of Crisis Theory and Intervention
1. Crisis is a turning point. It is both a danger and an opportunity. It is a

threat to homeostasis resulting in imbalance and disorganization. It
ensues when there is overwhelming threat and inability to cope.
2. There are two general types of crises. Maturational or developmen-

tal crises which are associated with life developmental stages and situ-
ational or accidental crises which are unexpected.
3. People are in a state of crisis when they face an obstacle to important

life goals, an obstacle that is for the time being, insurmountable using
customary methods of problem solving. The crisis period usually lasts
one to six weeks, after which more sophisticated intervention is needed.
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4. Crisis does not develop automatically nor does it develop quickly. There
are identifiable phases of development that lead to an active state of
crisis.
5. The balancing factors to be considered in determining an individual

in crisis are perception of the event, available support system, and
previous coping mechanisms used.
6. People in crisis are more open to learning new coping skills. They are
open to receiving professional help and learning new problem solving
techniques. They are easily amenable to suggestions and influences.
7. The focus of crisis intervention is on the here and now rather than on
the individual’s past. It emphasizes the healthy aspect of the person-
ality, not pathology. The individual is evaluated in terms of his ability
to cope, his strengths and potentials and his ability to solve problems.
The major concern is the social structure of the individual rather than
personality dynamics.
8. The goal of crisis intervention is the resolution of the immediate crisis.

Its focus is on current concerns. The therapist’s role is direct, sup-
pressive and that of an active participant. It is short term and no
attempt is made to produce drastic behavioral changes. It is a think-
ing, directive, problem-solving approach that focuses on the immedi-
ate problem of the client.
9. The resolution of crisis and the personality of crisis workers interre-

late. Any crisis intervener needs a colleague/supervisor with whom
he can discuss feelings and receive support and encouragement. In-
terveners should possess courage because pain involved in crisis is
never pleasant. He should also develop calmness and empathy to
think clearly for problem resolution. A non-judgmental attitude is also
essential. He should be cognizant of cultural values and should never
impose a different lifestyle or value system on the client.
I deliberately presented these concepts and principles at the end because

I want you to derive them from the previous discussion. It would be easier
to appreciate them at this time since you have been given the basic infor-
mation on crisis theory and intervention.
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Module 11 339
SAQ 11-5
Multiple choice. Encircle the right answer.
1. People in crisis are characterized by:

a. helplessness
b. being receptive to new learning
c. suggestibility
d. all of the above
2. Crisis can be considered:

a. as a danger
b. as an opportunity
c. a growth promoting behavior
d. all of the above
3. Balancing factors to be considered in crisis:

a. perception of the event
b. support system
c. previous coping mechanism
d. all of the above
4. Role of intervener in crises:

a. direct
b. active
c. suppressive
d. all of the above
5. Goal of crisis intervention is:

a. the resolution of immediate problem
b. the change of personality structure
c. the development of insight about the problem
d. all of the above
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SAQ 11-5 continued
6. Focus of crisis intervention:

a. here and now
b. need to explain briefly current concerns
c. present problem
d. all of the above
7. Crisis happens when:

a. life goal is blocked
b. usual coping does not work
c. support system is not available
d. all of the above
8. A crisis period usually lasts:

a. indefinite
b. 1 to 4 weeks
c. 1 to 6 weeks
d. 2 to 5 weeks
9. Indication for use of crisis intervention:

a. Neurotic personality patterns
b. Acutely disruptive emotional pain and circumstances
c. Sudden loss of ability to cope with situation
d. Maladaptive behavior patterns
10. Emphasis of crisis intervention:

a. healthy aspect of personality
b. pathological pattern of behavior
c. dependent state of decision making
d. degree of helplessness and suggestibility
Communication During Crisis

It is important to develop skills in talking to individuals in crisis. Take a
look at the example below.
Therapeutic dialogue with the client in crisis:
Nurse: (walks into client’s room, notices that Mr. T. is staring out the win-
dow with a sad expression on his face) Mr. T., you look sad. Is there
something upsetting you?
Client: Oh, you don’t have time to listen to me.
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Module 11 341
Nurse: Mr. T., I have 15 minutes now and I’ll have more later. Let’s go for a
walk and talk.
Client: (puts on his robe and continues to look at the floor as he walks down
the hall)
Nurse: I want you to know that I’m available to listen to whatever is troubling
you. So, just take a deep breath and get it off your chest.
Client: Well, you know I’m here because my ulcer is acting up, but what is
really bothering me is that I was fired from my job two weeks ago.
Nurse: Well, what are your feelings about that now?
Client: It’s strange, its like my life changed overnight. I’ve been working for
this company for 10 years. I’m just stunned. I feel I’m a failure. Maybe
I am a loser. Who is going to want to hire a failure? Until two weeks
ago, I felt confident, I enjoyed socializing with people I work with.
Now, I feel like they are avoiding me.
Nurse: Do you want to see the people you work with right now?
Client: Well, yes and no. I don’t know what to say to them.
Nurse: If you could get support from anyone right now, who would you want
to get it from?
Client: I’m not sure.
Nurse: Whom do you trust?
Client: My father, but I’m so ashamed. I don’t want to tell him.
Nurse: Let’s examine your feelings of being ashamed. Mr. T., have you ever
been fired before?
Client: No, never! Work has always been important to me.
Nurse: Tell me about the jobs you have had.
Client: I have worked for 25 years for 3 different companies. In this last one,
I moved up to a mid-management position.
Nurse: Well, it sounds to me like you have had a lot of success in your
career. You have worked for 25 years, right? That’s a lot of years and
you were never been fired before now. Mr. T., that doesn’t sound like
a work failure to me.
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Client: Well, my company has been having problems for a while. I just didn’t
think it would be me that they would let go. I thought Mr. J., my
supervisor, appreciated what I have done in my department.
Nurse: How did you receive notice that you were let go?
Client: I received a letter.
Nurse: It never ceases to amaze me how poorly administrators deal with

people.
Client: Yes, I always respected Mr. J. I expected more from him than that.
Nurse: Mr. T., after you are feeling better maybe you will want to go in and
talk with Mr. J. about what actually happened. But right now, let’s
talk about your father. The news is full of companies in trouble and
people losing their jobs. Don’t you think your father will be hurt if you
don’t tell him?
Client: Yes, he probably would be.
Nurse: How about giving him a call right now.
Client: Well, I guess I might as well get it over with. I’ll call him at the office.
Nurse: Good. I’ll be back to talk to you in about an hour.
In this interview, note the distorted perception of the stressful event. Be-
cause Mr. T. was fired from his job, he felt that he was a failure. In reality,
he had worked for 25 years without ever having been fired. The nurse
tried to encourage Mr. T. to view the situation in more realistic terms and
mobilize the social support of his father.
Activity 11-7
Think of your current work situation. Have you had an experi-
ence similar to the example I gave you? How did you work it out?
Did you feel comfortable? With this illustration, do you think you’ll
be able to handle it better next time?
What qualities did the nurse in this dialogue possess that made
her techniques workable? Can you identify those techniques?
There is always the first time for everything and practice makes
things better. As you practice, remember the information you have
learned from this module. Keep trying.
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Module 11 343
Summary
Nurses have gained experience in dealing with a variety of crises that
occur as a “normal” part of their work. They are expected to cope effec-
tively with crisis situations as well as help clients solve daily living pres-
sures affecting their physical and emotional health. Problem solving by
nurses is the basis for their nursing judgment and nursing interventions.
Additional information/knowledge on the fundamentals of crisis theory,

concepts, principles and interventions make the approaches more relevant
and potentially successful. The more expert the nurse becomes in her work,
the more likely she is to anticipate problem areas. Before crisis levels are
reached, she initiates planned intervention. Clinical experiences of nurses
result in considerable familiarity in dealing with a wide variety of emer-
gencies and crises. It is inevitable that these are not all planned experi-
ences but often require a high degree of creative problem solving skills.
The nurse is confronted with unexpected problems and must often
depend upon her own resources to find solutions. Theoretical knowledge
on conceptual problem solving is a must for all nurses.
More than this, the opportunity of assisting individuals in crisis to become

better people with stronger coping, mechanisms can be doubly satisfying.
Irrespective of academic preparation, all individuals who perform crisis
intervention need to have knowledge and understanding of human
behavior. More important, the precarious nature of crisis intervention
requires all persons working with clients in crises to possess certain per-
sonal characteristics. The nurse needs to be confident of her ability to help
make the client feel secure. Willingness to assume responsibility for the
unable client is essential. She must be able to think quickly and achieve
goals with little preparation time.
Crisis intervention is an actual entering into the life situation of a person,

family or group who is experiencing a crisis. This aims to decrease the
impact of the crisis event and assist the individual to mobilize his resources
and regain equilibrium.
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ASAQ 11-1
1906 1. Crisis intervention became a modality in its own right.
1950 2. Crisis intervention paralleled short-term psychotherapy.
1950-1960 3. Provision of emergency services in community facilities.
1950-1960 4. Recognition of support system to prevent crisis.
Mid 1960’s 5. Nurses’ prioritized crisis intervention in preventing psy-
chiatric problems.
1970’s 6. First recorded event of crisis intervention among pa-
tients with paralysis of the arm.
1990’s 7. Development of treatment models for crisis involving
marital and family conflicts and suicidal prevention.
Did you get them all correct? Good, you must have a good memory. But
remember you are just starting. Keep it up!
ASAQ 11-2
1. These are the people who significantly contributed to our understanding
of crisis theory and crisis intervention.
Overall theories influencing crisis theory:
a. Freud’s psychoanalytical theory

b. Rado’s adaptational psychodynamics
c. Erikson’s epigenetic development
Crisis theory and intervention:
a. Lindemann’s bereavement reactions

b. Caplan’s basic types of crises (developmental and situational)
Other contributions:
a. Aguilera and Measuk’s balancing factors in crisis

b. Parad and Leanick’s crisis sequence
c. Jacobson, Stricker and Morley’s approaches in crisis intervention
d. Baldwin’s types of emotional crises
e. Hendrick’s crisis prone individuals
f. Dewey, Merrifield and Guilford’s stages of crisis
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Module 11 345
2. Lindemann’s contribution — According to her, life experiences and

situations that generate emotional strain can be stressful and thus a
series of adaptive mechanisms occur leading to mastery of new situa-
tions or to failure with more or less lasting impairment to function.
Caplan’s contribution — assessment of crisis situation is based on the

following:
a. capacity of the person to withstand stress and anxiety and main-

tain equilibrium.
b. degree of reality recognized and faced in problem solving
c. stock of coping mechanisms used to maintain balance.
He defined crisis as a rise in inner tension, signs of anxiety and disor-

ganization of function resulting in emotional upset.
The first few questions I’m sure were answered perfectly. You just have to
recall and categorize them. The last question focused on the two major
crisis theorists (Lindemann and Caplan). I hope you master their contri-
butions. We cannot talk of crisis and intervention without going back to
Lindemann’s and Caplan’s concepts.
ASAQ 11-3
Developmental crisis or Maturational Situational crisis or Accidental crisis

crisis or Growth crisis
Examples: Examples:
Adolescence, aging process, failure of expectations, frustrations,
mid-life crisis or menopausal crisis incurable illness, separation
Main difference:
Developmental or maturational type — you cannot escape from it; it is a

normal aspect of growth and development of any individual.
Situational or accidental type — may or may not be experienced by the

individual. It may arise from transitions wherein one may not be in con-
trol of a situation due to external unexpected stressors.
For more specific types, Baldwin suggested different categories. Refer to

his table of types of emotional crises.
UP Open University
I can feel you answered this portion perfectly—am I right? Congratula-

tions! In which of the two types would you find it more comfortable to
intervene? You should be able to do well in both.
ASAQ 11-4
False 1. Knowing the four stages will help one understand how crisis
occurs, but each stage is a crisis situation by itself. A crisis be-
comes more complicated if there’s no resolution at an earlier
phase.
False 2. In actuality, it is in the third stage that he seeks outside assis-
tance/support, but one does not have to wait for that to be
able to give the necessary help.
True 3. Crisis can either make or break an individual. If intervention
comes too late, it’s either she becomes maladaptive or she may
have committed suicide. Remember, you may have only short
periods of time to save your client from the adverse effects of
the crisis.
True 4. Knowledge of the stages/phases helps one to intervene actively,
appropriately and successfully
True 5. Since it’s the overall feeling, you immediately have to reduce it
to make one accessible for further intervention.
How many correct answers did you get? Fine if you got them all correct.
If not you may need some review for reinforcement. Go back to the dis-
cussion portion of the above questions.
ASAQ 11-5
You should be able to get eight out of ten items correctly without looking
at the earlier pages for answers.
1. The answer is d (all) — People in crisis are unable to make decisions,

they feel helpless and thus become amenable to influence—they should
be helped to approach healthy people so they grow and become open
for better learning.
2. The answer is d (all) — Depending on the individual, the situation of

crisis can make or break a person. If one copes successfully, one be-
comes a stronger/better individual.
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Module 11 347
3. The answer is d (all) — Messick and Aguilera said that the three most
important balancing factors are perception of event, support system
and previous coping mechanism. These factors all have to be positive
and present to avoid crises.
4. The answer is d (all) — The therapist’s role is direct, suppressive and

that of an active participant. Techniques are varied and limited only
by the flexibility and creativity of the intervener.
5. The answer is a (resolution of immediate crisis) — Crisis intervention

differs from psychotherapy and psychodynamics. Crisis interven-
tion focuses merely on the restoration of the patient’s previous level
of functioning.
6. The answer is d (all) — The focus should be directed at the current/

present situation. There is no need to go into the past of the indi-
vidual. It concerns the here and now aspect of the individual.
7. The answer is d (all) — The situation becomes a crisis when you’re

not able to push on with your life goals nor cope using previous mecha-
nisms. In this situation you need help/assistance.
8. The answer is c (1 to 6) — Crisis intervention is time limited. There is

a crucial period for intervention. It requires a short treatment of 1 to
6 sessions compared to lengthy intervention in psychotherapy and
psychodynamics.
9. The answer is c (sudden loss of ability to cope with situation) — The

chief indication for using crisis interventions is sudden inability to
cope. The feeling of helplessness in terms of coping is present; how-
ever, crisis intervention is still preventive in nature.
10. The answer is a (healthy aspect of personality) — Even in crisis, we

are still able to relate with normal, healthy individuals. We wish to
reinforce the positive aspect to strengthen coping. We don’t want to
be too late.
How many correct answers did you get? I hope you were able to think
through each question and did not have to guess! If you did not get all the
answers you can go back to the text and review the difficult areas.
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References
Aguillera, D.C. and Messick, J.M. (1982). Intervention-theory and method-
ology. Missouri: C.V. Mosby Co.
Baldwin, B.A. (1987). A paradigm for the classification of emotional cri-
ses: Implications for crisis intervention. American Journal of Orthopsy-
chiatry, 48(3), 538.
Bandura, A., Adams, N. and Beyer, J. (1977). Cognitive processes mediat-
ing behavioral change. J Pers Soc Psychology, 35, 125.
Burgess A.W. and Baldwin, B.A. (1981). Crisis intervention: theory and prac-
tice. Englewoods Cliffs, New Jersey: Prentice Hall, Inc.
Caplan, G. (1964). Principles of preventive psychiatry. New York: Basic Books.
Chandler, S.C. (1989). Crisis theory and intervention. Psychiatric mental health
nursing adaptation and growth. 2nd Edition. J.B. Lippincott Co.
Gilliland, B.E. and James, R.L. (1993). Crisis intervention strategies. Belmont,
California: Brooks/Cole Publishing, Co.
Hendricks, J. Crisis intervention: Contemporary issues on site interveners.
Springfield, Illinois: Charles C. Thomas.
Janosik, E. and Davis, J. (1989). Psychiatric mental health nursing. Jones
and Barlett Publishers.
Kennedy, E. (1989). Crisis counseling-essential guide for non-professional coun-
selors. New York: Gill and Macmillan Ltd. Continuing Publishing Cor-
poration.
King, Joan. (1971). The initial interview: Basis for assessment in crisis inter-
vention, 10 (6), 247-256.
Maloney, E. (1971). The subjective and objective definition of crises. Pers-
pective of Psychiatric Care, 9 (6), 257-267.
Pasquali, E.A. (1981). Mental health nursing: A bio-psychocultural. USA:
C.V. Mosby Co.
Stuart, Gail. (1991). Principles and practice of psychiatric nursing. USA: Mosby
Year Book.
Varcaroses, E.M. (1990). Crisis intervention. Foundations of psychiatric mental
health Nursing. USA: W.B. Saunders Company.
Williams, S. Crisis intervention. Psychiatric Nursing.
Williams, Florence. (1971). Maturational crises. Perspective in Psychiatry,
IX (6), 241-245.
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Module 12 349
Module 12
Gender Concepts and
Issues in Health
Cora A. Añonuevo
D oes one’s gender influence his/her caregiving

abilities? Are female nurses more sensitive
to women’s health needs than male nurses?
Objectives
This module will dwell on a very interesting and At the end of this module,
familiar topic—gender— its socialization process you should be able to:
and the specific issues this socialization raises for
female and male nurses. Unlike the previous mod- 1. Define gender and
ules which outlined theories or models, this mod- gender socialization;
ule will be quite different because it will present 2. Explain the development
concepts and issues relevant to the subject mat- of gender self-concept;
ter of gender. I hope you will gain insights into 3. Describe the impact of
the impact of gender socialization of nurses, the gender socialization on
way they think, act and perform their duties. Fur- women in general and
thermore, understanding the role of gender as a nurses in particular; and
major predictor of health can enhance one’s sen- 4. Discuss strategies to
sitivity to people’s health needs. reduce gender inequali-
ties in health.
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Gender vs. Sex

Does the term “gender” have the same meaning as sex? What do we
mean by gender socialization? Before I proceed with my discussion, let us
first level off with our understanding of these words.
Gender is the social, economic and political relationships and differences

between women and men and the way they are socially constructed. The
environment or the social milieu therefore, exerts a major influence in the
development of gender.
Sex on the other hand, is the biological attribute that differentiates men
and women. These biological attributes are:
physical — the sexual organ that distinguishes a male from a female

reproductive capability — e.g., a woman is capable of going through
pregnancy and childbearing
chromosomal — females bear the X chromosome; males, the Y chromo-
some
hormonal — female ovaries produce the estrogen hormone; male testes
produce testosterone
Gender socialization is the term used to describe the process by which

men and women learn and acquire their roles and responsibilities, quali-
ties and behavior. By virtue of their being male or female, each one
behaves according to the culture of the society which sets the norms or
expectations concerning how they should think, act and perform. These
gender norms are powerful mechanisms that control human behavior
(Strasen, 1992).
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Module 12 351
SAQ 12-1
Write down in the appropriate boxes what you think or believe
are the roles/responsibilities and qualities/behaviors expected of
women and a men in our society.
Gender Roles/Responsibilities Qualities/Behaviors
Women
Men
Development of a Gender Self-Concept

A child learns self-concept by interacting with the environment, family
and peer group. The earliest form of self-concept learned is that of being
male or female. Strasen (1992) cited social psychologist George H. Mead
who argued that the development of self-concept is a cognitive process
learned by children when playing the role of their same-sex significant
others. Play is considered a significant part of gender socialization that
teaches children how to relate to their environment. The most crucial pe-
riod in the formation of gender identity is said to be from age three to six
years. During this period, boys tend to receive more negative reinforce-
ment for gender-inappropriate behavior from parents than girls do. Boys
also receive more pressure, praise, encouragement and punishment to
accomplish specific goals.
UP Open University
Traditional gender socialization has taught boys to be independent, ac-

tive and aggressive and girls to be dependent, verbal and social. Girls
traditionally have been taught to have low aspirations because histori-
cally, there were few roles and opportunities for them other than those of
wife and mother (Strasen, 1992).
Sociologists describe sex-role socialization as “instrumental” for men and

“expressive” for women. The characteristics of instrumental socialization
include the ability to compete, aggressiveness, the ability to lead, wield
power and accomplish tasks. Expressive socialization includes learning
to nurture, to be affiliative and to be sensitive to the needs of others
(Strasen, 1992). In learning gender self-concept, individuals develop be-
liefs about themselves, the roles expected of them, and their relationship
to others.
Activity 12-1
Take a few minutes to analyze the statements above. Do you think
that the gender socialization process of Filipino men and women
is also generally traditional as described? Write down what you
know from experience or from direct observation.

