Theoretical Foundations Of Nursing

THEORETICAL FOUNDATIONS OF NURSING A. ENVIRONMENTAL THEORY “I think one’s feelings waste themselves in words; they ought all to be distilled into actions which bring results.” Florence Nightingale (1860) F lo rence Nigh t inga le de f ined Nurs ing “theas act of utilizing the environment of the patient to assist him in his recovery” (1860 /1969) , tha t i t i nvo lves the nurse ' s initiative to configure environmental settings appropriate for the gradual restoration of the patient's health, and that external factors associated with the patient's surroundings affect life or biologic and physiologic processes , and h i s deve lopment . Environmental Factors Affecting Health Defined in her environmental theory are the following factors present in the patient’s environment: • pure or f resh a i r • pure wate r • su f f i c i en t f ood supp l i es • e f f i c i en t dra inage • c lean l iness • l i gh t ( espec ia l l y d i rec t sun l igh t ) Adequate ventilation has also been regarded as a factor contributing to changes of the patient’s process of illness recovery. Any deficiency in one or more of these factors could lead to impaired functioning of life processes or diminished health status. She also emphasized in her environmental theory is the provision of a quiet or noise-free and warm environment, attending to patient’s dietary needs by assessment, documentation of time of food intake, and evaluating it’s effects on the patient. Nightingale believed that the environment was the major component creating illness in a patient; she regarded disease as “the reactions of kindly nature against the conditions in which we have placed ourselves.” Her theory Contains three major relationships: • environment to patient • nurse to environment • nurse to patient

B. INTERACTIVE THEORIES INTERPERSONAL RELATIONS THEORY “The kind of person that the nurse becomes makes a substantial difference in what each patient will learn as he or she receives nursing care.” Hildegard Peplau (1952) She de f ined Nurs ing as an “interpersonal process of therapeutic interactions between an individual who is sick or in need of health services and a nurse especially educated to recognize, respond to the need for help.” Dr. Peplau emphasized the nurse-client relationship as the foundation of nursing practice. At the time, her research and emphasis on the give-and-take of nurse-client relationships was seen by many as revolutionary. She described the nurse-patient relationship as a four-phase phenomenon. Each phase is unique and has distinguished contributions on the outcome of the nurse-patient interaction. Phases Of Nurse-Patient Relationship 1. Orientation Individual/family has a “felt need” and seeks professional assistance from a nurse (who is a stranger). This is the problem identification phase. 2. Identification Where the patient begins to have feelings of belongingness and a capacity for dealing with the problem, creating an optimistic attitude from which inner strength ensues. Here happens the selection of appropriate professional assistance. 3. Exploitation The nurse uses communication tools to offer services to the patient, who is expected to take advantage of all services. 4. Resolution Where patient’s needs have already been met by the collaborative efforts between the patient and the nurse. Therapeutic relationship is terminated

and the links are dissolved, as patient drifts away from identifying with the nurse as the helping person. Nursing Roles In the course of the nurse-patient relationship, the nurse assumes several roles which empower and equip her in meeting the needs of the patient. 1 . Stranger Role: Rece ives the c l i en t the same way one meets a stranger in other life situations; provides an accepting climate that builds trust. 2 . Resource Role: Answers ques t ions . I n te rp re ts clinical treatment data, gives information. 3 . Teaching Role: Gives i n s t ruc t i ons and prov ides training; involves analysis and synthesis of the learner’s experience. 4 . Counseling Role: He lps c l i en t unders tand and integrate the meaning of current life circumstances; provides quidance and encouragement to make changes. 5 . Surrogate Role: He lps c l i en ts c la r i f y doma ins o f dependence, interdependence, and independence and acts on clients behalf as advocate. 6 . Leadership Role: He lps c l i en t assume max imum responsibility for meeting treatment goals in a mutually satisfying way. Additional Roles i nc lude : 1. Technical expert 2. Consultant 3. Health teacher 4. Tutor 5. Socializing agent 6. Safety agent 7. Manager of environment 8. Mediator 9. Administrator 10.Recorder observer 11.Researcher

