Modeling and Role modeling Theory 1983 (USA)

Modeling and Role modeling Theory 1983 (USA)
The modeling and role modeling theory was developed by three nursing expertise, Helen Lorraine Erickson, Evelyn. M. Tomlin and Mary Ann Swain. The initial publication of the theory was done in 1983 with the text; Modeling and Role modeling- A theory and Paradigm for Nursing. This book presents the theory in a very formal and readable style. The basis of theory is to focus on the person receiving nursing care, not on the nurse, care and the disease. Modeling and Role modeling is an interpersonal and interactive holistic theory of nursing that requires the nurse to assess (model), plan (role model) and intervene (five aims of intervention) on the basis of the client’s perspective of the world. The nurse always acknowledges the uniqueness and individuality of the client and appreciates that individuals, at some level, know what makes them ill and what makes them well (self care knowledge). The nurse assess the individual’s ability to mobilize resources needed to contend with stressors (adaptive potential) and assists individuals to recognize and obtain resources (internal and external) that are important for their health and healing (self care resources) and facilitates the use of these resources (self care action). The nurse acknowledges the individual’s need to be dependent and independent on support system (affiliated individuation). Concepts relating to the nurse who practices with a theory base of modeling and role modeling include facilitation, nurturance and unconditional acceptance.
Modeling
It is the process used by the nurse to develop an understanding of the client’s world as the client perceives it, the way an individual thinks, communicates, feels, believes and behaves. Role modeling is the facilitation of health. It involves the individualization of care based on the client’s model of the world and is the facilitation of the individual in attending, maintaining and promoting health through purposeful intervention.
Five aims of intervention
It is based on the five principles;

1. Build trust: The nursing process requires a trusting and functional relationship exists between nurse and client.
2. Promote client’s positive orientation: Affiliated individuation is dependent on the individual’s perceiving that he or she is an acceptable, respectable and worthwhile human being.
3. Promote client’s control: Human development is dependent on the individual’s perceiving that he or she has some control over his or her life, while concurrently sensing a state of affiliation.
4. Affirms and promotes client’s strengths: There is an innate drive towards holistic health that is facilitated by consistent and systematic nurturance
5. Self mutual goals that are health directed: Human growth is dependent on satisfaction of basic needs and facilitated by growth and satisfaction.

Self care
There are three aspects of self care in the modeling and role modeling theory

1. Self care knowledge
2. Self care resources
3. Self care action

Self care knowledge
This is an individual’s perception of factors associated with his or her personal health problems and individual perceptions of what is needed to help him. Nursing role is to assist the clients to resolve their problems by meeting their needs.
Self care resources
All individuals have internal and external resources that will help gain, maintain and promote an optimum level of holistic health. Primary internal self care resources for each individual result from the person having successfully negotiated developmental challenges such as autonomy, hope, control, purpose and wisdom. The external self care resources are being explored include perceptions, social support and the type of resources used when ill and well.
Self care action
It is the development and use of self care knowledge and self care resources. The basis of nursing is assisting clients in self care actions related to health. Self care is modeling and role modeling is used in planning and implementing rather than for determining the need for nursing care implementation. 

Additional concepts of Modeling and Role modeling Theory

• Affiliated Individuation

It is considered as motivation for human behavior. It occurs when a person perceives himself or herself as simultaneously close to separate from significant others.

• Adaptive potential

The adaptive potential assessment model (APAM) has three categories: equilibrium, arousal and impoverishment. Equilibrium has two possibilities: adaptive equilibrium and maladaptive equilibrium. Arousal and impoverishment has stress states. The model can assist the nurse in planning interventions for the client.
Nursing Metaparadigm
Person is a holistic being with interactive subsystems (biophysical, psychological, social and cognitive) and it implies that whole is greater than the sum of the parts. The environment in which people live in internal and external and includes both stressors and resources for adapting stressors. The model states health as a state of dynamic equilibrium among the various subsystems. They defined nursing is the holistic helping of persons with their self care activities in relation to their health. This is an interactive, interpersonal process that nurtures strengths to enable development, release and channeling of resources for coping with one’s circumstances and environment. The goal is to achieve a state of perceiving optimum health and contentment.
This theory suggests an interactive and interpersonal role for nursing. This has been applied to work with clients who are individuals, families and communities to empower them to direct care, based on self care knowledge, self care resources and self care actions, as the client’s perceived needs are addressed.

Nola.J.Pender Health Promotion Model 1982

Nola.J.Pender Health Promotion Model 1982
Nola.J.Pender was born in 1941 in Michigan. She earned diploma in nursing, B.S. in nursing, M.A. in human growth and development and PhD in Psychology and Education. She also did graduate level work in community health nursing at RUSH University, Chicago. The focus of her research was on health promotion. She did a research on ‘how people make decisions’ and based on this, initial version of Health Promotion Model (HPM) was published in 1982. She stated HPM as proposed a framework for integrating nursing and behavioral science perspectives as factors influencing health behaviors. The framework offered a guide for exploration of the complex biopsychosocial processes that motivate individuals to engage in behaviors directed towards the enhancement of health. The initial model had seven cognitive perceptual factors (importance of health, perceived control of health, definition of health, perceived health status, perceived self efficacy, perceived benefits and perceived barriers) and five modifying factors (demographic characteristics, biologic characteristics, interpersonal influences, situational influences and behavioral factors).
She identified the theoretical basis of the Health Promotion Model as drawing upon Social Cognitive Theory (Bandura, 1977). This theory emphasizes on self direction and self regulations are the abilities to direct and control one’s thinking and actions, perceptions of self efficacy involve one’s view of the personal ability to perform an identified set of actions. 

According to Pender et. al. (2006), Bandura identifies the following basic human capabilities;

• Symbolization - The ability to process and transform experience to create internal models to guide actions in the future.
• Forethought – The ability to anticipate possible consequences of potential actions and plan courses of action to achieve goals.
• Vicarious learning - The ability to obtain rules for selecting actions through observation of others without using trial and error.
• Self regulation- The ability to use internal standards and self evaluation to inspire and adjust behavior to external environment.
• Self reflection – The ability to consider one’s own thought process and change them.

