Jean Watson

Caring Science as Sacred Science

In todays world, nursing seems to be responding to the various demands of the
machinery with less consideration of the needs of the person attached to the
machine. In Watsons view, the disease might be cured, but illness would remain
because without caring, health is not attained. Caring is the essence of nursing and
connotes responsiveness between the nurse and the person; the nurse coparticipates with the person. Watson contends that caring can assist the person to
gain control, become knowledgeable, and promote health changes.
Major Concepts
Society provides the values that determine how one should behave and what goals
one should strive toward. Watson (1979) states:
Caring (and nursing) has existed in every society. Every society has had some
people who have cared for others. A caring attitude is not transmitted from
generation to generation by genes. It is transmitted by the culture of the profession
as a unique way of coping with its environment.
Human being is a valued person to be cared for, respected, nurtured, understood,
and assisted.
Health is the unity and harmony within the mind, body, and soul; health is
associated with the degree of congruence between the self as perceived and the
self as experienced.
Nursing is a human science of persons and human health illness experiences that
are mediated by professional, personal, scientific, esthetic, and ethical human care
transactions.
Actual caring occasion involves actions and choices by the nurse and the individual.
The moment of coming together in a caring occasion presents the two persons with
the opportunity to decide how to be in the relationship what to do with the
moment.
The transpersonal concept is an intersubjective human-to-human relationship in
which the nurse affects and is affected by the person of the other. Both are fully
present in the moment and feel a union with the other; they share a phenomenal
field that becomes part of the life story of both. (Watson, 1999)
Subconcepts
Phenomenal field
The totality of human experience of ones being in the world. This refers to the
individuals frame of reference that can only be known to that person.
Self

The organized conceptual gestalt composed of perceptions of the characteristics of

the I or ME and the perceptions of the relationship of the I and ME to others
and to various aspects of life.

Time
The present is more subjectively real and the past is more objectively real. The past
is prior to, or in a different mode of being than the present, but it is not clearly
distinguishable. Past, present, and future incidents merge and fuse. (Watson, 1999)
Nursing interventions related to human care originally referred to as carative factors
have now been translated into clinical caritas processes (Watson, 2006):
1. The formation of a humanistic-altruistic system of values, becomes: practice of
loving-kindness and equanimity within context of caring consciousness.
2. The instillation of faith-hope becomes: being authentically present, and enabling
and sustaining the deep belief system and subjective life world of self and onebeing-cared-for.
3. The cultivation of sensitivity to ones self and to others becomes: cultivation of
ones own spiritual practices and transpersonal self, going beyond ego self.
4. The development of a helping-trusting relationship becomes: developing and
sustaining a helping-trusting authentic caring relationship.
5. The promotion and acceptance of the expression of positive and negative feelings
becomes: being present to, and supportive of the expression of positive and
negative feelings as a connection with deeper spirit of self and the one-being-caredfor.
6. The systematic use of the scientific problem-solving method for decision making
becomes: creative use of self and all ways of knowing as part of the caring process;
to engage in artistry of caring-healing practices.
7. The promotion of interpersonal teaching-learning becomes: engaging in genuine
teaching-learning experience that attends to unity of being and meaning attempting
to stay within others frame of reference.
8. The provision for a supportive, protective, and(or) corrective mental, physical,
sociocultural, and spiritual environment becomes: creating healing environment at
all levels (physical as well as non-physical), subtle environment of energy and
consciousness, whereby wholeness, beauty, comfort, dignity, and peace are
potentiated.
9. Assistance with the gratification of human needs becomes: assisting with basic
needs, with an intentional caring consciousness, administering human care
essentials, which potentiate alignment of mindbodyspirit, wholeness, and unity of

being in all aspects of care, tending to both embodied spirit and evolving spiritual
emergence.
Watsons (1979) ordering of needs:
a. Lower Order Needs (Biophysical Needs)
- Survival Needs
- The need for food and fluid
- The need for elimination
- The need for ventilation
b. Lower Order Needs (Psychophysical Needs)
- Functional Needs
- The need for activity-inactivity
- The need for sexuality
c. Higher Order Needs (Psychosocial Needs)
- Integrative Needs
- The need for achievement
- The need for affiliation
d. Higher Order Need (Intrapersonal-Interpersonal Need)
- Growth-seeking Need
- The need for self-actualization.
10. The allowance for existential-phenomenological forces becomes: opening and
attending to spiritual-mysterious and existential dimensions of ones own life-death;
soul care for self and the one-being-cared-for.
Assumptions
-

Caring can be effectively demonstrated and practiced only interpersonally.

Caring consists of carative factors that result in the satisfaction of certain
human needs.
Effective caring promotes health and individual or family growth.
Caring responses accept a person not only as he or she is now but as what
he or she may become.
A caring environment is one that offers the development of potential while
allowing the person to choose the best action for himself or herself at a
given point in time.
Caring is more healthogenic than is curing. The practice of caring
integrates biophysical knowledge with knowledge of human behavior to
generate or promote health and to provide ministrations to those who are
ill. A science of caring is therefore complementary to the science of
curing.
The practice of caring is central to nursing. (Watson, 1979).

Relationships
-

Transpersonal caring field resides within a unitary field of consciousness

and energy that transcend time, space and physicality.
A transpersonal caring relationship connotes a spirit-to-spirit unitary
connection within a caring moment, honoring the embodied spirit of both
practitioner and patient, within a unitary field of consciousness.

A transpersonal caring relationship transcends the ego level of both

practitioner and patient, creating a caring field with new possibilities for
how to be in the moment.
The practitioners authentic intentionality and consciousness of caring has
a higher frequency of energy than noncaring consciousness, opening up
connections to the universal field of consciousness and greater access to
ones inner healer.
Transpersonal caring is communicated via the practitioners energetic
patterns of consciousness, intentionality, and authentic presence in a
caring relationship.
Caring-healing modalities are often noninvasive, nonintrusive, naturalhuman, energetic environmental field modalities.
Transpersonal caring promotes self-knowledge, self-control, and selfhealing patterns and possibilities.
Advanced transpersonal caring modalities draw upon multiple ways of
knowing and being; they encompass ethical and relational caring, along
with those intentional consciousness modalities that are energetic in
nature that honors wholeness, healing, comfort, balance, harmony, and
well-being. (Watson, 2005)

Strengths/Weaknesses
Strengths:
Watsons work can be used to guide and improve practice. It can provide the nurse
with the most satisfying aspects of practice and can provide the client with holistic
care.
The theory is relatively simple.
Watsons work is logical in that the carative factors are based on broad assumptions
that provide a supportive framework. The carative factors are logically derived from
the assumptions and related to the hierarchy of needs.
The carative factors delineate nursing from medicine.
Weakness:
Watsons theory becomes more complex when entering the area of existentialphenomenology, for many nurses may not have the liberal arts background to
provide the proper foundation for this area.
Analysis
It is undeniable that technology has already been part of nursings whole paradigm
with the evolving era of development. Watsons suggestion of purely caring
without giving much attention to technological machineries cannot be solely applied
but then her statement is praiseworthy because she dealt with the importance of
the nurse patient interaction rather than a practice confined with technology.
Watson stated the term soul-satisying when giving out care for the clients. Her
concepts guide the nurse to an ideal quality nursing care provided for the patient.

This would further increase the involvement of both the patient and the nurse when
the experience is satisfying.
In providing the enumerated clinical caritas processes, the nurse becomes an active
co-participant with the patient. Thus, quality of care offered by the nurse is
enhanced.

Virginia Henderson
The Principles and Practice of Nursing
I believe that the function the nurse performs is primarily an independent one
that of acting for the patient when he lacks knowledge , physical strength, or the
will to act for himself as he would ordinarily act in health, or in carrying out
prescribed therapy. This function is seen as complex and creative, as offering
unlimited opportunity for the application of the physical, biological, and social
sciences and the development of skills based on them. (Henderson, 1960)
Major Concepts
Human or Individual
-

Henderson considers the biological, psychological, sociological, and

spiritual components.
She defined the patient as someone who needs nursing care, but did not
limit nursing to illness care.

Society or Environment
-

She did not define environment, but maintaining a supportive

environment is one of the elements of her 14 activities.
She sees individuals in relation to their families but minimally discusses
the impact of the community on the individual and family.
She supports the tasks of private and public health agencies keeping
people healthy.

She believes that society wants and expects the nurses service of acting
for individuals who are unable to function independently.

Health
-

Health was not explicitly defined, but it is taken to mean balance in all
realms of human life.

