II.

CONCEPTUAL AND THEORETICAL MODELS OF NURSING PRACTICE

NURSING
As defined by the INTERNATIONAL COUNCIL OF NURSES as written by Virginia Henderson. Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles. the unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health, its recovery, or to a peaceful death the client would perform unaided if he had the necessary strength, will or knowledge. Help the client gain independence as rapidly as possible. CONCEPTUAL AND THEORETICAL MODELS OF NURSING PRACTICE A. NIGHTANGLES THEORY (mid-1800) Environmental Theory Focuses on the patient and his environment . Developed and described the first theory of nursing. Notes on Nursing: What It Is, What It Is Not. She focused on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act. She believed that in the nurturing environment, the body could repair itself. Clients environment is manipulated to include appropriate noise, nutrition, hygiene, socialization and hope. B. PEPLAU, HILDEGARD (1951) Interpersonal Theory Defined nursing as a therapeutic, interpersonal process which strives to develop a nurse- patient relationship in which the nurse serves as a resource person, counselor and surrogate. Introduced the Interpersonal Model. She defined nursing as an interpersonal process of therapeutic relationship between an individual who is sick or in need of health services and a nurse especially educated to recognize and respond to the need for help. She identified four phases of the nurse-client relationship namely: 1. Orientation: the nurse and the client initially do not know each others

goals and testing the role each will assume. The client attempts to identify difficulties and the amount of nursing help that is needed; 2. Identification: the client responds to help professionals or the significant others who can meet the identified needs. Both the client and the nurse plan together an appropriate program to foster health; 3. Exploitation: the clients utilize all available resources to move toward a goal of maximum health functionality; 4. Resolution: refers to the termination phase of the nurse-client relationship. it occurs when the clients needs are met and he/she can move toward a new goal. Peplau further assumed that nurse-client relationship fosters growth in both the client and the nurse. C. ABDELLAH, FAYE G. (1960) Typology of 21 Nursing Problems Defined nursing as having a problem-solving approach, with key nursing problems related to health needs of people; developed list of 21 nursingproblem areas. Typology of 21 Nursing Problems:
1. To promote good hygiene and physical comfort 2. To promote optimal activity, exercise, rest, and sleep 3. To promote safety through 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 physiologic responses of the body to disease conditions 10. To facilitate the maintenance of regulatory mechanisms and functions 11. To facilitate the maintenance of sensory function 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 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 light of physical and emotional limitations 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 cause of illness

Introduced Patient Centered Approaches to Nursing Model She defined nursing as service to individual and families; therefore the society. Furthermore, she conceptualized nursing as an art and a science that molds the attitudes, intellectual competencies and technical skills of the individual nurse into the desire and ability to help people, sick or well, and cope with their health needs. D. Jean Watson (1979) Philosophy and Science of Caring - Jean Watsons philosophy of transpersonal caring defines the outcome of nursing activity in regard to the humanistic aspects of life. - Nursing actions purpose is to understand the interrelationship between health, illness, and human behavior. Thus nursing is concerned with promoting and restoring health and preventing illness. - The caring process requires the nurse to be knowledgeable about human behavior and human responses to actual or potential health problems. - The nurse needs to know individual needs how to respond to others, strengths and limitations of the client and family, as well as of the nurse. - the nurse comforts and offers compassion and empathy to clients and their families. - Caring represents all factors the nurse uses to deliver care to the client. E. LEVINE, MYRA (1973) Conservation Theory Believes nursing intervention is a conservation activity, with conservation of energy as a primary concern, four conservation principles of nursing: conservation of client energy, conservation of structured integrity, conservation of personal integrity, conservation of social integrity. Described the Four Conversation Principles. She Advocated that

nursing is a human interaction and proposed four conservation principles of nursing which are concerned with the unity and integrity of the individual. The four conservation principles are as follows: 1. Conservation of energy . The human body functions by utilizing energy. The human body needs energy producing input (food, oxygen, fluids) to allow energy utilization output. 2. Conservation of Structural Integrity . The human body has physical boundaries (skin and mucous membrane) that must be maintained to facilitate health and prevent harmful agents from entering the body. 3. Conservation of Personal Integrity. The nursing interventions are based on the conservation of the individual clients personality. Every individual has sense of identity, self worth and self esteem, which must be preserved and enhanced by nurses. 4. Conservation of Social integrity. The social integrity of the client reflects the family and the community in which the client functions. Health care institutions may separate individuals from their family. It is important for nurses to consider the individual in the context of the family. F. JOHNSON, DOROTHY (1960, 1980) Behavioral Systems Model Focuses on how the client adapts to illness; the goal of nursing is to reduce stress so that the client can move more easily through recovery. Viewed the patients behavior as a system, which is a whole with interacting parts. The nursing process is viewed as a major tool. Conceptualized the Behavioral System Model. According to Johnson, each person as a behavioral system is composed of seven subsystems namely: 1. Ingestive. Taking in nourishment in socially and culturally acceptable ways. 2. Eliminative. Riddling the body of waste in socially and culturally acceptable ways. 3. Affiliative. Security seeking behavior. 4. Aggressive. Self protective behavior. 5. Dependence. Nurturance seeking behavior. 6. Achievement. Master of oneself and ones environment according to internalized standards of excellence. 7. Sexual role identity behavior G. ROGERS, MARTHA Unitary Human Being Considers man as a unitary human being co-existing with the universe, views nursing primarily as a science and is committed to nursing research.

