Evolution of Nursing

A. Introduction to Nursing Theory

The history of professional nursing began with Florence Nightingale. Nightingale envisioned nurses
as a body of educated women at a time when women were neither educated nor employed in public
service.
Nightingale's vision and establishment of a School of Nursing at St. Thomas Hospital in London
marked the genesis of modern nursing after her wartime service of organizing and caring for the
wounded Scutari during the Crimean War.
1. History of Nursing Theory
Greek word “theoria” = which means to speculate.
Research revealed that nursing studies lacked conceptual connections and theoretical
framework. Awareness of the need for concept and theory development coincided with the
evolution of nursing theory (Alligood, 2018).
The 1980s was a period of major development in nursing theory.
Three steps in theory development:
1st step-conceptual model or framework
Conceptual Model-comprises nursing works by theorists by pioneers in nursing.
- are sets of concepts that addresses phenomena to nursing that explain
relationships among them.
2nd step-building relationships with linkages between related concepts
-the connections between concepts
-development of the theoretical linkages provides an explanation of why the
variables are connected in a certain manner, the theoretical reason for particular
relationships (Alligood, 2018).
3rd step- relationship statements or propositions are developed to build a theory.
-In scientific terms, a theory implies that something has been proven and
is generally accepted as being true.
Significance of Nursing Theory for the Discipline and Profession
The term discipline and profession are interrelated.
A discipline is specific to academics and refers to a branch of education a department of
learning or a domain of knowledge (Alligood, 2018).
A profession refers to a specified field of practice, founded on the theoretical structure of the
science or knowledge of that discipline and accompanying practice and abilities (Alligood, 2018).

1. Significance for the Discipline

The nursing process is useful in practice but the primary focus is the patient or human being.
Knowledge of persons, health, and environment forms the basis for the recognition of nursing as
a discipline (Alligood, 2018).
2. Significance for the Profession
Nursing is recognized as a profession today because its development was guided by the criteria
for a profession. Theories and research are important to the discipline and profession (Alligood,
2018).
What is Nursing Theory?
• Is a conceptualization of some aspect of reality pertaining to nursing communicated for the
purpose of describing phenomena, explaining relationships between phenomena, predicting
consequences, or prescribing nursing care.
• Nursing theory represents organized information about phenomena unique to nursing
(Alligood, 2018).

PURPOSES OF NURSING THEORY

(Johnson and Webber, 2001)
• To provide us with valid and reliable knowledge for answering diverse questions, solving
complex problems, explaining unique phenomena and stimulating new theory.
• To facilitate an understanding of nursing knowledge.
• To contribute to the nursing knowledge base.
• To improve nursing practice (Alligood, 2018).
B. History and Philosophy of Science
1. Rationalism
Rationalist epistemology (scope of knowledge) emphasizes the importance of a priori
reasoning as the appropriate method for advancing knowledge. A priori reasoning uses deductive
knowledge by reasoning from the cause to an effect or from a generalization to a particular instance
(Alligood, 2018).
2. Empiricism
The empiricist view is based on the central idea that scientific knowledge can be derived
only from sensory experience (seeing, feeling, hearing, facts).
Empirical – when they can be observed and experienced through the senses.
Phenomenon -Greek word phainomen: something to be explained; an occurrence.
Observable connections or relationships between objects, events or ideas
3. Early Twentieth Century Views of Science and Theory (Alligood, 2018)
Philosophers focused on the analysis of theory structure, whereas the scientists focused on empirical
research (Brown, 1977). Positivism emerged as the dominant view of modern science (Gale, 1979).
Modern logical positivists believed that empirical research and logical analysis were two approaches
that would produce scientific knowledge (Brown, 1977).
4. Emergent Views
• The mission of nursing was defined as providing care and comfort to enhance healing and a
sense of well-being and to create a healthy environment that helps decrease suffering and
deterioration. Nurse defined their domain to include the patient and the environment in
which the care is given (Alligood, 2018).
• The Stage of Education and Administration was followed by the Stage of Research.From a
former focus on education, curriculum, teaching, administration, an interest in research
followed. Nurses began to engage in nursing inquiries and scientific endeavors and when
nurse researchers started to give emphasis syntax (process) rather than to content
(Alligood, 2018).
The two dominant forms of scientific inquiry has been defined:
1. Empiricism-which attempts to quantify experience and may test hypothesis or
porpositions.
 2. Phenomenology - qualitative research which study lived experiences and meanings of
events (Alligood, 2018).
A. Structure of Nursing Knowledge
Knowledge - the culmination of the integration of what is known theoretically,
experientially and intuitively and is influenced by assigning personal and collective
meaning (Alligood, 2018).
Theory provides knowledge.
1. Structure Level – arrangement of parts, framework.
2. Metaparadigm: Person, Health, Environment, Nursing
• Paradigm – an organizing framework that contains concepts, theories, assumptions,
beliefs, values and principles that form the way a discipline interprets the subject
matter with which it is concerned. It describes work to be done and frames an
orientation with which the work will be accomplished. (McEwen & Wills,2002)
• Metaparadigm – Is the core content of a discipline, stated in the most global or
abstract of terms. Its functions are to summarize the intellectual and social missions
of a discipline and place a boundary on the subject matter of that discipline (Kim,
1989).
• The metaparadigm of the discipline of nursing consists of four major concepts:
1. PERSON
May represent one individual, a family, a community, or all of mankind
• Composed of physical, intellectual, biochemical and psychosocial
2. HEALTH
• Ability to function independently; successful adaptation to life’s stressors;
achievements of one’s full life potential, and unity of mind, body and soul.
(Wagner, 1986)
• Represents the state of well-being mutually decided on by the client and the
nurse.