Nursing
-

Henderson believed that the unique function of the nurse is to assist the
individual, sick or well, in the performance of those activities contributing
to health or its recovery (or to a peaceful death) that he would perform
unaided if he had the necessary strength, will or knowledge. And to do this
in such a way as to help him gain independence as rapidly as possible.
(Henderson, 1991)

Subconcepts
14 Activities for Client Assistance
Physiological
-

Breathe normally
Eat and drink adequately
Eliminate body wastes
Move and maintain desirable postures
Sleep and rest
Select suitable clothes dress and undress
Maintain body temperature within normal range by adjusting clothing and
modifying environment
Keep the body clean and well groomed and protect the integument
Avoid dangers in the environment and avoid injuring others

Psychological Aspects of Communicating and Learning

10. Communicate with others in expressing emotions, needs, fears, or opinions
14. Learn, discover, or satisfy the curiosity that leads to normal development and
health and use the available health facilities
Spiritual and Moral
11. Worship according to ones faith
Sociologically Oriented to Occupation and Recreation
12. Work in such a way that there is sense of accomplishment
13. Play or participate in various forms of recreation

It is equally important to realize that these needs are satisfied by infinitely varied
pattern of living, no two of which are alike. (Henderson, 1960)
Assumptions
-

Nurses care for patients until patients can care for themselves once again.
Patients desire to return to health.
Nurses are willing to serve and that nurses will devote themselves to the
patient day and night. (Henderson, 1991)
Nurses should be educated at the university level in both arts and
sciences.
Henderson also believes that mind and body are inseparable. It is implied
that the mind and body are interrelated. (Henderson, 1966, 1991)

Strengths/Weaknesses
Hendersons work is relatively simple yet generalizable with some limitations. Her
work can be applied to the health of individuals of all ages. Limited in a way that it
can generally be applied to fully functional individuals.

Each of the 14 activities can be the basis for research. Although the statements are
not written in testable terms, they may be reformulated into researchable
questions.
Strength- The concept of nursing formulated by Henderson in her definition of
nursing and the 14 components of basic nursing is uncomplicated and selfexplanatory. Therefore, it can be used without difficulty as a guide for nursing
practice by most nurses.
Weakness- A major shortcoming in her work is the lack of a conceptual linkage
between physiological and other human characteristics.
Analysis
One cannot say that every individual who has similar needs indicated in the 14
activities by Henderson are the only things that human beings need in attaining
health and for survival. With the progress of todays time, there may be added
needs that humans are entitled to be provided with by nurses.
The prioritization of the 14 Activities was not clearly explained whether the first one
is prerequisite to the other. But still, it is remarkable that Henderson was able to
specify and characterize some of the needs of individuals based on Abraham
Maslows hierarchy of needs.
Some of the activities listed in Hendersons concepts can only be applied to fully
functional individuals indicating that there would always be patients who always

require aided care which is in contrary to the goal of nursing indicated in the
definition of nursing by Henderson.
Because of the absence of a conceptual diagram, interconnections between the
concepts and subconcepts of Hendersons principle are not clearly delineated.

Sister Callista Roy

The Roy Adaptation Model
Diagrammatic Representation of Human Adaptive Systems

The Regulator

The Cognator

Major Concepts
Environment- Conditions, circumstances and influences that affect the
development and behavior of humans as adaptive systems.
Health - A state and process of being and becoming integrated and whole.
Person- The human adaptive system and defined as a whole with parts that
function as a unity for some purpose. Human systems include people groups
organizations, communities, and society as a whole. (Roy & Andrews, 1999)
Goal of nursing- The promotion of adaptation in each of the four modes.
Adaptation
-

The process and outcome whereby thinking and feeling persons as

individuals or in groups use conscious awareness and choice to create
human and environmental integration.

Four Adaptive Modes

1. Physiologic-physical mode: physical and chemical processes involved in the
function and activities of living organisms; the underlying need is physiologic
integrity as seen in the degree of wholeness achieved through adaptation to
changes in needs. In groups, this is the manner in which human systems manifest
adaptation relative to basic operating resources. The basic need of this mode is
composed of the needs associated with oxygenation, nutrition, elimination, activity
and rest, and protection. The complex processes of this mode are associated with
the senses, fluid and electrolytes, neurologic function, and endocrine function.
2. Self-concept-group identity mode: focuses on psychological and spiritual integrity
and a sense of unity, meaning, purposefulness in the universe.
3. Role function mode: refers to the roles that individuals occupy in society fulfilling
the need for social integrity; it is knowing who one is, in relation to others.
4. Interdependence mode: the close relationships of people and their purpose,
structure and development individually and in groups and the adaptation potential
of these relationships.
Subconcepts
Adaptive responses are those that promote the integrity of the person. The persons
integrity, or wholeness, is behaviorally demonstrated when the person is able to
meet the goals in terms of survival, growth, reproduction and mastery. Ineffective
responses do not support these goals. (Roy & Andrews, 1991)

Coping mechanisms describe the control processes of the person as an adaptive

system. Some coping mechanisms are inherited or genetic, such as white blood cell
defense mechanism against bacteria that seek to invade the body. Other
mechanisms are learned, such as the use of antiseptics to cleanse a wound.
Two Coping Subsytems
A. Cognator subsystem- A major coping process involving four cognitive-emotive
channels: perceptual and information processing, learning, judgment, and emotion.

B. Regulator subsystem- A basic type of adaptive process that responds

automatically through neural, chemical, and endocrine coping channels.

Focal stimuli- Those stimuli that are the proximate causes of the situation.
Contextual stimuli- All other stimuli in the internal or external environment, which
may or may not affect the situation.
Residual stimuli- Those immeasurable and unknowable stimuli that also exist and
may affect the situation.

Assumptions
Scientific Assumptions
-

Systems of matter and energy progress to higher levels of complex selforganization.

Consciousness and meaning are constructive of person and environment
integration.
Awareness of self and environment is rooted in thinking and feeling.
Humans by their decisions are accountable for the integration of creative
processes.
Thinking and feeling mediate human action.
System relationships include acceptance, protection, and fostering of
interdependence.
Persons and the earth have common patterns and integral relationships.
Persons and environment transformations are created in human
consciousness.
Integration of human and environment meanings results in adaptation.

Philosophical Assumptions
-

Persons have mutual relationships with the world and God.

Human meaning is rooted in the omega point convergence of the

universe.
God is intimately revealed in the diversity of creation and is the common
destiny of creation.
Persons use human creative abilities of awareness, enlightenment, and
faith.
Persons are accountable for the processes of deriving, sustaining, and
transforming the universe.

Strengths/Weaknesses
Strengths:
-

The theory suggests the influence of multiple causes in a situation, which

is strength when dealing with multi-faceted human beings.
The sequence of concepts in Roys model follows logically. In the
presentation of each of the key concepts there is the recurring idea of
adaptation to maintain integrity. Every concept was operationally defined.
The concepts of Roys model are stated in relatively simple terms.
A major strength of the model is that it guides nurses to use observation
and interviewing skills in doing an individualized assessment of each
person.
The concepts of Roys model are applicable within many practice settings
of nursing.

Weaknesses:
-

Painstaking application of the model requires significant input of time and

effort.
Roys model has many elements, systems, structures and multiple
concepts.

Analysis
As one of the weaknesses of the theory that application of it is time-consuming,
application of the model to emergency situations requiring quick action is difficult to
complete. The individual might have completed the whole adaptation process
without the benefit of having a complete assessment for thorough nursing
interventions.
Adaptive responses may vary in every individual and may take longer time
compared to others. Thus, the span of control of nurses may be impeded by the
time of the discharge of the patient.

Unlike Levine, although the latter tackled on adaptation, Roy gave much focus on
the whole adaptive system itself. Each concept was linked with the coping
mechanisms of every individual in the process of adapting.
The nurses roles when an individual presents an ineffective response during his or
her adaptation process were not clearly discussed. The main point of the concept
was to promote adaptation but none were stated on how to prevent and resolve
maladaptation.

Lydia E. Hall
The Aspects of Care, Core, Cure
Halls Three Aspects of Nursing

Care and Core

Predominate

As Hall (1965) says; To look at and listen to self is often too difficult without the
help of a significant figure (nurturer) who has learned how to hold up a mirror and
sounding board to invite the behaver to look and listen to himself. If he accepts the
invitation, he will explore the concerns in his acts and as he listens to his
exploration through the reflection of the nurse, he may uncover in sequence his
difficulties, the problem area, his problem, and eventually the threat which is
dictating his out-of-control behavior.
Major Concepts
The individual human who is 16 years of age or older and past the acute stage of
a long-term illness is the focus of nursing care in Halls work. The source of energy
and motivation for healing is the individual care recipient, not the health care

provider. Hall emphasizes the importance of the individual as unique, capable of

growth and learning, and requiring a total person approach.
Health can be inferred to be a state of self-awareness with conscious selection of
behaviors that are optimal for that individual. Hall stresses the need to help the
person explore the meaning of his or her behavior to identify and overcome
problems through developing self-identity and maturity.
The concept of society/environment is dealt with in relation to the individual. Hall
is credited with developing the concept of Loeb Center because she assumed that
the hospital environment during treatment of acute illness creates a difficult
psychological experience for the ill individual (Bowar-Ferres, 1975). Loeb Center
focuses on providing an environment that is conducive to self-development. In such
a setting, the focus of the action of the nurses is the individual, so that any actions
taken in relation to society or environment are for the purpose of assisting the
individual in attaining a personal goal.
Nursing is identified as consisting of participation in the care, core, and cure
aspects of patient care.
Subconcepts
The Care Circle
It represents the nurturing component of nursing and is exclusive to nursing.
Nurturing involves using the factors that make up the concept of mothering (care
and comfort of the person) and provide for teaching-learning activities.
The professional nurse provides bodily care for the patient and helps the patient
complete such basic daily biological functions as eating, bathing, elimination, and
dressing. When providing this care, the nurses goal is the comfort of the patient.
Providing care for a patient at the basic needs level presents the nurse and patient
with an opportunity for closeness. As closeness develops, the patient can share and
explore feelings with the nurse.
The Core Circle
It is based in the social sciences, involves the therapeutic use of self, and is shared
with other members of the health team. The professional nurse, by developing an
interpersonal relationship with the patient, is able to help the patient verbally
express feelings regarding the disease process and its effects. Through such
expression, the patient is able to gain self-identity and further develop maturity.
The professional nurse, by the use of reflective technique (acting as a mirror to the
patient), helps the patient look at and explore feelings regarding his or her current
health status and related potential changes in lifestyle.