It is still true today that majority of Filipino women and men are
socialized in the traditional manner. Filipino women are encour-
aged to be “mahinhin” like Maria Clara. They are prepared to be
good homemakers, wives and mothers. They are expected to pur-
sue careers in the helping or nurturing roles such as being a nurse,
teacher or nutritionist. Filipino men generally have been social-
ized to be “macho” or strong, to act as principal breadwinners.
They are expected to become doctors, lawyers or engineers.
Of course, there are some men and women who do not restrict
themselves anymore to the traditional male- or female-defined
behaviors and roles. There are women who question their subor-
dinate role in society and believe that gender socialization should
be fair and just to both sexes. They point out that socialization
should be a process by which men and women can be at par with
each other in the social, economic and political fields.
I’m sure you are getting more interested in our discussion. Now let’s look
into the profession of nursing.
UP Open University
Module 12 353
Gender Socialization and

the Nursing Profession
Historically, nursing arose as a profession of and for women. Its tradition
was heavily influenced by a philosophy of benevolence and altruistic val-
ues, Christian morality and military authoritarianism. Its founders were
women with an exceptional gift for social reform. They took on, as their
mission, the improvement of public sanitary conditions and home health
care for the poor who were flooding newly industrialized urban centers.
Many of their efforts were directed specifically at the welfare of women
and children (Shea, 1990).
Condon (1992) cites Abel and Nelson who stated that caring is still a
practice associated almost exclusively with women. This is the result of
social division of domestic labor where women care not only for children
but for disabled friends and relatives.
Recently, however, our culture’s typical belief that caring and nurturing
activities are exclusive to women has been challenged. More and more
men are now entering the profession (Halloran, 1990). Consequently,
questions are raised about the role of nurses and how men can fulfill it.
The extent to which men and women differ in their enactment of the
caregiving role remains of high interest for researchers.
Gilloran (1995), for example, made a study in the realm of caregiving

where the impact of gender differences was examined. According to him,
gender makes a difference largely due to the culturally learned gender-
differentiated behaviors which people bring with them into the wards.
Majority of his female respondents believed that women had the edge
when it came to basic nursing care. Female nursing staff saw themselves
as more organized, more tidy and save more attention to detail. The com-
mon view was that these traits distinguished them and meant that they
were better carers than their male colleagues. Male nurses, on the other
hand, viewed themselves as more confident in the managerial tasks and
in making decisions in the wards. They perceived the female staff as less
able to make decisions and more dependent on their feelings. Contrary to
this, female nurses classified male nurses as slow to come forward when
hard or unpleasant work is has to be done.
According to Flanelly (1984), the conflict for the nurse, male or female, is
how to strike a balance between those caring traits often considered to be
intrinsically female and the skills and leadership abilities usually thought
of as characteristically male. Since these are learned abilities as supported
by many psychologists and sociologists, the nurse must be able to acquire
and exhibit both masculine and feminine characteristics. Strassen (1992)
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supported this view by saying that the professional nursing role requires
humanistic and emotive feminine qualities combined with a scientific and
rational masculine approach. Flanelly (1984) further stated that while
this demand may be a new challenge for men who enter the nursing pro-
fession, it is the identical demand that has been made on women throughout
the one hundred and more years of nursing.
Ask yourself whether you are aware of gender differences in providing

nursing care to clients. That is, of course, if you work with opposite sex
nurses in your work setting. Just reflect.
It is important therefore that as nurses, we should be conscious of our

gender socialization and how this is expressed in our dealings with our
clients and our demonstration of nursing care.
Gender: A Major Predictor of Health

Let’s move on and this time, we’ll focus our discussion on our clients. An
issue or question often raised is whether gender is a major predictor of
health. Several aspects of health have been found to bear differently upon
females as compared to males. This is because sex-roles or gender role
definitions and expectations lead to gender inequalities in health (Okojie,
1994).
The ideological foundation for gender inequality in many Third World

countries is patriarchy. Patriarchy has been defined as a “set of social
relations with a material base that enables men to dominate women.”
Patriarchy conditions women’s public and private behaviors vis-à-vis men
in the community and the household. It is reinforced by various institu-
tions—economic, political, social, legal and religious—all of which
emphasize women’s inferior position in the society. These have implica-
tions for women’s health status and health behaviors in the event of ill-
ness (Okojie, 1994).
While many of women’s health problems are similar to men’s, they are
harder to identify because symptoms are less obvious in women. Also,
because of reduced access to education, women are often poorly informed
about their health with the result that they fail to recognize early symp-
toms of infection and disease. In addition, women tend to suffer in silence
and do not come for treatment because the threshold of illness recognized
by the society on the illness-health continuum is so high for women that
they endure so much in order not to disrupt household organization
(Okojie, 1994).
UP Open University
Module 12 355
What are the health problems of women and girls in Third World coun-
tries like the Philippines?
Women’s health problems include those which affect their physical,

social and mental well-being as well as those which lead to female mor-
tality, especially maternal mortality. They experience these problems at
particular points of their life cycle. Consider the following health statistics
in the Philippines (Health Alert, 1993):
1. Infancy and childhood (0-9 years): The incidence of all forms of mal-
nutrition is much higher for females than males. The discrepancy may
include subtle forms of discrimination that favor sons in the family’s
allocation of food.
2. Puberty and adolescence (10-19 years): Females aged 13 and above

had much higher rates of anemia than males (National Nutrition Sur-
vey, 1995). Anemia goes as high as 43.62% among pregnant women
and 43% among lactating mothers. Iodine deficiency rates are as high
as 27.4% among pregnant women.
3. Adulthood (20-39 years): Pregnancy-related deaths remain among the

top 10 causes of maternal deaths. Hypertension, hemorrhage and in-
fections are preventable given adequate and prompt prenatal inter-
ventions.
4. Mid-Life (40-59 years): Cancers, particularly of the breast and cervix,

are now a leading cause of death, although these can be controlled by
early detection methods.
5. Elderly (60 years and above): Osteoporosis is a major problem for older
women because of the loss of estrogen production after menopause.
Rheumatism and arthritis are attributed to “binat,” or relapse, result-
ing from pregnancies many years back.
Compounding these health problems experienced by women is the lack

of access to health care including lack of access to information and health
facilities. Available data from the Department of Health showed that in
1987, only 65% of eligible women received prenatal services and 47%
received delivery care by trained health practitioners. Many obstetric wards
in government hospitals have two to three patients sharing one bed by
rotation.
Another major factor significantly contributing to women’s poor health is

the lack of gender sensitivity in the provision of health services. It has
been recognized that women are treated in an inferior way by health
UP Open University
professionals and therefore are hesitant to seek treatment (Vlasoff, 1994).

It has also been reported that patient/client communication and inter-
personal relations have been biased against women. Female patients are
treated rudely by health professionals and are blamed for coming late for
treatment. Women’s tendency to notice symptoms and seek help early is
often viewed by health professionals not as good preventive care but as
evidence of hypochondriasis (Robinson, 1994).
EQUALITY?
Γ Ε
Before I proceed, try this SAQ.
SAQ 12-2
1. Do you agree that female clients are treated inferiorly by health
professionals when they come for consultation and treatment?
If so, can you cite instances that relate to this statement?
2. What are the manifestations of gender inequalities in health?
Compare your responses with mine by referring to ASAQ 12-2 at the end
of this module.
UP Open University
Module 12 357
Strategies to Reduce Gender

Inequalities in Health
Given women’s disadvantaged position in society, reducing gender in-
equalities require measures and/or policies to reduce discrimination against
women which are woven into the political, cultural, economic and reli-
gious fabric of the society (Okojie, 1994). The 1979 International Conven-
tion on the Elimination of All Forms of Discrimination Against Women,
which was ratified by the Philippine Government, provides that coun-
tries “pursue by all appropriate means and without delay a policy of eliminat-
ing discrimination against women and in particular, to eliminate discrimina-
tion against women in the fields of health care in order to ensure access to health
care services, including those relating to family planning.”
What is being emphasized therefore is that to reduce inequalities in health,

actions on the macro level should be done. These should aim to: (1) im-
prove the status of women in society; (2) increase their autonomy in deci-
sion-making; and (3) improve availability of health services and quality of
care.
Robinson (1994) suggested steps in providing the best possible care to

female patients. Although these were addressed to physicians, I’m sure
that these recommendations will also be useful to nurses and other health
professionals.
1. Be aware of your own socialization and possible sex-role biases that

may affect your attitude toward female patients.
2. Avoid using patronizing, demeaning or sexist language. (An example

is a statement we frequently hear or say: “You’re really a woman,
you’re as unpredictable as the weather.” Another example is “A
woman’s role is confined to the bedroom.”)
3. Be aware of the sociocultural stresses on women. The fact that they

perform multiple roles in the home, community and society renders
women vulnerable to health hazards, physically and psychologically.
4. See women’s help-seeking behavior as an opportunity for preventive

health care: encourage them to give priority to their health.
5. Take women’s problems and symptoms seriously. Make a thorough

assessment rather than prematurely deciding on a physical or psy-
chologic diagnosis, or judge her as a hypochondriac.
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6. Routinely ask women about current or past abuse. Abuse can be emo-
tional, physical or sexual.
7. Learn about the incidence, causes, physical and emotional conse-

quences of violence against women to improve diagnosis, treatment
and care.
I think what Robinson wanted to put across was that health providers
should develop in themselves gender sensitivity and gender awareness.
Gender sensitivity is being aware of, and being open and responsive to
issues which have something to do with the social relations between
women and men within specific societies and cultures. Are you ready for
this challenge?
To conclude my discussion, I would like to share with you a beautiful

poem written by Nancy R. Smith. This poem captures the essence of gen-
der relations generally existing today (Hay, 1984).
For Every Woman

Nancy R. Smith
For every woman who is tired of acting weak when she knows she is strong,
There is a man who is tired of appearing strong when he feels vulnerable.
For every woman who is tired of acting dumb,

There is a man who is burdened with the constant expectation of “knowing
everything.”
For every woman who is tired of being called “an emotional female,”
There is a man who is denied the right to weep and be gentle.
For every woman who feels “tied down” by her children,

There is a man who is denied the full pleasure of shared parenthood.
For every woman who is denied meaningful employment and equal pay,
There is a man who must bear full financial responsibility for another human
being.
For every woman who was not taught the intricacies of an automobile,
There is a man who was not taught the satisfaction of cooking.
For every woman who takes a step toward her own liberation,
There is a man who finds that the way to freedom has been made a little
faster.
UP Open University
Module 12 359
Activity 12-2
Go back to the list of strategies to reduce gender inequalities in
health. Can you suggest at least one more strategy?

Generate gender-sensitive data. Epidemiological studies available
are often insufficient in giving data on gender. Specific problems
faced by either women or men can be hidden in the overall data,
resulting in lost opportunity for analysis and appropriate inter-
vention.
Summary
We have discussed the concepts of gender and gender socialization in
relation to their influence on nurses and the nursing profession and, their
impact on women’s health status and access to health care services. The
effect of stereotyping of men, women or nurses can influence their perfor-
mance and the way they think and behave. Hence, steps should be taken
to counteract or overcome its influence.
On the other hand, gender inequalities in health are a result of gender

inequalities in the social, economic and political spheres of society. Recog-
nizing this calls for improving the roles and status of women in society in
order to increase their capacity to control their lives and their health. It
also urges nurses and other health professionals to be gender-sensitive.
UP Open University
Answers to Self-Assessment Question
ASAQ 12-1
Gender Roles/Responsibilities Qualities/Behavior
Women wife assertive

mother understanding
caregiver loving, caring
reproduce sensitive
Men husband aggerssive

father independent
breadwinner hardworking
disciplinarian active
My description of a woman and a man may be different from what you

have listed down. This is not surprising because our responses are influ-
enced by our socio-cultural environment and by the way we have been
socialized into our gender roles. I grew up in a family where the siblings
are all females and we were brought up to fend for ourselves and care for
each other. I would say therefore that my description of a man and a
woman is a combination of traditional and unconventional concepts.
ASAQ 12-2
1. There are many instances where I personally observed that women,
especially those seeking pre-natal check up, are not treated with res-
pect by health professionals. They are solely blamed for getting too
many pregnancies. They are made to wait for a long time before they
are seen by the doctor. Sometimes women are not given the full infor-
mation about the benefits of family planning methods.
2. Gender inequalities in health care can be seen in the following:
a. Health problems are present at every stage of a woman’s life cycle

b. Differential access to and utilization of health care services by
women
c. A view that a woman’s illness is largely due to her behavioral or
psychological lapses.
If you have written down some situations that picture unfair treatment of
female patients, that’s good! That means you are aware of their situation.
Perhaps, now is the time to act to change the situation in their favor.
UP Open University
Module 12 361
References
Condon, E. (1992). Nursing and the caring metaphor: gender and politi-
cal influences on an ethics of care. Nursing Outlook, 40 (1).
Halloran, E.J. (1990). Men in nursing. Issues in Nursing. St. Louis: C.V.
Mosby, Co.
Gilloran, A. (1995). Gender differences in care delivery and supervisory
relationship: The case of psychogeriatric nursing. Journal of Advanced
Nursing, 21.
Flanelly, L. (1984). The masculine and feminine in nursing. Nursing Fo-
rum. 21 (4).
Food Nutrition Research Institute. (1995, August). Fourth-Nutrition Sur-
vey Phil. Part C. Clinical Nutrition Survey. Bicutan, Taguig, Metro Ma-
nila.
Hay, L.L. (1984). You can heal your life. California: Hay House, Inc.
Okojie, C.E. (1994). Gender inequalities of health in the third world. Social
Sciences and Medicine, 39 (9), 1237-1247.
Philippine Health Matters. (1995). Health Alert. Health Action Informa-
tion Network (HAIN).
Robinson, G.E. (1994). Treating female patients. Canadian Medical Asso-
ciation, 150 (9).
Strasen, L.L. (1992). The image of professional nursing: Strategies for action.
J.B. Lippincott Co.
Shea, C.A. (1990). Feminism: A failure in nursing? Current issues in nurs-
ing. St. Louis: C.V. Mosby, Co.
Vlasoff, C. (1994). Gender inequalities in health in the third world: Un-
charted ground. Social Sciences and Medicine, 39 (9), 1249-1259.
UP Open University
Unit I 363
Unit III
Bioethics in Nursing
F rom the days of Hippocrates to the time of Florence Nightingale up to

circa 1970s, medical ethics enjoyed a remarkable degree of continuous
traditional practice. A nurse was typified as an obedient health care helper
who executed health care services mainly upon the physician’s orders.
The physician sort of owns the patient because he had the overall control
of the patient’s life. It was in this line of philosophy during that time that
medical ethics was practiced.
Through the years, however, many changes in the biological sciences and
in health care delivery have occurred due to rapid scientific, technologi-
cal and social developments. Research discoveries and developments chal-
lenged many prevalent conceptions of the moral obligations of health pro-
fessionals and society in meeting the needs of the sick, handicapped, in-
jured, and older people.
Nursing has come a long way towards advancement and expertise in its
academic and technological aspects. Academic preparation has gone from
hospital-based apprenticeship to higher education in the university set-
ting. Nursing now has a minimum baccalaureate degree, making the nurse
a professional practitioner in hospitals, as well as home and community
settings. Nursing courses have become so advanced that specialization,
masters’ and doctoral preparations are now at par with any behavioral
or scientific discipline. Hence, nursing responsibilities have included higher
posts in clinical practice, specialized care, academic, administration, and
management in the preventive, promotive, rehabilitative, and therapeu-
tic health care services across gender and age groups.
UP Open University
With advances in biotechnology and biomedicine, there is a need to estab-

lish bioethical guidelines in order to draw a line between what is morally
and ethically correct and what is not. Because nurses are on the front line
of health care, there is a need to know which practices respect life and
which do not. As we move towards the 21st century, how and where
shall we base our activities to know whether what we are doing are within
the bioethical sphere?
Bioethics is a must knowledge. It is the living science of the conduct of

human life. Nursing’s raison d’être is the care of life, and improving the
quality of life of the clients we care for. Bioethics is considered a founda-
tion of our nursing activities.
Unit III is comprised of six modules, namely:
Module 13: Foundation and Principles of Bioethics in Nursing
Module 14: The Beginning of Life. This module discusses the formation
of conscience in the child.
Module 15: Autonomy. This module discusses respect and informed

consent.
Module 16: Beneficence. This module discusses nonmalificence and

guidelines on extraordinary means in critical cases and in
the dying.
Module 17: Justice. This module discusses the implication of micro and
macro allocation of resources with a focus on the Filipino
family, values, culture, customs, and tradition.
Module 18: Professional-Patient Relationship. This module discusses

privacy, veracity, fidelity, truth-telling and confidentiality.
UP Open University
Module 13 365
Module 13
Foundation and Principles of
Bioethics in Nursing
Letty G. Kuan
T he principles and concepts that we shall dis-