3. ENVIRONMENT
• The external elements that affect the person; internal and external conditions that
influence the organisms;
4. NURSING
• is a science, an art and a practice discipline and involves caring. Goals of nursing
include care of the well, care of the sick, assisting with self-activities, helping
individuals attain their human potential and discovering and using nature’s laws
of health.
• Each theory/model has its own definition of these terms, but the underlying
concepts are similar.
• Relationship among the Metaparadigm Concepts:
• Person and Health – Nursing is concerned with the principles and laws that
govern the life-process, well-being, and optimal functioning of human beings, sick
or well.
• Person and Environment – Nursing is concerned with the patterning of human
behavior in interaction with the environment in normal life events and critical life
situations.
• Health and Nursing – Nursing is concerned with the nursing action or processes
by which positive changes in health status are affected.
 • Person, environment and health – Nursing is concerned with the wholeness or
health of human beings, recognizing that they are in continuous interaction with
the environment. (Donaldson, Crowley, 1978, Gortner, 1980, Fawcett and
Malinski, 1996)

3. Philosophy – is an abstract type that sets forth the meaning of nursing phenomena
through analysis, reasoning and logical presentations (Alligood, 2018).

4. Conceptual Models- are a set of concepts that address phenomena central to

nursing in propositions that explains relationship among them (Fawcett & DeSanto-Madeya,
2013).
Latin concipere– to conceived, a new idea
• It is an idea, thought or notion conceived in the mind.
Concept is a term to describe a phenomenon or a group of phenomena.
The building blocks of theoriescan be:
• Abstract concepts - mentally constructed ex. Marital status
• Concrete concepts - directly experienced and relate to a particular time or place.
Ex. Single, married, widow, divorced
5. Theory
• It means as an organized information about related concepts pertaining to
phenomena occurring within a particular discipline (Johnson & Weber, 2001)
• It is generally an attempt to make sense of what we observed and experienced.
Components of Theory (McEwen & Wills, 2002)
1. PURPOSE - explains why the theory was formulated and specifies the context
and situations in which it should be applied. It. provide information about the
sociopolitical context in which the theory was developed
2. CONCEPTS AND DEFINITIONS- defines the concept in relation to other
concepts and permits the description and classification of phenomena. Operationally
defined concepts like to the concept to the real world and identify empirical referents
(indicators) of the concept that will permit observation and measurement.
3. THEORETICAL STATEMENTS
• Once a concept is fully developed and presented, it can be combined with other
concepts to create statements to describe the real world.
• They are statements about the relationship between two or more concepts and
are use to connect concepts to devise the theory.
4. STRUCTURE
• It provides overall form to the theory.
• Theory structuring includes determination of the order of appearance or
relationships, identification of central relationships and delineation of direction,
strength and quality of relationships.
• 5. ASSUMPTIONS
• They are notations that are taken to be true without proof.
• They are statements that describe concepts or connect two concepts that are
factual, accepted as truths, and represent values, beliefs or goals. (Meleis, 1997).
6. MODELS
• They are schematic representations of some aspect of reality.
• E.g. three-dimensional objects, diagrams,
TYPES OF THEORIES:
 Three levels of theory are:
1. Grand theories,
2. Mid-range theories,
3. situation-specific theories.
• Grand theories - are systematic construction of the nature of nursing, the mission of
nursing and the goals of nursing care.
• Mid-range theories - address specific phenomena or concepts and comprised
hypotheses with 2 or more concepts that are linked together in a conceptual system.