Motivations are discovered through the process of bringing into awareness the
feelings being experienced. With this awareness, the patient is now able to make
conscious decisions based on understood and accepted feelings and motivation.
The Cure Circle
It is based in the pathological and therapeutic sciences and is shared with other
members of the health team. During this aspect of nursing care, the nurse is an
active advocate of the patient.
Assumptions
-

The motivation and energy necessary for healing exist within the patient,
rather than in the health care team.
The three aspects of nursing should not be viewed as functioning
independently but as interrelated.
The three aspects interact, and the circles representing them change size,
depending on the patients total course of progress.

Strengths/Weaknesses
Strengths:
-

The use of the terms care, core, and cure are unique to Hall.
Halls work appears to be completely and simply logical.

Weaknesses:
-

Halls work is simple in its presentation. However, the openness and

flexibility required for its application may not be so simple for nurses
whose personality, educational preparation, and experience have not
prepared them to function with minimal structure. This and the selfimposed age and illness requirements limit the generalizability.

Analysis
Hall imposed an age requirement for the application of her theory which is 16 years
of age and above. This limits the theory since it cannot be disregarded that nurses
are faced with pediatric clients every now and then. Even though Hall confined her
concepts for that age bracket, the concepts of care, core and cure can still be
applied to every age group but again, none was specified.

The only tool of therapeutic communication Hall discussed is reflection. By

inference, all other techniques of therapeutic communication are eliminated.
Reflection is not always the most effective technique to be used.

The concept of a patient aggregate such as having families and communities as the
focus of nursing practice was not tackled. It is purely on the individual himself.
Although, the role of the family or the community within the patients environment
was modestly discussed.
In the focus of nursing care in Halls concepts, the individual must pass an acute
stage of illness for you to successfully apply her theory. Therefore, this theory
relates only to those who are ill. This indicates that no nursing contact with healthy
individuals, families, or communities, and it negates the concept of health
maintenance and disease prevention.

Ida Jean Orlando

The Dynamic Nurse-Patient Relationship
Orlandos nursing process discipline is rooted in the interaction between a nurse
and a patient at a specific time and place. A sequence of interchanges involving
patient behavior and nurse reaction takes place until the patients need for help, as
he perceives it, is clarified. The nurse then decides on an appropriate action to
resolve the need in cooperation with the patient. This action is evaluated after it is
carried out. If the patient behavior improves, the action was successful and the
process is completed. If there is no change or the behavior gets worse, the process
recycles with new efforts to clarify the patients behavior or the appropriate nursing
action.

The action process in a person-to-person contact functioning in secret. The

perceptions, thoughts, and feelings of each individual are not directly available to
the perception of the other individual through the observable action.

The action process in a person-to-person contact functioning by open disclosure.

The perceptions, thoughts, and feelings of each individual are directly available to
the perception of the other individual through the observable action.
Major Concepts
Orlando uses the concept of human as she emphasizes individuality and the
dynamic nature of the nurse-patient relationship. For her, humans in need are the
focus of nursing practice.
Although health is not specified by Orlando, it is implied. In her initial work, Orlando
focused on illness. Later, she indicated that nursing deals with the individual
whenever there is a need for help. Thus a sense of helplessness replaces the
concept of health or illness as the initiator of a need for nursing.
Orlando speaks of nursing as unique and independent in its concerns for an
individuals need for help in an immediate situation. The efforts to meet the
individuals need for help are carried out in an interactive situation and in a
disciplined manner that requires proper training.
Need is defined as a requirement of the patient which, if supplied, relieves or
diminishes his immediate distress or improves his immediate sense of adequacy or
well-being (Orlando, 1990). In many instances, people can meet their own needs,
do so, and do not require the help of professional nurses. When they cannot do so,
or do not clearly understand these needs, a need for help is present.
In the immediacy of nursing situation, each patients behavior must be assessed
to determine whether it expresses as need for help. Furthermore, identical
behaviors by the same patient may indicate different needs at different times. The
nursing action must also be specifically designed for the immediate encounter.
Subconcepts
Patient Behavior
-

This sets the nursing process discipline in motion.

All patient behavior, no matter how insignificant, must be considered an

expression of need for help until its meaning to a particular patient in the
immediate situation is understood.
The presenting behavior of the patient, regardless of the form in which it
appears, may represent a plea for help (Orlando, 1990).
Patient behavior may be verbal or nonverbal. Inconsistency between these
two types of behavior may be the factor that alerts the nurse that the
patient needs help.

Distress
-

The patients behavior reflects distress when the patient experiences a

need that he cannot resolve, a sense of helplessness occurs.
Some categories of patient distress are: physical limitations, adverse
reactions to the setting and experiences which prevent the patient from
communicating his needs (Orlando, 1990).

Nurse Reaction
-

The patient behavior stimulated a nurse reaction, which marks the

beginning of the nursing process discipline.
This reaction is comprised of three sequential parts (Orlando, 1972). 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.
The nurse does not assume that any aspect of her reaction to the patient
is correct, helpful, or appropriate until she checks the validity of it in
exploration with the patient (Orlando, 1990).
The nurse must learn to identify each part of her action so the process
becomes logical rather than intuitive and thus, disciplined rather than
automatic.

Orlando (1972) also provides three criteria to ensure that the nurses exploration of
her reaction with the patient is unsuccessful:
1. What the nurse says to the individual in the contact must match any or all of
the items contained in the immediate reaction, and what the nurse does
nonverbally must be verbally expressed and the expression must match one
or all of the items contained in the immediate reaction.
2. The nurse must clearly communicate to the individual that the item being
expressed belongs to herself.
3. The nurse must ask the individual about the item expressed in order to obtain
correction or verification from that same individual.

Nurses Action
Orlando (1990) includes only what she [the nurse] says or does with or for the
benefit of the patient as professional nursing action. The nurse initiates a process
of exploration to ascertain how the patient is affected by what she says or does.
The nurse can act in two ways: automatic or deliberative. Only the second manner
fulfills her professional function.
Automatic actions are those decided upon for reasons other than the patients
immediate need, whereas deliberative actions ascertain and meet this need.
The following list identifies the criteria for deliberative actions:
1. Deliberative actions result from the correct identification of patient needs by
validation of the nurses reaction to patient behavior.
2. The nurse explores the meaning of the action with the patient and its
relevance to meeting his need.
3. The nurse validates the actions effectiveness immediately after completing
it.
4. The nurse is free of stimuli unrelated to the patients need when she acts.
Assumptions
-

When patients cannot cope with their needs without help, they become
distressed with feelings of helplessness.
Nursing, in its professional character, does add to the distress of the
patient.
Patients are unique and individual in their responses.
Nursing offers mothering and nursing analogous to an adult mothering
and nurturing of a child.
Nursing deals with people, environment and health.
Patient need help in communicating needs, they are uncomfortable and
ambivalent about dependency needs.
Human beings are able to be secretive or explicit about their needs,
perceptions, thoughts and feelings.
The nurse patient situation is dynamic, actions and reactions are
influenced by both nurse and patient.
Human beings attach meanings to situations and actions that are not
apparent to others.
Patients entry into nursing care is through medicine.
The patient cannot state the nature and meaning of his distress for his
need without the nurses help or without her first having established a
helpful relationship with him.

Any observation shared and observed with the patient is immediately

useful in ascertaining and meeting his need or finding out that he is not in
need at that time.
Nurses are concerned with needs that patients cannot meet on their own.

Strengths/Weaknesses
Strengths:
-

Use of her theory assures that the patient will be treated as individuals
and they will have an active and constant input into their own care.
Assertion of nursings independence as a profession and her belief that
this independence must be based on a sound theoretical frame work.
Guides the nurse to evaluate her care in terms of objectively observable
patient outcomes.

Weaknesses:
-

Lack the operational definitions of society or environment which limits the

development of research hypothesis.
The theory focuses on short term care, particularly aware and conscious
individuals and on the virtual absence of reference group or family
members.