Assumptions of Revised Health Promotion Model

• Persons seek to create conditions of living through which they can express their unique human health potential
• Persons have the capacity for reflective self awareness, including assessment o their own competencies
• Person’s value growth in directions viewed as positive and attempts to achieve a personally acceptable balance between change and stability
• Individuals seek to actively regulate their own behavior
• Individuals in all their bio-psychosocial complexity interact with the environment, progressively transforming the environment and being transformed overtime
• Health professionals constitute a part of the interpersonal environment, which influence on persons throughout their life span
• Self initiated reconfiguration of person environment interactive pattern is essential to behavior change

Health Promotion Model (Revised Variables) 

Individual characteristics and experiences

The Individual characteristics and experiences divided into prior related behavior and personal factors. Prior related behaviors are important, as it is best for predicting the future behavior. The direct effect of prior behavior is possibly that of habit formation, since each time a behavior is performed, the habit is strengthened. The personal factors are described as biological (age, BMI and strength), psychological (self esteem and self motivation) and socio cultural (race, education and socio economic status) factors.  

Behavior specific cognition and affect

This includes perceived benefits of action, perceived barriers to action, perceived self efficacy, activity related affect, interpersonal influences and situational influences, all of which leads to a commitment to a plan of action and consideration of immediately competing demands and preferences. 

Perceived plan of action may be intrinsic benefits (feeling better) and extrinsic benefits (time to socialize while practicing the target behavior). Perceived barriers to action mean the barriers which influence action directly by blocking that action or indirectly by decreasing any commitment to act. The perceived ability to achieve a behavior is perceived self efficacy of; Can I do it?, What will happen if I do it?.

Activity related effect- There are three components to this affect; the act related emotional arousal, the self related self acting and the context related environment in which behavior occurs. Interpersonal influences are the person’s thoughts or beliefs about the behavior, attitudes and beliefs of others and may or may not accurately reflect those behavior, attitudes and beliefs. Situational influences include the options that are perceived as being available, demand characteristics and environmental features. For example, ‘no smoking’ sign is intended to discourage smoking. Commitment to plan of action initiates the behavior, to carry out a specific plan of action at a given time and place. Immediate competing demands and preferences are alternative behaviors that intrude into consciousness as possible courses of action immediately prior to the intended occurrences of a planned health promoting behavior. 

The variables of Health Promtion Model have strengths and limitations. It is strength for use in practice because looking at all of the variables provides a more complete picture of the client. The limitation of the model is lacking of the spiritual factors.

Jean Watson Theory of Everything-The Ten Primary Carative Factors 1979 (USA)

Jean Watson Theory of Everything-The Ten Primary Carative Factors 1979 (USA)
Jean Watson was born in 1940, earned a baccalaureate degree in nursing, a master’s degree in psychiatric nursing and Ph.D. from the University of Colorado. Dr. Watson was named as distinguished professor, widely published author and recipient of numerous awards including six honorary doctoral degrees. Theoretical construction from Dr. Watson theory is used as a guide to many nursing academic programs.
The purpose of Watson’s theory is caring, promotion of health, preserving dignity, respecting the wholeness and interconnectedness of humanity. The theory pictures the nursing as a healing art and science with sacred relationships. It is the need of hour for nurses to identify the healing traditions for caring relationships at the societal and planetary level. There are fundamental differences in ways of being (ontology), knowing (epistemology) and doing (praxis) within the traditional versus human science paradigm. The purpose of traditional science is identification and prediction. Human science is concerned with the meaning of the lived experience. Professional nursing within a traditional science and biomedical model is focused on ‘doing’ by controlling and manipulating physical and behavioral parameters through specific actions and environments that maintain physiological and behavioral homeostasis.
Contents of the theory
Current dimensions of the theory are;

1. Expanded views of self and person; embodied spirit
2. Having caring healing consciousness
3. Forgiveness and surrender as highest level of consciousness
4. Unitary consciousness
5. Advanced caring and healing modalities
6. Nurse as sacred healing environment
7. Trans personal caring relationships
8. The specifications of trans personal caring relationships depends upon
9. Moral commitment and consciousness needed to protect human dignity
10. Ability of a nurse to identify other’s inner condition
11. Feel a union with the others
12. Ability to realize another’s condition of being in the world
13. Nurse’s own life history and previous experience
14. The caring and healing modalities potentiate harmony, wholeness, comfort and promote inner healing by releasing disharmony.
15. Caring occasion or caring moment occurs whenever nurse and others come together with their unique life histories in a human to human transaction and has the potential for collectively expanding the field of interconnectedness consciousness of the universe in a way that expands the universal field of harmony and wholeness.

Ten carative factors
It was identified by Watson in 1979 at the age of 39 years, as characterizing a caring relationship based upon the nurse’s conscious, moral commitment to each person in such a way that facilitates healing. The carative factors are;

1. Forming a humanistic altruistic system of values
2. Enabling and sustaining faith and hope
3. Being sensitive to self and others
4. Developing a helping-trusting and caring relationships
5. Promoting and accepting the expression of positive and negative feeling
6. Engaging in problem solving caring process
7. Promoting trans personal teaching and learning
8. Attending to supportive, protective, physical, mental, societal and spiritual environments
9. Assisting with gratification of basic human needs while preserving human dignity and wholeness
10. Allowing for and being open to existential phenomenological and spiritual dimensions of caring and healing that can not be fully explained successfully.

Jean Watson has played a major role in reorienting nursing from a bio-medical, mechanistic model to one of caring as a trans personal interactive process. Dr. Watson believes that the caring occasion or caring moment opens up a higher energy field with potential for healing beyond body and self, with potential movement toward greater harmony, wholeness, health and spiritual evolution.

Sister Callista Roy’s Adaptation Model 1979 (USA)

Sister Callista Roy’s Adaptation Model 1979 (USA)
Sister Callista Roy was born on 1939, earned her B.S. in nursing from Los Angeles, M.S. in nursing and her doctorate in Sociology in 1977 from the University of California. She is the author, co author, professor and nurse theorist and known world wide for Roy Adaptation Model.  Her contributions to nursing are an Adaptation Model, Essentials of the Roy Adaptation Model, Theory Construction in Nursing, The Roy Adaptation Model: The Definitive Statement, Roy Adaptation Model Based Research, Twenty Five Years of Contributions to Nursing Science and Nursing Knowledge Development and Clinical Practice.
The Roy Adaptation Model has captured interest and respect since 1964 and she published her work in 1970 at the age of 31 years. She defined adaptation as ‘the process and outcome where by thinking and feeling persons, as individuals or in groups, use conscious awareness and choice to create human and environmental integration.’