Example: Health condition involved, Action of the nurse
• Situation-specific theories - focus on specific nursing phenomena that reflect
clinical practice and that are limited to specific population or to a particular field of
practice (Alligood, 2018).
Nursing Theoretical Works
A. Nursing Philosophies
1. Nightingale’s Environmental Theory
Florence Nightingale-The Lady with the Lamp
• The founder of modern nursing.
• Born in Florence, Italy on May 12, 1820.
• Complete her nursing training in 1851 (age 31) at Kaiserwerth, Germany, a Protestant
religious community; for approximately 3 months, declared her as a trained nurse.
• Began her nursing training in 1851 in Germany
• Pioneered the concept of formal nursing education
• Her experience in treating sick/injured soldiers in the Crimean War strongly influenced her
philosophy of nursing
• She formulated her values through years of working with charities, hospitals, & the military
• In 1860 Nightingale published Notes on Nursing
• Considered the first “nursing theorist”
• Pioneered the concept of formal nursing education
Nightingale’s Notes on Nursing:
• a guide to help organize & manipulate the environment for persons requiring nursing care
Nightingale’s Environmental Theory
• The first published nursing theory (1860)
• Persons are in relation with the environment
• Stresses the healing properties of the physical environment (fresh air, light, warmth, and
cleanliness)
• Nursing puts patients in the “best conditions” for nature to act upon them
• Health is “the positive of which the pathology is the negative”
• “Nature alone cures” (Alligood, 2018).

Theory basis: the inter-relationship of a healthful environment with nursing

External influences and conditions can prevent, suppress, or contribute to disease or death
Theory goal: Nurses help patients retain their own vitality by meeting their basic needs through
control of the environment
Nursing’s Focus: control of the environment for individuals, families & the community
 Three Types of Environments:
• Physical
• Psychological
• Social

Components of Nightingale’s Environmental Theory:

• Health of Houses
• Ventilation and Warming
• Light
• Noise
• Variety
• Bed and Bedding
• Cleanliness of Rooms and Walls
• Personal Cleanliness
• Nutrition and Taking Food
• Chattering Hopes and Advices
• Observation of the Sick
• Social Considerations (Alligood, 2018).

Nightingale’s Theory & Nursing’s Metaparadigm

– PERSON
• Referred to by Nightingale as “the patient”
• A human being acted upon by a nurse, or affected by the environment
• Has reparative powers to deal with disease
• Recovery is in the patient’s power as long as a safe environment exists

– ENVIRONMENT
• The foundational component of Nightingale’s theory
• Includes everything from a person’s food to a nurse’s verbal & nonverbal interactions with
the patient

– HEALTH
• Maintained by using a person’s healing powers to their fullest extent
• Maintained by controlling the environmental factors so as to prevent disease
• Disease is viewed as a reparative process instituted by nature
• Health & disease are the focus of the nurse
• Nurses help patients through their healing process (Alligood, 2018).

– NURSING
• Provides fresh air, light, warmth, cleanliness, quiet, and a proper diet
• Influences the environment to affect health

2. Watson’s Theory of Human Caring

JEAN WATSON
• Born in West Virginia
 • Educated : BSN, University of Colorado, 1964, MS, University of Colorado, 1966, PhD,
University of Colorado, 1973
• Dr. Jean Watson is Distinguished Professor of Nursing and holds an endowed Chair in Caring
Science at the University of Colorado Health Sciences Center
• She is founder of the original Center for Human Caring in Colorado and is a Fellow of the
American Academy of Nursing.
• Watson defined nursing “as a human science of persons and human health—illness
experiences that are mediated by professional, personal, scientific and ethical human care
transactions” (Watson, 1988, p. 54)
Major Elements of the Caring Theory
• Carative factors, evolving into Caritas factors
• Transpersonal Caring Relationships
• Caring occasion/Caring moment (Alligood, 2018)