Analysis
-

Compared to other nursing theories which are task oriented, Orlando gave
a clear cut approach of a patient oriented nursing theory. It uplifts the
integrity of an individualized nursing care. This strengthens the role of the
nurse as an independent nurse advocate for the patient.
The dynamic concept of the nurse-patient interaction was justified since
the participation of the patient in the relationship was sought. The whole
process is in constant revision through continuous validation of findings of
the nurses findings with that of the patient.
Because the nurse has to constantly explore her reactions with the
patient, it prevents inaccurate diagnosis or ineffective plans.
Since the model is applied to an immediate situation, its applicability to a
long term care plan is not feasible.
The concept of interaction also limits it to individuals capable of
conversing, a shared limitation with other nurse-client dynamic theories
unconscious patients are not covered by this theory.

Imogene M. King
Kings Conceptual System and Theory of Goal Attainment and Transactional Process
Dynamic Interacting Systems
King
has
interrelated
the
concepts
of
interaction,
perception,
communication,
transaction, self, role, stress,
growth and development, time,
and space into a theory of goal
attainment. Her theory deals
with a nurse-client dyad, a
relationship to which each
person
brings
personal
perceptions of self, role, and
personal levels of growth and
development. The nurse and
client communicate, first in
interaction
and
then
in
transaction, to attain mutually
set goals. The relationship
takes place in space identified by their behaviors and occurs in forward-moving
time.

INTERACTION

Major Concepts and Subconcepts

Open Systems Framework
Structure is presented in three open systems.
Function is demonstrated in reciprocal relations of individuals in interaction.
Resources include both people (health professionals and their clients) and money,
goods, and services for items needed to carry out specific activities.
Decision making occurs when choices are made in resource allocation to support
attaining system goals.
Personal Systems
Each individual is a personal system.
Interpersonal systems are formed by human beings interacting. Two interacting
individuals form a dyad; three form a triad, and four or more form small or large
groups. As the number of interacting individuals increases, so does the complexity
of the interactions.
King (1990) accepts Jersilds (1952) definition of self:
The self is a composite of thoughts and feelings which constitute a persons
awareness of his individual existence, his conception of who and what he is. A
persons self is the sum total of all he can call his. The self includes, among other
things, a system of ideas, attitudes, values, and commitments. The self is a persons
total subjective environment. It is a distinctive center of experience and
significance. The self constitutes a persons inner world as distinguished from the
outer world consisting of all other people and things. The self is the individual as
known to the individual. It is that to which we refer when we say I.
Growth and development can be defined as the processes in peoples lives
through which they move from a potential for achievement to actualization of self.
King defines body image as the way one perceives both ones body and others
reactions to ones appearance.

Space includes that space exists in all directions, is the same everywhere, and is
defined by the physical area known as territory and by the behaviors of those
occupy it.
Time is defined as a duration between one event and another as uniquely
experienced by each human being; it is the relation of one event to another event.
King (1986) added learning as a subconcept in the personal system but did not
further define it.
Interactions are defined as the observable behaviors of two or more individuals in
mutual presence.

King (1990) defines communication as a process whereby information is given from

one person to another either directly in face-to-face meeting or indirectly through
telephone, television, or the written word.
King defines transactions as a process of interactions in which human beings
communicate with the environment to achieve goals that are valued goal-directed
human behaviors.
The characteristics of role include reciprocity in that a person may be a giver at one
time and a taker at another time, with a relationship between two or more
individuals who are functioning in two or more roles that learned, social, complex,
and situational.
Stress is a dynamic state whereby a human being interacts with the environment
to maintain balance for growth, development, and performance, which involves an
exchange of energy and information between the person and the environment for
regulation and control of stressors.
Power is the capacity to use resources in organizations to achieve goals is the
process whereby one or more persons influence other persons in a situation is the
capacity or ability of a person or a group to achieve goals occurs in all aspects of
life and each person has potential power determined by individual resources and
the environmental forces encountered. Power is social force that organizes and
maintains society. Power is the ability to use and to mobilize resources to achieve
goals.
Status is the position of an individual in a group or a group in relation to other
groups in an organization and is identified that status is accompanied by
privileges, duties and obligation.

Decision making is a dynamic and systematic process b y which goal-directed

choice of perceived alternatives is made and acted upon by individuals or groups to
answer a question and attain a goal (King, 1990).
King (1986) added control as a subconept in the social system but did not further
define the concept.
Theory of Goal Attainment
Nursing is a process of action, reaction, and interaction whereby nurse and client
share information about their perceptions in the nursing situation. The nurse and
client share specific goals, problems, and concerns and explore means to achieve a
goal.
Health is a dynamic life experience of a human being, which implies continuous
adjustment to stressors in the internal and external environment through optimum
use of ones resources to achieve maximum potential for daily living.
Individuals are social beings who are rational and sentient. Humans communicate
their thoughts, actions, customs, and beliefs through language. Persons exhibit
common characteristics such as the ability to perceive, to think, to feel, to choose
between alternative courses of action, to set goals, to select the means to achieve
goals, and to make decisions.

Environment is the background for human interactions. It is both external to, and
internal to, the individual.
Action is defined as a sequence of behaviors involving mental and physical action.
The sequence is first mental action to recognize the presenting conditions; then
physical action to begin activities related to those conditions; and finally, mental
action in an effort to exert control over the situation, combined with physical action
seeking to achieve goals.
Reaction is not specifically defined but might be considered to be included in the
sequence of behaviors described in action.
Interaction is a process of perception and communication between person and
environment and between person and person represented by verbal and nonverbal
behaviors that are goal-directed.
Transaction is a process of interactions in which human beings communicate with
the environment to achieve goals that are valued; transactions are goal-directed
human behaviors.
Perception is each persons representation of reality.

Communication is defined as a process whereby information is given from one

person to another either directly in face-to-face meetings or indirectly through
telephone, television, or the written word.
Role is defined as a set of behaviors expected of persons occupying a position in a
social system; rules that define rights and obligations in a position; a relationship
with one or more individuals interacting in specific situations for a purpose.
Stress is a dynamic state whereby a human being interacts with the environment
to maintain balance for growth, development, and performance an energy
response of an individual to persons, objects, and events called stressors.
Growth and development can be defined as the continuous changes in
individuals at the cellular, molecular, and behavioral levels of activities the
processes that take place in the life of individuals that help them move from
potential capacity for achievement to self-actualization.
Time is a sequence of events moving onward to the future a continuous flow of
events in successive order that implies a change, a past and a future a duration
between one event and another as uniquely experienced by each human being
the relation of one event to another.
Space exists in every direction and is the same in all directions. Space includes that
physical area called territory. Space is defined by the behaviors of those individuals
who occupy it (King, 1990).

Assumptions
On the open systems framework, King stated
-

that each human being perceives the world as a total person in making
transactions with individuals an things in the environment
that transactions represent a life situation in which perceiver and thing
perceived are encountered and in which each person enters the situation
as an active participant and each is changed in the process of these
experiences.

When describing individuals, the model states that

-

individuals are social, sentient, rational, reacting beings, and

individuals are controlling, purposeful, action oriented, and time oriented
in their behavior (King, 1995).

Regarding nurse-client interactions, King (1981) believes that

perceptions of the nurse and client influence the interaction process;

goals, needs, and values of the nurse and the client influence the
interaction process;
individuals have a right to knowledge about themselves
individuals have a right to participate in decisions that influence their
lives, their health, and community services;
individuals have a right to accept or reject care; and
goals of health professionals and goals of recipients of health care may
not be congruent.

With regard to nursing, King (1981, 1995) wrote that

-

nursing is the care of human beings;

nursing is perceiving, thinking, relating, judging, and acting vis--vis the
behavior of individuals who come to a health care system;
a nursing situation is the immediate environment in which two
individuals establish a relationship to cope with situational events; and
the goal of nursing is to help individuals and groups attain, maintain, and
restore health. If this is not possible, nurses help individuals die with
dignity.

Relationships
-

Nurse and patient are purposeful interacting systems.

Nurse and client perceptions, judgments, and actions, if congruent, lead to
goal directed transactions.
If perceptual accuracy is present in nurse-client interactions, transactions
will occur.
If nurse and client make transactions, goals will be attained.
If goals are attained, satisfaction will occur.
If goals are attained, effective nursing care will occur.
If transactions are made in nurse-client interactions, growth and
development will be enhanced.
If role expectations and role performance as perceived by nurse and client
are congruent, transactions will occur.
If nurses with special knowledge and skills communicate appropriate
information to clients, mutual goal setting and goal attainment will occur
(King, 1981).

Strengths/Weaknesses
Strengths:
-

Kings theory of goal attainment does describe a logical sequence of

events.
For the most part, concepts are clearly defined.
Although the presentation appears to be complex, Kings theory of goal
attainment is relatively simple.

King formulated assumptions that are testable hypotheses for research.

Weaknesses:
Kings theory contains major inconsistencies:
-

She indicates that nurses are concerned about the health care of groups
but concentrates her discussion on nursing as occurring in a dyadic
relationship.
King says that the nurse and client are strangers, yet she speaks of their
working together for goal attainment and of the importance of health
maintenance.