The four major concepts of the RAM include:

1. Human as adaptive systems
2. The environment
3. Health
4. The goal of nursing

Human adaptive system
Roy conceptualizes the human system in a holistic perspective, which means the aspect of unified meaningfulness of human behavior in which the human system is greater the sum of individual parts.
Adaptation
The human adaptive system has input coming from the external environment as well as with in the system. Roy identifies inputs as stimuli and adaptation level. Stimuli are classified into three: focal, contextual and residual. The stimulus most immediately confronting the human system is the focal stimulus. Contextual stimuli are from the human systems internal and external world. Residual stimuli are those internal and external factors are unclear.
Adaptation level is the combining of stimuli that represents the condition of life process for the human adaptation system. The three levels defined by Roy are integrated, compensatory and compromised. Integrated process is present when the adaptation level is working as a whole to meet the needs of the human system. The compensatory process occur when the human’s response system have been activated and compromised process occur when the compensatory and integrated process are not providing for adaptation. 

Roy presents a unique nursing concept of control mechanisms:  the regulator and cognator.
The regulator subsystem has the components of input, internal process and output. Target organs and tissues under endocrine control produce regulator output response. Cognator control process is related to higher brain functions of perception, learning, judgment and emotion.

Roy categorizes family, group and collective system control mechanisms as the stabilizer and the innovator system. It suggests two goals: stabilization and change. Stabilizer process is those of established structure, values and daily activity where the work of the group is done and the group contributes to the general well being of society. The innovator subsystem identifies structure and processes that promotes change and growth. 

Four adaptive models
The coping processes, cognator-regulator and stabilizer-innovator promote adaptation in human adaptive system. Roy has identified four adaptive modes as categories for assessment of behavior resulting from cognator-regulator coping mechanisms in persons or stabilizer-innovator coping process in groups. These adaptive modes are

1. Physiological –physical
2. Self concept- group identity
3. Role function
4. Interdependence

Physiological –physical mode
The physiological mode represents the human system is physical responses and interaction with the environment. This is associated with fluid, electrolyte, elimination, nutrition, rest, neurologic function and endocrine function. The physical mode related to basic operating resources such as participants, physical facilities and fiscal resources.
Self concept- group identity mode
Self concept consists of a person’s beliefs about himself or herself at any given time. It has two components: physical self and personal self. Physical self includes body sensation and body image. Personal self includes self ideal, moral, ethical and spiritual belief. The group identity mode consists of interpersonal relationship, group self image, social milieu and culture.
Role function mode
It consists of a set of expectations of how a person in a particular position will behave in relation to a person who hold another position. It includes functions of the staff, decision making, initiative and delegation of the work to maintain in order to fulfill the expected responsibilities.
Interdependence mode
The mode focuses on the giving and receiving of love, respect and value with significant others and support systems. The underlying need of the mode is to nurture relationships.
Environment
She defined environment as all conditions that surround and affect the development and behavior of humans as adaptive systems, with particular consideration of person and earth resources.

The Roy Adaptation Model identifies the essential concepts relevant to nursing as the human adaptive system, the environment, health and nursing. The model suggests that nurses alter, increase, decrease, remove or maintain focal stimulus or if that is not possible, change the contextual stimuli so that the purposeful adaptation and transformation between the person and environment is promoted.

Betty Newman’s system model 1972 (USA)

                                           

Betty Newman’s system model 1972 (USA)
Betty Newman’s was born in 1924, received B.S. in Public Health Nursing and M.S. in public health from the University of California. She has practiced as bed side nurse and head of the department in various hospitals. Her contributions are lecturer, author, teacher and consultant in nursing.
The Newman’s system model was developed in 1970 with an overview of the physiological, psychological, socio cultural and developmental aspects of human beings. The model was published in 1972 in nursing research at the age of 48 years. The Newman’s system model diagram presents the major aspects such as basic structure, energy resources (physiological, psychological, socio cultural, developmental and spiritual variables), line of resistance, normal line of defense, flexible line of defense, stressors, reaction, primary, secondary and tertiary prevention, intra, inter and extra personal factors and reconstitution. The environment, health and nursing are inherent parts of the model. The client is represented in the diagram as a basic structure, surrounded by a series of concentric circles and is a living and open system. 

Basic structure and energy resources
It is made up of basic survival factors common to all. It includes physiological, psychological, socio cultural, developmental, genetic etc. Newman identifies system stability as occurring when the energy exchanges with the environment occur with out disrupting the characteristics of the system.
Client variables
She views the individual client considers the variables. The physiological (structure and function of the body), psychological (mental process and relationships), socio cultural (social and cultural expectations), developmental (growth and developmental) and spiritual (spiritual beliefs) variable.
Line of resistance
It protects the basic structure and become activated when the normal line of defense is invaded by environmental stressors.
Normal line of defense
It represents stability over time. When it is invaded, the client system reacts.
Flexible line of defense
It serves as a cushion and absorbs shock. It can be altered over a short period of factors such as inadequate nutrition, lack of sleep or in a danger situation.
Environment
It defines the environment as all the internal or external factors or influence that surrounds the client. The internal environment exists with in the client system and external environment exits in the outside the client system. She developed a third environment called created environment, which is intra, inter and extra personal environment.
Stressors
She classified stressors as intra, inter and extra personal in nature. Intra personal stressors are occurred with in the client system boundary, extra personal stressors occur outside the system boundary. Inter personal stressors occur outside the client system boundary but are proximal to the system.
Health
She identifies health as optimal system stability, harmony among the five variables or the optimal state of wellness at a given time.
Reaction
She discusses the reaction as negentropy and entropy.
Prevention as intervention
Primary prevention occurs before the system reacts to a stressor, includes health promotion strategies such as immunization, health education and life style changes. Secondary intervention occurs after the system reacts to a stressor. It includes appropriate treatment of symptoms. For example, use of analgesics to decrease pain. Tertiary prevention may begin at any point after system stability has begun to be reestablished. An example of tertiary prevention is participation in cardiac rehabilitation program after a cardio vascular surgery.
Reconstitution
It defined the return to and maintenance of system stability. It depends on successful mobilization of client resources to prevent further reaction to the stressors and represents a dynamic state of adjustment.
Newman also supports nursing as part of the model. The aim of nursing to help the client system attains, maintain or retain system stability. It can be achieved through assessment of actual and potential effects of stressor invasion and assist the client for optimal wellness through primary, secondary and tertiary modes of prevention.