H. OREM, DOROTHEA (1970, 1985) Self-care Model Emphasizes the clients self-care needs, nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental or social needs. Developed the Self-Care Deficit Theory. She defined self-care as the practice of activities that individuals initiate to perform on their own behalf in maintaining life, health, well-being. She conceptualized three systems as follows: 1. Wholly Compensatory : when the nurse is expected to accomplish all the patients therapeutic self-care or to compensate for the patients inability to engage in self care or when the patient needs continuous guidance in self care; 2. Partially Compensatory: when both nurse patient engage in meeting self care needs; 3. Supportive-Educative : the system that requires assistance decision making, behavior control and acquisition knowledge and skills. I. IMOGENE KING (1971, 1981) Goal Attainment Theory Nursing process is defined as dynamic interpersonal process between nurse, client and health care system. Postulated the Goal Attainment Theory . She described nursing as a helping profession that assists individuals and groups in society to attain, maintain, and restore health. If is this not possible, nurses help individuals die with dignity. In addition, King viewed nursing as an interaction process between client and nurse whereby during perceiving, setting goals, and acting on them transactions occurred and goals are achieved. J. BETTY NEUMAN Health Care System Model Stress reduction is a goal of system model of nursing practice. Nursing actions are in primary, secondary or tertiary level of prevention.

K. SIS CALLISTA ROY (Adaptation Theory) (1979, 1984) Views the client as an adaptive system. The goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function and interdependent relations during health and illness. Presented the Adaptation Model. She viewed each person as a unified biopsychosocial system in constant interaction with a changing environment. She contended that the person as an adaptive system, functions as a whole through interdependence of its part. The system consist of input, control processes, output feedback. L. LYDIA HALL (1962) Core, Care, Cure Theory The client is composed of the ff. overlapping parts: person (core), pathologic state and treatment (cure) and body (care). Introduced the model of Nursing: What Is It?, focusing on the notion that centers around three components of CARE, CORE and CURE. Care represents nurturance and is exclusive to nursing. Core involves the therapeutic use of self and emphasizes the use of reflection. Cure focuses on nursing related to the physicians orders. Care and cure are shared with the other health care providers. M. Virginia Henderson (1955) Nature of Nursing Model Introduced The Nature of Nursing Model. She identified fourteen basic needs. She postulated that the unique function of the nurse is to assist the clients, sick or well, in the performance of those activities contributing to health or its recovery, the clients would perform unaided if they had the necessary strength, will or knowledge. She further believed that nursing involves assisting the client in gaining independence as rapidly as possible, or assisting him achieves peaceful death if recovery is no longer possible. 14 basic needs breathing normally eating and drinking adequately eliminating body waste moving and maintaining a desirable position sleeping and resting selecting suitable clothes maintaining normal body temperature by adjusting clothing and modifying the environment keeping the body clean and well groomed to promote integument avoiding dangers in the environment and avoiding injuring others communicating w/others in expressing emotions ,needs,fears or opinions worshipping accdg. to one's faith working in such a way that one feels a sense of accomplishment playing or participating in various forms of recreation