The major limitation in relations to this characteristic is the effort required of the
reader to sift through the presentation of a conceptual framework and a theory with
repeated definitions to find the basic concepts.
Another limitation relates to the lack of development of application of the theory in
providing nursing care to groups, families, or communities.
It is not parsimonious, having numerous concepts, multiple assumptions, many
statements, and many relationships on a number of levels.
Analysis
The social systems portion of the open systems framework is less clearly connected
to the theory of goal attainment than are the personal and interpersonal systems.
The citation of the individual being in a social system was not clearly explained
considering that the social system encompasses other concepts and subconcepts in
her theory
The model presents interaction which is dyadic in nature which implies that its
applicability cannot be adapted to unconscious individuals.

Multitude of views and definition is confusing for the reader. Because of multiple
views on one concept such as what have been discussed in her concept of power
blurs the point that the theorist is trying to relate to the readers.

Florence Nightingale
Nursing: Notes on Nursing

Client and environment in balance

Note that the client, the nurse, and the major environment concepts are in balance;
that is; the nurse can manipulate the environment to compensate for the clients
response to it. The goal of the nurse is to assist the patient in staying in balance. If
the environment of a client is out of balance, the client expends unnecessary
energy.

The next figure depicts a client experiencing stress because of noise in the
environment. Nursing observations focus on the clients response to noise; nursing
interventions focus on reducing the noise and decreasing the clients unnecessary
energy expenditure. The nurses role is to place the client in the best position for
nature to act upon him, thus encouraging healing.

Major Concepts
Nursing
-

What nursing has to do is to put the patient in the best condition for
nature to act upon him (Nightingale, 1859/1992)
Nightingale stated that nursing ought to signify the proper use of fresh
air, light, warmth, cleanliness, quiet, and the proper selection and
administration of diet all at the least expense of vital power to the
patient.
She reflected the art of nursing in her statement that, the art of nursing,
as now practised , seems to be expressly constituted to unmake what God
had made disease to be, viz., a reparative process.

Human Beings- Human beings are not defined by Nightingale specifically. They are
defined in relationship to their environment and the impact of the environment upon
them.

Environment- The physical environment is stressed by Nightingale in her writing.

Nightingales writings reflect a community health model in which all that surrounds
human beings is considered in relation to their state of health.

Health
-

Nightingale (1859/1992) did not define health specifically. She stated, We

know nothing of health, the positive of which pathology is the negative,
except from the observation and experience. Given her definition that of
the art of nursing is to unmake what God had made disease, then the
goal of all nursing activities should be client health.
She believed that nursing should provide care to the healthy as well as the
ill and discussed health promotion as an activity in which nurses should
engage.

Subconcepts
Nightingales (1859/1992) statements:
Health of Houses- Badly constructed houses do for the healthy what badly
constructed hospitals do for the sick. Once insure that the air is stagnant and
sickness is certain to follow.
Ventilation and Warming
-

Keep the air he breathes as pure as the external air, without chilling
him.
Nightingale believed that the person who repeatedly breathed his or her
own air would become sick or remain sick.
Nightingale was very concerned about noxious air or effluvia or foul
odors that came from excrement
She also criticized fumigations, for she believed that the offensive
source, not the smell, must be removed.
The importance of room temperature was stressed by Nightingale. The
patient should not be too warm or too cold. The temperature could be
controlled by appropriate balance between burning fires and ventilation
from windows.

Light- Nightingale believed that second to fresh air the sick needed light. She noted
that direct sunlight was what patients wanted.
Noise- She stated that patients should never be waked intentionally or accidentally
during the first part of sleep. She asserted that whispered or long conversations
about patients are thoughtless and cruel. She viewed unnecessary noise, including
noise from female dress, as cruel and irritating to the patient.
Variety- She discussed the need for changes in color and form, including bringing
the patient brightly colored flowers or plants. She also advocated rotating 10 or 12
paintings and engravings each day, week, or month to provide variety for the
patient. Nightingale also advocated reading, needlework, writing, and cleaning as
activities to relieve the sick of boredom.

Bed and Bedding

-

She noted that an adult in health exhales about three pints of moisture
through the lungs and skin in a 24-hour period. This organic matter enters
the sheets and stays there unless the bedding is changed and aired
frequently.
She believed that the bed should be placed in the lightest part of the room
and placed so the patient could see out of a window. She reminded the
caregiver never to lean against, sit upon, or unnecessarily shake the bed
of the patient.

Personal Cleanliness
-

Just as it is necessary to renew the air round a sick person frequently to

carry off morbid effluvia from the lungs and skin, by maintaining free
ventilation, so it is necessary to keep pores of the skin free from all
obstructing excretions.
Every nurse ought to wash her hands very frequently during the day.

Nutrition and Taking Food

-

She noted that individuals desire different foods at different times of the
day and that frequent small servings may be more beneficial to the
patient than a large breakfast or dinner.
She urged that no business be done with patients while they are eating
because this was distraction.

Chattering Hopes and Advices

-

She wrote that to falsely cheer the sick by making light of their illness and
its danger is not helpful.
Nightingale encouraged the nurse to heed what is being said by visitors,
believing that sick persons should hear good news that would assist them
in becoming healthier.

Social Considerations- Nightingale supported the importance of looking beyond

the individual to the social environment in which he or she lived.
Assumptions
-

Nightingale (1860/1957/1969) believed that five points were essential in

achieving a healthful house: pure air, pure water, efficient drainage,
cleanliness and light.
A healthy environment is essential for healing. She stated that nature
alone cures.
Nurses must make accurate observations of their patients and be able to
report the state of the patient to the physician in an orderly manner.

Nursing is an art, whereas medicine is a science. Nurses are to be loyal to

the medical plan, but not servile.

Strengths/Weaknesses
Strengths:
-

The language she used to write her books was cultured and flowing,
logical in format, and elegant in style.
Nightingales theory has broad applicability to the practitioner. Her model
can be applied in most complex hospital intensive care environment, the
home, a work site, or the community at large.
Reading her work raises a consciousness in the nurse about how the
environment influences client outcomes.

Weaknesses:
-

There is scant information on the psychosocial environment when

compared to the physical environment.
The application of her concepts in the twentieth century is in question.

Analysis
In the era that we are in today, we are faced with environmental conditions beyond
what was ought to be natural and nurturing. Some of the global environmental
issues that we have now are the global warming, nuclear radiation threats, manmade environmental calamities and pollution. From these occurrences, Nightingales
model seemed to be very ideal. Her concept of providing fresh air to patients is in
question with todays industrialization effects.
In addition to the analysis of the concept of ventilation, it is not always beneficial for
all clients to have fresh air. Natural air has its impurities which in turn may infect
open wounds and drainages such as in burns.
With the idea of providing light, the light emitted by the sun today is proven to be
harmful already because of the destruction of the ozone layer of the Earth. Exposing
the patient constantly to direct sunlight may then be more destructive to patients
betterment than being beneficial.
It is true that a health environment heals as what Nightingale stated but the
question now is how our environment would remain health amidst the negative
effects of the progress of technology and industrialization.
Since the applicability of some of the concepts to specific situations today are nonfeasible, development of this theory is utterly needed to accommodate the changes
of the environment that we currently have. Still, above all this, it is very much clear

the Nightingales theory is superb as a starting point of the progression of our

profession and served as a catalyst for nursings improvement.

Faye G. Abdellah
Patient-Centered Approaches to Nursing
The focus of care pendulum
The nursing-centered orientation to
client care seems contrary to the
client-centered
approach
that
Abdellah professes to uphold. The
apparent contradiction can be
explained by her desire to move
away from a disease-centered
orientation. In her attempt to bring
nursing practice to its proper
relationship with restorative and
preventive measures for meeting
total client needs, she seems to
swing the pendulum to the opposite
pole, from the disease orientation to nursing orientation, while leaving the client
somewhere in the middle.
Major Concepts
She describe the recipients of nursing as individuals (and families), although she
does not delinate her beliefs or assumptions about the nature of human beings.
Health, or the achieving of it, is the purpose of nursing services. Although Abdellah
does not give a definition of health, she speaks to total health needs and a
healthy state of mind and body. (Abdellah et al., 1960)
Health may be defined as the dynamic pattern of functioning whereby there is a
continued interaction with internal and external forces that results in the optimal
use of necessary resources to minimize vulnerabilities. (Abdellah & Levine, 1986;
Torres & Samton, 1982).
Society is included in planning for optimum health on local, state, and
international levels. However, as Abdellah further delineates her ideas, the focus
of nursing service is clearly the individual.