Carative Factors
• Attempt to “honor the human dimensions of nursing’s work and the inner life world and
subjective experiences of the people we serve” (Watson, 1997, p. 50).
• THE TEN PRIMARY CARATIVE FACTORS:
1. The formation of a humanistic- altruistic system of values.
2. The installation of faith- hope.
3. The cultivation of sensitivity to one’s self and to others.
4. The development of a helping- trust relationship.
5. The promotion and acceptance of the expression of positive and negative feelings.
6. The systematic use of the scientific problem- solving method for decision making.
7. The promotion of interpersonal teaching- learning
8. The provision for a supportive, protective and/or corrective mental, physical, socio-
cultural and spiritual environment.
9. Assistance with the gratification of human needs.
10. The allowance for existential- phenomenological forces.
• Altruism –selfless concern in helping others.

Allowance for Existential-Phenomenological Forces

• Phenomenology is a way of understanding people from the way things appear to them,
from their frame of reference
• Existential psychology is the study of human existence using phenomenological analysis
• This factor helps the nurse to reconcile and mediate the incongruity of viewing the person
holistically while at the same time attending to the hierarchical ordering of needs (Alligood,
2018).

Watson’s Theory and the Four Major Concepts

1. Human Being
• - adopts a view of the human being as : “…a valued person in and of him or herself to be
cared for, respected, nurtured, understood and assisted; in general a philosophical view of a
person as a fully functional integrated self . He human is viewed as greater than and
different from, the sum of his or her parts” (Alligood, 2018).
2. Health
 - She believes that there are other factors that are needed to be included in the WHO
definition of health. She adds the following three elements:
1. High level of overall physical, mental and social functioning
2. General adaptive –maintenance level of daily functioning
3. The absence of illness ( or the presence of efforts that leads its absence) (Alligood, 2018).
3. Environment/ Society
- According to Watson caring (and nursing) has existed in every society. A caring attitude is
not transmitted from generation to generation. It is transmitted by the culture of the
profession as a unique way of coping with its environment (Alligood, 2018).
4. Nursing
- According to Watson “nursing is concerned with promoting health, preventing illness,
caring for the sick and restoring health”.
- It focuses on health promotion and treatment of disease (Alligood, 2018).

3. Benner’s Stages of Nursing Expertise Nursing Philosophies

• Patricia Benner is a Professor in the Department of Physiological Nursing in the School of
Nursing at the University of California, San Francisco.
• Dr. Benner received her bachelor's degree in nursing from Pasadena College, her master's
degree in medical surgical nursing from the University of California, San Francisco, and the
Ph.D. from the University of California, Berkeley, in Stress and Coping and Health under the
direction of Hubert Dreyfus and Richard Lazarus.
• Dr. Benner categorized nursing into 5 levels of capabilities: novice, advanced beginner,
competent, proficient, and expert.
• She believed experience in the clinical setting is key to nursing because it allows a nurse to
continuously expand their knowledge base and to provide holistic, competent care to the
patient.
• Her research was aimed at discovering if there were distinguishable, characteristic
differences in the novice’s and expert’s descriptions of the same clinical incident (Alligood,
2018).

Dr. Benner presented her research in: From Novice to Expert: Excellence and Power in Clinical
Nursing Practice.
• Novice, Advance Beginner, Competent, Proficient, and Expert are the different components
explained in her research (Alligood, 2018).

1. Novice
• The person has no background experience of the situation in which he or she is involved.
• There is difficulty discerning between relevant and irrelevant aspects of the situation.
• Generally this level applies to nursing students.
2. Advanced Beginner
• The advance beginner stage in the Dreyfus model develops when the person can
demonstrate marginally acceptable performance having coped with enough real situations
to note, or to have pointed out by mentor, the recurring meaningful components of the
situation.
• Nurses functioning at this level are guided by rules and oriented by task completion.
3. Competent
 • The competent nurse or nurse manager is able to prioritize tasks at hand by utilizing past
experiences. Benner (1982) describes the competent individual as someone who has been
on the job two or three years and is able to see actions in terms of goals or plans (p. 404).
The competent individual is able to work in an efficient and organized manner due to
conscious, deliberate planning (Benner, 1982). The competent leader is one who lacks the
multi-tasking talents and flexibility of proficient.
• 4. Proficient
• The performer perceives the information as a whole (total picture) rather than in terms of
aspects and performance.
• Proficient level is a qualitative leap beyond the competent.
• Nurses at this level demonstrate a new ability to see changing relevance in a situation
including the recognition and the implementation of skilled responses to the situation as is
it evolves.
5. Expert
• The expert individual has an extensive knowledge of situations that allows for confidence
and an intuitive grasp of complex patient situations (Dale et al., 2013).