cuss in this module pertain directly to nurs-
ing care. You will first study the foundation of
Objectives
bioethics with the corresponding bioethical con-
cepts before we discuss the primary principles.
should be able to:
Do not study this modules in haste. Take your
1. Discuss ideas that serve
time, relax your mind and have a positive atti-
as the foundation of
tude. We will discuss principles of bioethics. Take
bioethics;
these to heart. They should be the guidelines in
2. Discuss the relevance and
your actuations as you care for people who have
meaning of bioethics
the right to quality care. The principles can also
in our lives;
be your guidelines on how to conduct your own
3. Analyze bioethical issues
life as a person and as a professional nurse.
and dilemmas in nursing;
and
We study Bioethics because rapid changes in the
4. Conceptualize the impli-
society, environment, and especially in the fields
cations of bioethics in the
of medicine and biotechnology, touch our lives.
practice in nursing.
Our lifestyles have changed and we are often be-
set with questions as to what is permissible and
what is not.
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366 Theoretical Foundation of Nursing
Foundation of Bioethics
Bioethics is a living study of the conduct of human life. It is a relatively
new discipline. Its essence is derived from morality principles and ethics.
Its importance is felt by professionals vis-a-vis developments in the health
sciences. In the wake of these developments, bioethics helps to provide a
framework for moral, ethical judgment and decision-making. Let us be
clear that caring for people’s lives entails a continuous process of deci-
sion-making because we want to save lives and enhance quality of life at
all times.
The basis for our moral conduct primarily comes from our origin. This
includes our family and our traditions, customs, belief practices; the
nurturance and quality of living-rearing experiences; the society and en-
vironment we live in, and many other factors. This includes also the time,
season or epoch we live in.
When we study bioethics, we take into consideration all the elements that
are relevant to the conduct of life. We are in front of our very own selves,
our lifestyle, how we view life and how we react to life.
Bioethical discussions have been renewed in the wake of transplants, clon-

ing, donor harvesting, allocation of scarce resources, rejuvenating age-
old individuals and caring for critically-damaged or brain dead patients.
The use of extraordinary means in maintaining clinically dead individu-
als running expenses beyond the family’s finances, poses ethical problems
to health care services and health professionals. Issues and dilemmas re-
garding these problems continue to confuse people and many times issues
remain unresolved because of the absence of appropriate guidelines. Bio-
ethics hopes to provide a framework and guideline to our interventions.
Ethics is a generic term for various ways of understanding and examin-

ing the moral life of a person. As cited by Beauchamp and Childress (1994),
some approaches to ethics are normative. Being normative, actions are
based on standards of society and acts are judged by standards of what is
accepted as right or good action. Other approaches are descriptive. By
being descriptive, what people believe and how they act are phenomeno-
logically described. Still other approaches are analytic. People analyze
the concepts and methods of ethics in the light of what they observe,
believe and practice.
Reflection on problems of biomedical ethics within the health care pro-

fessions has evolved through formal codes of medical and nursing ethics,
codes of research ethics, and reports by government-sponsored commis-
sions. Let us also be clear from the start that biomedicine is a shorthand
expression for the biological sciences, medicine, nursing and health care.
UP Open University
Module 13 367
Morality addresses the question of what is right and what is wrong. We

are all born with a certain mind of direction and this is our gift. In Module
14, I will discuss this lengthily in the light of conscience formation and
nurturance. We often are mistaken when we confine our views of ethics
and morality to theoretical contexts.
The term morality as used by Beauchamp and Childress (1994) refers to

social conventions about right and wrong human conduct that are so
widely shared that they form a stable, communal consensus in a certain
population or in a certain specific society. In its broadest and most famil-
iar sense, common morality comprises socially approved norms of hu-
man conduct. Let us agree that common morality is a social institution
with a code of learnable norms. Common morality exists before we are
instructed in its relevant rules and regulations. As we grow beyond in-
fancy, we learn moral rules along with social rules, such as laws. Later in
life, we learn to distinguish general social rules held in common by mem-
bers of society from particular social rules fashioned for and binding on
the members of special groups such as members of the Philippine Nurses
Association.
Ethical theory and moral philosophy refer to philosophical reflection or

when we speak of morality’s nature and function. The purpose of a theory
is to enhance clarity, systematic order and precision of argument in our
thinking about morality.
The foundation of bioethics is in the very nature of our being human.

Each individual is born in love, with love and by love. Even individuals
born out of marriage are given the chance to be born in and with love
because of the nine months’ experience of gestational care. Basically then,
we tend to do good and right things from birth until such time that other
influences drive us to do evil and wrong acts. The experience of a solid
bonding between child and parents becomes a necessary foundation of a
caring, ethical person. Indeed the experience of the past predicts the events
of the future because as human beings, we are molded by everything we
have experienced in our life.
Metaethics involves analysis of these three: language, concepts and meth-

ods of reasoning. There are metaethical questions for analysis including
whether social morality is subjective or objective. These are mentioned
here to let you know that Bioethics is a vast field and is highly colored by
one’s upbringing and personality. Because of this, principles are built from
world views and translated into practice under the guidance of moral
laws.
Let us pause for a moment and answer some SAQs. Compare your
answers with those found at the end of the module only after you have
tried to answer the questions on your own. Reward yourself for all cor-
rect answers.
UP Open University
SAQ 13-1
What is the importance of a Bioethics course for the health profes-
sional?
SAQ 13-2
Ethics is a generic term for various ways of understanding and
examining the moral life of a person. What are some of the ap-
proaches that can be used?
UP Open University
Module 13 369
SAQ 13-3
What is the foundation of our innate Bioethics?
Development of Bioethics
There are five waves of development in the field of bioethics, each belong-
ing to a certain time and with a certain theme. In tabular presentation,
this development can be presented as follows:
Table 13.1. Development of bioethics (Kuan, 1993)
Wave no. Significant figures Bioethical principle

and Epoch
I. Creation Justice
Hammurabbi Justice
Moses Justice
II. Hippocrates Paternalism
III. New Testament: Jesus Christ Autonomy
IV. Media Compassion and veracity
Research Compassion and veraciy
Economics Compassion and veraciy
Pluralism Compassion and veraciy
V. Poverty Sharing and allocation
of resources
Super-rich Sharing and allocation
of resources
Migrants Sharing and allocation
of resources
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This presentation leans heavily on the Judeo-Christian tradition although

there are, of course, many other belief systems to be considered. Other
resources will trace the development of bioethics in a different way. De-
velopment will continue because with more advances in biomedicine and
biotechnology, more bioethical problems will arise and will need to be
addressed.
Let us now discuss each wave, and the significant figures, period and
principles of bioethics that were developed in each.
Justice
In the Bible, the principle of justice was the main conduct of life. When
Adam and Eve (Genesis 1:1 ff) succumbed to pride by disobeying God’s
command, man began to feel the pang of pain in life. Justice was defined.
If you disobey, you deserve a corresponding action. In this case, Adam
and Eve were driven out of Paradise and lost their gifts of integrity and
prosperity because of their disobedient act. What is shown here is that we
get what we merit. Obedience to the law and commandment of God means
rewards of integrity, prosperity and paradise. Disobedience to the law
and commandment of God means deprivation of integrity, prosperity and
a place in paradise. The principle of justice then demands that we give
what is due and we get what we merit for our conduct in life. This
principle of justice was also emphasized in the time of Hammurabbi. Dur-
ing their fights for land and resources (Exodus 1:1 ff), whoever won the
battle will get all the oxen, women, children, and belongings of the losing
party. If you win, you get all; if you lose, you have nothing. Another
significant event that defined this principle of justice was when Moses
came down from the mountain of Yahweh. He spent forty years there
(Exodus 32:1 ff) while his people were left in the desert. He brought back
two tablets containing the Ten Commandments. Those who lived by these
commandments enjoyed prosperity and peaceful living. Those who did
not, suffered all sorts of malediction. Justice is giving everyone his due. If
you are good, you get rewarded, if you are bad, you get punished.
In contemporary times, the principle of justice applies to everyone. In

court trials, those who are guilty of crime are punished, those who have
not committed crime, are set free. In health care, however, the principle
of justice implies that we give each one his/her due. If an individual
needs care, he/she has the right to be cared for because care is his/her
due. No one therefore has the right to refuse health care to someone who
is in need. This is emphasized in times of urgency and emergency. Re-
UP Open University
Module 13 371
gardless of the individual’s capacity to pay, health care must be given to

the person needing care because as health professionals, our first duty is
to save lives. This principle therefore clarifies this implication and this
application.
Theclient has the right to receive care

The health professional has the obligation to give that person the needed care
The principle of Justice reckons also with what St. Augustine in 1674
said: “the rights of any individual flow from justice” (Hammondsworth,
1972). Various philosophers tell us that justice means fairness. It also con-
notes entitlement. This concept interprets justice as fair, equitable, and
appropriate in the light of what is due or owned to persons. A situation of
justice is present whenever persons are entitled to benefits or burdens
because of their particular properties or circumstances. One who has a
valid claim based on justice has a right, and therefore is due something.
An injustice therefore involves a wrongful act or omission that denies
people benefits to which they have a right, or it may be that the sharing of
responsibility is not equal among responsible people.
The principle of justice applies also to the working condition of nurses. In

health care, appeals to justice or fairness rule out certain profitable prac-
tices, such as the exploitation of nurses through unpaid overtime, and
overchanging the government for patient services which are not done.
There is a need to know what is fair and just but there is also a corre-
sponding obligation to render quality service. If justice is to be fully prac-
ticed, human needs and efficient service must be equitable. Health care
must be available to all or there will always be injustice in the minds of
people. We shall discuss more about the implication and application of
the principle of justice in health care in Module 17.
Paternalism
The second wave of the development of Bioethics puts emphasis on pa-
ternalism. Hippocrates set the stage for paternalism. We see this con-
cretely among family physicians who are often seen as the supreme health
authority of the family’s health. The physician’s orders are often obeyed
at all cost because of the paternalistic philosophy. Usually no questions
are asked once orders are given because of the full trust and confidence
given to physicians in authority. Paternalism holds that an authority fig-
ure such as the state, or one’s father, knows best and that each individual
is obligated to comply with the authority.
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This thinking has been quite abused by many physicians even up to this
day. Physicians are often given the post of directorship or leadership in
health teams.
Paternalism is good if this takes a parental model of benevolent interven-

tion, one that likens the state to a protective parent caring for one incom-
petent minor. In some instances, paternalism is good if acts are done for
those with limited or no autonomy.
Basic books of philosophy and ethics cite Immanuel Kant and Stuart Mill
of the 1880s who described paternalism as “the principle and practice of
paternal administration: government as by a father, the claim or attempt
to supply the needs or to regulate the life of a nation or community in the
same way a father does those of the children.” The analogy with the fa-
ther presupposes two features of the paternal role: that the father acts
beneficently (that is, in accordance with the conception of the interests of
his children). Furthermore, he makes all or at least some of the decisions
relating to the children’s welfare, rather than letting them make those
decisions. In health care relationships, the analogy is extended further:
the professional has superior training, knowledge and insight and is in an
authoritative position to determine the patient’s best interests. From this
perspective, a health care professional is like a loving parent of dependent
and often ignorant and fearful children.
Paternalism, according to Beauchamp and Childress (1994), always in-

volves some form of interference with refusal to conform to another
person’s preference regarding his own good. Paternalistic acts typically
involve force or coercion, on the one hand, or deception, lying, manipula-
tion of information, or nondisclosure of information on the other. A pa-
ternalistic action necessarily places a limit on autonomous choice; because
paternalism is the institutional overriding of one person’s known prefer-
ences or actions by another person, where the person who overrides jus-
tifies the action by the goal of benefitting or avoiding harm to the person
whose will is overridden. The second wave of bioethics development was
anchored on paternalism. But over time, little by little, the person’s right
to choose and decide for himself was recognized.
Autonomy
With the New Testament, the principle of autonomy was born. Jesus Christ
showed through His teachings the primacy of man’s freedom to make
choices and decisions. He never forced any of his disciples to follow His
ways but He always prefaced with...”if you wish to become one of my
disciples, then come and follow me...” The gospels of Sts. Matthew, Mark,
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Module 13 373
Luke and John and even the accounts of the Acts of the Apostles, are
replete with episodes that show how much our Lord respected man’s
autonomy to decide for himself. His disciples exercised free will.
The word “autonomy” is derived from the Greek word autos meaning
self and the word nomos meaning rule, governance or law. Its first use
referred to the self-governance of the Hellenic city states. Accordingly,
autonomy has been extended to individuals and has acquired meanings
as diverse as self-governance, liberty, rights, privacy, individual choice,
freedom of the will, causing one’s behavior, and being one’s own person
(Beauchamp and Childress, 1994). The autonomous individual freely acts
in accordance with a self-chosen plan, analogous to the way an indepen-
dent government manages its territories and sets its policies. A person of
diminished autonomy, by contrast is, in at least some respect, controlled
by others or incapable of deliberating or acting on the basis of his or her
plans. For example, institutionalized persons such as prisoners and the
mentally retarded, often have diminished autonomy. Mental incapacita-
tion limits the autonomy of the retarded, and coercive institutionalization
constrains the autonomy of prisoners. We shall see implications and ap-
plications of autonomy in Module 15.
With autonomy, patients now have the choice and freedom to seek other
opinions to validate or enhance what the physician advised them to do.
Autonomy has given us the freedom to grow and develop towards matu-
rity and responsibility.
Compassion and veracity

The fourth wave of bioethics development brought us the principles of
compassion and veracity. This was made possible through the widespread
development of media avenues: print, visual, and audio. Happenings in
the world are known all over through newspapers, television, radio broad-
casts and the Internet. Immediate dissemination of information moves
the world to empathy, thus compassion is practiced.
For communication to be credible, it must contain three elements, namely:

(1) Logia which means substantial views of world truth; (2) Pathos which
means an element of empathy, ability to put one’s self in a true situation;
and (3) Ethos which means morally correct and true to the event. These
three elements comprise the principles of veracity. Mass media hasten the
practice of the principles of compassion and veracity.
The uphill development of research methods and corresponding research

findings also helped in the practice of compassion and veracity because
discoveries of sufferings or of new technologies create compassion for oth-
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ers. Veracity is strength, because in order to entice empathy, one must be

true and credible. It is for this reason that research technologies must be
perfected to give credence to research findings, and reporting of findings
must be true (Englehardt, et al., 1993).
Economics also develops the principles of compassion and veracity be-

cause with the economic climate of the country, we are able to see the
difficult times and the easy times depending on the country’s productiv-
ity or bankruptcy. Being cognizant of this condition, people’s compassion
is aroused because realities of economic situations are seen. Unemploy-
ment, retrenchment, marginalized salaries, exploitation of children and
women, are realities that can move us toward compassion. Pluralism has
its part in propagating the principles of compassion and veracity. The
Filipino culture of “pakiramdam” (feeling for the other) all the more adds
up to the practice of the principle.
Sharing and allocation of resources

The increasing number of Filipino people living below the poverty line,
and the existence of a very small percentage living in the super rich in-
come bracket, evoke the practice of the principle of sharing and alloca-
tion of resources. The fact that many of our people are found in all parts
of the world as migrant overseas workers tells us that Filipinos strive hard
in order to be able to share their resources with their families back home.
It is lamentable to see individuals die because of inability to buy needed
medicine. On the other hand, we see the waste of money by the few super
rich given to vices such as gambling, drinking and other unnecessary lei-
sure activities. Government policies need to give importance to the poor:
more should be shared with them so that they can live decent lives.
The principles of sharing and allocation of resources are seen more in

hospital settings. I’ve seen five individuals fight over the use of only one
available pacemaker. With such scarce resources and with so many indi-
viduals needing help, what guidelines should we follow to answer
everyone’s needs?
In this period in the development of bioethics, sharing and allocation of

resources will have to be the main guidelines in policy making. The con-
cept of triage will have to tied up to this principle and this calls for honest
competent health care workers who are endowed with justice, compas-
sion, and total caring traits.
With this narrative on the development of bioethics, let us now take time
out to do some self-assessment questions.
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Module 13 375
SAQ 13-4
Give examples that show:
1. How the principle of justice applies to the nursing profession
2. How the principle of veracity is practiced in nursing care
SAQ 13-5
How do Filipino migrant overseas workers illustrate the principle
of sharing and allocation of resources?
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Filipino Primary Principles of Bioethics

The primary principles of bioethics in the Filipino culture can be grouped
into three main divisions:
1. Goodness
2. Beneficence
3. Family
Goodness
The primary principle of goodness is demonstrated through the practice
of justice, respect for autonomy, compassion, veracity, fidelity and confi-
dentiality. Concretely, Filipinos practice this through delicate and gener-
ous hospitality. Goodness is also shown in community sharing of goods
including lending of money, materials, equipment and even human re-
sources. No other culture can demonstrate this goodness among kababayan
(compatriots). The concept of utang na loob (indebtedness or gratitude)
runs through generations because it is a traditional belief that good favors
done to one member should be perpetuated in acts of gratefulness for-
ever.
Goodness extends also to keeping secrets even if it would have been more
charitable to reveal the secret. Let me give you an example:
Aling Saling knows that her neighbor, Aling Minda has terrific
armpit odor. But because she wants to be good to Aling Minda,
she will keep this in confidence even if she knows she could have
been more charitable to others by frankly telling Aling Minda that
she needs to use a deodorant, for other people’s sake.
Confrontative dialogues are avoided because of the guise of being good

and not hurting the feelings of others.
In Bioethics, goodness is also veracity, but telling the truth should be done
with compassion and with full respect. What is needed to tell the truth is
appropriate timing and suitable occasion. This is where the Filipinos’ gift
of pakiramdaman (sensitivity) is of big help. In nursing, the primary prin-
ciple of goodness should be the motivating guideline in caring for patients
because goodness in health care means giving and caring so that the pa-
tient will feel better.
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Module 13 377
Beneficence
Beneficence as a primary principle of bioethics includes nonmaleficence
(doing no harm to anyone), attentiveness, pervenance (anticipating one’s
needs), positive reinforcement, helpfulness, positive paternalism, sharing,
and also truth-telling. In beneficence, all pesons should be treated au-
tonomously. No harm should be done to anyone and we should contrib-
ute to their welfare and growth. The role of others to take positive steps to
help others is emphasized in the principles of beneficence.
The term beneficence connotes blessings, acts of mercy, kindness, charity,

altruism, love, humanity and kindness. Broadly, beneficence stands for
all forms of action done for the benefit of others. In this context, benevo-
lence refers to the character trait or virtue of being disposed to act for the
benefit of others; and the principle of beneficence refers to the moral
obligation to act for the benefit of others. Many acts of beneficence are not
obligatory, but a principle of beneficence asserts an obligation to help oth-
ers achieve their important and legitimate interests as well as help them
attain full growth and development of their personhood.
Family
The third primary principle concerns the family. The family is very im-
portant in the Filipino culture. It is the solid bank one can rely on where
withdrawal of help and support is endless and the resource is never ex-
hausted. Everything revolves around the family; all principles of human
conduct of life begin and end in the family. The family encompasses all
bioethical principles and concepts. In the Visayan dialect, the parents are
regarded as the source of everything, hence the term ginikanan meaning
the Source. Parents are looked up to as mature, respectable, responsible
adults. The family therefore is the source of all right conduct, ethics, mor-
als, justice, autonomy, beneficence, respect and goodness that flow in con-
tinuity among the children from the eldest down to the youngest. This is
the reason why the family is a primary principle of bioethics because all
principles and concepts of bioethics come from this and are spread out to
others. The quality of our personhood often depends on the nurturance,
rearing and breeding we have received from the family.
With this discussion, let us see how much you have lerned by doing the
following self-assessment questions and activities. As I have said earlier,
you can always go back to the text if you are unsure about your responses.
Learning is oftentimes repetitious. What is essential is perseverance and
patience.
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Activity 13-1
Describe a Filipino family, preferably your own. List down all the
principles of bioethics and describe how they are practiced in your
family.
Summary
You have just finished Module 13. You will recall that this module is about
the Foundation and Principles of Bioethics. You have just learned from
the text that bioethics existed since the time of creation and the principles
together with the corresponding concepts of bioethics developed through
the years with significant events of the time. Starting with the exigencies
of justice, bioethics development ran along the lines of paternalism, au-
tonomy, compassion, veracity, and sharing and allocation of resources.
Respect for life is integrated in all stages from conception to death be-
cause bioethics is the living study of how we conduct our life.
You saw that the primary principles revolve around the most important
unit of society: the Family. From there, all principles, concepts, and vir-
tues of bioethics flow because it is the source of all goodness, beneficence
and autonomy. Let us live by these principles and then let the principles
guide our acts of giving service to others. Let us work towards quality
care, available to all regardless of age, status, color and creed.
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Module 13 379