learning , discovering or satisfying the curiosity that leads to normal development and health, and using available health facilities N. Madaleine Leininger (1978, 1984) Transcultural Nursing Model Developed the Transcultural Nursing Model. She advocated that nursing is a humanistic and scientific mode of helping a client through specific cultural caring processes (cultural values, beliefs and practices) to improve or maintain a health condition. O. Ida Jean Orlando (1961) Conceptualized. Deliberative Nursing Process She believed that the nurse helps patients meet a perceived need that the patient cannot meet for themselves. Orlando observed that the nurse provides direct assistance to meet an immediate need for help in order to avoid or to alleviate distress or helplessness. She emphasized the importance of validating the need and evaluating care based on observable outcomes. P. Ernestine Weidenbach (1964) Clinical Nursing A Helping Art Model Developed the Clinical Nursing A Helping Art Model. She advocated that the nurses individual philosophy or central purpose lends credence to nursing care. She believed that nurses meet the individuals need for help through the identification of the needs, administration of help, and validation that actions were helpful. Components of clinical practice: Philosophy, purpose, practice and an art. Q. Rosemary Parse (1979-1992) Theory of Human Becoming Introduced the theory of Human Becoming. She emphasized free choice of personal meaning in relating value priorities, co creating the rhythmical patterns, in exchange with the environment, and co transcending in many dimensions as possibilities unfold. R. Joyce Travelbee (1966,1971) She postulated the Interpersonal Aspects of Nursing Model. She advocated that the goal of nursing is for individual or family in preventing or coping with illness, regaining health, finding meaning in illness, or maintaining maximal degree of health. She further viewed that interpersonal process is a human-to-human relationship formed during illness and experience of suffering She believed that a person is a unique, irreplaceable individual who is in a continuous process of becoming, evolving and changing. S. Josephine Peterson and Loretta Zderad (1976) Provided the Humanistic Nursing Practice Theory. This is based on their belief that nursing is an existential experience.

 Nursing is viewed as a lived dialogue that involves the coming together of the nurse and the person to be nursed. The essential characteristic of nursing is nurturance. Humanistic care cannot take place without the authentic commitment of the nurse to being with and the doing with the client. Humanistic nursing also presupposes responsible choices. T. Helen Erickson, Evelyn Tomlin, and Mary Ann Swain (1983) Developed Modeling and Role Modeling Theory. The focus of this theory is on the person. The nurse models (assesses), role models (plans), and Intervenes in this interpersonal and interactive theory. They asserted that each individual unique, has some self-care knowledge, needs simultaneously to be attached to the separate from others, and has adaptive potential. Nurses in this theory, facilitate, nurture and accept the person unconditionally. U. Margaret Newman Focused on health as expanding consciousness. She believed that human are unitary in whom disease is a manifestation of the pattern of health. She defined consciousness as the information capability of the system which is influenced by time, space movement and is ever expanding. V. Patricia Benner and Judith Wrude l (1989) Proposed the Primacy and Caring Model. They believed that caring is central to the essence of nursing. Caring creates the possibilities for coping and creates the possibilities for connecting with and concern for others. W. Anne Boykin and Savina Schoenhofer Presented the grand theory of Nursing as Caring. They believed that all person are caring, and nursing is a response to a unique social call. The focus of nursing is on nurturing person living and growing in caring in a manner that is specific to each nurse-nursed relationship or nursing situation. Each nursing situation is original. They support that caring is a moral imperative. Nursing as Caring is not based on need or deficit but is egalitarian model helping. Moral Theories 1. Freud (1961) Psychosexual Theory Believed that the mechanism for right and wrong within the individual is the superego, or conscience . He hypnotized that a child internalizes and adopts the moral standards and character or character traits of the model parent through the process of identification.

 The strength of the superego depends on the intensity of the childs feeling of aggression or attachment toward the model parent rather than on the actual standards of the parent. Stages of Development Freud proposed that there were 5 stages of development. Freud believed that few people successfully completed all 5 of the stages. Instead, he felt that most people tied up their libido at one of the stages, which prevented them from using that energy at a later stage. ORAL Stage This occurs from birth to about 1 year, and the libido is focused on the mouth. The individual may be frustrated by having to wait on another person, being dependent on another person. Being fixated at this stage may mean an excessive use of oral stimulation, such as cigarettes, drinking or eating. ANAL Stage This period occurs about age 2 and 3 yrs. Here individuals have their first encounter with rules and regulations, as they have to learn to be toilet trained. This encounter with rules and regulations will dictate the later behavior with rules and regulations. The libido is focused anally, and frustration may arise from having to learn a somewhat complex cognitive and motor response. Being fixated at this stage can result in stinginess, stubbornness, or orderliness, as well as messiness. Essentially, behavior related to retention and expulsion may be related to experiences at this stage. PHALLIC Stage This period starts about age 4-5 years. Some critical episodes for development occur during this stage, but these episodes occur differently for boys and girls.

