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

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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)

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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)

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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.