SAQ 13-1
Bioethics became a relevant and required course for health professionals
in the early 1980s because of advances in biomedicine and biotechnology.
These advances created waves of issues and dilemmas regarding organ
donors, transplants, cloning, megascale engineering, space colonization,
allocation of scarce reosurces, use of extraordinary means for brain dam-
aged patients, and others. These dilemmas posed problems to health pro-
fessionals. In the wake of these developments that allow health care to
increase its potential to do good; there is also the increased potential for
harm. Most questions deal with the two ends of life: birth and death.
Bioethics as a course has become a necessity in order to provide a frame-
work for moral, ethical judgment and decision-making in health care.
ASAQ 13-2
Using the thinking of Beauchamp and Childress (1994), some approaches
to Ethics are normative, that is, they present standards of right or good
action. The descriptive approach reports what people believe and howthey
act. Still others analyze the concepts and methods of ethics. Normative
ethics usually refers to inquiry that attempts to answer the question: “What
general forms for the guidance and evaluation of conduct are worthy of
normal acceptance, and for what reason?”
ASAQ 13-3
Our innate Bioethics derives from the specific conduct of our lives as hu-
man beings. This stems from our original roots, family, the quality of child-
hood, bonding, rearing and nurturance we have experienced. This also
includes the quality of past successes and failures, and the quality of care
and coping we have experienced. All these lay down the foundation of
the innate primitive Bioethics in our personhood.
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ASAQ 13-4
With regards to the nursing profession, the principle of justice is applied
in preparation and placement. Nurses should be prepared academically
and technologically. Their academic and technical formation should make
them competent health carers. Once employed, salaries and hours of work
should be commensurate with their job description with due respect for
professional advancement. Justice demands that nurses be regarded as
partners and co-managers in health care.
The principle of veracity is exemplified with the accurate and the up-to-
date documentation of events, of what they do to patients, to colleagues
and to other partners in the health care team.
ASAQ 13-5
The increasing number of Filipinos going out of the country as migrant
overseas workers in almost all parts of the world signify their quest to
earn more so they can share more and allocate resources better to their
families and other relatives. With better income, there is hope for better
living.
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Module 14
The Beginning of Life
Letty G. Kuan
L ife begins the moment human sperm ferti-

lizes a mature human ovum. At this period
of fertilization, a human being is procreated in
Objectives
love and because of love. Usually, this procreation
ability is given to couples as a gift sealed and sanc- At the end of this module, you
tioned in the bond and sacrament of marriage. should be able to:
When a child is conceived as a result of rape or as
the outcome of an unwanted pregnancy, the dig- 1. Discuss the meaning and
nity of being conceived as a human being remains significance of the begin-
just the same. Respect due to an unborn human ning of life;
being starts at the moment fertilization takes 2. Explain the formation of
place. Tiny though the living cell may be, this al- the notion of “right” and
ready contains all the DNA and RNA destined “good” in the child;
for that individual. Thus, utmost care, respect and 3. Analyze the conscience
nurturance must be given to allow this tiny hu- education process in
man being to develop and grow into a fully func- children and adults; and,
tioning individual. 4. Outline the personal
bioethical guidelines in
You will learn from this module that at the be- caring for young minds.
ginning of life, there is an intrinsic goodness in
each one of us. Notions of what is good and right
develop as an individual grows up. The quality of this growth and devel-
opment is propelled by the quality of one’s home and societal environ-
ment.
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The Beginning of Life

Each living creature has a beginning. We all have individual, personal
origins. Man begins to exist as a human being at the very moment of
fertilization, that is, when the human sperm fertilizes the human ovum.
Life begins there. At that very moment, all the DNA and RNA needed for
thinking and cognitive capabilities are already contained in that tiny, liv-
ing, human cell. Hence, utmost care and nurturance are needed for this
organism to reach its full growth and development as a mature, fully-
functioning person. This fact renders wrong and bad any means or pro-
cedures that arrest the right to life and care due to this growing, living,
human being. “Decongestion of the woman’s womb” is murder. It is un-
just because that innocent, helpless, developing human being is deprived
of the human right to be cared for, to be born and to live. Abortion, al-
though legal in some countries, will always be regarded bioethically as a
violation of the unborn child’s right to live and grow with dignity. What
is legal is not always morally correct. Even extreme poverty cannot right
such a wrong act.
You will certainly read arguments and other opinions about the begin-
ning of life. Proponents of the “pro-choice” group will debate lengthily
and philosophically on their right to abort regardless of the gestational
age of the child. We cannot condone such activities, but neither can we
condemn those who perform such acts.
Your values, views on life, and the manner by which you conduct your-
self is very much influenced by how you were conceived, reared, nur-
tured, and educated as a child. Formation of values, correct manners and
right conduct start at the very moment a person exists.
There are two significant things we should remember in caring for babies
who are not yet born—physical environment, and psycho-emotional spiri-
tual ecology.
By physical environment, we mean that the child in the womb of the

mother must receive all the necessary nutrition. Care is directed towards
the mother’s health. This includes regular physical check-ups, sufficient
sleep, good nutrition, and clean surroundings. Maternal and Child Care
books emphasized that if an expectant mother lives in a polluted area,
does not get sufficient sleep, and does not have balanced nutrition, the
child born of her is bound to be problematic in terms of health and physi-
cal development. Once conception is accomplished, all care must be di-
rected towards giving the best affordable physical environment to that
child. The mother must be made aware of the importance of this phase of
life.
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Psycho-emotional-spiritual ecology refers to the love and spirituality of

the mother and father of the child. The child must be loved, wanted and
prayed over right from the very moment the mother is aware that she is
pregnant. Research findings point out that a happy, solid and spiritual
relationship between the father and mother during the child’s life in the
womb, produces a happy and lovable child who will grow up to be a
God-fearing and law-abiding citizen later on.
On the other hand, when children are born under the ecology of fear,
disavowal, anger, anxiety, and hatred, they turn out to be problematic in
behavior and personality, and become a menace to both society and com-
munity. Formation of a real good person starts at the very beginning of
life. This has been well supported by textbooks on humanities especially
those of Grialou (1953).
Children are like sponges that can absorb all liquids placed near them.
Dirty liquid is absorbed as quickly as clean liquid. It is the obligation of
parents, and us, nurses who care for babies and children, to pay attention
to what we do, say and demonstrate. Children learn through the senses
and are very imitative. Hence, language must be one of love and educa-
tion.
Bioethics, which is the living study of the conduct of human life, has its
relevance right from the very beginning of life. Children must be loved,
wanted, cared for, prayed over. They need responsible parents who will
stand by them from conception to adulthood. Once life is given to an
individual, that individual must be respected and given the right to be
born, to live, grow and develop. It is the nurse’s duty to make parents
realize their role from the very beginning. The quality of what children
receive at the beginning plays a major role in the direction, orientation,
and quality of their life as adults later on.
All right, let us pause and see how much of the text you have grasped.
Answer the following SAQs. You may compare your answers with those
at the end of the module, but work on your own answers first before
looking at the answers at the back.
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SAQ 14-1
1. When does life begin?
2. What is the significance of the beginning of life?
3. How can a nurse contribute favorably to a healthy beginning

of life?
Conscience: Its Formation and Acquisition

The nature of conscience
The general concept of conscience is difficult to discuss because it presup-
poses a certain form of self experience, without which access to the phe-
nomenon itself, as expressed in various ways, is not possible. In general,
the experience can be analyzed with some precision, since the bonds and
relations that give concreteness and possibility to human existence are of
such a nature that we consider ourselves responsible for what we think
and do. Therefore, the knowledge of a prescribed order is presupposed,
and toward this we adopt a positive or negative attitude. Since this knowl-
edge, on the basis of mythical, personal and universal experience does not
need to be regarded as reflective in origin, the phenomenon of conscience
can be present within a formally defined sphere, i.e., without a name
being assigned to it. In such cases, formal analysis of human conduct is
required, and especially an analysis of guilt consciousness, in order to
establish the nature of conscience in the given instance.
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Module 14 385
The Catholic World Encyclopedia (1992) discusses the universality of the

phenomenon of conscience. No culture has yet been found in which con-
science is not recognized as a fact. In contemporary times conscience
becomes more pronounced as a “problem” when we deal with bioethical
issues. Human conscience is troubled as it compares what is done with
what should have been done.
Among early societies, expressions such as “heart” and “loins” were used
instead of the word conscience, to indicate our innermost nature. In this
sense, conscience is something within our very nature. There is a ten-
dency to do good and to be right because goodness is within our hearts.
An ancient Egyptian text reads: “The heart is an excellent witness and
one must not transgress against its words. He must stand in fear of de-
parting from its guidance”. When we have done something good to our-
selves and to others, we feel an inner joy and we are at peace. On the
other hand, don’t we feel remorse and burdened when we have hurt
someone, or when we have done bad things to others?
Conscience can also be seen as manifestation of the divine world. Among

the Hindus for example, it is regarded as the “invisible God who dwells
within us”. The world order can be represented as individual figures,
who, reflecting moral awareness of the order that has been impaired or
destroyed, are interpreted as the avenging powers employed by the high-
est divinity, for example, the Erinyes, or Eumenides, Furies and Nemesis
(Catholic World Encyclopedia, 1992).
In ancient Greece, in the age of the Sophists when opposition of nature

and law was stressed, Socrates spoke of his indwelling “divine monitor”.
From that time and onwards, conscience was given a name which signi-
fies self-consciousness. It had the role of making moral judgments. It be-
came the substance and sphere of knowledge with respect to human ac-
tion, the spiritual ethical world order, and the existentially experienced
correlation of both, either as agreement or difference. And since feeling
and will play a significant role in the application of conscience to human
action, conscience then is more affirmative than consciousness and
abstract knowledge. There can and must be a good and bad conscience,
one that is active not only after the deed is done, but also before and
during, because in this kind of knowledge, the whole, ethical being is
continuously present.
In the process of secularization and modernization of thought, philoso-

phers such as Kant, Fichte, Darwin, Durkheim, Newman, Kierkegaard,
and others alluded to conscience as the “consciousness of an interior court
of justice in man.” Freud, on the other hand, regarded conscience as the
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suppression of the libido. Cicero declared that the consciousness of a life

well spent and the remembrance of numerous deeds well done is the cause
of the greatest joy (Catholic World Encyclopedia, 1992).
SAQ 14-2
For you, what does the term “conscience” mean?
The formation and education of conscience

What we have discussed so far are the meaning and nature of the term
conscience. By now you must have an idea of what conscience means to
you as an individual. Let us now see how conscience is formed and how
a young mind begins to know what is good and right versus what is bad
and wrong.
Conscience formation starts from the moment the child is conceived in

the womb of the mother. This is called the pre-forma factor. What consti-
tutes the pre-forma factor are the following:
1. The parents’ relationship with each other. If the father and mother
are not very open and honest, the child being conceived will likely
have a tendency not to tell the whole truth. When parents, on the
other hand, are very open, loyal and honest with each other, the baby
in the womb grows in an atmosphere of trust, truth and love, which
will manifest later on as honesty and trustworthiness. The quality of
the conjugal relationship is very important in the shaping of the child’s
innate positive traits.
2. The quality of sensory stimulation received in infancy and child-

hood. A child who grows up in an atmosphere of fine visual, auditory
and tactile stimuli is bound to learn language easily and be apprecia-
tive of things of beauty. The quality of touch received makes an indi-
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Module 14 387
vidual sensitive to the needs of others and will render that person
helpful to others. The process of conscience formation is shaped by
events and people, and by an individual’s response to them.
In early childhood, the child begins to make sensitive and accurate judg-
ments of moral values in concrete situations. This experience broadens
rapidly during childhood and adolescence but it is not until the years of
adulthood when mature insight is developed. Insofar as it is attainable
through human effort, a healthy adult conscience is made possible by
education and growth in liberty, and by psychological balance and growth
in maturity.
The period from birth to six years of age is a time of remote preparation
for moral action, during which the child consciously develops an attitude
toward authority, law and life. If parents create an environment of love
and emotional security; if they have a common approach to the child; if
their discipline is consistent, just and commensurate with the child’s abil-
ity to obey, the child’s attitude toward them as lawgivers will be positive
and will be predisposed to develop a healthy response to authority.
During these years, the child develops some self-control, internalizing regu-
lations established by parents. This is usually motivated by fear of punish-
ment and of losing the security of parental love. No connections need to
be made at this time between parental and divine law. God should be
presented as the loving and provident Father-Savior, rather than as Law-
giver-Judge. The reaction of the parent to a child’s behavior serves as a
conscience for the child, revealing the acceptability or “naughtiness” of
certain acts. The guilt one feels when disobeying or displeasing ones par-
ents is irrational and automatic.
At about the age of six or seven, the child exhibits a sudden concern for
knowing the rightness or wrongness of things. This is often referred to as
the age of reason; however, this is only the beginning of a long and labo-
rious process. The child begins to reevaluate and seeks reasons behind the
norms been followed. The child’s unconscious and instinctive behavior
patterns among his playmates and peer group at nine or ten years often
contradict those learned at home, forcing the child to think, and raising
conformity to values from automatic reflex to conscious obedience, though
obedience at this stage may not be fully chosen. This is why a child is
often rebellious at this age.
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SAQ 14-3
What are the pre-forma factors and why are they important in
conscience formation?
The speed with which the development of conscience is accomplished

depends upon the child’s autonomy, native intelligence, emotional con-
trol, self-image and moral instruction, as well as on the quality and vari-
ety of experiences. Some specific experiences that can aid in this gradual
rationalization of behavior are:
1. the opportunities for choice,

2. the experience of different levels of law,
3. the experience of deception, and
4. the discovery of failure and weakness in those on whom one depends.
From six or seven years, the child is generally given programmed instruc-
tion in a particular system of values in daily life. From the first awareness
of law until about nine or ten years, children maintain a rigid and logistic
attitude toward rules. Instruction must emphasize the essentially interior
nature of true morality.
Moral formation requires more than a knowledge of rules and norms of

behavior and accuracy of judgment in concrete situations. It demands
also the ability to guide one’s actions in accordance with the known and
desired good. It is not realized therefore in development of mind and judg-
ment alone; there must be affective (volitional and emotional) develop-
ment as well. The child must acquire a certain measure of interior and
exterior liberty before achieving full adult responsibility. Although the
child by the age of twelve years is capable of some discrimination
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Module 14 389
between right and wrong, and is capable of making some autonomous

decisions, conscience is not yet, strictly speaking, independent and per-
sonal, and the child is not therefore, responsible in the same sense as an
adult. The norms by which the child judges situations are those accepted
uncritically from parents, peers and teachers. Child-morality is only par-
tially conscious, and is a participation in the morality of others.
Whereas the young child sees morality in terms of universal and objective
law, the adolescent is chiefly preoccupied with personal and subjective
moral values. The adolescent sees the central importance of goals and
motives in the action of full persons. He is greatly concerned about social
justice and the rights of the individual, and will devote great energy to a
cause that captivates his idealism and imagination. The adolescent has a
simplistic approach to life and expects everyone, including himself, to live
up to an absolute ideal. Failure of the adult world to live up to professed
ideals, confuse him. The adolescent’s life is further complicated by having
to deal with conflict between his own standards, those of his peers, and
those of adults significant in his life. The adolescent now struggles through
emotional upheaval and social insecurity. There is a need to grow toward
autonomy in order to establish a unique and independent person before
parents and peers. This generally involves some rebellion against author-
ity figures, and perhaps deliberate violation of moral norms.
Moral education for the adolescent, building upon natural interests, usu-
ally centers around the meaning of personhood and freedom: the respon-
sibility of an individual to serve others, the need to stand against the group
at times, the choice of a vocation, and above all, sex, love and marriage.
Speaking now of adulthood and responsibility, the adult person is one

who, enlightened and strengthened by the indwelling spirit, has assumed
responsibility not only for actions, but for the self. The adult is a person
who has understanding of morality, has a subjective norm of his action,
can read the exigencies of a situation accurately, and responds consis-
tently with love and generosity. Such is an adult with a conscience.
The text you have just gone through is quite lengthy but it is very informa-
tive about conscience formation and education. It is now time to pause
and evaluate yourself by answering the following SAQs. What is impor-
tant is that you comprehend the text with your mind and heart. The text
is at your disposal, so you can go back to it several times as you wish.
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SAQ 14-4
Describe the significance of the period from birth to six years in
terms of conscience formation.
SAQ 14-5
Describe how moral education is best tackled for adolescents.
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Module 14 391
How did you fare with the SAQs? I am pretty sure you all your answers
are correct. Share what you have learned with your friends and the chil-
dren you care for. Now, let us move on to our next discussion.
Conscience Situations
Children are very observant and imitative. They build their own charac-
ter, language, and reactions to situations depending on what they see,
feel, and experience with adults close to them. It is for this reason that
children should feel that they are loved, that they have a family, that they
are secure and safe. Like sponges, children pick up anything from their
environment. Therefore, the home has a big role to play in the formation
and education of the child’s conscience and values. Street language, bois-
terous laughter, rough or bully actions, aggressive reactions, are all picked
up by the child. If role models typify good breeding, refined manners,
polite language and good taste, children are propelled to be good, and
will develop values, character and delicate conscience.
In this light, parents’ important responsibility in rearing and nurturance

cannot be overemphasized. Parents should involve themselves in choos-
ing television programs, or selecting games and reading materials for their
children. And when the child goes to school, a congruence and consis-
tency of values and opinions over issues should exist between parental
and school teachings. When incongruence and inconsistencies between
home and school exist, the young mind of the child is thrown into confu-
sion. Consider the following situations.
Situation 1 Conflict among parental teachings
A.B., a 4-year old toddler was taught by his mother to use the
bathroom whenever nature calls. The child was told that only ill-
mannered dogs urinate against walls or behind plants. The mother
was consistently telling the boy about this good manner but one
late afternoon, when A.B. went to the garden to pick some of the
toys he left there, he saw his father urinating behind a tree. The
little boy rushed back to the house, pale and shocked. The mother,
who was in the kitchen, asked A.B. what happened. The boy could
not talk, he was in such shock because his conscience told him
that what his father did was wrong.
The boy grew up to be an adolescent, without voicing out what