Definition of the Unique Function of Nursing “The nurse is temporarily the consciousness of the unconscious, the love of life for the suicidal, the leg of the amputee, the eyes of the newly blind, a means of locomotion for the infant, knowledge and confidence for the mother, the mouthpiece for those too weak or withdrawn to speak and so on.” Virginia Henderson (1955) Henderson de f ined Nurs ing as assisting “ the individual, sick or well, in the performance of those activities contributing to health or it’s recovery (or to peaceful death) that an individual would perform unaided if he had the necessary strength, will or knowledge”. She conceptualized the 14 Fundamental Needs o f humans . These needs are: • Brea th ing norma l l y • Eat ing and dr ink ing adequate ly • E l im ina t ing body wastes • Mov ing and main ta in ing des i rab le pos i t i on • S leep ing and res t ing • Se lec t ing su i tab le c lo thes • Main ta in ing body tempera tu re wi th in norma l range • Keep ing the body c lean and we l l - groomed • Avo id ing dangers i n the env i ronment • Commun ica t ing wi th othe rs • Worsh ipp ing acco rd ing to one ’ s f a i th • Work ing i n such a way tha t one f ee l s a sense o f accomplishment • P lay ing /pa r t i c ipa t ing i n var ious f o rms o f rec rea t ion • Lea rn ing , d i scover ing or sa t i s fy ing the cu r ios i t y tha t leads to normal development and health and using available health facilities. The Nurse-Patient Relationship Henderson stated that there are three levels comprising the nurse-patient relationship: 1 . The nurse as a substitute for the patient. I n t imes of illness, when the patient cannot function fully,

the nurse serves as the substitute as to what the patient lacks such, as knowledge, will, and strength in order to make him complete, whole and independent once again. 2 . The nurse as a helper to the patient. I n s i tua t i ons where the patient cannot meet his basic needs, the nurse serves as a helper to accomplish them. 3 . The nurse as a partner with the patient. As par tne rs , the nurse and the patient formulate the care plan together. Both as an advocate and as a resource person, the nurse can empower the patient to make effective decisions regarding his care plans.

Dynamic Nurse-Patient Relationship “The role of the nurse is to find out and meet the patient's immediate need for help. The patient's presenting behavior may be a plea for help, however, the help needed may not be what it appears to be.” Ida Jean Orlando (1961) Or l ando ' s theo ry was deve loped i n the l a te 1950s f rom observations she recorded between a nurse and patient. Despite her efforts, she was only able to categorize the records as "good" or "bad" nursing. It then dawned on her that both the formulations for "good" and "bad" nursing were contained in the records. From these observations she formulated the deliberative nursing process. Therefore, nurses need to use their perception, thoughts about the perception, or the feeling engendered from their thoughts to explore with patients the meaning of their behavior. This process helps the nurse find out the nature of the distress and what help the patient needs. Orlando's theory remains one the of the most effective practice theories available. The use of her theory keeps the nurse's focus on the patient. The strength of the theory is that it is clear, concise, and easy to use. While providing the overall framework for nursing, the use of her theory does not exclude nurses from using other theories while caring for the patient. Key Concepts of Three Interlocking Circles Theory • Acco rd ing to Ha l l , Nurs ing i s par t i c ipa t i on care, i n core and cure aspects, where CARE is the sole function of nurses, whereas the CORE and CURE are shared with other members of the health team • The major purpose of care is to achieve an interpersonal relationship with the individual that will facilitate the development of the core

Lydia Hall (1961)