Four Domains of Nursing Paradigm:

1. Client/ Person
• “The person is a self-interpreting being, that is the person does not come into the world
predefined but gets defined in the course of living a life.”- Dr. Benner
2. Health
• Dr. Benner focuses on the lived experience of being healthy and being ill.
• Health is defined as what can be assessed, whereas well being is the human experience of
health or wholeness.
• Well being and being ill are understood as distinct ways of being in the world (Alligood,
2018).
3. Environment/Situation
• Benner uses situation rather than environment because situation conveys a social
environment with social definition and meaningfulness.
• “To be situated implies that one has a past, present, and future and that all of these
aspects….influence the current situation.”- Dr. Benner
4. Nursing
• Nursing is described as a caring relationship, an “enabling condition of connection and
concern.” -Dr. Benner
• “Caring is primary because caring sets up the possibility of giving and receiving help.”
• Nursing is viewed as a caring practice whose science is guided by the moral art and ethics of
care and responsibility.
• Dr. Benner understands that nursing practice as the care and study of the lived experience
of health, illness, and disease and the relationships among the three elements (Alligood,
2018).

4. Erickson’s Caritative Caring Theory

• “Caritative caring means that we take “caritas” into use when caring for the human being in
health and suffering …. Caritative caring is a manifestation of the love that ‘just
 exists’…Caring communion, true caring, occurs when the one caring in a spirit of caritas
alleviates the suffering of the patient” (Eriksson, 1992c, pp. 204, 207).
The Theory of Caritative caring
• Spirituality as been influential in defining the value system which shapes the life of
individuals, including their past, present and future living existence here on earth.
• Patients place a high value on their spiritual and emotional needs and this correlates to
patient satisfaction with care.

Application of Eriksson's theory

• Causes all parties involved both patient and caregiver, to view and adapt a caring system
that involves the totality of an individual.
• This involves the human’s body, soul and spirit.
• The model suggests that the only way to care most effectively is by meeting all the needs of
the patient because he or she is a religious human being in some shape or another.
• Suggests that when providing total care, the spiritual component of the individual must be
assessed because it plays a vital part in how well the patient will be cared for, as well as the
overall healing outcome (Alligood, 2018).

Metaparadigm of the Four Major Concepts:

1. Human Being
• Is an entity of body, soul and spirit and fundamentally holy and is related to the idea of
human dignity, which means accepting the human obligation of serving with love and
existing for the sake of others (Alligood, 2018).
2. Nursing
• Love and charity as the basic motive of caring and gets its deepest formulation.
• Natural basic caring is expressed through tending, playing and learning in a spirit of love,
faith and hope (Alligood, 2018).
3. Environment
• Erickson’s uses the concept of “ethos” in accordance with Aristotle’s (1935, 1997) idea that
ethics is derived from ethos (Alligood, 2018).
• “ethos” originally refers to home or to the place a human being feels at home.
4. Health
• Means as a pure concept wholeness and holiness.
• Health is conceived as a becoming, a movement toward a deeper wholeness and holiness.

Nursing Conceptual Models

1. Roger’s Science of Unitary Human Beings Nursing Conceptual Model

Martha Rogers- Unitary Human Beings
• Roger believes that it is only through the knowledge of man/environment and their
interaction that nursing can truly understand clients and assist them to achieve health
(Roger, 1990)

• The central concern of this model is the nursing of unitary human beings. The theory is
centered on man/environment, which is indivisible. Roger believes that it is only through
 the knowledge of man/environment and their interaction that nursing can truly understand
clients and assist them to achieve health (Roger, 1990)
• Described the life process in human beings:
-wholeness, openness, unidirectionality pattern and organization and thought characterized
the life process (Alligood, 2018).
Subconcepts:
• Energy Field-It provides a way to view people and the environment as irreducible wholes.
• Openness- It refers to qualities exhibited by open systems; human beings and their
environment are open systems.
• Pan-dimensionality is defined as “non-linear domain without spatial or temporal attributes.”
• Pattern- Rogers defined the pattern as the distinguishing characteristic of an energy field
seen as a single wave.