shocked him. He became problematic, and had difficulties with
decision-making. Several doctors were consulted and it was only
very much later that A.B.’s case was clearly seen as a case of non-
verbalized split value confusion.
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Analysis by a neuropsychologist pointed out A.B.’s inability to rec-

oncile two aspects of his father’s parenthood: that of a loving fa-
ther behaving like an ill-mannered dog urinating behind the tree
in the garden. Several sessions were needed to orient A.B. back
toward unidirectional love and respect towards his father. Indeed,
congruence and consistency of teaching and action should carry a
harmonious line of continuity between parents so that children
grow up with the appropriate conscience and values.
Situation 2 Conflict between parents and teacher
J.J., a 7-year-old second grader, learned from the teacher that he

must always be honest, tell the truth and never tell a lie. Telling
lies will bring dishonor and malediction because the act is bad.
School children should always tell the truth because that is the
right thing to do, they will be rewarded and will always be at
peace with themselves.
Soon after class, with the lesson still fresh in J.J.’s mind, he was
fetched and brought home. While J.J. was eating his snack, the
phone rang. He picked up the phone and it was a man’s voice
asking for his father. The father, who was in the sala close to the
phone, told him to tell the guy on the phone that he was not around.
J.J. was in a dilemma, for him this was a grave lie and telling lies is
a grave and bad act. So the boy said that his father could not an-
swer him now which was a polite way without having to tell a lie.
But he got a slap on his face for giving that response on the phone.
Minutes later, the door bell rang. It was again J.J. who opened the
door. It was the man who called up earlier who was at the door
asking for his father. So J.J. told his father that a certain man was
at the door looking for him. The father told JJ to tell the man that
he was not home. J.J. could no longer contain his dilemma, so he
told his father that telling lies is bad and we should never tell lies.
What did J.J. get? A big spanking with the following comment
from the father: “J.J., if you do not tell lies, we will become very
poor, no money, no house, no food”. The boy was confused.
The next day in class, J.J. told the teacher what happened at home.
After a little discussion in class, he said, “Never mind, I prefer to
tell lies and be rich like my father. We will not have a nice big
home, money, nice food and cars if I tell no lies. By being honest
and telling the truth, I got a spanking so it’s better to tell lies”.
UP Open University
Module 14 393
These two cases are examples of what children suffer from adults. I am
sure you have similar and perhaps more interesting incidents that you
can narrate and analyze. Do you realize what pain and confusion we
give to children when we are incongruent and inconsistent in what we
say and in what we do in front of them? We can easily ruin their future by
our faulty behavior.
Juvenile delinquents start their delinquency from what they see, observe
and experience with adults. We definitely need role models. We need con-
gruent adults; we need consistent mature individuals to help young minds
acquire, form and develop their conscience and values. Each one of us
should be the congruent, consistent responsible role model for the chil-
dren of tomorrow.
Let us now pause and have some activities on conscience and the begin-
ning of life.
Activity 14-1
Observe a toddler play. Is she destructive with the toys? What
language was employed while play was going on? Then observe
an adult in the house who lives most of the time with the child.
Observe well, interact, analyze and look for similarities in their
behavior, language and actuation.

You should be able to see the similarity between the child’s mind
and actuation and that of the adult. Analyze why such similari-
ties are found between the child and the adult. Include in your
analysis Filipino rearing practices especially on the aspect of imi-
tation and role modeling.
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Activity 14-2
Give at least two cases where you observed:
1. incongruence of teachings and behavior between parents
2. inconsistencies of teachings and behavior between home and

school

There are instances in our life where we see divergence between
what is done and what should be done. To concretize this activity,
observe instances where there is divergence of teachings and be-
havior between parents and between home and school. Give your
own opinion why such situations exist.
Summary
You have learned from this module how significant the beginning of life is
to each one of us. Each child conceived has the human right to be cared
for, to be born, to be respected and to live with dignity. It does not matter
whether the human being is minutes old or nine months old—what we
have to bear in mind is that each fertilized ovum is a human individual
complete with all the DNA and RNA at the very moment of fertilization.
Due respect and care should be given to that beginning of life event. There
is already an innate goodness in that tiny human being.
Conscience, as you have studied, goes hand in hand with value acquisi-
tion, formation and education. Attitudes, actuations of parents and adults
are very important in the child’s personal struggle for growth and devel-
opment. We need role models more than ever because they are the living
books from which children learn most. Children are highly observant and
imitative. They live by what they pick up from the environment, society
and adults. Education should gear them towards full development of what
is good and useful for themselves, and for others. So let us sow good seeds
in them so they develop a sense of responsibility and accountability in life.
UP Open University
Module 14 395

ASAQ 14-1
1. Life begins the moment human sperm fertilizes a mature human ovum.
At this very moment when fertilization takes place, a human being is
procreated in love and because of love. This procreative ability is given
to couples as a gift when union is sealed or sanctioned by the sacra-
ment of marriage. Life has to be respected and be cared for right from
the very moment of its existence up to maturity and death.
2. The beginning of life means the new creation of an individual. It is

very significant because it marks the entrance of a newly created indi-
vidual into the world. It dictates to a certain degree the quality of life
which one will conduct as a growing, developing individual.
3. The nurse working in either the health care practice setting or in the
academe, must keep in mind that he/she has an important role in
emphasizing to parents their responsibility to provide a healthy physi-
cal, psycho-emotional, and spiritual environment to the baby in the
mother’s womb. This is done and concretized through a healthy lifestyle
and a good relationship between the father and mother at home and
at work. The nurse can encourage this during health teaching activi-
ties and most especially through role modeling by being congruent
and consistent in what one says and does to show respect for life.
ASAQ 14-2
For me, conscience is an inner voice, an innate faculty that tends to act
towards something that is good, proper and useful to self and others. The
words used to allude to conscience are “heart” and “loins”. These two
terms connote something that is intimate, interior, essential and vital.
Hence, conscience is the innate light that tells us to do good and avoid
evil. It is a super consciousness that helps us see what is good and what is
bad both for ourselves and for others.
ASAQ 14-3
The pre-forma factors are the quality of the parents’ relationship, and the
quality of sensory stimulation that the child receives from the womb of
the mother up to the childhood years. These factors are very important in
the acquisition, formation, and education of conscience because they in-
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fluence to a great extent the orientation and direction of the child’s think-
ing and actuation to what is good, right, correct, and proper both to self
and to others. Values are acquired, formed, and educated through these
factors. They help shape what a person is to self and to society.
ASAQ 14-4
The remote preparation for moral action takes place between birth and
six years of age. During this time, the child unconsciously develops an
attitude toward authority, law and life by absorbing the surrounding cli-
mate or environment. The child, being very observant and imitative at
this period, will imbibe all that is seen at home from parents, siblings and
significant others including values, beliefs, traditional practices, and man-
nerisms. The child’s orientation towards that of being respectful to au-
thorities, law-abiding and God-fearing is laid down during this remote
preparation period. And because active formation of conscience begins
here, all the more this period of a child’s life becomes very important.
Thus, all efforts and attention should be paid to this period with much
love and caring.
ASAQ 14-5
Building upon natural interests, the period of adolescence should strongly
emphasize moral education centering around the meaning of personhood,
freedom, the responsibility of an individual to serve others, the need to
stand against the group at times, the choice of a vocation and the need to
develop loving and lasting relationships.
UP Open University
Module 15 397
Module 15
Autonomy
Letty G. Kuan
A utonomous choices of persons have to be

respected. This is a principle that runs deep
in common morality. However, people do not
Objectives
agree totally regarding the nature of autonomy.
This sometimes results in endless debates. There
should be able to:
is indeed a need to analyze the principle of au-
tonomy especially as this relates to specific inter-
1. Discuss the meaning of
ventions in health care. We cannot talk of au-
autonomy on the part
tonomy without touching on the issue of informed
of the client, the family
or enlightened consent especially in clinical re-
and the health care
search.
professional;
2. Explain in concrete terms
In this module, we shall discuss the meaning of
the significance of
autonomy and significance of informed consent,
informed or enlightened
taking into consideration the Filipino culture and
consent;
traditional family practices. We shall be citing
3. Analyze situations in
some concrete clinical cases and learn together
health care that involve
some guidelines on what we should know about
autonomy issues; and
autonomy in the course of our professional life.
4. Describe a health care
We shall learn what makes a consent “informed”
professional’s attitude
or “enlightened” and we will examine our role to
toward autonomy and
help our co-professionals respect the autonomy
respect for autonomy.
of our clients.
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Meaning and Extent of Autonomy

The word autonomy is derived from the Greek words “autos” meaning
“self” and “nomos” meaning “rule,” “governance” or “law.” The origi-
nal usage of this word was for the self-rule or self-governance of the inde-
pendent Hellenic city states. Since then, the term has been extended to
individuals and has acquired diverse meanings and interpretations.
In the University of the Philippines System, for instance, we employ the

term “autonomous” for the operation of the different campuses which
are: UP Diliman, UP Manila, UP Los Baños, UP Visayas, UP Mindanao,
UP Baguio, and UP Open University. This means each campus can gov-
ern and subsist on its own and can make decisions without violating the
policies and regulations of the whole system. There is independence or
autonomy in the sense that one is able to see, judge, and decide what is
logical and best for the person to survive and enjoy living. In autonomy,
the individual is free from threats or any type of force or coercion. This
means that the individual is in full control of self, totally aware of what is
the issue, and in a capacity to make appropriate moves and decisions for
the best outcome.
The problem that comes next is: are there qualifications needed to exer-
cise autonomy? Can we say that people regardless of age, status, creed
and race have autonomy? This question can be answered affirmatively if
we regard autonomy as a human feature. However, autonomy can be
studied in many aspects. For instance, some theories on autonomy have
featured the traits of an autonomous person. An autonomous person must
have the capacity for self-governance. To govern one’s self, one must have
these capacities: to understand the issue and what the situation is all
about; to reason out and give one’s own opinion; to deliberate by weigh-
ing the pros and cons of the issue, and then eventually to make an inde-
pendent choice. Basic to making an independent choice is one’s capacity
to make decisions.
Beauchamp and Childress (1994:121) agree that even autonomous per-

sons with self-governing capacities often fail to govern themselves in their
choice because of temporary constraints imposed by illness, depression,
extreme fatigue, or because of ignorance, coercion or conditions that re-
strict options. These authors continue to state that an autonomous person
who signs a consent form without reading or understanding the form has
failed to act autonomously because of failure to read and understand what
the consent demanded. On the other hand, some individuals who are not
generally autonomous can at times make autonomous choices. As an ex-
UP Open University
Module 15 399
ample, some patients who are confined in mental institutions may be un-
able to care for themselves and are declared legally incompetent. How-
ever, they may still be able to make autonomous decisions such as stating
preferences for meals, refusing some medications and interventions, or
making choosing to talk to certain relatives and friends.
Some contemporary writers on ethical theory such as Dworkin (1988)

contend that autonomy is largely a matter of having the capacity to re-
flectively control and identify with one’s own basic or so-called first-order
desires or preferences through higher-level desires or preferences. To make
this clearer, let us take the example of an alcoholic who may have a desire
to stop drinking or a smoker who desires cigarettes but at the same time
also wants to quit smoking. An autonomous person in this situation is one
who has the capacity to rationally identify with, accept, or repudiate a
basic order desire or preference in a manner that is independent of the
manifestation of the desires. Such acceptance or repudiation of the lower
level in favor of the higher level, demonstrating the individual’s capacity
to change his or her preference structure, constitutes autonomy. How-
ever, when we consider the Filipino people in general, there is a common
tendency to consider hierarchy and family authority in making decisions,
even decisions for the self. Many of our decisions and actions are influ-
enced by people in authority such as the family. In order to practice au-
tonomy, there is a need to fully inform or educate the individual so he or
she can reach a decision that we can call appropriate self-governance.
For an action to be autonomous, requirements should touch mainly on a
substantial degree of understanding and freedom from constraint.
SAQ 15-1
What is the meaning of autonomy in general?
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SAQ 15-2
Does the concept of autonomy change when a person becomes a
patient? Explain your answer.
Summing up the principle of autonomy brings us to the corollary prin-

ciple of respect for autonomy. Respect for autonomy means we acknowl-
edge the individual’s right to hold views and opinions, to make choices,
and to take action based on personal values, traditions, and beliefs.
Respect is concretized through action, reaction and attitude. It means
allowing the person to act on his or her own, in other words, autono-
mously; and accepting the person positively for what he or she is to us.
Disrespect for autonomy involves attitudes and actions that ignore, in-
sult, belittle, despise, or demean a person.
Why respect an individual’s autonomy? Because all persons have uncon-

ditional worth and each one has the capacity to determine his or her own
destiny. Philosophers Immanuel Kant and John Stuart Mill have strong
contentions on their statement of personal destiny. To violate a person’s
autonomy is to treat that person merely as a means, that is, in accordance
with another’s goals with no regard to that person’s own goals. Such
treatment is a fundamental moral violation because autonomous persons
are ends in themselves capable of determining their destinies. We must
also consider the individuality of persons in shaping their own lives be-
cause each individual has the capacity to develop the self according to
personal convictions. This is as long as their development does not inter-
fere with the freedom of others. There should be an effort in each one of
us to respect and recognize what the person is worth without prejudice
and prejudgments.
UP Open University
Module 15 401
Autonomy of the client must be respected because this is a person’s right

to exercise freedom of decision and choices. As health care providers,
there is a need for each of us to keep this in mind so that the client is
assured of his/her practice of autonomy.
Now let us pause and see how much we remember. Challenge yourself
with the following SAQs. The answers can be found at the end of this
module, but answer the questions first to test yourself. Here we go!
SAQ 15-3
How is the idea of autonomy practiced in the Filipino family?
SAQ 15-4
How does a health care professional concretize the practice of au-
tonomy?
UP Open University
Informed or Enlightened Consent

Informed consent is also known as enlightened consent. Prior to any sub-
stantial interventions or research participation, clients must have full in-
formation on what the procedure is all about, the objectives, the need and
advantages. During the disclosure phase, alternative measures as well as
outcomes of the procedure (the positive and negative sides) are also made
clear to the client (Beauchamp and Childress, 1994).
Consent forms are legal documents and they serve as prima facie (first-
hand) evidence in court cases. Hence, consent must be obtained in obser-
vance of the following elements.
1. Threshold elements (preconditions)

2. Competence (to understand and decide)
3. Voluntariness (in deciding)
Competence covers the domain of being mentally, emotionally and physi-

ologically well and sane. This means that the individual is not under deci-
sion distress, not under the influence of any intoxicating chemicals, not
pathologically impaired, nor threatened by any form of coercion. In brief,
the person is sound and free to decide and make choices because he or she
is competent and understands what is going on.
1. Information elements
2. Disclosure (of material information)
3. Recommendation (of a plan)
4. Understanding (of the information and the plan)
Disclosure is full information of the matter. If the topic is about a proce-

dure such as surgical intervention, disclosure includes information about
the part of the body involved, the procedure to be done, the effects on the
whole system, the cost of the procedure and the outcome of the interven-
tion. In some instances, visual aids are necessary to facilitate understand-
ing of the procedure or intervention. Informed consent shall be obtained
by the health professional who performs the intervention or procedure.
The nurse is the witness to see to it that the elements of informed consent
are executed by the doctor.
Recommendation of a plan entails a two-way discussion on the advan-

tages and disadvantages of the proposed procedure and making clients
feel that the plan is for their utmost benefit. Alternative plans should be
offered so that clients are really given the best opportunity to choose what
they believe to be the best for themselves.
UP Open University
Module 15 403
Informed consent carries two main functions:
1. Protective — to safeguard against tension of integrity

2. Participative — to be involved in the health care decision making
If the client asks questions to validate what he or she thinks and if these
questions are satisfactorily answered, the understanding of the disclosure
and the recommendation of the plan is evident.
1. Consent elements
2. Decision (in favor of the plan)
3. Authorization (of the chosen plan)
4. Signature (execution of the consent through signature)
Consent obtained from the client starts when there is already a decision.
The chosen plan is clear and the client freely gives consent by voluntary
signing the consent form. At this point, there is no more hesitation or
vagueness of what the procedure or intervention is all about. All points
have been discussed and clarified. The signature of the person concerned
is affixed. This shows that the consent given is an informed and enlight-
ened one.
This whole process of informed or enlightened consent holds true for par-
ticipants of research projects, especially if the research entails some inva-
sive methodologies. Consent should always be obtained from all who
participate as subjects in research.
In research projects, disclosure should generally be made as to the aims,

methods, anticipated benefits and risks of the research. If there is any
anticipated inconvenience or discomfort, the subject has the right to with-
draw from the research.
Additional disclosures and special precautions to ensure that the persons

understand may also be necessary, including disclosure of the criteria used
for the selection of subjects. It may also be important to indicate that the
person has an opportunity to ask further questions.
Let us now go over the text through the following self-assessment ques-
tions and activities.
UP Open University
SAQ 15-5
What is informed or enlightened consent?
Activity 15-1
In your professional practice, informed consent is important, why
is this so? Give examples to illustrate.
SAQ 15-6
1. What comprises threshold elements?
2. What constitutes information elements?
UP Open University
Module 15 405
Activity 15-2
When can you say that the consent obtained is an informed or
enlightened one? Discuss your points by giving an example.
Autonomy and the Health Care Professional

There are situations in clinical practice that sometimes bewilder a health
care professional. Let us take for example, the hospital routine procedure
of giving a patient a bath everyday. More often than not, the patient sub-
mits to the routine activity even without our asking whether the patient
would have preferred not to have a bath that day. Taking for granted the
patient’s autonomy or personal preference happens often in our clinical
practice. It takes a finer sense of awareness of the other person’s rights to
be able to give due respect to another’s autonomy. Taking a person’s likes
or dislikes for granted is one demonstration of the violation of autonomy.
What does a health professional do when the patient is not in his or her
right senses when obtaining the informed consent? Who serves as the
patient’s advocate when a patient is in coma? What about minors, who
makes decision for them?
These questions often get vague answers considering the undefined stand
of health professionals. The field of bioethics as promoted by the Institute
of Ethics and Human Rights in Houston, Texas (1993) specifies the fol-
lowing:
1. When the patient is in a coma, unconscious or incapable of making a

decision, those closest to him or her such as the family or relatives may
decide for the best benefit of the patient.
2. In instances when there are no close relatives and decisions must be

made, the health professionals with honest desires and intentions to
give the best strategy or intervention to the patient may decide for the
patient. The health professionals are expected to execute their advo-
cacy role to the best outcome of the patient.
3. In cases of minors, parents and the family of the patient will assume
the patient’s autonomy and make the decision which should always
be the best for the patient.
UP Open University
It is morally necessary then for each health professional to handle with

care their advocacy and counselor roles. It is worthwhile to remind health
professionals that each patient is an individual equipped with his or her
rights and therefore has autonomy. It is our role to enhance this feeling of
self worth in each one. Hence, due respect should be carried in our very
attitude and in our very nature of how we respect ourselves as health
professionals and how we regard each one as a unique, dignified person.
Activity 15-3
There are instances when patients, due to physiological or
emotional maladies cannot exercise their autonomy in decision
making. Show in this instance the role of health professionals as
advocates of patients.
Activity 15-4
Discuss how health professionals may enhance respect for au-
tonomy in decision making. Give concrete examples.
Summary
This module taught you autonomy and respect for decision-making. You
have also seen what is informed or enlightened consent and the compo-
nents that are necessary in obtaining consent from patients. I hope you
have grasped the significance of informed consent as a legal document
and as an assurance of safety for the patient and for health care profes-
sionals. Invasive interventions must always have informed consent. The
process of securing consent is an excellent opportunity to teach and in-
form patients of what is best for them to attain quality living.
In the same manner, informed consent should be a part of the protocol of

the research process because most researches involve patients’ lives. Hon-
esty is a trait that we health professionals should carry in our very selves
when asking patients to sign informed or enlightened consent forms.
UP Open University
Module 15 407
Nurses must be aware that obtaining consent is not our main domain
because disclosure should be complete and this is the duty of the health
professional who will perform the intervention or procedure. In this case,
the responsibility falls on the physician, surgeon or whoever does the in-
tervention or procedure.
In the field of research, some exigencies of informed consent are expected.