Human-to-Human Relationship Model “A nurse does not only seek to alleviate physical pain or render physical care- she ministers to the whole person. The existence of suffering, whether physical, mental or spiritual is the proper concern of the nurse.” Joyce Travelbee (1966) Travelbee's experience in initial psych nursing practice at a Catholic charity hospital led her to believe that the care given in these type of institutions lacked compass ion . She f e l t nurs ing needed humanistic a " revolution" and a renewed f ocus on ca r ing as cen t ra l to nursing--she warned that if this didn't happen, consumers might seeka "new and different kind of health care worker". Trave lbee ' s i deas have grea t l y i n f l uenced the hospice movement. In her human-to-human relationship model, the nurse and the patient undergoes the following series of interactional phases: 1 . Original Encounter- th i s i s desc r ibed as the f i r s t impression by the nurse of the sick person and viceversa The nurse and patient see each other in stereotyped or traditional roles. 2 . Emerging Identities- th i s phase i s desc r ibed by the nurse and patient perceiving each other as unique individual. At this time, the link of relationship begins to form. 3 . Empathy- th i s phase i s desc r ibed as the ab i l i t y to share in the person’s experience. 4 . Sympathy- I t happens when the nurse wants to l e ssen the cause of the patient’s suffering. It goes beyond empathy. The nurse at this time should use a disciplined intellectual approach together with therapeutic use of self to make helpful nursing actions. 5 . Rapport- th i s i s desc r ibed as nurs ing i n te rven t i ons that lessens the patient’s suffering. The nurse and the sick person are relating as human being to human being. The sick person shows trust and confidence in the nurse.

C. SYSTEMS THEORIES System Model in Nursing Practice “Health is a condition in which all parts and subparts are in harmony with the whole of the client” Betty Neuman (1972) Her theory incorporated the concept of a whole person and an open system approach. The concept is aimed towards the development of a person in a state of wellness having the capacity to function optimally. The main role of the nurse in her theory is to help a person to adapt with environmental stimuli causing illnesses back to a state of wellness. Terms Related to Neuman’s System Theory Client Variables The clients’ variables can be one or combination of the following: physiological, sociocultural, developmental and spiritual. These variables function to achieve stability in relation to the environmental stressors experienced by the client. Lines of Resistance Lines of Resistance act when the Normal Line of Defense is invaded by too much stressor, producing alterations in the client’s health. Normal Line of Defense To achieve the stability of the system, the Normal Line of Defense must act in coordination with the normal wellness state. It must reflect the actual range of responses that is normally acted by clients in response to any stressors. It is the baseline in determining the level of client within the continuum of health. Flexible Line of Disease It serves as a boundary for the Normal Line of Defense to adjust to situations that threaten the imbalance within the client’s stability. Stressors These are forces that produce tensions, alterations or potential problems causing instability within the client’s

system. Reaction These are the outcomes or produced results of certain stressors and actions of the lines resistance of a client. It can be positive or negative depending on the degree of reaction the client produces to adjust and adapt with the s i tua t i on . Neuman spec i f i ed these reac t inegentropy ons as or entropy. Negentropy is set towards stability or wellness while Egentropy is set towards disorganization of the system producing illness.

Behavioral System Model “Each individual has a predisposition to act, with reference to the goal, in certain ways rather than in other ways” Dorothy Johnson (1971) Johnson believes that each individual has a focusing and repeating ways of acting which covers a behavioral system distinct to that individual. These behaviors are logical, fixed, predictable and adequately secure and persistent to be satisfying to depiction and clarification. Seven Behavioral Subsystems 1 . The Attachment or Affiliative Subsystem i s we l l known as the earliest response system to expand in the individual. The most favorable functioning of this subsystem allows social inclusion, closeness, and the pattern and continuance of a strong public bond. 2 . The Dependency Subsystem a re ac t i ons tha t t r i gge r nurturing behaviors from other individuals in the environment. The product of dependency behavior is consent, interest or appreciation, and physical support. 3 . The Ingestive Subsystem re la tes to the behav io r s surrounding the ingestion of food. Behaviors related to the ingestion of food may relate more to what is socially satisfactory in a specified culture, than to the biological necessities of the human being. 4 . The Eliminative Subsystem re la tes to behav io r s surrounding the secretion of waste products from the body. Human cultures have defined different socially acceptable behaviors for excretion of waste, but the continuation of such an outline remains from culture to culture. 5 . The Sexual Subsystem im i ta tes behav io r s rea l ted to procreation or reproduction. 6 . The Aggressive Subsystem re la tes to behav io r s concerned with the defense and self-preservation. 7 . The Achievement Subsystem con ta ins behav io r s tha t attept to control the environment. Intellectual,

physical, imaginative, mechanical, and communl skills are some of the areas that Johnson distinguishes.