Four dimensionality:
1. Energy fields
- field is a unifying concept, energy is signifies the dynamic nature of the field
It refers to qualities exhibited by open systems; human beings and their environment are
open systems.
2. Universe of open systems-Energy fields are open, infinite, and interactive
3. Pattern – distinguishing characteristic of energy field
4. Pandimensionality-nonlinear domain without spatial attributes

• Metaparadigm of four Major Concepts:

1. Nursing
-Nursing is a learned profession and is both a science and an art.
Focuses on concern with people and the world in which they live.
2. Person
-Rogers defines person as an open system in continuous process with the open system that
is the environment.
3. Health
-Rogers uses the term passive health to symbolize wellness and the absence of disease and
major illness (Rogers, 1970)
She said that wellness is a better term than health.
4. Environment
-Environmental fields are infinite and change is continuously innovative (Alligood, 2018).
2. Orem’s Self-care Deficit Model
• SELF- CARE DEFICIT THEORY OF NURSING-Dorothea Orem
• SELF- CARE-the ability of an individual to manage all activities needed to live and
survive. It is the practice of activities that individuals initiates to maintain life and
on their own behalf by in maintaining life health and well- being. (Orem 2001, as
cited in Tomey and Aligood)

UNIVERSAL SELF- CARE REQUISITES

1. Sufficient intake of air
2. Sufficient intake of water
3. Sufficient intake of food
 4. Satisfactory eliminative function
5. Activity balanced with rest
6. Balance between solitude and social integration
7. Prevention of hazards to life, human functioning, and human well - being
8. Being normal
• DEVELOPMENTAL SELF- CARE REQUISITES
• Every mature person has the ability to meet self-care needs, but when a person experiences
the inability to do so due to limitations, thus exists a self-care deficit.
• Nursing action focuses on identification of limitation/deficit and implementing appropriate
interventions to meet the needs of person (Alligood, 2018).

PATIENT’S ROLE
- Perform some self- care measures; willingly accept assistance, from nursing staff
- Meet self- care requirements, continue to learn and develop self- care activity
NURSING ROLE
- Compensate for self- care inabilities, support and protect
- Make judgments and decisions for patients
- Cultivate existing skills
- Perform some health care measures for the patient
-Compensate for any self- care limitations
- Assist patient as needed
• Help make decisions, help the patient to learn, update information periodically (Alligood,
2018).
3. King’s General Systems Framework Nursing Conceptual Model (by IMOGENE KING
Conceptual System and Middle-Range Theory of Goal Attainment
• “Theory is an abstraction that implies prediction based in resear ch. Theory without
research and research without some theoretical basis will not build scientific
knowledge for a discipline.” (King, 1997, p. 23)
•

• GOAL ATTAINMENT THEORY

1. Action
2. Reaction
3. Interaction
4. Open System- interacting systems (Alligood, 2018).

Interacting System Framework:

1. Personal- as a patient or a nurse. King emphasized the importance of body image, growth
and development, perception, self and time.
2. Interpersonal-form when two people or more people interact, forming dyads (two
people) or triads (three people)
3. Social system-is a more comprehensive interacting system of groups that make up
society. Within a social system, the concepts of authority, decision making, organization,
power, and status guide system (Alligood, 2018).
 King identified two methods for developing a theory:
• A theory can be developed and then tested in research
• Research provides data from which theory may be developed (Alligood, 2018).