Purpose, methodology and outcome of the study should be fully explained
so that the autonomy of the participant is respected.
In the domain of informed consent, the nurse as a witness must see to it

that the elements and thresholds of the consent are being observed and
correctly executed by the physician
The best way to demonstrate autonomy is to practice it on ourselves. We

can transmit respect to others through the honest conduct of our lives.
UP Open University
ASAQ 15-1
Autonomy in a general sense means self-governance, self-rule and self-
management going in the right and appropriate direction. This ability to
govern the self is dependent upon many factors such as sound mind, sound
body, full information on the issues, without force, coercion, or compul-
sion.
ASAQ 15-2
Autonomy in an individual who is at the same time a client or patient is
primarily the autonomy due to any normal person. Therefore, when a
person becomes a patient who is no longer capable of making decisions
because of mental, physiological or psychological aberrations, then all
decisions have to be charged to the family or the health care professionals
who will decide the best for him or her.
ASAQ 15-3
Autonomy in the Filipino family considers essentially the hierarchy of
family authority. Elders have to be traditionally consulted before any de-
cision is made. To concretize this statement, let me give one example.
Marietta, 23 years old, has decided to marry Alberto in six months’ time.
However, her choice of marrying Alberto is still subject to the approval of
the family. The elders’ advice has a big role in the decision.
ASAQ 15-4
Health care professionals can concretize the practice of autonomy by be-
ing first and foremost a role model in his or her freedom to decide what is
best for himself or for herself. This is demonstrated by respecting one’s
decision; not being influenced by others opinions; keeping an open mind
and respecting fully others’ choices, as well as enlightening clients when
their capacities to make decisions are clouded by vague understanding of
the issues.
UP Open University
Module 15 409
ASAQ 15-5
An informed consent is also called an enlightened consent. It is embodied
in a document called the “consent form” which is needed before any in-
vasive procedure such as surgery or before any research is done. It is said
to be an informed or enlightened consent when the patient or research
participant has been given full disclosure of what the procedure or re-
search is all about; when all possible effects, risks and alternative man-
agement have been honestly discussed; when there is free decision and
agreement of the patient; and when the person concerned affixes his or
her signature voluntarily.
ASAQ 15-6
1. In informed consent, the threshold elements are divided into three
parts. These are:
a. Threshold elements (preconditions)

b. Information elements (full disclosure)
c. Consent elements (voluntarism)
2. The components of information elements are:
a. There is full information or disclosure of what the matter is all

about. This includes material information on the procedure or re-
search to be done.
b. The intervenor recommends a plan of management; alternative
management is also discussed.
c. There is evidence that the person concerned understands the in-
formation and the plan by asking questions and validating his or
her comprehension of the matter.
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Module 16
Beneficence
Letty G. Kuan
B eneficence refers to action done for the good

of others. Nonmaleficence refers to preven-
tion of harm and the removal of harmful condi-
Objectives
tions. In line with these principles, we shall dis-
cuss guidelines on the use of extraordinary means At the end of this module, you
in critically injured individuals and for those should be able to:
whose clinical conditions are irreversible. The field
of Bioethics has evolved fast because of the con- 1. Discuss the principles
tinuously changing economics and lifestyles of of beneficence and
people all over the world. We have now classi- nonmaleficence; and
fied extraordinary measures as proportionate or 2. Analyze situations
disproportionate means depending on the patho- where the principles of
logic conditions of the sick as well as on their so- beneficence and
cioeconomic capabilities. nonmaleficence apply.
Our morality dictates that not only do we respect

a person’s autonomy but also that we contribute to their welfare. Let us
keep in mind that each person by nature, is good. Everyone possesses
kindness in the depths of their hearts and beings. Let us study together
the significance of beneficence in our dealings with ourselves and with
others.
As you go through the text, you will see that beneficence goes hand in
hand with our benevolence and prevenance. Benevolence is goodness in
each personhood. Prevenance on the other hand, is the attentiveness dic-
tated by kindness to anticipate what one needs. In each one of us, there is
that inner goodness that pushes us to alleviate the pain and discomforts
of other people.
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The Concept of Beneficence

Beauchamp and Childress (1994), Pesche (1990), and other bioethicists
associate beneficence with acts of mercy, kindness, and charity. Human-
ity, altruism, and love are also sometimes considered forms of beneficence.
Benevolence refers to the character trait or virtue of being inclined to do
good and act for the benefit of others. Many acts of beneficence are not
obligatory, but there are instances when one is obliged to do emergency
care to one who is hovering between life and death.
Some ethical theories like utilitarianism are based on the principle of be-
neficence. This means goodness and kind deeds form the backbone of the
utilitarian theory. Utilitarianism is defined as the moral and political right-
ness of an action and is determined by its contribution to the greatest
good of the greatest number.
Later thoughts on beneficence touch on obligatory beneficence and ideal

beneficence. Different philosophers like Bentham and Ross employed the
term beneficence to identify positive obligations to others. Many critics
though are suspicious of the claim that we have these positive obligations.
Bentham and Ross hold that beneficence is purely a virtuous ideal or an
act of charity, thus persons are not morally deficient if they fail to act
beneficently. These concerns rightly point to a need to clarify and specify
beneficence, taking care to note the limits of our obligations and the points
at which beneficence is optional rather than obligatory.
An example of beneficence is found in the New Testament in the Parable

of the Good Samaritan, which illustrates several problems in interpreting
beneficence. As the parable goes, a man traveling from Jerusalem to Jeri-
cho was beaten by robbers who left him “half dead.” After two other
travelers passed by the injured man without rendering help, a Samaritan
saw him, “had compassion, went to him and bound up his wounds,
brought him to an inn, and took care of him.” In having compassion and
showing mercy, the Good Samaritan expressed an attitude of caring for
the injured man. Both his motives and actions were beneficent.
The parable, however, suggests that positive beneficence is more an ideal

than an obligation because the Samaritan’s act serves to exceed ordinary
morality. Furthermore, suppose that the injured man, when encountered
by the Samaritan gives an advance directive indicating that he wants to
die. The Samaritan then would face a dilemma: should he respect the
injured man’s wishes or will he take care of him against his wishes?
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Module 16 413
Beneficence, then, is sometimes an admirable ideal of action that exceeds

obligations, and at other times is appropriately linked to other moral obli-
gations. Beauchamp and Childress (1994) and others ask: Are we ever
obligated to act beneficently? Does our moral obligation stem from our
feelings and duties to do good to our neighbor?
The questions can be initially addressed by noting that acts of beneficence

play a vital role in moral life quite apart from the principle of obligatory
beneficence. No one denies that many beneficent acts, such as the dona-
tion of a kidney to a stranger, are morally praiseworthy and not obliga-
tory. In organ donation, we are cautious because under the beneficent act
of giving one’s organ to another, we also touch the principle of steward-
ship. This principle of stewardship reminds us that we are care takers or
stewards of our body and that we cannot just give any part of our body
without due cause or the utmost benefit of another person in need.
Virtually everyone agrees that the common morality does not contain a
principle of beneficence that requires severe sacrifice and extreme altru-
ism. Only ideal beneficence incorporate such extreme generosity. We are
likewise not morally required to give benefits to persons on all occasions,
even if we are in a position to do so. For example, we are not morally
required to perform all possible acts of generosity or charity that would
benefit others. We can readily grant then, that ideal beneficence means
going out of one’s way in order to do good to others. Beneficence is plain
goodness to others without going out of one’s ways.
Nonetheless, several rules on obligatory beneficence form an important

part of morality. Because of the wide range of types of benefits, the prin-
ciple of beneficence supports an array of more specific moral rules, in-
cluding some that are already noted without referring to them as rules.
What we have to keep in mind are the following beneficent rules taken
from Principles of Biomedical Ethics (1994).
1. Protect and defend the rights of others

2. Prevent harm from occurring to others
3. Remove conditions that will cause harm to others
4. Help persons with disabilities
5. Rescue persons in danger
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SAQ 16-1
1. What is the principle of beneficence?
2. What do you mean by “ideal beneficence”? Give one example.
3. Discuss in your own words the meaning of “obligatory benefi-

cence”. Give one example.
SAQ 16-2
Discuss the principle of nonmaleficence. Give an example.
UP Open University
Module 16 415
SAQ 16-3
Try filling in the table below. Put a (P) in the boxes if the ideas on
the first column describe the principles of beneficence and/or
maleficense.
Beneficence Nonmaleficence
Doing good to others

Altruism
Preventing harm
Not inflicting harm
SAQ 16-4
Cite activities in your work setting that exemplify these five rules
of beneficence:
1. Protect and defend the right of others.
2. Prevent harm from occurring to others.
3. Remove conditions that will cause harm to others.
4. Help persons with disabilities.
5. Rescue persons in danger.
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Beneficence and Nonmaleficence and

their Implications on Certain Situations
The principle of nonmaleficence asserts an obligation not to inflict harm
intentionally. The maxim of medical ethics is Primum non nocere, which
means, “above all, do no harm to anyone.” An obligation of nonmaleficence
and an obligation of beneficence are both expressed in the Hippocratic
Oath: “I will use treatment to help the sick according to my ability and
judgment, but I will never use it to injure or harm them.”
This module discusses the distinctions between killing and letting go, with-
holding and withdrawing life-sustaining treatments and use of extraordi-
nary versus ordinary means.
Many controversies in biomedical ethics surround the terminally ill and

the seriously ill and injured. It is of prime importance that you have a
framework for decision-making about life-sustaining procedures and as-
sistance in dying. At the center of the framework is an interpretation of
the principle of nonmaleficence that sanctions rather than suppresses
quality of life judgments. This framework allows patients, guardians, and
health care professionals under certain conditions to accept or refuse treat-
ment after weighing the benefits and burdens of those treatments.
Beauchamp and Childress (1994) suggest the following scheme to distin-

guish the principle of nonmaleficence and beneficence without proposing
any normative ranking or hierarchical structure.
Nonmaleficence
• One ought not to inflict evil or harm
Beneficence
• One ought to prevent evil or harm
• One ought to remove evil or harm
• One ought to do or promote good
Each of these three forms of beneficence requires taking action by pre-

venting harm, removing harm and promoting good, whereas non-malefi-
cence only requires intentionally refraining from actions that cause harm.
Other philosophers and even some bioethicists may have other points by
which they make a distinction between nonmaleficence and beneficence.
For this discussion, nonmaleficence is explained using the term “harm”.
Nonmaleficence is not doing harm or inflicting evil on someone, espe-
cially physical harm. Nonmaleficence here is avoiding any intent or cause
that will lead to death.
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Module 16 417
Because there are many types of harm, the principle of nonmaleficence

supports many specific moral rules. Other principles, such as autonomy
and justice, are also occasionally called upon to help justify these rules. In
1988, Gert, a bioethicist working in moral-oriented disciplines, gave the
following typical examples of nonmaleficence.
1. “Do not kill.”

2. “Do not cause pain or suffering to others.”
3. “Do not cause offense to others.”
4. “Do not incapacitate others.”
5. “Do not deprive others of the goods of life.”
Obligations of nonmaleficence are obligations of not including harm, and

not imposing risks of harm. A person can harm or place another person
at risk without malicious or harmful intent and the agent of harm may or
may not really be morally or legally responsible.
To safeguard health care workers, hospitals and medical centers follow a

standard of due care. The standard of due care specifies that with emer-
gency or urgent cases, attempting to save lives after a major accident jus-
tifies the risks created by such emergency measures. Negligence in caring
for someone in need is considered a departure from the standard of due
care. In the Philippines, hospitals and medical centers, both of the gov-
ernment and private types, subscribe to this standard of due care.
When it comes to withholding versus withdrawing treatments, letting go

for the dignity of death versus committing assisted suicide, could very
well be an issue. This often places the health care professionals in a con-
fusing situation. Most of the time, the health care professional is guided
by his or her values, family practices, philosophies and beliefs. It is in
situations like these that guidelines are very much appreciated. However,
not all hospitals and medical centers have bioethics committees that can
issue bioethical guidelines.
Bioethics committees such as the Institutes of Ethics and Religion at Baylor

College of Medicine in Houston, Texas and the South East Asia Center for
Bioethics at University of Santo Tomas, Manila have made some guide-
lines for the following main issues.
Withholding versus Withdrawing Treatments
Many health care professionals and families feel guilty when treatment is
withdrawn (stopped) compared to when treatment is withheld (not
started). What about you, what feelings do you have regarding this issue
of withholding versus withdrawing treatment? I believe feelings and re-
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actions to this particular issue are as varied as our personalities. What we

shall discuss here are general guidelines to help us facilitate the process of
decision making.
Both withholding and withdrawing treatment are bioethical issues which

can be acted upon or justified by the following conditions:
1. When the case is irreversible and any form of treatment will not bene-
fit the patient.
2. When death is imminent or when patient is already dead.
When the condition is such that any intervention will not benefit the pa-
tient, then treatment is not obligatory. We have to respect the patient’s
call for dignity of death. However, caring should surround the person
until the time of death.
Ordinary versus Extraordinary Measures
Recent developments in Bioethics talk about use of ordinary and extraor-

dinary measures; whether these are proportionate or disproportionate to
the case and to the families concerned. An extraordinary measure entails
the use of aggressive modalities vis-à-vis the financial capabilities of the
family. There are cases where families who can very well afford it, con-
tinue to give extraordinary measures such as being hooked to respirators
and giving third generation antibiotics indefinitely. These measures do
not necessarily offer any benefit to the patient. The act is usually done to
ease the guilt feelings of the family, and for them to feel that they did
everything they could. However, these extraordinary measures are artifi-
cially prolonging the life of the patient. Obviously, these extraordinary
means are loading the patient with more burden and fatigue and are in
fact a hindrance to letting the person go in peace and dignity. Since fami-
lies who insist on these measures can afford them, the expenditures are
proportionate to their demands. What we can do as health care profes-
sionals is to help enlighten these families on the futility of the actions and
that resources can be better used in other channels resulting in more ben-
efit to others.
Ordinary measures comprise the provision of necessities of life and usu-

ally pertain to food, normal respiration and elimination process. Hence,
intravenous fluids, nasogastric tube feedings, indwelling catheters are con-
sidered necessary measures and may be sustained even if the case is irre-
versible. All measures considered to be ordinary may be sustained until
the time of death.
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Module 16 419
Subjecting patients to chemotherapy and hemodialysis when they are on

the verge of death may become disproportionately extraordinary because
of the burden on the patient’s already weak body vis-à-vis the interven-
tion costs. Again, the guideline is, when the intervention will offer no
benefit to the patient, then treatment should not be forced on the patient.
Killing versus Letting Go
Nowadays, we are beset with the issue of assisted suicide. Some first-
world countries have legalized the person’s choice to die at his or her own
chosen time. Assisted suicide is knowingly administering some help to
hasten death. In a way, this is a form of killing because something is intro-
duced in the body to end life earlier than its natural schedule.
Letting go, on the other hand, is allowing a patient to die by not adminis-
tering any hastening element. When treatments and extraordinary mea-
sures are withdrawn because these measures no longer offer any benefit
to the patient, you are actually allowing that person to die with dignity
at his or her time of final departure. What we have to keep in mind is that
we should always give the best care—surround the dying person with
much love, respect, and prayers.
The Do Not Resuscitate (DNR) order is indicated when the case is far
beyond reversibility and death is very certain. By not administering any
cardiopulmonary resuscitation in the event of cardiac arrest, we are actu-
ally letting the person go in peace and in dignity.
We should not feel guilty that we have not done our part in these
situatuions so long as we have rendered our best nursing care. In all these
instances, the principle of beneficence and nonmaleficence should be our
guides in the care of patients.
SAQ 16-5
Discuss the meaning of standard of due care.
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SAQ 16-6
What is meant by “letting go”?
SAQ 16-7
Describe an instance where the principle of beneficence is violated
in relation to administering an extraordinary measure.
SAQ 16-8
What is the general guideline for withdrawing treatment?
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Module 16 421
Summary
This module discussed the principle of beneficence and the accompany-
ing principle of nonmaleficence. Both principles point to one direction: to
attentively do good to others and to avoid inflicting harm. The field of
Bioethics which is the study of the human conduct of life, will always be
confronted by many issues. Why? Because of advances in biomedicine,
biotechnology, eco-engineering, and many other fields. Consequently, our
lifestyle also changes little by little because of the changes within the ecol-
ogy and society.
We also saw the implications of the principles of beneficence and

nonmaleficence in several concerns: “killing versus letting go”, “ordinary
versus extraordinary means” as well as “withholding versus withdraw-
ing treatments”. The Do Not Resuscitate Order for irreversible cases is
along the line of letting the patient go and die in dignity. Let us remember
that treatment is not obligatory when this does not offer benefit to the
patient. At all times, let us uphold that we are here to help patients live a
quality life, giving them utmost goodness and kindness at all times.
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ASAQ 16-1
1. Beneficence is an act of goodness, kindness, an action done for the
good and benefit of others. It comes from the Latin words “bene” mean-
ing good and “fiche” meaning to act or do.
2. Ideal beneficence is a benevolent act that involves going out of one’s

way to do good to others. An example of this ideal beneficence is the
following situation: A nurse was riding on a bus. Suddenly one of the
passengers fainted probably because of hypoglycemia and fatigue.
The nurse brings her to the nearest hospital, stays with her until she
regained full control of herself. In addition, she brought her back to
her home and gave her food. This act is virtuous and ideal; not every-
one would do such a good act for a stranger. The nurse felt she had to
do it because it was her inner extreme moral obligation that prodded
her to do so.
3. Obligatory beneficence is a mandatory act to do good, to give aid to

those who are in need. An example is: in emergency cases, no one
should be denied urgent care. To offer a glass of clean water when
someone is thirsty, to shelter the homeless, to feed the hungry, to give
love to abandoned children, are some examples of obligatory benefi-
cence.
ASAQ 16-2
The principle of nonmaleficence asserts an obligation not to inflict harm
intentionally on anyone. One ought not to inflict evil or harm. An ex-
ample is not of creating false rumors to destroy another’s reputation.
ASAQ 16-3
Both the principles of beneficence and nonmaleficence focus on doing
good to others. Both principles are attuned to altruism—to do acts of kind-
ness and goodness towards self and others because all by nature are good
and all deserve goodness. The difference lies in the nature of execution:
beneficence starts with preventing harm from happening to anyone. This
principle sees to it that any individual will not be harmed in the physical,
emotional, psychological, and spiritual sense. Nonmaleficence on the other
UP Open University
Module 16 423
hand, focuses mainly on the subject of not inflicting harm. In a sense,

these two principles have more similarities than differences because both
aim to do good deeds to others at all times.
ASAQ 16-4
Here are some examples of demonstrating the five rules of beneficence:
Rule 1: Protect and defend the rights of others.