Goal Attainment Theory “If the students can’t do the fundamentals, how can they use advanced knowledge.” Imogene King (1971) King stated that Nursing is a process o f action, reaction, and interaction whereby nurse and client share information about their perception in the nursing situation. Action Action is a means of behavior or activities that are towards the accomplishment of certain act. It is both physical and mental. Reaction In King’s theory, reaction is not specified but somehow relates reaction as part of action. According to her, reaction is a response to a stimuli. Interaction Interaction, as defined by King, is any situation wherein the nurse relates and deals with a clientele or patient. Open System It is the absence of boundary existence, where a dynamic interaction between the internal and external environment can exchange information without barriers or hindrances. King proposed that the nurse interacts in the system simultaneously at three different levels. These levels are independent and at the same time co-exist to influence over-all nursing practice. • Personal- how the nurse views and integrates self based from personal goals and beliefs • Interpersonal- how the nurse interrelates with a coworker or patient, particularly in a nurse-patient relationship • Social- how the nurse interacts with co-workers, superiors, subordinates and the client environment in general

Self-Care Theory “Individuals, families, groups and communities need to be taught self-care.” Dorothea Orem (1971) Orem de f ined Nurs ing as “The act of assisting others in the provision and management of self-care to maintain/improve human functioning at home level of effectiveness.” The theory focuses on activities that adult individuals perform on their own behalf to maintain life, health and well-being. It has a strong health promotion and maintenance focus. She identified 3 related concepts: 1 . Self-care - ac t i v i t i e s an I nd iv idua l per fo rms independently throughout life to promote and maintain personal well-being. 2 . Self-care deficit - resu l t s when se l f - ca re agency (Individual’s ability) is not adequate to meet the known self-care needs. 3 . Nursing System - nurs ing i n te rven t ions needed when Individual is unable to perform the necessary self-care activities: 1 . Wholly compensatory - nurse prov ides ent i re self-care for the client. Example : ca re o f a new born , ca re o f client recovering from surgery in a post-anesthesia care unit 2 . Partial compensatory - nurse and c l i en t perform care, client can perform selected self-care activities, but also accepts care done by the nurse for needs the client cannot meet independently. Example : Nurse can ass i s t pos t operative client to ambulate, Nurse can

bring a meal tray for client who can feed himself 3 . Supportive-educative - nurse ’ s ac t ions a re to help the client develop/learn their own self-care abilities through knowledge, support and encouragement. Example : Nurse gu ides a mother how to breastfeed her baby, Counseling a psychiatric client on more adaptive coping strategies. Twenty-One Nursing Problems “I never wanted to be a medical doctor because I could do all I wanted to do in nursing, which is a caring profession.” Faye Glen Abdellah (1960) The concept of Nursing in this theory is generally grouped into twenty-one problem areas for nurses to work out their judgment and appropriate care. Abdellah considers nursing to be an all-inclusive service that is based on the disciplines of art and science that serves individuals, sick or well with their health needs. Typology of Twenty-one Nursing Problems 1 . To main ta in good hyg iene . 2. To promote optimal activity; exercise, rest and sleep. 3 . To promote sa fe t y. 4 . To main ta in good body mechan ics . 5 . To f ac i l i t a te the main tenance o f a supp ly o f oxygen 6 . To f ac i l i t a te main tenance o f nut r i t i on 7 . To f ac i l i t a te main tenance o f e l im ina t ion 8 . To f ac i l i t a te the main tenance o f f l u id and e lec t ro l y te balance 9 . To recogn i ze the phys io log i c response o f the body to disease conditions 10 .To f ac i l i t a te the main tenance o f regu la to ry mechan i sms and f unc t i ons . 11 .To f ac i l i t a te the main tenance o f senso ry f unc t i ons 12 .To i den t i f y and accept pos i t i ve and negat i ve expressions, feelings and reactions 13 .To i den t i f y and accept the i n te r re la tedness o f emotions and illness. 14 .To f ac i l i t a te the main tenance o f e f fec t i ve verba l and non-verbal communication 15 .To promote the deve lopment o f produc t i ve i n te rpe rsona l relationship