Four Major Concepts:

1. Nursing
“Nursing is an observable behavior found in the health care system in society”
(King, 1971, p. 125)
“is to help individuals maintain their health so they can function in their roles”
(King, 1981, p. 3-4)
2. PERSON
Individuals are:
- Spiritual beings
- have the ability through their language to record their history and preserve their
culture
-are unique and holistic
-differ in their needs, wants and goals
3. HEALTH
-is a dynamic state in the life cycle, whereas illness interferes in that process.
Health “implies continuous adjustment to stress in the internal and external
environment through the optimum use of one’s resources to achieve the maximum
potential for daily living” (King, 1981. p. 5)
4. ENVIRONMENT
King (1981) believed that an “understanding of the ways that human beings
interact with their environment to maintain health was essential for nurses” (p. 2)
4. Nueman’s Systems Model
"The Neuman system model reflects nursing's interest in well and ill people
as holistic systems and in environmental influences on health. Clients' and nurses'
perceptions of stressors and resources are emphasized, and clients act in
partnership with nurses to set goals and identify relevant prevention
interventions. The individual, family or other group, community or social issues, all
are client systems which are viewed as composites of interacting physiological,
psychological, sociocultural, developmental and spiritual variables" (p. 322).

Background:
• Born in 1924 on a farm in rural Ohio - this background helped her develop
compassion for those in need.
Education:
• 1947- RN from diploma program in OH
• 1957-BSN, UCLA mental health & public health
• 1966-MSN, UCLA
• 1967-1973, UCLA faculty.
• Developed first community mental health program for graduate students at UCLA.
 • 1985- PhD Western Pacific University-clinical psychology.

Client system as a core:

• Flexible line of defense -The outermost ring of defense prevents invasionof
stressors.
• Normal line of defense - Represents the client systems normal or usual wellness
state.
• Lines of resistance - Involuntarily activated when a stressor invades normal line of
defense.

Neuman suggests a nursing process format in which the client, a recipient of care,
participates actively with the nurse to set goals and select interventions.

Betty Neuman's Systems Model Nursing Process Format

1. Nursing diagnosis: determined on the basis of assessment of the variables and
lines of defense and resistance that make up the specific client system.
2. Nursing goals: determined with the client for desired prescriptive changes to
correct variances from wellness.
3. Nursing outcomes: Nursing interventions are implemented using one or more of
the prevention as intervention methods.

The model proposes three levels of nursing intervention. How it's done: Prevention
as Intervention:
• Primary prevention as intervention- nursing actions
- preventing stressor invasion; providing resources to retain or strengthen existing
client/client system strengths; supporting positive coping and functioning;
motivating the client system toward wellness; educating the client system

• Secondary prevention as intervention-nursing actions

- protecting the client system's basic structure; mobilizing and optimizing the client
system's internal and external resources to attain stability and energy
conservation; facilitating purposeful manipulation of stressors and reactions to
stressors; motivating, educating, and involving the client system in mutual
establishment of health care goals; facilitating appropriate treatment and
intervention measures
• Tertiary prevention as intervention-nursing actions
-attaining and maintaining the highest possible level of client system wellness and
stability during reconstitution; educating, reeducating, and/or reorienting the
client system as needed; supporting the client system toward appropriate goals;
coordinating and integrating health services resources; providing primary and/or
secondary preventive intervention as required. The nurse evaluates the outcome
goals by: confirming attainment of outcome goals with the client system and
reformulating goals as necessary with the client system

5. Roy’s Adaptation Model

 Background:
• Sister Callista Roy was born on October 14, 1939 in Los Angeles, California.
• She was a member of the Sisters of Joseph of Carondelet.
• She attained a Bachelor of Arts in Nursing from the University of California in 1966.
• 1968 she began operationalizing her Adaptation Model when Saint Mary's College
adopted the adaptation framework for the philosophical foundation of the nursing
curriculum.
• She has published many books, chapters, and periodicals, and given lectures and
workshops that highlight
• Her nursing theory. She received the National Founder's Award for Excellence in
fostering Professional
• Nursing Standards in 1981, an Honorary Doctorate of Humane Letters in 1984, and
and Honorary Doctorate from Eastern Michigan University in 1986.
• In 1994, she published a related book entitled, “The Roy Adaptation Model: The
Definitive Statement”

• The Roy Adaptation Model is defined as “the process and outcome whereby the
thinking and feeling person uses conscious awareness and choice to create
human and environmental integration.”
• (Sister Callista Roy) Essential elements of this adaptation are considered to be the
person receiving nursing care, adapting nursing goals to any change, health,
environment, and the facilitation of adaptation. All of these elements are
interrelated and modes of adaptation are necessary to address these elements.