An example is explaining to the patient who will undergo surgery that he
or she has the right to know what the surgery is all about, what benefits
versus risks the surgery will bring, and that he or she has the right to
know the alternative management aside from the surgical intervention.
Rule 2: Prevent harm from occurring to others.

Putting up the side rails of the bed of a restless patient is an example of
preventing the occurrence of harm to others. Another example is using
double gloves when doing an intervention with an AIDS patient in order
to prevent harm from occurring to self and others. In the academic set-
ting, tutoring a failing student will help him or her to pass the course.
Rule 3: Remove conditions that will cause harm to others.

When caring for patients who are not mentally sound, pills, sharp ob-
jects, hazardous materials such as candles, gasoline and matches should
be safely kept away. Another example is avoiding talking about topics
that will depress or provoke patients to be violent.
Rule 4: Help persons with disabilities.

Examples are guiding and holding the hands of a blind or deaf individual
while crossing the street; reading a newspaper or book to someone who
has defective eyesight. There are many examples you can think of in your
practice.
Rule 5: Rescue persons in danger.

Several examples are: throwing a lifesaver to someone who is drowning;
cheering up someone who is depressed or suicidal. I’m sure you have
some more examples for this rule.
ASAQ 16-5
By standard of due care, we mean that during emergency or urgent cases,
there should be no negligence. All the risks that go with such emergency
measures are justified because of the sincere attempt to save a life. No one
should be refused treatment when the condition is life-threatening.
UP Open University
ASAQ 16-6
To “let go” is to allow a person to die with dignity. When death is immi-
nent and any form of treatment will no longer benefit the patient, no
extraordinary measures should be done so that the patient is allowed to
die naturally. To “let go” also means to surround that someone with loads
of loving touch, prayers, spiritual words from the family, friends and health
care givers.
ASAQ 16-7
The principle of beneficence is violated in relation to the administration of
an extraordinary measure when the advantages weigh less than the dis-
advantages. An example is this: keeping a 92 year old cancer patient whose
condition is irreversible under respirator and chemotherapy for months,
in the process consuming all the family’s resources. The money spent could
have gone to the scholastic needs of the grandchildren who were obliged
to stop schooling. Beneficence could have been applied to the living ones
who still have a long way to go to enjoy quality living.
ASAQ 16-8
The general guideline for withholding and withdrawing treatment in-
volves determining whether the case is definitely irreversible, death is im-
minent, and any treatment will be futile. In this case, there is no more
obligation to treat, but care should be maximized so that the person feels
loved and prepared for death.
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Module 17 425
Module 17
Justice
Letty G. Kuan
I s there justice in access to health care? to edu-

cation? to job placement? These questions re-
volve around the concept of some Filipinos that Objectives
justice is often equated with “chance”, “lottery”,
“strong connections”, “powerful influence”. At the end of this module, you
should be able to:
The term justice evokes fairness, what is
deserved, due, equitable, or appropriate in 1. Discuss the meaning of
society determined by norms that structure the the principle of justice as
terms of social cooperation. this applies to health care;
2. Distinguish between
In this module, we shall study the implications of microallocation versus
justice as it touches on the micro and macro allo- macroallocation of
cation of resources, focusing on the Filipino fam- resources; and
ily—its values, traditions, customs, and practices. 3. Analyze the implication
of the principle of justice
As you read, take note of your own family prac- on the Filipino family—
tices, values, customs, and traditions and see how culture, customs, values,
principle of justice applies. practices and traditions.
The Concept of Justice

The terms fairness, deserts (what is deserved) and entitlement (that to
which one is entitled) have been mentioned by various philosophers in an
attempt to explain the term justice. Justice is giving each one his or her
due. Let’s take an example. Someone who has been working hard on the
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job does not get the needed promotion while another one who gets pro-
moted without merit. The one who worked hard is entitled to something;
in this case, a promotion. An injustice therefore involves a wrongful act
or omission that denies people benefits to which they have a right to.
There are many types of justice according to Beauchamp and Childress

(1994):
1. Distributive justice — refers to fair, equitable, and appropriate dis-

tribution of responsibilities, or share of rights and roles.
2. Criminal justice — refers to the just infliction of punishment, or pen-
alty proportionate to the crime committed.
3. Rectificatory justice — refers to just compensation for transactional
problems such as breaches of contract and practice based on civil law.
Problems of distributive justice arise under conditions of scarcity and com-

petition. When the supply is limited, distributive justice requires that more
should be given to the one who needs most and to the one who will be
most benefited to attain quality life. When fairness is observed with hon-
est justification in allotting shares of limited goods, distributive justice flows
without much problem. When the available supply is too limited, and
there are just too many who desire to avail of the limited supply, some-
times it is resolved by lottery, giving each one a fair probability of being
selected.
Engelhardt, Keusch, Wildes (1995) and others have suggested the follow-
ing principles as valid material principles of distributive justice:
1. To each person an equal share

2. To each person according to need
3. To each person according to effort
4. To each person according to contribution
5. To each person according to merit
6. To each person according to free-market exchanges
There is no obvious barrier to the acceptance of more than one principle,

and some theories of justice accept all six as valid. A plausible moral theme
is that each of these material principles identifies a prima facie obligation
whose weight cannot be assessed independently of particular circum-
stances in which they are especially applicable. Additional specification
may also establish the relevance of these principles to a circumstance in
which they formerly had not been judged applicable.
Theories of distributive justice have been developed to specify and unite

our diverse principles, rules, and judgments. A theory attempts to con-
nect the characteristics of persons with morally justifiable distribution of
UP Open University
Module 17 427
benefits and burdens. For example, a person’s service, effort, or misfor-

tune might be the basis of distribution. Several systematic theories have
been proposed to determine how social burdens, including health care
goods and services, should be distributed or redistributed.
Some influential theories that go with the principle of justice are the fol-
lowing:
1. Utilitarian — emphasizes a mixture of criteria for the purpose of maxi-

mizing public utility
2. Libertarian — emphasizes rights to social and economic liberty, in-
voking fair procedures rather than substantive outcome
3. Communitarian — stresses the principles and practices of justice that
evolve through traditions in a community
4. Egalitarian — emphasizes equal access to goods in life that every ra-
tional person values
The acceptability of any theory of justice is determined by the strength of

its moral argument. But we must all seek to provide the best possible health
care for all citizens and promote public interest through cost-containment
programs. Gender, race, or social status should not become impediments
to having and getting what is due.
Activity 17-1
Using a concrete example in your professional practice, can you
discuss the meaning of the principle of justice?

The discussion should highlight the meaning of the principle of
justice in terms of being fair, what is deserved and what is due.
Respect for equitable appropriate distribution of either responsi-
bilities or privileges should be present.
An example is acknowledging a person’s efforts and giving awards

according to what was accomplished. The opposite example is al-
locating resources to someone who has close ties to the boss, or
taking in less worthy candidates for employment just because they
have strong political backers. Examples along this line are many.
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SAQ 17-1
Explain how the following differ from one another:
1. distributive justice
2. criminal justice
3. rectificatory justice
Activity 17-2
Give a concrete example to demonstrate the principle of “to each
person according to merit”.

An example would be promotion through objective measures of
merit, such as recorded achievements, and rated evaluation of
peers. The person who ranks first should get the corresponding
promotion.
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Module 17 429
SAQ 17-2
Compare and contrast the following theories of justice
1. Utilitarian vs. Egalitarian
2. Libertarian vs. Communitarian
Allocation of Scarce Resources

To allocate is to distribute by allotment. Such distribution does not pre-
suppose either a person or a system that rations services. A criterion of
ability to pay in a competitive market, for example, is a form of allocation.
Macroallocation decisions determine the funds to be expended and the

goods to be made available, as well as the methods of distribution.
Macroallocation decisions in the Philippines deal with how much of the
society’s resources will be used for various needs, including health-re-
lated expenditures. Government decides how much of the national bud-
get goes to health care and what proportion of available health funds
goes to which program.
Microallocation decisions, in contrast, determine who will receive par-

ticular scarce resources. This distinction between the macro and micro
levels of allocation is useful, but the line between them is not clear, and
oftentimes they intersect. In the Philippines, microallocation deals with
how a scarce resource is distributed among individuals with competing
claims to it. Health care providers select which patient will receive the
scarce resource.
Our moral intuition often drives us into two conflicting directions: either
to allocate more to treatment, or allocate more to prevention and educa-
tion. Determining which should receive a priority ranking in the alloca-
tion of health care resources is not easy because philosophies of people
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vary. In these instances, we can only recourse to giving a person his or her
due. It also means treating each one equally. We have to keep in mind
that justice in health care implies that every individual should:
1. Receive benefits due him or her by right such as life, minimum health
care, information for decision-making and confidentiality on private
information;
2. Receive benefits he or she deserves after balancing competing claims
of other persons against his/hers: such as equal opportunity to get an
ICU bed, a pacemaker or an organ transplant;
3. Share in the burden of paying for the cost of health care and health
research.
The statements below are based on what the Southeast Asia Center for
Bioethics (1995) recognizes:
1. Every human being has a fundamental right to health.

2. Individuals have the primary responsibility to promote their own
health.
3. As independent social beings, people have a right to seek the help of
others in fulfilling this responsibility. Reciprocally, people have the
duty to give the same help to others.
In all these, the principle of justice would at least require equal opportu-
nity for all.
SAQ 17-3
1. Why is allotment of resources in health care a prime concern
of health care providers?
2. Is “lottery draw” or games of chance in line with the principle

of justice? Explain your answer.
UP Open University
Module 17 431
Activity 17-3
Describe an actual case in your professional experience involving
macroallocation and microallocation of resources. Discuss how the
issue/problem was resolved. How did you feel about the matter?

Macroallocation decisions deal with how much of society’s re-
sources are used for various needs, including health related
expenditures. Government decides how much of the national bud-
get goes to health care, and what proportion of available health
funds goes to which program. Microallocation decisions, in turn,
deal with how a scarce resource is distributed among individuals
with competing claims to it. Health care providers select which
patient will receive the scarce resources based on agreed selection
criteria.
The Filipino Family and Its Principle of Justice

The Filipino family is included in the discussion of the principle of justice
because this is the beginning unit of society where seeds of justice are
implanted. It is the unit of the society that ingrains in the young mind
what is just and what is fair as exemplified by family members.
The Filipino family is seen as the solid bank where withdrawal of re-
sources is endless. In all kinds of crises, calamities, setbacks, and emergen-
cies, the family is an ever ready source of help, strength, and security.
This is an institution where each family member gets its allocation with-
out having to undergo prioritization, or screening. The family does not
disregard anyone.
The principle of justice here becomes questionable when parents play fa-
vorites among their children. By nature, parenting is fair and just because
each child is a product of the love and sacrifice of both the father and the
mother. Each child in the family is unique and has his or her particular
place in the hearts of parents and siblings.
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The principle of justice also explains why members of the family avoid
giving a bad name or bringing dishonor to the family. Parents invest their
time, talent and money on each child. All members of the family then
must endeavor to promote fair and honest rewards by bringing honor to
the family equal to the commitment and investment of the parents.
Now in your own reflection, think about how the principle of justice ap-
plies to the Filipino family.
Activity 17-4
Enumerate some Filipino family values, practices, customs and tra-
ditions that are related to the principle of justice. Are these good
for the country? Why or why not? Discuss your views.

Jot down values such as fair giving, fair sharing, prevenant atten-
tiveness, respect, thoughtfulness and practice of honest acknowl-
edgment, appreciation and equal sharing of res-ponsibilities. Be-
neficence and autonomy are also inherent in many Filipino fami-
lies. You may list other values, traditions, values, practices, and
customs. Be sure to explain how each one relates to the principle
of justice.
Activity 17-5
Comment on this case:
The youngest of 10 children is born with Down Syndrome. The

older children give their best to this youngest sibling. Allocation of
privileges is quite skewed towards this youngest. Is there justice in
the excessive care given to this child? Discuss.
UP Open University
Module 17 433

Family bonding is often enhanced with the presence of a child
with special needs. This family does not feel that it has violated the
principle of justice. Its actions are motivated by the desire to love
and care for the youngest child.
However, consider also that the youngest is one among 10 chil-

dren and it is likely that resources are very scarce. Reflect on your
position on this issue.
Summary
This module enlightened you on the principle of justice. You saw that
there are types of justice that emanate from this principle such as dis-
tributive, criminal, and rectificatory justice. In line with the discussion of
these justice classifications, you also saw the meaning of utilitarian,
communitarian, libertarian and egalitarian theories of justice.
Then we discussed allocation of resources in the macro and micro levels.

The Filipino family, being the reliable source of resources and values, is
like a solid bank founded on the principle of justice.
The principle of justice is important especially in countries like the Philip-

pines because we face corruption, abuse of kin relationships, and political
pressure in the context of scarce resources. I hope this module helped you
find ways and means to apply the principle of justice in your professional
practice and personal conduct of life.
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ASAQ 17-1
Distributive justice stresses fair, equitable, and appropriate sharing of
rights, roles, resources, responsibilities, and privileges. Criminal justice
stresses getting the penalty commensurate with the crime committed. This
means there should be no exception to the merited penalty. Rectificatory
justice, on the other hand, stresses the compensation due to breaches of
contract or for promises not kept. In other words, rectify the person who
did not observe his or her word of honor.
ASAQ 17-2
The utilitarian theory of justice aims to benefit the greatest number of
people, taking into consideration meager resources. The egalitarian theory
of justice demands that each one gets equal benefit regardless of the num-
ber. The libertarian theory of justice, on the other hand, considers rights
to social and economic liberty through fair procedures, rather than what
the outcome may bring. The communitarian theory of justice considers
the practices, traditions and customs of practicing justice in a commu-
nity.
These descriptions of the theories are, to a great extent, simplified. Be sure

to read more about them.
ASAQ 17-3
1. Allotment of resources is a prime concern of health care providers
especially in the Philippines because of the limited funds available for
the health care of many. Because of the scarcity of resources, funds
should be honestly given to those for whom treatment is due. The
Filipino practices of “lusot” (find a way out of the situation), “lakad”
(solicit support from influential people) and “lagay” (bribery) chal-
lenge the principle of justice. Health care providers should be wary of
improper utilization of resources for health care.
2. Sometimes, we have to use the method of “lottery draw” when there

are too many individuals equally needing a very limited supply of
equipment or treatment. However, utmost care and respect must be
extended to all those who were not selected.
UP Open University
Module 18 435
Module 18
Professional-Patient
Relationship
Letty G. Kuan
T his module on professional-patient relation-

ship discusses the relationship in terms of vir-
tue, character, principles, and rules in bioethics.
Objectives
Professional health care relationships are impor-
tant because health care delivery is a team effort.
should be able to:
Team work requires good relationships within the
1. Discuss the importance
team as well as between the patient, and the fam-
of the professional-patient
ily. Problems of adequate communication, coop-
relationship in health
eration and mutual support arise when the ethi-
care situations;
cal standards of some differ from those of others.
2. Analyze the significance
of privacy, veracity,
In individual patient care, the attending physi-
fidelity, truth telling and
cian is the leader. He or she is the person in au-
confidentiality in health
thority. Fellows, residents, interns, clerks, nurses,
care situations; and
therapists, dentists and pharmacists are his or her
3. Identify the focal virtue of
co-workers. Within the hospital, the administra-
effective professional-
tors are the persons in authority. Professionals
patient relationships.
such as physicians and nurses as well as the an-
cillary and maintenance staff are their co-work-
ers. The person in authority is always looked up to and there is danger
that this position may be abused or misused.
This module discusses privacy, veracity, fidelity, truth-telling and con-

fidentiality in relation to health professional-patient relationships.
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Privacy
Privacy may be defined as the individual’s control over access to himself
or herself extending to physical or informational inaccessibility. In brief,
the person has the right to control access. This kind of definition may
seem too limited. In this module, we shall study privacy perhaps in its
limited sense, focusing mainly on what the person’s rights are when he or
she is in a health care situation.
Filing of libel cases in court most often starts with intrusion into the person’s
private life. Intruding into one’s private life can stem from eavesdropping
and the target unknowingly loses some measure of privacy. What counts
as a loss of privacy and what affects an individual’s sense of loss of pri-
vacy is proportionate to what one values as strictly personal or very pri-
vate.
In hospital settings, when we emphasize “respect for the patient’s pri-

vacy,” we oftentimes allude to territorial inaccessibility and non-expo-
sure to others, as in screening the patient’s territorial area when giving
health care. Discussing the patient’s case publicly, as in student’s medical
rounds without asking the patient’s permission, is trespassing into the
patient’s privacy.
Let us keep in mind what Charles Fried (1990) said: “Privacy is a neces-
sary condition, the necessary atmosphere for maintaining intimate rela-
tionships of respect, love, friendship and trust.” “Without privacy”, Fried
argues, “these relationships are inconceivable.”
Privacy certainly has such instrumental value. We grant access to our-

selves in order to have and maintain such relationships. Whether we grant
someone else access to some aspect of our lives will depend on the kind of
relationship we want in pursuit of our goals. For example, we allow phy-
sicians access to our bodies in order to protect our health.
We often hear the expression, “I need breathing space.” In relationships,

this means a need to be with one’s self, to be private in order to decongest
the self from the other’s shadowing. In any relationship, we have to pro-
vide time for being alone, for being private, to breathe and to be just our-
selves and be inaccessible to others. In health care, each person is unique.
Each is private. Let us respect our patients’ needs for privacy, for mo-
ments of silence.
UP Open University
Module 18 437
Veracity
Veracity in its basic meaning is truthfulness. To be true is to accept one’s
self as one is. To respect veracity in relationships is to deal honestly with
patients and colleagues as they are. With veracity goes virtues of candor
and truthfulness, and these are the widely praised character traits of health
professionals in contemporary biomedical ethics.
Veracity is necessary in professional-patient relationships for three rea-