Dorothea Orem Self Care Deficit Theory 1971 (USA)

Dorothea Orem Self Care Deficit Theory 1971 (USA)
Dorothea Elizabeth Orem born on 1971 received her diploma in nursing from Providence Hospital School of Nursing, her Bachelor of Science and Master of Science in nursing education from Catholic University of America. She received several honorary degrees and national awards including Catholic University of America’s Alumni Association Award for nursing theory.
Orem (2001) states her general theory as follows: “Nursing has as its special concern man’s need for self care action and provision and maintenance of it on a continuous basis in order to sustain life and health, recover from disease and injury and cope with their effects. The condition that validates the existence of a requirement for nursing in an adult is the health associated absence of the ability to maintain continuously that amount and quality of self care that is therapeutic in sustaining life and health, in recovery from diseases or injury or in coping with their effects. With children, the condition is the inability of the parent or guardian as associated with the child’s health state to maintain continuously for the child the amount and quality of care that is therapeutic”.
Orem developed self care deficit nursing theory, which is composed of three interrelated theory:

1. Theory of self care
2. Theory of self care deficit
3. Theory of nursing system

Under these three theories, there are six central concepts and one peripheral concept:

1. Self care and dependent care
2. Self care agency and dependent care agency
3. Therapeutic self care demand
4. Self care deficit
5. Nursing agency
6. Nursing system

The peripheral concept is basic conditioning factors
Theory of self care
The concepts are self care, self care agency, self care requisites and therapeutic self care demand. Self care is the activities that individuals do it for themselves. Self care agency is the human’s acquired power and capabilities to engage in self care and is affected by basic conditioning factors such as age, gender, health state and pattern of living etc. The therapeutic self care demand is the total of activities needed over a period of time to meet the person’s known requirements for self care. Self care requisites are the reasons self care activities occur and are an expression of the hoped for results. It is categorized into three: universal, developmental and health deviation. Universal requisites means activities of daily living such as intake of air, water, food, rest etc. Developmental self care requisites are specific to the process of growth and development during life cycle changes. Health deviation self care requisites are related to change in human structure due to genetic variation or other defects. In the theory of self care, Orem explains what is meant by self care and list the various factors affect it.
The theory of self care deficit
When therapeutic self care demand exceeds self care agency, a self care deficit exists and nursing is required. Nursing may be necessary when individuals need to carry out complex self care or during illness or injury. Orem identifies the following five methods of helping that nurses may use:

1. Acting for or doing for another
2. Guiding and directing
3. Providing psychological support
4. Providing an environment to support personal development
5. Teaching

In clinical nursing practice, Orem (2001) has identified work operations include:

• Entering into and maintaining interpersonal relationships
• Design, plan and implement nursing care
• Respond to patient requests
• Coordinate nursing care
• Continue the patient care
• Use multisectoral approach
• Discharge the patient from nursing care

The theory of nursing systems
It includes nursing agency and nursing system. Nursing agency is a complex attribute of mature or maturing people educated and trained as nurses that enables them to act, to know and to help others meet their therapeutic self care demands. It is a power that nurse has to engage in effective nursing practice. Orem has identified three classification of nursing system to meet the self care requisites of the patient. The design and elements of the nursing system make four elements: the extent of the responsibility of the nurse in the health care situation, the various roles of the people in the situation, the reason for these being a nurse patient relationship and the actions to be carried out by the nurse and patient to meet therapeutic self care demand. These nursing systems are wholly compensatory, partly compensatory system and supportive-educative system.
Wholly compensatory system includes:

• Accomplishes patient’s self therapeutic care
• Compensates for patient’s inability to engage in self care
• Supports and protects the patient

Partly compensatory system includes:

• Performs some self care measures for patient
• Compensates for self care limitation of patient
• Assist the patient as required
• Performs some self care measures
• Regulates self care agency
• Accepts care and assistance from nurse

Supportive- educative system includes:

• Accomplishes self care
• Regulates the exercise and development of self care agency

To conclude, Orem indicates that nursing service to families and patients generally require some combination of aspects of two nursing systems, namely, the partly compensatory and supportive and educative nursing systems. It is applicable in nursing care with individuals in clinical side and community health practice.

Imogene King Theory of Goal Attainment 1971 (USA)