Nursing Problems
-

The clients health needs can be viewed as problems, which may be overt
as an apparent condition, or covert as a hidden or concealed one.
Because covert problems can be emotional, sociological, and
interpersonal in nature, they are often missed or perceived incorrectly. Yet,
in many instances, solving the covert problems may solve the overt
problems as well. (Abdellah, et al., 1960)

Problem Solving
-

Quality professional nursing care requires that nurses be able to identify

and solve overt and covert nursing problems. These requirements can be
met by the problem-solving process involves identifying the problem,
selecting pertinent data, formulating hypotheses, testing hypotheses
through the collection of data, and revising hypotheses when necessary
on the basis of conclusions obtained from the data. (Abdellah & Levine,
1986)

Subconcepts
Twenty-one Nursing Problems (Abdellah, 1960)
1. To maintain good hygiene and physical comfort.
2. To promote optimal activity: exercise, rest, and sleep.
3. To promote safety through the prevention of accidents, injury, or other
trauma and through the prevention of the spread of infection.
4. To maintain good body mechanics and prevent and correct deformities.
5. To facilitate the maintenance of a supply of oxygen to all body cells.
6. To facilitate the maintenance of nutrition of all body cells.
7. To facilitate the maintenance of elimination.
8. To facilitate the maintenance of fluid and electrolyte balance.
9. To recognize the physiological responses of the body to disease conditions
pathological, physiological, and compensatory.
10. To facilitate the maintenance of regulatory mechanisms and functions.
11. To facilitate the maintenance of sensory functions.
12.To identify and accept positive and negative expressions, feelings, and
reactions.
13.To identify and accept the interrelatedness of emotions and organic illness.
14.To facilitate the maintenance of effective verbal and nonverbal
communication.
15. To promote the development of productive interpersonal relationships.
16.To facilitate progress toward achievement of personal spiritual goals.
17.To create and/or maintain a therapeutic environment.
18. To facilitate awareness of self as an individual with varying physical,
emotional, and developmental needs.

19. To accept the optimum possible goals in the light of limitations, physical and
emotional.
20.To use community resources as an aid in resolving problems arising from
illness.
21.To understand the role of social problems as influencing factors in the case of
illness.
Assumptions
Abdellahs (Abdellah, Beland, Martin, & Matheney, 1973) assumptions relate to
change and anticipated changes that affect nursing; the need to appreciate the
interconnectedness of social enterprises and social problems; the impact of
problems such as poverty, racism, pollution, education, and so forth on health and
health care delivery; changing nursing education; continuing education for
professional nurses; and development of nursing leaders from underserved groups.
According to Abdellah and coworkers (1960), nurses should do the following:
1. Learn to know the patient.
2. Sort out relevant and significant data.
3. Make generalizations about available data in relation to similar nursing
problems presented by other patients.
4. Identify the therapeutic plan.
5. Test generalizations with the patient and make additional generalizations.
6. Validate the patients conclusions about his nursing problems.
7. Continue to observe and evaluate the patient over a period of time to identify
any attitudes and clues affecting this behavior.
8. Explore the patients and familys reaction to the therapeutic plan and involve
them in the plan.
9. Identify how the nurse feels about the patients nursing problems.
10.Discuss and develop a comprehensive nursing care plan.
Strengths/Weaknesses
Strengths:
-

As a logical and simple statement, Abdellahs problem-solving approach

can easily be used by practitioners to guide various activities within their
nursing practice.
The language of Abdellahs framework is readable and clear.
The theoretical statement places heavy emphasis on problem solving, an
activity that is inherently logical in nature.
The problem-solving approach is readily generalizable to client with
specific health needs and specific nursing problems.

Weaknesses:

The major limitation to Abdellahs theory and the 21 nursing problems is

their very strong nurse-centered orientation.
Little emphasis on what the client is to achieve was given in terms of
client care.
Failure of the framework to provide a perspective on humans and society
in general limits the generalizability of the theory.
Abdellahs framework is inconsistent with the concept of holism. The
nature of the 21 nursing problems attests to this. As a result, the client
may be diagnosed as having numerous problems that would lead to
fractionalized care efforts, and potential problems might be overlooked
because the client is not deemed to be in a particular stage of illness.

Analysis
With the aim of Abdellah in formulating a clear categorization of patients problems
as health needs, she rather conceptualized nurses actions in nursing care which is
contrary to her aim. Nurses roles were defined to alleviate the problems assessed
through the proposed problem-solving approach.

The problem-solving approach introduced by Abdellah has the advantage of

increasing the nurses critical and analytical thinking skills since the care to be
provided would be based on sound assessment and validation of findings.
One can identify that the framework is strongly applied to individuals as the focus of
nursing care. The inclusion of an aggregate of people such as the community or
society would make the theory of Abdellah more generalizable since nurses do not
only provide one-person service especially now that the community healthcare level
is sought to have higher importance than curative efforts in the hospital.

Betty Neuman
The Neuman Systems Model

The Neuman Systems Model views the client as an open system that responds to
stressors in the environment. The client variables are physiological, psychological,
sociocultural, developmental, and spiritual. The client system consists of a basic or
core structure that is protected by lines of resistance. The usual level of health is
identified as the normal line of defense that is protected by a flexible line of
defense. Stressors are intra-, inter-, and extrapersonal in nature and arise from the
internal, external, and created environments. When stressors break through the
flexible line of defense, the system is invaded and the lines of resistance are
activated and the system is described as moving into illness on a wellness-illness
continuum. If adequate energy is available, the system will be reconstituted with
the normal line of defense restored at, below, or above its previous level.
Nursing interventions occur through three prevention modalities. Primary prevention
occurs before the stressor invades the system; secondary prevention occurs after
the system has reacted to an invading stressor; and tertiary prevention occurs after
the system has reacted to an invading stressor; and tertiary prevention occurs after
secondary prevention as reconstitution is being established.
Major Concepts
Human being is viewed as an open system that interacts with both internal and
external environment forces or stressors. The human is in constant change, moving
toward a dynamic state of system stability or toward illness of varying degrees.
The environment is a vital arena that is germane to the system and its function.
The environment may be viewed as all factors that affect and are affected by the
system.

The internal environment exists within the client system. All forces and interactive
influences that are solely within boundaries of the client system make up this
environment.
The external environment exists outside the client system.
Health is defined as the condition or degree of system stability and is viewed as a
continuum from wellness to illness. When system needs are met, optimal wellness
exists. When needs are not satisfied, illness exists. When the energy needed to
support life is not available, death occurs.
The primary concern of nursing is to define the appropriate action in situations that
are stress-related or in relation to possible reactions of the client or client system to
stressors. Nursing interventions are aimed at helping the system adapt or adjust
and to retain, restore, or maintain some degree of stability between and among the
client system variables and environmental stressors with a focus on conserving
energy.
Open System
A system in which there is a continuous flow of input and process, output and
feedback. It is a system of organized complexity, where all elements are in
interaction.

Basic Stricture and Energy Resources

The basic structure, or central core, is made up of those basic survival factors
common to the species. These factors include the system variables, genetic
features, and strengths and weaknesses of the system parts.
Client variables
Newman views the individual client holistically and considers the variables
simultaneously and comprehensively.
-

The physiological variable refers to the structure and functions of the

body.
The psychological variable refers to mental processes and relationships.
The sociocultural variable refers to system functions that relate to social
and cultural expectations and activities.
The developmental variable refers to those processes related to
development over the lifespan.
The spiritual variable refers to the influence of spiritual beliefs.

Flexible line of defense- A protective accordion-like mechanism that surrounds

and protects the normal line of defense from invasion by stressors.

Normal line of defense- adaptational level of health developed over time and
considered normal for a particular individual client or system; it becomes a standard
for wellness-deviance determination.
Lines of resistance- Protection factors activated when stressors have penetrated
the normal line of defense, causing a reaction synptomatology. (Neuman, 1995)
Subconcepts
Stressors- a phenomenon that might penetrate both the flexible and normal lines
of defense, resulting in either a positive or negative outcome.
-

Intrapersonal stressors are those that occur within the client system
boundary and correlate with the internal environment.
Interpersonal stressors occur outside the client system boundary, are
proximal to the system, and have an impact to the system.
Extrapersonal stressors also occur outside the client system boundaries
but are at a greater distance from the system than are interpersonal
stressors. An example is social policy.