sons:
1. The obligation of veracity is based on respect owed to others. In ask-

ing patients their consent for any deemed necessary intervention, the
validity of the consent depends on the thorough information, full dis-
closure, and enlightenment given to the patient regarding the proce-
dures or intervention to be done. According to Alan Donagan (1978),
the “respect owed to other human beings includes respect for their
liberty.”
2. Veracity has a close connection to obligations of fidelity and promise-

keeping. When we communicate with others, we implicitly promise
that we will speak truthfully and that we will not deceive our
listeners. Voluntary participation in these social conventions engen-
ders an obligation of veracity, of truthfulness. An example that I could
think of is when a relationship is entered into during therapy or re-
search. The patient or research subject enters into a contract, thereby
gaining a right to the truth regarding diagnosis, prognosis and all other
pertinent information. The professional gains a right to truthful dis-
closure of information from patients and research subjects.
3. Relationships of trust between persons are necessary for fruitful inter-

vention and cooperation. At the core of these relationships is confi-
dence in and reliance on others to be truthful. Relationships between
health care professionals and their patients and between researchers
and their subjects ultimately depend on trust and adherence to rules
of veracity. These are all necessary to foster trust. On the other hand,
lying and inadequate disclosure show disrespect for persons, violate
implicit contracts, and threaten relationships.
Fidelity
By fidelity, we mean the obligation to act in good faith and to keep vows
and promises, fulfill agreements, maintain relationships and fiduciary res-
ponsibilities. Fiduciary responsibility refers to the contract of relation-
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ship we enter into with the patient. The model for fidelity is: keeping
one’s word of honor, loyalty to commitments and oaths, and reliability.
Why so? Because the model of fidelity leans on the values of loyalty and
trust as well as standing true to one’s word. In popular Spanish parlance,
this is known as palabra de honor. With fidelity goes the traits of maturity
and commitment of the person.
Fiduciary relationships bank on trust and confidence. This means that

once the physician or nurse enters into a relationship with the patient,
these professionals become the trustees of the patient’s health and wel-
fare. Hence, both the physician and the nurse are obligated to maintain
the contract of care. They cannot withdraw their care without giving
notice to the patient, the relatives or responsible friends, who need enough
time to look for their replacement attendants. (Ramsey, 1970).
The Council on Ethical and Judicial Affairs on Health Care (1992) speci-
fies that “abandonment is a breach of fidelity, and infidelity amounting to
disloyalty.” Whether or not a promise was made, such infidelity under-
mines trustworthiness, honesty, and loyalty.
According to Benjamin and Curtis (1987), “traditionally, nurses have been

discouraged from developing and acting on their own ethical judgments.
Although the institutions of nursing and medicine developed separately
until the late eighteenth century, the increasing importance of the hospi-
tal in health care brought nursing under the dual command of physicians
and hospital administrators.”
Recent codes of nursing ethics define the moral responsibility of nurses in

sharply different ways from the codes of two or three decades ago. In
America, for example, in 1950, the American Nurses Association stressed
the nurse’s obligation to carry out the physician’s orders, but the 1976
revision stressed the nurse’s obligation to the client. Whereas the original
code emphasized the nurse’s obligation to protect the reputation of asso-
ciates, the later code emphasized the obligation to safeguard the client
and the public from the “incompetent, unethical or illegal” practices of
any person (Hastings Report, 1984).
In the same manner, the Philippine Nursing Law, particularly RA 7164,

passed, promulgated and executed in 1992, emphasizes the role of the
nurse as the client advocate or patient advocate who can do indepen-
dent nursing measures. In brief, the nursing profession acts on ethical
guidelines, independent of the command of physicians or hospital ad-
ministrators.
UP Open University
Module 18 439
This demands keen assessment, competence, and fidelity to the patient

and to the profession for every nurse who cares for patients regardless of
creed, race, or age. Fidelity is possible when one knows what is beneficent
to others and when one respects the autonomy of others, because these
lead to honesty and trust.
Activity 18-1
In health care, the professional-patient relationship is very impor-
tant. Explain how this applies in the following contexts:
a. clinical practice
b. teaching responsibility

You should touch on actual professional-patient relationships
existing between physician-nurse, nurse-patient, and nurse-fam-
ily highlighting respect, confidentiality, openness.
SAQ 18-1
We talked about fiduciary fidelity. What does this term mean?
Why do we talk about this when we speak of professional-patient
relationship?
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Truth Telling
Every competent person has a right to information about himself or her-
self, and about what is planned for him or her. All information must be
disclosed so that correct decisions are arrived at both for the moment and
for the future. Truth telling then is the right of every individual to know
what the situation is all about. To override a patient’s right to the truth
needs a very strong justification. The most common situation is when
truth telling will harm the patient or others because coping mechanisms
needed to accept facts are weak.
In the Filipino culture, the two traits of family orientation to illness and
the non-confrontational attitude affect truth telling. Family orientation
to illness means family members are often informed of serious diagnose
before the patient is told. Many times, the family may request the doctor
not to tell the patient the truth, as in the case of cancer, because telling the
patient may bring more harm. The non-confrontational attitude, on the
other hand, prevents us from disclosing unpleasant views. Doctors may
hesitate to tell a patient that he or she is dying. Most physicians still sub-
scribe to the death denial culture. At times, doctors use euphemisms and
oftentimes this results in wrong conclusions and inappropriate decisions.
But these are realities we cannot ignore because the family is a very essen-
tial component of Filipino culture and they have the right to know the
truth.
The non-confrontational attitude of Filipinos prevents issues from being

addressed. The following situation is an example. Myra knows that her
friend Lisa’s husband is having an affair with his secretary. Myra cannot
confront Lisa to tell her what she knows because this might do harm to
the relationship. In reality, graver conflicts between husband and wife
are bound to arise by not confronting Lisa with the truth while the affair
is at its early stage.
Another example is hearsay. Rumors have no roots but they fly far and
wide and they bring damage to the persons concerned. Non-validation
and non-confrontation are aspects of some Filipino characteristics trace-
able to shame or hiya.
Confidentiality
Keeping in confidence all that one has learned in the course of caring for
the patient and the family, is a very strong basis for an effective and work-
ing professional-patient relationship. To confide in someone like a physi-
UP Open University
Module 18 441
cian or nurse, one has to feel secure that secrets are securely guarded and
kept in confidence. Confidentiality often does not apply to families be-
cause each member knows or will try to know about each other.
Let us make the distinction between infringement on privacy and in-

fringement on confidentiality. The difference is this: An infringement of
X’s right to confidentiality occurs only if the person to whom X disclosed
the information in confidence fails to protect the information, or deliber-
ately discloses it to someone without X’s consent. In contrast, a person
who, without authorization, enters a hospital records room or computer
data bank, violates the right to privacy rather than confidentiality. In sum,
only the person or institution to whom information is given in a confiden-
tial relationship can be charged with violating rights of confidentiality.
Nurses, physicians, and guidance counselors are some of the profession-

als among whom confidentiality must be observed, respected, and guarded
because many confidences are revealed to them in the course of the exer-
cise of their profession. These professionals must have keen ears to listen,
big hearts to understand, and very small mouths to talk. Once secrets are
confided, they should be sealed with much respect because with confi-
dentiality, there is trust.
In health care, truth-telling and confidentiality are essential components

that must always be respected. Smooth professional-patient relationships
happen when truth telling and confidentiality along with the other com-
ponents of a relationship such as privacy, veracity, and fidelity, are hon-
estly kept and respected at all times. Hence, we need constant discern-
ment of our words and critiques so that we are reminded of the magni-
tude of our responsibilities in all our relationships with others.
Activity 18-2
Analyze the following situation and briefly explain what traits of
the professional-patient relationship are involved in the case.
Brenda, a 42 year old mother of two was found to be HIV positive.

She does not know that her husband goes to the bar while he trav-
els to the province to promote the products he carries. You as the
clinic nurse learned about the blood examination result. The doc-
tor told you to keep the information in confidence. But Brenda is
your close friend. How will you help Brenda?
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Analysis of this case should touch on respect, veracity, confidenti-
ality, truth telling and appropriateness.
SAQ 18-2
What aspects of Filipino culture alter the dimensions of truth tell-
ing and confidentiality?
Virtues in Professional Life

Virtues of nurses reflect oftentimes the models of the nursing profession
and its roles and responsibilities. In the model of yesteryears, the nurse
was regarded as the “handmaid” of the physicians; thus she was expected
to portray the passive virtues of obedience and submission. In contem-
porary models, the nurse is a co-manager, a partner in health care and
has an active role of advocacy for patients. Hence, the prominent virtues
to be portrayed include respect for autonomy, justice, persistence, and
courage. Obedience to rules is demanded in the traditional model, but
constant attention to patients’ rights and preservation of the nurse’s in-
tegrity are emphasized in contemporary autonomy models, especially
those that call on the nurses to be the patients’ advocate.
UP Open University
Module 18 443
In the health care profession, we often say that a virtuous person has a
virtuous character. It is difficult to describe all the virtues in a person, but
some virtues are more focal and proximate for health care professionals
(Beauchamp and Childress, 1994).
1. Compassion. This is a trait that combines an attitude of active regard

for another’s welfare with an imaginative awareness and an emo-
tional response of deep sympathy, tenderness and discomfort at the
other’s misfortune or suffering. Compassion presupposes sympathy,
has affinities with mercy and is expressed in acts of beneficence that
attempt to alleviate the misfortune or suffering of the other person.
Unlike integrity, which is inwardly focused on the self, compassion is
outwardly focused on other selves. The trait of compassion resembles
closely the moral sentiment of care.
People all over the world feel reassured and cared for when they sense
that you are a person of compassion. It is therapeutic to feel compas-
sion in the health care professional because this is an assuring assis-
tance. The health care professionals who express no emotion in their
behavior, only professional skill, often fail to provide what patients
most need. Emotional engagement and communication are important
parts of human relationships in general, and health care in particular.
2. Discernment. The virtue of discernment rests on sensitive insight in-

volving acute judgment and understanding, and it results in decisive
action. Discernment includes the ability to make judgments and reach
decisions without being unduly influenced by extraneous consider-
ations, fears or personal attachments. Discernment often pairs in ac-
tion with courage and fidelity to one’s duty.
Practicality of mind and common sense have big roles in the exercise
of discernment. With discernment goes the virtue of prudence. A per-
son of practical wisdom knows which goals should be chosen and
knows how to realize them in particular circumstances, while keep-
ing emotions within proper bounds and carefully selecting from among
the range of possible actions. Beauchamp and Childress (1994) quoted
Aristotle, “the practically wise person understands how to act with
the right intensity of feeling in just the right way, at just the right time,
with the right balance of reason and desire”.
In general, the person of discernment identifies what a circumstance

calls for in the way of human responsibilities. For example, a discern-
ing nurse will find ways and see when a patient in despair needs
empathic comfort more than privacy. If comfort is the right choice,
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the discerning nurse will find the appropriate type and level of conso-
lation in order to be helpful rather than intrusive. Discernment is a
necessary condition in a good decision.
Discernment is an essential component of care. It is a talent and an

ability to understand what needs to be done for patients. It is also an
ability to understand how to do caring by giving sensitive responses.
Discernment is a consistent and constant trait and is a great factor in
providing quality care.
3. Trustworthiness. To trust someone is to have a confident belief in

and reliance upon the ability and moral character of another person.
Trust entails confidence that another will act with the right motives
in accord with moral norms. Baier (1986) emphasizes that such trust
is often the most important ingredient in our choice of one physician
rather than another. A perceived lack of trustworthiness in a physi-
cian may be the primary reason for a patient’s decision to switch to
another. Trust binds friendship and intimate relationship.
If friends part ways and married couples separate, the basic cause of
the break-up is usually a loss of trust. Oftentimes, infidelity sets in
when trust is no longer present in the relationship. In the professional-
patient relationship and even in ties among friends, trust seals the
bond of openness and confidentiality.
When a physician trusts his or her nurse, the professional relationship

propels effective teamwork. By the same token, when a patient trusts
his or her nurse, the interaction invites compliance to treatment and
other forms of therapy. We have to cultivate trust in our ourselves
because trust is a very essential factor in fostering congenial profes-
sional-patient relationships.
4. Integrity. By integrity we mean soundness, reliability, wholeness, and

integration of moral character. Oftentimes, integrity is seen as moral
integrity which refers to fidelity in adherence to moral norms. Integ-
rity describes two aspects of a person’s character. The first is a coher-
ent integration of aspects of the self—emotions, aspirations, and knowl-
edge so that each complements and does not frustrate the others. The
second is the character trait of being faithful to moral values and stand-
ing up in their defense when they are threatened or under attack. An
individual with integrity is endowed with values that are consistent
and constant in practice. There is also congruence and genuineness in
his or her words and actions. In a professional-patient relationship,
people with integrity easily win friendship and reliance from others.
UP Open University
Module 18 445
We have covered in this module some of the admirable traits that foster
and maintain the professional-patient relationship. Let us pause shortly
for the following self-assessment activities.
Activity 18-3
Interview nurses who graduated in the 1950s and 1960s. Inter-
view also those who graduated in the 1990s or later. Ask them
what virtues are associated with nursing. Compare their responses.

Your comparison should highlight this, among other themes:
1. earlier times — handmaids of physicians (obedience, submis-

sion)
2. modern times — patient advocacy (assertiveness)
SAQ 18-3
Is trustworthiness similar to the virtues of integrity and discern-
ment? Explain your views.
UP Open University
Summary
We have seen in this module the essence of the professional-patient rela-
tionship. This relationship anchors its strength on effective teamwork
which in turn counts on certain traits, character, and virtues that every
professional health carergiver must possess. In the process, we learned
the meanings and significance of privacy, veracity, fidelity, truth telling,
and confidentiality.
Health care professionals must have such virtues as compassion, discern-

ment, trustworthiness and integrity, among others. Compassion, discern-
ment, trustworthiness and integrity make the health care professionals
worthy to carry and maintain effective professional-patient relationships.
Caring is highly based on therapeutic interaction between the caregiver
and the client. This relationship is a contract enveloped in mutual trust
and confidence.
Now that we have seen the importance of the components of an effective

professional-patient relationship, let us all strive to cultivate and develop
the traits, virtues, and character needed to help us become better profes-
sional caregivers.
I hope you enjoyed studying this module and will share with others what-
ever you have learned.
UP Open University
Module 18 447

ASAQ 18-1
Fidelity is acting in good faith, keeping one’s word of honor by fulfilling
promises. Fiduciary fidelity is the faithfulness or loyalty we maintain and
keep once we get into a contract a patient. Fiduciary fidelity capitalizes
on trust; in a relationship each one is trustworthy and places trust on one
other.
ASAQ 18-2
The Filipino culture is primarily a family-oriented and family-linked cul-
ture. Specific to the Filipino culture are two prominent traits:
1. Family orientation to illness — the family members must know about

the disease first before the member concerned. Illness is a family con-
cern; and
2. Non-confrontational attitude — we conform even if it is against our
will. We avoid confrontation for fear of hurting others.
Because of these two Filipino traits, truth telling and confidentiality are
altered in health care.
ASAQ 18-3
Trustworthiness is shown when someone you believe to be solidly true,
loyal, and good will stand by you through thick and thin. In some ways,
trustworthiness has semblance to integrity, because integrity means sound-
ness, reliability, wholeness and integration of the person’s moral charac-
ter. There is coherence of the person’s words, actuations and his or her
way of life. Discernment, on the other hand, is the ability to make judg-
ments and decisions without being unduly influenced by fears or per-
sonal interests. This means the person is reliable in his or her judgments
because he or she is true and loyal to his or her philosophy of life. Hon-
esty, loyalty and reliability are common among the three virtues of trust-
worthiness, integrity and discernment. All three are necessary for a suc-
cessful or effective professional-patient relationship.
UP Open University
Unit III References

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Theoretical Foundations

University of the Philippines

Copyright © 2000 by Cora A. Anonuevo, Carmencita M. Abaquin, Araceli

Published in the Philippines by the UP Open University

First printing, 1997

Layout by Dang Cadalo

Printed in the Philippines

Module 1 Nursing Theories: Conceptual Framework

Module 2 Client-Centered Nursing Theories

Module 3 Client-Centered Nursing Theories: Roy, Levine, Hall

Module 4 Nurse-Client Dynamics

Module 5 Client-Nurse Environment Dynamics

Module 6 The General Systems Theory

Module 7 Developmental Theories

Module 9 Theories of Change

Module 10 Theories/Models on Communication

Module 11 Crisis Intervention Theory

Module 12 Gender Concepts and Issues in Health

Module 13 Foundation and Principles of Bioethics in Nursing

Module 14 The Beginning of Life

Module 18 Professional-Patient Relationship

One of the concepts you learned very early in your

behavior of knowing and seemingly not knowing can be explained by the

Table 1.1. Definitions of a theory

Author Definition of a Theory

Pinnel and Menesis (1986) Systematic set of interrelated concepts,

Walker and Avant (1983) Internally consistent group of relational

Chin and Krammer (1991) Creative and vigorous structuring of ideas

Dickoff and James (1968) Conceptual system or framework invented

Ellis (1968) Coherent set of hypothetical, conceptual,

Purpose answers the question, “why is the theory formulated?” It also

Definitions give meaning to concepts. They make concepts clearer and

Concepts are defined explicitly or implicitly. An example of an explicitly

Propositions are expressions of relational statements between and among

Assumptions are accepted “truths” that are basic and fundamental to

1. Systematic, logical and coherent

There must be orderly reasoning and no contradictions between and

2. Creative structuring of ideas

Theory Practice Theory

The first strategy, theory-practice-theory, implies that theory develop-

Theories developed using the practice-theory strategy were based upon

The research-theory strategy is used by those who believe that theories

Theory Research Theory

The theory-research-theory strategy is another approach to theory de-

Figure 1-1. Development of nursing theory

1. Theory guides and improves nursing practice.

Past and present problems in nursing might be solved through theory

2. Theory guides research.

According to Meleis (1985), “the primary use of theory is to guide

3. Theory contributes to the development of the discipline’s body of

Nursing must have a foundation of theoretical knowledge that is based

4. Theory enhances communication.

It provides a common language for understanding a phenomenon so

Historical Development of Nursing Theories

The history of theory development in nursing began with the writings of

Nightingale’s theory focused on the control of the environment of indi-

Literature on the philosophy of nursing, as well as conceptual models

The writings of Dickoff, James and Wiedebach on “Theory in a Practice

The 1980s were characterized by acceptance of the significance of theory

Prior to 1960 60s and 70s 80s 80s to present

For purposes of this course, we will differentiate types of theories:

Grand theories consist of broad conceptual frameworks that reflect wide

Middle-Range theories are less complex and narrower in scope than