Imogene King Theory of Goal Attainment 1971 (USA)
Imogene King was born in 1923. She received her basic nursing education from St.John’s Hospital School of Nursing, Missouri and M.S. in nursing from St.Louis University and Ed.D from Colombia University. She also did her post doctoral study in research design, statistics and computers.
King’s ‘Toward a Theory for Nursing: General concepts of Human Behavior ‘was published in 1971 at the age of 48 years and ‘Theory of Nursing: systems, concepts and process’ in 1981. In 1997, King identified her framework as a conceptual system. The conceptual system includes goal, structure, functions, resources and decision making.  Here, the health as the goal of nursing, structure is three open systems, functions are demonstrated in relations of interaction and transaction. Resources include people, money and services for items needed to carry out specific activities. Decision making occurs when choices are made in resources allocation to support attaining system goals. The conceptual system is composed of three interacting system: the personal, interpersonal and social systems.
Personal system
The sub concepts are perception, information, energy, self growth and development, body image, apace, time and learning. King discusses perception as a process in which data obtained through the senses and from memory are organized, interpreted and transformed. The characteristics of self are the dynamic person, who is an open system and whose actions are oriented. The growth and development is the process in people lives through which they move from potential for achievement to actualization of self. Body image is characterized as very personal and subjective. The space is a physical area known as territory and by the behaviors of those who occupy it. She defines time as interval between the4 two events that is experienced differently by each person. She stated that when personal systems come in contact with one another, they form interpersonal systems.
Interpersonal system
The sub concepts are interpersonal relations, communication, interaction, transaction, role and stress. King included interpersonal relations as a concept of interpersonal system. Interaction is defined as the observable behavior of two or more persons in mutual presence. Communication involves the exchange of information between persons. Transaction is a series of exchanges between human being and environment. The role has three elements such as a set of expected behaviors in the social system, a set of rules with a position and relationship of two or more persons who are interacting in a particular situation. King defines stress as an ever changing condition in which as individual, through environmental interaction, seeks to keep equilibrium to support growth and development and activity. These interpersonal systems join together to form layer systems known as social system.
Social system
The sub concepts are social organization, role, status, authority, power, decision making and control. An organization is characterized by a structure that orders positions and activities and ruled by individuals who make use of resources to meet organizational goals. King defines authority as an active, reciprocal process of transaction in which the actor’s experience, understanding and values influence the meaning, legitimacy and acceptance of those in organizational positions associated with authority. Power includes organizational capacity, to use resources to meet goals. Decision making is defined as the orderly process through which choices related goals are made among identified possible activities. From the above mentioned conceptual model, she derived the theory of goal attainment.
King’s theory of goal attainment
The original concepts of theory are interaction, perception, communication, transaction, self, role, stress, growth and development, time and personal space. Interaction is the observable verbal and non verbal goal directed behaviors of two or more people in mutual presence and includes perception and communication. Interaction brings different ideas, attitudes and perceptions to the exchange called transaction. Perception is the reality as seen and experience by the individual. The elements of perception are the importing of energy from the environment and organizing it by information, transforming energy, processing, storing and exporting information.
Role is defined as set of behaviors, decision making is the process of making choices from the many available choices and health is goal of nursing. King indicates the outcome is an individual’s state of health or ability to function in social roles. From the theory of goal attainment, she has developed predictive propositions that a) perceptual accuracy, role congruence and communication leads to transaction 2) transaction leads to goal attainment 3) goal attainment leads to satisfaction and effective nursing care.
The theory is useful, testable and applicable to nursing practice. It is widely generalized and not situation specific. It is based on the review of literature and provides the reader with a set of resources for further study. Her work provides nursing with an excellent example of profession.

Nursing and theory development

(By Utente:Jollyroger (Own work) [CC BY-SA 2.5 (http://creativecommons.org/licenses/by-sa/2.5)], via Wikimedia Commons)

Nursing and theory development

 
“Nursing is a profession with unique body of knowledge and well principled skills, emphasis on care of human being during ill health to health continuum by meeting the needs physically, psychologically, socially and medically with modification of environment of individual, family and community through nursing practice, education and research”.

Theoretical thinking
The first unit of theory is concept. A concept is an idea or thought comes to mind through experience or observation. The concepts are divided into two; empirical and abstract. The empirical concepts (phenomena) are observed through senses, for example, heart rate and abstract concepts (intuition) are not observable, for example, caring.
The term metaparadigm indicates the boundaries of a discipline which summarizes the mission of the same discipline. There are four metaparadigm related to nursing; person, health, environment and nursing. The person represents individual, family or community. Health is a state of well being and environment is the surroundings of the person and nursing is the practice of the science based on the aspect of ‘care’, ‘cure’ and ‘prevention’. A proposition explains the relationships between the concepts. 

“A theory is a creative arrangement of concepts with definitions and its propositions in general, which describes the phenomena or intuition and its relationships, predict the actions and reactions through the research and solve problems in the reality”.

“A conceptual framework is a pictorial representation of theory or conceptual model”.

“A conceptual model is a creative arrangement of concepts related to specific event or problem in the reality with definitions and its propositions, which describes the phenomena or intuition and its relationships, predict the actions and its reactions through the research and solve the problems in the reality”. 

Barnum (1998) stated that a complete nursing theory is one that contains context, content and process. Context is an environment, content is the subject and process is the way of act to use the theory.
Smith and Liehr (2003) suggested three rungs for the model; philosophical, theoretical and empirical. The philosophical (highest) rung represents the beliefs and assumptions which are true and fundamental to a theory. The theoretical (middle) rung is abstract and consists of the symbols, ideas and concepts of the theory and empirical (lowest) rung is concrete, which is observed by senses. 

Levels of theory
Chinn and Kramer (2004) stated that theory is divided into micro, macro, midrange, atomistic or wholistic. Micro and atomistic suggests narrow range, where as, macro and wholistic implies a broad range. Middle range theories deal with a portion of nursing’s total concern but not with the totality of the discipline. Grand theory covers broad areas of concern with a discipline and meta theory is about theoretical process and theory development. Middle range theories are based on day to day research, narrow in scope, limited number of concepts and propositions, less abstract and more applicable to practice.
Im (1999) stated that situation specific theories are focused on specific nursing intervention phenomena, limited to specific population, are not intended to be universal theories and are may or may not be testable.

Dickoff and James (1968) developed theory on four levels:
Level 1: factor isolating – is descriptive in nature and naming or classifying the events.
Level 2: factor relating – associating or correlating factors
Level 3: situation relating – explains and predicts how situations are related
Level 4: situation producing – it requires sufficient knowledge about how and why situations are related. Level 4 being the most powerful, as it controls rather than description, explanation or prediction. 

Fawcett (2005) described various types of middle range theory. She stated that middle range theories describe what a phenomenon is, explain why it occurs and predict how it occurs. Middle range descriptive theories describe only one concept or classify a phenomenon. Middle range explanatory theories specify relations between two or more concepts and middle range predictive theories predict relationship between concepts. 

Johnson and Webber (2005) propose a criterion based critique model for nursing theories.
Phase 1: Intention of the theory

• Criterion I: understandable meaning
• Criterion II: consistent boundaries
• Criterion III: understandable language

Phase 2: Concepts and propositions

• Criterion IV: identify the major concepts
• Criterion V: formulation of propositions
• Criterion VI: understand and interpret the propositions

Phase 3: Usefulness in nursing practice

• Criterion VII: explains and predicts the phenomena
• Criterion VIII: influences nursing practice

Theories provide a platform to facilitate critical thinking to explain phenomena, identify the relationship between the concepts, solve the problems in the reality and predict the actions and reactions in the future. As new knowledge and discoveries emerge in nursing realms, the boundary of art and science of the discipline of nursing dissolves and fuses together.