Stability- A state of balance or harmony requiring energy exchanges as the client

adequately copes with stressors to retain, attain, or maintain an optimal level of
health thus preserving system integrity.
Degree of Reaction- The amount of system instability resulting from stressor
invasion of the normal line of defense.
Entropy- A process of energy depletion and disorganization moving the system
toward illness or possible death.
Negentropy- A process of energy conservation that increases organization and
complexity, moving the system toward stability or a higher degree of wellness.
Input/output- The matter, energy, and information exchanged between client and
environment that is entering or leaving the system at any point in time.
Reconstitution- The return and maintenance of system stability, following
treatment of stressor reaction, which may result in a higher or lower level of
wellness.
Prevention as intervention
Intervention modes for nursing action and determinants for entry of both client and
nurse into the health care system.
Primary prevention occurs before the system reacts to a stressor; it includes health
promotion and maintenance of wellness. Primary prevention focuses on
strengthening the flexible line of defense through preventing stress and reducing

risk factors. This intervention occurs when the risk or hazard is identified but before
a reaction occurs. Strategies that might be used include immunization, health
education, exercise, and lifestyle changes.
Secondary prevention occurs after the system reacts to a stressor and is provided in
terms of existing symptoms. Secondary prevention focuses on strengthening the
internal lines of resistance and, thus, protects the basic structure through
appropriate treatment of symptoms. The intent is to regain optimal system stability
and to conserve energy in doing so. If secondary prevention is unsuccessful and
reconstitution does not occur, the basic structure will be unable to support the
system and its interventions, and death will occur.
Tertiary prevention occurs after the system has been treated through secondary
prevention strategies. Its purpose is to maintain wellness or protect the client
system reconstitution through supporting existing strengths and continuing to
preserve energy. Tertiary prevention may begin at any point after system stability
has begun to be reestablished (reconstitution has begun). Tertiary prevention tend
to lead back to primary prevention. (Neuman, 1995)
Assumptions
-

Each client system is unique, a composite of factors and characteristics

within a given range of responses.
Many known, unknown, and universal stressors exist. Each differs in its
potential for disturbing a clients usual stability level or normal line of
defense. The particular interrelationships of client variables at any point in
time can affect the degree to which a client is protected by the flexible
line of defense against possible reaction to stressors.
Each client/client system has evolved a normal range of responses to the
environment that is referred to as a normal line of defense. The normal
line of defense can be used as a standard from which to measure health
deviation.
When the flexible line of defense is no longer capable of protecting the
client/client system against an environmental stressor, the stressor breaks
through the normal line of defense.
The client, whether in a state of wellness or illness, is a dynamic
composite of the interrelationships of the variables. Wellness is on a
continuum of available energy to support the system in an optimal state
of system stability.
Implicit within each client system are internal resistance factors known as
lines of resistance, which function to stabilize and realign the client to the
usual wellness state.
Primary prevention relates to general knowledge that is applied in client
assessment and intervention, in identification and reduction or mitigation
of possible or actual risk factors associated with environmental stressors
to prevent possible reaction.

Secondary prevention relates to symptomatology following a reaction to

stressors, appropriate ranking of intervention priorities, and treatment to
reduce their noxious effects.
Tertiary prevention relates to the adjustive processes taking place as
reconstitution begins and maintenance factors move the client back in a
circular manner toward primary prevention.
The client as a system is in dynamic, constant energy exchange with the
environment. (Neuman, 1995)

Strengths/Weaknesses
Newman reports that the model was designed but can be used by other health
disciplines, which can be viewed as either a strength or weakness. As a strength, if
multiple health disciplines use the model, a consistent approach to client care would
be facilitated. As a weakness, if the model is useful to a variety of disciplines, it is
not specific to nursing and thus may not differentiate the practice of nursing from
that of other disciplines.
Strengths:
-

The major strength of the model is its flexibility for use in all areas of
nursing administration, education, and practice.
Neuman has presented a view of the client that is equally applicable to an
individual, a family, a group, a community, or any other aggregate.
The Neuman Systems Model, particularly presented in the model diagram,
is logically consistent.
The emphasis on primary prevention, including health promotion is
specific to this model.
Once understood, the Neuman Systems Model is relatively simple, and has
readily acceptable definitions of its components

Weakness:
-

The major weakness of the model is the need for further clarification of
terms used. Interpersonal and extrapersonal stressors need to be more
clearly differentiated.

Analysis
The delineation of Neuman of three defense lines was not clearly explained. In
reality, the individual resist stressors with internal and external reflexes which were
made complicated with the formulation of different levels of resistance in the open
systems model of Neuman.

Neuman made mention of energy sources in her model as part of the basic
structure. It can be more of help when Neuman has enumerated all sources of
energy that she is pertaining to. With such, new nursing interventions as to the
provision of needed energy of the client can be conceptualized.
The holistic and comprehensive view of the client system is associated with an open
system. Health and illness are presented on a continuum with movement toward
health described as negentropic and toward illness as entropic. Her use of the
concept of entropy is inconsistent with the characteristics of entropy which is
closed, rather than an open system.

Madeleine M. Leininger
Culture Care Diversity and Universality
Leiningers Sunrise Model
The cultural care worldview flows into knowledge about individuals, families, groups,
communities, and institutions in diverse health care systems. This knowledge
provides culturally specific meanings and expressions in relation to care and health.
The next focus is on the generic or folk system, professional care system(s), and
nursing care. Information about these systems includes the characteristics and the
specific care features of each. This information allows for the identification of
similarities and differences or cultural care universality and cultural care diversity.
Next are nursing care decisions and actions which involve cultural care
preservation/maintenance, cultural care accommodation/negotiation and cultural
care re-patterning or restructuring. It is here that nursing care is delivered.

Major Concepts
Transcultural nursing is defined as a learned subfield or branch of nursing which
focuses upon the comparative study and analysis of cultures with respect to nursing
and health-illness caring practices, beliefs, and values with the goal to provide
meaningful and efficacious nursing care services to people according to their
cultural values and health-illness context.
Ethnonursing is the study of nursing care beliefs, values, and practices as
cognitively perceived and known by a designated culture through their direct
experience, beliefs, and value system (Leininger, 1979).

Nursing is defined as a learned humanistic and scientific profession and discipline

which is focused on human care phenomena and activities in order to assist,
support, facilitate, or enable individuals or groups to maintain or regain their wellbeing (or health) in culturally meaningful and beneficial ways, or to help people face
handicaps or death.
Professional nursing care (caring) is defined as formal and cognitively learned
professional care knowledge and practice skills obtained through educational
institutions that are used to provide assistive, supportive, enabling, or facilitative
acts to or for another individual or group in order to improve a human health
condition (or well-being), disability, lifeway, or to work with dying clients.
Cultural congruent (nursing) care is defined as those cognitively based
assistive, supportive, facilitative, or enabling acts or decisions that are tailor-made
to fit with individual, group, or institutional cultural values, beliefs, and lifeways in
order to provide or support meaningful, beneficial, and satisfying health care, or
well-being services.
Health is a state of well-being that is culturally defined, valued, and practiced, and
which reflects the ability of individuals (or groups) to perform their daily role
activities in culturally expressed, beneficial, and patterned lifeways.
Human beings are believed to be caring and to be capable of being concerned
about the needs, well-being, and survival of others. Leininger also indicates that
nursing as a caring science should focus beyond traditional nurse-patient
interactions and dyads to include families, groups, communities, total cultures, and
institutions.
Society/environment are not terms that are defined by Leininger; she speaks
instead of worldview, social structure, and environmental context.
Worldview is the way in which people look at the world, or at the universe, and
form a picture or value stance about the world and their lives.
Cultural and social structure dimensions are defined as involving the dynamic
patterns and features of interrelated structural and organizational factors of a
particular culture (subculture or society) which includes religious, kinship (social),
political (and legal), economic, educational, technologic and cultural values,
ethnohistorical factors, and how these factors may be interrelated and function to
influence human behavior in different environmental contexts.
Environmental context is the totality of an event, situation, or particular
experience that gives meaning to human expressions, interpretations, and social
interactions in particular physical, ecological, sociopolitical and/or cultural settings.

Culture is the learned, shared and transmitted values, beliefs, norms, and lifeways
of a particular group that guides their thinking, decisions, and actions in patterned
ways.
Culture care is defined as the subjectively and objectively learned and transmitted
values, beliefs, and patterned lifeways that assist, support, facilitate, or enable
another individual or group to maintain their well-being, health, improve their
human condition and lifeway, or to deal with illness, handicaps or death.
Culture care diversity indicates the variabilities and/or differences in meanings,
patterns, values, lifeways, or symbols of care within or between collectives that are
related to assistive, supportive, or enabling human care expressions.
Culutre care universality indicates the common, similar, or dominant uniform
care meanings, pattern, values, lifeways or symbols that are manifest among many
cultures and reflect assistive, supportive, facilitative, or enabling ways to help
people. (Leininger, 1991)
Subconcepts
Generic (folk or lay) care systems are culturally learned and transmitted,
indigenous (or traditional), folk (home-based) knowledge and skills used to provide
assistive, supportive, enabling, or facilitative acts toward or for another individual,
group, or institution with evident or anticipated needs to ameliorate or improve a
human life way, health condition (or well-being), or to deal with handicaps and
death situations.
Emic- Knowledge gained from direct experience or directly from those who have
experienced. It is generic or folk knowledge.
Professional care system(s) are defined as formally taught, learned, and
transmitted professional care, health, illness, wellness, and related knowledge and
practice skills that prevail in professional institutions usually with multidisciplinary
personnel to serve consumers.
Etic- Knowledge which describes the professional perspective. It is professional care
knowledge.
Ethnohistory includes those past facts, events, instances, experiences of
individuals, groups, cultures, and instructions that are primarily people-centered
(ethno) and which describe, explain, and interpret human lifeways within particular
cultural contexts and over short or long periods of time.
Care as a noun is defined as those abstract and concrete phenomena related to
assisting, supporting, or enabling experiences or behaviors toward or for others with
evident or anticipated needs to ameliorate or improve a human condition or lifeway.