16 .To f ac i l i t a te prog ress toward ach ievement o f persona l

spiritual goals 17.To create and maintain a therapeutic environment 18.To facilitate awareness of self as an individual with varying needs. 19 .To accept the opt imum poss ib le goa l s 20 .To use commun i ty resou rces as an a id i n reso lv ing problems arising from illness. 21 .To unders tand the ro le o f soc ia l prob lems as influencing factors Helping Art of Clinical Nursing "My thesis is that nursing art is not comprised of rational nor reactionary actions but rather of deliberative action." Ernestine Wiedenbach (1964) Wiedenbach conceptualizes nursing as the practice identification of a patient’s need for help through observation of presenting behaviors and symptoms, exploration of the meaning o f those symptoms wi th the patient, determining the cause(s) of discomfort, and determining the patient’s ability to resolve the discomfort or if the patient has a need for help from the nurse or other healthcare professionals. Nursing primarily consists of identifying a patient’s need for help. If the need for help requires intervention, the nurse facilitates the medical plan of care and also creates and implements a nursing plan of care based on needs and desires of the patient. In providing care, a nurse exercises sound judgment through deliberative, practiced, and educated recognition of symptoms. The patient’s perception of the situation is an important consideration to the nurse when providing competent care. According to Wiedenbach there are four elements to c l i n i ca l nurs ing (1): philosophy, (2) purpose, (3) practice, and (4) art. • The nurses ’ ph i l osophy was the i r a t t i tude and belief about life and how that effected reality for them. Philosophy is what motivates the nurse to act in a certain way. Wiedenbach also believed that there were 3 essential components associated with a nursing

philosophy: ○ Reverence for life ○ Respect for the dignity, worth, autonomy and individuality of each human being ○ Reso lu t i on to ac t on persona l l y and professionally held beliefs • Nurses ’ purpose i s tha t wh ich the nurse wants to accomplish through what she does. It is all of the activities directed towards the overall good of the patient. • Prac t i ces a re those obse rvab le nurs ing ac t ions that are affected by beliefs and feelings about meeting the patient’s need for help. • The Ar t o f nurs ing i nc ludes unders tand ing patient’s needs and concerns, developing goals and actions intended to enhance patient’s ability and directing the activities related to the medical plan to improve the patient’s condition. The nurses also focuses on prevention of complications related to reoccurrence or development of new concerns.

The Conservation Model "Ethical behaviour is not the display of one's moral rectitude in times of crisis. It is the day-to-day expression of one's commitment to other persons and the ways in which human beings relate to one another in their daily interactions.” Myra Levine (1977) She defined nursing as supportive & therapeutic interventions based on scientific or therapeutic knowledge. Nursing actions based on four principles: • conse rva t ion o f energy • s t ruc tu ra l i n teg r i t y • persona l i n teg r i t y • soc ia l i n teg r i t y

D. DEVELOPMENTAL THEORIES Adaptation Model “The model provides a way of thinking about people and their environment that is useful in any setting. It helps one prioritize care and challenges the nurse to move the patient from survival to transformation.” Sister Callista Roy (1979) She viewed humans as biopsychosocial beings constantly interacting with a changing environment and who cope with their environment through Biopsychosocial adaptation mechanisms. There are two categories of coping mechanisms according to Roy namely the regulator and the cognator subsystems: • Regulator Subsystem t ransp i res th rough neut ra l , chemical and endocrine processes like the increase in vital signs-sympathetic response to stress. • Cognator Subsystem, on the othe r hand , occurs th rough cognitive-emotive processes. For instance, are the effects of prolonged hospitalization for a four-year old child. The degree of internal or external environmental change and the person’s ability to cope with that change is likely to determine the person’s health status. Nursing interventions are aimed at promoting physiologic, psychologic, and social functioning or adaptation.