Martha Rogers Science of Unitary Human Beings Model, 1970 (USA)

(By Unknown photographer [Public domain], via Wikimedia Commons)

Martha Rogers Science of Unitary Human Beings Model, 1970 (USA)

Martha Rogers was born on 1914 and earned a bachelor’s degree in nursing from George Peabody College, master’s degree in public health nursing from Columbia University and doctorate in nursing from the John Hopkins University. She was a teacher and mentor to an impressive list of nursing scholars and theorists. Rogers continued her work and writing until her death in 1994. 

Martha Rogers described her theory of Unitary Man in 1961 and stated that person was a ‘Unitary energy system’ in ‘continuous mutual interaction with the universal energy system’, ‘dramatically influenced nursing by encouraging nurses to consider the person as a whole entity when planning and delivering care’.

She published the book in 1970 at the age of 56 years; An introduction to the theoretical basis of nursing science, Rogers outlined the five assumptions that provide the foundation for the discipline of nursing.

1. Man is a unified whole possessing his own integrity and manifesting characteristics that are more than and different from the sum of his parts.
2. Man and environment are continuously exchanging matter and energy with one another.
3. The life process evolves irreversibly and unidirectionally along the space time continuum.
4. Pattern and organization identify man and reflect his innovative wholeness.
5. Man is characterized by the capacity for abstraction and imagery, language and thought, sensation and emotion.

Rogers condensed the assumptions to five blocks of the conceptual system (Rogers, 1992):

1. Energy fields
2. Pan dimensionality
3. Pattern
4. Unitary persons
5. Environment 

An energy field is defined as the distinguishing characteristics of an energy field perceived on a single wave. It is the unique configuration of relationships of a particular system. Areas of human field’s pattern that have been explored include pain, stress, hope, time etc.

She identified two energy fields of concern to nurses, which are integrated; human field and environmental field. The human field can be conceptualized as a person or groups, family or community. These fields can not be broken into sub systems. She interpreted the nursing care is holistic, meaning a summation of parts to arrive at the whole, where a nurse would assess the domains, subsystems identified, then synthesize the accumulated data to arrive at a picture of the total person. A change in one field causes alterations in other field. Both are integrated, can not be separated.

The fields are pan dimensional, defined as ‘a non linear domain with out spatial or temporal attributes’. Pan dimensional reality transcends traditional notions of space and time, which can be understood as perceived boundaries only.

Principles of homeodynamics

She defined the three principles of homeodynamics are reasoning, helicy and integrality. It describes the nature of change in the human environmental field process.

Principle of resonancy specifies the continuous change from lower to higher frequency wave pattern in human and environmental fields. Rogers elaborated: ‘individuals experience lesser diversity and greater diversity, time as slower, faster and unmoving’.

The principle of helicy is the continuous innovative unpredictable, increasing diversity of human and environmental field patterns. This describes the nature of change. The principle of integrality is continuous mutual human fields and the environmental field process. It specifies the context of change as the integral human environmental field process where person and environment are inseparable.

Together, postulates of Rogerian nursing science suggest that the human and environmental field change continuously, flow in lower and higher frequencies. Rogers believed that they serve as guides both to the practice of nursing and to research in the science of nursing.

Dorothy Johnson Behavior System Model 1968 (USA)

Dorothy Johnson Behavior System Model 1968 (USA)

Dorothy Johnson was born in Savannah, Georgia in 1919. She earned her bachelor of science in nursing from Vanderbilt University and her master’s in public health from Harvard University. At the age of 49 years, Johnson proposed the nursing care facilitated the client’s maintenance of a state of equilibrium. She said that clients were ‘stressed’ by internal and external stimulus. The nursing care should reduce the stimulus and facilitate the client’s natural defenses. She defined nursing as ‘external regulatory force which acts to preserve the organization and integration of the patient’s behavior at an optimum level under those conditions in which the behavior constitutes a threat to physical and social health or in which illness is found’.

Based on the definition, the four nursing goals are to assist the patient to become a person whose behavior is commensurate with social demands, who is able to modify his behavior in ways that support biologic imperative, who is able to benefit to the fullest extent during illness from the physician’s knowledge and skill and whose behavior does not give any evidence of unnecessary trauma as a consequence of illness.

Major concepts of the model

Person

The client is seen as a collection of behavioral subsystems that interrelate to form the behavioral subsystems. The system may be defined as those complex, overt actions or response to stimulate in the environment. Johnson has identified seven behavioral subsystems in the client. According to this, each subsystem has to be protected from noxious stimulus. Second, it must be nurtured and last, it must be stimulated to prevent stagnation of growth. 

The subsystems are:

• Attachment and affiliation
• Dependency
• Elimination
• Sexuality
• Ingestion
• Aggression
• Achievement

Attachment and affiliation–It is identified as first response systems to develop in an individual. It allows social inclusion, intimacy and the formation and maintenance of a strong bond, which provides the individual with sense of security.

Dependency- It allows and develops cooperative and independent role relationships with in human social system. They use interpersonal skills to achieve intimacy. 

Ingestion – It is related to food intake. The aim of the subsystem is to sustain life, to relieve discomfort and to obtain physical pleasure from intake of food.

Elimination- It relates to behavior surrounding the excretion of waste products from the body. It also helps the client to adjust to alterations in biological capabilities related to waste excretion while maintaining a sense of control over waste excretion.

Sexuality- It relates to procreate, to gratify or attract to fulfill expectations associated with one’s sex, to care for others and to be cared about by them.

Aggression- It relates to behaviors concerned with protection and self preservation. Johnson views the aggressive subsystem as one that generates defensive response from the individual when life or territory is threatened.

Achievement- It means mastery or control of self or the environment. Intellectual, physical, creative, mechanical, social skills are some of the areas that Johnson (1980) recognizes.