Oedipus conflict - the boy begins to have sexual desires for his mother, and sees his father as a rival for her affections. The boy begins to fear that his father is suspicious of his longing for his mother, and that the father will punish him for his desires. That punishment, the boy fears, will be castratation, which brings us to the second critical episode for this stage. Castration anxiety. The fear of castration makes the boy anxious. This anxiety begun with the fear of punishment from the father leads to the boy thinking that the father hates him eventually becomes unbearable and the boy renounces his sexual feelings for his mother and chooses instead to identify with his father, and hopes to someday have a relationship with a woman (though not his mother) just like dear old dad has with his mother. The story for girls is slightly different. The oral and anal stages are the same for both girls and boys, so the focus of affection and attention is on the mother for both. But this focus changes, for girls, from the mother to the father, when the girls realize that they don't have penises, so they develop penis envy. This realization coupled with the knowledge that her

mother doesn't have a penis leads to her thinking her mother unworthy, and becoming attracted to her father, as he does have a penis. Just as with boys, girls begin to suspect the same sex parent knows about their attraction to the opposite sex parent, and they hate them for it. These feelings go round and round for awhile until the point when the girls renounce their feelings for their fathers and identify with their mothers. LATENCY Stage This period occurs after the oedipus conflict has been resolved and the feelings that were aroused during that time have subsided. This lasts from about the age of 7 until puberty, and this is a period of rest where there are no developmental events GENITAL Stage Begins at puberty involves the development of the genitals, and libido begins to be used in its sexual role. However, those feelings for the opposite sex are a source of anxiety, because they are reminders of the feelings for the parents and the trauma that resulted from all that. 2. Erikson (1964) Psychosocial Development Theory Eriksons theory on the development of virtues or unifying strengths of the good man suggest that moral development continuous throughout life. He believed that if the conflicts of each psychosocial developmental stages favorably resolved, then an ego strength or virtue emerges. Trust vs. mistrust. Babies learn either to trust or to mistrust that other will care for their basic needs including nourishment, sucking, warmth, cleanliness and physical contact. Autonomy vs. shame and doubt. Children learn either to be self sufficient in many activities, including toileting, feeding, walking and talking or to doubt their own abilities. Initiative vs. guilt. Children want to undertake many adult like activities, sometimes overstepping the limits set by parents and feeling guilty. Industry vs. inferiority. Children busily learn to be competent and productive or feel inferior and unable to do anything well. Identity vs. role confusion. Adolescents try to figure out Who Am I?. They establish sexual, ethnic, and career identities, or are confused about

Oral-Sensory (birth to 1 year)

Musculo-anal (1-3 years)

Locomotor-Genital (3-5 years)

Latency ( 6-11 years) Adolescence (12-18 years)

what future roles to play. Intimacy vs. isolation. Young adults seek companionship and love with another person or become isolated from others. Generativity vs. stagnation. Middle aged adults are productive, performing meaningful work, and raising a family, or become stagnant and inactive. Integrity vs. despair. Older adults try to make sense out of their lives, either seeing life as a meaningful whole or despairing at goals never reached and questions never answered.

Young Adulthood (19-35 years)

Adulthood (35-50 years)

Maturity (50+ years)

3. Kohlberg Moral Development theory Suggested three levels of moral development. He focused on the reason for the making of a decision, not on the morality of the decision itself. 1. At first level called the premolar or the preconventional level, children are responsive to cultural rules and labels of good and bad, right and wrong. However children interpret these in terms of the physical consequences of the actions, i.e., punishment or reward. 2. At the second level, the conventional level, the individual is concerned about maintaining the expectations of the family, groups or nation and sees this is right. 3. At the third level, people make postconventional, autonomous, or principal level. At this level, people make an effort to define valid values and principles without regard to outside authority or to the expectations of others. These involve respect for other human and belief that relationship are based on mutual trust. 4. Peter (1981) Rational Morality based on Principles Proposed a concept of rational morality based on principles. Moral development is usually considered to involve three separate components: moral emotion (what one feels), moral judgment (how one reasons), and moral behavior (how one acts). In addition, Peters believed that the development of character traits or virtues is an essential aspect or moral development. And that virtues or character traits can be learned from others and encouraged by the example of others. Also, Peters believed that some can be described as habits because they are in some sense automatic and therefore are performed

habitually, such as politeness, chastity, tidiness, thrift and honesty. 5. Gilligan (1982) Included the concepts of caring and responsibility. She described three stages in the process of developing an Ethic of Care which are as follows. 1. Caring for oneself. 2. Caring for others. 3. Caring for self and others. She believed the human see morality in the integrity of relationships and caring. For women, what is right is taking responsibility for others as self-chosen decision. On the other hand, men consider what is right to be what is just. Spiritual Theory Fowler (1979) Described the development of faith. He believed that faith, or the spiritual dimension is a force that gives meaning to a persons life. He used the term faith as a form of knowing a way of being in relation to an ultimate environment. To Fowler, faith is a relational phenomenon: it is an active made-of-being-in-relation to others in which we invest commitment, belief, love, risk and hope.