Care as a verb is defined as actions and activities directed toward assisting,

supporting, or enabling another individual or group with evident or anticipated
needs to ameliorate or improve a human condition or lifeway or to face death.
Three modes of nursing care decisions and actions
(a) Cultural care preservation is also known as maintenance and includes those
assistive, supporting, facilitative, or enabling professional actions and decisions that
help people of a particular culture to retain and/or preserve relevant care values so
that they can maintain their well-being, recover from illness, or face handicaps
and/or death.
(b) Cultural care accommodation also known as negotiation, includes those
assistive, supportive, facilitative, or enabling creative professional actions and
decisions that help people of a designated culture to adapt to or negotiate with
others for a beneficial or satisfying health outcome with professional care providers.
(c) Culture care repatterning, or restructuring includes those assistive,
supporting, facilitative, or enabling professional actions and decisions that help a
client(s) reorder, change, or greatly modify their lifeways for new, different, and
beneficial health care pattern while respecting the client(s) cultural values and
beliefs and still providing a beneficial or healthier lifeway than before the changes
were coestablished with the client(s). (Leininger, 1991)
Culture shock may result when an outsider attempts to comprehend or adapt
effectively to a different cultural group. The outsider is likely to experience feelings
of discomfort and helplessness and some degree of disorientation because of the
differences in cultural values, beliefs, and practices. Culture shock may lead to
anger and can be reduced by seeking knowledge of the culture before encountering
that culture.
Cultural imposition refers to efforts of the outsider, both subtle and not so subtle,
to impose his or her own cultural values, beliefs, behaviors upon an individual,
family, or group from another culture. (Leininger, 1978)
Assumptions
-

Different cultures perceive, know, and practice care in different ways, yet
there are some commonalities about care among all cultures of the world.
Values, beliefs, and practices for culturally related care are shaped by, and
often embedded in, the worldview, language, religious (or spiritual),
kinship (social), political (or legal), educational, economic, technological,
ethnohistorical, and environmental context of the culture.
While human care is universal across cultures, caring may be
demonstrated through diverse expressions, actions, patterns, lifestyles,
and meanings.

Cultural care is the broadest holistic means to know, explain, interpret,

and predict nursing care phenomena to guide nursing care practices.
All cultures have generic or folk health care practices, that professional
practices vary across cultures, and that in any culture there will be cultural
similarities and differences between the care-receivers (generic) and the
professional care-givers.
Care is distinct, dominant, unifying and central focus of nursing, and, while
curing and healing cannot occur effectively without care, care may occur
without cure.
Care and caring are essential for the survival of humans, as well as for
their growth, health, well-being, healing, and ability to deal with handicaps
and death.
Nursing, as a transcultural care discipline and profession, has a central
purpose to serve human beings in all areas of the world; that when
culturally based nursing care is beneficial and healthy it contributes to the
well-being of the client(s) whether individuals, groups, families,
communities, or institutions as they function within the context of their
environments
Nursing care will be culturally congruent or beneficial only when the
clients are known by the nurse and the clients patterns, expressions, and
cultural values are used in appropriate and meaningful ways by the nurse
with the clients.
If clients receive nursing care that is not at least reasonably culturally
congruent (that is, compatible with and respectful of the clients lifeways,
belief, and values), the client will demonstrate signs of stress,
noncompliance, cultural conflicts, and/or ethical or moral concerns.

Strengths/Weaknesses
The complexity of the Sunrise Model can be viewed as both a strength and a
limitation. The complexity is a strength in that it emphasizes the importance of the
inclusion of anthropological and cultural concepts in nursing education and practice.
On the other hand, the complexity can lead to misinterpretation or rejection.
Strengths:
-

Leiniger has developed the Sunrise Model in a logical order to

demonstrate the interrelationships of the concepts in her theory of Culture
Care Diversity and Universality.
Leiningers theory is essentially parsimonious in that the necessary
concepts are incorporated in such a manner that the theory and it model
can be applied in many different settings.
It is highly generalizable. The concepts and relationships that are
presented are at a level of abstraction which allows them to be applied in
many different situations.
Though not simple in terms, it can be easily understood upon first contact.

Weakness:
-

The theory and model are not simple in terms.

Analysis
It was stated that the nurse will help the client move towards amelioration or
improvement of their health practice or condition. This statement would be of great
difficulty for the nurse because instilling new ideas in a different culture might
present an intrusive intent for the insiders. Culture is a strong set of practices
developed over generations which would make it difficult to penetrate.
The whole activity of immersing yourself within a different culture is timeconsuming for you to fully understand their beliefs and practices. Another is that it
would be costly in the part of the nurse.
Because of its financial constraints and unclear ways of being financially
compensated, it can be the reason why nurses do not engage much with this king of
nursing approach.
Because of the intrusive nature, resistance from the insiders might impose risk to
the safety of the nurse especially for cultures with highly taboo practices.
It is highly commendable that Leininger was able to formulate a theory which is
specified to a multicultural aspect of care. On the other side, too much was given to
the culture concept per se that Leininger failed to comprehensively discuss the
functions or roles of nurses. It was not stated on how to assist, support or enable
the client in attuning them to an improved lifeway.

Katharine Kolcaba
Comfort Theory
INTRODUCTION
-

The comfort theory is a nursing theory that was first developed in the
1990s by Katharine Kolcaba.
Kolcaba's theory has the potential to place comfort once again in the
forefront of healthcare.(March A & McCormack D, 2009).

CONCEPTS AND DEFINITIONS ( Kolcaba, 2010)

Kolcaba described comfort as existing in 3 forms: relief, ease, and transcendence.

Also, Kolcaba described 4 contexts in which patient comfort can occur: physical,
psychospiritual, environmental, and sociocultural.

Kolcaba described comfort as existing in 3 forms: relief, ease, and transcendence.

If specific comfort needs of a patient are met, for example, the relief of
postoperative pain by administering prescribed analgesia, the individual
experiences comfort in the relief sense.
If the patient is in a comfortable state of contentment, the person experiences
comfort in the ease sense, for example, how one might feel after having issues that
are causing anxiety addressed.
Lastly, transcendence is described as the state of comfort in which patients are able
to rise above their challenges.
Health Care Needs are those identified by the patient/family in a particular practice
setting.
Intervening Variables are those factors that are not likely to change and over which
providers have little control (such as prognosis, financial situation, extent of social
support, etc).
Comfort is an immediate desirable outcome of nursing care, according to Comfort
Theory
Health Seeking Behavior (HSBs):
Institutional Integrity - the values, financial stability, and wholeness of health care
organizations at local, regional, state, and national levels.
Best Policies are protocols and procedures developed by an institution for overall
use after collecting evidence.
DESCRIPTION OF THE THEORY
Nursing
-

Nursing is described as the process of assessing the patient's comfort

needs, developing and implementing appropriate nursing interventions,
and evaluating patient comfort following nursing interventions.
Intentional assessment of comfort needs, the design of comfort measures
to address those needs, and the reassessment of comfort levels after
implementation.

Assessment may be either objective, such as in the observation of wound

healing, or subjective, such as by asking if the patient is comfortable.

Health
-

Health is considered to be optimal functioning, as defined by the patient,

group, family or community

Person/Patient
-

Patients can be considered as individuals, families, institutions, or

communities in need of health care

Environment- Any aspect of the patient, family, or institutional surroundings that

can be manipulated by a nurse(s), or loved one(s) to enhance comfort.

CONCLUSION
Holistic comfort is defined as the immediate experience of being strengthened
through having the needs for relief, ease, and transcendence met in four contexts of
experience (physical, psychospiritual, social, and environmental) (Kolcaba, 2010)
The theoretical structure of Kolcaba's comfort theory has real potential to direct the
work and thinking of all healthcare providers within one institution. (March A &
McCormack D, 2009).

1. Florence Nightingale- Environmental Theory

- First nursing theorist
- Unsanitary conditions posed health hazard (Notes on Nursing, 1859)
5 components of environment
Ventilation, light, warmth, effluvia, noise
External influences can prevent, suppress or contribute to disease or death.
Nightingales Concepts
-

Person- Patient who is acted on by nurse, Affected by environment, Has

reparative powers
Environment- Foundation of theory. Included everything, physical,
psychological, and social
Health- Maintaining well-being by using a persons powers, Maintained by
control of environment

Nursing- Provided fresh air, warmth, cleanliness, good diet, quiet to

facilitate persons reparative process
2. Fay Abdella- Topology of 21 Nursing Problems
- Health- Excludes illness, No unmet needs and no actual or anticipated
impairments
- Person- One who has physical, emotional, or social need, The recipient of
nursing care.
- Environment- Did not discuss much, Includes room, home, and community
3. Jean Watson
- Person- Human being to be valued, cared for, respected, nurtured,
understood and assisted
- Environment- Society
- Health- Complete physical, mental and social well-being and functioning
- Nursing- Concerned with promoting and restoring health, preventing
illness