To conclude, Johnson’s behavioral system model is based on nursing care, advocates on behavioral functioning of the patient. The client is composed of 7 subsystems and each subsystem related to 4 structural characteristics: drive, set, choices and observable behavior. An imbalance in any behavioral subsystem results in diseases and nurse’s role is to assist the client to return to a state of equilibrium.

Ida Jean Orlando Nursing Process theory 1962 (USA)

(By National Cancer Institute [Public domain], via Wikimedia Commons)

Ida Jean Orlando Nursing Process theory 1962 (USA)

Ida Jean Orlando Pelletier (1926-2007) had worked as practitioner, educator,researcher and consultant in nursing. Throughout her career, she was active in various organizations including the Massachusetts Nurse’s Association and the Harvard Community Health Plan. She described the nursing process based on the interaction between patient and nurse. She has written a book “The dynamic nurse patient relationship” explains the factors which enhanced the integration of mental health of the people in the basic nursing curriculum and published in 1961 at the age of 36 years.

She defined the nursing is responsible to individuals who suffer or anticipate a sense of helplessness, it is focused on the process of care in an immediate experience, it is concerned with providing direct assistance to individuals in whatever setting and they are found for the purpose of avoiding, relieving, diminishing or curing the individual sense of helplessness. According to her theory, nurse patient relationship includes patient behavior, nurse’s reaction and professional function.

Patient behavior
The nursing process discipline is set in motion by patient behavior. It represents a plea for help. It may be verbal or non verbal. Verbal behavior consists of patient’s language in the form of complaints, requests, demands etc. Non verbal behavior includes physiological manifestations such as heart rate, perspiration, avoiding eye contact etc. If the nurse were not able to help the patient, helplessness would be developed. It reflects the distress, physical limitations and adverse reactions to the setting and experience which the patient from communicating his needs.

Nurse’s reaction
The patient behavior stimulates a nurse’s reaction, which paves the way for beginning of nursing process discipline. The reaction is comprised of three parts. First, the nurse perceives the behavior through any of her senses. Second, the perception leads to automatic thought. Finally, the thought produces an automatic feeling. For example, the nurse sees a patient in restless, thinks that she is in pain and confirms with the patient that she has correctly identified the need for help and to identify the nursing action appropriately to resolve it.

Nurse’s action 
Once the nurse has validated her reaction of the patient’s behavior through exploration with him, she can complete nursing process discipline with the nurse’s action. The nurse can act in two ways: automatic and deliberative. Automatic actions are ‘those decided upon for reactions other than the patient’s immediate needs. For example, the nurse gives the sedative to patient to sleep because the physician ordered it. But deliberate actions result from the correct identification of patient’s needs by validation of the nurse’s reaction to patient behavior. It fulfills her professional function

Professional function
Nurses often work with other professions and supposed to coordinate the patient care with them. Naturally, at times conflicts will arise between the actions appropriate to the nurse’s profession and those required by the job. Non professional actions of nurse leads to inadequate patient care. A well defined function of the profession can help to prevent and resolve the conflict.

Comparison of the Orlando’s process discipline and nursing process

It consists of seven phases. These are assessment, diagnosis, outcomes, plan of action, implementation and evaluation.

Assessment of the nursing process corresponds to the sharing of the nurse’s reaction to the patient behavior. The collection of data includes only information relevant to identifying patient’s need for help.

The product of the nursing process analysis is nursing diagnosis. The statement of the nursing process includes formally written problem related to etiological factors and signs and symptoms.

The outcome and plan of action phase involves writing outcomes, goals and objectives and deciding on appropriate nursing action.

The implementation phase involves the final selection of actions and carries out it. The evaluation phase asks whether the outcomes achieved or not.

This theory has much to offer to nursing. It guides nurses through their interactions with patients and ensure that they will be treated as individuals and focuses on patient’s needs rather than the demands of professional setting. Orlando should be considered as a nursing theorist who made significant contribution to the advanced nursing practice. She helped nurses to focus on patient needs rather than institutional demands. Here, nurse is viewed as a ‘care giver’ for the patient, not a ‘hand maiden’ for the physician. 

Faye Glenn Abdellah 21 Nursing Problems Theory 1960 (USA)

Faye Glenn Abdellah 21 Nursing Problems Theory 1960 (USA) 

Faye Abdellah was one of the first nursing theorists. She earned her bachelor’s degree, master’s and doctorate of nursing from Colombia University. She has been awarded many academic honors from civilian and military sources. Abdellah’s patient centered approach to nursing was developed inductively from her clinical practice at the age of 41 years and is considered as human needs theory. It is also relevant to community setting also. She considered the object of nursing as ‘patient’ rather than client or consumer. She developed the concept of nursing diagnosis in nursing care plan.

Abdellah and colleagues (1960) developed a list of 21 nursing problems.

To maintain good hygiene and physical comfort

To promote optimal activity, exercise, rest and sleep

To promote safety through prevention of accidents, injury, or other trauma and through the prevention of the spread of infection

To maintain good body mechanics and prevent and correct deformities

To facilitate the maintenance of supply of oxygen

To facilitate the maintenance of nutrition

To facilitate the maintenance of elimination

To facilitate the maintenance of fluid and electrolyte balance

To recognize the physiologic responses of the body to disease conditions

To facilitate the maintenance of regulatory mechanics and functions

To facilitate the maintenance of sensory function

To identify and accept positive and negative expressions, feelings and reactions

To identify and accept the interrelatedness of emotions and organic illness

To facilitate the maintenance of effective verbal and nonverbal communication

To promote the development of interpersonal relationships

To facilitate progress toward achievement of personal spiritual goals

To create and maintain a therapeutic environment

To facilitate awareness of self as an individual with varying physical, emotional and developmental needs

To accept the optimum possible goals in the light of physical and emotional limitations

To use community resources as an aid in resolving problems arising from illness

To understand the role of social problems as influencing factors in the cause of illness

They also identified a list of 10 steps and skills in nursing to be used in developing nursing care plan.