Transcultural Theory “Care is the heart of nursing; Care is power; Care is essential to healing; Care is curing; and Care is the central and dominant focus of nursing and transcultural nursing decisions and actions.” Madeleine Leininger (1985) She stated that Nursing is a learned humanistic and scientific profession and discipline which is focused on human care phenomena and activities in order to assist, support, facilitate, or enable individuals or groups to maintain or regain their well being (or health) in culturally meaningful and beneficial ways, or to help people face handicaps or death. Transcultural nursing as a l ea rned sub f i e ld or branch of nursing which focuses upon the comparative study and analysis of cultures with respect to nursing and healthillness caring practices, beliefs and values with the goal to provide meaningful and efficacious nursing care services to people according to their cultural values and healthillness context. It focuses on the fact that different cultures have different caring behaviors and different health and illness values, beliefs, and patterns of behaviors. Awareness of the differences allows the nurse to

design culture-specific nursing interventions.

Philosophy and Science of Caring “Caring in nursing conveys physical Acts but embraces the mind-body-spirit as it reclaims the embodied spirit as its focus attention.” Margaret Jean Watson (1979) Watson proposes seven assumptions about the sc ience o f caring and ten primary carative factors to f o rm the framework of her theory. The basic assumptions are: • Car ing can be e f fec t i ve ly demons t ra ted and prac t i ced only interpersonally; • E f fec t i ve ca r ing promotes hea l th and i nd iv idua l or family growth; • Car ing responses accept a person not on ly as he or she is now but as what he or she may become; • A ca r ing env i ronment i s one tha t o f fe r s the development of potential while allowing the person to choose the best action for himself or herself at a given point in time • Car ing i s more “hea l thogen ic” than i s cu r ing . The practice of caring integrates biophysical

knowledge of human behavior to generate or promote health and to provide care to those who are ill. A science of caring is therefore complementary to the science of curing. • The prac t i ce o f ca r ing i s cen t ra l to nurs ing Ten Carative Factors 1 . The promot ion o f a human is t i c - a l t ru i s t i c sys tem o f values 2 . I n s t i l l a t i on o f f a i th - hope 3 . The cu l t i va t i on o f sens i t i v i t y to one ’ s se l f and othe rs 4. The development of a helping-trusting, human caring relationship 5 . Promot ion and acceptance o f the express ion o f pos i t i ve and negative feelings. 6 . The sys temic use o f the sc ien t i f i c prob lem-so lv ing method for decision making 7 . The promot ion o f i n te rpe rsona l teach ing - l ea rn ing 8 . The prov i s i on f o r suppor t i ve , pro tec t i ve and corrective mental, physical, socio-cultural and spiritual environment 9 . Ass i s tance wi th the gra t i f i ca t i on o f human needs 10 .The a l l owance f o r ex i s ten t ia l phenomeno log i ca l f o rces

The Science of Unitary Human Beings, and Principles of Homeodynamics “Nursing is an art and science that is humanistic and humanitarian. It is directed toward the unitary human and is concerned with the nature and direction of human development.” Martha Rogers (1970) Nursing interventions seek to promote harmonious interaction between persons and their environment, strengthen the wholeness of the individual and redirect human and environmental patterns or organization to achieve maximum health. There are 5 Basic Assumptions: 1 . The human be ing i s a un i f i ed who le , possess ing individual integrity and manifesting characteristics that are more than and different from the sum of parts. 2 . The i nd iv idua l and the env i ronment a re continuously exchanging matter and energy with each

other 3 . The l i f e processes o f human be ings evo lve i r reve rs ib l y and unidirectionally along a space-time continuum 4 . Pa t te rns i den t i f y human be ing and re f l ec t the i r innovative wholeness 5 . The i nd iv idua l i s charac te r i zed by the capac i ty f o r abstraction and imagery, language and thought, sensation and emotion

Theory of Human Becoming “Nursing is a scientific discipline, the practice of which is a performing art.” Rosemarie Rizzo Parse (1981) Three assumptions about Human Becoming • Human becoming i s f ree ly choos ing persona l mean ing in situation in the inter-subjective process of relating value priorities • Human becoming i s co - c rea t ing rhy thmic pat te rns or relating in mutual process in the universe • Human becoming i s co - t ranscend ing mul t id imens iona l l y with emerging possibilities. References: Octaviano, Eufemia F., RN, RM, MN, EdD, Balita, Carl E.,

RN, RM, MAN, DrHum.“Theoretical Foundations of Nursing: The Philippine Perspective”, 2008 . http://nursingcrib.com http:// http://en.wikipedia.org/wiki/