4 Modes of Adaptation:
1. The physiologic-physical mode-physical and chemical processes of the human
system, knowledge of the nurse about the normal processes. (5 Needs):
• Oxygenation- describes the pattern of oxygen use related to respiration and
circulation.
Nutrition- describes the pattern of nutrients for body repair and
development.
• Elimination- describes the pattern of elimination and waste product.
• Activity and rest- manage energy
• Protection
2. Self-concept- group identity mode- the composite of beliefs and feelings held about oneself,
need to know who one is
• focus on the psychological and spiritual aspects of the human system
• 3. Role function mode – set of expectations about how a person occupying one
position behaves toward a person occupying another position.
• The need to know who one is in relation to others.
4. Interdependence mode-pertaining to interdependent relationships of individuals and groups
• Focus on the close relationship of people and their purpose.

Nursing Process
• Behavioural Assessment – refers to the responses that relates to the four adaptive
modes.
 • Assessment of stimuli – in this assessment, the nurse collects data about the focal,
contextual and residual stimuli affecting the client resulting to ineffective
behaviours or adaptive responses requiring nursing support.
• Nursing diagnosis- refers to the typology of nursing needs.
• Goal Setting- refers to what nurse’s want to achieve.
• Plans for Implementation- the purpose of planning is to manage the focal problem.
• Evaluation- goal behaviours are compared to the clients output.

Four Major Concepts of Roy Adaptive Model (RAM)

1. Nursing- Roy define nursing as “health care profession that focuses on human
life processes and patterns and emphasizes promotion of health for individuals,
families, groups and society as a whole”.
2. Person
• “As an adaptive system, the human system is described as a whole with parts that
function as unity for some purpose. Human systems include people as individuals
or in groups, including families, organizations, communities and society as a
whole”.
3. Health
• Is a state and process of being and becoming integrated and a whole person. It is a
reflection of adaptation that is the interaction of the person and the environment.
• 4. Environment “all the conditions, circumstances and influences surrounding a nd
affecting the development and behavior of persons or groups with particular
consideration of the mutuality of person and earth resources.

6. Johnson’s Behavioral System Model

• In 1968 Dorothy first proposed her model of nursing care as fostering of “the
efficient and effective behavioral functioning in the patient to prevent illness".
• She also stated that nursing was “concerned with man as an integrated whole and
this is the specific knowledge of order we require”.
• In 1980 Johnson published her conceptualization of “behavioral system of model
for nursing” this is the first work of Dorothy that explicates her definitions of the
behavioral system model.
The Behavioral System Model by Dorothy Johnson describes the person as a behavioral system
with seven subsystems: the achievement, attachment-affiliative, aggressive-protective,
dependency, ingestive, eliminative and sexual subsystem.

Metaparadigm of the Four Major Concepts:

1. Johnson views “human being” as having two major systems, the biological system and the
behavioral system. It is role of the medicine to focus on biological system where as Nursing's
focus is the behavioral system
2. “Society” relates to the environment on which the individual exists. According to Johnson an
individual’s behavior is influenced by the events in the environment
3. “Health” is a purposeful adaptive response, physically mentally, emotionally, and socially to
internal and external stimuli in order to maintain stability and comfort.
 4. “Nursing” has a primary goal that is to foster equilibrium within the individual .she stated that
nursing is concerned with the organized and integrated whole, but that the major focus is on
maintaining a balance in the Behavior system when illness occurs in an individual.
• Based on this definition there are four goals of nursing are to assist the patient:
Whose behavior commensurate with social demands.
Who is able to modify his behavior in ways that it supports biological imperatives
Who is able to benefit to the fullest extent during illness from the physicians
knowledge and skill.
Whose behavior does not give evidence of unnecessary trauma as a consequence
of illness
• Assumptions about structure and function of each subsystem
1. “From the form the behavior takes and the consequences it achieves can be inferred what
“drive” has been stimulated or what “goal” is being sought”
2. Each individual has a “predisposition to act with reference to the goal, in certain ways rather
than the other ways”. This predisposition is called as “set”.
3. Each subsystem has a repertoire of choices or “scope of action”
4. The fourth assumption is that it produce “observable outcome” that is the individual’s
behavior.

• Each subsystem has three functional requirements

1. System must be “protected" from noxious influences with which system cannot cope”.
2. Each subsystem must be “nurtured” through the input of appropriate supplies from the
environment.
3. Each subsystem must be “stimulated” for use to enhance growth and prevent stagnation