Know the patient

Differentiate the significant data

Make generalizations from the data

Identify the therapeutic plan

Test the generalizations with the patient and make additional generalizations

Validate the patient’s conclusions regarding the problem

Frequent evaluation and follow up

Explore the patient and family reaction to therapeutic plan

Identify the nurse’s reaction to patient and family

Develop a comprehensive nursing care plan based on the needs

This patient centered approach is very useful in nursing practice and education. She categorized nursing problems based on the individual needs and developed a typology of nursing care and skills. It is widely considered as major contributions to nursing into Nightingale’s ideal of becoming a profession.

­­­­­­­Virginia Henderson 14 basic need theory 1955 (USA)

(By Mennonite Church USA Archives [No restrictions], via Wikimedia Commons )

Virginia Henderson 14 basic need theory 1955 (USA) 

Virginia Henderson was born in Missouri and graduated in nursing from Colombia University. She was a well known nursing educator and author. She developed a concept of nursing from her educational and practical experiences at the age of 55 years. She stated nursing as a “Nursing is primarily assisting the individual (sick or well) in the performance of those activities contributing to health or its recovery (or peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. It is likewise the unique contribution of nursing to help the individual to be independent of such assistance as soon as possible” (Harmer and Henderson, 1955).

The major assumption of the theory that the nurse care for patients until they can care for themselves. She defined the patient who needs nursing care with supportive environment. The concept of this theory involved the nurse attending 14 activities to assist the individual towards independence.

Breathe normally

Eat and drink adequately

Eliminate body wastes

Move and maintain desirable postures

Sleep and rest

Select suitable clothes

Maintain body temperature with in normal range by adjusting clothing and modifying environment

Keep the body cleaned and well groomed and protect the integument

Avoid dangers in the environment

Communicate with the others in expressing emotions, needs or fears

Worship according to one’s faith

Work in such a way that there is a sense of accomplishment

Play and participate in various forms of recreation

Learn, discover or satisfy the curiosity that leads to normal development and health and use the available health facilities.

To conclude, Henderson’s work is parsimonious in its presentation, but complex in its scope. The 14 statements cover the whole of the practice of nursing and her vision about the nurse’s role on patient care contributed to that complexity.

Peplau's Interpersonal Relations Theory 1952 (USA)

Peplau's Interpersonal Relations Theory 1952 (USA)

A pioneer in nursing, named Dr.Hildegard Peplau published the book 'Interpersonal Relations in Nursing' in 1952 at the age of 43 years . Nursing is a therapeutic healing art, assists the individual who is sick and in need of health care. The relationship between nurse and patients develops based on need or problems from one of them, they begin to develop goal and objectives, prepares plan of action, implement to solve a problem. They approach this course of action from diverse backgrounds and with individual uniqueness. 

Peplau divided the interpersonal relationship into four phases. 

1. Orientation
2. Identification
3. Exploitation 
4. Resolution

In 1997, Peplau wrote that the nurse patient relationship is composed of three phases such as orientation, working and termination phases.

Orientation Phase

In the initial phase, the nurse and patient meet as two strangers. The person are in the need of help and the other side, the person who are ready to help. Both of them are deeply influenced by values, culture, race, preconceived ideas, beliefs, past experiences and expectations. While understanding this, the nurse, the patient and the family work together to recognize, clarify and define existing problem. In the beginning, they are strangers. At the end of the stage, they are working together to identify the problem and providing comfortable environment with one another.

Working Phase

This is otherwise described as identification and exploitation phase. During identification phase, both the patient and the nurse clarify each other's perceptions and expectations, build a working relationship for identifying the problem and choosing appropriate assistance. Once the problem is identified and the goals are set, both of them move to working phase, in which the patient takes advantage of all services available.Thus, the nurse and the patient utilize the available services to solve it.Progress is made toward the final step, the termination phase.

Termination Phase

It is in the process of terminating a professional relationship. Once the problems are solved and the goals are met, both of them move into termination phase. During successful termination, the patient drifts away from identifying with the helping person, the nurse. The patient becomes independent from the patient. Termination occurs only with the successful completion of the previous phase. 

To conclude, Peplau stressed that both the patient and the nurse mature as the result of therapeutic interaction. When two persons are met in a creative relationship, there is a continuing sense of mutuality and togetherness throughout the experiences. She has developed a unique view for understanding the nurse patient relationship.

Theory of Florence Nightingale 1860 (United Kingdom)

Florence Nightingale

Nursing: Notes on Nursing

Florence Nightingale, born in 1820, considered as the founder of nursing. During her career, she proposed a model regarding nursing, what it is and what it is not. Here, she explained very well regarding the factors influencing patient's health and various ways to modify it to achieve the optimum health.

She proposed four major concepts with ten canons at the age of 40 years. The major concepts and canons are

• Physical Environment- It consists of external factors in which patient is being influenced such as
• Ventilation and warming
• Light and noise
• Cleanliness of the rooms
• Health of the houses
• Bedding
• Personal cleanliness
• Variety

• Psychological Environment- It consists of factors which influences the emotional status of the patient such as  chattering hopes and advices. It doesn't mean to assure the patient regarding his/her disease condition falsely but, the nurses can keep the patient active by indulging him/her in activities.
• Nutritional Status- She noted the importance of taking healthy foods at frequent intervals rather than heavy meals. The food should be easily digestible, healthy and tasty for the patient.
• Nursing Care Plan and Management- It signifies the importance of planning the patient care with the proper use of fresh air, light, warmth, cleanliness, calm environment and proper diet.

She identified the five major environmental factors for optimal health such as pure fresh air, pure water, effective drainage, cleanliness and especially direct sunlight. This theory emphasis on attending the patient with nursing care objectives, assess the negative factors in the environment, prepare a plan to manipulate the negative into positive ones, for example provide a wrinkle free bed, change the bed linen daily, open the windows for fresh air, keep dim lights in the night etc, implement it and evaluate the progress of the patient by frequent follow up.

Strengths and weakness

This theory had written in detail regarding the nursing: what it is. It paves the ways for the nursing administrators to propose policies and protocols for nursing care in hospitals and community.

I feel that this theory is not applicable to unconscious patients. Nowadays, patients are being treated in cool environment by using air conditioning method in hospitals, which is optimum temperature to curb the growth of micro organisms and for fresh air rather than out door polluted air and harmful ultraviolet radiations from the sun.